The Effect of Taping on Patellar Position and Patellofemoral Pain
Brian M. Stinton
December 13, 2004
University of Medicine and Dentistry of New Jersey
Critical Literature Review and Scientific Writing
IDST6400
Dr. Craig Scanlon
Introduction
Patellofemoral pain is one of the most common reasons for a person to seek help from a physical therapist. Patellofemoral pain is generally described as anterior knee or retropatellar pain that is aggravated by such activities as stair ascent or descent, squatting, kneeling, jumping or prolonged factors like sitting and standing. Such activities are known to increase the joint reaction forces at the patellofemoral joint, possibly causing pain (Salsich, Brechter, Farwell, and Powers, 2002). The occurrence of patellofemoral pain in females is two to three times as common as in males, and once present it frequently causes people to cease aggravating activities (Christau, 2004). Despite the prevalence of patellofemoral pain, little is known regarding the etiology of the condition. Several factors that are believed to contribute to patellofemoral pain are decreased joint flexibility, a large Q angle (Quadriceps angle), patella alta, genu recurvatum, increased subtalar joint pronation, tight hamstrings or gastrocnemius muscles, tightness at the iliotibial tract and trauma (Larsen, Andreasen, Urfer, Mickelson, and Newhouse, 1995). The most widely accepted cause of patellofemoral pain is maltracking of the patella believed to be related to weakness at the vastus medialis oblique muscle. The VMO inserts into the medial aspect of the patella at a 40-45 degree angle to the horizontal plane and acts to dynamically stabilize the patella medially. It also acts to prevent lateral deviation or rotation of the patella by the action of the larger vastus lateralis muscle (Christau, 2004). A study by Westfall and Worrell (1992) indicates that the VMO is the only muscle that can move the patella medially and that it works tonically throughout the entire range of motion. In an effort to relieve some of the stress and pain at the patellofemoral joint with aggravating activities, many clinicians have begun to use taping to allow patients to perform exercises under supervision that would usually cause pain. The theory behind taping is that it passively corrects patellar tilt, lateral glide and rotation to keep the patella within the trochlear groove during activity (Kowall, Kolk, Cassisi, Nuber, and Stern 1993).
Patellar taping was first introduced as a method of treatment for patellofemoral pain syndrome by McConnell in 1986. She advocated specific strengthening exercises directed at the quads and VMO as well as patellar mobilization, stretching of the lateral knee structures and the use of tape to inflict a medial patellar glide. McConnell believed that gliding the patella medially would enhance the efficiency of the VMO and facilitate strengthening and therapy. Her initial studies showed a 92% improvement in Patellofemoral pain (McConnell, 1986). McConnell initially advocated patellar taping as a means of facilitating a more effective quads contraction during rehabilitation, a point that has been the topic for several research articles.
Since the release of McConnell’s original research, many authors have been conducting studies to assess the effectiveness of patellar taping at reducing pain and whether taping can effectively alter patellar position. The majority of the studies have shown taping to be effective at reducing pain, but researchers tend to conflict on whether pain reduction arises from a change in patellar position or some other means.
In the current age of insurance and cost effective treatment, doctors are constantly seeking the most efficient method of treatment for their clients. In regards to treatment of patellofemoral pain, conservative management is the most common treatment option that is chosen. Treatment of patellofemoral pain most frequently consists of strengthening exercises to the quadriceps muscle, specifically the vastus medialis oblique, the hamstrings, as well as the hip and ankle musculature to provide increased support and proprioceptive input. Conservative treatment also incorporates stretching of the tight lateral structures, primarily the iliotibial tract, as well as stretching of the hamstrings, quadriceps and gastrocnemius muscle, all of which can have an impact of the mechanics of the patellofemoral joint. The purpose of this review was to examine the research regarding patellar taping in an effort to answer the following question: Does McConnell taping effectively alter the position of the patella to reduce pain during activity associated with patellofemoral pain syndrome?
Methods
Several of the databases available for online searches were used to find articles pertaining to McConnell taping and patellofemoral syndrome. Initially, the Medline database, going back to 1996, was searched for pertinent articles. However, one of the original papers on this topic by McConnell herself was written prior to 1996 and so the database search was expanded to include articles from 1966 to present. Search terms used in the searches were knee joint and patella, both of which were exploded, patellofemoral joint, patellofemoral pain syndrome, McConnell, and taping or tape. These terms were mapped to Mesh headings. An author search using McConnell, J was also performed in an effort to find any relevant research that Ms. McConnell may have performed.
