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LUBLIN 2013

New Approaches in Joints Pain

Tennis Elbow

edited by Karolina Janikowska, Katarzyna Chomiuk

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Reviewer: Ewa Kołodziej, CPT

Edited by: Karolina Janikowska, Katarzyna Chomiuk

Copyright © 2013 Karolina Janikowska. All rights reserved.

Published by Medunio 2013, Lubartowska 38/19, Lublin

Photo: Michał Wroński

ISBN : 978-83-938086-0-1

First edition

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CONTENTS

The influence of the physical therapy on pain and elbow function in

patients with lateral epicondylitis .......................................................... 3

The role of Mulligan Therapy Concept in treatment of "tennis elbow"

symptoms ............................................................................................. 20

The review of the mobilization with movement techniques in

management of tennis elbow ............................................................... 35

Effects of Kinesio® taping in patients with symptoms of lateral

epicondylalgia ...................................................................................... 43

Review of the musculofascial Kinesio® taping applications for the

lateral epicondylalgia – part 1 ............................................................. 59

Review of the musculofascial Kinesio® taping applications for the

lateral epicondylalgia – part 2 ............................................................. 66

Kinesio® taping application for elbow pain ....................................... 76

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Karolina Janikowska, Joanna Fidut

The influence of the physical therapy on pain and elbow function in patients with lateral epicondylitis

Background

Lateral epicondylitis is one of the most common cause of elbow pain related to the pathology

of the muscle extensor carpi radialis brevis [1,2]. In every population it can affect from from 1

to 3 % of active working people[3]. It can impaired the function of the dominating hand in

men and women [1,4]. The disorder is often defined as the repetitive strain injury of the

muscles attached to the lateral epicondylitis [5]. Previous studies pointed the tennis elbow as

the type of tendinitis what suggested the presence of the acute inflammatory process. Current

research investigating the absence of inflammatory marker in patients with tennis elbow

indicating the term “tendinosis” or “tendinopathy” as more appropriate to reflect the chronic

process [6,7]. The basic symptom of the tennis elbow is pain localized in the area of the

lateral epicondyle aggravating with hand grips and resistance applied to the muscles of the

forearm during the wrist extension[8].

The conservative therapy is based on use of ultrasound, cryotherapy, heat, electrical and laser

stimulation or extracorporeal shock wave therapy [9-15]. The other possible treatment is

based of pharmacological preparates e.g. non- steroidal anti-inflammatory drugs (NSAID),

corticosteroids prepared for the injections in the area of the lateral epicondyle [16-19].

Modern therapies focus on the botulinum toxin type A injections in improving the healing of

the tendons attached to the lateral epicondyle [20,21]. Another type of injections performed in

this area is use of the platelet-rich plasma extracted from the patient’s own blood and the

effect of the autologos growth factors [22,23]. The physical therapy seems to be still more

accessible for the patient and less invasive than even very promising biological treatment.

4

Aim of the study

The aim of the was to assess the influence of physical therapy set based on ultrasound, laser

and hydromassage stimulation on pain and the functional status of the patients with lateral

epicondylalgia.

Material and methods

The study was conducted on group of 28 patients (19 men and 9 women) diagnosed with

lateral epicondylalgia who suffered for at least three months and failed to the conventional

therapy. The exclusion criteria for the study was: previous injury of the elbow in anamnesis,

structural changes in the area of the elbow, osteoarthritis of the elbow, receiving any therapy

for lateral epicondylitis during last 4 weeks, cervical spine changes and symptoms of

radiculopathy, skin changes, allergy observed after tape application, inflammation in the

elbow area and general contraindication for each of the physical therapy method.

During the study the patients underwent physical examination of the upper limbs.

The standardized questionnaires e.g. Quick DASH (Disability of the Arm, Shoulder and

Hand) and PRTEE (Patients’ Related Tennis Elbow Examination) were used to assess the

functionality in this condition. To determinate the severity of the pain the visual-analog scale

(VAS) was applied.

DASH and Quick DASH

The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure is 30-item, self-

report questionnaire developed to measure physical function and symptoms in patients with

musculoskeletal dysfunctions of the upper limb. It was released in 1996 [24]. This tool was

designed by the Institute for Work & Health and the American Academy of Orthopaedic

Surgeons (AAOS) and supported by the American Association for Hand Surgery, the

American Orthopaedic Society for Sports Medicine, the American Shoulder & Elbow

Surgeons, the American Society for Surgery of the Hand, the Arthroscopy Association of

North America and the American Society of Plastic and Reconstructive Surgeons [25]. The

QuickDASH is a shortened version of the DASH Outcome Measure. Instead of 30 items, the

QuickDASH based on 11 items to measure functionality and symptoms of patients with any

musculoskeletal disorders of the upper limb. Scoring is divided into the two components: the

disability/symptom section, consisting of 11 items, scored 1-5 and the optional high

performance sport/music or work modules with 4 items, scored 1-5. To calculate the score at

5

least 10 of the 11 items must be completed. Bacause this tool was developed to measure the

disability, the scaling was ranked from 0 indicating least disability to 100 indicating most

disability. The researcher should be aware of the direction of the scales [26]. This tool

included also two optional modules intended to assess symptoms and function in athletes,

performing artists and high degree physical performance workers. Both instruments are valid,

reliable and responsive and can be used for clinical and research purpose [26,27]. The tools

are characterized by rating of intra-class correlation coefficient on 0.94 and Cronbach’s alpha

also on. 0.94 [28].

The Patient-rated Tennis Elbow Evaluation (PRTEE)

This instrument enables quantitative rating by the patient of pain and functional impairment

associated with lateral epicondylitis, commonly called “tennis elbow”. PRTEE is an

instrument that has been developed specifically for use with this disorder, and is increasingly

being included in research, especially randomized controlled trials.

The questionnaire consist of a 15-item, with five addressing pain and ten concerned with

functional impairment. Each of the item are rated with use of 0 – 10 numerical scale to assess

the average pain or difficulty they have faced over the previous week during various activities

that usually cause pain in tennis elbow. In this system the pain and function are weighted

equally in the total score [29,30]. Higher scores present greater severity and the maximum

score is 100. Major advantages of this instrument are its simplicity, shortness and specificity

to lateral epicondylitis [31,32]. The characteristic of the test is based on recent study used a

four-week test-retest period and calculated Intraclass Correlation Coefficient values of 0.81

for the pain sub-score and 0.76 for the total score. In another studies the Cronbach's alpha

coefficients were high for both the pain and function sub-scales (0.84 and 0.93, respectively)

[33,34].

