THE EFFECT OF FATIGUE ON BALANCE IN ANKLE TAPE VS LACE UP
BRACE CONDITIONS USING A STAR EXCURSION BALANCE TEST ON
CHRONICALLY UNSTABLE ANKLES

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Mallory R. Bieringer

Research Advisor, Dr. Rebecca Hess
California, Pennsylvania
2011

ii

iii

ACKNOWLEDGEMENTS

I would like to take this opportunity to thank
everyone who played such an important role in the
completion of this thesis.

First, I am so grateful to Dr.

Hess as well as the rest of my committee, Dr. Carol
Biddington and Dr. Tom West whose comments and ideas I made
great use of for this study.

Their contributions,

knowledge, and experience were most valuable to the
creation of this project and kept me motivated on my path
to completion.
I would also like to thank the students, colleagues,
and faculty at California University of Pennsylvania for
their efforts and to the student-athletes and physically
active population who participated in my study; I truly
appreciate all of your time and effort for the development
of data-driven learning.
Finally, I thank my family for continuously supporting
me through my ups and downs and understanding my desire to
complete my Master of Science Degree.

I can’t thank you

all enough: Mom, Dad, Missy, Mandy, and my twin nephews,
Aidan and Logan.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . . ii

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS .
LIST OF TABLES
INTRODUCTION
METHODS

. . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . . 6

Research Design. . . . . . . . . . . . . . . . 6
Subjects

. . . . . . . . . . . . . . . . . . 7

Preliminary Research. . . . . . . . . . . . . . 8
Instruments . . . . . . . . . . . . . . . . . 9
Procedures. . . . . . . . . . . . . . . . . . 15
Hypothesis

. . . . . . . . . . . . . . . . . 18

Data Analysis

. . . . . . . . . . . . . . . . 19

RESULTS . . . . . . . . . . . . . . . . . . . 20
Demographic Data

. . . . . . . . . . . . . . 20

Hypothesis Testing

. . . . . . . . . . . . . 22

Additional Findings . . . . . . . . . . . . . 23
DISCUSSION

. . . . . . . . . . . . . . . . . 25

Discussion of Results . . . . . . . . . . . . 25
Conclusion . . . . . . . . . . . . . . . . . 28
Recommendations . . . . . . . . . . . . . . . 29
REFERENCES

. . . . . . . . . . . . . . . . . 31

v
APPENDIX A: Review of Literature
Chronic Ankle Instability
Ankle Anatomy

. . . . . . . . . 35

. . . . . . . . . . . 37

. . . . . . . . . . . . . . . 37

Injuries to the Ankle . . . . . . . . . . . 39
Use of Prophylactic Support

. . . . . . . . . 41

Tape . . . . . . . . . . . . . . . . . . . 42
Semi-Rigid and Lace-up braces

. . . . . . . 45

Balance Testing . . . . . . . . . . . . . . . 47
Types of Balance Tests

. . . . . . . . . . 47

Drop Landing . . . . . . . . . . . . . . . 48
Star Excursion Balance Test
Effects of Fatigue
Summary

. . . . . . . . 50

. . . . . . . . . . . . 52

. . . . . . . . . . . . . . . . . . 53

APPENDIX B: The Problem . . . . . . . . . . . . . 56
Statement of the problem . . . . . . . . . . . . 57
Definition of Terms . . . . . . . . . . . . . . 57
Basic Assumptions . . . . . . . . . . . . . . . 59
Limitations of the Study . . . . . . . . . . . . 59
Significance of the Study. . . . . . . . . . . . 60
APPENDIX C: Additional Methods .

. . . . . . . . . 62

Data Collection Sheet (C1) . . . . . . . . . . . 63
Informed consent form (C2) . . . . .

. . . . . . 66

Fatigue Protocol (C3) . . . . . . . . . . . . 70
Pictures of SEBT (C4) . . . . . . . . . . . . . 75

vi
IRB: California University of Pennsylvania (C5) . . . 77
REFERENCES . . . . . . . . . . . . . . . . . . 90
ABSTRACT . . . . . . . . . . . . . . . . . . . 94

vii
LIST OF TABLES
Table

Title

Page

1

Demographic Data . . . . . . . . . . .

21

2

Descriptive Statistics for Condition . . .

23

1

INTRODUCTION

One of the most common injuries that occur with
sporting events or physical activity is a lateral ankle
sprain.1-6 The level of severity varies with each injury as
well as the mechanism of injury.

The majority of ankle

sprains that occur are inversion injuries and can lead to
residual symptoms such as pain, repeated sprains, and
episodes of “giving way.”7 The result of recurring sprains
producing these residual signs and symptoms can be
expressed as chronic ankle instability (CAI).

CAI is

described as modified mechanical joint stability due to
recurring disruptions to ankle integrity with secondary
perceived and observed insufficiency in neuromuscular
control.6-8 These disruptions can be a result of ankle
injury or repeated turning in of the ankle, especially on
uneven surfaces.
Ankle sprains that occur most often do not develop
lateral ligamentous instability, but those that do are
thought to be due to a loss of mechanoreceptors.23

Not all

acute sprains result in chronic ankle instability, 80% of
acute sprains make a full recovery with conservative
management, and the other 20% develop mechanical or

2
functional instability resulting in CAI.23 There is a
recurrence rate as high as 80% among active individuals
after an initial ankle injury.6-8 In order to reduce these
instances of injury, it has been recommended to use a
prophylactic ankle brace or taping technique.4,5 This
bracing or taping method assists in limiting ankle range of
motion that results in lateral ankle sprains.4,5
The ankle, as a joint of the lower extremity in close
proximity to the base of support, plays an integral role in
maintaining balance.

Balance is generally defined as

condition where the body’s center of gravity (COG) is
maintained within its base of support is defined as
balance.4,5,7-9 Dynamic and functional balance are similar
where maintenance of the COG is within the limits of
stability over a moving base of support.14

What sets these

two forms of balance apart is that functional balance
includes sport-specific task such as throwing and
catching.14

Balance can influence athletic performance for

athletes and other physically active individuals.9 Dynamic
balance is explained as sustaining center of mass over the
base of support when that base of support is moving or when
an external perturbation is applied to the body.7,10

In

other words, the individual is attempting to maintain their
base of support while they complete a given movement.8 CAI

3
can be an added restraint and cause difficulty in
maintaining an individual’s base of support when that base
of support is moving, and could consequentially impede
balance.1,7,8 The use of prophylactic ankle braces and tape
have become some of the more common ways utilized to
provide added support to the ankle joint and prevent injury
of the ankle during physical activity. Studies have found
that, with the use of ankle braces or proprioception
training programs, ankle sprains can be prevented.4,5,12
There are few dynamic balance protocols that assess
dynamic balance control with the use of equipment, but one
such test is the Star Excursion Balance Test (SEBT).13

The

SEBT is a test of dynamic postural control that involves
having the subject maintain a base of support with one leg,
while maximally reaching in different directions with the
opposite leg.10

This must be performed without compromising

the base of support of the stance leg.10

Studies have

demonstrated high intratester and intertester reliability
when using the SEBT as an assessment of dynamic balance.22
Earl and Hertel et al22 established the usefulness of the
SEBT for recruitment of lower extremity musculature
contraction.

Evidence indicates that the SEBT is a

sensitive test for screening musculoskeletal impairments
such as chronic ankle instability.10,13

Throughout an event

4
or athletic competition, fatigue may modify neuromuscular
control and can decrease the body’s ability to maintain
stability.4

Gribble8 demonstrated that CAI produced an

increased deficiency in dynamic postural control related to
fatigue using a SEBT.

Through the use of a fatigue

protocol, there may be a reported drop in muscle force
below 59% of peak torque, which may result in postural
control deficits and an increased risk of musculoskeletal
injury.11
Studies have examined how bracing has affected the
SEBT and time to stabilization following a fatigue protocol
with the use of bracing on healthy volunteers.4,12 They
concluded that prophylactic bracing did not disrupt lower
extremity balance reach, but that Active Ankle® bracing was
the best option for providing dynamic stability.4,12

There

have been no studies examining how fatigue can affect
balance using the SEBT and utilizing a prophylactic bracing
or taping condition in healthy volunteers, however.

There

have been various protocols demonstrated to induce fatigue
but the more recent development of functional fatigue
protocol has not been studied.3,4,8 This fatigue protocol
offers exercises that are more comparable to sport specific
movements to stimulate the same fatigue symptoms that would
occur during an athletic event.4

5
As of late, authors have used functional fatigue
protocols with SEBT for dynamic balance data collection.
However, the effect of prophylactic bracing and taping
techniques has not been tested in combination with a
functional fatigue protocol using a SEBT.

Therefore, the

purpose of this study was to examine the effects of
functional fatigue on dynamic balance with the use of tape
and lace-up bracing.