Since the major focus of the paper was the effect of McConnell taping on pain, McConnell was included as a keyword when searching. This may have proved to be a limiting factor while searching as many of the same articles had been found in multiple databases searched. However, the author search combining McConnell, J. with both knee and patella produced a large number of useful articles. After completing searches in the Medline databases, searches were performed in Cinahl, Sumsearch, and Pubmed. These searches produced few articles that were not included in the Medline searches. The only limiting factor that was used during the course of the article search was the English language as there were several articles located in German, Norwegian and Japanese.
|
Initial number of articles retrieved via unfiltered search |
31 |
|
RCT articles filtered with true control group |
5 |
|
RCT articles filtered with true control group and adequate follow-up period. |
1 |
|
Articles using repeated measures design |
13 |
As seen in the above table, very few true randomized controlled trials were found after searching through the various databases. Performing searches in the Cochrane databases revealed similar information.
Review of the Literature
After reading through the articles that were selected for inclusion in the review, the results could be broken up into several comparative sections. They are as follows:
Upon reviewing the article searches, five studies that could be considered randomized controlled trials were found. Some of these trials were not RCTs in the true definition of the term, but there was a degree of blinding as well as randomization of subjects to groups. The majority of the studies that were retrieved and reviewed were Cohort studies using repeated measures, within subjects designs. This design, while not as valuable as an RCT in terms of levels of evidence, was an effective method used by the various authors as it was able to determine an immediate effect of taping on levels of pain in subjects tested. The majority of the studies that were performed were well controlled studies that presented applicable clinical evidence. One case study was included in the body of research provided to present the effect of taping compared to the use of a Palumbo brace. This study however, seemed to present evidence that was both biased and outdated.
Patellar position
One of the most common beliefs of the cause of patellofemoral pain is lateral tracking of the patella, either due to tight lateral structures or a weak VMO. McConnell advocated the use of patellar taping to produce a medial patellar glide to improve tracking and to possibly facilitate a more efficient quadriceps contraction. Some researchers, however dispute the theory that taping can alter the position of the patella.
Pfieffer et al. (2004) performed a study that involved 18 healthy women and the effect of taping on patellar position both prior to and after exercise. In order to get an accurate assessment of patellar position, MRIs were performed at four different knee angles; 0°, 12°, 24° and 36° prior to taping, after taping and then again after having each participant perform a standardized exercise regimen. Lateral patellar displacement was the measure used to quantify the movement of the patella relative to the medial femoral condyle, referenced in the frontal plane (Pfeiffer et al., 2004). Radiographic images revealed that at all four angles tested, a significant medial displacement occurred between the no tape and taped conditions, meaning that patellar taping did produce a significant change in position. Paired post hoc t tests were performed and concluded that these results were statistically significant. After exercise however, the authors compared the no tape with the tape/exercise condition to assess if the medial glide had been maintained. In all test conditions, except 36°, the patella had demonstrated a greater lateral displacement that the position at which it had originally been imaged.
A repeated measures cohort study performed by Larsen et al., (1995) produced results that were similar to Pfeiffer et al. (2004). Larsen et al. examined 20 healthy men, with no prior history of patellofemoral problems to assess the effect of taping on patellar position both before and after exercise. X-ray images were taken of the subjects’ two knees prior to taping, after taping and after exercise. While Pfeiffer et al chose to take images of their subjects in a non-weight bearing position; subjects in the Larsen et al. study were imaged in partial weight bearing in approximately 40 degrees of knee flexion. The authors chose this position, referred to as a modified Merchant view, for the purposes of this study because it provided a more functional view of the patellofemoral joint and it also allowed for an active quadriceps contraction in a closed chain position. Merchant congruence angle, or patellofemoral congruence angle (PFC), was the primary outcome measure used as a means of assessing patellar subluxation.
Larsen et al. found that no difference in baseline measures of patellar position, but that patellar taping produced an average medial displacement of 9° among subjects prior to exercise. Comparisons were then made between the baseline measures and the images taken after exercise. These comparisons revealed no significant difference between the two sets of images, suggesting that taping was ineffective at maintaining the medial glide achieved prior to exercise.
