Choosing The Right Ankle Brace For Your Patient

Choosing an ankle brace is often like choosing a car: The options have become limitless. As with picking cars, dealing with athletes’ finicky behavior often makes choosing a brace just as difficult. Prior to going to podiatry school, I was a student trainer in college so I have done thousands of tape jobs and am appreciative of a good ankle brace.

When Tim Dutra, DPM, discussed the benefits of taping in his June 2015 Sports Medicine column in Podiatry Today, he failed to mention how annoying athletes can be in regard to taping and bracing (i.e. too tight, too loose, etc).¹ I managed every sport at my college and have treated athletes ranging from All Army athletes to Olympians so I have dealt with my share of whiny athletes. It is interesting to see differences among positions within each sport. Dealing with an offensive lineman, defensive back or quarterback may require a different brace for each position.²

Personality surely plays a role in deciding the type of bracing required among athletes. In the Army, dealing with a truck driver is far different than dealing with an Army Ranger or SEAL team member.³ Trying to get boots, let alone a high-top basketball shoe or cleat, over some of these braces can be a severe challenge.

Recognizing The Challenges With Brace Fit
Additionally, it is always a challenge fitting patients with braces. One problem in the past was the so-called unisex brace, which translates to “doesn’t fit anyone.” Many companies have only small, medium, large and XL sizes. Finding a brace to fit a child or teenage girl or a morbidly obese patient with diabetes has always been a challenge. Thankfully, companies are now making right and left male and female braces in multiple sizes, including children’s sizes. Custom bracing was always reserved for anterior cruciate ligament braces but those same companies have finally seen the need for custom ankle braces. You are not going to get an NFL noseguard or NBA center with size 22 shoes in an XL off-the-shelf unisex brace.

One notable bracing challenge I had was years ago at Fort Bragg. I was the residency director of the Fort Bragg program at the time. I had a family come in with an 8-year-old girl. Her mother was concerned because the girl was tripping and falling all the time during soccer. The parents wanted a brace.

The only problem was the child. She had a ball and socket ankle joint so it was no wonder that she fell all the time.^4-5 It was a challenge getting her a small enough brace. It took weeks of research and buying multiple braces before we got to the brace she actually liked and would wear. Frankly, that is when I made it my mission to familiarize myself with as many braces that are out there.

Tailoring Brace Selection And Prescription To The Needs Of The Individual Patient
As podiatric surgeons, we do not always get to pick our athletes. My experience not just as a trainer but as an Army surgeon is that athletes are just picky. So you might check out three different brace companies to find the right match. Every month, a company will likely contact you about a newfangled brace. The companies will boast that their braces are the most comfortable and stable braces on the market. However, it is critical that we tailor our braces to our athlete. One brace is not going to work for every athlete.^6-9  

As clinicians, we need to understand why we are prescribing ankle braces. Whether it is for prophylactic measures or treating a specific condition, there is a brace out there that athletes should be able to wear to get them through practice and games, or simply get them through their season until they are able to have surgery.^6,10-11 Ankle braces are not just for ankle instability. We can utilize braces when inserts fail. Researchers have demonstrated that ankle braces are much more tolerable than custom orthotics.¹² We can minimize the symptoms associated with overpronation by utilizing an ankle brace. In my view, the Richie Brace and Arizona AFO are simply custom ankle braces that we have used for years to help treat posterior tibial tendon dysfunction.

Currently, the Army is trying to standardize ankle braces in an attempt to save money. That is great but as the only surgeon involved in this discussion with the Army, I continually have to remind them that we need choices in style, stability and comfort. I always liken this fiscal conundrum to a large hospital asking (I mean telling) six orthopedic surgeons to use the same total knee implant. It is not going to happen. Try telling 50 podiatrists and 140 orthopedic surgeons in the Army system to use the same brace. It is not practical or feasible. The same principles apply to private practice. Why should you carry a large supply of braces when you can order online or simply have your company representative bring in his or her company’s entire line to consider for your patient?

