Effectiveness of External Ankle SupportBracing and Taping in Rugby Union

Patria A. Hume1 and David F. Gerrard2

1 Department of Sport and Exercise Science, University of Auckland, Auckland, New Zealand2 School of Physical Education, University of Otago, Dunedin, New Zealand

Contents Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 1. External Ankle Support and Ankle Injury Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 2. Effect of External Support on Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 3. How the External Support May Act on the Joint to Prevent Injury . . . . . . . . . . . . . . . . . . . 296 4. Degree of Restriction in the End Range of Motion (ROM) Provided by an External

Ankle Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 5. Effectiveness of External Ankle Support in Restricting End ROM During Exercise . . . . . . . . . . 299 6. Effect of External Ankle Support on Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 7. Resistance to Inversion Torque Provided by External Ankle Supports . . . . . . . . . . . . . . . . . 302 8. Effect of External Ankle Support on Muscle Activation Patterns . . . . . . . . . . . . . . . . . . . . 303 9. Effect of External Ankle Support on Balance and Proprioception . . . . . . . . . . . . . . . . . . 30410. Effect of External Ankle Support on Ground Reaction Forces . . . . . . . . . . . . . . . . . . . . . 30711. Implications of the Laws of Rugby on the Use of External Ankle Support . . . . . . . . . . . . . . . 30712. Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

Summary Ankle inversion sprain is common in rugby. This review outlines researchevidence relating to the effects of external ankle support by means of bracing andtaping, on the incidence of ankle injuries, how performance is affected by support,how support may act at the joint (with respect to end range of motion, strength,resistive torque, muscle activation patterns and proprioception) to prevent injury,and how exercise changes the effectiveness of support. In addition, the implica-tions of the laws of rugby for the use of external support are discussed. Prospectiveepidemiological studies have shown a decrease in the incidence of ankle injurywith external ankle support use. The effectiveness of external ankle support wasdependent upon the material properties and application method of the tape orbrace, and on the athlete’s status of ankle stability or previous injury. Experimen-tal studies have indicated that the degree of ankle inversion restriction provided,and the degree of loss of restriction after exercise, were dependent upon theexternal support tested. External ankle support has been reported to have no effecton performance, or to have an adverse effect on performance in a variety ofmovement tasks. No prophylactic external ankle support has been shown to im-prove performance. If an external support is to provide mechanical support to aligament it should exceed the strength of the ligament, which for the anteriorfibular ligament is a force limit of between 6 and 56kg. Tape can provide onlylimited mechanical support of the ankle joint complex, but it may have pro-

REVIEW ARTICLE Sports Med 1998 May; 25 (5): 285-3120112-1642/98/0005-0285/$14.00/0

© Adis International Limited. All rights reserved.

prioceptive effects. Taping may work as a psychological reminder, so that theathlete consciously moderates lower limb–loading behaviour. There is equivocalevidence of the effect of brace use on ground reaction force excursions, balanceability and ankle strength. It is concluded that while there have been many inves-tigations of the effects of tape and some forms of brace on ankle range of motionwith and without exercise, there is equivocal evidence regarding the mechanismby which an external support acts. It is recommended that future research addressthe effects of external ankle support during dynamic exercise and that bracemanufacturers utilise the information in the development of future brace designsto help reduce the risk of ankle inversion sprain injury. As external support candecrease the incidence of ankle inversion sprain the International Rugby Boardshould consider the use of ankle braces in rugby, allowing for stiff lateral com-ponents of the brace.

The lateral ligament complex of the ankle is themost common site of injury in sports partici-pants.[1-6] For example, the ankle is the site of morethan one third of all injuries sustained by malebasketball players[7] and 17.7% of injuries that oc-cur in netball players are ankle sprains.[8] Liu andJason[9] stated that the lateral ligament complexaccounted for 38 to 45% of all injuries, and forone-sixth of all sports injury time loss from anklesprains. Over 1400 new claims (5% of the $NZ34million spent on sports injury) were registered andpaid by the NZ Accident Compensation and Rehab-ilitation Corporation in the 1989/90 financial yearfor sports injuries,[10] and there were 36 471 newand ongoing claims at a cost of $NZ95 million in1996 (21 320 new claims totalling $NZ26 million).Rugby had the highest number and cost of claims,accounting for 25% of new and ongoing claims and23% of the costs.[11] Rugby union had the largestnumber (22.2%) of ankle injury claims. Anklesprains tend to occur at foot strike during runningor landing from a jump[12] when the ankle jointcomplex (comprised of the anatomical anklejoint/talocrural joint and the subtalar joint) isplantarflexed and supinated1.[13]

Instability of the ankle joint complex can pre-dispose an athlete to injury. Stability can be af-fected by both the structural and functional compo-nents of the body. The orientation of the joint and

control of the joint movement is determined by theshape of the articulating surfaces and by thestrength and position of ligaments and musclescrossing the joint. There is evidence in the litera-ture that a large number of ankle sprains amongathletes are in part related to the anatomical struc-ture of the foot and ankle region.[12,14] The struc-tural anatomy of the ankle joint complex predis-poses the joint to inversion sprain injury. The anklejoint works in conjunction with the subtalar jointproviding for smooth transmission of forces duringgait. Dorsiflexion and plantarflexion occur primar-ily in the ankle joint. Pronation and supination oc-cur in the subtalar joint.[12] ‘The ligaments associ-ated with a given limb joint are widely accepted asthe structure responsible for its stability (i.e. pre-venting distraction of the bones away from eachother during loading), whereas the role of the asso-ciated muscles in that functional capacity, althoughsuspected, have been neglected’ (Barratta et al.[15]).Therefore, the anatomical arrangement of thebones (i.e., the shape of the joint and the axes ofmotion), the origin and insertion of the muscles andligaments, the angle of pull of the muscles on thebone at a particular moment through the range ofmotion (ROM), the viscoelastic properties of theligaments, the structural response of the connectivetissues and nerves and level of proprioception andstrength can all affect the stability of the joint andits susceptibility to injury. The dimensions of theseindividual components determine the ROM of ajoint, while the degree of resistance of ligaments

1 Supination is described as a combination of inversion,adduction and plantar flexion of the foot.

286 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

and muscle to force will determine whether an an-kle sprain will occur. The degree of flexibility andstrength of muscles surrounding a joint will in partpredispose the joint to injury, or prevent injury, de-pending on the balance of the two (i.e. a very flex-ible joint with inadequate strength to control jointmovement may be more prone to injury than a flex-ible and strong joint or a stiff and strong joint). Thefunction of a joint is controlled by the central andperipheral nervous systems. This includes the mus-cle stretch reflex which is in part a protectivemechanism for a joint to prevent excessive ROM.The neuromuscular system also has the potentialto protect the ankle joint complex if there is pre-activation of muscle pairs about the joint (co-activation). Antagonist muscle activity may in-crease or decrease to compensate for the changingeffect of gravity in the variation of the muscle’seffective length, loading direction and the forcelevel generated by the agonist muscles. Withoutmuscle pre-activation, sudden inversion relies onthe strength of the ligaments and the anatomicalalignment, as the muscle reflex time is too long toprevent excessive inversion.

The ROM allowable in each direction at thesubtalar and ankle joints is restricted by the liga-ments surrounding these joints. However, liga-ments do not function well when forced to limitabnormal motion occurring around a joint.[12] Theindividual contributions of strength, flexibility andneuromuscular co-ordination in stabilising the anklejoint complex are unknown.

To provide justification for the belief that exter-nal ankle support (e.g. ankle taping or bracing)leads to ankle stabilisation, several epidemiologyand experimental studies have been completed.The aim of the review was to outline epidemiolog-ical and scientific evidence relating to the effec-tiveness and possible mechanisms of bracing andtaping in reducing the risk of injury. The effects ofexercise on the effectiveness of support, how per-formance is affected by support and the implica-tions of the laws of rugby for the use of externalsupport are discussed.

Although there were no studies which reportedusing rugby players, epidemiological studies onother sports are relevant to rugby in that the move-ment patterns and injury circumstances are similar;that is, they deal with landing in confined areas andon other players’ feet and involve changing direc-tion. The experimental studies which investigatethe mechanisms of taping and bracing on anklejoint motion are relevant to rugby ankle injuries.

This review examines the prophylactic use ofexternal support as distinct from a previous reviewof the management and rehabilitation of ligamentinjuries to the ankle using external ankle sup-port.[16]

1. External Ankle Support and AnkleInjury Rates

The effectiveness of external ankle support inpreventing injury would be indicated by epidemio-logical evidence that external ankle support use re-duced injury. Such research would require baselineinjury information obtained before the applicationof external ankle support, and periodic monitoringof a wide variety of variables during external anklesupport use. Factors such as the frequency and in-tensity of training, the type of sport played, thespirit in which the games were played, the cause ofinjury and the severity of injury would need to beconsidered. Due to the time, cost and effort re-quired, few such prospective studies have beencompleted. However, a study by Garrick andRequa[17] is often cited as evidence that taping canlead to a reduction in injury. These authors reportedthat ankle taping led to a reduction in the incidenceof ankle sprains in basketball. The prospective,randomised case-control study documented all in-juries for 2562 intramural university basketballplayers in the US, over 2 seasons (1972 to 1973).Baseline injury data were collected during the firstyear for players in scheduled games. During thesecond year, teams and players who agreed to par-ticipate in the study were randomly assigned to 1of 4 conditions, varying with regard to the degreeof mechanical stabilisation provided by externalsupport (tape or no-tape, with low-top or high-top

Effectiveness of External Ankle Support 287

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

shoes). Players were divided into 3 groups for anal-ysis: no prior ankle or knee injury, occasional in-jury and frequent injury. Ankle and knee sprainswere reported by 66 (2.6%) of the players and theseplayers were questioned about their injuries. 1163of the players (45.4%) had their ankles taped dur-ing the season. There was a significant decrease inankle injuries with increased external support.Table I shows that injury rates were highest for the‘low-top shoe no-tape’ players and lowest for the‘high-top shoe taped’ players. The rate for the ‘low-top shoes with tape’ condition was lower than therate for the ‘high-top shoes and no-tape’ conditionindicating that tape possibly had more of an effectthan shoe type. Players who had a previous ankleinjury were twice as likely to be re-injured (27.7injuries per 1000 playing hours for injured playersand 13.9 for previously noninjured players). Thetaped injury rate was lower than the no-tape injuryrate for players with or without a history of anklesprain (table I).

Garrick and Requa[17] concluded that the use ofpreventive ankle taping, in addition to decreasingthe likelihood of re-injury, offered some protectionfor the ankles of the previously uninjured player –although this was only observed for those wearinghigh-top shoes. A limitation of the study was that,due to the small proportion of players being in-jured, the numbers in each of the study groups weresmall. No detail was provided on the position, skilllevel or playing time. Thus, claims based on thisand other similar studies should be treated withcaution, particularly when the definition of injuryhas not been clearly stated.

The effectiveness of wearing a laced stabiliseror taping in preventing ankle injuries and re-injurieshas been investigated retrospectively over 6 sea-

sons of collegiate football practices and games.[18]

For 1.5 years, during practices and games, the play-ers all had taped ankles, and, for the remaining 4.5years, the players chose their type of ankle support.During 51 931 exposures to injury (46 789 practiceexposures and 5142 game exposures), the 297players sustained 224 ankle injuries and 24 re-injuries. Tape was worn during 38 658 exposuresto injury (233 players), and stabilisers during 13658 exposures (127 players). Tape had been wornwhen 159 of the injuries and 23 of the re-injuriesoccurred; a stabiliser had been worn when 37 of theinjuries and 1 of the re-injuries occurred. The com-bination allowing the fewest injuries overall waslaced ankle stabilisers and low-top shoes (in con-trast to the findings of Garrick and Requa,[17] whoreported high-top shoes provided less risk). Injuryrate calculations based on the figures reportedwould indicate a rate of 9.3 injuries per 1000 expo-sures for the laced ankle compared with 6.0 injuriesper 1000 exposures for the taped ankle. Playerswere able to choose their own support and ex-change it over time, therefore the results may beconfounded. Stabilisers can be re-tightened, whichwould return the amount of support to the initialapplication; however, whether supports were re-tightened is unknown. As the specific type or con-figuration of tape or brace was not reported, andthere was no control of skill level or player posi-tion, nor any comparison with an unsupportedankle, recommendations on the best type of bracecan not be made based on this study. In addition,comparisons between the 2 studies described abovewere difficult given the nature of different move-ment patterns in the various sports. Giel[19] alsonoted criticisms of the study in that it was retro-spective and the ankle supports were not randomlyassigned.

In a review of the use of prophylactic anklebraces for preventing lateral ankle sprains, Reis-berg and Verstraete[20,21] revealed methodologicalflaws and, frequently, inappropriate extrapolationof results. Existing research was deemed inade-quate and not definitive enough to warrant confi-dent use of particular supportive modes. Reisberg

Table I. Injury rates per 1000 playing hours among 2562 USintramural university basketball players[17]

Condition No tape Taped

Low-top shoes 33.4 17.6

High-top shoes 30.4 6.5

Previous ankle injury 140.0 22.1

No previous ankle injury 17.9 10.9

288 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

and Verstraete[20,21] called for more reliable scien-tific functional data and empirical conclusionswhen researching the use of prophylactic anklebraces.

In contrast to Reisberg and Verstraete,[21]

Sitler[22] stated in a review of the effectiveness ofexternal support in reducing injury that althoughthe clinical research regarding ankle supports waslimited, it appeared that they were effective in re-ducing the incidence of acute ankle injuries.Sitler[23] then conducted a randomised clinicalstudy to prospectively determine the efficacy of asemirigid ankle stabiliser in reducing the fre-quency and severity of acute ankle injuries in 1601healthy2 US Military Academy cadets playing bas-ketball (clinical, functional or radiographic evi-dence of ankle instability before participation).Athletic shoe, playing surface, athlete exposure,ankle injury history and brace assignment were sta-tistically or experimentally controlled. Ankle in-jury was defined as ‘. . . acute trauma to the ankleligaments that resulted in an athlete’s inability toparticipate in basketball one day after the injury’(Sitler et al.,[23] p. 454). The cadets experienced atotal of 13 430 athlete exposures in the 1990 and1991 intramural basketball seasons. Use of anklestabilisers significantly reduced the frequency ofankle injuries; however, the reduction was depend-ent on the nature of injury (fewer contact injuriesoccurred among those who wore braces). Attitudetoward ankle stabiliser use improved as use of thestabiliser increased. Sitler’s study addressed sev-eral of the methodological flaws identified byReisberg.

Lindenberger et al.[24] reported that tape has asignificant prophylactic effect against lateral liga-ment injuries, with Jerosch et al.[25] stating (in areview) that application of a prophylactic bracecould prevent an estimated 30 ankle sprains per1000 athletic exposures.

