Prophylactic taping is a popular external stabilizing technique used to prevent ankle injuries during sports (22). Taping has been shown to reduce both the incidence and the severity of ankle sprain injuries (2,7,22). The reduction is generally greater for athletes with a history of ankle sprain, although positive effects have also been shown for those with no prior injury (22,39). Taping limits excessive range of motion (ROM) at the tibiotalar and subtalar joints (7) and may also increase local proprioceptive output (34,35).
Despite the effectiveness of ankle tape in reducing the likelihood and severity of sprain-type injuries, unnatural constraint of the ankle may increase the risk of injuries to proximal joints such as the knee. Studies of ski-boot performance suggest that tall stiff boots afford excellent protection to the ankle but may contribute to knee injuries through boot-induced anterior drawer during a fall (29,38). Although ankle tape is much less stiff than a ski boot, altered knee joint kinematics during simple tasks performed with nonrigid ankle bracing has been observed (36). Recent research articles have quantified knee joint loading during landing tasks undertaken with ankle bracing (19,24,40), but there is no consensus among the results as to knee injury potential. Furthermore, no studies have attempted to measure knee joint loads during performance of more complex dynamic tasks (e.g., running and cutting) with ankle taping or bracing.
Although occurring less frequently, knee injuries are usually more severe than ankle injuries (10,31) and present a significant economic and social cost to both the sports sector and the wider community (21). Anterior cruciate ligament (ACL) ruptures are a common and debilitating injury occurring in many different sports (1,14,21). Noncontact trauma accounts for 50%-80% of ACL injuries, which arise most often during sidestepping, cutting, and landing maneuvers (5,12). Unplanned sidestepping maneuvers place the ACL at particular risk (4,8,20,30). Laboratory and video analysis suggest that high quadriceps extension forces combined with valgus and internal rotation moments are a primary cause of ACL injuries (12,23). However, although anatomic, ergonomic, environmental, and physiological factors influencing ACL injury have been identified (11,12,27,32), there are limited biomechanical data from which a relationship between ankle taping and knee injuries may be inferred.
The primary objective of the present study was to compare knee joint biomechanics during running and cutting tasks performed with and without ankle tape. Because we aimed to simulate typical injury situations encountered by players during a team game (specifically, Australian football), all tasks were to be executed under both planned and unplanned conditions. We hypothesized that use of ankle tape would increase knee joint loading and decrease peak knee flexion angle during all tasks. Our secondary aim was to quantify the effects of ankle taping on ankle joint loading, for which we hypothesized that taping would reduce the peak joint angles, ROM, and ankle joint moments.
Twenty-two male participants (mean ± SD: age = 22.1 ± 2.3 yr, height = 1.85 ± 0.08 m, mass = 82.9 ± 6.7 kg) were recruited for the study. All subjects had semiprofessional or elite experience as players of Australian Rules football. We elected to recruit semiprofessional players because in our long experience measuring knee joint loading in unskilled college students and amateur and semielite football players (4,12,17,26), the latter are most reliable and reproducible in their performance of the running and cutting tasks. This is important in reducing potential fatigue associated with multiple unsuccessful trials that may affect data quality. Players with a history of knee or ankle surgery were excluded from this study. Our previous work comparing the differences between different sidestepping techniques revealed effect sizes of about 0.5 (n = 11) (4). To achieve similar effect sizes, which represented moderate functional differences, 20 subjects were required for an 80% power and alpha of P < 0.05. All test procedures were approved by the Human Research Ethics Committee at The University of Western Australia (UWA), and all subjects gave their written informed consent before data collection.
A self-adhesive 38-mm ankle tape was used in all ankle taping trials (Leukoplast; Smith & Nephew Rehabilitation Pty Ltd., North Ryde, Australia). Taping was applied by the same qualified athletic trainer for each participant, and the taping technique used was that described in the Sports Medicine Australia trainer's manual (37). Only the ankle of the dominant leg was taped; leg dominance was determined by having subjects perform a sidestep with each leg and nominate their preferred side. The subject was seated on a table of a height approximately equal to that of the trainer's waist. The dominant leg was shaved with a disposable razor from approximately mid-calf to mid-foot. With the foot positioned in dorsiflexion and slight eversion, two overlaid anchor straps were placed approximately 10 cm above the malleoli. Two stirrups were added, both commencing on the medial side of the anchor strap. Two figures of six from the medial side and two from the lateral side were then added, with taping concluded by two heel locks.
