Research Review By Jessica Sleeth©

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Date Posted:

September 2011

Study Title:

Effect of ankle taping on knee and ankle joint biomechanics in sporting tasks

Authors:

Stoffel KK, Nicholls RL, Winata AR et al.

Author's Affiliations:

Department of Orthopedic Surgery, Fremantle Hospital, Fremantle Western Australia; School of Sports Science, Exercise and Health, The University of Western Australia

Publication Information:

Medicine & Science in Sports & Exercise 2010; 42(11): 2089-2097.

Background Information:

Prophylactic ankle taping is common with many athletes, particularly those with previous ankle injuries. Although the efficacy is debated, there is evidence that ankle taping reduces the incidence and severity of sprain injuries, with a greater reduction in frequency of injury for those with a history of ankle sprains (1). Taping reduces the range of motion (ROM) at the tibiotalar and subtalar joints to help stabilize the ankle, but some feel it may subsequently increase the risk of injury to the knee.

Knee injuries are generally more severe than ankle injuries and may be more traumatic to athletes. A common knee injury is rupturing of the anterior cruciate ligament (ACL), which can occur in almost any sport – both contact and noncontact. Research shows that high quadriceps extension forces combined with internal rotation is a main cause of ACL injuries (2). To date, there is limited research investigating a potential relationship between ankle taping and knee injuries.

The goal of this practical study is to compare knee joint biomechanics during running and cutting tasks performed with and without ankle taping. To mirror typical sport injury scenarios (specifically in Australian football), data was collected in planned and unplanned conditions. The authors hypothesize that ankle taping will increase knee joint loading and decrease peak knee flexion during all tasks; and that taping will reduce the peak joint angles, ROM, and ankle joint movements.

Pertinent Results:

With ankle tape, both planned and unplanned running and sidestep trials showed significantly reduced peak internal rotation and peak varus moments at the knee. Sidestepping trials (thought to produce the most ACL injuries) with tape showed 18% less peak internal rotation in both planned and unplanned trials.

Ankle taping reduced ankle abduction and adduction ROM for both running and sidestepping trials – with the greatest reduction in unplanned trials (19% compared to 10% planned). Inversion and eversion ROM and peak inversion angle were also reduced in the running trials, but not significantly in the sidestepping trials. Peak dorsiflexion/plantarflexion moments were increased during sidestepping trials with tape (13% planned, 22% unplanned), while the mean eversion moment in unplanned trials was reduced by 26%. Peak varus moment and varus impulse (also associated with risk of ACL injury) were higher during planned trials, compared to unplanned. Peak varus moment was 4-6% higher for planned running trials, compared to unplanned. It was also 18-22% higher for sidestepping trials. The authors conclude that ankle tape significantly reduced the peak knee varus moment in both planned and unplanned trials. Internal rotation impulse at the knee was greater during unplanned sidestepping trials with ankle tape. Similarly, ankle dorsiflexion/plantarflexion ROM increased for all unplanned running trials. Ankle tape decreased peak ankle eversion by 16% during the planned sidestepping trials and decreased dorsiflexion/plantarflexion ROM by 30% when running.

In general, sidestepping produces more external moments at the knee joint than running. The authors measured peak internal rotation moment, valgus impulse, and peak valgus moment, which were 50%, 77%, and 78% higher for unplanned sidestepping than running trials, respectively. A greater ROM occurred for dorsiflexion/plantarflexion (22-38%) and inversion/eversion (15-48%) during sidestepping. In the sidestepping trials peak abduction and eversion moments were significantly higher, while during the running trials peak dorsiflexion, eversion, and the peak dorsiflexion moment were greater.

Clinical Application & Conclusions:

The authors determined that ankle taping provides protective benefits to the knee during running by reducing internal rotation, varus moments and varus impulses. Thus, their results differ from their original hypothesis that ankle taping would increase knee joint loading. The results complement previous studies that demonstrated positive associations between ankle bracing and knee joint loading. Lloyd (2001) found that trials with ankle bracing resulted in more knee flexion, at initial ground contact, which reduces ACL injury (4). ACL injury occurs with flexion combined with peaks in internal rotation, and varus/valgus moments typically seen in sidestepping movements. This study demonstrated increased valgus and internal rotation moments at the knee joint in sidestepping compared to running trials. In both planned and unplanned trials, taping reduced both peak internal rotation and varus moments.

The study results indicate that varus and internal rotation moments were reduced during unplanned running and sidestepping trials and internal rotation impulse decreased during unplanned sidestepping. Ankle taping can also significantly decrease knee and ankle joint loads during planned actions. Significant differences in peak varus moment during both planned running and sidestepping tasks with varus and internal rotation impulse also decreased during taped sidestepping trials. Ankle taping may provide multiple benefits for athletes, since almost all sporting activities involve planned and unplanned movements. The benefits may be partly mechanical (reduction in ankle dorsiflexion/plantarflexion ROM) and proprioceptive (not measured in this study, but previously linked to reduced lower-limb loading). The authors suggest further research, particularly involving proprioception.

The authors caution against the assumption that ankle taping provides complete protection to the knee. Increased valgus impulse was seen during sidestepping trials with ankle tape, which can increase ACL loading (this was not a statistically significant result in this study, however). Modifications to foot position and angle can affect the point of application of ground reaction forces, knee joint movement, and ACL strain (5). It is also possible that ankle taping can change an athlete’s technique, thus increasing joint loads (6).

