Orthopedic Casts, Braces and Splints

Number: 0009

Note: Most Aetna traditional plans cover durable medical equipment (DME) as a standard benefit.  Standard Aetna HMO plans do not cover DME without a policy rider.  Please check benefit plan descriptions for details.  Certain orthopedic casts, braces and splints are covered under HMO plans without the DME rider because their use is integral to the treatment of certain orthopedic fractures and recovery after certain orthopedic procedures.

The following braces may be considered medically necessary for the listed indications when they are used to treat disease or injury.

1. Back Braces

   1. Lumbar Orthosis, Lumbar-Sacral Orthosis, and Thoracic-Lumbar-Sacral Orthosis.

      Aetna considers a lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis medically necessary for any of the following indications:

      1. To facilitate healing following an injury to the spine or related soft tissues; or
      2. To facilitate healing following a surgical procedure on the spine or related soft tissue (see section on Post-operative Back Braces below); or
      3. To reduce pain by restricting mobility of the trunk; or
      4. To support weak spinal muscles and/or a deformed spine.

      Supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis are considered experimental and investigational for other indications because their effectiveness for indications other than the ones listed above has not been established.  Following a strain/sprain, supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis (back supports, lumbo-sacral supports, support vests) are used to render support to an injured site of the back.  The main effect is to support the injured muscle and reduce discomfort.  The following additional criteria apply to custom-fitted and custom-fabricated back braces.

      1. A custom-fitted back brace (a prefabricated back brace modified to fit a specific member) is considered medically necessary where there is a failure, contraindication or intolerance to an unmodified, prefabricated (off-the-shelf) back brace.
      2. A custom-fitted back brace is considered medically necessary as the initial brace after surgical stabilization of the spine following traumatic injury.
      3. A custom-fabricated back brace (individually constructed to fit a specific member from component materials) is considered medically necessary if there is a failure, contraindication, or intolerance to a custom-fitted back brace.
      4. Custom-fitted and custom-fabricated back braces are considered experimental and investigational when these criteria are not met.

      Note: Back braces are considered DME, except when used as a post-operative brace (see section I, B).

   2. Post-Operative Back Braces:

      Aetna considers post-operative back braces medically necessary to facilitate healing when applied within 6 weeks following a surgical procedure on the spine or related soft tissue.

      A post-operative back brace is used to immobilize the spine following laminectomy with or without fusion and metal screw fixation is considered medically necessary.  This brace promotes healing of the operative site by maintaining proper alignment and immobilization of the spine.  Post-operative back braces are considered experimental and investigational for other indications because their effectiveness or indications other than the one listed above has not been estalbished.

      Note: Post-operative back braces are considered part of the surgical protocol for certain back operations.

   3. Inflatable Lumbar Supports

      Inflatable lumbar supports (Tech Belts, air belts) have not been proven to be effective treatments for back injuries.

      Note: Inflatable lumbar supports do not meet Aetna's definition of covered DME because they are not durable (not made to withstand prolonged use) and because they are not mainly used in the treatment of disease or injury or to improve body function lost as the result of a disease or injury.*

   4. Protective Body Socks

      Note: Protective body socks do not meet Aetna's definition of covered DME because they are not made to withstand prolonged use.

2. Knee Braces

   1. Functional Knee Braces and Rehabilitation Braces:

      1. Knee braces may be custom-fitted prefabricated or custom-made.  Custom-made functional braces (also known as "custom-fabricated" or "molded" knee orthoses) are considered medically necessary if the member meets criteria for a prefabricated knee brace below but is unable to be fitted with a custom-fitted prefabricated knee brace.  Examples of situations in which a person may meet criteria for a custom-made knee brace include, but are not limited to: (i) a deformity of the knee or leg that interferes with fitting; (ii) disproportionate size of thigh and calf; (iii) minimal muscle mass upon which to suspend an orthosis.  Exceptionally tall or short stature or obesity does not, by itself, establish the medical necessity for custom-made functional knee braces.  Exceptionally tall persons can usually be fitted with a prefabricated brace with extensions, short persons can usually be fitted with a pediatric prefabricated brace, and obese persons can usually be fitted with a prefabricated knee brace with extra large straps.  Custom-fabricated orthoses are not considered medically necessary for treatment of knee contractures.  Custom-fabricated orthoses are considered experimental and investigational when criteria are not met.
      2. Knee braces composed of high-strength, lightweight material are considered medically necessary for persons who meet criteria for a knee orthosis and whose weight is greater than 250 lbs.  Knee braces composed of high-strength, lightweight material are considered experimental and investigational for other indications.
      3. Prefabricated rigid knee orthoses without joints and knee orthoses with joints that lock a knee into a particular position are considered medically necessary DME for persons with non-fixed flexion contractures of the knee.  These knee orthoses are considered experimental and investigational for other indications.  A prefabricated knee orthosis with locking joints and inflatable air support chambers is considered experimental and investigational because there is no proven clinical benefit to the inflatable air bladder incorporated into the design of this knee orthosis.
      4. Knee orthoses with varus or valgus adjustment are considered medically necessary for ambulatory persons with the following indications:
          
         
         1. Aseptic necrosis of the tibia/fibula; or
         2. Failed total knee arthroplasty; or
         3. Knee ligamentous disruption; or
         4. Meniscal cartilage derangement; or
         5. Moderate to severe unicompartmental osteoarthritis; or
         6. Tibial plateau fracture.

