PM R 11 (2019) 681-693

www.pmrjournal.org

Original Research—CME
The Effectiveness of Kinesiotaping, Sham Taping or Exercises Only
in Lateral Epicondylitis Treatment: A Randomized Controlled Study
Esra Giray, MD, Duygu Karali-Bingul, MD, Gulseren Akyuz, MD

Abstract

Abstract
Background: Lateral epicondylitis is a common musculoskeletal condition presenting with pain and tenderness over the lateral epi-
condyle and dorsal forearm, pain and weakness in gripping and limitations in daily activities. It is proposed that kinesiotaping, a new
application of adhesive taping, reduces pain and improves muscle function.
Objective: To compare efficacy of kinesiotaping, sham taping, or exercises only in the treatment of lateral epicondylitis.
Design: Double-blind, randomized, controlled trial.
Setting: Tertiary medical center, university hospital.
Participants: Thirty patients with lateral epicondylitis for less than 12 weeks.
Methods or Interventions: Patients were randomized into three groups: kinesiotaping plus exercises (n = 10), sham taping plus exer-
cises (n = 10), and control (exercises only) (n = 10) groups. All recipients were provided a home exercise program including strengthen-
ing and stretching exercises. In kinesiotaping and sham taping groups, tapings were performed and changed every 3–4 d for 2 weeks.
Main Outcome Measure(s): The primary outcome was the patient-rated tennis elbow evaluation (PRTEE). Pain visual analogue scale
(VAS), grip strength, and the disabilities of the arm, shoulder and hand (QuickDASH) scales were secondary outcomes. Evaluations
were done at baseline, posttreatment, and at 4 weeks after treatment. The immediate effect was also assessed by VAS and grip
strength immediately after real and sham tapings.
Results: PRTEE total scores at posttreatment and at 4 weeks after treatment were statistically significantly lower in kinesiotaping
plus exercises group compared to sham taping plus exercises group and exercises only group. The effects of kinesiotaping were larger
than sham taping and only exercises at posttreatment (d = −1.21, d = −1.33) and at 4 weeks after treatment (d = −1.39, d = −1.34).
Repeated-measures ANOVA showed a significant interaction between the time and the groups (F 2950 = 4849; P = .006). Significant
between-group differences were found in QuickDASH score and VAS at rest at 4 weeks after treatment, VAS at daily activity at post-
treatment and 4 weeks after treatment when kinesiotaping plus exercises and sham taping plus exercises groups and kinesiotaping
plus exercises and exercises only groups were compared. Real taping but not sham taping immediately led to an increase in grip
strength, decrease in VAS at rest and VAS at daily activity (P = .0017, P = .041, P = .028; respectively).
Conclusions: Kinesiotaping in addition to exercises is more effective than sham taping and exercises only in improving pain in daily
activities and arm disability due to lateral epicondylitis.
Level of Evidence: I

Introduction 40% of people experience lateral epicondylitis at some

point during their lifetime.2 Lateral epicondylitis
Lateral epicondylitis, the most commonly diagnosed develops as a result of a variety of activities that involve
pathology of the the elbow, is characterized by pain and excessive and repetitive use of the forearm extensors,
tenderness over the lateral epicondyle and dorsal fore- so it is prevalent among tennis players and workers who
arm, pain and weakness in gripping, limitations in daily perform highly repetitive hand tasks.3 Upper limb injuries
activities, and deterioration in quality of life.1–4 About constitute 18% of work related claims, which is almost

© 2019 American Academy of Physical Medicine and Rehabilitation

https://dx.doi.org/10.1002/pmrj.12067
682 Kinesiotaping for Lateral Epicondylitis