6

METHODS

The primary purpose of this study was to determine the
effects of a functional fatigue protocol on dynamic balance
while utilizing a prophylactic bracing technique and tape.
The methods section will help present an overview of how
this study was conducted. This section includes the
following subsections:

research design, subjects,

instruments, procedures, hypotheses, and data analysis.

Research Design

This research was a quasi-experimental, within
subjects, repeated measures design.

Independent variables

in this study were condition (brace or tape) and fatigue
(fatigue or non-fatigue).

The dependent variable was the

measure of functional balance using the SEBT following a
fatigue protocol during the application of both conditions.
A limitation to this study is the inability to generalize
the results beyond college-aged physically active students
demonstrating CAI at a Division II University.

Strength of

this study was that the fatigue, non-fatigue condition was
controlled by testing SEBT pre-and post-fatigue.

7

Subjects

Subjects included 15 volunteer students (7 males, 8
females), 18 years and older, termed physically active with
CAI from California University of Pennsylvania.

Physically

active individuals were defined as accruing 60 minutes of
daily physical activity or 30 minutes of moderate to
vigorous exercise three to four days a week.16

Subjects

meeting these criteria were recruited from undergraduate
classes in Health Science and NCAA Division II athletic
teams. Subjects volunteered to participate in this study
with no coercion from coaches or faculty after the
researcher had explained the purpose.
A Data Collection sheet (Appendix C1) was used to
report subject’s criteria of physically active or NCAA
athlete, and determine whether a participant reported CAI
using the Ankle Instability Instrument (AII) developed by
Docherty.15

Two questions of the AII were used to determine

qualification for CAI: “Have you ever sprained an ankle?”,
and “Have you ever experienced a sensation of your ankle
‘giving way’?”

Along with answering yes to these two

questions, the subjects also had to answer affirmatively to
at least one other question on the instrument.6,15

The AII

8
has been observed to be a reliable measure of self-reported
CAI.6,15
Any subject who experienced visual, vestibular,
balance disorder, severe lower extremity injury, and/or a
concussion within the last six months was disqualified from
this study as these conditions may reportedly hinder an
accurate balance assessment.

In order to protect the

subjects’ identity, a number was used instead of their
names in the study; this also assisted in blinding the
researcher when checking the data collection sheet.
Subjects were assigned to all four testing periods with at
least three days between each session to prevent the
presence of any delayed onset muscle soreness during
testing times. Prior to any testing, subjects read and
signed the Information Consent Form (Appendix C2).

Preliminary Research

Preliminary research was designed to help familiarize
the researcher with bracing techniques, the fatigue
protocol, SEBT, and for a determination of the time that
was necessary for testing each subject under the different
conditions.

The procedure for the testing sessions was

based upon previously performed research.10,12

Scoring of

9
the SEBT using an average distance for the reaching limb in
five directions(distance in centimeters)were the functional
scores used for analysis.

Testing procedures were

performed on three adult volunteers who were studying or
working at California University of Pennsylvania.

These

volunteers were within the same age range as the desired
population.

The pilot research helped to determine how

many trials were adequate for the SEBT for the subjects to
become familiar and minimize any learning effects.
Previous research4 found that six practice trials should be
performed in order to minimize learning effects.

However,

our preliminary study showed that three practice trials in
each of the five directions were adequate in minimizing
learning effects.

Instruments

The following instruments were used in this study:
Data collection sheet (Appendix C1), fatigue protocol
(using a electronic metronome and the Vertec™ vertical jump
tester)(Appendix C3), SEBT (Appendix C4), Johnson and
Johnson Coach® Athletic Tape, and a lace-up ASO brace.

10
Data Collection Sheet
Data collection sheet (Appendix C1) included the
subject number, age, gender, chronically unstable ankle
(R/L), vertical jump maximum height, leg length, whether
subjects NCAA athlete or physically active/recreational
athletes, and all SEBT scores for each condition on all
four testing sessions.

Fatigue Protocol
The fatigue protocol (Appendix C3) used for this study
has been used in previous research.4,8,12 Three stations were
used in the fatigue protocol including a Modified Southeast
Missouri agility drill (SEMO), stationary lunges, and quick
jumps with the use of data collected from the subjects’
vertical jump height.
The SEMO was composed of a series of forward sprints,
side shuffles, and back peddling.4

The SEMO was completed

in a rectangle of 12 X 19 ft (3.6 X 5.7 m) as performed in
Shaw and Gribble’s4 study.

Following this station the

subjects immediately began the stationary lunges that were
timed with a metronome.

The distance of lunge was

determined by the measures of the subject’s true leg length
from the anterior superior iliac spine to the distal
portion of the medial malleolus prior to the protocol.

11
Each lunge was performed five times equaling ten lunges
total with alternating lunge legs.4

One lunge was performed

every two seconds using a metronome.4

Starting with their

feet together they would step forward with their lunging
leg and place their leading foot firmly on the ground.
Subjects had to avoid any sideways tilting or swaying in
the upper body and bring the lower body to a position where
the front thigh became parallel with the floor during hip
and knee flexion, while maintaining an upright torso. They
would then return to standing position while their hands
remained on their hips.

Proper technique was critical to

fatigue the individual.
Finally, as the last step of the fatigue protocol, the
subjects performed 10 quick jumps.

To set up this station,

the individuals maximal vertical jump height was recorded
using the Vertec™ vertical jump tester.

This system

measures from 6 to 12 feet with color-coded vanes that
offer half-inch measurements for immediate feedback.
First, the subjects’ standing height was measured by
standing under the Vertec™ vertical jump tester and
reaching up to touch the highest point possible while
maintaining both feet flat on the ground.

Second,

participants performed a two-footed maximal vertical jump
reaching to the highest point possible on the Vertec™.

12
From Shaws’4 study, each participant was given three jump
trials to determine their greatest jump height, that height
was then recorded.4 The standing reach height was then
subtracted from the individuals maximal vertical jump
height in order to get their Vertmax.4 The quick jumps were
performed double legged with both arms above the head
reaching for a distance that was 50% of their Vertmax
previously recorded.

This was done ten times reaching for

a tape placement on the wall for the subject to hit each
time with both hands.4

Again, correct form was critical for

fatigue to be reached and if the form was not correct, the
jump was not counted.

If the tape was not touched with

both hands, the jump was not counted.

Each subject was

able to establish a baseline time with the first testing
session to determine fatigue in the subsequent testing
trials.

Participants continued to complete each station

until the time to finish the stations increased by 50% when
compared to their baseline times.4

Star Excursion Balance Test (SEBT)
The SEBT (Appendix C4) is a functional test of dynamic
balance in which the postural control system is challenged
while the body’s center of mass is moved in relation to its
base of support.8,10,13

The SEBT uses eight tape lines that

13
extend at 45° increments from the center grid point in the
shape of a star(Appendix C4).13,10

Five of the lines were

used for the individual subject tests depending on the
reach leg.

The five lines were named as such;

anterolateral (AL), anterior (A), posterior (P),
posterolateral and lateral (L), according to the direction
of excursion in relation to the stance leg.10,13

In terms of

the direction of excursion, the subjects always had the
chronically unstable ankle as their stance leg and their
reach was always lateral, never medial.10 Previous studies
have used three or five of the reaching directions, this is
due to the fact that we were mainly concerned with
sagittal-plane kinematics of the stance leg.24

During the

final test trial, the distance between center of the grid
and the point the subject’s leg touched was marked with a
sticky tab, and measured with a tape measure, according to
suggested test protocols.

Markers were removed following

pre-fatigue, non-fatigue conditions so that they did not
serve as visual “markers” for the subjects.
Subjects’ hands had to remain on the hips at all
times, and if the subject used the reaching leg for support
at any time, removed his or her foot from the center of the
grid, or was unable to maintain balance on the support leg,
the trial was discarded and repeated.10 Participants wore

14
their own shoes versus standard testing shoes because
during regular physical activity, their personal form of
shoes would be worn with the ankle brace.

The subjects

each performed three trials of the SEBT as a warm-up for
the recorded trial.

The distance from the center of the

grid to the reach point was measured and recorded on the
data sheet for the directions of A, AL, L, PL, and P.
Taking the average score of these five reach points for pre
and post-fatigue offered a mean score for each excursion
that was performed.14 Higher scores in centimeters indicated
better balance. The distance scores (centimeters) for each
direction of the SEBT grid were averaged and normalized to
leg length (reach distance/leg length x 100 = percentage of
leg length).10

Tape and Brace
The Ankle Stabilizing Orthosis (ASO brace) is made up
of a durable ballistic nylon material with an elastic cuff
closure.17-19

Advanced support is achieved through exclusive

non-stretch nylon stabilizing straps that emulate the
stirrup method of an athletic taping application.18,19
The calcaneus is secured, which effectively locks the heel.
Each participant was fitted for the brace according to the
manufacturer’s guidelines based on shoe size.18,19

The

15
participants were instructed on proper application of the
ASO brace and the brace was applied by the same certified
athletic trainer according to the manufacturer’s guidelines
prior to each testing session.17
Johnson and Johnson Coach® Athletic Tape 1½ inch nonelastic adhesive tape was used for taping sessions.

