Manual Therapy (2000) 5(3), 142150 # 2000 Harcourt Publishers Ltd doi:10.1054/math.2000.0354, available online at http://www.idealibrary.

com on

Review article

Patellar taping: is clinical success supported by scientic evidence?

K. Crossley*, S. M. Cowan*, K. L. Bennell*, J. McConnell{
*

Centre for Sports Medicine Research and Education, School of Physiotherapy, The University of Melbourne, Australia; {McConnell and Clements Physiotherapy, Sydney, Australia

SUMMARY. Patellofemoral pain syndrome (PFPS) is a common condition presenting to physiotherapy and sports medicine practices. Despite its prevalence, the aetiology, pathogenesis, and recommended treatment remain unclear. One component of treatment for PFPS that has been subjected to scrutiny is patellar taping. This taping was designed to realign the patella within the femoral trochlea, thus reducing pain from PFPS and improving both quadriceps and patellofemoral joint function. Clinical and research ndings conrm that the pain associated with PFPS is signicantly reduced with patellar taping. Therefore, research has aimed at determining the mechanisms of this pain relief. The means by which patellar tape can relieve pain may provide insight into the aetiology and risk factors for PFPS, thus allowing more appropriately designed treatment regimes and preventative strategies. There is evidence to suggest that patellar tape improves patella alignment (measured radiographically) and quadriceps function (torque production and extensor moments). Evidence that patellar tape enhances the activation of individual vastii (magnitude or timing) is limited in quality and quantity, which probably reects the diculties inherent in measuring this complex question. There is preliminary evidence for improved knee control during gait in association with patellar tape. This paper critically reviews the studies that have examined the eects of patellar taping and makes informed recommendations for further research and clinical practice. # 2000 Harcourt Publishers Ltd

INTRODUCTION Patellofemoral pain syndrome (PFPS) is a common condition sustained by the general and sporting populations (Levine 1979; Devereaux & Lachmann 1984; Baquie & Brukner 1997). Clinically, PFPS manifests as anterior knee pain or peripatellar pain aggravated by activities such as prolonged sitting, squatting and stair climbing. Despite its prevalence, the aetiology, pathogenesis and recommended treatment remain unclear. It has been proposed that patients with PFPS have lateral displacement of the patella within the femoral trochlea (Merchant 1988). This lateral malalignment of the patella may result from a number of factors
Kay Crossley BAppSci (Physio), GradDip (Research) PhD candidate, School of Physiotherapy, The University of Melbourne, Victoria, 3010, Australia, Sallie M. Cowan, BAppSci (Physio); Grad Dip (ManipPhyt) PhD candidate, Kim L. Bennell, BAppSci (Physio); PhD, Senior Lecturer, Jenny McConnell, BAppSci (Physio); Grad Dip (ManipPhyt); MBiomedEng, Principal Physiotherapist. Correspondence to KC. Tel.: +61 39344 4171; Fax: +61 39344 4188; E-mail: k.crossley@pgrad.unimelb.edu.au 142

including impaired activation or timing of the vastus medialis obliquus (VMO) (Voight & Weider 1991), tight lateral soft tissue structures (Ahmed et al. 1987; Merchant 1988) or bony malalignment, and may lead to areas of increased stress on the patellofemoral joint (Outerbridge 1961). Conservative treatment for PFPS often consists of a variety of components designed to improve patellar alignment including quadriceps retraining (especially VMO), stretching lower limb muscles, patella mobilizing, correcting foot biomechanics with orthoses and patellar taping or bracing (McConnell 1986; Kujala 1991; Eng & Pierrynowski 1992; O'Neill et al. 1992; McConnell 1996; Thomee 1997; Harrison et al. 1999). To date, these treatment techniques have rarely been scientically evaluated in combination, and even less often evaluated independently. Patellar taping was originally developed by Jenny McConnell, an Australian physiotherapist, as a novel component of the treatment for PFPS (McConnell 1986). Since this landmark paper, patellar taping has attained widespread acceptance in the treatment of this condition. However, despite clinical success, the mechanisms that explain the eect of patellar taping

