Chapter 6 Foot and Ankle

The procedures for taping the majority of sports injuries are illustrated in this and the following chapters. The purpose of these procedures is to provide protection while allowing functional movement, thus preventing further damage to the injured structure or adjacent areas. Inherent in each approach, and essential to accurate assessment of every injury, are medical diagnosis, treatment and appropriate follow-up.

T.E.S.T.S. charts in this section put each taping technique into perspective relative to total injury management. They include key points under the headings of Terminology, Etiology, Symptoms, Treatment and Sequelae. These charts are meant as helpful guides and are not to be considered as in-depth analyses with all possible complications.

A thorough understanding of the techniques illustrated in these chapters, combined with experience in handling a wide range of injuries, will enable the taper to adapt and apply effective taping techniques to the many unusual and/or challenging situations which inevitably arise.

ANATOMICAL AREA: FOOT AND ANKLE

FOOT AND ANKLE TAPING TECHNIQUES

The articulations of the foot and ankle are numerous and complex. The joints of the foot and curvature of the arches of the foot permit adaptation to irregular terrain. These joints offer suppleness and shock absorption through elasticity. This varied bony architecture and mobility predisposes to different types of injuries. Taped support can alleviate many stresses related to these conditions.

The talo-crural (the true ankle) joint is mainly responsible for dorsiflexion and plantarflexion while the sub-talar joint allows more lateral mobility – inversion and eversion (sideways deviation) – permitting the foot to adapt to all angles of incline or slope. This relatively mobile ankle joint complex is dependent on numerous ligaments for its stability, and on tendons for its dynamic support. Forces through this relatively fragile joint make it vulnerable to stresses. The ankle is most easily injured during weight-bearing activities which require quick changes of direction.

A variety of taping techniques are highly effective in supporting both ligamentous and musculo-tendinous conditions related to the ankle joint. With the application of proper taping techniques, the athlete can rapidly resume normal competitive activity and/or intense training.

In this and the following chapters, details on the following items will prove useful:

• specific purpose of each taping technique

• conditions appropriate for specific applications

• list of materials

• special notes

• positioning for taping procedure

• illustrated procedure

• highly informative sidebar tips

• a sample condition (injury) in a T.E.S.T.S. chart form

SURFACE ANATOMY

Right ankle and foot, from the medial side. The most prominent surface features are the medial malleolus, the tendo-calcaneus at the back and the tendons of tibialis anterior and extensor hallucis longus at the front.

Right ankle and foot, from the lateral side. The most prominent surface features are the malleolus, the tendo-calcaneus at the back and the tendons of tibialis anterior at the front.

TAPING FOR TOE SPRAIN

Purpose

• Support of first metatarsophalangeal (MTP) joint

• Allows moderate flexion and some extension

• Limits the range of flexion, extension and adduction

Indications for use

• Sprains of the first metatarsophalangeal (MTP) joint.

• For medial collateral ligament sprain: abduct the toe and reinforce the medial restraining tape strips.

• For plantar ligament sprain (hyperextension injury): reinforce the X on the plantar surface to limit extension.

• For lateral collateral ligament sprain: reinforce with buddy taping to the first toe (for an example of buddy taping with fingers, see p. 209).

• For dorsal capsular sprain (hyperflexion): reinforce the X on the dorsal surface to limit flexion.

• Hyperflexion of first MTP joint: ‘turf toe’.

• Contusion of the first MTP joint: ‘jammed toe’, ‘stubbed toe’.

Skin toughener spray/adhesive spray

2 cm (3/4 in) non-elastic tape

NOTES:

• The styloid process at the base of the fifth metatarsal is a sensitive area vulnerable to pressure, pain and blisters if tape is too tight.

• To avoid constriction, minimal tension must be used when wrapping circumference anchors.

• Application of lubricant to adjacent toes and/or the inside of the toe box of the shoe will prevent chafing.

• Trimming toenails will lessen the risk of irritation.

