Mulligan's Mobilization in Rotator Cuff Pathology

The Effect of Adding Thoracic Mobilization to Mulligan's Mobilization With Movement in Individuals With Rotator Cuff Pathology

Rotator cuff pathology is defined as the degeneration or tear of one or more of the muscles or tendons of the rotator cuff, namely the supraspinatus, infraspinatus, teres minor, and subscapularis. Shoulder girdle biomechanics are not solely comprised of the glenohumeral joint but are built upon a kinetic chain involving the synchronized movement of the scapula, clavicle, and thoracic spine. In this context, the concept described in the literature as the "Regional Dependence" model argues that functional impairment in a distal segment like the shoulder may stem from or exacerbate limitations in a more proximal region like the thoracic spine. Conventional treatment approaches that focus solely on the shoulder joint may have limited clinical outcomes due to neglecting the fundamental link in the kinetic chain. Maintained natural apophyseal glides (SNAGs), a cornerstone of Mulligan's Concept in spinal rehabilitation, are a dynamic manual therapy technique aimed at correcting microscopic misalignments in facet joints during active movement. The aim of this randomized controlled trial is to investigate the effects of thoracic mobilization added to the Mulligan movement shoulder mobilization technique on pain intensity, range of motion, proprioception, and upper extremity functionality in individuals with rotator cuff pathology, and to evaluate the superiority of this combined approach over shoulder mobilization alone. Assessments will be performed before treatment and at the end of the 3-week intervention. Rest and activity pain intensity will be assessed using the Pain Numerical Rating Scale (PMR), shoulder range of motion using a digital goniometer, thoracic kyphosis degrees using a smartphone with the 'Angle Meter' software installed and calibrated gyroscope and accelerometer sensors, functionality using the Shoulder Pain and Disability Index (SPAI), and proprioception using a laser pointer and target device. The obtained data will be compared using appropriate statistical analysis methods. This study is expected to provide scientific evidence regarding the clinical effectiveness of thoracic mobilization technique added to shoulder mobilization technique applied in conjunction with conventional treatment in individuals with rotator cuff pathology, and to contribute to filling the methodological gap mentioned in the literature.

Study Overview

• Status: Not yet recruiting
• Conditions: Rotator Cuff Injuries
• Intervention / Treatment: Procedure: Mulligan Mobilization with Movement; Other: Conventional Physiotherapy Program; Procedure: Thoracic Spine Mobilization

• Study Type: Interventional
• Enrollment (Estimated): 40
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Ayşe Merve Tat, Assistant Professor; Phone Number: +900505243111; Email: aysemervetat@yyu.edu.tr

Study Locations

• Turkey (Türkiye)
  • Tuşba
    • Van, Tuşba, Turkey (Türkiye), 65080
      • Van Yuzuncu Yıl University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Having been diagnosed with unilateral rotator cuff pathology (impingement syndrome, tendinopathy, or partial tear) by a specialist physician through clinical examination and/or radiological imaging (USG/MR);
• Being between 18 and 65 years of age;
• Having shoulder pain that has persisted for at least 3 months;
• Having a positive result on at least two of the Neer, Hawkins-Kennedy, and Empty Can tests;
• Having a pain intensity of at least 3/10 on the Pain Numerical Rating Scale (NPRS) during rest or activity;
• Having sufficient cognitive ability to follow simple instructions and administer the tests;
• Having a Mini Mental State Test score ≥24;
• Having the ability to provide signed informed consent and agreeing to participate in the study voluntarily.

