Context: Although taping has been proven effective in reducing ankle sprain events in individuals with chronic ankle instability, insight into the precise working mechanism remains limited. Objectives: To evaluate whether the use of taping changes ankle joint kinematics during a sagittal and frontal plane landing task in subjects with chronic ankle instability. Design: Repeated measure design. Setting: Laboratory setting. Participants: A total of 28 participants with chronic ankle instability performed a forward and side jump landing task in a nontaped and taped condition. The taping procedure consisted of a double “figure of 6” and a medial heel lock. Main Outcome Measures: 3D ankle joint kinematics was registered. Statistical parametric mapping was used to assess taping effect on mean ankle joint angles and angular velocity over the landing phase. Results: For both the forward and side jump, a less plantar flexed and a less inverted position of the ankle joint were found in the preparatory phase till around touchdown (TD) in the taped condition (P < .05). In addition, for both jump landing protocols, a decreased dorsiflexion angular velocity was found after TD (P < .05). During the side jump protocol, a brief period of increased inversion angular velocity was registered after TD (P < .05). Conclusions: Taping is capable of altering ankle joint kinematics prior to TD, placing the ankle joint in a less vulnerable position at TD.

Chronic ankle instability (CAI) is a frequently reported residual pathology as a result of an initial ankle sprain event.1 A prevalence study identified CAI in 23.4% of all high school and college athletes.2 The high prevalence of CAI is caused by a multifactorial underlying mechanism and is believed to be a combination of deficits in proprioception, neuromuscular control, strength, and postural control.3 These deficits predispose individuals with CAI to new episodes of giving way and ankle sprain events. Such ankle sprain events are commonly described as a combination of plantar flexion, inversion, and adduction, leading to damage to the anterolateral capsuloligamentary structures.4 Treatment modalities aim at reducing new events and at increasing functionality using both internal, for example, strength training of the peroneus longus muscle,5 and external, for example, tape or brace,6 therapeutic protective strategies.

Taping is a frequently used external treatment modality in individuals with CAI. The use of tape has been proven to effectively result in a 2- to 4-fold reduction of the ankle sprain incidence, especially in those with a history of an ankle sprain.7 Individuals with CAI may very well present inadequate activation of the peroneus longus rendering them susceptible for injury by failing to recover from an inciting ankle sprain event.8 Therefore, athletes with CAI may find support in the use of tape during sport activities in which high demands are imposed on the ankle joint. The exact working mechanism of taping remains as of yet unclear and has been attributed to mechanical restriction,9 to improved sensorimotor control by potentially affecting proprioception,10 motoneuron pool excitability,11 and lower-leg muscle activity,12 as well as to psychological effects.13

From an ankle sprain mechanism perspective, the main purpose of taping should primarily be to control the ankle inversion and plantar flexion angle during the preparatory and reactive phase during a landing event. As evidenced by cadaver study, increased plantar flexion at touchdown (TD) increases the vulnerability to excessive inversion.14 Furthermore, individuals with CAI have been reported to land with a more inverted ankle joint, which has been suggested to create a vulnerable situation.15 Based on this premise, the effect of taping during the preparatory phase on the ankle joint configuration at TD might play an important role in the ankle sprain mechanism rather than the end range mechanical restriction of joint mobility. This seems logical as studies have shown a decrease of the pure mechanical end range angular restriction when assessed before and after an exercise protocol.16 In addition, tape reduces angular velocity during an ankle sprain event, which permits a relatively greater peroneal activation per degree of motion than an untaped condition in healthy subjects, potentially reducing sprain risk.17 Within the CAI population—and in general—literature on the effect of taping on ankle kinematics at TD is still limited.18,19 Although not at TD, Chinn et al18 have shown, for example, a favorable change in foot position during various time frames of the gait cycle in both the sagittal plane and frontal plane in a taped condition. Delahunt et al19 did show a decreased plantar flexion at the ankle joint just before (50 ms) and at initial contact during a single-leg sagittal plane drop landing. They found, however, no frontal plane effect. Clearly, more research is necessary in this population evaluating the effect of ankle taping on ankle kinematics during the entire impact phase of dynamic tasks in various movement planes.

