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The effects of patellar taping on pain

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subjects with patellofemoral pain
syndrome

Article in Clinical Rehabilitation · December 2002

DOI: 10.1191/0269215502cr563oa · Source: PubMed

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 Clinical Rehabilitation
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The effects of patellar taping on pain and neuromuscular performance in subjects with
patellofemoral pain syndrome
Gabriel YF Ng and Jenny MF Cheng
Clin Rehabil 2002 16: 821
DOI: 10.1191/0269215502cr563oa

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Clinical Rehabilitation 2002; 1 6: 821–827

The effects of patellar taping on pain and

neuromuscular performance in subjects with
patellofemoral pain syndrome
Gabriel YF Ng and Jenny MF Cheng Department of Rehabilitation Sciences, The Hong Kong Polytechnic University,
Hong Kong

Received 23rd March 2002; returned for revisions 9th May 2002; revised manuscript accepted 20th July 2002.

Objective: To examine the immediate effects of patellar taping on pain and

relative activity of vastus medialis obliquus to vastus lateralis in subjects with
patellofemoral pain and patellofemoral joint malalignment.
Design: Pre- and post-treatment design, with order of testing determined
randomly.
Setting: Outpatient physiotherapy department.
Subjects: Fifteen subjects with patellofemoral joint pain and malalignment.
Interventions: With and without patellar taping with a standard force of
application.
Main outcome measures: Pain and surface EMG activity ratio of vastus
medialis obliquus to vastus lateralis during single-legged semi-squat with 20%
of extra body weight loading.
Results: There was a signiŽcant decrease in anterior knee pain (p < 0.001)
and vastus medialis obliquus to vastus lateralis activity ratio (p = 0.05) during
single-legged standing after patellar taping.
Conclusions: Patellar taping can reduce pain in people with patellofemoral
pain syndrome and patellofemoral malalignment but it decreases the relative
activity of vastus medialis obliquus to vastus lateralis. Such a decrease in
relative activity of vastus medialis obliquus after taping implies that it may not
be suitable to combine patellar taping with vastus medialis obliquus facilitative
exercise training.

