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Elastic Bandaging for Orthopedic and Sports Injuries Prevention and
Rehabilitation: A Systematic Review
Article in Journal of sport rehabilitation · May 2016
DOI: 10.1123/jsr.2015-0126
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“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Note: This article will be published in a forthcoming issue of
the Journal of Sport Rehabilitation. The article appears here in
its accepted, peer-reviewed form, as it was provided by the
submitting author. It has not been copyedited, proofed, or
formatted by the publisher.
Section: Systematic Review
Article Title: Elastic Bandaging for Orthopedic and Sports Injuries Prevention and
Rehabilitation: A Systematic Review
Authors: Konstantinos Fousekis1, Evdokia Billis1, Charalampos Matzaroglou1, Konstantinos
Mylonas2, Constantinos Koutsojannis, and Elias Tsepis1
Affiliations: 1Department of Physiotherapy, Technological Educational Institute (TEI) of
Western Greece, Egio, Greece. 2Clinical and Sports Physiotherapist, Egio, Greece.
Running Head: Elastic bandaging in sports and orthopedics
Journal: Journal of Sport Rehabilitation
Acceptance Date: May 24,2 016
©2016 Human Kinetics, Inc.
DOI: http://dx.doi.org/10.1123/jsr.2015-0126
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Elastic bandaging for orthopedic and sports injuries prevention and rehabilitation: a
systematic review.
Running title: Elastic bandaging usage in orthopedics
Konstantinos Fousekis PhD,1 Evdokia Billis PhD,1 Charalampos Matzaroglou MD,
PhD,3 Konstantinos Mylonas PT,2 Constantinos Koutsojannis, Elias Tsepis, PhD.4
1. Assistant Professor in Physiotherapy, Department of Physiotherapy, Technological
Educational Institute (TEI) of Western Greece. Egio 25100, Greece.
2. Clinical and Sports Physiotherapist, Egio 25100, Greece
3. Assistant Professor in Orthopedics and Traumatology, Department of
Physiotherapy, Technological Educational Institute (TEI) of Western Greece. Egio 25100,
Greece.
4. Associate Professor of Physiotherapy, Department of Physiotherapy, Technological
Educational Institute (TEI) of Western Greece. Egio 25100, Greece.
Author contributions: All authors contributed almost equally to this work; Konstantinos
Fousekis, Charalambos Matzaroglou, Evdokia Billis and Elias Tsepis designed the
research; Konstantinos Fousekis, Konstantinos Mylonas and Charalambos Matzaroglou
performed the research; Konstantinos Fousekis and Konstantinos Mylonas analyzed the
data and all authors together wrote the paper.
Correspondence to: Konstantinos Fousekis, PT, PhD, Assistant Professor in
Physiotherapy, Department of Physiotherapy, Technological Educational Institute (TEI)
of Western Greece , Egio, Psaron 6, PC:25100, Greece, e-mail: [email protected]
Telephone: +003 02691022058, Fax: +oo3 026910-61250
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Abstract
Context: Elastic bandages are commonly used in sports to treat and prevent sports injuries.
Objective: To conduct a systematic review assessing the effectiveness of elastic bandaging in
orthopedic and sports injuries prevention and rehabilitation. Evidence Acquisition: We
searched the following electronic databases: MEDLINE, CINAHL, SPORTDiscus, EMBASE and
Physiotherapy Evidence Database (PEDro), with key words ‘elastic bandaging’ in combination,
respectively, with (1) first aid, (2) sports injuries, (3) orthopedic injuries and (4) sports injuries
prevention and rehabilitation. Research studies were selected based upon the use of the term
‘elastic bandaging’ in the abstract. Final selection was made by applying inclusion and exclusion
criteria to the full text. Studies were included if they were English, peer-reviewed clinical trials
on the effects of elastic bandaging for orthopedic injuries prevention and rehabilitation.
Evidence Synthesis: Twelve studies met the above criteria and were included in the final
analysis. Data collected included number of participants, condition being treated, treatment
used, control group, outcome measures and results. Studies were critically analyzed using the
PEDro scale. Conclusions: The studies in this review fell into two (2) categories: studies in
athletes (N=2) and non-athletes (N=10). All included trials had moderate-to-high quality, scoring
(≥5 on the PEDro scale). The PEDro scores for the studies in athletes and non-athletes ranged
from 5 to 6 out of 10 and from 5 to 8 out of 10, respectively. The quality of studies was mixed,
ranging from higher to moderate methodological quality clinical trials. Overall, elastic
bandaging can assist proprioceptive function of knee and ankle joint. Because of the moderate
methodological quality and insufficient number of clinical trials, further effects of the elastic
bandaging could not be confirmed.