Therefore, the aim of this study was to evaluate whether changes in landing ankle kinematics (joint angle and angular velocity) during a sagittal and frontal plane landing task could be found from the use of prophylactic taping in individuals with CAI. Our null hypothesis was that both kinematics would not change in the taped condition compared with the nontaped condition.

Methods

Design

This study has a repeated measure design performed in a laboratory setting with the aim of assessing the effect of mean ankle joint angles and angular velocity over the landing phase.

Participants

A total of 28 participants with CAI (10 men and 18 women, age: 22.25 [2.96] y, height: 173.3 [10.1] cm, weight: 71.0 [10.6] kg, body mass index: 23.8 [2.8]; Cumberland ankle instability score: 15.0 [3.7]; foot and ankle disability index: 88.2% [7.2%]; foot and ankle disability sports subscale: 69.0% [9.6%]) participated in this study. All participants had to meet all of the following inclusion criteria: a history of an ankle sprain resulting in prohibiting participation in sport, recreational, or other activities for at least 3 weeks; episodes of giving way; repetitive ankle sprains; feelings of instability and weakness around the ankle joint (Cumberland ankle instability score < 24); recreationally active defined by a minimum of 1.5 hours of cardiovascular activity a week. Exclusion criteria were ankle fracture or surgery, lower-limb complaints at the moment of testing (not related to CAI), and known equilibrium disorders. Study protocol was performed unilaterally. In case of bilateral CAI, the most unstable ankle was selected for screening and analysis based on the lowest Cumberland ankle instability score. This study was performed according to international ethical standards and approved by the Ghent University Hospital ethics committee.20 All participants signed the informed consent at beginning of the study.

Procedures

For the taping procedure, the skin was clean-shaven and covered with an adhesive spray (Tensospray® Hypoallergenic spray; Scott Medical Ltd, Lisburn, Northern Ireland). A 4-cm wide, nonelastic Strappal® tape was used. The applied amount of straps was minimal to be able to evaluate its specific effect on ankle joint kinematics, without locking the entire ankle and foot complex. Two tape straps were chosen that are frequently used in clinical practice, often as reinforcement straps to finish off (eg, a closed basket weave ankle tape or an elastic figure of 8). A double “figure of 6”21 and a single heel lock22 were applied to stabilize the ankle joint (Figure 1) in terms of limiting plantar flexion,14 inversion,15 and eversion23 motion, which are associated with ankle sprains and CAI. Throughout the taping procedure, the foot was held in a neutral 90° position. The “figure of 6” was applied to restrict plantar flexion and inversion of the hind foot. This taping procedure started on the medial side of the foot on the navicular bone going toward the sole of the foot, underneath the calcaneocuboid joint to the lateral side, and then going with tension slightly anterior to the lateral malleolus over the anterior talofibular ligament complex up to the lower leg. Subsequently the tape crossed to the medial side around the tibia, ending with a circular motion around the lower leg (Figure 1). This was then repeated a second time (a 3-cm overlap). To control the eversion motion, a medial heel lock was used. The tape started on the anterior surface of the tibia going laterally above the lateral malleolus, over the insertion of the achilles tendon and calcaneus to the medial side of the calcaneus. Then the tape went underneath the sole of the foot to the lateral edge to come back up and end on the dorsum of the foot. A proximal and distal anchor was added to fixate the tape ends. The same researcher applied all tapes.

Figure 1
Figure 1

—Taping procedure: a double “figure of 6” combined with a medial heel lock (without distal anchor).

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2018-0234

Participants had to perform a barefooted landing from a forward and sideways jump across a hurdle. To avoid learning effect and the influence of fatigue, participants were randomized with a block size of 4 to perform the protocol first with or without tape. The jumping distance was standardized to 40% and 33% of participant’s height for forward and side jump, respectively. Hurdle height was set at 30 cm for the forward jump and 15 cm for the side jump.24 Participants had to push off on both feet and land on the tested limb in the middle of a force plate (250 Hz; AMTI, Watertown, MA). As a warming up exercise for both the nontaped and taped condition, participants were allowed to familiarize themselves with the landing tasks. Participants were allowed to use their arms freely but on landing, they had to place their hands immediately on their pelvis and maintain balance for at least 5 seconds. For the actual testing procedure, 5 successful trials were registered for each of the 2 jump tasks. Trials were discarded if participants did not “stick” the landing, removed their hands from their pelvis, did not take off from both feet simultaneously, touched the ground with the contralateral leg, or pushed their legs together to maintain balance. All participants first performed the forward landing, followed by the side landing. A rest period of 30 seconds was used between trials, 3 minutes between jump tasks, and 10 minutes between conditions.

