During physical activity, the integrity of a joint and its associated structures can be compromised, especially during high-risk activities that may introduce injurious mechanisms. Sports medicine clinicians can supplement mechanical support to a joint through a variety of taping techniques using elastic and nonelastic materials. Guidelines have been established that define taping procedures as standard interventions for domains such as “prevention” and “immediate care.”
Taping techniques are used extensively by athletic trainers and other sports medicine professionals to prevent excessive joint movements, especially in sports known to have a high risk for particular injuries. For example, a person is at an increased risk of sustaining a lateral ankle sprain while participating in the sport of basketball compared with the sport of baseball. Therefore providing additional support to the ankle complex of a basketball player to restrict motions outside the anatomic limits, thus reducing the risk of an injury to the joint structures, is a common preventative measure. A variety of taping techniques have been designed to limit unwanted joint motion or provide biomechanical support to a joint to alleviate discomfort during movement. Additionally, after evaluating the structures that may have been subject to an injurious mechanism during participation in an activity, a clinician may determine that the individual can continue to participate after immediate supplementation of joint stability with a taping technique.
Several techniques with either elastic or nonelastic tape can be used to implement taping interventions. Taping materials are available from numerous manufacturers and come in a range of widths and lengths. Elastic tape, which is typically made in widths between 1 and 4 inches (2.5 to 10.2 cm), is used to provide some additional stability while still allowing a large freedom of movement; to secure pads or other protective implements to a body part; or to provide compression. Nonelastic tape can provide more joint support than elastic tape when used in applications intended to restrict excessive movements, and typical widths are between 1 and 2 inches (2.5 to 5.1 cm). Tape may be applied directly to skin that has been shaved or is devoid of hair (e.g., the sole of the foot), or if the patient does not wish to shave the area that will be taped, a thin layer of foam, called prewrap, may be wrapped around and over the skin surface to be taped.
A newer material gaining popularity in clinical practice is self-adherent tape and prewrap. This material adheres to itself but does not stick to the skin. Additionally, it is a very pliable material with high tensile properties, which means that it can be molded very easily to a body part and still provide a level of mechanical stiffness. The theoretic advantage is that it can provide less skin irritation compared with traditional nonelastic and elastic adhesive tape materials. Additionally, the self-adherent prewrap is believed to contribute to the mechanical strength of the taping technique, unlike regular prewrap.
Prophylactic taping techniques can be applied to any part of the body, and the techniques used to apply the nonelastic and elastic materials have many variations. Because lower extremity injuries are more prevalent in sports and these injuries are more likely to be preventable with use of taping techniques than are upper extremity injuries, this overview will focus on some common techniques and associated outcomes related to foot, ankle, and knee taping. It should also be noted that any taping technique may be and often is modified by a clinician to meet the preventative and treatment needs and comfort of the patient. Therefore the following descriptions are suggested guidelines for some of the more common taping techniques used in sports medicine settings.
Plantar Fascia/Arch Taping
Plantar fasciitis (fasciosis) is estimated to affect more than 10% of the general population. The most common causes of this pathology relate to a high body mass index and an increased pronation of the midfoot with subsequent flattening of the medial longitudinal arch. Pain that persists along the midfoot and extends to the insertion of the plantar fascia at the calcaneus, especially with the first few steps after a period of non–weight bearing, may benefit from added support to the midfoot. Low-Dye and other forms of arch support taping techniques are intended to supplement the structural support of the medial longitudinal arch and the plantar fascia, creating a windlass mechanism needed for normal ambulation.
These taping techniques involve strips of tape that initiate over the insertion of the plantar fascia at the calcaneus or encircle the heel and then extend to the base of each metatarsal head. Elastic or nonelastic tape can be used, with 0.5-inch widths typically employed. The strips slightly overlap each other, with a strip that secures the tape under the metatarsal heads. Versions of low-Dye taping typically involve continuing a strip of tape under the medial longitudinal arch and pulling up toward the lateral surface of the shank, effectively pulling the foot out of a pronated position ( Fig. 40-1 ). Additional strips of elastic tape may be wrapped around the midfoot to support the fan-shaped collection of strips supporting the arch of the foot.
