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. 2021 Mar 26;29(5):276–287. doi: 10.1080/10669817.2021.1904348

The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review

Christos Savva a,✉, Christos Karagiannis a, Vasileios Korakakis b, Michalis Efstathiou c
PMCID: PMC8491707  PMID: 33769226

ABSTRACT

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

KEYWORDS: Manual therapy, manipulation, mobilization, tendinopathy

Introduction

Tendinopathy is a common work- and sport-related painful musculoskeletal condition that often leads to chronic tendon pain, decreased function, and lower health-related quality of life [1–4]. It has been reported that approximately 30% of musculoskeletal pain consultations in a general practice setting are related to tendinopathy, with significant socio-economic repercussions [5–7]. Rotator cuff and lateral elbow tendinopathy are the most common tendinopathies of the upper limb, whereas Achilles and patellar tendinopathy have been mentioned as the common tendinopathies of the lower limb [8,9].

Tendon pain is exacerbated by overuse activities or excessive mechanical loading and often presents with other symptoms, including local swelling and stiffness in the involved joint [10,11]. The pathophysiology behind the degenerative structural changes and the decline of material properties of the tendon tissue are not fully understood [4,12–14], and the source of tendon pain remains unknown [15]. Although healthy tendons are mostly aneural and avascular, the appearance of new abnormal vessels accompanied by extensive sensory nerve ingrowth into the tendon has been argued to be the potential source of tendon pain [16,17]. Specifically, this vasculo-neural ingrowth has been associated with a local increase in neurotransmitters, including glutamate, as well as an increase in substance-P positive nerve fibers, suggesting a link between tissue changes and the presence of tendon pain [8,17–19].

Physical therapy treatments and modalities, which have been proposed to reduce tendon pain and disability, have been examined in systematic reviews [1,20,21]. Based on available evidence, tendinopathy may benefit from a multimodal treatment approach, including the application of exercise and progressive loading strategies, electrophysical agents, extracorporeal shock wave therapy, and manual therapy [20,22–25]. Although the body of research on the management of tendinopathy is increasing, few randomized controlled trials have been performed, and therefore, there is still a need for additional high-quality trials that will allow firmer conclusions on the effectiveness of these interventions [26–28].

In recent years, joint mobilization and manipulation have received research and clinical attention for their role and contribution in the management of various musculoskeletal conditions, including low back pain, neck pain, chronic ankle sprain, cervicogenic headache, and dizziness [29–32]. Joint mobilization and manipulation are passive, skilled movements applied by clinicians to provide improvement in joint mobility and pain [33]. In addition, these techniques have been advocated for the management of tendon pain [34–36]. Limited evidence suggests that the application of joint mobilization and manipulation locally or proximally to the affected joint may reduce tendon pain, indicating that these techniques could be considered as an analgesic intervention for the management of tendinopathy [35,37]. However, these findings remain inconclusive, and the underlying mechanism of the demonstrable analgesic effect is still poorly understood and under investigation [38].

The purpose of this review was to summarize the available literature with regards to the potential analgesic effect and analgesic mechanism of joint mobilization and manipulation in tendinopathy.

Search strategy

A comprehensive search was conducted for articles published in English language from inception to November 2000 in the following electronic databases: PubMed and all EBSCO Host databases (including Academic Search, CINAHL, Health Source, SportDiscus). The complementary use of MeSH terms, subject headings, text-word searching was implemented by using keywords related to both tendinopathy (i.e., rotator cuff tendinopathy, lateral and medial elbow tendinopathy, etc.), manual therapy techniques (i.e., mobilization, thrust manipulation) and potential mechanisms behind the analgesic effect of these techniques (i.e., hypoalgesic, pain relieving).