Key words: Elastic bandaging, injury prevention and rehabilitation, orthopaedics, sports
physiotherapy
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Context
The term sports taping is used to describe various techniques for supporting an
anatomic region of an athlete with the usage of a fabric tape which either wrapped around an
anatomical structure (e.g. joint) or is affixed on it (e.g. skin-muscle). The need for supporting an
anatomical region is based on creating conditions for orthopedic injuries prevention and
protection as well as for adequate control of an acute injury in terms of edema formation
reduction and joint immobilization. 1-5
The epidermal material used for sports taping is divided into three (3) types and
respective techniques: a) the ‘elastic non-adhesive bandaging’ (ENAB) using elastic bandages
(bandage), b) ‘taping’ using non-elastic adhesive bandage (tape), and c) ‘kinesiotaping’ using
elastic adhesive tape (kinesiotape-elastic adhesive tape). 6 All three (3) types of sports taping
are applied a) in joints with functional deficits due to previous injuries, and b) in myodermal
structures for better proprioceptive activation and neuromuscular control or better metabolic
function. In both cases, sports taping can increase the athlete’s sense of safety as it enhances
joints stability and reduces occurrence of injuries.6-8
Although taping and kinesiotaping are the predominant therapeutic techniques used in
orthopedic and sports rehabilitation, 9-12 ENAB is used a) for compression of an anatomic
region,13 b) for decreasing or accelerating the time needed to achieve maximal joint range of
motion (ROM),13 c) to support other rehabilitative equipments such as cold-packs,14 and d) for
partial or total joint immobilisation.15 ENAB is also extensively used in treating sports injuries in
the acute stage and particularly during the first 48 hours of an injury. Bandaging of the injured
area may limit damage only to the tissue already affected and prevent possible hypoxic damage
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
of surrounding tissues. Furthermore, compression produced by the elastic bandage increases
tissue pressure thereby reducing excessive oedema and hematoma formation. For this purpose
ENAB can also be used in combination with other therapeutic interventions such as
cryotherapy.16 Applications of ENAB are also common in post-operative rehabilitation because
of their contribution in intra-articular bleeding elimination and analgesia.17,18 Additionally,
compression of the extremities via elastic bandaging also increases venous return in patients
with abnormal flow. 19,20
Despite the clear supremacy of other taping techniques (taping-kinesiotaping) in terms
of improving joint neuromuscular control and stability, 9-12 ENAB is used by many athletes both
amateur and professional ones for injury prevention.13,21,22 On that basis, it has been reported
that ENAB can improve position sense of a) of the knee in non-athletes 23 and in healthy dance
athletes, 24 and b) the elbow in non-injured males. 25 Nevertheless, although a body of research
exists regarding the potential efficacy of ENAB for either prevention or treatment of sports
injuries, there has not yet been a systematic review of this literature, exploring ENAB's true
clinical efficacy.
Objective
The purpose of this systematic review was to critically analyze previously published
literature to determine the documented effectiveness of ENAB both as a preventative means
and as a treatment strategy for orthopedic and sports injuries.
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Evidence Acquisition
Published studies relating to ENAB were identified using a computerized literature
search in PubMed, Sportdiscus, EMBASE, CINAHL and Physiotherapy Evidence Database
(PEDro). Three (3) reviewers (KF, KM,CM) performed independent searches in February 2015.
Keyword used in the search was “elastic bandaging” in combination with respectively “first-
aids”, “sports injuries”, “orthopedic injuries” and “sports injuries prevention and
rehabilitation”. Reference lists of identified studies were also evaluated for relevant literature.
The lists were compared, and articles identified by the three reviewers were collected in full
text. The initial search using multiple combinations of these key words resulted in 96 studies.
The three (3) reviewers (KF, KM and CM) screened the full-text articles for inclusion in
the review based on a set of inclusion and exclusion criteria. Inclusion criteria were as follows:
studies (1) published in a peer-reviewed journals, (2) containing sufficient data to critically
appraise the study according to PEDro criteria, (3) including, the use of ENAB as a treatment
method (4) being published in English, (5) addressing treatment for an orthopedic condition, (6)
involving adults. Pilots and case studies were not included in the analysis. A total of 12 research
articles 18,24-34 met the inclusion criteria and were reviewed (Figure 1).