Introduction diffuse pain in the knee, usually aggravated by

‘Patellofemoral pain syndrome’ (PFPS) is a term
commonly used to describe anterior knee pain.1
The general pattern of PFPS is insidious onset of
A ddress for correspondence: G abriel Ng, D epartmen t of
R ehabilitation Sciences, The Hong Kong Polytechnic Uni-
versity, H ung H om, H ong Kong. e-mail: rsgng@polyu.edu.hk
© Arnold 2002
walking stairs, deep squatting, kneeling, pro-
longed sitting, and standing up from sitting.2
There are many predisposing factors for
patellofemoral pain. Witvrouw et al.3 identiŽ ed
four that have predictive values for the develop-
ment of patellofemoral pain, which included
tightness of the gastrocnemius and quadriceps,
delayed re ex of vastus medialis obliquus, hyper-
10.1191/0269215502cr563oa
822 G Y F N g and JM F Cheng
mobility of patella, and decreased power of the
quadriceps muscle.
H ypermobility of patella and weakness of vas-
tus medialis obliquus are regarded as causative
factors for abnormal patellar movement.4,5 In
order to maintain normal patellofemoral joint
alignment, physiotherapists often emphasize vas-
tus medialis obliquus training and facilitation for
rehabilitation of people with patellofemoral joint
pain.6–9
R esearchers have reported on ways to facili-
tate vastus medialis obliquus activity, such as
using different hip, knee and ankle exercise posi-
tions,10–14 the types of exercise,15,16 and open ver-
sus closed kinetic chain muscle action.17,18 In a
paper by McConnell,4 a >90% success rate was
reported in clinical outcomes of patellar taping in
conjunction with functional weight-bearing exer-
cise for people with patellofemoral pain syn-
drome. It was concluded that appropriate taping
procedures could reduce pain, correct abnormal
patellofemoral joint alignment and facilitate
VMO , thus allowing normal pain-free move-
ments of the knee.
H ilyard 9 stated that patellar taping should be
used as a temporary measure for correction of
abnormal patellar movements. D oucette and
G oble 6 reported that patellar taping and passive
stretching of the lateral structures reduced
patellofemoral joint malalignment. O thers have
reported that the taping procedure reduced pain
in subjects with patellofemoral pain syndrome 12,19
but did not facilitate vastus medialis obliquus
activation 8,12 as reported by McConnell.4
Previous studies on patellar taping had not
standardized the taping force 8,12,19 and some had
used a single tape 12 which might not correct mul-
tiple components of patellofemoral joint
malalignment. In light of that, there is a need to
examine the effectiveness of taping for people
who have patellofemoral joint malalignment with
a standard taping force and procedures that are
speciŽ c for correcting all the malalignment com-
ponents.
This study aimed to investigate the immediate
effects of patellar taping with a standard force of
application on pain and VMO to vastus lateralis
activity ratio during semi-squat in people with
PFPS and patellofemoral joint malalignments.
Method
Subjects diagnosed with PFPS by their attending
physicians and patellofemoral joint malalign-
ment, referred for physiotherapy were invited to
participate in this study. The inclusion criteria
were males and females aged between 15 and 45
years who had no resting pain but reproducible
patellofemoral pain during the patellar grinding
test and walking stairs but no experience with
patellar taping. Subjects were excluded if they
had foot pronation on standing, true leg length
difference of more than 2 cm, previous knee joint
surgeries, loose bodies or signs of acute in am-
mation in the knee.
Fifteen subjects (seven females) were recruited
for this study. Their mean age was 32 ± 6.6 years,
mean height was 1.7 ± 0.11 m, mean body weight
was 63.6 ± 12.82 kg, and mean body mass index
was 22.6 ± 2.32 kg/m 2. The ethics review commit-
tee of the H ong Kong Polytechnic U niversity
reviewed and approved the procedures. A ll sub-
jects gave their written consent prior to testing.
E ach subject performed 5 minutes of station-
ary cycling exercise with light resistance for
warm-up. The tests involved measurement of
knee pain and E MG activity of vastus medialis
obliquus and vastus lateralis during single-legged
static semi-squat exercise, before and after patel-
lar taping. The order of testing (with or without
taping) was randomized by the subject choosing
one of two identical cards indicating which con-
dition was to be tested Ž rst.
The testing procedures
Two pairs of disc type A g/A gCl surface elec-
trodes with diameter of 1 cm (Nihon Kohden,
Japan) were used to record E MG of vastus medi-
alis obliquus and vastus lateralis. Skin prepara-
tion involved shaving, light abrasion with Ž ne
sandpaper and cleansing with methylated spirit.20
E lectrodes with conduction gel applied were ap-
plied placed over the mid-point of both muscles
along their muscle Ž bre directions and a ground
electrode was applied over the tibial tuberosity
of the same side. The distance between each elec-
trode pair on the same muscle was 2.5 cm. These
electrodes were not removed after application
until completion of all the tests so as to increase
the reliability of E MG recordings.21