         For persons with these indications, valgus or varus bracing alleviates pressure on the medial or lateral compartment of the knee.  These knee orthoses are considered experimental and investigational for other indications because their effectiveness for indications other than the ones listed above has not been established.

      5. The following prefabricated knee braces are considered medically necessary when criteria below are met:

         1. Knee immobilizer;
         2. Knee orthosis with double uprights and adjustable flexion and extension joints;
         3. Knee orthosis with double uprights, adjustable flexion and extension joint, and medial-lateral and rotational control;
         4. Knee orthoses with double uprights and thigh and calf pads (Swedish-type knee orthosis).

         Medical necessity criteria:

         1. Member has recent (within 6 weeks prior to brace application) surgical intervention or injury to the ligaments of the knee requiring range of motion limitations.  Note: When used for this indication, the knee brace is considered a rehabilitation brace (also known as a post-operative or post-injury brace) and is considered an integral part of the orthopedic protocol.  Examples include: Bledsoe Postop Brace, DonJoy IROM Brace, or
         2. Member is ambulatory and has instability due to ligament insufficiency/deficiency or reconstruction.  Note: When used for this indication, the knee brace is considered a functional (derotational) knee brace and is considered DME.  Examples include: Lenox Hill Brace, Boston Knee Brace, DonJoy CI Brace.
         3. These prefabricated knee orthoses are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones lsited above has not been established.
             
         Note: Socks and braces sleeves are considered medically necessary supplies when used in conjunction with knee orthoses.

         Note: Please see DMERC policy for guidelines on the reasonable usable lifetime of knee orthoses.  These guidelines also provide the medically necessary frequency of replacement interfaces. 

   2. Prophylactic Knee Braces

      Prophylactic knee braces are designed to reduce the likelihood or severity of knee ligament injuries in a relatively normal (stable) knee.

      Prophylactic knee braces are considered experimental and investigational.  The American Academy of Orthopedic Surgeons has concluded that prophylactic bracing has not been proven to be effective and, in some cases, may actually contribute to knee injury.

   3. Osteoarthritis Braces (Unloader Braces)

      Aetna considers prefabricated unloader braces medically necessary DME as an alternative to surgery for members with severe symptomatic osteoarthritis of the knee who have pain that has failed to respond to medical therapy and knee bracing with a neoprene sleeve, who have progressive limitation in activities of daily living, and who do not have any of the following:

      1. Arthritis other than osteoarthritis; or a recent knee operation (within the previous 6 weeks); or
      2. Diseases that would preclude use of a brace (e.g., skin disease, peripheral vascular disease, or varicose veins); or
      3. Inability to apply the brace because of physical limitations such as arthritis of the hands or inability to bend over; or
      4. Paresis or other disease that would preclude ambulation; or
      5. Severe cardiovascular deficit; or
      6. Symptomatic disease of the hip, ankle or foot.

      A custom-fabricated unloader brace is considered medically necessary for members who meet criteria for a prefabricated unloader brace and meet medical necessity criteria for a custom-made brace noted in the section on functional and rehabilitation knee braces above.  Unloader braces are considered experimental and investigational when criteria are not met.

      Examples: Generation II Unloader, Orthotech Performer, Vixie Enterprise MKSIII

   4. The Ottobock E-Mag Electronically Locking Knee Brace

      Aetna considers the Ottobock E-Mag electronically locking knee brace experimental and investigational because there is a lack of evidence regarding its effectiveness.

3. Cast-Braces (also called Fracture Braces)

   1. Comfort, Non-Therapeutic

      Comfort, non-therapeutic cast-braces are considered medically necessary DME after a fracture or surgery.  Comfort, non-therapeutic cast-braces are considered experimental and investigational for other indications because their effectiveness for indications other than the ones listed above has not been established.  These braces are often used after the patient has been in a walking cast.  They are usually removable.  Molded casts, which allow the user to remove the cast to bathe the affected extremity, can also be used when a fracture is slow to heal or non-healing.  The use of these removable casts replaces monthly cast changes.  A removable cast of this type offers no therapeutic advantages over a non-removable cast.

