February 2012

Original research: Taping alters ankle biomechanics

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This study found that closed basket-weave ankle taping significantly affects ankle range of motion and time to peak vertical ground reaction force, which can have implications higher up the kinetic chain that appear to vary from one indivi­dual to another.

By Matthew L. Santos-Vitorino, MS, ATC, LAT, Sue Shapiro, EdD, ATC, LAT, Kathy Ludwig, PhD, and Claire Egret, PhD

In the current era of medicine, everything is questioned. Curriculum and practice worldwide have adopted an evidence-based approach, with the goal of validating everything being done for patient health care. The same is true with allied health and sports medicine professions. Practices that have been used for decades are now being reevaluated and sometimes discarded if they are not proven beneficial. Yet one of the most performed tasks in sports medicine, ankle taping, remains a mainstay of practice despite little published evidence of its benefit on the lower extremity.

Ankle sprains are one of the most common injuries in sports. To combat this problem standard practice by most sports medicine clinicians is to either tape or brace the joint.1 These restrictive modalities decrease range of motion (ROM) to lower the risk of further injury.1 The ankle taping system also affects overall ankle proprioception,2 as general consensus is that ankle injuries recur due to the loss of proprioception caused by initial injury.3

There is insufficient data showing the effects of closed basket-weave ankle taping on lower extremity kinetics and kinematics. Many studies1,2,4,5 have focused on single aspects of kinetics or kinematics in the lower extremity or on a single joint, but few studies utilizing motion analysis have demonstrated a broader kinetic or kinematic basis for ankle taping.

Literature

Many past studies have examined aspects of ankle taping and its relationship to ROM, reaction time, and postural stability. University of Wisconsin researchers6 examined muscle latencies during unexpected inversion stress. In this study, participants were placed on an apparatus designed so that one side could drop at any time, resulting in unanticipated ankle inversion. Electromyography demonstrated that muscle latencies during inversion were not affected by bracing with a semirigid hinged ankle brace.  This is important because bracing is utilized less often than taping1,2,4 and has been shown to restrict ROM to a lesser degree,4,7,8 though more recent research suggests that may be true only for dorsiflexion.9 A 2000 study9 found that bracing decreased plantar flexion, inversion, and eversion ROM at the ankle to the same degree as taping, and the limit in ROM for dorsiflexion was significantly greater with tape.

One study by DiStefano et al5 examined ground reaction force (GRF) after forced dorsiflexion, then again after maximal plantar flexion, while the participants were braced. The authors concluded that ankle braces significantly decreased sagittal plane ROM at the ankle and significantly altered knee flexion during landing.5 Despite the significant changes at the ankle and knee, no significant change was found in the vertical GRF sustained during landing.5 This study is more relevant to sport because it looked at forces generated during plantar flexion, a motion predominantly used in athletics for power and locomotion.

Muscle length and power

The idea that force is related to length of a muscle has been discussed for many years.10 More than 100 years ago, physiologist Magnus Blix showed that muscle length was key in determining maximum isometric power.  In a series of three papers published from 1891 to 1894, Blix determined that muscle force production, whether at a maximal or submaximal level, was dependent on length.10

A recent study by Ruiter et al11 concluded that the length dependency of force production output during concentric contractions differed from that during a maximal isometric contraction. As a muscle lengthens, but before it over-lengthens, there is a point at which maximal cross-bridge attachments can be attained. Ideally, this is where the greatest amount of power can be generated. In addition to the concentric forces muscles produce, research10,12-16 shows that eccentric muscle function is crucial for producing shock-absorbing and energy efficient movements. These eccentric muscle contractions add stability and protection during human movement.12 There is an inverse relationship between the force on a muscle and the speed with which that muscle can be shortened.13

Limitations of bracing and taping

More recent research has examined the possibility that restricting motion at the ankle can negatively affect motion at the knee, potentially increasing the risk of knee injury.17-20 This line of investigation has also been discussed in the nonresearch community.21 Several studies suggest the decrease in normal ankle kinematics can lead to overcompensation at the knee, leading to the increased risk of injury.18-21 Despite these numerous findings that suggest a negative global effect on proximal joints when the ankle is taped, more recent studies fail to show an increased risk with braced ankles.22 A 2011 study of California high school athletes found that lace-up braces not only decreased the occurrence of acute ankle injury but also produced no increased risk of knee injury.22 Though the study applied a commonly used ankle brace, the lace-up brace is less effective at restricting ROM, especially in dorsiflexion, compared with tape.3,8 This is important because tape is still the more commonly used method of reducing ROM at the ankle.

