- Email: [email protected]
Shoulder taping in the clinical setting
R E H A B I L I TAT I O N
Shoulder taping in the clinical setting . . . . . . . . . . . . . . . .
David Kneeshaw
Shoulder taping is used frequently in the clinical setting as a helpful adjunct to other physiotherapy modalities when treating shoulder pathology and dysfunction. Discussion of proposed mechanisms of action is detailed, as are some of the regularly utilised techniques in the clinical setting. # 2002 Harcourt Publishers Ltd
Introduction
David Kneeshaw Bachelor of Applied Science (Physiotherapy), Member Australian Physiotherapy Association, Principal Physiotherapist Balmain Physiotherapy Centre, Montague Street, Balmain, Sydney, Australia Correspondence to: D. Kneeshaw E-mail: [email protected] Received January 2001 Revised March 2001 Accepted April 2001 ........................................... Journal of Bodywork and Movement Therapies (2002) 6(1), 2^8 # 2002 Harcourt Publishers Ltd doi: 10.1054/jbmt.2001.0233, available online at http://www.idealibrary.com on
Taping has been widely used by therapists as an aid for prophylaxis and rehabilitation for many years. Research has been more frequently conducted in recent history and the benefits of taping are still under contention (McNair et al. 1995; Perlau et al. 1995; Gilleard et al. l998). However, it is still widely accepted in clinical practice that taping applied in the correct manner and situation is an important and useful treatment modality (Gilleard et al. 1998; Powers et al. 1997; Ernst et al. 1999; Alt et al. 1999; Gerrard et al. 1998). As yet the mechanisms of action of taping are inconclusive though most theories focus on proprioceptive and mechanical effects with lesser effects hypothesized to be psychological (Hume et al. 1998). Taping is considered an important modality in treatment of shoulder dysfunction as it stimulates greater proprioceptive feedback and helps to improve scapulo-humeral rhythm and joint
position (Morrissey 2000; Gerrard et al. 1998; Allingham 1998; Watson 2000). The aim of this paper is to provide examples of shoulder taping and to discuss the possible mechanisms behind their success.
Clinical anatomy and relevance to taping theory The shoulder complex is made up of three joints—the gleno-humeral or scapulo-humeral joint, the acromioclavicular joint and the scapulothoracic joint (Moore 1985: Kibler 1998). The shoulder is a highly mobile complex, more so than any other peripheral joint, with over 16 000 different positions available, measured on a three-dimensional topographical analysis on a degreeby-degree basis (Moseley et al. 1992). This flexibility results in the region being stabilized by both static and dynamic components (Ginn 1993; Davies & Dickoff-Hoffman 1993; Warner et al. 1990; Kibler 1998), with dynamic stabilizers
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Shoulder taping in the clinical setting
being more important than other peripheral joints (Davies & DickoffHoffman l993). As the humeral head’s radius is on an average three times that of the glenoid fossa, increased flexibility is a trade-off for reduced stability (Davies & DickoffHoffman l993). The resultant necessity is for an intricate coordination of rotator cuff muscle activation timing and correct passive tissue length characteristics to maintain the humeral head centrally rotating against the glenoid fossa (Kibler 1998). The scapulo-thoracic joint is not a true physiological joint, but is arguably the most crucial of the three shoulder joints as it is considered the major base of support for shoulder motion (Kibler 1998; Davies & Dickoff-Hoffman, 1993). The position of the scapula will determine the angulation of the glenoid fossa and thus the relative location of the humeral head to the acromion (Kibler 1998; Moseley et al. 1992; Glousman et al. 1988; Pink & Perry 1996). Hence its position is the prime determinant of the size of the sub-acromial space and also the vulnerability of the supraspinatus tendon to impingement at rest and through movement (Kibler 1998; Davies & Dickoff-Hoffman 1993). As the supraspinatus tendon has been shown to be hypovascular at resting position (Warner et al. 1990) it is imperative that the scapula be suitably oriented to negate the effects of compression and possible further reduction in circulation to the tendon. Most throwing and serving sports are performed with shoulder elevation between 70 and 110 degrees (Kibler 1998; Davies & Dickoff-Hoffman 1993). This is where the dynamic stabilizers need to perform at their greatest compressive force to locate the humeral head in the socket and the scapula needs to have rotated to the applicable position to gain proper joint congruence. The orientation of
the rotator cuff fibres reinforces that this range is where their involvement is most necessary. Kibler has published a list of roles the scapula plays in shoulder function (Table 1). For these functions to be performed well there must be a complementary relationship between the inert capsular and connective tissues and the contractile elements, such as their length, flexibility and activation timing and strength (Davies & Dickoff-Hoffman l993). The acromio-clavicular joint acts as a strut for the scapula to rest against the thorax, providing stability through elevation (Kibler 1998; Shamus & Shamus 1997). The combination of crankshaft shape and the acromio-clavicular ligaments (Kibler l998; Shamus & Shamus 1997) allows enough translation and rotation to complete full abduction (all other things being equal). The joint is susceptible to injury via frank trauma such as direct falls, or accumulated microtrauma from repetitive stresses such as throwing, serving or rugby tackling. It has been reported to be the most commonly sprained joint of the shoulder (Shamus & Shamus 1997). Rehabilitation of the injured shoulder invariably involves retraining of the specific function of the contractile elements throughout motion and altering the resting length of these components to improve length-tension relationships, thereby improving scapulo-humeral rhythm and posture (Brukner & Khan 1997).