equal to the prevalence of back injuries.1,2 Although the although the taping technique was diamond shaped,
burden due to lateral epicondylitis is considerable, there which is different from the usual technique proposed by
is insufficient evidence on the most effective manage- Kenzo Kase.22,23 In another study comparing the effects
ment.5,6 Conservative treatment includes exercise ther- of kinesiotaping, cold pack and transcutaneous electrical
apy, joint mobilization techniques, education on activity stimulation, and extracorporeal shock wave therapy in
modification, and pharmacologic treatments. No conclu- patients with newly diagnosed LET, the kinesiotaping
sive evidence exists that there is one preferred method group was found to be superior to others in improving out-
of nonsurgical treatment for this condition.1,3,6,7 For comes but the study lacked long-term follow-up.24 A ran-
those patients who do not respond to noninvasive treat- domized, double-blinded, crossover study investigated
ment modalities, more invasive therapies such as injec- the immediate effects of kinesiotaping and sham taping;
tions of steroid, prolotherapy, platelet-rich plasma, and again, long-term effects were not evaluated.25
botulinum toxin A have been used prior to surgical
A recent systematic review on the effects of kinesio-
treatment.8–10 Numerous terms including tennis elbow, taping for neck and upper extremity conditions concluded
lateral epicondylalgia, tendonitis, tendinosis, and tendi- that evidence from high-quality and adequately powered
nopathy have been used to describe this condition. Lat-
studies are needed.26 Although studies have suggested a
eral elbow tendinopathy (LET) seems to be the most promising effect of kinesiotaping in LET treatment, there
appropriate term because histopathological studies is a lack of properly designed randomized controlled trials
showed that degenerative changes rather than inflamma-
to support existing beneficial effects.3,15,23,24 Given
tion play a role in pathophysiology.3,4 Repetitive trauma these results, in a properly designed RCT with follow-up,
and overstretching of the tendon result in microtears, we aimed to compare efficacy of kinesiotaping and sham
disrupt regularity of collagen fibers, and finally lead to
taping in addition to exercises or exercises only in the
tendinosis. Histopathologic studies have shown fibrosis, treatment of LET.
partial or complete rupture of tendons, disorganized col-
lagen, and sometimes osseous calcification in later stages
of LET. During this process biochemical irritation stimu- Materials & Methods
lates nociceptors, causes pain and tenderness; weaker
junction to bone causes weakness in grip strength.11–14 Study Design
Understanding pathophysiology of LET enables clinicians
to choose appropriate treatments targeting pathol- The study was designed as a single center, double-
ogy.4,15,16 The main treatment principles of tendinopathy blinded, sham-controlled, randomized, parallel-group
management are regarding exercises and load control.2 It trial.
has been demonstrated that eccentric exercises help ten-
don healing by improving collagen alignment and stimu- Participants and Interventions
lating collagen cross-linkage formation and thus improve
strength.15,17,18 Although load control and exercises are Thirty patients (mean age 44.46  9.92; 26 female,
useful for tendinopathy rehabilitation, it is hard to per- 4 male patients) who were admitted to the outpatient
form exercises without reducing pain.19 Kinesiotaping, clinic of physical medicine and rehabilitation of a univer-
which is a new application of adhesive taping, was devel- sity hospital were randomized into three groups: Group
oped by Kenso Kase (a chiropractor) and it is used for 1 (kinesiotaping plus exercises), Group 2 (sham taping
treating a variety of musculoskeletal injuries. It is pro- plus exercises), and Group 3 (control - exercises only
posed to (1) unload and decompress underlying soft tis- group). To ensure group concealment, randomization
sues via formation of convolutions that result in was done by an independent researcher who is not
increased subcutaneous space and improved circulation, involved with any other aspect of the trial via using opa-
(2) alleviate pain by increasing stimulation of skin mech- que, sealed envelopes containing a message revealing
anoreceptors causing blocking of the signals due to gate which group the patient would be allocated (the assessors
control theory, and (3) facilitate or inhibit muscle func- were blinded to the allocation). The randomization code
tion via cutaneous stimulation depending on the tech- was given only to the physician who would apply taping
nique applied.3,15,20,21 A before-after design study and the interventions were started. Patients and asses-
demonstrated that kinesiotaping provided improvements sors were blinded to treatment allocation. Assessments
in pain, grip strength, and function in patients with LET; were done after the removal of tape to ensure masking
however, the study lacked a sham group. Another study of assessors. To ensure blinding of immediate assess-
evaluating the effects of kinesiotaping in addition to ments, patients wore long-sleeved jackets to hide any
eccentric exercises compared to sham tape and exercises taping from the evaluator. Also, the blinding integrity
and exercises alone showed long-term improvements in was assessed at the end of the study. Participants were
all groups; however, the assessors were not blinded to asked to guess their treatment allocation. The blinded
interventions.15 Shakeri et al found that kinesiotaping investigators were also asked to guess the patient
was superior to placebo taping in improving disability, allocation.
 E. Giray et al. / PM R 11 (2019) 681–693 683