The analgesic effect of joint mobilization and manipulation for the management of the most common tendinopathies

Rotator cuff tendinopathy

Evidence from a recent review of systematic reviews suggests strong recommendation for exercise therapy as a first-line treatment to improve tendon pain, mobility, and function in patients with rotator cuff tendinopathy (RCT) [21]. Conversely, moderate evidence of no effect was reported for other commonly prescribed ‘passive’ interventions, such as laser therapy, extracorporeal shock wave therapy, pulsed electromagnetic energy, and ultrasound [21]. Despite the strong evidence of no effect of ‘passive’ treatments in the management of RCT, manual therapy (applied to the shoulder girdle, cervical, and thoracic spine), in combination with exercise, is suggested to further reduce tendon pain and improve function in the short term [21].

The pain-relieving effect of these techniques as a monotherapy, compared to a placebo intervention or along with other interventions, such as exercise, electrotherapy, or education, has been evaluated in randomized controlled trials, and these studies have been scrutinized in subsequent systematic reviews (Table 1) [37–41]. Results showed that when these techniques were applied in isolation or compared to a placebo intervention, a significant analgesic effect was produced in favor of joint mobilization and manipulation [38,41]. In addition, when manual therapy techniques were used in conjunction with electrotherapy and education, a superior analgesic effect has been noticed compared to other treatment approaches [38]. The beneficial contribution of the joint mobilization and manipulation to exercise therapy for the treatment of RCT in the initial phase of the treatment and up to the very short-term follow-up has been shown by producing superior outcomes in pain intensity compared to exercise alone [21,38,41,42].

Table 1.

The efficacy of joint mobilization and manipulation in rotator cuff tendinopathy

Author and year Study design Participants Intervention Results Level of evidence
21 Systematic Review Patients with SSP MTT, exercise therapy and other interventions including passive physical modalities, exercise, taping, corticosteroids and electrotherapy. MMT in conjunction with exercise therapy can provide short-term improvement in tendon pain and function. High
38 Systematic Review Patients with RCT MTT, exercise therapy, electrotherapy and education. MTΤ can decrease pain when applied alone or in conjunction with other interventions including exercise, electrotherapy, and education but it is unclear if it can improve function. Moderate
39 Systematic Review Patients with SI MTT and exercise therapy. MTT plus exercise provides improvement in pain, disability and quality of life. Low
40 Systematic Review Patients with SI MTT, exercise therapy and other interventions including kinesio taping, acupuncture therapy, low-level laser therapy, localized injection of nonsteroidal anti-inflammatory drugs and arthroscopic subacromial decompression. MTT provides better effect on pain reduction when applied with exercise. Low
37 Systematic Review Patients with RCD Thrust manipulation, exercise therapy, electrotherapy, cryotherapy, and heat therapy. Thrust manipulation plus exercise provides improvement in pain and disability compared to sham. Low
42 Systematic Review Patients with RCD MTT and exercise therapy. MTT combined with exercise provides improvements in pain and function. Low
41 Systematic Review Patients with SI MTT, exercise therapy, corticosteroid injections, nonsteroidal anti-inflammatory drugs, extracorporeal shockwave therapy and taping. MMT plus exercise is superior to placebo or exercise alone for tendon pain and function, but only at short-term follow-up. Moderate
43 Systematic Review Patients with SI MTT, exercise therapy, ultrasound, acupuncture, corticosteroid injection, lazer, and pulsed electromagnetic field. MMT with exercise provides short to medium-term effect on tendon pain and disability. Low
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SSP, subacromial shoulder pain; MTΤ, manual therapy techniques; RCT, rotator cuff tendinopathy; SI, subacromial impingement; RCD, rotator cuff disease

The effectiveness of manual therapy as a stand-alone treatment remains controversial mainly due to methodological considerations in the published literature. The main limitations are the small scale of randomized controlled trials, with short-term follow-ups, heterogeneous samples of participants, and absence of sufficiently described ‘types’ of manual interventions [39,43,44]. As a result, findings from these low-quality studies strengthen the evidence and have limited generalizability despite their potential contribution to standard clinical practice. Nevertheless, strong evidence indicates that manual therapy may be integrated as additional therapy to exercise in the management of RCT.

