ankle taping proprioception · ankletaping andproprioception: s. robbinset al. methods subjects...

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Br. J. Sports Med., Vol. 29, No. 4, pp. 242-247, 1995Copyright © 1995 Elsevier Science Ltd

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Ankle taping improves proprioception before and

after exercise in young men

Steven Robbins, Edward Waked* and Ron RappeltDepartment of Mechanical Engineering, Concordia University and McGill University Centre for Studies in Aging,Montreal, Canada; *Divisions of Geriatric Medicine and Experimental Medicine, Montreal General Hospital,Montreal, Canada; tAthletics Department, Concordia University, Montreal, Canada

Ankle sprains are common sports injuries. Inadequate footposition awareness is thought to be the fundamental causeof these injuries. Ankle taping may decrease risk of injurythrough improving foot position awareness. The benefit oftaping is thought to decrease with duration of exercisebecause of poor tape adherence to human skin. This studywas a randomized, crossover, controlled comparison ex-periment that tested the hypothesis that ankle tapingimproves foot position awareness before and after exercise.A sample of 24 healthy young blindfolded volunteers,wearing their own athletic shoes, indicated perceived slopedirection and estimated slope amplitude when bearing fullbody weight and standing on a series of blocks. The topslope of the blocks varied between 00 and 250, in 2.50increments, to orient the plantar surface with respect to theleg toward pronation, supination, plantarflexion, and dorsi-flexion, relative to its position on a flat surface. Footposition awareness, which was considered the reciprocal ofsurface slope estimate error, varied with testing condition,particularly when surface slope was greater than 100,presumably the most important range considering ankleinjuries. In this higher range absolute position error was4.230 taped, and 5.530 untaped (P < 0.001). Followingexercise, in the higher range absolute position error was2.5% worse when taped and 35.5 % worse when untaped(P < 0.001). These data support the hypothesis that ankletaping improves proprioception before and after exercise.They also indicate that foot position awareness declineswith exercise. Compared to barefoot data (position error1.9 70), foot position error was 107.5% poorer with athleticfootwear when untaped (absolute position error 4. 110), and58.1% worse when taped (position error 3.130). Thissuggests that ankle taping partly corrects impaired pro-prioception caused by modem athletic footwear andexercise. Footwear could be optimized to reduce theincidence of these injuries.(Br J Sports Med 1995; 29: 242-247)

Keywords: Ankle sprain, ankle taping, proprioception,exercise, sports medicine, biomechanics, athletic footwear,injury prevention.

Ankle sprains are the most frequently reported injury insport. Studies have shown that 90-95 % are inversionscausing partial or complete rupture of the anteriortalofibular ligament and occasionally the calcaneofibularligament.1 2 Complete recovery from the initial injury is

most probable, although reinjury often results inmoderation or discontinuation of sports activities.2Ankle sprains have become such a pervasive problem incertain competitive sports, such as basketball, that mostparticipants are disabled by them every season, much tothe frustration of those attempting prevention.

Ankle taping has become the principal means ofpreventing ankle sprains in sport.3 Whereas taping wasonce thought to stabilize the ankle mechanically, thisnow seems unlikely considering reports that show nomeasurable stabilizing effect of tape after as little as 20minutes of exercise.' Accordingly, ankle taping is nowthought to prevent ankle injury mainly through im-proving the user's judgment of position and orientationof the plantar surface with respect to the leg. This footposition awareness, in the domain of proprioception, isusually referred to as kinaesthetic sense.' Stated inphysiological terms, this theory supposes that unitingthe skin of the foot with the leg by ankle tapingprovides cutaneous sensory cues of plantar surfaceposition and orientation through traction of tape eitheron hairy skin of the leg and foot, or plantar skin, or both.Presumably humans use this information in anticipationof foot contact with a surface either to position theplantar surface before the support phase to attenuateforces causing inversion, or to command muscle supportto sustain these forces, thereby preventing ligamentloading, or both. By this reasoning, ankle sprains arecaused by impaired foot position awareness resulting ininadequate use of these anticipatory manoeuvres underconditions such as sports, when there is insufficient timeto respond to the actual loading event.

The effect of ankle taping on foot position awarenesshas never been examined. We describe here a ran-domized, crossover, controlled comparison experimentwhich tests the hypothesis that ankle taping improvesfoot position awareness before and after exercise. It isaccomplished through measuring the precision withwhich 12 taped and 12 untaped healthy young shodvolunteers judged support surface orientation andestimated slope when bearing full body weight on aseries of surfaces differing in angle and orientationbefore and after exercise, which consisted of playingbasketball and running for 30 minutes.

