Accepted Manuscript

Effects of Kinesio Taping® on knee function and pain in athletes with patellofemoral
pain syndrome

Elaheh Aghapour, Fahimeh Kamali, Ehsan Sinaei

PII: S1360-8592(17)30012-8
DOI: 10.1016/j.jbmt.2017.01.012
Reference: YJBMT 1477

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 27 August 2016

Revised Date: 13 January 2017
Accepted Date: 21 January 2017

Please cite this article as: Aghapour, E., Kamali, F., Sinaei, E., Effects of Kinesio Taping® on knee
function and pain in athletes with patellofemoral pain syndrome, Journal of Bodywork & Movement
Therapies (2017), doi: 10.1016/j.jbmt.2017.01.012.

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 ACCEPTED MANUSCRIPT

Title page:

Effects of Kinesio Taping® on knee function and pain in athletes with patellofemoral

pain syndrome

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Elaheh Aghapour1, Fahimeh Kamali1,2*, Ehsan Sinaei1

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1
Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University

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of Medical Sciences, Shiraz, Iran
2
Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences,

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Shiraz, Iran

*
Corresponding author:
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Name: Fahimeh Kamali

Fax: +98 713 6272495

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Tel: +98 713 6261081

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E-mail: fahimekamalii@gmail.com

Mailing address: School of Rehabilitation Sciences, Shiraz University of Medical

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Sciences, Chamran Blvd., Abiverdi 1 St., P.O.Box:71345-1733, Shiraz, Iran.

Ethical approval: Shiraz University of Medical Sciences Ethics Committee (Reference

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number: CT-92-6832).
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Effects of Kinesio Taping® on knee function and pain in athletes with patellofemoral

pain syndrome

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ABSTRACT

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Objective: To compare the knee performance and pain in athletes with patellofemoral

pain syndrome (PFPS) before and after applying Kinesio Tape® (KT) on vastus

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medialis obliquus (VMO) muscle.

Participants: Fifteen participants (10 females, five males) with unilateral PFPS were

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examined and compared under taped and untaped conditions.
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Intervention: VMO of the involved leg was taped from origin to insertion, with 75% of

KT's maximal length tension.

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Main Outcome Measures: Maximal eccentric and concentric peak torques of

quadriceps were measured at 60 and 180°/s angular velocities by an isokinetic

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dynamometer. Functional performance and pain were evaluated by functional tests

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(step-down and bilateral squat) and visual analog scale, respectively.

Results: Paired t-test showed statistically significant increase in VMO peak torque and
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also repetition of step- down test and bilateral squat after using KT. Pain intensity was

also decreased significantly following KT application (p<0.05).

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Conclusions: KT application over VMO can decrease pain and improve the functional
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performance, generally and quadriceps muscle strength, particularly, in athletes with

PFPS. However, more research is needed to evaluate the long-term effects of this

therapeutic procedure.
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Keywords: patellofemoral pain syndrome; Kinesio Tape®; isokinetic; athletes; vastus

medialis obliquus

Nomenclature:

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PFPS = patellofemoral pain syndrome

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KT = Kinesio Tape®

VMO = vastus medialis obliquus

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VL = vastus lateralis

VAS = visual analog scale

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1. INTRODUCTION

Patellofemoral pain syndrome (PFPS), which feels as a diffuse retropatellar or

peripatellar pain aggravated by activities, is the most prevalent diagnosed orthopedic

pathology in physically active individuals (McConnell 1986). It is also one of the most

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common knee disorders experienced by athletes in variety of sports (Bolgla and Boling

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2011), which accounts for about 30% of all injuries seen in sport medicine clinics and

9% of all injuries in young athletes (LaBella 2004). In addition to pain, feeling of

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crepitus and functional deficits are other related manifestations of PFPS (Al-Hakim,

Jaiswal et al. 2012) that generally leads to decreased activity level. This problem can

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also cause athletes to limit their sportive activities (Petersen, Ellermann et al. 2014).
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Retropatellar localized pain gets aggravated during physical activities e.g. stair

climbing, squatting and prolonged sitting, which can increase the load on patellofemoral
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joint (Whittingham, Palmer et al. 2004). The precise underlying etiology of PFPS is still

unknown. However, it is believed that quadriceps weakness, increased Q-angle, joint

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laxity, overuse injuries and biomechanical changes in lower extremity are the main
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contributing factors (Loudon, Wiesner et al. 2002; Whittingham, Palmer et al. 2004).