Lateral elbow tendinopathy (tennis elbow)

Physical therapy interventions for lateral elbow tendinopathy (LET) have been explored in the literature, and conservative management is recommended [45–48]. Exercise therapy has been identified as the most common treatment in the management of LET [27], with limitations when applied as monotherapy [49]. Qualitative synthesis and pooled effect estimates from several systematic reviews have limited generalizability for the effectiveness of specific interventions, due to the indirect comparisons investigated in the literature [27,35,46,50]. Given that a great variety of conservative interventions are used in the standard clinical practice [35], it seems implausible to separate treatment approaches with solely ‘passive’ or ‘active’ components and make definitive conclusions about a specific conservative treatment.

Joint mobilizations and manipulation, directed at the cervical and thoracic spine or the elbow and the wrist, have been shown to be effective on both pain and function in patients with LET [35]. These techniques classified into three groups (mobilization with movement, Mill’s manipulation, and regional mobilization techniques) [35] have been evaluated alone [51,52] or combined with other interventions, including therapeutic exercise [53–55], low-level laser therapy [56], injections [57], education [58], and cold therapy (Table 2) [59]. Regarding mobilization with movement, findings revealed significant improvements in pain-free grip strength and pressure pain thresholds, over the short term compared to the placebo mobilizations, control conditions, or other treatment regimens including modalities (i.e., ultrasound) and exercise [45–47,60–62]. Concerning the Mill’s manipulation – described as small-amplitude high-velocity thrust techniques performed at the end of elbow extension, while the wrist and hand are held flexed – evidence suggests no effect in physical function capacity and conflicting results in pain [35]. Limited evidence showed that wrist manipulation (or scaphoid manipulation) provides short-term improvement in tendon pain (Table 2) [63–65]. Cervical and thoracic postero-anterior glides, lateral cervical glides, cervical traction, and cervical/thoracic spine manipulation (at the C5-C6 vertebral level and cervicothoracic junction) can produce immediate short-term hypoalgesic effects and improvements in grip strength (Table 2) [51,52,66–69]. Mobilization with movement or regional spinal and peripheral mobilizations did not provide a long-lasting effect on pain, nor did these treatments show significant between-group differences during short-term follow-up. Nevertheless, it can be argued that these techniques may be used to reduce pain before exercise rehabilitation [66], providing clinicians a window of opportunity for tendon loading exercise, which is typically otherwise associated with pain.

Table 2.

The efficacy of joint mobilization and manipulation of lateral elbow tendinopathy

