eMedicine Specialties > Sports Medicine > Foot and Ankle

Ankle Taping and Bracing

Douglas A Reeves Jr, MD, Team Physician, Clemson University, Clemson, South Carolina
T Jeff Emel, MD, Director, Department of Sports Medicine, Eastern Oklahoma Orthopedic Center

Updated: Apr 28, 2009

Introduction

Ankle sprains are the most common sports-related injuries in the United States, accounting for an estimated 2 million injuries per year.¹  This correlates to significant time away from games and practices. A practical method of decreasing the number and severity of these injuries would obviously be of great benefit. For this reason, the concept of prophylactic ankle wrapping was introduced more than 60 years ago.² The purpose of this article is to review the mechanics of ankle taping and to discuss ankle bracing.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains - First Aid and Emergency Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

Related eMedicine topics:
Ankle Fracture
Ankle Injury, Soft Tissue 
Ankle Sprain
Dislocation, Ankle
Recurrent Ankle Sprains

Background

Ankle sprains occur in nearly all types of sporting events. To understand ankle sprains, one must first understand ankle anatomy. The ankle joint (or talar joint) has 3 bones and 3 groups of stabilizing ligaments. The talus articulates in a hinge fashion with both the tibia and the fibula. The distal tibia and fibula are stabilized by the tibiofibular ligaments (anterior and posterior), also known as the syndesmosis.

The thick deltoid ligament supports the medial aspect of the ankle and helps to limit eversion. The medial ankle is inherently more stable than the lateral ankle and is, therefore, the site of fewer injuries. Most ankle sprains are inversion injuries involving either complete or partial tearing of the lateral ligament complex, which is composed of 3 distinct ligaments: the anterior talofibular, the calcaneofibular, and the posterior talofibular. These ligaments are usually injured in a sequential fashion from anterior to posterior, depending on the severity of the inversion.

In contrast to previous beliefs, rapid lateral body movement actually accounts for relatively few inversion sprains. Most ankle sprains occur when landing from a jump, with the foot in an inverted, plantar-flexed position.^1,3,4,5 Several studies support the theory that ankle sprains frequently involve disruption in ankle proprioception preventing the ankle from being able to protect itself. Eversion ankle sprains, on the other hand, are usually are not related to inadequate proprioception but are the result of outside forces (eg, contact with another player).

Studies examining the effectiveness of external ankle stabilization have had conflicting results. Some reports show no change in injury rates, most have found at least some decrease in inversion sprains although the mechanism for this protection is still somewhat unclear. It seems logical that external devices should increase the structural stability of the ankle (ie, "stiffen the ankle joint") and make the ankle less susceptible to inversion. Although this is true to some extent, at least one study has shown that regular taping can lose most of its supportive effect after only short periods of exercise.

How, then, do taped ankles or braced ankles decrease the incidence and severity of sprains in taped or braced athletes? The answer most likely lies in a study by Robbins, which found that taped participants had improved proprioception both before and after exercise compared with untaped controls.⁶ The author theorized that the traction and/or pressure imparted to the skin of the foot and ankle via taping or bracing provided improved sensory input and, thus, improved proprioception, resulting in fewer ankle sprains.

Another study comparing the neuromuscular properties of taped versus untaped ankles introduced a measure known as the proprioceptive amplification ratio (PAR).⁷ This number incorporates neuromuscular properties such as proprioception and degree of mechanical stress. These results indicated that taping did provide increased ankle protection.

Another common concern often expressed by the public is that prolonged taping or bracing of the ankle results in weak ankles that then become more prone to injury; this would obviously be a strong case against the use of ankle taping or ankle bracing. However, Cordova et al studied the effects of consistent ankle brace use on the peroneus longus muscle, an important stabilizer of the ankle, particularly against inversion, the most common type of ankle injury.⁸  This study showed that peroneus longus latency to inversion was not changed by the prolonged wearing of an ankle brace.

Taping

Skin preparation  

Several different methods of skin preparation are used in today's athletic training rooms. The most common is to simply clean and dry the lower leg, ankle, and foot. A layer of prewrap (a thin, foamlike material) is applied to the area to be taped. Some athletes prefer to shave the hair from around the area and to have the tape applied directly to the skin. A quick drying adherent is recommended and may be sprayed onto the skin to allow for better tape adhesion. Often, heel and lace pads (foam squares with petroleum jelly or other lubricant) are applied to areas of high friction (ie, the dorsum of the ankle and the distal Achilles tendon) to prevent blisters.

