1 Introduction

Tendinopathy is a condition in which pain arises on tendon near origin or insertion due to repetitive activities and reduced functional level, it occurs when the tendon does not properly heal.^1,2 Thirty percentage of tendinopathies of musculoskeletal conditions are shoulder pain related where supraspinatus tendinitis is the third most prevalent problem.³ (see Fig. 3 & Fig. 4)

Sports and repeated work or day today activities involves in supraspinatus tendon, which bring supraspinatus tendinitis in the rotator cuff of shoulder joint.^4,5 Generally aging brings injuries of supraspinatus tendon.⁶ Function of the supraspinatus muscle is shoulder abduction which travels over the humeral head.⁷ Supraspinatus tendon which get impingement when it is repetitively moving over acromion process of scapular bone can lead to inflammation of supraspinatus tendon. When it is reached this level, and unexpected force may leads to partial or complete tendon rupture.⁷

Based on Neer's description, the tendon of supraspinatus muscle undergoes a predictable breakdown in three stages: first one is edema and haemorrhages, second is fibrosis and tendinitis, and final tendon rupture.⁸

Supraspinatus tendinitis is associated with limited shoulder joint ROM, feeling pain, discomfort during give body weight while lying on the shoulder which is affected, tenderness and a detrimental loss of strength and power of shoulder muscles.⁹

Conventional way of treating supraspinatus tendinitis adds shoulder swings, painless ROM exercises, shoulder joint active assisted exercises, resistance exercises which improves muscle strength, and pain reducing physiotherapy modalities like ultrasound.^9,10

Elaborated research has been done on Mulligan's Manual Mobilization method, known as "Mobilization with Movement" (MWM), which demonstrates its benefits in treating joint functional deficits and various pathologies.¹¹ Mobilization with movement (MWM) involves a physiotherapist applying accessory mobilization through active functional and movement which is performed in last range and pain free passive stretch.¹²

Passively mobilizing the joints will increase the blood circulation to joints, minimizing the inflammatory responses, swelling, pain and breaking adhesions.¹³ MWM methods are used to rectify dysfunctions related to changing positions after cold trauma like strain which results in reduction of pain and keep range of motion with desired level.^14–22

So that non-invasive intervention should be taken as not a successful one when patient is not showing any significant changes after 90 days of co-ordinated and complicated clinical and rehabilitation programs. Generally 6 months of traditional treatment, many patients got significant changes from non invasive treatment interventions. Conventional treatment take 3–6 month to get recover, so that the main aim of this study to find out the use of Mulligan mobilization technique in patients with Grade II supraspinatus tendinitis.

Dearth of published research on Mulligan mobilization with ultra sound application on shoulder joint range of motion and pain, this quasi experimental study has been undertaken to find out the results of these interventions in grade II supraspinatus tendinitis patients.

Objectives of this study is to analyse and interpret the effect of movement with mobilization based on Mulligan's manual approach in subject with supraspinatus tendinitis, to find out the effect of conventional therapy in subject with supraspinatus tendinitis and comparing the effect of mulligan mobilization and conventional therapy in subject with supraspinatus tendinitis.

This study's alternate hypothesis is stating that there may be statistically significant effect in patients with grade II supraspinatus tendinitis by using Mulligan mobilization with ultrasound application than conventional rehabilitation.

2 Methodology

A quasi experimental study was designed to analyse and interpret the effect Mulligan mobilization with ultrasound application on grade II supraspinatus tendinitis patients. In a pain and neurorehabilitation centre situated in Madurai, Tamilnadu, India this study was conducted for 8 months from February 2023 to October 2023. Based on sample size calculation, 50 male subjects were taken through convenient sampling method and they have been made into control group and experimental group with 25 subjects for each group. Study inclusion criteria added age group of 30–60 male subjects diagnosed of grade II supraspinatus tendinitis based on Neer's classification with confirmation of special tests and signs and symptoms of grade II supraspinatus grade II tendinitis for the past one month and taking non steroidal anti inflammatory drugs suggested by physician. Exclusion criteria other grades of supraspinatus tendinitis, any past shoulder surgical interventions, instability of shoulder joint due to other reasons, acromioclavicular joint arthritis, non cooperative subjects, serious neuromuscular, cardiovascular diseases, systemic illness and serious COVID-19 cases were excluded from this study (See Table 1). Participant's informed consent was taken. Ethical standards were maintained based on Helsinki declaration and ethical approval was taken from Institutional Ethical Committee and Review Board of Santosh College of Physiotherapy, Tirunagar, Madurai, Tamilnadu, India (SCP/UG/001/2022).