The

tape was applied by the same certified athletic trainer for
each session.

The method of ankle taping that was chosen

is comparable in support to an ASO brace.

A closed basket

weave taping technique was applied to the chronically
unstable ankle.

The technique consisted of applying non-

elastic adhesive tape over the individual’s skin. The
basket weave contains a heel lock method which is
implemented in the ASO brace.

Subject’s ankle position was

at 90°, two anchors were placed at the top and one on the
foot, through the arch.

Three stirrups and three

horseshoes were then applied followed by two figure eights
and two sets of heel locks to complete the tape support.

Procedures

The study was approved by the California University of
Pennsylvania Institutional Review Board (IRB) (Appendix
C5).

Prior to the study, the researcher met with all

16
potential subjects to explain the concept of the study and
to offer the Informed Consent Form (Appendix C2) so that
each subject was made aware and understood the requirements
and risks of involvement in the study.

The qualifications

for these subjects, as mentioned in the subject section,
requirements, testing dates, and approximate time frames
for each session, ranging from 10 to 45 minutes, were also
announced.
Previous to the first testing session, qualifications
for the subjects were presented again.

Once understanding

the testing procedures and approving of them, subjects
signed the Informed Consent Form and the researcher
completed the Data Collection Sheet (Appendix C1) for each
subject.

Prior to beginning each test, the researcher

explained the test procedure and methods.

Following the

collection of data on the subjects that performed the
study, they were asked to report to the lab on four
separate occasions. These testing days needed to be, at the
minimum, three days apart to avoid delayed onset muscle
soreness.

Fatigue Protocol
For the initial session, the subjects’ maximal
vertical height was determined to create the quick jumps

17
portion of the fatigue protocol.

Next, both legs of the

individual were measured for length from the anterior
superior iliac spine to the medial malleolus while the
individual laid in a supine position.4

This length

determined the reach distance for the lunging task portion
of the fatigue protocol.4

Lastly, the fatigue protocol was

explained to the subjects and demonstrated during the
initial session.

The subjects were able to practice this

protocol one time before they performed it for the study.
The initial practice was only a walk through as to not
fatigue the individual before the actual testing times were
recorded.

The second time through the fatigue protocol was

timed and that timed trial was used for the other three
testing sessions in order to establish a point of fatigue
for each subject.

Star Excursion Balance Test (SEBT)
During each of the four testing sessions with the two
different support conditions the subjects were tested with
the SEBT before and after performing the fatigue, nonfatigue.

Using their unstable ankle as their stance leg

their center point and the first metatarsophalangeal joint
was positioned on the center grid, they were instructed to
use their reach leg (non CAI) and reach the maximal

18
distance possible to touch the line with the most distal
component of the reach foot without any additional
support.10 The limb was then restored to the starting point
at the center of the grid, while maintaining single-leg
stance with the other leg.

In any direction, leaning was

allowed as long as the hands remained on subjects’ hips and
the reach leg did not touch the floor in any other place
but the maximal reach.

Distances in centimeters were

recorded for all five directions for the chronically
unstable ankle.

The test needed to be repeated if the

subject rose the stance foot from the center of the grid,
if the reach foot was used to provide support when touching
the ground, or if the subject lost his or her equilibrium
at any point in the trial. The distance scores (cm) for
each direction of the SEBT grid were averaged and
normalized to leg length (reach distance/leg length x 100 =
percentage of leg length).10

Hypothesis

The following hypothesis was based upon previous
research and the researcher’s intuition based on a review
of the literature.

19
The use of a lace-up style brace will allow for
better dynamic balance compared to tape as scored on
the SEBT following a fatigue protocol.

Data Analysis

A within-subjects repeated measures ANOVA was used to
determine the differences within subjects’ SEBT scores on
two tests (fatigue/non-fatigue) and between two conditions
(lace-up brace and Johnson and Johnson Coach® athletic
tape).

All data was analyzed by SPSS version 18.0

statistical software package for windows at an alpha level
of ≤0.05.

20
RESULTS

The purpose of this study was to examine the effects
of functional fatigue on dynamic balance with the use of
tape and lace up bracing.

Subjects were tested using the

SEBT before and after a stint of fatigue or rest and were
tested under both levels of brace condition, lace-up brace
or tape, depending on which session was being performed.
The SEBT was used to measure dynamic balance and functional
balance respectively.

The following section includes:

demographic information, hypothesis testing, and additional
information.

Demographic Data

A total of 15 subjects (7 males, 8 females), mean age
of 20.8y ± 1.52, completed this study. A total of 7
subjects testing positive for chronic ankle instability of
the right ankle, and 8 testing positive for the left ankle
using the AII (Appendix C1).

All subjects were volunteers

and physically active individuals at California University
of Pennsylvania which included 14 physically
active/recreational athletes and 1 NCAA Division II
athlete. During the time of testing, the subjects who

21
completed this study did not experience any visual,
vestibular, balance disorder, severe lower extremity
injury, and/or a concussion within the last six months that
may hinder an accurate balance assessment.

Demographic

data (Table 1) were collected by the researcher at the
beginning of the study.
Table 1. Demographic Data
Male and Female (N = 15)
Minimum

Maximum

Mean

18

23

20.8

1.52

Leg Length (cm)

81.3

99.1

90.98

5.78

Vertmax

29.2

74.9

48.61

15.47

Mean

SD

Age

(y)

(cm)

SD

Male (N = 7)
Minimum
Age

(y)

Leg Length (cm)
Vertmax

(cm)

Maximum

18

23

20.86

1.68

88.9

99.1

95.46

3.93

33

74.9

60.41

14.62

Female (N = 8)
Age

(y)

18

22

20.75

1.49

Leg Length

(cm)

81.3

91.4

87.06

3.99

Vertmax

(cm)

29.2

43.2

38.28

5.82

22
Hypothesis Testing

Hypothesis testing was performed using data from the
15 subjects who completed all four testing sessions.
Descriptive statistics of the SEBT for the two prophylactic
bracing techniques (lace-up brace and Johnson and Johnson
Coach® Athletic Tape) are shown in Table 2. The distance
scores (cm) for each direction of the SEBT grid were
averaged and normalized to leg length (reach distance/leg
length x 100 = percentage of leg length).
Using a within-subject repeated measures factorial
ANOVA, the hypothesis was tested at an alpha level of ≤
0.05.

For final analysis, difference scores were computed

between pre- and post- fatigue or non-fatigue conditions.
A positive difference indicated maximized lower extremity
reach distances, or better functional balance, with one
limb while maintaining balance on the contralateral limb in
the post-test.

A negative difference indicates a decreased

lower extremity reach distance, or an inferior quality of
functional balance, in the post-test.

23
Table 2. Descriptive Statistics for Condition
Fatigue Condition
Minimum

Maximum

Mean

SD

Tape

(cm)

.40

9.56

3.56

2.61

Brace

(cm)

-3.30

8.16

2.29

3.57

Non-Fatigue Condition
Tape

(cm)

-1.23

8.31

3.42

2.85

Brace

(cm)

-.02

9.45

3.18

2.34

Hypothesis: The use of a lace-up style brace will
allow for better dynamic balance compared to tape as scored
on the SEBT following a fatigue protocol.
Conclusion:

The within-subjects repeated measures

ANOVA was calculated comparing the two levels of
prophylactic bracing conditions (lace-up brace and Johnson
and Johnson Coach® Athletic Tape).

No significant effect

was found (F(1,14) = 1.309, P ≥ .05).

Additional Findings

An additional repeated measures ANOVA was performed to
examine the relationship among SEBT post-test scores and
gender.

There was no significant difference between gender

for post-test SEBT scores (F (1,14) = .360, P ≥ .05).

The

24
mean for females was not significantly different (m =
2.718) than the males (m = 3.566), and the mean difference
between the two groups was (m = .849).

The average number

of run-throughs each subject completed before reaching a
point of fatigue was from three to five complete cycles.
Fatigue time ranged from 57 seconds to one minute, fifteen
seconds.

25
DISCUSSION

The following section is divided into three
subsections: Discussion of Results, Conclusions, and
Recommendations.

Discussion of Results

The primary purpose of this study was to determine the
effects of a functional fatigue protocol on dynamic balance
while utilizing a prophylactic bracing technique (semirigid lace-up ASO brace) and tape.

The researcher wanted

to investigate this topic, as some controversy still exists
on what preventative method for ankle injuries is most
effective in providing stability and preventing ankle and
lower extremity injuries.

No significant differences were

found between condition (tape and brace) following fatigue,
non-fatigue conditions on balance as measured by the SEBT.
This finding between brace and tape in a fatigue, nonfatigue condition on functional balance extends and is
consistent with findings of previous studies.5,8,20,21
Nonetheless, the use of a lace-up style brace was assumed
to allow for better dynamic balance compared to tape as
scored on the SEBT following a fatigue protocol.

