Abstract
Purpose/Background:
No evidence exits regarding the magnitude of the change in foot posture following the “modified reverse‐6” (MR6) taping procedure, either alone or in combination with the “low‐dye” (LD) taping technique. The purpose of this study was to investigate the change in the height and width of the midfoot after application of the MR6 and the MR6 plus the LD (MR6+LD) taping technique and determine how long those changes last.
Methods:
Eleven individuals (2 female and 9 male) were recruited for this study and were tested under each of two experimental conditions, the MR6 and the MR6+LD taping technique. The order of testing for the two conditions was randomly determined. For each condition, the height and width of the midfoot at 50% of each subject's foot length was initially measured and then again immediately following the application of the tape. These measurements were repeated four hours later immediately prior to running two miles on a treadmill, again immediately after running, and finally after another four hours.
Results:
The dorsal arch height increased significantly with both the MR6 and MR6+LD taping, but only the MR6+LD remained statistically greater after four hours, a bout of exercise and again at the end of the day. The mean width of the midfoot significantly decreased with both taping procedures. The change in the width of the midfoot remained significantly decreased in both taping conditions after exercise and throughout the day.
Conclusions:
Both taping procedures are able to significantly change the height and width of the medial longitudinal arch of the foot, but the change lasted longer when the two taping procedures were combined.
Levels of Evidence:
Level 3, Prospective Cohort Study
Keywords: Adhesive Taping, Durability, Foot and Ankle
INTRODUCTION
Anti‐pronation taping has been advocated by several authors to reduce pain and symptoms caused by excessive foot pronation.1‐5 Although several different taping techniques have been described in the literature to limit excessive foot pronation, the “low‐dye” and “Reverse‐6” techniques have received the greatest attention. The low‐dye (LD) technique was originally described by Dr. Ralph Dye and has been shown to increase the height of the medial longitudinal arch1,6‐9 as well as provide short‐term relief of symptoms associated with plantar fasciitis.3,8,10 The mean reported change in the height of the medial longitudinal arch using the LD technique with individuals demonstrating mild to moderate calcaneal eversion and a mild to moderate decrease in the height of the medial longitudinal arch on weight bearing was 4.5mm with a range of between 3.1mm to 7.2mm.1,6,7,9
In a recent systematic review, Cheung et al11 reported that while adhesive taping was more effective than footwear and foot orthoses in controlling foot pronation, the low‐Dye technique was less effective than other taping techniques such as the Reverse‐6 that is applied with portions of the tape proximal to the talocrural joint. The Reverse‐6 taping (R6) technique therefore traverses both malleoli and has been advocated to control excess foot pronation.5,12 Previous research, however, has indicated that talocrural joint range of motion, especially plantar flexion, may be restricted when tape is applied in this manner.13
Vicenzino et al reported that combining the LD and R6 taping techniques resulted in a greater change of the height of the navicular bone.5 The combining of the LD and R6 taping techniques was referred to as the “Augmented Low‐Dye” (ALD).4,14‐16 The mean reported change in the height of the medial longitudinal arch using the ALD technique with individuals who had at least a 10mm navicular drop was 9.4mm with a range of between 8.0mm to 10.8mm.4,15
Inelastic tape has been used almost exclusively with either the LD or R6 taping techniques in order to control foot pronation and restrict foot movement.10,15,17,18 Only one published study was found in which elastic tape was used to restrict motion of the medial longitudinal arch. This study was a case series and reported on the use of a “modified” R6 taping technique using elastic tape to not only reduce symptoms of excess foot pronation, but also as a way to determine the degree of orthotic posting based on the amount of change seen in the height of the medial longitudinal arch following taping.19 In that study, the original R6 taping technique described by Vicenzino et al5 was modified by first altering the path of the tape so that it did not cross the medial or lateral malleoli and possibly hinder talocrural joint range of motion and second by using elastic rather than inelastic tape to improve comfort.19 While the Meier et al case series study demonstrated that the “modified Reverse‐6” (MR6) taping technique was clinically effective, it is unclear exactly how much foot motion was actually restricted as well as how long the effect of the tape lasted. In addition, it is unknown whether the combination of the LD and the MR6 techniques may be more effective than just using the MR6 procedure.