Assessing The Pros And Cons Of Different Types Of Braces
Essentially there are five types of braces: sleeves, straps, stirrups, lace-ups and hybrids. We can classify all these on a graph running from most comfortable to most stable. Unfortunately, there is an inverse relationship between comfort and stability. It is critical for us as podiatrists to find the right balance for our athletes.^13-14 There may be some trial and error.

Luckily, there are multiple companies out there that have complete lines of braces covering each category. I do not endorse any specific company. There is a significant amount of biomechanical research out there that we can use to determine the type of brace required. Ultimately, you are still going to rely on your patients to find a brace that they like.¹⁵   

Sleeves. Sleeves are clearly the least stable and often very comfortable. We all have seen Brett Favre in commercials endorsing “copper” sleeves. Sleeves are products that are easily accessible at almost every drugstore and sporting goods store. Accordingly, do not waste your time carrying these items in your office. Often patients will utilize sleeves simply as compressive devices but caution patients on the sole use of this modality if they have gross instability. Also bear in mind that patients can make the sleeves too tight.

Many of my patients will utilize the sleeve under an ankle brace or with their Army boots for comfort. In general, these are excellent first-line treatment modalities that your patients can purchase on their own.

Straps. Strap-style braces utilize cloth straps, which patients can wrap around the ankle, creating the classic heel-lock figure eights that we are all accustomed to using during a tape job. These straps will vary in thickness and flexibility. The material utilized will affect performance and comfort. These braces are very popular among collegiate and professional athletes. They are frankly very cheap and again are excellent first-line braces.  

I will caution that some of these strap style braces can become what I refer to as “Velcro nightmares” for patients. To make matters worse, some of these braces have so many straps that I can barely figure out how to put the brace on. If the brace is too complicated, adherence will likely become an issue.  

You will need to remind patients that over-tightening the straps can eventually lead to numbness or, worse, cut the patient. Tighter is not better.   

Stirrups. Stirrup style braces were the first really popular ankle braces in the 1990s.¹⁵ We are all familiar with the classic Aircast Air Stirrup. Companies have revised the design to allow for customization of the stirrup. Patients can adjust air bladders with a pump and put gel-filled bladders into the freezer or even heat them in a microwave. One can adjust the stirrups by adding metal or plastic strips to increase rigidity for greater control. One can increase the height to accommodate for syndesmosis or tibia-fibula fracture support. Regardless, stirrup-style braces are really not in use for sports. They are really alternatives for splints and controlled ankle motion (CAM) walkers.  

The one stirrup style brace that is for sports is the Aircast AirSport (DJO Global). Many companies now have similarly designed devices. What makes the Aircast AirSport brace so great is its simplicity, having only two straps and an enclosed sleeve.

I was involved in the product testing of this device with Special Forces while I was at Fort Bragg many years ago. At the same time, the 82nd Airborne Test Group was utilizing an AirSport stirrup style brace to prevent ankle fractures. After two years of testing with the Aircast AirSport device, we saw a decrease in ankle fracture rates but unfortunately saw a fourfold increase in tibia-fibula fractures above the brace. Some units such as the 82nd Airborne still to this day utilize a stirrup style brace but utilize a far less rigid stirrup for airborne operations, reducing the risk of injury above the brace.
Companies have taken the current stirrup design and added a hinge to increase the comfort and functional characteristics of the stirrup style brace.16

Lace-ups. Lace-up style braces are the true original style ankle braces. They are often made of rigid materials and are very stable. However, they are frequently very uncomfortable.^8-10 The classic brace that most surgeons are familiar with is the Swede-O brace.¹⁵ As a result, companies have made adjustments to the design and materials that have improved the functional capabilities and comfort of these style braces. Everything from speed laces to Velcro straps have helped the lace-up design.

Hybrid. Companies have designed a hybrid style brace, which takes all the key characteristics of sleeve, straps, stirrup and lace-up braces. These hybrid braces are very comfortable and stable, and frankly look a lot more stylish than some of the older style braces. In the Army, my patients have preferred to utilize these hybrid style braces far more often for work and play. As with anything, the hybrid braces are significantly more expensive, ranging from $75 to $200. I cannot say whether these braces are better but patients seem to like them and will wear them.  