In a study using a much smaller sample size of nine subjects, Somes, Worrell, Corey and Ingersoll (1997) chose to examine the effects of taping on patellar position in both the open and closed chain position in people with patellofemoral pain who had reported a decrease in pain with taping. Open chain radiographs were taken with the knee positioned in 45° of flexion while the closed chain x-rays were taken with the subjects standing in a squat position with the knees flexed at 40°. Radiographs were performed with and without tape applied to the subjects’ knees prior to performing a step-down exercise. Somes et al. chose to examine PFC and lateral patellofemoral angle (LPA) to determine patellar position. PFC is the angle formed by bisecting the sulcus angle of the patella and gives a measure of the medial or lateral position of the patella within the trochlear groove while LPA is a measure of medial or lateral tilt.
Upon analysis of the radiographs, the authors determined that taping in a closed chain position produced the greatest change in LPA, but that no significant difference was seen among the four conditions with respect to the congruence angle. On further analysis, it was also seen that the closed chain position alone increased medial patellar tilt and medial patellar glide. Somes et al. concluded that taping was able to produce a significant change in patellar tilt, but not in medial glide. These results however, unlike those of Pfeiffer et al. (2004) and Larsen et al. (1995), were not compared pre- and post-exercise and cannot as a result, be weighted equally.
Bockrath, Wooden, Worrell, Ingersoll, and Farr (1993) performed a slightly different study, but also used taping to measure the PFC of subjects with patellofemoral pain syndrome. Twelve subjects were involved in this study which had the subjects perform an isometric quadriceps contraction with the knee held in 45° of flexion. Radiographs were taken before and after taping and subjects also performed a step down with and without taping to assess level of pain with activity. While the construct of this study was much more controlled than that of Somes et al. (1997), Bockrath et al. assessed patellar rotation and PFC angles, the results were similar. A significant reduction in pain was noticed by participants during the step down exercise, but no significant improvement in patellar rotation or PFC at 45° of knee flexion was observed with patellar taping.
While the above mentioned studies seem to disagree on the extent of change in patellar position with taping, other forms of intervention claim to be more effective at correcting patellar tracking. A case study was performed by Worrell, Ingersoll and Farr (1994) involving a 15 year old female with a history of patellofemoral pain for three years following patellar dislocation. Since the original injury, she had suffered subsequent subluxations five to six times with each episode followed by a period of pain and swelling. During the course of the literature review, this seemed to be the only case involved that studied the effectiveness of tape with someone who had recurrent subluxations. Worrell et al. sought to compare taping with a Palumbo brace and also with a control condition to assess the effects on PFC, LPA and lateral patellar displacement (LPD) at eight different knee angles on MRI. Following a course of PT and home exercise, with which the patient showed poor compliance, MRI images were taken at 10°, 17°, 25°, 30°, 34°, 39°, 41°, and 45° of knee flexion under three conditions: no tape, tape and use of a Palumbo brace. While taping did not produce a significant change in patellar position, an equal reduction in pain was seen with both taping and use of the brace.
Taping Compared to Other Interventions
While the use of patellar taping has not been shown to produce an effective change in patellar position to this point, several studies have compared taping as an effective means of treating patellofemoral pain when compared with other interventions. In a prospective randomized study involving 25 patients with patellofemoral pain, Kowall et al. (1993) compared a physical therapy regimen to one involving patellar taping. The authors in this study sought to evaluate the effectiveness of patellar taping by measuring pain levels, peak quadriceps torque, and electromyographic (EMG) activity of the vastus medialis oblique and the vastus lateralis. Subjects were randomly assigned into either a taping group (experimental) or a no tape group (control). Each group attended physical therapy sessions twice a week for four weeks, supervised by a licensed physical therapist and patients in the experimental group were instructed in self taping techniques after evaluation by the physical therapist. Subjects were also instructed in a home exercise program. Upon completion of the intervention period, the subjects were reassessed and the results were compared. Both groups demonstrated a significant reduction in pain, but this difference was not statistically significant between groups, with the tape group demonstrating a slightly larger decrease in pain. Both groups demonstrated an increase in peak quadriceps torque and VMO/VL activity during activity, but neither difference was statistically different between groups. The authors concluded that there was no added benefit to the inclusion of patellar taping to a physical therapy regimen for patellofemoral pain.
