Knee Braces: Debate Hinges on Evidence : Many Football Coaches Are Mandating Their Use, but Some Medical Researchers See Them as Being Virtually Useless

An inventor from Hungary, on vacation in California, telephoned the Rams last year, saying he had devised a foolproof knee brace that would prevent serious knee injuries.

Come right over, the traveler was told. The Rams have been looking for that very item now for going on 50 years.

“The brace proved foolproof, all right,” Ram equipment manager Don Hewitt recalled the other day.

“I strapped it on my own knee, so I know. The problem was, I couldn’t run. It was so blasted heavy that I couldn’t even walk.”

Scratch another knee brace.

During the evolution of mankind, the knee, somehow, unhappily, reached its present regrettable state, utterly failing to evolve into a football-worthy hinge.

Except for a broken neck, the most devastating football injury is still a wrecked knee. Unfortunately, it is also among the most common.

According to one research group, “(College football) players face a 23% chance of knee injury each season--and a 64% chance in a four-year career.”

Said Hewitt: “I’d call that a sobering stat.”

Enter knee braces. In recent years, 10 or 12 different kinds have been invented and used. None is perfect, but most seem helpful, and thousands are now being worn by college and high school players.

But, at their Hawaii convention last month, just as the elders of the National Football League moved to make knee braces mandatory in training camp this year, they were interrupted.

Are you ready for this?

A great knee brace controversy has erupted in America.

A colossal argument is dividing coaches, researchers and other authorities into two camps:

--Some swear by knee braces.

--Some swear at them--having concluded that the braces actually cause more injuries than they prevent.

Ram physician Robert K. Kerlan, a nationally known knee expert, is one of many orthopedists who remain confident that there’s a place for the brace.

“When we use a knee brace on an individual we feel needs it, we feel comfortable about using it,” Kerlan said.

Nevertheless, the drive to compel its use as a preventive tool has suddenly stalled. Recent studies at Washington, Arizona and other universities have found that mass use of knee braces is unproductive and may even be counterproductive.

In Seattle, Carol C. Teitz, a doctor who supervised Washington’s knee research project at 71 U.S. colleges, summed up: “Overall, players who wore braces on the knees had significantly more injuries to the knee than players who did not.”

In Tucson, during a four-year study of the Arizona football team, George F. (Kim) Hewson, the U.S. ski team orthopedist, found: “ . . . no significant reduction in number or type of knee injuries (by players wearing braces). Knee injury prevention was not improved by . . . bracing.”

But this is all statistical nonsense to Dan Henning, offensive coach of the Washington Redskins, who directed the NFL’s most comprehensive study of knee braces when he coached the Atlanta Falcons in 1983-86.

“The problem with (knee brace) research is that it is necessarily always incomplete,” he said. “That’s because there’s no statistical way to measure the number of knee injuries prevented by bracing.”

To Henning, the case for braces was made in his Atlanta research.

“We required every player to wear them in practice and also in games, even receivers and running backs,” he said. “And our knee injury rate went down. The only major knee injuries we had were due to not wearing braces.”

So, apparently, the experts are irreconcilably divided and yearning for more evidence.

Meanwhile, some of those most affected by the controversy have grown increasingly wary:

--The NFL Players Assn. in recent months has been pushing the league to follow the lead of the United States Football League and the proposed new spring league, the American Football Federation, both of which have mandated braces. But confronted by the new studies, the NFLPA backed away from its stand last month in Hawaii.

--Several NFL coaches, who in recent seasons have unilaterally required braces, are re-examining their position. In Seattle, for example, Seahawk linemen and linebackers won’t be compelled to wear them again this season.

“We’ve made it mandatory for the last six years,” Seahawk Coach Chuck Knox said. “But because of the new evidence, we’re only going to recommend this year, not (order) it.”

Jim Mora, coach of the New Orleans Saints, hasn’t decided what course to take. For three years, including two in the USFL, Mora has required most of his players to wear knee braces.

“We may make it optional this season,” he said.

Some NFL coaches have decided to put their money on another possible preventive altogether--exercising. In this group is Coach Chuck Noll of the Pittsburgh Steelers, who recommends forgetting preventive knee braces.

