Freeman et al (1965) seem to be among the first to describe functional instability as 'a term . . . to designate the disability to which the patients refer when they say that their foot tends to "give way"'. Although once of secondary importance to mechanical problems, there is now more interest in the concept of functional instability of the ankle and the role of taping and bracing to alleviate it. As a result, for many years authors have investigated the role of taping and bracing on the proprioception enhancement of the chronically injured ankle (Glick et al 1976, Hamill et al 1986, Jerosch et al 1995, Karlsson & Andreasson 1992, Lentell et al 1995, Robbins et al 1995).
Proprioceptive control of the ankle (and thus the effect of taping and bracing) has been measured by a variety of tests, such as peroneal reflex activity (Ashton-Miller et al 1996, Feuerbach et al 1994, Karlsson & Andreasson 1992, Konradsen & Hojsgaard 1993, Konradsen et al 1993, Lohrer et al 1999), joint angle reproduction (Jerosch et al 1995, Lentell et al 1995, Refshauge et al 2000, Spanos et al 2008) and movement threshold (Konradsen et al 2000).
Epidemiological studies have established the ability oftape and braces to prevent recurrent ankle injury. The most commonly cited study on injury prevention is that of Garrick & Requa (1973), which studied the effect of taping on 2563 basketball players with previous ankle sprains over two successive seasons. They concluded that a zinc oxide stirrup with horseshoe and figure-of-eight technique, in combination with a high-top shoe, had a protective influence (6.5 injuries per 1000 games) for preventing ankle sprains.
Ankle braces may also lead to a reduction in the incidence and severity of acute ankle sprains in competition (Bahr 2001), such as basketball (Sitler et al 1994), men's football (soccer) (Surve et al 1994, Tropp et al 1985) and women's football (Sharpe et al 1997). Although the studies reviewed provide important information regarding efficacy of tape or a brace, criticisms have been made regarding study design, external validity, confounding variables and sample size (Sitler et al 1994). These should also be considered before selecting the appropriate technique or device.
A Cochrane review (Handoll et al 2001) summarized the relative risk of ankle sprains after application of braces and calculated that ankle bracing brought about a 50% reduction in the number of ankle sprains (relative risk (RR) = 0.53). The reduction was greatest for patients with previous ankle sprains.
Two studies have looked at the effects of prewrap on taping that may ease the reservations among clinicians of the effects of prewrap or underwrap on taping. Manfroy et al (1997) assessed 20 healthy subjects performing 40 minutes of exercise and found no statistically significant differences in experimental limitation of inversion moments between ankle taping with and without prewrap. Ricard et al (2000) measured the amount and rate of dynamic ankle inversion using a trapdoor inversion platform apparatus and concluded that applying tape over prewrap was as effective as applying it directly to skin.
The lack of comparative studies between different taping techniques helps to explain why the choice of tape by athletes and physiotherapists is often governed by personal preference, the experience of the person applying the tape and a general feel as to the correct technique.
Of those few studies, Rarick et al (1962) favoured a basketweave with stirrup and heel-lock technique. Frankeny et al (1993) concluded that the Hinton-Boswell method (in which the ankle is taped in a relaxed plantarflexed position) provided greatest resistance to inversion. Metcalfe et al (1997) compared zinc oxide closed basketweave with heel locks and figure-of-eight, reinforced with moleskin tape to a Swede-O-Universal brace, and found no differences between the three methods in terms of talocrural and subtalar range of motion.
Of course, neither ankle taping nor bracing can be regarded as helpful if an athlete's sports performance is affected. A systematic review and metaanalysis of 17 randomized controlled trials (Cordova et al 2005) analysed the effect of ankle taping and bracing on performance. They calculated that there was a performance decrease in sprint speed (1%), agility speed (1%) and vertical jump (0.5%); the worst effect was from a lace-up style brace. Although these figures seem reassuringly trivial, two questions remain: will such small decreases affect the performance of sports people at the elite level? Do the benefits of preventing ankle injury outweigh the small risks of detriment to performance?
The investigations into the relationship between mechanical and functional aspects of ankle taping are paralleled over the years by those on patellar taping. It is well known that McConnell (1986) originally described patellar taping as part of an overall treatment programme for patellofemoral pain syndrome (PFPS) and theorized that this technique could alter patellar position, enhance contraction of the vastus medialis oblique (VMO) muscle, and hence decrease pain.