Physiotherapists do this in a number of ways — soft-tissue release, electrotherapy, stretching, strengthening and proprioceptive re-training. It is considered that taping is a useful adjunct in facilitating these modalities to provide the biomechanical and proprioceptive changes necessary to stimulate repair and promote a good outcome. It has been known for some time that neuromuscular receptors are damaged after injury (Davies & Dickoff-Hoffman 1993; Forwell & Carnahan 1996; Perlau et al. 1995) and obviously to achieve the best results these deficits must be rectified. Useful taping techniques and their possible mechanisms of action will be discussed in a later section of this article.
Taping overview Taping is a widely used treatment modality. Its use could be considered an extension of the traditional compression and crepe bandages that in themselves have been demonstrated to improve proprioception in research conducted on injured knees (Perlau et al. 1995). The effects have been shown to last well after the application of the tape (Perlau et al. 1995). In the author’s knowledge, there are no definitive studies to explain the theories that have surfaced surrounding how and why taping succeeds. There is, however, general acceptance that it does benefit the patient despite conflicting evidence of its efficacy. Following
Table 1 Roles of the scapula in shoulder function (Kibler1998) 1st Role 2nd Role 3rd Role
4th Role
To be a stable part of the glenohumeral articulation Retraction and protraction along the thoracic wall The scapula must rotate in the cocking and acceleration phases to clear the acromion from the rotator cuff to decrease impingement and coracoacromial arch compression Being a link in the proximal-to-distal sequencing of velocity, energy, and forces that allows the most appropriate shoulder function
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the success in taping ankles for increased stability and taping knees to improve patello-femoral function (Gerrard 1998; Refshauge 2000; Ernst et al. 1999), shoulder taping has steadily diversified to include several often-used techniques that will be outlined in later sections. The two most frequently proposed mechanisms of taping are the proprioceptive and mechanical (Moseley 2000; Ernst et al. 1999; Gerrard 1998), with an assumption that taping has a positive psychological effect (Hume et al. 1998). Tape is said to stimulate neuromuscular pathways via increased afferent feedback from cutaneous receptors (Parkhurst & Burnett 1994; Perlau et al. 1995; McNair et al. 1995) which with expert re-training can facilitate a more appropriate neuromuscular response. The mechanical effects are to re-locate the joints in such a way as to stabilize the joint (Gerrard 1998; Kibler 1998), provide a splint or alter length-tension relationships (Moseley 2000; Watson 2000; Allingham 1998; McConnell 2000; Parkhurst & Burnett 1994) to create the required musculo-skeletal posture or motor pattern. As far as the psychological factor is concerned, there is the obvious placebo effect of receiving attention, but also the heightened consciousness resulting from the feeling of applied tape. There continues to be contention in the literature as to whether taping makes a significant contribution to patient improvement and if the proposed mechanisms are valid (Refshauge et al. 2000; Ernst et al. 1999; Alt et al. 1999; Powers et al. 1997; McNair et al. 1996). In the clinical setting the first step to success with taping is to make the correct diagnosis and identify the pertinent causative factors of which the therapist can attempt to change. In the author’s opinion, the
difficulty in shoulder taping lies in the paucity of stable structures upon which to anchor tape. This reduces the ability of the tape to splint the joint, but should not reduce the other mechanical or proprioceptive actions. If the chosen application initially provides the desired result it should be re-applied in conjunction with relevant treatment and exercise until the symptoms disappear or the desired motor pattern has been achieved free of tape (Morrissey 2000).
Taping techniques The following section will describe often-used taping techniques and discuss possible reasons for their success and the neuromuscular processes behind them. The techniques discussed include Allingham’s strap, Watson’s strap, the various techniques to inhibit or facilitate shoulder girdle muscles, the acromio-clavicular strap and the external rotation limitation strap. Currently there is still contention as to the effects of taping — the author has attended two lectures of Jenny McConnell and Craig Allingham, who have both created taping techniques, but could not give definite answers as to why the technique had their desired effect. The usual priming procedures should be employed before applying tape — cleaning excess oils off the skin and then applying a hypoallergenic adhesive barrier gel. The first tape should be a mesh, hypoallergenic tape, applied without tension. Finally the rigid, zinc oxide tape can be applied with the desired tension. The client should be careful when removing the tape to pull slowly back along the extent of the tape and thus avoiding irritation of the skin. McConnell (2000) believes that reckless removal of tape and the subsequent skin irritation is the greatest hindrance to early re-application.
Allingham’s strap Allingham’s strap (Fig. 1) is used for impingement syndrome of the rotator cuff insertion underneath the acromion. Allingham (1998) believes that the technique is most useful in the acute and sub-acute stages of impingement. Firstly apply three hypoallergenic mesh tapes from mid-shaft of the lateral humerus to the mid-belly position of middle and upper trapezius. Following this lay down three rigid tapes, sideby-side from anterior to posterior deltoid without tension to the sub-acromial space and then moderate to firm tension to the latter position. Patients often comment ‘my arm feels supported as if in a sling’. The longitudinal bunching of the trapezius fibres which are oriented from the acromion to the spine in a virtually horizontal fashion serve to improve these fibres’ cross-bridging capacity which will enhance the muscle’s length-tension relationship (Bak & Magnusson 1997). The increased ability of these fibres to contract causes a lateral rotation of the scapula upon attempts at scaption, which in turn clears the rotator cuff tendon from the acromion. Therefore the procedure serves to fulfil the third role of the scapula, as defined by Kibler (1998). As the supraspinatus is hypovascular at the lower reaches of abduction (Warner et al. 1990),
Fig. 1 Allingham’s strap.
