October 2012

Ankle bracing: Exploring effects on proximal joints

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Research suggests that the ankle’s ability to absorb its share of energy during landing from a jump is altered with the use of an ankle brace. The extent to which this effect might influence risk of injury to other lower extremity joints or soft tissues, however, remains unclear.

By Jacob K. Gardner, MS

Ankle sprain is one of the most common injuries experienced during athletic activities.1,2 In 2007, an epidemiologic study of 15 collegiate sports2 showed that more than 50% of injuries occurred in the lower extremities. When considering all possible injuries, ankle sprains were the most common, accounting for 15% of total injury reports. Sprains to the ankle are not only a huge concern in terms of athletes’ health, but also a major issue terms of the athletes’ contribution to the team. A 2009 study on soccer injuries3 noted that acute ankle sprains could result in a few days to a few weeks of time lost from play. When the injury was more severe, the time lost from play was increased, in some cases lasting to up to several months.

Of course, athletes do not want to miss practices and games because of injuries. Some athletes may just push through the pain, and most do not seek professional treatment.4 Once a sprain has occurred, the athlete is more susceptible to a subsequent injury due to increased ankle instability. In fact, McKay et al discovered that basketball players with a history of ankle injury were nearly five times more likely to suffer a sprain than those with no history.4 Clearly, the prevention of ankle sprains during sporting events is an important goal for many athletes, coaches, and trainers.

Although ankle joint sprains occur in just about every sporting activity, the incidence rate is notably higher in activities involving jumping and landing movements (e.g., basketball and volleyball).2 A study of ankle injuries in basketball players showed the most common injury mechanism was landing, which was the mechanism for 45% of injuries in the study.4

As a result of the high incidence of ankle sprains, most athletes who experience an ankle injury have their ankle taped or wear a brace to reduce the risk of further injury. Many athletes, and even entire sports teams, have begun to proactively fight the incidence of sprains. These teams tape or brace their ankles, not necessarily because their athletes have experienced previous sprains (although sometimes this is the case), but because they want to reduce the chances of a primary injury. This approach has the potential to promote athletes’ ankle health and decrease time lost from play.

Thus, it seems intuitive that all athletes should wear ankle braces during practice and game play. However, several researchers have suggested that during landing maneuvers externally supporting the ankle may potentially have negative effects on other joints or body structures.5-9 Therefore, it is important to study not only the effects of braces on the frontal plane motions of the ankle, but also how ankle braces influence other planes of motion in the ankle joint as well as on other lower extremity joints.

Do braces help prevent ankle sprains?

A study by Ashton-Miller et al suggests that injuries to the ankle ligaments occur when the angle of the subtalar joint exceeds 30° of inversion.10 Thus, most laboratory protocols include experiments performed within this 30° limit so as not to risk injuring study participants. In lab based studies examining the inversion movements passively, braces have been shown to be effective at reducing frontal plane ankle excursions by 15% to 70%, depending on the type of brace used.11,12 During more dynamic movements, such as inversion drop tests, braces have effectively reduced the peak ankle inversion angle.12,13 Zhang et al,12 for example, had healthy participants stand on a trapdoor controlled with a pneumatic trigger release. During each trial, and without the participant’s prior knowledge, the door was released and the surface of one foot dropped to a 30° angle in the frontal plane. The researchers found that ankle braces were effective at reducing frontal plane peak inversion angles by 7.5° to 12.5° depending on the type of brace worn.12

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In a more demanding task, Chen et al13 had participants drop onto an inverted surface from a suspended bar. Compared to a conventional drop test, dropping onto an inverted surface is more similar to stepping on another player’s foot when landing from a jump, which has been shown to be a common mechanism of ankle injury during sports activities such as volleyball.14 The authors found the inverted surface was in fact more taxing on the ankle, resulting in earlier maximum inversion angle and velocity, compared with an inversion drop test. Furthermore, wearing an ankle brace while landing on an inverted surface reduced the contact plantar flexion angle, dorsiflexion range of motion (ROM), dorsiflexion velocity, and maximum inversion angle. The results showed the brace was effective in controlling ankle movements in a more demanding task, which may be a more appropriate method of testing brace effectiveness.

