The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players.
McGuine TA, Hetzel S, Wilson J, Brooks A. Am J Sports Med. 2011 Sep 16. [Epub ahead of print]
Ankle injuries are common in high school sports and it has been estimated that 24% of all ankle injuries among high school athletes are sustained by football players. Lace-up braces are commonly used with the goal of preventing ankle injuries. Unfortunately, there is limited data about the efficacy of lace-up braces among adolescent football players. Therefore, McGuine et al assessed whether using a lace-up ankle brace reduced the number and severity of acute first-time and recurrent ankle injuries sustained by high school football players during one football season. Furthermore, they assessed if using lace-up ankle braces influence the incidence and severity of other lower extremity injuries. The researchers randomly divided 51 high schools (1 dropped out) into either control (not braced; ~1100 athletes) or braced group (~1000 athletes), which received the Donjoy Ankle Stabilizing Brace. Prior to the season, athletes completed a questionnaire that included questions about their demographics, level of competition (freshman, junior varsity, and varsity), expected playing position, and history of injury/surgery. The research staff measured each athlete to ensure proper brace fit and instructed them on how to wear the brace. Athletes were told to wear their braces at all team-organized events throughout the season. All participating school’s athletic trainers maintained daily exposure calendars, recorded all injury details throughout the season, and noted the use of any external support (taping or bracing). Also recorded by the athletic trainers, were the days lost due to injury; this was later used to define injury severity. After adjusting for athletes’ sex, history of previous ankle injuries, grade level, competition level, body mass index, shoe height (mid top or low top), and cleat type (molded or detachable); the incidence of acute ankle injury was 61% lower in the braced group compared to the control group. A benefit of bracing was found for athletes with and without a history of ankle injuries. The number needed to treat (click here for a second definition) with bracing to prevent 1 first-event acute ankle injury was 28.3 athletes. Acute ankle injury severity was not different between groups. Furthermore, the rate and severity of other lower extremity injuries was not different between the braced and control groups.
This article complements a previous SMR post that summarized similar findings by these authors when they evaluated lace-up ankle braces among high school basketball players. Among high school football players, we can estimate from this study that approximately 2 to 3 acute ankle injuries could be prevented among a team of 60 players during one season (based on the number needed to treat). Furthermore, if we apply this study’s data to the number of high school football players in the United States the authors estimate that lace-up braces may reduce the number of acute ankle injuries among high school football players by 39,000. The authors propose the lace-up braces represent a cost-effective strategy compared to the costs of tape or not doing anything at all, to prevent acute ankle injuries. This type of research is critical to help demonstrate the benefit of injury prevention strategies. It is a positive sign that this group has evaluated the benefit of prophylactic ankle bracing in two populations. We need more research like this for other braces as well as a better understanding of the factors that influence implementation and compliance. If the athletes won’t wear the brace or participate in the injury prevention program then it doesn’t matter how effective the treatment may be. Do these new findings persuade you to recommend more ankle braces? Are you currently using any prophylactic bracing in your sports medicine clinic?
Written by: Jeffrey B Driban
Reviewed by: Kyle Harris
McGuine TA, Hetzel S, Wilson J, & Brooks A (2011). The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. The American journal of sports medicine PMID: 21926383
Great write-up, Jeff.
"An ounce of prevention is worth a pound of cure." We all know that participating in sports such as football may result in injuries. These preventive measures are necessary.
As you stated, "If the athletes won’t wear the brace or participate in the injury prevention program then it doesn’t matter how effective the treatment may be." I find this post to be quite persuasive, and hope that those who play sports heed your advice.
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Thanks for the comments everyone! Do you think that studies like this one will encourage you to promote more ankle bracing among your athletes?
Any ideas on how we can encourage our athletes to wear the brace and wear the brace correctly?
Compliance will probably be better if the athlete buys into the intervention and finds the brace comfortable (which may require trying different braces for some people).
Great information about sport, It is a really very deep research and thanks for shering it with us …
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This as well as the study by the same group done on the basketball players are great studies. They epitomize the type of research that needs to and should be being done at this day and age. They are extremely detailed and thorough in their research design and examined an intervention that is commonly used, prospectively. This study solidifies my opinions on bracing and allows me to give statistical data and numbers to athletes, coaches, parents, and school boards who may question the efficacy of bracing. I think what needs to be investigated further is why, in both studies, the injury severity was unchanged? Is this a clinician diagnostic issue or is the brace not doing what we think it is? I think it is great to show that they are effective but further research is warranted to determine the mechanism by which braces work. If they were truly limiting ROM would you not expect injury severity to be decreased? Is the brace changing how their foot moves throughout swing phase or the way they bear weight during stance phase? Is it simply the proprioception and compressive nature of the brace or is combination of all these components? Maybe an ankle sleeve or compression wrap is all that is needed?
