Golf is a lifetime sport, and more than 60 million people participate in this sport, regardless of age and sex (16,33). The popularity of golf continues to increase with the development of new golf courses, and people play more rounds of golf every year (51). In addition, golf has substantial potential for future growth since it was reintroduced as a competitive sport in the 2016 Rio Olympic Games (32).
Golf has been considered a docile and nonstrenuous sport (33). However, many previous studies have reported that various musculoskeletal injuries commonly occur during the golf swing, which involves strong force and range of rotational movement, created as a consequence of substantial linear and angular momentum that is generated and controlled throughout the whole body (10,14,22,29,33,35,37). A German study on the epidemiology of musculoskeletal problems in golfers by Gosheger et al. (22) reported that sports injuries occurred at a rate of 3.06 injuries and 2.07 injuries per professional and amateur golfers, respectively. These golf-related injuries resulted from overuse and inadequate conditioning, which are similar causes of other sports-related injuries (47).
Most golf injuries occur in the upper extremities and low back; however, 15–18% of total injuries affect the lower body (33,36), and knee injuries account for approximately 8% of all golf injuries (35). In unskilled golfers, the rate of knee injuries (9.3%) is lower than that of upper limb injuries, such as elbow (33%) and wrist (20%) injuries (33,36), whereas in skilled golfers, the rate of knee injuries (7%), especially of the lead knee, is similar to upper limb injuries, such as hand (7.1%) and shoulder (7.1%) injuries (33,36). The rate of injuries for unskilled and skilled golfers is related to poor technique and repetitive and frequent practice, respectively (40). However, the mechanism of a golf-related knee injury had not yet been clearly identified (19,33).
Body weight should be balanced equally between the lead and trail legs in the address position of the golf swing (38). However, in the backswing phase, the rate of body weight on the trail leg increases, whereas during the downswing and follow-through phases, 75–80% of the body weight transfers to the lead leg resulting in a maximum of 756 N of compressive force with 0.54–0.63 N·m·kg−1 of external varus moment at the lead knee joint (33,37,53). This external varus moment, which is about 9–33% greater than daily activities such as gait or stair climbing, is insufficient to result in an acute knee injury (33). However, it may cause and lead to overuse or degenerative conditions such as osteoarthritis to the medial cartilage or microinjury to the lateral collateral ligament of the lead knee joint (8,33,55). Golfers with overuse injuries to the knee joint are absent from competition or training for an average of 21.9 days, and 30.4% of them suffer from knee injuries for over 1 year (22).
Sports participants are always exposed to the risk of injury, and in some cases, these injuries lead to permanent disability (5). Because the treatment of sports-related injuries is often difficult and it is associated with a significant amount of time and a high cost, preventive strategies and activities related to sports injuries are very important (39). Sports taping has long been used for rehabilitation and prevention of sports-related injuries in elite athletes, as it provides external stabilization of the musculoskeletal system with mechanical support, realignment, or proprioceptive effects (2,20,54). Rigid tape (conventional tape) increases stability by restricting translation and rotation generated in the unstable joint (3,43); however, elastic tape, such as Kinesiology tape, corrects joint alignment and improves muscle balance around the joint while maintaining full or partial range of motion of the joint (1,12,28,30).
The aims of this study were to evaluate the immediate effects of rigid and elastic sports taping for limiting varus moment at the lead knee by analyzing the position of the knee joint on the frontal plane with or without sports tape during golf swing within low- and high-handicapped golfers. Ultimately, it might help to provide important information for preventive strategies and activities of golf-related knee injuries.
Experimental Approach to the Problem
This study was designed to evaluate the immediate effects of sports taping for limiting varus moment at the lead knee. To address this problem, rigid and elastic sports taping and placebo taping were applied on the lead knee, and the position of the knee joint on the frontal plane was analyzed during golf swing. Experiments were conducted in the laboratory for 3-dimensional analysis, and all participants performed a warm-up with their own clubs for adapting to the indoor environment. Afterward, participants took the swing with and without sports taping on the lead knee. The mean knee angles in the front plane were measured depending on the phase and club, and compared between with and without sports taping. All tests were carried out on the same day.
Thirty-eight right-handed elite golfers participated in this study. All participants had no history or complaints of chronic pain, major injury, or surgery. Each participant provided informed written consent and completed a self-report questionnaire regarding their demographic information, current affiliation, and health status. Each participant was assigned to the low-handicapped group (LHG; <1 handicap index; n = 15) or high-handicapped group (HHG; ≥3 handicap index; n = 16) according to the handicap system of the Korea Professional Golf Association (9). Seven participants were excluded because they had 1 or 2 handicap points. Participants' characteristics are shown in Table 1. The study was approved by the ethics board of the Korean Institute of Sport Science.
