Ankle Taping and Bracing

Ankle sprains are the most common sports-related injuries in the United States, accounting for an estimated 2 million injuries per year.[1, 2] This results in 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 70 years ago.[3] The purpose of this article is to review the mechanics of ankle taping and to discuss ankle bracing.

Ankle taping and bracing are fixtures of both athletic training and sports medicine.[4, 5, 6] 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.

For patient education information, see the Foot, Ankle, Knee, and Hip Center and Sprains and Strains - First Aid and Emergency Center, as well as Ankle Sprain and Sprains and Strains.

Ankle bracing and taping are used for the prevention of ankle injuries, especially in athletes with a past history of ankle sprains.[2, 7, 8] The brace or tape is applied before practice or competition.

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.

Anatomy

Ankle sprains occur in nearly all types of sporting events. Acute ankle sprain is the most common lower-extremity injury in athletes, accounting for 16-40% of such injuries.[9]

To understand ankle sprains, one must first understand ankle anatomy. The ankle (talar) joint has three bones and three 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 limit eversion. The medial ankle is inherently more stable than the lateral ankle and therefore is 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 three distinct ligaments: anterior talofibular, calcaneofibular, and 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, plantarflexed position.[1, 10, 11, 12]  Several studies support the theory that ankle sprains frequently involve disruption in ankle proprioception that prevents the ankle from protecting itself. Eversion ankle sprains, however, usually are not related to inadequate proprioception but are the result of outside forces (eg, contact with another player).

Procedural planning

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, braces are likely more cost-effective than taping.[1, 4, 13, 14, 15]  Estimates in the past have shown that ankle taping is approximately three times more expensive than bracing over the course of a competitive season.[16]

Disadvantages of bracing include the fact that many athletes feel less comfortable or stable when wearing braces than they do when the ankle is taped. Braces also can become torn or lost and require replacement. A study of ankle bracing in college varsity volleyball players found that bracing, whether soft or rigid, led to a significant decrease in vertical jump height.[17]

Many studies have compared taping versus bracing of the ankle.[18] Prospective studies have met with difficulty in controlling all of the variables associated with ankle injuries (eg, playing surface, shoe wear, individual inherent stability, and intensity of competition on both a team and individual level).

Most of these studies have shown that braces are slightly more effective than taping but that both are better than no support. One study found that simply wearing high-top instead of low-top shoes prevented some ankle injuries and that athletes wearing high-top shoes plus taping had more than 50% fewer injuries than those wearing low-top shoes plus taping.

A study comparing the effects of self-adherent tape and lace-up ankle braces on ankle range of motion (ROM) and dynamic balance in collegiate football players found that both interventions were effective in reducing ROM in all directions as compared with baseline and that dynamic balance did not differ between the two techniques.[19]

Studies examining the effectiveness of external ankle stabilization have had conflicting results. Some reports have shown no change in injury rates, but most have found at least some decrease in inversion sprains. Two studies involving high school basketball and football players showed that the use of lace-up ankle braces (vs unbraced controls) reduced the incidence of acute ankle injuries but did not reduce the severity of these injuries.[20, 21]

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 classic study has shown that regular taping can lose most of its supportive effect after only short periods of exercise.[22]

How, then, does taping or bracing decrease the incidence and severity of sprains? A possible answer was suggested in a study by Robbins and Waked, which found that taped participants had improved proprioception both before and after exercise compared with untaped control subjects.[23]  The authors theorized that the traction 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.

However, in a systematic review and meta-analysis of eight studies by Raymond et al, the evidence suggested that using an ankle brace or ankle tape had no effect on proprioceptive acuity in participants who had recurrent ankle sprain or functional ankle instability.[24]

A study of 24 healthy university students by Long et al found that those who had above-average proprioceptive performance when not taped had worse scores when taped, whereas those who had below-average proprioceptive performance when not taped had better scores when taped.[25]  The investigators suggested that taping might amplify sensory input in a way that enhances the proprioception of poor no-taping performers but causes an input overload that impairs proprioception in good performers.

A study of 53 netball players by Smyth et al found that ankle tape, whether applied by a sports and exercise physiotherapist or self-applied, led to improved proprioception acuity during a netball session.[26]

A study by Lohrer et al comparing the neuromuscular properties of taped versus untaped ankles introduced a measure known as the proprioceptive amplification ratio (PAR).[27]  This number incorporates neuromuscular properties such as proprioception and degree of mechanical stress. These results indicated that taping did provide increased ankle protection.