Prophylactic training programmes have beenused by a few authors in an attempt to determinewhat interventions are effective in reducing the in-

cidence of ankle injury. A prophylactic programmefor 180 male soccer players which focused ontraining, equipment, tape, rehabilitation, exclu-sion, information and supervision was reported asbeing effective in reducing injuries by 75%.[26]

However, tape was only one of 7 individual com-ponents, therefore, the effectiveness of tapingalone was unknown. Only players with previousankle sprain or clinical instability were taped (n =52) so the prophylactic effect of tape on healthyankles was not assessed. The definition of injurywas not clear and no information on the type ofshoes was given.

Proprioceptive/coordination training has beenreported to be as effective as an orthosis in decreas-ing injuries in 25 senior male Swedish footballplayers.[27,28] However, the results could also beinterpreted as indicating that proprioception train-ing is no better than tape in decreasing injury. Theconclusions of the authors were based on low num-bers, and significant differences were unlikelybased on the small sample size.

Players with previous ankle injury are more atrisk of re-injury than players with no prior injurysustaining their first ankle injury,[17] irrespective ofthe prophylactic prevention.[27,28] External supportuse by players with previous ankle injury hasshown a protective effect,[27,28,29] while there hasbeen no protective effect shown for players withno prior injury.[27,28] In a study[30] of the effect ofthe Aircast® Sports Stirrup ankle brace on theincidence of ankle sprains in senior soccer players(258 with previous ankle sprains, 246 uninjured)during one playing season, it was concluded thatthe semirigid orthosis significantly reduced the in-cidence of recurrent ankle sprains in soccer playerswith previous history of ankle sprains. For playerswith previous sprains, wearing an orthosis resultedin a significantly lower rate of ankle sprain (0.14injuries/1000 playing hours) compared with thenon-braced players (0.86). The ankle sprain injuryrate was significantly higher in the non-bracedgroup with previous sprains (0.86) compared withthe non-braced group without previous sprains(0.46).

2 In this review, a healthy individual is defined as a personwith no history of ankle injury.

Effectiveness of External Ankle Support 289

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

A later study by Sharpe et al.[29] of female soccerplayers with a previous history of ankle sprains in-dicated that prophylactic ankle bracing was effec-tive in reducing the incidence of ankle sprains. Uni-versity soccer players’ medical records over a5-year period were retrospectively reviewed andall of the players who had a previous sprain toeither one or both ankles were identified (38 play-ers; 56 previously injured ankles). Each previouslysprained ankle received one of four interventions:(i) a canvas laced ankle brace (n = 19); (ii) taping(n = 12); (iii) a combination of taping and anklebracing (n = 8); or (iv) no external support (n = 17).All 4 groups had a similar exposure to practice ses-sions and games, with a total of 1717 practice ex-posures and 650 competitive game exposures forthe 4 intervention groups. The recurrence fre-quency for the braced group (0%) was significantlylower than that of the taped (25%), taped andbraced (25%) and no support (35%) groups.

The relatively few studies that have investigatedpreventive measures to reduce the frequency ofankle injuries in sport, have failed to provide un-equivocal evidence of the effectiveness of externalankle support. Several studies, even given the lim-itations mentioned, do seem to indicate that tapingor bracing may be effective in reducing the ankleinjury rate,[17,18,23,24,26-28] particularly for athleteswith previous ankle injury. The effectiveness ofankle taping or bracing is dependent upon theathlete’s level of ankle stability or previous in-jury.[23,28] However, the relationships between shoeor surface types, movement patterns and externalankle support, need further clarification. None ofthe studies have measured the effect of externalankle support on the severity of injury. There is, apaucity of prospective well controlled studieswhich address preventive external ankle supportand, therefore, no clear recommendations can begiven as to whether particular taping techniques ortypes of braces are useful as a preventive strategy.Accurate assessment of the injury data and circum-stances surrounding injured and noninjured playersis required to address the effectiveness of externalankle support and the risk of ankle injury. The type

of tape or brace, technique used to apply the tape,the length of time the tape or brace is in use, allneed to be considered. In addition the adherence oftape to the skin, and the tensioning of the tape stripsneeds to be examined.[31] For a good research de-sign there must be accurate assessment of the pre-sence of previous ankle injury and random alloca-tion to control and experimental groups withinteams during the same period of time. The circum-stances surrounding the injury (i.e. the mechanismof injury and contributing factors), the condition ofthe brace or tape, measures of exposure, severity ofinjury and playing position need to be recorded. Aquestionnaire study indicated that an athlete’s per-ceived comfort, support and performance restric-tions were contributing factors that may directlyinfluence the effectiveness of ankle bracing.[32]

2. Effect of External Support on Performance

The impact on athletic performance is a criticalconsideration when choosing ankle support de-vices for competitive athletes.[33] ‘Although anklebracing may prevent injury, many players believethat braces restrict athletic performance. This be-lief discourages use of braces and obviates the in-jury protection that bracing provides’.[7]

External support has been reported to have noeffect on performance (table II) in jumping, sprintor shuttle activities,[7,33-43] or to have an adverseeffect on performance (table III) in running andjumping activities[32,42,44-51] dependent upon thebrace or tape tested. No prophylactic brace hasbeen shown to improve performance.

Shoes have also been used as an external anklesupport. Systematic changes in resistance of a shoeupper by adding stiffeners to the sides of high-topbasketball shoes, have resulted in decreased ROMof the ankle joint (measured using an Inman de-vice) and a subsequent decrease in performancetimes through an obstacle course[50] for 6 individ-uals (3 with previously injured ankles).

As studies using the same performance tests(vertical jump or shuttle run) have shown contrast-ing results, it is difficult to conclude whether one

290 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

particular movement pattern is affected more byexternal ankle support than any other. The restric-tion of ROM may adversely affect performance inrunning and jumping activities, but it seems to bedependent upon the type of support tested.

28 studies reported that with one exercise periodthe ankle supports provided significantly less sup-

port than pre-exercise (table IV). Scott[76] reportedno significant difference in support betweenbraced and non-braced conditions before or after20 minutes of exercise. This was in contrast toother studies[48,69,72-74] which used a similar meth-odology but used a different brace or tape. There-fore, careful consideration needs to be given to the

Table II. Studies in which external support has been reported to have no significant effect on performance

Study Methods Results

Bocchinfuso et al.[34] 8 male and 7 female healthy high school basketball playerscompleted a vertical jump, 80-foot sprint, shuttle run and4-point run performance wearing Active Ankle TrainingBrace, Aircast® Sports Stirrup . Non-braced control group

Neither brace significantly facilitated or adverselyaffected performance involving speed, agility orvertical jump

Gross et al.[35] 8 males and 8 females (with no history of ankle injury) on40m sprint run, figure-of-eight run and standing vertical jumpwearing DonJoy Ankle Ligament Protector (ALP) and Aircast®

Sports Stirrup

Neither brace had any significant effect onfunctional performance and there was nodifference between braces. 75% of participantsreported that Aircast® Sports Stirrup was morecomfortable than ALP, and 63% indicated that ALP provided more support than Aircast® SportsStirrup

Macpherson[36] and Macpherson et al.[37]

25 healthy varsity/junior varsity football players completedvertical jump, 40-yard (36m) sprint, and 20-yard (18m) shuttlerun wearing Aircast® Sports Stirrup or DonJoy RocketSoc

No significant effect of either brace on anyperformance tests compared with a non-bracedcontrol group

Pienkowski et al.[7] 12 high school basketball players wore Universal ,Kallassy and Aircast® Sports Stirrup ankle training bracewhile completing vertical jumping, standing long jumping,cone running and 18.3m shuttle run before and after 1 weekof brace use

Athletic performance was not significantly affectedby any of the ankle brace designs and no braceaffected athletic performance in a specific activitymore than another

Verbrugge[33] 26 male athletes performed an agility run, a 40 yard sprintand a vertical jump while wearing Aircast® Sports Stirrupankle bracing, adhesive ankle taping or no support

Neither taping or bracing had any significant effecton agility, sprinting speed or vertical jumping ability.Participants reported more comfort using the bracethan a standard ankle taping procedure

Wiley & Nigg[38] 12 individuals performed jumping and a figure-of-eightrunning test wearing Malleoloc ankle joint orthosis

Malleoloc orthosis did not affect performance

Gross et al.[39] 14 males and 9 females with a history of 2 or more lateralankle sprains of the same ankle and no sprains of thecontralateral ankle. Compared DonJoy ALP and Aircast®

Sports Stirrup over a 40m sprint, a figure-of-eight run and a standing vertical jump. Day 1: both ankles unbraced, thenrecurrently sprained ankle braced with one of the types oforthoses. Day 2: repeat of day 1 with the other orthosis.Participants rated the orthoses for comfort and support

Neither orthosis was significantly different from the or from the unbraced condition in any of theperformance tests. 74% of participants reportedthe Aircast® Sports Stirrup to be morecomfortable than the ALP and 61% indicated thatthe Aircast® Sports Stirrup provided moresupport than the ALP

Jerosch et al.[40] 23 athletes with functionally unstable ankle joints, and 18healthy volunteers performed a Japan test and a speciallydesigned single-leg jumping test using an Aircast® brace, aLigafix Air brace, a Malleoloc brace and a tape bandage

The stabilising devices had no negative effect onperformance in either test

Locke[41] 24 varsity and junior varsity boy and girl basketball teammembers with no history of functional ankle joint instability, or prior experience with a prophylactic ankle stabiliser,completed a 24m sprint, a 12m shuttle run and a verticaljump. Participants were randomised to the DonJoyRocketSoc (n = 11) or no brace (n = 13). The braced group were bilaterally braced during every practice, game and test session during the 1995/1996 season

The DonJoy RocketSoc neither enhanced norinhibited performance in activities involving speed,agility or vertical jumping over the 3-month season

Effectiveness of External Ankle Support 291

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

type of brace tested, as all braces may not providerestriction to inversion motion.

Effectiveness of tape seems to depend on howthe tape is applied and factors other than the mech-anical support of taping may explain the effective-ness of ankle taping preventing ankle sprains.[56]

Anderson[72,73] suggested that the major functionof a brace is to restrict the amount of foot inversion

during the fall before actual landing occurs ratherthan functioning as a force bypass for the lateralligaments during loading after foot contact. Glicket al.[75] stated that tape would fail to support theankle mechanically (i.e. as a means of externalsupport) after 20 minutes of exercise, and that anankle with an increased talar tilt may be moreprone to injury than one with a normal talar tilt.

Table III. Studies in which external support has been reported to have a significant effect on performance

Study Methods Results

Coffman &Mitze[44]

4 collegiate basketball players and 4 collegestudents completed a vertical jump and a speed test(sprint length of basketball court) using no support,ankle taping and Aircast® Sports Stirrup bracing

Vertical jump and speed were reduced significantly with tapeuse compared with the control group. Brace use significantlyreduced speed but not vertical jump. Aircast® Sports Stirruphad less of an effect on performance than the tape

Greene & Wight[45]

12 female participants during 90 min softballpractice had passive ankle motion measured whilewearing the Aircast® Sports Stirrup , Swede-Obrace or DonJoy Ankle Ligament Protector (ALP)

Aircast® Sports Stirrup produced significantly slower baserunning times than Swede-O brace or ALP brace

Burks et al.[46] 30 college athletes with both ankles supported by Swede-O brace, Kallassy brace, tape orwithout support, performed broad jump, verticalleap, 10-yard (9m) shuttle run and 40-yard (36m)sprint

Compared with the no support condition: ankle tapingsignificantly decreased performance in vertical jump, shuttle run and sprint; Swede-O bracing decreased performance in vertical jump, broad jump and sprint; Kallassy bracingdecreased performance in vertical jump. Performance wassuperior with no ankle protection

Paris[42] 18 elite soccer players wearing nonelastic adhesivetape, Swede-O brace, New Cross brace,McDavid brace or no tape, tested on motorperformance for speed, balance, agility and verticaljumping

Vertical jump performance was significantly reduced whenparticipants wore New Cross braces. There were nosignificant differences in tests of speed, balance and agilityamong any of the support conditions

Beriau et al.[32] 85 healthy high school athletes wearing Aircast®

Sports Stirrup , Aircast® Training brace,Swede-O brace and DonJoy ALP while running an agility course

Ankle braces produced slower agility times compared with theno brace condition. Times using the DonJoy ALP and Aircast®

Training brace were significantly slower than for otherconditions. The authors concluded that there were limitedpractical performance effects upon agility while wearing anankle brace

MacKean et al.[47] 11 female basketball players on vertical jump, jump shot, sprint drill and submaximal treadmill runwearing no support, tape, Swede-O-Universal ,Active Ankle and Aircast® Sports Stirrup braces on both ankles

Overall performance impaired by ankle support. Active Anklebrace impaired performance the least of the support devices.Vertical jump was significantly lower with ankle tape comparedwith no tape. Jump shot accuracy was significantly better withtape compared with the Swede-O-Universal . Oxygenconsumption and energy expenditure were significantly higherwith the Aircast® Sports Stirrup compared with tape

Hochman &Nowalkowski[48]

Effect of ankle taping (anchors, stirrups and heellocks) and Mikros ankle bracing on vertical jumps completed after 90 min exercise with tape

No significant differences between ankle taping and anklebracing for jumping distance. There were significant decreaseswith supportive applications compared with control group forjumping distance

Metcalfe et al.[49] 10 healthy female college students completed a vertical jump and a Southeast Missouri agility test wearing tape (closed basketweave), tape withmoleskin stirrup reinforcement (closed basketweaveand moleskin stirrup), a lace-up brace (Swede-O-Universal ) or no support. Motor tests wereconducted on 2 separate days

Vertical jumps were significantly shorter, and performance timessignificantly slower, for all 3 ankle prophylactics compared withthe no support condition. There was no difference between the3 prophylactics

292 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

Table IV. Effects of a single exercise period on the effectiveness of external support to restrict range of motion (ROM)

Study Methods Results and conclusions

Malina et al.[52] Passive plantar flexion-inversion for 10 male participants.Cable tensiometer and ROM indicator measured ankleROM under 4 conditions: basketweave and stirrupsapplied to the skin; basketweave and stirrups appliedover a stockinette; a Louisiana wrap; and basket weave,stirrups and heel locks. ROM measured pre-support,post-support and post-exercise with support, for eachsupport condition on a different day. Exercise for 5 min(jumping jacks, vertical jumps, squat jumps, sidestepsand an agility run)

Stockinette condition significantly reduced ROM afterexercise but other conditions did not. With exercise, ankle supports provided significantly less support thanpre-exercise

Rarick[53] Passive inversion and eversion for 5 male participants (aged 21 to 28y). ROM measured pre-tape, post-tapeand post-exercise for: basketweave; basketweave andstirrups; basketweave and heel locks; basket weave,stirrups and heel locks. Exercise for 10 min (running,jumping, pivoting, quick steps and stops)