The inclusion criteria were (1) symptom duration less maximum strength and density and increasing the resis-
than 12 weeks, (2) tenderness and pain over LET, and tance each week; and two sets of 10 repetitions for the
(3) provocation of the lateral elbow pain with at least wrist flexor and extensor muscle groups composed of
one of the following tests – resisted middle finger exten- 20 s of stretching and 10 s of relaxing using the unaf-
sion (Maudley’s test), resisted wrist extension or passive fected hand.24 In kinesiotaping and sham taping groups,
stretch of wrist extensors (Mill’s test). Also, diagnosis tapings were performed by a trained and certified physi-
was confirmed by ultrasound by a physiatrist who has cian and changed every 3 days for 2 weeks. Therefore,
6 years of experience with diagnostic musculoskeletal each patient had four tapings in total. Kinesiotaping was
ultrasound by assessing the morphologic characteristics applied by using muscle inhibition and fascia correction
of the common extensor tendon (echotexture, calcifica- techniques on forearm as described by Kase et al
tion, tear) and its insertion (spur, erosion, irregularity), (Figure 1). An X-shaped strip from wrist to lateral epicon-
thickness, and blood flow signals on power Doppler dyle of the humerus and an approximately 10 cm Y-
imaging.27–29 The exclusion criteria were (1) diagnosis of shaped strip was prepared before application. Short tails
cervical spondylosis or radiculopathy; (2) diabetes melli- of the X-strip were applied to the dorsal side of the hand
tus; (3) concomitant neuropathy, entrapment neuropa- without any tension, the crossing part was applied to the
thy, or polyneuropathy; (4) systemic arthritic dorsal wrist with maximum tension, and long tails were
conditions; (5) pregnancy; (6) history of surgery or acute fixed along the muscles of extensor carpi radialis and
trauma in the elbow; (7) history of injection and/or phys- extensor carpi ulnaris to lateral epicondyle without ten-
iotherapy, ergonomic or home exercise program for LET; sion. The Y-strip was applied by using fascia correction
and (8) allergy to tape. method. Tails of the Y-band were applied using an oscilla-
The study was conducted after approval from the tion motion. On the other hand, sham taping was per-
ethics committee of the university school of medicine in formed with two narrow I-shaped strips from the same
accordance with the Declaration of Helsinki (approval taping material, applied to forearm avoiding muscle ori-
number: 09.2017.004). It was registered on the Clinical gin and insertion points and without applying tension
Trials Registry and the registration number is (Figure 1).22 All participants were informed to remove
NCT03074500. Oral and written informed consents were tape if any adverse effect (such as skin irritation)
obtained from all patients after explanation of the inter- occurred. Also, to ensure that no dermatologic allergic
ventions. To ensure the control group’s blinded status, reaction would occur, a small patch test of kinesiotaping
patients received separate informed consent forms after had been applied on the volar side of the patient’s fore-
approving a preliminary consent form that explained that arm as a rapid allergy screening test.
the patients were invited to participate in a clinical During the study period, oral or topical nonsteroidal
research study on the effectiveness of nonsurgical thera- anti-inflammatory drugs (NSAIDs) were not prescribed or
pies for LET. Control group received an informed consent allowed to the patients; however, they were allowed to
form for exercise treatment for the management of LET take occasional analgesics (such as paracetamol) if
and kinesiotaping groups received informed consent for needed. The home exercise program and restriction of
kinesiotaping and exercise treatments. NSAIDs were regularly reviewed by phone calls twice a
All groups received education on activity modification week in the exercises only group and during tapings in
and home exercise program that included stretching and the kinesiotaping and sham taping groups.
eccentric strengthening exercises as described by Wege-
ner, Eraslan, and Struijs et al.15,24,30 Eccentric strength- Outcome Measures
ening exercise was performed in the seated position
with maximum elbow extension, forearm pronation, and All evaluations were performed by an investigator
maximum wrist extension. From this position, the blinded to treatment allocation.
patients slowly lowered their wrists to flexion for
30 counts using the contralateral hand to return the wrist Primary Outcome Measure of the Study
to maximum extension. The patients were instructed to
continue the exercise even if they experienced mild dis- Patient Rated Tennis Elbow Evaluation Questionnaire
comfort and to quit the exercise if the pain became intol- (PRTEE)
erable. For patients who could perform the eccentric The primary outcome measure of the study was PRTEE,
exercise without minor discomfort or pain, the load was which evaluates pain and disability/function in patients
increased using free weights based on the 10 repetition with LET. The PRTEE is a 15-item questionnaire designed
maximum of the patients. Three sets of 10 repetitions to measure the forearm pain and disability in patients
were performed during each treatment, with a 1-min rest with LET [19]. The PRTEE allows patients to rate their
interval between each set. The eccentric exercises con- levels of tennis elbow pain and disability from 0 to
sisted of the following: three sets of 10 repetitions for 10 and consists of 2 subscales: (1) pain subscale [5 items]
wrist and elbow flexion; two sets of 10 repetitions for (0 = no pain, 10 = worst imaginable); and (2) function
wrist extension strengthening, starting with 50% of subscale [specific activities - 6 items, usual activities -
684 Kinesiotaping for Lateral Epicondylitis

Figure 1. The application of true (A) and sham taping (B).