Pain assessment - Visual-analog scale (VAS)

Visual-analog scale is a psychometric response scale which can be used in questionnaires.

This measurement instrument can be used for subjective characteristics or attitudes that are

impossible to measure directly. Pain assessed in VAS scale is a unidimensional measure of

pain intensity. Respondents express their level of agreement to a statement by pointing a

position along a continuous line between two end-points on a 100-mm long horizontal line.

Usually it takes less than 1 minute to complete the measure [35,36]. Scoring on VAS is

determined by measuring with ruler the distance (mm) on the 10-cm line between the “no

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pain” anchor and the patient’s mark, providing a range of scores from 0–100. According to

the research, the visual analogue scales have superior metrical characteristics than discrete

scales, therefore a wider range of statistical methods can be applied to the measured

parameters [37,38]. The characteristic of the instrument is based on calculated intraclass

correlation coefficients (ICC) on 0.97 for acute pain and Cronbach’s alpha varies depending

on the studies from 0.79 to 0.91 [39,40].

The pain was assessed as a total feeling, during the wrist extension, during palpation the area

of the lateral epicondyle, during the hand grip, during stretch of extensor carpi radialis brevis

(ECRB) muscle and during movements of elbow.

Therapy process

All procedures where performed by one certified physical therapy practitioner with used of

original devices dedicated to the method. The application were performed during 10 days.

Examples of the pain localization, physical examination and physical therapy are presented on

the figures (Fig. 1-9 ).

Data collection and analysis

Patients underwent the examination and fulfilled the questionnaires at the beginning of the

therapy and after completing it. The data collected were taken into the statistical analysis and

present in the results. All data were expressed by mean ±standard deviation. The normality of

the data distribution was estimated with use of Shapiro-Wilk test. The Wilcoxon rank-sum

test was used for comparison of the two related groups of the data. The alfa significance level

was set at 0.05. P value of less than 0.05 will be considered to indicate statistical significance.

Statistical analyses was performed with use of Statistica 10.0 software (StatSoft).

Results

The study group consist of 28 patients (19 men and 9 women). The mean age of the patients

was 42,8 ± 7,6 years. None of the patient were tennis player or professional athlete. The

occupation of the patients was mostly in office or physical work in agriculture. Most difficult

and painful activity were associated with the hand grip and the palpation of the lateral

epicondyle. In all patients the elbow of the dominating hand was affected. All patients were

underwent the set of conventional physical therapy and still have symptoms seriously

impairing their daily

7

The pain measured during different hand and elbow position is presented in table 1.

The average total pain experienced during last week before set of physical therapy

application was around 6,2 . After completing all sets of the application patients rated their

overall pain just on 3,7. Before the therapy the most painful for the patients were the

movement of wrist extension and all procedures performed with affected hand grip. The best

improvements in pain severity were observed in these measurements.

The highest impairment measured with the Quick DASH Outcome Measure was observed in

additional work module and in this module the highest improvement was observed. The

statistical analysis proved the statistically significant decrease of the patients functionality

deficit express by the results of the Quick DASH (data presented in table 2).

The Patient-rated Tennis Elbow Evaluation (PRTEE), specially designed diagnostic

instrument dedicated for the tennis elbow allowed to assess the pain and function, before and

after completing the set of physical therapy. There were equal statistically significant

improvement in domain of pain and function assessed by the patient (p<0.05). The results are

presented in table 3.

Table 1. The comparison of the main results of the Quick Dash Measure Outcome in patients

before and after the physical therapy application.

Pain measured with VAS scale

during

before physical therapy

application

after physical therapy

application

total feeling of pain 6,2 ± 0,68 3,7 ± 0,41

wrist extension 6,2 ± 0,42 3,6 ± 0,7

lateran epicondyle palpation 6,18 ± 0,79 3,95 ± 0,5

hand grip 6,3 ± 0,65 3,45 ± 0,52

stretch of ECRB 6,0 ± 0,41 3,7 ± 0,5

elbow flexion 3,4 ± 0,39 2,17± 0,09

elbow extension 3,28 ± 0,26 2,28 ± 0,18

forearm pronation 2,42 ± 0,22 2,1 ±0,20

forearm supination 2,60 ± 0,14 2,0 ± 0,17

α= 0.05, in all analyses p<0.05

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before and after physical therapy application.

Main module-

Restriction Index

Additional module-

work

Additional module-

sport

Before

physical therapy

application

0,70 ± 0,12 0,80 ± 0,14 0,76 ± 0,18

After

physical therapy

application

0,34 ± 0,08 0,32 ± 0,04 0,52 ± 0,20

The mean

improvement

0,36 0,52 0,24


Table 3. The comparison of the pain, function and total results of the Patient-rated Tennis

Elbow Evaluation (PRTEE) fulfilled by patients before and after physical therapy

application.

Pain PRTEE

Function

PRTEE Total PRTEE

Before

physical therapy

application

0,76 ± 0,12 0,72 ± 0,16 0,74 ± 0,14

After

physical therapy

application

0,30 ± 0,2 0,26 ± 0,08 0,28 ± 0,05

The mean

improvement

0,46 0,46 0,46


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Discussion

The study showed that application of the physical therapy can significantly reduce the pain

occurring during the wrist extension and hand grip. There are several studies presenting

different physical therapy methods and its role. Dingemanse and Randsdorp in their

literature review found the potential effectiveness of ultrasound and laser light but pointed

the need of high-quality RCTs examining different intensities and on long-term follow-up

results [41 ]. According to the Oken and Kahraman a brace has a shorter beneficial effect

than ultrasound and laser therapy in reducing pain, and that laser therapy is more effective

than the brace and ultrasound treatment in improving grip strength [42].Barr and Cerrisola

showed that corticosteroid injections are effective at short-term follow-up, and

physiotherapeutic interventions are effective at intermediate- and long-term follow-up [43]. In

studies comparing the steroid injections and physical therapy was observed that physical

therapy does not have significant effect on symptoms in patients receiving steroids injections

[44].