General principles of ankle taping⁹

• Learn how to tear the tape. It can be difficult and frustrating at first, but, with practice, tearing tape becomes quite simple. Hold the tape between the thumb and index finger of each hand with little to no gap between the thumbs. Quickly pull the hands in opposite directions to complete the tear.
• Avoid tape wrinkles as these can lead to blisters and discomfort. First, smooth the tape while it is being applied, as you do not get a second chance. Second, learn to use the angles naturally supplied by the body part. Forcing the tape in a direction it does not want to go only serves to increase wrinkles and makes the taping less effective.
• In general, tape strips should overlie each other by about one half the width of the tape. Each area should be covered by 2 layers of tape. Uncovered areas within the taped ankle lead to blisters.
• Do not use excessive force when applying tape. Constriction of blood flow is possible when tape is applied too tightly.

Types of tape

Many different types of athletic tape are manufactured. For standard ankle application, the tape of choice is 1.5- or 2-in (3.8- or 5.1-cm) white, porous, athletic tape or nonelastic tape.

Tape Application

Position

The ankle should be in the neutral position (90°). The athlete should be seated comfortably, with the knee at full extension and only the distal half of the lower leg off the table (see Images 1-2).

Preparation

See Skin preparation.

Realizing that some steps are optional, prepare for taping as follows: (1) clean and dry the skin, (2) apply tape adherent, (3) apply heel and lace pads, and (4) apply prewrap from the midfoot to one third of the way up the lower leg.

Procedure

There are several variations on a standard tape application for the ankle. The following is one of the more commonly used techniques taught to undergraduate athletic trainers:

1. Place anchor strips (2 or 3) approximately one third of the way up the lower leg below the bellies of the distal aspect of the gastrocnemius. This is the proximal tape anchor. Place a distal anchor around the midfoot. These anchors may be partially taped directly to the skin to provide increased adherence (see Image 3).
2. Now, apply the first stirrup (see Image 4). Start this strip at the medial side of the upper anchors, go down over the medial malleolus, cross under the foot, come up over the lateral malleolus, and end on the lateral side of the anchors. The theory behind this is to tape the foot more in eversion than inversion so that one does not predispose an athlete to injury.
3. Next, apply a horseshoe by taping from the inside of the midfoot anchor, back across the Achilles tendon, and ending on the outside of the anchor (see Image 5).
4. Repeat the stirrup and horseshoe 2 more times each, moving the position of each by one half the width of the tape; this should produce a basket-weave appearance. The first stirrup covers the posterior half of the malleoli, the second covers the middle of the malleoli, and the third covers the anterior half.
5. Place closure strips (usually 5 or 6). Start at the malleoli and work up. An additional 1 or 2 strips may be needed to enclose the midfoot. After this step, no areas within the body of the tape job should be uncovered except for the posterior portion of the heel, which is not to be taped.
6. Figure of 8: Start at the dorsum of the ankle. Go medially around the bottom of the foot and back up to the dorsum. Proceed around the back of the leg and finish at the starting point. Imagine a figure 8 bent about 60^o in the middle (see Image 6).
7. Lateral heel lock: Start with the tape anterior to the lateral malleolus. Go medially across the dorsum of the foot aiming for the longitudinal arch. Proceed across the plantar aspect of the foot to just posterior to the base of the 5th metatarsal. Now go up and posterior on the lateral side of the calcaneus, across the Achilles tendon and its insertion on the calcaneus. Go around to the medial side of the ankle, partially overlapping the malleolus. Finish on the anterior aspect of the ankle, and tear the tape (see Images 7-9).
8. Medial heel lock: The heel locks are the most difficult part of the tape job to apply and often take practice to master. Start anterior to the medial malleolus. Go down on the lateral side to where the other strip is coming up to go posteriorly around the calcaneus. Proceed straight across the plantar aspect of the foot to the longitudinal arch. Go up and posterior on the medial side of the calcaneus, across the Achilles tendon and its insertion on the calcaneus. Next, go around the lateral side of the ankle, partially covering the malleolus. Finish on the anterior aspect of the ankle, and tear the tape.
9. Repeat both the lateral and medial heel lock one more time each. Heel lock application techniques are varied. The above is a commonly accepted example.
10. Final closure strips: Apply final circular strips around the foot and lower leg as needed to tidy up the tape job and to ensure that no open spaces or weak spots are present (see Image 10).