Shoulder Pain and Disability Index (SPADI) and shoulder joint active abduction and external rotation range of motion were the dependent variables was pre, post and in 1 month follow up were measured and documented for statistical analysis.

The Shoulder Pain and Disability Index (SPADI) and a goniometer were used to capture baseline assessments of functional disability and shoulder range of motion. Control and experimental groups were received general physiotherapy interventions of ice therapy application, and active shoulder joint capsular stretches, and mobility exercises of the shoulder joint.

2.1

2.1 Intervention

Both groups received ultrasound therapy with a frequency of 1MHz and 0.8w/cm² intensity for 7 minutes, followed by 10 minutes of ice cube massage and shoulder joint mobility exercises. Shoulder joint anterior, posterior and inferior capsular stretches were performed actively with a 30-s hold and 5 repetitions (See Fig. 1).

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Fig. 1 Ultrasonic therapy application (Source: Author).

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The experimental group underwent Mulligan mobilization with movement in addition to ultrasound therapy. Mulligan's mobilization with movement for shoulder joint with 10 repetitions, rest period for 30 seconds after each set, 6 sessions in a week for 2 weeks (See Fig. 2)

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Fig. 2 Mulligan movement with mobilization (MWM) for shoulder joint abduction application (Source: Author).

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Fig. 3 X ray of supraspinatus grade II tendinitis (Source: Author).

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Fig. 4 MRI of supraspinatus grade II tendinitis (Source: Author).

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Outcomes of dependent variables of SPADI, shoulder joint abduction, internal and external rotation range of motion from both groups after interventions, 1 month follow up were collected and documented for statistical analysis.

3 Data analysis

4 Results

This table shows that median (IQR), z value and p value of SPADI and Shoulder Abduction and External Rotation ROM in Control Group after the intervention of ultra sound therapy with conventional rehabilitation for shoulder. There is not statistically significant improvement in SPADI but there was statistically significant increase in shoulder joint abduction and external rotation ROM after intervention of ultra sound therapy with conventional Rehabilitation in control group with p < 0.05∗∗∗ (see Table 2).

This table shows that median (IQR), z value and p value of SPADI and Shoulder Abduction and External Rotation ROM in Experimental Group after the intervention of ultra sound therapy with conventional rehabilitation for shoulder. There is statistically significant improvement in SPADI, Shoulder Abduction and External Rotation ROM after intervention of ultra sound therapy with conventional Rehabilitation in control group with p < 0.05∗∗∗ (see Table 3).

This table shows that median (IQR), z value and p value of SPADI and Shoulder Abduction and External Rotation ROM between Control Group and Experimental Group after the interventions. There is statistically no significant difference in SPADI and Shoulder Abduction and External Rotation ROM after interventions between groups with p < 0.05^NS. Thus there is homogeneity in variables before interventions between groups (see Table 4).

This table shows that the post median (IQR), z value and p value of SPADI and Shoulder Abduction and External Rotation ROM between Control Group and Experimental Group after the interventions. There is statistically significant improvement in SPADI and Shoulder Abduction and External Rotation ROM after interventions between groups with p < 0.05∗∗∗ (see Table 5).

This table shows that pre, post, follow up median (IQR), Kruskal Wallis H value and p value of SPADI and Shoulder Abduction and External Rotation ROM between pre, post and 1 month follow up values. There is statistically significant difference in SPADI and Shoulder Abduction and External Rotation ROM on pre, post and 1 month follow up values between groups with p < 0.05∗∗∗ (see Table 6).

