Kinesio Taping, Wrist Splinting, and Epicondylitis Bandaging in Managing Lateral Epicondylitis: A Prospective Comparative Study

Introduction

Lateral epicondylitis (LE) is a common musculotendinous degenerative disorder of the extensor origin at the lateral humeral epicondyle [1]. LE, commonly known as tennis elbow, is a critical orthopedic problem that affects 50% of tennis players, and is especially common among individuals who are new to playing tennis and who are just learning the one-handed ‘backhand’ movement [2]. Although lateral epicondylitis is called tennis elbow, tennis is a factor in only 5–10% of cases. It occurs in 40–50% of tennis players at some point in their lives, and occurs in 59 of every 1000 industrial workers [3].

This disease is a significant public health problem. Lateral elbow pain occurs in 10.5% of individuals working to increase arm strength and 2.4% have a confirmed LE diagnosis [4]. LE, which is reported to affect 1–3% of adults every year worldwide and is one of the most common soft tissue injuries, is more common in individuals ages 35–50 years who frequently perform grip and repetitive wrist movements. Although it is more common in men, its duration and severity are higher in females. The dominant arm is mainly affected, and bilateral involvement is rare [5].

The exact mechanism is unknown, and a specific etiology is not defined in 30% of patients. However, it is known that LE occurs due to damage to the forearm muscles after excessive use and involves degeneration of the tendon of the extensor carpi radialis brevis muscle at the insertion site of the lateral epicondyle region [6]. LE, also known as lateral epicondylalgia, is characterized by decreased muscle strength, range of motion, and joint mobility, associated with localized inflammation developing at the insertion site of the wrist extensor tendons to the lateral epicondyle of the humerus, resulting in significant pain and loss of function [7]. Although the signs and symptoms of LE are clear, and its diagnosis is easy, there is no definitive treatment method accepted and applied by all clinicians [8].

Lateral epicondylitis (tennis elbow) is a type of repetitive strain injury resulting from common extensor tendon overload. This study aimed to compare outcomes from treatment with kinesio taping, wrist dorsiflexion splinting, and epicondylitis bandaging on pain, disability, and hand grip strength in 54 patients with lateral epicondylitis.

Material and Methods

INCLUSION CRITERIA:

The study enrolled patients who were ≥18 years of age and had no history of elbow surgery. Participants must have pain and sensitivity, with symptom duration less than 12 weeks. Patients with a positive result in one of the provocation tests (Maudsley’s Test – resisted middle finger extension extensor carpi radialis test), resisted wrist extension, or passive stretching of the wrist extensors (Mill’s Test) were included.

EXCLUSION CRITERIA:

Exclusion criteria were are under 18 years, did not consent to participate in the study, had previous surgery on the elbow, cervical spondylosis and radiculopathy, endocrine disease, autoimmune disease, concomitant entrapment neuropathy or polyneuropathy, pregnancy, systemic inflammatory disease, acute trauma, deformity in the upper extremity, metabolic disease, elbow arthritis, allergy to kinesio tape or orthoses, and received treatment for lateral epicondylitis in the past (exercise, injection, NSAIDs).

KINESIO TAPING METHOD: We used the diamond taping method as the kinesio tape application method. It consisted of 4 pieces of sports tape with adhesive backing, approximately 7 to 10 cm long. In this technique, the tapes were placed in a diamond shape from distal to proximal, while simultaneously applying a perpendicular traction force to the soft tissues towards the lateral epicondyle (Figure 2). This was applied with the elbow in a slightly flexed position. Kinesio taping was renewed every week by the same person. Patients were given a 6-week home program of stretching exercises for lateral epicondylitis.

EPICONDYLITIS BANDAGE METHOD:

A forearm strap with a pressure pad was used. The position of the brace was 2–3 cm distal to the lateral epicondyle over the muscle belly of the wrist extensors. Epicondylitis bandaging was applied to the patients continuously for 6 weeks. In case of discomfort, it was allowed to be removed for a maximum of 1 hour per day. Patients were given a 6-week home program of stretching exercises for lateral epicondylitis.

WRIST DORSIFLEXION SPLINT METHOD:

Prefabricated wrist support with dorsal reinforcement was used. The wrist was fixed at 15–30 degrees of dorsiflexion. A wrist dorsiflexion splint was applied to the patients continuously for 6 weeks. In case of discomfort, it was allowed to be removed for a maximum of 1 hour per day. Patients were given a 6-week home program of stretching exercises for lateral epicondylitis.

