Braces And Splints For Common Musculoskeletal Conditions

[Jaunita Rousu]

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Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.

Braces and splints can immobilize and protect joints, reduce pain, decrease swelling, and facilitate healing of acute injuries. They are also used for injury prevention and chronic pain reduction, and to alter the function of a joint. The medial unloading (valgus) knee brace is an option for patients with medial knee osteoarthritis, but evidence of long-term benefit is limited. The patellar stabilizing brace helps maintain proper patellar alignment but has mixed results in treating patellofemoral pain syndrome. The patellar tendon strap is effective in treating pain from patellar tendinopathy. The knee immobilizing splint is used after surgery to prevent reinjury and for acute or presurgical management of quadriceps rupture, patellar tendon rupture, medial collateral ligament rupture, patellar fracture or dislocation, and other acute traumatic knee injuries. Use of a functional ankle brace is more effective than immobilization or a compression wrap in terms of functional outcomes after an acute ankle sprain and prevention of future ankle sprains. The thumb spica splint is effective for the treatment of thumb carpometacarpal osteoarthritis and de Quervain tenosynovitis, and may be used for patients with suspected scaphoid fractures. A wrist splint has short-term effectiveness in treating symptoms of carpal tunnel syndrome but may not be more effective than other conservative therapies.

Family physicians often treat musculoskeletal conditions for which bracing or splinting can be useful (Table 1).1 In 2015, U.S. spending on orthopedic braces, casting supplies, and splints was estimated at $1.2 billion, and these expenses are expected to increase as insurance companies cover less of these products.2

Braces and splints can immobilize and protect joints, reduce pain, decrease swelling, and facilitate healing of acute injuries. They are also used for injury prevention and chronic pain reduction, and to alter the function of a joint. It is important for the family physician to choose the appropriate brace or splint for the patient's condition, and to determine the correct size, fit, and duration of use. Selection of an inappropriate brace or splint may lead to delayed healing or further injury. Unnecessarily prolonged use can lead to joint stiffness and muscle weakness, which may increase the risk of injury. Even when used correctly, braces and splints should not replace an adequate rehabilitation program.

Knee braces are used to improve joint function in medial knee osteoarthritis (OA), stabilize patellofemoral articulation in patellofemoral pain syndrome (PFPS), assist with treatment of patellar tendinopathy, and immobilize the knee after an acute injury.

The medial unloading (valgus) knee brace (Figure 11) is an option for treating pain from medial compartment OA and varus malalignment of the knee. The brace applies an external valgus force on the knee, reducing the load on the medial compartment. The use of medial unloading knee braces has greater benefit in decreasing pain and improving knee function compared with conservative treatment alone.3 An eight-year prospective study showed that wearing this type of brace for six months can halve the chance of knee arthroplasty compared with three months of use, and patients who wore the brace for two years were less likely to require surgery at eight years' follow-up.4 However, another prospective study examining the effectiveness of medial unloading knee braces at 2.7 years and 11.2 years showed short-term but not long-term benefits, with use decreasing significantly over time.5 A Cochrane review comparing various knee braces, foot orthotics, and conservative therapies for the treatment of medial compartment OA concluded that the optimal choice for orthosis is unclear, and that long-term data on their effectiveness are lacking.6

PFPS is a common cause of anterior knee pain in younger patients. The etiology of PFPS is multi-factorial, and patellar malalignment and instability are thought to have major roles. Patellar stabilizing braces are commonly used to maintain proper patellar alignment in patients with patellar instability, patellar tracking abnormalities, and PFPS.7 These braces are made of an elastic material with additional straps or a buttress to provide patellar support (Figure 2). Despite the biomechanical effectiveness of these braces, two systematic reviews found insufficient evidence to support their long-term use for the treatment of PFPS vs. exercise therapy alone.8,9 Another systematic review found a small benefit for treating PFPS with patellar stabilizing braces.10

Patellar tendinopathy is a painful chronic condition resulting from repetitive stress. This condition is common in physically active persons and is relatively easy to diagnose in patients presenting with pain, swelling, and tendon thickening localized to any portion of the patellar tendon. Patellar tendon straps (Figure 3) are placed across the midportion of the tendon to reduce tensile stress.11 They have been shown to reduce pain and positively alter biomechanical alignment during physical activity.12 A randomized controlled trial (RCT) found patellar tendon straps to be as effective as patellar taping in improving pain from patellar tendinopathy.13

Knee immobilizing splints (Figure 4) are often used after surgery to help prevent unwanted movement that could reinjure the leg or harm the healing area. They can also be used to stabilize the knee joint and cushion it from impact. Indications for knee immobilizing splints include the acute or presurgical management of quadriceps rupture, patellar tendon rupture, medial collateral ligament rupture, patellar fracture or dislocation, and other acute traumatic knee injuries.1

Ankle sprains are the most common acute sports-related injury, comprising about one-fourth of these injuries.14,15 Because early mobilization after an ankle sprain leads to better outcomes, braces that immobilize the ankle are not recommended.16 Functional ankle braces provide compression and allow for mobility during physical activity while protecting against inversion and eversion of the joint. Functional ankle braces with the best evidence of effectiveness for the prevention and treatment of ankle sprains include the soft lace-up ankle brace (Figure 5) and semirigid air stirrup brace (Figure 6). Many lace-up ankle braces also have straps to provide additional support. The semirigid air stirrup brace has thermoplastic lateral stirrups lined with foam, gel, or air compartments along the medial and lateral malleoli.

One RCT showed that the use of a semirigid air stirrup brace for 12 months was superior to an eight-week neuromuscular training program for the prevention of recurrent ankle sprains.17 In another RCT, the air stirrup brace outperformed an elastic compression wrap in terms of functional outcomes up to one month after acute lateral ankle sprains.18 This is consistent with findings of a Cochrane review, which concluded that air stirrup braces and lace-up ankle braces are more effective than elastic compression wraps in reducing the time to return to physical activity.19 Other studies found no significant differences between various types of braces for the prevention of inversion ankle sprains.20 Although ankle taping can be effective for preventing ankle sprains, braces may be more practical, consistent, and cost-effective.20,21 There is insufficient evidence to determine how long an ankle brace should be worn to prevent reinjury after an acute ankle sprain.1

The thumb spica splint immobilizes the thumb by crisscrossing layers of material around it. Thumb spica splints are used for a multitude of thumb and wrist injuries and disorders, and are available in three common forms: thermoplastic (custom-fitted), prefabricated (Figure 7A), and fiberglass (Figure 7B). A trial of conservative management for thumb carpometacarpal OA concluded that prefabricated thumb spica splints are generally more comfortable, less expensive, and as effective as thermoplastic splints.22

One of the most common forms of OA involves the thumb carpometacarpal joint, with an overall prevalence of 15%.23 Management is challenging because of the unique joint anatomy and its disabling features when symptomatic. Most data supporting thumb spica splinting for OA are based on case reports and observational studies. However, two systematic reviews evaluating the use of splints for thumb carpometacarpal OA showed that they improved pain scores, particularly in the long term (longer than three months, up to seven years).24,25 A seven-year prospective study showed that 70% of patients awaiting surgery for thumb carpometacarpal OA were able to postpone or avoid surgery after conservative treatment with joint protection and splinting.26

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