Bracing before and after an injury can be a valuable tool in the prevention and treatment of sports-related ankle injuries.
By Josh McGinty, PT, DPT, ATC, OCS
Physical therapists (PTs) evaluate and treat ankle injuries and dysfunction throughout all settings. PTs working with athletes should be involved in all aspects of ankle bracing, from prevention to postinjury. One of the most common injuries in athletics is a lateral ankle sprain. The American Academy of Orthopedic Surgeons reports that 25,000 people per day sustain ankle injuries.1 PTs should be involved in the full continuum of care for patients. Therefore, PTs should be mindful of the stages of healing and how they relate to bracing throughout that continuum of care, from acute treatment to full return to sport.
Prophylactic Bracing for Injury Prevention
When working with athletes at all levels, the PT may be involved in recommending, ordering, supplying, and educating about the use of prophylactic ankle bracing. Prophylactic bracing can reduce incidence, severity, and limit missed time for all athletes. Prophylactic bracing reduces the risk of first-time ankle sprains.2 While ankle taping has long been used as injury prevention in sport, Prophylactic bracing may be a more economical and practical injury prevention method among the general athletic population and especially among athletes who have a history of ankle injuries. Quality ankle braces can be used throughout an entire season, while taping at every event or practice can become expensive. In addition, the athlete doesn’t require skilled assistance after initially being trained in the application of the ankle brace.
Today’s functional ankle bracing allows the patient to move freely, and there are models designed to fit in most athletic shoewear. Higher-end prophylactic bracing options in athletes who perform considerable amounts of lateral movement are the Breg Ultra High-5 ankle brace manufactured by Breg Inc, Carlsbad, Calif, and the Össur Rebound ankle brace available from Össur, headquartered in Reykjavik, Iceland. The Bledsoe Axiom by the Texas-based company Bledsoe and the Don Joy Velocity from DonJoy, a company of the Vista, Calif-based DJO Global, are functional ankle braces that provide more rigid support medially and laterally and are more appropriate for sagittal plane or straightforward athletes. Each of these braces allows for hinged rigid support to better control inversion and eversion while allowing for full dorsiflexion and plantarflexion.
Other more economical options for bulk/team prophylactic bracing are lace-up ankle braces with medial and lateral stirrup straps. DonJoy, Össur, Breg, Bledsoe, and many other manufacturers make high-quality comparable braces in this category. These are the most common prophylactic ankle braces used throughout all sports. PTs need to fully understand the type of brace, or application, and may need to educate the patient and/or coaching staff about correct donning of the brace.
If injury occurs while an athlete is braced, it is important for the PT to assess whether the athlete was wearing the brace correctly and if the brace fits properly. That information will also be used to determine options already available to the athlete as he or she returns to sport later.
Postinjury Ankle Bracing
Postinjury, the PT should be highly involved in initial treatment of the foot and ankle. The therapist needs to understand that overwhelmingly, early controlled mobilization versus full immobilization produces better outcomes following grade I or II lateral ankle sprain. If ordered by the physician, the PT may be the main source of education about proper use of ankle bracing and initial rehab exercises and modalities following an acute injury. The PT must remember the healing time frames as he or she is involved in the progression from acute injury to return to sport.
Prescription of ankle bracing after injury depends on the tissue or structure involved and whether the medical doctor is going to restrict weight-bearing. Initially, an athlete may be placed in a stirrup splint or, for better comprehensive support, a pneumatic walking boot. If a fracture has occurred, the physician may cast or place the patient in a walking boot. The Össur Rebound walker or the Don Joy Aircast boot both can provide good utility for these needs. A pneumatic walking boot allows for complete immobilization and compression of the foot and ankle, while allowing ease of removal for early rehabilitation. The PT will educate the patient about proper donning/doffing of the bracing, in coordination with rehabilitation. As the patient progresses from stages of controlled immobilization to functional bracing, the PT will safely guide the patient from initial nonweight-bearing exercises, into static balance exercises, and then into dynamic balance activities.
A recent study focused on athletes who sustained a lateral ankle sprain, and compared three groups. One group included ankle-bracing-only subjects, a second group was composed of subjects who underwent neuromuscular training, and a third group was a “combination group.”3 The study’s author found that the ankle bracing group had less recurrence of injury than the neuromuscular training group. This demonstrates the importance of ankle bracing and the need for bracing to be a part of the rehabilitation program.
During some phases of rehabilitation after an ankle injury, the use of bracing is not appropriate as the therapist will want to work on proprioception and strength without the assistance of bracing. As the patient moves into more dynamic/sport-related type of activities, the patient will benefit from using the brace or type of bracing with which they will return to sport. The use of bracing during the later stages of rehab will protect and support the injured tissue and allow the patient to become familiar and comfortable with use of the bracing.
The type of functional bracing used will vary depending on the sport, morphology of the athlete, sport-specific shoe wear, and even types of movement required for the athlete. The therapist should also consider the mechanism of injury, and even the type of surface on which the athlete is competing when prescribing/recommending a functional ankle brace.
Bracing for Sports Injury Treatment
Physical therapists are an integral part of the sports medicine paradigm. They should work with all members of the sports medicine team on ankle bracing, prophylactic and postinjury. A physical therapist who is knowledgeable and experienced with all the options for functional bracing will lead to more accurate and appropriate brace recommendation. The physical therapist should be proactive in discussing the bracing used with referring physicians, salesmen, and other sports medicine team members.
Josh McGinty, PT, DPT, ATC,OCS, is co-owner of Southern Rehab & Sports Medicine in LaGrange, Ga, which specializes in orthopedics and sports medicine. McGinty graduated from the University of Alabama with a degree in athletic training, and received a doctorate of physical therapy from the University of Alabama at Birmingham. For more information, contact PTPEditor@allied360.com.