Setting and Procedure for 3-Dimensional Motion Analysis
Twelve Raptor-E infrared cameras (Motion Analysis, Santa Rosa, CA) were used to collect the knee joint position data of passive reflective markers at a sampling rate of 250 Hz (Figure 1). Nonlinear transformation was used for the 3-dimensional space (4 × 10 × 3 m) with the Global Coordinate System, and marker signals were low-pass filtered using a fourth-order Butterworth with a 24-Hz cutoff frequency (15). After filtering, Visual 3D software (C- Motion, Inc., Rockville, MD) was used to calculate the joint kinematics.
After measuring the height and weight of each participant, reflective markers, using a 6 degree-of-freedom marker set, were attached to the full body by a single investigator (52). Also, additional reflective markers were placed on the head of each golfer's own driver and 5-iron club. To objectively assess the golf swing through real-time monitoring, the Trackman system (Trackman Golf, Vedbæk, Denmark) was used because it has been previously validated for golf and proven to identify the ball launch and flight characteristics (42). The Trackman system was located 2.4–3.6 m away from the participant, and it was calibrated on the same line as the center of the target area (42). Each participant performed a warm-up exercise and was able to adapt to the indoor environment after swing practice with their own driver and 5-iron clubs (13). All participants were required to launch their shots to approximately the center of the target area, and data from 2 straight swings, i.e., swings in which the left and right deviation was within 10 m from the line, were collected (42). Afterward, rigid taping (RT), elastic taping (ET), and placebo taping (PT) were applied to the lead knee joint, and the aforementioned process was repeated. Each taping session was separated by 5-minute rests to minimize the carry-over effects of tape on cutaneous sensation (27). All participants were instructed not to change their set-up position before each swing by marking the position of both of their feet on the floor.
Using the trajectory obtained from the marker on the head of the club, the golf swing was divided into 5 events that distinguish 4 phases. The 5 events were the peak of backswing (E1), parallel to the ground during downswing (E2), ball impact (E3), parallel to the ground during follow-through (E4), and finish (E5, (56)). Phase 1 (P1), phase 2 (P2), phase 3 (P3), and phase 4 (P4) were defined as the time from E1 to E2, from E2 to E3, from E3 to E4, and from E4 to E5, respectively (Figure 2). The key outcome measures were the mean valgus (negative) and varus (positive) knee angles in the frontal plane during each phase.
Sports Taping Methods
The same individual performed the RT, ET, and PT techniques for all participants in the preset position for motion analysis. Before applying the tape to the lead knee, the skin was cleaned with an alcohol swab (45).
The RT technique was the modified taping technique reported by Anderson et al. (3) which provides lateral stability of the knee joint. Three strips of a 15-cm rigid tape (Euro Tape; Muller, Prairie du Sac, WI) were applied to the lateral aspect of the knee. The first strip was placed from under the fibular head, and it was attached to the midpoint of the thigh. Then, the second and third strips were crossed in a star shape at the mid-joint line of the lateral aspect of the knee (Figure 3). To prevent skin irritation, hypoallergenic undertape (Fixomull stretch; Beiersdorf Australia Ltd., Syndey, New South Wales) was naturally applied without any force in the same manner before placing the rigid tape (27).
The ET technique as reported by Hendry et al. (26) was used to correct knee joint alignment. Participants were instructed to perform knee flexion of 25° with slight hip internal rotation. The elastic strip (Kinesio USA Corporation, Ltd., Albuquerque, NM) was applied on the midline of the calf. Then it was passed over the tibia to the posterior knee-joint line and the anterior midline of the thigh to provide internal torsion force (Figure 4). The applied tension reported by Howe et al. (28) was modified in this study as follows; 0% tension was applied at the beginning, approximately 75–100% of maximal tension was applied to the posterior knee-joint line, and then approximately 25–50% of maximal tension was applied to the endpoint at the mid thigh.
For the PT technique, the same elastic tape (Kinesio USA Corporation) was used. Because any effect on lateral stability and alignment of the knee joint had to be avoided with PT, 2 strips were placed 15 cm over the patellar base and under the patellar apex with 0% tension (Figure 5).
All data were analyzed using SPSS version 19.0 for Windows (SPSS, Inc., Chicago, IL), and data are presented as mean and SD. Shapiro-Wilk tests were used to assess the normality of the data. As all data were normally distributed, one-way analysis of variance with a posthoc LSD test was used to analyze the position of the knee joint that was significantly different before and after the 3 taping techniques were used in each phase within each group. Statistical significance was identified at p ≤ 0.05.
