Can athletic braces actually prevent injury?
We review the medical literature to see if ankle, back, knee, or shoulder braces actually prevent injuries in sport.
Many professionals already know that athletic braces will not completely prevent injuries. However, it can be confusing for athletes, and even medical professionals, to know fact from fiction regarding their effectiveness in reducing injury risk amidst the advertisements and widespread use by popular athletes.
If a brace is not needed, at best, the athlete will be out hundreds of dollars (the average cost of an ACL brace is $592). At worst, they gain a false sense of security which may put the athlete at a greater risk of injury.
Performance and medical professionals need to be aware of the research findings so we can better inform our athletes.
Here we review the available medical literature to help guide your decision making.
Ankle Braces to Prevent Injury
Ankle injuries account for 22.6% of all injuries in high school athletics with many athletes suffering from repeat injuries.
A 2013 systematic review looked at the literature over a 10-year period. The authors concluded that “there is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.”
The authors note 4 randomized control trials finding that braces reduce the incidence of ankle sprains in asymptomatic athletes in basketball and football (the incidence was reduced but not the severity of acute ankle injuries).
Before you go out and make ankle bracing mandatory for all athletes, there is a distinction on which athletes will benefit. Keep in mind that athletes with a previous ankle sprain have a 21% increased risk of another ankle sprain.
Two systematic reviews (Olmstead et al. and Dizon et al.) found braces to be more protective in athletes with a previous history of ankle injury. In fact, a significant reduction in ankle injuries was found in athletes with a previous injury history, but there was NO reduction in athletes without a previous injury.
In fact, in a 2013 National Athletic Trainers Association (NATA) position statement, they question the relevance of prophylactic taping/bracing for entire teams.
To add another wrinkle, a 2004 BJSM article found that the use of an orthotic was ineffective in preventing ankle sprains in athletes who have suffered 4 or more sprains in their careers.
Taping vs. Bracing?
Many already know that ankle taping rapidly loses its initial level of resistance to motion during exercise. But, most studies on the mechanical effect of taping have demonstrated some level of motion restriction even after exercise (Here, here, here).
In a 2000 meta-analysis of 19 studies of different types of ankle support on ankle motion before and after activity, significantly greater restrictions after exercise was found in semi-rigid stirrup braces than for taping or lace-up type braces. Therefore, semi-rigid bracing may be more appropriate when an athlete initially returns to sport after ankle injury.
This does NOT mean that an athlete who once sprained their ankle is forever destined to an athletic career of prophylactic ankle brace/taping dependence. A few studies have shown that the risk level of ankle re-injury declines back to ‘baseline’ over a 1-2 year period post-injury (here, here, here).
Therefore, the use of prophylactic bracing/taping is recommended for the remainder of a season after an ankle injury, but rehabilitation to restore range of motion, joint mobility, neuromuscular re-education, and strengthening needs to be integrated to avoid dependence on external supports.
Knee Bracing to Prevent Injury
Functional knee braces are commonly prescribed by medical providers despite the research confirming their effectiveness. In fact, in a AOSSM survey, 63% of surgeons prescribe functional knee braces use for their ACL-reconstruction patients.
In a 2017 systematic review, it was concluded that “limited evidence exists supporting the use of routine functional bracing to decrease the rate of re-injury after ACL reconstruction.”
In a 2012 literature review, the authors state: “…biomechanical and clinical studies do not support the use of current bracing technologies due to reported lack of control of anterior tibial translation, strain shielding the ACL graft, and improvements in long-term patient outcomes.”
Though, some biomechanical studies show that bracing does limit tibial translation, but only up to 140N with the bracing effects diminishing under higher loads commonly found in athletic activities (here, here, here).
Despite this, many athletes report benefits with bracing including a feeling of heightened stability and confidence while wearing the brace. But, bracing to improve proprioception is still inconclusive as there are studies that support (here, here) and refute (here, here) their effectiveness.
So, why do we see widespread prophylactic use in sports in athleteswithout a history of knee injury? In particular, collegiate football linemen? Again, the literature is mixed. A 2009 review by Rishirai et al. reported that 24 studies found a decrease in knee injury rates while another 12 studies found no effect.
It should be noted that there is no conclusive evidence on the negative impact on performance while wearing a knee brace (here, here). So, with that, some medical staff feel the benefits
outweigh the risks when prescribing prophylactic bracing.
Personally, I have witnessed dependency and hesitancy to perform by athletes when a brace is broken or lost before competition.
Prophylactic use of knee braces to prevent injury may or may not be warranted for athletes after ligamentous injury who are returning to higher-risk sports, but medical and performance professionals need to educate our athletes so they can independently make their own informed decision.
Back Belts to Prevent Injury
Most of the information in this section is from Dr. Stuart McGill, a world-renown researcher on the causal mechanisms of back pain as well as moustache grooming.
Here, we’ll be referring to the use of back belts for athletic performance training.
McGill provides his guidelines in his Ultimate Back Fitness and Performance book:
- There is no question that belts improve lifting performance by allowing athletes to generate a few more Newton-meters of torque in the torso through elastic recoil of a bent torso
- However, if a neutral spine is preserved throughout the lift, this effect is minimal
- In other words, to obtain the maximal effect from a belt, the lifter must lift poorly and in a way that exposes the back to a much higher risk of injury!
If a powerlifter wants to lift a few more pounds, wear a belt. If a non-powerlifter athlete wants to groove motor patterns for other athletic tasks that demand a stable torso, it is probably better not to wear one.
For more details on the biomechanical rationale for McGill’s guidelines, I highly recommend his research and books.
Shoulder Braces to Prevent Injury
It is common practice, especially in contact and non-overhead throwing athletes, to return to play wearing a shoulder stabilization brace to reduce the risk of recurrent subluxations/dislocations.
Braces can help prevent the shoulder from being placed into compromising positions such as end-range abduction and external rotation. However, many athletes find wearing the brace cumbersome and impossible in sports that require overhead play.
For recently injured athletes, they report subjective improvement in shoulder stability while in the brace. In a 2002 study, the authors found that simple neoprene bracing improves proprioception which may help justify these subjective reports.
But do they actually prevent injuries?
In a 2016 clinical review in Sports Health, the authors found only one study (Dickens et al.) to evaluate the effectiveness of shoulder bracing to prevent recurrent instability. It was found that there was no difference in instability events in contact athletes with and without a brace. The authors concluded that:
“Further research is needed to evaluate the effectiveness of brace wear on preventing instability symptoms and recurrent dislocations.”
Therefore, the evidence to support prophylactic shoulder bracing is unclear. Depending on the sport and position, a brace may be an appropriate option to help an athlete to finish a season. But, we need to educate our athletes that the risk of recurrence is still high even while wearing a brace.
The appropriate use of prophylactic bracing depends on many variables. But, as medical and performance professionals, we need to stay up-to-date on the research when communicating with our athletes and their parents. Hopefully, this review provides you some talking points during those conversations.