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are unclear. Does patellar taping have a mechanical or neuromuscular inuence on the patellofemoral joint or are taping eects attributed only to placebo? The purpose of this paper is to review the studies that have examined patellar taping and to make informed recommendations for further research and clinical practice. DESCRIPTION OF PATELLAR TAPING The purported aim of patellar taping is to create a mechanical medial realignment of the patella, thus centralizing it within the trochlea groove and improving patellar tracking (McConnell 1986). This realignment of the patella within the trochlea has been proposed to aect the function and activation of the vastii. Theoretically, patellar taping may either enhance the magnitude of activation and/or timing of the vastus medialis obliquus (VMO) relative to the vastus lateralis (VL) muscles or decrease the activation and/or timing of the VL relative to the VMO. In addition to the eects on the knee musculature, it has been proposed that patellar tape improves knee kinematics during gait. McConnell has devised a classication to describe abnormal patellar alignment. The four main malalignments include excessive lateral glide; excessive lateral tilt; excessive posterior tilt of the inferior pole and excessive rotation (McConnell 1986; McConnell 1996). Patellar taping is designed to correct these malalignments and has four basic components, medial glide, medial tilt, anterior tilt and rotation. Further taping may be required to unload painful structures (e.g. a painful fat pad) (McConnell 1996) or inhibit the activation of VL (Grelsamer & McConnell 1998). The choice of taping techniques is based partly on the assessment of patellar alignment, and partly on the attainment of pain reduction. Appropriate taping combinations should decrease the patient's pain by at least 50% during provocative activities and this may require a number of taping components. Patellar tape is employed as part of the treatment for PFPS if it decreases knee pain. This pain relief is desirable, since knee pain and eusion can inhibit the quadriceps (Spencer et al. 1984; Stokes & Young 1984) and lead to increased loading of the patellofemoral joint. Therefore, in order to provide eective re-training of the quadriceps function, exercises should be performed painfree. The pain reduction experienced with tape enables the patient to perform their exercises and activities of daily living without pain. Ideally, tape is worn all day every day, especially in the early stages of treatment, and is continued until the patient is painfree. Patients are advised to remove the tape and reapply it if the pain from PFPS re-occurs.
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METHODOLOGICAL ISSUES When reviewing the literature investigating patellar taping it is clear that there are a number of methodological issues common to clinical research that aect our ability to interpret the ndings. These issues include treatment selection, choice of outcome measures and the presentation of results. Most studies have evaluated patellar taping in isolation from other treatment techniques and the results of these studies provide useful information regarding the specic eects of patellar taping. However, patellar taping is rarely used in isolation in clinical practice and such designs cannot evaluate the interaction of taping with other treatment components. Therefore the ability to generalize the results to clinical practice is limited. Lack of adequate outcome measures makes it dicult to accurately evaluate the eects of treatment. The assessment of pain is imperative but problematic, since pain is subjective and pain scales and functional impairment scales often have high variability and low sensitivity. Objective outcome measurements of treatment success may include radiological patellar alignment or measures of functional impairment, including gait kinematics and muscle function. While these might be more sensitive to change, it is not clear whether these measurements correspond to perceived pain and dysfunction associated with PFPS. In addition, changes in pain following patellar taping were not always documented and thus it was not possible to correlate impairment changes with pain. Finally, many studies present their methodology and results in a manner that makes them dicult to interpret and compare with other studies. In particular, studies that do not express their power or raw data make it dicult to evaluate the possibility of a type two error for non-signicant results. Many patellar taping studies have only been published in abstract format with insucient detail about their methodology to accurately critique the studies. Therefore, abstracts have not been included in this review unless the abstract was of sucient length to evaluate the methodology. THE ROLE OF PATELLAR TAPING IN THE REDUCTION OF PAIN Scientic ndings support the clinical observation of pain reduction with patellar taping. Numerous studies have demonstrated an immediate decrease in pain during a provocative task (as measured on a 10 cm visual analogue scale VAS) following the application of patellar taping (Kenna 1991; Conway et al. 1992; Bockrath et al. 1993; Worrell et al. 1994; Cerny 1995; Herrington & Payton 1997; Powers et al.
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1997a; Somes et al. 1997, Handeld & Kramer 2000). In most studies the physiotherapist was trained in the assessment of patellar position and the application of tape. The results of these studies indicate considerable pain reduction and are summarized in Table 1. Few studies have controlled for a potential placebo eect of taping, where subjects report a pain reduction due to the belief that taping may be benecial. The only study that performed a double blind evaluation of patellar taping in PFPS subjects is presented in abstract form (Arcand et al. 1998). One other study investigated the placebo eect of taping on knee pain in patients with patellofemoral joint osteoarthritis (Cushnaghan et al. 1994). The authors found that medial patellar tape induced a signicantly greater pain reduction than the placebo (lateral) tape. A recent trial that did not describe any attempts at blinding the tape condition, found that patellar tape was associated with signicantly less pain after isokinetic testing than a placebo tape condition (Handeld & Kramer 2000). The limited information available suggests that medial patellar taping may have benets in addition to placebo, but it is evident that further studies are required to conrm or refute this. Despite the large number of studies that have evaluated immediate pain relief due to patellar tape, there is a paucity of studies evaluating patellar tape as it is used in clinical practice. One randomized, controlled trial of 25 patients evaluated the outcome of adding patellar taping to a 4 week physiotherapy treatment programme (Kowall et al. 1996). No additional improvements in pain relief, muscle torque or EMG activity due to patellar taping were demonstrated. While the groups appeared to be well matched, this study had a small sample (n=25) and it is possible that they had inadequate power to detect any real dierence between treatment groups. Furthermore, there was no evidence that tape reduced pain in these subjects and the tape was only applied during
Table 1. Immediate eect of patellar tape on pain from PFPS Author Subjects