      Example: Cam Walker

   2. Functional Cast-Brace

      Functional cast-braces are considered medically necessary after a fracture or surgery.  These have become the standard brace for certain fractures, including tibial-femoral fractures.  The functional cast-brace is used following a short period of standard fracture treatment using a non-weight bearing or partial weight-bearing cast, or immediately following surgery.  It allows protected weight bearing, and motion of the joints above and below the fracture.  The joints are moved earlier, contractures are prevented, and early healing is effected due to the weight bearing.  Functional cast-braces are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

      Examples: Patellar tendon bearing (PTB) cast brace, PTB fracture brace, MAFO (molded ankle-foot orthosis) fracture brace with pelvic band, Achilles tendon hinged brace

      Note: Functional cast-braces are considered integral to the treatment of the fracture.

4. Rehabilitation Braces

   Aetna considers other post-operative and post-injury braces medically necessary when applied within 6 weeks of surgery or injury.  These braces are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

   Note: Rehabilitation braces are considered an integral part of the surgical or fracture care protocol.

5. Cervical (Neck) Braces

   Cervical (neck) braces are considered medically necessary DME for members with neck injury and other appropriate indications.

   Example: Philadelphia Cervical Collar

   Note: Cervical foam neck collars do not meet Aetna's definition of covered DME because they are not durable, and not made to withstand prolonged use.*

6. Childhood Hip Braces

   Specialized hip braces are considered medically necessary for children with hip disorders to stabilize the hip and/or to correct and maintain hip abduction.  These hip braces are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

   Example: Pavlik Harness, Frejka Pillow Splint, Friedman Strap

   Note: Childhood hip braces are considered integral to the management of hip disorders in children.

7. Braces for Congenital Defects

   Aetna considers orthopedic braces medically necessary in the treatment of congenital defects.  Aetna also considers replacement braces medically necessary when the member has outgrown the previous brace or because his/her condition has changed such as to make the previous brace unusable.  This includes scoliosis braces.

   1. Plastic Braces (MAFOs)

      Increasing use is made of plastic braces.  These devices have various names and are often called molded ankle-foot orthoses (AFOs) or molded ankle-foot orthoses (MAFOs).  They may also be called orthotics.  For information on ankle-foot orthotics, see CPB 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs).  Orthotics of this type should not be confused with simple, removable orthotic arch supports or shoe inserts.  For information on foot orthotics, see CPB 0451 - Foot Orthotics.

   2. Wheaton Brace

      A Wheaton Brace is considered medically necessary DME to treat metatarsus adductus in infants replacing the need for serial casting.  A Wheaton Brace is considered experimental and investigational for other indications because its effectiveness for indications other than the one listed above has not been established.

   3. Scoliosis Braces

      For Aetna's policy on scoliosis braces, see CPB 0398 - Idiopathic Scoliosis.

8. Splints and Immobilizers

   Certain orthopedic problems are routinely treated with splints or splint-like devices.  The following are considered medically necessary:

   1. Acromio-clavicular splint (also called a Zimmer splint)
   2. Carpal tunnel splints
   3. Clavicle splint (also called a figure-8 splint)
   4. Denis Browne Splint for children with clubfoot or metatarsus valgus to maintain and correct abduction
   5. Dynasplints under circumstances specified in CPB 0405 (See CPB 0405 - Mechanical Stretching Devices for Contracture and Joint Stiffness)
   6. Finger splints
   7. Shoulder immobilizer.
       

9. Unna Boots

   Unna boots are considered medically necessary only for non-fracture care.  Unna boots have no proven value when used in conjunction with fracture treatment.  They can be used to treat sprains and torn ligaments, provide protection for other soft tissue injuries and may be used after certain surgical procedures as a protective cover to promote healing.  Occasionally they are used in the first days after a fracture before a cast is put on.  Their use in this regard is controversial.

10. Air Casts

    Air Casts are considered medically necessary for treatment of fractures or other injuries (i.e., sprains, torn ligaments).  Air Casts (air splints) are used as an alternative to plaster casts to immobilize an elbow, ankle, or knee.  Air Casts are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

11. Miscellaneous Covered Services

    1. Casting of a sprain is considered medically necessary.

    2. Casting following surgical procedures is considered medically necessary.

12. Fiberglass versus Plaster Casts

    The casting material used in fracture care can be either fiberglass or plaster.  The choice of material is dictated by the individual situation and is left to the discretion of the treating doctor.