4 items] (0 = no difficulty, 10 = unable to do). The pain The Disabilities of the Arm, Shoulder, and Hand
(ICC = 0.89), function (1CC = 0.83), and the total (QuickDASH) Scale
(ICC = 0.89) scores all demonstrated excellent reliability. The QuickDASH contains 11 items evaluating physical
When the reliability was assessed by subgroups (men vs function and symptoms in people with any musculoskele-
women; chronic vs acute; work related vs nonwork tal disorder of the upper limb. QuickDASH scale has been
related), the ICCs were all greater than 0.75.22,31 PRTEE proven to be a useful self-report. QuickDASH has been
has been validated in Turkish by Altan et al.31 found to be reliable and valid according to the study done
by Düger et al.32
Secondary Outcomes Age, gender, affected side, dominant side, duration of
symptoms, and Nirschl Scale for grading LET via symptom
Painless and Maximum Grip Strengths severity were recorded as demographic values. Nirschl
Strengths were measured by using a handheld dyna- scoring (0–7) classifies LET by the pain phase as a guide
mometer (JAMAR, Sammons Preston, Inc., Bolingbrook, to the severity of the problem.3
IL) in the standardized recommended position by American All evaluations were performed before treatment,
Society of Hand Therapy, with a rest period of 20 s. Three after treatment, and 4 weeks after treatment. In addi-
trials were performed and mean values were recorded.23 tion, VAS at rest, VAS at daily activity, and grip strengths
were also assessed in kinesiotaping and sham taping
groups to evaluate immediate effect, immediately after
Visual Analogue Scale (VAS) initial tape application.
Pain was assessed with VAS at rest, daily activity, and
night on a 10-cm scale. All patients were asked to mark
their pain level that corresponds to their pain intensity Sample size
on the line between “0,” representing “no pain,” and The sample size estimation was performed using the
“10,” representing “the worst pain imaginable.” The dis- GPower V.3.1.7 (University of Kiel, Kiel, Germany). It
tance between “0” and the mark made by the patients was determined that seven individuals for each group
was measured.24 must be recruited to detect a difference at 5% type 1 error
 E. Giray et al. / PM R 11 (2019) 681–693 685

level with 95% power when the average expected value in Assessment of Primary Outcome Measure: PRTEE
the first group was 64.22, with a standard deviation of
16.34 and the average expected value in the second group No differences were found between the groups regard-
was 37.3, with a standard deviation of 18.82 based on the ing the PRTEE baseline scores (Figure 3). PRTEE total
PRTEE questionnaire scores at posttreatment (at 2 weeks) scores at posttreatment and at 4 weeks after treatment
reported in the previous research conducted by Dilek were statistically significantly lower in kinesiotaping plus
et al3 evaluating the effects of kinesiotaping on pain, grip exercises group compared to sham taping plus exercises
strength, and function in patients with LET. group and exercises only group (Table 2, Figures 4 and
5). There were large effects for an improved PRTEE at
posttreatment and at 4 weeks after treatment for kine-
Statistical analysis siotaping plus exercises group when compared to sham
taping plus exercises group and exercises only group
IBM SPSS Statistics for Windows, Version 20,0 (Armonk, (Table 2). Additionally, repeated-measures ANOVA showed
NY) was used to perform all of the analysis. The histogram a significant interaction between the time and the groups
and normality plots and Shapiro-Wilk normality test were (F 2950 = 4849; P = .006) (Figure 6).
used to evaluate the distribution of variables prior to test
selection. Descriptive statistics were presented as Assessment of Secondary Outcome Measures
median (25–75%) for the nonnormally distributed quanti-
tative and ordinal data and number (minimum-maximum) Significant between group differences were found in
for the categorical variables. The Mann-Whitney U test QuickDASH score and VAS at rest at 4 weeks after treat-
was used to analyze differences between groups. Effect ment and VAS at daily activity at posttreatment and
sizes were also calculated for the between-group com- 4 weeks after treatment when kinesiotaping plus exer-
parisons by using GPower V.3.1.7 (University of Kiel, Kiel, cises and sham taping plus exercises groups and kinesio-
Germany) as previously described by Guo et al10; 95% CI taping plus exercises and exercises only groups were
was also calculated for the effect sizes via an Excel compared (Table 2). VAS at rest, VAS at daily activities,
spreadsheet.33 The effect sizes were generally defined and grip strength showed statistically significant
as small (d = 0.2), medium (d = 0.5), and large improvements when the true tape immediately applied
(d = 0.8).34 The PRTEE scores were submitted to a 2-way (P = .041, P = .028, P = .0017; respectively). VAS and
repeated measure analysis of variance (ANOVA) with time grip strength did not improve significantly when true tap-
(before treatment, after treatment and 4 weeks after ing was immediately applied (P = .834, P = .734). Imme-
treatment) as the within-subject factor and group (kine- diate effect assessment showed lower VAS scores at rest
siotaping plus exercises, sham taping plus exercises, and and at daily activities in the kinesiotaping group com-
exercises only groups) as the between-subject factor. pared to sham taping (Table 3).
Bonferroni correction was applied to within-group com- Participants and assessors did not guess correctly the
parisons of treatment efficacy. The reported P values treatment allocation beyond random chance
associated with the F statistics for the ANOVAs were level (P > .05).
adjusted via Greenhouse-Geisser correction. For all ana-
lyses, statistical significance was set at P < .05. Discussion