Three-dimensional kinematics was registered with an 8 camera optoelectronic setup (250 Hz, Oqus; Qualisys, Gothenburg, Sweden). Spherical reflective markers (12 mm) were placed on the lower limb—lateral malleolus, medial malleolus, lateral epicondyle, medial epicondyle, and a cluster of 4 on the lateral side of the leg—and on the foot/ankle complex—calcaneus, and first and fifth metatarsal head—to capture ankle motion.25

Kinematic and kinetic data were processed using Visual3D (C-Motion Inc, Germantown, MD). Marker data were filtered using a fourth-order Butterworth low-pass filter of 15 Hz and force data using a critically damped low-pass filter at 15 Hz. Euler rotations were used to calculate joint motion. Rotation around the x-, y-, and z-axis defined, respectively, plantar-/dorsiflexion, in-/eversion, and ab-/adduction. The force plate was used to detect TD with a threshold for the vertical component set at 15 N. Joint angular position and joint angular velocity were calculated for the landing phase defined from 200 milliseconds prior to and 200 milliseconds after TD.26 Data were then normalized to 101 data points over this time period.

Statistical Analysis

The total amount of trials needed to perform 5 successful trials for the taped and nontaped condition were compared using paired sample t tests (α = .05) for both the forward and the side jump. To compare ankle kinematics (ankle position and velocity) between the taped and nontaped condition, a curve analysis by means of 1-dimensional statistical parametric mapping was performed. Statistical parametric mapping allows the calculation of the traditional t statistics over the entire normalized time series. For this analysis, paired sample t tests were performed, with α = .05. The use of statistical parametric mapping is no longer new to the field of biomechanics, and we therefore refer to detailed descriptions and validations of this method elsewhere.27,28

Results

Three participants (2 females and 1 male) reported discomfort during the testing procedure, and their data were discarded for further analysis. There were no significant differences in the amount of trials needed to perform 5 successful trials between the taped and nontaped condition for both the forward (P = .63) and the side jump (P = .91).

During the forward jump (Figure 2), for the taped compared with the nontaped condition, a significantly (P < .05) less plantar-flexed ankle joint was found between 84 milliseconds prior to and 24 milliseconds after TD (average difference of 3.12°), a less inverted joint angle between 76 and 16 milliseconds prior to TD (average difference of 1.56°), and a less abducted joint angle between 200 to 136 milliseconds (average difference of 2.21°) prior to and 92 to 104 milliseconds (average difference of 1.61°) after TD. In addition, a significantly decreased dorsiflexion angular velocity was observed after TD between 4 to 20 milliseconds (average difference of 60.50 deg/s) and 92 to 104 milliseconds (average difference of 36.99 deg/s), and a significantly decreased eversion angular velocity between 60 and 68 milliseconds (average difference of 26.44 deg/s) after TD for the taped compared with the nontaped condition.

Figure 2
Figure 2

—Tape effect on ankle kinematics during the forward jump. Mean kinematic trajectories (joint angle and angular speed) with SD clouds with underneath the SPM results are presented for the ankle joint. SPM{t} is the trajectory of the paired sample t statistic. The dotted horizontal line indicates the random field theory threshold for significance. Any clusters of SPM{t} that exceeded this threshold were considered significantly different at the level of P < .05, visualized in gray. ABD indicates abduction; ADD, adduction; DF, dorsiflexion; EV, eversion; INV, inversion; PF, plantar flexion; SPM, statistical parametric mapping; TD, touchdown.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2018-0234

During the side jump, for the taped compared with the nontaped condition, a significantly (P < .05) less plantar-flexed ankle joint was found between 64 milliseconds prior to and 8 milliseconds after TD (average difference of 2.07°), a less inverted joint angle between 72 milliseconds prior to and 24 milliseconds after TD (average difference of 2.57°), and a less abducted joint angle between 168 and 112 milliseconds prior to TD (average difference of 2.01°) for the side jump (Figure 3). In addition, a significantly decreased dorsiflexion angular velocity after TD was found between 8 and 36 milliseconds (average difference of 72.03 deg/s), and a significantly increased inversion angular velocity between 20 and 24 milliseconds (average difference of 72.03 deg/s) and decreased eversion velocity at 68 milliseconds (average difference of 23.34 deg/s) after TD for the taped compared with the nontaped condition.