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Allingham’s tape is important in allowing proper repair of damage by increasing the sub-acromial space. Improper biomechanics as a result of muscle inhibition is a significant problem in the acute phase of injury, so the reduction in shoulder hitching with Allingham’s strap is beneficial in reducing recovery times. The humeral head is likely to be more effectively compressed by the stimulated horizontally aligned muscle fibres. As described by Kibler (Kibler 1998), proximal stability is necessary for upper limb rehabilitation, and correct scapular orientation is therefore one of the primary targets, provided by the Allingham’s straps. The greatest proprioceptive input for the upper limb is from the shoulder (Forwell & Carnahan 1996) and the extra cutaneous mechanoreceptor and intramuscular receptor input provided by taping should also be of benefit. Watson’s strap Watson’s strap (Fig. 2) is best utilized for those with ‘drooping shoulders’ (Watson 2000) which is demonstrated by those with anterior and medial rotation and anterior tilt of the scapula. This resting position is an indicator of poor muscle tone in the rhomboids and lower traps, and from the author’s clinical experience, hypomobile scapulae.
Fig. 2 Watson’s strap.
There may be excessive traction stresses on the upper trapezius, which results in chronic spasm and also the possibility of functional thoracic outlet syndrome (Watson 2000; Leung et al. 1999). The net effect is reduced sub-acromial space and dysfunctional scapulo-humeral rhythm. The clinician elevates and laterally rotates the affected scapula with one hand after attaching tape to a point anterior of the lower third of the scapula, in the axilla (which in the cases of hirsute armpits, should be shaved around 48 h before application to avoid skin irritation). Then the tape is attached to the spine of the opposing scapula, effectively re-locating the drooped shoulder and helping to resolve the above mentioned postural deficits. The re-location of the scapula has both mechanical and proprioceptive effects. The obvious mechanical effect is the re-location itself that improves the length-tension relationship of rhomboids by shortening this underactive muscle (Morrissey 2000). It has been demonstrated that patellar position and muscle activation in the VMO can be positively affected with taping (Gerrard 1998) and it should be the case that the scapula is no different. The action of the tape to improve rhomboids and upper/ middle trapezius contraction should encourage greater scapular stability, early lateral rotation of the scapula and thus increase sub-acromial space. The shortening of the rhomboids and middle trapezius fibres should aid in the activation of the force couples of rhomboids and serratus anterior for scapular stability (Kibler 1998; Watson 2000). The proprioceptive effect is the feedback loop developed by the gross alteration in scapula position, hopefully stimulating better muscle co-ordination. As with any taping, Watson’s strap will have effects on providing more afferent feedback to
the sensori-motor cortex (Morrisey 2000; Perlau et al. 1995; McNair et al. 1995). Though cutaneous mechanoreceptors are considered more important in the distal part of the upper limb (McNair et al. 1995), the author suggests that there must be altered stimulus by virtue of tape on skin — this is still a contentious point (Forwell & Carnahan 1996; Bullock & Sexton 1993). Simple elasticised bandages have been shown to improve proprioception (Perlau et al. 1995), therefore it is expected that taping should prove to do the same. This, in conjunction with the psychological reminder the tape provides (Hume et al. 1998), should aid in re-training proper scapulohumeral rhythm (Voight et al. 1996). Scapular-stabilising tapes There are various tapes that are meant to re-locate the scapulae and alter muscle activation levels to improve scapular stability (Figs 3–5). A study was cited in this journal that demonstrated immediate reduction in upper trapezius activity with a cross-tape (O’Donovan, 1997, cited in Morrissey 2000). It is likely that the derangement of fibres from this lateral bunching reduces the ability of the actin and myosin to crossbridge (Parkhurst & Burnett 1994). McConnell uses a gross bunching
Fig. 3 Upper trapezius inhibition utilising the lateral bunching of muscle fibres to reduce recruitment.
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neuromuscular elements, it is more likely that motor patterns are developed by the disruption or augmentation of more actin-myosin cross-bridges and the reduced/ increased activity in muscles with the relevant training exercises. The varieties of techniques are most often used for scapula retraction and upper trapezius inhibition. Fig. 4 Facilitation of serrotus anterior and rhomboids.
Fig. 5 Facilitation of scapular retraction and depression.
technique to reduce vastus lateralis activation in patello-femoral rehabilitation (2000). As previously mentioned longitudinal bunching should promote greater muscle activation through an increased number of available cross-bridges, so these techniques should follow the rule of lateral bunching of overactive muscles and longitudinal bunching for under-active muscles. The author believes that this mechanism is of much greater significance than other effects such as augmentation of cutaneous inputs (though every little bit helps!), and is therefore in some disagreement with Morrissey (2000) who in this journal, July 2000 remarked that changes in motor patterns with these scapula techniques is effectively cutaneously mediated proprioceptive biofeedback. This author feels that as there is greater proprioceptive feedback from
Acromio-clavicular strap Previous studies demonstrate the positive effects of the acromioclavicular (AC) strap (Fig. 6) in rehabilitation of ligamentous injuries around the acromioclavicular joint (Shamus & Shamus 1997). This technique primarily works on the mechanical action of taping by imitating the stabilizing properties of the surrounding ligaments and joint capsule. Damage to the joint reduces its capability to act as a strut for the scapula (Kibler 1998; Shamus & Shamus 1997) and the likely resultant distal clavicular elevation reduces the crankshaft’s ability to translate and rotate correctly to allow proper, full elevation. Though it has an important role in shoulder function, this commonly sprained joint (Shamus & Shamus 1997) is a less complex one, which lends itself to successful taping. The tape is applied firstly at the coracoid process and applied in a posterior
Fig. 6 Acromio-clavicular joint strap.