While the

26
results did not support the hypothesis that the lace-up
brace would allow for better dynamic balance when compared
to tape after fatigue, all second reaches were further in
brace and tape condition when comparing the results of preand post fatigue. To note, a majority of the subjects
stated that they worked harder on the second reach to
exceed their original reach indicating that some form of
visual feedback may have been used.

Two components of

visual feedback could potentially contribute to these
second reaches including information about the position of
the reach leg and the distance from which the subject had
reached on the pre-fatigue condition.
These findings were similar to Gribble et al8 who
tested subjects with chronic ankle instability also showing
no statistical significance for the influence of ankle
brace application when testing dynamic postural stability
with a time to stabilization technique.

Wikstrom et al20

also reported that when testing a semi-rigid and soft brace
using a jump-landing protocol there was no significant
difference observed between braced and no-braced conditions
for any of their measures of dynamic stabilization in the
anterior/posterior and medial/lateral directions in
subjects with functionally unstable ankles. The components

27
of dynamic stability do not appear to be improved with the
application of the ankle support.
Hardy et al5 performed a study comparing three brace
types, un-braced, semi-rigid, and lace-up using a SEBT.
Their results were similar to the present study in showing
that the bracing condition had no effect on any of the Star
Excursion Balance Test directional measures.

The actual

reach differences due to bracing were less than 5.08 cm in
length.

They concluded that neither braces actually

diminished dynamic balance when compared to the control
condition (no brace).
Another study comparable to our results performed by
Cordova and Takahashi et al21 tested ankle range of motion
for ankle-joint displacement with videography during droplanding trials under three conditions (un-braced, semirigid, and tape).

There were no differences observed

between the tape and semi-rigid brace conditions when
testing ankle range of motion.

Their study revealed that

not only did the ankle tape significantly restrict anklejoint range of motion, but so did a semi-rigid ankle brace
when performing a 1-legged drop landing.
It was expected that there would be a difference among
brace conditions in SEBT directions due to previous
findings that showed restricted ROM with semi-rigid and

28
lace-up ankle braces.

The multidirectional nature of the

SEBT and lack of significant findings in this study may
suggest that performance on a dynamic balance task is
maintained regardless of whether tape, brace, or nothing is
worn as supported by the findings above.

Athletes and

physically active individuals vary in their opinions on
which brace provides more stability and preventative
measures to the lower extremity.

How an athlete feels

about a prophylactic ankle device is very important as
well.

To eliminate the chance of brace discomfort due to

improper fitting, the researcher fit all braces to the
subjects according to the manufacturer’s instructions.

Conclusion

This study revealed that prophylactic bracing was no
different than taping following a fatigue protocol in
physically active healthy individuals demonstrating CAI.
Also, reaching farther on all second tests may be the
nature of balance tests using this method.

In this case,

the certified athletic trainer can inform the athlete or
physically active individual that taping and/or bracing may
have the same effects on dynamic stability and potentially,
injury prevention, whether they are fatigued or not.

29
Recommendations

It is important for the certified athletic trainer to
understand that a prophylactic device or tape can be worn
during sports to provide support and possibly prevent
injury.

Though the present study may not show

effectiveness, the results of this study may provide an
essential direction in examining the importance of muscle
re-education following an initial ankle injury.

Testing

various brands of prophylactic braces on diverse
populations could be done to compare the results.

For

example, using specific athletes and sports, performing on
different age groups, or use in high schools vs. college
sports.

Since this study created an acute fatigue

condition, another recommendation is to do twenty minutes
of activity or more for the fatigue portion to see if it’s
more effective in tape losing its motion limiting
properties.

This should be done to see if the tape will

still produce the same results as when it has its motion
limiting properties.

Testing for use in sports such as

soccer and ice hockey that have more long term fatigue may
produce different results.

The results from this study

might help certified athletic trainers choose prophylactic

30
devices and taping methods better for injury prevention
during activity.

31
REFERENCES
1.

Robbins S, Waked E. Factors Associated with ankle
injuries. Sports Med. 1998; 25(1): 63-72.

2.

Abian-Vicen J, Alegre LM, Fernandez-Rodriguez JM, Lara
AJ, Meana M, Aguado X. Ankle taping does not impair
performance in jump or balance tests. J Sports Sci
Med. 2008; 7: 350-356.

3.

Bot S, Verhagen E, Mechelen WV. The effect of ankle
bracing and taping on functional performance: A review
of the literature. Int SportMed J. 2003; 4(5).

4.

Shaw MY, Gribble PA, Frye JL. Ankle bracing, fatigue,
and time to stabilization in collegiate volleyball
athletes. J Athl Train. 2008; 43(2): 164-171.

5.

Hardy L, Huxel K, Brucker J, Nesser T. Prophylactic
ankle braces and star excursion balance measures in
healthy volunteers. J Athl Train. 2008; 43(4): 347351.

6.

Doeringer JR, Hoch MC, and Krause BA. The effect of
local ankle cooling on spinal reflex activity in
individuals with chronic ankle instability. Athl
Train Sports Health Care. 2009; 1(2): 59-64.

7.

Brown C, Mynark R. Balance deficits in recreational
athletes with chronic ankle instability. J Athl
Train. 2007; 42(3): 367-373.

8.

Gribble PA, Hertel J, Denegar CR, Buckley WE. The
effects of fatigue and chronic ankle instability on
dynamic postural control. J Athl Train. 2004; 39:
321-329.

9.

Blackburn T, Guskiewicz KM, Petschauer MA, Prentice
WE. Balance and joint stability: the relative
contributions of proprioception and muscular strength.
J Sport Rehab. 2009; 9: 315-328.

32
10.

Gribble PA, Hertel J. Considerations for normalizing
measures of the star excursion balance test.
Measurement Physical Education Exercise Science.
2003; 7: 89-100.

11.

Lohkamp M, Craven S, Walker-Johnson C, Greig M. The
influence of ankle taping on changes in postural
stability during soccer-specific activity. J Sports
Rehab. 2009; 18: 482-492.

12.

Hardy L, Huxel K, Brucker J, Nesser T. Prophylactic
ankle braces and star excursion balance measures in
healthy volunteers. J Athl Train. 2008; 43(4): 347351.

13.

Hertel J, Miller J, Denegar CR. Intratester and
intertester reliability during the star excursion
balance tests. J Sport Rehab. 2009; 9: 104-116.

14.

Iwamoto M. The relationship among hip abductor
strength, dynamic balance, and functional balance
ability [master’s thesis]. California, Pennsylvania:
California University of Pennsylvania; 2009.

15.

Docherty C, Gansneder BM, Arnold BL, Hurwitz SR.
Development and reliability of the ankle instability
instrument. J Athl Train. 2006; 41(2): 154-158.

16.

Warburton D, Charlesworth S, Ivey A, Nettlefold L,
Bredin SD. A systematic review of the evidence for
Canada’s physical activity guidelines for adults.
Intern J Behavioral Nutrition Physical Activity.
(2010): 7(39).

17.

DiStefano LJ, Padua DA, Brown CN, Guskiewicz KM. Lower
extremity kinematics and ground reaction forces after
prophylactic lace-up ankle bracing. J Athl Train.
2008; 43(3): 234-241.

18.

Gudibanda A, Wang Y. Effect of the ankle stabilizing
orthosis on foot and ankle kinematics during cutting
maneuvers. Research Sports Medicine. 2005; 13(2): 111127.

33
19.

Gallagher SP. Which ankle brace is right for your
patient? Biomechanics Magazine, Mag Body Movement Med.
August 1996.

20.

Wikstrom E, Arrigenna, M, Tillman, M, Borsa P. (2006).
Dynamic postural stability in subjects with braced,
functionally unstable ankles. J Athl Train. 43 (2-S),
15.

21.

Cordova M, Takahashi Y, Kress GM, Brucker JB, Finch A.
Influence of external ankle support on lower extremity
joint mechanics during drop landings. J Sport Rehab.
2010; 19 (2): 136-148.

22.

Earl JE, Hertel J. Lower extremity muscle activation
during the star excursion balance test. J Sport Rehab.
2001; 10(2): 93-104.

23.

Fong D, Hong Y, Chan L, Yung PS, Kai-Ming C. A
systematic review on ankle injury and ankle sprain in
sports. Sports Medicine. 2007; 37(1): 73-94

24.

Gribble PA, Robinson RH, Hertel J, Denegar CR. The
effects of gender and fatigue on dynamic postural
control. J Sport Rehab. 2009; 18(2): 240-257

34

APPENDICES

35

APPENDIX A
Review of Literature

36
Ankle pathologies are among the most prevalent
injuries treated by athletic trainers.

As a result, there

have been many techniques used over the years to help
prevent injury and re-injury to the ankle joint.

The use

of prophylactic ankle braces by the athletic population to
help stabilize an unstable or previously injured ankle
joint has become one of the most popular methods.