The research limitation

The limitation of the study is small group of the patients included who underwent whole

process of the examination and full set of physical therapy methods application, therefore the

study can be underpowered. Another limitation is the lack of the control group included into

the process of randomization. To exactly determine the effect of combination of ultrasound,

laser light and hydro massage application in patients with symptoms of tennis elbow there is a

need of randomized controlled trial what was pointed also in other studies.

Conclusions

Combination of the laser light, ultrasound and hydro massage applied for the elbow seems to

be effective as supportive therapy of patients with lateral epicondylitis. It leads to decrease of

the severity of the pain, improve patients functionality assessed with standardized

questionnaires .

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Fig. 1. The lateral view of the left elbow model. The lateral epicondyle matched with three red

places for muscle attachement.

Fig. 2. Painful area matched with the cross.

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Fig. 3. Painful area of the lateral epicondyle during palpation.

Fig. 4. Examination of the elbow movements – forearm pronation.

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Fig. 5. Examination of the elbow movements – forearm supination.

Fig.6. Application of the laser light for the lateral epicondyle.

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Fig. 7. Application of the ultrasound for the lateral epicondyle.

Fig. 8. Application of the hydro massage for the upper limb.

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Fig. 9. Application of the magnetic field for the lateral epicondyle.

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Summary

Background:

Lateral epicondylitis is a condition characterized by the pain in a region of the lateral

epicondylus of humerus, weakness of the forearm muscles, grips forces and general

dysfunctions of upper extremity. The standard management of the lateral epicondylitis

consists of physical therapy methods, pharmacological treatment, immobilization and surgical

techniques.

Aim of the study :

The aim of the study was to estimate the symptoms reduction and the improvement of the

functionality of upper limb after ultrasound, laser light and hydro massage application in

patients with "tennis elbow" symptoms.

Material and methods:

The study group consisted of 28 patients with tennis elbow treated with the physical therapy

methods. All procedures were performed by certified physical therapy specialist with certified

devices. The VAS, PRTEE scales and Quick DASH questionnaires were used to assess the

effectiveness of this management. The range of motion, the pain free grip strength and the

maximal strength of the grip was tested at the beginning and the end of the therapy. The data

collected were analyzed with use of Statistica 10.0 software. The significance level of 0.05 (α

= 5%) was adopted.

Results:

The significant reduction of pain in the lateral epicondylus region measured in VAS scale and

values of the PRTEE and Quick DASH questionnaire were observed in the study group. The

pain during the hand grip and the wrist, elbow movements were significantly improvement in

group of patients treated with combination of laser light, ultrasound and

hydromassage(p<0.05).

Conclusions:

Combination of the laser light, ultrasound and hydro massage can be an effective method in

decreasing symptoms of "tennis elbow", mostly the pain and hand grip.

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The role of Mulligan Therapy Concept in treatment of "tennis elbow" symptoms

Background

Tennis elbow is a common name for lateral epicondylitis (LE). This condition is based on

tendinitis of the extensor carpi radialis brevis muscle [1,2]. Depending on the study it can

affect from 1 to 3 % of the population [3]. The incidence of the lateral epicondylitis is equally

distributed among both genders, but mostly affects the dominant upper limb [1,4 ].

The repetitive strain injury is described as the most common cause of the lateral epicondylitis

[5]. In historical approach the tennis elbow was included in the type of tendinitis and

suggested the presence of the acute inflammatory process. According to the research

investigating the absence of inflammatory marker in patients with tennis elbow the term

“tendinosis” or “tendinopathy” is more appropriate to reflect the chronicity of the condition

[6,7]. Pain localized in the area of the lateral epicondyle of the elbow is most common

symptom of the tennis elbow and aggravates with hand grips and resistance applied to the

muscles of the forearm responsible for wrist extension. [8]. The conservative physical therapy

is based on use of ultrasound, cryotherapy, heat, electrical and laser stimulation or

extracorporeal shock wave therapy [9-15]. The conventional therapy include the

pharmacological preparates e.g. non- steroidal anti-inflammatory drugs (NSAID),





effect of the autologos growth factors [22,23]. The physical therapy is still more accessible for

the patient and less invasive than even very promising biological treatment but require new

approach focusing on the core of the patients problem. One of the new ideas in manual

therapy is mobilization with movement according the Brian Mulligan Concept. The

techniques include a sustained lateral glide to the elbow joint with concurrent physiological

21

movement and allows to correct the faulty position of the elbow joint that can causa the

tennis elbow symptoms [24,25].

Aim of the study

The aim of the was to assess the influence of the manual therapy based on mobilization with

movement according to the Brain Mulligan Concept on pain and the functional status of the

patients with lateral epicondylalgia.


The study was conducted on group of patients (14 men and 5 women) diagnosed with lateral

epicondylalgia who suffered for at least three months and failed to the conventional therapy.

The exclusion criteria for the study was: previous injury of the elbow in anamnesis, structural

changes in the area of the elbow, osteoarthritis of the elbow, receiving any therapy for lateral

epicondylitis during last 4 weeks, cervical spine changes and symptoms of radiculopathy,

osteoporosis, inflammation in the elbow area.


The standardized questionnaries e.g. Quick DASH (Disability of the Arm, Shoulder and



(VAS) was applied.

DASH and Quick DASH











musculoskeletal disorders of the upper limb.Scoring is divided into the two components: the


22









also on. 0.94 [30].





being included in research, especially randomized controlled trials. The questionnaire consist

of a 15-item, with five addressing pain and ten concerned with functional impairment. Each of

the item are rated with use of 0 – 10 numerical scale to assess the average pain or difficulty

they have faced over the previous week during various activities that usually cause pain in

tennis elbow. In this system the pain and function are weighted equally in the total score

[31,32]. Higher scores present greater severity and the maximum score is 100. Major

advantages of this instrument are its simplicity, shortness and specificity to lateral

epicondylitis [33,34]. The characteristic of the test is based on recent study used a four-week

test-retest period and calculated Intraclass Correlation Coefficient values of 0.81 for the pain

sub-score and 0.76 for the total score. In another studies the Cronbach's alpha coefficients

were high for both the pain and function sub-scales (0.84 and 0.93, respectively) [35,36].








23


pain” anchor and the patient’s mark, providing a range of scores from 0–100.