In Conclusion
Overall, bracing is a very important modality for athletes. As podiatrists, we need to ensure these athletes are wearing proper shoe gear as well. If there are high-top versions of a cleat or basketball shoe, you need to make sure the brace will fit inside that shoe. Often athletes will have to go up a shoe size to be able to accommodate an orthotic and ankle brace together. For the military, it is always a challenge getting braces under Army boots.  

Dr. Spitalny is a staff podiatrist at General Leonard Wood Army Community Hospital in Fort Leonard Wood, Mo. He is an Adjunct Faculty member with the DePaul Podiatric Residency Program in St. Louis.

References

1. Dutra T. Essential insights on athletic taping for common sports injuries. Podiatry Today. 2015; 28(6):68-71.
2. Lee WC, Kobayashi T, Choy BT, Leung AK. Comparison of custom-moulded ankle orthosis with hinged joints and off-the-shelf ankle braces in preventing ankle sprain in lateral cutting movements. Prosthet Orthot Int. 2012;36(2):190-5.
3. Newman T, Croy T, Hart J, Saliba S. The effects of prophylactic ankle bracing on dynamic reach distance and obstacle course performance in military cadets. Mil Med. 2012;177(5):567-72.
4. Farwell KE, Powden CJ, Powell MR, McCarty CW, Hoch MC. The effectiveness of prophylactic ankle braces in reducing the incidence of acute ankle injuries in adolescent athletes: a critically appraised topic. J Sport Rehabil. 2013;22(2):137-42.
5. Miller EA, Hergenroeder AC. Prophylactic ankle bracing. Pediatr Clin North Am. 1990;37(5):1175-85.
6. Frey C, Feder KS, Sleight J. Prophylactic ankle brace use in high school volleyball players: a prospective study. Foot Ankle Int. 2010;31(4):296-300.
7. Bot SD, van Mechelen W. The effect of ankle bracing on athletic performance. Sports Med. 1999;27(3):171-8.
8. McGuine TA, Hetzel S, Wilson J, Brooks A. The effect of lace-up ankle braces on injury rates in high school football players. Am J Sports Med. 2012;40(1):49-57.
9. McGuine TA, Brooks A, Hetzel S. The effect of lace-up ankle braces on injury rates in high school basketball players. Am J Sports Med. 2011;39(9):1840-8.
10. DiStefano LJ, Padua DA, Brown CN, Guskiewicz KM. Lower extremity kinematics and ground reaction forces after prophylactic lace-up ankle bracing. J Athl Train. 2008;43(3):234-41.
11. Jerosch J, Thorwesten L, Bork H, Bischof M. Is prophylactic bracing of the ankle cost effective? Orthopedics. 1996;19(5):405-14.
12. Nishikawa T, Kurosaka M, Yoshiya S, Lundin TM, Grabiner MD. Effects of prophylactic ankle supports on pronation during gait. Int Orthop. 2002;26(6):381-5.
13. Denton JM, Waldhelm A, Hacke JD, Gross MT. Clinician Recommendations and Perceptions of Factors Associated With Ankle Brace Use. Sports Health. 2015;7(3):267-9.
14. Verhagen EA, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010;44(15):1082-8.
15. Simpson KJ, Cravens S, Higbie E, Theodorou C, DelRey P. A comparison of the Sport Stirrup, Malleoloc, and Swede-O ankle orthoses for the foot-ankle kinematics of a rapid lateral movement. Int J Sports Med. 1999;20(6):396-402.
16. Alfuth M, Klein D, Koch R, Rosenbaum D. Biomechanical comparison of 3 ankle braces with and without free rotation in the sagittal plane. J Athl Train. 2014 Sep-Oct;49(5):608-16.

Editor’s note: For further reading, see “Essential Insights On Athletic Taping For Common Sports Injuries” in the June 2015 issue of Podiatry Today or “A Guide To Treating Ankle Sprains From Start To Finish” in the July 2006 issue.

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