Author and year Study design Participants Intervention Outcome measure Results
51 Single-blinded randomized pilot study 10 patients with LET Group A: received cervical spine manipulation.
Group B: received a sham cervical spine manipulation [manual contact].		 PPT, TPT, CPT, GSM Cervical spine manipulation produced an increase in PPT and improvement in pain-free GSM.
52 Single-blinded randomized, placebo-controlled trial 30 patients with LET Group A: received thoracic costovertebral mobilization.
Group B: received a sham ultrasound therapy.		 GSM, SC, ST An increased was noticed in pain-free grip strength and SC as well as a decrease in ST for patients in the intervention group.
53 Single-blinded randomized controlled trial 198 patients with LET Group A: received mobilization with movement, exercise.
Group B: received corticosteroid injections.
Group C: Wait and see group, encouraged to wait.		 GIS, GSM, VAS, PFFS Patients of the intervention group showed superior outcomes in terms of pain and pain free grip strength compared to injection group and wait and see group.
54 Single-blinded randomized controlled trial 165 patients with LET Group A: received corticosteroid injection combined with mobilization with movement and exercises.
Group B: received placebo corticosteroid injection combined with mobilization with movement and exercises.
Group C: received only corticosteroid injections.
Group D: received placebo corticosteroid injections.		 Likert scale, global rating of change scores, VAS, PRTEES The use of corticosteroid injection vs placebo injection resulted in worse outcomes after 1 year, and physiotherapy did not result in any significant differences.
55 Single-blinded randomized pilot trial 20 patients with LET Group A: received exercises.
Group B: received deep transverse friction massage and Mill’s manipulation.		 VAS, TEFS Patients of both groups demonstrated reduction in pain and improvement in functional status. However, the improvement was greater in the exercise group.
56 Non-randomized clinical trial 60 patients with LET Group A: received exercises and low- level laser therapy.
Group B: received deep transverse friction massage, Mill’s manipulation and low- level laser therapy.		 VAS, GSM, PRTEES Patients of both groups demonstrated an equal improvement in pain, pain free grip strength and function.
57 Single-blinded randomized controlled trial 177 patients with LET Group A: received deep transverse friction massage, Mills manipulation exercises and corticosteroid injections.
Group B: received deep transverse friction massage, Mills manipulation exercises and placebo corticosteroid injections.
Group C: Wait and see group, encouraged to wait.		 Likert scale, VAS, GSM, PFFI Corticosteroid injections combined with deep transverse friction massage, Mills manipulation and exercises provide short-term improvements.
58 Single blind randomized controlled trial 120 patients with LET Group A: received prolotherapy injections.
Group B: received education, manual therapy techniques and exercise.
Group C: received prolotherapy injections combined with education, manual therapy techniques and exercise.		 PRTEES, Likert scale, NPRS, GSM Improvements were noticed compared with baseline status for all outcomes and groups.
59 Single blind randomized controlled trial 40 patients with LET Group A: received mobilization with movement, exercise, and cold therapy.
Group B: received exercise and cold therapy.		 VAS, PRTEES, GSM Patients of the group who received mobilization with movement, exercise and cold therapy demonstrated greater improvement in pain, pain free grip strength and function compared to the other group.
63 Non-randomized clinical trial 30 patients with LET Group A: received deep transverse friction, Mill’s manipulation and pulsed ultrasonic therapy
Group B: received manipulation of wrist in addition to pulsed ultrasonic therapy.		 NPRS, GSM Patients of the wrist manipulation group exhibited more significant improvements in pain and grip strength compared to the other group.
64 Randomized controlled trial 30 patients with LET Group A: received pulsed ultrasonic therapy, exercises, and mobilization with movement.
Group B: received pulsed ultrasonic therapy, exercises and wrist manipulation.
Group C: received pulsed ultrasonic therapy and exercises.		 VAS, TEFS, hand strength Improvement in strength, functional performance and pain was detected in wrist manipulation and mobilization with movement, respectively.
65 Randomized pilot study 31 patients with LET Group A: received manipulation of the wrist.
Group B: received ultrasound, friction massage, and exercises.		 GIS, NPRS, GSM, PPT Manipulation of the wrist appeared to be more effective than ultrasound, friction massage, and exercises over the short term.
66 Single-blinded randomized pilot study 10 patients with LET Group A: received exercises and joint mobilization directed at the elbow and wrist joints.
Group B: received exercises and joint mobilization directed at the elbow and wrist joints combined with cervical mobilization.		 NPRS, GSM, DASH Greater improvement in all outcome measures was noticed in the group received cervical mobilization.
67 Single-blinded randomized pilot study 18 patients with LET Group A: received cervical spine manipulation.
Group B: received thoracic spine manipulation.		 PPT, GSM Cervical spine manipulation produced greater hypoalgesic effect than thoracic spine manipulation.
68 Double-blinded randomized pilot study 15 patients with LET Group A: received cervical spine mobilization.
Group B: received sham cervical spine manipulation.
Group C: Control group.		 PPT, GSM, ULTT, VAS Cervical spine mobilization provoked hypoalgesic effect, improvement in grip strength, neurodynamics and pain scores.
69 Double-blinded randomized study 24 patients with LET Group A: received mobilization with movement directed at the elbow joint.
Group B: received manual contact over the elbow joint without any movement (placebo group].
Group C: involved no manual contact between the therapist and the subject [control group).		 PPT, GSM Mobilization with movement appeared to provide improvement in pressure pain threshold and grip strength.
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LET, lateral elbow tendinopathy; PPT, pressure pain threshold; TPT, thermal pain threshold; CPT, cold pressure threshold; GSM, grip strength measurement; SC, skin conductance; ST, skin temperature; GIS, global improvement scale; VAS, visual analogue scale; PFFS, pain-free function scale; PRTEES, patient-rated tennis elbow evaluation score; TEFS, tennis elbow function scale; PFFI, pain-free function index; NPRS, numeric pain rating scale; DASH, disability of the arm, shoulder, and hand questionnaire; ULTT, upper limb tension test

Other tendinopathies

Research on the effectiveness of joint mobilization and manipulation in other upper or lower limb tendinopathies is sparse, mainly comprising retrospective case-series and case studies (Table 3).