Lead Knee Position on the Frontal Plane for Each Section With the Driver Club
Table 2 shows the lead knee joint position on the frontal plane for each condition with the driver club. In the LHG, the knee position with ET (−4.01 ± 3.13), RT (−4.07 ± 3.12), and PT (−4.14 ± 3.15) was significantly larger decreased movement toward knee varus than that without taping (−3.83 ± 3.12) in P1 (p = 0.001). In the HHG, RT (−5.80 ± 3.23) caused decreased movement toward knee varus compared with no taping (−5.54 ± 3.17) and ET (−5.63 ± 3.11) in P1 (p = 0.014); however, ET (−1.35 ± 2.69) and PT (−1.05 ± 2.49) in the HHG were associated with greater increased movement toward knee varus than that before the taping technique was applied (−1.59 ± 2.83) in P3 (p = 0.019).
Lead Knee Position on the Frontal Plane for Each Section With the 5-Iron Club
Table 3 shows the lead knee joint position on the frontal plane for each condition with the 5-iron club. In the LHG, the knee position had significantly larger decreased movement toward knee varus with RT (−4.07 ± 3.12) and PT (−4.08 ± 3.12) than that without taping (−3.80 ± 3.26) and ET (−3.95 ± 3.12) in P1 (p = 0.006). Rigid taping (−1.81 ± 2.42) and PT (−1.81 ± 2.42) were associated with decreased movement toward knee varus before the taping technique was applied (−1.50 ± 2.62) in P2 (p = 0.019).
This study investigates the changes of the lead knee position on the frontal plane when applying sports taping techniques. In the LHG, the knee position on the frontal plane was decreased movement toward knee varus after applying the RT and ET techniques during P1 when the driver club was used. However, decreased movement toward knee varus was only associated with the RT technique during the P1 and P2 when the 5-iron club was used. In the HHG, decreased movement toward knee varus was associated with the RT technique during P1, but increased movement toward knee varus was associated with the ET technique during P3 when the driver club was used.
Sports taping has been suggested as a method of treating and preventing knee injury, as it can provide external support, motion control, proprioceptive input, kinesthetic reminders, or stress redistribution, but the mechanism of these effects has not been clearly elucidated (28,44,46). Arnold and Dcherty (4) reported that sports taping limited the range of motion of ankle inversion to 37–61%; Verhagen et al. (50) found that ankle taping caused ankle inversion and eversion in the proper range and reduced mechanical ankle instability; and Anderson et al. (3) noted that knee taping controlled tibiofemoral translation and showed mechanical effects on decreasing knee instability. The results of this study showed that applying taping techniques in the LHG when using the driver club caused decreased movement toward knee varus in the phase from the peak of backswing to parallel to the ground during downswing than that with no application of taping technique. During the same phase, the HHG when using the driver club had decreased movement toward knee varus after the RT technique than that before. Also, when using the 5-iron club, the LHG who applied the RT technique had decreased movement toward knee varus in the phase from the peak of backswing to the back impact. These results indicated that the taping technique reduces varus moment generated in the lead knee from the peak of the backswing in golf (33) and it sustains mechanical support, which is one of the possible injury prevention mechanisms for limiting extreme range of motion in the joint (44).
The greater trunk rotation produced by strong back muscles leads to more stress on the lead knee joint and changes in the joint alignment of the lead knee through compensation of the thigh and hip muscles during golf swing (13). We applied 2 types of taping techniques to provide lateral stability to the lead knee (3) and correct joint alignment by controlling tibial rotation against the femur (26). Rigid tape, which is relatively firm and solid, is used for lateral stability; conversely, elastic tape, contributing to the unloading of an inflamed soft tissue structure by facilitating joint realignment, is used for joint alignment (49,54). Previous reviews about the comparison of taping effects on patellofemoral pain syndrome by Chang et al. (11) reported that rigid tape contributes to patellar alignment and tracking, and elastic tape relieves pain, but evidence for patella alignment correction is insufficient. In this study, RT was more effective for reducing knee varus moment than ET, although there was no significant difference. This result probably occurred because of the characteristics of ET, as it can be stretched to 130–140% of its original length, which enables a greater range of motion (11,54). Thus, the tension of ET, which was applied to limit partial- or full-joint motion in this study, is insufficient for alignment correction (21).