In this study, the comparative effectiveness of kinesio-

Results taping, sham taping in addition to exercises, and only
exercises for LET were evaluated. Kinesiotaping in addi-
The Consolidated Standards of Reporting Trials tion to exercises was superior to sham taping plus exer-
(CONSORT) diagram for recruitment of participants is cises and exercises only in improving pain and disability.
shown in Figure 2. Among 41 patients with LET assessed Real taping but not sham taping also decreased pain and
for eligibility, 33 met the inclusion criteria and enrolled increased grip strength immediately after application.
to the study. Among the 33 patients, there were 3 drop In the present study, the analysis showed a significant
outs, one patient showed allergy to tape, one was lost effect for time regarding PRTEE scores. Similar to these
to follow-up and one patient was administered steroid results, Dilek et al3 found improvements by time in VAS
injection due to exacerbation of pain related to his occu- at rest, daily activities and night, grip strength, and
pation. Thirty of them completed the full 2-wk study with PRTEE. They applied kinesiotaping for 2 weeks by using
a 4-wk follow-up. Data from the three groups each includ- muscle technique from origin to insertion and evaluated
ing 10 patients were gathered and analyzed. No differ- the effects at 2 weeks and 6 weeks after treatment. How-
ences were found between the groups regarding ever, the study included neither placebo nor control
demographic and baseline parameters (Table 1 and group.
Table 2). None of the participants reported using any oral Similar to the method of the present study, Wegener
or topical NSAIDs or paracetamol during the study period. et al15 compared the effects of real taping and sham
686 Kinesiotaping for Lateral Epicondylitis

Figure 2. Consort diagram of study.

taping for 12 weeks in conjunction with exercises and Short Form-36, pain-free grip strength, and occupational
exercises alone in patients with both acute and chronic self-assessment scale. Unlike the results of our study, no
LET. They detected improvements in all groups in PRTEE, statistically significant differences were detected
 E. Giray et al. / PM R 11 (2019) 681–693 687

Table 1
Baseline demographic and clinical characteristic of the groups
Kinesiotaping plus Sham taping plus Exercises
exercises (n = 10) exercises (n = 10) only (n = 10) P value
Age
Median (25-75%) 46.5 (32.5, 53.5) 45 (41.5, 52.25) 41.5 (34.75, 53.25) .753*
Gender (F/M) 9/1 8/2 9/1 .75†
Occupation
Homemaker 8 (%80) 7 (%70) 8 (%80) .85†
Worker 1 (%10) 3 (%30) 2 (%20)
State officer 1 (%10)
Nirschl Score
Median (min-max) 5 (3-7) 4.5 (3-5) 5 (1–6) .492*
Affected side (R/L) 9/1 6/4 7/3 .30†
Dominant side (R/L) 10 / 0 10 / 0 9/1 .36†
Duration of symptoms (week) Median (25-75%) 7 (5.5, 8) 8 (4, 10.5) 7 (5.5, 12) .816*
VAS at rest (cm)Median (25-75%) .715*
1.5 (0, 3.25) 1.5 (0, 3.25) 3 (0, 4)
VAS daily activity (cm) .103*
Median (25-75%) 6.5 (5, 7.25) 7.5 (6.75, 8) 7 (5,7)
VAS at night (cm) .837*
Median (25-75%) 2.5 (0, 4.5) 2.5 (0, 3.5) 3.5 (0, 5.75)
Painless grip strength (kg) .897*
Median (25-75%) 14 (8, 19.75) 12 (2, 25) 13 (9.5, 20.5)
Grip strength (kg)
Median (25-75%) 20 (14.75, 27.5) 19.5 (14.75, 30.25) 23.5 (15, 28.25) .958*
*P > .05 using Kruskal-Wallis test.
†
P > .05 using chi-square test.

