EFFECT OF MCCONNELL TAPING ON PAIN, ROM & GRIP STRENGTH IN PATIENTS WITH TRIANGULAR FIBROCARTILAGE COMPLEX INJURY

Dr. Shahid Mohd. Dar* MPT (Orthopaedic & Sports), Dr. R. Arunmozhi** MPT (Sports & Rehabilitation), Babloo Sharma*** MPT (Sports)

ABSTRACT STUDY OBJECTIVES: To find out the efficacy of McConnell Taping on Pain, Range of Motion and Grip strength in subjects with Triangular Fibrocartilage Complex (TFCC) injury. DESIGN: An Experimental Study. SETTING: All the Subjects were selected from various sports center from Dehradun and SAI Guwahati. Methods: A total of 28 subjects were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were divided into two Groups (A= Taping & B= Conventional Therapy). OUTCOME MEASURE: Grip Strength, Range of Motion for Wrist and Forearm & Numerical Pain Rating Scale. RESULTS: The result of the study shows that both McConnell Taping and Conventional Therapy are effective in improving the Range of Motion, Grip Strength and reducing the Pain level. Both groups showed significant improvement when comparison was made within the group. However, there is significant reduction in pain level between the groups for Group A (p=0.000). CONCLUSION: The present study demonstrates that both McConnell Taping and Conventional Treatment are effective in improving the Grip Strength, Range of Motion and reducing the Pain level in subjects with TFCC injury. However, it can be concluded that McConnell Taping is the better form of treatment in improving the Grip Strength, Range of Motion and reducing the Pain level in subjects with TFCC injury.

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KEY WORDS: TFCC, Taping, Grip Strength, Range of Motion, Numerical Pain Rating Scale, Conventional Therapy.

INTRODUCTION The triangular fibrocartilage complex (TFCC) is a special structure at the ulno-carpal articulation.8 It is composed of semicircular biconcave

The problem that arises from soft tissue injury of this important structure is distal radio ulnar joint (DRUJ) instability. The DRUJ is a diarthroidal trochoid articulation, which is an incongruent articulation; only around 20% of its stability is produced by osseous articular contact. Soft-tissue structures of the TFCC play a critical role in intrinsic joint stability.7 Wrist injuries are often complex and their management will vary greatly; as such it is vital that the correct diagnosis is made. If we look specifically at the athletic population TFCC tears are more frequently seen in gymnastics, hockey,

fibrocartilage or articular disc called the TFC, the palmar and dorsal distal radioulnar ligaments, a meniscus homolog, ulnolunate and ulnotriquetral ligaments and the extensor carpi ulnaris tendon (ECU) subsheath.7,17 Functionally,
8

the

TFCC

extends the radio-carpal articulation, permitting pronation and supination. The TFCC is a

cartilaginous and ligamentous structure, important in the stabilization of the distal radial ulnar joint and in the absorption of load between the distal ulna and the volar carpus.7,17 The articular disc of the TFCC separates the ulna and the proximal carpal row, and carries about 20% of the axial load from wrist to forearm.17 Injuries to the TFCC occur with repetitive ulnar loading (e.g., bench press, racquet sports) or acute traumatic axial load with rotational stress (e.g., FOOSH).
17

racquet/batting sports, boxing, and pole vaulting. This is due to the repetitive high forces on the wrist that will often be in extension or ulnar deviation, or both (Parmelee-Peters & Eathorne, 2005).30 The most common mechanism of injury to the TFCC occurs with axial loading, ulnar deviation, and forced extremes of forearm rotation. Injury may also be associated with localized swelling, crepitus, grip weakness and sense of instability.7 The initial treatment for TFCC injury may include splinting, rest, anti-inflammatory

Most injuries to the TFCC have a

component of hyperextension of the wrist and rotational load. Injury to the TFCC is the most common cause of ulnar-sided wrist pain. Ulnarsided wrist pain made worse with ulnar deviation, wrist extension, or heavy use is the common complaint of an athlete who has a TFCC injury. TFCC injuries are more commonly seen in such sports as gymnastics, hockey, racquet sports, boxing, and pole vaulting.
17 7

medications, cryotherapy, electrotherapy modalities and physiotherapy techniques like manual and exercise therapies.23 Biomechanical adjustments may be required to comprehensively manage the injury and reduce the incidence of recurrence.23 These include on court stroke analysis and if necessary, modifications to the athletes stroke mechanics, or their equipment, such as adjustments of the grip size,
2