Basketweave, stirrups and heel-lock conditions providedmost restriction of ROM. Tape restriction to inversion plantarflexion decreased up to 40 to 50% after 10 to 20 minexercise due to stretching and weakening of tape anddecreased adhesion owing to sweating

Alves et al.[54] 27 healthy participants (ages 18 to 36y) in a combinedpassive ankle inversion-eversion movement: pre-braceapplication; immediately post-brace application (Aircast®

Sports Stirrup , DonJoy Ankle Ligament Protector(ALP), Swede-O ankle support and Kallassy anklesupport); and following 10 min exercise session

All 4 braces significantly limited ROM compared withunbraced ankle, before and after exercise. Aircast® SportsStirrup and ALP significantly limited ROM more thanSwede-O ankle support and Kallassy ankle support,before and after exercise

Fumich et al.[55] ROM measured with Inman device. College footballplayers (n = 16) completed a 2.5 to 3h football practice

Tape reduced ROM 10 to 14°, but loosening occurred afterexercise. Greatest mechanical resistance in plantarflexion,inversion neutral and plantarflexion inversion. Resistancedecreased 50% (6°) after exercise. Post-exercise residualrestriction provided by tape was still greater than untapedstate, which may indicate a possible benefit of tape

Frankeny etal.[56]

Inversion (using an Inman ankle mortise motion analyser)for 9 male participants (aged 21 to 32y) with 5 frequentlyused taping methods and 3 skin preparations before andafter a 15 min exercise session

Hinton-Boswell method provided greatest inhibition toinversion with minimal restriction of plantar and dorsiflexionof the ankle. Tincture of benzoin increased effectiveness oftaping compared with prewrap or direct tape to skin. 50% ofsupporting strength lost in all taping methods after exercise

Stuessi et al.[57] Inversion movement of the ankle during running with andwithout an Aircast® Sports Stirrup ankle brace filmed at50 fps for 11 participants (5 male and 6 female) withankle instability problems while running over the forceplate. Special shoe sole to force supinatory movement

During unloaded conditions range of supination was 25 to50°. Aircast® Sports Stirrup brace decreased supinationrange to 8 to 24°. Restriction was individual and varied from 10 to 30° between participants. Aircast® decreasedinversion in running from 5-8° to 2-5°. Significant differenceswere seen in the medial and lateral force in 7/11 and inankle velocity in 6/11 participants

Hamill[58] 10 healthy males completed 10 walking trials in 4 conditions: pre-exercise; pre-exercise with brace;post-exercise; and post-exercise with brace. Aircast®

Sports Stirrup ankle brace use randomly presentedwithin pre-exercise and post-exercise conditions.Rear-foot angles during walking after an eccentricexercise protocol were calculated from film (100Hz).Participants were fatigued by 70 maximal eccentricactions of ankle everters with 15 sec between each action

Exercise reduced rear-foot touchdown angle (i.e. in a moreinverted position). Brace affected rate of calcaneal eversionvelocity (i.e. there was an increased time to maximumeversion)

Martin &Harter[59]

10 participants videotaped before and after 20 minvigorous exercise in 4 separate testing sessions.Effectiveness of adhesive taping, lace-up brace andsemirigid orthosis with a no-support control group inlimiting maximum inversion angle under dynamic loadsimposed by repetitive walking (6.4 km/h) and running(14.5 km/h) on an 8.5° laterally tilted treadmill.

Post-exercise inversion significantly less restricted thanpre-exercise inversion at 4 mph (6 km/h). Semi-rigidorthosis significantly restrained inversion compared with allother conditions at both 4 and 9 mph (14.5 km/h). Lace-upbrace significantly restrained inversion compared withadhesive tape at 9 mph and to adhesive tape and controlgroup at 4 mph.

Continued over page

Effectiveness of External Ankle Support 293

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

Table IV. Contd

Study Methods Results and conclusions

Bartold[60] 48 healthy individuals tested for adhesive ankle taping, 4 ankle orthoses (Unilock , Gridiron , Swede-O and Rocketsoc ) and a control group before, during and after 30 min running on a treadmill. Maximal, activeweight-bearing inversion and eversion were measuredusing 2-dimensional kinematics

Taping had maximal losses in restriction for inversion and eversion after 30 min exercise. Support reduced forUnilock (18%), Gridiron (22%), Swede-O (21%) and Rocketsoc (3%)

Hughes &Stetts[61]

29 participants (each own control) randomly assigned toleft or right ankle group with Gibney basketweave withdouble heel-lock taping or a semirigid thermoplasticsupport system. Active inversion ROM measuredpre-support, pre-exercise and post-exercise (20 minsprinting, relays, forward and backward running, lateralrunning and 1.25 miles run-walk) with a Leightonflexometer attached to a foot device

Both supports showed comparable decrease in supportafter exercise compared with original ROM. No significantdifference in restriction between tape or splint. Functionalsemirigid support was not a more effective external supporttechnique than ankle taping. No comparisons were madebetween pre- and post-exercise or pre- and post-supportapplication

Gross et al.[62] Passive inversion and eversion for 16 healthyparticipants (8 female and 8 male, aged 20 to 32y).Biodex and Leighton Flexometer used to measureROM with Aircast® Sports Stirrup , Swede-O braceor tape. Each support measured on separate day with 2 rest days before next test. ROM measured pre-support,post-support and post-exercise (10 min figure-of-eightrunning and 20 unilateral toe raises)

Inversion and eversion significantly reduced followingapplication of support and remained significantly reducedcompared with control group for the support conditionsfollowing exercise. Aircast® Sports Stirrup and tapeprovided more restriction than Swede-O bracepost-exercise. All braces were equal for eversion postexercise

Gross et al.[63] Passive inversion and eversion for 22 healthy ankles for9 female and 2 male participants (aged 18 to 36y). CybexII and Newman myometer measured ROM withAircast® Sports Stirrup brace or tape (basketweaveplus figure-of-eight and heel-lock). Each support testedon a separate day with 2 to 7 days rest between testingdays. Ankle ROM measured pre-support, post-supportand post-exercise (5 min figure-of-eight running and 20unilateral toe raises on a 6-inch (15cm) step with support)

Post-application and post-exercise ROM significantly lessfor both support systems compared with pre-application.Post-exercise inversion restriction was significantly lessthan pre-exercise ROM for ankle taping. Aircast® SportsStirrup limited ankle inversion significantly more thanankle taping following exercise. Even after exercise bothtape and brace reduced ROM significantly compared withpre-application. Aircast® Sports Stirrup significantlyreduced eversion compared with tape

Greene &Roland[64]

30 healthy participants (15 female and 15 male) with noprevious history of wearing ALP brace. ROM measuredusing the Lido isokinetic device for pre-brace,post-brace and post-exercise (2 min vertical jumping, 10 min forward, backward and lateral running around arectangular path, 3 min standing long jump and 5 minfigure-of-eight 3 × 10m course) with brace conditions

Significant decrease in ankle active inversion and eversionafter 20 min exercise. Significant decrease in inversion andeversion even after 20 min exercise, but brace did notinterfere with maximum inversion/eversion torque production

Alves et al.[54] Passive inversion and eversion for 27 healthyparticipants (13 female and 14 male, aged 18 to 36y).Cybex II and cable tensiometer measured ROM withAircast® Sports Stirrup , ALP, Swede-O , or Kallasybrace. Two braces tested per day for pre-brace,post-brace and post-exercise (5 min cycling, 2 minrunning court lines, 2 min 5 x 15m cutting run, 1 minlateral jumps over a line) with brace conditions. 7 daysrest between tests

Brace led to 18 to 29% restriction of initial ROM measures,and after exercise restriction was reduced to 12 to 27%restriction of initial measures. All braces significantly limitedankle ROM before and after exercise, with the ALP andSport Stirrup limiting ROM more than Kallasy orSwede-O braces

Gross et al.[65] 16 healthy participants (8 males, 8 females). Passive foot and ankle eversion and inversion motion measured onBiodex dynamometer before support application(DonJoy ALP and newly developed ankle tapingprocedure), with application and then after exercise (10min figure-of-eight running and 20 unilateral toe raises).

Both ankle supports significantly reduced eversion and inversion post-application and following exercisecompared with pre-application. Eversion increasedsignificantly following exercise for both ankle supportsystems compared with post-application. Inversiondisplacement following application was greater for ALP than ankle taping system. The 2 ankle-supportsystems did not differ significantly following exercise foreversion or inversion measurements

294 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

Table IV. Contd

Study Methods Results and conclusions

Wiley & Nigg[38] Malleoloc ankle joint orthosis on 12 participants(history of inversion ankle sprain and increased anteriortranslation) completed active and passive ROM inversionpre- and post-exercise (jumping and a figure-eightrunning test)

Malleoloc restricted active ROM and passive inversionsubstantially, reduced the other movement degrees offreedom only minimally, provided the same movementrestriction before and after exercise

Laughman etal.[66]

Three-dimensional ROM, measured withelectrogoniometer and foot switches, during walkingalong a flat path and then along a slope for 20 healthyparticipants (10 male and 10 female, aged 20 to 45y),pre-tape, post-tape (closed basketweave with heel lockand half figure-of-eight) and post-exercise [15 minfigure-of-eight running and 20 toe raises off a 6-inch(15cm) step]

Application of tape to ankle pre-exercise resulted in 26.7%decrease in inversion-plantar flexion. After exercise, 18.6%restriction remained which was statistically significantcompared with pre-exercise ROM

Myburgh etal.[67]

12 squash players wore tape (basketweave, stirrup andheel locks) on left foot and guard (Futuro and Ace )on right foot. Electrogoniometers measured joint motionwith the participant seated

Ankle guards did not provide significant support for any ofmotions measured, while tape did restrict joint motion by 20 to 40% before exercise. After 1h exercise, support haddiminished to below that of ankle guard with only 10%residual restriction

Wilkerson[68] Passive downward and inward motion within sagittal andfrontal planes for 30 male college football players.Footplate and goniometer measured ROM for one anklewith standard tape applied, and for other ankle with tapeapplied in a modified form, pre-tape, post-tape andpost-exercise (2 to 3h football session) with tape

Both forms of tape decreased ROM. Initial restriction of40% with tape decreased to 20% restriction after exercise

Sprigings etal.[69]

Inversion experiment (backward inverting step of 30°) for 6 college males with Louisiana wrap or taped withGibney heel lock

External ankle support did not take the place of peroneuslongus muscle activity. ROM decreased by 15° for inversionand 20° for plantar flexion. Wrapping decreased ROM ininversion by 10° and in plantar flexion by 15°

Hochman &Nowalkowski[48]

90 min exercise, taped ankles, ROM measured on atilt-board

Following exercise, tape lost its support

Vaes et al.[70,71] Passive talar tilt using x-ray, an Inmann stress apparatusand electromyography. Talar tilt measured for 51 ankleswith tibiotalar instability, pre-support, with elasticbandage, with tape (Gibney basketweave), and then post exercise (30 min jumping, zigzag running, hopping,figure-of-eight running and directional-change runs) withthe tape

Significant decrease in talar tilt with tape but not with elasticbandage. Decrease in talar tilt due to tape remainedsignificant after exercise.

Anderson[72]

and Andersonet al.[73]

Calcaneal inversion angles, times and ground reactionforces measured when participant’s right foot (15 womenand 15 men) bearing bodyweight, suddenly inverted to a side slope of 22° on an inversion tilt-board, with andwithout nonrigid subtalar stabiliser (STS) ankle brace.Two min exercise incorporated lateral movements andsprinting

Brace significantly reduced maximum calcaneal inversionangle for overall drop, significantly lengthened inversiontime for overall drop and significantly reduced calcanealpeak inversion velocity during loading and for overall drop.Following exercise STS ankle brace continued to providesignificant reduction in calcaneal inversion angle andvelocity, although some of its effectiveness was lost

Money[74] 13 healthy participants tested for ankle plantarflexion-inversion ROM before and after 20 mincontinuous multidirectional aerobic stepping on an 8-inch(20cm) platform. Participants tested on a plantar flexion,inversion stress platform which had an initial position of20° of plantar flexion and was used to lower the ankleinto 35° of inversion in the weight-bearing position

AirStirrup ankle brace significantly restrictedankle-complex inversion angular displacement as comparedwith control condition before and after exercise

Glick et al.[75] Running gait of 6 participants, 4 with significant talar tilt,measured using simultaneous electromyography andcinematography

Cloth ankle wrap did not stabilise ankle mortise in any of theparticipants. With tape strapping the ankle mortise was heldfor 20 min for 1 participant, 15 min for 3 participants and 2 min for 2 participants

Continued over page

Effectiveness of External Ankle Support 295

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

Bauer[77] concluded that athletic tape would fail tosupport the ankle effectively during and after exer-cise (table V).

There were 4 studies[45,77-79] using multiple ex-ercise periods where support significantly reducedROM, but the level of restriction decreased overfurther exercise periods. Two studies[80,81] used mul-tiple exercise periods, during which support signif-icantly reduced ROM, and continued to restrictmotion over further exercise periods (table V).

3. How the External Support May Acton the Joint to Prevent Injury

Given that external support may decrease per-formance, and that the effectiveness of brace re-striction may change with use during exercise, it isimportant to understand the mechanism by whichexternal support acts so that the positive aspectscan be utilised. Hughes and Stetts[61] stated that‘ . . . the ultimate goal of any external support is toprevent inversion sprains (rolling over on the out-side of the foot and tearing the ankle ligaments)through restriction of available inversion (wherethe sole of the foot is tilted inwards). It is assumedthat by restricting active inversion the motionavailable to the athlete at the extreme of inversionwill also be limited’, and that ‘ . . . indications fortaping are based on the assumption that some typeof external supportive material increases ankle sta-bility by reinforcing the ligamentous structures ofthe ankle and restricting motion such as extreme

inversion, which is the culprit in most ankleinjuries’.

It is believed by many athletes, trainers and phy-sicians, that the application of tape to the ankleafter injury (such as a mild inversion sprain) willresult in an ankle sufficiently stabilised to return toathletic activity. Subotnick[12] has stated that amoderate sprain with a partial tear could be reducedto a mild sprain by taping, and that competitioncould be allowed if the athlete was able to jump upand down on the involved ankle and run withoutpain. However, with exercise, the support providedby external ankle support may be considerablydecreased and put the ankle at a greater risk of re-injury.

Miller and Hergenroeder[82] stated that adhesivetape does offer protection against ankle sprainsduring activity, and that ‘ . . . laced stabilisers offeran equal or possibly greater amount of support, areless costly and easier to apply, and can beretightened frequently during activity. The Air-stirrup® may be indicated for patients with a his-tory of ankle injury who are undergoing a gradua-ted rehabilitation program. Nevertheless, theAirstirrup® has not been shown to provide signifi-cantly greater inversion restriction than taping orlace-on braces and is not recommended as a first-line method of support for individuals with no his-tory of recent ankle sprain. High-top shoes arebetter when the ankle is taped, although low-topshoes are better when a laced stabiliser is worn.

