Shoulder pain is a common musculoskeletal condition, with an incidence of at least 1 per 100 people per year, and up to 2.5 per 100 per year among individuals aged 42 to 46 years [1]. The lifetime occurrence of shoulder region pain has been reported to range from 7% to 36% of the total population. Shoulder pain represents up to 10% of all referrals to physiotherapy clinics [1]. The overall prevalence of sport injury in Para Athletics throwers was found to be 40% during the past 12 months, with the most frequently-involved region of the body being the elbow (25.3%) and the shoulder (22.8%) [2]. The most prevalent types of injury, were muscle injuries and tendinopathies [2].
A major cause of shoulder pain in athletes engaged in repetitive overhead movements is rotator cuff (RC) tendinopathy [3]. It is a broad term that covers a variety of tendon and muscle disorders, ranging from partial to complete tears of RC tendons and other surrounding tissues such as the long head of the biceps tendon and subacromial bursa [4]. Symptoms of rotator cuff tendinopathy include pain, weakness, and difficulty performing overhead activities. It can also limit participation in sports and physical activities, ultimately affecting overall health and quality of life [5]. While the RC unit is generally very functional, tears are nevertheless quite common, particularly among older adults and athletes [6]. While rotator cuff-related shoulder pain can have many causes, the most common is the narrowing of the subacromial space due to compression and inflammation [7].
Overhead athletes who engage in sports involving repetitive overhead shoulder movements, such as tennis, baseball, volleyball, golf and javelin throwing, often experience injuries to the shoulder, elbow and wrist, as the repeated force exerted on the shoulder joint can lead to both adaptive changes and pathological structural damage [8]. Overhead athletes are thus prone to the overuse of tendons, ligaments, and the joint capsule, or joint instability, resulting in shoulder pain [9].
Several interventions can be used to improve athletic performance [10]. Conservative treatments for rotator cuff tendinopathy include electrotherapies such as ultrasound therapy and laser, manual mobilization, exercise, and cutaneous taping [1]. Taping is widely employed to treat and prevent sports-related injuries as part of physiotherapy programs [11]. One such example is Kinesio tape (KT), used in clinical settings, on its own or in combination with other treatments, to help manage pain, reduce inflammation, and improve the functional activities of patients experiencing shoulder pain. KT is commonly applied as part of the rehabilitation process for musculoskeletal injuries [12,13].
One possible consequence of rotator cuff tendinopathy is a reduction in acromiohumeral distance (AHD) during overhead arm movements. As such, to prevent rotator cuff disorders, it is important to maintain the subacromial space during overhead arm movements; this can be achieved by scapular taping, which has been found to be effective [14]. Tanoori et al report significantly higher mean peak torque and power in a group of healthy tennis players with Kinesio taping than matched with rigid tape or no tape [10]. However, in a study of participants with rotator cuff-related pain, De Oliveira et al found the range of motion, symptoms, functional limitations, and AHD measurements to be almost equally improved in both a group receiving KT (experimental) and a group without KT (control group) [7]. Durgut et al found KT combined with exercise to improve activity-related pain and upper extremity function, leading to reduced disability [15].
This study aims to evaluate the effects of functional Kinesio taping combined with a six-week rehabilitation program on the AHD measurement at 0˚ arm positions in overhead athletes with RC tendinopathy. It also assesses the impact of Kinesio taping on pain, quality of life and the level of disability in these athletes.
The study was designed as a two-arm, parallel randomized clinical trial conducted at the Pain and Spine Clinic Islamabad, Pakistan, from June 2021 to December 2021. The study was approved by the review board of Riphah College of Rehabilitation and Allied Health Sciences Islamabad, Riphah International University (Ref: RIPHAH/FR&AHS/REC/Letter-1004) and registered in Clinical Trials (NCT05331963). All study participants gave their written informed consent before participation. All the participants were evaluated at baseline and after six weeks of follow-up.
The participants were selected through a non-probability convenience sampling technique. A random number generator was used to assign participants to either the experimental group (KT group) or the control group (no KT group). Numbers between one and 36 were chosen, with the first 18 participants selected placed in the experimental group and the remaining 18 assigned to the control group. All the participants were compensated for their ultrasonography expenses.
The inclusion criteria comprised the following: overhead activity athlete (cricket, tennis, badminton and volleyball), age range from 18 to 35 years, diagnosis of subacromial impingement syndrome, experiencing symptoms for at least one to three months; in addition, positive results for three out of the following five special tests: i) painful arc, ii) pain or weakness with resisted external rotation and/or abduction, iii) Neer test, iv) Hawkins Kennedy test, and v) empty can test/Jobe test; presence of mild, moderate and severe disruption of supraspinatus tendon on ultrasound images of the AHD.
