An Illustrated Guide To Taping Techniques Principles and Practice Second Edition

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle 16 repeat step 15 again on the lateral 17 view from lateral side. 17a to balance stability, apply the ankle lock side, overlapping the previous strip by on the medial side. three-quarters. 88

foot and ankle 6 17b less tension when pulling up on the 18 re-anchor proximally. 19 close up the tape job by starting proximally Lateral ankle sprain: rehabilitation stage medial side. and working distally, applying the strips lightly and overlapping each previous strip by half, ensuring all the gaps are covered in order to avoid blisters. 89

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle 20a apply a simple figure of eight to close 20b Pull up with firm tension over the lateral 20c Bring the tape horizontally behind the and to reinforce the ankle tape. Use side before crossing the ankle anteriorly achilles tendon. either non-elastic tape or an elastic with less tension. adhesive bandage. Start anteriorly, tip: crossing the ankle towards the medial When pulling the EAB up with tension, hold aspect of the midfoot and pass under the the tape against the underlying tape below foot. the point at which you want to apply the tension. Apply tension and then press up Note: against the underlying tape. Move your point of contact to where you want to release If using an elastic adhesive bandage (EAB), allow the tape to recoil before applying, when no tension is the tension and hold the tape against the needed. underlying tape here. Allow the EAB to recoil before proceeding with the technique. 90

foot and ankle 6 21 finish anteriorly, crossing the starting point 22 complete the closing-up strips, covering Lateral ankle sprain: rehabilitation stage of the strip. the forefoot and distal anchors. tip: tip: 23 Starting gently, test the degree of inversion A 1 cm (½ in) heel lift (bevelled at the front Apply a second figure of eight if necessary and plantarflexion restricted by the tape. edge) will raise the heel and reduce stress to cover any open areas (overlap the first add reinforcement strips if these move- on the injured ligaments. Particularly useful figure of eight by half). ments are not adequately limited or if they during the subacute stage when weight cause pain. bearing commences. Note: Note: Weight bearing and gradually increasing For return to dynamic activity, a heel activity must only be permitted if pain free, locking figure of eight or a reverse figure of both during and after activity. eight can be applied in place of the regular figure of eight. 91

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: foot And Ankle T reatment Early injUry: lateral ankle SPrain • R.I.C.E.S. • taping: first 48 hours: Acute Ankle Injury (open basketweave) (p. 76) (typically a combination of two ligaments: calcaneo-fibular and anterior • therapeutic modalities talo-fibular) Later • continued therapy including: T erminoloGy • see sprains chart (p. 36) a. therapeutic modalities • inversion sprain b. transverse friction massage • ‘turned’ ankle c. modified fitness activities • progressive pain-free rehabilitation including: E tioloGy a. range of motion • forced inversion with plantarflexion b. flexibility • ‘rolling over’ on ankle c. strength: non-weight bearing to weight bearing (endurance, then power) • often secondary to inadequate rehabilitation of a previous ankle sprain d. proprioception • gradual painfree reintegration to sports activity with specific taping (reduced proprioception) • prevention of recurrent sprains • the most commonly injured combination of ankle ligaments S eqUelae S ymPtomS • anterior talo-crural and sub-talar instability if ligaments are not supported • local pain, swelling, discolouration and tenderness anteriorly and inferior to in a shortened position during healing phase the lateral malleolus • weakness and/or tendinitis of peroneal muscles • active movement testing: pain on plantarflexion with inversion • extensor digitorum longus is often injured simultaneously, predisposing to • passive movement testing: pain on plantarflexion with inversion • resistance testing (neutral position): no significant pattern of pain with chronic residual weakness • reduced proprioception moderate resistance • repeated injury caused by poor proprioception and joint instability • stress testing: • chronic swelling in the sinus tarsi and around the tip of the lateral malleolus a. pain, with or without laxity, on anterior ‘drawer’ test (forward gliding of the talus under the tibio-fibular mortice) indicates a 1st- or 2nd-degree sprain of the anterior talo-fibular ligament b. instability on forward displacement of the talus away from the lateral malleolus indicates a 3rd-degree sprain of the same ligament c. pain with or without some laxity on talar tilt test indicates a 1st- or 2nd-degree sprain of the fibulo-calcaneum d. instability or ‘opening up’ on the talar tilt test (often with little or no pain) is indicative of a 3rd-degree sprain of this ligament R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support 92

foot and ankle 6 Ankle SPrAIn rehABIlItAtIon – AdVAnced Lateral ankle sprain SPecial adaPtationS: SPort-SPecific ankle taPinG variationS During the subacute and rehabilitation stage of ankle sprains, the tape job is adapted to the varying needs of the injury. Each tape job must be adjusted for the anatomy of the specific ligament, the degree of injury and the current stage of healing. As the athlete gradually returns to sports activity, his or her sport-specific requirements must also be accommodated. Note: Prior to initial application of ankle rehabilitation taping strategies, the ankle must be fully evaluated by a qualified person, for example a doctor, in order to identify the injured structures and to ensure that no other complications exist. The following specialized strip adaptations may be used by the experienced taper in combination with the previously described strips to adapt to a wide range of situations. Specialized strips for sports-specific techniques include: • fanned stirrups: allows freer plantarflexion (useful when tight boots are required for a specific sports activity) • V-lock: for extra heel stability (useful when the number of tape strips must be • heel-locking figure of eight: kept to a minimum, i.e. when the athlete must wear tight boots) • reverse figure of eight: reinforces stability when the level of recovery permits a return to activity reinforces stability without restricting plantarflexion (useful when plantarflexion is needed for sports participation) 93

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle SPecialized StriP: fanned StirrUPS Advantages Disadvantages Purpose • reduced limitation of plantarflexion • offers lateral support over three angles • allows more plantarflexion than straight • thickness is localized under heel basketweave stirrups Procedure • mimics multi-angled ligamentous support • allows minimal tape thickness over bony prominences • useful when tight-fitting footwear is required as in figure skating, ice hockey, speed skating and downhill skiing where tape thickness over the malleoli must be kept to a minimum 78 1 Begin taping by applying steps 1–8 (step 6 2 apply the first stirrup, starting from the 3 attach the second stirrup, passing directly is optional) of Ankle rehabilitation taping. upper anchor posteriorly on the medial over the medial malleolus, passing under side, passing under the heel, and pulling the heel and pulling up again with strong up with a strong tension on the finish more tension over the lateral malleolus to the anteriorly on the lateral side of the anchor. anchor, ending slightly posterior than the first stirrup. 94

foot and ankle 6 Fanned stirrups 4 apply the third stirrup, starting more 5 re-anchor these stirrups proximally (at the view from the side. anteriorly on the medial side and finishing posterior to the lateral malleolus on the top) and proceed to the complete tape job tip: lateral side. as in steps 15–22 of Ankle rehabilitation Ensure that the tape is high enough at the taping. back so that it is at the same level when it crosses itself again anteriorly. Note: These stirrups are applied in combination with the horizontal strips to form a modified basketweave, offering more stable support, particularly for anterior and posterior (talo-fibular or deltoid) ligament sprains. 95

