british medical journal

Taping the patella medially: a new treatment for osteoarthritis oftheknee joint?Janet Cushnaghan, Conor McCarthy, Paul DieppeAbstractObjective-To test the hypothesis that medialtaping of the patella reduces the symptoms ofosteoarthritis of the knee when the patellofemoraljoint is affected.Design-Randomised, single blind, crossovertrial of three different forms of taping of the kneejoint. Each tape (medial, lateral, or neutral) wasapplied for four days, with three days ofno treatmentbetween tape positions.Subjects-14 patients with established, sympto-matic osteoarthritis ofthe knee and both clinical andradiographic evidence of patellofemoral compart-ment disease.Main outcome measures-Daily visual analoguescale ratings for pain; patients' rating ofchange witheach treatment; and tape preference.Results-Medial taping of the patella was signifi-cantly better than the neutral or lateral taping forpain scores, symptom change, and patient pre-ference. The medial tape resulted in a 25% reductionin knee pain.Conclusion-Patella taping is a simple, safe,cheap way of providing short term pain relief inpatients with osteoarthritis of the patellofemoraljoint..IntroductionOsteoarthritis of the knee is a major cause of painand disability in older people.'2 There is no specifictreatment to modify the disease; current treatment isaimed at reducing symptoms and improving function.3Analgesic and anti-inflammatory drugs are used widely,in spite of potential side effects and doubts about theirefficacy.'-5 Some forms of physical therapy, such asquadriceps exercises, are known to be of benefit,6 andwalking aids can improve function. Surgical pro-cedures, particularly knee joint prostheses, are increas-ingly being used. However, most current treatmentsare both expensive and potentially dangerous.Simple, inexpensive treatment is needed for commondisorders such as knee osteoarthritis, which is not lifethreatening but can cause years of pain and handicapfor a large number of people in the community.Inexpensive interventions that give patients somecontrol over their symptoms are particularly attractive.If effective, they could reduce the financial burden ofthese patients as well as improving their quality oflife.Recent reports have emphasised the importanceof the patellofemoral compartment in knee osteo-arthritis.78 Disease of this part of the joint can causesevere pain, particularly when the patient -is usingstairs, squatting, or kneeling.9 Malalignment of thepatella, with consequential abnormal force distributionon the lateral facet, is thought to be the cause of thesesymptoms. Taping of the patella to pull it medially,followed by quadriceps exercises, has recently beenrecommended for the treatment of young people withanterior knee pain arising from the patellofemoral joint(chondromalacia patellae). 1I However, data fromcontrolled clinical trials to support such recommen-dations have not been published. The aims of thisstudy were, firstly, to evaluate the symptomatic benefitBMJ VOLUME 308 19 MARcH 1994 753FIG 1-Tape being applied with force to pull patella into medialpositionof knee taping designed to realign the patella in oldersubjects with knee osteoarthritis and, secondly, toapply rigorous clinical trial methodology to a physicalform oftreatment.Patients and methodsThe study protocol was approved by the local ethicscommittee. Fourteen consecutive patients attending ahospital based rheumatology clinic who fulfilled entrycriteria and were willing to take part were recruited tothe study. Entry criteria included the American Collegeof Rheumatology criteria for knee osteoarthritis,'2anterior knee pain, and difficulty walking and withsteps and stairs. The mean age of the patients was 70 4years (range 55-84) and the mean duration of kneesymptoms was 8-3 years (range 1-20); 10 patients werewomen.Current radiographs of both knees were obtained toestablish disease severity and compartmental involve-ment. Standing anteroposterior views for the tibio-femoral joint and skyline views in 450 flexion (whichvisualise the two facets of the patellofemoral joint andits alignment) were reviewed by a single observer andgraded according to a recently described system.'3All patients had radiographic evidence of osteoarthritis(defined as definite joint space narrowing withosteophytosis) in the patellofemoral compartment,predominating in the lateral facet in 12 cases. Evidenceof osteoarthritis in the tibiofemoral joint was alsopresent in all cases, although in eight of the 14 patientsthe disease was more severe in the patellofemoral thanin the tibiofemoral compartment.