Table IV. Contd

Study Methods Results and conclusions

Scott[76] 13 healthy participants for ankle plantar flexion-inversionROM before and after 20 min step-aerobics, with orwithout Active Ankle brace. Participants tested onplantar flexion, inversion stress platform with initialposition of 20° plantar flexion. Ankle in 35° inversion in the weight-bearing position

No significant difference in support between brace andnon-braced conditions before or after exercise

Metcalfe et al.[49] Subtalar ROM measured by a goniometer in 10 healthycollege females before, during and after 20 mincontinuous exercise under 4 conditions: tape (closedbasketweave), tape with moleskin stirrup reinforcement(closed basketweave and moleskin stirrup), a lace-upbrace (Swede-O-Universal ) or no support

In comparison with no support: tape with moleskinsignificantly restricted all ROMs (plantar flexion,dorsiflexion, inversion, and eversion), tape significantlyrestricted all ROMs except plantar flexion andSwede-O-Universal significantly restricted all ROMsexcept eversion

296 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

Elastic guards help reduce ankle oedema but do notprovide ankle stability’.

One means of assessing whether external sup-port can prevent injury or protect against re-injuryis to examine the effects of such support duringparticular movements thought to contribute to in-

jury. For example, inversion and plantar flexionbeyond a normal ROM have been cited as the pri-mary mechanism of ankle inversion sprains.[45,53,54]

Assuming that most ankle injuries are due toinversion causing damage to the lateral ligaments,it is necessary that taping and bracing provide a

Table V. Exercise effects on external support: multiple exercise periods where support significantly reduced range of motion (ROM), butdecreased restriction over further exercise periods

Study Methods Results

Paris et al.[78] Plantar-dorsiflexion and inversion-eversion ROM of 30 participants before and after 15, 30, 45 and 60 mintreadmill exercise

Swede-O , SubTalar Support-brace and nonelasticadhesive tape significantly reduced pre-exercise ROM in all directions compared with unsupported ankles. Ankleinversion ROM significantly increased after 15 min exercisefor all 3 supports. SubTalar Support brace showed asignificant inversion ROM increase between 15 and 30 minpost-exercise. Ankle plantarflexion ROM significantlyincreased after 15 min exercise for tape and SubTalarSupport-brace, and after 30 min with Swede-O brace.Tape had significant increases in plantarflexion ROM after30, 45 and 60 min of activity. Both braces offered longerpost-exercise support than tape, while Swede-O braceretained support longer than SubTalar Support

Greene &Hillman[79]

Passive inversion and eversion for 14 healthy ankles (7 male participants, aged 18 to 21y). Ankle stabilitydevice and analogue torque meter used to measureROM with the DonJoy Ankle Ligament Protector (ALP)brace or basketweave tape, pre-support, post-support,post 10 min exercise with support, post 60 min exercisewith support, and post 3h exercise (3h volleyballtraining) with support

Tape restricted ROM by 41% initially but restriction was only15% after exercise. Maximal loss of restriction after 20 min ofexercise. Brace had initial restriction of 42% and afterexercise restriction was 37%

Greene &Wight[45]

Passive ankle inversion and eversion measuredpre-brace, post-brace and post 20, 40 and 90 minsoftball exercise with brace for 12 female participants(aged 18 to 22y). Both ankles measured using anklestability device and analogue torque meter groups witheither an Aircast® Sports Stirrup , ALP or Swede-Obrace applied

The Swede-O brace showed 35% of initial post-braceinversion restriction after exercise, with 12% for the Aircast®

Sports Stirrup brace, and 8% for the ALP

Bauer[77] 9 measures of active ankle inversion (using Cybex II) forparticipant before tape, with ankle taped, after exercisewith ankle taped (6 exercise periods), and post-exercisewithout ankle taped

Taping ankle resulted in decreased ROM (41.6% restriction)before exercise. After 30 min exercise only 6.6% restrictionremained, with 45% of ROM regained after 20 min exercise

Morris &Musnicki[80]

Passive inversion/eversion and dorsi/plantar flexion inright ankles of 20 participants (10 male and 10 female)measured pre-tape, with tape (Gibney closedbasketweave), post 10 min exercise (jogging around a gymnasium - 5 min each way) with tape and post 20 min exercise with tape (10 min jogging repeated)

Inversion and eversion ROM significantly reduced with tape,even after exercise. Tape less effective after 10 min butrestriction after 20 min was still significant compared withpre-tape condition for inversion/eversion and dorsi/plantarflexion

Tweedy et al.[81] Active inversion with ankle in 42° plantar flexioninversion with a pedal goniometer. 13 healthy Australianrules footballers (aged 17 to 30y) wore each brace(Leuko or Nessa Ankle brace) once. Measurementstaken before and after brace application pre-exercise,after 20 min activity (running, side-stepping andjumping), and after a further 20 min of identical drills

Both braces significantly restricted inversion compared withno-brace condition for all measurements. No significantdifferences in ankle inversion between the 2 braces at any of the measurement times

Effectiveness of External Ankle Support 297

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

means of stabilising the ankle to prevent excessiveinversion. Possible mechanisms by which tape andbraces may provide stabilisation are as follows:• by providing resistance to motion to decrease

end ROM (limit of inversion motion) whichwould result in less strain on the ligaments

• by increasing muscle activation, which mayspare the amount of force developed on the lig-aments and tendons

• the brace-tissue interface could redistributeloads away from the ankle joint complex centre

• the rearfoot angle (inversion/eversion) could beplaced in a neutral position on landing

• the rate of loading to reach the end ROM coulddecrease

• the ankle torque (rotatory effect) could increasefor a given ROM

• the moment arm at the joint could decrease(with a smaller lever arm a decreased forcewould result)

• the tape or brace may act to reinforce the liga-ments by taking the force in their place.McLean[83] discussed proposed mechanisms of

adhesive strapping in sport and stated that ‘. . . ad-hesive tape can act as a secondary ligament pro-vided it is applied to areas of skin which are rela-tively immobile and the tape aligned in such a wayto prevent the extremes of physiological jointrange’, and that ‘ . . . in isolation, neither tape northe strength of the tape/skin interface would resistthe predicted force required to rupture componentsof the lateral ligament, but when combined with thebody tissues, strapping improves the capacity todissipate the energy associated with potentiallytraumatic forces’.

The construction style and quality of materialscould affect all of the above suggested mecha-nisms. Tensile tests have indicated that a force of75N per cm of width would break tape,[84] there-fore, for a 2.5cm wide tape, the breaking strengthis approximately 187N. The average elastic modu-lus of elastic tapes has been reported to be 269 N/cmas compared with 1280 N/cm for stiff tapes.[85] Oncadavers, the anterior fibular ligaments disruptedat forces between 6 and 56kg.[85] This indicated

that the strength of tape was lower than the strengthof the anterior talofibular ligament. If an externalsupport is to provide mechanical support to a liga-ment it should exceed the strength of the ligament.

Firer[86] reviewed the literature on the effective-ness of taping in preventing injury to the lateralligament complex of the ankle, and concluded thattaping could protect against injury, but that themechanism for this was uncertain. Mechanical fac-tors were found to play a role, but these decreasedwith exercise (i.e. stretching of the tape), and themajor effect of taping was suggested to be in-creased muscle activation of the underlying musclegroups. Firer posed 3 questions: (i) is there scien-tific evidence that taping reduces the incidence ordegree of injury; (ii) by what mechanism does tap-ing work; and (iii) can taping be harmful, indirectlycausing other injuries? These questions still remaininadequately addressed for taping and bracing.

Paris[87] reviewed the scientific evidence per-taining to ankle support, with particular referenceto strength changes (during isometric inversion andeversion) and motor performance (such as speed,balance, agility and vertical jump) associated withtaped, braced and unsupported ankles. Literaturereporting wear, comfort and budgetary considera-tions were documented. It was concluded that com-mercial ankle braces present a viable alternative totaping techniques and that, in selecting an appro-priate prophylactic technique, weight must begiven not only to budgetary and protection/supportfactors, but also to scientific evidence relating tothe effect of the techniques/devices on the athlete’smotor performance.[87] In a later review, Paris[78]

indicated that the cumulative information on theeffects of taped versus braced ankle support orinterbrace comparisons was inconclusive. A partic-ular criticism was that ankle brace studies have col-lected data soon after support conditions were ad-ministered.

Martin[59] stated that the prudence of prophylac-tic ankle taping continues to be questioned as re-cent studies have indicated that other forms of an-kle stabilisation are more effective means of injuryprevention. Norris,[88] in a review of the compo-

298 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

nents, application and mechanisms of taping,suggested that mechanical support is provided bytaping through limitation of joint range and anincrease in resistance to movement. Functionalsupport may be achieved by a reduction in musclereaction time and a facilitation of muscle contrac-tion mediated by skin stimulation through a pro-prioceptive mechanism. A learning process wasalso proposed.

Bruns and Staerk[89] tested the mechanicalstabilising effect of different orthotic devices andartificially applied muscular strength with pero-neal muscles in cadaveric ankle joints and in vivo.Orthotic devices (Mikros , talocrural bandageand figure-of-eight taping), as well as muscularstrengths of 150N applied to the peroneal muscles,produced a significant reduction in mechanical an-kle instability. However, none of these methodsalone could normalise the talar tilt and anteriordrawer sign to that of a stable ankle joint.

Few studies have explicitly investigated themechanism by which tape or a brace may reducestress in the ankle. Pinkowski and Paulos[90] re-viewed studies which examined the effectivenessof ankle orthoses and noted that the most com-monly assessed parameter was ankle motion (seesection 4). Whether a support provides restrictionto inversion by acting as a mechanical barrier, bydirecting force away from the joint centre or byincreasing muscle activation and reducing thestress on the ligaments, has not yet been adequatelydetermined. This literature review now examinesin detail the possible mechanisms of ankle bracing,including evidence for mechanical restriction withexternal support use, and the effect of external sup-port on strength, muscle activation patterns, bal-ance, proprioception and ground reaction forces.

4. Degree of Restriction in the EndRange of Motion (ROM) Provided by an External Ankle Support

Rearfoot ROM, subtalar joint inversion angle,3

talar tilt4 or ankle joint ROM are all terms used todescribe the flexibility of the ankle joint complexin the sagittal plane of motion. ROM and activation

of muscles at the joint have been measured in anattempt to determine the effects of external supporton the stability of a joint. A reduced ROM may beattained through external mechanical restriction(provided by the design characteristics and mate-rial stiffness properties of the brace or tape) or bya change in the muscle activation patterns (due topressure on the tissues surrounding a joint). Con-traction of the muscles surrounding the joint wouldresult in compression of the joint and provide morestability. Many studies (see table VI) have reportedthat human ankle motion can be significantlylimited with brace [38,91,94-96,100,101] or tapeuse,[92,96,97,100] while other studies have reportedno significant change in ROM[76] or talar tilt[98]

with brace use. Furthermore, many studies haveinvestigated the effect of exercise on the effects ofbraces or tape (see section 5).

5. Effectiveness of External AnkleSupport in Restricting End ROM During Exercise

When taping material stretches, or the limbsweats during exercise, taping is known to loosen.There is ample anecdotal evidence from matchsituations to support this. Several authors have in-vestigated the effect of exercise on the ability ofexternal ankle supports to restrict ROM. A varietyof supports (e.g. tape, brace, cloth wraps) havebeen tested using a variety of methods. The major-ity of studies have investigated passive anklemotion,[45,52,54,62,63,66,68,70,79,80] with several stud-ies measuring active motion,[61,64,73,77] or dynamicmotion.[58,102,103] The motions most frequentlymeasured at the ankle were inversion and eversion,total ROM and in some cases the degree of talartilt. One study measured 3-dimensional anklemotion using an electrogoniometer.[66] Protocolshave used combinations of external support pre-and post-exercise. Exercise periods have com-

3 Subtalar joint inversion angle can be calculated usinghigh speed cinematographic techniques and markers placedon the posterior knee, the Achilles tendon and the distalcalcaneus.4 Talar tilt is calculated using x-ray images.

Effectiveness of External Ankle Support 299

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

monly ranged from 5 to 20 minutes, but studiesinvolving 3 hours of volleyball practice,[79] andanother involving 2 to 3 hours of football prac-tice,[68] have been reported. The number of individ-uals tested has ranged from 1 to 30.

Many studies have reported a significant decreasein ROM restriction provided by external support,after exercise (i.e. the support provided significantly

less restraint to ankle joint inversion after exercisethan when the support was first applied, or thanwithout support after exercise). Tape use has beenreported to significantly limit inversion before andafter exercise[45,52,53,55,56,59,61-64,66-71,77-81] but tolose considerable amounts of restriction after exer-cise compared with the pre-exercise condi-tion.[48,52,53,55,56,59,61-63,66-68,70,71,77-81] Other studies

Table VI. Studies demonstrating that ankle motion can be significantly limited with brace use

Study Methods Results

Kimura et al.[91]

18 healthy participants with no prior ankle injury had ankleinverted to 35° on an inversion-tilting platform. Trials wearingAircast® Sports Stirrup ankle brace or no-brace were filmed

Aircast® Sports Stirrup ankle brace significantlyreduced subtalar ankle inversion angle compared withno-brace. 9.8° mean reduction in range of motion(ROM) with brace, corresponding to 33% of the averagerange of inversion motion

Scheuffelen etal.[92]

14 healthy participants and 9 with a history of recurrent anklesprain completed unexpected inversion movements of 20 and30° while standing on a tilt platform wearing Aircast® SportsStirrup , Adimed Stabil 2 , MHH-Splint , tape or a normalrunning shoe. Inversion measured with a goniometer

All devices reduced inversion by approximately 40%compared with a control group

Scheuffelen etal.[93]

Achilles tendon angle during sudden inversion to 20 and 30° on a tilt platform for 13 participants and during runningmovements on a treadmill at 8 and 12 km/h for 12 participants.Tested devices were Aircast® Sports Stirrup , Mikros ,MHH-Splint Caligamed , Push brace, fast Gips tape,Jogging shoe, Adimed Stabil 2 shoe and Adipromed StabilSuper shoe

30 to 70% reduction in Achilles tendon anglemovements during inversion tilt and during runningcompared with control ankle condition. Significantdifferences among tested devices in dorsal-plantar andeversion-inversion planes

Lofvenberg &Karrholm[94]

14 ankles with symptoms of chronic lateral instability. Talar andcalcaneal rotations measured using stereophotogrammetricanalysis, with and without Strong ankle orthosis duringmanual adduction tests with a 5Nm torque

Significant reduction of talar and calcaneal plantarflexion, internal rotation, and varus angulation whenorthosis applied

Lindley &Kernozek[95]

11 college football athletes were videotaped (200Hz) during40-yard (36m) sprints while wearing adhesive tape withmoleskin, Airstirrup training orthosis, Active Ankle trainerorthosis, or DonJoy Ankle Ligament Protector (ALP). Maximumplantar flexion and dorsiflexion were measured

ALP was the only supportive device that wassignificantly more restrictive in functional ROM duringrunning than the control group

Gehlsen etal.[96]

10 male volunteers completed isokinetic dynamometer ankleplantar flexion and dorsiflexion ROM while passive ROM wasmeasured with a Zimmer goniometer. Active Ankle , Aircast®

Sports Stirrup , Swede-O-Universal , protective tape wrapand control treatments

Prophylactic guards significantly limited ROM, and therewas a difference in the magnitude of ROM permitted bythe support devices

Geyer &Siebert[97]

Filmed high jumping with or without boots and with or withouttaping

Little difference in pronation between taped and untapedtake-off ankle pronation without boots. In jumping withspike boots a marked pronation during take-off withouttape, and with ankle taping a 77% reduction inmaximum malleolar medialisation, 33% reduction ofpronation time and 8.2% reduction in time of maximumpronation in the take-off ankle

Carroll et al.[98]

6 college-age females with unstable ankle joints x-rayed at 5 levels of force (up to 150N with bare ankle then Swede-Obrace

Brace reduced talar tilts (though not significantly) andankle inversion torque increased with increased force

Karlsson &Andreasson[99]

Mechanical stability measurements using standardised stressradiographs

No significant reduction of anterior talar translation ortalar tilt with tape as compared with no tape

300 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

have reported that although the restriction in ROMwas reduced with exercise, the restriction was stillsignificantly greater than without any tape sup-port,[55,62,63,70,71,77,79,81] altough some studiesfound otherwise.[66,67,80] One study reported nosignificant change in anterior talar tilt with tapecompared with no-tape.[99] Tape, therefore, losesits restrictive ability to a significant extent withexercise, although there may be more support thanwithout any tape at all.