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle SPecialized StriP: v-lock Advantages Disadvantages Purpose • reinforces lateral stability • offers a combination of lateral stability and heel • does not restrict talar tilt as effectively as the • locks the heel locking with one single strip single ankle lock Procedure • useful when tight-fitting footwear is required, as in figure skating, ice hockey, speed skating and downhill skiing where tape thickness over the malleoli (ankle bones) must be kept to a minimum 1 Begin taping by applying steps 1–8 (step 6 2 Place the tape under the heel before pulling 3 Gently wrap the roll of tape behind the heel, is optional) of Ankle rehabilitation taping. up on the anterior end and affixing it to the crossing low enough on the lateral side to upper anchor, anteromedially. cross over the lateral malleolus. fanned stirrups may also be used. tip: 4 Pull the tape snugly across the lateral malleolus to the dorsum of the foot. Ensure that the foot is everted (pulled outward) by the pull of this step. tip: Lateral shearing of the tape and careful attention to the ‘take-off’ direction will help in achieving the best taping ‘line’ without wrinkling the tape. 96

foot and ankle 6 Strip: v-lock 5 Wrap the tape without tension anteriorly view from lateral side. view from medial side. across the ankle. tip: Note: 6 Pass medially to the plantar surface under Repeated applications using practice tape This strip can also be applied to the medial the arch, going in a posterior direction. strip will improve technique. side for added stability and heel locking effect. Care must be taken not to allow 7 Pull up strongly posterior over the lateral inversion and to adjust the tension during malleolus. application when taping for lateral ankle sprains. 8 attach the strip to the anchor posteromedially. 97

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle SPecialized StriP: Heel-lockinG Purpose Advantages fiGUre of eiGHt • offers added reinforcement with specific heel • useful in sports requiring more dorsiflexion Procedure stabilization and where there is less demand for extreme plantarflexion • restricts full plantarflexion Disadvantages • limits lateral mobility • restricts plantarflexion • allows almost full dorsiflexion 1 Begin taping by applying steps 1–5, 7–14 5 cross the ankle anteriorly, moving down 6 Pull the tape up and back with strong of Ankle rehabilitation taping. fanned the medial side and under the instep, tension posterior to the lateral malleolus stirrups may also be used if desired. slightly posterior to the starting point. angle and pass behind the achilles tendon. the tape in a posterior direction under the 2 Start strip on the dorsum of the foot, from plantar surface. lateral to medial, pass under the instep. tip: 3 Pull up strongly on the lateral side. The ankle must be adequately dorsiflexed 4 carefully cross the tape over the extensor in order to allow the tape to pass tendons (without wrinkling) and pass posteriorly without bending, wrinkling or horizontally behind the medial side to wrap causing a pressure ridge. around the achilles tendon. tip: Ensure that strong tension is used when pulling up on the lateral side for all three strips. 98

foot and ankle 6 7 continue carefully around the front of the 8 return posteriorly behind the achilles 9 Pull up strongly on the lateral side to end Heel-locking figure of eight ankle. tendon again, this time crossing the heel by crossing the previous strips anteriorly. from the medial side, using less tension, tip: and pass under the instep. Repeated application using a practice strip will aid in judging taping angles and will improve proficiency significantly. view from the medial side. 99

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle SPecialized StriP: reverSe fiGUre Purpose Advantages of eiGHt • offers added reinforcement with specific heel • as this strip allows plantarflexion, it is Procedure stabilization to a taped ankle particularly useful in sports that require a greater functional range of plantarflexion (basketball, • restricts dorsiflexion volleyball, gymnastics, various track and field sports) • limits lateral mobility of ankle and controls heel • controls heel from both sides • allows almost full plantarflexion Disadvantages • less stability in plantarflexion than offered by the other figure of eight strips 1 Begin taping by applying steps 1–5, 7–14 3 Pass tape under the instep heading in a 4 Pull the tape up and back with strong of Ankle rehabilitation taping. fanned posterior direction. tension, moving behind the lateral stirrups may also be used if desired. malleolus (locking the heel laterally), and wrap the tape carefully around the achilles 2 Start strip on the dorsum of the foot, tendon. crossing from lateral to medial. 100

foot and ankle 6 Reverse figure of eight 5 Bring the tape forward on the medial side. 6 cross the achilles tendon again, bringing 7 Pull up strongly on the lateral side and carefully pass over the extensor tendons the tape down across the medial side of finish the strip by crossing over the starting anteriorly and return posteriorly. the heel (locking it), then moving anteriorly point on the dorsum of the foot. under the plantar surface. Note: Be sure to avoid wrinkling or sharp angling Note: of the tape when crossing these tendons. To severely limit dorsiflexion, position the ankle in slightly more plantarflexion and pull tightly when locking the heel from each side. view from the medial side. 101

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle Ankle SPrAIn rehABIlItAtIon – AdVAnced Note: These procedures are intended as SUBSection for individUal liGament SPrainS guidelines and suggestions and are by no means ‘carved in stone’. They represent The following is a detailed subsection on ankle sprains that may not be of interest to all readers. It is practical adaptations that have proven included to provide healthcare professionals intensively treating athletes with methods of specific taped useful through theorization, application of support for isolated ligament sprains. knowledge and experience. The T.E.S.T.S. charts in this section describe location and make-up of the individual ligaments in tip: Terminology. The sequence and frequency of occurrence are included with Etiology, Symptoms, Treatment To develop your skills and techniques, and Sequelae. This section illustrates how the rehabilitation taping elements are adjusted and adapted for never stop questioning and adapting, as the progressive stages of healing, the anatomy of the individual ligaments, and the varying demands of you apply anatomical and physiological different sports. principles to your taping. The purpose of this subsection is to show how taping can be designed to support specific ligaments and how it can be constantly progressed and adapted to meet the changing needs of the healing structure and the varying demands of different sports. Should any given technique not provide the necessary pain-free support, consider the following: • question the original diagnosis and reassess the injury • question the stage of healing: has the ankle suffered from further injury or an aggravation of the original injury, thereby prolonging the subacute stage? • question the appropriateness of this taping technique for this injured structure and this stage of healing • question your technique of application: could your skills be improved? (practise with a test strip) • are the fundamental needs of the athlete met with adequate support yet sufficient mobility? 102

foot and ankle 6 SPECIFIC ANKLE REHABILITATION TAPING FOR ISOLATED TALO-FIBULAR LIGAMENT SPRAIN Anterior talo-fibular ligament sprain Positioning: SUB-ACUTE: (beginning to weightbear) PROGRESSIVE STRIP ADAPTATIONS RETURN TO SPORT: (training, then competition) seated, with the calf • activity depends on stage of healing FUNCTIONAL: (moderate to dynamic activity) • reinforced support supported and the foot • how much swelling? • adequate support for individual ligaments • adaptations for specific needs of sport held at a 90 degree angle • weightbearing only if no pain! • enough mobility for moderate activity BASIC STRIPS • if swelling is likely, use a BASIC PREPARATION • if swelling persists, continue • use heel and lace pads (clean, shave, felt ‘J’-lateral side with felt ‘J’ spray) (bevel the edges) underwrap • for increasing activity use anchors heel and lace pads LATERAL SUPPORT modified basketweave composed of: • continue with • continue with Stirrups • 3 stirrups (vertical) modified basketweave modified basketweave (extra pull on lateral side (extra pull particularly on lateral (start medially and pull up for both horizontal and horizontal strips) strongly on lateral side) vertical strips) • Interlock stirrups with • for more mobility, fanned stirrups 2 horizontal strips (strong can be used lateral pull) REINFORCEMENT • lateral locks • continue with • continue with Ankle locks with main tension pulling up on 1 lateral V-lock 1 lateral V-lock STABILIZATION last component (posterior 1 medial V-lock 1 medial V-lock Figure 8 variations vertical strip) CLOSING UP: • heel locking figure 8 • continue with heel locking figure 8 or • medial V-lock for added stability (always • if more plantar flexion needed for with main tension pulling from pull up strongly on lateral side) behind heel horizontally across sport, use reverse figure 8 (ensure medial malleolus • heel-lift (optional) that end-range plantar flexion is limited with previous locking • simple figure 8 strips) (start medially and pull up • if tight, rigid boots are necessary, strongly on lateral side) omit this step (ensure plantar flexion is Purpose: restricted with this strip) • supports anterior talo-fibular ligament • prevents inversion • add felt heel-lift for weightbearing • limits inward rotation of foot, end-range eversion and end-range plantar flexion • permits functional plantar flexion TIP: Visualize location and direction of ligament being supported during tape application. 103