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the over grip, the strings and string tension, the weight balance of the racket, or the grip placement (continental, eastern, semi-western, and western).23 Physiotherapists and Athletic Trainers often use athletic tape methods to support and prevent sport related injuries. Athletic tape is effective due to its reported ability to provide stability, maintain proper structural alignment, facilitate proprioception and also its neuromuscular effects. The aim of taping is to reduce healing time, to protect and support the wrist, and prevent future injury.23 In response to the limited effective taping options for wrist injuries involving the TFCC and/or ECU tendon, Kathleen Stroia and Kathy Martin applied the McConnell principles of unloading to the wrist.23 Stroia and Martin experimented with various tape applications and created a clinically effective tape technique, consisting of 1) an unload, 2) a block, and 3) a re-direction tape for players who sustained wrist injuries involving the TFCC and/or ECU tendon.23 This tape technique is effective for injuries involving both the TFCC and ECU as they are in close proximity to each other, and due to the co-morbid nature of ECU tenosynovitis and TFCC pathologies.23 This tennis-specific wrist taping technique protects and supports the injured

METHODS An experimental study design was conducted on total of 28 subjects who were recruited from various sports center in and around Dehradun and SAI Guwahati based on the inclusion and exclusion criteria. The subjects were divided into two groups after the informed consent was signed. Subjects with prediagnosed cases of TFCC injury were included in the study. Group A (Taping + Conventional Therapy, n=14) and Group B (Conventional Therapy, n=14). Pre intervention measurements of pain, range of motion and grip strength were taken out using Numerical Pain Rating Scale, Universal Goniometer and Hand Dynamometer. Both the groups were received intervention for total of 8 days with a rest period on the 4th day. Subjects were excluded from the participation if they present with any neurological deficit of the reference extremity, ay other reason of wrist and hand pain of the reference extremity, history of fracture or any other musculoskeletal surgery of wrist, pain or movement restriction more than 6 weeks and subjects with h/o TFCC injury less than 48 hours. Grip strength (pound)11,18, Range of Motion (degree)15 for Wrist and Forearm and Numerical Pain Rating Scale13,28 was taken as outcome measure before and after the total session of treatment. All the subjects were assessed for outcome on 1st day (before the intervention), 4th day and the final data was collected on 8th day. Protocol for Group A (Taping): Tennis Specific Unload, Block and Redirection Tape Technique were applied according to the principle of

structures; however it restricts only the desired motions (supination, ulnar deviation, and extension). The technique meets the desired goal of allowing a player to play with more support which improves function, while restricting extreme range of motion. It is designed to consider the anatomy and pathophysiology of the injury and the biomechanics of the two-handed backhand.23

McConnell taping. This tennis-specific wrist taping

3

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technique

protects

and

supports

the

injured

structures; however it restricts only the desired motions (supination, ulnar deviation, and extension).23 The technique meets the desired goal of allowing a player to play with more support which improves function, while restricting extreme range of motion. It is designed to consider the anatomy and patho-physiology of the injury and the biomechanics of the two-handed backhand.23 1 subjects was dropout before the 4th day assessment.
Fig. 1.3: Tape with redirectional technique for supination

Fig. 1.4: Tape with supination end range block Fig. 1.1: Fixomull Stretch with Gutter

Protocol for Group B (Conventional Therapy): Conventional treatment of TFCC was given, which include rest to the part, Ultrasound Therapy and Home Exercise Program.23,2 The parameter for Ultrasound was Frequency: 3 MHz, Intensity: 1.4W/cm2, Time: 6 minutes, Mode: Continuous.6 2 subjects were dropout, 1 before the 4th day and other after the 4th day assessment. DATA ANALYSIS
Fig. 1.2: Tape with directional force

Data was analyzed by using SPSS software (version 16). Paired t-test was applied to compare the data within the groups whereas Independent t-

Scientific Research Journal of India Volume: 2, Issue: 1, Year: 2013

test was applied to compare the data between the groups. The p value was set at (0.05) with 95% confidence interval. RESULTS
Table 1.1: Comparison of Pre and Post Grip Strength score for Group A and B
MEAN PRE POST PRE SD t POST p

GROU PA

64.102

78.308

18.6662 9

24.674

Fig. 1.6: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B
-6.697 .000

GROU PB

52.5

69.306

20.7864 4

24.55889

-7.824

.000

Table 1.3: Comparison of Pre and Post Pain Score for Group A and Group B
MEAN PRE GROUP A GROUP B 5.3077 5.8333 POST 0.6154 1.3333 PRE 0.63043 1.19342 SD t POST 0.50637 0.65134 26.836 12.539 .000 .000 p

Fig. 1.5: Comparison of Pre and Post Grip Strength score for Group A and B Fig. 1.7: Comparison of Pre and Post Pain Score for Group A and Group B