Greg, great questions: Just a few thoughts and may be others can chime in.
I think what needs to be investigated further is why, in both studies, the injury severity was unchanged? Is this a clinician diagnostic issue or is the brace not doing what we think it is?
This is an interesting aspect. It would be interesting to have a better understanding of the mechanisms of injuries but then this become a much more burdensome study when there are so many people involved. It could certainly be an issue of how severity is defined or it could be that nothing is going to protect you from an ankle sprain when you land on someone’s foot or you receive a last millisecond perturbation that makes you land wrong. In the end, I’m content having a lower risk of injury as long as it doesn’t increase the severity.
I think it is great to show that they are effective but further research is warranted to determine the mechanism by which braces work.
This point was also raised by Phillip Gribble et al last year (https://www.ncbi.nlm.nih.gov/pubmed/20129116). There seems to be some groups looking towards the influence of braces on balance, reflexes, range of motion etc.
Is the brace changing how their foot moves throughout swing phase or the way they bear weight during stance phase?
This is an interesting question that I’m not sure I’ve seen in the literature; particularly when it comes to running.
Is it simply the proprioception and compressive nature of the brace or is combination of all these components? Maybe an ankle sleeve or compression wrap is all that is needed?
Another interesting idea. It would be reasonable to do a similar study to McGuine but do it as a comparative effectiveness trial comparing two types of braces/sleeves. I suspect braces provide several types of physiological benefits as well as psychological. For example, see the post from April about how ankle taping increases the perception of stability but not actual stability: https://sportsmedresearch.blogspot.com/2011/04/ankle-taping-increases-perception-of.html
I couldn't help but chime in a little here. Greg, I think you raise some great questions. I am especially interested in the idea of a future study to decipher if a brace is equally as effective as a compression sleeve. I think Jeff's idea of a comparative effectiveness trial would yeild some interesting results. Your other question regarding the clinical diagnostic issue is another intersting one. I think the way McGuine's studies have defined severity (days lost due to injury) could be modified and specified. Some questions that jump into my head are, were there any days lost because the athlete was not in practice (work or class conflict)? That is a problem I have in my practice. Is there a possibility that the athletic trainers in the study had competitions and caring or evaling that athlete was not as much of a priority? Some interesting things to think about, thanks of the post!
First off, I think this is a great article, and I've had great success in having my basketball athletes adhere to brace use after sharing this information with them.
Bringing in other studies about ankle ligament injury, a growing number of studies are looking into ultrasonic imaging to detect changes in ligament length following injury.
I think that comparing this practice to the athletic trainer's (or orthopedic's) evaluation can show the reliability of a clinicians diagnostic skill. I believe this is a step that can be taken towards determining if the brace is performing the functions that we believe it is.
Jay: Thanks for the comments. I think one of things that keeps coming up all over the site is the importance of us to educate our patients about the consequences of injuries (to promote prevention programs and proper reporting of injuries) and why our interventions might be beneficial. This can promote placebo effects, improve compliance, and help the patient be a part of making decisions to manage an injury.
Rehab and injury prevention are collaborative projects between the clinicians and the patient. If everyone is not on the same then we're going to have problems.