Testing was carried out using our established motion analysis procedures (3-5,17,18). Retroreflective markers were fixed to bony landmarks as per the UWA lower-body marker set (6). Three-dimensional marker motion was tracked using a 12-camera, 250-Hz Vicon motion analysis system (Oxford Metrics Ltd., Oxford, UK). Ground reaction forces during stance were collected at 2000 Hz using a 1200 × 600-mm AMTI force plate (Advanced Mechanical Technology Inc., Watertown, MA).
Subjects were required to perform, in random order, repeated trials of three tasks: a straight run, a 45° sidestep, and a 45° crossover cut. All sidestep and cutting tasks were performed off the subject's dominant foot. Data from crossover-cut trials were not analyzed, but this task was included in the test battery to reduce the potential anticipation of a sidestep-the crossover cut was performed from the same foot as a sidestep but resulted in the opposite direction of travel afterward (e.g., to the right for a right-footed subject, whereas the same subject would travel to the left after a sidestep). Inclusion in the test protocols of cutting tasks that required the subject to travel either to the right or to the left reduced anticipatory affects, which may have caused changes in technique and ultimately affected joint loading (17,18). Subjects were instructed not to target the force plate. During a 10-min warm-up and practice period, each subject adjusted the starting position of their approach run so their dominant foot landed wholly on the force plate. The tasks were performed on an indoor runway of 20 m length and 15 m width, with the force plate located at approximately 15 m along its length. These tasks were practiced until the subjects could consistently achieve the required approach speed of 5.5 ± 0.5 m·s−1 (±10% of the goal speed of 5.5 m·s−1) (4,5,17,18), with infrared timing gates used to monitor the running speed. Tape markings on the floor at 45° to the approach direction were used to indicate the required angle for the sidestep and crossover cut.
All tasks were conducted under preplanned and unplanned conditions (4). A target board mounted with a set of three light-emitting diodes corresponding to each of the three tasks was positioned at the end of the runway and used to inform the subject which task to undertake. For preplanned trials, a light was illuminated at the commencement of the approach run to indicate the required direction of travel. For the unplanned condition, the light was activated 400 ms before the subject reaching the force plate.
The subjects performed all three tasks with the ankle taped and untaped; the order of undertaking the taped or the untaped trials was determined by a random draw at the commencement of testing. A total of 36 trials were performed by each subject (2 × tape states (tape/no tape) × 2 conditions (planned/unplanned) × 3 tasks (run/sidestep/crossover) × 3 trials of each task). The randomization of these trials was determined using custom in-house software, which required input of the total number of tasks, number of conditions, and number of trials for each task. An additional level of randomization was added as the trials within taping or nontaping cohort were conducted with replacement-although the subjects were told how many successful trials of each task they had to undertake, they were not told if each trial they undertook was successful or not so they could not calculate the number of trials remaining for each condition. Previously published research from our group has used the same procedure (5,17).
Ankle joint centers were predefined on the basis of the placement of markers on the medial and lateral malleoli. These markers were removed during the dynamic trials. A six-marker pointer was used to identify the three-dimensional location of the medial and lateral femoral epicondyles of each leg, and the hip and knee joint centers were identified from algorithms on the basis of the performance of functional knee and hip tasks such as squats and hip flexion-extension-adduction-abduction rotations (6). Foot abduction or adduction and rear-foot inversion or eversion angles were measured using a calibrated rig (6).
Kinematic and inverse dynamic calculations were performed in VICON Workstation and Bodybuilder (VICON Peak, Oxford, UK), using the UWA lower-body model (6). Before modeling, both the ground reaction force and the position data were filtered using a fourth-order 18-Hz zero-lag low-pass Butterworth filter. The cutoff frequency was selected using residual analysis and visual inspection of the resulting kinematic and kinetic data. The knee joint axis was located by calculating a mean helical axis using a custom MATLAB program (Mathworks Inc., Natick, MA), with the knee center identified as the midpoint of the femoral epicondyles along this line (6). Spheres were fitted to each thigh marker trajectory to find a hip joint center relative to the pelvis anatomical coordinate system. Moments were calculated with inverse dynamics (6,25) and expressed as external moments, using body segment parameters obtained from published values (16).