The electrodes were connected to an input box
(JB -210J, Nihon Kohden, Japan) and an ampli-
Ž er (A VB-21, Nihon Kohden, Japan) that per-
formed linear enveloping between 15 and 1000
H z and differential ampliŽ cation of 1000´. The
common mode rejection ratio of the ampliŽ er
was 80 dB. The ampliŽ ed signals were full-wave
rectiŽ ed and input to an A D converter (SP 0147
D ata translation, U K), which sampled at 2500 H z
and output the digitized signals to a personal
computer with G lobal Lab software for analysis.
D uring testing, subjects put on a weight belt
equivalent to 20% of their body weight on their
waist to simulate the effect of acceleration in
ascending stairs. They were to stand single-legged
on the side with PFPS pain and assume a 30º
knee  exion position, measured by a goniometer,
for 5 seconds. Subjects placed their hands lightly
on a chair in front for balance. A t the end of the
5 seconds, they were to indicate on a 10-cm visual
analogue scale (VA S) the level of pain in their
knee. The VA S was a sliding scale with the words
‘no pain’ written on one end and ‘maximum pain’
on the other so as to guide the subject of the
direction on the scale when indicating their lev-
els of pain.
D uring the 5 seconds, E MG signals were
recorded. The raw signals were full-wave recti-
Ž ed and the signals between the 2nd and 3rd sec-
onds were processed with a root mean square
processing technique for both muscles. The E MG
activity ratio of vastus medialis obliquus to vas-
tus lateralis was calculated and then used for
analysis. A nother recording was taken 2 minutes
later to establish the between-trial reliability of
the E MG measurement.
Patella assessment and taping procedures
Before taping the patella, the patellofemoral
joint alignment of each subject was assessed using
a standard procedure.4 D espite the reliability of
this assessment procedure for patellofemoral
joint alignment being not very high,22,23 this pro-
cedure is popular among clinicians and it does
not involve X-ray exposure such as in the Mer-
chant angle measurement.24 Therefore this
assessment procedure was used in our study to
resemble the clinical practice. Three components
of alignment were assessed, namely, medial/lat-
eral glide, medial/lateral tilt and rotation.
Patellar taping for patellofem oral pain 823
Medial/lateral glide was assessed by comparing
the distance between the mid-point of patella to
the medial and lateral femoral epicondyles. Nor-
mally, the distance should be similar on both
sides. If the patella was displaced laterally, the
distance on the lateral side would become
smaller. Medial/lateral tilt was assessed by com-
paring the height of the two borders of patella on
the transverse plane. If the lateral border was
more protruded, it indicated a lateral tilt. The
Ž nal component was rotation, which was assessed
by examining the orientation of the longitudinal
axis of patella with that of femur. If the distal end
of the patellar axis pointed laterally to the
femoral axis, it indicated lateral rotation of
patella.
A fter the assessments, three tapes were
applied to correct each component of malalign-
ment.4 For example, to correct for lateral tilt, a
5-cm-wide adhesive tape (Strappal, Smith &
Nephew) was applied Ž rmly over the mid-line of
patella and the other end of the tape was con-
nected to a strain gauge transducer (R onso E lec-
tronic, H ong Kong) with a digital force display
unit. The examiner pulled on the strain gauge
transducer until a force of 1.5–2 kg was displayed
and at the same time she secured the tape to the
medial aspect of the knee to depress the medial
border of patella (Figure 1). If a subject had only
one component of malalignment, after correcting
for that component, the other two tapes would
still be applied but without tension. This was to
standardize the cutaneous stimulation by the
tapes on all subjects.
A ll the tests were completed within the same
session and adequate rest was given between
each testing procedure to avoid muscle fatigue.
In order to control inter-rater variability, only
one examiner, who was a physiotherapist with
good experience in treating patellofemoral pain
syndrome, performed the assessments, taping and
conducted the tests.
D ata analyses
Within-subject reliability of E MG measure-
ment was assessed with the intraclass correlation
coefŽ cient (ICC) model(1,1) and 95% conŽ dence
interval according to Bland and A ltman.25 The
level of pain and E MG activity ratio of vastus
medialis obliquus to vastus lateralis with and
824 G Y F N g and JM F Cheng
Figure 1 Taping to control medial/lateral tilt of patella.
without taping were analysed using paired t-tests
with a set at 0.05.
Results
A ssessment of patellofemoral joint alignment
revealed that 10 subjects had patellar rotation,
nine had lateral tilt and eight had lateral glide.
O ut of the 15 subjects tested, Ž ve had one com-
ponent, seven had two components and three had
all three components of malalignment.
The ICC results for E MG measurements
ranged from 0.70 to 0.92 with and without taping.
These indicate that the reliability of E MG mea-
surements for these subjects is moderate to
high.26 The 95% conŽ dence intervals for the vas-
tus medialis obliquus with and without taping
were 4.77 to –4.77 and 15.32 to –8.81 µV respec-
tively, and that for vastus lateralis were 1.95 to
–2.64 and 5.93 to –3.53 µV respectively. R esults
Table 1 Means (SD) and results of paired t-tests for the
visual analogue scale (VAS) and EMG activity ratio of
vastus medialis obliquus versus vastus lateralis with and
without patellar taping
Parameters Without taping With taping p-value
VAS 2.3 (2.02) 1.2 (1.66) <0.001
EMG ratio 1.8 (0.93) 1.6 (0.82) <0.05
of the paired t-tests revealed that subjects had a
statistically signiŽ cant decrease in pain (p <
0.001) and the E MG ratio of vastus medialis
obliquus to vastus lateralis (p = 0.05) after the
taping procedure (Table 1).
Discussion
The unique feature of this study is that we stan-
dardized the taping force. The rationale is that if
taping had a signiŽ cant mechanical effect,4–6 it
would depend on the tension of the tapes. The
1.5–2 kg of taping force was determined by mea-
suring the force developed by the examiner dur-
ing her normal practice of patellar taping.
Clinical messages
• Patellar taping is an effective means of
modulating patellofemoral joint pain but it
cannot facilitate the relative activity of
vastus medialis obliquus compared with vas-
tus lateralis.
• Muscle training for vastus medialis obliquus
coupled with patellar taping should be done
with caution.