-- -- The study design was a single blind, blind observer,50 60 70 crossover trial of three different forms of taping of theore on visual knee joint. In each patient only the most troublesomealogue scale knee at entry, nominated by the patient, was treated.zin scores ly The order ofthe three treatments was randomised (butBars indieateintervals; not balanced) by random number allocation before theentry of the first patient; of six possible orders, fourwere used three times and one twice. The three types oftaping were: neutral, in which the tape was applieddirectly over the front of the patella, without anypressure; medial, in which the tape pulled the patella tothe medial side of the knee joint; and lateral, in whichthe tape was used to pull the patella to the lateral side.The taping consisted of a strip of Leukotape P(Beiersdorf, UK) applied by the same person ineach case (figure). This same therapist, who remainedblind to all pain scores and other outcome datathroughout the study, applied all tapes. The singleobserver was blinded to the tape application and orderof taping. Patients were not told which type ofapplication was thought likely to be effective.Knee pain was recorded with 10 cm visual analoguescales before and 1 hour after each tape application.Each tape was kept on for four days and overall pain oneach of the four days was recorded in a diary, againwith 10 cm visual analogue scale. After four dayspatients removed the tape and were asked to scorechange in symptoms in the treated knee joint (better,the same, or worse) compared with those presentbefore the tape treatment. After a three day interval theprocedure was repeated for the second tape positionand after a further four days' tape application and threeday interval, they entered the third and final arm of thestudy. At the end of the study period the assessorrecorded which week of treatment each patient hadpreferred.The crossover analysis was carried out using theoutcome measures as the dependent variables, withanalysis by patient, week of trial, treatment, and carry-over effect (previous treatment), using recommendedprocedures.14 Data were also submitted to oneway analysis of variance. Patient preferences wereexamined by an exact test, carried out under the nullhypothesis.ResultsAll patients tolerated the procedures well, keepingall tapes on for the full four days. No adverse reactionswere encountered. No significant period effect wasdetected, neither was there any carryover effect,precluding the need for further complex crossoveranalyses. The severity of pain did not differ one hourafter each tape application. Comparisons of the dailyvisual analogue pain scales for each ofthe three types oftreatment showed a significant reduction in pain for themedial tape compared with the lateral and neutral tapes(fig 2) (P <0 05, Student's t test; visual analogue scoreswere checked for normality with a Shapiro-Wilk test).The hypotheses that neutral tape was significantlydifferent from either lateral or medial taping werefurther investigated for pain recorded on each day oftreatment. As shown in table I, medial but not lateraltaping produced a signficant reduction in pain fromday two onwards. The patients' change scores alsofavoured the medial tape (table II), significantly more"better" scores being recorded for the medial tape thanfor taping in the neutral or lateral positions (P< 0.05,TABLE i-Patients' perception of pain (scores on 10 cm visualanalogue scale)Mean (SE) 95% confidenceVaiable difference interval P valueNeutral v medial taping:Day 1 7 0 (7 9) -9-8 to 23-7 0 39Day 2 19-0 (6 2) 5-9 to 32-1 0 007Day3 17-7 (7-1) 2-8to32-6 0-022Day 4 15-5 (6 2) 2-4 to 28-6 0-023Neutral v lateral taping:Day 1 -8-6 (8 8) -27-2 to 9-9 0 34Day 2 -8-9 (6 9) -23 4 to 5-6 0-21Day 3 -6-7 (7 8) - 23-2 to 9-7 0 40Day4 -8-0 (6 9) -22-5 to 6-5 0-26BMJ VOLUME 308 19 MARCH 1994NeutralMedial I -e30 40SCanFIG 2-Diatypadirection oftape.95% confidence ip-0 025754TABLE n-Effect oftaping onpatients' conditionTapingMedial Lateral NeutralChange:Better 9 2 2Same 4 6 6Worse 1 3 4Not recorded 0 3 2Kruskal-Wallis test). Eight patients preferred theweek the medial tape had been applied, compared withone preferring the lateral and three the neutral tapeposition (two were unable to express a preference).Analysis of these data under the assumption thatsubjects who did not express a preference were splitequally resulted in a significant difference betweenmedial and neutral preferences (9 v 4; P<0 05) but nodifference between lateral and neutral positions.DiscussionThe data indicate that tape applied with a forcepulling the patella medially reduced knee pain and waspreferred to taping in the lateral or neutral positions.The differences for all observations except pain at onehour or one day were statistically significant, and allfavoured the medial taping. The degree of pain reliefwas clinically as well as statistically significant, manypatients spontaneously reporting great relief as well asimproved function.The trial was carefully designed to preserve blindingto tape positions and likely benefits for both thepatients and the observer. The use of three similarphysical procedures by the same therapist in ran-domised order provides a relatively powerful test ofmedial taping and illustrates that rigorous trial tech-nology can be applied to physical as well as drugtreatments. The use of the same therapist and sameobserver for the whole study, neither of whom hadexpectations that were likely to influence the study,strengthens the design. The randomisation led to allbut one of six possible orders being used, and the datahad sufficient rank to be analysed. The absence of anyperiod or carryover effect, and the confidence intervalsfor the pain recordings, suggest that the data are valid.Patellofemoral joint osteoarthritis is common, tworecent studies indicating that this