• Careful application of a minimum amount of tape is particularly important when taping for sports that require tight-fitting shoes or boots.

For additional details regarding an injury example, see T.E.S.T.S. chart (p. 61).

Positioning

Sitting on treatment table with injured foot slightly overhanging the end of the table.

Procedure

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

3. Place an anchor of 2 cm non-elastic tape around the distal toe at the base of the toenail.

4. Place two anchors of 3.8 cm (1½ in) non-elastic tape around the instep and arch of the foot.

5. Place a longitudinal supporting strip of 2 cm non-elastic tape from distal to proximal between the anchors.

6. Begin a plantar X with a longitudinal strip diagonally from the lateral aspect of distal anchor to the medial aspect of the proximal anchor on the plantar aspect of the first MTP joint.

7. Cross this with a second strip from the medial aspect of the distal anchor, crossing the MTP joint at its midpoint on the plantar aspect.

NOTE:

Abduct the toe slightly and apply two strips with tension when taping for a medial collateral ligament sprain or bunions.

NOTE:

Extension must be adequately limited with this X when taping hyperextension injuries.

8. Begin dorsal X with a 2 cm strip from the medial aspect of the distal anchor to the dorsal aspect of the proximal anchor.

9. Finish the dorsal X by crossing this strip from the lateral aspect of the distal anchor to the medial aspect of the proximal anchor, crossing the X over the dorsal MTP joint.

NOTE:

Flexion must be adequately limited with this X when taping for hyperflexion injuries.

10. Close up taping with light circumferential strips covering sites of the original anchors with 2 cm tape, starting proximally and moving distally, overlapping each previous strip by half.

11. Test tape for adequate restriction to ensure functional pain-free support.

NOTE:

The colour, temperature and sensation must be checked to verify that circulation has not been compromised.

ANATOMICAL AREA: FOOT AND ANKLE

INJURY: TOE SPRAIN

TERMINOLOGY

• sprain of medial or lateral collateral ligament

• hyperflexion with capsular injury

• hyperextension with capsular injury

• sprain of the plantar ligament

• ‘jammed’ toe; ‘stubbed’ toe; ‘turf’ toe

ETIOLOGY

• sudden forced flexion, extension or abduction

• sudden longitudinal impact against a hard surface

• repetitive dorsiflexion of great toe (as in kicking a ball or sprinting) can cause a synovitis

• chronic sprain

• inadequately supportive footwear on artificial turf

SYMPTOMS

• tenderness of the first metatarsophalangeal joint

• often swollen

• active movement testing:

a. pain on end-range flexion with hyperflexion injuries

b. pain on end-range extension with hyperextension injuries

c. pain on end-range abduction with medial collateral ligament sprain

• passive movement testing:

a. pain on end-range flexion with hyperflexion injuries

b. pain on end-range extension with hyperextension injuries

c. pain on end-range abduction with medial collateral ligament sprain

• resistance testing (neutral position): no significant pain on moderate resistance

• stress testing:

a. pain with or without laxity on medial (or lateral) stress with 1st- and 2nd-degree sprains of the medial (or lateral) collateral ligaments

b. instability with less pain in 3rd-degree sprains

TREATMENT

Early

• R.I.C.E.S.

• taping for: Toe Sprain (see p. 57)

• therapeutic modalities

Later

• continued treatment including:

• therapeutic modalities

• passive mobilizations if painful or stiff

• flexibility

• strengthening exercises

• gradual pain-free reintegration to sports activities with taped support

• a shoe with stiff soles for reinforcement may be necessary

• dynamic weight-bearing activity should start only after 45 ° of pain-free dorsiflexion is attained

SEQUELAE

• pain

• chronic swelling

• diminished mobility

• weakness

• chronic synovitis

• flexor hallucis longus tendinitis

• degenerate changes leading to hallux rigidus (stiff first toe)

