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In this presentation,

I would like to demonstrate the 

application of strapping as it relates to 

both inversion and E version sprains 

and strains of the ankle.

First,

I would like to discuss strains,

strains involve the 

tendons which pass over 

the ankle.

Traditionally,

the achilles tendon posteriorly,

the peroneal tendons 

laterally and the tiballi 

anterior tendons are 

affected with 

ankle strains.

Strains you will remember are an 

overstretching of these tendons 

which result from ankle 

injuries played in various sports 

strains.

Treatment essentially 

involves in the first phase,

a suitable rest period.

By that 1st 24 to 48 

hours,

the person would rest the ankle 

and thereby give rest to the affected 

tendon restriction of 

movement,

stressing the tendon by strapping is 

also essential.

So that if the perennial tendons were affected,

one would strap the ankle appropriately to 

minimize movement at that particular 

portion of the ankle.

A cushion heel may be applied 

to the heel of the foot to 

reduce shock and forces which 

are transmitted through the calcaneus up through 

the fibula and the tibia 

as well.

The oral administration of anti inflammatory 

agents is probably advisable.

Now,

springs are a more 

serious form of injury in terms of 

the ankle and involve tearing 

of the ligaments which bind 

the tarsal and meta taal bones 

together.

The ligaments most commonly affected are the 

lateral ligament uh from the 

head of the fibula to 

the tailor and the calcaneus 

and on the medial side,

from the tibia 

portion via the deltoid ligament 

to the and the calcaneus.

Because springs are a 

tearing of these ligaments through 

overstretching sheer or compressive 

forces.

Swelling occurs.

There may be a collection of blood 

which finds itself trapped around the lateral mali 

or the media mole.

In which case,

this would have to be evacuated 

um before treatment could 

begin,

but essentially treatment begins in the 1st 

24 to 48 hours.

With the application of ice.

Traditionally,

one would raise the ankle and leg 

in an elevated position,

30 to 45 degrees.

Apply ice in a crushed,

crushed ice in a towel to the 

from the dorsum of the foot to one third of the 

ankle wrap it very tightly around the ankle 

over which you would apply a tensor bandage for 

approximately 15 to 20 minutes.

This would occur approximately 

23,

maybe four times a day for the 

first day or two until the swelling had 

subsided.

The advantage with elevation obvious 

is obvious in that gravity would assist the flow of 

secretions from the foot and ankle and help 

restore normal lymphatic 

and blood circulatory flow.

Since there is a tearing 

of the ankle ligaments,

the lateral or the medial ligaments 

following the application of ice.

In that 1st 24 to 48 hours,

the ankle should be bandaged and by 

bandaged,

we mean the application of an elastic 

crepe bandage tightly 

bound around the ankle.

Um in a normal 

pattern,

beginning distal and working proximal.

This in turn will help 

minimize swelling 

at that time.

The patient is instructed in the proper use 

of crutches and is told that he 

cannot take any weight through that foot.

So this foot in essence,

is being rested because the patient is not allowed 

to use it for walking.

Following that 48 hour period,

the acute stage of edema 

has subsided.

The application of 

support in the form of strapping 

is essential at this 

point in time,

the treatment is 

directed towards supporting the 

ankle.

The patient is now allowed to partially weight,

bear and may continue to partially weight 

bear for a period of 3 to 4 

weeks.

The progression there being from partial weight bearing 

initially to a more full weight bearing 

state.

Towards the end,

this with the support is allowing the 

ligament to heal.

At this point.

I'd like to demonstrate the typical 

inversion sprain 

involving the lateral 

ligaments of the ankle.

In which case,

the patient,

if he were standing upright,

four ft would become twisted,

putting an added strain on these ligaments 

as they attach 

to the points indicated,

the strain is usually very sharp,

very quick very abrupt,

resulting in tearing of 

these fibers.

This particular type of sprain accounts for 

90% of all ankle injuries.