According to the research, the visual analogue scales have superior metrical characteristics

than discrete scales, therefore a wider range of statistical methods can be applied to the

measured parameters [39,40]. The characteristic of the instrument is based on calculated

intraclass correlation coefficients (ICC) on 0.97 for acute pain and Cronbach’s alpha varies

depending on the studies from 0.79 to 0.91 [41,42].




Therapy process

All procedures where performed by one certified in Mulligan Therapy practitioner with used

of original belt for mobilization. The whole therapy was divided into 6 sets with 2-3 days of

break between sets. All patients were instructed to practice some exercises related to the

therapy at home. The process of the diagnosis and the therapy is presented on pictures (Fig. 1-

4).


Patients underwent the examination and fulfilled the questionarries at the beginning of the







Results

The study group consist of 19 patients, 14 men and 5 women. The mean age of the patients



and painful activity were associated with the hand grip. In all patients the elbow of the

dominating hand was affected. All patients were underwent the set of conventional physical

therapy and still have symptoms seriously impairing their daily

24


The average total pain experienced during last week before entering the manual therapy

according to the Mulligan Concept was around 6. After completing all sets of the therapy

patients rated their overall pain just on 2,2. Before the therapy the most painful for the

patients were the movement of wrist extension and all procedures performed with affected

hand grip. The best improvements in pain severity were observed in these measurements.






instrument dedicated for the tennis elbow allowed to assess the pain and function before and

after completing the set of manual therapy according to the Brian Mulligan Concept. There

were statistically significant improvement in domain of pain and function assessed by the

patient (p<0.001). The results are presented in table 3.


before and after the manual therapy according to the Brian Mulligan Concept.


during before Mulligan therapy

after Mulligan therapy


wrist extension 6,89 ± 0,56 3,10 ± 0,56


hand grip 6,73 ± 0,45 3,05 ± 0,40

stretch of ECRB 6,00 ± 0,47 2,57 ± 0,69

elbow flexion 3,03 ± 0,19 2,01± 0,22

elbow extension 2,98 ± 0,16 2,08 ± 0,19




25


before and after the manual therapy according to the Brian Mulligan Concept.

Main module-

Restriction Index

Additional module-

work

Additional module-

sport

Before

Mulligan Therapy

0,72 ± 0,11 0,81 ± 0,13 0,81 ± 0,14

After

Mulligan Therapy

0,1 ± 0,02 0,12 ± 0,03 0,60 ± 0,12

The mean

improvement

0,61 0,69 0,21



Elbow Evaluation (PRTEE) fulfilled by patients before and after the manual therapy

according to the Brian Mulligan Concept.

Pain PRTEE

Function

PRTEE Total PRTEE

Before

Mulligan Therapy

0,8 ± 0,12 0,76 ± 0,16 0,78 ± 0,14

After

Mulligan Therapy

0,16 ± 0,08 0,14 ± 0,02 0,15 ± 0,05

The mean

improvement

0,64 0,62 0,63


Discussion

In our study we observed the male domination. Similarly to the other observation the elbow of

the dominated hand was affected [1,4]. We observed the statistically significant decrease of

the pain measured in all situations reported in the table 1. and expressed with visual analog

scale. Previous studies indicated the effectiveness of the mobilization with movement

especially in fields of pain reduction and improving the hand grip using the same measure

tools [43]. Geetu and Miller in their papers also prove the role of application these techniques

26

in enhancing the functional performance according to the Mulligan Concept [44, 45,46].

There are nine randomized controlled trials pointing the effectiveness of the mobilization with

movement in pain reduction [47]. According to some research mobilization with movement

for the elbow was capable of inducing physiological effects similar to those reported for some

forms of spinal manipulation [48]. Mulligan Concept of the manual therapy allows to

increase the patients pain free range of motion of the elbow and wrist [49,50,51]. The use of

this techniques seems to be effective even in high performance patients e.g. rock climbers

[52].



process of the examination and all sets of mobilizations with movement of Brian Mulligan

Manual Therapy Concept, therefore the study can be underpowered. Another limitation is the

lack of the control group included into the process of randomization. To exactly determine the

effect of mobilization with movement in Mulligan Therapy in patients with symptoms of

tennis elbow

Conclusions

The mobilization with movement according to the Brian Mulligan Manual Therapy Concept

seems to be effective as supportive therapy of patients with lateral epicondylitis. It leads to

decrease of the severity of the pain, improve patients functionality assessed with standardized

questionnaires .

27

Fig. 1. Mobilization with movement.

Fig. 2. Mobilization with movement in elbow flexion.

28

Fig. 3. Assessment of the origin of the elbow pain.

Fig. 4. Automobilization with therapeutic belt.

29

Fig. 5. The painful area of the lateral epicondyle matched with cross.

30

Summary

Background:

"Tennis elbow" is a condition characterized by the pain in a region of the lateral epicondylus

of humerus, weakness and dysfunctions of upper extremity. The standard management offers

methods of pharmacological and physical therapy, immobilization or surgical techniques.

Recently manual therapy is more often applied in this condition especially with techniques of

Mulligan Therapy Concept, which is a modern and still not well known method.

Aim of the study:

The aim of the study was to estimate the symptoms reduction after manual therapy applied

according to Mulligan Therapy Concept in patients with lateral epicondylitis.


The group consisted of 19 patients with tennis elbow symptoms treated with the Mulligan

Therapy Concept. The mobilizations with movement with the use of mobilization belt were

applied on affected elbow during the 6 sessions of therapy. All procedures were performed by

certified Mulligan Therapy Concept practitioner. The VAS, PRTEE scales and Quick DASH

questionnaires were used to asses the effectiveness of this management.

Results:

The significant reduction of pain in the lateral epicondyle region and values of the PRTEE

and Quick DASH Outcome Measure were observed.

Conclusion:

Manual therapy including the mobilization with movement according to the Mulligan Therapy

Concept is a promising method in decreasing symptoms of "tennis elbow", especially the

pain, especially during the hand grip and patients’ functionality.

31

References


2005. p. 412e7.





4. LaFreniere JG. Tennis elbow: evaluation, treatment, and prevention. Phys Ther

1979;59:742e6.




22(4):813–836.



Hypotheses. 2006; 67(6):1400–1402.


Med. 2010 Oct;29(4):577-97.

9. Kamien M. A rational management of tennis elbow. Sports Med 1990;9:173e91.











1998;16:145e51.



32



Syst Rev 2001;(4). CD003686.
















4.




July 3, 2013.

