At last month’s American Podiatric Medical Association (APMA) National Meeting in Seattle, I had the privilege of moderating a fascinating session titled “Controversies in Podiatric Sports Medicine,” which attracted a standing room only crowd in one of the main lecture halls. Topics such as “When to Operate on a Jones Fracture” and “Management of Second MTP Pathologies in the Runner” stimulated lively debate amongst the panelists.
One topic I presented was the role of prophylactic ankle bracing in the adolescent athlete. Most of us are getting increased numbers of inquiries from concerned parents who are now hearing from coaches of youth athletic teams that ankle braces are required for all participants. This is becoming prominent in club volleyball where coaches are recommending ankle braces for all participants from age 8 through 20. Where did this notion come from and what is the justification?
While ankle sprains are the most common injury in athletics, the three sports with the most common incidence of sprains are soccer, volleyball and basketball. Club volleyball has far greater participation from female athletes and in comparison to their male counterparts, females have been documented in several studies to have a greater risk of ankle sprains.1
A Closer Look At The Literature On Bracing
The literature reveals at least eight studies on the role of preventive or prophylactic ankle bracing. However, only three of the published studies utilized a randomized, prospective comparative design (Level II evidence).1-3
The studies by Sitler and colleagues and Surve and co-workers both focused on male athletes only.2,3 Both showed a significant preventive effect of external braces to prevent an ankle sprain in both basketball and soccer. However, Surve and colleagues showed this preventive effect only in athletes with a previous history of sprains.
The more recent study by Frey and co-workers underscores some of the problems with interpretation of data and conclusions that may be un-justified.1 This study was the first to evaluate the role of preventive ankle bracing in high school volleyball players. Researchers randomly assigned five different types of ankle braces (three lace-up and two semi-rigid) to 957 athletes almost equally divided between males and females. Forty-two patients were in the control group. Note the large disparity between the size of the test group and control group.
Researchers followed the players for one entire season of high school volleyball and documented all ankle sprains.1 The results of the study were quite clear and emphatically spelled out: “Regardless of gender, there was no significant difference in the ability of each brace to prevent injury (p = 0.691). In addition, the braced group did not have any significant advantage in preventing injury when compared to the control group (p = 0.824).”
While you would think this is the end of the story, the authors dug deeper to find some differences among subgroups of the participants.1 Indeed, when looking at women who suffered a sprain, there was an increased incidence of sprain with the cloth lace-up braces in comparison to the semi-rigid braces. Also, there was a protective effect of semi-rigid braces among participants but only if they had never suffered a previous sprain.
Therefore, this study showed no protective benefit in the incidence of an ankle sprain with the use of ankle braces worn by high school volleyball players.3 Yet the authors “ … conclude that ankle braces should be recommended for female players with or without a history of ankle sprains. When a brace is used, a rigid or semi-rigid device should be used.”
The authors drew this erroneous conclusion by looking at smaller sub-groups of participants wearing certain types of braces. Furthermore, the findings contradict the previously published works of Sitler and co-workers, and Surve and colleagues.2,3
Making Recommendations To Athletes
There remain several unanswered questions today about the role of prophylactic ankle braces.
1. What is the benefit for previously injured athletes in comparison to healthy athletes with no previous history of ankle sprains?
2. Are there greater benefits for male versus female athletes?
3. Since there are vast differences in the design of ankle braces available on the market, which design is superior?
4. Are there differences in the effectiveness of ankle bracing depending upon the type of sport or the position the athlete plays?
5. Are there negative effects with ankle braces, particularly among young healthy athletes with no previous history of injury?
Since these questions are unanswered, particularly when it comes to healthy adolescent athletes, the podiatric physician can be confident telling an anxious parent that there is no science to back up the claim by a coach that wearing ankle braces will prevent a sprain in youth sports.
At the same time, there is growing evidence to suggest that certain types of ankle braces may prevent a sprain in certain sports, particularly in adults with a previous history of an ankle sprain.
Recently, I was pleased to be invited to be part of a multidisciplinary panel of experts tasked by the National Athletic Trainers Association to develop specific guidelines for the prevention and treatment of ankle sprains. This much needed project will review all scientific evidence on this subject and make specific recommendations for the clinician and athlete. This will be a year-long endeavor and I hope to provide updates in this blog over the next 12 months.
1. Frey C, Feder KS, Sleight J. Prophylactic ankle brace use in high school volleyball players. Foot Ankle Int 2010; 31(4):296-300.
2. Sitler MR, Horodyski M. Effectiveness of prophylactic ankle stabilizers of prevention of ankle injuries. Sports Med 1995; 20(1):53-7.
3. Surve I, Schwellnus MP, Noakes T, Lombard C. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the sport-stirrup orthosis. Am J Sports Med 1994; 22(5):604-605.