Prevention is key in the field of athletic training, but is there such a thing as too much prevention, and not allowing the body to develop neuromuscularly, and adapt to specific changes and variances of movement? I agree with the study, and have used lace up ankle braces as a preventative tool. For instance, the institute I went to school at, the coach required that all the volleyball players were active ankles. Our incidence of injury wasn't large, but we did have a couple of ankle sprains throughout the season. My point to the notion of over-prevention is the idea that we are placing a brace on an ankle, that is still developing (in the case of high school athletes), movement patterns, variability, and also developing strength with muscles and ligaments. An otherwise, healthy, efficiently moving and adaptable motor system. What happens the other 20 hours a day when that athlete is not in that ankle brace, and participating in ADLs, does the ankle "forget" how to move properly because it doesn't have the assistance of the brace to control movement variability and change degrees of freedom and motion? Also, what happens if that athlete forgets his ankle brace one day, is he at a larger risk of injury that particular day because his ankle is now not used to the movement without the ankle brace. Its interesting to read the results of the study and find that 60% decrease in ankle sprains, but there weren't more ankle sprains occurring without the brace to start with. Don't get me wrong, prevention is key, and if an ankle brace can help that, then super, but we also have to understand the body wants to protect itself, and if we take away those mechanisms because the brace overpowers them, then we are subjecting our athletes to new injuries. Adaptations of movement occur, and muscles may shut down because of the lack of need for them to perform those balance demands, proprioception, kinesthetic awareness, etc it previously had to before the brace. As a whole picture point of view, incorporate strengthening, flexibility, ROM, proper mechanics and fundamental exercises, and allow for proper equipment use, we could also see a decrease in ankle sprains. Bracing is a key preventative tool, when coupled with those other elements of injury prevention, and not as a crutch. Looking at the results again, it also stated that the rate of injury and the severity showed no differences between the controls and the braced athletes, indicating that yes there was the decrease in ankle sprains, but not necessarily from the ankle braces themselves. This is key.
Great article, and it brought up great points about the benefits of ankle braces as a tool for preventions. Coupled with other interventions it could help. Thanks for the post.
Hi Alyson, I think you raise a very good point about wanting to have prevention strategies that don't interfere with their neuromuscular (NM)development. I take a slightly different view in that I think the ADLs represent an opportunity for them to continue to develop their NM control. Instead of viewing it as 4 hours of bracing leading to the ankle "forgetting" I would view it as 20 hours of the ankle "learning". The problem there however is that they are developing NM that might be relevant to more aggressive conditions. This is where forgetting a brace for a game or practice could be a problem. I'm not sure if we know whether the athlete who forgets his/her brace is at greater risk for an injury that day b/c they are "dependent" on the brace. That's an interesting question.
It is probably also important to consider that the brace is probably not overpowering the ankle. Instead I suspect it may be more likely that the brace is providing better proprioceptive feedback to the ankle which is helping the ankle to stabilize. With that said, I used to recommend to my athletes that wore braces that they incorporate single-balance exercises into their workouts or warm ups to promote balance and some strengthening.
In regards to the lack of difference in severity of injury between controls and braces I would probably caution against thinking this is b/c the braces weren't helping. I think this is showing us that even in a brace some high force events are going to lead to an injury no matter what we're wearing. This shows the braces do still allow some movement and may be serving more in a proprioceptive role.
I agree with you of thinking about the other 20 hours as the ankle learning, and also as the ankle brace as more of an assistive device to allow for an unstable ankle to become more familiar with the NM feelings of movement, and the increase proprioception. A device that will allow for the ankle to work, but also assist in what the ankle is lacking in stability and strength because of the injury. I hadn't thought about it that way. I also agree with the notion that ankle braces protect the ankle from injury mechanisms, but still can be subject to injury. The added proprioception is key to allow for more of an awareness of movement to allow for proper movement corrections. I still think that ankle braces can be overused at times, as a crutch because those athletes or patients haven't attempted to adhere to an rehab program or strengthening program. This is where I see a problem, and more of what I should have conveyed in my previous message.
Have you found in your experience that those who wear ankle braces for longer after sustaining an injury, complain of more recurrent instability or chronic symptoms?
Thank you for the insight, I am a new ATC with just 4 years of undergraduate experience, and enjoy learning from others who are just as passionate about AT as I am.
Hi Alyson: I have no experienced issues with athletes who wore ankle braces for longer duration complaining of recurrent instability or chronic symptoms. That might be from just working with a small sample that has gone through that. Also, as I said before I usually would also have them do extra balance exercises before practice or at home. One common thing they would do is have a catch on one foot before practice.
I strongly feel that in the field of Athletic Training, prevention is a number one priority. For that reason, this article was very helpful. Ankle injuries are so common that any prevention research is key. In sports such as football and basketball, ankle injuries are presented more than any other lower extremity injury. Therefore, having the athletes all wear a preventative ankle braces would be very effective. At least, they would be effective in the athletes whose positions require a higher amount of ankle stability.
I also agree that it would be more cost efficient to buy braces to use for the whole season rather than taping the athletes before every practice who like having it there just for the comfort or extra sense of support.
This sparks further research into whether or not using a brace as prevention would also be more effective in other areas of the body such as the wrists or knees.
Great questions for future research. Thanks for the comment.