5 Discussion

Except SPADI in control group, the statistical analysis of this study demonstrates marked improvement in the outcomes for both groups (Tables 2 and 3). Homogeneity between groups on baseline values before interventions was there (Table 4). Post intervention mean values of outcomes shoulder abduction range, external rotation range and SPADI in Mulligan's mobilization with movement group showed statistically significant p-value in when compared to control group with p < 0.05 (Table 5) and in the 1 month follow up also (Table 6). Thus alternative hypothesis is accepted. These results got in the outcomes which states that the significant effect of Mulligan Movement with Mobilization (MWM) with ultra sound application on muscle flexibility and joint mobility which supports shoulder joint range of motion in the experimental group.

Mulligan concept is a significant technique in manual therapy field and a usual choice among clinical physiotherapists. By which patients can do painless movements, and increase overall functional outcomes. Mobilization with movement (MWM) involves a physiotherapist applying accessory mobilization through active functional and movement which is performed in last range and pain free passive stretch.¹² Mulligan's method for joints of the limbs combines persistent application of gliding force manually to correct position related dysfunctions along contemporaneous movement happening based on physiological function, which can be done by the patient actively or the therapist doing it passiveley.¹⁷According to research, MWM can result in reduction of pain, and influence the sympathetic functioning of autonomic nervous system.¹⁸

Joint flexibility, joint play movement, muscle function, and fascial release were improved by correct application Mulligan Movement with Mobilization which is an effective technique of manipulation. The changes in the outcomes of this study are reflecting and that is ably supported by study of V. Meena et al. (2020) in which significant increases in shoulder joint ROM, increased comfort level and muscle strength, overall ability of doing functional activities with intervention of Mulligan's MWM intervention for shoulder pain related conditions.²⁶ And this study results endorses Gokhan Doner et al. (2012) study on Mulligan's Movement with Mobilization method with stretching shoulder muscles passively were found to be beneficial in relieving rest pain and improving shoulder ROM and overall function.²⁷

Based on this study results, there was statistically significant benefits of Mulligan Movement with Mobilization (MVM) in treating pain, reduced Range of motion and muscle strength related to supraspinatus grade II tendinitis. The possible physiology behind that MWM has improving the flexibility of muscles governing the shoulder joint along with capsule and improving the joint functions as a whole. Anyway proper randomized control trials with homogeneity on demographic characteristics of inclusion of subjects may explore more based on this study results further in future.

6 Limitations

Small sample size of this study which may restricts the generalizability of the findings.

One month follow-up may not be enough. 3 month follow up may be considered.

Dosage and sessions of interventions may be increased.

Adding various outcomes related to shoulder function and quality of life may be more effective.

7 Future recommendations

Larger sample size would provide more robust and representative results.

Longer duration and follow-up studies are recommended to examine the long-term benefits of treatments.

Visual Analog Scale (VAS) for pain and other functional outcomes related to shoulder function and quality of life questionnaires like SF 36 may be used as outcomes.

8 Conclusion

This study provides statistical significant data to support the effect of Mulligan's movement with mobilization in treating supraspinatus tendinitis patients' pain, functional impairment, and range of motion. And also Mulligan's Mobilization with Movement technique along with therapeutic ultrasound application and conventional physiotherapy treatment excels over traditional physiotherapy interventions as shoulder pain management, and increased shoulder joint abduction and external rotation range in grade II supraspinatus tendinitis.

Funding/sponsorship

This research did not receive any specific grants from funding agencies in the public, commercial, or not for for-profit sectors.

Ethical approval

SCP/UG/001/2022 - Institutional Ethical Committee and Review Board, Santosh College of Physiotherapy, Madurai, Tamilnadu, India.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not for profit sectors.

CRediT authorship contribution statement

M. Premkumar: Conceptualization, Formal analysis, Methodology, Writing – original draft, Project administration. A.R. Sureshkumar: Conceptualization, Investigation, Writing – original draft, Writing – review & editing, Investigation, Project, Supervision. Madhuripu: Formal analysis, Data Collection, Methodology, Investigation. S. Kavitha: Formal analysis, Data Collection, Methodology, Investigation.