The findings in this study seem to conflict with the results of a study by Harrison, Sheppard and McQuarrie (1999). Using a RCT design, 113 subjects between the ages of 12 and 35, all diagnosed with patellofemoral pain syndrome were randomly assigned to either a home strengthening and flexibility program, an exercise program monitored by a PT, seen three times weekly for one month, and a group receiving exercise, taping and biofeedback three times weekly for one month. The results of the research by Harrison et al. indicate that the exercise and tape group showed significantly greater improvement on several outcomes measures when compared to the exercise only group. The taping group did not show a significant difference when compared to the home exercise group, yet the authors determined from their results that faster improvements in patients with PFPS could be seen when taping is included in the treatment program.
In a smaller randomized controlled trial involving 71 subjects with patellofemoral pain lasting greater than 1 month, Crossley, Bennel, Green, Cowan and McConnell (2002) compared a physical therapy regimen with a placebo intervention. The PT regimen consisted of strengthening exercises to the affected limb, stretching exercises, patellar taping and a home exercise program. The placebo program consisted of placebo taping, sham ultrasound and the light application of a therapeutic gel (Crossley et al. 2002). While this study did not isolate the effect of taping alone, the authors were able to conclusively prove that the relative risk of a marked improvement by those in the PT intervention group was 3.39 (95% CI, 1.69 to 6.8). While these results may seem conclusive, the use of the sham group as a comparison was a poor choice and the improvements made by the intervention group do not isolate the effect of taping alone, only while included with other interventions.
Although the study by Crossley et al. did not isolate the effect of taping on activity, Wilson, Carter and Thomas (2002) did assess the effect of three methods of taping with activity compared to a no-tape group. In this study, subjects performed four separate step downs, one each with medial glide taping, lateral taping, neutral taping and the fourth with no taping. The order of taping was randomized to decrease threats to validity. All three taping conditions produced a significant decrease in the level of pain on a numerical pain rating scale when compared to the no-tape condition, but the authors were surprised when the results indicated the greatest reduction in pain with the lateral and neutral glide methods. This study does not necessarily refute the findings of McConnell (1986) in her original research, but suggests that the reduction in pain seen with taping is due to some other mechanism than correcting patellar position.
A randomized controlled trial performed by Clark, Downing, Mitchell, Coulson, Syzpryt and Doherty (2000) compared a physical therapy program with taping to several other interventions. Subjects were randomly assigned to one of four groups: 1) exercise, taping and education, 2) exercise and education, 3) taping and education and 4) education only. The results of this study indicated that patients who had performed exercises were more likely to be satisfied with discharge from care at three months than the group that had not. Patients in the exercise groups had also shown significantly better pain scores at one year follow-up than those who did not receive exercise intervention. The use of tape in this study did not produce sufficient enough results to warrant discharge, but the authors did state that the use of tape in the exercise group allowed for the performance of painful exercises.
The Effect of Taping on EMG Activity
Many theories exist regarding the cause of patellofemoral pain. One of the main factors thought to cause patellofemoral symptoms is maltracking of the patella. Lateral tracking of the patella may be caused by tight lateral structures such as the iliotibial band or the lateral retinaculum. Lateral tracking of the patella may also be due to weakness or improper firing of the VMO relative to the VL. Cowan, Bennell and Hodges (2002) chose to study the effects of taping on the temporal aspects of VMO and VL activity. They recruited 22 participants for their study, 10 of which were symptomatic, and these subjects were required to perform a step-down exercise under three conditions, with tape, with placebo tape and without tape. Analysis of EMG activity revealed that in asymptomatic subjects, the onset of VMO activity occurred before the VL during the concentric phase of the step-down and simultaneously during the eccentric phase (Cowan et al. 2002). When subjects with PFPS performed the same activity without tape, the onset of VL activity occurred prior to the VMO in both the concentric and eccentric phases. After therapeutic taping, temporal activity of the VMO was restored to that of the control group; no differences were seen between the placebo and no tape conditions. In asymptomatic subjects, no differences in EMG activity were seen among the three conditions.
Christau produced similar results to those of Cowan et al. In a comparison of 30 women, half diagnosed with PFPS and half healthy, increased VMO activity (10-20%) was seen across all angles of measurement for the symptomatic group under three different taping conditions. In contrast, the healthy subjects demonstrated a decrease in VMO activity. Subjects were asked to perform isokinetic leg press movements at 30 degrees/second and EMG data were collected on the VMO and VL throughout the range of motion under three different conditions; medial glide, lateral glide and neutral glide. Assessments were made for 10° increments from 0°-10° up to 80°-90°. Another finding in this study seemed to contrast that of Wilson et al. (2003). Christau found that the reduction in pain during the leg press was greatest for the medial glide and neutral glide, and less so for the lateral glide, but that VMO activity increased under all taping conditions, while Wilson et al. found the greatest reduction in pain with neutral and lateral glides.