Figure 3
Figure 3

—Tape effect on ankle kinematics during the side jump. Mean kinematic trajectories (joint angle and angular speed) with SD clouds with underneath the SPM results are presented for the ankle joint. SPM{t} is the trajectory of the paired sample t statistic. ABD indicates abduction; ADD, adduction; DF, dorsiflexion; EV, eversion; INV, inversion; PF, plantar flexion; SPM, statistical parametric mapping; TD, touchdown.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2018-0234

Discussion

The aim of our study was to evaluate the effect of ankle taping on ankle joint landing kinematics in participants with CAI. Our results showed that the tape straps we applied were capable of altering the ankle joint position during the landing phase before and at TD. Our null hypothesis could therefore be rejected. For both jump directions, there was decreased plantar flexion and inversion position around the TD event. Although unclear whether based on mechanical restriction or changes in sensorimotor control, our study results confirm the potential of taping of influencing joint position before and at TD. After TD, the effect rapidly disappeared. As these adaptations have an obvious impact on the factors contributing to the ankle sprain mechanism, our study results suggest that altering the landing position might be one the underlying mechanisms for the preventative effect of taping on ankle sprain events in chronically unstable ankles.

Overall, both forward and side landings showed less plantar-flexed ankle joint configuration during approximately the last 75 milliseconds prior to TD, which dissipated immediately after initial contact. These results coincide with the study of Delahunt et al19 indicating a decreased plantar flexion at 50 milliseconds before and at TD during a frontal plane vertical drop in individuals with CAI. In view of the previously cited study of Wright et al14 on the importance of the effect of ankle plantar flexion on injury vulnerability, this can be clearly considered as a protective mechanism. This means that our “figure of 6” tape effectively affects sagittal plane ankle position in the unloaded landing approach. One could easily argue that this demonstrates a mechanical restriction, yet it is still possible that in more plantar-flexed joint angles more tension on the tape also triggers the sensorimotor system to a greater extent.

As opposed to Delahunt et al,19 we did find an effect of our tape straps on frontal plane landing kinematics. We found a reduced inverted position for both the forward and the side jump during approximately the last 75 milliseconds prior to TD. This effect can be again considered a protective mechanism in view of ankle sprain kinematics assuring a favorable ankle configuration at TD. As in the sagittal plane, the kinematic difference disappeared rapidly after TD with loading of the ankle joint. These acting ground reaction forces after landing push the ankle joint into the “normal” joint trajectory. In addition, we applied a medial heel lock to control frontal plane motion for eversion as well, as there is evidence for increased eversion associated with respectively ankle sprains23 and CAI.29 If we look at our eversion motion after TD, we do observe positive t values indicating a presumably small effect (average difference of 0.6° and 0.1° after TD for, respectively, the forward and side jump) based on our heel lock tape after TD, although not reaching the significance level.

In addition, while taping results in desirable alterations in joint landing configuration joint, our results showed differences in angular velocity between the taped and untaped condition. In the sagittal plane, joint angular velocity toward dorsiflexion immediately after TD is significantly reduced in the taped condition. This might be considered as a normal consequence seen that after TD the foot is pushed into the normal dorsiflexion motion but starting from a decreased plantar-flexed position with less angular distance to be traveled. Similarly, side jump results showed an increased inversion angular velocity immediately after TD. Although we would have expected this velocity to be lower based on the taping procedure, our data clearly suggest that in the loaded position our tape effect disappears. Figure 3 shows that after TD during a side jump, the ankle joint first moves further toward inversion for a short period before everting, consistent with previously reported ankle kinematics.30 As the foot position at TD was less inverted in the taped condition before moving toward the maximum inverted position, this difference had to be bridged resulting in the higher velocity. Therefore, the benefits of altered ankle configuration may well be inadvertently compromised by increased joint angular velocities. Nonetheless, it appears that the improved joint landing configuration has a greater benefit than if one were to try to reduce joint angular velocities by landing in a joint angular configuration that is closer to the maximum inverted position during stance. The observed angular inversion velocity in the taped condition is also not close to speeds documented from real ankle sprain events, going from 509 to 1488 deg/s.31