A Cochrane Review (2005) evaluated 14 randomized trials of ankle bracing, with results demonstrating that external ankle support was associated with a reduction in ankle sprains. The authors suggest, from the results of this study, that the prophylactic benefits of ankle taping may be task-specific. For example, all trials showed reduced peak ankle inversion angle (inversion accounts for 75% of ankle strain injuries), but when analyzed separately, ankle taping did not positively influence peak inversion while sidestepping.

The influence of ankle taping on knee injuries is complex and may depend on multiple factors, such as injury history, physical conditioning and dynamic movement strategies of the athlete, footwear, and environmental conditions. It is necessary to further investigate the effect of ankle taping on the knee joint by analyzing muscle activation patterns and comparing previously injured participants to those without knee or ankle injuries. The authors conclude the article by stating: “…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.”

Study Methods:

Participants:
  • 22 males, average 22.1 ± 2.3 years old
  • Semiprofessional or elite experience playing Australian Rules Football
  • Players with history of knee or ankle surgery excluded from study
Data Collection Method:
  • 38mm self-adhesive ankle tape applied to dominant leg by the same athletic trainer for all participants. Taping method used is described in Sports Medicine Australia trainer’s manual
  • Used established motion analysis procedures (3), which includes retroreflective markers on bony landmarks
  • Participants were given a 10 minute warm-up and practice period. Then, in random order, subjects performed repeated trials of a straight run, a 45 degree sidestep, and a 45 degree crossover cut. Data from crossover trials not was analyzed (used to reduce anticipation of sidestep)
  • Tasks were completed on an indoor runway, 20m long by 15m wide, with the analysis force plate located at the 15m mark
  • The researchers used a target board to alert the participant to the task. Prior to beginning the trial, planned tasks were available on the target board. Participants were alerted to unplanned tasks 400ms before reaching the force plate (determined that 400ms was enough time for the participant to complete the action, but have it be virtually unplanned)
  • Participants performed all 3 tasks (36 trials total) with ankles taped and untaped (order drawn at random) and tasks planned or unplanned
Data Analysis:
  • Ankle joint centers determined by markers on medial and lateral malleoli. A 6-marker pointer was used to identify the 3-dimensional location of the medial and lateral femoral epicondyles of each leg
  • Kinematic and inverse dynamic calculations performed in VICON Workstation and Bodybuilder
  • Kinematic and kinetic parameters for the ankle and knee joints calculated for the weight acceptance phase of the stance (heel strike to first trough)
  • Knee kinematic parameters analyzed: peak and average knee flexion angle. Ankle kinematic parameters analyzed: peak dorsiflexion and plantarflexion joint angles, dorsiflexion/plantarflexion ROM, peak abduction and adduction joint angles, abduction/adduction ROM, peak inversion and eversion joint angles, and inversion/eversion of ROM
  • Kinetic parameters calculated for the knee: peak varus and valgus moments, peak internal rotation moments, average flexion/extension moments and varus/valgus moment impulses. Kinetic parameters determined for the ankle: peak dorsiflexion/plantarflexion moments, peak abduction/adduction moments, peak eversion/inversion moments, and the corresponding impulses
  • Participant data for each parameter was grouped and averaged for each trial
  • Statistical analysis completed with SPSS software
  • 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 ANOVA, with significance set at P<0.05. em="">Post hoc tests with Bonferroni correction used to evaluate the interaction of ankle tape with condition or task

Study Strengths / Weaknesses:

The authors report the following study suggestions for future work based on some weaknesses of this study that could be modified for further trials:
  • Enroll participants with previous knee and ankle injuries and compare to those without.
  • Take into account the effects of ankle tape over time – research shows that the effectiveness decreases considerably after 10-20 minutes of exercise. The testing was 20-30 minutes, therefore may not reflect true conditions of game. (EDITOR’S NOTE: I think this is a huge factor with ankle taping. As a former competitive volleyball player, I can say that even the best ankle tape job loses its effectiveness in a short time. It might be interesting to also compare more rigid braces to taping in similar conditions.)
  • The study only included men with elite experience with Australian Rules Football. It is well established that the incidence of reported noncontact ACL injuries is more frequent in women, thus further trials should definitely include women.
  • Data collection and analysis relied solely on the dominant foot, which is potentially the more skilled foot, thus under-representing injury potential.

Additional References:

  1. Bahr R, Lian O, Bahr IA. A two-fold reduction in the incidence of acute ankle sprains in volleyball after the introduction of any injury prevention program: A prospective cohort study. Scand J Med Sci Sports 1997; 7(3):172-177.
  2. Chomiak J, Junge A, Peterson L, Dvorak J. Severe injuries in football players. Influence factors. Am J Sports Med 2000; 28(5 suppl):s58-68.
  3. Besier Tf, Lloyd DG, Ackland TR. Muscle activation strategies at the knee during running and cutting maneuvers. Med Sci Sports Exerc 2003; 35(1):119-127.
  4. Lloyd DG. Rationale for training programs to reduce anterior cruciate ligaments in Australian football. J Orthop Sports Phys Ther 2001; 31(11):645-654.
  5. Besier TF, Lloyd DG, Ackland TR, Cochrane JL. Anticipatory effects on knee joint loading during running and cutting maneuvers. Med Sci Sports Exerc 2001; 33(7):1176-1181.
  6. Dempsey AR, Lloyd DG, Elliot BC, Steele JR, Munro BJ. Changing sidestep cutting technique reduces knee valgus loading. Am J Sports Med 2009; 37(6):2194-2200.