Whether this force is optimum for the patellar
taping procedure is not known. Further study is
warranted to determine the relationship of ten-
sion in the tapes with the clinical outcome.
Patellofemoral pain and patellar taping
Pain has a potent inhibitory effect on quadri-
ceps muscle contraction, particularly if it is
accompanied by knee joint effusion.27 It is impor-
tant to avoid aggravating the pain during exer-
cises in people with patellofemoral pain. The
mechanism of pain modulation with the taping
procedure is unclear. McConnell4 explained this
from a mechanical perspective that taping cor-
rected the abnormal patellar position, thus re-
orientated the bone inside the femoral trochlea
groove. This would result in better surface con-
tact and load distribution of the patellofemoral
joint. A radiographic study reported that the
patella was displaced medially by 9° with the
Merchant congruence angle measurement after
taping,15 which suggests that taping has a
mechanical effect on patella.
H owever, Bockrath et al.28 did not Ž nd any sig-
niŽ cant mechanical effects of patellar taping on
12 subjects with patellofemoral pain syndrome,
but they found signiŽ cant reduction in pain dur-
ing descending stairs from a mean VA S of 4.3 to
2.4. They explained the pain modulation from the
neurological perspective that cutaneous stimula-
tion from the adhesive tapes inhibited the pain
sense via stimulation of the large Ž bres as
reported in the pain gate theory.29 More recently,
H errington and Payton 8 reported that pain was
most intense during non-weight-bearing isomet-
ric quadriceps contraction at full knee extension
and 120°  exion and taping had the most pro-
found pain-modulation effect between 0° to 30°.
They hypothesized that the pain-modulation
effect of taping could be due to mechanical repo-
sitioning of patella, cutaneous stimulation of the
nervous systems and placebo effect.
When comparing our results to those of Bock-
rath et al.28 in terms of the amount of pain reduc-
tion, both studies have found about 50%
reduction in pain with taping. O ur subjects had a
mean VA S of 2.3 before taping which went down
to 1.2 after taping (Table 1). This is clinically sig-
niŽ cant because at low level of pain (<2.5 in
VA S), a reduction of 48% in the VA S score is
Patellar taping for patellofem oral pain 825
clinically meaningful and signiŽ cant in both nor-
mal subjects and subjects with postsurgical
wound pain.30
EMG activity with taping
O ur Ž nding of a decrease in vastus medialis
obliquus to vastus lateralis activity ratio after tap-
ing is interesting. O ur raw data revealed that
most subjects had decreased in vastus medialis
obliquus activity after taping, rendering a
decrease in the E MG activity ratio. This contrasts
to the report of McConnell4 that patellar taping
facilitated vastus medialis obliquus activity. In
the review by Callaghan,31 it is clearly pointed out
that there is no agreement on the muscle facili-
tative action of taping, and some previous
studies on patellar taping had not demonstrated
a facilitative effect of taping on vastus medialis
obliquus activity.8,12
A study by Mungovan et al.32 on subjects with-
out patellofemoral pain has shown that after
medial patella taping, there was a decrease in the
activity ratio of vastus medialis obliquus to vas-
tus lateralis. This is similar to our present Ž nding
which does not favour the notion that patellar
taping facilitates vastus medialis obliquus activ-
ity. A possible reason might be the mechanical
effect of the tapes, which had corrected the patel-
lar malalignment and stabilized the patella.15
Since vastus medialis obliquus is primarily a
patellar stabilizer 33 during knee extension, if
malalignment of patella is already corrected by
the tapes, vastus medialis obliquus activity might
not need to be increased during knee extension.
H owever, this is a hypothesis that needs to be
tested with further studies.
Limitations of this study
The parameters we measured are of impair-
ment in nature. R eduction in pain does not nec-
essarily infer better function. Further studies
should measure functional outcome of the sub-
jects such as performance in sport. The fact that
we only tested 15 subjects aged between 20 and
40 years has limited the generalizability of our
Ž ndings to people outside this age range. The
precision of assessing the patellofemoral joint
alignment may not be very high. Further studies
need to be done to establish the reliability of this
measurement. E ven though we controlled for the
826 G Y F N g and JM F Cheng
number of tapes and the force level, we did not
include a placebo testing condition in which all