“They’re not the answer, and I don’t think they ever were,” Noll said. “They fall into the area of wishful thinking. Well-meaning people are repelled by serious knee injuries and want to do something about it. And very often, bracing seems to work at first. But it’s the wrong answer.”

What’s the right one?

“Strong legs and bended knees,” Noll said. “This is a game that has to be played with the knees always bent, and if you do that, and if you (use weights to) make the knee areas as strong as possible, you’re on the right track. Whenever the leg is straight, any player is vulnerable. Bend it.”

Former coach Tommy Prothro called this the hitting position.

The Denver Broncos are among the teams lining up on Noll’s side. Line coach Alex Gibbs said: “The longer you’re in this league, the less likely you are to want bracing.

“The key (to knee injury prevention) is a strong lower body. I mean balanced strength. You have to develop the leg totally. The (knee) injuries we’ve had were caused by imbalances--by guys who had developed the front muscles at the expense of the others.

“It’s tricky. You’ve got to have a good weight (coach) who understands the importance of balanced strength.”

At his Inglewood clinic, Kerlan prescribes exercising or bracing as the case demands.

“Two things can help the knee a great deal--weight training and flexibility exercises,” he said. “Both strengthen the (knee’s) support muscles. Both are equally important.

“You (stretch and twist) the muscles to strengthen the legs against sideways stress. . . . Weight training increases strength, power and endurance, which help the knee without (putting on braces).”

Are serious knee injuries increasing?

“No, the only thing that changes is the degree of media attention,” Kerlan said. “Their attention increases when prominent players are hurt. Serious (knee) injuries are still proportional to the number of those playing football.”

THE BOMB

“So-called preventive (knee ) braces are not preventive and may in fact be harmful.” --Dr. Carol C. Teitz.

The bomb was dropped three months ago in the January issue of the Journal of Bone and Joint Surgery.

Climaxing three years of research and study by the departments of orthopedics and biostatistics at the University of Washington, Teitz told Journal readers: “We cannot recommend the use of (knee) braces in an attempt to prevent injury to collegiate football players.”

She said her 1985 survey showed that “players who wore braces had a significantly higher rate of (knee) injury than players who did not, 9.4% to 6.4%.”

A year earlier, Teitz said, the rate was even higher, 11% to 6%.

She added: “There was no significant difference . . . when players were grouped by the type of brace worn.”

She gathered her data in telephone interviews with athletic trainers reporting on 6,307 players at 71 colleges in 1984 and in questionnaires filled out by 61 trainers reporting on 5,445 players in 1985.

The study impressed the editor of the Journal of Bone and Joint Surgery, Henry R. Cowell, who said: “In a sense, it is difficult to understand how (the knee brace) came to be so extensively used when (so) few data are available to support its use.”

Cowell, who holds both MD and Ph.D degrees, added: “On the other hand, (football players have) a high incidence of injury to the knee. . . . Risk of (knee) injury (amounts to) as high as 44% during a four-year playing career. Thus, individual coaches, trainers and team physicians have adopted the use of an unproved device in an attempt to help their players avoid injury.”

Teitz’s conclusions took her considerably further than other knee-brace researchers have ventured. After Dr. Hewson’s study of Arizona football players in 1981-84, he concluded--in a 1986 report for the American Journal of Sports Medicine--only that knee injury prevention isn’t improved by bracing.

But together, the two studies strongly suggest that as an injury prevention device, the knee brace may be of questionable value.

This has come as a major surprise to most football coaches, including the hundreds of high school coaches who in recent years have made the wearing of knee braces mandatory.

In response, though, most coaches continue to trust the evidence of their own eyes in preference to the results of outside surveys, however scholarly.

Among the many not convinced by the conclusions of either Teitz or Hewson are Knox, Mora and Henning of the NFL, and Terry Donahue of UCLA.

Donahue, who has studied Teitz’s report and the other surveys, still mandates knee braces for all Bruin linemen and linebackers.

“Our own research is conclusive in terms of our own situation,” Donahue said. “With (knee braces), we’ve had a reduction in career-ending-type (knee injuries). . . . Our medical people agree (with Donahue) that the Washington study was (inconclusive).”