Brace use has been reported to significantlylimit inversion before and after exercise in manystudies,[45,54,55,57-59,63-65,73,74,78,79] while few stud-ies have reported no change in ROM with brace usebefore and after exercise.[75,76] Several studieshave reported multiple exercise periods in whichthe residual restriction decreased but still remainedsignificantly greater than in the pre-brace, pre-exercise condition.[45,54,79] Initial restriction ofROM varied from 25 to 40%, with restrictions of8 to 35% after exercise.

Although taping may influence the stability ofthe ankle during the first 10 to 20 minutes of exer-cise, studies of braces have shown that they pro-vide more support than tape. The level of remain-ing restriction after exercise was dependent uponthe type and form of tape application, or the typeof brace. None of the studies measured the effectof exercise on the ankle without tape or brace. Ifinversion restriction is still significantly greaterthan without support then the result is a positiveone given that exercise could lead to a greaterROM of the taped ankle post-exercise comparedwith pre-exercise. However, given that very fewstudies have shown a significant restriction aftershort periods of low intensity exercise, taping hasequivocal effects on restriction of ROM. As theROM was not measured in a weight-bearing posi-tion in several studies, the forms of support mayhave responded differently in the weight-bearingposition. Improvements to studies might includelonger exercise periods that better simulate an ac-tual sports situation, with measurements made dur-ing actual performances.

Findings vary from study to study, which maybe due in part to the type of brace tested, includingflimsy elastic material braces or braces with rigidparts. It is therefore essential when comparingstudies that the brace structure and materials areclearly described before any assumptions are madeabout their effectiveness.

6. Effect of External Ankle Support on Strength

Ankle braces have been variously reported tohave no effect on peak torque strength (strength inproducing a rotation about the ankle joint) at theankle joint complex,[37,64,104] and to limit peaktorque strength.[96]

Greene and Roland[64] reported that the DonJoyALP brace did not interfere with the maximumtorque production for 30 individuals with no pre-vious history of wearing an ankle ligature protector(ALP) brace. Paris and Sullivan[104] also reportedno significant differences between 6 ankle-testingconditions (unsupported, nonelastic adhesive-taped, Swede-O , New Cross , Airstirrup andsubtalar stabiliser–braced) for isometric strength(mean and peak force values) of rearfoot inversionand eversion (assessed by a hand-held dynamom-eter) for the dominant feet of 36 male students. Itwas concluded that the orthoses did not restrict thelower leg musculature. In contrast, Gehlsen etal.[96] reported a significant difference between andamong ankle supports (Active Ankle , Aircast®

Sports Stirrup , Swede-O-Universal and pro-tective tape wrap) for plantar flexion peakisokinetic strength, and total work, suggesting thatankle joint prophylactic guards did limit force pro-duction and total work for the 10 male volunteers(aged 23.5 ± 3.7 years).

Brace use can significantly increase the time toreach peak torque. Huang[43] randomly assigned 12male and 12 female student athletic trainers to ath-letic tape, ankle brace or control groups. Partici-pants’ left and right ankles were tested twice forkinaesthesia function, muscle peak torque strengthand time to peak torque on a Biodex isokineticmachine before and after 12 weeks of application

Effectiveness of External Ankle Support 301

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

of the tape or brace. There was no change in anklekinaesthesia or muscle peak torque strength withtape or brace use. The control group had a signifi-cantly shorter time to peak torque than the anklebrace and athletic tape groups for ankle inversionat 30, 60 and 120° per second. The ankle bracegroup was significantly faster than the athletic tapegroup at 30 and 60° per second, but not at 120° persecond. Whether the mechanism for the increasedtime to peak torque at the ankle is the externalmechanical resistance of the brace, or a change inthe ankle joint muscle activation patterns is notevident from the reported literature.

7. Resistance to Inversion TorqueProvided by External Ankle Supports

Studies using cadavers[105] and foot forms[106,107]

have indicated that external support provides resis-tance to ROM, but that after inversion periods ofresistance the support can be reduced to that of con-trol conditions (see study details below). The testconditions reported have utilised passive inversionrather than active inversion which would be possi-ble if the limbs of living individuals were used. Forexample, Bunch et al.[107] compared the amount ofresistance to inversion torque provided by prophy-lactic taping (Gibney basket weave and heel locks),cotton wrapping and 5 lace-on braces (Mikros7 inch, Mikros 9 inch, Swede-O , Ank-L-Aid and Cramer Stabilzer ). A specially in-strumented polyurethane foot form with supportsapplied was inverted for 350 cycles. Prior to theinversion motion cycles, the adhesive tape pro-vided the best level of support and was approxi-mately 25% stiffer than the best laced support and70% stiffer than the cotton wrap. However, after350 inversion cycles, the percent of loss of support(21%) was also highest for the tape compared withthe change in support (4.5 to 8.5%) of the lace-onbraces. No significant difference was found in theamount of support offered by tape and the 2 bestankle braces after 350 cycles.

Pope et al.[106] compared 4 types of ankle taping(stirrup, horseshoe, basketweave, basketweaveplus figure-of-eight) on a model of the human ankle

joint. A mechanical testing machine appliedmoments to the model at controlled loading rates.Deflection and torque to failure and tangent stiff-ness were determined. Loadings of one ankle jointin vivo indicated that angular deflection to initiatepain was 7.6°. Only the figure-of-eight and the fulltaping could withstand 8° of angular displacementon the model prior to failure. Dynamic loads duringsports were calculated to apply torques of 420Nmto the ankle joint (3 times bodyweight at a leverarm of 0.2m). Only figure-of-eight taping with 3 ormore wraps had adequate strength to withstand thismoment. A force of 75 to 101N was required to tearthe tape away from both human tissue and the pros-thetic foot during mechanical testing and the tapingfailed by shearing away from the surface of the footor shrinking, rather than rupture of the tape.

Shapiro et al.[105] used 5 cadaveric ankles todetermine the effects of 8 different prophylacticbraces (including the Aircast® Sports Stirrup andthe gel cast) and tape, with both low-top and high-top shoes, on resisting an inversion moment ap-plied to the ankle. The ankles were tested in neutralflexion and 30° plantar flexion. The passive resis-tance to inversion was significantly increased withhigh-top shoes for all braces and tape conditions.All of the braces resisted inversion to a comparableor greater level than the freshly applied tape.‘Braces that were not as effective as freshly appliedtape nevertheless retained the advantage over tapein that they could be easily readjusted and theireffectiveness restored, whereas the quality of thesupport provided with tape deteriorated withusage’(Shapiro et al.[105]). No tests were reportedby Shapiro et al.[105] to support this statement.

A study of 22 living participants with chronicankle instability evaluated passive ankle resistanceduring control, flexible and semi-rigid brace con-ditions.[108] It was reported that the semi-rigid andflexible braces tolerated significantly greatertorque forces and were associated with smaller in-version ranges than the control condition. A longertest period should be used to evaluate any changein the resistance provided over time with passiveor active exercise.

302 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

8. Effect of External Ankle Support onMuscle Activation Patterns

It has been proposed that adhesive tape stimu-lates the skin receptors and facilitates muscle con-traction. For example, Surve et al.[30] suggestedthat the main effect of an orthosis was to improveproprioceptive function of the previously injuredankle, rather than to provide mechanical supportalone. However, studies have reported that the mag-nitude, duration or timing of muscle activation pat-terns may[75,93,97,99,109,110] or may not[57,69,75,92,110,111]

change with use of external support such as bracingor taping (table V). Daanen et al.[111] commentedthat ‘. . . if the supports have a mechanical effect,the pronator muscles need to generate less force.This should be visible as a reduced electromyo-graphic response of these muscles. Further, if a re-flex mechanism is involved, the pronator musclesmust contract in an earlier stage after the inver-sion’. The main criticism of the previous researchon muscle activity and brace or tape use is thatthere has been not been a comparison of muscleactivity magnitude or timing characteristics con-trolling for the degree of ROM. The muscle activ-ity at percentages of ROM have not been reported,therefore any decrease in muscle activity couldhave been from the degree of mechanical restric-tion alone and not attributable to any change inmuscle activation due to external support.

Atrophy of the supporting muscles of the anklemay occur through lack of conditioning owing todisuse. Taping or bracing may diminish muscleactivation amplitude and inhibit the natural injuryprevention motion of the ankle joint[109] by restrict-ing ROM. However, in contrast to muscle atrophywith brace use, as suggested by Ferguson,[109]

Sprigings et al.[69] reported that external ankle sup-port (Louisiana wrap or taped with a Gibneyheel lock) did not take the place of peroneus longusmuscle activity during a backward inverting stepto 30°. There was no significant change in muscleactivity with, or without, tape or wrap use duringthe inverting step, and muscle activity increasedwith the degree of taping for the normal step. Thegreatest change in muscle activity occurred be-

tween normal stepping and the inverting step whenthere was no ankle support. Glick et al.[75] also re-ported that, in 2 individuals with insignificant talartilt, the external ankle support had no effect on themuscle activity during running gait. However, in 3of 4 individuals with significant talar tilt withankles taped, the muscles (major evertors such asperoneus brevis and peroneus longus and the majorinvertor tibialis anterior) started to contract earlierand stayed active longer during walking. This mayresult in the ankle being everted earlier in theweight-bearing phase of walking/running, prevent-ing ankle inversion injury. Glick et al.[75] con-cluded that ‘. . . the advantage of taping is probablyattributable to its stimulating effect on the peroneusbrevis muscle, or in short to a dynamic action . . .’and that ‘. . . strong peroneus brevis muscles ap-pear to be important in supporting the ankle mor-tise for prevention of injury’.

Karlsson and Andreasson[99] suggested thatankle tape restricted extremes of ankle motion (al-though this statement was not supported by theirown results of no significant reduction of anteriortalar translation or talar tilt with tape) and helpedshorten the reaction time of the peroneus musclesby affecting the proprioceptive function of theankle. These results support those of Glick et al.,[75]

in that the unstable ankles showed earlier initiationof muscle activation with tape use, and the resultsof Loos and Boelens,[112] who reported facilitationof peroneal activity by tape.

Thonnard et al.[113] tested the hypothesis thatankle mechanoreceptors have enough time toevoke muscular response in order to recover bal-ance from inversion. Latencies of the peroneus bre-vis and tibialis posterior muscle activation re-sponses, evoked by inversion of the foot on a tiltingplatform, were measured for 7 healthy volunteers(23 to 32 years). It was reported that the peri-articularpassive structures were unable to absorb the mech-anical energy of the inversion sprain, the time nec-essary to reach the angle of capsular-ligamentousrupture was inferior to the reflex latencies observedand the ankle sprain could only be avoided by an-ticipated active muscle stiffness. Isakov et al.[114]

Effectiveness of External Ankle Support 303

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

reported that protection was provided mainly bypassive tissue. 22 individuals (recurrent sprain vs acontrol group) were subjected to a sudden inver-sion while standing on a potentiometer. The EMGlatency of the peroneal muscles was 60 to 80 msecfor both groups, indicating that reflex contractionof the peroneal muscles due to inversion had norole in protecting the ankle.

Muscle activity in the peroneus longus shouldbe less when the ankle is supported, if tension isrelated to muscle activation patterns, but studieshave reported no significant differences in pero-neus longus activity with or without a brace.[57]

McKanna and Finch[110] suggested in their studythat a decrease in ankle muscle activity of soleus,peroneus longus and anterior tibialis may havebeen due to the restriction of movement due to tapeapplication or the muscles relying on the tape forsupport (table VII).

9. Effect of External Ankle Support onBalance and Proprioception

Ankle proprioception is widely regarded as animportant factor that affects susceptibility to anklesprain, but the precise mechanisms by which pro-prioceptive abilities may enhance ankle stabilityare not well understood.[117] Brace use has beenreported to increase proprioception[118-123] or tohave no effect on ankle kinaesthesia[43] or bal-ance.[27,42,124-126] However, Bennell and Goldie[51]

reported that for 24 healthy individuals (mean age24.8 ± 4.4 years) use of tape or a brace had a sig-nificant detrimental effect on postural control,5

while elastic bandage had no significant effect. Re-striction of ankle movement was given as a possi-ble explanation for the results, since postural con-trol was impaired only by the ankle supports whichlimited ankle motion. Huang[43] reported no changein ankle kinaesthesia with tape or brace use for 12male and 12 female student athletic trainers.