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: foot And Ankle T reatment Early injUry: anterior talo-fiBUlar liGament SPrain • R.I.C.E.S. • taping, first 48 hours: Acute ankle injury (open basketweave) (p. 76) T erminoloGy • therapeutic modalities • anterior portion of lateral ligamentous complex Later • short, superficial band of fibres • continued therapy including: • from the anterior portion of lateral malleolus forward to the neck of the a. therapeutic modalities talus b. transverse friction massage • see anatomy illustration, p. 55 • modified fitness activities • progressive pain-free rehabilitation including: E tioloGy a. range of motion • forced inversion with plantarflexion b. flexibility • ‘rolling over’ on ankle c. strength: non-weight bearing to weight bearing (endurance, then power) • the most commonly injured ankle ligament d. proprioception • often secondary to inadequate rehabilitation of a previous ankle sprain • gradual pain-free reintegration to sports activity with specific taping. Ankle rehabilitation taping for isolated anterior talo-fibular ligament sprain: (reduced proprioception) see p. 103 (when injured in combination with fibulo-calcaneal ligament, • often injured in combination with the fibulo-calcaneal ligament refer to lateral ankle sprain, p. 82) • prevention of recurrent sprains S ymPtomS • local pain, swelling and discolouration S eqUelae • tenderness just anterior to the lateral malleollus • anterior talo-crural instability if ligament is not supported in a shortened • active movement testing: pain on plantarflexion with inversion • passive movement testing: pain on plantarflexion with inversion position during healing phase • resistance testing (neutral position): no significant pattern of pain with • weakness and/or tendinitis of peroneal muscles • chronic residual weakness of extensor digitorum longus (often injured moderate resistance • stress testing: simultaneously) • reduced proprioception a. pain, with or without laxity, on ‘anterior drawer’ test (forward gliding of • repeated injury caused by poor proprioception and joint instability the talus under the tibio-fibular mortice) indicates a 1st- or 2nd-degree • chronic swelling in the sinus tarsi sprain b. instability on forward displacement of the talus away from the lateral malleolus with or without pain can be indicative of a 3rd-degree sprain. An audible ‘click’ may be present R.I.C.E.S. : Rest, Ice, Compress, Elevate, Support 104

foot and ankle 6 SPECIFIC ANKLE REHABILITATION TAPING FOR ISOLATED CALCANEO-FIBULAR LIGAMENT SPRAIN Calcaneo-fibular ligament sprain Positioning: SUB-ACUTE: (beginning to weightbear) PROGRESSIVE STRIP ADAPTATIONS RETURN TO SPORT: (training, then competition) seated, with the calf • activity depends on stage of healing FUNCTIONAL: (moderate to dynamic activity) • reinforced support supported and the foot • how much swelling? • adequate support for individual ligament • adaptations for specific needs of sport held at a 90 degree angle • weightbearing only if no pain! • enough mobility for moderate activity BASIC STRIPS • if swelling is likely, use a BASIC PREPARATION • if swelling persists, continue • use heel and lace pads (clean, shave, felt ‘J’-lateral side with felt ‘J’ spray) (bevel the edges) underwrap • for increasing activity use anchors heel and lace pads LATERAL SUPPORT modified basketweave composed of: • continue with • for more mobility, fanned stirrups Stirrups • 3 stirrups (vertical) modified basketweave can be used (extra pull on lateral side, (start medially and pull up particularly for vertical strip) • if sprain is limited only to this strongly on lateral side) ligament horizontal strips • Interlock stirrups with are optional 2 horizontal strips (strong lateral pull) REINFORCEMENT • 2 lateral locks • 2 lateral locks • continue with 2 lateral and Ankle locks (pull up strongly on (extra pull on 1 medial locks or lateral side) lateral side) • if tight boots are necessary, STABILIZATION • simple figure 8 • 1 medial lock 1 lateral lock plus 1 V-lock Figure 8 variations (start medially and pull up (with less tension) replaces second lateral lock strongly on lateral side) (V-lock with extra pull on • heel locking figure 8 horizontal part and final for added stability (always lateral vertical strip) pull up strongly on lateral side) • continue with heel locking figure 8 or CLOSING UP: • add felt heel-lift for weightbearing • heel-lift (optional) • if more plantar flexion needed for sport, use reverse figure 8 (ensure that end-range plantar flexion is limited with previous locking strips or with closing figure 8) • if tight, rigid boots are necessary, omit this step Purpose: • supports calcaneo-fibular ligament • prevents inversion • limits end-range eversion and extreme plantar flexion • permits functional plantar flexion TIP: Visualize location and direction of ligament being supported during tape application. 105

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: foot And Ankle T reatment Early injUry: calcaneo-fiBUlar liGament SPrain • R.I.C.E.S. • taping: first 48 hours: Acute Ankle Injury (open basketweave) (p. 76) T erminoloGy • therapeutic modalities • middle third of the lateral ankle ligamentous complex Later • long, strong, cordlike band • continued therapy including: • from tip of fibula inferiorly, and posteriorly to lateral tubercle on the a. therapeutic modalities calcaneus b. transverse friction massage • see anatomy illustration, p. 55 c. modified fitness activities • progressive pain-free rehabilitation including: E tioloGy a. range of motion • a medial force on the lower leg when a dorsiflexed foot is relatively fixed in b. flexibility c. strength: non-weight bearing to weight bearing (endurance, then power) or forced into inversion d. proprioception • more often sprained than medial side due to: • gradual reintegration to sports activity with specific taped support. See Ankle Rehabilitation taping for isolated fibulo-calcaneal ligament sprain: a. a thinner, weaker less continuous ligamentous complex p. 105 (when injured in combination with anterior talo-fibular ligament, b. medial malleolus, being higher, offers less stability, allowing the talus to refer to taping for lateral ankle sprain, rehabilitation stage: p. 82 • prevention of recurrence of injury rock medially when stressed • most frequently injured in combination with the anterior talo-fibular S eqUelae • lateral instability if ligament is not supported in a shortened position during ligament the healing phase S ymPtomS • peroneal strain often accompanies this sprain, predisposing to persistent • local pain, swelling and discolouration • tenderness on lateral side of ankle inferior and slightly posterior to the tip of weakness and/or tendinitis of peroneal muscles • reduced proprioception the malleolus • recurrent sprains • active movement testing: pain on inversion • chronic swelling inferior and posterior to tip of lateral malleolus • passive movement testing: pain on inversion • arthritic changes • resistance testing (neutral position): no significant pattern of pain on moderate resistance • stress testing: a. pain with or without some laxity on talar tilt test indicates a 1st- or 2nd-degree sprain b. instability or ‘opening up’ on the talar tilt test (often with little or no pain) can be indicative of a 3rd-degree sprain of this ligament R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support 106