Variations

The standard tape job described has many variations. To discuss them all would go beyond the scope of this article; therefore, only a few of the simpler changes are mentioned.

• Many athletic trainers are beginning to use a tape known as power tape in their ankle applications. Power tape has a higher tensile strength and is more water resistant than traditional white tape. However, it has the disadvantage of being harder to tear.
• Elastic tape may be used for the heel locks, or it may be used to reinforce the normal heel locks. This is often reported as both more comfortable for the athlete or to give the athlete a sense of more stability.
• Another variation uses 1.5-in (3.8-cm) moleskin strips for stirrups and is referred to as "power strapping."  This is often used on previously injured ankles.
• Another taping variation that should be mentioned is that of ankle "spatting," which is placing tape on the outside of the sock and shoe. Although this may provide minimal external support, it does not have the same efficacy as regular ankle taping or bracing and is, therefore, not recommended for use by itself.
• The most recent variation in ankle taping is to replace prewrap with "flex" tape. This tape is more durable than prewrap and resembles elastic tape, but flex tape is adherent only to itself and not to skin. In some training rooms, this type of tape is being incorporated more and more into the ankle application with less use of white athletic tape.

Ankle Bracing

The concept of ankle bracing evolved from ankle taping. Braces are being used instead of traditional taping by many athletes at all levels of competition. They offer several advantages in that they are self-applied, reusable, and readjustable. In the long run, they are likely more cost-effective than taping.^1,9,10,11,12

Braces generally come in 2 types, although small variations exist depending on the manufacturer. The first is nonrigid and resembles a thick canvas or nylon lace-up sock. Some nonrigid braces are also made of neoprene. The nonrigid style imparts some compression to the ankle and may help in injury prophylaxis but provides little medial or lateral stability to the ankle.

The second type of ankle brace is the semirigid. Its construction is similar to the nonrigid but with the added feature of molded plastic struts or air cushions. These are incorporated into the medial and lateral sides of the brace, similar in orientation to the stirrups used in ankle taping. These braces provide more stability and are often are chosen during the rehabilitation and return-to-play phases of ankle injury.

Most nonrigid and semirigid braces also use fabric straps to simulate heel locks. These are usually on the outside of the brace and fastened with Velcro.

Many athletes do not feel as comfortable or as stable wearing braces relative to taping, which can be a disadvantage to treatment. Braces also can become torn or lost and require replacement.

Many studies have been completed comparing taping versus bracing of the ankle to try and determine which is the better method. Prospective studies have met with difficulty in controlling all of the variables associated with ankle injuries (eg, playing surface, shoe wear, individual inherent stability, intensity of competition on both a team and individual level). Most have shown that braces are slightly more effective than taping but that both are better than no support. One interesting study found that simply wearing high-top instead of low-top shoes prevented some ankle injuries and that high tops plus taping had more than 50% fewer injuries than low tops plus taping.

The CAST trial was a randomized controlled trial designed to estimate the clinical effectiveness and cost-effectiveness of 3 methods of ankle support compared with double-layer tubular compression bandage.¹³ Results of the study showed that the below-knee cast and the Aircast brace offered cost-effective alternatives to tubular bandage for acute severe ankle sprains, with the below-knee cast having the advantage in terms of overall recovery at 3 months. Because no differences in long-term outcome were noted, the investigators suggest that practitioners should consider likely compliance and acceptability to patients when choosing a brace.¹³

Summary

Ankle taping and bracing are fixtures of both athletic training and sports medicine.^9,14 Although studies regarding effectiveness and technique are not all in agreement, it seems clear that bracing or taping of the ankle will continue to be a mainstay in the prepractice and precompetition routine.

The sports medicine physician should understand the concepts and techniques of ankle bracing and taping so that advice and guidance can be offered to athletes and athletic training staff. Ankle bracing and taping should not be used in place of aggressive rehabilitation, including strengthening and proprioceptive exercises. Rather, both should be used in conjunction with rehabilitation in terms of injury prevention.

Multimedia

Media file 1: Ankle taping and bracing. Correct position: Note the foot at 90º with athlete seated comfortably.

Media file 2: Ankle taping and bracing. Lateral view of correct position. In this picture, heel and lace pads are already in place.

Media file 3: Ankle taping and bracing. Anchor strips. Note the placement of tape along natural angles of the calf to avoid wrinkles.