direction to around the mid-section of the thoracic cage. Rigney’s strap The author first saw the final technique for discussion on a representative rugby union player who required surgery to the rotator cuff and anterior joint capsule. He was however also required to complete the season’s rugby and as such was taped by his club’s physiotherapist, Mr Luke Rigney, to prevent further damage and allow him to effectively compete. To control his multi-directional instability, which most frequently manifested itself in the abducted, externally rotated position, the following taping technique was used (Fig. 7). The position for taping is important — abduction to 908 and full internal rotation. Elastic anchor tapes are wrapped around the distal humerus and mid-thorax. From the posterior and inferior of the humeral anchor lay a rigid tape anteriorly across the superior part of the glenohumeral joint ending at the second anchor. Continue taping with a more anterior accent. The mechanical effect is to reduce the shoulder’s available external rotation in abduction and therefore reduce likelihood of dislocation and rotator cuff stresses. There are obvious limitations to this taping — it is difficult to tape without hindering the throwing or serving action because of the reduced capacity for wind-up in the preparatory phase. This technique is therefore similar to the ankle taping post-inversion injury where the tape acts to limit available range of motion. There would also seem to be a proprioceptive effect of significant proportions. Though progressive external rotation in elevation the strong pull on the skin, excites cutaneous mechanoreceptors which will send greater afferent feedback to
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Shoulder taping in the clinical setting
Fig. 7 Rigney’s strap
the central nervous system to promote an earlier reflex activation of the relevant rotator cuff muscles (McNair et al. 1995; Perlau et al. 1995; Parkhurst & Burnett 1994). It is assumed that the sensori-motor cortex is tricked into believing the capsule and muscles are at a greater length than in reality, which as in the stretch-shortening cycle (Hutton & Atwater 1992) may produce a stronger antagonistic contraction to limit the problem movement, properly orient the humeral head and reduce anterior ‘opening up’.
Conclusion Taping is a widely used modality that has been shown to be of marked benefit in the clinical setting. Shoulder taping can be more difficult compared to other body regions due to its complex stabilizing mechanisms and the necessity for dynamic stability produced from contractile structures. Research into its efficacy and to clearly define the mechanisms behind shoulder taping seems to be required. However it should be considered that taping is a useful adjunct to physiotherapeutic treatment due to weight of success in clinical experience. Taping and then re-training movement has the added
benefit of making the patient aware of the big picture, that is to alter the causative factors of shoulder injury and reduce the likelihood of reinjury. This effect and the relief of symptoms taping can produce make it an important part of shoulder rehabilitation.
REFERENCES Allingham C 1998 Shoulders 98. Lecture notes. Australian Physiotherapy Association-sanctioned course, Sydney, Australia Alt W, Lohrer H, Gollhofer A 1995 Functional properties of adhesive ankle taping: neuromuscular and mechanical effects before and after exercise. Foot and Ankle International 20(4): 238–245 Bak K, Magnusson SP 1997 Shoulder strength and range of motion in symptomatic and pain-free elite swimmers. The American Journal of Sports Medicine 25(4): 454–459 Brukner P, Khan K 1997 Clinical Sports Medicine Chapters 4 and 12. McGrawHill Book Company, Sydney Bullock-Saxton JE, Janda V, Bullock MI 1993 Reflex activation of gluteal muscles in walking. An approach to restoration of muscle function for patients with lowback pain. Spine 18(6): 704–708 Davies G, Dickoff-Hoffman MS 1993 Neuromuscular testing and rehabilitation of the shoulder complex. Journal of Orthopaedic and Sports Physical Therapy 18(2): 449–457 Ernst GP, Kawaguchi J, Saliba E 1999 Effect of patellar taping on knee kinetics of
patients with patellofemoral pain syndrome. Journal of Orthopaedic and Sports Physical Therapy 29(11): 661–667 Forwell LA, Carnahan H 1996 Proprioception during manual aiming in individuals with shoulder instability and controls. Journal of Orthopaedic and Sports Physical Therapy 23(2): 111–119 Gerrard DF 1998 External knee supports in rugby union. Effectiveness of bracing and taping. Sports Medicine 25(5): 313–317 Gilleard W, McConnell J, Parsons D 1998 The effect of patellar taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Physical Therapy 78(1): 25–32 Ginn K 1993 The shoulder — clinical anatomy and rehabilitation (Undergraduate lecture) University of Sydney, Cumberland College of Health Sciences, Sydney, Australia Hume PA. Gerrard DF 1998 Effectiveness of external ankle support. Bracing and taping in