Mulligan Mobilization in Lateral Elbow Tendinopathy

May 11, 2026 updated by: KubraBali, Istanbul Kent University

Effects of Mulligan Mobilization With Movement Technique on Pain, Muscle Stiffness, Grip Strength, and Function in Patients With Lateral Elbow Tendinopathy

The aim of this study is to investigate the short-, medium-, and long-term effects of Mulligan Mobilization with Movement (MWM) added to an exercise program on pain, functionality, and biomechanical parameters in individuals with lateral elbow tendinopathy, compared to sham mobilization and exercise-only interventions.

The primary hypothesis is that the addition of true MWM to exercise will result in greater improvements in pain intensity, grip strength, pressure pain threshold, kinesiophobia, wrist joint position sense, and the mechanical properties of the extensor muscles compared to placebo (sham MWM) and exercise alone.

This study is designed as a three-arm randomized placebo-controlled trial. A total of 45 participants will be allocated to one of three groups: MWM plus exercise, sham MWM plus exercise, and exercise alone. Assessments will be conducted at baseline, immediately post-intervention, and at 3- and 6-month follow-ups.

The primary outcome measure is pain intensity. Secondary outcomes include functionality, grip strength, pressure pain threshold, kinesiophobia, wrist proprioception, and the mechanical properties of the extensor carpi radialis brevis muscle assessed using Myoton.

This study aims to determine the effects of manual therapy independent of placebo and to evaluate the sustainability of these effects over time. Additionally, by objectively assessing the mechanical and proprioceptive characteristics of the muscle-tendon unit alongside clinical outcomes, the study is expected to provide a novel contribution to the literature. The findings are anticipated to enhance the understanding of the mechanisms underlying conservative treatment approaches in lateral elbow tendinopathy and to support evidence-based clinical decision-making.

Study Overview

Status

Not yet recruiting

Conditions

Intervention / Treatment

Detailed Description

Lateral elbow tendinopathy (LET) is a common tendon pathology that develops as a result of excessive and repetitive use of the forearm extensor muscles or direct trauma to the lateral epicondyle [1]. The extensor carpi radialis brevis is most frequently affected, and it is clinically characterized by pain over the lateral epicondyle and increased tenderness during gripping activities [2], [3]. The annual incidence is approximately 3%, increasing to 7-10% in individuals aged 40-60 years [4]. A higher prevalence (29%) has been reported in occupations requiring intensive hand and wrist use [5], [6]. Physiotherapy is recommended as a first-line and cost-effective treatment approach in LET [7], [8]. Among manual therapy applications, Mobilization with Movement (MWM) is an intervention specific to the Mulligan concept that combines mobilization with active movement [9], [10], [11].

The positive effects of MWM added to exercise on pain and functionality in the short and medium term have been reported [12], [13]. However, the influence of contextual factors on outcomes and methodological limitations in sham intervention protocols have been emphasized [14], [15]. There is still a need for high-quality studies evaluating the effects of manual therapy independent of placebo [16]. In addition, the effects of manual therapy interventions on proprioceptive outcomes and the mechanical properties of muscles have not been sufficiently investigated. This study aims to contribute to the literature by examining the effectiveness of MWM added to exercise across different time periods using a placebo-controlled design.

Furthermore, while the effects of exercise and manual therapy interventions in LET are mostly evaluated through clinical outcomes such as pain and function, studies investigating their effects on wrist joint position sense and the mechanical properties of the muscle-tendon unit (stiffness, tone, elasticity, relaxation time, and creep) are limited [17], [18]. The objective assessment of these parameters may contribute to a better understanding of the neurophysiological and mechanical processes underlying clinical improvement.

This study is designed as a three-arm randomized placebo-controlled trial to investigate the short-, medium-, and long-term effects of Mulligan Mobilization with Movement (MWM) added to an exercise program on pain, functionality, grip strength, pressure pain threshold, kinesiophobia, wrist joint position sense, and the mechanical properties of the extensor muscles in individuals with LET, compared with sham mobilization and exercise-only interventions.

The study will be conducted between May 2026 and May 2027 in patients with LET who are referred by an orthopedic specialist to the Laboratory of the Department of Physiotherapy and Rehabilitation at Istanbul University-Cerrahpaşa. Written informed consent will be obtained from all individuals who meet the inclusion criteria and agree to participate.

Participants who meet the inclusion criteria will be assigned to three groups using a random number list generated by an independent researcher through an online randomization program (www.randomizer.org). A simple randomization method will be applied, and each participant will have an equal probability of being allocated to one of the three groups. Allocation concealment will be ensured using sealed, opaque, and sequentially numbered envelopes prepared in advance. Participants will be assigned to their respective groups after baseline assessment.