between groups at 3 months and 6 months post randomi- 3 weeks and VAS during activity and QuickDASH scores
zation. Neither assessors nor patients were blinded; decreased significantly in both groups after treatment
therefore, the authors acknowledged the potential bias whereas pain pressure threshold and grip strength did
that might have affected their results and interpretations not. Similar to the findings of our study reduction in
of findings. QuickDASH scores after treatment was greater in real
In another study investigating the efficacy of kinesio- taping than sham taping. Unlike our results, no significant
taping in LET, short-term effects of kinesiotaping and changes detected in outcomes immediately after inter-
extracorporeal shock wave therapy along with physio- vention. Similarly, Chang et al36 also demonstrated that
therapy were compared.24 All the patients underwent the application of kinesiotaping and placebo taping had
physiotherapy program consisting of cold pack, transcu- the same effect on pain and wrist flexor strength in base-
taneous electrical stimulation and home exercise pro- ball pitchers with medial epicondylitis. Kinesiotaping,
gram including stretching and strengthening exercises when applied to healthy college tennis athletes without
for 3 weeks. PRTEE score and pain intensity decreased diagnosis of LET, was found to be associated with less of
and maximum grip strength increased in all groups after a decrease in muscular strength than seen in no tape con-
treatment. Similar to results of our study, kinesiotaping dition.37 However, the study was funded by the Kinesio-
group was superior to others in improving function and taping Association, which should be taken into
disability. We found no difference between groups consideration in the interpretation of the results. Cho
regarding grip strength. In contrast to the findings of our et al25 investigated the immediate effects of true and
study, the researchers found an improvement in grip sham kinesiotaping in racquet sport players. Both kinesio-
strength in the kinesiotaping group was more than other taping and sham taping yielded improvements in pain-
groups. Blinded outcome assessment had been performed free grip strength but kinesiotaping exhibited superiority
in the aforementioned study, but the patients were over sham taping in controlling pain experienced during
assessed only once and the study lacked follow-up of resisted wrist extension. However, the study reported
participants. only immediate effects. Sham taping procedure was sim-
Similar to our study, Shakeri et al23 investigated both ilar to that of real taping except that sham taping was
lasting and immediate effects of real and placebo kinesio- applied as tension free. Mechanisms of action of kinesio-
taping in LET with myofascial trigger point in forearm taping are still theoretical lacking the histopathological
muscles. They applied diamond taping, a kinesiotaping evidence. It is proposed that kinesiotaping may facilitate
technique that is different from technique described by or inhibit muscle function via cutaneous stimulation
Kenzo Kase.22,35 Real and sham taping were applied for depending on the technique applied and is used as an
Table 2
Intergroup changes in outcome variables 688
Kinesiotaping plus Sham taping plus Exercises Kinesiotaping plus exercises vs Sham taping Kinesiotaping plus exercises vs
exercises (n = 10) exercises (n = 10) only (n = 10) plus exercises Exercises only
P Effect Mean Difference (% P Effect
Median (25-75%) Median (25-75%) Median (25–75%) value* Size 95 CI) value† Size Mean Difference (%95 CI)
PRTEE-Total
Baseline 49 (43.88, 73) 53.75 (48.62, 63) 49.25 (41, 57.5) .677 .677
Posttreatment 26.5 (16.87, 39.75) 50.25 (42, 58.37) 46.25 (37.5, 54.12) .019‡ −1.21 −18.3 (−32.5 - −4.1) .014‡ −1.33 −17 (−29.02 - −4.98)
4 weeks after treatment 29.25 (16.37, 47.12) 47.5 (41.37, 61.37) 44.5 (38.87, 53.62) .023‡ −1.39 −19.45 (−32.6 - −6.3) .021‡ −1.34 −16.75 (−28.54 - −4.96)
QuickDASH
Baseline 50 (41.5, 74.43) 46.57 (38.6, 62.49) 46.59 (33.81, 57.39) .677 .344
Posttreatment 29.5 (10.4, 59.7) 47.72 (38.04, 53.97) 39.77 (33.52, 49.42) .161 −0.63 −12.19 (−30.51-6.13) .257 −0.41 −7.88 (−25.77-10.01)
4 weeks after treatment 18.18 (4.55, 34.1) 47.72 (34.62, 56.81) 39.75 (31.81, 46.59) .013‡ −1.48 −23.85 (−38.98 - −8.72) .019‡ −1.4 −20.22 (−33.77 - −6.67)
VAS at rest (cm)
Baseline 1.5 (0, 3.25) 1.5 (0, 3.25) 3 (0, 4) .907 .482
Posttreatment 0 (0, 0.25) 0.5 (0, 3) 1 (0, 3.5) .129 −0.75 −1.1 (−2.48-0.28) .12 −0.81 −1.3 (−2.81-0.21)
4 weeks after treatment 0 (0, 0) 1.5 (0.75, 3) 1 (0, 3.25) .002‡ −1.64 −1.6 (−2.52 - −0.68) .036‡ −1.14 −1.4 (−2.56 - −0.24)
VAS at daily activity (cm)
Baseline 6.5 (5, 7.25) 7.5 (6.75, 8) 7 (5, 7) .76 >.999
Posttreatment 3 (2, 5) 7 (5.75, 8) 5 (5, 7) .002‡ −1.77 −3.3 (−5.05 - −1.55) .12 −1.39 −2.4(−4.03 - −0.77)
4 weeks after treatment 3 (1.75, 5.25) 6.5 (4.75, 7.25) 5.5 (5, 7) .006‡ −1.51 −2.8 (−4.54 - −1.06) .013‡ −1.36 −2.4 (−4.06 - −0.74)
VAS at night (cm)
Baseline 2.5 (0, 4.5) 2.5 (0, 3.5) 3.5 (0, 5.75) .699 .846
Post treatment 0 (0, 0.25) 2 (0, 3.5) 1 (0, 3.25) .087 −0.53 −1.1 (−3.06–0.86) .183 −0.39 −0.8 (−2.73–1.13)
4 weeks after treatment 0 (0, 0) 2 (0, 3.25) 0 (0, 3.25) .023‡ −0.71 −1.4 (−3.26–0.46) .196 −0.30 −0.6 (−2.48–1.28)
Painless Grip Strength (kg)
Baseline 14 (8, 19.75) 12 (2, 25) 13 (9.5, 20.5) .622 .909
Posttreatment 17.5 (14.75, 28.25) 13 (10, 21.25) 15 (9.5, 20.5) .24 0.45 5.6 (−6.12–17.32) .161 0.69 6.7 (−2.46–15.86)
4 weeks after treatment 20 (17, 28.75) 14.5 (10, 24.5) 14.5 (9.5, 20.5) .255 0.61 5.7 (−3.14–14.54) .058 1.05 8 (0.87–15.13)
Grip Strength (kg)
Kinesiotaping for Lateral Epicondylitis