A common concern is that prolonged taping or bracing of the ankle may result in weak ankles that are actually more prone to injury. Should this concern prove well founded, it would obviously make a strong case against the use of ankle taping or bracing. However, a study by Cordova et al suggested that this concern is unfounded.[28] These researchers determined that consistent ankle brace use did not change the latency to inversion of the peroneus longus (an important stabilizer of the ankle, particularly against inversion, the most common type of ankle injury).

Kemler et al compared 4 weeks of soft bracing with 4 weeks of taping in 157 patients with acute lateral ankle ligamentous sprains, assessing recurrence and residual symptoms at 1 year.[29]  They found the rates of recurrence and the incidence of residual symptoms to be similar in the two groups.

A systematic review and meta-analysis of 44 studies by Nunes et al found that Kinesio taping of the ankle did not yield significant improvement of ankle function or performance in either patients with ankle injuries or patients with healthy ankles.[30]

A systematic review and meta-analysis by Biz et al (eight studies; N = 270) of Kinesio taping in athletes with chronic ankle instability found that such taping was associated with improved gait functions, reduced joint ROM in inversion and eversion, decreased muscle activation of the peroneus longus, and decreased postural sway in the midlateral direction.[31]

A study by Li et al found that Kinesio taping could increase the isokinetic strength of the ankle dorsum muscle and plantarflexion in college basketball players with functional ankle instability, thereby improving their balancing ability during dynamic sport activity.[32]

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.

Braces generally come in two types, though small variations exist from one manufacturer to the next. The first type 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 type. Its construction is similar to the nonrigid type 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 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.

For taping, 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 the images below).

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.

Keeping in mind that some steps are optional, prepare for taping as follows:

• Clean and dry the skin
• Apply tape adherent
• Apply heel and lace pads
• Apply prewrap from the midfoot to one third of the way up the lower leg

Before embarking on ankle taping, it is important to know how to tear the tape properly. This 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, which can lead to blisters and discomfort. First, smooth the tape while it is being applied; it cannot be smoothed afterward. Second, learn to use the angles naturally supplied by the body part (see the image below). 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 two layers of tape. Uncovered areas within the taped ankle lead to blisters. In addition, do not use excessive force when applying tape. Constriction of blood flow is possible when tape is applied too tightly.

There are several variations on a standard tape application for the ankle. One of the more commonly used techniques taught to undergraduate athletic trainers is discussed below.

Anchor strips

Place two or three anchor strips 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 the image below).

First stirrup

Now, apply the first stirrup (see the image below). 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 process is to tape the foot more in eversion than inversion so that one does not predispose an athlete to injury.

Horseshoe

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 the image below).

Repeat the stirrup and horseshoe two 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.

Closure strips

Place five or six closure strips. Start at the malleoli and work up. An additional one or two 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.

Figure-eight

The so-called figure-eight strapping is started at the dorsum of the ankle. Imagine the numeral 8 bent about 60º in the middle (see the image below). 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.

Heel lock

Heel lock application techniques are varied. The following is an example of a commonly accepted approach.

Lateral heel lock taping is started 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 fifth metatarsal. Now, go upward and posteriorly 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 the images below).

Medial heel lock taping is the most difficult part of the procedure and often takes practice to master. Start anterior to the medial malleolus. Go downward 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 upward and posteriorly 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.

Repeat both lateral and medial heel lock taping one more time each.

Final closure strips

Apply final circular closure 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 the image below).

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.

Power tape

Many athletic trainers have begun 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. It would be used in place of the white tape for the standard ankle taping as described above. It has the disadvantage of being harder to tear and more prone to wrinkling.

Elastic tape

Elastic tape may be used for the heel locks, or it may be used to reinforce the normal heel locks. Athletes often report that this tape is more comfortable or gives them a sense of greater stability.

Moleskin strips

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.

Outside taping

Another taping variation that should be mentioned is that of ankle "spatting," in which tape is placed 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 therefore is not recommended for use by itself.

Flex tape

Yet another variation in ankle taping is to replace prewrap with "flex" tape. Flex tape is more durable than prewrap and resembles elastic tape, but it 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 itself, with less use of white athletic tape.