Among the above-mentioned factors, quadriceps muscle strength is a key parameter that
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is closely associated with PFPS (Herrington 2001; Goharpey, Shaterzadeh et al. 2007;

Osorio, Vairo et al. 2013). The evidences show that quadriceps muscle is generally
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weaker in patients with PFPS than healthy individuals (Osorio, Vairo et al. 2013).
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Quadriceps inhibition and atrophy can lead to decreased muscle peak torque, which is a

defined predisposing factor for PFPS (Herrington 2001). Muscle imbalance in heads of

the quadriceps, i.e. vastus medialis obliquus (VMO) and vastus lateralis (VL) can

eventually lead to patellar tilting to the lateral side of the knee joint, which in turn
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aggravates the symptoms (Lee and Cho 2013). It is reported that VMO strength plays an

important role in opposing PFPS symptoms through acting as a dynamic medial

stabilizer of the patella. That is to say, insufficiency and delay in VMO activation can

lead to lateralization of the patella, known as "patella maltracking", which consequently

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decreases the function of the knee joint (O'Sullivan and Popelas 2005; Lee and Cho

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2013).

PFPS treatment symptoms can be clinically challenging due to its multifactorial

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nature. Up to now, a variety of therapeutic methods has been practiced in order to

address PFPS including electrotherapy modalities (Lake and Wofford 2011), stretching

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and strengthening exercises (Alba-Martín, Gallego-Izquierdo et al. 2015), balance
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training (Mahmoud and Kamel 2015), patellar braces (Lun, Wiley et al. 2005), patellar

mobilization (Stakes, Myburgh et al. 2006), biofeedback training (Park and Kang 2014),
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and so forth. However, athletes usually prefer therapeutic measures which do not restrict

their ability to participate in sportive exercises. With respect to this issue, KT, which
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has gained high popularity over recent years, can be an ideal option to tackle PFPS.
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KT is one of the most commonly used stretchable tapes in sport injuries in terms
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of prevention, treatment and also enhancing athletes' performance (Wong, Cheung et al.

2012; Montalvo, Buckley et al. 2013). KT and its method of application were first
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introduced by Kenzo Kase in 1973 (Tsai, Hung et al. 2009). Depending on the direction
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of application, KT may have facilitatory or inhibitory effects on the muscle (Kase,

Wallıs et al. 2003). Despite the prevalence of KT application in recent years, its

efficiency in injured athletes is still a matter of debate (Montalvo, Buckley et al. 2013),

while there is limited evidence which supports its role in facilitating muscle strength in

PFPS (Kase, Wallıs et al. 2003; Wong, Cheung et al. 2012; Montalvo, Buckley et al.
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2013). According to Herrington (Herrington 2001), patellar taping can significantly

improve pain and quadriceps strength in subjects with PFPS. In another study,

Freedman reported that KT can significantly decrease pain and improve functional

performance in individuals with PFPS, while sham KT does not have any therapeutic

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effect (Freedman, Brody et al. 2014). Conversely, the results of the previous studies

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have indicated that KT probably is not capable of enhancing muscle strength in healthy

subjects (Fu, Wong et al. 2008; Wong, Cheung et al. 2012).

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To the best of the author's knowledge, to date no study has examined the effect

of applying KT specifically for VMO in athletes with PFPS. As a consequence, the

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present study was designed in order to investigate the effectiveness of KT as an
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accessible, simple to apply, and non-invasive technique on knee performance in athletes

with PFPS.
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2. METHOD AND MATERIALS

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2.1. Subjects
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Fifteen athletes (ten females and five males) with unilateral PFPS who referred
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to sport physiotherapy clinics of Shiraz University of Medical Sciences in Shiraz, Iran,

from December 2013 and March 2014, were recruited by simple sampling. Sample size
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was calculated with SPSS software on the basis of information from a previous related
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study (α=0.05, β=0.2, power=80%)(Wong, Cheung et al. 2012). All subjects gave

informed consent prior to their participation and ethical code was obtained from Ethics