Baseline 20 (14.75, 27.5) 19.5 (14.75, 30.25) 23.5 (15, 28.25) .88 .733
Posttreatment 22.5 (17.5, 29.25) 20 (14.5, 27.25) 24 (19, 25.75) .404 0.17 2.2 (−10.1–14.5) .97 0.28 1.6 (−6.02–11.22)
4 weeks after treatment 25 (21.5, 28.75) 21 (12, 28) 24 (18.5, 27) .271 0.36 3.9 (−6.2–14) .519 0.44 3.4 (−3.82–10.62)
CI, Confidence interval; PRTEE, Patient-Rated Tennis Elbow Evaluation; QuickDASH, Disabilities of the Arm, Shoulder, and Hand questionnaire; VAS, Visual Analogue Scale.
*P value for pairwise comparison between kinesiotaping plus exercises and sham taping plus exercises groups.
†
P value for pairwise comparison between kinesiotaping plus exercises and exercises only groups.
‡
P < .05 using Mann-Whitney U test.
 E. Giray et al. / PM R 11 (2019) 681–693 689

Figure 3. PRTEE baseline scores.

Figure 4. Changes in median PRTEE scores over time for the three groups.

adjunct to rehabilitation of musculoskeletal disor- into account. The financial costs of kinesiotaping treat-
ders.20,38 Also, its effect on pain can be explained by gate ment include continuing education classes (time and
control theory. Kinesiotaping may inhibit transmission of money) as well as the tape itself. However, performing
pain afferent inputs from A delta and C fibers to cortex the intervention does not take very long, and its effects
by stimulating slow threshold sensory neurons of touch can potentially last more than 1 d. Future randomized
(A beta mechanoreceptors). This mechanism might be controlled trials should also include a cost-effectiveness
causing inhibition of pain-spasm circle that results in analysis.39
nerve depolarization and a reduction in pain. Another Exercise programs reduce pain and improve function,
mechanism proposed for pain relief resulting from kine- reversing the pathology of LET. It is proposed that eccentric
siotaping is that kinesiotaping improves pain intensity by training results in tendon strengthening by stimulating
increasing circulation.21,23 This theory is important for mechanoreceptors in tenocytes to produce collagen, which
choosing placebo tape application. Previous studies is probably the key cellular mechanism explaining the
applied tape with no tension as a placebo; however, tape recovery from tendon injuries. Increasing the load on the
may still stimulate mechanoreceptors.25 In the present tendon is one of the main principles when performing
study, kinesiotape is not placed at a painful region to eccentric exercises because increasing the load clearly sub-
avoid stimulating mechanoreceptors over the jects the tendon to greater stress and forms the basis for the
painful area. progression of the program. Pain during exercise stands as a
Although it is not the main focus of the present study, barrier to gain the optimal intensity needed.19 Results of
cost-effectiveness is another issue that should be taken the current study have demonstrated the promising effect
690 Kinesiotaping for Lateral Epicondylitis

(A) (B)

(C)

Figure 5. PRTEE data for each individual is graphed over time in groups.

of kinesiotaping in mitigating the pain of exercise perfor- inferior to those of exercises only group. Also, positive
mance, which is commonly seen as a barrier to gaining the effects of real taping on pain and function were superior
intensity needed to overcome the instigating anatomical to sham taping. To the best of our knowledge, this is the first
elements. Exercises were chosen for use in the active con- double-blind randomized controlled study investigating the
trol group in the current study because exercises have been effects of real and placebo kinesiotaping for LET. Double-
the mainstay of tendon rehabilitation. The exercise pro- blind randomized controlled design and estimation of
gram is rarely delivered as an isolated treatment, but it effects sizes can be viewed as strengths of the study, which
would be unethical to provide no treatment for a group to enhances the generalizability of the findings.
investigate effects of kinesiotaping. An exercise program It was proposed that the natural course of LET lasts
is usually combined with other treatment methods.40 between 6 months and 2 years. However, recent reports
Improvements gained in kinesiotaping group were not have shown that symptoms may persist for many years
 E. Giray et al. / PM R 11 (2019) 681–693 691

Figure 6. Group x time interactions for PRTEE.

