Lateral Epicondylitis (LE) is a lesion affecting the common tendinous origin of the wrist extensors. It was Morris (1982) who called “LAWN TENNIS ARM”. Major (1883) and Winckworth (1883) are responsible for coining the term (Lawn) TENNIS ELBOW. It is a painful and debilitating condition which is caused by degeneration (tendinosis) of the extensor carpi radialis brevis tendon (ECRB) usually within 1-2cms of its attachment to the lateral epicondyle of the humerus. The average duration of a typical episode of lateral epicondylitis is between six months and two years. The dominant arm is commonly affected, with a prevalence of 1- 3% in the general population, but this increases to 19% at 30-60 years of age and appears to be more long standing and severe in women.

Predisposing factors like poor sports techniques in tennis such as back hand stroke, using arm instead of body, heavy stiff racket, large handle size and too tight strings and other occupational tasks involving repetitive movements of the wrist and hands should be given importance and according to it modifications should be done. Eg: Excessive use of hammer, faulty body mechanics while using computer, musicians, electricians, etc. Being primarily a mechanical type of overuse injury, featuring pain associated with disturbed sleep, aggravated by movement particularly of the wrist and decrease in grip strength.

Nirchl was the first to describe the prime etiological factor, which he described, is a force overload at the extensor aponeurosis leading to the following steps:-

A mechanical predisposition of the elbow to stress overload on the basis of a disadvantaged leverage force system.

Inadequate forearm extensor power and endurance to withstand moments of force placed against the forearm (intrinsic overload).

Inadequate forearm extensor flexibility (extrinsic overload).

Overwhelming moments of force or repetition in the face of reasonable muscle power, endurance and flexibility (intrinsic and extrinsic overload).

The pathomechanics behind lateral epicondylitis is the ERCB being under maximum tension when it contracts in a position of forearm pronation, wrist flexion and ulnar deviation. When the forearm is pronated, the head of the radius rotates anteriorly against the ECRB tendon, producing a fulcrum of mechanical irritation accounting for the pain over the head of the radius. This irritation is maximized when combined with elbow extension and flexion of the wrist. This position is typical for a backhand shot in racquet sports. Additional forces act on the ECRB tendon each time when the extensor carpi radialis longus and extensor digitorum tendons contract or lengthen. Clinical diagnosis of LE is done by a positive Mill’s and Cozen’s test.

Rehabilitation for epicondylitis must address all aspects of the injury and furthermore lower the risk of recurrence. Many treatment techniques are employed to resolve the pain and dysfunction of lateral epicondylitis. The practical treatments reported in the literature for epicondylitis consist of local corticosteroid injections, oral local non-steroidal anti-inflammatory drugs (NSAIDs), local application of non-steroidal pain relieving gels, physiotherapies including stretching and manipulation (including the Mulligan’s Mobilization with Movement), strengthening, extracorporeal shockwave therapy, taping, bracing, etc.

In mild cases of injury, the irritated muscle will respond to rest and ice. Ultrasound therapy helps to reduce pain and enhance the healing process. Friction massage treatment effectively strengthens the musculotendinous junction. Faulty elbow joint mechanics are corrected with specific joint mobilization techniques. Sports specific training may rectify improper backhand swing techniques one uses during tennis. Counterforce braces are used to provide compression and can help minimize the force of contraction. Strengthening for epicondylitis often involves activities using eccentric strengthening. Eccentric exercise over time decreases pain in an individual suffering from epicondylitis. Extracorporeal shockwave therapy (ESWT) involves administration of shockwaves causing mircotrauma to an area to induce the healing process.

1.1 NEED FOR THE STUDY

The incidence of lateral epicondylitis is increasing day by day and the appropriate management for this is still not clear. As lateral epicondylitis afflicts not only athletes but the working class also, a growing need for evidence based treatment is required. So there is growing concern regarding the conventional ultrasound therapy effectiveness versus Mulligan’s Mobilization with Movement (MWM). The MWM techniques can be described as the application of a manual force (‘Mobilization’) across a joint that is sustained during the performance of an impaired action (‘Movement’). This study is sought to compare and to find out the effectiveness of mulligan’s mobilization technique along with ultrasound therapy compared to ultrasound therapy alone in the management of lateral epicondylitis.

1.2 SPECIFIC OBJECTIVE

To compare the effectiveness of Mulligan’s MWM with Ultrasound therapy versus Ultrasound therapy alone in pain reduction, increase in grip strength and functional outcome in patients with lateral epicondylitis.

1.3 HYPOTHESIS

There will be a significant difference in pain, grip strength and functional outcome with Mulligan’s MWM along with Ultrasound therapy in patients with lateral epicondylitis.