Committee, Vice-Chancellory for Research of Shiraz University of Medical Sciences

(Reference number: CT-92-6832). The patients were included if they had at least three

sessions of 2-hour physical activity per week, over six months prior to the study.
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Reporting aggravating anterior knee or retropatellar pain during hopping and

running, ascending and descending steps, squatting and prolonged sitting, as well as

obtaining scores between 45 and 70 (out of 100) on the Kujala questionnaire (Nijs, Van

Geel et al. 2006) and scores between three to six (out of 10) on visual analogue scale

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(VAS) during resistive knee extension were the other inclusion criteria. We considered

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the upper point of six for VAS and lower point of 45 for Kujala, in order to exclude

subjects with high levels of pain and disability, who were assumed not to be able to

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complete functional tests and isokinetic evaluations. In addition, at least one of these

valid diagnostic tests of PFPS, i.e. eccentric step down, patellar apprehension and vastus

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medialis coordination tests had to be positive (Nijs, Van Geel et al. 2006). We recruited
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only the participants who suffered from PFPS in their dominant leg in order to avoid

bias in evaluations.
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The patients were excluded if they had neurological or rheumatoid diseases, low

back or hip pain, fractures or surgeries in their lower limbs, received physical therapy
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treatments or cortico steroid injections in knee joint over the past three months and used
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opioid or analgesic drugs in last 72 hours prior to the study. Patients with internal knee

derangements and problems related to meniscus, ligaments or tendons as well as patellar

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subluxation or dislocation and subjects with bilateral PFPS were also excluded. An

orthopedist would confirm the definite diagnosis of PFPS.

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2.2. Procedures

All 15 participants were asked to attend two sessions with one week interval, in

order to avoid carry-over effects. During the first session, subjects completed the Kujala

questionnaire and their characteristic data were recorded and isokinetic and functional

tests were carried out without any intervention. During the second session, VMO of the
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involved leg was taped and then all the assessments were repeated. Pain intensity was

also evaluated by VAS, at the beginning and end of each session and the mean

difference of pain pre-post performing isokinetic and functional tests in each session

was considered for analyzing.

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2.3. Intervention

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Patient's shaved thigh was cleaned with alcohol. With the patient laid supine

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with hip in 30º and knee in 50º flexion, VMO was taped with a 5-cm Y-shaped KT

(Kinesio Tape® -South Korea) from the origin to the insertion, in order to gain

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facilitatory effect (Słupik, Dwornik et al. 2006). This method of application is defined

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by Kenzo Kase as the standard KT application for VMO (Kase 2016) (see figure 1).

Place figure 1 here

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To provide muscle facilitation effect, KT was applied with 75% of its maximal length
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tension (Kase 2016). This tension was confirmed by measuring the change in length of

KT, before and after being stretched.

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2.4. Outcome measures

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isokinetic tests
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Concentric and eccentric muscle strength of quadriceps was measured at speeds

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of 60 and 180 º/s by an isokinetic dynamometer (Biodex System 4, Biodex Medical

system, Inc; New York, USA) (see figure 2). The dynamometer was calibrated before

each session. All participants were acquainted with the equipment before testing. The

participants were seated in the chair of the dynamometer instrument in the position

described by Dvir et al. (Dvir, Halperin et al. 1991) and carried out 10 repetitions at
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each speed, with a 10-second rest between each repetition. A repetition comprised

completing a full cycle of concentric followed by eccentric quadriceps contraction.

They were asked to work with sub-maximally effort for the first seven repetitions as

warm-ups, which ensured us that they were familiarized with the instrument. Afterward,

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the last three trials of concentric and eccentric quadriceps contractions with maximal

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effort were performed. Average peak torque of the last three repetitions was recorded.

They were verbally encouraged and were allowed to get visual feedback from the

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monitor screen. The same protocol was then repeated after two minutes recovery for the

second test velocity.