It is

understood that after a repetitive or exhausting workout
the mechanical stabilization provided by braces can
decrease, potentially allowing an increase in ankle
displacement.

Literature shows that semi-rigid and rigid

braces are the most common form of ankle orthosis used for
injury prevention due to the fact that tape has been shown
to lose its rigidity over time.
The purpose of this literature review is to evaluate
the effects of fatigue on support while wearing two
different brace types including tape and lace-up on
individuals termed with chronic ankle instability. The
topics that will be discussed include; 1) Chronic Ankle
Instability, 2) Use of Prophylactic Support, 3) Balance
Testing and 4) Summary.

37
Chronic Ankle Instability

Chronic ankle instability (CAI) is due to repeated
disruptions to ankle integrity which causes altered
mechanical joint stability.1

CAI can result in perceived

and observed deficits in neuromuscular control.1 The
majority of ankle injuries occurs on the lateral aspect of
the ankle joint that can result from the motions of
inversion and plantarflexion.1-3

Ankle Anatomy
Bones that make up the ankle are the distal end of the
tibia and fibula as well as the talus, and calcaneus.4,5
The inferior tibiofibular joint, the talocrural joint, and
the subtalar joint are made up by the articulations between
these bones. The amount of force that the fibula is said to
transmit through the body is anywhere from 0 to 12%, a much
smaller percent than the tibia.6 The primary joint of this
region which endures the most weight bearing and force
absorption is the talocrural joint.4,5

The talocrural joint

is a synovial hinge joint and allows for one degree of
freedom or planar movement, dorsiflexion and plantarflexion
and is considered the main ankle joint.

Laxity of this

joint is found in 75% of subjects with a history of ankle

38
sprains.25

The subtalar joint allows for the movements of

eversion and inversion of the ankle as well as pronation
and supination in the weight bearing position, also only
one degree of movement in the transverse plane.4,6

Due to

the subtalar joint and talocrural joint working in close
quarters, laxity in one leads to laxity in the other in
two-thirds of those with ankle instability.25

Following an

injury to the ankle, ligaments can become more lax and
ultimately lead to more ankle injuries and chronic
instability.3,5,7
Static stabilization of the ankle joint is provided by
the ligaments of the ankle, and is often a point of injury.
The tibia provides an extensive site for medial ligament
attachment, in particular, the deltoid ligament.

The

function of this ligament is to resist eversion of the
ankle.

The most familiar and well-known ligaments are the

tibiofibular ligaments, which secure the tibia and fibula
together. The tibiofibular joint has a fibrous structure
known as the interosseous membrane that provides the union
between these two structures.31

Lateral attachments of

ligaments for the ankle originate off the distal fibula.26
Lateral ligaments consist of the posterior talofibular
ligament (PTF), anterior talofibular (ATF), and
calcaneofibular (CF) ligaments which attach the fibula to

39
the calcaneous.6,26

The anterior talofibular ligament is the

most anterior lateral of the three and is also the most
frequently injured followed by the calcaneofibular, which
sits between the three ligaments.

The least often injured

is the posterior talofibular ligament.

The deltoid and

lateral ligaments work to provide support to the talocrural
and subtalar joints.
The combinations of motions that occur at the ankle
complex are considered its functional anatomy.

When in a

weight bearing position during inversion, the ankle joint
goes into further inversion due to the anatomy and the
forces being applied to it, creating an explanation as to
why most injuries occur to the ankle when put in this
position.

When there is any injury to the ankle, it can

cause difficulty in performing the motions and will lead to
ankle instability.

Alterations in normal biomechanics can

then cause injury to other areas of the body due to the
relationship one part of the body has with another part of
the body.31

Injuries to the Ankle
There are various ankle structures that can be injured
while participating in athletics.

Common injuries include

sprains, strains, and fractures, with sprains among the

40
most frequent. Sprains of the ankle represent 38-50% of
sports injuries.9 Nearly 85% of the ankle sprains that do
occur are inversion ankle sprains and can range in their
severity.8,9

Inversion sprains occur when the ankle is

inverted and plantar flexed causing damage to the anterior
talofibular ligament, the calcaneofibular ligament, or
both.

Another mechanism of injury to the ankle is eversion

and dorsiflexion, this forceful movement causes damage to
the tibiofibular joint on the medial aspect of the ankle
joint.

A direct blow, compression, shear forces,

rotational forces, or falling are mechanisms for a fracture
to the ankle joint.
Beynnons et al27 stated that the most common risk
factor for ankle sprains is a previous injury or sprain.
Sprains can often lead to chronic pain or instability of
the ankle in 20 to 50% of cases.10 This will mean increased
risk for re-injury of that ankle.

Individuals who are

termed with CAI often experience frequent sprains, and
episodes of “giving way”.7 Risk factors that can contribute
to initial or re-injury of an ankle include gender, height,
weight, foot type, foot size, limb dominance, range of
motion, muscle strength, functional instability, and
laxity.27

All of these factors are known as intrinsic

factors because they are all values that an object

41
maintains within itself.

Extrinsic risk factors are those

that act outside of the body and act upon the body as a
whole.

The extrinsic risk factors for ankle injury are

shoe type, duration of the activity, and position of the
player.27
Functional instability is considered an intrinsic
factor.

This can be defined as the feeling of instability

or recurrent ankle sprains due to deficits in the
individuals proprioception or due to neuromuscular
deficits.

Functional ankle instability can cause chronic

ankle instability, which in turn causes athletes to take
longer to stabilize.

Clinicians feel that the use of tape,

semi-rigid brace, or a lace-up brace could be an effective
way to prevent injury or re-injury to the athlete’s ankles.8
A criticism of tape is that the support it provides
declines by 40 to 50% after approximately five minute of
exercise.

Ankle braces are easily retightened during

exercise to avoid any loss of support to the injured
ankle.10

Use of Prophylactic Support

One of the most common methods for preventing lateral
ankle sprains is the use of external support, such as ankle

42
taping or bracing.

Prophylactic comes from the Greek word

for “advance guard” and defined as a preventative measure;
in this case, a preventative measure for ankle sprains.12
Several studies have followed the effects of ankle braces
and tape for their general purpose in ankle injury
prevention.2,9-11,13-16,20-21 There have also been studies that
have evaluated the use of these devices to prevent injury
by decreasing range of motion or increase proprioception.28

Tape
One method of bracing for stabilization that is
applied to the ankle to prevent injury or re-injury is
tape.

The ankle is the most commonly taped part of the

body with but the lateral ligament complex of the ankle
still being the single most frequently injured structure
during athletic activity.29 Used in a variety of sports,
tape offers mechanical support and increases
proprioception.9,10

Tape can be a costly tool because it

must be re-applied daily. Unlike tape, a semi-rigid or
rigid bracing technique can be reused.

It is questionable

whether a taping technique can withstand the stressors of
fatigue and time while continuing to supply the same amount
of support.

According to research, tape is quite effective

43
in limiting ankle range of motion but loses most of these
effects after about twenty min of exercise.10-11,29
Refshauge et al13 studied whether taping the ankle
would help improve the detection of inversion and eversion
movements at the ankle, to possibly reduce the instance of
injury.13

They concluded that the use of tape to prevent,

or have any effect on the movement of the ankle into
plantar flexion and inversion, had little effect.

The tape

was shown to loosen after a period of exercise which
actually hindered the ability of the individual to detect
the ankle movement and correct it before injury occurred.13
Lohkamp14 assessed individual’s postural stability with
and without tape following a stint of fatiguing on a
treadmill.

The stability test was performed so that the

subject would have to respond quickly to sudden ankle
plantar flexion and inversion (the same movements for a
lateral ankle sprain) during a single leg stance.

The

effects of the tape after the prolonged exercise decreased.
The reaction time to stabilization was significantly
longer, the longer the exercise was performed.

As a

result, the researchers concluded that fatigue had a
negative effect on the joint position sense, seeing as it
took longer for stabilization to attain.14

44
The aim of another study was to compare the results of
the effectiveness of a reusable ankle brace vs. athletic
tape in its ability to restrict ankle inversion before and
after exercise.15

The subjects were tested before and after

an exercise period as seen in the previous studies, to
determine any differences in the tape or braces’ ability to
restrict the movement of ankle inversion.15

Results showed

that both the tape and the lace-up brace were effective in
restricting movement better than no prophylaxis at all.15
Post exercise showed little difference in the taping and
bracing style that was not significantly different to the
study.15

Both were still effective in restricting

inversion range of motion of the ankle pre and post
exercise.15
The effectiveness of tape on limiting motion shows no
significance and exercise times before tape loses its
motion limiting properties do vary.29 The main purpose of
the taping method is to limit excessive range of motion,
prevent injury, and increase mechanical support of the
ankle.29

45
Semi-rigid and Lace-up Braces
Braces are another common method of ankle injury
prevention.

The application of these braces may vary from

tie-on, straps, slide-on forms, or a combination of all
applications.