There will be a significant difference in pain, grip strength and functional outcome with only Ultrasound therapy in patients with lateral epicondylitis.

There will be a significant difference in pain, grip strength and functional outcome in between the groups who underwent Mulligan’s MWM along with Ultrasound therapy and only Ultrasound therapy.

1.4 PROJECTED OUTCOME

Based on the literature review, it is expected that the participants with lateral epicondylitis, who will be treated with Mulligan’s mobilization with movement technique along with ultrasound therapy, improve significantly in pain reduction, increase in grip strength and functional outcome.

1.5 OPERATIONAL DEFINITION

Lateral Epicondylitis: Lateral Epicondylitis (LE) is a lesion affecting the common tendinous origin of the wrist extensors

Mulligan’s MWM: MMWM is a manual therapy treatment technique in which a manual force, usually in the form of a joint glide, is applied to a motion segment and sustained while a previously impaired action is performed.

Ultrasound: Electrotherapeutic modality used to reduce pain and enhance healing.

CHAPTER – II

LITERATURE REVIEW

The effectiveness of Mulligan’s MWM along with ultrasound therapy compared to ultrasound therapy alone in the management of lateral epicondylitis were evaluated. Out of this 66 patients, 46 were randomized and divided into 2 groups and the remaining who could not be randomized comprised the control group. Group 1 was treated with ultrasound therapy along with Mulligan’s MWM and group 2 was treated with ultrasound therapy alone and both these groups followed a progressive exercise program. VAS, isometric grip strength, weight test and grip strength were used as outcome measures. Results showed that Mulligan’s MWM along with ultrasound group had greater improvements than ultrasound alone group and control group in VAS, weight test and grip strength . Ultrasound therapy alone group was superior to control group on VAS and weight test. (Moneet Kochar and Ankit dogra, 2002)

The initial response to a manual therapy technique i.e. MWM for Tennis elbow was demonstrated. 25 subjects with lateral epicondylitis were allotted into one group pre-test post-test study. The outcome measures evaluated were pain with active motion, pain free grip strength and maximum grip strength. Pre-test and post-test had been done. Their results showed that MWM was effective in allowing the subjects to perform movements pain free which were previously painful and improved grip strength immediately. Hence, they concluded that Mulligan’s mobilization with movement is a promising intervention modality for the treatment of patients with lateral epicondylitis. (Abbot J H et al, 2001)

The effectiveness of MWM compared with manipulation of wrist on pain, strength, ADL were evaluated in patients with lateral epicondylitis. A total of 30 patients were taken and randomly assigned to one of the 3 groups i.e group A (Mulligan’s MWM +US), group B (wrist manipulation + US) and group C (US only). The outcome measures used were VAS, functional performance and weights. Results showed that all the 3 groups showed improvements in VAS score. Group A and group B showed significant improvement in strength and functional performance when compared with group C. So they concluded that both Mulligan’s MWM and wrist manipulation are equally effective in reducing pain, improving strength and functional performance when compared with conventional treatment regimen. (Geetu Manchanda and Deepak Grover, 2008)

The effectiveness of 3 treatment options for lateral epicondylitis i.e, corticosteroid injection, physiotherapy and wait and see option were compared in a study of 6 week intervention period. There were 185 patients who were enrolled in this study, were randomized to 3 groups consisting of group 1 (corticosteroid injection), group 2 (physiotherapy) and group 3 (wait and see). The outcomes were assessed before randomization and at 3, 6, 12, 26 and 52 weeks after randomization. Primary outcome was severity of elbow complaints using questionnaire and secondary outcome included pain free grip strength, maximal grip strength and pressure pain threshold. They concluded that immediate and short term improvements were seen in corticosteroid injection group whereas, sustained improvements resulted from physiotherapy. (Smidt N et al, 2008)

The effectiveness of bracing only, Physical therapy, Physical therapy and bracing were evaluated in patients with tennis elbow. 180 patients were randomized and allotted to 3 groups i.e. group A (Brace only), group B (physical therapy) and group C (physical therapy and bracing). Main outcomes evaluated were success rate, pain, disability and satisfaction. Follow up was 1 year. Their study results showed that physical therapy was superior to brace only at 6 weeks for pain, disability and satisfaction. Contrarily, brace only treatment was found to be superior on ability of daily activities. Combination treatment was superior to brace only treatment on severity of complaints, disability and satisfaction. So they concluded that brace might be useful as initial therapy and combination therapy has no additional advantage compared to physical therapy but is superior to brace only for short term. (Struijs P A et al, 2004)