Kinematic and kinetic parameters for the ankle and knee joints were calculated for the weight acceptance phase of stance, defined as the period from heel strike to the first trough in the unfiltered vertical ground reaction force. This phase was selected because the maximum knee valgus and the internal rotation moments typically occur during this period, and it is also possible to identify peak varus moments in this phase (5,18). In addition, peak ankle moments could be detected in this phase in all planes of motion. However, because peak knee flexion or extension moments could not be identified in this phase, only the average knee flexion or extension moments were determined. Ankle and knee moment impulses were calculated by fitting a cubic spline to the corresponding moments. The spline was interpolated to 101 points and integrated over the period of weight acceptance to determine both the positive and the negative moment impulses.
Summarizing, the knee kinematic parameters analyzed were the peak and the average knee flexion angle, and the ankle kinematic parameters assessed were the peak dorsiflexion and plantarflexion joint angles, the dorsiflexion or plantarflexion ROM, the peak abduction and adduction joint angles, the adduction or abduction ROM, the peak inversion and eversion joint angles, and the inversion or eversion ROM. Kinetic parameters calculated for the knee were peak varus and valgus moments, peak internal rotation moments, average flexion and extension moment, varus and valgus moment impulses, and flexion and extension moment impulses. Kinetic parameters determined for the ankle included peak dorsiflexion and plantarflexion moments, peak adduction and abduction moments, and the peak eversion and inversion moments and the corresponding impulses for all these ankle moments.
Subject data for each parameter were grouped and averaged for each trial type. Data for crossover-cut trials were not considered in the analysis. Statistical analysis was conducted using the Statistical Package for the Social Sciences for Windows (Version 14.0; SPSS Inc., Chicago, IL). The main effects of tape (tape/no tape), condition (planned/unplanned), and task (run/sidestep) on joint kinetics and kinematics were evaluated using a three-way repeated-measures ANOVA, with significance set at P < 0.05. We then further investigated the main effects of tape using post hoc tests with Bonferroni correction to evaluate the interaction of ankle tape with condition or task.
Peak internal rotation moment and peak varus moment at the knee were significantly reduced during all running and sidestepping trials (planned and unplanned) when undertaken with ankle tape (Table 1). For taped sidestepping trials, which according to our hypothesis would produce the greatest ACL injury risk, peak internal rotation moment was reduced by 18% for both planned and unplanned tasks. Likewise, varus impulse was reduced by 5% (planned) and 8% (unplanned) tasks. Although the effects did not achieve statistical significance, there was a trend toward increased peak valgus moment (planned sidestepping) and valgus impulse (unplanned sidestepping) at the knee when tape was used (P = 0.056).
Use of taping reduced ankle adduction or abduction ROM for running and sidestepping tasks (Table 1). The reduction was greatest for unplanned tasks (19% for both running and sidestepping compared with 10% for planned trials of each task). Similarly, inversion or eversion ROM (30%) and peak inversion angle (41%-50%) were reduced for the run trials but yielded no significant change for sidestepping (Fig. 1). During all sidestepping tasks, peak dorsiflexion-plantarflexion moment was increased by use of ankle tape (13% for planned tasks and 22% for unplanned tasks), and mean eversion moment was reduced 26% for unplanned trials.
Two variables known to be related to ACL injury risk (peak varus moment and varus impulse) were higher during planned compared with unplanned tasks (Table 2). Peak varus moment was 4%-6% higher for planned running tasks compared with unplanned tasks and 18%-22% higher for sidestepping tasks, with the lower result in each case corresponding to the task being undertaken with ankle tape. Therefore, use of ankle tape significantly reduced peak knee varus moment in both planned and unplanned tasks. Internal rotation impulse at the knee was greater only for unplanned sidestepping tasks undertaken with ankle tape compared with planned trials. Likewise, ankle dorsiflexion-plantarflexion ROM was increased for all running tasks in unplanned conditions. The use of ankle tape reduced the peak ankle eversion angle by 16% during preplanned sidestepping tasks and reduced dorsiflexion-plantarflexion ROM by up to 30% for running activities.
External moments at the knee joint were generally higher during sidestepping than during running tasks (Table 3). In particular, several variables known to be related to ACL injury risk including peak internal rotation moment (50%), valgus impulse (77%), and peak valgus moment (78%) were significantly higher for unplanned sidestepping than observed during equivalent running tasks. At the ankle (Table 4), a greater range of movement was evident for dorsiflexion or plantarflexion (22%-38%) and inversion or eversion (15%-48%) during sidestepping. Peak abduction and eversion moments were significantly higher during sidestepping than running trials, whereas peak dorsiflexion, eversion angle, and peak dorsiflexion moment were greater for all running tasks.