It is becoming clear from recent literature reviews on this subject (Callaghan 1997, Crossley et al 2000) that studies thus far on patients with PFPS have been inconclusive regarding patellar taping enhancement of VMO contractions and taping realignment of patellar position. Nevertheless, there are several studies assessing taping's effect on chronic patellofemoral pain, summarized in a systematic review and meta-analysis (Warden et al 2007). Combined analysis of 13 eligible trials showed that medially directed taping decreased chronic non-arthritic patellar pain immediately and significantly when compared to placebo tape and no tape. The placebo effect probably accounted for 50% of the pain reduction.
More recently, there has been speculation that there is a more subtle role for patellar taping in providing sensory feedback, thereby influencing the proprioceptive status and neuromuscular control of the patellofemoral joint. For example, Callaghan et al (2002) showed that a simple application of one 10-cm strip of patellar taping significantly improved the knee proprioceptive status of healthy subjects whose proprioception was graded as 'poor'. At the same time, Baker et al (2002) showed that patients with PFPS had worse proprioception compared to a group of healthy subjects. Callaghan et al (2008) developed these findings further and measured an improvement in proprioception of PFPS patients by applying non-directional patellar tape. It is tempting therefore to speculate that patellar taping enhances proprioception in patients with patellofemoral pain, and this may explain the short-term subjective improvement without any firm evidence of patellar realignment or VMO-enhanced contractions.
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Handoll H, Rowe B, Quinn KM et al 2001 Interventions for preventing ankle ligament injuries. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD000018. DOI: 10.1002/14651858.CD000018 Jerosch J, Hoffstetter I, Bork H et al 1995 The influence of orthoses on the proprioception of the ankle joint. Knee Surgery, Sports Traumatology, Arthroscopy 3:39-46 Karlsson J, Andreasson GO 1992 The effect of external ankle support in chronic lateral ankle joint instability. American Journal of Sports Medicine 20(3):257-261 Kerkhoffs GM, Rowe BH, Assendelft WJ et al 2002a Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003762. DOI: 10.1002/14651858.CD003762 Kerkhoffs GM, Struijs PA, Marti RK et al 2002b Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD002938. DOI: 10.1002/14651858.CD002938 Konradsen L, Hojsgaard C 1993 Pre-heel-strike peroneal muscle activity during walking and running with and without an external ankle support. Scandinavian Journal of Medicine and Science in Sports 3:99-103 Konradsen L, Ravn J, Sorensen AI 1993 Proprioception at the ankle: the effect of anaesthetic blockade of ligament receptors. Journal of Bone and Joint Surgery (Br) 75-B(3):433-436 Konradsen L, Beynnon BD, Renstrom PA 2000 Techniques for measuring sensorimotor control of the ankle: evaluation of different methods. In: Lephart SM, Fu FH (eds) Proprioception and neuromuscular control in joint stability, 1st edn. Human Kinetics, Champaign, pp 139-144 Larsen E 1984 Taping the ankle for chronic instability. Acta Orthopaedica Scandinavica 55:551-553
Laughman RK, Carr TA, Chao E et al 1980 Three dimensional kinematics of the taped ankle before and after exercise. American Journal of Sports Medicine 8(6):425-431 Lentell G, Baas B, Lopez D et al 1995 The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. Journal of Orthopaedic and Sports Physical Therapy 21(4):206-215 Lohrer H, Alt W, Gollhofer A 1999 Neuromuscular properties and functional aspects of taped ankles. American Journal of Sports Medicine 27(1):69-75 McCluskey GM, Blackburn TA, Lewis T 1976 A treatment for ankle sprains. American
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Ricard MD, Sherwood SM, Schulthies SS et al 2000 Effects of tape and exercise on dynamic ankle inversion. Journal of Athletic Training 35(1):31-37 Robbins S, Waked E, Rappel R 1995 Ankle taping improves proprioception before and after exercise in young men. British Journal of Sports Medicine 29(4):242-247 Rucinski TJ, Hooker DN, Prentice WE et al 1991 The effects of intermittent compression on edema in postacute ankle sprains. Journal of Orthopaedic and Sports Physical Therapy 14(2):65-69
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Taping for pain relief
Minimizing the aggravation of inflamed tissue - unloading painful structures 21 Effect of tape 22 Patellar taping 23
Unloading neural tissue - a strategy for managing chronic low-back and leg pain 23 Shoulder taping - repositioning or unloading 26 Conclusion 27 References 28
Pain is the most frequent complaint of patients presenting for treatment at sports medicine clinics. However, pain is usually not the result of an acute one-off injury but of habitual imbalances in the movement system which over time cause chronic problems. The management of musculoskeletal symptoms is therefore extremely challenging for the clinician, as symptom reduction alone is not sufficient for a successful treatment outcome, particularly when dealing with athletes who need to be finely tuned for the extraordinary demands placed on their bodies. Often it is difficult for the clinician to determine the cause and origin of the pain as there may be confounding hyper/hypomobility problems of the surrounding soft tissues. One of the greatest challenges for a patient is finding appropriate strategies to stabilize any unstable segments, as success in this area will ensure fewer recurrences and perhaps a higher return of function.