The next sprain I would like to demonstrate is the e 

version sprain again,

much less common than 

the inversions brain but nevertheless 

occurs more frequently associated 

with uh an individual who 

whose feet are planted firmly on the ground and 

is struck from the lateral aspect of the of 

the of the calf involving 

a sudden sheer force,

twisting force,

resulting in a 

tearing of the deltoid ligament on the medial 

aspect of the ankle.

On the slide.

Before you,

you have demonstrated an E 

version sprain showing tearing 

of the lateral ligament 

as well as the tendons 

strains.

Sprains rather need not be 

this severe but can be 

ligamentous injuries.

In the next slide are classified 

and graded by the degree of severity.

A first degree ligamentous injury 

is a mild injury where no 

instability of the joint 

occurs.

In this case,

there would be a minor amount of tearing,

the patient would be treated as indicated 

and good results for 

normal function would be expected 

in a second degree minimal 

instability of the 

talofibular calcaneal joint 

exists and the patient 

demonstrates some increased symptomatology 

in that he has more severe pain,

more severe swelling,

perhaps some bleeding and so on.

In a third degree,

the complete disruption of the ligament 

either from its insertion on the 

describe bones,

the fibula or the tibia 

and maximal instability occurs 

now and the only correction at this 

point is through 

surgery,

it should be pointed out that treatment of ankle 

sprains without support and by 

support,

we mean strapping or a plaster boot,

regardless of what other means is used can be 

accurately described as non treatment.

I would now like to 

consider healing 

as it relates to sprains,

prevention of a re sprain which 

commonly occurs following the initial 

sprain is as 

important as the prevention of the ankle sprain.

Initially,

since ligaments do not heal these ligaments on the 

lateral aspect of the ankle do not heal by the formation of 

new ligamentous tissue,

but rather by fibrous scar tissue,

it is essential that once the 

ankle has been sprained,

it is far more susceptible to re sprain 

common sense would tell you that if this 

ligament has been torn and 

stretched and it heals in a 

lengthened state that the 

tendency towards re sprain becomes 

very classical.

This increased susceptibility may be reduced 

only by holding the sprained ligaments in a 

position of firm support 

so that the formation of the scar tissue will be 

minimal.

And that insofar as possible,

the fibers of the ligaments will heal in 

close proximity to each other.

So that once the strapping has been removed,

although fibrous scar tissue is present,

the ligament is in a shortened healing 

state,

thus preventing the prevention of a re 

spring providing more stability 

for the ankle.

At this point in time,

I should like to demonstrate the 

actual strapping process involving the 

ankle.

But before we do,

we would like to indicate the types of 

materials that are required in order to strap the 

ankle.

First of all the 

material we are using here is called pro wrap.

It's a very 

fine um 

polyethylene type of material which is 

wrapped over the foot prior to the administration 

of the tape.

This is done for basically two reasons.

One,

it will prevent a 

reaction between the patient and the 

tape because the tape never comes in contact with the 

skin.

Uh two,

it will also add 

um some support to the next 

items which we use,

which are the four by four 

gauzes with Vaseline pads in 

them.

The next material we use is the 

uh quick drawing tape adhesive 

um which is used in 

conjunction with the pro wrap so that it's sprayed on the 

ankle.

First,

the pro wrap is applied and then taping can 

begin the tape we use is the 

Johnson and Johnson Porus 

tape.

This particular role is a three inch roll.

Uh Normally we would recommend a one inch 

tape uh for purposes of taping 

today.

Uh I have decided to just tear this 

tape and uh apply it 

in a one inch strip.

Scissors are helpful particularly in 

the removal of the strapping.

Once it has been applied 

at this point,

I would now like to begin the demonstration 

by showing you the 

application of the four by four gauze with the 

Vaseline pads on the dorsum 

of the foot,

you have the flexor retinaculum,

which is a band of 

fibers moving transversely across the dorsum 

of the foot under which the tendons,

the tibial interior um pass 

if you were to apply the tape directly to the skin,

without this gauze.

Um and without the Vaseline irritation at 

this point would occur simply because the person's foot 

is continually flexing and extend dose,

flexing and and uh and planter 

flexion.

So we take the,

the gauze and we simply just 

lay it on the flexor retinaculum 

on the dorsum of the foot.