The ACL has received particular attention in biomechanics research because of the long rehabilitation associated with ACL injuries and the subsequent potential for degenerative joint disease (15). The present study investigated the relationship between knee joint loading and use of nonrigid ankle taping. Past research on ankle taping has focused on ankle movement restriction (9,13), the efficacy of tape in preventing ankle injuries (2,7,22), and effects on local proprioception (34,35). Ankle injuries, especially lateral ankle sprains, are common during sports activities, and the popularity of prophylactic ankle supports has increased in recent years (22). However, despite previous research that has quantified knee joint loading during landing tasks undertaken with ankle bracing (19,24,40), the influence of ankle taping on knee biomechanics in open dynamic sporting maneuvers has been the subject of limited examination.
Our results indicate that nonrigid ankle taping provides some protective benefits to the knee during running and cutting through a reduction in internal rotation and varus moments and varus impulse. This refutes our initial hypothesis that ankle constraint would increase knee joint loading, a premise which was developed on the basis of the results from ski-boot testing (29,38) and the lack of consensus from analysis of landing tasks undertaken with ankle bracing (19,24,40). Our results do, however, correspond with those of previous research using ankle bracing during dynamic athletic tasks, which have also demonstrated positive outcomes for knee joint loading. DiStefano et al. (19) tested the effects of ankle bracing on lower-limb loading during landing from a jump. Trials undertaken with ankle bracing demonstrated significantly increased knee flexion at initial ground contact, which is known to reduce ACL loading (26). Importantly, no differences in vertical ground reaction forces were noted between braced and unbraced conditions, suggesting that lower-limb loading was not increased by use of a brace. Joseph et al. (24) also demonstrated protective effects at the knee from the use of a medially stabilized ankle brace during landing tasks. Use of the brace significantly decreased knee valgus angles, which are associated with ACL loading (5). Sidestepping and unplanned maneuvers are known to increase knee valgus, varus, and internal rotation moments compared with those generated during running (3-5,12,26). The currently accepted mechanism for an ACL injury is external flexion moments combined with peaks in the internal rotation and varus or valgus moments, such as those typically observed in sidestepping activities (5,12,27). In this study, sidestepping induced greater valgus and internal rotation moments at the knee compared with running tasks (Table 3). Use of taping reduced peak internal rotation and varus moments during all running and sidestepping tasks (planned and unplanned) (Table 1).
Taping may provide a further protective effect at the knee by reduction of external moments during unplanned tasks. Unplanned sidestepping maneuvers place the ACL at particular risk of injury (4,8,20,30). Our results indicated that moments that are typically high in cases of noncontact ACL injury, including varus and internal rotation moments (4), were reduced in unplanned maneuvers undertaken with ankle tape (Table 1). Internal rotation and varus moments were reduced during both unplanned running and sidestepping tasks, and internal rotation impulse was reduced during unplanned sidestepping. However, use of taping also resulted in significant reductions in knee and ankle joint loads during planned tasks. Significant differences in peak varus moment for both planned running and sidestepping tasks with varus and internal rotation impulse also reduced for taped sidestepping tasks (Table 2). Because most sports performances involve both planned and unplanned tasks, this indicates a potential broad-ranging protective effect from the use of ankle tape. The nature of this effect may be in part mechanical because our results indicate a reduction in ankle dorsiflexion-plantarflexion ROM during both planned and unplanned taped trials (Table 2). Likewise, proprioceptive effects from the use of tape were not measured in this study but have been previously linked to reduction in lower-limb loading during dynamic athletic performance (34,35). Further research is recommended in this area.
Although some positive benefits for knee joint loading through use of ankle taping were evident from this study, it would be premature to conclude that ankle taping provides a totally protective effect to the knee. Although not statistically significant, the trend for increased valgus impulse during sidestepping tasks undertaken with ankle tape indicates potential for increased ACL loading. Changes to foot position and angle during stance-which may realistically occur when taping is used to constrain the ankle joint-have previously been shown to influence the point of application of ground reaction forces and subsequent knee joint moments and ACL strain (4,38). Similarly, use of taping has been shown to affect negatively athletic technique in some individuals (9,13). Recent research conducted by our group demonstrated that changes in athletic technique during sidestepping tasks can significantly increase knee joint loads (17,18). If the use of athletic taping were to prompt negative motor changes in susceptible individuals, knee injury potential would have to be considered as elevated for these athletes. Careful observation of technique and performance with use of ankle taping is recommended.