We conducted a study to investigate whether ankle taping allows the ankle to sustain a greater amount of GRF than an untaped condition, and if there are differences between genders and in ROM. We also assessed muscular activity and impulse differences between taped and untaped conditions. Another aim of this study was to see if there were changes in kinematics and VGRF between men and women while in the taped condition.

Methods and materials

Our study involved 19 volunteer participants (nine women); all were college athletes aged 18 to 23 years. Participants were free of ankle injury within the previous six months and were able to perform the following actions without any sign of struggle or discomfort: five-minute jog at three mph; jumping from a predetermined landmark; and landing after jumping.

Investigators asked participants to perform active dorsiflexion and plantar flexion and measured and recorded ROM with a 12-in Jamar goniometer. Measurements were taken three times for both dorsiflexion and plantar flexion, and an average was used when processing data. Investigators collected dorsiflexion and plantar flexion data while participants were both taped and not taped.

Next, the participants were equipped with a series of reflective markers placed on top of their clothes and skin. A total of 16 markers were placed on the participants’ bodies from waist to feet. Researchers placed markers placement bilaterally and on the anterior superior iliac spine; posterior superior iliac spine; midthigh; joint line of the knee; midshaft of the fibula; lateral malleolus; calcaneus; and the metatarsal phalange joint of the fourth toe. The markers were used in conjunction with a seven-camera motion capture system for motion analysis.

Participants then stood at a predetermined landmark and jumped onto the force plate with one foot in front of them, landing on the dominant leg (reported by participants before testing). Once contact with the force plate was made, each participant performed one maximal vertical leap, again landing on their dominate leg. This procedure was practiced up to 10 times or until the participant was comfortable with the action.

Participants repeated trials three times with tape and three times without tape; a standard coin flip determined the order of taped and nontaped trials. The taping technique used was the Gibney closed basket weave, the standard ankle taping used in athletic training.23

Application of the closed basket-weave ankle taping for this study was performed as follows: the foot was placed on a table in front of the clinician, who applied adherent spray to the distal lower leg, ankle, and foot. Next, the clinician applied prewrap from the midcalf to the base of the fifth metatarsal. Two anchor strips were applied at the midcalf and two at the base of the foot. Following the anchor strips, a stirrup strip was placed from the medial aspect to the lateral aspect. Next, a horseshoe strip was applied over the stirrup strip. This process of stirrup followed by a horseshoe was repeated three times. After the stirrups and horseshoes, two sets of heel locks were applied, alternating the beginning sides. Then, a figure eight was applied, beginning at the medial aspect of the lower leg and finishing on the anterior of the lower leg. Closing strips were applied from the foot end to the calf until complete.23

Instrumentation

Investigators used a force plate installed in the floor of the biomechanics lab to measure GRF. This force plate is operated simultaneously with a seven-camera Vicon nexus motion capture analysis system. The Vicon system data was processed using Vicon nexus software.

Results

Kinematics. We found no significant interaction between gender and the taped condition on the combined dependent variable of dorsiflexion and plantar flexion (p > .05). There was no significant main effect for gender (p > .05). There was a significant main effect for the taped condition (p < .001). Follow-up univariate tests found significant differences within the taped and untaped groups for both dependent variables. Dorsiflexion and plantar flexion in the taped condition were significantly lower than in the untaped condition (dorsiflexion, p < .001; plantar flexion, p < .001). Both of these dependent variables had effect sizes greater than .800 (Table 1).