Herrington and Peyton (1997) studied the effect of taping on VMO and VL activity levels as well as the effect of taping on levels of pain. In a repeated measures design, subjects performed a crit test (five-second isometric contractions at 120°, 90°, 60°, 30° and 0° of knee flexion in random order) under taped and non-taped conditions. All subjects achieved a significant reduction in pain with taping, the greatest of which occurred at 0° and 30° of knee flexion. Electromyographic data was analyzed on ten of the subjects, and all ten subjects demonstrated greater VMO activity than that of the VL before and after taping. Vastus medialis oblique activity also increased in favor of the VMO in the VMO/VL ratio after taping, but the changes were not statistically significant. Conversely, Ng and Cheng (2002) demonstrated that that the subjects in their study had shown a decrease in VMO activity after taping. However, the subjects in that study demonstrated varying degrees of malalignment as compared to the subjects in the study by Herrington and Payton who had shown a lateral glide only. Normal VMO/VL EMG ratio should be 1:1 in healthy patients and significantly less for those with patellofemoral symptoms (McConnell 1996). Studies have shown significant variation in this ratio in PFPS patients and the results of this study support that variation.
Discussion
In McConnell’s initial study on the efficacy of patellar taping, she reported a clinical success rate of 92% for the reduction of patellofemoral symptoms with activity (McConnell, 1986). However, a major limiting factor with this initial study was that it did not involve a control group and that it lacked objective evidence to support the use of taping (Kowall et al. 1993). In order to either support or refute these findings, randomized controlled trials are the most effective and trusted methods of doing so.
In the early stages of the literature review, Cochrane reviews were searched for pertinent studies about the treatment of patellofemoral pain. The majority of the reviews that were found indicated that few true randomized controlled trials have been performed on this subject. This may be due the lack of true diagnostic criteria for PFPS. The term seems to be a “catch-all” used by both doctors and physical therapists to classify patients with knee pain. Although there were a few RCTs found, the bulk of the studies that were used in this review were repeated measures designs in which neither the patient nor the treating therapist was blind. Part of the reason for the lack of blinding is that a treating therapist can see a person’s knee and judge from skin folds in which direction the patella is being pulled. In the study by Crossley et al., subjects were asked to guess into which group they were placed at the conclusion of the research. Of the 64 participants that were available for questioning, 81% responded that they had been placed in the physical therapy group. Of the participants in the PT group, 76% guessed correctly, and in the placebo group 35% of the subjects thought they were in the PT group.
One of the other major limiting factors of the research studies found was the lack of a sufficient follow-up period. This may be due to the fact that the majority of the studies examined the effect of taping on the level of pain with a specific activity, within a finite period of time. Therapeutic taping is most commonly used as an adjunct tool in the clinic to allow patients to perform activities that would otherwise be too painful to perform. Recurrent use of tape over a prolonged period may also cause skin breakdown.
The patient populations that were selected for the studies were appropriate. Ages ranged from 12 to 43 years of age, and a majority of the studies included larger numbers of females in their cohorts. The use of a younger population eliminates the possible influence of osteoarthritis and other degenerative age related factors. The proportion of females to males in the studies also reflects the clinical population of patients that present with PFPS.
Threats to validity during the course of research can significantly compromise the results that are achieved. If the construct of a study is not well controlled, or if procedures are poorly conducted, results that are not clearly conclusive may not be well received by readers of that research. Several of the studies mentioned, including Crossley et al. (2002), Bockrath et al. (1993) and Somes et al. (1997), had the subjects perform taping to their own knees prior to activity during the intervention. While instructing a patient in self-taping techniques is a good idea for performance of home exercises, this practice may not be prudent for the purposes of research. Self-taping may increase the external validity of the results, but the threats to the construct of the research and internal validity outweigh the benefits. One of the other major threats to validity seen in many of the articles was the use of small sample sizes. While some researchers neglected to mention whether a power analysis was performed prior to the study, as was the case with Kowall et al. (1993), others started with a small sample that was made smaller by the inability to include some of the research results, as was the case with Somes et al.