It's important in this particular patient 

who sustained a an 

inversion sprain which is directed 

this way,

the ligaments on the lateral aspect of the ankle 

were damaged.

And so to 

minimize movement and 

provide stability,

we simply ask that the patient keep the 

foot in the neutral position 

or slightly Dorsey flexed.

In this case,

the patient can keep it in the neutral position.

The next gauze pad is applied 

posteriorly to the 

achilles tendon 

to prevent irritation of the tendon as 

well as the underlying bursa.

At this point in time,

we take the 

ra adhesive spray and spray 

the ankle 

in essentially two places,

one third of the calf and the dorsum of the foot,

the pro wrap now can be 

applied,

it will cling to that adhesive.

And we follow a simple figure of eight 

pattern to cover 

the gauze 

pads sufficiently 

and enclosed the heel working our 

way up 

the caf 

having done that,

we are now ready to begin 

the actual taping.

In the first case,

two things we would like to 

establish are the 

anchors.

The first anchor is placed one third of 

the calf like so 

and it's basically just laid 

on.

There's a slight amount of tension on that but very slight.

The second anchor is placed on 

the dorsum over the dorsum of the foot 

and around the 

soul.

It's important here to 

tear the tape in such a fashion 

so that it does not bind upon 

itself.

So in other words,

a gap exists between both sides of the 

tape.

And the reason we do this is that when the person is 

finally taped,

strapped and stands on that foot,

this gap in the tape here allows 

for the meal bones to 

splay out.

Thus providing for more 

comfort.

Having applied both stirs,

both anchors rather top and bottom.

We would now like to begin the taping,

asking the patient to hold the ankle in the 

neutral position.

We begin on the medial side just 

posterior to 

the.

So it comes down just posterior to that.

And it's basically just laid on at which point 

as you come across,

the sole of the foot tension is 

applied,

which in turn wants to 

avert the foot.

Now remember that this is an inversion sprain involving 

the ligaments on the lateral aspect.

So that by pulling at this point,

you are now shortening these ligaments and then 

you attach that to the anchor at the 

top.

And then it's just a simple case of 

placing it down the next 

piece of tape which we call the 

bisector begins 

again,

everything begins on the media aspect.

In this particular case,

on the four ft anchor 

proceeds around the back of the heel,

around the side and is 

locked into place on the 

four ft anchor.

On the other side,

you'll notice very little tension has been applied a slight amount but very 

little on this particular case.

This bisector is in turn 

locking the first strip in place.

We would now like to apply the second strip 

which is going to be applied slightly posterior but 

overlapping the first coming again 

across the sole of the foot 

at which point you now apply tension 

again and it now passes 

basically over the lateral 

and then is firmed down 

on the ankle.

This is a rapid petition 

pattern in that we now applies the second 

bisector covering the 

second stir up.

So you can see the pattern stir up one bisector,

one,

stir up two bisector two.

You will also note that everything begins immediately on 

the inversion sprain.

If you had an E version sprain involving 

the deltoid ligament,

you would begin everything on the lateral aspect 

again.

Third strip is slightly 

anterior to the first stirrup 

comes right over the medium across 

the sole of the foot.

Again,

tension is applied at that 

point.

And you can see the indentation on the foot here 

is allowing for that tension 

to take,

take up the slack and the ligament and it comes in just 

slightly interior to the first stir.

The pattern from here on in is simply the 

application of the bisectors 

to close in the 

dorsum of the foot.

So you can see the pattern that's emerged.

We have three stirrups,

we have three bisectors and we simply just 

continue along now with the application 

of more bisectors.

And this firmly locks in the 

strips at a higher level.

The next important step in strapping 

the ankle 

is the heal lock,

probably the most important piece of tape that you will 

apply.

When you tape the ankle.

The heel lock is designed to 

specifically 

counteract any 

over stretching of the lateral ligaments.

You may feel that at this point that these 

ligaments are well supported.

But in actual fact,

this ankle can be 

inverted and averted slightly.

The heel lock 

begins on the media aspect 

of the ankle,

just like the stirrups comes down 

across the sole of the foot and 

we'll go very slowly on this so that you pick it up,

it comes across the dorsum of the foot.