The following exclusion criteria were applied: any history of shoulder surgery and acute injury in the past year, adhesive capsulitis (all stages), and instability or dislocation of any joint of the shoulder complex, complete tear of supraspinatus on USG; additionally, any contradictions for Kinesio tape, including allergy to adhesive, malignancy sites, cellulitis, skin infection or open wounds.
The sample size was calculated by the Open Epi tool with 95% CI and 80% study power. The mean (SD) values of the post-test DASH score of the experimental and control group (32.47 ± 14.17 and 22.81 ± 9.16) were taken from a previous study [16]. The total calculated sample size was n = 48. Due to limited time and resources, a total of 21 participants were recruited: 10 in the experimental group and 11 in the control group.
Both groups received a six-week intervention consisting of 10 sessions. Each session lasted 30–45 minutes. The intervention was administered twice a week for the first four weeks and then once a week for the last two weeks. All interventions were conducted at the physiotherapy department of the Pain and Spine Clinic, Islamabad and were supervised by a professional physiotherapist. Home exercises were provided to the patients for them to perform unsupervised. However, the physiotherapist ensured that all the exercises were easy and convenient to follow and recovery was based on regularly following the exercises.
The experimental group (KT group) received Kinesio taping along with a rehabilitation program.
The taping procedure was performed by a therapist who is a certified Kinesio Tape practitioner (CKTP). Kinesio tape measuring 5cm×5cm with a stretch capability of up to 70% was used. Firstly, excessive skin hair was removed, and then the skin was cleaned with isopropyl alcohol. A strip of KT was then cut to match the distance between the greater tuberosity of the humerus and the inferior border of the scapula. The edges of the tape were rounded to enhance tape adherence. With the patient in a sitting position, both arms on the side of the body, the patient was asked to fully retract the scapula and depress the shoulders and scapula to their maximum. The tape was applied from the inferior-medial aspect of the clavicle with 0% stretch, and then moved along with the fibers of the upper trapezius muscle with 75% stretch before ending at the T12 again with 0% stretch (Fig. 1). After applying the KT, the therapist then rubbed the tape from both ends for proper adhesion.
Application of kinesio tape
The underlying principle of this taping protocol is to provide mechanical correction of the scapula and to maintain the proper balance between scapular muscles [4]. After applying the tape, the patient was instructed to go home and keep the tape on for at least 72 hours. The patient was also told that they could bathe and carry on with their normal daily activities. However, they were advised to remove the tape in the event of an allergic reaction. It was emphasized that the patient should be careful when putting on or taking off clothes to avoid rolling the tape from the corners. The kinesio tape was applied at the end of every session to the participants in the experimental group.
The rehabilitation program was identical for both the experimental and control groups. All the exercises were preceded by a warm-up session to prepare the tissues for more intense exercise. This program consisted of range of motion, stretching and resisted exercise followed by patient education (Table 1).
Detail intervention protocol
| Duration | Experimental Group | Control Group | |
|---|---|---|---|
| KT application | Rehabilitation Program | Rehabilitation Program only | |
| Week 1 to 6 | Kinesio taping on skin for 72 hours on every session | Part A: Range of Motion (2–3 sets of 3–10 reps per day)
| Same as Experimental group |
Part B: Resisted Exercises (1–3 sets of 10–15 reps per day)
| |||
Part C: Stretching Exercises (2×30secs)
| |||
Part D: Patient Education
| |||
The participants were evaluated at baseline and after six weeks of intervention using the following tools: ultrasonography (USG), Western Ontario Rotator Cuff index (WORC), Disabilities of Shoulder, Arm and Hand questionnaire (DASH), and subjective pain assessment on a Visual Analogue Scale (VAS).
The subacromial space/AHD was visualized and measured using diagnostic ultrasound with Aquasonic ultrasound gel as the coupling medium. The AHD was measured by a radiologist who was trained in diagnostic ultrasound and blinded to the randomization. The USG was performed using an ultrasound scanner (Canon Aplio i600) with a frequency range of 1 to 22 MHz and a curved probe to capture images. The ultrasound probe was placed on the anterior-lateral surface of the acromion process, and aligned with the longitudinal axis of the humeral head, to allow simultaneous viewing of the acromion process and humeral head. The AHD was then measured from the inferior surface of the acromion process to the superior surface of the humeral head, specifically from the bright white cortical layers of both the acromion and humerus bone. The acromiohumeral distance was measured at the resting position (0° elevation) of the shoulder. The inter-rater ICC for the AHD was 0.95 with a 95% confidence interval (CI) of 0.88–0.98, indicating that diagnostic ultrasound is a highly reliable tool for measuring AHD [17].