rugby union. Sports Medicine 25(5): 285–312 Hutton RS. Atwater SW 1992 Acute and chronic adaptations of muscle proprioceptors in response to increased use. Sports Medicine 14(6): 407–421 Kibler B 1998 The role of the scapula in athletic shoulder function. The American Journal of Sports Medicine 26(2): 325–337 Leung YF, Chung OM, Ip PS, Wong A, Wai YL 1999 An unusual case of thoracic outlet syndrome associated with long distance running. British Journal of Sports Medicine 33: 279–281 McConnell J 2000 New South Wales (Australia) Sports Physiotherapy Group lecture on Recent research on patellar taping. Australian Physiotherapy Association-sanctioned lecture, Sydney, Australia McNair PJ, Marshall RN, Maguire K, Brown C 1995 Knee joint effusion and proprioception. Archives of Physical Medicine and Rehabilitation 76(6): 566–568 McNair PJ, Stanley SN, Strauss GR 1996 Knee bracing: effects on proprioception. Archives of Physical Medicine and Rehabilitation 77(3): 287–289 Moore KL 1985 Clinically Oriented Anatomy Chapter 6. Williams and Wilkins, Baltimore Morrissey D 2000 Proprioceptive shoulder taping. Journal of Bodywork and
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Movement Therapies 4(3): 189–194 Moseley JB, Jobe FW, Pink M, Perry J, Tibone J 1992 EMG analysis of the scapular muscles during a shoulder rehabilitation program. The American Journal of Sports Medicine 20(2): 128–135 Parkhurst TM, Burnett CN 1994 Injury and proprioception in the lower back. Journal of Orthopaedic and Sport Physical Therapy 19(5): 282–294 Perlau R. Frank C, Fick G 1995 The effect of elastic bandages on human knee proprioception in the uninjured population. The American Journal of Sports Medicine 23(2): 25l–255 Powers CM, Landel R, Sosnick T, Kirby J, Mengel K, Cheney A, Perry J 1997
The effects of patellar taping on stride characteristics and joint motion in subjects with patellofemoral pain. Journal of Orthopaedic and Sports Physical Therapy 26(6): 286–291 Refshauge KM, Kilbreath SL, Raymond J 2000 The effect of recurrent ankle inversion sprain and taping on proprioception at the ankle. Medicine and Science in Sports and Exercise 32(1): 10–15 Shamus JL, Shamus EC 1997 A taping technique for the treatment of acromioclavicular joint sprains: a case study. Journal of Orthopaedic and Sports Physical Therapy 25(6): 390–394 Warner JJP, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R 1990 Patterns
of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement. The American Journal of Sports Medicine 18(4): 366–374 Watson L 2000 Level 1 and 2 Lyn Watson Shoulder Course. Lecture notes. Australian Physiotherapy Association-sanctioned course, Sydney, Australia Voight ML, Hardin JA, Blackburn TA, Tippett S, Canner GC 1996 The effects of muscle fatigue on and the relationship of arm dominance to shoulder proprioception. Journal of Orthopaedic and Sports Physical Therapy 23(6): 348–352
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Shoulder taping in the clinical setting . . . . . . . . . . . . . . . .
David Kneeshaw
Shoulder taping is used frequently in the clinical setting as a helpful adjunct to other physiotherapy modalities when treating shoulder pathology and dysfunction. Discussion of proposed mechanisms of action is detailed, as are some of the regularly utilised techniques in the clinical setting. # 2002 Harcourt Publishers Ltd
Introduction
David Kneeshaw Bachelor of Applied Science (Physiotherapy), Member Australian Physiotherapy Association, Principal Physiotherapist Balmain Physiotherapy Centre, Montague Street, Balmain, Sydney, Australia Correspondence to: D. Kneeshaw E-mail: [email protected] Received January 2001 Revised March 2001 Accepted April 2001 ........................................... Journal of Bodywork and Movement Therapies (2002) 6(1), 2^8 # 2002 Harcourt Publishers Ltd doi: 10.1054/jbmt.2001.0233, available online at http://www.idealibrary.com on
Taping has been widely used by therapists as an aid for prophylaxis and rehabilitation for many years. Research has been more frequently conducted in recent history and the benefits of taping are still under contention (McNair et al. 1995; Perlau et al. 1995; Gilleard et al. l998). However, it is still widely accepted in clinical practice that taping applied in the correct manner and situation is an important and useful treatment modality (Gilleard et al. 1998; Powers et al. 1997; Ernst et al. 1999; Alt et al. 1999; Gerrard et al. 1998). As yet the mechanisms of action of taping are inconclusive though most theories focus on proprioceptive and mechanical effects with lesser effects hypothesized to be psychological (Hume et al. 1998). Taping is considered an important modality in treatment of shoulder dysfunction as it stimulates greater proprioceptive feedback and helps to improve scapulo-humeral rhythm and joint
position (Morrissey 2000; Gerrard et al. 1998; Allingham 1998; Watson 2000). The aim of this paper is to provide examples of shoulder taping and to discuss the possible mechanisms behind their success.
