Mulligan and Proprioceptive Neuromuscular Facilitation Techniques in Individuals With Rotator Cuff Lesions

Rotator cuff lesions are among the most common causes of shoulder pain and functional limitation, often resulting from overuse, degenerative changes, impaired neuromuscular control, or acute trauma. These conditions may lead to significant restrictions in daily living activities and decreased quality of life. Conservative physiotherapy remains the primary treatment approach for individuals with partial-thickness rotator cuff tears, emphasizing pain relief, range of motion restoration, neuromuscular control, and functional improvement. Recent literature suggests that manual therapy techniques, when combined with exercise programs, may enhance clinical outcomes by providing additional benefits in pain modulation, joint mobility, and sensorimotor function.

This study is designed to investigate and compare the clinical efficacy of two commonly used manual therapy techniques-Mulligan Mobilization With Movement (MWM) and Proprioceptive Neuromuscular Facilitation (PNF)-in individuals with rotator cuff lesions. Although both approaches are widely used in clinical practice, there is currently no comparative research evaluating their relative effectiveness on pain, functionality, proprioception, and quality of life. By integrating these techniques into a structured physiotherapy program, the study aims to determine whether either method provides superior therapeutic benefits.

A total of 45 participants aged 30-70 years with a confirmed diagnosis of partial supraspinatus tear will be included. Diagnosis will be established by a physical medicine and rehabilitation specialist and verified through appropriate imaging techniques. Participants will be randomly allocated into three groups: (1) Conventional Physiotherapy (Control), (2) Mulligan + Conventional Physiotherapy, and (3) PNF + Conventional Physiotherapy. All groups will receive a standardized physiotherapy program consisting of wand exercises, Codman pendulum exercises, stretching, finger-ladder exercises, strengthening with elastic bands tailored to individual capability, and TENS applied at 100 Hz for 20 minutes per session. This program will be administered four times per week for three weeks under physiotherapist supervision.

In the Mulligan group, the MWM technique will be applied prior to the exercise program. The intervention will target shoulder flexion, abduction, internal rotation, and external rotation. Using a mobilization belt to optimize joint gliding, the therapist will guide the participant through active, pain-free movements while applying a sustained accessory glide. The technique will initially be performed for 10 repetitions in the first two sessions and progressed to 3 sets of 10 repetitions in later sessions.

In the PNF group, a "hold-relax active movement" approach will be used to enhance proprioceptive input, neuromuscular activation, and functional movement patterns. Participants will perform isometric contractions in the shortened range of the agonist muscle, followed by relaxation and quick passive movement into the elongated range of the antagonist pattern. They will then perform isotonic contractions of the agonist. This cycle will be repeated several times until adequate muscle activation or fatigue is achieved. PNF will also be performed prior to the conventional exercise program.

Outcome measurements will be performed at baseline and at the end of the three-week intervention period. Pain intensity will be assessed using the Visual Analog Scale (VAS), and shoulder joint range of motion will be measured using the Goniometer Pro smartphone application, which has demonstrated good validity and reliability. Functional disability will be evaluated using the Turkish version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, while proprioception will be measured through joint position sense testing at 60 degrees of flexion and abduction using Goniometer Pro. Quality of life will be assessed through the Rotator Cuff Quality of Life (RC-QoL) questionnaire, which has been validated for Turkish-speaking patients with rotator cuff pathology.

Statistical analyses will be conducted using SPSS 25.0. Normality will be tested through skewness-kurtosis values. Depending on distribution, within-group comparisons will utilize paired t-tests or Wilcoxon signed-rank tests; between-group comparisons will use one-way ANOVA or Kruskal-Wallis tests. When significant group differences are identified, appropriate post-hoc analyses will be performed. A significance level of p < 0.05 will be adopted.

This study is expected to contribute important evidence regarding the comparative effectiveness of Mulligan MWM and PNF techniques for rotator cuff lesions. The findings may support clinicians in selecting the most beneficial manual therapy approach to optimize patient outcomes in terms of pain reduction, functional capacity, proprioceptive accuracy, and overall quality of life. The results may also guide future research focusing on combined manual therapy and exercise interventions for shoulder pathologies.

Inclusion criteria

• Male and female participants between 30 and 70 years of age.
• A diagnosis of partial supraspinatus tear made by a physical medicine and rehabilitation s-specialist.
• Confirmation of the diagnosis through radiological imaging methods.
• No history of any shoulder surgery.
• Shoulder symptoms persisting for more than 4 weeks.

Exclusion criteria

• Individuals who are unable to cooperate or who have mental health problems.
• Individuals who have participated in any shoulder-related physiotherapy program within the last 3 months.
• Individuals with other musculoskeletal conditions that may affect the shoulder region.