knee braces
Better bracing means better healing
by Scott Fried

The mail order durable medical equipment (DME) industry as we’ve known it is dead. From my viewpoint as an orthopedic surgeon who spends much of his day talking people out of surgery and into more conservative care, this is a tragedy.   

In its initial inception, access to and distribution of braces via mail order helped millions of people find relief from pain and heal. The medical community has long known that the appropriate use of braces, splints and medically indicated devices helps patients improve—often without surgery—so that they can have a better quality of life.

As a surgeon, I have a unique opportunity to view orthotic bracing and the use of braces and splints in a different way. The nature of orthopedic injuries is that the underlying problem in many cases is inflammation and/or soft tissue or ligament injury. Braces work wonders in helping patients avoid surgical intervention. This is especially the case for customizable dynamic, semi-flexible, step-down braces. This type of brace not only protects from further injury but also ensures the ability to live life in the brace, progressively decreasing the amount of rigidity and support as healing progresses.

The Upside

The downfall of the mail order DME industry presents a golden opportunity for providers. Thanks to new rules and regulations, instead of using braces that have been designed to fit a code, providers are now able to use braces that are designed to fit their patient. Doing what is right and doing what is  profitable are not mutually exclusive. The cost of surgery, therapy, medications and treatment of complications is extensive when compared to the price of a properly fitted orthotic brace. Bracing is not only more humane but also provides better economics for the entire health care system.

However, one glaring problem I see is that many off-the-shelf braces are poorly made and designed. Many of these braces are not indicated for a client’s diagnosis and often cannot be customized and fitted by a person with expertise, and the patient is not always shown the proper way to wear and use them.

The good news is that this is a golden opportunity for the DME industry to get it right—and a reminder that providers can do bracing and orthopedics well.

Custom Bracing

The answer is simple—utilize customizable, semi-flexible, step-down braces that can be placed on a patient, then fitted, cut, molded and adjusted to them to fit appropriately and address the issues stated in the diagnosis. This is good medicine and it is good business.

With slight modifications in the delivery system, the industry can move on to a model where patients are appropriately evaluated and diagnosed and given a prescription for a brace that fits the code, is appropriate for the diagnosis and will help treat them. Orthotists, certified fitters and therapists as well as physicians can apply a brace to the patient and be sure that it is appropriate for the medical diagnosis, that it is customized to address that individual’s personal anatomy as well as specific medical problems and that the patient understands how to use the brace. This practice also eliminates the question as to whether a brace is reasonable, appropriate and medically necessary for reimbursement. These are key factors to be met to address the concerns of governing bodies who oversee the bracing industry.

In my 15 years in this industry, it has never ceased to amaze me that patients are placed in braces that are clearly not indicated for their diagnosis. For instance, a hand or wrist with arthritis, tendinitis, tennis elbow or ligament injury should indeed be placed in a wrist-neutral semi-flexible, dynamic step-down brace that allows limited motion with appropriate protection and the option of resting the digits if arthritis is present. This brace should also allow the patient to function for daily activities such as writing, eating, personal care or typing on a computer. Contrast this with use of intrinsic palsy braces that fit the code but don’t allow any hand function. Appropriate braces for the given diagnosis are just good medicine.

The same holds true for shoulder devices. I am bewildered at how a patient with rotator cuff tendinitis, shoulder arthritis or rotator cuff injury and or cervical or brachial plexus radiculopathy can be given an airplane abduction shoulder brace that holds the arm in 90 degrees of abduction all the time. This brace cannot easily be worn on a regular basis. Without the ability to step down and have immobilization progressively lessened with only intermittent abduction through the course of the day, this brace would in fact be contraindicated medically. A progressive step-down brace that allows daily activity and function with the ability to intermittently place the shoulder in airplane abduction can help prevent frozen shoulder. This allows the patient to live their life fully, to heal and to find relief for their pain without having to be completely unstrapped from the brace and left unsupported to even get through a doorway.

Back braces also need to be adjustable, with easily removable elevated or lowered panels; they should also have the ability to add, remove and heat mold panels that can then be fitted to appropriately support the involved areas of the spine, whether thoracic lumbar sacral orthosis (TLSO) or lumbar sacral orthosis (LSO) brace. The ability to heat mold a brace and have it conform to the patient easily, or to cut the brace to fit for size and use it in a progressive step-down manner, is essential to allowing patients to gain optimal clinical relief.

In essence, what I am offering here is a glimpse at the future of mail order DME and medical bracing. Appropriate braces customized to the patient that allow the option to progressively step down are the future. Braces do not need to be complex designs, just appropriate and designed with medicine, anatomy and the understanding of human physiology in mind, which can be optimally applied through a simple mechanism of connecting each patient with a fitter with expertise.

This brings the bracing and mail-order DME industry full circle to providing superb medical care and alternatives to surgery to patients who are in need. It simply doesn’t get any better than that.

Scott Fried, D.O., F.A.O.A.O., is board certified in orthopedic surgery and did a fellowship in hand and upper extremity surgery at Thomas Jefferson University Hand Center. He is president of Doctor in the House and chief surgeon at The Upper Extremity Institute. Doctor in the House is dedicated to developing and manufacturing medical products, especially braces and splints to allow patients to heal and avoid surgery. You can contact him (610) 277-1990 x 151 or by email at