Numerous researchers have investigated the effect of exercise on the ability of taping procedures to maintain the observed postural changes in the foot.1,7,8,17,20 Using just the LD taping procedure, Holmes, et al reported that in individuals with a pronatory foot posture, arch height increased by 7.2mm immediately following taping and was reduced to 4.4mm after 10 minutes of walking. Ator and colleagues reported a 3.8mm increase in the height of the navicular bone immediately following application of the LD taping technique in individuals with a pronatory foot posture, but this was reduced to just 1.45mm after 10 minutes of jogging.1,7 On the other hand, Vicenzino and associates reported that the height of the navicular bone was increased by 8.6% immediately after applying the LD technique to otherwise healthy females with observable increased foot pronation. The height of the navicular bone was reduced to 94.2% of the person's resting navicular bone height (14.1% reduction) after 10 minutes of jogging. The navicular bone height was 91.3% of the person's resting navicular bone height (17.0% reduction) after 20 minutes of jogging.5
The studies using the “augmented low‐dye” procedure reported between 12.9% to 18.8% or 5.9mm to 8.0mm increase in arch height immediately following application of the tape.4,5,14 After 10 minutes of exercise, arch height remained 8.6% or between 5.0mm and 5.9mm higher than before the tape was applied.4,5,14 After 20 minutes of exercise, arch height was 5.7% or 3.5mm higher than before the tape application.4,5 Again, each of the previously cited studies utilized inelastic tape. No such studies have been conducted specifically looking at the MR6 taping procedure using neither elastic tape nor its combination with the LD taping procedure on the height or width of the midfoot. Cornwall and associates, however, did report that the MR6 taping technique can be applied consistently from one session to the next as well as between therapists. In that study, they reported a 3.9mm increase in the height of the medial longitudinal arch after the application of the tape.21
The purpose of this study was two fold. First, investigate the change in the height and width of the midfoot after application of the MR6 and the MR6 plus the LD (MR6+LD) taping technique, and second, determine how long those changes last over time and after a single bout of exercise.
METHODS
Because this study involved the use of two commonly used anti‐pronation taping procedures, only individuals with a Foot Posture Index of +4 or greater were included in this study. A minimum FPI of +4 or greater was chosen because it represents subjects with a pronatory foot posture in which foot taping is likely to be used in a clinical setting to either control motion and reduce a patient's symptoms. Thirteen individuals (4 women, 9 men) with a mean age of 27.3 years and without a history of injury or pain to either of their feet for at least 6 months prior to participating in the study were recruited (Table 1). The Internal Review Board at Northern Arizona University approved the study and all of the subjects read and signed an informed consent prior to participating.
Table 1.
Demographic Information on the Subjects Used in the Study. Values in Parentheses are Standard Deviations.
| Age (yrs.) | Height (cm) | Weight (kg) | FPI | |
|---|---|---|---|---|
| Female (n=4) | 30.8 (6.7) | 169.8 (2.1) | 61.8 (6.6) | 5.1 (2.0) |
| Male (n=9) | 25.8 (1.3) | 179.8 (4.9) | 78.3 (8.4) | 7.0 (2.1) |
| Total (n = 13) | 27.3 (4.3) | 176.7 (6.3) | 73.2 (11.0) | 6.5 (2.2) |
All subjects reported to the Laboratory for Foot and Ankle Research at Northern Arizona University before 8:00am on the day of data collection. After measuring each subject's height and weight, the Foot Posture Index (FPI) of each subject's foot was assessed using the methods described by Redmond.22 The FPI has been shown to have good intra‐clinician reliability (ICC=0.928 to 0.937) and moderate inter‐clinician reliability (ICC=0.525 to 0.655).23 Next, each subject was asked to stand on a foot measurement platform that has previously been described by McPoil et al.24,25 Using this platform, the height of the dorsum of the arch (DAH) and the width of the mid‐foot (MFW) were measured using a digital caliper (Mitutoyo America Corporation, Aurora, IL) at 50% of the subject's overall foot