Journal of Sport Rehabilitation, 1998,7,33-43

0 1998 Human Kinetics Publishers. Inc.

Migration and Design Characteristics of

Functional Knee Braces
Bruce Brownstein
Functional braces are often used as part of a comprehensive rehabilitation
protocol following ligamentous injury of the knee. One of the common problems of a functional knee brace is distal migration. This study was undertaken
to identify the migration tendencies of 14 commonly used functional knee
braces and the design and measurement characteristics that contribute to migration. Two subjects performed 15 min of exercise (5 min each on a treadmill, slide board, and stair machine), and brace position was measured preand postexercise. All 14 braces migrated somewhat. Nine of the braces had
migration of less than 5 mm and were considered superior. The brace design
(active or passive) had a significant effect @ < .05) on migration. No difference @ > .05) was noted for brace type (custom vs. off the shelf) or fit method
(cast vs. measuring tool). Based upon this evaluation, an active brace design is
recommended for functional knee braces.

Functional knee braces have been used as part of a comprehensive rehabilitation program after ligamentous injury for 25 years. The first functional brace
was developed by Dr. James Nicholas and Jack Castiglia in the late 1960s. The
original Lenox Hill Brace was designed to restrain anteromedial subluxation and
later redesigned to prevent anterolateral subluxation as well. Since that time, at
least two dozen braces have been marketed as an adjunct treatment of the anterior
cruciate deficient knee (4).
The ideal knee brace accurately and appropriately controls motion about the
knee, does not migrate, and is comfortable, durable, available, easily measured, and
easy to apply (2). Both clinical experience and a review of the literature (1,3) indicate
that the ideal knee brace does not exist. One of the most frequent problems is brace
migration, which results in an imbalance between brace and knee joint mechanics (6,
7, 10-15). A brace that is not in the correct position may place the user at risk for
injury (6, 10, 13). If a brace migrates during activity, the participant must stop to
readjust the appliance.This reduces patient complianceas well as brace effectiveness.
Bruce Brownstein is with SOAR Research, 51 West 81st St., Suite 9J, New York, IVY,
10024.

Brownstein

34

The purpose of this study was to evaluate the amount of distal brace migration that occurs during brief periods of activity. It was assumed that the brace with
the least amount of migration may be the most effective, since it has the greatest
chance to function optimally. No attempt was made to evaluate the efficacy of
different brace designs beyond the ability of the brace to remain in its proper location. A second purpose was to examine migration as a function of design pararneters. The parameters investigated were active versus passive design, custom versus off the shelf, and casted versus measured braces.
An active design implies that a force is always present to restrain anterior
tibial displacement. Passive braces allow a certain amount of displacement before
the brace attempts to restrain motion. Active and passive hinge designs are available in both custom and off-the-shelf designs. Custom braces are tailored to the
contours of the individual, using either a measuring instrument or by casting. Casting involves making a mold of the patient's leg, which the manufacturer then uses
to build a brace. Measuring instruments enable the clinician to quantify the shape
of the leg. This information is then used by the manufacturer to create a brace
tailored to an individual's leg shape. Off-the-shelf braces are available in standard
sizes and provide little adjustability for individual leg shapes. Off-the-shelf braces
can be stocked in the clinician's office, while custom braces must be ordered from
the company for each patient.
Manufacturers of custom braces state that their braces generally provide a
better fit and are more effective, while providers of off-the-shelf braces emphasize
their cost-effectivenessand availability. Little research exists to guide the clinician
in making a choice regarding brace effectiveness. Almost all of the current research has been performed on cadavers (3, 6, 10, 16). The present study was designed to rank the performance of various knee braces under simulated sports
movement conditions, not to evaluate the ability of each brace to limit tibial translation with respect to the femur. It is hoped that the data presented will enable the
clinician to make an informed decision when choosing a functional brace.
This study was funded in part by the Sutter Corporation as part of a market
study on functional brace manufacturers, service, and brace performance, conducted as a component of due diligence procedures prior to purchasing the rights
to the Cincinnati Brace from Knee Technologies, Inc. (Cincinnati, Ohio). The Cincinnati Brace (later renamed Talon) was one of the braces evaluated in this investigation.