13. The Spine and Scapula Stabilizing Brace (the S3 Brace)

    The Spine and Scapula Stabilizing brace (the S3 brace) is considered experimental and investigational because of insufficient evidence of its effectiveness.  According to the manufacturer, the vest-type Spine and Scapula Stabilizing brace (the S3 brace) (AlignMed, Inc., Santa Ana, CA) is designed to help restore normal shoulder kinematics.  It consists of a Velcro strapping system with "propioceptive padding" and mesh vest "to allow biofeedback to patients".  According to the manufacturer, "this neural feedback, along with the vest's innate postural support, could potentially emphasize proper shoulder muscular mechanics".  Evidence for the S3 brace consists of unpublished abstracts examining the effect on shoulder kinematics in normal subjects as well as subjects with "scapular dyskinesis".  There are no published clinical outcome studies of the S3 brace.

*Note: Certain non-durable items (e.g., arm slings, Ace bandages, splints, foam cervical collars, etc.) may be eligible for payment in some circumstances even though they are not durable and do not fit within the definition of DME.  These non-durable items may be covered when charges are made by a hospital, surgical center, home health care agency, or doctor for necessary medical and surgical supplies used in connection with treatment rendered at the time the supply is used.  However, charges for take home supplies (i.e., extra bandages, cervical pillows, etc.) are not covered.  Please check benefit plan descriptions for details.

For Aetna's policy on orthopedic shoes, orthotics and supportive devices for the feet, see CPB 0451 - Foot Orthotics.

This policy is based primarily on Medicare DMERC criteria for spinal orthoses and knee orthoses.

Knee braces may be custom-fitted or custom-made.  A custom-fitted prefabricated brace is one which only measurements and a sizing chart are needed for fitting.  A custom-made (custom-fabricated or made-to-order) knee brace is one that requires an initial impression of the knee for fitting.  Knee orthoses that are custom-fitted require the assistance of an orthotist in adjusting the brace to the correct size, but do not require an initial impression of the knee for fitting.  Custom-made functional knee braces have not been shown to be medically superior to custom-fitted prefabricated functional knee braces.  Therefore, use of custom-made functional knee braces is reserved for those patients who are hard to fit because of a deformity of the knee or leg that interferes with fitting.  Exceptionally tall persons can be fitted into an custom-fitted prefabricated brace with extensions, short persons can be fitted with a pediatric custom-fitted prefabricated brace, and obese persons can be fitted into an custom-fitted prefabricated knee brace with extra large straps. 

A classification scheme devised by the American Academy of Orthopedic Surgeons (AAOS) divides knee braces into three categories:

1. Prophylactic knee braces are designed to reduce the likelihood of severity of knee ligament injuries in a relatively normal knee.
2. Functional knee braces are designed to improve stability for an unstable or postoperative knee in activities of daily living and sports.
3. Rehabilitative (or Rehabilitation) knee braces are designed to allow protected motion of an injured knee treated operatively or nonoperatively early after the injury.

Each of these types of braces will be discussed in turn below.

Prophylactic Knee Braces:

Prophylactic knee braces and other protective gear (such as helmets, elbow pads, gloves, eye goggles, etc.) are considered safety items and are therefore not covered under terms of Aetna’s policies.  Please check benefit plan descriptions.

The common occurrence of medial collateral sprains in football and other sports led to the fabrication of prophylactic hinge braces designed to prevent or attenuate this injury.  These braces have lateral or sometimes medial and lateral hinges designed to absorb valgus impact to the knee.  Prophylactic knee braces are available custom-fitted prefabricated (not custom-made) and without a prescription. 

The effectiveness of prophylactic knee braces for collateral ligament injury to the knee is controversial.  Prophylactic knee braces have not been shown to be effective.  Indeed, some studies have shown that the risk of knee injury may be increased with use of prophylactic knee braces.  Hald and Fandel (1996) explained that recent research has raised questions about the possibility of such braces "preloading" knee structures and predisposing the wearer to an increased risk of ligament injuries.  These investigators concluded that "[w]e now feel that time and money might be better spent on preventive conditioning than for braces."

Functional Knee Braces:

Functional knee braces are considered medically necessary if they are needed for activities of daily living, such as standing, walking, and climbing stairs, and thus are worn throughout the day.  Functional knee braces are considered not medically necessary when used primarily for sports, because participation in sports is considered an elective activity.

Functional knee braces are designed to provide support to the knees made unstable by injury or to provide additional protection following surgery to correct such instabilities.  They are usually recommended in the postoperative period and after completion of rehabilitation when full activity is resumed, or for the patient with a diagnosis of anterior cruciate ligament insufficiency in whom a nonoperative approach is used.

Some of these braces are ready-made in sizes to provide for immediate fit (so-called custom-fitted prefabricated braces).  Others require custom construction based on some form of cast molding or measurement of the person’s leg (so called custom-made or custom-fabricated braces).  Functional braces usually involve some form of hyperextension stop, as well as straps or fitted shells to control rotation.  There is no clear-cut advantage of shell braces over strap braces.