Low levels of postural equilibrium control havebeen reported to increase the risk of ankle jointinjury.[127] Friden et al.[126] used stabliometry tomeasure postural equilibrium control in the frontalplane during single leg stance for 55 young healthyindividuals and 14 patients with unilateral ankleligament injuries, with and without an ankle brace.When the brace was used, none of the parametersshowed any significant difference compared withthe uninjured leg; however, the body sway param-eters allowed discrimination between the injuredand uninjured legs. Tropp et al.[27] also usedstabliometric recordings to show that taping (stir-rup and horseshoe followed by figure-of-eight andheel-lock) did not influence the balancing abilityof 38 soccer players (mean age, 26.6 years). Allplayers had a history of previous ankle injury anda functional instability of the ankle. 26 players(68.4%) showed mechanical ankle instability asdemonstrated by a pathological anterior drawersign. The difference in stabliometric recordingswas not significant for the group of individualswho used ankle taping (31.6%) or for the group ofparticipants as a whole. Functional ankle instabil-ity was reported to increase the risk of ankle jointinjury. This was further supported by Hertel etal.[128] who reported no significant effect on centreof balance and postural sway with anaesthesia ofthe anterior talofibular ligament for 16 individuals.Sway scores were higher for the dynamic weight-bearing as compared with non–weight-bearingtests.

Kinzey et al.[124] reported the unexpected find-ing that 24 male participants with no history ofankle injuries relocated their centre of pressureonly during the control condition rather than whenwearing any of the 3 ankle braces. The task per-formed was a one-legged modified Romberg testwith 6 variations altering the visual, vestibular andproprioceptive inputs.

Hamer et al.[129] reported that strapping had nosignificant effect on wobble board performance. 24uninjured female volunteers (mean age, 19.6 years)completed wobble board performance tests, beforeand after exercise (5, 10, 15 minutes of stand-

5 Postural control was determined by the variability ofmediolateral ground reaction force and frequency of foottouch-downs by the nonsupporting leg, while the participantattempted to maintain a one-legged stance posture withhis/her eyes closed.

304 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

ardised exercise) with and without a modifiedGibney ankle strapping.

Rivers[125] investigated the influence of 20 min-utes of cryotherapy, or Aircast® Sports Stirrupbracing, on total body balance, compared with acontrol condition. 25 healthy males and females,who had demonstrated proficiency in Bongo

Board balance (defined as the ability to stay inbalance for at least 40 seconds in a 1-minute trial)completed a pre-trial treatment period and 5 post-trial tests on 3 separate testing days. Brace use didnot significantly affect total body balance for anyof the post-trial tests when compared to the pre-trial test. However, there was a significant decrease

Table VII. Studies showing that magnitude, duration or timing of muscle activation patterns may change with external support use

Study Methods Results

Daanen etal.[111]

Peroneus longus electromyogram (EMG) when anklebare, taped or braced (push-brace of mediumstrength). 3 male and 6 female healthy participants(aged 20 to 24y) completed 5 consecutive inversions to 30, with 8 plantarflexion, on a trapdoor

No significant differences in muscle activation amplitude ortiming with the brace compared with tape or control conditions

Konradsen &Ravn[115]

Peroneal reaction time in 10 participants with ankleinstability tested with and without ankle taping

Prolonged peroneal reaction time in participants with ankleinstability. Functional instability was induced by aproprioceptive reflex defect

Karlsson &Andreasson[99]

Reaction time measured for 20 athletes with chroniclateral unilateral ankle instability, using EMG of theperoneus muscles, after a simulated ankle sprain on a tilting trapdoor

Reaction time significantly slower in the unstable ankles thanin the stable contralateral ankles. Tape significantly shortenedreaction time, although not back to normal. The greatestimprovement in reaction time with tape was achieved inankles with the highest degree of mechanical instability

Scheuffelen etal.[92]

14 healthy participants and 9 participants with a history of recurrent ankle sprain measured duringunexpected inversion movements of 20 and 30°. EMGof gastrocnemius, peroneus longus, tibialis anterior andvastus medialis measured

No significant correlation between inversion rate andfunctional innervation of the 3 muscles

Scheuffelen etal.[93]

Muscle activity of peroneus longus, tibialis anterior,gastrocnemius medius and vastus medialis weremeasured during a sudden inversion to 20 and 30°while standing on a tilt platform for 13 participants, as well as running movements of 8 and 12 km/h on a treadmill for 12 participants

During running muscle activation patterns were not specificallymodulated by the shoe or brace characteristics. Duringinversion conditions muscle activation was significantlysmaller in the orthoses as compared with the control condition

Geyer &Siebert[97]

Taping during pronation in high jumping using surfaceEMG

Increased activity of peroneus longus by 30.7% with ankletaping. Activity of other jump supporting muscles of the lowerextremity was influenced little

Stuessi et al.[57] Inversion movement of the ankle during running withand without an Aircast® Sports Stirrup ankle braceinvestigated for 5 male and 6 female participants withankle instability problems. 8 running strides werecompleted wearing a specially constructed shoe with a sole medially very hard and laterally very soft to forcethe foot into supination

No significant differences in peroneus longus activity with orwithout a brace

McKanna &Finch[110]

10 female students completed 10 jogging trials (8 km/h) for tape, Swedo brace or no support, beforeand after 30 min basketball exercise. EMG of soleus,peroneus longus and anterior tibialis measured

A significant interaction between exercise and trial conditionfor time of contraction in the 3 muscles. Total time of muscularaction in the jog was decreased after exercise. No significantdifference in peak muscle activity, but total muscle activity was significantly lower in taped condition before exercise in all 3 muscles

Geyer et al.[116] EMG with or without taping for 6 ballet dancers withstable or unstable ankles and painful or pain-free feet.Three standard ballet positions were performed

Activity of peroneus longus and supinator muscles tibialisposterior showed significant changes in height and antagonistreflex patterns. These changes were highest in dancers withunstable ankle joints and metatarsalgia

Effectiveness of External Ankle Support 305

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

in total body balance during the first 3 minutes postcryotherapy when compared to pre-trial. The firstbrace post-trial test showed a significantly worsetotal body balance when compared with brace post-trial tests 2, 3 and 4.

Proprioception is often measured using posi-tioning or tracking tasks with no visual input.Feuerbach et al.[130] asked 10 individuals to matcha criterion ankle position with their eyes closed andwith, or without, an Aircast® Sports Stirrup ap-plied. The protocol was then repeated with the anter-ior talofibular ligament anaesthetised for group 1and the anterior talofibular ligament and calcaneo-fibular ligament anaesthetised for group 2. No sig-nificant differences were seen in the matchingpositions for group 1 versus group 2, or for anaes-thetised versus non-anaesthetised groups. In a laterstudy,[118] again with the Aircast® Sports Stirrupand anaesthesia of the anterior talofibular and/orcalcaneofibular ligaments, 12 noninjured partici-pants attempted to match 9 reference ankle jointpositions while their eyes were closed. Error inmatching the reference positions (calculated from3-dimensional ankle joint orientations) was signif-icantly less with brace use than without; however,there was no significant difference in error scoresbetween the nonanaesthetised and anaesthetisedconditions. Feuerbach et al.[130] concluded fromboth studies that ligament mechanoreceptors didnot contribute significantly to ankle joint pro-prioception, and that the afferent feedback fromskin, muscle, and other joint receptors lead to animproved ankle joint position sense. The Aircast®

Sports Stirrup significantly improved ankle jointposition error, and therefore may increase afferentfeedback from cutaneous receptors and lead to im-proved position sense.

Repositioning error may be partly dependentupon the direction of joint motion. The ability of26 participants with stable ankles to actively repro-duce a passively positioned joint angle (30° plantarflexion or 15° inversion) with braced, taped andcontrol condition ankles was examined in a studyby Heit et al.[123] They observed that for the plantarflexion test, both the braced condition and the taped

condition significantly enhanced the joint positionsense compared with the control condition. How-ever, for the inversion test, only the taped conditionsignificantly enhanced the joint position sensecompared with the control condition.

Robbins et al.[119] reported that attaching a pieceof tape from the foot to the leg provided sensorycues to foot position via the hairy skin of the legsand/or plantar surface of the foot rather than via thestructures suggested by Karlsson et al.[99,131,132]

Robbins et al.[119] analysed the kinaesthetic sense(perceived slope angles when blindfolded) of 24healthy individuals (aged 21 to 31 years) with noprevious injuries affecting the ankle joint beforeand after 30 minutes of exercise (basketball andrunning). Half of the participants were taped(basketweave with 2 heel locks). Taping appearedto positively influence foot position awarenesswhen the slope (plantarflexion, dorsiflexion, inver-sion or eversion) was above 10°. Untaped partici-pants wearing shoes were unable to distinguish be-tween a flat surface and a slope of 20°. There wasalso a significant underestimation of the slope be-fore and after exercise (5.3° error prior to exerciseand 35.5% greater error after exercise). Taped in-dividuals showed better results with neutral tomoderate error (4.2° pre-exercise error and 2.5%greater after exercise). It was concluded that theamount of muscle contraction recruited to supportthe foot was relative to the perceived foot position.The large slope ankle underestimation by the un-taped participants could suggest inadequate sup-port of the foot and increased risk of inversion in-jury. The study design would have been improvedby use of muscle activation measurements todemonstrate any increased activity of the peronealmuscles, and a lateral slope to replicate an inver-sion simulation.

The functional and proprioceptive capabilitiesof the ankle joints of 14 healthy, active athletes and16 active patients with unstable ankle joints havebeen tested.[25,120,121] The influence on the anklejoint of a Mikros lace-on brace, Aircast® SportsStirrup brace and taping, during a single legstance test, a single leg jumping course test and an

306 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

angle reproduction test was evaluated. Scores onthe single leg jumping course were better (lower)without any stabilising device. However, in theother 2 tests, trials with orthoses were lower com-pared with the unsupported condition. TheMikros and Aircast® Sports Stirrup bracessignificantly reduced scores compared with taping.The error rate in the single leg stance test was low-est for Mikros and Aircast® Sports Stirrupbraces, followed by unsupported, and highest fortaping. Mikros and Aircast® Sports Stirrupwere significantly different from the unsupportedcondition. Angle reproduction was better for theMikros , Aircast® Sports Stirrup and tapingthan for the unsupported condition. It was con-cluded that the Mikros and Aircast® Sports Stir-rup braces improved the functional and pro-prioceptive capability of both the injured andnoninjured ankles.

In summary, positioning error may decreasewith use of external support, while the effect onbalance is equivocal, although likely to have noeffect. The reaction time of the peroneus brevis andlongus muscles may be shortened by affecting theproprioceptive function of the ankle ligaments andjoint capsule. An increased proprioceptive abilitycould therefore lead to an increased balancing abil-ity or postural control, which are integral compo-nents of sports participation.

10. Effect of External Ankle Support onGround Reaction Forces

Brace use has been reported[58] to decrease forceexcursions compared with non-brace, while otherstudies[102,103] have reported that support did notmoderate mediolateral force.

Hamill et al.[58] studied the effect of the Aircast®

Sports Stirrup ankle brace on force moderationduring walking after an eccentric exercise proto-col. Ten males, none with previous ankle injury,completed 10 trials walking over a force plate in4 conditions: pre-exercise; pre-exercise with thebrace; post-exercise; and post-exercise with thebrace. Brace use was randomly presented withinthe pre-exercise and post-exercise conditions. The

participants were fatigued by completing 70 max-imal eccentric actions of the ankle everters with 15seconds between each action. There were signifi-cant differences in the sum of the force in themediolateral direction and impulse with or withoutthe brace with pre or post-exercise. The force ex-cursions were smaller for the brace than non-brace.This was in contrast to the findings of Hamill etal.[102] and McIntyre et al.[103] who investigated ex-ternal ankle supports in dynamic situations and re-ported that support did not moderate mediolateralforce.

McCaw and Johnson[133] investigated the effectof ankle taping (figure-of-eight basketweave) onground reaction forces during drop landings. Threemale recreational basketball players dropped 6cmto a force plate from hanging onto a scaffold. Agoniometer was used to measure ankle ROM be-fore the drop. Ten trials were collected pre-tape,immediately following tape, after 12 minutes ofrunning and after removal of the tape. No statisticalanalyses were conducted. Taping reduced the ankleROM, but there were no trends evident for themagnitude or temporal characteristics of the forcedata when comparing tape and no-tape conditions.

Given the paucity of literature on the effect ofexternal ankle support on ground reaction forces,further studies are required.

11. Implications of the Laws of Rugbyon the Use of External Ankle Support

Various sports have laws and rules that prohibitthe use of braces. For example the InternationalRugby Board Law 4 (2)[134] states that a player maynot wear braces or supports which include anyrigid or reinforced material. Most of the commer-cial braces available in New Zealand cannot there-fore be worn during sport. According to Law 4(1),[134] however, a player may wear soft thin padsof cotton wool, sponge, rubber or similar soft mat-erial, provided they are attached to the body byadhesive tape and are not sewn into the jersey,shorts or undergarments. This could allow a playerto use tape or any other material support (as longas it did not include rigid material) for support of

Effectiveness of External Ankle Support 307

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

the ankle. Unfortunately, it seems that the benefitsof ankle support in reducing the risk of ankle sprainare gained mostly from the mechanical restrictionprovided by the rigid or reinforced materials in abrace. Evidence is equivocal as to the benefits of anon–rigid-type support (such as tape) in providinga ‘proprioceptive effect’ (increased awareness ofthe joint position). Tape cannot provide enoughmechanical restriction to restrict ankle motion thatwould result in an ankle sprain.

12. Conclusions and Recommendations

This paper reviewed epidemiology and experi-mental research on the effectiveness of externalankle support in reducing inversion and conse-quently ankle inversion sprains. Bracing and tap-ing aim to support the ankle structure by providingexternal mechanical restriction to large ROMs(that would result in ankle sprain), and possibly byincreasing the activation of the muscles supportingthe joint to reduce the stress on the ligaments hold-ing the joint together.

Various forms of external support such as tap-ing, bracing and shoes may provide protectionfrom ankle inversion injury. Prospective epidemio-logical studies have shown a decrease in the inci-dence of ankle injury with external ankle supportuse. The effectiveness of external ankle supportwas dependent upon the material properties and ap-plication method of the tape or brace, and on theathletes level of ankle stability or previous injury.Experiments to investigate the support provided bybracing or taping have used study populationswhich have included healthy ankle joints and thosesuffering from significant talar tilt or with unstablejoints (mechanical instability). Passive and activeROM and muscle activation characteristics havebeen measured in an attempt to determine theeffects of external support on the stability of theankle joint. An external ankle support should pro-tect against extreme inversion amplitudes if therisk of injury is to be reduced.[93] Although externalankle support restricted ROM, the amount of re-striction was reduced with exercise in the studiesreviewed. The extent of restriction and the degree

of loss of restriction after exercise was dependentupon the external support tested. Tape can provideonly limited mechanical support of the ankle jointcomplex, but it may have proprioceptive effects.Taping may work as a psychological reminder, sothat the athlete consciously moderates lower limb–loading behaviour. External ankle support was re-ported to decrease performance in a variety ofmovement tasks with use of some types of externalankle supports; however, other studies have re-ported no effect on performance. No prophylacticexternal ankle support has been shown to improveperformance. If an external support is to providemechanical support to a ligament it should exceedthe strength of the ligament, which for the anteriorfibular ligament is a force limit of between 6 and56kg.