R.I.C.E.S. : Rest, Ice, Compress, Elevate, Support

ANATOMICAL AREA: FOOT AND ANKLE

TAPING FOR LONGITUDINAL ARCH SPRAIN/PLANTAR FASCIITIS

Purpose

• supports plantar aspect of foot (functionally shortens and reinforces the longitudinal arches – medial more than lateral)

• permits plantarflexion mobility

• limits extension (dorsiflexion) of the midtarsal joints

Indications for use

• plantar fasciitis

• acute or chronic midfoot sprains

• flat feet or fallen arches

• medial knee pain caused by flat feet

Skin toughener spray/adhesive spray

2.5 cm (1 in) non-elastic tape

3.8 cm (1½ in) non-elastic tape

NOTES:

• Remember the foot will spread when weight bearing, rendering the tape job tighter.

• Pressure on the base of the fifth metatarsal can cause pain.

• Pressure on the neighbouring blood vessels can cause pain and compromise circulation.

• Tape thickness must be kept to a minimum for sports requiring tight-fitting footwear.

• Excessive medial tension must be avoided, especially in ankles predisposed to inversion sprain.

For additional details regarding an injury example, see T.E.S.T.S. chart (p. 67).

Positioning

Either lying prone with knee slightly bent or sitting facing the taper (as illustrated).

Procedure

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary.

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

3. Place anchor strips of 3.8 cm non-elastic tape using very light tension around the foot at the level of the heads of the metatarsals to allow for splaying of the metatarsals when weight bearing.

4a Using firm tension, place a strip of 2.5 cm non-elastic tape from the head of the first metatarsal under the arch of the foot and around the heel.

4b Finish at the medial aspect of the first metatarsal, tensioning the tape to shorten the medial arch.

5a Starting from the lateral aspect of the anchors plantar surface, apply a second strip with strong tension, crossing the transverse arch diagonally around the heel.

5b Pass behind the heel without tension and finish over the lateral aspect of the head of the fifth metatarsal.

6. Repeat steps 4a,b and 5a,b as necessary.

7. Close up with circumferential strips of 3.8 cm non-elastic tape. Apply with a light pressure as the natural spread of the foot on weight bearing will tighten the tape job. Start at the head of the metatarsals, overlapping each previous tape by at least a half, progressing towards the heel.

8. Test for degree of support. There should be a significant reduction of pain on weight bearing.

NOTE:

If ankle stability is a concern a figure of eight can be added; see steps 9 and 10.

9. Apply two overlapping horizontal strips of 3.8 cm non-elastic tape.

NOTE:

Apply lubricant and heel and lace pads to the anterior ankle and posterior heel if friction spots are likely to develop.

10a Start figure of eight strip on the dorsum of the foot (top) from lateral to medial. Pass under the arch and pull up on the lateral side of the foot to resist inversion.

10b Continue around behind the heel and complete the figure of eight.

ANATOMICAL AREA: FOOT AND ANKLE

CONDITION: PLANTAR FASCIITIS

TERMINOLOGY

• chronic or acute inflammation of plantar fascia

• heel spurs

ETIOLOGY

• intrinsically tight plantar fascia

• poor foot biomechanics

• sudden change in training routine, i.e. distance, frequency, speed, change of terrain

• poorly supportive or new footwear

• secondary to midfoot sprain or tarsal hypomobility

SYMPTOMS

• pain and tenderness on plantar aspect of foot, more concentrated on the medial aspect of the calcaneal attachment

• active movement testing: no significant pain on weight bearing

• passive movement testing: pain on full stretch of fascia

• resistance testing (neutral position): no significant pain

• pain on first steps after resting

• pain on weight bearing, particularly on push-off

TREATMENT

• therapy including:

• R.I.C.E.S.

• therapeutic modalities

• Support: taping: Longitudinal Arch (see p. 62).