We found no significant interaction between tape and gender with regard to knee and hip functional ROM in the sagittal plane during landing, (p > .05). There was no significant main effect for tape (p < .05). However, there was a significant main effect for gender (p > .05), and follow-up analysis found that knee functional ROM was significantly higher in men than in women (p < .001). There was no significant difference in hip ROM between genders (p > .05) (Table 2).

Kinetics. Results of the multivariate analysis of variance (MANOVA) for the vertical GRF during jumping and landing show no significant interaction between gender and tape (p > .05) and no significant main effect for gender (p >.05) or for tape (p > .05).

Time to peak VGRF during landing. When studying the variable of time to peak VGRF, there was no significant interaction between tape and gender (p >.05) and no significant main effect for gender (p >.05). There was a significant main effect found for taping (p < .05). Time to peak VGRF was significantly shorter in the taped condition (Table 3).

These results show that the closed basket-weave ankle taping significantly decreases plantar flexion and dorsiflexion at the talocrual joint. The closed basket-weave ankle taping significantly increases joint ROM at the knee in men. Lastly, the application of tape at the ankle significantly decreases the time to peak VGRF during landing. The results also show that application of ankle taping did not significantly affect the magnitude of VGRF sustained by the body.

Discussion

This study of closed basket-weave ankle taping investigated several kinematic and kinetic effects on the lower extremity. Similar to the findings of Paris et al,8 our study found the application of ankle tape significantly decreased ROM for both plantar flexion and dorsi­flexion. As stated in previous literature, a restricted ROM affects the biomechanics of the taped joint as well as those of surrounding joints.13,14,18,24-26

We also found that the time from initial contact to peak VGRF was significantly decreased with tape. This finding agrees with that of Saeki et al,27 who in 1995 found that ankle tape was associated with decreased time from landing to peak floor reaction force in a side-step movement. They suggested that this significant change could affect VGRF absorption.

When analyzing the landing motion kinetically and kinematically, we see that the ability to control a landing and stay stable throughout the landing is dependent on muscles’ ability to contract eccentrically. As noted in previous research10,11,13 eccentric contraction of the lower extremity musculature during landing absorbs the forces applied to the body. The length-power relationship dictates that longer muscle fibers elicit greater force, so if a decreased degree of ROM allows for less than normal lengthening of a muscle fiber, then decreased ROM will also lead to decreased force production from that muscle. The statistical significance of the decrease in time to peak VGRF shows that the time the body had to eccentrically contract was limited by the taping application. And if the time available for eccentric contraction was decreased, then the body’s ability to absorb the sustained forces was most likely affected.

One of three hypotheses can be made. First, if a muscle’s role as a stabilizer is limited by tape, that role must be filled through the compensatory action of another muscle. Second, the amount of force generated by the restricted muscle has to be increased over a smaller muscle volume. Finally, a larger amount of the VGRF sustained by the body is transferred to structures not typically involved in force attenuation.

In our male participants taped trials resulted in a 3° increase in knee ROM compared with untaped trials. In women volunteers, however, knee ROM decreased by 5° with tape. Even though this difference is not statistically significant, it may be important in clinical practice. These data show that women compensate for loss of ankle ROM and eccentric contraction capabilities by decreasing knee flexion, while men compensate by increasing knee flexion.

A study by Joseph et al28 similarly concluded that the jumping and landing movements of men and women were significantly different. That study also suggested men and women utilize a completely different kinematic strategy while landing, and this difference tends to show women collapsing while landing and allows for a greater valgus ROM.28

We can see trends in data on jumping and landing sequences, muscular recruitment, and women throughout several different studies. Yu and Garrett29 found that women with decreased knee flexion while landing sustained a great amount of anterior cruciate ligament (ACL) loading, which could subsequently increase the risk of an ACL tear. Their study showed a direct correlation between decreased knee flexion in women and increased risk of injury to the ACL, while the current study showed how a taping application can decrease knee flexion 5° during landing.