Another approach to the prevention of ankleinjury is to use ‘proprioceptive training’ to enhancethe neuromuscular response to ankle motion.Increased flexibility would allow an ankle to gothrough a particular ROM without reaching thelimits of motion at which injury is more likely tooccur. Increased muscle strength in the lower limbwould allow the muscles to resist the motion whichtends to result in ankle sprain. An increase in neu-romuscular response time would allow the individ-ual to react more quickly to a possibly injuriousevent. There is equivocal evidence of the effect ofexternal support use on ground reaction force ex-cursions, balance ability and ankle strength.

In a majority of studies, the use of braces hasalso been shown to be more effective than tapingin reducing the ankle joint ROM and loading rate.Bracing is more cost-effective in the long term,movement restriction is maintained, there is lessskin irritation than with tape and a brace can beapplied and re-applied more consistently by play-ers. The use of braces should therefore be consid-ered as an alternative to tape. This would dependon the laws of sport permitting their use as a pre-ventive measure, for reducing the risk of ankleinjury or re-injury.

It is concluded that while there have been inves-tigations of the effects of tape and some forms of

308 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

brace on ankle ROM restriction provided by exter-nal ankle support with and without exercise, andon the effects of external ankle support on perfor-mance, there is little data on the mechanism bywhich the external support acts. The quantificationof ankle motion restriction by a brace in an actualsporting situation is necessary,[91] but has not yetbeen accurately conducted owing to technical dif-ficulties. Future research should address the effectsof external ankle support during dynamic exerciseand brace manufacturers should utilise the informa-tion in the development of future brace designs tohelp reduce the risk of ankle inversion sprain injury.

A 3-dimensional video analysis with electromyo-graphy and force measurements would allow quan-tification of the effects of external support duringsport specific landings. Periodic measurementsduring simulated game situations would provide ameasure of the effectiveness for movements withina particular sport. Individual differences could belarge, therefore, determination of the amount ofvariation that could be expected for a brand ofbrace would be beneficial for those purchasing orprescribing a brace. Experiments to determine themechanism by which an external ankle supportworks would aid in development of ankle supportseffective in reducing ankle inversion injury.

In summary, it has been reported that:• External ankle support has reduced ankle inver-

sion and as a consequence the risk of ankle in-version sprains.

• The degree of restriction of ankle inversion isvariable, depending on the type of external sup-port used.

• The amount of ankle support provided by tapingwas significantly reduced over time, generallyafter only 20 minutes of exercise.

• There was either no effect on, or a decrease in,the performance of a variety of movement taskswith the use of some types of external anklesupports.

• Little information is available on how externalsupport works to reduce injury.

• Co-ordination training was as effective as tap-ing in decreasing ankle sprain injuries.

It is recommended that:• Given the possibility of a reduced risk of ankle

injury with the use of rigid or reinforced braces,and the reduced restrictive support provided bytape after only 20 minutes exercise, the rules insport should be adapted to allow for the use ofbraces which do not have any sharp edges, butwhich do have rigid or reinforced material.

• Braces should be used in preference to tape asan external support, owing to their longer termcost-effectiveness, ease of re-application, main-tenance of movement restriction and decreasedrisk of skin irritation compared with tape. Thetaping of ankles in sport may be considered ap-propriate if applied by a suitably qualified tapestrapper, if re-applied after 20 minutes of exer-cise and if the player is not known to suffer fromany tape allergy.

• Where there is a clear history of recurrent ankleinjury in a sports player, the use of an externalankle support during both practice and trainingshould be encouraged, in combination with anankle proprioception training programme.

• Brace manufacturers should utilise biomech-anical and epidemiological information in thedevelopment of future brace designs.

• Consideration should be given to other factorsthat contribute to ankle sprains in sport, includ-ing shoe design, surface conditions and thephysical condition of the players.In conclusion, it seems that the benefits of ankle

support in reducing the risk of ankle sprain aregained mostly from the mechanical restriction pro-vided by the rigid or reinforced materials in thebrace. Evidence is equivocal as to the benefits of anon-rigid type support (such as tape) in providinga ‘proprioceptive effect’ (increased awareness ofthe joint position). Tape cannot provide enoughmechanical restriction to restrict ankle motion thatwould result in an ankle sprain.

Acknowledgements

The authors thank Dr Barry Wilson and Dr David Chalmersfor their guidance during the review. Patria Hume acknow-ledges support from the Otago Targeted Research Grant (Univer-sity of Otago) and from the Ross Fellowship (Knox College).

Effectiveness of External Ankle Support 309

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

References1. Ryan AJ, Cox JS, Inniss B, et al. Ankle sprains: A round table.

Physician Sports Med 1986; 14 (2): 101-82. Chan KM, Yuan Y, Li CK, et al. Sports causing most injuries in

Hong Kong. Br J Sports Med 1993; 27 (4): 263-73. Schafle MD. Common injuries in volleyball: treatment, preven-

tion and rehabilitation. Sports Med 1993; 16 (2): 126-94. Holmer P, Sondergaard L, Konradsen L, et al. Epidemiology of

sprains in the lateral ankle and foot. Foot Ankle Int 1994; 15(2): 72-4

5. Shawdon A, Brukner P. Injury profile of amateur Australianrules footballers. Aust J Sci Med Sport 1994; 26 (3-4): 59-61

6. Bladin C, McCrory P. Snowboarding injuries: an overview.Sports Med 1995; 19 (5): 358-64

7. Pienkowski D, McMorrow M, Shapiro R, et al. The effect ofankle stabilizers on athletic performance. A randomized pro-spective study. Am J Sports Med 1995; 23 (6): 757-62

8. Hume PA. Netball injuries in New Zealand. N Z J Sports Med1993; 21 (2): 27-31

9. Liu SH, Jason WJ. Lateral ankle sprains and instability prob-lems. Clin Sports Med 1994; 13 (4): 793-809

10. Hume PA, Marshall SW. Sports injuries in New Zealand:Exploratory analyses. N Z J Sports Med 1994; 22 (2): 18-22

11. Accident Rehabilitation and Compensation Insurance Corpora-tion. Injury Statistics 1994/1995. Wellington: Accident Rehab-ilitation and Compensation Insurance Corporation, 1996

12. Subotnick SI. Foot and ankle biomechanics in walking and run-ning. In: Subotnick SI, editor. Sports medicine of the lowerextremity. New York: Churchill Livingstone, 1989: 159-78

13. McConkey JP. Ankle sprains, consequences and mimics. In:Shephard RJ, Taunton JE, editors. Foot and ankle in Sport andExercise. Basel: Karger, 1987: 39-55

14. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Man-agement, and Rehabilitation. New Jersey 07632: EnglewoodCliffs, 1983

15. Baratta R, Solomonow M, Zhou BH, et al. Muscular coactiva-tion: the role of the antagonist musculature in maintainingknee stability. Am J Sports Med 1988; 16 (2): 113-22

16. Balduini FC, Vegso JJ, Torg JS, et al. Management and rehabil-itation of ligamentous injuries to the ankle. Sports Med 1987;4: 364-80

17. Garrick JG, Requa RQ. Role of external support in the preven-tion of ankle sprains. Med Sci Sports 1973; 5 (3): 200-3

18. Rovere GD, Clarke TJ, Yates CS, et al. Retrospective compari-son of taping and ankle stabilizers in preventing ankle inju-ries. Am J Sports Med 1988; 16 (3): 228-33

19. Giel D. Ankle stabilizers: more effective than taping? PhysicianSports Med 1988; 16 (1): 59-60

20. Reisberg S, Verstraete MC. Reusable prophylactic ankle support:A review of the literature. J Sport Rehab 1992; 1 (4): 290-9

21. Reisberg S, Verstraete MC. Reusable prophylactic ankle support.A review of the literature. J Sport Rehabil 1993; 2 (1): 43-52

22. Sitler MR. Role of prophylactic knee and ankle bracing in injuryreduction. J Sport Rehabil 1992; 1 (3): 223-36

23. Sitler M, Ryan J, Wheeler B, et al. The efficacy of a semirigidankle stabilizer to reduce acute ankle injuries in basketball. Arandomized clinical study at West Point. Am J Sports Med1994; 22 (4): 454-61

24. Lindenberger U, Reese D, Andreasson G, et al. The effect ofprophylactic taping of ankles [PhD thesis]. Department ofTextile Technology, Chalmers University of Technology,Göteborg, 1985

25. Jerosch J, Thorwesten L, Bork H, et al. Is prophylactic bracingof the ankle cost effective? Orthopedics 1996; 19 (5): 405-14

26. Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccerinjuries: supervision by doctor and physiotherapist. Am JSports Med 1983; 11 (3): 116-20

27. Tropp H, Ekstrand J, Gillquist J. Factors affecting stabilometryrecordings of single limb stance. Am J Sports Med 1984; 12(3): 185-8

28. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains.Am J Sports Med 1985; 13 (4): 259-62

29. Sharpe SR, Knapik J, Jones B. Ankle braces effectively reducerecurrence of ankle sprains in female soccer players. J AthleticTraining 1997; 32 (1): 21-4

30. Surve I, Schwellnus MP, Noakes T, et al. A fivefold reductionin the incidence of recurrent ankle sprains in soccer playersusing the Sport-Stirrup orthosis. Am J Sports Med 1994; 22(5): 601-6

31. Passerallo AJ, Calabrese GJ. Improving traditional ankle tapingtechniques with rigid strapping tape. J Athletic Training 1994;29 (1): 76-7

32. Beriau MR, Cox WB, Manning J. Effects of ankle braces uponagility course performance in high school athletes. J AthleticTraining 1994; 29 (3): 224-6

33. Verbrugge JD. The effects of semirigid Air-Stirrup bracing vs.adhesive ankle taping on motor performance. J Orthop SportsPhys Ther 1996; 23 (5): 320-5

34. Bocchinfuso C, Sitler MR, Kimura IF. Effects of two semirigidprophylactic ankle stabilizers on speed, agility, and verticaljump. J Sport Rehabil 1994; 3 (2): 125-34

35. Gross MT, Everts JR, Roberson SE, et al. Effect of DonjoyAnkle Ligament Protector and Aircast Sport-Stirrup orthoseson functional performance. J Orthop Sports Phys Ther 1994;19 (3): 150-6

36. Macpherson K. Effects of a semirigid and a softshell prophy-lactic ankle stabilizer on performance [microfiche]. Eugene(OR). University of Oregon Microform Publications, 1995

37. Macpherson K, Sitler M, Kimura I, et al. Effects of a semirigidand softshell prophylactic ankle stabilizer on selected perfor-mance tests among high school football players. J Orthop1995; 21 (3): 147-52

38. Wiley JP, Nigg BM. The effect of an ankle orthosis on anklerange of motion and performance. J Orthop Sport Phys Ther1996; 23 (6): 362-9

39. Gross MT, Clemence LM, Cox BD, et al. Effect of ankle ortho-ses on functional performance for individuals with recurrentlateral ankle sprains. J Orthop Sports Phys Ther 1997; 25 (4):245-52

40. Jerosch J, Thorwesten L, Frebel T, et al. Influence of externalstabilizing devices of the ankle on sport-specific capabilities.Knee Surg Sports Traumatol Arthrosc 1997; 5 (1): 50-7

41. Locke AB. Effect of a softshell prophylactic ankle stabilizer onperformance in events involving speed, agility, and verticaljump during long-term use [thesis]. Eugene (OR): MicroformPublications, International Institute for Sport & Human Per-formance, University of Oregon, 1996: 1 (86)

42. Paris DL. The effects of the Swede-O, New Cross, and McDavidankle braces and adhesive ankle taping on speed, balance,agility, and vertical jump. J Athletic Training 1992; 27 (3):253-6

43. Huang CH. Lace-up ankle brace and athletic tape related toankle kinesthesia and strength [microfiche]. Eugene (OR):University of Oregon Microform Publications, 1994

44. Coffman JL, Mitze NL. A comparison of ankle taping and theAircast Sport Stirrup on athletic performance. Athletic Train-ing 1989; 24 (2): 123

45. Greene TA, Wight CR. A comparative support evaluation ofthree ankle orthoses before, during, and after exercise. J OrthopSport Phys Ther 1990; 11 (10): 453-66

46. Burks RT, Bean BG, Marcus R, et al. Analysis of athletic per-formance with prophylactic ankle devices. Am J Sports Med1991; 19 (2): 104-6

47. MacKean LC, Bell G, Burnham RS. Prophylactic ankle bracingvs taping: effects on functional performance in female basket-ball players. J Orthop Sports Phys Ther 1995; 22 (2): 77-81

310 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

48. Hochman D, Nowalkowski E. Alternate methods of ankle sta-bilization. J Can Athlet Ther Assoc 1982; 9 (1): 11-3

49. Metcalfe RC, Schlabach GA, Looney MA, et al. A comparisonof moleskin tape, linen tape, and lace-up brace on joint re-striction and movement performance. J Athletic Training1997; 32 (2): 136-40

50. Robinson JR, Frederick EC, Cooper LB. Systematic ankle sta-bilization and the effect on performance. Med Sci SportsExerc 1986; 18 (6): 625-8

51. Bennell KL, Goldie PA. The differential effects of externalankle support on postural control. J Orthop Sport Phys Ther1994; 20 (6): 287-95

52. Malina RM, Plagenz LB, Rarick LG. Effects of exercise uponmeasurable supporting strength of cloth and tape ankle wraps.Res Q 1962; 34: 158-65

53. Rarick GL. The measurable support of the ankle joint by con-ventional methods of taping. J Bone Joint Surg Am 1962; 44(6): 1183-90

54. Alves JW, Alday RV, Ketcham DL, et al. A comparison of thepassive support provided by various ankle braces. J OrthopSport Phys Ther 1992; 15 (1): 10-8

55. Fumich RM, Ellison AE, Guerin GJ, et al. Measured effect oftaping on combined foot and ankle motion before and afterexercise. Am J Sports Med 1981; 9 (3): 165-70

56. Frankeny JR, Jewett DL, Hanks GA, et al. A comparison ofankle-taping methods. Clin J Sport Med 1993; 3 (1): 20-5

57. Stuessi E, Tiegermann V, Gerber H, et al. A biomechanical studyof the stabilization effect of the Aircast Ankle Brace. In:Jonsson B, editor. Biomechanics XA. Champaign (IL): HumanKinetics Publishers, 1987: 159-64

58. Hamill J. Exercise moderation of foot function during walkingwith a re-useable semirigid ankle orthosis. Clin Biomech1988; 3: 153-8

