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Mulligan Mobilization With Movement: Can It Be Used for the Management of Any Tendinopathy?

1 Physiotherapy Program, Department Health Sciences, School of Sciences, European University of Cyprus, Nicosia, Cyprus
*Corresponding author: Dimitrios Stasinopoulos, Physiotherapy Program, Department Health Sciences, School of Sciences, European University of Cyprus, Nicosia, Cyprus. Tel: +35-722713044, E-mail: [email protected].
Trauma Monthly. 22(1): e27312 , DOI: 10.5812/traumamon.27312
Article Type: Letter; Received: Feb 3, 2015; Revised: Mar 1, 2015; Accepted: Mar 4, 2015; epub: Apr 24, 2016; collection: Jan 2017

Keywords: Tendinopathy; Mulligan; Tennis Elbow; Manipulation; Lateral Elbow Tendinopathy

Dear Editor,

Tendinopathies represent one of the most common sports/musculoskeletal injuries in modern Western societies. Achilles and patellar tendinopathy are the most prevalent tendinopathies of the lower limbs, whereas rotator cuff (mainly supraspinatus) and lateral elbow tendinopathy (LET) are the most common tendinopathies of the upper limbs (1). Inflammatory cells and prostaglandins are absent in tendinopathy (1). In contrast, the presence of fibroblasts and disorganized collagen are increased in tendinopathy (1). Therefore, tendinopathy is a degenerative condition and not an inflammatory one as clinicians thought some decades ago.

Many medical and physiotherapeutic treatment modalities have been proposed for the management of LET. Autologous blood injection can be recommended as a conservative medical treatment approach for LET patients (2, 3). However, this letter focuses on the physiotherapeutic management of LET rather than its conservative medical management.

Many physiotherapeutic strategies have been proposed for the management of tendinopathy. These strategies involve electrotherapeutic modalities, such as therapeutic ultrasound, extracorporeal shockwave therapy, low-level laser, and ion transfer medication, and non-electrotherapeutic modalities, such as exercise training, deep transverse friction, taping, and needle therapy. Many manual therapies have been advocated for the management of tendinopathy, but there is minimal experimental evidence to support the efficacy of such therapies (4).

Mulligan mobilization with movement (MMWM) is the most common and the most frequently studied manipulative technique for the management of LET. The MMWM technique is a non-thrust manipulative technique performed in the following fashion: The therapist first identifies a physical activity that the patient reports to be painful. Most often, this entails the patient clenching the fist, a task that is frequently impaired in LET. The patient is next instructed to perform the identified painful task while the therapist provides a laterally directed glide to the elbow (5). Current evidence supports the application of MMWM in providing not only immediate benefits but also improving outcomes at follow-up (short and long term) (6). However, the results of these studies could not be generalized to the population because more studies are needed with larger sample sizes, established parameters of MMWM prescription (amount of force, repetitions, sets, frequency, and rest periods), valid outcome measures, adequate follow-up, and comparison with commonly used treatments in current clinical practice (6, 7). The question that arises is whether an analogous manipulation procedure may be found for the rehabilitation of other tendinopathies comparable to that used in the management of LET, or whether practical difficulties might arise in attempting such a manipulation at other joints.

The recommended physiotherapy techniques are intended to reduce pain and increase function in patients with tendinopathy but have extremely dissimilar mechanisms of action. A physiotherapeutic treatment approach is effective when it inverses the pathophysiology of the tendinopathy and does not only improve the symptoms, as taping does (8). Nowadays, eccentric exercises are the most effective physiotherapeutic approach for patients with tendinopathy (9, 10) and achieves the above goal. The question that arises is whether the MMWM technique can result in the same mechanism, or whether it can only be used for symptom relief.

In writing this letter, it is not my intention to increase the knowledge of physiotherapists but rather to generate questions about why they do not use the same treatment protocol for the management of all tendinopathies. My intention is to address question of why MMWM is suitable only for the management of LET. It is considered that even if a similar MMWM technique is found for the management of all tendinopathies, this technique will not be used as the only treatment. Rather, it will be combined with other physiotherapy approaches such as eccentric training, (the most promising treatment in the management of tendinopathy for the time being) physical modalities and/or taping.


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