242

Address for correspondence: Dr Steven Robbins MD, 800 Rene-Levesque Blvd. West, Suite 2010, Montreal, Canada H3B 1X9.

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Ankle taping and proprioception: S. Robbins et al.

MethodsSubjectsTwenty four university students participated in thisexperiment on a voluntary basis. All were in goodhealth, without disabilities affecting their ability to walkor run, or history of serious leg injuries. Mean age was

26.6 years (range 21.0-31.0, SD 2.9). Mean height was169.9 cm (range 146.0-190.5, SD 9.7). Mean bodyweight was 71.7 kg (range 59.5-88.1, SD 7.7).

Footwear

Subjects wore their own athletic shoes both for testingduring exercise and no-exercise sessions.

Support surfacesSupport surfaces consisted of blocks constructed oftextured melamine covered particle board, with centrepoint height of 20 cm and surface dimensions of30 cm x 30 cm. The top surface of each block was

sloped at a different angle ranging from 00 to 250 fromthe horizontal in increments of 2.50. Through rotationof blocks, surface slopes of between 00 and 250 were

attained so as to place the plantar surface of subjects insupination, pronation, plantarflexion, and dorsiflexion,relative to the position on a flat surface.

Ankle taping procedureAnkle taping was performed by a certified athletictherapist from the sports medicine clinic at ConcordiaUniversity. Before taping, skin was shaved, cleansed,and dried. The taping procedure was the Gibney basketweave with a double heel lock, using 37 mm Johnson &Johnson coach's adhesive tape applied directly to theskin. This method was chosen because it was mostwidely used among competitive athletes surveyed.

ConditionsEach subject participated in two testing sessions:exercise and a no-exercise control. In the exercisecondition, subjects performed basketball and runningfor a 30 minute period. Conversely, subjects in the no-exercise condition rested in a non-weightbearing pos-

ition for 30 minutes. In each testing session, subjectswere assigned either to a taped or an untaped group ina counterbalanced pattern. Subjects in the taping group

had both ankles taped. Ankle tape was not applied tosubjects in the untaped group, but conditions were

otherwise identical to the taping group (Table 1).

Testing methodMagnitude estimation is the form of psychophysicaldirect scaling used in the present experiment. By thismethod, the subject estimates, usually with a ratio scale,perceived amplitude of sensory continua.6 This vali-dated method was popularized by Stevens and has beenused to examine a host of sensory stimuli in humans.7 8Although quantification of subjective phenomena mayconvey a certain imprecision, these methods are ex-tremely sensitive and reliable. Test-retest reliabilitywith this method is extremely high, usually exceeding0.90.6

Foot position sense testing was performed underquasi-static conditions, that is, similar to locomotioninsofar as the task required behavioural accommodationto foot support surface slope and maintenance of stableequilibrium when weight was transferred to the block,yet differing from locomotion in that there was noforward movement. Subjects estimated the perceiveddirection and amplitude of surface slope once theyapplied full body weight to a series of blocks. Allsubjects wore goggles which were modified with theaddition of translucent adhesive tape to the bottom halfof the lens in order to prevent them from viewing theblocks and using this information in judging surfaceslope. Estimates of surface slope were based on a ratioscale from zero to 15, where zero corresponded to ahorizontal surface and 15-37.50. The 12.50 differencebetween actual maximum slope and scale maximum wasdesigned to allow overestimation of surface slope.Subjects were told that a surface angle might be repeatedmore than once during each testing condition althoughthis never occurred. The order of presentation of surfaceblocks was counterbalanced across exercise first, andangles second. Subjects were given reference values of00, 12.50, and 250 every 11 estimates. The methodrequired subjects to stand vertically with 00 flexion atthe knee. This was ensured by instructions to subjects,and monitoring by the experimenter. Blocks were placedagainst a wall which provided support if balance waslost (Figure 1).

Experimental procedureSubjects were told that the purpose of the experimentwas to measure how ankle taping affects judgment ofsupport surface angle. Written consent was obtainedaccording to guidelines proposed in the Declaration ofHelsinki of the World Medical Association. The rightleg of subjects was first tested. Taped and untapedsubjects participated in a 30 minute exercise session

Table 1. Mixed experimental design incorporating a repeated measures design across exercise condition and a between subjects design fortaping condition. A total of 24 subjects was randomly assigned to one of the two ankle taping conditions. Measurements of foot positionsense were taken before and after the exercise and no exercise conditions.