physiotherapy exercises. This use of patellar tape does not reect routine clinical practice. In conclusion, it is dicult to draw any meaningful conclusions from this study regarding the potential eects of taping. There are no other randomized, controlled trials that have included patellar taping in the treatment of PFPS. However, two case-series (McConnell 1986; Gerrard 1989) evaluated a treatment regimen for PFPS that included patellar taping. Both studies reported good (83%) to excellent (90%) success rates. Although taping may have contributed to the reported success in these clinical trials, taping was not evaluated independently. Furthermore, case-series do not include a comparison group thus limiting the strength of evidence for the eects of tape. While it is clear that patellar taping can reduce the pain associated with PFPS, it is unknown how this pain reduction ts into the overall picture of PFPS. It is possible that the reduction in pain may result from improved patellofemoral joint function. Conversely, pain reduction may aect the function of the patellofemoral joint thus contributing to further pain reduction. A number of physical impairments, including patellar alignment, quadriceps function and gait kinematics, have been investigated with respect to patellar taping. In the following sections the evidence to support the eect of patellar taping on patellar re-alignment, quadriceps function and knee kinematics during gait will be discussed, although it is not possible to determine whether these factors contribute to or result from the pain relief associated with patellar taping. CAN PATELLAR TAPE RE-ALIGN THE PATELLA? Clinical measurements of patellar position have poor reliability (Fitzgerald & McClure 1995; Tomisch et al. 1996; Watson et al. 1999). In contrast, radiographic

Activity

VAS pre tape [cm] np 7.7 8.8 np np np 4.4+0.4

VAS post tape [cm] np 1.7 0.3 np np np 2.0+0.2

%pain change

Conway et al. 1992 Powers et al. 1997 Worrell et al. 1994 Somes et al. 1997 Cerny 1995 Herrington & Payton 1997 Bockrath et al. 1993