the tapes had no tension. Therefore, we cannot
conclude whether the pain modulation is due to
a placebo effect. These factors should be consid-
ered in future studies examining the efŽ cacy of
patellar taping.
Conclusion
The patellar taping procedure reduces anterior
knee pain during semi-squat for people with
patellofemoral pain and patellofemoral joint
malalignment but it cannot facilitate vastus medi-
alis obliquus activity. Patellar taping does not
increase the relative activity of vastus medialis
obliquus to vastus lateralis and clinicians should
be mindful of this when prescribing vastus medi-
alis obliquus strengthening exercise in conjunc-
tion with the patellar taping procedure.
References
1 A rroll B, E llis Pegler E , E dwards A , Sutcliffe G .
Patellofe moral pain syndrome – a critical review of
the clinical trials on non-ope rative therapy. A m J
Sports M ed 1997; 25: 207–12.
2 H ost JV, Craig R , Lehman R C. Patellofem oral
dysfunction in tennis players – a dynam ic problem .
Clin Sports M ed 1995; 14: 177–203.
3 Witvrouw E , Lysens R , Bellem ans J, Cambier D ,
Vander straeten G . Intrinsic risk factors for the
developme nt of anterior knee pain in an athletic
populatio n. A two-year prospective study. A m J
Sports M ed 2000; 28: 480–89.
4 McConne ll J. The managem ent of chondrom alacia
patellae: A long term solution. A ust J Physiother
1986; 32: 215–23.
5 McConne ll J. Managem ent of patellofem oral
problem s. M anual T her 1996; 1: 60–66.
6 D oucette SA, G oble M. The effect of exercise on
patellar tracking in lateral patellar com pression
syndrom e. A m J Sports M ed 1992; 20: 434–40.
7 G errard B. The patello-fem oral pain syndrom e: a
clinical trial of the McConnell programm e. A ust J
Physiother 1989; 35: 71–79.
8 H errington L, Payton CJ. E ffect of corrective taping
of the patella on patients with patellofem oral pain.
Physiotherapy 1997; 83: 566–72.
9 H ilyard A . R ecent developm ents in the managem ent
of patellofem oral pain: the McConne ll program me.
Physiotherapy 1990; 76: 559–65.
10 Wild JJ Jr, Franklin TD , Woods G W. Patellar pain
and quadricep s rehabilit ation. A n E MG study. A m J
Sports M ed 1982; 10: 12–15.
11 H anten WP, Schulthies SS. E xercise effect on
electrom yographic activity of the vastus medialis
oblique and vastus lateralis muscles. Phys T her 1990;
70: 561–65.
12 Cerny K. Vastus medialis oblique/vastus lateralis
muscle activity ratios for selected exercise in persons
with and without patellofem oral pain syndrom e.
Phys T her 1995; 75: 672–83.
13 Ng G YF, Man VY. E MG analysis of vastus medialis
obliquus and vastus lateralis during static knee
extension with different hip and ankle positions.
N Z J Physiother 1996; 24: 7–10.
14 Lam PLL, Ng G YF. A ctivation of the quadricep s
muscle during sem isquatting with different hip and
knee positions in patients with anterior knee pain.
A m J Phys M ed R ehabil 2001; 80: 804–808.
15 Larsen B, A ndreasen E , U rfer A , Mickelson MR ,
Newhouse KE . Patellar taping: a radiograp hic
exam ination of the medial glide technique . A m J
Sports M ed 1995; 23: 465–71.
16 Mirzabeigi E , Jordan C, G ronley JK. Isolation of the
vastus medialis oblique muscle during exercise. A m
J Sports M ed 1999; 27: 50–53.
17 Steinkam p LA , D illingham MF, Markel MD .
Biomechanical considerat ions in patellofem oral joint
rehabilita tion. A m J Sports M ed 1993; 21: 438–44.
18 D oucette SA, Child D D . The effect of open and
closed chain exercise and knee joint position on
patellar tracking in lateral patellar com pression
syndrom e. J O rthop Sports Phys T her 1996; 23:
104–10.
19 Cushnagha m J, McCarthy C, D ieppe P. Taping the
patella medially: a new treatm ent for osteoart hritis
of the knee joint? B M J 1994; 308: 753–55.
20 G ilmore KL, Meyers JE . U sing surface E MG in
physiother apy research. A ust J Physiother 1983; 29:
3–9.
21 Ng G YF. R eproducib ility of respirat ory muscle
surface E MG is poor for between -day recordings.
Physiother Can 1993; 45: 111–15.
22 Fitzgerald G K, McClure PW. R eliability of
measure ments obtained with four tests for
patellofem oral alignment . Phys T her 1995; 75:
84–92.
23 Watson CJ, Propps M, G alt W, R edding A , D obbs
D . R eliability of McConnell’s classiŽ cation of
patellar orientat ion in sym ptomat ic and
asym ptomat ic subjects. J O rthop Sports Phys T her
1999; 29: 378–85.
24 Merchan t A C, Mercer R L, Jacobsen R H , Cool CR .
R oentgen ographic analysis of patellofem oral
congruence . J B one Joint Surg 1974; 56A : 1391–96.
25 Bland JM, A ltman D G . Statistical methods for
assessing agreeme nt between two methods of clinical
measure ment. T he L ancet 1986; February 8: 307–10.