The WORC was used to measure shoulder-related quality of life. The instrument comprises 21 items categorized into five groups: i) six items for Physical symptoms, ii) four items for sports and recreation functions, iii) four items for work functions, iv) four items for lifestyle functions, and v) three items for emotional function. The instrument provides clear instructions to the patients and explains each item in every category. According to the literature, the WORC shows the strongest correlation with the DASH (r = 0.69) and ASES (r = 0.73) as a discriminative instrument [18]. The scores can be converted to percentages or presented in their raw form. A score of 0 indicates the best possible total score, meaning the patient has no decline in shoulder-related quality of life (QoL). A score of 100 indicates the worst total score, meaning the patient has an extreme decline in shoulder-related QoL [19].
The DASH questionnaire is used to assess functional disorders, physical disability, and symptoms of the upper limbs. It includes 30 questions, with a score of 100 indicating the most severe disability [7].
This scale is used to rate pain on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst pain [4]. The VAS score is calculated by measuring the distance between the no pain or 0 anchor and the point where the patient makes a mark. Studies have shown that the test-retest reliability of this scale is higher among educated people (r = 0.94, p = 0.001) than among uneducated patients (r = 0.71, p = 0.001) [20].
This was a single-blinded study: the assessor was unaware of the group. The same radiologist performed the ultrasound for all participants and the same researcher applied the KT to all participants.
The data were analyzed using the IBM Statistical Package for Social Sciences (SPSS, v20). The Shapiro-Wilk test was applied to check the normality of the data. As the data was normally distributed, an independent t-test was applied for between-group analysis and a paired t-test for within-group analyses. The significance level was adopted as p < 0.05.
A total of 21 athletes participated in the study. They were randomly divided into KT and No-KT groups using random number generation. The KT group included 10 participants, and the No-KT group included 11 (Figure 2). Among the participants, 33.3% (n = 7) were female and 66.6% (n = 14) were male. The mean age of the participants was 26 ± 4.83, with a minimum age of 19 years and a maximum of 35. Of the participants, 57.1% were right-affected shoulders, and 42.9% were left affected. Cricket bowlers and tennis players each constituted 28.6% of the total, active golfers made up 19%, while volleyball players accounted for only 9.5%. The remaining 14.3% of participants were active in other overhead sports. Out of the 21 participants, 9.5% reported mild or the worst shoulder pain on the visual analogue scale (VAS), 47.6% reported moderate pain, and 33.3% reported severe pain.
CONSORT diagram
The between-group analysis indicated no significant differences in VAS values post-treatment (p ≥ 0.05). Additionally, no significant differences in acromio humeral distance were noted between the KT (1.14 ± 0.71) and no-KT group (1.24 ± 0.65) following treatment (p ≥ 0.05). No significant differences in DASH score were noted between KT (−31.9 ± 8.5) and no-KT (−31.1 ± 10.9) post-treatment (p ≥ 0.05). Also, no significant post-treatment differences in WOC score were observed between the groups for the overall score or five component scores (p > 0.05) (Table 2).