The three reviewers assessed all selected studies for methodological quality according
to standardized PEDro scale (Table 1). The PEDro scale is an evaluation checklist developed for
the Physiotherapy Evidence Database by the Centre for Evidence-Based Physiotherapy. 35 This
scale examines quality based on 11 criteria, 10 of which are scored. Points were summed and
presented as a score out of 10. For this review, investigations with PEDro scores of 6 and over
out of 10 were considered of high quality, 4 to 5 of moderate quality, and 0 to 3 were
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
considered of low quality. The PEDro scale examines mainly the internal validity and
interpretability of the studies and not their clinical utility. All reviewers were unaware of each
other’s results until all studies were independently assessed. Agreement upon the final score
was achieved through discussion amongst the 3 reviewers.
Levels of Evidence and Strength of Recommendation
The level of evidence for the included studies and strength of recommendation for the
use of ENAB in sports injuries prevention and rehabilitation was determined using the criteria
suggested by the Oxford Center for Evidence Based Medicine. 36
Evidence Synthesis
A total of 12 research articles were reviewed. 18,24-34 Summary of included studies is
presented in Table 2. The studies in this review included both, athletes 26,34 and non-athletes.
18,24,25,27-34 All included trials were of moderate-to-high quality, scoring an average PEDro score
of 5.6 on the PEDro scale (Table 3). The PEDro scores for the studies in athletes and non-
athletes ranged from 5 to 6 out of 10 and from 5 to 8 of out of 10, respectively.
RCT: Randomised Control Studies, CT:Clinical Trials, ENAB: Elastic non-adhesive
bandaging, IPC: Intermittent pneumatic compression, OA: Osteoarthritis, VAS: Visual analogue
scale, ACL: Anterior cruciate ligament, ROM: Range of motion
Effects of ENAB in functional outcome after musculoskeletal-sports injury
Four of the selected papers studied the effects of ENAB on functional outcomes in
patients after sports injuries. 18,26-28 Gunay et al 26 evaluated the effect of using Aircast®
orthosis and ENAB application on the physical performance of 60 elite male football players
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
with ankle injuries. Battery of tests used included examination of ankle ROM, one maximum
repetition test for the ankle dorsal and plantar flexors, fingertip rise test, jump tests and 10-
step/sec test. Their results showed that ENAB restricted non-weight bearing ankle dorsi/plantar
flexion ROM by 9.85±3.74 degrees (p<0.05) and inversion-eversion ROM by 10.70±4.14 degrees
(p<0.05) compared to no bandaging. The use of ENAB did not hinder performance in any of the
four aforementioned functional tests.
Similar results with those of Gunay et al 26 were found in Boyce et al’s study 18 in an
attempt to determine the functional outcome of the ankle of non-athletes after a moderate or
severe inversion injury. They compared the effects of a standard treatment with Aircast ankle
brace against ENAB application in a randomized control study (RCT) of high methodological
quality (7/10 PEDro). Their findings showed that the use of an Aircast ankle brace improved
ankle joint functional capacity at 10 days (Karlsson score : mean 50 v 35, p = 0.028, 95%
confidence interval 1.7 to 27.7) and at one month (Karlsson score mean 68 v 55, p = 0.029, 95%
confidence interval 1.4 to 24.8) compared to standard management procedure with ENAB.
Furthermore, it should be reported that there was no difference between the effects of the two
techniques in ankle joint swelling (mean ankle girth: elastic bandage 14.4 cm, Aircast ankle
brace 8.5 cm; p = 0.09) and pain (mean pain scores-VAS: elastic bandage 2.9, Aircast ankle
brace 1.8; p = 0.07). Nevertheless, due to the absence of a control group, it is not possible to
draw definite conclusions about whether the ENAB group fared better than no bandage at all.
Leanderson & Wredmark 28 also evaluated the effects of treatment with ENAB or an Air-
Stirrup® ankle brace in patients with severe ankle sprains. Their results showed that patients
treated with the Air-Stirrup® ankle brace were more mobile (Active range of motion in
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
dorsiflexion/plantarflexion in 10 weeks after injury: Air-Stirrup® ankle brace: 95% of the
uninjured ankle; ENAB: 87% of the uninjured ankle) in the initial phase of rehabilitation and
had shorter sick leave.