Functional knee braces are fabricated from a variety of materials, including carbon composites, aluminum, and kevlar.  Despite their relatively high cost, knee braces composed of carbon composites (also known as carbon fiber or graphite) are favored by competitive athletes because of their lightness.  There are, however, no medical advantages of carbon fiber braces over braces composed of materials that are heavier, but equally as strong, such as steel or aluminum.  A variety of suspension systems and knee joint designs are used in functional knee braces.  There is, however, no evidence of medical benefits from one knee joint design over another.  Therefore, custom-made braces is considered medically necessary only for persons who cannot be fit into off the shelf braces because deformity.  Even persons who are very tall or markedly obese, however, can be fitted with custom-fitted prefabricated functional braces that have been modified with attachments, such as extensions and extra long straps.

Functional knee braces are most commonly used in persons with prior ligamentous knee injuries.  The ligaments of the knee include the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the lateral collateral ligament (LCL), and the medial collateral ligament (MCL).  The use of functional braces for injuries involving each of these ligaments is described below:

Up to 70 % of acute ACL injuries occur during sports.  Episodes occur during sports requiring quick turns, sudden stopping, jumping, or lateral movements (such as football, volleyball, basketball, and racquetball).  The diagnosis of an acutely torn anterior cruciate ligament (ACL) is based on the circumstance of the injury as reported by the patient and the stability assessment during the physical examination.  Lachman’s test of assessing the anterior translation of the tibia on the femur with the knee in 20 to 30 degrees of flexion is the most accurate diagnostic examination.  For patients treated conservatively, optional bracing has been used after rehabilitation to assist patients in returning to low-demand activity.  However, neuromuscular rehabilitation and activity modification are far more important.

The use of the functional brace for the ACL-deficient knee remains controversial.  Laboratory studies have shown that functional braces do not prevent abnormal tibial displacement, even at physiologic loads.  However, persons with prior cruciate ligament injuries subjectively feel more secure in these devices.

Loss of the anterior cruciate ligament has been associated with a loss of ability to detect knee joint motion due to disruption of normal efferent pathways.  Some have conjectured that knee braces can substitute for this lost pathway, and that subjective improvements while wearing the brace are due to heightened propioception (position sense), although the evidence supporting this hypothesis is inconclusive.  Others feel that psychological support may be the greatest benefit of functional braces.  Despite the subject’s subjective improvement, giving away episodes can occur in spite of wearing the functional brace.  The AAOS concluded that the “scientific rationale for this ‘security’ is not clear, but perhaps related to the fact that the devices do provide warmth and increased knee awareness” (AAOS, 1991).

No study has demonstrated medically significant advantages of custom-made functional knee braces over custom-fitted prefabricated functional knee braces in patients with knee ligament injuries.  Because the benefits of functional knee braces are due to their ability to effect heightened propioception and to the sense of security the impart, the precise fitting of the brace, as through custom-fabrication or custom-molding, is not essential to its effectiveness.

More than 50 functional braces are on the market, with no clear-cut advantage for any brand.  “[B]eing aware of the growing number of ‘off the shelf’ functional braces on the market, physicians and clinicians must decide whether the custom-made brace is worth the extra cost to the athlete or patient if the protection offered is propioceptive in nature” (Harrelson, 1991).  Reider explained that “[w]e currently favor the new generation of custom-fitted prefabricated braces for economic reasons, saving the more expensive custom-molded types for the harder-to-fit athlete” (Reider et al, 1996).

In proving that one brace is superior to another, the manufacturer must demonstrate brace efficacy in studies designed to approximate the in vivo situation.  Current studies do not provide adequate evidence to conclude that custom-made functional knee braces result in medical benefits beyond those provided by custom-fitted prefabricated braces.  The manufacturer claiming superiority of their brace must be asked to verify claims and to provide documentation of efficacy.

The medial collateral ligament is the most commonly injured knee ligament in sports.  Persons with a first-degree MCL sprain need only wear a knee immobilizer for a few days, and no functional brace is necessary.

A first-degree sprain is, by definition, an injury to the ligament in which there is no increased laxity of that ligament.  If there is laxity present, then there is either a second- or third-degree sprain.  A second-degree sprain is differentiated clinically from a third degree sprain by the feel of the "end-point" on examination and the amount of laxity.  A second-degree sprain has a "firm" end point on stressing, as the ligament fibers that were not torn in the injury become taut.  A third-degree sprain has a "soft" end point, as translation is gradually stopped when other ligaments and tendon fibers (secondary restraints) become taut.

For the patient with a second-degree MCL sprain (partial tear), it is appropriate to prescribe an custom-fitted prefabricated functional knee brace after the rehabilitative knee brace is removed, and have the patient use this brace for up to 8 weeks after injury.