PATIENT EVALUATION:

Patients were evaluated using the visual analog score (VAS), the Disabilities of the Arm, Shoulder (DASH) score, the PRTEE (Patient-Rated Tennis Elbow Evaluation) score, and hand grip strength at baseline and at 3 and 6 weeks.

The VAS is a scoring system used to numerically evaluate subjective data. It is generally used in pain assessment [9]. A 10-cm vertical line was used. After the patient indicated the pain level on this line, the distance from this point to the starting point was measured and a numerical value was obtained.

The DASH score is widely used in evaluating upper-extremity functions. It has 30 items that measure and analyze a patient’s upper-limb functions and symptoms. Each item is scored from 1 (no difficulty) to 5 (extreme difficulty). The total score varies from 0 to 100: higher scores mean a greater functional disability [10]. In this study, a questionnaire form was used.

The PRTEE score is a self-reported outcoming measure that aims to evaluate the pain and functional impairment of patients with epicondylitis. It has 15 items measuring symptoms within the last week. The score for each question ranges from 0 (no pain or difficulty) to 10 (extreme pain or difficulty). Higher scores reflect greater levels of pain and disability [11]. In this study, a questionnaire form was used.

Maximum hand grip strength was measured with a hand dynamometer (CAMRY^® electronic hand dynamometer). Three measurements were taken at 10-minute intervals and the average value was recorded.

STATISTICAL ANALYSIS:

Data were analyzed using SPSS (Version 28.0. Armonk, NY: IBM Corp). The normality of dependent variables was checked using the Shapiro-Wilk test. Analysis of variance (ANOVA) was used to compare groups for variables showing normal distribution. The Bonferroni test was applied to make pairwise comparisons between groups. For variables not showing normal distribution, the Kruskal-Wallis test was used to determine the differences between groups. The Wilcoxon test was used for pairwise comparisons between groups. All results are shown as mean±SD. The significance level was defined as P<0.05.

In the calculation carried out using the data from Akkurt et al “Comparison of an epicondylitis bandage with a wrist orthosis in patients with lateral epicondylitis” study, and the study’s effect size was assumed to be d: 0.715. It was calculated that the determined effect size should be studied with 80% power, 5% margin of error, and a total of 54 samples in the calculation for two-way statistical significance [12].

Results

DEMOGRAPHICS OF THE STUDY POPULATION:

A total of 54 patients – 28 (57.3%) females and 26 (42.7%) males – were included in the study. The distribution of demographic and clinical findings of the patients is denoted in Table 1, showing that the mean age of the patients was 42.59±8.43, the mean height was 169.43±10.82 cm, the mean body weight was 76.33±15.17 kg, and the mean body mass index was 26.44±3.59 kg/m2.

The right hand was dominant in 43 of the study’s patients, while the left was dominant in 11. Lateral epicondylitis was diagnosed in the right elbow in 40 of the patients and the left elbow in 14. While lateral epicondylitis was on the dominant side in 39 patients, it was on the opposite side in 15.

TREATMENT OUTCOME PARAMETERS:

When the VAS, PRTEE, DASH, and hand grip strengths of the patients who used kinesio tape, wrist dorsiflexion splint, and epicondylitis bandage in the treatment were compared, no significant difference was found between the results before treatment or at 3 and 6 weeks after treatment (Table 2).

Discussion

When the conservative methods applied in the 6-week treatment of lateral epicondylitis were compared, no significant difference was found between kinesio tape, wrist dorsiflexion orthosis, and epicondylitis bandage in terms of VAS, DASH score, PRTEE score, and hand grip strength. All 3 treatment methods were found to be beneficial.

LE is one of the most common diseases of the musculoskeletal system. LE treatment aims to palliate pain and restore functional capacity. All patients should initially avoid repetitive and strenuous wrist activities. There are various treatment options for LE, the most common are conservative options. The first-line conservative methods recommended for LE include rest, splinting, physiotherapy, and electrotherapeutic treatments (eg, laser, ESWT, ultrasound) [13–15]. When first-line treatments are not effective enough, local CS, PRP, dry needling, autologous blood application, prolotherapy, and injection methods such as botulinum toxin can be used [16]. Acupuncture and electromagnetic field applications can be applied as alternative methods to these treatments. The recovery rate in patients diagnosed with LE following conservative treatments is between 75% and 90%. It is a self-limiting process even when left untreated, and up to 90% of patients recover with conservative methods within 1 year [17].

