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brj sp med 1991 25 3 evaluation of knee braces in swedish ice hockey players y tegner md phd and r lorentzon md phd2 1 department oforthopaedics the ermeline clinic ...

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            BrJ Sp Med 1991; 25(3)
            Evaluation of knee braces in Swedish ice hockey
            players
            Y. Tegner MD, PhD' and R. Lorentzon MD, PhD2
            1 Department ofOrthopaedics, The Ermeline Clinic, Lulea, Sweden
            2 Department ofOrthopaedics, University Hospital ofUmea, Umea, Sweden
            In this retrospective investigation we have determined the                  The purpose of this investigation was to determine
            rate and types of knee injuries among Swedish ice hockey                 the number of hockey players of elite and first
            players, and related these data to the use of knee braces.               division calibre who had knee injuries. We also
            Thirty-seven of the originally selected 50 hockey teams                  wanted to relate these injuries to the use of functional
            (74%) of elite or first division calibre took part in the                knee braces and to find out whether knee injuries
            study, and 600 players answered a questionnaire. A total                 occurred while wearing a brace.
            of 254 previous knee injuries sustained while playing
            hockey were reported by 243 players; tears of the medial
            collateral ligament (60%), meniscus (15%) or anterior                    Material and methods
            cruciate ligament (12%) were the most commonly reported                  All teams playing in the two highest divisions of the
            injuries. Prophylactic knee braces were worn by 138 (23%)                Swedish ice hockey league were selected for this
            of the players. Of these, 122 (88%) had earlier sustained a
            knee injury, and 16 had not. A total of 17 knee injuries had             study. A total of 50 teams was included. The players
            occurred while the players were wearing a brace. Six of                  in 12 of these teams (the elite teams) are semi-
            these players had previously uninjured knees while 11                    professional hockey players, while those of the first
            had repeat injury in a brace despite earlier successful                  division teams, in most cases, are pure amateurs. We
            rehabilitation or operation. The most common injury in                   prepared a comprehensive questionnaire which was
            braced knees was a tear of the medial collateral ligament.               distributed by the team physicians to all players. It
               We conclude that the number of knee injuries is high                  contained questions about previous knee injury, type
            among Swedish ice hockey players, and that the efficacy                  ofinjury, treatment, the use of a knee brace, and type
            of functional knee braces to reduce knee injuries is                     of brace. After a group briefing, the players, one by
            questionable.                                                            one in cooperation with the physician, completed the
            Keywords: Functional knee brace                                          questionnaire. All knee injuries that had occurred
                                                                                     during the players' hockey career were to be reported
            Ice   hockey is inherently associated with many                          but only those that had been diagnosed by a
            potential dangers, because of the fast and random                        physician were registered. The players were especial-
            nature of the game with frequent and often forceful                      ly asked if knee injuries had occurred when wearing a
            contact between players1-3. A high incidence of                          knee brace.
            injury during hockey games has recently been
            demonstrated3 but major injuries were rare (8%),                         Results
            complete tear of knee ligaments being the most                           A total of 600 players answered the questionnaire.
            common severe injury. According to insurance                             These players belonged to 37 ofthe originally selected
            statistics,  knee injuries account for approximately                     50 teams (74%). The players in nine out of 12 elite
            30% of all injuries that result in significant disability                teams answered.
            and handicap4. In an effort to prevent or to minimize                       A total of 254 previous knee injuries sustained
            these serious injuries, or to prevent repeated injury,                   during hockey play were reported (42% of the
            orthotic braces for the knee have been developed and                     players). The most commoninjuries were a tear ofthe
            marketed. These braces have gained widespread use                        medial collateral ligament (60% of all injuries), a
            in hockey players despite the paucity of scientific                      meniscal lesion (15%) or a tear of the anterior cruciate
            documentation on their efficacy.                                         ligament (12%) (Table 1).
                                                                                        The treatment of players wearing braces was as
                                                                                     follows:    players with medial collateral ligament
            Address forcorrespondence: Y. TegnerMD, PhD, Department of               injuries were all treated without surgery and had
            Orthopaedics, The Ermeline Clinic, PO Box 195, S-951 23 LuleA,           thus an instability in their knees. All meniscus lesions
            Sweden                                                                   were treated with arthroscopic meniscectomy. Play-
            C 1991 Butterworth-Heinemann Ltd.                                        ers with posterior cruciate injury were also treated
            0306-3674/91/030159-03                                                   without surgery. Of the 27 patients, 18 with anterior
                                                                                                                       Br J Sp Med 1991; 25(3)      159
                           of knee braces in Swedish ice hockey players: Y. Tegner and R. Lorentzon
              Evaluation
             Table 1. Types of knee injuries in 243 ice hockey players                  the 138 players using the brace, 122 (88%) had earlier
                                                                                        sustained a knee injury, and 16 had not. A total of462
             Type of injury                                          No.      %         players were not using a brace, and 130 (28%) of
                                                                                        them had had a previous knee injury. The present
             Tear of                                                                    use of knee brace in relation to previous knee injury
                Medial collateral ligament                           154     60.8       diagnoses is shown in Table 2.