Clinical anatomy and relevance to taping theory The shoulder complex is made up of three joints—the gleno-humeral or scapulo-humeral joint, the acromioclavicular joint and the scapulothoracic joint (Moore 1985: Kibler 1998). The shoulder is a highly mobile complex, more so than any other peripheral joint, with over 16 000 different positions available, measured on a three-dimensional topographical analysis on a degreeby-degree basis (Moseley et al. 1992). This flexibility results in the region being stabilized by both static and dynamic components (Ginn 1993; Davies & Dickoff-Hoffman 1993; Warner et al. 1990; Kibler 1998), with dynamic stabilizers
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Shoulder taping in the clinical setting
being more important than other peripheral joints (Davies & DickoffHoffman l993). As the humeral head’s radius is on an average three times that of the glenoid fossa, increased flexibility is a trade-off for reduced stability (Davies & DickoffHoffman l993). The resultant necessity is for an intricate coordination of rotator cuff muscle activation timing and correct passive tissue length characteristics to maintain the humeral head centrally rotating against the glenoid fossa (Kibler 1998). The scapulo-thoracic joint is not a true physiological joint, but is arguably the most crucial of the three shoulder joints as it is considered the major base of support for shoulder motion (Kibler 1998; Davies & Dickoff-Hoffman, 1993). The position of the scapula will determine the angulation of the glenoid fossa and thus the relative location of the humeral head to the acromion (Kibler 1998; Moseley et al. 1992; Glousman et al. 1988; Pink & Perry 1996). Hence its position is the prime determinant of the size of the sub-acromial space and also the vulnerability of the supraspinatus tendon to impingement at rest and through movement (Kibler 1998; Davies & Dickoff-Hoffman 1993). As the supraspinatus tendon has been shown to be hypovascular at resting position (Warner et al. 1990) it is imperative that the scapula be suitably oriented to negate the effects of compression and possible further reduction in circulation to the tendon. Most throwing and serving sports are performed with shoulder elevation between 70 and 110 degrees (Kibler 1998; Davies & Dickoff-Hoffman 1993). This is where the dynamic stabilizers need to perform at their greatest compressive force to locate the humeral head in the socket and the scapula needs to have rotated to the applicable position to gain proper joint congruence. The orientation of
the rotator cuff fibres reinforces that this range is where their involvement is most necessary. Kibler has published a list of roles the scapula plays in shoulder function (Table 1). For these functions to be performed well there must be a complementary relationship between the inert capsular and connective tissues and the contractile elements, such as their length, flexibility and activation timing and strength (Davies & Dickoff-Hoffman l993). The acromio-clavicular joint acts as a strut for the scapula to rest against the thorax, providing stability through elevation (Kibler 1998; Shamus & Shamus 1997). The combination of crankshaft shape and the acromio-clavicular ligaments (Kibler l998; Shamus & Shamus 1997) allows enough translation and rotation to complete full abduction (all other things being equal). The joint is susceptible to injury via frank trauma such as direct falls, or accumulated microtrauma from repetitive stresses such as throwing, serving or rugby tackling. It has been reported to be the most commonly sprained joint of the shoulder (Shamus & Shamus 1997). Rehabilitation of the injured shoulder invariably involves retraining of the specific function of the contractile elements throughout motion and altering the resting length of these components to improve length-tension relationships, thereby improving scapulo-humeral rhythm and posture (Brukner & Khan 1997).
Physiotherapists do this in a number of ways — soft-tissue release, electrotherapy, stretching, strengthening and proprioceptive re-training. It is considered that taping is a useful adjunct in facilitating these modalities to provide the biomechanical and proprioceptive changes necessary to stimulate repair and promote a good outcome. It has been known for some time that neuromuscular receptors are damaged after injury (Davies & Dickoff-Hoffman 1993; Forwell & Carnahan 1996; Perlau et al. 1995) and obviously to achieve the best results these deficits must be rectified. Useful taping techniques and their possible mechanisms of action will be discussed in a later section of this article.
Taping overview Taping is a widely used treatment modality. Its use could be considered an extension of the traditional compression and crepe bandages that in themselves have been demonstrated to improve proprioception in research conducted on injured knees (Perlau et al. 1995). The effects have been shown to last well after the application of the tape (Perlau et al. 1995). In the author’s knowledge, there are no definitive studies to explain the theories that have surfaced surrounding how and why taping succeeds. There is, however, general acceptance that it does benefit the patient despite conflicting evidence of its efficacy. Following
Table 1 Roles of the scapula in shoulder function (Kibler1998) 1st Role 2nd Role 3rd Role
4th Role
To be a stable part of the glenohumeral articulation Retraction and protraction along the thoracic wall The scapula must rotate in the cocking and acceleration phases to clear the acromion from the rotator cuff to decrease impingement and coracoacromial arch compression Being a link in the proximal-to-distal sequencing of velocity, energy, and forces that allows the most appropriate shoulder function
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the success in taping ankles for increased stability and taping knees to improve patello-femoral function (Gerrard 1998; Refshauge 2000; Ernst et al. 1999), shoulder taping has steadily diversified to include several often-used techniques that will be outlined in later sections. The two most frequently proposed mechanisms of taping are the proprioceptive and mechanical (Moseley 2000; Ernst et al. 1999; Gerrard 1998), with an assumption that taping has a positive psychological effect (Hume et al. 1998). Tape is said to stimulate neuromuscular pathways via increased afferent feedback from cutaneous receptors (Parkhurst & Burnett 1994; Perlau et al. 1995; McNair et al. 1995) which with expert re-training can facilitate a more appropriate neuromuscular response. The mechanical effects are to re-locate the joints in such a way as to stabilize the joint (Gerrard 1998; Kibler 1998), provide a splint or alter length-tension relationships (Moseley 2000; Watson 2000; Allingham 1998; McConnell 2000; Parkhurst & Burnett 1994) to create the required musculo-skeletal posture or motor pattern. As far as the psychological factor is concerned, there is the obvious placebo effect of receiving attention, but also the heightened consciousness resulting from the feeling of applied tape. There continues to be contention in the literature as to whether taping makes a significant contribution to patient improvement and if the proposed mechanisms are valid (Refshauge et al. 2000; Ernst et al. 1999; Alt et al. 1999; Powers et al. 1997; McNair et al. 1996). In the clinical setting the first step to success with taping is to make the correct diagnosis and identify the pertinent causative factors of which the therapist can attempt to change. In the author’s opinion, the
difficulty in shoulder taping lies in the paucity of stable structures upon which to anchor tape. This reduces the ability of the tape to splint the joint, but should not reduce the other mechanical or proprioceptive actions. If the chosen application initially provides the desired result it should be re-applied in conjunction with relevant treatment and exercise until the symptoms disappear or the desired motor pattern has been achieved free of tape (Morrissey 2000).
