REHABILITATION

ities of daily living and the brace is purely intended for return to sport, you need to consider the intended sport and the level at which they wish to compete. As a general rule rigid braces with hinges are banned in sports such as rugby and football. But if the aim was to return to a friendly game of 5 a-side football, then, in the agreement of the other players it may be acceptable to wear a functional brace. This would not be an option for anyone wishing to return to football at any kind of competitive level. Alternatively, take the scenario of someone who has ruptured their ACL, who is not generally active but may ski once a year, or take part in activites such as jogging or tennis at low intensities. In this instance, they may opt for conservative management and rehabili- tation with the option of wearing a brace for their desired activities.

2. Identification of pathology The correct type of brace depends on the underlying pathology and the movement to be protected. Most companies provide braces specifically for MCL, ACL, PCL and combination injuries.

3. Good fit The brace should be a good fit and most manufacturers provide details of the measurements required to ascertain the correct size of brace to order. This calls into question the appropriate time to have one fitted. This would normally occur towards the end of a rehabilitation programme when muscle hypertrophy has reached a plateau, as any further muscle hypertrophy may hinder a good fit of the brace.

4. Availability and cost The cost of a brace can vary from anywhere between under a £100 for an off the shelf brace to over £600 for a custom made brace. If you are working within the National Health sector you may be restrict- ed to the types of braces and manufacturers you can chose from, depending on local contracts. In excep- tional cases there may be funding available for clients with specific needs. In the private sector it will depend on whether braces are covered by the respective insurance companies, if not, then it will depend on the depth of the client’s pocket!

5. Comfort and ease of use Braces should be comfortable to wear and easy to use. This sounds obvious, but they

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will be left in the training bag if they are not. Clients should be shown how to correctly fit the brace with regard to the location of the hinge component and securing the brace. Advice should also be given on maintenance of the brace and parts that might need replacing with wear.

Migration of the brace can be a problem with high intensity exercise and this can be another cause of the brace being aban- doned. In this instance, a knee sleeve worn underneath the brace may prevent this from happening. Adverse skin reactions have been known to occur, so appropriate warnings should be given and the skin should be inspected for any signs after using the brace.

CONCLUSION Knee braces do have a role to play in return to sport following injury or surgery. However, the evidence for their ability to restrict unwanted movement and protect ligaments at high loads and physiological strains incurred in many sports is limited. The choice of brace is primarily dependent on the underlying pathology, the type, level and rules of the sport and cost. Braces should not be used instead of a well-designed rehabilitation programme that incorporates strength and condition- ing, proprioceptive enhancement, functional and sports specific training. Return to sport should not be allowed unless a full rehabilitation programme has been successfully completed.

THE AUTHOR

Dr Zoe Hudson, MCSP, PhD is a senior clini- cal lecturer and associate director of the MSc in Sports and Exercise Medicine at The Royal London Hospital (Mile End). She completed her PhD on tissue engineered implant for reconstruction of the ACL. She has a number of published research studies to her name and is the editor of the international peer- reviewed journal, Physical Therapy in Sport. Zoe has worked in sport for the last 10 years at both national and international level. Recent major competitions include the Commonwealth Games in Manchester 2002 and the Sydney Olympics in 2000.

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