30 15 1 9 10 20 12

KINCOM testing squatting 8 inch step-up 8 inch step-down 9 inch step-down isometric quadriceps contrction 8 inch step-down

17* 78* 97 45* 94 13* 55*

PFPS: Patellofemoral pain syndrome. VAS: Visual analogue scale. *Signicant dierence between tape and non-tape conditions. np: means and standard deviations were not provided in the research paper. *: calculated from mean data presented. % pain change-(VAS pre tape-VAS post tape)/VAS pre-tape. Manual Therapy (2000) 5(3), 142150 # 2000 Harcourt Publishers Ltd

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measurements have been reported to be reliable and objective and thus used with more condence when assessing patellar position (Bockrath et al. 1993; Larsen et al. 1995). The three most common radiographic measurements of alignment are the patellofemoral congruence angle (PFCA), the lateral patellofemoral angle (LPFA) and the lateral patellar displacement (LPD) (Fig. 1). The PFCA represents lateral patellar glide and lateral tilt, the LPFA represents lateral patellar tilt, while the LPD quanties the position of the patella in the frontal plane relative to the medial femoral condyle in millimetres. Although some authors refer to the patellar rotation angle as the LPFA, the two angles are not synonymous. Measurements of the patellar alignment may dier between weight bearing and non-weight bearing radiographs (Somes et al. 1997). Somes et al. (1997) noted a non-signicant medialization (tilt and glide) in the weight-bearing compared to non-weight-bearing conditions in a pilot study. Since patellar taping was designed to change the tracking of the patella in a functional weight-bearing position and it is likely that measurements of patellar alignment will dier from non weight-bearing to weight-bearing, most studies have evaluated the eects of patellar taping in a weight-bearing position.

Evidence of patellar malalignment in PFPS Patellar malalignment has been documented in PFPS populations. Using the Merchant technique (Merchant et al. 1974) several authors conducted large studies, establishing mean values for healthy controls and subjects with patellar subluxation or chondromalacia (Merchant et al. 1974; Laurin et al. 1978; Aglietti et al. 1983). Patellar alignment diered considerably between the two groups and based on these studies, radiological examination of patellar alignment as assessed by the Merchant technique can be considered to be `abnormal' if the PFCA is >+58, LPFA=18 or LPD=1 mm. No studies have compared patellar alignment in normal healthy subjects with PFPS subjects using a weight-bearing radiograph and therefore no `normal' and `abnormal' values have been determined for weight-bearing patellar alignment. Eect of patellar taping on radiographic alignment of the patella A small number of studies have evaluated the eects of patellar taping on radiographic patellar alignment in PFPS patients and healthy controls and their results are summarized in Table 2. Two studies have provided evidence that medial patellar taping can confer a radiographic positional change of the patella in PFPS subjects (Roberts 1989; Somes et al. 1997). Roberts (1989) found a signicant change in the LPFA and LPD with patellar tape in 22 knees with PFPS. The magnitude of the change was small (1.28 and 1.1 mm respectively) but the authors suggest that this may be sucient to create a subtle alteration in intra-articular or inter-osseous pressure. Somes et al. (1997) was able to demonstrate a signicant improvement in LPFA in a small group (n=6) of PFPS patients when the radiological measures were performed in weight-bearing, but no signicant dierence when performed non weight-bearing. Both studies (Roberts 1989; Somes et al. 1997) found a non signicant trend towards improved PFCA. In contrast, one study demonstrated no change in PFCA or patellar rotation angle with patellar tape, despite a signicant reduction in pain perception (Bockrath et al. 1993). However, this study is dicult to interpret since the 12 PFPS patients were receiving treatment (including taping) that may have previously altered the patellar position. In addition, the radiographs were taken in non weight-bearing (with isometric quadriceps contraction) and the patellar rotation angle is not used in any other studies. In healthy volunteers, medial patellar taping signicantly improved the PFCA (Larsen et al. 1995) but this improvement lessened after 15 min of vigorous exercise. Interestingly, the non-taped patellae were displaced laterally after the exercise period
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Fig. 1Radiographic measurements of patellar position. (a) Lateral patellofemoral angle (LPFA) is the angle formed by a line joining the summits of the femoral condyles and a line joining the summits of the femoral condyles. A smaller LPFA angle indicates greater lateral patellar tilting. (b) Lateral patellar displacement (LPD) is the distance between the highest point of the medial femoral condyle and the most medial border of the patella (BC). A positive LPD indicates a lateral position of the patella, While a negative LPD indicates a medial displacement of the patella. (c) Patellofemoral congruence angle (PFCA) is the angle formed between a line bisecting the sulcus angle and a line connecting the apex of the sulcus to the lowest aspect of the patellar ridge. A positive angle represents a laterally positioned patella and a negative angle represents a medially positioned patella. # 2000 Harcourt Publishers Ltd