So it's down from the media side across the soul.

Now over the dorsum of the foot 

around to the 

soul and the tape,

basically the direction of the tape at this 

point dictates where you must go next.

It has to now go between 

behind the lateral,

at this point,

you're applying tension,

it comes across the back of the heel 

again,

over the dorsum of the foot 

under the soul and again,

the tape dictates direction it is now 

behind the me mo so exactly 

what we've accomplished and then it 

finally ends up on the dorsum of the foot once 

more.

Now we'll do that again just so that everyone 

catches it.

But what we have in effect accomplished is a 

locking mechanism across the 

lateral aspect of the heel 

first.

And this in turn puts the 

lateral ligament in a very 

shortened position.

The next step of the same heal lock is to 

counteract that by applying tension to the 

media aspect of the heel.

And uh at that point,

you have a stabilizing force which 

locks that heel into place to 

demonstrate.

Once more,

we begin on the media aspect 

down across the sole of the 

foot over the dorsum 

down under the sole again.

And at that point,

you're ready for your first lock,

tear off some extra tape there.

And at that point,

you want to apply the tension,

that's the significant tension point.

And so then you go across the lateral aspect 

of the heel,

the tape direction basically tells you you can't come across the 

media part,

you've got to come over the dorsum of the foot again 

and under the heel and then you're now 

ready for the medial heel 

lock,

which then in turn brings the tape 

right back onto the dorsum of the foot.

Following the application of 

one,

perhaps two heel locks.

The simple application of a,

a figure of eight 

can be applied to the 

ankle to secure 

the tape from the heel locks.

Now,

at that point,

we have applied the necessary strips,

three stirrups,

three bisectors,

all overlapping each other and then close the ankle 

in with the remaining bisectors.

We then applied our first,

he lock down from the 

medial aspect because this is an inversion sprain.

So we want to avert the foot,

keep the ligament in a shortened position down from the medial 

aspect across the sole of the foot over the dorsum of 

the foot around behind 

the posterior lateral 

across the back over the dorsum once more 

under the sole around behind the 

and then back over ending up on the dorsum of the 

foot.

One final stage 

to this is to apply once 

more.

A sealing anchor 

to the tape at the top and 

bottom of the strapping.

So the first anchor is applied.

Second anchor is applied on the 

top over the first anchor and that 

seals the basic strips and the 

heel lock.

And then at the bottom,

following the same principle,

again,

the tape is applied allowing a gap 

in the bottom of the foot all this 

time.

It's important that the person keep that foot in a dorse flex 

position should problems arise in that 

voluntary cooperation of the patient 

not be present.

You can take a piece of tape 

and circle the lower portion of the 

foot like so and 

hand the remaining portion of the tape to 

the person.

So that in this particular case,

and he pulls on the tape,

he's pulling himself into a Dorsey flexed,

averted position.

Thus allowing for you to tape the 

final check on the taping that has been 

applied is determined with the patient 

in the standing position,

either partial weight bearing or fully weight bearing.

In this case,

the patient is almost fully weight 

bearing by asking the 

patient in this 

stance,

whether or not the tape is too tight on the lateral aspects 

is a good indicator as to whether the tape 

over a period of the next 12 to 24 

hours is going to limit 

circulation to the toes.

If the tape is too tight,

then a simple cut 

along the lateral aspect about an inch,

inch and a half long or the medial aspect,

an inch,

an inch and a half long may be made.

Such a cut will now be demonstrated 

simply going in,

take a small cut,

then ask the patient once more.

How does that feel?

If it,

it is required that you go a little further,

you can,

it's important not to cut too far into the tape.

Otherwise,

you are weakening the strapping 

as it is as it is shown 

it's important as well to note that 

in athletes,

this tape would be applied pre and post 

game time.

And in the non athlete such as this patient,

he attends the physiotherapy department daily for the 

application of the tape.

The duration again is somewhere between two and 

four weeks.

This can be determined by the ongoing assessment 

and the stability of the sub tailored joint.

In summary,

the important points to remember in taping the 

ankle are.