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Place figure 2 here

functional tests
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Subjects also performed step-down test and bilateral squatting, in a random

sequence. The reliability of these functional tests had been proven (Loudon, Wiesner et
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al. 2002).
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"Step- down" is a unilateral test performs on a 20 cm-height platform, in which the

subject steps forward and downward toward the floor with the heel and then return to
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full extension. The numbers of repetitions in 30 seconds is recorded.

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For bilateral squat test, the examinees stand with knees in full extension, hip-
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width apart. Afterwards, they bend their knees to 90º and then return to full extension.

One cycle consists of straight standing to 90º knee flexion and back to start position.

The numbers of cycles during 30 seconds defines the score of this test.

2.5. Statistical analysis

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Data were analyzed with SPSS software, version 16 (IBM Inc., Chicago, IL,

USA). Regarding normality of all data analyzed by one-sample Kolmogorov–Smirnov

test, paired t-test was used to measure any differences between taped and untaped

conditions. A p-value of under 0.05 was considered as statistical significance in all the

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evaluations.

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3. RESULTS

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All the 15 recruited subjects completed the trial. Demographic data of

participants are summarized in table 1 (see table1). As Table 2 shows, pain intensity,

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assessed by VAS reduced significantly after VMO taping (p=0.020). In terms of

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isokinetic evaluations, normalized peak torque increased significantly following the

application of KT on VMO. P-values were 0.032 and 0.040 for concentric contractions
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and 0.017 and <0.001 for eccentric contractions, respectively at 60 and 180°/s velocities.

According to Table 2, number of repetitions of step down and bilateral squat tests
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increased significantly (p<0.001), which imply a considerable improvement in athletes'

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functional performance (see table2).

Place tables here

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4. DISCUSSION
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The results of our study demonstrated that KT application on VMO decreases

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pain, which is consistent with previous studies (Osorio, Vairo et al. 2013). This pain

reduction can be attributed to neurological suppression, due to stimulation of cutaneous

mechanoreceptors (Campolo, Babu et al. 2013). In a relatively similar study, Freedman

et.al compared the effects of real and sham KT on pain intensity during functional tasks

in patients with PFPS and reported a significant decrease in pain following real KT
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(Freedman, Brody et al. 2014). However, their method of taping was different from

ours, in a way that they taped from middle of femur to the middle of tibial shaft, in

order to support the patella. In this study, our target muscle was VMO and we did not

change the alignment of the patella. As a result, pain reduction in our experiment

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seemed to be more than biomechanical effects, due to gate control theory; KT can

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stimulate neuromuscular pathways via increasing afferent feedback. It is suggested that

KT may clinically be helpful for the purpose of pain relief in patients with PFPS (Aytar,

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Ozunlu et al. 2011), and can be used as an adjunct to the traditional physical therapy,

without any proven negative side effect (Montalvo, Buckley et al. 2013).

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According to the present study, application of KT on VMO can lead to greater
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concentric and eccentric peak torques at 60 and 180º/s velocities. Based on the

literature, there is a lack of consensus regarding the ability of KT to increase quadriceps

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muscle peak torque. Majority of the previous researches conducted into this field have

reported that KT cannot increase quadriceps peak torque in healthy individuals, (Fu,
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Wong et al. 2008; Wong, Cheung et al. 2012; Poon, Li et al. 2015; Yeung, Yeung et al.
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2015)which is inconsistent with the findings of our study. It is obvious that the

participants in the mentioned studies were healthy individuals, who did not have any
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symptom of pain, imbalance or impairment, which evinces the reason of incongruence

with our results. It should be noticed that there is a reverse relation between pain
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intensity and muscle peak torque (Herrington 2001; Osorio, Vairo et al. 2013). It is
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believed that decreasing pain can result in greater quadriceps activity by boosting the

afferent inputs into the dorsal horn of spine and consequently decreasing the inhibition

placed upon alpha motor neuron excitability (Herrington 2001; Herrington 2004).

Therefore, the improved isokinetic strength seen in this study can be attributed to pain
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relief induced by KT. According to the literature, applying KT can enhance muscle

excitability. It is also believed that KT can increase blood circulation, which in turn may

affect muscle functions (Halseth, McChesney et al. 2004; Akbaş, Atay et al. 2010).