Isolated third-degree MCL injuries (complete tear) may be treated with a hinged rehabilitative brace, rather than a knee immobilizer, for the first 6 weeks after injury.  (An isolated MCL sprain is one where the ACL and PCL (posterior cruciate ligament) have been proven intact by MRI and instrumented laxity testing.)  It is recommended that following the acute injury, a functional brace be worn for 4 to 6 months.

The posterior cruciate ligament is infrequently injured.  Functional bracing has little role in PCL injuries because there is no clinical benefit or biomechanical evidence for the use of a functional brace in the PCL-injured knee.

The lateral collateral ligament is the least frequently injured of all the knee ligaments in sports because the knee is usually protected from a blow to the medial side by the person's other leg.  Treatment for first- and second-degree sprains follows the same program and a very similar time frame that was used for MCL injuries.  A custom-fitted prefabricated functional brace is appropriate for the patient that desires early return to activity.  Operative referral is necessary for patients with third-degree sprains.

Evidence is insufficient to support the use of knee braces as a treatment for patellofemoral pain syndrome.  In a Cochrane review on orthotic devices for treating patello-femoral pain syndrome, D'hondt et al (2002) concluded that the evidence from randomized controlled trials is currently too limited to draw definitive conclusions about the use of knee and foot orthotics for the treatment of patellofemoral pain.  The authors stated that future high quality trials in this field are warranted. An earlier systematic evidence review of treatments for patellofemoral pain similarly concluded that, "[d]ue to the low quality and quantity of the current evidence, the use of patellofemoral orthoses ... cannot be supported or refuted" (Crossley et al, 2001).  In a review on the management of patients with patello-femoral pain syndrome, Dixit and colleagues (2007) stated that there is little evidence to support the routine use of knee braces or non-steroidal anti-inflammatory drugs. 

Rehabilitative (or Rehabilitation) Knee Braces:

Rehabilitative (or rehabilitation) braces are used as alternatives to knee immobilizers used immediately after surgery or injury to both control knee motion and protect the knee during rehabilitation.  Rehabilitative knee orthoses offer the patient early limited mobility to improve recovery time and decrease the effects of disuse on the graft or reconstructed ligament.

Rehabilitative knee orthoses are custom-fitted prefabricated, and can be ordered either as small, medium, or large, or by a size chart.  Most of them can be adjusted within each size to allow for edema or atrophy, and thus can be conveniently stocked in a hospital or clinic for quick fittings.

In collateral ligament injuries that do not involve a complete tear (second degree injuries), the torn fibers are internally splinted from excessive stress by the intact ligament fibers, and the use of the knee immobilizer or rehabilitative brace is only for comfort.

There are few objective studies offering objective data about the stabilizing effects of various types, and no guidelines for choosing any particular rehabilitative knee brace over another.  Choice of rehabilitation brace is usually based on availability, ancillary features, and ease of use.

Rehabilitative knee braces do not require precise fitting (and, hence, are never custom-made) because their size must be repeatedly readjusted throughout the course of rehabilitation to accommodate changes in swelling that occur following injury or surgery to the knee.

The Ottobock E-Mag Electronically Locking Knee Brace:

The Ottobock E-Mag electronically locking knee brace supposedly offers wearers increased stability when standing and helps patients achieve a more active lifestyle. It features an electronically controlled lock that is activated by a small remote control to provide absolute stability in the stance phase.  The lock is activated with the touch of a button, allowing the wearer to support themselves with both arms and stand safely at all times.  The Ottobock E-Mag's special feedback system also informs the wearer when the joint is opening.

The WorkSafeBC Evidence-Based Practice Group’s report on the “E-MAG Active” (Edeer and Martin, 2010) stated that “E-MAG Active has recently been introduced by Otto Bock as a SCKAFO [Stance Control Knee Ankle Foot Orthoses] that utilizes an electromagnetic technique (hence, the name E-MAG which refers to this Electronic Magnet).  It became available in the market in North America in December 2008 …. To use E-MAG Active the patient is required to have both functional extensors and flexors of the hip with a strength of 3 to 5 (based on the Kendall and Kendall scale).  The patient must also have the capacity for full extension of the knee, both prior to the initial contact and at the terminal stance (to lock and unlock the knee) …. Otto Bock recommends E-MAG Active for “patients that present with flaccid paralysis/paresis of the knee extensors coupled with limited ankle ROM” …. Currently, there are no review articles, or any other study papers (case reports, comparative studies, or cost effectiveness studies) specifically about E-MAG Active …. There is no specific coverage policy regarding E-MAG Active at WorkSafeBC …. The policy manual of the US Department of Veterans Affairs contains a section on “orthotics” but does not include a specific policy regarding E-MAG Active or SCKAFOs in general …. We did not come across any specific coverage policy on E-MAG Active from any of the searched workers compensation organizations or health insurance companies”.

