Lateral epicondylitis (LE) also known as tennis elbow, results from an overuse injury due
to eccentric overload on the common extensor tendon, particularly at the origin of the
extensor carpi radialis brevis (ECRB). This condition is frequently triggered by
repetitive strain during tasks involving repeated gripping and loaded wrist extension.
Lateral epicondylitis affects 1% to 3% of population, especially in middle-aged people.
In addition, patients with LE suffer from pain or burning on the common extensor origin
of the forearm that may radiate into the upper arm or downward to the forearm. The pain
can be exacerbated with resisted wrist extension, forearm supination and middle finger
extension. The initial approach to manage lateral epicondylitis involves conservative
therapy, including eccentric training, stretching and local manual therapy.
In individuals with lateral epicondylitis, the experience of mechanical hyperalgesia
characterized by increased pain sensitivity during cold application is indicative of
potential central sensitization. Central sensitization involves heightened reactivity of
nociceptors within the central nervous system, resulting in increased responsiveness to
both normal and sub-threshold afferent input. This heightened sensitivity also includes
increased responsiveness to non-noxious stimuli and an elevated pain response triggered
by stimuli originating outside the area of injury, indicating an expanded receptive
field. Furthermore, cervical dysfunction is observable in individuals with LE even in the
absence of neck pain indicating the involvement of central sanitization. The potential
influence of cervical manual therapy on reducing mechanical hyperalgesia aligns with
addressing central sensitization, contributing to a comprehensive approach in managing
pain and sensitivity associated with lateral epicondylitis.
Its hypothesized that spinal manual therapy on the cervical spine is likely to yield
positive short-term outcomes on pain-free grip and the pain threshold elicited by
pressure over the lateral humeral epicondyle. As the mechanism of manual techniques
proves effective on mechanical, neurophysiological, and peripheral receptors while
inducing supraspinal pain inhibition related with sympathoexcitation3, hypoalgesia could
occur following the application of these techniques.
Mulligan's mobilization and SNAGS approach involves applying force and direction to the
facet joint, reaching the end range of motion. This technique aims to restore the
original position of cervical spine facet joint which possibly impacts the hyperalgesia
frequently associated with lateral epicondylitis. Moreover, mobilization with movement
induces biomechanical changes in the vertebrae, affecting central processing. It
restrains pain mechanisms, reduces neck dysfunction, and improves neck disability.
Notably, previous studies investigated, that they have indicated the need for further
research to determine the effects of spinal manipulation on hypoalgesia. Furthermore,
other study previously explored the effects of manual therapy on the thoracic spine
concerning pain-free grip and sympathetic activity in patients with lateral epicondylitis
producing favorable outcomes needing additional exploration when including the cervical
spine.
As such, the main objective of this study is to evaluate Mulligan's technique
effectiveness in relieving mechanical and cold hyperalgesia in individuals with lateral
epicondylitis, with a specific emphasis on the cervical spine region. Additionally, the
research aims to investigate the impact of Mulligan's technique on central sensitization
in the cervical spine and its influence on lateral epicondylitis.