An interesting study by Ubell et al15 analyzed participants landing from a broad jump while wearing a modified shoe that caused 24° of forced ankle inversion on landing. The aim of the study was to see if ankle braces could help participants reduce forced ankle inversion on landing. Investigators compared three types of ankle braces with an unbraced control condition. Results showed that when the participants landed without an ankle brace, they were able to prevent the ankle from reaching the full 24° of inversion about 24% of the time. When they landed with ankle braces applied, they increased their success rate to 34% to 52%, depending on the type of brace worn.

The results of these lab-based studies suggest that ankle braces effectively reduce ankle inversion ROM, and thereby decrease the risk of ankle injury. Not surprisingly, prospective as well as epidemiological studies have reported that ankle braces help limit the frequency of ankle sprains.16-21 One example was a well-controlled prospective study analyzing 1601 US military cadets during two years of intramural basketball play.17 Investigators split the cadets into two groups: one group that wore prophylactic ankle braces (n = 789) and an unbraced control group (n = 812). During two years of play, cadets reported 46 ankle injuries. Of those injuries, occurred in the ankle brace group and 35 occurred in the control group. The results indicate that players in the control group were at three times greater risk of sustaining an ankle injury than those wearing the brace.

Clearly, research has established that ankle braces are effective for reducing ankle injuries in competitive and recreational athletics. On the surface, there is no apparent downside to using ankle braces during athletic endeavors. However, as mentioned previously, several researchers have suggested there may be potential negative effects of using an ankle brace as a prophylactic device.6,9,19,22-27

Are there risks of using ankle braces?

One of the potential problems with ankle bracing is “brace overuse.” Although evidence exists for the benefits of ankle brace use, some researchers suggest that wearing a brace might restrict ankle ROM more than is optimal.22,23 Too much restriction could potentially increase the risk of injury, a concept that may reinforce the old adage, “use it or lose it.” Essentially, the theory suggests that players can become too dependent on the brace to do the work necessary to restrict inversion ROM, relying less on their own ankle muscle and ligamentous structures. This could possibly lead to soft tissue atrophy in the ankle joint and decrease the ankle’s ability to restrict excessive ranges of motion when the athlete is not braced.24-26

In 1973, Garrick and Requa proposed that an ideal ankle brace would externally support the ankle ligaments at only the end ranges of motion, just before ligament failure. Additionally, the brace would not interfere with the sagittal plane ankle movements.28 However, more recent studies have shown that during dynamic movements such as landing from a jump, braces do limit ankle joint range of motion in the sagittal plane (limiting dorsiflexion is the biggest concern),6,19,27,29 something they were not designed to do. This is a key point as the purpose of sagittal plane movements, specifically during landing, is energy absorption or attenuation through eccentric muscle activity.31 Several studies have demonstrated the importance of eccentric muscular control of the lower extremities for energy absorption during jump landings.23,30,31

The application of an ankle brace can limit the ankle from engaging its full range of motion during drop landings. In particular, a reduction in dorsiflexion ROM may prevent the ankle joint from absorbing its typical share of energy. Consequently, an increased load may be transmitted up the body. If so, the knee, hip, and or other soft tissue structures may be required to take up the slack and absorb the remaining energy. It’s possible this scenario would lead to injuries to structures that may not be well equipped to absorb an additional amount of energy. Kareem Abdul-Jabbar, who played in the National Basketball Association for 20 years (1969-1989), may have been the first to propose this idea. Abdul-Jabbar attributed his long career to low-cut shoes, saying, “Your skeletal system was built to absorb shock. If you bind your ankles, the stress is going to get transferred to the next available joint—your knee.”32