Airaksinen et al 27 showed that the decrease in edema in ankle sprains with ENAB
application was significantly exponential with time during the four-week follow-up (from 105mL
to22mL in the fourth week after ENAB application, r = 0.997, p < 0.001). However intermittent
pneumatic compression treatment applied together with ENAB accelerated ankle sprain
rehabilitation procedure (ankle edema, ROM, pain, limb dysfunction) compared to the
application of ENAB or IPC alone.
The findings of the above studies [18, 26-28] do not clearly determine the role of ENAB
against no bandage application on functional outcomes after musculoskeletal-sports injury.
Evidence to date suggests that rehabilitation with the use of ENAB may be inferior to braces in
achieving more effective edema reduction and an earlier return to optimal functional status
after ankle joint injuries.
Effect of ENAB in joint proprioception
Seven (7) research trials assessed the effects of ENAB in joint proprioception in
orthopaedic pathologies and in healthy individuals. 24,25,29,30-33 Three (3) of them investigated
the effect of ENAB in proprioception of patients with knee osteoarthritis. 29,30,33 Hassan et al 29
evaluated whether knee ENAB in subjects with knee osteoarthritis (OA) would decrease pain
and improve knee joint neuromuscular control. Their high quality (7/10 PEDro) study showed
that ENAB significantly reduced knee pain (pre-bandage application: median VAS 4.36, IQR 3.84
–4.90; after 20 minutes of bandage application: median VAS 3.80, IQR 3.3–4.3, p<0.001),
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
improved static postural sway (pre-bandage: median sway 4.50, IQ range 3.5–6.4; bandage
applied: median sway 4.45, IQ range 3.4–6.3, p=0.027), in subjects with OA. These findings are
supported from the results of Barrett, et al (1991), who indicated that ENAB improves position
sense of accuracy in OA knees by 40%. 30 In contrast to previous findings, Hewitt et al 33
reported that ENAB did not significantly affect movement detection in 10 women aged > 65
years with moderate to severe knee OA. In particular, in this study, the 70% detection level for
the OA group with ENAB application was 2.9±1.0o and without the bandage was 2.9±0.8o. In the
control group, movement detection levels after ENAB application was 2.1±0.6o and 2.4±0.6o
without a bandage.
The proprioceptive function of the knee after external stabilization with ENAB has also
been evaluated in patients with patellar pain syndrome 31 and anterior cruciate ligament
deficiency.32 Both studies although graded as having moderate quality (5/10 PEDro) they
reported that ENAB improved injured knee joint angle reproduction capability. 31,32
Similar positive findings to the influence of ENAB in knee proprioception are found in
the ankle’s neuromuscular function. 24,25 Khabie et al 25 in a RCT of high methodological quality
(6/10 PEDro) reported a significant improvement in elbow position sense (2.2° ± 1.2°, P <.004)
after elbow ENAB application in twenty healthy volunteers, thus, implying a proprioceptive
facilitative role of ENAB. Based on this finding authors concluded that tactile cues from
cutaneous or other extraarticular receptors may play a role in elbow proprioception.
Furthermore, Wong et al 24 reported that knee ENAB decreased significantly the absolute error
(mean absolute errors of blindfolded set angle reproduction: ENAB=4.38, No ENAB=9.37,
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
p<0.001) produced in joint angle reproduction test during passive knee motion compared to no
ENAB application in 26 non injured dance students.
Effects of ENAB in joint range of motion (ROM)
Yamamoto et al 34 in a study with a small number of participants (N=4) evaluated the
effectiveness of the ankle ENAB and taping on tallar tilt (TT) range of motion (ROM) in judo
athletes. Their results showed that talar tilt angles were decreased (1-9°) after ENAB, but after
90 min of judo training, the talar tilt ROM were again the same as those without support ankle.
As expected taping was more effective in decreasing talar tilt ROM than ankle ENAB in judo
athletes and this restrictive effect remained after 90 min of competitive judo training.
As mentioned before, Gunay et al 26 also reported that ENAB can decrease ankle ROM
in terms of eversion/inversion and dorsal/plantar flexion. Nevertheless it was also determined
that Aircast® orthosis created a statistically significant restriction in joint range of motion,
compared to the ENAB in terms of eversion and inversion.