The efficacy of physiotherapy compared with wait and see approach and corticosteroid injections over 52 weeks were investigated in tennis elbow. 198 participants were randomized into 3 groups consisting of Group A (MWM), group B (corticosteroid injection) and group C (wait and see). Primary outcome measures used were global improvement, painfree grip force and assessor’s rating of severity. The secondary outcome measures used were VAS, pain free function questionnaire. Results showed that there was significant difference for all primary outcome measures at 6 weeks that favoured injection over wait and see group. Corticosteroid injection was also superior to physical therapy on all outcome measures except global improvement. But at 52 weeks follow up, the corticosteroid injection group was worse on all outcome measures compared with physiotherapy group and 2 out of 3 measures compared with wait and see group. So they concluded in their study that MWM and exercise has a superior benefit to wait and see and corticosteroid injections. (Leanne Bisset, Bill vicenzino et al, 2009)

The effectiveness of 4 treatment protocols on lateral epicondylitis was compared. A total of 48 patients were used in this study and were randomly divided into 4 groups consisting of group A (ultrasound +home program), group B (ultrasound +10% hydrocortisone + home program), group C (TENS + home program) and group D (corticosteroid injection + home program). Outcome measures used were assessed using Mc Gill pain questionnaire. Results showed that there was decrease in mean pain intensity after the 5 day treatment time. Hence, their study indicated that all the 4 treatment protocols were effective in reducing pain. (John S. Halle, et al, 1986)

A systematic review was done to evaluate the literatures regarding MWM at peripheral joints to determine the overall efficacy related to MWM prescription. Electronic databases (Cinahl, Medline and Amed via Ovid, Pubmed and Medline via Ebsco Health databases, Cochrane via Wiley and PEDro) were searched to identify all studies pertaining to MWM at peripheral joints. Two researchers independently reviewed the papers and cross examined reference lists for further potential studies. Methodological quality was being assessed using the Downs and Black checklist and the tables were compiled to determine study characteristics. Total of 25 studies were analysed (4 true RCTs,6 RCTs with participants as own control, 3 quasiexperimental, 3 non experimental, 4 case studies, 5 case reports ). Results showed the efficacy of MWM at peripheral joints established for various joints and pathologies in 24 out of 25 studies. Hence, they concluded that manual therapy technique can be widely used and advocated for many aspects of peripheral joint dysfunction. (Wayne Hing et al, 2008)

A systematic review was done to evaluate the available evidence of effectiveness of physiotherapy for lateral epicondylitis. 23 RCT’s identified by highly sensitive search strategy in 6 databases in combination with reference checking was taken. Results showed that 14 studies out of 23 satisfied atleast 50% of internal validity criteria. The pooled estimate of treatment effects of 2 studies on ultrasound compared to placebo ultrasound showed statistically significant and clinically relevant differences in favour of ultrasound. Hence they concluded that, despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions for lateral epicondylitis due to contradicting results, insufficient power and low number of studies per intervention and hence more better designed, conducted and reported RCT’s are needed. (Nynke Smidt, Willem Assendelft et al, 2002)

The effectiveness of ultrasound in lateral epicondylitis was evaluated in 76 patients, out of which 38 were randomly allocated to receive ultrasound and 38 for placebo. Treatment was given for 4-6 weeks. Improvement in pain, weight lifting and grip strength was seen in ultrasound group. Hence, they concluded that ultrasound enhances recovery in most patients with lateral epicondylitis. (Binder et al, 1985)

A study to determine whether Mulligan’s MWM was capable of inducing physiological effects that were similar to those reported for some forms of spinal manipulation was conducted. 7 women and 17 men with chronic lateral epicondylalgia participated in the study. This study evaluated whether MWM at the elbow produces concurrent hypoalgesia and sympathoexcitation. It demonstrated an initial hypoalgesic effect followed by concurrent sympathoexcitation. Decrease in pain resulted in increased pain- free grip strength and pressure pain thresholds. Sympathoexcitation was indicated by changes in blood pressure, heart rate and cutaneous sudomotor and vasomotor function. This study showed that a Mulligan’s mobilization with movement treatment technique exerted physiological effects similar to that was reported for some spinal manipulations. (Paungmali et al, 2003)

CHAPTER- III

MATERIALS AND METHODS

3.1 STUDY DESIGN

Pre test and post test design with comparison treatment –

A Quasi Experimental Study Design:

Quasi Experimental Study Design was adopted for the study. With the help of this study design, the pre test and post test values were assessed for one group before and after the intervention and compared.

3.2 STUDY SE