Joint stability requires the interaction of three different subsystems -the passive (the bones, ligaments, fascia and any other non-contractile tissue such as discs and menisci), the active (the muscles acting on the joints) and the neural (central nervous system and nerves controlling the muscles) subsystems (Panjabi 1992a). The most vulnerable area of a joint is known as the neutral zone, where little resistance is offered by the passive structures (Panjabi 1992b). Dysfunction of the passive, active or neural systems will affect the neutral zone and hence the stability of the joint. The size of the neutral zone can be increased by injury and decreased with muscle strengthening. In the spine, for example, stability of a segment can be increased by muscle activity of as little as 1-3% (Cholewicki et al 1997). Uncompensated dysfunction, however, will ultimately cause pathology.
How long will it take before uncompensated movement causes symptoms? The answer to this question is probably best determined by Dye's model of tissue homeostasis of a joint (Dye 1996). Dye contends that symptoms will only occur when an individual is no longer operating inside his/her envelope of function, reaching a particular threshold and thereby causing a complex biological cascade of trauma and repair, manifesting clinically as pain and swelling. The threshold varies from individual to individual, depending on the amount and frequency of the loading (Dye 1996, Novacheck 1997). Four factors (anatomic, kinematic, physiological and treatment) are pertinent in determining the size of the envelope of function (Dye 1996, Dye et al 1998). The therapist can have a positive influence on the patient's envelope of function by minimizing the aggravation of the inflamed tissue and can perhaps even increase the patient's threshold of function by improving the control over the mobile segments and the movement of the stiff segments (McConnell 2000).
MiNiMiZiNG THE AGGRAVATiON OF INFLAMED TiSSUE - UNLOADiNG PAiNFUL STRUCTURES
The concept of minimizing the aggravation of inflamed tissue is certainly central to all interventions in orthopaedics. Clinicians have a number of weapons in their armoury, such as anti-inflammatory medication, topical creams, ice, electrotherapy modalities, acupuncture and tape, to attack pain and reduce inflammation. It is in the chronic state that pain is more difficult to settle and sometimes symptoms seem to be increased by the very treatment that is designed to diminish them. For example, a patient with chronic low-back and leg pain with restricted forward flexion, treated in slump to increase range, experiences a marked exacerbation of the symptoms. This patient becomes reluctant to have further treatment for fear of further increase in pain; thus, the range becomes more restricted, further reducing the patient's activity. Another patient, with chronic fat pad irritation, is given straight-leg-raise exercises, only to find the pain worsens, so avoids further treatment and limits activity, which hastens the quadriceps atrophy, resulting in lateral tracking of the patella and further increases in pain. The infrapatellar fat pad is one of the most pain-sensitive structures in the knee and must be respected as a potent source of anterior knee symptoms (Dye et al 1998).
Key to the success of management of these patients is to unload the inflamed soft tissues to break the endless cycle of increased pain and decreased activity, which allows the clinician to address the patient's poor dynamic control. The principle of unloading is based on the premise that inflamed soft tissue does not respond well to stretch (Gresalmer & McConnell 1998). For example, if a patient presents with a sprained medial collateral ligament, applying a valgus stress to the knee will aggravate the condition, whereas a varus stress will decrease the symptoms. Tape can be used to unload (shorten) the inflamed tissue and perhaps improve joint alignment by providing a constant low load on the soft tissue. It has been widely documented that the length of soft tissues can be increased with sustained stretching (Herbert 1993, Hooley et al 1980). If the tape can be maintained for a prolonged period of time, then this, plus muscle training of the stabilizing muscles actively to change the joint position, be it patellofemoral (PF) or glenohumeral, should have a significant effect on the mechanics.