Levels of Evidence and Strength of Recommendation
The quality of included clinical trials and randomized control studies was generally low
and their levels of evidence is limited to level 2-b and 3-b evidence. As a result of the
aforementioned methodological quality issues and poor strength of studies the strength of
recommendation for the use of ENAB for prevention and rehabilitation of injuries is of grade B,
thus indicating uncertainty for its use.
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Discussion
This is the first study to systematically review moderate and high quality research
studies, in exploring the evidence for ENAB application for preventing or rehabilitating sports
injuries . The present review revealed initially that although the technique is widely used by
Medical Doctors, Sports Physiotherapists and athletes and various health professionals and
they have been written several books on ENAB application techniques, 5,37 relevant research is
extremely small. We reviewed six (6) randomized controlled trials 18, 25,27,28,31,32 and six (6)
clinical trials 24,26, 29, 30,33,34 which studied the effects of ENAB alone or compared with other
therapeutical techniques of joint mechanical support. The quality of these trials was moderate
with an average PEDro validity score of only 5.8. However, most studies had acceptable scores.
Surprisingly, there is no research on a) the effect of ENAB in acute stage of injuries and
b) the necessity of its usage as first aid technique for the reduction of edema and hematoma
formation. However, two studies have highlighted that, despite this lack of scientific evidence,
ENAB is currently used as first line treatment in more than 70% of British emergency
departments. 38,39 The usage of ENAB in Emergency departments and sports fields for
management of acute injuries is probably based on the theory that compression via ENAB
contributes to reduced edema accumulation and increased venous return. 40,41
Τhe scientific studies evaluated in this review do not give clear answers on the impact
of ENAB on either injury prevention or rehabilitation. More specifically, there are no studies
evaluating the effects of ENAB on injury prevention based on prospective trials and
examination of related parameters over time. Nevertheless, their findings regarding joint
proprioceptive adaptations and ROM after ENAB application can be of critical importance given
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
that kinaesthetic disorders (especially deficits in joint position sense and sense of efforts
following musculoskeletal injury) can alter normal kinetic patterns and thus lead to re-injuries.
For example, the deficient proprioceptive function (sense of position) of the ankle joint has
been connected with incorrect biomechanical kinetic patterns at foot landing (excessive foot
supination) and theoretically increased risk of ankle re-injury.42-44 Τhus, efforts for improvement
of the lower extremities neuromuscular control through specialized proprioceptive exercises
and probably external mechanical support (such as ENAB) can be of great importance in injury
prevention. In this direction, the current review found a small amount of evidence supporting
the idea that ENAB improves knee and ankle proprioception in in patients with OA, meniscal
problems and healthy individuals. 24,25,29,30-32 These positive effects after ENAB application in
joints neuromuscular and kinaesthetic function can be attributed on irritation of kinaesthetic
receptors and subsequent improvement of joint position. Moreover, although it is non-evident,
it seems reasonable to suggest that ENAB by skin compression (and hence a better activation of
sensory receptors of the skin and underlying tissues) 45,46 can activate faster muscular response.
For example, ankle ENAB probably reduces the reaction time of peroneal muscles thus
inhibiting dangerous loading of the ankle generated by violent supination.
Although supported indirectly from only two studies in this review, it seems that ENAB
has a minimal protective function in terms of reduction of injury risk through improvement of
joint stability. More specifically, ENAB can lead to a significant reduction in both passive and
active ROM. 26,34 This ROM reduction which is immediately observed after ENAB application
progressively decreases with exercise.34 The protective effects of joint ENAB application, though
have not been directly reported in relevant studies, can also be attributed to possible reduction
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
of medium and maximum speed within which joint ROM is achieved. This biomechanical
adaptation hypothetically can increase the period of time before dangerous loading of the joint
and can thus, provide sufficient time for joint protective mechanisms (proprioceptive
information and muscular response) to act for elimination or reduction of the injury risk. Such
protective biomechanical adaptations have been clearly reported in ankle and shoulder taping
studies,8,47-48 and, in theory, can be attributed to a lesser extent to ENAB.