Taping techniques The following section will describe often-used taping techniques and discuss possible reasons for their success and the neuromuscular processes behind them. The techniques discussed include Allingham’s strap, Watson’s strap, the various techniques to inhibit or facilitate shoulder girdle muscles, the acromio-clavicular strap and the external rotation limitation strap. Currently there is still contention as to the effects of taping — the author has attended two lectures of Jenny McConnell and Craig Allingham, who have both created taping techniques, but could not give definite answers as to why the technique had their desired effect. The usual priming procedures should be employed before applying tape — cleaning excess oils off the skin and then applying a hypoallergenic adhesive barrier gel. The first tape should be a mesh, hypoallergenic tape, applied without tension. Finally the rigid, zinc oxide tape can be applied with the desired tension. The client should be careful when removing the tape to pull slowly back along the extent of the tape and thus avoiding irritation of the skin. McConnell (2000) believes that reckless removal of tape and the subsequent skin irritation is the greatest hindrance to early re-application.
Allingham’s strap Allingham’s strap (Fig. 1) is used for impingement syndrome of the rotator cuff insertion underneath the acromion. Allingham (1998) believes that the technique is most useful in the acute and sub-acute stages of impingement. Firstly apply three hypoallergenic mesh tapes from mid-shaft of the lateral humerus to the mid-belly position of middle and upper trapezius. Following this lay down three rigid tapes, sideby-side from anterior to posterior deltoid without tension to the sub-acromial space and then moderate to firm tension to the latter position. Patients often comment ‘my arm feels supported as if in a sling’. The longitudinal bunching of the trapezius fibres which are oriented from the acromion to the spine in a virtually horizontal fashion serve to improve these fibres’ cross-bridging capacity which will enhance the muscle’s length-tension relationship (Bak & Magnusson 1997). The increased ability of these fibres to contract causes a lateral rotation of the scapula upon attempts at scaption, which in turn clears the rotator cuff tendon from the acromion. Therefore the procedure serves to fulfil the third role of the scapula, as defined by Kibler (1998). As the supraspinatus is hypovascular at the lower reaches of abduction (Warner et al. 1990),
Fig. 1 Allingham’s strap.
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Allingham’s tape is important in allowing proper repair of damage by increasing the sub-acromial space. Improper biomechanics as a result of muscle inhibition is a significant problem in the acute phase of injury, so the reduction in shoulder hitching with Allingham’s strap is beneficial in reducing recovery times. The humeral head is likely to be more effectively compressed by the stimulated horizontally aligned muscle fibres. As described by Kibler (Kibler 1998), proximal stability is necessary for upper limb rehabilitation, and correct scapular orientation is therefore one of the primary targets, provided by the Allingham’s straps. The greatest proprioceptive input for the upper limb is from the shoulder (Forwell & Carnahan 1996) and the extra cutaneous mechanoreceptor and intramuscular receptor input provided by taping should also be of benefit. Watson’s strap Watson’s strap (Fig. 2) is best utilized for those with ‘drooping shoulders’ (Watson 2000) which is demonstrated by those with anterior and medial rotation and anterior tilt of the scapula. This resting position is an indicator of poor muscle tone in the rhomboids and lower traps, and from the author’s clinical experience, hypomobile scapulae.
Fig. 2 Watson’s strap.
There may be excessive traction stresses on the upper trapezius, which results in chronic spasm and also the possibility of functional thoracic outlet syndrome (Watson 2000; Leung et al. 1999). The net effect is reduced sub-acromial space and dysfunctional scapulo-humeral rhythm. The clinician elevates and laterally rotates the affected scapula with one hand after attaching tape to a point anterior of the lower third of the scapula, in the axilla (which in the cases of hirsute armpits, should be shaved around 48 h before application to avoid skin irritation). Then the tape is attached to the spine of the opposing scapula, effectively re-locating the drooped shoulder and helping to resolve the above mentioned postural deficits. The re-location of the scapula has both mechanical and proprioceptive effects. The obvious mechanical effect is the re-location itself that improves the length-tension relationship of rhomboids by shortening this underactive muscle (Morrissey 2000). It has been demonstrated that patellar position and muscle activation in the VMO can be positively affected with taping (Gerrard 1998) and it should be the case that the scapula is no different. The action of the tape to improve rhomboids and upper/ middle trapezius contraction should encourage greater scapular stability, early lateral rotation of the scapula and thus increase sub-acromial space. The shortening of the rhomboids and middle trapezius fibres should aid in the activation of the force couples of rhomboids and serratus anterior for scapular stability (Kibler 1998; Watson 2000). The proprioceptive effect is the feedback loop developed by the gross alteration in scapula position, hopefully stimulating better muscle co-ordination. As with any taping, Watson’s strap will have effects on providing more afferent feedback to
the sensori-motor cortex (Morrisey 2000; Perlau et al. 1995; McNair et al. 1995). Though cutaneous mechanoreceptors are considered more important in the distal part of the upper limb (McNair et al. 1995), the author suggests that there must be altered stimulus by virtue of tape on skin — this is still a contentious point (Forwell & Carnahan 1996; Bullock & Sexton 1993). Simple elasticised bandages have been shown to improve proprioception (Perlau et al. 1995), therefore it is expected that taping should prove to do the same. This, in conjunction with the psychological reminder the tape provides (Hume et al. 1998), should aid in re-training proper scapulohumeral rhythm (Voight et al. 1996). Scapular-stabilising tapes There are various tapes that are meant to re-locate the scapulae and alter muscle activation levels to improve scapular stability (Figs 3–5). A study was cited in this journal that demonstrated immediate reduction in upper trapezius activity with a cross-tape (O’Donovan, 1997, cited in Morrissey 2000). It is likely that the derangement of fibres from this lateral bunching reduces the ability of the actin and myosin to crossbridge (Parkhurst & Burnett 1994). McConnell uses a gross bunching
Fig. 3 Upper trapezius inhibition utilising the lateral bunching of muscle fibres to reduce recruitment.
