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]