As reflected in the literature, no defining research to this point has been able to conclusively determine a causative factor for patellofemoral pain syndrome. Many researchers have implicated patellar lateral tracking as a primary source. Maltracking may be caused by tight lateral structures, the iliotibial band or the lateral retinaculum (McConnell 1996), or possibly by weakness at the quadriceps, specifically the VMO. Tight hamstrings can externally rotate the lower leg and shift the tibial tubercle laterally which would increase the Q angle. In addition, tight hamstrings can also increase activation of the agonist and antagonist muscles crossing the knee joint (Christau, 2004). As patients with these problems develop patellofemoral pain, compensatory gait mechanics may then be adopted in an effort to minimize joint reaction forces and decrease patellofemoral pain (Salsich, et al. 2002). To this point, the standard of treatment for PFPS includes strengthening of the quadriceps and hamstrings muscles, as well as surrounding hip musculature and lower limb musculature as well, stretching of tight structures, hamstrings, quadriceps, ITB, gastrocnemius. Incorporation of closed kinetic chain and higher level activities is warranted as pain decreases in an effort to return the patient to athletic activities.
The vast majority of studies presented have shown that patellar taping produces a statistically and/or clinically significant reduction in the level of pain. The mechanism of pain relief has yet to be determined, but has been shown in several studies not to be due to a change in patellar position as originally thought by McConnell. Additional research is needed to try to determine the exact mechanism of pain relief that is caused by patellar taping. Many articles tend to refute the theory that taping can effectively maintain a change in patellar position with activity. These studies have examined the effect of taping with high level exercises, not more controlled therapeutic exercise. More research is needed to study whether a change in patellar position can be maintained during less aggressive exercise and whether taping can produce a change in position throughout the ROM.
Clinical Implications
Patients seek aid from physical therapists for a variety of reasons. More often than not, pain is the root of most office visits. As skilled healthcare workers, we want to be able to assist our patients in the most efficient way possible. While the majority of the studies reviewed failed to demonstrate that patellar taping was effective at altering patellar position, nearly all of the studies reviewed proved that taping can effectively decrease pain. Therefore, the clinical effectiveness of McConnell taping may lie in the tape’s ability to reduce pain, allowing the acute patient to perform exercises that would otherwise be irritating.
Both Christau (2004) and Wilson et al. (2003) had tested the effect of taping with various patellar glides (medial, neutral and lateral) and found similar results regarding pain reduction. These studies indicate that regardless of the glide used, a significant reduction in pain could be achieved through the use of tape. These studies may support the theory that afferent information, sent as a result of the application of tape, is responsible for pain relief. While the application of patellar tape may not change the position of the patella, it may provide beneficial sensory stimulation that would assist the patient during the course of rehab.
People with patellofemoral syndrome most frequently experience pain with loading of the quadriceps muscle and with increased joint reaction forces to the knee joint. Herrington (2001) performed a repeated measures cohort study and found that subjects had less pain with higher speeds on isokinetic testing than at lower speeds. While this study indicates that the inclusion of higher velocity exercise may be beneficial both for the rehabilitation of patellofemoral symptoms as well as a more rapid return to sport, it also supports the use of patellar taping as an adjunct to conventional therapy. The application of tape with slower paced exercise, both concentric and eccentric, will help to reduce pain with these types of activities and to facilitate recovery of function and muscle strength.
In addition to being unable to participate in athletic activities, those with patellofemoral symptoms may adopt compensatory gait mechanics to minimize stress and pain at the knee joint. Patients with PFPS are often aggravated by such activities as ascending and descending stairs, squatting and kneeling. With gait, as well as higher level activities, joint reaction forces and loading at the knee contribute to patellar pain. While Powers et al. (1997) concluded that no immediate improvement in gait mechanics was achieved with patellar taping, increased loading at the knee was achieved with taping. This increase in loading may then translate to a greater willingness on the part of the patient to attempt painful activities and to accept increased joint reaction forces.
Clinically, the use of McConnell’s methods of taping may not translate into a “medialized patellar position” as originally thought. The evidence does not seem to indicate that. What is shown in the evidence though is that, for reasons unknown, patellar taping is very effective at reducing pain during stressful activities. Patellar taping at this point should not be considered a long term solution to treating anterior knee pain as an insufficient number of studies have been performed to this point. Taping at this point though should be considered as an effective tool to be used with the appropriate patient to temporarily reduce pain to allow for effective performance of rehabilitation and to be used to progress towards the resumption of normal, functional activities.