In a systematic review, van de Water and Speksnidjer examined the short-term effects of taping techniques on treating the pain and disability associated with plantar fasciosis. The limited evidence that was reviewed showed a positive short-term effect (<1 week) on pain reduction with taping techniques compared with control conditions and other interventions; however, the evidence regarding the impact on patient disability was inconclusive. Similar positive short-term effects of taping on stiffness were observed in combination with iontophoresis, with continued benefits observed after 4 weeks of continued treatment. Relief of pain and symptoms through external support of the foot beyond a week may require additional interventions, such as orthotics, which are discussed later in this chapter.
Sprains to the first metatarsophalangeal (MTP) joint are common in field sports and can be quite debilitating. “Turf toe,” as it is commonly called, can result from a hyperextension or hyperflexion mechanism to the great toe (the first MTP joint), which limits the ability of the patient to push off during ambulation. A taping technique may be used to resist the painful motion of the MTP joint by looping 0.5-inch strips of tape to pull the toe into flexion or extension. Additional strips are wrapped around the midfoot to anchor the strips and complete the technique.
The most common anatomic injury among physically active persons is to the ankle. Subsequently, taping of the ankle for preventive and immediate treatment purposes is the most common technique used in clinical practice. Because of anatomic and biomechanical principles, the lateral ligaments are the most commonly affected structures of the ankle complex. The purpose of a typical ankle-taping technique is to limit plantar flexion and inversion of the ankle complex, which are injurious movements associated with a lateral ankle sprain.
The most common technique for providing support to the lateral ankle complex is called the “closed basket weave.” In this technique, which is typically performed with 1.5-inch nonelastic tape, the strips of tape are applied as “anchors,” “stirrups,” and “heel locks,” which will cover the ankle complex from the midshank distally to the tarsals ( Fig. 40-2 ). The combination of strips will position the ankle complex into a dorsiflexed and slightly inverted position. The strips of nonelastic tape may either be applied to skin that has been shaved or over a layer of prewrap. Additionally, thin square foam pads with petroleum jelly may be placed over the insertion of the Achilles tendon on the calcaneus and over the talus to reduce friction over these skin areas that could be irritated as a result of the crossing of the applied strips of tape.
To provide mild stability and compression for an athlete with an acute ankle injury, a clinician may utilize an “open basket weave” taping technique. The sequence of application of the anchor and stirrup strips of nonelastic tape is similar to that of the closed basket weave technique, but the crisscrossing heel locks are not applied with nonelastic tape, leaving the dorsum of the foot exposed ( Fig. 40-3 ). The heel locks are applied with elastic tape under small amounts of tension or with an elastic bandage. The primary purpose of this technique, which provides some support to the ankle complex, is to furnish comfortable compression to help minimize the early stages of the inflammatory process.
Many forms of external prophylactic support are available for the knee, with rigid braces being the choice of most clinicians for long-term wear and prevention of injury. However, taping techniques can be applied to provide stability to the knee joint during physical activity. Most available knee braces are designed to supplement the cruciate and/or collateral ligaments of the knee. Taping techniques can be applied to mimic or supplement the limitations to knee movement that these rigid braces are intended to create.
Protection against excessive valgus or varus forces that may threaten the medial and lateral collateral ligaments can be achieved by crisscrossing strips of tape over the medial or lateral surfaces of the knee joint and securing them proximally and distally to the thigh and shank ( Fig. 40-4 ). Additional support can be provided to the cruciate ligaments with this technique by wrapping these crisscrossed strips around the anterior and posterior aspects of the thigh and shank ( Fig. 40-5 ). The angle of each strip is varied to comprehensively support the knee joint complex.