• Rest: reduction of weight-bearing activities

• selective stretching of tendo Achilles and plantar fascia

• strengthening of plantar muscles

• heel lifts can be helpful in acute phase (a bevelled doughnut depression will reduce pressure pain)

SEQUELAE

• injury often becomes chronic without correct treatment

• development of heel spurs

• tight tendo Achilles complex

• may predispose to shin splints

• orthotics may be indicated

R.I.C.E.S. : Rest, Ice, Compress, Elevate, Support

ANATOMICAL AREA: FOOT AND ANKLE

TAPING FOR: PREVENTIVE PROPHYLACTIC ANKLE SPRAINS

Purpose

• offers bilateral ankle stability with specific reinforcement of the lateral ligaments

• restricts inversion and some eversion

• allows almost full range of dorsiflexion and plantarflexion

Indications for use

• preventive taping to protect lax ligaments and ‘weak’ ankles

• final stages of ankle sprain rehabilitation, when less specific ligamentous reinforcement is sufficient

• chronic inversion sprains

• for chronic medial sprains (deltoid ligament): reverse strips (steps 6–8, 10–12, 14 and 16) to reinforce medial rather than lateral support

MATERIALS

Razor

Skin toughener spray/adhesive spray

Lubricant

Heel and lace pads

Underwrap/Comfeel™

3.8 cm (11/2 in) or 5 cm (2 in) non-elastic tape ± 5 cm elasticized tape for closing

NOTES:

• It is essential to confirm the site of any injury or laxity prior to taping, so that appropriate reinforcements can be made.

• The athlete should be asked if they have any taping preferences. e.g. light tape or tight. Tension can be adjusted to suit during the procedure.

• Pressure on the base of the fifth metatarsal can cause pain. Pressure on the neighbouring blood vessels can cause pain and compromise circulation.

• Proprioception retraining is extremely important to ensure a total recovery programme.

For additional details regarding an injury example, see T.E.S.T.S. chart (p. 61).

Positioning

Lying supine (face up) or long sitting (knees extended) with ankle held at 90 ° angle over the end of the table and supported at the midcalf (a 90 ° angle is the ‘normal standing’ angle).

TIP:

The taping surface should be high enough that the taper can work comfortably without risking back strain.

Procedure

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary.

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

3. Apply lubricant to lace and heel pads to the two ‘danger’ areas where blisters frequently occur.

TIP:

Cover the Achilles tendon including its attachment to the heel and superficial extensors.

4. Apply underwrap to the area to be taped.

NOTE:

Comfeel™ may be applied prior to lace and heel pads and would negate the need for underwrap. The more contact between the tape and the skin, the more likely you are to have an unyielding tape job.

5. Using light tension, apply two overlapping, circumferential anchor strips of 3.8 cm non-elastic tape at the forefoot and two below the calf bulk (at the musculo-tendinous junction).

TIP:

When applying the anchor strips midcalf, be sure that the strip is held horizontally at the back and wraps around the natural contours, rising up to cross more superiorly on the anterior surface.

NOTE:

These anchors must be in direct contact with the skin to ensure support.

6. Apply a stirrup of 3.8 cm non-elastic tape. Starting from the upper anchor medially, pass under the calcaneum and pull up slightly on the lateral side to end on the upper anchor laterally.

TIP:

Make sure the ankle is held at an angle of 90 ° throughout this procedure and make sure you secure the stirrup to the anchor before tearing the tape from the roll.

7. Apply a second and third stirrup (if necessary) slightly anterior to the preceding one.

8. Repeat the proximal anchor (5) to hold the end of the stirrups in place.

9a Apply the first heel/ankle lock beginning on the anterior shin, pass towards the lateral aspect of the ankle superior to the malleolus.

9b Continue cautiously behind the Achilles tendon and under the heel.

9c Pull up over the lateral side, applying strong tension, and fix securely on the lateral upper anchor. Alternatively this can be pulled over the area of the anterior talo-fibular ligament region and back toward the origin.

10. Repeat the lock.

11. Apply medial lock by reversing this strip and finishing on the medial side for added stability.

TIP:

Apply medial tension only when pulling up on the medial side.