length. (Figure 1) All measurements of dorsal arch height and midfoot width were performed by one of the paper's authors (AF) using the methods described by McPoil et al which have been shown to be reliable.25 The subjects were then randomly assigned to one of the two taping conditions; 1) the “modified Reverse‐6” using elastic tape (MR6) or 2) the “modified Reverse‐6” using elastic tape plus the low‐dye technique using cloth tape (MR6+LD). Immediately following the application of the tape, the subject's dorsal arch height and midfoot width was measured again. (Figure 2). After the second set of measurements, the individual was instructed to go about their normal daily activities, but to refrain from exercise or any vigorous activity. At noon on the test day (four hours after being taped), subjects returned to the laboratory and again DAH and MFW measurements taken. Immediately following this third set of measurements, the subject ran on a treadmill at a self‐selected speed for two miles. Immediately following the exercise intervention, DAH and MFW measurements were taken again. After this fourth set of measurements, subjects were again asked to go about their normal daily activities, but refrain from exercise or any vigorous activity. Finally, subjects returned to the laboratory for a final time at approximately 5:00pm and the DAH and MFW were measured for the fifth and last time. After this final measurement, the tape was removed and its thickness was measured in the regions where the foot measurements were obtained using a digital caliper so that this value was not included in the change in navicular height or width from the pre‐tape condition. One week later, each subject returned to the laboratory and the entire above procedure was repeated except that the other taping procedure was applied.
Figure 1.
(a) Photo of Measuring the DAH at 50% of Overall Foot Length Prior to Tape Application. (b) Photo of Measuring the MFW at 50% of Overall Foot Length Prior to Tape Application.
Figure 2.
(a) Photo of Measuring the DAH at 50% of Overall Foot Length After Tape Application. (b) Photo of Measuring the MFW at 50% of Overall Foot Length After Tape Application
The MR6 taping technique used in this study was the same as described by Meier, et al and utilized elastic tape (Elastakon®, Johnson & Johnson, New Brunswick, NJ).19 The LD taping technique used in this study followed that described by several previous researchers and utilized cloth athletic tape (Coach Athletic Tape®, Johnson & Johnson, New Brunswick, NJ).6,17,26 A single person (MWC) applied each of the taping techniques on all subjects. This person was a licensed physical therapist with over 30 years of clinical experience, including frequent application of both taping techniques.
Statistical Methods
Descriptive statistics were used to represent subject demographics as well as the height and width of the medial longitudinal arch. Tests of normalcy and homogeneity of variance were performed to ensure that subsequent use of inferential statistical analyses were appropriate. Two‐way analysis of variance (ANOVA) tests were used to determine if there was a significant difference between the two taping procedures or time on the height and width of the medial longitudinal arch. If a significant interaction effect was found, a repeated measures one‐way analysis of variance (ANOVA) was performed for each tapping condition followed by simple contrast comparisons of each time period with that of the first time period. Finally, a series of t‐tests were used to determine if there was a significant difference between the two taping procedures at each of the measured time periods. In order to compensate for the large number of statistical comparisons performed, an alpha level of 0.02 was used for all individual and group tests of statistical significance.
RESULTS
Main Effects.
The result of the 2‐way ANOVA test of DAH showed that there was a significant (p=0.016) main effect between the two taping conditions and the five time periods (p=0.000). There was no significant (p=0.133) interaction, however between the two main effects. The result of the series of t‐tests indicated that arch height was significantly (p<.02) different between the two taping procedures for each time measurement except for the initial measurement before the tape was applied. See Table 2 and Figure 3.
Table 2.