foot and ankle 6 SPECIFIC ANKLE REHABILITATION TAPING FOR ISOLATED POSTERIOR TALO-FIBULAR LIGAMENT SPRAIN Posterior talo-fibular ligament sprain Positioning: SUB-ACUTE: (beginning to weightbear) PROGRESSIVE STRIP ADAPTATIONS RETURN TO SPORT: (training, then competition) seated, with the calf • activity depends on stage of healing FUNCTIONAL: (moderate to dynamic activity) • reinforced support supported and the foot • how much swelling? • adequate support for individual ligament • adaptations for specific needs of sport held at a 90 degree angle • weightbearing only if no pain! • enough mobility for moderate activity BASIC STRIPS • if swelling is likely, use a BASIC PREPARATION • if swelling persists, continue • use heel and lace pads (clean, shave, felt ‘J’-lateral side with felt ‘J’ spray) (bevel the edges) underwrap • for increasing activity use anchors heel and lace pads LATERAL SUPPORT modified basketweave composed of: • continue with • continue with modified Stirrups • 3 stirrups (vertical) modified basketweave basketweave REINFORCEMENT (extra pull on lateral side, (extra pull, particularly on lateral Ankle locks (start medially and pull up particularly for vertical strips) horizontal strips) strongly on lateral side) • Interlock stirrups with • 2 lateral locks • for more mobility, fanned 2 horizontal strips (strong (extra pull on lateral side) stirrups can be used lateral pull) • 2 lateral locks • 1 medial lock • continue with 2 lateral and (pull up strongly on lateral side) (with less tension) 1 medial locks or STABILIZATION • simple figure 8 • heel locking figure 8 • if tight boots are necessary, Figure 8 variations (start medially and pull up for added stability (always 1 lateral lock plus 1 V-lock strongly on lateral side) pull up strongly on replaces second lateral lock lateral side) (V-lock with extra pull on horizontal part and final CLOSING UP: • add felt heel-lift for weightbearing • continue using heel-lift lateral vertical strip) • continue with heel locking figure 8 or • if injury was caused by extreme dorsiflexion or if more plantar flexion needed for sport, use reverse figure 8 • if tight, rigid boots are necessary, omit this step Purpose: • supports posterior talo-fibular ligament • prevents inversion • limits dorsiflexion and lateral rotation of foot • permits functional plantar flexion TIP: Visualize location and direction of ligament being supported during tape application. 107

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: foot And Ankle injUry: PoSterior talo-fiBUlar liGament SPrain T erminoloGy T reatment • posterior band of the lateral ligamentous complex Early • R.I.C.E.S. • deep, thick fibres • taping: first 48 hours: Acute Ankle Injury (open basketweave) (p. 76) • therapeutic modalities • from the posterior aspect of the malleolus to the posterior-lateral tubercle of Later the talus • Continued therapy including: • see anatomy illustration, p. 55 a. therapeutic modalities b. transverse friction massage (this ligament is difficult to access: deep in E tioloGy • extreme forced dorsiflexion the peroneal tendons) c. modified fitness activities • weight-bearing plantarflexion with stressed external rotation of the foot • progressive pain-free rehabilitation: a. range of motion • rare as an isolated tear b. flexibility c. strength: non-weight bearing to weight bearing (endurance, then power) • usually only ruptured in severe sprains or dislocations d. proprioception • gradual pain-free reintegration to sports activity with specific taping. See • pole vaulters, parachute jumpers and ice hockey players (high-speed impact Ankle rehabilitation taping for isolated posterior talo-fibular sprains, with boards) are prone to this injury p. 107 • prevention of further sprains S ymPtomS • local pain, swelling and discolouration S eqUelae • lateral instability if ligament is not supported in a shortened position during • tenderness posterior to the lateral malleous deep into the peroneal tendons the healing phase • active movement testing: pain on end-range dorsiflexion possible • weakness of ankle musculature • reduced proprioception • passive movement testing: posterio-lateral pain on end-range dorsiflexion • peroneal weakness and/or tendinitis • resistance testing (neutral position): no significant pattern of pain on moderate resistance • stress testing: a. posterolateral pain often can be felt when stressing the deltoid ligament on the medial side (eversion of the calcaneus causes simultaneous pinching and compression of the injured ligament) b. pain, with or without laxity, on the ‘posterior drawer’ test (backward gliding of the talus under the tibia), worse with outward rotation of the foot, indicates a 1st- or 2nd-degree sprain c. instability (the fibula slides forward and the head of the talus moves laterally) on backward displacement of the talus, with or without pain, indicates a possible 3rd-degree sprain R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support 108

foot and ankle 6 SPECIFIC ANKLE REHABILITATION TAPING FOR ISOLATED DELTOID LIGAMENT SPRAIN Deltoid ligament sprain Positioning: PROGRESSIVE STRIP ADAPTATIONS seated, with the calf supported and the foot SUB-ACUTE: (beginning to weightbear) FUNCTIONAL: (moderate to dynamic activity) RETURN TO SPORT: (training, then competition) held at a 90 degree angle • activity depends on stage of healing • adequate support for individual ligament • reinforced support BASIC STRIPS • how much swelling? • enough mobility for moderate activity • adaptations for specific needs of sport BASIC PREPARATION • weightbearing only if no pain! (clean, shave, • if swelling is likely, use a • if swelling persists, continue with • use heel and lace pads spray) felt horseshoe underwrap felt horseshoe-medial side anchors (bevel the edges) • for increasing activity use heel and lace pads LATERAL SUPPORT modified basketweave composed of: • continue with modified basketweave • continue with modified basketweave Stirrups • 3 stirrups (vertical) (extra pull on medial side, (extra pull, particularly on medial side) for both horizontal and (start laterally and pull up vertical strips) • for more mobility, fanned stirrups strongly on medial side) can be used • Interlock stirrups with 2 horizontal strips REINFORCEMENT • 2 medial locks • 2 medial locks • if tight boots are necessary, 1 medial lock Ankle locks (pull up strongly on lateral side) (extra pull on lateral side) plus 1 V-lock replaces second medial STABILIZATION lock (V-lock with main tension pulling up Figure 8 variations • 1 lateral lock on last component posterior vertical strip) CLOSING UP: (with less tension) • 1 lateral V-lock replaces the lateral • simple figure 8 • if anterior fibres are involved, use a lock (with main tension pulling up from (start tape medial to lateral and pull up heel-locking figure 8 (with medial behind heel and across anteriorly: strongly on medial side) support) or horizontal component) • add felt heel-lift for • if posterior fibres are involved, use • continue with medial heel-locking weightbearing a reverse figure 8 (with medial support) figure 8 or (to support medial side, start tape from medial to lateral and always • if more plantar flexion is needed for pull up strongly on the medial side) sport, or posterior fibers are involved, use reverse figure 8 • when posterior fibres are (supporting medial side) involved, continue to use heel-lift • if tight, rigid boots are necessary, omit this step Purpose: • supports medial collateral ligament complex • prevents eversion • limits dorsiflexion and lateral flexion • limits end-range inversion and extreme flexion • permits functional plantar flexion TIP: Visualize location and direction of ligament being supported during tape application. 109

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: foot And Ankle T reatment Early injUry: deltoid liGament SPrain R.I.C.E.S. T erminoloGy • taping: first 48 hours: Acute Ankle Injury (open basketweave with medial • medial lateral ligamentous complex • superficial and deep portions reinforcement) (p. 76) • from the medial malleolus anteriorly to the navicular (superficial) and to • therapeutic modalities Later the talus (deep), inferiorly to the calcaneus and posteriorly to the talus • continued therapy including: (both superficial and deep fibres) • see anatomy illustration, p. 54 a. therapeutic modalities b. transverse friction massage E tioloGy • modified fitness activities • a lateral force on the lower leg when foot is relatively fixed in extension • progressive pain-free rehabilitation including: • less often sprained than lateral complex due to: a. range of motion b. flexibility a. thicker, stronger, more continuous ligament fibres c. strength: non-weight bearing to weight bearing (endurance, then power) b. lateral malleolus being lower offers more stability to medial side by d. proprioception • gradual pain-free reintegration to sports activity with specific taping. See preventing a lateral talar tilt Rehabilitation taping for isolated deltoid ligament sprain, p. 109 • occurs in wrestlers and parachute jumpers • prevention of recurrent sprains S ymPtomS S eqUelae • local pain, swelling and discolouration • medial instability if ligament is not supported in a shortened position • locations of tenderness around medial malleolus is indicative of injury site • active movement testing: pain on eversion during the healing phase • passive movement testing: pain on eversion • reduced proprioception • resistance testing (neutral position): no significant pattern of pain on • weakness of ankle musculature • longer healing time moderate resistance • tibialis anterior tendinitis or associated strain • stress testing: a. medial pain with or without some laxity on talar tilt test in 1st- and 2nd-degree sprains b. anterior pain with or without some laxity on anterior drawer test is indicative of injury to the anterior fibres – 1st- and 2nd-degree sprains c. posterior pain with or without some laxity on posterior drawer test is indicative of damage to the posterior fibres – 1st- and 2nd-degree sprains d. complete instability on any of the above three tests is indicative of a possible 3rd-degree sprain which is often less painful than 2nd degree R.I.C.E.S. : Rest, Ice, Compress, Elevate, Support 110