24. Mulligan BR. Mobilisation with movement. J Man Manip Ther 1993;1(4):154e6.

25. Miller J. Mulligan concept e management of tennis elbow. Can Physiother Assoc Ortho

Div Rev; 2000 May/June:45e6.







Hand Therapy 2001a; 6(4):109-118.


33











33 Rompe, J.D., T.J. Overend, and J.C. MacDermid, Validation of the Patient-rated Tennis


34 D'Vaz, A.P., A.J. Ostor, C.A. Speed, et al. Pulsed low-intensity ultrasound therapy for


45(5): p. 566-70.















December 2001.

41. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales:

a critical review. Psychol Med 1988;18:1007–19.

42. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a

comparison of six methods. Pain 1986;27:117–26.

34

43. Amro A, Diener I, Bdair W, Hameda IM, et all. The effects of Mulligan mobilisation with

movement and taping techniques on pain, grip strength, and function in patients with lateral

epicondylitis. Hong Kong Physiotherapy Journal (2010) 28, 19e23.

44. Geetu M, Deepak G. Effectiveness of movement with mobilization compared with

manipulation of wrist in case of lateral epicondylitis. Indian J Physiother Occup Ther 2008;2.

45. Miller J. Mulligan concept e management of tennis elbow. Can Physiother Assoc Ortho

Div Rev; 2000 May/June:45e6.

46. Mulligan BR. Mobilisation with movement. J Man Manip Ther1993;1(4):154e6.

47. Heiser R, O'Brien VH, Schwartz DA. The use of joint mobilization to improve clinical

outcomes in hand therapy: A systematic review of the literature. J Hand Ther. 2013 Sep 14.

48 Heiser R, O'Brien VH, Schwartz DA. The use of joint mobilization to improve clinical

outcomes in hand therapy: A systematic review of the literature. J Hand Ther. 2013 Sep 14

49. Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of

movement in subjects with lateral epicondylalgia. Man Ther. 2001 Aug;6(3):170-7.

50. Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy

in treating lateral epicondylalgia. J Man Manip Ther. 2008;16(4):225-37.

51. Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T. Effects of a manual therapy

technique in experimental lateral epicondylalgia. Man Ther. 2006 May;11(2):107-17.

52. González-Iglesias J, Cleland JA, del Rosario Gutierrez-Vega M, Fernández-de-las-Peñas

C. Multimodal management of lateral epicondylalgia in rock climbers: a prospective case

series. J Manipulative Physiol Ther. 2011 Nov;34(9):635-42.

35

Joanna Fidut, Karolina Janikowska

The review of the mobilization with movement techniques in management of tennis elbow

Brain Mulligan Mobilization with Movement Concept

The Mulligan Concept is an integrative part of practice of many current manual therapist.

Author of this method Brain Mulligan built his techniques on the principles of manual therapy

proposed by Kaltenborn and focused on restoration the physiological movement of the joints.

It consists of the Sustained Natural Apophyseal Glides (SNAG's) applied for the spine and

MWMs for the extremities.

The principles of the Mulligan Concept are based on the painless motion and therapy. The

therapist should first identify the signs described by Maitland and including for example loss

of joint movement, pain occurring during movement, pain related to the resisted wrist

extension. Therapy include accessory glide performed parallel or perpendicular to the joint

plane. The therapist need to find the correct plane and grade of mobilization to not recreated

the patient’s pain. The success of the therapy is confirmed by significant comparable sign

indicating no pain. Another element of the concept is the passive overpressure applied at the

end of the range, again causing no pain for the patient. The self-treatment is possible with use

of these mobilization with movement techniques.

The aim of this paper is to review and present most common techniques of Brian Mulligan

Concept used in lateral epicondylitis therapy (Fig. 1-10).

36

Fig. 1. Mobilization with movement with use of mobilization belt and wrist extension.

Fig. 2. Mobilization with movement with use of mobilization belt and hand grip.

37

Fig. 3. Mobilization with movement with use of mobilization belt and hand grip in elbow

flexion and forearm supination.

Fig. 4. Mobilization with movement in wrist extension with force applied to the hand.

38

Fig. 5. Automobilization of the elbow with use of the wall in wrist extension and hand grip.

Fig. 6. Mobilization with movement and patients motion of flexed wrist.

39

Fig. 7. Mobilization with movement and patients motion to wrist extension.

Fig. 8. Mobilization with movement with passive overpressure.

40

Fig. 9. Mobilization with movement with passive overpressure applied to the elbow.

41

Fig. 10. The autostretching technique for the wrist extensors.

42

References:

1. Mulligan, BR. Manual Therapy ‘NAGS’, ‘SNAGS’, ‘MWMS’ etc. (6th Ed), Orthopedic

Physical Therapy Products, 2010.

2. Mulligan, BR. Self Treatments for Back, Neck, and Limbs, A new approach (2nd Edition).

Orthopedic Physical Therapy Products, 2006.

3. Vicenzino B, Hing W, Rivett D, Hall T. Mobilisation with Movement: The art and the

science by Bill Vicenzino, Wayne Hing, Darren Rivett and Toby Hall, and forewords written

by Brian Mulligan and Professor Gwedolen Jull. Churchill Livingstone, Australia, 2011.

4. Mulligan BR. Manual Therapy, "NAGS", "SNAGS", "MWMS: etc. Plane View Press

Wellington. 1995.

5. Mulligan BR. Mobilizations with Movement (MWMS), Journal of Manual and

Manipulative Therapy, Vol. 1, No. 4, 1993.

6 Vincenzino, B., Wright, A. Effects of a Novel Manipulative Physiotherapy Technique on

Tennis Elbow, A single Case Study, Manual Therapy, 1,1995.

7. Wilson E. The Mulligan Concept: NAGS, SNAGS, and mobilisations with movement.

Journal of Bodywork and Movement Therapies 5(2): 81–89.

43


Effects of Kinesio taping in patients with symptoms of lateral epicondylalgia

Background

Lateral epicondylitis is one of the most common cause of elbow pain related to the pathology

of the muscle extensor carpi radialis brevis [1,2]. In every population it can affect from from 1

to 3 % of active working people[3]. It can impaired the function of the dominating hand in

men and women [1,4 ]. The disorder is often defined as the repetitive strain injury of the

muscles attached to the lateral epicondylitis [5]. Previous studies pointed the tennis elbow as

the type of tendinitis what suggested the presence of the acute inflammatory process. Current

research investigating the absence of inflammatory marker in patients with tennis elbow

indicating the term “tendinosis” or “tendinopathy” as more appropriate to reflect the chronic

process [6,7]. The basic symptom of the tennis elbow is pain localized in the area of the

lateral epicondyle aggravating with hand grips and resistance applied to the muscles of the

forearm during the wrist extension[8].