The above results regarding neuromuscular adaptations after ENAB application though
derived from studies of moderate methodological quality seem logical. It is reasonable to
expect a ROM reduction and better stabilization of a joint after ENAB application (mechanical
compression and neuromuscular enhancement provided from the elastic material). Superiority
of non-elastic adhesive tape (taping) and of Aircast® orthosis compared to ENAB in joint ROM
control was also expected due to their specific characteristics (rigid-anelastic). Several other
studies have shown that anelastic taping of a joint or the application of an Aircast® orthosis will
lead to a significant reduction in both passive and active range of ankle motion. 8, 50,51
Literature regarding enhancement of sports injuries rehabilitation processes through
ENAB has been limited to the comparison between ENAB and semi-rigid ankle supports. 18, 26-28
Evidence to date suggests that rehabilitation with the use of ENAB may be useful in
terms of edema reduction and controlled ROM in non-weight bearing. Furthermore the use of
ENAB did not affect functional performance compared to rigid braces. Existing evidence reports
that ENAB is less effective than semi-rigid ankle supports in terms of a) time to return to work
or sports and b) subjective instability on short-term. 18, 26-28 This conclusion is supported by
several other studies 52,53 reporting that although no adverse results are connected with ENAB
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
applications, the use of ankle braces is superior to an elastic support or ENAB. Patients treated
with ENAB took longer to return to work 28,53 and reported increased subjective instability. 52
However, despite known limitations accompanying the use of ankle braces (reduced functional
capacity and reduced compatibility with sports shoes) there are no comparisons between ENAB
and other taping techniques (taping-kinesiotaping) concerning their effectiveness for injury
management.
The findings of this review are unable to fully support the use of ENAB against other
taping techniques for musculoskeletal injury prevention and rehabilitation. In particular, there
are no randomized controlled studies with satisfactory methodological quality to compare the
effects from the application of all three taping techniques on critical parameters, such as joint
mechanical support and improvement of stability (which is the dominant aim of a sports taping
application) as well as enhancement of athlete’s functional capacity.
It seems that clinical sports physiotherapists should probably limit the use of ENAB to
the acute stage of injuries and in reducing edema-hematoma procedures. In this case the
external mechanical compression must be based upon an elastic taping material to avoid the
risk of excessive arterial compression. The main objectives of the subacute phase of a
rehabilitation program for orthopaedic and sports injuries such as reduction or avoidance of
dangerous final parts of injured joint ROM in conjunction with neuromuscular control
enhancement seems better served by anelastic taping techniques and specific types of joint
orthosis. Nevertheless, even minimal positive effect of ENAB and the ease of implementation in
relation to the other sports taping techniques indicate the necessity of applying it in cases
where the anelastic taping cannot be applied.
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
The main limitations of this review relate to the scarcity of studies and the lack of
sufficient methodological quality scientific surveys. Specifically, although ENAB is a common
therapeutic procedure, research about its effects a) is minimal and b) is related
to several methodological issues, such as small number of participants and vague description of
critical data (p-values etc). Furthermore there are no studies testing the effects of ENAB versus
no ENAB application on injury rates or return to sport. As presenting studies evaluated only
proprioception and/or functional outcomes, definite conclusions regarding injury risk, re-injury
risk or return to sport are only inferential and not directly supported by the evidence presented
cannot be made. Additionally, reported reductions in active ROM were performed in non-
weight-bearing conditions and it is not clear whether these reductions could reflect weight
bearing situations or provide any meaningful protection in an athletic environment. The most
impressive of all was that there were only two studies which evaluated
the effect of ENAB in athletes. It is therefore evident the lack of data to extract definitive
conclusions about the value of ENAB clinical application. Furthermore, statistical comparisons
of data was not possible as the studies evaluated in this review examined completely
different variables and parameters regarding use of ENAB. Therefore, the survey
data evaluated in this review could not critically appraised by categories, i.e. by outcome
measures, body region, injury type, prevention, or treatment outcomes and examined
independently. On this basis, this review was based clearly on the qualitative
evaluation of the studies through PEDRo scale rather than on the comparative quantitative
evaluation of the studies’ results.
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Future research should focus on the effects of ENAB on injury prevention by conducting
prospective injury prevention trials. Other scientific topics that need to be addressed include a)
quantification of ENAB true influence on swelling control and on active, passive and weight-
bearing joint ROM and b) consideration on whether ENAB is appropriate for all kinds of athletes
or whether kinesiological and sport-specific considerations require different interventions.
Research also should clarify which type of taping (ENAB, taping, kinesiotaping) is most effective
in terms of improving functional outcome after an injury (ROM, strength, neuromuscular
control and return to play times).