Mean Values for Dorsal Arch Height and Midfoot Width at Each Measurement Time Period and For Each Taping Procedure. Values in Parentheses Are Standard Deviations.
| Variable | Time | MR6 | MR6+LD | p‐value |
|---|---|---|---|---|
| DAH | T0 (Pre) | 63.5 (5.1) | 63.8 (5.3) | 0.244 |
| T1 (Immed Post) | 65.8 (4.8) | 67.0 (4.6) | 0.470 | |
| T2 (Post 4 hrs.) | 64.1 (5.0) | 65.2 (4.7) | 0.024 | |
| T3 (Post Ex) | 63.9 (5.3) | 64.8 (4.6) | 0.041 | |
| T4 (Post 8 hrs.) | 63.8 (5.0) | 65.0 (4.9) | 0.017 | |
| MFW | T0 (Pre) | 84.6 (6.1) | 85.1 (6.4) | 0.270 |
| T1 (Immed Post) | 82.2 (5.7) | 83.4 (5.4) | 0.041 | |
| T2 (Post 4 hrs.) | 82.0 (5.5) | 83.4 (5.2) | 0.003 | |
| T3 (Post Ex) | 83.2 (5.5) | 84.2 (5.6) | 0.015 | |
| T4 (Post 8 hrs.) | 82.2 (5.3) | 83.6 (5.6) | 0.006 |
DAH= Dorsal arch height; MFW= Midfoot width
Figure 3.
DAH Over Time For the Modified Reverse‐6 and the Modified Reverse‐6 Plus Low‐Dye Taping Procedures. Error Bars Represent Standard Errors of the Mean.
The result of the 2‐way ANOVA test of MFW showed that there was a significant (p=0.005) main effect between the two taping conditions and the five levels of time periods (p=0.000). There was no significant (p=0.334) interaction, however between the two main effects. The result of the series of t‐tests indicated that midfoot width was significantly (p<.02) different between the two taping procedures for each time measurement except for the initial measurement before the tape was applied. See Table 2 and Figure 4.
Figure 4.
MFW Over Time For the Modified Reverse‐6 and the Modified Reverse‐6 Plus Low‐Dye Taping Procedures. Error Bars Represent Standard Errors of the Mean.
Modified Reverse‐6 Technique.
Table 3 contains the mean values of the DAH and MFW over time for the MR6 condition. As can be seen, DAH increased by an average of 2.2mm immediately after applying the tape and then decreased by 77.3% after four hours of general activity to 63.6mm. After running two miles, the DAH decreased another 4.5% to 63.5mm and by the end of the day the DAH was only .3mm above the pre‐tape condition, which meant that the height of the arch was only 4.5% above the pre‐tape condition. The result of the one‐way ANOVA test and post‐hoc comparisons indicated that only the DAH measurement immediately after taping the foot was significantly different from the pre‐taping measurement (p=0.000). See Table 3 and Figure 5a.
Table 3.
Mean Values of the Dorsal Arch Height and Width of the Over Time for the Modified Reverse‐6 Taping Technique. Values in Parentheses are Standard Deviations.
| DAH (mm) | MFW (mm) | |
|---|---|---|
| Pre‐Tape | 63.5 (5.1) | 84.6 (6.8) |
| Post‐Tape (0 Hours) | 65.8 (4.9) | 82.2 (6.6) |
| Pre‐Exercise (4 Hours) | 64.1 (5.0) | 82.0 (6.4) |
| Post‐Exercise (4.5 Hours) | 63.9 (5.3) | 83.2 (6.4) |
| Post‐Exercise 2 (8 Hours) | 63.8 (5.0) | 82.2 (6.2) |
DAH= Dorsal arch height; MFW= Midfoot width
Figure 5.
DAH (a) and MFW (b) Over Time for the MR6 Taping Condition. Error Bars Represent Standard Errors of the Mean.
The MFW decreased by an average of 2.8% or 2.3mm immediately after applying the tape and then decreased another 0.2mm after four hours of general activity. After running two miles, the MFW had increased by 1.1mm and after another four hours of general activity, the MFW had decreased 0.9mm. The result of the one‐way ANOVA test and post‐hoc comparisons indicated that each of the MFW measurements while the foot was taped was significantly less (p=0.000) compared to the pre‐taping measurement. See Table 3 and Figure 5b.
Modified Reverse‐6 Plus Low‐Dye Technique.
