NPC Archive Item: Patellar taping for chronic knee pain

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MeReC Rapid Review

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Warden SJ, et al. Patellar taping and bracing for the treatment of chronic knee pain. Arthritis Rheum 2008;59:73–83

What is the background to this?
Therapeutic taping and bracing of the patella (the bone that forms the kneecap) are commonly used for people with knee pain, e.g. as a result of osteoarthritis. This article systematically reviewed the literature and carried out meta-analyses of the effects of both interventions to identify if their was clinical evidence of benefits in reducing pain relative to each other, to no tape/brace or sham effects, and when used in different ways.

What does this study claim?
This study claims to be the first detailed analysis of these two interventions. It identified that there was evidence that tape applied to exert a medially-directed force to the patella produces a clinically meaningful change in chronic pain. However, evidence to support the use of patella bracing was limited and disputable.

How does this relate to other studies?
There are very few good-quality trials examining the benefits of these two interventions. The reviewer’s identified only 16 eligible randomised controlled trials (RCTs) of patella taping, and three of bracing, and many of these trials had methodological limitations. Few of the studies included concealed allocation of treatment, and blinding of the therapist, patient or assessor. The authors also suspected publication bias from the asymmetry of funnel plots.

Draft NICE guidance on osteoarthritis, due for publication this year, recommends that patients are offered paracetamol and/or topical non-steroidal anti-inflammatory drugs NSAIDs) in the first instance if pain is a problem. If these are insufficient to control pain then oral NSAIDs, either traditional or COX-2 selective, with appropriate consideration of the patient’s cardiovascular and gastrointestinal risk (see MeReC Extra No. 2007), can be considered. In view of the paucity of evidence supporting its use, NICE does not make specific recommendations for knee taping; however, it does recommend that “people with biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles as an adjunct to core therapy”. CKS guidance recommends considering non-drug treatment for all people with knee osteoarthritis at all stages, including patellar taping, braces, use of a cane in the contralateral hand, exercise, and  weight loss in those who are overweight/obese (BMI>28kg/m2).

So what?
This study provides reasonable evidence that medially-directed knee taping can reduce chronic knee pain. Further research is needed to establish whether other forms of knee taping or bracing have any benefits in reducing knee pain.

Medially-directed knee taping is a simple, inexpensive and harmless therapy, which appears to produce clinically meaningful pain relief in some patients. It therefore deserves serious consideration as an option for those suffering from chronic knee pain, alongside, or in addition to, analgesics and other non-drug measures (e.g. exercise, weight loss, and use of canes). However, to ensure that optimal benefit is obtained, the knee taping needs to be done by a person with appropriate training (normally a physiotherapist).

Study details
Of the 16 eligible RCTs, 13 investigated patellar taping or bracing effects in individuals with anterior knee pain, and three investigated taping effects in individuals with knee osteoarthritis. On a 100-mm scale, tape applied to exert a medially-directed force on the patella decreased chronic knee pain compared with no tape by 16.1mm (95% confidence interval [CI] 10.0 to 22.2; P < 0.001) (n=282) and sham tape by 10.9mm (95%CI 3.4 to 18.4; P< 0.001) (n=242). For anterior knee pain and osteoarthritis, medially-directed tape decreased pain compared with no tape by 14.7mm (95%CI 6.9 to 22.8; P< 0.001) (n=212) and 20.1mm (95% CI 14.3 to 26.0; P< 0.001) (n=76), respectively. Evidence for patellar bracing benefits was only available from three studies (none in osteoarthritis). Medially-directed bracing was associated with a significant decrease in reported pain of 14.6 (95%CI 3.8 to 25.5mm, P<0.01) (n=119), although the reduction compared with sham bracing (1.3mm) was not significantly different.

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