Materials and Methods

Fourteen commercially available braces were measured and fit to the knees of 2
subjects. The subjects were selected to represent different body types. Subject 1
was a 25-year-old female who was 5 feet 7 in. tall and weighed 118 lb. Subject 2
was a 28-year-old male who was 6 feet 6 in. tall and weighed 205 lb. Neither
subject had an anterior cruciate ligament deficiency, although Subject 2 had under-

Functional Knee Braces

35

gone an arthroscopic lateral retinacular release 2 years prior to the study. Both
subjects were physically active, although neither was participating in organized,
competitive athletics at the time of the study.
The 14braces used were Bledsoe Proshifter and Force (MedicalTechnology
Inc., Grand Prairie, TX), CE-2000, Goldpoint, and Defiance (Smith & Nephew
Donjoy, Inc., Carlsbad, CA), CTi-2 and MVP (Innovation Sports, Irvine, CA), GI1
Sport Brace (Generation I1 USA, Bothell, WA), Lenox Hill Spectralite (3M, St.
Paul, MN), Omni TS-7 and Elite (Omni Scientific, Inc., Martinez, CA), Performer
(Orthopedic Technology Inc., Tracy, CA), Talon (Sutter Corporation, San Diego,
CA), and Townsend (Townsend Design, Bakersfield, CA). Six of the braces (TS-7,
Elite, Performer, Lenox Hill, GII, and Townsend) required casting. Four of the
braces (Talon, CE 2000, Defiance, and CTi-2) were custom fit to patient thigh and
leg circumference and contours using a measuring device. The remaining braces
(Proshifter, Force, Goldpoint, MVP) were off-the-shelf braces sized according to
circumference measurements only.
The braces were measured and fit according to the manufacturers' specifications. The author has had extensive experience measuring and fitting braces using
different methods, and all of the braces in this study were familiar to the author.
Following application, the subject was permitted to move about for 1-2 min.
The brace straps were then readjusted if necessary. The position of the brace was
marked on the subject's leg by locating the top of the lateral strut. The position was
remarked after exercise, and the difference was measured using skin calipers. The
difference between pre- and postexercise position was defined as distal migration.
The subjects were not allowed to manually adjust the brace during exercise.
Each exercise bout lasted 15 rnin and was divided equally between stair climbing on a commercial device, treadmill running at 5 mph, and using a slide board.
The slide board (Euroglide by Improve Human Performance) mimics the lateral
motion used in activities such as speed skating. Stair climbing was performed on a
StairMaster4000-PT (Randall Medical Industry) set to Level 8. Two of the braces
were evaluated on a Tectrix ClimbMax (Tectrix Corporation) set to an equivalent
pace. Rest periods of 45 min were allowed between brace evaluations.Testing was
conducted over a period of several days, with no more than 3 braces evaluated on
a given day.

Results
The data were analyzed using SPSS 6.1 for the Macintosh. The raw data were
input to an SPSS spreadsheet and then sorted according to the variable(s) being
tested. Table 1 shows the design and fitting characteristics of each brace. Figure 1
shows the migration data following exercise. Analysis of variance was used to
determine whether migration was different between brace models. Table 2 shows
the results of the ANOVA. A difference was noted in the migration after exercise
between brace models. Duncan's Multiple Range test was then used as a post hoc

Brownstein

36

Table 1 Brace Migration Data, Type of Brace Design, and Fitting Method
(Braces Listed Alphabetically)
Brace (Manufacturer)

TYP~

Fit method

CE-2000 (Donjoy)
CTi-2 (Innovation)
Defiance (Donjoy)
Elite (Omni)
Force (Bledsoe)
Goldpoint (Donjoy)
GII (Generation USA)
Lenox Hill (3M)
MVP (Innovation)
Performer (OrthoTech)
Proshifter (Bledsoe)
Talon (Sutter)
TS-7 (Ornni)
Townsend