12. Begin closing up the tape job from the top (lightly), ensuring all gaps (windows) are covered in order to avoid blisters.

13a Apply a simple figure of eight to close and support the taping. Start anteriorly, crossing medially without tension.

13b Pull the tape down towards the medial aspect of the arch.

13c Pass under the foot and pull up with firm tension over the lateral side before crossing the ankle.

13d Bring the tape horizontally behind the Achilles tendon, finishing anteriorly, crossing the starting point.

14. Complete the closing up strips, covering the forefoot if not already completely enclosed.

NOTE:

A second figure of eight can be applied to offer greater support or to cover any remaining open areas.

15. a. Test the degree of restriction. b. Inversion should be significantly restricted. c. Plantarflexion should be limited by at least 30 °.

NOTE:

Medial view of the finished tape job is shown in this photograph.

ANATOMICAL AREA: FOOT AND ANKLE

TAPING FOR: ANKLE SPRAIN/CONTUSION: ACUTE STAGE

Purpose

• gives lateral stability through splinting and compression

• permits some plantarflexion and dorsiflexion

• controls swelling without compromising arterial and nerve supply (removal of the safety strip permits easy release of tension in case of progressive swelling)

Indications for use

• acute (inversion) lateral ankle sprain

• acute (eversion) medial ankle sprains: reverse strips to support medially damaged structures

• acute postcast removal

• splinting for suspected ankle fracture: use less tension and apply equally to both sides

• acute ankle contusion: apply tension to injured side

MATERIALS

Razor

Skin toughener spray/adhesive spray

3.8 cm (1½ in) non-elastic tape

Foam/felt/gel pad cut into a U or J shape

5 cm (2 in) or 7.5 cm (3 in) elastic adhesive bandage

NOTES:

• Ensure that the correct diagnosis has been made. If in doubt, refer!

• Take care to apply adequate, localized compression over the basic taping without compromising circulation. (Take care not to cause a tourniquet effect.)

• Ensure that the athlete has been thoroughly instructed in (and understands) the immediate care for the first 72 hours: R.I.C.E.S.

Check regularly for signs of numbness, swelling or cyanosis (blueish colouring) of the toes.

• Should the tape become too tight due to continued swelling (even after R.I.C.E.S.) loosen the tape or completely reapply.

For additional details regarding an injury example, see T.E.S.T.S. chart (p. 36–38).

Positioning

Lying supine (face up) with a cushioned support under the midcalf and with the injured ankle held at 90 ° throughout this procedure (a 90 ° angle is the ‘normal standing’ angle).

Procedure

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

3. Apply two open anchors of 3.8 cm non-elastic tape around the lower third of the calf. Be sure to leave an opening at the front.

TIP:

Ensure the anchors at horizontal at the back of the calf apply to the skin then follow the natural contours of the skin.

4. Apply two anchors around the midfoot, leaving an open space on the dorsum (top).

5. Apply a stirrup of 3.8 cm non-elastic tape from the upper anchor on the medial side, cover the posterior edge of the medial malleolus, pass beneath the heel and slightly behind the lateral malleolus. Pull up strongly to apply specific tension over the lateral side and affix the tape to the upper anchor laterally.

NOTE:

When taping medially injured structures, this stirrup is applied in reverse, starting on the lateral side and pulling up strongly on the medial side.

6. Apply an open anchor around the upper end of this stirrup, overlapping the original anchor by a half anteriorly.

7. Apply a horizontal strip from the anchor on the medial side of the foot, passing around the calcaneum below the level of the malleoli, applying tension as it is applied to the lateral side of the anchor.

8. Stabilize this horizontal strip with a vertical forefoot anchor, overlapping the previous anchor by a half.

9. Apply a second stirrup as in step 5, overlapping the previous stirrup by half anteriorly.

10. Anchor the stirrup as in step 6, moving lower on the calf and covering the previous anchor by a half.

11. Apply a horizontal strip overlapping the previous strip by half proximally, pulling strongly on the lateral side.

12. Repeat steps 8 and 9, overlapping the previous strips and always pulling strongly on the lateral side.

TIP:

Be sure the ankle is kept at an angle of 90 ° throughout this procedure.