The literature shows that manual therapy, including manual mobilization of the elbow and wrist and myofascial therapy, can be used to rehabilitate patients with LE who have myofascial and articular lesions, and manual therapy can provide short-term pain relief in patients with LE. Manual therapy combined with eccentric exercises is more effective than the ‘wait-and-see’ approach [18].

The literature contains studies comparing different manual therapy applications and different physiotherapy approaches with these applications. A study comparing the effectiveness of Mulligan and Cyriax approaches used in rehabilitating patients with LE found that the Cyriax approach was more effective in controlling pain in patients with LE, while the Mulligan approach improved function [19]. A study by Reyhan et al [20] examined the effect of the Mulligan approach in LE rehabilitation, showing the positive impact of this approach, in addition to exercise and cold application, on pain and function in patients with LE. Richer et al [21] investigated the effectiveness of manual therapy and local cryostimulation approaches applied in LE rehabilitation, reporting that only manual myofascial point therapy and mobilization approaches provided positive results in patients with LE. The combined application of manual therapy and local cryostimulation approaches did not provide additional improvement in pain and function. Considering that any orthopedic problem may cause different findings and symptoms in patients and that the severity of these findings and symptoms may vary, it is thought that applying manual therapy approaches selected appropriately for each patient alone or with different rehabilitation approaches is an important option. In addition, nerve mobilizations and manual therapy have become critical preferred approaches in the rehabilitation process of musculoskeletal problems [22].

Steroid injections were once considered the standard in the treatment of lateral epicondylitis, but have become controversial in recent years, and it has been reported that long-term (week 12) results are the same or worse than for other treatments [23].

Eraslan et al [24] examined the short-term effects of KT on pain and function in patients with LE, finding that KT is effective in reducing pain intensity and increasing function in patients with LE. A study by Sultanoğlu et al [25] on the short-term effectiveness of KT in LE rehabilitation reported that KT improves pain and function in patients with LE. Koçak et al [26] examined the short-term effects of steroid injection and KT, concluding that both methods, either alone or in combination, reduce pain and increase function in patients with LE. A meta-analysis of randomized controlled trials by Zhong et al [27] reported that KT applied during the rehabilitation of patients with LE effectively reduced pain and improved function. Therefore, using this method alone or combined with different physiotherapy approaches or pharmacological treatments is an important option in LE rehabilitation [28].

When we compare this study with the studies in the literature, we see that the kinesio tape method supports the benefits of the treatment of lateral epicondylitis in terms of functional scores and wrist grip strength, as in the study of Shamsoddini et al [29]. Cho et al [30] compared kinesio taping with sham taping, finding that the benefit of kinesio taping was not a placebo effect, but was beneficial in the treatment of lateral epicondylitis and reduced pain [30].

The use of orthoses may be beneficial in conservative treatment. Epicondylitis, kinesio taping, and wrist dorsiflexion splints can be used to treat epicondylitis. A study comparing epicondylitis bandaging with exercise alone reported that it was superior to exercise during daily activities, but exercise was more successful in improving pain, disability, and patient satisfaction [31]. A placebo-controlled study evaluating pain and pain-free grip strength observed that epicondylitis bandaging was ineffective [32], and extension splints were superior to epicondylitis bandaging in reducing pain. In contrast to these results, a randomized study reported that wrist splints and epicondylitis tapes significantly improved pain, grip strength, and tenderness [33]. Kinesio taping is another conservative treatment method. The application of tape twice a week along the muscle to inhibit extensor muscles can reduce pain, increase grip strength, and improve functioning. It has also been reported to effectively treat pain in medial epicondylitis [34].

Lateral epicondylitis can be treated with conservative and nonsurgical methods, and spontaneous resolution is generally expected within 8–12 months. Since long-term application of a wrist brace or splinting can cause negative consequences, including forearm muscle weakness and atrophy, using a combination of conservative management methods before developing chronic pain and functional disability can yield superior clinical outcomes in pain resolution, wrist range of motion, and grip strength [35].

Our study has certain limitations. Firstly, the sample size was small, with only 54 participants, so the study’s findings might not be generalizable. With a larger sample size, the results would be more statically powerful and would enhance the chance of conducting subgroup analyses of patient characteristics that can affect treatment response. The study only lasted 6 weeks and did not assess long-term effects. In the future, blending different treatment modalities may be more useful for optimizing conservative treatment of epicondylitis.

Conclusions

Outcomes of conservative treatment of lateral epicondylitis using epicondylitis bandaging, wrist dorsiflexion splinting, and kinesio taping support were not significantly different in terms of VAS, DASH score, PRTEE score, and hand grip strength.