                Meniscus                                              38     15.0          Seventeen new knee injuries had occurred while
                Anterior cruciate ligament                            31     12.3        the players were using a brace (Table 3). Six players
                Meniscus and medial collateral ligament               15       6.0       wearing a functional brace as pure prophylaxis had a
                Posterior cruciate ligament                            3       1.2       knee injury in previously uninjured knees. Five of
              Fracture                                                 5       2.0                                        medial collateral ligament
              Patellar dislocation                                     2       0.2       these players sustained
              Miscellaneous                                            6       2.5       injuries, and one a tear of the anterior cruciate
             Total                                                   254                 ligament. Eleven players had repeat injury despite
                                                                                         wearing a knee brace. Four of these 11 injuries
                                                                                         occurred in anterior cruciate-deficient knees. Two
              cruciate ligament injury had had surgery. Some of                          cases had a subluxation resulting in Grade I-II medial
              them still had a demonstrable instability after the                        collateral ligament injuries, one case had a tear of the
              operation.                                                                 medial meniscus, and another case had a successful
                The indication for bracing the players was thus in                       anterior cruciate ligament reconstruction ruined. The
              some instances purely prophylactic and in some                             remaining seven players who had repeat injuries had
              instances in the light of a demonstrable rotatory                          earlier had a tear of the medial collateral ligament.
              instability. In most of the cases the brace was used to                    Five of these had a new tear of the medial collateral
              protect a previously injured knee.                      currently          ligament, one a tear of the medial meniscus, and one
                Amongthe600hockeyplayers, 138 (23%)                                      an unspecified major knee injury.
              used a derotation brace to protect one or both knees.
              The brace most frequently used was the Swedish                             Discussion
              Knee Brace (LIC, Solna, Sweden) (Figure 1), which is
              a modification of the Lennox Hill derotation brace. Of                     This investigation reveals a high number of signifi-
                                                                                         cant knee injuries among Swedish ice hockey players
                                                                                         of elite or first division calibre. Thus, in a population
                                                                                         of 600 players, 243 (40.5%) had sustained a knee
                                                                                         injury during hockey play. Although most injuries
                                                                                         are Grade II-III medial collateral ligament tears, even
                                                                                         more serious knee injuries might occur by the same
                                                                                         type of trauma. Therefore, there is definitely a need
                                                                                         for an effective prophylactic knee brace in ice hockey
                                                                                         players.
                                                                                         Table 2. Number of players using a knee brace, in relation to
                                                                                         previous knee injury diagnoses
                                                                                         Type of injury                             No. using       No. not
                                                                                                                                      brace       usingbrace
                                                                                         Tearof                                         69             83
                                                                                           Medial collateral ligament                    8             30
                                                                                           Meniscus                                     27              4
                                                                                           Anterior cruciate ligament                   12              3
                                                                                           Meniscus and medial collateral
                                                                                              ligament        ligament                   3              0
                                                                                            Posterior cruciate                           3             10
                                                                                         Miscellaneous
                                                                                         Total                                         122            130
                                                                                         Table 3. Knee injuries in players wearing a brace
                                                                                          Type of injury                                       No. ofplayers
                                                                                         Tearof               ligament                               12
                                                                                            Medial collateral                                          2
                                                                                            Medial meniscus ligament                                  2
                                                                                            Anterior cruciate                                          1
               Figure 1. Swedish Knee Brace, which is a modification of                     Unknown
              the Lennox Hill derotation brace, was originally designed                  Total                                                       17
              to protect anterior cruciate ligament deficient knees
              160    Br J Sp Med 1991; 25(3)
                                                         ofkneebracesinSwedishicehockeyplayers: Y. TegnerandR. Lorentzon
                                              Evaluation
            The efficacy of functional knee braces to protect the      in this study. Nor is it possible to determine any
          knee in hockey players has hitherto not been                 change in severity of knee injuries introduced by the
          reported. On the other hand, there are several               braces. To be able to make accurate comparisons
          studies evaluating the effectiveness of prophylactic         between players wearing, or not wearing, knee
          knee braces in American football players5-10. Four of        braces, a large study population must be prospective-
          these studies found a reduction of medial collateral         ly followed.
          ligament injuries associated with using a brace, while         We can conclude, however, that the number of
          two of them reported increased knee injury inci-             knee injuries among Swedish elite hockey players is
          dence. No consensus arises from these studies                high and that most of the knee-injured players do
          because ofconflicting results as well as methodologic-       wear a brace and, at the present time, the injury-
          al problems'1. The number of knee injuries among             preventive effect of the knee braces is questionable.
          hockey players wearing a knee brace seems to be              Today there is no persuasive evidence to recommend
          unacceptably high. Despite bracing, serious knee             the use or to advise against functional braces as
          injuries do still occur in previously uninjured knees        prophylactics to reduce knee injuries in ice hockey
          as well as in earlier injured, but fully rehabilitated,      players.
          knees.