Between-group analysis of variables
| Variable | Groups | Mean SD | Mean difference | aP value |
|---|---|---|---|---|
| AHD before treatment | KT | 7.80 ± 1.23 | −0.260 | 0.65 |
| No-KT | 8.10 ± 1.37 | |||
| AHD after treatment | KT | 8.98 ± 1.10 | −0.365 | 0.13 |
| No-KT | 9.34 ± 1.60 | |||
| VAS before treatment | KT | 2.20 ± 0.78 | −0.436 | 0.74 |
| No-KT | 2.63 ± 0.80 | |||
| VAS after treatment | KT | 0.60 ± 0.51 | −0.309 | 0.98 |
| No-KT | 0.90 ± 0.70 | |||
| DASH before treatment | KT | 47.00 ± 13.38 | −1.618 | 0.15 |
| No KT | 48.61 ± 18.68 | |||
| DASH after treatment | KT | 15.01 ± 7.07 | −2.345 | 0.39 |
| No KT | 17.44 ± 8.96 | |||
| Physical Symptoms (WORC) before treatment | KT | 49.25 ± 20.68 | 1.859 | 0.94 |
| No KT | 47.39 ± 21.08 | |||
| Physical Symptoms (WORC) after treatment | KT | 18.49 ± 9.95 | −3.746 | 0.01 |
| No KT | 22.23 ± 22.00 | |||
| Sports (WORC) before treatment | KT | 61.49 ± 15.54 | −0.414 | 0.93 |
| No KT | 61.90 ± 13.45 | |||
| Sports (WORC) after treatment | KT | 27.43 ± 10.51 | 2.284 | 0.90 |
| No KT | 25.14 ± 10.43 | |||
| Work (WORC) before treatment | KT | 60.74 ± 15.14 | 0.340 | 0.35 |
| No KT | 55.07 ± 11.30 | |||
| Work (WORC) after treatment | KT | 34.92 ± 10.90 | 2.756 | 0.76 |
| No KT | 32.16 ± 11.02 | |||
| Lifestyle (WORC) before treatment | KT | 55.59 ± 20.17 | −5.528 | 0.22 |
| No KT | 61.11 ± 12.29 | |||
| Lifestyle (WORC) after treatment | KT | 26.75 ± 9.79 | −0.704 | 0.06 |
| No KT | 27.45 ± 16.03 | |||
| Emotions (WORC) before treatment | KT | 63.50 ± 20.25 | 8.590 | 0.65 |
| No KT | 54.90 ± 22.25 | |||
| Emotions (WORC) after treatment | KT | 37.18 ± 13.38 | 16.552 | 0.49 |
| No KT | 20.62 ± 11.95 | |||
| WORC Total score before treatment | KT | 55.94 ± 19.67 | −0.778 | 0.37 |
| No KT | 56.71 ± 14.20 | |||
| WORC Total score after treatment | KT | 24.68 ± 10.66 | −2.647 | 0.72 |
| No KT | 27.32 ± 11.39 |
AHD- Acromio Humeral Distance, DASH- Disabilities of Arm, Shoulder and Hand, VAS- Visual Analogue Scale, WORC- Western Ontario Rotator Cuff Index,
Independent t-test, Significance level - p < 0.05
Within-group analysis showed significant differences between baseline and week 6 in all variables (VAS, AHD, DASH scores, WORC scores) for both the KT group and the No-KT group p < 0.05 (Table 3).
Within-group analysis
| Variable | Observation | Experimental (KT group) | Control (No KT group) | ||||
|---|---|---|---|---|---|---|---|
| Mean SD | t value | aP value | Mean SD | t value | aP value | ||
| AHD | Pre | 7.84 ± 1.23 | −504 | 0.001 | 8.10 ± 1.37 | −6.27 | 0.000 |
| Post | 8.90 ± 1.10 | 9.34 ± 1.60 | |||||
| VAS | Pre | 2.20 ± 0.78 | 7.236 | 0.000 | 2.63 ± 0.80 | 8.859 | 0.000 |
| Post | 0.60 ± 0.51 | 0.90 ± 0.70 | |||||
| DASH | Pre | 47.0 ± 13.3 | 11.8 | 0.000 | 48.6 ± 18.6 | 9.46 | 0.000 |
| Post | 15.01 ± 7.07 | 17.01 ± 8.9 | |||||
| Physical Symptoms (WORC) | Pre | 49.25 ± 20 | 7.259 | 0.000 | 47.3 ± 21.08 | 24.26 | 0.000 |
| Post | 18.49 ± 9.9 | 22.0 ± 22.0 | |||||
| Sports (WORC) | pre | 61.49 ± 15.5 | 7.645 | 0.000 | 61.9 ± 13.5 | 19.21 | 0.000 |
| Post | 27.4 ± 10.5 | 25.1 ± 10.4 | |||||
| Work (WORC) | Pre | 60.7 ± 15.1 | 8.542 | 0.000 | 55.0 ± 11.3 | 13.77 | 0.000 |
| Post | −34.9 ± 10 | 32.19 ± 11.0 | |||||
| Lifestyle (WORC) | Pre | 55.5 ± 20.1 | 4.07 | 0.003 | 61.1 ± 12.1 | 8.97 | 0.000 |
| Post | 26.75 ± 9.79 | 27.4 ± 16.9 | |||||
| Emotions (WORC) | Pre | 63.5 ± 23.2 | 4.87 | 0.001 | 54.9 ± 23.2 | 8.14 | 0.000 |
| Post | 37.1 ± 13.3 | 20.61 ± 11.9 | |||||
| WORC Total score | Pre | 55.9 ± 19.6 | 8.52 | 0.000 | 56.71 ± 14.2 | 14.53 | 0.000 |
| Post | −24.6 ± 10.6 | 27.3 ± 11.39 | |||||
AHD- Acromio Humeral Distance, DASH- Disabilities of Arm, Shoulder and Hand, VAS- Visual Analogue Scale, WORC- Western Ontario Rotator Cuff Index,
Independent t-test, Significance level - p < 0.05
This randomized controlled trial aimed to assess the impact of Kinesio taping on the subacromial space in athletes with rotator cuff tendinopathy. The study did not find any significant differences in AHD, VAS, DASH or WORC scores between the group that received Kinesio taping together with physiotherapy (KT) and those who received physiotherapy alone. However, significant differences were observed between the pre- and post-treatment values of AHD, VAS, DASH and WORC in both the KT and no-KT groups. This is the first such data on the effects of KT on the subacromial space, as well as on pain, disability, and quality of life of overhead athletes.