Active
Passive
Active
Active
Active
Active
Passive
Passive
Passive
Passive
Active
Active
Active
Passive

Measure tool
Traceltool
Measure tool
Cast
Off the shelf
Off the shelf
Cast
Cast
Off the shelf
Cast
Off the shelf
Traceltool
Cast
Cast

Average Migration by Brace

Brace

Figure 1 -Data on average migration of each knee brace following exercise protocol.
All measurements are in millimeters.

test to determine which brace models allowed more migration than the others. The
results are ranked according to the amount of average migration. Table 3 shows
that groupings were possible at the p = .05 level. There was a significant difference between braces that migrated less than 5 mrn (CE-2000, CTi-2, Defiance,
Elite, Goldpoint, Performer, Proshifter, Talon, TS-7) and those that migrated more
than 5 rnm (Force, Generation 11, Lenox Hill, MVP, Townsend). Among the sec-

Functional Knee Braces

37

Table 2 One-Way ANOVA on Migration Data Grouped by Brace Model

Source

df

Sum of squares

Mean squares

F ratio

F prob.

Between groups
Within groups
Total

13
14
27

366.8661
58.1875
425.0536

28.2205
4.1563

6.7899

.OM5

Note. Results show a significant difference between brace models with respect to

migration during exercise.

ond group, a further distinction was made between the Lenox Hill and MVP, both
of which migrated less than the Force, Generation 11, and Townsend braces. The
statistical testing was similar to the method used by Beck et al. in their evaluation
of the ability of functional braces to control anterior displacement (1).
Migration data were then grouped according to design (active vs. passive),
type (custom vs. off the shelf), and fit (measured vs. cast). Tables 4,5, and 6 show
the results o f t tests run on the average migration data according to type, subject,
and fit method. Only brace type (active vs. passive) demonstrated a statistical difference ( p < .05) in the migration data. There was no difference in the migration
between custom (10 braces) and noncustom (4 braces) fit or in the average migration for each subject across all brace models. The former finding may have been a
result of the unbalanced number of observations in the two groups and may not
entirely reflect the similarity of means and standard deviations.

Discussion
Functional knee braces play a different role in the rehabilitation process than they
used to. In the past, reconstruction techniques and rehabilitation protocols did not
allow activities that required the use of bracing until the end stages of rehabilitation. The combination of newer technology and accelerated rehabilitation has shifted
the role of functional bracing to an adjunct tool in the early phase of the rehab
process. Braces are used to facilitate early functional activities and are often discontinued once the patient's strength is adequate and neuromuscular reconditioning has been achieved. This is the time that the patient returns to vigorous activity.
In some rehabilitation protocols, a brace is not required unless sufficient laxity (as
determined by instrumented testing) is present following reconstruction.
Several studies have analyzed the relationship between knee joint forces
and brace design. Using a computer model to determine the effect of hinge placement, Walker et al. (14, 15) determined that inaccurately applied braces could superimpose abnormal forces and moments across the joint. Regalbuto et al. (10)
noted higher axial forces if the brace hinge axis was shifted proximally or distally.

Table 3 Duncan's Multiple Range Comparison Test

Mean

Brace
Tal
TS7
Pro
Perf
Ce2
Def
Go1
Eli
Cti2
M ~ P
Lhb
GI1
Twn
For

Tal

TS7

*
*
*
*

*
*
*

Pro

Perf

Ce2

Def

Go1

Eli

Cti2

*
*
*
*

*
*
*

*
*
*

*
*

*
*

*
*

Mvp

Lhb

GI1

Twn

For

*
*

Note. Tal (Talon), TS7 (TS-7), Pro (Proshifter), Perf (Performer), CE2 (CE-2000), Def (Defiance), Go1 (Goldpoint), Eli (Elite), Cti2 (CTi-2),
Mvp (MVP), Lhb (Lenox Hill Brace), GII (Generation 11), Twn (Townsend), For (Force). Asterisk indicates significant difference in migration
between brace models ( p = .05). For example, the MVP brace migrated more than Tal and TS7 braces, but not more than the others, while the
GI1 brace migrated more than the Tal, TS7, Pro, Perf, CE2, Def, Gol, Eli, and Cti2.