Several studies29-31 concluded that increases in knee valgus ROM leaves women at a greater risk of ACL injury. Combined with the findings of Pollard et al,32 this series of facts becomes more interesting. Pollard found that during a landing sequence, women who have decreased knee flexion also exhibited increased valgus angles.32 When coupling all the data from the female-based kinematic studies we see a trend that shows decreased knee flexion promotes increased valgus angles, leading to increased loads on the ACL.29-32 Taken together with findings from the current study, which suggests ankle taping decreases knee flexion in women, this body of research shows potential a link between the use of ankle taping and increased joint loads on the ACL.

Further evaluation of individuals in our study produced astonishing results. One participant, for example, had at least 15% increases in VGRF at the ankle and in knee ROM and hip ROM with the application of tape. This same participant, also when taped, had a 23% loss in VGRF at the ankle during the take off following a landing. Another participant had decreases in all force production categories, increases in all VGRF categories, increases in functional ROM, and losses in time to peak VGRF. At least five participants saw individual trials vary at least 15% for all the VGRF categories as well as 10% changes, whether increases or decreases, in the joint moment categories.

On larger scale, every participant had a change of at least 15% (in some cases more than 25%) in at least two categories. These individual kinetic and kinematic changes in response to taping, which may have clinical importance, are masked when trial results are averaged. On the other hand, another negative effect of looking only at means is the inclusion of outliers that may not be clinically relevant.

Findings from this study show that closed basket-weave ankle taping significantly decreases active plantar flexion and dorsiflexion in the talocrural joint and decreases the amount of time from initial contact to peak VGRF. This suggests that a decrease in active ROM significantly affects the body’s natural eccentric muscle contraction, which is needed during the landing motion. Although no significant effect of taping was seen for VGRF, significant differences seen in ROM demonstrate that the application of tape results in biomechanical adaptations.

Clinical implications

Despite having fewer statistically significant results than expected, this study does have potential clinical implications. The variability in responses to taping seen in individual participants supports the idea that athletes are truly different; therefore clinicians should tailor its application to each athlete based on a clinical evaluation.

A review of the literature1,4,33 found that 85% of all sprains in the body are ankle sprains and showed that the ankle can sprain in multiple ways; it makes sense that responses to taping would be similarly varied. With a better understanding of factors contributing to this variability, clinicians can improve their current approach to ankle taping at several junctures: prior to taping, by using an in-depth evaluation to predict an athlete’s individual response to tape; during taping, by positioning the foot to maximize support while minimizing compensatory effects; and in some cases, by deciding not to tape at all and completely preventing any potentially harmful effects. All of these paths to improved outcomes can be accomplished with thorough evaluation of each patient and the application of impeccable clinical skills.

The apparent effect of taping on the force-absorbing mechanisms in the lower extremity has potential consequences for athlete performance if force is being transferred to proximal joints or if the same muscles are working harder to compensate for ROM restrictions. The continued need to sustain these forces, especially for an untrained body, could lead to the increased risk of further ankle sprain, muscle strain, stress fracture, and other overuse and compensation injuries.

Conclusion

This study’s results indicate that closed basket-weave ankle taping significantly affects ROM and time to peak VGRF. These results, along with knowledge of the physical laws that act on the body, suggest that ankle taping has more biomechanical effects than assumed. Although this study did not find significant increases in VGRF or significant changes in the entire movement patterns of the lower extremity, results from individual participants show the restriction of ankle ROM can vary significantly among individuals and affect them differently.

The findings of this study add to existing knowledge about the effects of the ankle taping, but further research and new testing instruments are needed to find additional clinical evidence for recommending the prophylactic use of ankle tape. The need to understand ankle taping and its effects on biomechanics and performance is significant because of its widespread application in athletics. The possible trends seen by linking studies are alarming, and future research needs to more fully investigate issues at the kinetic and kinematic levels. In the age of evidence-based medicine, even such commonplace practices should no longer be used without in-depth investigation.

Matthew Santos-Vitorino, MS, ATC, LAT, is the head athletic trainer at Westminster Christian School in Miami, FL. Sue Shapiro, EdD, ATC, LAT, is associate professor and director of athletic training; Kathy Ludwig, PhD, is associate professor of biomechanics; and Claire Egret, PhD, is associate professor of biomechanics at Barry University in Miami, FL.

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