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neuromuscular elements, it is more likely that motor patterns are developed by the disruption or augmentation of more actin-myosin cross-bridges and the reduced/ increased activity in muscles with the relevant training exercises. The varieties of techniques are most often used for scapula retraction and upper trapezius inhibition. Fig. 4 Facilitation of serrotus anterior and rhomboids.
Fig. 5 Facilitation of scapular retraction and depression.
technique to reduce vastus lateralis activation in patello-femoral rehabilitation (2000). As previously mentioned longitudinal bunching should promote greater muscle activation through an increased number of available cross-bridges, so these techniques should follow the rule of lateral bunching of overactive muscles and longitudinal bunching for under-active muscles. The author believes that this mechanism is of much greater significance than other effects such as augmentation of cutaneous inputs (though every little bit helps!), and is therefore in some disagreement with Morrissey (2000) who in this journal, July 2000 remarked that changes in motor patterns with these scapula techniques is effectively cutaneously mediated proprioceptive biofeedback. This author feels that as there is greater proprioceptive feedback from
Acromio-clavicular strap Previous studies demonstrate the positive effects of the acromioclavicular (AC) strap (Fig. 6) in rehabilitation of ligamentous injuries around the acromioclavicular joint (Shamus & Shamus 1997). This technique primarily works on the mechanical action of taping by imitating the stabilizing properties of the surrounding ligaments and joint capsule. Damage to the joint reduces its capability to act as a strut for the scapula (Kibler 1998; Shamus & Shamus 1997) and the likely resultant distal clavicular elevation reduces the crankshaft’s ability to translate and rotate correctly to allow proper, full elevation. Though it has an important role in shoulder function, this commonly sprained joint (Shamus & Shamus 1997) is a less complex one, which lends itself to successful taping. The tape is applied firstly at the coracoid process and applied in a posterior
Fig. 6 Acromio-clavicular joint strap.
direction to around the mid-section of the thoracic cage. Rigney’s strap The author first saw the final technique for discussion on a representative rugby union player who required surgery to the rotator cuff and anterior joint capsule. He was however also required to complete the season’s rugby and as such was taped by his club’s physiotherapist, Mr Luke Rigney, to prevent further damage and allow him to effectively compete. To control his multi-directional instability, which most frequently manifested itself in the abducted, externally rotated position, the following taping technique was used (Fig. 7). The position for taping is important — abduction to 908 and full internal rotation. Elastic anchor tapes are wrapped around the distal humerus and mid-thorax. From the posterior and inferior of the humeral anchor lay a rigid tape anteriorly across the superior part of the glenohumeral joint ending at the second anchor. Continue taping with a more anterior accent. The mechanical effect is to reduce the shoulder’s available external rotation in abduction and therefore reduce likelihood of dislocation and rotator cuff stresses. There are obvious limitations to this taping — it is difficult to tape without hindering the throwing or serving action because of the reduced capacity for wind-up in the preparatory phase. This technique is therefore similar to the ankle taping post-inversion injury where the tape acts to limit available range of motion. There would also seem to be a proprioceptive effect of significant proportions. Though progressive external rotation in elevation the strong pull on the skin, excites cutaneous mechanoreceptors which will send greater afferent feedback to
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Fig. 7 Rigney’s strap
the central nervous system to promote an earlier reflex activation of the relevant rotator cuff muscles (McNair et al. 1995; Perlau et al. 1995; Parkhurst & Burnett 1994). It is assumed that the sensori-motor cortex is tricked into believing the capsule and muscles are at a greater length than in reality, which as in the stretch-shortening cycle (Hutton & Atwater 1992) may produce a stronger antagonistic contraction to limit the problem movement, properly orient the humeral head and reduce anterior ‘opening up’.
Conclusion Taping is a widely used modality that has been shown to be of marked benefit in the clinical setting. Shoulder taping can be more difficult compared to other body regions due to its complex stabilizing mechanisms and the necessity for dynamic stability produced from contractile structures. Research into its efficacy and to clearly define the mechanisms behind shoulder taping seems to be required. However it should be considered that taping is a useful adjunct to physiotherapeutic treatment due to weight of success in clinical experience. Taping and then re-training movement has the added
benefit of making the patient aware of the big picture, that is to alter the causative factors of shoulder injury and reduce the likelihood of reinjury. This effect and the relief of symptoms taping can produce make it an important part of shoulder rehabilitation.
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