foot and ankle 6 SPECIFIC ANKLE REHABILITATION TAPING FOR ISOLATED ANTERIOR INFERIOR TIBIO-FIBULAR LIGAMENT SPRAIN Anterior inferior tibio-fibular ligament sprain Positioning: PROGRESSIVE STRIP ADAPTATIONS seated, with the calf supported FUNCTIONAL: (moderate to dynamic activity) and the foot held at 10 SUB-ACUTE: (beginning to weightbear) • adequate support for individual ligament RETURN TO SPORT: (training, then competition) • activity depends on stage of healing • enough mobility for moderate activity • reinforced support degrees of plantar flexion • how much swelling? • adaptations for specific needs of sport BASIC STRIPS • weightbearing only if no pain! BASIC PREPARATION • if swelling is likely, use a • if swelling persists, continue • use heel and lace pads (clean, shave, felt horseshoe-lateral side with felt horseshoe spray) (bevel the edges) underwrap • for increasing activity use anchors heel and lace pads LATERAL SUPPORT modified basketweave composed of: • continue with • continue with Stirrups • 3 stirrups (vertical) modified basketweave modified basketweave REINFORCEMENT (extra pull on medial side (ensure foot is held in slight Ankle locks (start under foot and pull up for horizontal strips) plantar flexion) STABILIZATION equally on both sides) Figure 8 variations • Interlock stirrups with • 1 lateral V-lock (extra pull • if much plantar flexion is needed CLOSING UP: 2 horizontal strips on horizontal part and final for sport, fanned stirrups • 1 lateral V-lock lateral vertical strip) can be used (extra pull on horizontal part and final lateral • 1 medial V-lock (extra pull • continue as before with vertical strip) on final vertical strip) 1 lateral V-lock plus 1 medial V-lock • simple figure 8 • reverse figure 8 (ensure that extreme plantar (for added stability and prevention • continue with reverse figure 8 flexion is restricted of dorsiflexion) (ensure that end-range plantar flexion is with this strip) (extra pull when crossing heel limited with previous locking strips both laterally and medially) or with closing figure 8) • initially add 1.5 cm (3.4 in) thick felt heel-lift for • heel-lift imperative • if tight, rigid boots are necessary, weightbearing to avoid omit this step dorsiflexion Purpose: • supports medial collateral ligament complex • prevents eversion • limits dorsiflexion and lateral flexion • limits end-range inversion and extreme flexion • permits functional plantar flexion Note: this taping does not directly reinforce the fibers of the injured ligament, but reduces the stresses caused by extremes of motion TIP: Visualize location and direction of ligament being supported during tape application. 111

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: foot And Ankle injUry: anterior inferior tiBio-fiBUlar liGament SPrain T erminoloGy T reatment • anterior aspect of the ligamentous mortice of the talo-crural joint Early • R.I.C.E.S. (ankle proper) running from the anterolateral border of the tibia to the • taping: first 48 hours: Acute Ankle Injury (open basketweave – position anteromedial border of the fibula meeting just superior to the talus. This ligament is thinner and weaker than its counterpart, the posterior inferior with slight plantarflexion) tibio-fibular ligament • therapeutic modalities • see anatomy illustration, p. 55 Later: • continued therapy including: E tioloGy • stressed in full dorsiflexion: the wider aspect of the talus jams between the a. therapeutic modalities b. transverse friction massage malleoli • modified fitness activities • stressed severely when a dorsiflexed foot is rotated laterally, forcing the • progressive pain-free rehabilitation including: a. range of motion malleoli to separate b. flexibility • can be accompanied by posterior fibulo-calcaneal ligament sprain c. strength: non-weight bearing to weight bearing (endurance, then power) • common injury in competitive alpine skiing d. proprioception • prevention of recurrent sprains S ymPtomS • gradual pain-free reintegration to sports activity with specific taping. See • local pain, swelling and discolouration rehabilitation taping for isolated anterior inferior tibio-fibular ligament • tenderness anteriorly on palpation between the tibia and fibula just superior sprains, p. 111 • needs greater non-weight bearing (NWB) rehabilitation phase due to to the talus inherent displacing stress caused by weight bearing • active movement testing: pain on dorsiflexion at end-range; increased with S eqUelae active eversion • lateral talo-crural instability if ligament is not supported in shortened • passive movement testing: pain on dorsiflexion at end-range • resistance testing (neutral position): no significant pattern of pain on position during healing phase • permanent instability of the ankle mortice moderate resistance • dysfunction of the superior tibio-fibular joint • stress testing: • peroneal strain and residual weakness often accompany this sprain • weakness of all ankle musculature a. palpable displacement when squeezing malleoli together (may be • recurrent injury accompanied by pain from pinching of ligament fibres) b. marked diastasis (opening up) of malleoli on forced varus in 3rd-degree sprains c. in chronic cases, there is often an audible click on forced varus into an excessive range R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support 112

foot and ankle 6 AnAtomIcAl AreA: the cAlf mAterIAlS The calf taPinG for calf contUSion or Strain Razor Skin toughener spray/adhesive spray Purpose 7.5 cm (3 in) elastic adhesive bandage • applies localized specific compression to the bruised or torn tissues (decreases subsequent swelling, 3.8 cm (1½ in) non-elastic tape 7.5 cm (3 in) or 10 cm (4 in) elastic wrap bleeding and the chances of further tissue damage in the area) 1.5 cm felt heel lift • supports the calf muscles by elastic reinforcement assisting plantarflexion • prevents full stretch of the musculo-tendinous unit by restricting dorsiflexion • limits inversion significantly when heel lock is used • allows full plantarflexion and eversion Indications for use • calf strains or contusions in muscle bulks or musculo-tendinous junctions Notes: • The exact site of the contusion or strain must be localized. • Underwrap is not recommended as it significantly lessens the effectiveness of the taping technique. If necessary, a hypoallergenic liquid such as Comfeel™ can be used instead. • Cold packing of the area should be started immediately. For additional details regarding an injury example, see T.E.S.T.S. chart, p. 117. 113

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle Positioning Lying prone at the end of a low bench with a folded towel placed under the thigh superior to (above) the patella and the calf extending over the end of the bench. Procedure 1 make sure the area to be taped is clean Note: 4b Stretch the tape fully and keep it stretched and relatively hair free; shave if necessary This first layer of tape forms a foundation laterally. for the compression strips, which avoids 2 Check skin for cuts, blisters or areas of excessive tension on the skin. irritation before spraying with skin toughener or spray adhesive. Spray circumferentially to 4a Prepare to apply the first pressure strip the entire calf and let dry completely. directly below the centre of the site of injury: fold back 10 cm at the end of a 3 localize the exact site of the contusion roll of 7.5 cm elastic adhesive tape in one hand, and hold the remainder of the roll in or muscle strain. Beginning 7.5 cm below the other. the lower aspect of the injury, using light tension, wrap 7.5 cm elastic adhesive tape around the limb. repeat this strip, overlapping the previous one by 1.25 cm ( 1 in) until the entire injured area is covered 2 and surpassed by 7.5 cm. 114

foot and ankle 6 4c apply strong pressure to the limb equally 4d Being careful to keep the strip from 4e finish encircling the limb with the other with both hands while maintaining the detaching, release the tension while end of the strip in the same manner, lateral stretch until the tape reaches holding the stretched part against the limb, completely overlapping the tape ends at three-quarters of the way around the limb. before adhering the tape end without any the back. tension at all. Note: Application of this strip causes some discomfort. 115