146 Manual Therapy Table 2. Studies evaluating the eects of patellar tape on radiographic patellar position at 30458 knee exion Author Subjects Position No tape Somes, et al. 1997 Larsen, et al. 1995 Roberts 1989 Bockrath, et al. 1993 6 PFPS 20 healthy 19 PFPS 12 PFPS WB NWB WB WB WB 71.5+23.1 4.7+7.1 71.8*a 718.8+18.4 715.8+19.9 PFCA (8) Tape 77.9+18.8 0.6+7.4 711.2*a 720.7+17.9 715.7+18.4 No tape 17.7+17
a

LPFA (8) Tape 28.9+17.4a,b 8.6+4.1b na 8.0+9.3a na

8.2+5.3 na 6.8+9.0a na

PFPS: Patellofemoral pain syndrome. PFCA: Patellofemoral congruence angle [more negative value=more medial displacement]. LPFA: lateral patellofemoral angel [more positive value=more medial tilt]. WB: Weight-bearing. NWB-non weight-bearing. *: estimated from graphical data presented. a: Signicant dierence between tape and no-tape condition, P50.05. b: Signicant dierence between weight-bearing and non weight-bearing condition, P50.05.

while the taped group remained relatively more medially displaced than the non-taped patellae. Although no statistical analyses were performed after exercise, the authors suggested that the patellar tape might have prevented excessive lateral patellar shift due to exercise. The eects of patellar tape on the position of the patella, as determined radiographically, need to be established after exercise in a PFPS population. No additional information can be obtained from the studies that have evaluated patellar alignment using magnetic resonance imaging (MRI) (Worrell et al. 1994; Worrell et al. 1998). The images were taken in a variety of knee exion angles, in a non weight-bearing position and with conicting results. Lack of consistency in the results may be due to a number of factors including dierent measurement procedures (Weight-bearing versus non weightbearing), taping techniques and subject attributes. Although dierent taping techniques could account for variation between results, one study (Roberts 1989) found no dierences between medial tilt and medial glide taping. Other studies failed to fully describe their taping techniques, thus making comparisons dicult. Also, patients with PFPS could be expected to exhibit dierent responses to patellar taping than healthy controls since PFPS patients are more likely to demonstrate abnormal alignment. It is possible that subgroups of patients with `abnormal' patellar alignment may respond dierently than those with `normal' patellar alignment. No study has attempted to analyze the subgroups separately. It is interesting to note that no correlation was found between the changes in pain scores and radiographic patellar alignment measurements (Roberts 1989; Bockrath et al. 1993; Somes et al. 1997). Despite these controversies, it appears the majority of studies concur that patellar taping can improve the radioManual Therapy (2000) 5(3), 142150