There is some debate as to whether tape can actually change joint position. Most of the research has examined changes in patellar position. Some investigators have found that tape changes PF angle and lateral patellar displacement, but congruence angle is not changed (Roberts 1989). Others have concurred, finding no change in congruence angle when the patella is taped, but congruence angle is measured at 45° knee flexion, so subtle changes in patellar position may have occurred before this (Bockrath et al 1993). A recent study of asymptomatic subjects found that medial glide tape was effective in moving the patella medially (P = 0.003), but ineffective in maintaining the position after vigorous exercise (P < 0.001). But tape seemed to prevent the lateral shift of the patella that occurred with exercise (P = 0.016) (Larsen et al 1995). The issue for a therapist, however, is not whether the tape changes the patellar position on X-ray, but whether the therapist can immediately decrease the patient's symptoms by at least 50%, so the patient can exercise and train in a pain-free manner.
The effect of tape on pain, particularly PF pain, has been fairly well established in the literature (Bockrath et al 1993, Cerny 1995, Conway et al 1992, Gilleard et al 1998, Powers et al 1997). Even in an older age group (mean age 70 years) with tibiofemoral osteoarthritis, taping the patella in a medial direction resulted in a 25% reduction in knee pain (Cushnagan et al 1994). However, the mechanism of the effect is still widely debated.
It has been found that taping the patella of symptomatic individuals such that the pain is decreased by 50% results in an earlier activation of the vastus medialis oblique (VMO) relative to the vastus lateralis (VL) on ascending and descending stairs. The VMO during stair descent activated 8.3° earlier than the VL in the taped condition, as taping the patella not only resulted in an earlier activation of the VMO but a significantly delayed activation of the VL (Gilleard et al 1998). This result has recently been confirmed by Cowan et al (2002), where it was found that tape leads to a change in the onset timing of the VMO relative to the VL compared with placebo tape and no tape.
Patellar taping has also been associated with increases in loading response knee flexion, as well as increases in quadriceps muscle torque (Conway et al 1992, Handfield & Kramer 2000, Powers et al 1997). When the quadriceps torque of symptomatic army personnel was evaluated in taped, braced and control conditions, it was found that the taped group generated both higher concentric and eccentric torque than both the control and braced groups. There was, however, no correlation between the increase in muscle torque and the amount of pain reduction (Conway et al 1992).
It has been suggested that patellar tape could influence the magnitude of VMO and VL activation but the results of a limited number of studies have not supported this contention (Cerny 1995).
Patellar taping is unique to each patient, as the components corrected, the order of correction and the tension of the tape are tailored for each individual based on the assessment of the patellar position. The worst component is always corrected first and the effect of each piece of tape on the patient's symptoms should be evaluated by reassessing the painful activity. It may be necessary to correct more than one component. After each piece of tape is applied, the symptom-producing activity should be reassessed. If the tape does not change the patient's symptoms immediately or even worsens them, one of the following must be considered:
• the patient requires tape to unload the soft tissues
• the tape was poorly applied
• the assessment of patellar position was inadequate
• the patient has an intra-articular primary pathology which was inappropriate for taping.
If a posterior tilt problem has been ascertained on assessment, it must be corrected first, as taping over the inferior pole of the patella will aggravate the fat pad and exacerbate the patient's pain. With acute fat pad irritation, the pain is exacerbated by extension manoeuvres such as straight-leg raises and prolonged standing (McConnell 1991). Therefore any treatment that involves quadriceps setting will exacerbate the symptoms.
UNLOADING NEURAL TISSUE - A STRATEGY FOR MANAGING CHRONIC LOW-BACK AND LEG PAIN
Tape may be used to unload inflamed neural tissue. The unloading tape enables the patient to be treated without an increase in symptoms, so that, in the long term, treatment is more efficacious. The mechanism of the effect is yet to be investigated, but tape could:
• inhibit an overactive hamstring muscle, which is a protective response to mechanical provocation of neural tissue
• have some effect on changing the orientation of the fascia
• have just a proprioceptive effect, working on the pain gate mechanism (Jerosch et al 1996, Verhagen et al 2000).
The tape is applied along the affected dermatome region such that the soft tissue is lifted up towards the spine. The buttock is always unloaded (Fig. 3.1), starting medial in the gluteal fold, taping proximal to the greater trochanter while lifting the soft tissue up towards the iliac crest. This is followed by a tape which is parallel to the natal cleft, ending at the posterior superior iliac spine (PSIS), and a third tape joining the first two tapes from
Figure 3.2 For S1 distribution of pain, the posterior thigh is taped, with the skin being lifted to the buttock. If the proximal symptoms worsen, the tape diagonal should be reversed.
lateral to medial. A diagonal strip is placed halfway down the thigh over the appropriate dermatome and the soft tissue is lifted towards the spine (for S1 dermatome, see Fig. 3.2).