Conclusions
Consequently, it is difficult to draw definitive conclusions concerning the effects of ENAB
for prevention and rehabilitation of orthopedic and sports injuries. While there is moderate
evidence suggesting improved ankle proprioception in terms of enhancing kinesthesia and
neuromuscular control in subjects wearing elastic bandage there is insufficient evidence for the
effects of ΕΝ-ΑΒ application on other critical parameters such as joint ROM and stability and
functional outcome after injury.
Randomized controlled studies focusing on different aspects of ENAB application are
necessary to determine the effect of its application and establish its 'working context' in an
effort to create ideal conditions for prevention and rehabilitation of musculoskeletal and sports
injuries.
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
References
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“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Figure 1. Consort diagram showing flow of studies through the review
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Table 1. Physiotherapy Evidence-Based Database Scale [35]
PEDro Criteria
1. Participants were randomly allocated to groups (in a crossover study, participants were
randomly allocated to the order in which the interventions were received).
2. Allocation was concealed.
3. The groups were similar at baseline with regard to the most important prognostic indicators.
4. There was blinding of all participants (as per wording of original guidelines).
5. There was blinding of all therapists who administered the intervention.
6. There was blinding of all assessors who measured at least one key outcome.
7. The follow-up of all participants entered into the trial was adequate.
8. All participants for whom outcome measures were available received the intervention or
control condition as allocated or, when this was not the case, data for at least one key
outcome were analyzed on the basis of ’’intention to treat.‘‘
9. The results of between-group statistical comparisons were reported for at least one key
outcome.
10. The study provided both point measures and measures of variability for at least one key
outcome.
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Table 2. Overview and summary of included studies
Reference Objectives Subjects Design Primary outcome
measure Results
Effects of elastic bandaging in functional outcome after ankle sprains
Boyce et al 18 To determine the effect of
ENAB and bracing in
functional outcome of the
ankle joint after a moderate
or severe inversion injury,
50 patients
(non
athletes)
RCT Modified Karlsson
scoring method
(maximum score 90).
Swelling Pain score
(at 10 days)
Aircast® orthosis for the
treatment of lateral ligament
ankle sprains produces a
significant improvement in
ankle joint function at both 10
days and one month compared
ENAB
Gunayet al 26 To evaluate the effect of
using an Aircast® orthosis
and ENAB application on
the physical performance of
athletes with ankle injuries.
60 elite
male
football
players
CT Ankle range of
motion Tibialis
anterior strength,
tibialis posterior and
peroneal muscles;
fingertip rise test,
Single- and double-
feet vertical jump
tests 10-step/sec test
for the gastrosoleus
The Aircast® orthosis was m
ENAB ore effective than the
ENAB in reducing injury risk,
preventing repetitive injuries
and providing an early return to
sports.
Airaksinen,
et al 27
To evaluate ENAB alone
and with intermittent
pneumatic compression
(IPC) therapy for the
rehabilitation of acute ankle
sprains
44 patients
(non
athletes)
RCT Edema Degree of
ankle motion Pain
Limb dysfunction
ENAB together with IPC
treatment resulted in faster
rehabilitation during the four-
week follow-up than did
bandaging alone
Leanderson
& Wredmark 28
To evaluate the effects of
treatment with an Air-
Stirrup® ankle brace or a
compression bandage in
73 patients
with grades
II and III
ankle sprain
RCT Clinical examination
Sickness Impact
Profile questionnair,
Karlsson's scoring
Patients treated with the Air-
Stirrup® ankle brace was more
mobile in the initial phase of
rehabilitation and had a shorter
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Reference Objectives Subjects Design Primary outcome
measure Results
patients with severe ankle
sprains
scale Recording of
sick leaves
sick leave.
Effect of Bandaging on proprioception
Wong et al 24
To determine the effects of
ENAB and ankle weight in
ankle joint proprioception
(joint position sence)
26 non
injured
dance
students
CT Reproduction of an
ankle set angle
ENAB and ankle weights
improve ankle proprioception
Hassan et al 29
To investigate whether
ENAB of the knee in
patients subjects with knee
osteoarthritis (OA) would, in
the short term (a) reduce
pain, (b) improve knee joint
proprioception, and (c)
decrease sway
68 patients
with knee
OA
Cross
over,
within-
subject
study
Knee pain (VAS)
Knee proprioception
Static postural sway
Knee ENAB reduces knee
pain and improves static
postural sway in patients with
OA
Barrettet al 30 To inestiaget joint position sense in OA knees with and without ENAB
Eighty-one
normal and
45 OA
knees
CT Perception of the
position
ENAB improves position sense
accuracy in subjects with OA
by 40%
Khabie et al 25
To investigate the effect of
ENAB and injection of an
intra-articular anesthetic on
both elbow position sense
and detection of motion
Twenty
uninjured
male
volunteers
RCT Reproduction of an
ankle set angle (with
Biodex
dynamometer).