hyperalgesia, which is associated with high pain scores,

Table 3 decreased function, and longer symptom duration.2 It
Immediate effects of kinesiotaping has been previously reported that the risk of experience
Kinesiotaping a poorer short-term outcome, and chronic LET is signifi-
plus exercises Sham taping plus cantly higher among patients with nerve symptoms,
(n = 10) exercises (n = 10) higher VAS, and QuickDASH scores and work-related onset
Median (25–75%) Median (25–75%) P value
of LET.41,42 We excluded patients with nerve symptoms
VAS at rest (cm) and the three groups were similar in terms of etiology,
Baseline 1.5 (0, 3.25) 1.5 (0, 3.25) .907
Immediate 0 (0, 0.5) 1.5 (0, 3.25) .034*
duration of symptoms, and baseline VAS and QuickDASH,
effect which can be viewed strengths of the present study.
VAS at daily activity (cm)
Baseline 6.5 (5, 7.25) 7.5 (6.75, 8) .76
Immediate 5 (1.5, 6.25) 7 (6, 8) .007†
Study Limitations
effect
Painless grip strength (kg) The limitations of this study are small sample size and
Baseline 14 (8, 19.75) 12 (2, 25) .622 relatively short follow-up time. Also, only patients with
Immediate 17 (10, 23) 13 (3.75, 27.75) .447 symptom duration less than 12 weeks were included so
effect
Grip Strength (kg)
the results of the study cannot be generalized for chronic
Baseline 20 (14.75, 27.5) 19.5 (14.75, 30.25) .88 LET. Home exercise program rather than supervised exer-
Immediate 22 (16.5, 29.25) 19.5 (14.5, 32.5) .82 cise program can be viewed as another limitation.43 But
effect patients were checked rigorously by phone calls. Because
VAS, Visual Analogue Scale. the LET is a disorder related to work, supervised exercises
*P < .05 using Mann Whitney U test. are not practical and may lead to absence from work.
†
P < .01 using Mann Whitney U test. Patients’ compliance with a supervised exercise program
can be higher than patients’ compliance to home exercise
and recurrence is common. Therefore, LET is not self- programme.19 Therefore, future studies investigating the
limiting and is associated with ongoing pain and disability effectiveness of a supervised exercise program for the
in a substantial proportion of sufferers.13 Presence of sen- management of LET in addition to kinesiotaping may pro-
sitization of the nervous system, given the reduced vide additional useful information for the management of
thresholds to nociceptive withdrawal and greater tempo- LET. Exposure to the treatment team, which was not similar
ral summation, may lead to a more chronic process. It has between groups, can be considered as another limitation of
previously been reported that patients with LET exhibit the study. The control group was contacted by phone
692 Kinesiotaping for Lateral Epicondylitis

whereas the taping groups had twice weekly in-person con- or eccentric exercises alone for lateral elbow tendinosis. Hand
tact. This could also add a confounder to the results. Therapy. 2016;21(4):131-139.
16. Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow
tendinopathy: one size does not fit all. J Orthop Sports Phys Ther.
Conclusions 2015;45(11):938-949.
17. Malliaras P, Maffulli N, Garau G. Eccentric training programmes in
Kinesiotaping in addition to exercises is more effective the management of lateral elbow tendinopathy. Disabil Rehabil.
2008;30(20–22):1590-1596.
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daily activities and arm disability due to LET. effective treatment for lateral epicondylitis? A systematic review.
Clin Rehabil. 2014;28(1):3-19.
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The authors would like to thank all the participants of 20. Giray E, Karadag-Saygi E, Mansiz-Kaplan B, Tokgoz D, Bayindir O,
this study. We thank Alperen Dogdas, Husnu Can Yasar, Kayhan O. A randomized, single-blinded pilot study evaluating the
Mehmet Oguzcan Alada, Yunus Emre Sirikci, and Zekeriye effects of kinesiology taping and the tape application techniques
Yuce for providing envelopes for the randomization and in addition to therapeutic exercises in the treatment of congenital
muscular torticollis. Clin Rehabil. 2017;31(8):1098-1106.
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ness of orthotic intervention, kinesiotaping, and paraffin treat-
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Disclosure

E.G., D.K.-B. Department of Physical Medicine and Rehabilitation Marmara G.A. Department of Physical Medicine and Rehabilitation and Division of Pain
University School of Medicine, Istanbul, Turkey. Correspondence E. G.; Depart- Medicine Marmara University School of Medicine, Istanbul, Turkey
ment of Physical Medicine and Rehabilitation, Marmara University School of Disclosure: none
Medicine, Istanbul, Turkey, Marmara University School of Medicine Pendik
Research and Training Hospital, Department of Physical Medicine and Rehabilita- All financial disclosures and CME information related to this article can be found
tion, Istanbul, Turkey, Fevzi Çakmak Mahallesi, Tepe Sokak, No: 41, Üst Kaynarca, on the mē ® site (http://me.aapmr.org/) prior to accessing the activity.
Pendik, _lstanbul, Turkey. Email: esra.giray@marmara.edu.tr; girayesra@hotmail.
com
Disclosure: none Submitted for publication May 18, 2018; accepted December 4, 2018.

CME Question
Compared to sham taping, which of the following pain relief mechanisms is unique to kinesiotaping?
a. Stimulation of mechanoreceptors
b. Increased circulation
c. Facilitation of muscle function
d. Activation of pain afferent inputs
Answer online at http://me.aapmr.org