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle 5 repeat the pressure strip, overlapping by 6 continue repeating the pressure strips, Note: half the tape width above the last strip moving proximally until the entire tape base more proximally, focusing the pressure is covered. The finished compression taping should directly over the injury. have no wrinkles, should be neat in tip: appearance and have continuous, Note: Ensure that the tape job extends at least localized pressure over the injured site from This may be quite painful when pressure is one full tape-width lower and higher than distal to proximal. applied directly over the site. the area of the injury. 7 for dynamic support, use the compression taping as the proximal anchor and apply the achilles tendon taping technique. this will protect and support the entire musculo-tendinous unit for weight-bearing activities. (See achilles tendon taping technique, p. 118.) 116

foot and ankle 6 AnAtomIcAl AreA: cAlf T reatment Calf strain Early injUry: calf Strain • R.I.C.E.S. • taping: Compression Taping T erminoloGy • heel lift • gastrocnemius or soleus strain • therapeutic modalities • Achilles tendon complex strain: ‘pulled’ heel cord • active contraction of dorsiflexors to induce relaxation and improve flexibility • degree of severity: 1st to 3rd – see strain chart, p. 36 • torn Achilles tendon: 3rd-degree strain of calf (isometric at first) Later E tioloGy • continued therapy including: • sudden forced dorsiflexion during active plantarflexion • explosive plantarflexion against resistance a. therapeutic modalities • overstretching b. flexibility • external impact to calf (contusion) c. strengthening • inadequate warm-up d. proprioception • rehabilitation programme: non-weight bearing initially, progressing to S ymPtomS dynamic pain-free reintegration with taped support • history of sudden sharp pain • transverse friction massage (only after several weeks when scar tissue is • ‘pop’ sensation adhering) • feeling of ‘being shot’ in the calf • varying degrees of pain at injury site S eqUelae • local swelling and gradual discolouration • scarring • active movement testing: • haematoma if massaged too early • inflexibility a. no significant pain on non-weight bearing movements • weakness b. calf pain on active plantarflexion if weight bearing • highly prone to re-straining/cramping c. calf pain on dorsiflexion if tight calf is being stretched • passive movement testing: pain on dorsiflexion (1st and 2nd degrees) • resistance testing (neutral position): a. pain on mild to moderate resistance and weakness of plantarflexion (1st and 2nd degrees of severity) b. inability to plantarflex with little or no pain is indicative of 3rd degree of severity (complete rupture) R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support 117

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: cAlf mAterIAlS taPinG for acHilleS tendon injUry Razor Skin toughener spray/adhesive spray Purpose Underwrap • supports the Achilles tendon with elastic reinforcement assisting plantarflexion 3.8 cm (11⁄2 in) non-elastic tape • prevents full stretch of the musculo-tendinous unit by restricting full dorsiflexion 5 cm (2 in) elastic adhesive bandage • limits inversion significantly when heel lock is used 7.5 cm (3 in) elastic adhesive bandage • permits full plantarflexion and eversion 2 cm (3⁄4 in) felt or dense foam heel lift Indications for use • Achilles tendon strain • Achilles tendinitis • diffuse heel pain (possible bursitis) • calf strain; use in combination with Compression Taping • calf contusion: use in combination with Compression Taping • peroneus longus strain or tendinitis: use in combination with Peroneus Longus Support Strips, p. 125 • tibialis posterior strain or tendinitis: use in combination with Tibialis Posterior Support Strips, p. 129 Notes: • Be sure that a thorough assessment of the region has been carried out prior to taping. • If a third-degree strain is suspected, the athlete must be seen by a surgeon as soon as possible. • Evaluate the site of injury; pain may be located at the base of the Achilles tendon, in the belly of the muscle or at the musculo-tendinous junction. • During taping, neutral alignment of the foot can be controlled by the taper whose thigh is used to counter-pressure against the athlete’s great toe. • Because Achilles taping pulls the foot into plantarflexion, the ankle is rendered less stable and the risk of an inversion sprain is increased (step 13 demonstrates preventive measures). • Once taped, a felt or foam heel lift in the athlete’s shoe will shorten and help support the Achilles tendon by improving its mechanical advantage. For additional details regarding an injury example see T.E.S.T.S. chart, p. 124. 118

foot and ankle 6 Position Achilles tendon injury Lying prone (face down) with the shin resting on a cushioned support and the foot protruding over the edge of the table (for steps 1–4 it is more convenient to have the subject supine with the lower limb extending over the end of the table at midcalf ). Procedure 1 make sure the area to be taped is clean 3 apply underwrap without tension around 4 apply two circumferential anchors of 3.8 cm and relatively hair free; shave if necessary. the ankle up to lower one-third of calf. non-elastic tape at the level of heads of the Avoid wrinkles. metatarsals. 2 check skin for cuts, blisters or areas of irritation before spraying with skin Note: tip: toughener or spray adhesive. Heel and lace pads should be used when Be sure to allow some splaying of the the taping is to assist the athlete to resume metatarsals. training or competition. 119

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle 5 at this stage, ask the athlete to turn and 6a a. apply the first vertical strip using either 6c Support this strip without loosening its lie prone to facilitate the rest of the taping tension and carefully apply the last 5 cm technique. Using only slight tension, apply 5 cm or 7.5 cm elastic adhesive bandage. of tape with virtually no tension before two circumferential anchors of 5 cm elastic fix it firmly, without tension, to the plantar cutting the tape from the roll. adhesive bandage at the midbelly of the surface of the foot. b. Pull upwards from calf muscle. the centre of the back of the calcaneus with strong tension to the lower edge of the calf anchor. tip: Allow the ankle to plantarflex. 120

foot and ankle 6 Achilles tendon injury 7 repeat step 6, passing just laterally to the 8 repeat step 6, passing just medially to 9 close up the calf portion of the tape centre of back of heel, pulling up firmly to the centre of back of heel, controlling job with circumferential strips of elastic control the medial tilt of the calcaneus. the lateral tilt and forming a ‘v’ over adhesive tape. the achilles tendon posteriorly before tip: re-anchoring strips at both ends. Maintain strong tension while adhering the upper end of this strip to the calf anchor Note: before cutting the tape Special reinforcement strips should be added after this strip before going on to step 9. 121

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle 10 reposition the athlete in the supine 13a a lateral lock is applied to offer stability to 13b Wind the tape around behind the achilles position to facilitate the next steps. the lateral ankle. Beginning on the medial tendon to catch the heel from the medial side of the upper anchor, pass down side. 11 apply non-elastic tape anchor to the across the anterior skin. midfoot over the heads of the metatarsals. Note: 12 close up the foot portion of the tape job with circumferential strips of non-elastic Once the foot is held in plantarflexion, ankle tape, overlapping each previous strip by stability is compromised based on the half. demands of the sport and the individual’s ankle stability; the use of one or two ankle locks is recommended as outlined in the following, optional, procedure (steps 13 and 14). 122

foot and ankle 6 Achilles tendon injury 13c lock the heel and pull the tape up with 14 repeat step 13 (a–c) a second time on the 16 close up the entire tape job, covering any strong tension on the lateral side before lateral side. open areas. affixing it to the upper anchors. 15 re-anchor these locks. 17 test limits of taping restriction to ensure adequate pain-free support. dorsiflexion Note: must be limited by at least 30°. there A medial lock can also be applied to should be no pain on passive dorsiflexion. reinforce stability in particularly vulnerable ankles. 18 for the acute and subacute stages cut a 2cm felt heel lift, bevelled at the anterior (front) edge, and place it under the heel to raise it, thereby reducing tension on the tendon. tip: It is best to add heel lifts to both feet for a balanced gait. 123