The first group will be the MWM + Exercise Group, in which Mulligan Mobilization with Movement will be applied in addition to exercise; the second group will be the Sham MWM + Exercise Group, in which sham mobilization will be applied in addition to exercise; and the third group will be the Exercise Group, in which only an exercise program will be applied. The physiotherapist (KB) who will administer the intervention will be informed of the group allocation prior to treatment.

Demographic and clinical data of the participants will be recorded in a case report form. All assessments will be performed before treatment, immediately after treatment, and at the 3rd and 6th months.

The primary outcome measure is pain intensity, assessed using the Numeric Pain Rating Scale. Secondary outcome measures include pressure pain threshold assessed with a pressure algometer, maximum and pain-free grip strength measured using a hand dynamometer, functionality evaluated with the Patient-Rated Tennis Elbow Evaluation, kinesiophobia assessed using the Tampa Scale for Kinesiophobia, mechanical properties of the extensor carpi radialis brevis muscle measured using a Myoton device, and wrist joint position sense assessed using a digital goniometer.

Sample size calculation was performed using G*Power (version 3.1, Heinrich-Heine University Düsseldorf, Germany). A medium effect size (f = 0.25) was assumed. The Type I error rate was set at α = 0.05, and statistical power was set at 90%. Considering a possible dropout rate of 15%, a total of 45 participants will be included in the study.

Eligibility 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

Study Type

Interventional

Enrollment (Estimated)

45

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • Turkey (Türkiye)
      • Istanbul, Turkey (Türkiye)
        • Istanbul Unıversity Cerrahpasa, Faculty of Health Sciences
        • Contact:
        • Principal Investigator:
          • Kubra Balı, Master Science
        • Sub-Investigator:
          • Ipek Yeldan, Professor

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult

Accepts Healthy Volunteers

No

Description

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

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: MWM + Exercise Group
Participants will receive Mulligan Mobilization with Movement combined with a structured exercise program targeting the extensor muscles.
Other: Mobilization with Movement (MWM)
MWM is a manual therapy technique in which a therapist applies a sustained lateral glide to the radial head using a belt while the patient performs active gripping movements. The intervention is designed to restore pain-free movement by combining joint mobilization with functional activity.
Other: Exercise
The exercise program targets the extensor carpi radialis brevis muscle and includes isometric, concentric, and eccentric strengthening exercises. Exercises are performed in a structured manner and progressed according to a pain-monitoring model allowing mild tolerable pain.
Sham Comparator: Sham MWM + Exercise Group
Participants will receive sham Mulligan Mobilization combined with the same structured exercise program targeting the extensor muscles.
Other: Exercise
The exercise program targets the extensor carpi radialis brevis muscle and includes isometric, concentric, and eccentric strengthening exercises. Exercises are performed in a structured manner and progressed according to a pain-monitoring model allowing mild tolerable pain.
Other: Sham Mobilization with Movement (Sham MWM)
Sham MWM involves positioning the Mulligan belt in the same manner as the active intervention; however, no therapeutic joint mobilization force is applied. Participants perform active gripping movements while receiving a non-therapeutic simulation of mobilization.
Experimental: Exercise Group
Participants will receive only a structured exercise program targeting the extensor muscles without any manual therapy intervention.
Other: Exercise
The exercise program targets the extensor carpi radialis brevis muscle and includes isometric, concentric, and eccentric strengthening exercises. Exercises are performed in a structured manner and progressed according to a pain-monitoring model allowing mild tolerable pain.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Pain Intensity
Time Frame: 1 minute
Numeric Pain Rating Scale
1 minute

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Pressure Pain Threshold
Time Frame: 1 minute
Algometer
1 minute
Maximum Grip Strength
Time Frame: 1 minute
Hand Dynamometer
1 minute
Pain-free Grip Strength
Time Frame: 1 minute
Hand Dynamometer
1 minute
Functionality
Time Frame: 5 minute
Patient-Rated Tennis Elbow Evaluation
5 minute
Kinesiophobia
Time Frame: 5 minute
Tampa Scale for Kinesiophobia
5 minute
Mechanical Properties of the Extensor Carpi Radialis Brevis Muscle
Time Frame: 3 minute
MyotonPro
3 minute
Wrist Joint Position Sense
Time Frame: 2 minute
Dijital Goniometer
2 minute

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Istanbul Kent University

Collaborators

Istanbul University - Cerrahpasa

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

May 15, 2026

Primary Completion (Estimated)

May 15, 2027

Study Completion (Estimated)

October 1, 2027

Study Registration Dates

First Submitted

May 11, 2026

First Submitted That Met QC Criteria

May 11, 2026

First Posted (Actual)

May 15, 2026

Study Record Updates

Last Update Posted (Actual)

May 15, 2026

Last Update Submitted That Met QC Criteria

May 11, 2026

Last Verified

May 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • E-83460662-050.04-1627561

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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