Patellofemoral pain syndrome (PFPS) is a classification of pathology that presents with anterior knee pain or retropatellar pain. The etiology of PFPS has multiple origins, with many attributed to malalignment and poor tracking of the patella in relation to the femoral groove, resulting in pain. One of the many treatments proposed to alleviate the symptoms of PFPS are taping techniques to reposition the patella statically and dynamically. After performing a systematic review, Aminaka and Gribble concluded that patellar corrective taping techniques have positive outcomes for alleviating pain and improving function, but the explanatory mechanisms are not well established by the existing literature, probably because of the complexity and variability of the pathology, which also helps to explain why so many variations of patellar taping techniques exist.
A basic tenet of patellar taping techniques is to determine the form of malalignment and maltracking that exists (e.g., patella alta or medial rotation) and then to attempt to use specialized tape to pull and reposition the patella into the opposite direction or combination of directions. The specialized tape is then used to maintain the corrected position to alleviate excessive pressures between the posterior surface of the patella and the trochlear groove of the femur. One popular collection of these techniques was developed by McConnell, but many variations on these techniques exist and may be successful for individual patient needs. In general, these applications are intended to be worn for longer periods because the symptoms may persist beyond physical activity into activities of daily living. Subsequently, specialized (and often more expensive) taping materials are used. A common technique is to draw the patella medially, using the tape to hold the position statically and encourage a new movement pattern during dynamic positioning ( Fig. 40-6 ). Additional adjustments in the tilt, rotation, and vertical placement of the patella can be made with the taping technique.
Length of Wear/Length of Effectiveness
The materials used for most athletic taping techniques are not designed for long-term wear. These materials provide a significant amount of stability and movement limitation immediately after application, with most of the published evidence focused on ankle-taping techniques. However, because they are cloth-based products, exposure to moisture, heat, and tension will quickly reduce the biomechanical stiffness properties of the materials in as little as 10 minutes after application. One study suggests that although both elastic and nonelastic cloth-based tapes will lose tensile strength after 30 minutes of exercise, elastic tape may not lose as much tension as nonelastic tape and may be more comfortable. Limited investigation regarding the amount of joint restriction after application and the effects of participating in exercise as it pertains to the newer category of self-adherent tape materials suggests that these newer materials may provide more sustainable stability to the ankle, specifically in restricting inversion movement, compared with nonelastic cloth tape. More research is needed to determine how to improve the restrictive properties of taping materials to maximize their effectiveness.
Evidence pertaining to the optimal period of lasting strength of taping materials used to treat the foot and knee conditions discussed in this chapter is quite limited. One can only project that the properties of taping materials that have been studied in relation to ankle taping would apply to these materials when they are used on other joints of the lower extremity and are subjected to similar demands of physical activity. In most cases, taping techniques are designed for short-term wear (a few hours) before being removed. Although a taping technique may be applied every day for many weeks or months (i.e., the length of a sport competition season), some techniques, such as the low-Dye and arch support techniques for plantar fasciitis, are typically applied as an intermediary until a more permanent orthotic can be obtained for the patient.
An exception are the materials used for patellofemoral corrective taping, which are applied with the intent of having the patient wear the material on the skin potentially for several days to receive the benefit of the repositioned patella during all forms of physical and daily living activities. These materials are constructed of a more robust substance that resists moisture and maintains its mechanical stiffness. The cost of these materials, such as Leukotape (Beiersdorf, Wilton, CT), is much higher per roll than cloth-based elastic and nonelastic tapes, and they severely limit joint movement, which explains why clinicians may choose not to use these materials in the daily application of most of the taping techniques that have been described in this chapter.
Debate is ongoing in the literature and in clinical practice with regard to which prophylactic support for reducing injury in the lower extremity is the most effective and cost efficient. Typically, the comparisons are between taping and bracing of the joints of the lower extremity. Although taping is a staple among sports medicine clinicians, investigation into the efficacy of taping techniques for the prevention of injury is relatively limited, with the majority of this literature focused on ankle injuries.