Supraspinatus thickness or RC tendon tear were assessed only in two patients: the USG imaging revealed a mild tear of the supraspinatus in one patient from the KT group and a moderate tear in one from the no-KT group. In both patients, the ultrasonography value changed after six weeks of treatment; these values were not included in the Results, as these were only single subjects.
The WORC index indicated a high emotion score before treatment among the female KT participants, and an overall significant improvement in emotions and depression was noted for both male and female athletes in the KT group. Hence, it appears that KT also has some psychological effects.
The pathophysiology of rotator cuff tendinopathy is associated with a reduction in subacromial space (SAS) and decreased shoulder rotational ranges [21]. Kineso taping has recently become commonplace in rehabilitation and injury prevention [22], and has been found to achieve immediate improvements in pain and ROM [23]. Although the present study did not assess the immediate impact on pain and disability, no significant differences in pain and disability were noted between the groups; however, this lack of significance may be attributed to the small sample size.
Previous research did not find KT therapy to achieve any significant difference in AHD, either immediately or after 48 hours of KT application [24]. Similarly, our study showed no differences in AHD between groups. However, a significant difference in AHD was noted in the KT group after the six-week intervention, which may be due to the combined effect of the rehabilitation program and KT.
No significant differences were noted between the groups in any of the tested outcomes. These statistics suggest that KT did not affect the subacromial space. Instead, the improvement could be attributed to the rehabilitation program, which includes range of motion (ROM), stretching, strengthening, and postural correction exercises, resulting in a decrease in overall AHD measurements.
A critical review of 17 articles in the Orthopedic Journal of Scandinavia found 12 to not have enough evidence or results to support the use of KT with an exercise program; in contrast, five studies had some support, while three showed that short-term use of KT could be beneficial for short term effects only [25]. As such, there is a need for more appropriate research, specifically in the overhead athlete population, to support the effectiveness of KT and confirm whether it merits consideration when combined with exercise. A study found KT to have significant potential to increase AHD and reduce the risk of developing the rotator cuff tendinopathy [26]. This is confirmed by our present findings, which reveal an improvement in AHD and functional ROM.
One limitation of this study is that it does not take into account the shape of the acromion process when measuring the AHD. According to the literature, the acromion process can present as a hooked, curved or flat shape[27]. Although these results are controversial, it is possible that the shape and angle of the acromion process could impact the measurement of the acromiohumeral distance[28]. Another limitation of the study is the inclusion of wide range of study participants from 18 to 35 years of age, and all participants received the same scapular taping technique to mechanically correct the position of the scapula and related structures; however, the study did not include any variables to measure whether the taping improved slouched posture. As such, further study is needed to more precisely determine the effect of scapular taping. Finally, the smaller number of participants could impact the overall results, as this may result in a lack of power in differentiating between groups.
Nevertheless, the present study uses a novel approach to measure the AHD and other specified outcomes. Furthermore, while most previous studies have only assessed the effect of KT alone on recovery, our findings demonstrate combination of KT with a rehabilitation program.
Clinicians, athletic trainers, and physiotherapists should not only focus on Kinesio taping for improving the symptoms in patients with rotator cuff tendinopathy, but consider its use in combination with rehabilitation. However, further clinical trials with larger sample sizes are needed: these should aim to account for the shape of the acromion process, and include the variable for slouch postures.
Our findings indicate that both the combined use of Kinesio taping with a rehabilitation program and a rehabilitation program alone can improve acromiohumeral distance measured with 0° arm elevation in overhead athletes with rotator cuff tendinopathy; both treatment programs also yielded improvements revealed by ultrasound examination, pain assessment, functional disability, and quality of life after a six-week intervention. However, the Kinesio taping didn’t provide any additional benefits over the physiotherapy program alone.