Media file 4: Ankle taping and bracing. First stirrup. Note the medial-to-lateral direction of placement.

Media file 5: Ankle taping and bracing. First horseshoe.

Media file 6: Ankle taping and bracing. Figure of 8.

Media file 7: Ankle taping and bracing. First step of lateral heel lock.

Media file 8: Ankle taping and bracing. Second step of lateral heel lock.

Media file 9: Ankle taping and bracing. Final step of lateral heel lock.

Media file 10: Ankle taping and bracing. Completed tape job.

References

1. Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20. [Medline]. [Full Text].

2. Quigley TB, Cox J, Murphy J. A protective wrapping for the ankle. JAMA. 1946;123:924.

3. Bahr R, Karlsen R, Lian O, Ovrebø RV. Incidence and mechanisms of acute ankle inversion injuries in volleyball. A retrospective cohort study. Am J Sports Med. Sep-Oct 1994;22(5):595-600. [Medline].

4. Rifat SF, McKeag DB. Practical methods of preventing ankle injuries. Am Fam Physician. Jun 1996;53(8):2491-8, 2501-3. [Medline].

5. Robbins S, Waked E, Rappel R. Ankle taping improves proprioception before and after exercise in young men. Br J Sports Med. Dec 1995;29(4):242-7. [Medline]. [Full Text].

6. Robbins S, Waked E. Factors associated with ankle injuries. Preventive measures. Sports Med. Jan 1998;25(1):63-72. [Medline].

7. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med. Jan-Feb 1999;27(1):69-75. [Medline].

8. Cordova ML, Cardona CV, Ingersoll CD, Sandrey MA. Long-term ankle brace use does not affect peroneus longus muscle latency during sudden inversion in normal subjects. J Athl Train. Oct 2000;35(4):407-411. [Medline]. [Full Text].

9. Johnson GB. Athletic taping and bandaging. In: Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Philadelphia, Pa: Lippincott- Raven; 1998:635-8.

10. Pedowitz DI, Reddy S, Parekh SG, Huffman GR, Sennett BJ. Prophylactic bracing decreases ankle injuries in collegiate female volleyball players. Am J Sports Med. Feb 2008;36(2):324-7. [Medline].

11. Mickel TJ, Bottoni CR, Tsuji G, et al. Prophylactic bracing versus taping for the prevention of ankle sprains in high school athletes: a prospective, randomized trial. J Foot Ankle Surg. Nov-Dec 2006;45(6):360-5. [Medline].

12. Hume PA, Gerrard DF. Effectiveness of external ankle support. Bracing and taping in rugby union. Sports Med. May 1998;25(5):285-312. [Medline].

13. [Best Evidence] Cooke MW, Marsh JL, Clark M, et al, on behalf of the CAST trial group. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. Feb 2009;13(13):iii, ix-x, 1-121. [Medline]. [Full Text].

14. McKeon PO, Mattacola CG. Interventions for the prevention of first time and recurrent ankle sprains. Clin Sports Med. Jul 2008;27(3):371-82, viii. [Medline].

15. Broglio SP, Monk A, Sopiarz K, Cooper ER. The influence of ankle support on postural control. J Sci Med Sport. Jun 10 2008;epub ahead of print. [Medline].

16. Caine D, Cochrane B, Caine C, Zemper E. An epidemiologic investigation of injuries affecting young competitive female gymnasts. Am J Sports Med. Nov-Dec 1989;17(6):811-20. [Medline].

17. Knapik JJ, Darakjy S, Swedler D, Amoroso P, Jones BH. Parachute ankle brace and extrinsic injury risk factors during parachuting. Aviat Space Environ Med. Apr 2008;79(4):408-15. [Medline].

18. Stewart R. [Personal communication] Clemson University; 2006, 2008.

19. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med. Jul-Aug 1985;13(4):259-62. [Medline].

Keywords

ankle taping and bracing, ankle brace, wrap ankle, ankle support, ankle braces, ankle tape, ankle taping, ankle bracing, ankle wrapping, prophylactic ankle bracing, prophylactic ankle taping

Contributor Information and Disclosures

Author

Douglas A Reeves Jr, MD, Team Physician, Clemson University, Clemson, South Carolina
Douglas A Reeves Jr, MD is a member of the following medical societies: American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

T Jeff Emel, MD, Director, Department of Sports Medicine, Eastern Oklahoma Orthopedic Center
T Jeff Emel, MD is a member of the following medical societies: American College of Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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