Semi-rigid and lace-up braces have been

tested under several conditions and have continued to show
more effective to ankle stability then tape alone.12-14 This
is due to the fact that braces do not loosen as the taping
can after exercise.

Also, the braces offer different sizes

and different levels of stability so that you can adjust
the tightness of the brace according to pain level or the
amount of swelling that may have accrued following an
injury.
Some studies have compared the effectiveness of soft
braces (lace-up style) to semi-rigid braces to see which
prevents injury better.

Verhagen et al30 tested the effects

of brace, tape, and shoes on ankle range of motion.

Ankle

taping, non-rigid braces, and semi-rigid braces all showed
significant ankle ROM restriction following exercise.

On

the other hand, only the semi-rigid bracing retained
significant restriction after a certain amount of exercise,
while the other two measures showed loosening over time.30
Cordova and Dorrough16 performed a study using the
three different bracing methods, semi-rigid, lace-up, and a

46
control group (no brace at all).

Average angular

displacement as well as the average angular velocity of the
ankle using a motion analysis system was tested.

Results

showed that the semi-rigid brace had significantly reduced
rear foot angular displacement and the angular velocity
compared with the controlled conditions as well as the
lace-up style which also showed less rear foot angular
displacement and velocity when compared to the control
condition.16

The study also showed that both the semi-rigid

and the softer lace-up brace significantly restricted
inversion angular displacement by 61% and 46% when they are
compared with the control condition during a sudden
inversion.16 The semi-rigid condition demonstrated a 38%
reduction in inversion motion when it was compared with the
lace-up brace.16 Both studies indicate that the semi-rigid
brace would be preferred to the lace-up, but that the laceup is preferred to no brace at all in the goal of
restricting rear foot motion and angular velocity.
Just as with tape, research has supported the idea
that bracing reduces risk of injury by providing support,
which limits excessive range of motion and enhances
proprioception.

This idea and use of prophylactic

tape/bracing for injury prevention has become more popular
over the years due to cost effectiveness.

The comfort of a

47
brace depends on foot structure and type of brace used as
the semi-rigid braces contain hard inserts while the soft
braces are a canvas lace-up or strap on form.31

Balance Testing

Balance is the most important factor dictating
strategies of movement within the closed kinetic chain.17
Ability of balance is necessary for general life activity
as well as for athletic performance.

Balance is defined as

the ability to maintain the body’s center of gravity (COG)
within the base of support provided by the feet.17

Types of Balance Tests
There are several ways to measure balance including
the Biodex Balance System (BBS), Romberg test, Star
Excursion Balance Test (SEBT), and Balance Error Scoring
System (BESS).17
and dynamic.

Balance is commonly categorized as static

Static balance means sustaining the center of

mass over a motionless base of support, such as maintaining
balance during quiet stance.23

Dynamic balance is defined

as maintaining a center of mass over the bass of support
while the base of support is moving or there is an external
affect to the body that causes a shift in the base of

48
support.7,18,19

Functional balance is another form of balance

that is analogous to dynamic balance with the addition of
sport-specific tasks such as throwing and catching.17
Dynamic postural-control tasks require a greater
degree of corresponding movement patterns using
contributions from several joints.22

This is an important

aspect for the physically active population due to the fact
that several of the movements relate to an athletic event
or competition and maintaining equilibrium can increase
function and ability of the athlete to perform at their
best level.

As a theory of motor learning, dynamical

systems states that sensorimotor system organization
involves an interaction of a variety of variables including
task, environment, and organism.7

When the dynamic is

changed by these constraints, a new pattern is developed by
higher brain-center inputs and peripheral inputs for the
different conditions.7

Drop Landing
The primary mechanism of many lower extremity injuries
that occurs in many sports is the task of landing from a
jump.

Drop landings are a common test performed to

determine the dynamic balance and stability of the ankle
under several conditions.20

The jumps are good tools when

49
attempting to measure ability to absorb forces at the ankle
joint.

It is an option to allow a force platform to

determine the position of the ankle and how long it takes
for the ankle to maintain a state of stability after a drop
jump from a certain height.

This is a more functional test

compared with the long-established postural control
measures because it works to simulate a functional
technique for assessing the effects of fatigue on
neuromuscular control and dynamic stability.2
Wikstrom et al32 used subjects with functional ankle
instability to determine a Dynamic Postural Stability Index
(DPSI) while wearing semi-rigid, rigid, and no brace after
a two-legged jump to the height equivalent to 50% of their
maximum vertical jump and land on a single leg.

Though

they expected to find these devices improve proprioception
and dynamic postural stability, it was shown that dynamic
postural stability was not improved during the jump
protocol under either the soft or semi-rigid brace
conditions over the no-brace condition.

It was not known

from this study that ankle bracing could improve the
dynamic stability when the participant is fatigued.
An example of this drop landing procedure was
performed in a study by Cordova et al (2010) utilizing 13
healthy subjects that were active in recreational

50
basketball.16

The subjects were asked to perform a one

legged drop landing from a standardized height under three
different ankle-support conditions.16

They were then

instructed to perform five landing trials under each of the
three ankle supports including a semi-rigid brace, no
brace, and ankle taping.16

The data was collected using a

force platform as used in other studies.

The results

showed that there was significantly less ankle joint ROM
under both conditions.16 There were also no differences
reported between the tape and the semi-rigid brace
conditions.

The study was also able to conclude that the

ankle tape significantly restricted ankle-joint ROM as well
as the semi-rigid ankle brace when the subjects are
performing a one-legged drop landing.16

Star Excursion Balance Test
The star excursion balance test is a measure of
dynamic postural control where the individual maintains a
stable base of support while they complete a given
movement, in this case, a star pattern on a grid
platform.18,21

This is a functional test of dynamic balance

that challenges an individual’s LOS and has high
intratester and intertester reliability.17

SEBT is used as

a tool to assess or screen for musculoskeletal impairments

51
including chronic ankle instability which has demonstrated
a decrease in anterior reaching distance when compared to
uninjured control subjects.18 It assesses maximum reach with
one leg while maintaining a base of support with the other
leg.22
In Hardys’21 study of prophylactic ankle braces and the
star excursion measures, they use an SEBT multidirectional
test to study and record dynamic balance.21

Dynamic

postural control places added demands on proprioception,
ROM, and strength in order to perform the tasks and
maintain balance.18

The eight directions marked on the grid

included A, AM, M, PM, P, PL, L, and AL.

18,19,21

Each of the

directions are placed at a 45° angle to the next
direction.2,18,19,21

Reach distances were then measured to the

nearest 0.5 cm and recorded for each of the directions.22
Leg length of each individual will correlate with the reach
distance as well because understandably, a longer limb
would give an advantage in a further reaching distance.18
To eliminate this factor, leg length of each subject will
be recorded and the means of SEBT will be divided by the
leg length in order to

normalize performance data.

Hertels’19 stated that if and when the examiner feels as
though the reach foot provided too much stability to the
testing limb, if equilibrium was lost, or the stance foot

52
was lifted from its place on the center grid then the trial
must be discarded and repeated.19
Single-limb dynamic balance can be assessed in
multiple directions using the SEBT.

Participants assume a

single-leg stance and reach as far as possible in eight
directions, thereby challenging their dynamic balance.

If

plantar-flexion and dorsiflexion are limited by a lace-up
style brace, reach in the anterior and posterior SEBT
directions may be limited.

Similarly, if inversion and

eversion were restricted by a semi-rigid brace, we expect
to see decreased performance in the medial and lateral SEBT
directions (Hardy).

By demonstrating that CAI subjects

could not reach as far as the non-CAI subjects while
maintaining a stable base of support, previous researchers
have established the SEBT as valid in differentiating the
dynamic postural control of those with and without CAI.1

Effects of Fatigue
Fatigue can impair the proprioceptive and kinesthetic
properties of joints, including the ankle joint.1,7

Adding

fatigue can increase the threshold of muscle spindle
discharge, which in turn disrupts the feedback and alters
joint awareness.1,3

There have been studies performed where

the researchers used different measures of postural

53
stability which can account for the difference in results
when testing CAI and single-leg stance.1,7,13,23,32
Neuromuscular patterns that are necessary to complete a
dynamic balance test and these patterns would appear to be
altered in the presence of CAI.1
Shaw et al2 compared dynamic stability using time to
stabilization among Division I volleyball players wearing a
lace-up brace and a semi-rigid brace prior to and after
induced fatigue.

After fatigue of the subjects, dynamic

stability was determined better when wearing the lace-up
brace.

This suggests some ankle bracing may have positive

influences on dynamic stability when fatigue is introduced
to excite a high level of physical activity.

Summary

The majority of ankle injuries occurs on the lateral
aspect of the ankle.1-3

Ligaments of the lateral ankle

originate from the distal fibula and consist of the
posterior talofibular, anterior talofibular, and
calcaneofibular ligaments.6

Repeated injuries to the ankle

can lead to chronic ankle instability which may be reduced
by taping/bracing.