While taping has not been proven effective at providing a change in patellar position, it has been proven to reduce pain. Studies that have compared a standard PT regimen with the standard plus taping have also not shown a significant difference in level of pain (Kowall et al., 1993, Clark et al., 2000). Taping however, can still be considered an effective clinical tool when used with the correct patient population. If a person with acutely painful patellofemoral symptoms is unable to perform appropriate exercises due to pain, then taping in this case would be an appropriate method of treatment. Taping has been proven to reduce pain and this reduction in pain may then allow this patient to perform tasks that would otherwise be too painful to be attempted. This example, as well as others that are similar, is what makes patellar taping a useful and effective method of treatment.
Conclusion
Although the research has not proven that patellar taping effectively alters the position of the patella during exercise, this does not mean that taping is not a clinically effective tool. Nearly every article has proven that patellar taping is very effective at reducing the level of pain during exercise, especially during activities that create large patellofemoral joint reaction forces which would usually cause pain in affected patients (Salsich et al. 2002). What has been determined by this review is that more research is necessary to determine the factors that create a reduction in pain, whether that reduction is due to afferent nerve stimulation, sensory nerve inhibition, or whether the method of the patellar glide has a significant impact on pain reduction. Clinicians should not hesitate to use taping during the course of PT sessions in clients who have patellofemoral symptoms in an effort to allow them to perform therapeutic exercises. While using tape has not been indicated for long term use or even use outside of the clinic as in athletic activities, it has been proven in the literature that it can be helpful in the short term at reducing pain with activities.
Bibliography
Bockrath, K., Wooden, C., Worrell, T., Ingersoll, C. D., Farr J. (1993). Effects of patella taping on patella position and perceived pain. Medicine & Science in Sports and Exercise, 25(9), 989-92.
Clark, D. I., Downing, N., Mitchell, J., Coulson, L., Syzpryt, E. P., Doherty, M. (2000). Physiotherapy for anterior knee pain: a randomised controlled trial. Annals of the Rheumatic Diseases, 59(9), 700-704.
Christau, E. (2004). Patellar taping increases the vastus medialis oblique activity in the presence of patellofemoral pain. Journal of Electromygraphy and Kinesiology, 14(4), 495-504.
Cowan, S. M., Bennell, K. L., Hodges, P. W. (2002). Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome, Clinical Journal of Sports Medicine, 12(6), 339-47.
Crossley, K., Bennell, K., Green, S., Cowan, S., McConnell, J. (2002). Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Journal of Sports Medicine, 30(6), 857-65.
Harrison, E. L., Sheppard, M. S., McQuarrie, A. M. (1999). A randomized controlled trial of physical therapy treatment programs in patellofemoral pain syndrome. Physiotherapy Canada, 51(2), 93-100.
Herrington, L. (2001). The effect of patellar taping on quadriceps peak torque and perceived pain: a preliminary study. Physical Therapy in Sport. 2(1), 23-28.
Herrington, L., Payton, C. J. (1997). Effects of corrective taping of the patella on patients with patellofemoral pain. Physiotherapy, 83(11), 566-72.
Kowall, M. G., Kolk, G., Nuber, G. W., Cassisi, J. E., Stern, S. T. (1993). Patellar taping in the treatment of patellofemoral pain: a prospective randomized study. American Journal of Sports Medicine, 24(1), 61-6.
Larsen, B., Andreasen, E., Urfer, A., Mickelson, M. R., Newhouse, K. E. (1995). Patellar taping: a radiographic examination of the medial glide technique. American Journal of Sports Medicine, 23(4), 465-71.
McConnell, J. (1986). The management of chondromalacia patellae: A long term solution. Australian Journal of Physical Therapy. 4(32), 215-222.
McConnell, J. (1996). Management of patellofemoral problems. Manual Therapy. 1(2), 60-66.
Ng, G. Y., Cheng, J. M. (2002). The effects of patellar taping on pain and neuromuscular performance in subjects with patellofemoral pain syndrome. Clinical Rehabilitation. 16(8), 821-7.
Pfeiffer, R. P., DeBeliso, M., Shea, K. G., Kelley, L., Irmischer, B., Harris, C. (2004). Kinematic MRI assessment of McConnell taping before and after exercise. American Journal of Sports Medicine. 32(3), 621-8.
Powers, C. M., Landel, R., Sosnick, T., Kirby, J., Mengel, K., Cheney, A., Perry, J. (1997). The effects of patellar taping on stride characteristics and joint motion in subjects with patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy. 26(6), 286-291.