In general, results of clinical studies have shown that ankle taping reduces the rate of ankle sprain. In an early study, Garrick and Requa reported that taping produced a twofold decrease in ankle sprains in intramural basketball players with a history of an ankle sprain and a threefold decrease in players who had no history of ankle sprains. The literature continues to suggest that this intervention is effective at reducing ankle injury rates during physical activity and participation in sports compared with not wearing a prophylactic support. Similarly, a large amount of research supports the use of prophylactic ankle braces for the reduction of the incidence of ankle sprains. However, the existing evidence does not seem to support a difference in the effectiveness of ankle taping versus ankle bracing, meaning that both forms of prevention are useful in reducing ankle sprain incidence. The short- and long-term cost of materials may be an important deciding factor and will be discussed later in this chapter.
Although low-Dye and other taping techniques are used successfully in clinical practice to alleviate excessive pronation and plantar fasciitis and fasciosis symptoms, the published evidence regarding these techniques is quite limited. Typically, this treatment is used initially to alleviate symptoms, but long-term use is commonly avoided in favor of other forms of mechanical correction and support of the foot through orthotics and tissue treatment to reduce inflammation and irritation. A systematic review supported the clinical use of low-Dye and other similar taping techniques, concluding that taping techniques are a short-term, effective treatment for pain associated with plantar fasciitis/fasciosis, but the evidence for the use of these techniques to improve disability is inconclusive. Similarly, a more recent investigation stated that use of the low-Dye taping technique was able to decrease patient-reported pain during walking and jogging immediately after application, but long-term effects were not assessed. Therefore it appears that these taping techniques can provide an immediate and short-term resolution of pain in patients with plantar fasciitis.
Taping techniques for PFPS continue to be a popular intervention in clinical practice. The repositioning of the patella may be able to change the movement patterns of the lower extremity, but the primary outcome variable that has been studied is alleviation of pain. Previous systematic reviews of the literature support the use of patellofemoral repositioning taping techniques to alleviate pain in short- and long-term periods, whereas another review suggests that the literature is too inconclusive to make a clinical recommendation. Although continued work is needed to verify how this category of taping technique is able to alleviate symptoms of patellofemoral pain, it appears it may represent a viable intervention for patients with this pathology.
Criticisms of Taping Techniques
One frequent criticism of taping techniques is that the applications will limit performance during physical activity. Cordova et al. performed a meta-analysis and concluded that external ankle supports, including taping, do not significantly hinder most measures of physical performance. Most patients will be cognizant of the taping application immediately upon application because of the intended restrictive or supportive nature of the technique. This effect may be positive, because these techniques are likely providing stimulation to cutaneous receptors, which may be supplementing the neuromuscular control systems that will provide dynamic stability to the joint.
Length of Effectiveness
As mentioned previously in this chapter, the materials used in athletic taping techniques do not maintain structural stiffness for very long after application. Although the short period of structural stiffness is a legitimate criticism of these materials, the evidence shows that the use of taping techniques can reduce injury rates and pain associated with pathology. Thus in spite of their tendency to lose mechanical stiffness, taping techniques are an effective intervention. A likely explanation is the increased afferent signaling generated by taping applied to the skin. An increase in proprioceptive information may be generating feedforward responses in the central nervous system that contribute to improved muscle reaction and dynamic stability and subsequently a decrease in injurious positions and alleviation of pain.
Most of the existing literature supports the effectiveness of all forms of ankle prophylactic support for the prevention of ankle sprains. However, the cost of materials and the time to apply them must be considered by clinicians. Olmsted et al. showed that ankle taping and bracing were effective at reducing ankle sprains, especially in athletes with a history of ankle instability. However, during a full athletic competition season, taping an ankle is three times more expensive than bracing an ankle. Similarly, Mikel et al. found ankle taping and bracing to be equally effective at reducing ankle sprains in high school football players, but taping an ankle every day for an entire season would cost more than providing a brace that could be applied every day. Additionally, taping requires substantially more time by the clinician to administer the taping techniques every day.
Athletic taping techniques are used commonly by sports medicine clinicians as an effective intervention to provide joint stability and relieve painful symptoms associated with lower extremity pathologies. Although some limitations are associated with these techniques, the evidence supports the use of these materials and techniques, especially in the prevention of injuries. Clinicians need to consider the cost and needs of the patient in selecting the most appropriate techniques and materials to meet the goals of injury prevention and initial treatment that these interventions can provide.