In 1992, Devita and Skelly demonstrated how the lower extremities could alter individual joint contributions of energy absorption. Participants in their study performed drop jumps using soft and stiff landings, and joint moment and power contributions were calculated for each joint. The results showed that during soft landings, the ankle, knee, and hip absorbed 37%, 37%, and 25% of the energy, respectively. However, when the participants landed stiffly, the joint contributions were altered with the ankle, knee, and hip absorbing 50%, 31%, and 20% of the energy, respectively.31

Similar work by McCaw and Cerullo built on this idea by adding ankle brace conditions to their study. They found that landing stiffly resulted in a 5° loss of sagittal plane ankle joint ROM that was similar to the effect of landing softly while wearing an ankle brace.6 Essentially, the effect of wearing an ankle brace in a soft landing was similar to landing stiffly without wearing an ankle brace at all. This study did not report on joint work, but the authors did note that wearing certain braces restricted ankle dorsiflexion angular velocity by about 110°/s, which may suggest a reduction in energy absorption by the ankle during landing.

A more recent study analyzed the effects of two different types of braces on joint energy absorption during landings compared with an unbraced control.9 In this study researchers had participants drop off a raised platform and land on one leg in a self-selected landing style. The results showed that when landing with a more restrictive brace the ankle joint experienced a 5% decrease in relative work compared with the unbraced condition. Additionally, the knee joint of the landing limb experienced a nonsignificant 4% increase in relative work when landing with the more restrictive brace. However, it is not clear if similar changes would be seen in bilateral landings.

To date, very few studies have reported on the effects of ankle brace usage and knee injuries during sports activities involving landing. Two studies by McGuine et al did report on the incidence and severity of knee injuries in high school athletes; one during football33 and one during basketball.34 In both studies there were no differences in the number or severity of injuries between braced and unbraced athletes. Football is not typically considered a landing type of sport, but the study does provide some insight into the effects of season-long use of braces. Interestingly, during the basketball study, the researchers reported a trend showing lower extremity injuries such as acute muscle or tendon strains were more prevalent when players used braces. It should be noted however, that both studies analyzed only high school athletes and used soft lace-up style braces exclusively. It is not known whether other types of braces or a different population would reveal similar results.

More research is necessary to improve understanding of the effects of ankle braces on the lower extremity joints during drop landings. It is fairly clear that restrictive ankle braces can alter the energy absorption characteristics of the ankle itself. However, more data are needed to develop a better understanding of if or how other joints or soft tissue structures are affected.

Conclusion

It is clear from the existing literature that ankle braces can reduce incidence of ankle injuries in recreational and competitive athletics alike. This is true for sports involving high frequencies of jump landings as well as sports that do not necessarily encounter much jumping/landing activity. In terms of potential adverse effects, the research is also fairly clear that the ankle’s ability to absorb its share of energy during landings is altered with brace use. Currently, however, there is not enough information to determine the impact of prophylactic ankle braces on other joints or soft tissue structures of the lower extremities. Earlier studies have shown promising results, but more research is needed to determine the long-term effects of prophylactic brace use on lower extremity kinematics, kinetics, and neuromuscular function. More epidemiological studies are also needed to assess whether the use of prophylactic ankle braces is associated with an increase in knee or hip injuries.

Coaches, athletes, and practitioners should be aware of the potential for negative side effects of long-term ankle brace use. They should continue to monitor the literature to make well-informed decisions about the use of an ankle brace as a prophylactic device. It is the opinion of this author that athletes with a history of ankle injuries should definitely consider using an ankle brace during practice and game play. However, for those without a history of injury, other methods of preventing sprains, such as muscle strengthening, may be more beneficial for the athlete. Ultimately, care should be taken when considering the use of an ankle brace as a prophylactic device.

Jacob K. Gardner, MS, is a PhD candidate in biomechanics in the Department of Kinesiology, Recreation, and Sport Studies at the University of Tennessee in Knoxville.

Acknowledgements: The author would like to thank Steve McCaw, PhD, and Songning Zhang, PhD, for their valuable feedback on this review.

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