The direction of the tape depends on symptom reduction. The symptoms above the tape should be reduced immediately; the distal symptoms, however, may be exacerbated. If the proximal symptoms are worsened, the tape direction should be changed immediately (if worse, reverse), which should have the effect of improving the symptoms. Distal symptoms will be improved when a diagonal strip is placed midway down on the
Figure 3.2 For S1 distribution of pain, the posterior thigh is taped, with the skin being lifted to the buttock. If the proximal symptoms worsen, the tape diagonal should be reversed.
lower leg over the symptomatic dermatome and the soft tissue is lifted proximally (Fig. 3.3). Once the tissues are unloaded the patient can be treated without an increase in symptoms.
When managing low-back and leg pain, the clinician may need to change the treatment focus, so that the treatment is not just directed at the involved segment but addresses the contributory factors. Patients with chronic back and leg pain often have internally rotated femurs; this reduces the available hip extension and external rotation range, causing an increase in the rotation in the lumbar spine when the patient walks. The internal rotation in the hip also causes tightness in the iliotibial band and diminished activity in the gluteus medius posterior fibres, so the pelvis exhibits dynamic instability. The lack of control around the pelvis further increases the movement of an already mobile lumbar spine segment. It has been established that excessive movement, particularly in rotation, is a contributory factor to disc injury and the torsional forces may irrevocably damage fibres of the annulus fibrosis (Farfan et al 1970, Kelsey et al 1984). Therefore, an excessive amount of movement about the lumbar spine because of limited hip movement and control, in combination with poor abdominal support, may be a significant factor in the development of low-back pain. Treatment of chronic low-back pain should be directed at:
• increasing hip and thoracic spine mobility to ensure a more even distribution of the motion through the body for functional activities
• improving the stability, rather than mobility, of the relevant lumbar segments. This involves muscle control of the multifidus, transversus
abdominis (TA) and the posterior fibres of the gluteus medius. As it can take a considerable period of time for specific muscle training to be effective, tape can be used to help stabilize the vulnerable lumbar segments while the muscles are being trained (Fig. 3.4).
The shoulder, like the PF joint, is a soft-tissue joint whereby its position is controlled by the soft tissues around it. Poor muscle function, particularly around the scapula, and stiffness in the thoracic spine will severely affect shoulder function, making it susceptible to instability and impingement problems. In fact, most shoulder pathology relates to these two factors in some way. Impingement causes mechanical irritation of the rotator cuff tendons, resulting in haemorrhage and swelling, usually as a result of:
• encroachment from above - either congenital abnormalities or osteophyte formation
• swelling of the rotator cuff tendons - usually an overuse tendinitis associated with poor biomechanics, such as a faulty throwing or swimming technique
• excessive translation of the humeral head. Chronic anterior instability results in increased translation of the humeral head in an anterosuperior direction narrowing the subacromial space. Laxity of the anterior shoulder develops over time due to repeated stressing of the static stabilizers at the extremes of motion, for example the cocking motion in pitchers.
It is possible to increase the space available for the soft-tissue structures by repositioning the humeral head (Fig. 3.5).
The aim of the tape is to lift the anterior aspect of the humeral head up and back so that there is increased space between the acromion and the elevating humerus. The tape is anchored over the inferior border of the scapula. Care must be taken not to pull too hard anteriorly, as the skin is sensitive in this region and will break down if not looked after properly. The tape can remain in situ for about a week, depending on symptom reduction. Improving thoracic spine mobility and muscle training of the scapular and glenohumeral stabilizers must be addressed in treatment to ensure long-term reduction in symptoms. Athletic individuals with shoulder problems often have extremely poor trunk and pelvic stabilization, which also needs to be addressed in treatment to improve their athletic performance.
Musculoskeletal pain can be difficult to treat as the clinician not only has to identify the underlying causative factors to restore homeostasis to the system, but also has to ensure that the treatment does not unnecessarily exacerbate the symptoms. In some cases the clinician may need to unload the painful structures before commencing any other intervention. Tape can be used successfully to achieve this aim. Tape not only unloads painful tissue but it can facilitate underactive muscles as well as inhibit excessive muscle activity. The therapist receives immediate feedback from the patient as to whether the tape application has been successful or not. Tape can be adapted to suit the individual patient. It is readily adjusted and the tension can be varied. Tape is relatively cost-effective and time-efficient, so the therapist should be innovative and creative if symptom reduction has not been achieved, as tape can facilitate treatment outcome.
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