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: cAlf T reatment • therapy including: injUry: acHilleS tendinitiS a. ice T erminoloGy b. therapeutic modalities • Achilles tendon inflammation (irritation) c. transverse friction massage • chronic heel cord strain • Achilles tendon taping, p. 118 • heel lift E tioloGy • modified training programme • structural strain from repeated quick push-offs as in repetitive running • total rehabilitation programme with emphasis on full flexibility, eccentric • sudden change in training; increased distance, speed or intensity; change of strengthening through range of motion and dynamic proprioception • progressive reintegration to regular sports activity with taped support as terrain (example: hills vs level ground) above • new footwear: inadequate heel support • inadequate warm-up and stretching S eqUelae • subsequent to a gastrocnemius (calf) strain • persistent pain • scarring/thickening of tendon S ymPtomS • inflexibility • tenderness plus swelling around tendon • weakness of calf • localized pain (usually mid-tendon) spreads as condition progresses • imbalance of ankle musculature flexibility and/or strength • acute posterior heel pain on weight-bearing plantarflexion (particularly after • bursitis • calcification of tendon or bursa resting) • active motion testing: possible pain on plantarflexion • passive movement testing: usually painful on dorsiflexion • resistance testing (neutral position): possible weakness and marked pain on moderate resistance 124

foot and ankle 6 AnAtomIcAl AreA: cAlf mAterIAlS Peroneus longus tendon injury taPinG for: PeroneUS lonGUS tendon injUry Razor Skin toughener spray/adhesive spray Purpose Underwrap • supports peroneus longus tendon with elastic reinforcement assisting plantarflexion with eversion 5 cm (2 in) elastic adhesive bandage • prevents full stretch of the musculo-tendinous unit by restricting dorsiflexion and inversion 7.5 cm (3 in) elastic adhesive bandage • permits full plantarflexion plus eversion 2 cm (¾ in) felt or dense foam heel lift Indications for use 3.8 cm (1.5 in) non-elastic tape • peroneus longus tendon strain • peroneus longus tendonitis Notes: • Be sure that a thorough assessment of the region has been carried out prior to taping. • IF A THIRD-DEGREE STRAIN IS SUSPECTED, THE ATHLETE MUST BE SEEN BY A SURGEON AS SOON AS POSSIBLE. For additional details regarding an injury example see T.E.S.T.S. chart, p. 128. 125

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle Positioning Lying supine (face up) to start, then prone (face down) with the shin resting on a cushioned support and the foot protruding over the edge of the table. Procedure 1 Begin taping by applying steps 1–8 of 2a affix, without tension, a strip of 5 cm (2 in) 2c maintain strong tension and affix the tape Achilles tendon taping, p. 118 elastic adhesive bandage to the plantar to the calf anchors. Note: surface of the foot, starting on the medial Strips must be re-anchored before side and leading diagonally across to the tip: proceeding. lateral side of the heel. Apply the last 5 cm (2 in) of tape with no tension before cutting tape from roll. 126 2b Holding the foot in plantarflexion and significant eversion, pull the tape up strongly across the lateral side of the heel. tip: Following the direct line of pull of this tendon.

foot and ankle 6 Peroneus longus tendon injury 3 repeat strip 2a–2c a second time, slightly 4 continue the tape job with the Achilles 5 test limits of taping restriction to ensure more anterior (1 cm). taping technique (lateral heel-locking adequate pain-free support. a. dorsiflexion reinforcement is less critical in this tape job because the ankle is already pulled into with inversion must be restricted by at least eversion). 30°. b. there should be no pain on passive dorsiflexion with inversion. tip: Use a heel lift to reduce the strain on the tendon when weight bearing. 127

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: cAlf T reatment • therapy including: injUry: PeroneUS lonGUS tendinitiS a. ice T erminoloGy b. therapeutic modalities • chronic overuse syndrome of peroneus longus c. transverse friction massage • tenosynovitis (inflammation of tendon and sheath) • modified activity initially • taping for Peroneus Longus adaptation of Achilles Tendon Taping E tioloGy • selective strengthening of peroneus longus; non-weight bearing initially, • poor foot biomechanics (more common with high arches) progressing gradually to eccentric full weight bearing • weakness and/or inflexibility of lateral ankle muscles • flexibility then strengthening of all ankle musculature • chronic overstretch or overuse • thorough biomechanical assessment and re-education • subsequent to peroneus longus strain or chronic ankle sprains • orthotics may be indicated • inadequate foot support • gradual (pain-free) reintegration to sports activities with taped support as • repeated running on hard surfaces above • sudden change in terrain, speed, intensity, frequency, resistance, etc. • total rehabilitation: progressive exercise programme for flexibility, strength • uncommon incidence: seen in figure skaters and dynamic proprioception S ymPtomS S eqUelae • swelling and cramping • scarring • localized thickening and tenderness of tendon • inflexibility • localized heat and redness along tendon possible • weakness of evertors • crepitation • muscle imbalance • active movement testing: • chronic tendinitis • chronic subluxing or dislocating of tendons a. weight-bearing: pain on plantarflexion particularly if associated with eversion • predisposition to ankle sprains b. non-weight bearing: possible pain on plantarflexion with eversion • lateral compartment syndrome c. localized pain during active dorsiflexion with inversion (if tight peroneus is being stretched) • passive movement testing: pain on dorsiflexion with inversion (1st- and 2nd-degree sprains) • resistance testing (neutral position): pain with or without weakness on eversion with plantarflexion Note: Inability to evert in plantarflexion with little or no pain can be indicative of a 3rd-degree strain – tendon rupture. 128

foot and ankle 6 AnAtomIcAl AreA: cAlf mAterIAlS Peroneus longus tendinitis taPinG for: tiBialiS PoSterior tendon injUry Razor Skin toughener spray/spray adhesive Purpose Underwrap • supports tibialis posterior tendon with elastic reinforcement assisting plantarflexion with inversion 5 cm (2 in) elastic adhesive tape • prevents full stretch of the musculo-tendinous unit by restricting dorsiflexion and eversion 7.5 cm (3 in) elastic adhesive tape • limits inversion significantly when heel lock is used 2 cm (¾ in) felt or dense foam heel lift • permits full plantarflexion Indications for use 3.8 cm (1½ in) white tape • tibialis posterior tendon strain • tibialis posterior tendinitis Notes: • Be sure that a thorough assessment of the region has been carried out prior to taping. • IF A THIRD-DEGREE STRAIN IS SUSPECTED, THE ATHLETE MUST BE SEEN BY A SURGEON AS SOON AS POSSIBLE. For additional details regarding an injury example see T.E.S.T.S. chart, p. 132. 129

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle Positioning Lying supine (face up) to start with, then lying prone (face down) with the shin resting on a cushioned support and the foot protruding over the edge of the table. Procedure 1 Begin taping by applying steps 1–8 of 2a affix, without tension, a strip of 5 cm (2 in) 2c maintain strong tension and affix the tape Achilles tendon taping, p. 118. elastic adhesive tape to the plantar surface to the calf anchors. Note: of the foot, starting on the lateral side and Re-anchor strips before proceeding. leading diagonally across to the medial tip: side of the heel. Apply the last 5 cm of tape with no tension 130 before cutting. 2b Holding the foot in plantarflexion and significant inversion, pull the tape up strongly across the medial side of the heel. tip: Following the direct line of pull of the posterior tibialis tendon.

foot and ankle 6 Peroneus longus tendinitis 3 repeat strip 2a–2c a second time, slightly 4 continue the tape job with the Achilles 5 test limits of taping restriction to ensure more anterior (1 cm). taping, p. 118. adequate pain-free support. a. dorsiflexion with eversion must be limited by at least Note: 30° or more. b. there should be no pain on It is essential to reinforce lateral ligament passive dorsiflexion with eversion. structures with a heel lock to prevent inversion. tip: Use a heel lift to reduce the strain on the tendon when weight bearing. 131