Increased tactile inputs ensuing KT application is another mechanism for improvement.

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Its ability to change the excitability of the central neuronal system through interacting

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with motor control was reported in previous studies (Fu, Wong et al. 2008). Chen et al.

showed that VMO taping can alter the timing of VMO activation and improve

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VMO/VL ratio (Chen, Hong et al. 2007).

Moreover, our study indicated that KT had a significant effect on improving

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functional tests i.e. step-down and bilateral squat. In a study in 2010, Akbas et. al.
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revealed that KT could not add any extra effect to conventional exercises in treatment of

women with PFPS (Akbaş, Atay et al. 2010). However, their findings do not necessarily
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mean that KT is ineffective regarding pain and functional performance; furthermore, the
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exercise plus KT group in their trial showed faster improvement in hamstring muscle
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flexibility compared to exercise-only group. Since there is no strong relation between

isokinetic strength assessment and functional tests, it is proposed that both isokinetic
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dynamometry and functional test must be carried out in order to assess the functional

ability of subjects with PFPS (Goharpey, Shaterzadeh et al. 2007). Additionally,

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functional tests have the benefit of evaluating the knee joint under the conditions that
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imitates real functional demands. Performance on functional tests depends on many

variables including pain, neuromuscular coordination, muscle strength, and joint

integrity (Loudon, Wiesner et al. 2002). It is also suggested that KT can improve

proprioception by various mechanisms including normalizing muscle tone, relieving

pain intensity, exciting skin receptors, and correcting malalignments (Słupik, Dwornik
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et al. 2006). Hence, the decreased perceived pain and improvement of ability to generate

peak torque as well as enhancing proprioception in situ could lead to increased number

of repetitions of tests in this study, which suggests the improvement of functional

performance.

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Study limitations

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We encountered some limitations in the present study including the lack of long-

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term evaluations and a real control group, which we hope to be considered in the future

studies. Furthermore, our sample size was rather small and should be increased in future

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studies. Such modifications can provide more reliable and generalizable results upon the

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efficacy of VMO KT in athletes with PFPS.

5. CONCLUSIONS
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Our study showed that applying KT on VMO can decrease pain and improve the
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functional performance, generally and quadriceps muscle strength, particularly, in

athletes with PFPS. Therefore, it can be suggested to prescribe VMO taping as an

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effective therapeutic technique in the rehabilitation programs of this population.

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Conflict of interest: None.

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Acknowledgments:

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The present article was extracted from the master thesis written by Elaheh Aghapour

and was financially supported by Shiraz University of Medical Sciences grants No.

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6832. The authors would like to thank the Research Consultation Center (RCC) of

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Shiraz University of Medical Sciences for their invaluable assistance in English-

language editing of this article.

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Table 1: Demographic characteristics and baseline values

Parameter mean±SD

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Age(yr) 24.3±4.4

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Height(m) 1.64±6.5

Weight(kg) 57.2±14.1

U
Visual Analog Scale 3.66±0.89

Kujala score 64.86±5.82

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Table 2: The comparison of perceived pain, functional performance and

normalized peak torque, before and after vastus medialis Kinesio Taping®

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variable Untaped Taped p-value
(mean+SD) (mean+SD)
Pain Difference
VASa(0-10)

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2.86 ±1.76 1.6 ±1.35 0.020*

Functional Performance
Step-down 15.6±4.3 20.01±5.8 <0.001*

SC
Bilateral squat 14.9±4.3 19.6±5.9 <0.001*

Peak Torqueb
Concentric, 60 105.4±43.2 137.6±46.9 0.032*

U
Concentric, 180 82.7±26.8 101.4±27.2 0.040*
Eccentric, 60 171.1±63.3 205.7±45.1 0.017*
Eccentric, 180 167.1±31.9 193.7±34.9 <0.001*
a
visual analog scale b AN
contraction type, angular velocity º/s

* Significant differences between two conditions (p< 0.05)

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CAPTIONS TO ILLUSTRATIONS

PT
Fig. 1. Vastus medialis obliquus kinesio taping

Fig. 2. Isokinetic test

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Fig. 1

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Fig. 2

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