59. Martin N, Harter RA. Comparison of inversion restraint pro-vided by ankle prophylactic devices before and after exercise.J Athletic Training 1993; 28 (4): 324-9

60. Bartold SJ. Optoelectronic analysis of support provided byadhesive taping and ankle orthoses before, during and afterexercise [abstract]. Annual Scientific Conference in SportsMedicine; 1993 Oct 26-31; Melbourne, 34

61. Hughes LH, Stetts DM. A comparison of ankle taping and asemirigid support. Phys Sports Med 1983; 11 (4): 99-103

62. Gross MT, Lapp AK, Davis JM. Comparison of Swede-O-Universal Ankle Support and Aircast Sport-Stirrup orthosesand ankle tape in restricting eversion-inversion before andafter exercise. J Orthop Sport Phys Ther 1991; 13 (1): 11-9

63. Gross MT, Bradshaw MK, Ventry LC, et al. Comparison ofsupport provided by ankle taping and semirigid orthosis.J Orthop Sport Phys Ther 1987; 9 (1): 33-9

64. Greene TA, Roland GC. A comparative isokinetic evaluation ofa functional ankle orthosis on talocalcaneal function. J OrthopSport Phys Ther 1989; 11 (6): 245-52

65. Gross MT, Batten AM, Lamm A, et al. Comparisons of DonJoyAnkle Ligament Protector and subtalar sling ankle taping inrestricting foot and ankle motion before and after exercise.J Orthop Sport Phys Ther 1994; 19 (1): 33-41

66. Laughman RK, Carr TA, Chao EY, et al. Three-dimensionalkinematics of the taped ankle before and after exercise. Am JSports Med 1980; 8 (6): 425-31

67. Myburgh KH, Vaughan CL, Isaacs SK. The effects of ankleguards and taping on joint motion before, during, and after asquash match. Am J Sports Med 1984; 12 (6): 441-6

68. Wilkerson GB. Comparative biomechanical effects of thestandard method of ankle taping and a taping method de-signed to enhance subtalar stability. Am J Sports Med 1991;19 (6): 588-95

69. Sprigings EJ, Pelton JD, Brandell BR. An EMG analysis of theeffectiveness of external ankle support during sudden ankleinversion. Can J Appl Sport Sci 1981; 6 (2): 72-5

70. Vaes P, de Boeck H, Handelberg F, Opdecam P. Comparativeradiological study of the influence of ankle joint strapping andtaping on ankle stability. J Orthop Sport Phys Ther 1985; 7(3): 110-4

71. Vaes P, de Boeck H, Handelberg F, Opdecam P. Comparativeradiologic study of the influence of ankle joint bandages onankle stability. Am J Sports Med 1985; 13 (1): 46-50

72. Anderson DL. The role of external non-rigid ankle bracing inthe prevention of inversion injuries [microfiche]. Eugene(OR): University of Oregon Microform Publications, 1993

73. Anderson DL, Sanderson DJ, Hennig EM. The role of externalnonrigid ankle bracing in limiting ankle inversion. Clin JSport Med 1995; 5 (1): 18-24

74. Money SM. Biomechanical comparison of support provided bythe Airstirrup Ankle Training Brace pre- and post-exercise[microfiche]. Eugene (OR): University of Oregon MicroformPublications, 1994

75. Glick JM, Gordon RB, Nishimoto D. Prevention and treatmentof ankle injuries. Am J Sports Med 1976; 4 (4): 136-41

76. Scott JZ. Effect of the active ankle brace in controlling ankleplantarflexion, inversion stress before and after exercise.Eugene (OR): University of Oregon, 1994

77. Bauer T. The effectiveness of ankle taping and considerationsfor alternatives. In: Kreighbaum E, McNeil A, editors. 6thInternational Symposium on Biomechanics in Sports. Boze-man (MT): International Society of Biomechanics in Sports,1988: 407-18

78. Paris DL, Vardaxis V, Kokkaliaris J. Ankle ranges of motionduring extended activity periods while taped and braced. JAthletic Training 1995; 30 (3): 223-8

79. Greene TA, Hillman SK. Elongation and forces of ankle liga-ments in a physiological range of motion. Am J Sports Med1990; 18 (5): 498-506

80. Morris HH, Musnicki W. The effect of taping on ankle mobilityfollowing moderate exercise. J Sports Med Phys Fitness1983; 23 (4): 422-6

81. Tweedy R, Carson T, Vicenzino B. Leuko and Nessa Anklebraces: effectiveness before and after exercise. Aust J Sci MedSport 1994; 26 (3-4): 62-6

82. Miller EA, Hergenroeder AC. Prophylactic ankle bracing.Pediatr Clin North Am 1990; 37 (5): 1175-85

83. Mclean DD. Use of adhesive strapping in sport. Br J Sports Med1989; 23 (3): 147-9

84. Andreasson G, Edberg B. Rheological properties of medical tapeused to prevent athletic injuires. Textile Res J 1983 Apr; 53

85. St Pierre R, Rosen J, Whiteside T, et al. The tensile strength ofthe anterior talofibular ligament. Foot Ankle 1983; 4: 83-5

86. Firer P. Effectiveness of taping for prevention of ankle ligamentsprains. Br J Sports Med 1990; 24 (1): 47-50

87. Paris DL. Comparisons of tape and commercial braces on anklesupport, performance, injury prevention, and budget. In: Ten-enbaum G, Raz Liebermann T, editors. 2nd Maccabiah Win-gate International Congress on Sport and Coaching Sciences.Netanya (Israel): Wingate Institute, 1993: 255-8

88. Norris CM. Taping: components, application and mechanisms.Sports Exerc Injury 1994; 1 (1): 14-7

89. Bruns J, Staerk H. Mechanical ankle stabilisation due to the useof orthotic devices and peroneal muscle strength. An experi-mental investigation. Int J Sports Med 1992; 13 (8): 611-5

90. Pinkowski JL, Paulos LE. Prophylactic knee and ankle ortho-ses. In: Renstroem PAFH, editor. Sports injuries: basic prin-ciples of prevention and care. Boston: Blackwell ScientificPublications, 1993: 374-87

91. Kimura IF, Nawoczenski DA, Epler M, et al. Effect of the Air-Stirrup in controlling ankle inversion stress. J Orthop SportPhys Ther 1987; 9 (5): 190-3

92. Scheuffelen C, Gollhofer A, Lohrer H, et al. Functional signif-icance of braces and special shoes in subjects with and with-out chronic instability of the ankle joint. In: Proceedings of

Effectiveness of External Ankle Support 311

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)

the XIIIth International Congress on Biomechanics; 1991 Dec9-13: Perth. Perth: Univ. of Western Australia, 1991: 173-5

93. Scheuffelen C, Rapp W, Gollhofer A, et al. Orthotic devices infunctional treatment of ankle sprain: stabilizing effects duringreal movements. Int J Sports Med 1993; 14 (3): 140-9

94. Lofvenberg R, Karrholm J. The influence of an ankle orthosison the talar and calcaneal motions in chronic lateral instabilityof the ankle. A stereophotogrammetric analysis. Am J SportsMed 1993; 21 (2): 224-30

95. Lindley TR, Kernozek TW. Taping and semirigid bracing maynot affect ankle functional range of motion. J Athletic Training1995; 30 (2): 109-12

96. Gehlsen GM, Pearson D, Bahamonde R. Ankle joint strength,total work, and ROM: comparison between prophylactic de-vices. Athletic Training 1991; 26 (1): 62-5

97. Geyer M, Siebert WE. Complex movement analysis: dynamicstudy of the effect of a tape bandage on pronation in high-jumping with three-dimensional movement analysis and elec-tromyography. Sportverletz Sportschaden 1991; 5 (2): 103-7

98. Carroll MJ, Rijke AM, Perrin DH. Effect of the Swede-O anklebrace on talar tilt in subjects with unstable ankles. J SportRehabil 1993; 2 (4): 261-7

99. Karlsson J, Andreasson GO. The effect of external ankle supportin chronic lateral ankle joint instability. An electromyographicstudy. Am J Sports Med 1992; 20 (3): 257-61

100. Lyle TD, Corbin CB. Restriction of ankle inversion: taping ver-sus an ankle brace. Phys Educator 1992; 49 (2): 88-94

101. Morin GE. The effect of an air stirrup ankle brace on rearfootcontrol [Microfiche]. Eugene (OR): University of OregonMicroform Publications, 1989

102. Hamill J, Knutzen KM, Bates BT, et al. Evaluation of two ankleappliances using ground reaction force data. J Orthop SportPhys Ther 1986; 7 (5): 244-9

103. McIntyre DR, Smith MA, Denniston NL. Effectiveness ofstrapping techniques during prolonged dynamic exercises.Athletic Training 1983; 18 (1): 52-5

104. Paris DL, Sullivan SJ. Isometric strength of rearfoot inversionand eversion in nonsupported, taped, and braced anklesassessed by a hand-held dynamometer. J Orthop Sport PhysTher 1992; 15 (5): 229-35

105. Shapiro MS, Kabo JM, Mitchell PW, et al. Ankle sprain prophy-laxis: an analysis of the stabilizing effects of braces and tape.Am J Sports Med 1994; 22 (1): 78-82

106. Pope MH, Renstrom P, Donnermeyer D, et al. A comparison ofankle taping methods. Med Sci Sports Exerc 1987; 19 (2): 143-7

107. Bunch RP, Bednarski K, Holland D, et al. Ankle joint support:a comparison of reusable lace-on braces with taping and wrap-ping. Physician Sports Med 1985; 13 (5): 59-62

108. Hartsell HD, Spaulding SJ. Effectiveness of external orthoticsupport on passive soft tissue resistance of the chronicallyunstable ankle. Foot Ankle Int 1997; 18 (3): 144-50

109. Ferguson ABJ. The case against ankle taping. J Sports Med1973; 1 (2): 46-7

110. McKanna J, Finch A. Effects of external ankle support uponIEMG activity in the lower limb while running. In: Tant CL,editor. Ninth International Symposium of the InternationalSociety of Biomechanics in Sports. Ames (IA): Iowa StateUniversity, 1991: 123-6

111. Daanen HAM, Deegenaars WC, Fraterman H, et al. Muscularreponse to sudden ankle inversion: differences between ataped, braced and bare ankle. In: Anderson PA, Hobart DJ,Danoff JV, editors. Excerpta Medica ElectromyographicalKinesiology. Amsterdam: Elsevier Science Publishers B.V.,1991: 107-10

112. Loos T, Boelens P. The effect of ankle-tape on lower limb muscle-activity. Int J Sports Med 1984; 5 (5 Suppl.): 45-6

113. Thonnard JL, Plaghki L, Willems P, et al. Pathogenesis of anklesprain: testing of an hypothesis. Acta Belg Med Phys 1986; 9(2): 141-5

114. Isakov E, Mizrahi J, Onna I, et al. The control of genurecurvatum by combining the Swedish knee-cage and an ankle-foot brace. Disabil Rehabil 1992; 14 (4): 187-91

115. Konradsen L, Ravn JB. Prolonged peroneal reaction time inankle instability. Int J Sports Med 1991; 12 (3): 290-2

116. Geyer M, Bergmann C, Siebert WE. Overuse syndrome in bal-let: study of the effect of a tape bandage of the upper anklejoint with motion analysis. Sportverletz Sportschaden 1993;7 (2): 78-83

117. Wilkerson GB, Nitz AJ. Dynamic ankle stability: mechanicaland neuromuscular interrelationships. J Sport Rehabil 1994;3 (1): 43-57

118. Feuerbach JW, Grabiner MD, Koh TJ, et al. Effect of an ankleorthosis and ankle ligament anesthesia on ankle joint pro-prioception. Am J Sports Med 1994; 22 (2): 223-9

119. Robbins S, Waked E, Rappel R. Ankle taping improves pro-prioception before and after exercise in young men. Br JSports Med 1995; 29 (4): 242-7

120. Jerosch J, Bischof M. The effect of proprioception on functionalstability of the upper ankle joint with special reference tostabilizing aids. Sportverletz Sportschaden 1994; 8 (3): 111-21

121. Jerosch J, Hoffstetter I, Bork H, et al. The influence of orthoseson the proprioception of the ankle joint. Knee Surg SportsTraumatol Arthrosc 1995; 3 (1): 39-46

122. Zablonski GL. The effect of ankle bracing and taping on pro-prioception [dissertation abstract]. D’Youville College, 1994

123. Heit EJ, Lephart SM, Rozzi SL. The effect of ankle bracing andtaping on joint position sense in the stable ankle. J SportRehab 1996; 5 (3): 206-13

124. Kinzey SJ, Ingersoll CD, Knight KL. The effects of selectedankle appliances on postural control. J Athletic Training 1997;32 (4): 300-3

125. Rivers DA. The influence of cryotherapy and Aircast bracingon total body balance and proprioception. Eugene (OR): Uni-versity of Oregon, 1995

126. Friden T, Zatterstrom R, Lindstrand A, et al. A stabilometrictechnique for evaluation of lower limb instabilities. Am JSports Med 1989; 17 (1): 118-22

127. Tropp H, Ekstrand J, Gillquist J. Stabilometry in functional in-stability of the ankle and its value in predicting injury. MedSci Sports Exerc 1984; 16 (1): 64-6

128. Hertel JN, Guskiewicz KM, Kahler DM, et al. Effect of anklejoint anethesia on center of balance, postural sway, and jointposition sense. J Sport Rehabil 1996; 5: 111-9

129. Hamer PW, Munt AM, Harris CD, et al. The influence of anklestrapping on wobbleboard performance, before and after ex-ercise. Aust Physiother 1992; 38 (2): 85-92

130. Feuerbach JW, Grabiner MD, Koh TJ, et al. Effect of Aircastapplication and ankle ligament anesthesia on ankle jointproprioception. Second North American Congress onBiomechanics; 1992 Aug 24-28; Chicago 415-6

131. Karlsson J, Peterson L, Andreasson G, et al. The unstable ankle:a combined EMG and biomechanical modeling study. Int JSport Biomech 1992; 8 (2): 129-44

132. Karlsson J, Sward L, Andreasson GO. The effect of taping on anklestability. Practical implications. Sports Med 1993; 16 (3): 210-5

133. McCaw ST, Johnson KM. The effect of ankle taping on groundreaction forces during drop landings. The Second NorthAmerican Congress on Biomechanics. Chicago: 1992: 107

134. International Rugby Football Board. Laws of the Game of RugbyFootball. London: International Rugby Football Board, 1996

Correspondence and reprints: Dr Patria Hume, Departmentof Sport and Exercise Science, University of Auckland,Tamaki Campus, Private Bag 92019, Auckland, New Zealand.E-mail: p.hume@auckland.ac.nz

312 Hume & Gerrard

Adis International Limited. All rights reserved. Sports Med 1998 May; 25 (5)