Scapular Bracing:

Cole et al (2013) noted that overhead athletes commonly have poor posture.  Commercial braces are used to improve posture and function, but few researchers have examined the effects of shoulder or scapular bracing on posture and scapular muscle activity.  These researchers examined if a scapular stabilization brace acutely alters posture and scapular muscle activity in healthy overhead athletes with forward-head, rounded-shoulder posture (FHRSP).  A total of 38 healthy overhead athletes with FHRSP were included in this study.  Participants were assigned randomly to 2 groups: (i) compression shirt with no strap tension (S) and (ii) compression shirt with the straps fully tensioned (S + T).  Posture was measured using lateral-view photography with retro-reflective markers.  Electromyography (EMG) of the upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) in the dominant upper extremity was measured during 4 exercises (scapular punches, W's, Y's, T's) and 2 gleno-humeral motions (forward flexion, shoulder extension).  Posture and exercise EMG measurements were taken with and without the brace applied.  Head and shoulder angles were measured from lateral-view digital photographs.  Normalized surface EMG was used to assess mean muscle activation of the UT, MT, LT, and SA.  Application of the brace decreased forward shoulder angle in the S + T condition.  Brace application also caused a small increase in LT EMG during forward flexion and Y's and a small decrease in UT and MT EMG during shoulder extension.  Brace application in the S + T group decreased UT EMG during W's, whereas UT EMG increased during W's in the S group.  The authors concluded that application of the scapular brace improved shoulder posture and scapular muscle activity, but EMG changes were highly variable.  They stated that the use of a scapular brace might improve shoulder posture and muscle activity in overhead athletes with poor posture.  One important drawback of this study was the variable fit of the scapular brace on each participant.  Braces were provided in 6 sizes to fit the participants, and the investigators involved in the application of the braces were trained by a representative from the manufacturer on how to fit each brace for each participant.  However, the material of the compression top often gathered during movement, and the participants with short torsos had more difficulty with fit than did other participants.  Other drawbacks included: (a) 1 type of brace application was used – different brace applications might affect posture and EMG differently, and using a different method might be more beneficial; and (b) although every effort was made to blind the participants and the primary investigators to ensure the validity of the results, it cannot be ruled out that the subjects might have altered their posture and muscle activity simply because of research participation.