Exclusion Criteria:

• Having undergone previous surgery on the shoulder or thoracic region;
• Having full-thickness rotator cuff tears requiring surgical indication;
• Having adhesive capsulitis, shoulder instability, labrum tears, or calcific tendinitis;
• Having cervical radiculopathy or neurological diseases affecting the upper extremity;
• Having uncontrolled diabetes, inflammatory rheumatic diseases (rheumatoid arthritis, etc.), or malignancy;
• Having severe osteoporosis, unstable vertebral fractures, or active infection in the thoracic region;

having received steroid (cortisone) or PRP injections to the shoulder region within the last 3 months.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Control Group; Conventional Physiotherapy Program, Mulligan Mobilization with Movement	Procedure: Mulligan Mobilization with Movement; Mobilization with Movement technique applied to the shoulder joint according to Mulligan concept to improve pain and range of motion.; Other: Conventional Physiotherapy Program; Conventional physiotherapy program including hot pack application (20 minutes), TENS (80-100 Hz frequency, 50-100 µs impulse duration, 20 minutes), therapeutic ultrasound (1-3 MHz frequency, 1.0-1.5 W/cm² intensity, continuous mode, 7 minutes), and supervised exercise program consisting of pendulum exercises, stick exercises for range of motion, scapular stabilization exercises (retraction, Y-W-T), and progressive strengthening exercises (isometric and dynamic) for rotator cuff muscles.
Experimental: Intervention Group; Conventional Physiotherapy Program, Mulligan Mobilization with Movement and Thoracic Spine Mobilization	Procedure: Mulligan Mobilization with Movement; Mobilization with Movement technique applied to the shoulder joint according to Mulligan concept to improve pain and range of motion.; Other: Conventional Physiotherapy Program; Conventional physiotherapy program including hot pack application (20 minutes), TENS (80-100 Hz frequency, 50-100 µs impulse duration, 20 minutes), therapeutic ultrasound (1-3 MHz frequency, 1.0-1.5 W/cm² intensity, continuous mode, 7 minutes), and supervised exercise program consisting of pendulum exercises, stick exercises for range of motion, scapular stabilization exercises (retraction, Y-W-T), and progressive strengthening exercises (isometric and dynamic) for rotator cuff muscles.; Procedure: Thoracic Spine Mobilization; Manual mobilization techniques applied to thoracic spine segments to improve thoracic mobility and contribute to shoulder function.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Thoracic kyphosis angle	Participants' thoracic kyphosis degrees will be measured via a smartphone equipped with 'Angle Meter' software, a digital inclinometer.	From enrollment to the end of treatment at 3 weeks
Proprioception	Proprioception will be assessed using a laser pointer and millimeter graph paper. The laser pointer will be secured to the participant's arm just above the lateral epicondyle, parallel to the arm, using an elastic bandage. The participant will be positioned in a seated position 1 meter away from the millimeter graph paper. The amount of linear deviation on the millimeter graph paper will be converted into angular error using a trigonometric formula based on the distance between the center of the shoulder joint and the paper.	"From enrollment to the end of treatment at 3 weeks
Range of motion	Range of motion will be assessed using a universal goniometer.	"From enrollment to the end of treatment at 3 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Shoulder pain	Shoulder pain will be assessed with Numerical Pain Rating Scale. Pain intensity is assessed on a numerical scale of 0-10; 0 = no pain, 5 = moderate pain, 10 = unbearable pain.	From enrollment to the end of treatment at 3 weeks
Shoulder Functionality	Functionality will be assessed with Shoulder Pain Disability Index.	From enrollment to the end of treatment at 3 weeks

Collaborators and Investigators

• Sponsor: Yuzuncu Yil University

Study record dates

Study Major Dates

• Study Start (Estimated): April 20, 2026
• Primary Completion (Estimated): September 20, 2026
• Study Completion (Estimated): October 20, 2026

Study Registration Dates

• First Submitted: April 6, 2026
• First Submitted That Met QC Criteria: April 6, 2026
• First Posted (Actual): April 13, 2026

Study Record Updates

• Last Update Posted (Actual): April 13, 2026
• Last Update Submitted That Met QC Criteria: April 6, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Exercise; Manual therapy; Rotator cuff injuries; Shoulder joint; Thoracic Vertebrae
• Additional Relevant MeSH Terms: Shoulder Injuries; Wounds and Injuries; Rupture; Tendon Injuries; Behavior; Rotator Cuff Injuries; Motor Activity; Musculoskeletal Physiological Phenomena; Musculoskeletal and Neural Physiological Phenomena; Physiological Phenomena; Movement
• Other Study ID Numbers: YuzuncuYil 2026- Shoulder MT

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No