A recent Cochrane review (22) evaluated 14 randomized trials of ankle bracing (with data for 8279 participants). A significant reduction in the number of ankle sprains was evident for players using external ankle support. Although the findings of the present study suggest that some prophylactic benefits could be obtained for taping of the ankle, our results suggest these may be task specific. Across all trials, ankle taping reduced the peak ankle inversion angle by 16%, thereby decreasing the potential for inversion trauma, which accounts for 75% of ligament strain injuries (39). However, when results were considered separately for each motor task, use of ankle tape caused no significant reduction in peak inversion during the sidestepping task (21.3° with tape compared with 22.7° without; Table 1). Sidestepping is considered a greater risk for ankle injuries because this task exhibited peak inversion angles more than four times greater than those evident during the straight run (mean of 16.6° compared with 3.1°; Table 3). Many ankle sprains occur during the combined movement of inversion and plantarflexion of the foot-ankle complex, which is typical of cutting tasks (13). During sidestepping, only sagittal plane motion (dorsiflexion or plantarflexion) was reduced by ankle taping. DiStefano et al. (19) demonstrated similar results for tasks involving landing: although participants were wearing an ankle brace, plantarflexion at initial ground contact, maximum dorsiflexion, and dorsiflexion ROM were all significantly reduced.
The effect of ankle taping on risk of knee injury is complex and probably depends on multiple factors including injury history, physical conditioning and dynamic movement strategies of the athlete, type of footwear, and environmental conditions. To further quantify the effects of ankle tape on knee joint, muscle activation patterns must be analyzed to determine whether taping affects the ability of the muscles surrounding the joint to support the externally applied loads. The effects of ankle tape must also be compared in athletes with a previous history of knee or ankle injury. Subjects with prior incidence of major ankle or knee injury were excluded from the present study. Ankle taping has been shown to significantly reduce the reinjury rate and severity of ankle injuries in previously injured players (22,39), but little is known about the potential effects on loading at other joints. Similarly, the effects of ankle tape-protective or otherwise-over time remain to be quantified. The effectiveness of ankle tape decreases considerably after 10-20 min of exercise (28,33). Meana et al. (28) reported a loss in dynamic support of over 40% after a 30-min bout of exercise in athletes using ankle tape. Our testing sessions were typically 20-30 min in duration; therefore, our results may not reflect the injury risk faced by sportspeople participating in events of longer duration. This research was conducted using semiprofessional and elite male athletes, and further research is required to examine any gender-specific effects because it is well established that the incidence of reported noncontact ACL injuries is more frequent in women than that in men (23). Likewise, our conclusions are restricted to cutting tasks performed off the subject's dominant foot. This is particularly important because the preferred foot could be presumed to be the more skilled foot, and therefore our data may underrepresent the injury potential during such cutting maneuvers. Additional research should also investigate the effect of ankle taping on proprioceptive output to identify the mechanism by which use of tape affects local and proximal joint loading.
Use of ankle tape may provide some protective benefit to the knee because of the reduced peak internal rotation and varus moments and impulse during both planned and unplanned maneuvers. However, a trend toward increased valgus loading during sidestepping indicates the complexity of the relationship between ankle constraint and knee joint loading. The use of taping provided prophylactic benefits to the ankle through enhanced mechanical stability and reduced external loading. However, this prophylactic benefit may be limited because ankle tape provided no significant reduction in peak inversion motion during sidestepping compared with running.
This project was funded by a grant from the Fremantle Hospital Medical Research Foundation. The results of the present study do not constitute endorsement by the American College of Sports Medicine.
Conflict of interest statement: None of the authors had professional relationships with any companies or manufacturers that may benefit from the results of the study. In addition, the funding body, Fremantle Hospital Medical Research Foundation, had no influence over the design, conduct, analyses, and conclusions of this study.
Funding disclosure: Funding received for this work was not received from any of the following organizations: the National Institutes of Health, the Wellcome Trust, and the Howard Hughes Medical Institute.
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