Table 4 contains the mean values of the DAH and MFW over time for the MR6 condition. As can be seen, DAH increased by an average of 3.1mm or 4.9% immediately after applying the tape and then decreased by 1.7mm after 4 hours of general activity. After running 2 miles, the DAH decreased another 0.4mm and by the end of the day, the DAH was only 1.9mm above the pre‐tape condition. The result of the one‐way ANOVA test and post‐hoc comparisons indicated that the DAH measurement was still significantly (p=0.000) different from the pre‐taping measurement after wearing the tape for 8 hours and after running for 2 miles. See Table 4 and Figure 6a.
Table 4.
Mean Values of the Dorsal Arch Height and Width of the Midfoot Over Time for the Modified Reverse‐6 Plus Low‐Dye Taping Techniques. Values in Parentheses are Standard Deviations.
| DAH (mm) | MFW (mm) | |
|---|---|---|
| Pre‐Tape | 63.8 (5.5) | 85.1 (6.9) |
| Post‐Tape (0 Hours) | 67.0 (4.8) | 83.4 (5.7) |
| Pre‐Exercise (4 Hours) | 65.2 (4.9) | 83.4 (5.5) |
| Post‐Exercise (4.5 Hours) | 64.8 (4.7) | 84.2 (6.0) |
| Post‐Exercise 2 (8 Hours) | 65.0 (4.9) | 83.6 (5.8) |
DAH= Dorsal arch height; MFW= Midfoot width
Figure 6.
DAH (a) and MFW (b) Over Time for the MR6+LD Taping Condition. Error Bars Represent Standard Errors of the Mean.
The MFW decreased by an average of 1.5mm immediately after applying the tape and then decreased only another 0.02mm after four hours of general activity. After running two miles, the MFW rather than decreasing, increased by 0.7mm and after another 4 hours of general activity, the MFW had again decreased by 0.4mm. The result of the one‐way ANOVA test indicated that each of the MFW measurements while the foot was taped was significantly less (p=0.027) when compared to the pre‐tape measurement. See Table 4 and Figure 6b.
DISCUSSION
Both of the taping procedures utilized in this study were able to significantly increase the height of the dorsal arch and decrease the width of the midfoot immediately after the tape was applied. There was, however, no statistical difference between the two taping procedures in their ability to maintain this change. The magnitude of change in the height of the arch seen in the current study is smaller than the majority of previously published literature using other taping techniques. Previous studies have reported increases of 3.8mm,1 4.0mm,9 and 7.2mm7 in the height of the arch using the low‐dye taping technique. A systematic review reported that the low‐dye taping technique resulted in a 5.9mm increase in arch height.27 In contrast, however, a 3.1mm increase in the height of the medial longitudinal arch was reported by Whitaker, et al using the low‐dye taping procedure, which is much closer to what has been found in the current study.6 Previous research using the “augmented” low‐dye technique have reported 8.0 and 10.8mm increases in the arch height.4,14 The smaller change scores obtained in the current study may be related to the use of elastic rather than inelastic tape. Abian et al, however, demonstrated that elastic tape limited motion of the ankle to a greater extent than inelastic tape, even after 30 minutes of vigorous exercise, which would be a significant advantage of elastic tape over inelastic tape.28 Another possibility for the smaller observed change in arch height may be related to the subjects sampled in the current study. Although the current study only included those individuals with an FPI greater than or equal to +4, it is possible that the subject's foot mobility did not allow for large changes in arch height. For example, Vicenzino et al included only those individuals with a navicular drop of at least 10mm in their study and reported a change of 10.8mm in arch height immediately after applying the “augmented” low‐dye taping procedure.4 It is important to note, that Meier and colleagues19 obtained a reduction in foot related symptoms with an average change in dorsal arch height of 2.6mm. As such, it appears that a relatively small change in dorsal arch height may reduce tissue loading of the foot and therefore impact a patient's symptoms. Certainly, further research is warranted dealing with the use of elastic rather than inelastic tape as well as determining the minimal change in the medial longitudinal arch height that is necessary to produce positive clinical outcomes.