compartment of theClinical implications* Osteoarthritis of the knee joint is one of thecommonest causes of chronic pain and disabilityin the community* Current treatment is by physiotherapy andusing analgesic and anti-inflammatory drugs-expensive or potentially dangerous measures* Simple, safe, inexpensive measures toalleviate pain are needed* Medial taping of the patella resulted inconsiderably reduced pain in patients withosteoarthritis affecting the patellofemoral com-partment* Patella taping may provide a simple thera-peutic measure, which patients can learn to usethemselves, to reduce some of the burdenresulting from knee osteoarthritisknee joint is the one most commonly affected.78 Thedisease causes considerable pain and disability.'5 All ofthe 14 patients treated had radiographic evidence ofpatellofemoral osteoarthritis, as well as symptoms(anterior knee pain) that are likely to arise from thissite. The mechanism of pain relief by taping may be byrelieving pressure on the damaged lateral facet of thepatellofemoral joint and improving tracking of thepatella and function ofthe quadriceps mechanism.'011 16Both the mechanism of action and the value of thistreatment in relation to other interventions requirefurther investigation. The reasons for the delay inachieving significant relief ofpain are unclear.Knee osteoarthritis presents a serious health careproblem: the combination of its effect on patients andthe therapeutic procedures used produce a hugeburden on society.' 217 Simple, safe, physical treatmentprocedures such as taping could be of great value andmight be combined with other simple, non-invasiveinterventions such as improved patient contact.'8 Inour experience, patients are able to learn to apply theirown patella tape after minimal instruction. Thisprovides them with a low cost, easy means oftreatmentthat is under their own control. Relief of symptomsmight be maintained by concurrent exercises tostrengthen the medial part of the quadriceps muscle topermanently realign the patella.61l1' 16This study was performed over a relatively shortperiod and does not prove that taping is either safe oreffective in the long term. Further trials to investigatetaping in other patient groups, with longer periods oftaping, and to test the relative costs and benefits of thisand other interventions in knee osteoarthritis shouldbe undertaken.We thank Dr Philip Young for statistical advice and theArthritis and Rheumatism Council for financial support.1 Office of Population Censuses and Surveys. Morbidity statistics from generalpractice 1981-1982. London: HMSO, 1986. (Series MBSNo 1.)2 Spector TI), Hart DJ. How serious is knee osteoarthritis? Ann Rheum Dis1992;51:1 105-6.3 Dieppe PA. Management of osteoarthritis of the hip and knee joints. CurrentOpinion in Rheumatology 1993;5:487-93.4 Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI. Comparison of ananti-inflammatory dose of ibuprofen, an analgesic dose of ibuprofen andacetaminophen in the treatment of patients with osteoarthritis of the knee.NEnglJ7Med 1991;325:87-91.5 Dieppe PA, Frankel SJ, Toth B. Is reasearch into the treatment of osteo-arthritis with non-steroidal anti-inflammatory drugs misdirected? Lancet1992;341:353-4.6 Marks R. Quadriceps strength training for osteoarthritis of the knee: aliterature review and analysis. Physiotherapy 1993;79:13-8.7 McAlindon TE, Snow S, Cooper C, Dieppe PA. Radiographic pattems of kneeosteoarthritis in the community: the importance ~<>the pateliofemoral joint.Ann Rheum Dis 1993;51:844-9.8 Ledingham J, Regan M, Jones A, Doherty M. Radiographic pattems andassociations of osteoarthritis of the knee in patients referred to hospital. AnnRheum Dis 1993;52:520-6.9 Iwano T, Kurosawa H, Tokuyama H, Hoshikawa Y. Roentgenographic andclinical findings of patellofemoral osteoarthritis. Clin Orthop RelatedResearch 1990;252:190-7.10 McConnell JS. The management of chondromalacia patellae: a long termsolution. AustJPhysiother 1986;32:215-23.11 McConnell JS. Training the vastus medialis oblique in the management ofpatellofemoral pain. Proceedings of the 10th Intemational Congress WCPT,1987, Sydney.12 Altnan RD. Critieria for classification of clinical osteoarthritis. J Rheum1991;18 (suppl 27):10-2.13 Spector TD, Cooper C, Cushnaghan J, Hart DJ, Dieppe PA. A radiographicatlas ofknee osteoarthritis. London: Springer-Verlag, 1992.14 Senn S. Crossover trials in clinical research. Chichester: Wiley, 1993:137.15 McAlindon TE, Cooper C, Kirwan JR, Dieppe PA. Knee pain and disabilty inthe community. BrJRheum 1992;32:189-92.16 Doucette SA, Goble EM. The effect of exercise on pateilar tracking in lateralpatellar compression syndrome. AmYSporu Med 1992;20:434-40.17 Dieppe PA. Osteoarthritis: the scale and scope of the clinical problem. In:Osteoarthritis: current research and prospects for pharmacologial inteumennon.IBC Technical Services Ltd, 1991.18 Rene J, Weinberger M, Mazzuca SA, Brandt KD, Katz BP. Reduction of jointpain in patients with knee osteoarthritis who have received monthlytelephone calls from lay peraonnel and whose medicsl treatment regimenshave remained stable. Arthritis Rheum 1992;35:51 1-5.(Accepted29November 1994)BMJ VOLUME 3

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