Multiple Range Tests: Duncan test with significance level .05

Step
2
3
4
5
Range
3.03
3.17
3.28
3.33

'a

6
3.37

7
3.40

8
3.42

9
3.44

10
3.46

11
3.47

12
3.47

13
3.48

14
3.48

a
T

i5'
s

Functional Knee Braces

39

Table 4 t Tests Comparing Migration Data Between 2 Subjects

t tests for independent samples of subject
Variable
Number of cases
Mean

Migrate
Subject 1
Subject 2

14
14

3.9464
5.7679

SD

SE of mean

3.117
4.604

0.833
1.230

Mean difference = -1.8214.

t tests for equality of means
t value
Variances

Equal
Unequal

-1.23
-1.23

df

2-tail sig.

SE of diff.

96%CI for diff.

26
22.85

.231
.233

1.486
1.486

(-4.876, 1.233)
(-4.896, 1.254)

No difference was found between the two subjects based upon migration data for all braces.

Distal placement also generated higher anterior-posterior forces on the lateral side.
In general, posterior placement produced the lowest forces. Lew et al. (6) and
Lewis et al. (7) studied the pistoning forces in braces as a function of placement.
Both they and Regalbuto et al. (11) determined that inaccurate placement of the
brace hinge was a factor in producing abnormal brace and joint forces. The type
and magnitude of forces were related to the placement of the brace axis rather than
the type of hinge being used. If one accepts this research, then the brace used
should migrate minimally and have a hinge that is posteriorly placed. In this study,
braces which meet that criterion include the Talon, CE-2000, Defiance, TS-7, and
Proshifter.
Functional knee braces use a variety of hinge designs and suspension systems to mimic the knee joint axis behavior and location (9). According to Walker
et al. (15), the nature of the hinge (uniaxial, polyaxial, etc.) does not affect brace
function since the hinge itself is external to the joint. Generally speaking, the brace
design can be identified as either passive or active (6). No published studies were
found that determined whether either design is more effective in promoting functional knee joint stability. The data presented here indicate that an active brace
migrates less than a passive brace, perhaps because of the forces present between
Ithe brace and the leg.
All of the braces tested in this study migrated a measurable amount (average
migration from 0.25 to 11 rnrn). Walker et al. (15) offset the hinge of their braces
by 5 rnm to measure abnormal joint mechanics. If one accepts this amount as the
maximum allowable distal migration, then 8 of the braces in this study met this
criterion of acceptability. Of these 8 braces, 7 are considered by the manufacturers
to be of an active design.

Brownstein

Table 5 t Tests for Differences in Migration Data Based Upon Fit Method
(Custom vs. Off the Shelf)
t tests for independent samples of fit
Variable
Number of cases

Mean

SD

SE of mean

Migrate
Custom
Off the shelf

4.6250
5.4375

4.058
3.934

0.907
1.391

20
8

Mean difference = -.8 125.

t tests for equality of means
t value
Variances

Equal
Unequal

-.48
-.49

df

2-tail sig.

SE of diff.

96% CI for diff.

26
13.34

,633
,633

1.684
1.661

(-4.274,2.649)
(-4.391,2.766)

No difference in migration noted based upon fitting method.