Although the effects of sports taping have not been proven, many elite athletes think that sports taping prevents injuries; therefore, they participate in competitions or sports activities with greater confidence because of the placebo effect of taping (34,44). A previous study by Sawkins et al. (44) reported that when PT was applied to individuals with ankle instability, it improved their perceived stability, confidence, and reassurance, which may positively influence injury prevention. A study that identified a difference in isokinetic elbow peak torque with and without taping the biceps brachii reported that PT by Fratocchi et al. (18) was associated with less eccentric peak torque than that with kinesiotaping, but there was greater eccentric peak torque with PT than that without taping. To evaluate the postulated mechanisms of the effects of sports taping (17), we used PT in this study. Increased knee valgus with PT was found in 2 phases as follows; from the peak of the backswing to parallel to the ground during downswing and from the peak of the backswing to impact when using the driver club and the 5-iron club, respectively. Although PT was applied so it did not influence knee lateral stability or alignment, this result is associated with the expectancy theory, i.e., the patient's belief or expectation, which is one of the hypotheses of the placebo effect (7,31). To assess the effect of sports taping and its mechanisms, further studies should include randomized controlled trials with more intensive PT.
Swing mechanism and movement patterns are completely different depending on one's golf-skill level (13). Generally, more skilled golfers show a greater shifting body weight to the lead leg during downswing than less skilled golfers, and this movement keeps the center of pressure on the medial side to provide a more stable base (41). The patterns of golf-related injuries are also different depending on one's golf skill level; more skilled golfers injure the left wrist or lower back because of a high frequency of practice, whereas less skilled golfers injure various parts of the body such as the lower back, wrist, elbow, or shoulder because of technical errors such as an incorrect swing and miss-hits (6,25,37). This study's results showed differences between golf skill levels as follows; the range of knee joint position was greater in the LHG (−0.38 to 0.58°) than that in the HHG (−5.60 to 1.24°) during golf swing before taping was applied. Also, the LHG tended to have decreased movement toward knee varus after taping was applied than that before taping was applied with no statistical difference, whereas the HHG showed random patterns of knee position during golf swing and an increased movement toward knee varus after taping was applied than that before taping was applied from the parallel to the ground of downswing. These results are also considered because of technical errors of the HHG in golf swing. A future study is needed to identify the relationship between different skill levels and injuries to the knee joint, upper extremities, and lower back to improve golf-related injury prevention.
The lead knee on the frontal plane has a constant pattern of movement during golf swing. Before ball impact, maximum valgus moment occurs at the lead knee (19). Then the moment steadily decreases as the position of the ground reaction force changes when body weight is transferred from the trail leg to the lead leg; finally, maximum varus moment occurs from the ball impact event (19,33). This study also showed that valgus and varus at the lead knee were found at the peak of the backswing and at the end of swing, respectively, in both the LHG and HHG before and after taping was applied. The change in local biomechanical factors such as joint loading and alignment provides abnormal loading conditions to the joint and causes or advances osteoarthritis (55); this change, combined with the transverse rotation torque, can result in a degenerative tear because internal collagenous structures such as menisci are transformed (35). A recent research study on elite athletes by Gosheger et al. (23) reported that the prevalence rate of osteoarthritis in the knee (16–95%) was higher than that of the hip (2–60%) and ankle (3%). One study by Guten (24) found that 33% of 35 golfers with knee pain were suffering from osteoarthritis, and they had lateral meniscus tears, loose bodies, and chondromalacia patella. Therefore, in this study, sports taping was applied to reduce varus moment, which is the primary factor for generating force in the medial compartment of the knee (55), and the lead knee position was quantitatively analyzed through motion analysis. The finding of this study was that, with the use of sports taping, the low-handicapped golfers who used both the driver and 5-iron club had decreased movement toward knee varus during downswing, but the high-handicapped golfers who used only the driver club had decreased movement toward knee varus during the early phases of downswing. These results of this study may contribute to golf-related knee injury prevention and rehabilitation programs. However, it has been reported that the taping can become loose after 10 minutes and have no beneficial effects after 30 minutes (4,48). Therefore, a future study is necessary to determine the duration of knee taping and compare the effects of sports taping with external support devices of the knee for golfers with knee pain.
This study was designed to identify the effects of sports taping for reducing the varus moment on the lead knee of elite golfers during the golf swing. The movements of knee joint on frontal plane were also shown from the peak of backswing to the finish, which has potential further injuries for golfers' knee. Based on the results of this study, professional and amateur golfers, coaches, and sport practitioners in the field consider the sports taping as strategies to prevent or rehabilitate golf-related knee injuries. They use this information to develop the most appropriate training methods in healthy sports activities.
The authors declare that there is no conflict of interest regarding the publication of this article. This research received no specific funding from any agency in the public, commercial, or not-for-profit sectors.
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