Mulligan Mobilization in Lateral Elbow Tendinopathy

Lateral elbow tendinopathy (LET) is a common musculoskeletal condition characterized by pain and tenderness over the lateral epicondyle, particularly during gripping and resisted wrist or finger extension. The extensor carpi radialis brevis is frequently involved. Conservative management is generally recommended as the first-line approach, with exercise and manual therapy commonly used to reduce symptoms and improve function.

Mobilization with Movement (MWM), a manual therapy technique within the Mulligan Concept, combines a sustained accessory joint glide with active movement. Previous studies have reported improvements in pain and function following MWM in individuals with LET. However, contextual and placebo-related effects associated with manual therapy may contribute to observed clinical outcomes, and the specific contribution of MWM when added to exercise remains unclear. Placebo-controlled investigations are therefore needed to better distinguish the effects of MWM from nonspecific treatment effects.

In addition to conventional clinical outcomes, alterations in proprioception and the mechanical characteristics of the involved musculature may be relevant to LET. Wrist joint position sense and mechanical properties of the extensor carpi radialis brevis, including muscle tone, stiffness, elasticity, relaxation time, and creep, may provide additional information regarding neuromuscular and mechanical changes associated with treatment. These parameters have received comparatively limited attention in previous studies of conservative management for LET.

This study is a three-arm randomized, placebo-controlled trial designed to investigate the effects of adding MWM to an exercise program in individuals with LET. Participants will be allocated to an MWM plus exercise group, a sham MWM plus exercise group, or an exercise-only group. This design will allow the effects of MWM to be examined in comparison with both a sham manual therapy intervention and exercise alone.

The study will be conducted at the Laboratory of the Department of Physiotherapy and Rehabilitation at Istanbul University-Cerrahpasa. Participants will be randomly allocated in equal proportions to the three study groups using a computer-generated randomization sequence prepared by an independent researcher. Allocation concealment will be maintained using sequentially numbered, sealed, opaque envelopes that will be opened after completion of the baseline assessment.

The intervention period will last 4 weeks. Outcomes will be assessed at baseline, 2 days after completion of the 4-week intervention, and 24 weeks after completion of the intervention. The study will evaluate clinical outcomes together with measures of muscle performance, mechanical pain sensitivity, proprioception, and muscle mechanical properties to determine both the short- and long-term effects of the interventions.

The sample size was calculated using G*Power version 3.1. A medium effect size (f = 0.25), a Type I error rate of 0.05, and statistical power of 90% were used for the calculation. Allowing for an anticipated dropout rate of 15%, a total of 45 participants are planned to be included.

Inclusion criteria

• Inclusion Criteria
• Age between 18 and 60 years
• Presence of unilateral lateral elbow pain and tenderness for at least 3 months
• Diagnosis of lateral elbow tendinopathy confirmed by the following four criteria:
• Local tenderness over the lateral epicondyle
• Positive Cozen's test
• Positive Maudsley's test
• Positive Mill's stretch test

Exclusion criteria

• History of surgery around the elbow
• History of elbow dislocation, fracture, or extensor tendon rupture
• History of fracture of the humerus, ulna, or radius within the past year
• Receipt of any treatment for LET within the past 6 months (e.g., physiotherapy, exercise, manual therapy, dry needling, orthosis)
• Presence of cervical referred pain and/or radiculopathy (positive Spurling test)
• Signs of peripheral nerve involvement
• Corticosteroid injection within the past 6 months
• History of rheumatologic disease
• Presence of cancer or tumor