Literature has indicated that tape

loses its rigidity and stability over time with activity

54
due to loosening up or absorbing sweat, which in turn,
causes it to lose its stability purposes.13,14

Tape offers

little or no support to the ankle for better correction of
movement following a pattern of ankle injury after a
fatigue protocol has been performed.2,10

Semi-rigid and

lace-up bracing has been tested under several conditions
and has shown to be more effective to ankle stability than
tape alone.13-15

With the use of prophylactic bracing, it is

proposed that dynamic balance will be enhanced after a
functional fatigue protocol.
Dynamic balance is an important aspect for the
physically active population due to the fact that several
of the movements relate to an athletic event or competition
and maintaining equilibrium can increase function and
ability of the athlete to perform. There are several ways
to measure balance including the Biodex Balance System
(BBS), Romberg test, Star Excursion Balance Test (SEBT),
and Balance Error Scoring System (BESS).17

The SEBT is

reported valid and reliable tool used to assess or screen
for musculoskeletal impairments including chronic ankle
instability which has demonstrated a decrease in anterior
reaching distance when compared to uninjured control
subjects.18

It is a test that has demonstrated high

reliability for testing functional balance.18,19,22

Tape and

55
a measuring tape are the only tools needed to administer
the test.
With the added support of colleague’s experimental
research and the increased knowledge on the effectiveness
of bracing injured ankles, advances towards the use of
prophylactic bracing over taping techniques for injury
prevention can be established.

It is important to clarify

the advantages and disadvantages of prophylactic bracing
and taping techniques following a functional fatigue
protocol to better simulate their use in an athletic
competition or recreational athletic setting.

56

APPENDIX B
The Problem

57
THE PROBLEM

Statement of the Problem
Ankle injuries are common in sports and prevention of
these injuries has been well studied over the years.
Clinicians have turned to the use of preventative measures
such as prophylactic ankle braces to prevent the injury or
re-injury of the ankle.

In general, the literature

suggests that bracing is suggested to be more effective
than the taping method due to the fact that tape can loosen
with time and fatigue of the tape causing a decrease in the
limiting properties of the brace itself.

The purpose of

this study is to determine what affects a functional
fatigue protocol would have on dynamic balance when using
bracing versus taping techniques.

Definition of Terms
The following definitions of terms were defined for
this study:
1)

Ankle Instability Instrument (AII) – the AII
determines whether a participant reports CAI (chronic
ankle instability.34

AII has been observed to be a

reliable measure of self-reported CAI.34

58
2)

Balance – the body’s ability to maintain its center of
gravity within the base of support.39

3)

Dynamic Balance - dynamic balance means that the
subject is maintaining a center of mass over the bass
of support while the base of support is moving or
there is an external affect to the body that causes a
shift in the base of support.39,38,36

4)

Fatigue protocol - a test performed to fatigue the
lower extremity and prophylactic brace before and
following a SEBT.31

5)

Physically active – an individual who currently
performs physical activity for 20 min at least three
times a week.

6)

Prophylactic device - a device that is applied to the
ankle to provide support and increase stability as
well as help with prevention of injury or re-injury to
the ankle.12

7)

Star Excursion Balance Test (SEBT) – dynamic balance
test that the subject performs with their reach leg in
five directions: A, AM, M, PM, P.38,36

59

Basic Assumptions
The following were basic assumptions of this study:
1)

All participants will fully understand the
instructions provided and give a maximum effort during
testing.

2)

The subjects will be honest in completing the
demographics form provided.

3)

The subjects will perform to the best of their ability
during the fatigue and star excursion testing periods.

4)

The star excursion balance test will be a valid and
reliable tool to measure the stabilization of the
brace prior to and following the fatigue protocol.

5)

Testing instruments are valid and reliable tools for
measuring the dependent variables.

6)

All subjects will volunteer with no coercion from
coaches or faculty.

Limitations of the Study
Test results can be generalized for only the NCAA
Division II collegiate athletes and physically active
adults.

Since the testing was done in the lab, the results

could represent assumptive functional measures of balance.

60
Significance of the Study
The scope of this study was to examine the effects of
a functional fatigue protocol on dynamic balance while
utilizing a prophylactic ankle brace or taping technique.
Dynamic balance will be determined using an SEBT.

Chronic

ankle instability is modified mechanical joint stability
due to recurring disruptions to ankle integrity with
secondary perceived and observed insufficiency in
neuromuscular control.37

In order to reduce these instances

of injury it has been recommended to use a prophylactic
ankle brace or taping technique.29,26

This bracing or taping

method assists in limiting ankle range of motion that
results in lateral ankle sprains.29,26

The evidence has

provided that the SEBT is a sensitive test for screening
musculoskeletal impairments such as chronic ankle
instability.38

Previous research has found effects of

functional fatigue on drop landings or SEBT using no brace
or lace up brace conditions but none have focused on the
comparison of tape versus brace conditions following the
same functional fatigue protocol.

This information may

assist athletic trainers and conditioning coaches as well
as the general public which is physically active in
determining what form of prophylactic bracing or taping

61
technique would be more beneficial to preventing injury or
re-injury.

62

APPENDIX C
Additional Methods

63

APPENDIX C1
Data Collection Sheet

64
Data Collection Sheet
Subject # ____

Date __________________

Age: _______

Gender: ______________

Chronically Unstable Ankle:

R / L

Maximal Vertical Jump Height ___________
Leg Length __________
□

NCAA athlete

□

Physically active/recreational athlete

SEBT TEST SCORES SHEET
Subject #

Test 1
Pre-Fatigue
A
AM
M
PM
P
PL
L
AL

Tape
Reach Dist
(cm)

Post-Fatigue
A
AM
M
PM
P
PL
L
AL

Tape
Reach Dist
(cm)

65

Test 2
Pre-Non
Fatigue

Tape
Reach Dist
(cm)

A
AM
M
PM
P
PL
L
AL

Test 3
Pre-Fatigue

A
AM
M
PM
P
PL
L
AL

Tape
Reach Dist
(cm)

A
AM
M
PM
P
PL
L
AL

ASO Brace
Reach Dist
(cm)

A
AM
M
PM
P
PL
L
AL

Test 4
Pre-Non
Fatigue

Post- Non
Fatigue

Post-Fatigue

ASO Brace
Reach Dist
(cm)

A
AM
M
PM
P
PL
L
AL

ASO Brace
Reach Dist
(cm)

Post- Non
Fatigue
A
AM
M
PM
P
PL
L
AL

ASO Brace
Reach Dist
(cm)

66

APPENDIX C2
Informed Consent Form

67
Informed Consent Form

1.

Mallory Bieringer has requested my participation in a
research study at this institution. The title of the
research is The Effect of Fatigue on Balance in Ankle
Tape VS Lace-up Brace Conditions Using a Star
Excursion Balance Test.

2.

I have been informed that the purpose of the research
is to examine the effect of fatigue on a dynamic
balance test under two conditions, tape and brace, in
NCAA Division II collegiate athletes and physically
active volunteers 18 years of age and older, enrolled
at California University of Pennsylvania.

3.

My participation in this study will involve the SEBT
for dynamic balance testing. I will report to the
laboratory on 4 separate occasions, a minimum of three
days apart. Determination of my maximum vertical jump
will be done using a Vertec jump training system and I
will be given three trials to do so. I will then
perform a pre test of the SEBT with either a tape or
brace condition. Following the pre test, I will
either be asked to remain inactive or perform a
functional fatigue protocol consisting of three
stations. Three stations of this functional fatigue
protocol include the Modified Southeast Missouri
agility drill, stationary lunges, and quick jumps.
After I have performed the functional fatigue protocol
or remained inactive for the same time period as the
functional fatigue protocol would take, I would be retested with the SEBT while still wearing the brace or
tape condition. All of the testing will be conducted
on one day in the athletic training room in Hamer Hall
for approximately one hour for each subject.

4.

I understand there are foreseeable risks or
discomforts to me if I agree to participate in the
study. The possible risk is falling during the
functional balance testing using the SEBT where risks
can be decreased by using the researcher as a spotter
for myself. Any injuries that may occur during the
balance testing can be treated at the athletic
training room at Hamer Hall provided by the
researcher, Mallory Bieringer. This risk is no more

68
than normal physical activity that normal physically
active individuals would be exposed to during daily
activities.
5.

There are no viable alternative procedures available
for this study.

6.

I understand that the possible benefit of my
participation in the research is contribution to
existing research and may aid in understanding which
condition, brace or tape, is more effective for
dynamic balance using the SEBT following a functional
fatigue protocol.

7.

I understand that the results of the research study
may be published but that my name or identity will not
be revealed. In order to maintain confidentiality of
my records, Mallory Bieringer will maintain all
documents in a secure location in which only the
student researcher and research advisor can access.

