I’m a college football junkie, so I’ve been watching football all day. (Yes, I’m up right now watching my alma mater – Wake Forest – play, and it didn’t start until 11:30 PM). One thing I’ve noticed in each game I’ve watched is that every team’s offensive linemen wear protective knee braces. I’ve known that professional teams use custom-made knee braces to protect the knees of players without a prior injury from my time with the St. Louis Rams during my fellowship. The parents of a high school player recently asked me in my clinic about getting one of these braces made for their son. It led to an interesting discussion about the effectiveness of these braces at preventing injury.
In the September–October 2010 issue of the journal Sports Health, Michael Salata et al. performed a systematic review of previously published articles that looked at the effectiveness of prophylactic knee bracing in football. The authors note that there has always been controversy regarding the effectiveness of these braces. They point to the position statement of the American Academy of Orthopaedic Surgeons regarding prophylactic bracing. “Prophylactic knee braces may provide limited protection against injuries to the MCL in football players. Scientific studies have not demonstrated similar protection to other knee ligaments, menisci, or articular cartilage.”
The authors in this study searched the medical literature for research studying prophylactic bracing to prevent medial collateral ligament injuries in football. They narrowed the articles they reviewed to the six that they felt were the best studies. There was one randomized controlled trial done at the United States Military Academy among intramural football players who were assigned to either a group that wore knee braces or a group that did not wear knee braces. Two other studies followed high school football players prospectively, and the other three followed NCAA football players prospectively.
In the randomized controlled trial, the authors of that study did find that prophylactic knee bracing significantly reduced MCL injuries. One of the prospective cohort studies involving Big Ten football showed a trend toward decreased MCL injuries with bracing but not a significant difference. Two of the other prospective cohort studies showed no significant difference in the incidence of knee injuries between braced and non-braced players as well as no difference in the severity of the knee injuries that occurred. One study actually showed an increase in ligament injuries in the group of players who wore a brace. Finally one study not only showed a higher rate of knee injuries in the group who wore braces but also showed an increase in foot and ankle injuries among players who wore a brace.
Salata et al. conclude in this study that there is insufficient evidence to suggest that bracing prevents knee injuries or decreases the severity of knee injuries. “Data do suggest that in the high-risk positions of offensive and defensive line, linebacker, and tight end, bracing may be effective in both preventing and decreasing severity of MCL injuries in the college athlete. Medical evidence does not support the routine use of bracing in high school football players.”
Braces to prevent knee injuries?
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So why do college and professional football players, or at least those who play certain positions, wear these custom-made knee braces? In my opinion, it really comes down to risks and benefits. From a brief search I performed, it seems that the average NFL offensive lineman earns approximately $850,000 per season. If you assume that the player will play 16 games, this averages over $53,000 per game. An MCL injury would potentially cost a player one to six weeks in terms of missed games. Therefore, if a brace prevented a player from having an MCL injury, it potentially saves the team between $50,000 and $300,000 in terms of paying a player who wouldn’t be playing. That is a large amount to save compared to the $1000-$1500 that these braces cost. In addition to the financial argument, college and professional teams need their top players in the game to give them the best chance to win, and a player sitting on the sidelines injured cannot help that team win.
When I have parents of players ask me about the braces, or even when the player asks about wearing one himself, I like to have a long discussion presenting the pros and cons. In my experience, most athletes expect a decrease in performance and give that as a reason not to wear them. I think that with the current technology that goes into these braces, most athletes, especially linemen, can play with no decreased performance.
While definitive evidence that these braces decrease knee injuries is lacking, some studies have shown a trend toward decreased MCL injuries. I can understand a parent taking all possible precautions to minimize the chance that such an injury occurs to his or her son. If the athlete feels comfortable in the brace and can play at the same level in it, then I have no problem with him wearing one. Insurance often will not pay for custom-made braces when no injury has occurred, so parents often have to pay for them out of pocket. It’s not uncommon for the schools, or athletic department booster clubs, to pay for them for players at certain positions. It is a decision that must be made with careful consideration, but as this study suggests, there is no definitive evidence that proves that all football players need to use these protective braces.
