Comments on the article “The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review“

Dear editor,

I read with great interest and would like to congratulate Savva et al. [1] for their interesting narrative review that contributes to the understanding of joint mobilization and manipulation analgesic effect in tendinopathy. I would like to emphasize the importance of the study since the consequences are still unclear in terms of adopting the ideal conservative physiotherapy approach for dealing with tendinopathy management. The findings of this study aid in the decision making of clinicians, researchers, academicians, policy makers, and, ultimately patients. Precisely because of the significant influence that these findings may have on clinical practice, Ι would like to raise some topics that Ι believe might complement the discussions provided by the authors and enhance the interpretation of the study results. Specifically, I would like to report the following:

1. In the Rotator Cuff Tendinopathy paragraph, Table 1 includes many terms such as subacromial shoulder pain, subacromial impingement and rotator cuff disease. Moreover, there is the term rotator cuff–related shoulder pain [2]. I think that Savva et al. [1] thought that all these terms are similar to the terminology ‘Rotator Cuff Tendinopathy’. This variety of terms suggests that there is disagreement amongst authors in this field as to which is the most suitable. However, while recommending that some future research should review the terminology to resolve the problem of inconsistency, the narrative review by Savva et al. [1] employed the term Rotator Cuff Tendinopathy because their paper reports on the analgesic effect of joint mobilization and manipulation in tendinopathy. However, the authors should clarify the issue that they categorized all these papers together, although some papers may not be related directly to tendinopathy but were included in the narrative review.

2. The study design of Pieters et al. (2020) [3] article referred to in Table 1 of the article is an umbrella review and not a systematic review.

3. Mill’s manipulation is not applied as monotherapy in the management of Lateral Elbow Tendinopathy (LET). Cyriax and Cyriax [4] claimed substantial success in treating LET using transverse friction massage (TFM) in combination with Mill’s manipulation, which is performed immediately after TFM. For it to be considered a Cyriax physiotherapy intervention, the 2 components should be used together in the order mentioned when the ‘problematic’ tendon is the extensor carpi radialis brevis [5].

4. The authors should clarify their reasons for excluding the published article ‘Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarised polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis’ [6] from LET studies.

5. The authors wrote in the article ‘these techniques have been advocated for the management of tendon pain [34–36]’. The title of reference 36 is ‘Cervical traction combined with neural mobilization for patients with cervical radiculopathy: a randomized controlled trial’. Can the authors clarify how the above-mentioned article helps the management of tendon pain?

6. The literature investigating the effects of joint mobilization and manipulation in patients with lower limb tendinopathies (Achilles and patellar tendinopathy) is sparse and not reported in the narrative review. Therefore, the results of your article relate to upper limb tendinopathies. This could have been clarified in your conclusion section of the abstract.

7. Mobilization with movement, Mill’s manipulation (erroneously mentioned in the article – see comment number 3), and regional mobilization techniques are commonly used for the management of LET. The question that arises is whether a similar manipulation process may be found for the management of lower limb tendinopathies comparable to that used in the treatment of LET, or whether practical difficulties might arise in attempting such manipulation techniques at other joints [7,8]. Furthermore, the question that arises is if the above recommended manual techniques can only be used for symptom relief or whether these techniques can reverse the tendinopathy pathophysiology [7,9].

8. Finally, future research should assess why and how joint mobilization and manipulation could lower the pain in tendinopathy (mechanism of action).

Overall, I trust that the topics raised in this letter might help interpret the findings of the present narrative review. I acknowledge the difficulties in performing this narrative review study and once again congratulate the authors for their hard work.

Disclosure statement

No potential conflict of interest was reported by the author(s).