The conservative therapy is based on use of ultrasound, cryotherapy, heat, electrical and laser

stimulation or extracorporeal shock wave therapy [9-15]. The other possible treatment is

based of pharmacological preparates e.g. non- steroidal anti-inflammatory drugs (NSAID),





effect of the autologos growth factors [22,23]. The physical therapy seems to be still more

accessible for the patient and less invasive than even very promising biological treatment but

require new approach and techniques focusing on the core of the patients problem. One of the

new ideas in manual Kinesio® taping developed by Kenzo Kase. The concept is based on

application of the special elastic tapes to the skin, over and around muscles in order to assist

and give support or to prevent over-contraction. Kinesio® Taping affects also the activation

of the neurological system, the circulatory system and improve healing of overcontracted

muscles [24,25].

Aim of the study

44

The aim of the was to assess the influence of the manual Kinesio® taping application on pain

and the functional status of the patients with lateral epicondylalgia.


The study was conducted on group of patients (15 men and 8 women) diagnosed with lateral

epicondylalgia who suffered for at least three months and failed to the conventional therapy.

The exclusion criteria for the study was: previous injury of the elbow in anamnesis, structural

changes in the area of the elbow, osteoarthritis of the elbow, receiving any therapy for lateral

epicondylitis during last 4 weeks, cervical spine changes and symptoms of radiculopathy, skin

changes, allergy observed after tape application, inflammation in the elbow area.


The standardized questionnaires e.g. Quick DASH (Disability of the Arm, Shoulder and



(VAS) was applied.

DASH and Quick DASH











musculoskeletal disorders of the upper limb. Scoring is divided into the two components: the






45





also on. 0.94 [30].





being included in research, especially randomized controlled trials.

The questionnaire consist of a 15-item, with five addressing pain and ten concerned with

functional impairment. Each of the item are rated with use of 0 – 10 numerical scale to assess

the average pain or difficulty they have faced over the previous week during various activities

that usually cause pain in tennis elbow. In this system the pain and function are weighted

equally in the total score [31,32]. Higher scores present greater severity and the maximum

score is 100. Major advantages of this instrument are its simplicity, shortness and specificity

to lateral epicondylitis [33,34]. The characteristic of the test is based on recent study used a

four-week test-retest period and calculated Intraclass Correlation Coefficient values of 0.81

for the pain sub-score and 0.76 for the total score. In another studies the Cronbach's alpha

coefficients were high for both the pain and function sub-scales (0.84 and 0.93, respectively)

[35,36].









pain” anchor and the patient’s mark, providing a range of scores from 0–100. According to

the research, the visual analogue scales have superior metrical characteristics than discrete

scales, therefore a wider range of statistical methods can be applied to the measured

46

parameters [39,40]. The characteristic of the instrument is based on calculated intraclass

correlation coefficients (ICC) on 0.97 for acute pain and Cronbach’s alpha varies depending

on the studies from 0.79 to 0.91 [41,42].




Therapy process

All procedures where performed by one certified in Kinesio® Taping Method practitioner

with used of original Kinesio® Tex Gold tape for application. The application were perfomed

during 4 weeks. All patients were instructed to deal with the applied tape at home. The

process of the diagnosis and the Kinesio® Tex Gold tape application is presented on pictures

(Fig. 1-7).


Patients underwent the examination and fulfilled the questionnaires at the beginning of the







Results

The study group consist of 23 patients, 15 men and 8 women. The mean age of the patients



and painful activity were associated with the hand grip and the palpation of the lateral

epicondyle. In all patients the elbow of the dominating hand was affected. All patients were

underwent the set of conventional physical therapy and still have symptoms seriously

impairing their daily


47

The average total pain experienced during last week before entering Kinesio®taping

application was around 5,5. After completing all sets of the application patients rated their

overall pain just on 3,5. Before the therapy the most painful for the patients were the

movement of wrist extension and all procedures performed with affected hand grip. The best

improvements in pain severity were observed in these measurements.






instrument dedicated for the tennis elbow allowed to assess the pain and function, before and

after completing the set of Kinesio®taping application There were equal statistically

significant improvement in domain of pain and function assessed by the patient (p<0.01). The

results are presented in table 3.


before and after the Kinesio® taping application.


during

before Kinesio®taping

application

after Kinesio®taping

application


wrist extension 6,2 ± 0,52 3,3 ± 0,6


hand grip 6,13 ± 0,55 3,55 ± 0,50

stretch of ECRB 6,10 ± 0,51 3,07 ± 0,65

elbow flexion 3,43 ± 0,29 2,21± 0,21

elbow extension 3,48 ± 0,46 2,38 ± 0,2




48


before and after the Kinesio®taping application.

Main module-

Restriction Index

Additional module-

work

Additional module-

sport

Before

Kinesio®taping

application

0,70 ± 0,10 0,80 ± 0,12 0,78 ± 0,16

After

Kinesio®taping

application

0,14 ± 0,04 0,18 ± 0,02 0,62 ± 0,1

The mean

improvement

0,54 0,62 0,16



Elbow Evaluation (PRTEE) fulfilled by patients before and after Kinesio®taping application.

Pain PRTEE

Function

PRTEE Total PRTEE

Before

Kinesio®taping

application

0,78 ± 0,14 0,74 ± 0,16 0,76 ± 0,15

After

Kinesio®taping

application

0,20 ± 0,1 0,16 ± 0,04 0,18 ± 0,07

The mean

improvement

0,58 0,58 0,58


49

Discussion

The study showed that application of the Kinesio® Tex Gold tape can significantly reduce the

pain occurring during the wrist extension and hand grip. The experimental study of Liu and

Chen with use of ultrasound proved the role of these application in enlarging muscle motion

[25]. The research of the Chang and Wang suggest that application of the Kinesiot® taping

and placebo-taping have the same effect on pain conditions and wrist flexor stenght [43].