6 Section 2: Practice B978-0-7234-3482-5.00006-X, 00006 Foot and Ankle AnAtomIcAl AreA: cAlf Note: Inability to invert in plantarflexion with little or no pain can indicate a injUry: tiBialiS PoSterior tendinitiS 3rd-degree strain – tendon rupture. T erminoloGy T reatment • chronic overuse syndrome of tibialis posterior • therapy including: • shin splints • tenosynovitis (inflammation of tendon and sheath) a. ice b. therapeutic modalities (laser or ultrasound can be particularly helpful) E tioloGy c. transverse friction massage • overly pronated or flat feet • modified activity initially • poor foot biomechanics (a fixed forefoot inversion with a valgus calcaneus) • taping for Tibialis Posterior adaptation of Achilles Tendon taping, p. 118 • weakness and/or inflexibility of medial ankle muscles • selective strengthening of tibialis posterior; non-weight bearing initially, • chronic overstretch or overuse progressing to eccentric full weight bearing • subsequent to tibialis posterior strain or chronic ankle sprains • strengthening and flexibility of all ankle musculature • inadequate foot support • thorough biomechanical assessment and re-education • repeated running on hard surfaces • orthotics may be indicated • sudden change in terrain, speed, intensity, frequency, resistance, etc. • gradual pain-free reintegration programme with taped support as above • common in joggers and ballet dancers • total rehabilitation: progressive exercise programme for flexibility, strength and dynamic proprioception S ymPtomS • pain posterior to medial malleolus extending up to posteromedial border of S eqUelae • scarring tibia (can radiate down to the medial arch) • inflexibility • localized swelling and thickening of tendon • weakness of invertors • exquisitely tender on palpation of inflamed site • muscle imbalance • local heat and redness over tendon possible • chronic tendinitis • crepitation • chronic shin splints • active movement testing: • deep posterior compartment syndrome (surgical splitting of fascia a. weight bearing: pain, particularly at push-off sometimes necessary in severe cases) b. non-weight bearing: possible pain on plantarflexion with inversion • predisposition to stress fractures c. pain on dorsiflexion with eversion • passive movement testing: pain on dorsiflexion with eversion • resistance testing (neutral position): pain with or without weakness on resisted inversion with plantarflexion 132

Chapter 7Knee and thigh 2Section The knee is a modified, hinged weight-bearing joint dependent on several structures for stability: • medial and lateral collateral ligaments to prevent lateral (sideways) shearing movements • anterior and posterior cruciate ligaments to prevent anterior (forward) and posterior (backwards) displacement during movement • menisci (two wedge-shaped cartilages) form mechanical spacers to cushion forces, guide movements and add to overall stability. The patella, while improving the biomechanical efficiency of the quadriceps and protecting the femoral condyles, can often be a source of knee pain. The knee is frequently injured during sporting activity, especially contact sports, due to several factors: • heavy weight-bearing demands on the knee during sporting activities • mechanical disadvantages at extremes of performance, e.g. a relatively weak medial collateral ligament and its attachment to the medial meniscus • extremes of force as seen in tackling that can lead to severe injuries such as anterior cruciate ligament ruptures. Correct taping and treatment for knee problems allow the athlete to continue sports participation with minimal risk of sustaining further injury. Taped support assists stability to the injured structure, enhances end-range proprioceptive feedback, and promotes healing by allowing dynamic function. 133

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh 1 72 7 3 15 6 14 14 5 17 6 2 8 16 15 6 12 7 18 10 13 13 9 11 9 2 Medial knee. 4 19 1 Anterior knee. Muscles 3 Lateral knee. Behind the knee on the lateral side, the rounded   1. Quadriceps: rectus femoris tendon of biceps femoris (12) can be felt easily, with   2. Quadriceps: vastus medialis 13. Patellar tendon/ligament the broad, strap-like iliotibial tract (17) in front   3. Quadriceps: vastus lateralis 14. Semitendinosus of it, with a furrow between them. On the medial   4. Gastrocnemius 15. Medial collateral ligament side, two tendons can be felt: the narrow rounded   5. Semimembranosus 16. Lateral collateral ligament semitendinosus (14) just behind the broader   6. Adductor magnus Fascia semimembranosus (5). At the front, the patellar 17. Iliotibial tract ligament (13) keeps the patella (7) at a constant Bones Hollows distance from the tibial tuberosity (9), while at the 18. Popliteal fossa side the adjacent margin of the femoral condyle and   7. Patella Nerves tibial plateau can be palpated.   8. Margin of lateral condyle of femur 19. Common peroneal   9. Tibial tuberosity 134 10. Margin of tibial plateau 11. Head of fibula Tendons and Ligaments 12. Biceps femoris

Knee and Thigh 7 11 6 Knee and thigh 9 10 7 8 1 4 1 3 5 9 52 7 6 3 2 7 8 4 7 10 medial aspect of the flexed knee: bones lateral aspect of the flexed knee: bones and muscles and soft tissues   1. Medial femoral condyle   1. Lateral femoral condyle   2. Medial tibial condyle   2. Lateral meniscus   3. Medial meniscus   3. Lateral tibial condyle   4. Sartorius   4. Head of fibula   5. Gracilis   5. Lateral collateral ligament   6. Adductor magnus   6. Rectus femoris   7. Semimembranosus   7. Vastus lateralis   8. Semitendinosus   8. Iliotibial tract   9. Medial collateral ligament   9. Biceps femoris 10. Vastus medialis 10. Common peroneal nerve 11. Rectus femoris 135

7 Section 2: Practice B978-0-7234-3482-5.00007-1, 00007 Knee and Thigh Anatomical Area: Knee and Thigh Materials Taping for Medial Collateral Ligament Knee Sprain Razor Skin toughener spray/adhesive spray Purpose Underwrap • supports the medial collateral ligament (MCL) by tightening the medial aspect of the joint line 7.5 cm (3 in) and 10 cm (4 in) elastic adhesive • prevents the last 15° of knee extension and external rotation of the tibia under the femur bandage • allows almost full flexion and functional extension of the knee 5 cm (2 in) and 3.8 cm (1½ in) non-elastic tape Indications for use 15.2 cm (6 in) elastic wrap • MCL sprains: 1st and 2nd degree Skin lubricant • post immobilization of 3rd-degree MCL sprains Heel and lace pads • for medial meniscus injuries: emphasize spiral strips which cause internal rotation of the tibia Notes: • Ensure that the correct diagnosis has been made. If in doubt, refer! • Always assess which knee and which side of that knee was injured (the athlete may have sustained spraining on the medial aspect and bruising on the lateral aspect of the same knee). • During exercise, increased blood circulation causes swelling of thigh muscles. Ensure that circumferential strips are affixed with only light tension, avoiding constriction and possible cramping of thigh and calf muscles. • Avoid taping over the patella, as this can cause compression, pain and subsequent problems. For additional details regarding an injury example see T.E.S.T.S. chart, p. 144. 136

Knee and Thigh 7 Positioning Tip: Knee sprain (MCL) Standing upright. Place a roll of tape under the heel of the foot of the injured knee, so that the knee is slightly flexed. The foot is turned inwards to medially rotate the tibia under the femur (releasing the For stability, have the athlete lean against a tension from the MCL). Eighty percent of the body weight should be supported by the uninjured side. wall or couch (plinth) for support. Procedure 1 Make sure the area to be taped is clean 2 Check skin for cuts, blisters or areas of irri- 5 Apply underwrap from midthigh to midcalf. and relatively hair free; shave if necessary. tation before spraying with skin toughener or spray adhesive. 3 Place lubricated pads over the hamstring tendons. 4 Spray midthigh and midcalf with skin toughener or adhesive spray. 137