graphic position of the patella. These results need conrmation in a large sample of PFPS patients, with the radiographs taken in a weight-bearing position, and ideally after a period of exercise. PATELLAR TAPE AND QUADRICEPS FUNCTION Quadriceps muscle activity plays an integral but complex role in PFPS. An increase in quadriceps muscle force can directly heighten the patellofemoral joint reaction force during gait (Bu et al. 1988). Therefore, in an attempt to reduce the load on the patellofemoral joint, patients with PFPS may adopt adaptive mechanisms to decrease quadriceps force. However, decreased quadriceps contractions may lead to a diminution of the shock absorption during weight bearing thus further increasing the load on the patellofemoral joint. In addition, the complex synergistic relationship of the vastii, may impact on the alignment of the patella within the trochlea, thus aecting the distribution of stress on the patellofemoral joint. In the following sections the authors will review the impact of tape on quadriceps as a functional unit, and on the relationship of the individual vastii. Measurements of quadriceps torque, moments or power may give an indication of quadriceps function. Studies have shown that quadriceps function (Bennett & Stauber 1986; Thomee et al. 1995; Powers et al. 1997b) is decreased in subjects with PFPS. Treatment for PFPS should aim to increase the ability of the patellofemoral joint to withstand the forces associated with quadriceps contraction. Patellar tape may assist in improving the function of the quadriceps. Using isokinetic dynamometry, two studies found that patellar tape signicantly increased the
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quadriceps torque (Conway et al. 1992; Handeld & Kramer 2000). Handeld and Kramer (2000) demonstrated signicantly greater concentric quadriceps torque in PFPS subjects with patellar tape compared with placebo tape. Conway et al. (1992) found that patellar tape was associated with greater eccentric and concentric quadriceps torque, and since the improved quadriceps torque was not correlated with changes in pain this improvement cannot be explained simply by pain reduction. In addition, a recent well-described study by Ernst et al. (1999) found signicantly greater knee extensor moments and power during a vertical jump and lateral step up in a taped condition compared to placebo tape and no tape conditions in PFPS subjects. There are several possible explanations for the increased knee extensor torque, moment and power associated with patellar taping. Conway et al. (1992) proposed that the distal displacement of the patella during knee exion is limited by anchoring the patellar tape to the medial aspect of the femur. This would maintain the knee extensor moment arm in a more advantageous position, thus accounting for the increase in quadriceps function. In addition, Ernst et al. (1999) suggested that changes in knee extensor moment might be aected by changing trunk position during the functional tasks. Change in pain (not reported) associated with patellar taping may alter the movement strategies thus increasing knee extensor torque. Alternatively, improvements in the VMO:VL ratio may potentially improve the eciency of the quadriceps mechanism thus accounting for the improvements seen with taping. These hypotheses need to be explored in further studies. Another explanation for the improvements in quadriceps function is that patellar tape may provide proprioceptive input and cutaneous stimulation to facilitate motor performance. However, since the knee extensor torque improved signicantly with patellar tape and did not with the placebo tape it is unlikely that the results were due to cutaneous stimulation from the tape. Can patellar tape aect the activation or timing of the vastii? Coordinated contraction of the medial and lateral components of the vastii is required to maintain patellar alignment. In the normal population, the activity of VMO and VL is relatively balanced in terms of both activation levels and timing (Mariani & Caruso 1979; Wild et al. 1982; Reynolds et al. 1983; Brownstein et al. 1985; Walter et al. 1985; Flynn & Soutas-Little 1993; Gryzlo et al. 1994; Schaub & Worrell 1995; Signorile et al. 1995; Smith et al. 1995; Worrell et al. 1995; Lange et al. 1996; Powers et al. 1996; Isear et al. 1997; Karst & Willett 1995; Morrish & Woledge 1997; Cowan et al. 2000).