Vicenzino and Brooksbank in their research pointed the improvement in pain-free grips

strength after Kinesio® taping application significantly higher than in control and placebo

groups [44]. The literature about the Kinesio®taping application and its role in lateral

epicondylitis improvement is very limited and based mostly on the application proposed by

the developer of the method [45].



process of the examination and all sets of Kinesio®taping application, therefore the study can

be underpowered. Another limitation is the lack of the control group included into the process

of randomization. To exactly determine the effect of mobilization Kinesio®taping application

in patients with symptoms of tennis elbow there is a need of randomized controlled trial.

Conclusions

Kinesio®taping application seems to be effective as supportive therapy of patients with lateral

epicondylitis. It leads to decrease of the severity of the pain, improve patients functionality

assessed with standardized questionnaires .

50

Fig.1. Application starts with placing the middle of the one short stripe over the most painful

area with 50% stretch.

Fig.2. Endings of the one short stripe over the most painful area are placed with no tension.

51

Fig.3 The second short stripe of the tape is placed with 50% tension in the middle and should

cross the previous stripe in the most painful area of the elbow.

Fig.4 Endings of the second short stripe over the most painful area are also placed with no

tension.

52

Fig.5. Basis of the third long stripe is placed with no tension over the elbow on the lateral part

of arm.

Fig.6. The tape is placed over the most painful area of the elbow and along with the forearm

muscles with 25 % tension.

53

Fig.7. Finished application of the Kinesio ® Tex Gold tapes. The stripe is applicated on the

forearm with no tension.

54

Summary

Background:

"Tennis elbow" is a condition characterized by the pain in a region of the lateral epicondylus

of humerus, weakness of the forearm muscles, grips forces and general dysfunctions of upper

extremity. The standard management of the lateral epicondylitis consists of physical therapy

methods, pharmacological treatment, immobilization and surgical techniques. Recently the

Kinesio® taping method is more often applied in patients with symptoms of this condition.

The elastic properties of Kinesio® Tex Tape applied according to the Kinesio® Taping

Method can enhance the function of muscle fibers and decrease the pain.

Aim of the study :

The aim of the study was to estimate the symptoms reduction and the improvement of the

functionality of upper limb after Kinesio®taping application in patients with "tennis elbow"

symptoms.


The study group consisted of 23 patients with tennis elbow treated with the physical therapy

methods and Kinesio® taping applications. All procedures were performed by certified

physiotherapist and Kinesio taping practitioner with use of Kinesio® Tex tape. The VAS,

PRTEE scales and Quick DASH questionnaires were used to assess the effectiveness of this

management. The range of motion, the pain free grip strength and the maximal strength of the

grip was tested at the beginning and the end of the therapy. The data collected were analyzed

with use of Statistica 10.0 software. The significance level of 0.05 (α = 5%) was adopted.

Results:

The significant reduction of pain in the lateral epicondylus region measured in VAS scale and

values of the PRTEE and Quick DASH questionnaire were observed in the study group. The

pain during the hand grip and the wrist, elbow movements were significantly improvement in

group of patients treated with application of the Kinesio® Tex Gold tapes (p<0.05).

Conclusions:

Kinesio® taping is a promising and effective method in decreasing symptoms of "tennis

elbow", mostly the pain and hand grip.

55

References


2005. p. 412e7.





4. LaFreniere JG. Tennis elbow: evaluation, treatment, and prevention. Phys Ther

1979;59:742e6.




22(4):813–836.



Hypotheses. 2006; 67(6):1400–1402.


Med. 2010 Oct;29(4):577-97.

9. Kamien M. A rational management of tennis elbow. Sports Med 1990;9:173e91.











1998;16:145e51.



56



Syst Rev 2001;(4). CD003686.
















4.




July 3, 2013.

24. Kase K, Hashimoto T, Tomoki O. Development of kinesio taping perfect manual. Kinesio

Taping Association 1996; 6-10: 117–8.

25. Liu YH, Chen SM, Lin CY, Huang CI, Sun YN. Motion tracking on elbow tissue from

ultrasonic image sequence for patients with lateral epicondylitis. Conf Proc IEEE Eng Med

Biol Soc. 2007;2007:95-8.






57



Hand Therapy 2001a; 6(4):109-118.











33 Rompe, J.D., T.J. Overend, and J.C. MacDermid, Validation of the Patient-rated Tennis


34 D'Vaz, A.P., A.J. Ostor, C.A. Speed, et al. Pulsed low-intensity ultrasound therapy for


45(5): p. 566-70.















December 2001.

58

41. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a

critical review. Psychol Med 1988;18:1007–19.

42. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison

of six methods. Pain 1986;27:117–26.

43. Chang HY, Wang CH, Chou KY, Cheng SC. Could forearm Kinesio Taping improve

strength, force sense, and pain in baseball pitchers with medial epicondylitis? Clin J Sport

Med. 2012 Jul;22(4):327-33.

44. Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A. Initial effects of elbow

taping on pain-free grip strength and pressure pain threshold. J Orthop Sports Phys Ther. 2003

Jul;33(7):400-7.

45. Kase K, Wallis J. The latest kinesio taping method. Ski-J 2002.

59

Joanna Fidut, Katarzyna Chomiuk, Karolina Janikowska

Review of the musculofascial Kinesio® taping applications for the lateral epicondylalgia – part 1

Background

Kinesio® taping was developed by Kenzo Kase in early 1970’. The concept is based on




muscles. Kinesio Taping is currently being used by therapists to modify muscle tone, move

lymphatic fluids, correct movement patterns, and improve body posture. The Kinesio®

Taping Method is a unique method of applying Kinesio® Tex Tape in a specific manner to

create change in the tissue under the applied tape. The experimental study of Liu and Chen

with use of ultrasound proved the role of these application in enlarging muscle motion. The

research of the Chang and Wang suggest that application of the Kinesiot® taping and

placebo-taping have the same effect on pain conditions and wrist flexor stenght. Vicenzino

and Brooksbank in their research pointed the improvement in pain-free grips strength after

Kinesio® taping application significantly higher than in control and placebo groups. The

literature about the Kinesio®taping application and its role in lateral epicondylitis

improvement is very limited and based mostly on the application proposed by the developer

of the method.

Muscular and fascial Kinesio®taping application (Fig. 1-10.)

Description and preparation of the Kinesio® Tex Gold tape.