            The efficacy of a knee brace is certainly dependent
          upon its design and stability. The brace most
          commonly used by Swedish hockey players has been
          investigated earlier in goniometric and biomechanical        References
          studies. It has been clearly shown that this brace will
          reduce rotation and abduction/adduction of the                1  SimFA, ChaoEY. Injurypotentialinmodemicehockey. AmI
          knee'2. The ability of this brace to resist externally       2   Sports Med 1978; 6: 378-84.
          applied forces is low13. This might explain a bad                Sim FA, Simonet WT, Melton U, Lehn TA. Ice hockey
          prophylactic effect of this brace.                           3   injuries. Am J Sports Med 1987; 15: 30-40.
            In a study of this nature there are several                    Lorentzon R, Wedren H, Pietila T. Incidence, nature, and
          methodological problems. The study is retrospective,             causes of ice hockey injuries: a three-year prospective study
          where the ice hockey players               a                     of a Swedish elite ice hockey team. Am I Sports Med 1988; 16:
                                          answered     question-       4   392-6.
          naire. There is a risk that the individuals may forget a         Folksam. Idrottsskador 1976-1983. Udevalla, Sweden: Bohus-
          significant knee injury and to overestimate another          5   lanningens tryckeri AB, 1985.
          one. In order to reduce this error the questionnaires            Hansen BL, Ward JC, Diehl RC. The preventive use of the
         were answered by the players in cooperation with                  Anderson knee stabler in football. Physican Sports Med 1985;
                                                                       6   13: 75-81.
          their team physician, and only injuries diagnosed by             Hewson GF, Mendini RA, Wang JB. Prophylactic knee
         a physician were registered.                                  7   bracing in college football. Am J Sports Med 1986; 14: 262-6.
            Another problem is non-response of a number of                 Rovere GD, Haupt AA, Yates CS. Prophylactic knee bracing
         the teams to the questionnaire: their injury rate could       8   in college football. Am I Sports Med 1987; 15: 111-16.
         have differed from that of the teams answering the                SchrinerJL, Schriner DK. The effectiveness ofknee bracing in
                                                                           preventing knee injuries in high school athletes. Presented at
         questionnaire. In an ongoing prospective study,                   the American College of Sports Medicine annual meeting,
         where we register all injuries in Swedish elite ice           9   Nashville, Tennessee, May 26-29, 1985.
         hockey, we have, after 2 years of registration, found             Taft TN, Hunter S, Fundurbeck Jr, CH. Presentation at the
         no major difference in knee injury rate between                  American Orthopaedic Society for Sports Medicine, Nash-
                                                                      10  ville, Tennessee, July 2, 1985.
         different  teams (Tegner and Lorentzon, to be                     Teitz CC, Hermansson RK, Kronmal RA et al. Evaluation of
         published). One might thus assume that there does                the use of braces to prevent injury to the knee in collegiate
         not exist any major differences in injury rate between       11  football players. I Bone Joint Surg [AmI 1987; 69A: 2-9.
         different teams.                                                 Garrick JG, Requa RK. Prophylactic knee bracing. Am I Sports
            Correlation between injury rate and exposure time         12  Med 1987; 15: 471-6
                                                                          Tegner Y, Pettersson G, Lysholm J, Gillquist J. The effect of
         is also of interest, but, because of the design of this          derotation brace on knee motion. Acta Orthop Scand 1988; 59:
          study, we could not perform such a correlation study.       13  284-7.
            The absolute efficacy of the braces in preventing             TegnerY, Odelgard B, Jonsson G. The development ofaknee
         knee injuries in hockey players cannotbe determined              injury protective brace for ice hockey players. In Castaldi GR,
                                                                          HoernerEF, eds. Safety in IceHockey. AnnArbor: ASTM, 1989.
                                                                                                  Br J Sp Med 1991; 25(3) 161
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...Brj sp med evaluation of knee braces in swedish ice hockey players y tegner md phd and r lorentzon department oforthopaedics the ermeline clinic lulea sweden university hospital ofumea umea this retrospective investigation we have determined purpose was to determine rate types injuries among number elite first related these data use division calibre who had also thirty seven originally selected teams wanted relate functional or took part find out whether study answered a questionnaire total occurred while wearing brace previous sustained playing were reported by tears medial collateral ligament meniscus anterior material methods cruciate most commonly all two highest divisions prophylactic worn league for earlier injury not included six are semi previously uninjured knees professional those repeat despite successful cases pure amateurs rehabilitation operation common prepared comprehensive which braced tear distributed team physicians it conclude that is high contained questions about ...

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