Is a splint beneficial for a patient with severe arthritis in the knee during physical therapy?

Use of Splints During Physical Therapy for Severe Knee Arthritis

Yes, knee braces and orthoses are conditionally recommended during physical therapy for patients with severe knee osteoarthritis, particularly for those with compartmental disease, as they can reduce pain and improve function when used under the guidance of an experienced physical therapist. 1, 2

Evidence-Based Recommendation

Bracing for Knee Osteoarthritis

• Knee braces are conditionally recommended for patients with knee involvement, particularly those with medial or lateral compartment disease 1, 2
• The American College of Rheumatology specifically recommends that bracing and orthoses be prescribed and used under the guidance of an experienced occupational therapist or physical therapist to ensure appropriate item selection and fit 1
• Evidence shows that knee braces (especially sleeves and elastic bandages) demonstrate small but consistent positive effects on pain reduction in knee osteoarthritis 1
• Medial unloading (valgus) knee braces are an option for patients with medial knee osteoarthritis, though evidence of long-term benefit is limited 3

Integration with Physical Therapy

• Physical therapy is strongly recommended as a core treatment for all patients with knee osteoarthritis, regardless of pain severity 1, 2
• Comprehensive physical therapy programs lasting 8-12 weeks with 3-5 sessions per week produce superior outcomes when directly supervised 2
• Bracing should be viewed as an adjunctive modality that complements, rather than replaces, the primary therapeutic exercise program 2, 4
• The combination of manual therapy with supervised exercise and appropriate bracing may enhance overall treatment outcomes 2

Clinical Implementation Algorithm

Step 1: Initiate Core Physical Therapy

• Begin structured exercise program immediately, including both strengthening (quadriceps, lower limb resistance) and aerobic components 2
• Ensure at least 12 directly supervised sessions for optimal outcomes 2

Step 2: Assess Need for Bracing

• Evaluate for compartmental disease (medial vs. lateral) 1, 2
• Consider bracing if patient has:
  • Persistent pain during weight-bearing activities
  • Joint instability or laxity 5
  • Difficulty participating in exercise due to pain 1

Step 3: Professional Fitting

• Refer to physical or occupational therapist for proper brace selection and fitting 1
• Avoid over-the-counter braces without professional guidance, as improper fit reduces effectiveness 1

Step 4: Monitor and Adjust

• Reassess pain and function at 6-12 weeks 6
• Continue exercise program regardless of brace use, as exercise provides the most durable long-term benefits 2, 6

Critical Considerations and Pitfalls

Common Mistakes to Avoid

• Do not use bracing as a substitute for exercise therapy – exercise remains the cornerstone of treatment with the most durable benefits 1, 2
• Do not delay exercise because of pain – clinical trials demonstrate that patients with pain and functional limitations benefit from exercise programs, with no uniformly accepted pain threshold that contraindicates exercise 1, 2
• Do not prescribe braces without professional fitting – improper selection and fit significantly reduces therapeutic benefit 1

Realistic Expectations

• Bracing provides modest symptomatic relief but does not alter disease progression 1, 4
• Benefits are most apparent during weight-bearing activities and may be temporary 3
• Patient preference plays a role, as some individuals find braces uncomfortable or burdensome despite potential benefits 1

Complementary Interventions

• Consider combining bracing with other adjunctive modalities during physical therapy:
  • Thermal agents (ice or superficial heat) for symptom management 2
  • Appropriate footwear with shock-absorbing insoles 2
  • Walking aids to reduce joint loading 2
  • Manual therapy techniques 2, 5

Quality of Evidence

The recommendation for knee bracing is conditional based on very low certainty evidence 1, meaning the decision should involve shared decision-making between the patient and treating clinician. The evidence base is stronger for exercise therapy (low to moderate certainty) 2, 7, which is why bracing should always be viewed as adjunctive to, not replacement for, a comprehensive physical therapy program focused on strengthening and aerobic exercise.