8.

I have been informed that I will not be compensated
for my participation.

9.

I have been informed that any questions I have
concerning the research study or my participation in
it, before or after my consent, will be answered by

Student Researcher:

Graduate Faculty Thesis Advisor:

Mallory Bieringer
PO BOX 204
Roscoe, PA 15477
734-347-1993
Bie0029@calu.edu

Rebecca Hess, Ph.D.
B6 Hamer Hall
California University of
Pennsylvania
California PA, 15419
724-938-4359
Hess_ra@calu.edu

10.

I understand that written response may be used in
quotations for publication but my identity will remain
anonymous.

11.

I have read the above information. The nature,
demands, risks, and benefits of the project have been
explained to me. I knowingly assume the risks
involved, and understand that I may withdraw my

69
consent and discontinue participation at any time
without penalty or loss of benefit to myself. In
signing this consent form, I am not waiving any legal
claims, rights, or remedies. A copy of this consent
form will be given to me upon request.
Subject’s
Signature____________________________________Date__________
12.

I certify that I have explained to the above
individual the nature and purpose, the potential
benefits, and possible risks associated with
participation in theis research study, have answered
any questions that have been raised, and have
witnessed the above signature.

13.

I have provided the subject/participant a copy of this
signed consent document if requested.

Investigator’s
Signature_________________________________Date_____________
Approved by the California University of Pennsylvania IRB:
Start date _02_/_04_/__2011__, End Date: _02_/_03_/_2012__

70

Appendix C3
Fatigue Protocol

71

Three stations were used in the fatigue protocol
including a Modified Southeast Missouri agility drill
(SEMO), stationary lunges, and quick jumps with the use of
data collected from the subjects’ vertical jump height.
The SEMO was composed of a series of forward sprints,
side shuffles, and back peddling.4

The SEMO was completed

in a rectangle of 12 X 19 ft (3.6 X 5.7 m) as performed in
Shaw and Gribble’s study due to testing space.

Following

this station the subjects immediately began the stationary
lunges that were timed with a metronome.

The distance of

lunge was determined by the measures of the subject’s true
leg length from the anterior superior iliac spine to the
distal portion of the medial malleolus prior to the
protocol.

Each lunge was performed five times equaling ten

lunges total with alternating lunge legs.4

One lunge was

performed every two seconds using a metronome.4

Starting

with their feet together they would step forward with their
lunging leg and place their leading foot firmly on the
ground.

Subjects had to avoid any sideways tilting or

swaying in the upper body and bring the lower body to a
position where the front thigh became parallel with the
floor during hip and knee flexion, while maintaining an
upright torso. They would then return to standing position

72
while their hands remained on their hips.

Proper technique

was critical to fatigue the individual.
Finally, as the last step of the fatigue protocol, the
subjects performed 10 quick jumps.

To set up this station,

the individuals maximal vertical jump height was recorded
using the Vertec™ vertical jump tester.

This system

measures from 6 to 12 feet with color-coded vanes that
offer half-inch measurements for immediate feedback.
First, the subjects’ standing height was measured by
standing under the Vertec™ vertical jump tester and
reaching up to touch the highest point possible while
maintaining both feet flat on the ground.

Second,

participants performed a two-footed maximal vertical jump
reaching to the highest point possible on the Vertec™.
From Shaws’4 study each participant was given three jump
trials to determine their greatest jump height, that height
was then recorded.4 The standing reach height was then
subtracted from the individuals maximal vertical jump
height in order to get their Vertmax.4 The quick jumps were
performed double legged with both arms above the head
reaching for a distance that was 50% of their Vertmax
previously recorded.

This was done ten times reaching for

a tape placement on the wall for the subject to hit each
time with both hands.4

Again, correct form was critical for

73
fatigue to be reached and if the form was not correct, the
jump was not counted.

If the tape was not touched with

both hands, the jump was not counted.

Each subject was

able to establish a baseline time with the first testing
session to determine fatigue in the subsequent testing
trials.

Participants continued to complete each station

until the time to finish the stations increased by 50% when
compared to their baseline times.4

74
Stationary Lunges

Quick Jumps

75

Appendix C4
Pictures of SEBT

76

Star Excursion Balance Test (SEBT)

(http://www.efdeportes.com/efd135/upper-body-exercise-on-dynamic-postural-control.htm)

77

APPENDIX C5
Institutional Review Board

78

79

80

81

82

83

84

85

86

87

88

89
Institutional Review Board
California University of Pennsylvania
Psychology Department LRC, Room 310
250 University Avenue
California, PA 15419
instreviewboard@cup.edu
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair

Ms. Bieringer,
Please consider this email as official notification that your proposal titled "
The Effect of Fatigue on Balance in Ankle Tape vs Lace Up Brace
Conditions Using a Star Excursion Balance Test on Chronically Unstable
Ankles” (Proposal #10-024) has been approved by the California University
of Pennsylvania Institutional Review Board as submitted, with the following
stipulation:
(1) The consent form must include a statement that participants must
be over 18 years of age.
Once you have made this revision, you may immediately begin data
collection. You do not need to wait for further IRB approval. [At your
earliest convenience, you must forward a copy of the revised consent form
for the Board’s records].

(1)

(2)
(3)
(4)

The effective date of the approval is 02-04-2011 and the expiration date is
02-03-2012. These dates must appear on the consent form .
Please note that Federal Policy requires that you notify the IRB promptly
regarding any of the following:
Any additions or changes in procedures you might wish for your study
(additions or changes must be approved by the IRB before they are
implemented)
Any events that affect the safety or well-being of subjects
Any modifications of your study or other responses that are necessitated
by any events reported in (2).
To continue your research beyond the approval expiration date of 02-032012 you must file additional information to be considered for continuing
review. Please contact instreviewboard@cup.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

90
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4. Martini F, Timmons MJ, Tallitsch RB. Human Anatomy.
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6. Starkey C, Ryan JL. Evaluation of Orthopedic and
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Lara AJ, Meana M, Aguado X. Ankle taping does not
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Sci Med. 2008; 7: 350-356.
10. Bot Sandra D M, Verhagen E ALM, Mechelen W V. The
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11. Kadakia AR, Haddad SL. The role of ankle bracing and
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371-375.
14. Lohkamp M, Craven S, Walker-Johnson C, Greig M. The
influence of ankle taping on changes in postural
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Rehab. 2009; 18: 482-492.
15. Thomas LD, Corbin CB. Restriction of ankle
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Merrick MA. Prophylactic ankle bracing reduces rearfoot
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21. Hardy L, Huxel K, Brucker J, Nesser T. Prophylactic
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Finch AE. Influence of external ankle support on
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26. Prentice W. Arnheim’s Principles of Athletic Training
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27. Beynnon B, Murphy D, Alosa D. Predictive Factors for
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29. Bragg R, Macmahon J, Overom E, Yerby S, Matheson G,
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ABSTRACT

Title:

THE EFFECT OF FATIGUE ON BALANCE IN ANKLE
TAPE VS LACE UP BRACE CONDITIONS USING A
STAR EXCURSION BALANCE TEST ON CHRONICALLY
UNSTABLE ANKLES

94

Researcher:

Mallory Bieringer

Advisor:

Dr. Rebecca Hess

Date:

May 2011

Research Type: Master’s Thesis
Context:

With the added support of colleague’s
experimental research and the increased
knowledge on the effectiveness of bracing
injured ankles, advances towards the use of
prophylactic bracing over taping techniques
for injury prevention can be established.
Previous studies have not examined the
effects of fatigue and bracing on
individuals with chronic ankle instability
while utilizing a prophylactic ankle brace
or taping method.

Objective:

The primary purpose of this study was to
determine the effects of a functional
fatigue protocol on dynamic balance while
utilizing a prophylactic bracing technique
and tape.

Design:

This research was a quasi-experimental,
within subjects, repeated measures design.
Independent variables in this study were
condition (tape and semi-rigid bracing
technique) and fatigue (fatigue and nonfatigue). The dependent variable was the
measure of functional balance using SEBT
following a fatigue protocol during the
application of both conditions.

Setting:

The testing was performed in a controlled
laboratory setting by the researcher.
Fifteen physically active individuals with
chronic ankle instability volunteered for
this study (7 males, 8 females).

Participants:

Interventions: Each subject was assigned to four testing
sessions under both conditions (brace
condition, fatigue condition) and a SEBT was

95
used to measure dynamic balance and
functional balance, respectively.
Main Outcome Measures:
SEBT scores were computed from all test
trials and differences in reach were
examined among all variables.
Results:

The within-subjects repeated measures ANOVA
was calculated comparing the two levels of
prophylactic bracing conditions (lace-up
brace and tape). No significant effect was
found (F(1,14) = 1.309, P ≥ .05).

Conclusion:

There appears to be no significant
difference between the use of tape or laceup brace following a fatigue protocol on
individuals with chronic ankle instability
when testing functional balance.

Word Count:

322