Table 1.2: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B
MEAN PRE GROUP A GROUP B 67.692 POST 71.692 PRE 4.38529 SD t POST 2.35884 p

Table 1.4: Comparison of Grip Strength between Group A and Group B

MEAN SD GROUP A 18.66629 24.674 GROUP B 20.78644 24.55889 t p

-3.399

.005 GROUP A PRE POST 64.102 78.308 GROUP B 52.5 69.306

68.75

71.667

3.76889

3.25669

-2.244

.046

1.464 .913

.157 .371

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Fig. 1.8: Comparison of Grip Strength between Group A and Group B Table 1.5: Comparison for Wrist Extension ROM between Group A and Group B
MEAN GROUP A PRE POS T 67.692 71.692 GROUP B 68.75 71.667 GROUP A 4.38529 2.35884 SD GROUP B 3.76889 3.25669 t p

Fig. 1.10: Comparison of NPRS between Group A and Group B

Results of the study showed that there is significant reduction in pain and improvement in grip strength

-.648 .023

.523 .982

and range of motion in both the groups after the intervention. However, Group A (Taping) showed more reduction in pain score when compared to Group B and this was found to be statistically significant p=.005 post intervention. Other variables also showed improvement but it was statistically non-significant. DISCUSSION Hand and wrist trauma accounts for 3-9% of all athletic injuries.12 An injury to the TFCC is very

Fig. 1.9: Comparison for Wrist Extension ROM between Group A and Group B

important as it is the most common cause of ulnar side wrist pain and limited wrist function in work or in sports.29 According to Kathleen Stroia et al., when

Table 1.6: Comparison of NPRS between Group A and Group B

MEAN GROUP A PRE 5.3077 GROUP B 5.8333 GROUP A 0.63043 SD GROUP B 1.19342 t p

the wrist is loaded into supination, ulnar deviation and extension, the TFCC, ECU tendon and sheath are loaded with significant stress. This is the typical position of the non-dominant wrist during the two-

-1.393

.177

handed backhand stroke, it also occurs during a forehand stroke.23

POST

0.6154

1.3333

0.50637

0.65134

-3.091

.005

Scientific Research Journal of India Volume: 2, Issue: 1, Year: 2013

The present study was done to find out the efficacy of Taping in terms of grip strength, range of motion and pain score in subjects with Triangular Fibrocartilage Complex Injury. The most probable reason for the reduction in pain after the application of tape could be due to reduction of strain on the injured structure in both the acute phase and also during the ongoing repair and rehabilitation phase. Supporting an injured joint with tape is widely believed to be helpful in reducing pain, preventing exacerbation of the injury and promoting tissue healing. This technique met the desired goal of allowing the players to play with full support and improved function as said by the Kathleen Stroia in his study.
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neurophysiological model the tape may exert an effect on grip strength by primarily altering pain perception, either locally at the wrist by inhibiting nociceptors, facilitating large afferent fiber input into the spinal cord and/or possibly by stimulating endogenous processes of pain inhibition thereby increasing the grip strength and reducing the pain level as according to the Alireza Shamsoddini et al in his study.22 Limitations of the study are small sample size and different grades of the TFCC injury was not taken into consideration. So the further

recommendation for future studies need to be done with broader dimension, on the workers who are mainly involved with hand and wrist work, and its effectiveness can also be checked with other taping

Another possible effect of tape could be due to a direct mechanical effect on the TFCC, presumably by somehow improving the internal mechanics or by protecting the damage tissues from excess forces and as a result, decrease in pain and improving grip strength.26 Along with it, this method of taping technique also disperses the stress generated by the muscle during contraction which results in decreasing the pain level by reducing the painful inhibition. The possible mechanism behind the reduction in pain is due to its neurophysiologic effects on the nervous system, particularly the nociceptive system. In this

technique. CONCLUSION The present study demonstrates that both the technique is effective in improving the grip strength, range of motion and reducing the pain in subjects with TFCC injury. However, Taping technique used in this study proves to be effective in reducing the pain in subjects with TFCC injury. So, it can be concluded that Taping is the better choice of treatment in subjects with TFCC injury along with other therapeutic modalities.

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CORRESPONDENCE

* Asst. Prof. Department of Physiotherapy, Dolphin (PG) Institute, Dehradun (UK) ** Associate Prof. Department of Physiotherapy, SBS PGI Biomedical and Research, Dehradun (UK) *** Student Researcher, Dolphin (PG) Institute, Dehradun (UK). Email: babloo83_sharma@yahoo.com