The application is based on three parts of the tape. One part (black on Fig. 1) is a one short

strip prepared for the direct application over the most painful area. Second tape (black on Fig.

1) is for the same purpose. Third tape (blue on Fig.3) is a long strip prepared to be placed

from arm to the forearm. The endings of the tapes should be rounded. All application are

performed with use of Kinesio® Tex Gold tapes.

60

Fig.1. Kinesio® Tex Gold tapes cut for before the application. Initial preparation is important

and strips of kinesiology tape are cut so the ends are rounded.

Fig.2. Application starts with placing the middle of the one short stripe over the most painful

area with 50% stretch.

61

Fig.3. Endings of the one short stripe over the most painful area are placed with no tension.

Fig. 4. Placed first part of the application.

62

Fig.5. The second short stripe of the tape is placed with 50% tension in the middle and should

cross the previous stripe in the most painful area of the elbow.

Fig.6. Endings of the second short stripe over the most painful area are also placed with no

tension.

63

Fig.7. Basis of the third long stripe is placed with no tension over the elbow on the lateral part

of arm.

Fig.8. The tape is placed over the most painful area of the elbow and along with the forearm

muscles with 25 % tension.

64

Fig.9. The stripe is applicated on the forearm with no tension.

Fig.10. Finished application of the Kinesio ® Tex Gold tapes.

65

References:

Kase K, Wallis J. The latest kinesio taping method. Ski-J 2002.

Kase K, Hashimoto T, Tomoki O. Development of kinesio taping perfect manual. Kinesio


Kinesio Taping Perfect Manual by Kinesio Taping Association, 2Ed.

llustrated Kinesio Taping manual, 4th Ed.

Clinical Kinesio Taping - DVD.

Kase K, Wallis J. Clinical Therapeutic Applications of the Kinesio Taping Method 3rd

Edition, Ski-J 2003.

66


Review of the musculofascial Kinesio® taping applications for the lateral epicondylalgia – part 2

Background
















of the method.



The application is based on two parts. One tape (black on Fig. 1) is a one long strip prepared

for the muscle application. Second tape (blue on Fig. 1) is dedicated for the fascia application

and divided into two strips from the basis. The endings of the tapes should be rounded. All

application are performed with use of Kinesio® Tex Gold tapes.

67

Fig.1. Kinesio® Tex Gold tapes cut for before the application. Initial preparation is important

and strips of kinesiology tape are cut so the ends are rounded.

Fig.2. Placing the basis of muscle application on dorsal surface of the wrist with no tension.

68

Fig.3. Application of the tape with light tension (25%).

Fig.4. The end of the tape should be placed near to lateral epicondyle.

69

Fig.5. Basis placed with no stretch and application of the strips with 75% stretch from

posterior area of the elbow.

Fig.6. Placing the end of the tape with no tension close to the medial epicondyle of the right

elbow.

70


71



The application is based on two parts. One tape (black on Fig. 1.) cut vertically to the basis is

prepared for the muscle application. Second strip of the tape (pink on Fig. 2.) is dedicated for

the fascia application. The endings of the tapes should be rounded. All application are

performed with use of Kinesio® Tex Gold tapes.

Fig.8. Kinesio® Tex Gold tapes cut for before the application.

72

Fig.9. Placing the basis of muscle application with no tension over the elbow.

Fig.10. Application of the upper and lower strip with light tension (50%).

73

Fig.11. Placing the end of strip on the dorsal surface of the forearm with no tension.

Fig.12. Placing the basis of the tape with no tension below the lateral epicondyle of the elbow.

74

Fig.13. Application of the tape with 75% stretch from posterior to anterior area of the elbow.

Fig.14. Placing the end of the tape with no tension close to the medial epicondyle of the

elbow.

75


References:









76


Kinesio® taping application for elbow pain

Background
















of the method.

Fascial Kinesio®taping application for lateral epicondylalgia (Fig. 1-7).


Application

The application is based on two parts. One tape (black on Fig. 1) is a one short strip prepared

for the fascial application. Second tape (pink on Fig. 1.) is also dedicated for the fascia

application. The endings of the tapes should be rounded. All application are performed with

use of Kinesio® Tex Gold tapes.

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Fig.1. the Kinesio® Tex Gold tapes cut for before the application.

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Fig.2. Placing the basis of muscle application on medial surface of the elbow with no tension.

Fig.3. Application of the tape with 75% stretch over the painful lateral epicondyle of the

elbow.

Fig.4. Placing the end of strip with no tension.

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Fig.5. Basis of the second tape placed with no tension just below the black stripe.

Fig. 6. Application of the second strip with 75% stretch from the medial to the lateral area of

the elbow.

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Fig.7. Finished fascial application of the Kinesio ® Tex Gold tapes.

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Kinesio®taping application for lateral epicondylalgia.


The application is based on one Kinesio® Tex Gold tape with rhombus-shaped cut in the

middle of the tape (Fig.8-11). It can be used for placing over the medial and lateral epicondyle

depending on the pain origin. The endings of the tapes should be rounded. All application are

performed with use of Kinesio® Tex Gold tapes

Fig.8. Kinesio® Tex Gold tape cut for before the application.

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Fig.9. Placing the basis of muscle application on lateral surface of the elbow with 50%

tension.

Fig.10. Application of the tape with no tension.

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Fig.11. Finished application of the Kinesio® Tex Gold tape around the area of painful lateral

epicondyle.

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Muscular Kinesio®taping application for lateral epicondylalgia (Fig.11-16)


The application is based one long stripe of the Kinesio® Tex Gold tape (Fig. 11) prepared for

the muscle application. The proximal part has two rhombus-shaped holes dedicated for II and

III finger. The endings of the tapes should be rounded. All application are performed with use

of Kinesio® Tex Gold tapes.

Fig.11. Kinesio® Tex Gold tapes cut for before the application. Initial preparation is

important and strips of kinesiology tape are cut so the ends are rounded.

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Fig.12. Placing the proximal part of tape on the II and III finger with no tension.

Fig.13. Placing the basis of the proximal part of tape on the palmar side of the hand.

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Fig.14. Application of the stripe on the dorsal part of the hand.

Fig.15. Application of the rest of the stripe on forearm along to the extensor muscles with

25% tension.

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Fig.16. Finished application of the Kinesio ® Tex Gold tapes. The end of the tape should be

placed near to lateral epicondyle with no stretch.

References:









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