Two limitations of this study should be examined. Fist, the use of nonimpaired
subjects rather than ACL-deficient subjects may have affected the results of brace
migration. Second, the small sample size (N = 2) made statistical analysis of the
variables in question difficult. The tradeoff in this study was a greater number of
braces versus more subjects with fewer braces.
Nonimpaired subjects were selected for two reasons. First, all available people
with chronic ACL-deficient knees were already using one type of functional brace.
The relative level of comfort between a brace style that a subject has used for some
time and a new brace style may affect a subject's performance. Second, the excessive translation of the tibia on the femur was assumed to be minimized by the
functional brace and the weight-bearing exercise conditions imposed by the equipment selected. Wojtys et al. (16), who measured tibia1 translation and rotation in
braced, ACL-deficient cadaver knees, found that anterior translation and external
rotation were reduced in all cases (14 braces), although there was a great deal of
variability. They also noted that strap tension and brace application are important
variables of brace performance.
Little evidence exists to indicate that ACL deficiency affects brace migration. Previously published studies on motion between the tibia and femur following sectioning of the ACL do not indicate an increase in distraction and compression of the tibia on the femur (translation along the longitudinal axis). Gerber and
Matter (5) noted a downward and forward shift of the centrode defined by instant
center of rotation analysis in the ACL-deficient knee. There are technical problems

Functional Knee Braces

41

Table 6 t Tests for Migration Data Based Upon Design (Active vs. Passive)
t tests for independent samples of type
Variable
Number of cases

Mean

SD

SE of mean

Migrate
Active
Passive

3.4688
6.7083

3.468
3.963

0.867

16
12

1.144

Mean difference = -3.2396.

t tests for equality of means
Variances
t value

Equal
Unequal

-2.30
-2.26

df

2-tail sig.

SE of diff.

96% CI for cliff.

26
21.95

.030*
.034*

1.407
1.435

(-6.132, -.347)
(-6.217, -.263)

Significantdifference @ < .05)noted between means based upon hinge design type.
with this type of analysis. Marans et al. (8) did not find a change in superiorlinferior
tibial motion during gait in ACL-deficient knees. Moreover, the exercise techniques
used in our investigation were all weight bearing. Relative distraction of the tibia with
respect to the femur should be minimized, if not eliminated. Therefore, the use of
nonirnpaired subjects should not affect the distal migration of the functional braces
used in this study. It was assumed that a brace which migrates on a nonimpaired knee
would not migrate less on an ACL-deficient knee. A brace that migrates excessively
(>5 mm) on a nonimpaired knee should not be recommended for an ACL-deficient
knee, particularly during high-level, high-performance athletics or dance.
A second limitation of this study was the number of subjects ( N = 2) used for
the evaluation of distal migration. The cost of braces precluded a full examination
(N > 10) of each brace, although a larger sample size would have allowed more
powerful statistical analysis. The choice was made to examine as many braces as
possible ( N = 14). The braces chosen were nationally marketed brands. Follow-up
study on subjects with ACL-deficient knees to confirm the assumptions made in
this investigation would be beneficial.
No difference was found in brace migration based upon fit method or type
(custom/off-the-shelf) characteristics. There has been some debate as to whether
custom braces fit better or are more comfortable. The data from this investigation
indicate that the fit obtained with a custom brace versus an off-the-shelf brace does
not affect brace migration. The same can be said about the brace fitting method.
There was no difference between braces that were casted or measured via a tool.
For the clinician and the patient, fitting a brace with a measurement tool takes less

Brownstein

42

time than casting. The braces that migrated minimally have an active design and
are fitted with a tool or are off the shelf. These included CE-2000, CTi-2, Defiance,
Proshifter, and Talon. It should be noted that 10 of the braces used in this study
were custom, while only 4 were off the shelf. At the time of the study, a limited
number of off-the-shelf models were available nationally. It is not clear whether
using more off-the-shelf models would have yielded different results. The results
from this study indicate that the hinge design is the key variable, not the fitting
method. Clinicians are advised to also consider the ease of application and comfort
of the brace (2). The subjects in this study did report on these factors; however,
both are highly subjective and require larger samples to analyze.
Brace design type is the variable that most affects migration of functional
braces. Migration is important since it affects the patient's willingness to wear a
brace. Improperly located braces can impose abnormal forces across the knee joint.
If a brace migrates during activity, then the possibilities of reduced effectiveness
and superimposed forces on the knee joint must be considered as risk factors. According to the information from this study, an active brace should be used to avoid
migration, regardless of whether the brace is custom or off the shelf and regardless
of the method of fitting the brace.