26 Portne y LC, Watkins MP. Foundations of clinical
research. A pplications and practice, second edition.
New York: A ppleton and Lange, 2000.
27 Stokes M, Young A . The contribut ion of re ex
inhibition to arthro genous muscle weakness. Clin Sci
1984; 67: 7–14.
28 Bockrat h K, Wooden C, Worrell T, Ingersoll CD ,
Farr J. E ffects of patella taping on patella position
and perceived pain. M ed Sci Sports E xer 1993; 25:
989–92.
29 Melzack R , Wall PD . Pain mechanisms: a new
theory. Science 1965; 150: 971.
30 Campbell WI, Patterson CC. Q uantifying meaningful
Patellar taping for patellofem oral pain 827
changes in pain. A naesthesia 1998; 53: 121–25.
31 Callaghan MJ. Patellar taping, the theory versus
the evidence: a review. Phys T her R ev 1997; 2:
181–83.
32 Mungovan SF, H enley E C, R enton A L, Turner G R .
The effect of patellofem oral taping on E MG activity
and torques produced about the knee joint during
standing up from a seated position. Proceedings of
W orld Confederation of Physical T herapy, L ondon ,
1991: 1304–306.
33 Lieb FJ, Perry J. Q uadriceps function – an
anatom ical and mechanical study using amputated
limbs. J B one Joint Surg 1968; 50A : 1535–48.