Salsich, G. B., Brechter, J. H., Farwell, D., Powers, C. M. (2002). The effects of patellar taping on knee kinetics, kinematics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. Journal of Orthopaedic & Sports Medicine. 32(1), 3-10
Somes, S., Worrell, T. W., Corey, B., Ingersol, C. D. (1997). Effects of patellar taping on patellar position in the open and closed kinetic chain: a preliminary study. Journal of Sport Rehabilitation. 6(4), 299-308.
Worrell, T. W., Ingersoll, C. D., Farr, J., (1994). Effect of patellar taping and bracing on patellar position: an MRI case study. Journal of Sport Rehabilitation. 3(2), 146-53.
Westfall, D., Worrell, T. (1992) Anterior knee pain: The role of the VMO. Journal of Sports Rehabilitation. 1, 317-325.
Wilson, T., Carter, N., Thomas, G. (2003). A multicenter, single-masked study of medial, neutral, and lateral patellar taping in individuals with patellofemoral pain syndrome. Journal of Orthopaedic and Sports Physical Therapy. 33(8), 437-48.
Appendix
Appendix A
An example of an Ovid Medline search
Database: Ovid MEDLINE(R) <1966 to September Week 4 2004>
Search Strategy:
--------------------------------------------------------------------------------
1 knee joint.mp. or exp Knee Joint/ (28660)
2 exp PATELLA/ or patella.mp. (6989)
3 patellofemoral joint.mp. (475)
4 1 or 2 or 3 (33123)
5 patellofemoral syndrome.mp. (13)
6 patellofemoral pain syndrome.mp. (112)
7 5 or 6 (124)
8 (McConnell tape or taping).mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (427)
9 7 and 8 (12)
10 from 9 keep 1-10 (10)
Appendix B
An example of a Cinahl search
Database: CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to October Week 1 2004>
Search Strategy:
--------------------------------------------------------------------------------
1 exp Knee Joint/ (1211)
2 exp PATELLA/ or patella.mp. or CHONDROMALACIA PATELLA/ (435)
3 1 and 2 (117)
4 exp Knee/ or exp "Taping and Strapping"/ or exp Physical Therapy/ or McConnell.mp. (25447)
5 2 and 4 (163)
6 (tape or taping).mp. [mp=title, cinahl subject headings, abstract, instrumentation] (1541)
7 5 and 6 (36)
8 from 7 keep 3,13,23,27-30,35 (8)
9 from 8 keep 1-8 (8)
Appendix C
A later author search for “McConnell”
Database: Ovid MEDLINE(R) <1966 to September Week 5 2004>
Search Strategy:
--------------------------------------------------------------------------------
1 knee joint.mp. or exp Knee Joint/ (28691)
2 exp PATELLA/ or patella.mp. (6997)
3 patellofemoral joint.mp. (476)
4 1 or 2 or 3 (33159)
5 patellofemoral syndrome.mp. (13)
6 patellofemoral pain syndrome.mp. (112)
7 5 or 6 (124)
8 (McConnell tape or taping).mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (427)
9 7 and 8 (12)
10 (mcconnell j or mcconnell ja or mcconnell jb or mcconnell jc or mcconnell jd or mcconnell je or mcconnell jf or mcconnell jg or mcconnell jh or mcconnell jj or mcconnell jj jr or mcconnell jk or mcconnell jl or mcconnell jm or mcconnell jp or mcconnell jr or mcconnell jr 3rd or mcconnell js or mcconnell jv or mcconnell jw).au. (399)
11 10 and knee.mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (9)
12 (mcconnell j or mcconnell ja or mcconnell jb or mcconnell jc or mcconnell jd or mcconnell je or mcconnell jf or mcconnell jg or mcconnell jh or mcconnell jj or mcconnell jj jr or mcconnell jk or mcconnell jl or mcconnell jm or mcconnell jp or mcconnell jr or mcconnell jr 3rd or mcconnell js or mcconnell jv or mcconnell jw or mcconnell jw jr).au. (400)
13 (12 and patellofemoral.mp.) or knee.mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (43506)
14 12 and patellofemoral.mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (10)
15 from 14 keep 3-5,8,10 (5)
16 (12 and tape.mp.) or taping.mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (429)
17 16 and patella.mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (37)
18 from 17 keep 2,13,16,18,26-27,29-30,34-36 (11)
19 from 18 keep 1-10 (10)