The observed change in the width of the midfoot in the current study cannot be compared to previous research as no studies could be found that looked at this variable following taping. Because foot pronation involves movement in both the frontal and transverse plane, the addition of midfoot width in the current study provides additional information regarding how taping may be able to control foot motion. In addition, the ability of foot taping to control both height and width changes is clinically relevant given the 2008 paper by Vicenzino and associates in which a change in midfoot width from non‐weight bearing to weight bearing was found to be one of four variables that were predictive of a successful treatment of patellofemoral pain using foot orthoses.29 As such, this finding is unique and adds additional information to the current understanding of the effect of taping of the foot. The increase in the width of the midfoot immediately after running 2 miles and then subsequently decreasing four hours later was seen with both taping procedures and was statistically significant. (Table 4 and Figure 4). Although further research is warranted, this slight increase in midfoot width immediately after exercise could be attributed to increased fluid within the foot as a result of the running. If this is the case, such stretching of the elastic tape could then rebound as the fluid is reduced. Franettovich and colleagues15 found that anti‐pronation taping using the reverse‐6 method resulted in a reduction in electromyographic activity of the tibialis anterior and tibialis posterior muscles during walking. It is therefore possible that such a reduction in muscle activity following taping could result in increased fluid retention, which then increased the width of the midfoot. Certainly, additional research is warranted related to this finding. A reduction in muscle activity secondary to taping may have a deleterious effect if used over a long period of time.
The majority of the studies that have looked at the duration of the effect of LD taping on foot posture have used a brief bout of exercise, usually less than 20 minutes.7,18,20,30 Many of these studies have shown a relatively short‐term effect (less than 20 minutes) from the tape. A systematic review in 2006 by Radford2 concluded that the increased arch height seen following application of the LD taping technique was no longer present following 10 to 20 minutes of exercise (jogging).8 Investigations using the “augmented LD” technique have demonstrated a more sustained change compared to the LD technique alone, but again, they have not looked at anything greater than 20 minutes of exercise.4,5,14 Because the current study looked at the effect of time as well as a bout of exercise on the duration of the change in foot posture following taping, it is difficult to compare the results of the current study with that of past research.
The results of the current study do indicate that although either taping procedure may be used to obtain an immediate change in the height and width of the medial longitudinal arch, however, the two taping procedures differed with respect to how long that effect lasted. The change in the height of the arch after using the MR6 technique was no longer significant after four hours of general activity. DAH with the MR6+LD procedure, on the other hand, was still significantly different from the pre‐tape measurement at each time period throughout the day of testing. This finding indicates that augmenting the LD technique with the MR6 results in a more sustained change in DAH. In addition, the results of the current study indicate that the augmentation of the LD taping technique with the MR6 technique using elastic tape results in a more sustained effect, especially with respect to the change in the width of the midfoot.
It appears that although the LD taping technique is able to alter the posture of the foot, the change is primarily in the vertical direction since a greater change in the width of the midfoot seen when only the MR6 taping procedure was used. As such, it appears that if the goal of taping the foot is to increase the height of the arch, the MR6+LD procedure would be sufficient, however, if the objective is to decrease the width of the midfoot, the MR6 or the MR6+LD procedure would be effective. Such findings have clinical implications since previous research has identified arch height and mobility of the midfoot to be related to patellofemoral pain.29,31
Although the MR6 taping procedure alone resulted in the greatest decrease in the width of the medial longitudinal arch, combining both taping procedures demonstrated the ability to maintain the change throughout the day of testing. Additional research is certainly needed investigating the two taping methods used in the current study. This is especially true with regard to whether there is a difference between either procedure being able to reduce clinical symptoms of pain and dysfunction caused by excessive foot pronation and whether there is a minimal height or width change needed to reduce symptoms and improve function. In addition, there is also only anecdotal evidence that individuals prefer the elastic tape compared to inelastic tape because it is more comfortable and there is less skin irritation and blister formation. As such, future research should look at the influence of patient acceptance or preference on successful clinical outcomes.
Conclusion
Based upon the results of this study, the MR6 taping technique using elastic tape may be applied alone or with the LD taping technique in order to alter the height and width of the medial longitudinal arch. In addition, the changes seen in the width of the medial longitudinal arch remain statistically different from that produced immediately after applying the tape with either technique. The duration of the affected change is even more pronounced when the MR6 and LD taping procedures are combined.
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