In Seattle, where Knox has deferred to the evidence of the same study, he remains personally committed to knee braces.

“My experience is that they’ve helped cut down knee injuries,” he said. “We’ve had many cases of bent braces--with only minor sprains. . . . We’ve had players back in three, four weeks who would have been lost for the season (if they hadn’t worn braces).”

In New Orleans, flatly contradicting Teitz’s finding, Mora said: “We’ve looked at a lot of film, and I can’t think of a single (occasion) when a knee brace made an injury more severe.

“What you see in films are many instances when there would have been severe (knee) injuries if the players hadn’t worn braces.”

In Atlanta, Henning’s experience was the same. So, the battle lines have been drawn. It’s the empirical evidence of many coaches vs. the scientific evidence of a few scholars.

And the battle has just begun. It could be years before the whole truth is known.

THE BRACE

“Some football players just can’t function if their knees are braced.” --Dr. Robert K. Kerlan

By far the most widely used knee brace in football today is the Anderson Knee Stabler, which was invented 10 years ago by George Anderson, who has been the Raiders’ trainer for all of their 27 seasons.

“The Stabler has been tested by more than 150,000 football players,” said Anderson, who devised it for only one player, former quarterback Ken Stabler.

It has since been recommended by so many coaches that Anderson’s is the one they mean, as a rule, when they talk about a knee brace.

Yet there are many other kinds, and most are widely used and similarly effective. “They have one thing in common,” former Atlanta coach Henning said. “They’re all good braces. Any brace on the market that has a good fastener and doesn’t slip is a good one. There’s no point in recommending any specific brace.”

Said Anderson: “The object (of an effective brace) is to keep the player’s lateral stability. This requires a double-hinged brace. When he is hit from the outside, the brace distributes the blow above and below the knee.”

The Anderson Stabler has disadvantages as well as advantages, Kerlan said. “The advantages are that it has acceptability and is easy to apply. The problem is that like most braces, it doesn’t prevent the cruciate ligament (injury).”

That’s the career ender. The anterior cruciate ligament can tear even if the player isn’t hit. Commonly, that happens when there is sudden rotational stress, as when the foot is planted. No known preventive brace guarantees against this injury.

But, proportionately, there are few cruciate tears.

“The medial collateral ligaments (on either side of the knee) are much more apt (to tear), and our brace was designed to prevent that,” Anderson said, speaking for the Stabler and most other preventive braces.

In Teitz’s survey, the nation’s college trainers reported 555 medial collateral injuries in 1984-85 to 80 anterior cruciate injuries.

Some football players hate all braces, whether they are helpful or not. The objection comes mainly from receivers and offensive and defensive backs.

“They think a knee brace slows them down,” Henning said, suggesting that the opposition to braces is mostly psychological.

“In the tests, there’s no difference whatever in a football player’s speed, brace or no brace.”

Nor do artificial fields seem to increase the incidence of knee injuries.

“There are more injuries, of course, on artificial turf,” Kerlan said. “The NFL would legislate against (artificial turf) today if it weren’t for the domed stadiums--but not because of knee injuries. There are as many serious knee injuries on grass as there are on (artificial turf).”

Kerlan doubts that bracing will ever be mandatory in the NFL--even if the perfect brace emerges and wins the endorsement of all, including the research scholars.

“It’s fair to say that some football players just can’t function if their knees are braced,” he said. “It’s a good idea to legislate helmets, but not (knee braces). Players have a right to perform, if they wish to, without the (handicap of a brace--even if that puts them at greater risk).”

That, however, is an argument for down the road. The question today is whether preventive knee braces are helpful or harmful--and the only sure winners may be the lawyers:

--Youngsters suffering knee injuries have been able to sue in recent years whenever they played for coaches who failed to mandate knee braces.

--Now, in addition, they can sue if they are injured when ordered to wear knee braces--on the theory that the Washington research group has correctly identified a villain.

All coaches and school districts are, in other words, being caught in a nasty cross fire.

“The guys who love to file big damage suits will have a field day now,” an L.A. high school coach said.

“But then, come to think of it, what else is new?”