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While it is commonly proposed that the onset of activation of VMO occurs after that of VL in the PFPS population the literature has provided conicting results. (Voight & Weider 1991; Grabiner et al. 1994; Powers et al. 1996; Witvrouw et al. 1996; Karst & Willett 1995; Gilleard et al. 1998). Similarly the question as to whether there is a dierence in activation levels between VMO and VL in the PFPS compared to the normal asymptomatic population remains contentious (Mariani & Caruso 1979; Petschnig et al. 1991; Souza & Gross 1991; Boucher et al. 1992; Powers et al. 1996; Miller et al. 1997; Morrish & Woledge 1997; Sheehy et al. 1998). Despite the discrepancies in the literature, some patients with PFPS demonstrate decreased activation levels and delayed EMG onset of both VMO and VL (Powers et al. 1996; Morrish & Woledge 1997). A recent study utilizing a direct measure of EMG onset timing found that VMO activity onset was signicantly later than VL in PFPS subjects during stair ascent and descent (Cowan et al. 2000). Regardless of the sequence or levels of activation in the PFPS population, the question remains as to whether patellar taping aects the activation or timing of VMO and/or VL. One of the proposed benets of patellar taping arises through its eect on the activity of VMO and VL. Taping the patella could enhance the activation or timing of VMO relative to VL or alternatively decrease the activation or timing of VL relative to VMO. Eect of patellar taping on the magnitude of VMO and VL activation McConnell (1986) suggested that patellar tape would facilitate selective enhancement of the VMO. In a preliminary report, McConnell reported that the activity of VMO was enhanced with a medical glide of the patella during a maximal quadriceps contraction in two symptomatic subjects. Two subsequent studies have failed to replicate this nding. Cerny (1995) and Herrington & Payton (1997) investigated the impact of patellar taping on the magnitude of VMO and VL EMG activity during isotonic and isometric exercises respectively. Although patellar taping was found to decrease pain in PFPS subjects there was no signicant change in the activation levels of VMO and VL or the VMO:VL ratio in either the PFPS group or the asymptomatic group. Studies that have demonstrated positive eects of taping on the EMG activation of VMO relative to VL have only been published in abstract form (Nicholas et al. 1996; Christou & Carlton 1997; Millar et al. 1999). Presently, it appears that patellar taping does not change the EMG activity of VMO and VL. However, there is a paucity of well-described studies in this area. Additionally, there are diculties inherent in evaluating the isolated EMG activation of separate vastii. In order to compare the relative activation of
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the two muscles the magnitude of EMG activity is normalised, usually to a maximal quadriceps contraction. A maximal quadriceps contraction is likely to provoke pain in PFPS patients and thus the validity of the normalization techniques may be questioned. A within-subject design to evaluate taping eects on individual muscles or utilization of a ratio of VMO to VL EMG activity may be used to provide more meaningful outcomes. Studies should include the provision of a placebo taping condition to control for the eects of placebo cutaneous simulation in the absence of mechanical displacement. In addition to taping the patella, taping of the lateral thigh has been proposed as a technique that can alter the balance of VL and VMO activity. This tape is applied very rmly in a horizontal direction across the VL muscle belly and the mid thigh level and is proposed to inhibit the activity of VL (Grelsamer & McConnell 1998). A recent withinsubject, placebo controlled trial found that this inhibitory tape signicantly reduced the EMG activity of VL compared with no tape or placebo tape in a stair descent task (Tobin & Robinson 2000). The eects of this inhibitory tape on VMO were inconclusive. The authors concluded that stimulation of the type IV nociceptors could have had a direct inhibitory eect on the VL. This intriguing nding needs further investigation in a PFPS population. Eect of patellar taping on the temporal relationship of VMO and VL activation The onset timing of VMO and/or VL may be altered by the use of patellar tape but this has only been investigated in one study. In a well-described study, Gilleard et al. (1998) investigated the temporal relationship of VMO and VL in subjects with PFPS in a stair stepping task. The onset of VMO EMG activity was found to occur earlier in the movement on both ascent and descent of the stairs when the patella was taped. Interestingly, on stair descent the onset of VL EMG activity occurred later in the movement in the taped condition. Unfortunately, the authors presented the data on the onset of VMO and VL EMG activity in terms of knee angle at muscle onset rather than as a direct measure of EMG timing. At this stage, while the results of Gilleard et al. (1998) are encouraging, further research is required to fully determine whether patellar taping can enhance the temporal control of VMO and VL. This research should include direct measures of EMG onset timing and a placebo taping group. THE EFFECT OF PATELLAR TAPE ON THE KNEE JOINT DURING GAIT The patellofemoral joint reaction force during the load acceptance component of stance phase during