1. American Academy of Orthopedic Surgeons. The use of knee braces. Position Statement. Chicago, IL: American Academy of Orthopedic Surgeons; 1987.
2. American Academy of Orthopedic Surgeons. Protective equipment. In: Athletic Training and Sports Medicine. 2nd Edition.  Rosemont, IL: American Academy of Orthopedic Surgeons; 1991: 705-719.
3. Reider B, Belniak R, Miller DW. Football. In: Sports Medicine: The School-Age Athlete. 2nd Edition. B Reider, ed. Philadelphia, PA: W.B. Saunders Co.; 1996: 613-645.
4. Hald RD, Fandel DM. Taping and bracing. In: Office Sports Medicine. 2nd Edition. MB Mellion, ed. Philadelphia, PA: Hanley & Belfus, Inc.; 1996: 337-354.
5. Harrelson GL. Knee rehabilitation. In: Physical Rehabilitation of the Injured Athlete. JR Andrews, GL Harrelson, eds. Philadelphia, PA: W.B. Saunders Co.; 1991: 328-329.
6. Littenberg B, Weinstein LP, McCarren M, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am. 1998;80(2):174-183.
7. Alexy C, De Carlo M. Rehabilitation and use of protective devices in hand and wrist injuries. Clin Sports Med. 1998;17(3):635-655.
8. Buckley SL. Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop. 1997;338:60-73.
9. McFarland EG, Curl LA, Urquhart MW, Kellam K. Shoulder immobilization devices. Orthop Nurs. 1997;16(6):47-54.
10. Kramer JF, Dubowitz T, Fowler P, et al. Functional knee braces and dynamic performance: A review. Clin J Sport Med. 1997;7(1):32-39.
11. Jerosch J, Thorwesten L, Bork H, Bischof M. Is prophylactic bracing of the ankle cost effective? Orthopedics. 1996;19(5):405-414.
12. Liu SH, Mirzayan R. Current review. Functional knee bracing. Clin Orthop. 1995;317:273-281.
13. Fernandez-Feliberti R, Flynn J, Ramirez N, et al. Effectiveness of TLSO bracing in the conservative treatment of idiopathic scoliosis. J Pediatr Orthop. 1995;15(2):176-181.
14. Albright JP, Saterbak A, Stokes J. Use of knee braces in sport. Current recommendations. Sports Med. 1995;20(5):281-301.
15. Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop. 1994;14(2):211-213.
16. McIvor JB, Ross P, Landry G, Davis LA. Treatment of femoral fractures with the cast brace. Can J Surg. 1984;27(6):592-594.
17. Dieppe P, Chard J, Faulkner A, et al. Osteoarthritis. In: Clinical Evidence. 2000;4:649-663.
18. Zuelzer WA. Knee bracing. In: Physical Rehabilitation of the Injured Athlete. JR Andrews, GL Harrelson, eds. Philadelphia, PA: W.B. Saunders Co.; 1991; Ch. 14:211-220.
19. No authors listed. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee. 2000 update. Arthritis Rheum. 2000;43(9):1905-1915.
20. Hewett TE, Noyes RF, Barber-Westin SD, et al. Decrease in knee joint pain and increase in function in patients with medial compartment arthrosis: A prospective analysis of valgus bracing. Orthopedics. 1998;21(2):131-138.
21. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am. 1999;81(4):539-548.
22. Lindenfeld TN, Hewett TE, Andriacchi TP. Joint loading with valgus bracing in patients with varus gonarthrosis. Clin Orthop. 1997;344:290-297.
23. van Rhijn LW, Plasmans CM, Veraart BE. Changes in curve pattern after brace treatment for idiopathic scoliosis. Acta Orthop Scand. 2002;73(3):277-281.
24. Gepstein R, Leitner Y, Zohar E, et al. Effectiveness of the Charleston bending brace in the treatment of single-curve idiopathic scoliosis. J Pediatr Orthop. 2002;22(1):84-87.
25. TriCenturion, LLC. Spinal orthoses: TLSO and LSO. Local Medical Review Policy. Medicare DMERC Region A. Policy No. TLSO20030701. Columbia, SC: TriCenturion; July 1, 2003. Available at: http://www.tricenturion.com/content/lmrp_current_dyn.cfm. Accessed February 5, 2004.
26. CIGNA HealthCare Medicare Administration. Knee orthoses - DRAFT (DL18253). Region D DMERC Local Coverage Determination. Philadelphia, PA: CIGNA Medicare; September 10, 2004. Available at: http://www.cignamedicare.com/dmerc/LMRP_LCD/draft/KneeOrth_draft.html. Accessed January 4, 2005.
27. CIGNA HealthCare Medicare Administration. Article for knee orthoses. DRAFT Policy Article (A22446). Philadelphia, PA: CIGNA Medicare; September 10, 2004. Available at: http://www.cignamedicare.com/dmerc/LMRP_LCD/draft/Articles_draft/
    KneeOrth_art_draft.html. Accessed January 4, 2005.
28. Brouwer RW, Jakma TSC, Verhagen AP, et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2005;(1):CD004020.
29. Pollo FE, Jackson RW. Knee bracing for unicompartmental osteoarthritis. J Am Acad Orthop Surg. 2006;14(1):5-11.
30. Korthals-de Bos IB, Gerritsen AA, van Tulder MW, et al. Surgery is more cost-effective than splinting for carpal tunnel syndrome in the Netherlands: Results of an economic evaluation alongside a randomized controlled trial. BMC Musculoskelet Disord. 2006;7:86.
31. Crossley K, Bennell K, Green S, McConnell J. A systematic review of physical interventions for patellofemoral pain syndrome. Clin J Sport Med. 2001;11(2):103-110.
32. D'hondt NE, Struijs PA, Kerkhoffs GM, et al. Orthotic devices for treating patellofemoral pain syndrome. Cochrane Database Syst Rev 2002;(2):CD002267.
33. Chew KT, Lew HL, Date E, Fredericson M. Current evidence and clinical applications of therapeutic knee braces. Am J Phys Med Rehabil. 2007;86(8):678-686.
34. Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75(2):194-202.
35. Warden SJ, Hinman RS, Watson MA Jr, et al. Patellar taping and bracing for the treatment of chronic knee pain: A systematic review and meta-analysis. Arthritis Rheum. 2008;59(1):73-83.
36. WorkSafeBC Evidence-Based Practice Group, Edeer D, Martin CW. E-MAG Active, a newer Stance Control Knee Ankle Foot Orthosis (SCKAFO) in the context of workers’ compensation. Richmond, BC: WorksafeBC Evidence-Based Practice Group; December 2010. Available at: http://www.worksafebc.com/health_care_providers/assets/pdf/e-mag-sckafo.pdf. Accessed November 1, 2012.
37. Cole AK, McGrath ML, Harrington SE, et al. Scapular bracing and alteration of posture and muscle activity in overhead athletes with poor posture. J Athl Train. 2013;48(1):12-24.