Table 3.

The efficacy of joint mobilization and manipulation in other tendinopathies

Author and year Study design Participants Intervention Outcome measure Results
73 Case study 1 patient with medial elbow tendinopathy Scaphoid mobilization and radio-ulnar mobilization, combined with friction massage, ischemic compression of trigger points around the medial epicondyle area, eccentric exercises and ice. Not reported At a one-year follow up, the patient reported complete resolution of symptoms with no recurrence.
74 Case study 1 patient with medial elbow tendinopathy Carpal and radio-ulnar mobilization and manipulation, combined with myofascial release, stretching, forearm muscle strengthening, electrical stimulation and ice. NPRS, wrist flexor strength At the end of treatment protocol [including 7 treatment visits], the patient showed significant improvement in pain and flexor strength and therefore she could perform activities of daily living with little discomfort.
]75 Case study 1 patient with de Quervain’s disease Mobilization with movement and conventional joint mobilization techniques applied to the first carpometacarpal, radiocarpal, and midcarpal joints along with superficial heat, ice, iontophoresis, active range-of-motion exercises and transverse friction massage directed to the first dorsal tunnel. Universal goniometer, NPRS Over the course of 2 months, the patients presented improvement for all motions of the wrist and first carpometacarpal joint as well pain reduction.
  Case series 4 patients with de Quervain’s disease Mobilization with movement of the first carpometacarpal joint combined with eccentric muscle training, and high-voltage electrical stimulation. NPRS, DASH At 6-month follow-up, all patients reported minimal pain and disability.
77 Case series 3 patients with de Quervain’s disease Several techniques including carpometacarpal thrust and non-thrust manipulation, end range radiocarpal mobilization and mobilization with movement of the first carpometacarpal joint were applied combined with strengthening exercises, and grip proprioception training. NPRS, DASH, GSM At 6-month follow-up, all patients reported minimal pain and disability and improvement in GS.
Jayaseelan et al., 83 Case series Three patients with Achilles tendinopathy Joint mobilization, manipulation and mobilization with movement were applied to the foot and ankle joint in addition to eccentric loading exercises and calf stretching. NPRS, VISA-A, PPT, GROC Immediate improvements in pain and function were detected. These improvements were maintained at a nine-month e-mail follow up.
34 Case series Three patients with Achilles tendinopathy Joint mobilization and manipulation were applied to the foot and ankle joint along with hip mobilization. VISA-A, FAAM, GROC Improvements in pain and function were detected maintained at one-year follow-up.
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NPRS, numerical pain rating scale; DASH, disabilities of the arm, shoulder and hand questionnaire; GSM, grip strength measurement; VISA-A, Victorian institute for sport assessment questionnaire; PPT, pressure pain thresholds; GROC, global rating of change scale; FAAM, foot and ankle measure

To our knowledge, no RCTs are available with regards to treatment approaches that can reduce pain in patients with medial elbow tendinopathy (MET) [47,70–72]. Two case studies have reported the analgesic effect of joint mobilization, which is applied as an adjunct treatment with other conservative interventions in MET [73,74]. Two different manual therapy techniques were implemented in the case-reports (scaphoid mobilization and radio-ulnar mobilization), and both patients received a number of soft tissue techniques and modalities, as well as a home exercise program [73,74].