The application of ENAB
improves position sense
Jerosch et al 31
To investigate the effects of
ENAB on knee joint
proprioception of patients
43 patients
with a
patellar pain
RCT Passive angle
reproduction test
ENAB improves injured knee
joint angle reproduction
capability
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Reference Objectives Subjects Design Primary outcome
measure Results
with patellar pain syndrome
syndrome–
Control
group: 30
healthy
volunteers
Jerosch et al 32
To investigate the effects of
ENAB in proprioception of
the ACL-deficient knees
25 patients
with an
rupture of
the ACL
Controls: 30
healthy
volunteers
RCT Angle reproduction
test
ENAB has positive influence
on acl-deficient knees
proprioception
Hewitt et al 33
To investigate whether OA
or ENAB of the knee affects
movement detection.
10 women
aged > 65
years with
knee OA
and 10
healthy
women as
controls
CT Movement detection
levels at 0.5°/second,
ENAB did not affect
movement detection
Effect of bandaging on sports injury prevention
Yamamoto et
al 34
To compare the effects of
ankle ENAB and taping in
ankle talar tilt ROM in judo
athletes .
4 University
judo
athletes
with ankle
instability
CT Talar tilt (TT) angles Ankle taping was more
effective than ENAB in
eliminating the talar tilt during
judo practice
RCT: Randomised Control Studies, CT:Clinical Trials, ENAB: Elastic non-adhesive bandaging, IPC: Intermittent pneumatic compression, OA: Osteoarthritis,
VAS: Visual analogue scale, ACL: Anterior cruciate ligament, ROM: Range of motion
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
Table 3. Physiotherapy Evidence Database (PEDro) Scale Scores
PEDro Scale Boyce et
al [18]
Wong et al [24]
Airaksinen et al. [27]
Leanderson &
Wredmark [28]
Hassan et al
[29]
Barrett, et al [30]
Khabie et al [25]
Jerosch et al
[31]
Jerosch et al
[32]
Yamamoto et al [34]
Hewitt et al [33]
Gunay et al [26]
Subjects were randomly allocated
to groups Y N Y Y Y N Y N N N N N
Allocation was concealed
Y N N N N N N N N N N N
The groups were similar at baseline regarding the most
important prognostic indicators
Y Y Y Y Y Y Y Y Y Y Y Y
There was blinding of all subjects
N N N Y N N N N N N N N
There was blinding of all therapists who
administered the therapy
N N N N Y N N N N N N N
There was blinding of all assessors who measured at least one key outcome
N N Ν N Ν N N N N N N Ν
Measures of at least one key outcome
were obtained from more than 85% of
the subjects initially
Y Y Y Y Y Y Y Y Y Y Y Y
“Elastic Bandaging for Orthopedic and Sports Injuries Prevention and Rehabilitation: A Systematic Review” by Fousekis K et al.
Journal of Sport Rehabilitation
© 2016 Human Kinetics, Inc.
PEDro Scale Boyce et
al [18]
Wong et al [24]
Airaksinen et al. [27]
Leanderson &
Wredmark [28]
Hassan et al
[29]
Barrett, et al [30]
Khabie et al [25]
Jerosch et al
[31]
Jerosch et al
[32]
Yamamoto et al [34]
Hewitt et al [33]
Gunay et al [26]
allocated to groups
All subjects for whom outcome measures were
available received the treatment or
control condition as allocated
Y Y Y Y Y Y Y Y Y Y Y Y
The result of between-group comparisons are
reported for at least one key outcome
Y Y Y Y Y Y Y Y Y Y Y Y
The study provides both point measures
and measures of variability for at least
one key outcome
Y Y Y Y Y Y Y Y Y Y Y Y
Total score 7 5 5 7 7 5 6 5 5 5 5 5
Y=Yes, N=No
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