Summary
Of the 14 braces tested for migration under exercise conditions, all migrated a
measurable amount, ranging from 0.25 mm to 11 rnm. If functional braces are to
be used as part of a comprehensive protocol for treating ligamentous knee injuries,
then the brace selected for use must perform under realistic conditions. This study
shows that there is a difference in the migration characteristics of braces based
upon their design, with active braces migrating less than passive ones. Further
study regarding performance of knee braces under actual exercise conditions is
required.

References
1. Beck, C., D. Drez, J. Young, W.D. Cannon, and M.L. Stone. Instrumented testing of
functional knee braces. Am. J. Sports Med. 14:253-256, 1986.
2. Cawley, P.W., E.P. France, and L.E. Paulos. Comparison of rehabilitativeknee braces:
A biomechanical investigation. Am. J. Sports Med. 17:141-146, 1989.
3. Cawley, P.W., E.P. France, and L.E. Paulos. The current state of functionalknee bracing
research. A review of the literature.Am. J. Sports Med. 19:226-234, 1991.
4. France, E.P., P.W. Cawley, and L.E. Paulos. Choosing functional knee braces. Clin.
Sports Med. 9:743-750, 1990.
5. Gerber, C., and P. Matter. Biomechanical analysis of the knee after rupture of the anterior cruciate ligament and its primary repair. An instant centre analysis of function. J.
Bone Joint Surg. 65-B:391-399, 1983.

Functional Knee Braces

43

6. Lew, W.D., C.M. Patrnchuk, J.L. Lewis, and J. Schmidt. A comparison of pistoning
forces in orthotic knee joints. Orthot. Prosthet. 36:85-95, 1984.
7. Lewis, J.L., W.D. Lew, C.M. Patrnchuk, and G.T. Shybut. A new concept in orthotics
design. Orthot. Prosthet. 37: 15-23, 1984.
8. Marans, H.J., R.W. Jackson, N.D. Glossop, and M.C. Young. Anterior cruciate ligament insufficiency: A dynamic three-dimensional motion analysis. Am. J. Sports Med.
17:325-332,1989.
9. Millet, C.W., and D.J. Drez. Principles of bracing for the anterior cruciate ligament
deficient knee. Clin. Sports Med. 7:827-833, 1988.
10. Regalbuto, M.A., J.S. Rovick, and P.S. Walker. The forces in a knee brace as a function
of hinge design and placement. Am. J. Sports Med. 17535-543, 1989.
11. Regalbuto, M.A., R. Schrager, J.S. Rovick, and P.S. Walker. The effectiveness of knee
braces as a function of hinge design and placement. Proceedings of the Orthopedic
Research Society, San Francisco, p. 246, 1987.
12. Scott, E.R., and H.H. Mita. Comparing the paths of orthotic knee joints and normal
human knees. Unpublished master's thesis, Division of Physical Therapy, Stanford University, 1985.
13. Walker, P.S. Engineering principles of knee prostheses. In Disorders of the Knee, A.J.
Helfet (Ed.). Philadelphia: Lippincott, 1974, pp. 261-274.
14. Walker, P.S., M.D. Kurosawa, J.S. Rovick, and R.A. Zirnrnerman. External knee joint
design based on normal motion. J. Rehabil. Res. Dev. 22:9-22, 1985.
15. Walker, P.S., J.S. Rovick, and D.D. Robertson. The effects of knee brace hinge design
and placement on joint mechanics. J. Biomech. 21:965-974, 1988.
16. Wojtys, E.M., P.V. Loubert, S.Y. Samson, and D.M. Viviano. Use of a knee brace for
control of tibial translation and rotation. J. Bone Joint Surg. 72-A: 1323-1329, 1990.

Acknowledgment
This research project was funded in part by a grant from Sutter Corporation, San
Diego, California.