Although our tape favorably corrected joint position at TD, the ground reaction forces imposed after TD wiped out the prelanding taping kinematic effect. These ground reaction forces were clearly higher than what the mechanical restriction of the limited tape straps could withstand. Especially for the frontal plane kinematics during the side jump, results showed no decreased maximal inversion after TD, although foot position was favorably corrected before and at TD. These results support the idea of the effect of taping on altering joint positions at TD as an underlying working mechanism. In this theory, the tape prohibits malalignment at the moment of TD, potentially avoiding malicious potency of ground reaction forces when the joint is placed in a vulnerable position.

Several limitations have to be borne in mind. As we only included subjects with CAI without comparison to a healthy population, we cannot claim that the observed kinematic effect is specific for this population nor that it is a general effect. Furthermore, we only used a minimal amount of straps. In clinical practice, a combination of several taping techniques is frequently used, especially when engaging a sporting activity in which higher demands are imposed on the ankle joint. It should be further explored if such taping protocols which have a higher locking effect on the ankle joint have a similar effect on the angular position of the ankle joint prior to, at, and also after TD. However, as these straps are frequently used in clinical practice in addition to, for example, a figure of 8 elastic tape, we believe our results to be transferable to clinical practice. In addition, in our study, the effect of sporting activities over time on the restrictive effects of the tape has not been accounted for. Several studies have shown that tape loses some of its mechanical restrictions.16 It would be interesting to see if prolonged load changes the landing kinematics in the taped condition or if its assumed sensorimotor control effect remains. Incorporating electromyography will increase insight into the neuromuscular effect of tape. Finally, this study was performed barefooted, which could have influenced landing kinematics. This was chosen as the effect of footwear on ankle joint kinematics may be influenced by the applied tape, for example, due to alterations to in-shoe friction and/or pressure distributions, making inferences around the isolated taping effect void. This should be also addressed in future research.

Conclusions

Our study shows that even limited tape straps are capable of altering ankle joint kinematics prior to TD during the landing phase of a forward and side jump landing task. This is believed to be crucial in the ankle sprain mechanism as inappropriate positioning before and at impact might leave the ankle joint susceptible to injury.14 Although unclear whether based on mechanical restriction or changes in sensorimotor control, our study results confirm the potential of taping for influencing joint position before and at TD.

These findings strengthen the assumption that—at least in part—the underlying working mechanism of prophylactic ankle taping, when used in patients with chronic ankle stability, is that it benefits the joint configuration at TD.

Acknowledgment

The authors have no conflicts of interest to disclose.

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De Ridder, Willems, De Blaiser, and Roosen are with the Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. Vanrenterghem is with the Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium. Verrelst is with Human Physiology Research Group, Faculty LK, Vrije Universiteit Brussel, Brussels, Belgium.

De Ridder (Roel.DeRidder@ugent.be) is corresponding author.
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    —Taping procedure: a double “figure of 6” combined with a medial heel lock (without distal anchor).

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    —Tape effect on ankle kinematics during the forward jump. Mean kinematic trajectories (joint angle and angular speed) with SD clouds with underneath the SPM results are presented for the ankle joint. SPM{t} is the trajectory of the paired sample t statistic. The dotted horizontal line indicates the random field theory threshold for significance. Any clusters of SPM{t} that exceeded this threshold were considered significantly different at the level of P < .05, visualized in gray. ABD indicates abduction; ADD, adduction; DF, dorsiflexion; EV, eversion; INV, inversion; PF, plantar flexion; SPM, statistical parametric mapping; TD, touchdown.

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    —Tape effect on ankle kinematics during the side jump. Mean kinematic trajectories (joint angle and angular speed) with SD clouds with underneath the SPM results are presented for the ankle joint. SPM{t} is the trajectory of the paired sample t statistic. ABD indicates abduction; ADD, adduction; DF, dorsiflexion; EV, eversion; INV, inversion; PF, plantar flexion; SPM, statistical parametric mapping; TD, touchdown.

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