Similarly, a paucity of quality studies examining the efficacy of conservative treatments including mobilizations and manipulations exists for de Quervain’s disease. Two case-series and one case-report have been published [75–77], utilizing mobilizations with movement, or mobilization with movement in conjunction with joint mobilization and manipulation as a component of a multimodal treatment plan (Table 3). Manual therapy techniques combined with exercise, modalities, and proprioceptive training have been used in patients suffering from de Quervain’s disease.

Lower limb joint mobilizations and manipulation have been explored in some musculoskeletal conditions of the lower limb, such as patellofemoral pain syndrome, hip and knee osteoarthritis, but studies in tendinopathies are scarce [78–82]. Only two case reports have been conducted aiming to evaluate the efficacy of joint mobilization and manipulation in Achilles tendinopathy (Table 3) [34,83]. The main finding of both studies was that the subtalar and talocrural joint mobilization and manipulation can improve pain and increase the range of movement in the involved joints at the short term [34,83]. The combination of interventions along with the study design prevents firm conclusions and clinical implications regarding mobilizations in MET, de Quervain’s disease, and lower limb tendinopathies. This preliminary evidence suggests that manual therapy may be a potential contributor in the management of tendinopathy, as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

Clinical rationale for the application of joint mobilization and manipulation in tendinopathy

Recognition of potential mechanisms related to the development of tendon pain

Tendon pain remains enigma [4,7,84]. Histopathological examination of surgical specimens from patients with tendon pain showed several degenerative changes, including cellular hyperactivity and increase in cell numbers, increase in ground substance, collagen disorganization, and neovascularisation [8,12,85,86]. It has been argued that tendon pain may result from inflammation or collagen disorganization [86]. However, literature remains unclear regarding inflammation’s role in the pathogenesis of tendinopathy as most of histopathological studies have concluded that there is an absence of sufficient inflammatory cells in the presence of tendinopathy [13,87]. Tendon pain is often provoked when the affected tendon is loaded, although many studies have shown that painless tendons can also be degenerate in appearance, questioning the role of collagen disorganization in tendinopathy [14,84,88].

The role of vasculo-neural ingrowth in tendinopathy has been controversial and is still poorly understood [8,85,89]. The blood supply in the normal tendon is poor. However, in tendinopathy, the new blood vessels provide less oxygen and nutrients to tendon tissues, producing hypoxia [6,90]. This has been termed a ‘vascular pathogenesis’ where the presence of restricted blood flow is associated with stronger tendon pain, discomfort and physical limitations [91]. Specifically, microdialysis research revealed high levels of lactate within the tendinopathy lesions combined with necrotic tenocytes, blocked arteries, and anaerobic enzymes [85,92,93]. These findings within tendinopathy have lent further support to the role of hypoxia in tendon pain production.

While some studies relate tendon pain with the proposed hypoxia-induced pathogenesis, others argue that the mechanism of tendon pain is related to peripheral and central mechanisms of nociception modulation suggesting pain system changes [94]. Studies have shown high concentrations of neurotransmitter glutamate in patients with painful tendinopathies [15] producing biochemical stimulation of the nociceptors and changes in the pain/nociceptive system [6,95]. This neurogenic inflammation [94] mediated via the increased and sustained concentrations of neuropeptides including glutamate and substance P produces a reduction in pressure pain thresholds, mechanical hyperalgesia, and nervous system sensitization [18,96,97]. This altered central pain processing has been hypothetically related to persistent tendon pain and motor system impairments, including diminished strength and altered motor control in tendinopathy [45,98,99].

Descending inhibitory pain mechanism and sympathetic excitation effects may play an important role in tendon pain reduction

Animal and human studies have shown that joint manual therapy techniques have a profound influence on nociceptive stimulus via the possible excitation of the descending inhibitory pain mechanism [31,100,101]. Despite that the underlying mechanism for tendon pain relief remains poorly understood [33]. The former can plausibly explain the mobilization and manipulation induced pain reduction in tendinopathy when these techniques were applied on a joint proximal to the injured joint and affected tendon [38,62,69,102,103].