13. Repeat steps 10 and 11, overlapping again in the same manner.

14. Repeat steps 8–11 until all the gaps are covered.

NOTE:

None of the strips should overlap anteriorly.

15. Apply a pair of vertical strips, lightly covering the tape ends on either side of the gap anteriorly from the shin to the ankle.

16. Apply a second pair of parallel strips from the forefoot, pulling up slightly and covering the previous strips at the ankle.

17. Gently test the degree of restriction. There must be no laxity on lateral stressing. The pain should be significantly reduced on testing.

18. Apply a final, single, safety strip to close the remaining area.

TIP:

Allow slight plantarflexion while applying this strip to ensure continuous adhesion of the tape at the front of the ankle.

NOTE:

This safety strip is easily loosened in case of progressive swelling.

19. If added control of swelling is needed, cut a felt, foam or gel pad in the shape of a U or J to fill the hollows around the malleolus (bevel the edges).

20a Apply an elasticized bandage to hold it in place using a figure of eight pattern.

20b Stretch the elastic wrap each time as it crosses the lateral side and relax the tension while covering the medial side. Continue with gradually diminishing tension until the bandage covers the entire tape job.

21. Keep the foot elevated as much as possible during the first 48–72 hours.

TIP:

Cushions, pillows or rolled-up towels can be placed under the mattress if an appropriate bolster is not available.

NOTE: THIS TAPE JOB IS NOT DESIGNED FOR WEIGHT-BEARING ACTIVITIES!

ANATOMICAL AREA: FOOT AND ANKLE

TAPING FOR LATERAL ANKLE SPRAIN: REHABILITATION STAGE

Purpose

• offers lateral stability with specific reinforcement

• prevents inversion

• restricts end-range plantarflexion and some eversion

• allows almost full dorsiflexion and functional plantarflexion

Indications for use

• lateral ankle sprains (INVERSION sprain)

• injuries of the calcaneo-fibular and the anterior talo-fibular ligaments: in combination, the most common ankle sprain

• for medial ankle sprains (deltoid ligament): use a horseshoe instead of a J shape on the medial side in step 6 and reverse steps 9–11 and 15–16 for medial instead of lateral reinforcement

MATERIALS

Razor

Skin toughener spray/adhesive spray

Underwrap/Comfeel™

Heel and lace pads

3.8 cm (1.5 in) non-elastic tape

2 cm (¾ in) felt, foam or gel pad cut into a U or J shape

2 cm (¾ in) heel lift

7.5 cm (3 in) elastic wrap

Taping is adapted throughout the progressive rehabilitation healing stages:

1. subacute stage: (48–72 hours post injury): support with felt J and heel lift while beginning to bear weight

2. functional stage: specific ligamentous support with reinforcement of stability for moderate to dynamic activity

3. return to sport stage: reintegration with support adapted to specific sports requirements ranging from training to competition.

NOTES:

• Ensure that the injury has been properly evaluated by a competent sports medicine specialist, and that X-rays have been taken, particularly if an avulsion fracture is suspected.

• DO NOT USE THIS TECHNIQUE FOR AN ACUTE ANKLE INJURY. It should only be applied when acute swelling has subsided (for acute ankle injury taping see appropriate guide).

• Placement of a felt horseshoe controls residual perimalleolar swelling, particularly useful in the subacute phase when localized swelling can become chronic.

• Partial weight bearing with crutches is recommended when starting to bear weight.

• Progression to full weight bearing is permitted only if pain free.

• Use of a heel lift assists ‘push-off’ and reduces the need for dorsiflexion range, allowing weight bearing with less effort and stress.

• Weight-bearing activities may be continued and progressed only if there is no pain during or after activity.

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Tags: An Illustrated Guide To Taping Techniques Principles and Practice

Jul 18, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

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