Exercise condition No exercise condition

Ankle condition Pre-measurement Post-measurement Pre-measurement Post-measurement

Tape (n = 12) 1 2 3 4No tape (n = 12) 5 6 7 8

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Figure 1. Sketch of experimental setup used in the presentexperiment. Subjects were asked to estimate perceiveddirection and amplitude of surface slope once they appliedfull body weight to a series of blocks when barefoot and whenwearing footwear. A wall was used for support. Legs werestraight.

consisting of running and basketball, whereas the no-exercise subjects rested. The right leg was then re-testedfollowing either the exercise or no-exercise sessions.The room where testing was performed was well lit andventilated. Subjects exercised in a gymnasium above thetesting room.

Data analysisFoot position estimate error quantifies difference be-tween perceived foot position derived from estimates ofsurface slope and actual slope of surface. Absolute meanestimate error assigns a positive value to errors, whetherthey be underestimation or overestimation of actualposition. This measure gives the best indication ofoverall precision of estimates. Net mean estimate erroris positive for overestimation and negative for under-estimation of actual foot position. It indicates orien-tation of position error. Surface slope, net mean error,and absolute mean error were examined as a function ofperceived surface slope using analysis of variance forrepeated measures, according to a tape x exercise xangle design, in which the tape factor consisted of twolevels (taped, untaped), exercise factor consisted of two

levels (exercise, no-exercise), and angle factor consistedof 11 levels representing the angled blocks subjectswere tested with (00-250; 2.50 increments). Post-hocanalysis was performed via Student t tests withBonferroni adjustment. Test method reliability wasassessed using Pearson product moment correlationcoefficient. The criterion for statistical significance wasset at ac = 0.05 for all tests.

ResultsPre-exercise compared to no-exercise conditionsThere was no significant difference in perceived surfaceslope [F(10,220) = 2.05, P < 0.231], net mean estimateerror [F(10,220) = 3.50, P < 0.112], and absolute meanestimate error [F(10,220) = 2.61, P < 0.216] for bothtaped and untaped subjects. This indicates no error dueto condition order and subject selection.

Foot position awareness as a function of slopeplaneThere were no significant differences in perceivedsurface slope [F(30,476) = 5.19, P < 0.229], absolutemean estimate error [F(30,476) = 6.89, P < 0.201], andnetmean estimate error [F(30,476) = 12.11, P < 0.156],in relation to plane of orientation of support surface.Consequently data from both sagittal and frontal planeorientations were combined for the analysis thatfollows.

Perceived surface slope as a function of actualsurface slope (Figure 2)All main effects and two way interactions weresignificant. There was a significant three way interactioneffect for tape x exercise x angle [F(10,220) = 5.19,P < 0.001].

Absolute mean estimate error as a function ofactual foot position (Figure 3)All main effects and two way interactions weresignificant. There was a significant three way interactioneffect for tape x exercise x angle [F(10,220) = 4.03,P < 0.001].

Net mean estimate error as a function of actualsurface slope (Figure 4)All main effects and two way interactions weresignificant. There was a significant three way interactioneffect for tape x exercise x angle [F(10,220) = 3.03,P < 0.001].

Reliability of testing methodThe testing method displayed test-retest reliabilitycoefficient of 0.91 for both taped and untaped subjectsin the no-exercise condition. Test-retest reliabilitycoefficient for the exercise condition was 0.89.

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Exercise Group No-Exercise Group Control Group30

25

20

15

10

5

00 1 0 20 0 1 0 20 0 1 0 20 30 40 50Pre-Measurement Period Post-Measurement Period Pre-Measurement Period Post-Measurement Period

Surface Slope Surface Slope(degrees) (degrees)

Figure 2. Perceived surface slope following a 30 min exercise session (left) and a 30 min no-exercise control session (right) for bothtaped and untaped subjects.

Exercise Group

0 10 20Pre-Measurement Period

0 10 20Post-Measurement Period

15

10

5

0

No-Exercise Control Group

0 10 20Pre-Measurement Period

0 10 20Post-Measurement Period


Figure 3. Absolute mean estimate error following a 30 min exercise session (left) and a 30 min no-exercise control session (right)for both taped and untaped subjects.