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gait is a summation of the quadriceps force and knee exion (Bu et al. 1988). Since the knee exion excursion directly increases the patellofemoral joint reaction force and also increases the eccentric quadriceps demand, it is likely that patients with PFPS will decrease the amount of knee exion during early stance. This adaptive mechanism was conrmed by Dillon et al. (1983) during the stance phase of walking gait in PFPS patients compared to healthy subjects. This nding was replicated in fast walking velocities (Powers et al. 1999) but conicting results have been noted for free velocity walking. In PFPS patients, signicantly less knee exion during early stance during free velocity walking was noted by some authors (Greenwald et al. 1996; Nadeau et al. 1997) but not others (Powers et al. 1997b; Gilleard et al. 1998; Powers et al. 1999). Signicantly slower walking velocities in the PFPS subjects (Powers et al. 1997b; Powers et al. 1999) could account for the lack of dierence in knee exion between the PFPS and healthy subjects. Reduced knee exion and reduced speed of walking are believed to be compensatory mechanisms used by PFPS patients to reduce the load on the patellofemoral joint. This will decrease the demand on the quadriceps, and may lead to further weakness and patellofemoral dysfunction. Restoration of normal gait kinematics is an important component of improving function. Powers et al. (1997a) assessed the inuence of patellar taping on gait characteristics and joint motion in 15 PFPS patients. The patellar tape resulted in a small but signicant increase in loading response knee exion during the taped condition while walking at two speeds, up and down ramps and up and down stairs. Although the magnitude of this change was small (average 3.48) it indicates an ability to load the knee joint with condence during all gait conditions. In addition, they found that stride length improved following the taping procedure during the ascending ramp condition. This nding requires conrmation in a study using a larger samples, after a short period of exercise and compared to placebo tape. CONCLUSION Patellofemoral pain syndrome is a complex problem. The aetiology remains unclear, and most researchers and clinicians concur that there are subgroups of patients with dierent features that may contribute to PFPS. Development of PFPS may be associated with increased patellofemoral joint stress, resulting from a dysfunction of patellar tracking in conjunction with patellofemoral joint loading. The exact cause of pain associated with PFPS is also unknown and thus the mechanisms to explain pain relief associated with patellar taping are equally unclear. Patellar tape may aect the alignment of the patella, function of the
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quadriceps or the ability of the patellofemoral joint to withstand joint reaction forces but it is unknown whether these eects are causes or consequences of PFPS pain. This paper has reviewed the literature and discovered preliminary evidence to support these hypotheses, but insucient evidence to conrm them. Further studies are required to either ratify or refute these conjectures. Research should focus on the eects of patellar tape compared to placebo tape in subjects with PFPS. Possible mechanisms for the pain relief associated with patellar tape can then be tested, and include motor control of the vastii during functional tasks, patellar alignment and patellofemoral joint loading during functional activities. Identication of the mechanisms that explain the pain reduction associated with patellar tape may provide some insight into the aetiology of PFPS. In clinical practice, patellar tape provides a useful treatment technique. Clinical and research evidence supports relief of pain associated with PFPS and therefore, by including patellar tape in the treatment of PFPS, clinicians can implement painfree rehabilitation programmes. Since knee pain may inhibit the quadriceps, pain reduction is desirable. Pain reduction will also enhance patient compliance with the rehabilitation programme, and improve patient satisfaction. Therefore, while research is required to identify the mechanisms to explain the eects of patellar tape, it can be used with condence as a safe and inexpensive adjunct to a rehabilitation programme in the management of PFPS.

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