DiscussionNeurophysiological and perceptual investigations haveshown that kinaesthetic sense-and therefore foot

position awareness-is derived almost entirely frommuscle and tactile receptors.9 Older notions assumedcontributions from joint capsular receptors, unspecifiedarticular surface receptors, ligament receptors, and

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tendon organs.'0 " Joint capsule and articular receptorsplay no significant role in kinaesthetic sense since totaljoint replacement, which presumably eliminates theseinfluences, has no effect on joint position awareness."

Furthermore, anaesthesia of joint ligaments causes no

decline in joint position sense.'2 Finally, discharge fromprimary afferents from tendon organs does not vary inrelation to small changes in joint position, and thereforecannot account for precise joint position awareness.'0

Our results indicate that taping influenced footposition awareness mainly when the surface slope was

greater than 100, presumably the range of interestregarding ankle injuries, considering that engagementof ligaments occurs in this range. Absolute error in thishigher range was 4.340 with tape and 5.150 without it,19% greater (P < 0.001). Untaped subjects wearingmodern athletic footwear showed no position aware-

ness whatsoever, and therefore could not distinguishbetween a flat surface and surface slope of 200.

Overall, absolute mean estimate error was 3.950 and4.810, before and after exercise, respectively-anincrease of 22 %. The benefit of taping was fairlyuniform throughout the range of surface slopes. Ab-solute mean estimate error increased by 7% followingexercise in the taped group, whereas the untaped groupshowed an increase of 39%. Taping therefore showedits greatest benefit to foot position awareness followingexercise.

Taped subjects moderately overestimated plantarsurface slope before exercise (net error 1.590) but error

direction was neutral following exercise (net error0.170). Untaped subjects moderately underestimatedactual surface slope (net error - 1.460), which worsenedmodestly with exercise (- 1.580). The above evaluation

masks imprecision of position sense at acute surfaceslopes, above 100, which is probably most relevant toankle sprains; therefore we analysed these data sep-arately. With analysis restricted to surface slope of 100

and greater, untaped subjects strongly underestimatedsurface slope before exercise (net error -5.7°), andunderestimated it further after exercise (net error

-6. 780). When taped, the direction of error was neutralbefore exercise, but changed to moderate under-estimation (net error 2.520) after exercise. Sincehumans presumably command muscle contraction tosupport their foot relative to perceived foot position,underestimation of surface slope suggests inadequatesupport, the precondition for inversion injury accordingto the proprioception theory.

While taping improves foot position sense whenhumans wear athletic footwear, it remains poor com-

pared to the barefoot condition if we use barefoot pre-exercise data available from a previous report forcomparison.' Absolute foot position error was 4.110,3.130, and 1.960 for athletic footwear, athletic footweartaped, and barefoot, respectively. Therefore whencompared to the barefoot condition, foot positionawareness was 107.5 % worse in untaped subjects withathletic footwear, and 58.1% worse in ankle tapedsubjects wearing athletic footwear. Since the mostobvious difference between being barefoot and wearingshoes is that when barefoot the plantar surface is indirect contact with the weightbearing surface andsubject to intense shear, it seems probable that in-formation emanating from plantar cutaneous mechano-receptors is required for precise foot position sense, as

shown by McCloskey and Gandevia.9The above data support the hypothesis tested: taping

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improves foot position awareness. A further conclusionis that taping counters underestimation of foot positionangle caused by modem athletic footwear. The in-escapable conclusion is that footwear use is ultimatelyresponsible for ankle injury. The conclusion is consistentwith observations made among populations wherebarefoot activity is the norm. Ankle sprains areuncommon in these groups. Since the benefit of tapingremains even when ankle supporting function hasdeclined (after exercise), there is support for the notionthat traction of tape on the skin of the leg and foot isused by humans to judge foot position.5

In conclusion, this experiment provides the strongestphysiological evidence yet presented of potentialusefulness of ankle taping in sport. From anotherperspective it suggests that most ankle injuries are notinherent to sport, but rather are caused by footwear.Since ankle injuries may be the most common injury insport, it follows that identifying and redesigningfootwear to optimize this sense may well be the mostpromising approach to reducing injury incidence in allsports.

AcknowledgementsWe thank Lynette Jones for suggestions related to perception. Thiswork was supported in part by the Natural Sciences and EngineeringResearch Council of Canada Grant OGPIN 013, and the Helen McCallHutchinson Clinical Gerontology Scholarship.

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16 Robbins SE, Waked EG, MacClaran J. Proprioception and stability:foot position awareness as a function of age and footwear. AgeAgeing 1995; 24: 67-72.

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