It seems that the application of mobilization and manipulation techniques on peripheral and spinal joints activates the periaqueductal gray region area of the midbrain, stimulates the noradrenergic descending system, and at the level of the spinal cord, the nociceptive afferent barrage is reduced and mechanical hypoalgesia is induced along with a period of sympathetic excitation [31,104,105]. The sustained increased concentrations of neuropeptides including glutamate and substance P within the tendinopathy lesions stimulate the tendon nociceptors and produce tendon pain [18,96]. These noxious stimuli are initially transferred to the dorsal horn of the spinal cord and then to the cerebral cortex of the brain, resulting in the perception of tendon pain. Literature on upper limb tendinopathies revealed that the cervical and thoracic spine mobilization and manipulation were related to tendon pain and strength improvements; an effect that was evident through increased pressure pain thresholds, decreased patient-rated pain intensity, and increased pain-free grip strength following application [52,69,100,106]. The effectiveness of these manual therapy techniques could be explained through a mechanism that inhibits the nociceptive afferent barrage at the level of the spinal cord and produces analgesic effect on tendon pain through the activation of the descending inhibitory pain pathways [31]. The literature also supports that the sympathetic excitation could also play an important role in the reduction of tendon pain. Studies have shown that spinal or peripheral mobilization and manipulation produce an immediate and short-term activation of the sympathetic nervous system [107,108]. This sympathetic excitatory response to mobilizations and manipulation is related to increased vasodilation and improvements in blood circulation in the upper and lower limbs [109–111]. Therefore, the produced vasodilation, combined with an increase in oxygenation in the area of tendinopathy, could improve the restricted blood flow and hypoxia within the tendinopathy lesions and potentially reduce tendon pain.

Implications for research and practice

Findings of the current literature support that joint mobilization and manipulation applied alone or in combination with other conservative active or ‘passive’ interventions may be effective in reducing tendon pain in RCT and LET [35,38,41,46]. However, these findings are based on small randomized controlled trials with several methodological limitations, including short-term follow-ups, small sample size, and heterogeneous sample configuration [43,51,52]. In addition, literature on other tendinopathies is very limited regarding the identification of the techniques that can reduce tendon pain. Based on these limitations, future randomized controlled studies using larger sample sizes are required to further enhance our knowledge on the analgesic effect of joint mobilization and manipulation in tendinopathy.

Tendon pain is often related to limited joint motion, and this diminishes muscle strength and motor control, producing impairments in physical performance, loss of function, and reduced quality of life [1,112]. Based on the kinetic chain principles that the upper and lower limb are systems of linked segments working together to perform daily activities, the produced muscle weakness may contribute to a generalized muscle weakness in the affected limb and consequently reduce the strength of functional/daily activities [88]. Evidence on this topic suggests that RCT may produce scapular muscle imbalance, loss of control of normal resting scapular position, and dynamic scapular motion leading to scapular protraction [113,114]. In addition, the rotator cuff strength and grip strength are adversely affected by LET and MET since wrist movements are painful and weak [115–117]. Recent studies have also detected weakness and reduced endurance of scapular muscles in patients with LET [118,119]. In patellar and Achilles tendinopathy, evidence suggests that dysfunction in lumbopelvic control may lead to alterations in the load distribution within the lower limb kinetic chain [9,88,120,121].

Tendon pain reduction following joint mobilization and manipulation has been found in several studies, suggesting that these techniques could be considered as an analgesic modality in tendinopathy rehabilitation. This tendon pain reduction could facilitate pain-free movements or activities which were otherwise painfully limited. Through the analgesic effect of manual therapy techniques, a window of opportunity can be provided to clinicians to manage patients’ altered proprioceptive input and movement patterns in order to restore impaired physical performance and disability [31]. Based on this notion, joint mobilization and manipulation can be applied combined with a progressive loading exercise program of the extremity (kinetic chain) to normalize the upper and lower limb kinetic chain.

Conclusion

There is limited evidence for the role of joint mobilization and manipulation in the management of tendinopathy. Studies on RCT and LET recommend these techniques, applied alone or along with other interventions, for the tendon pain reduction, although in other tendinopathies randomized controlled trials are required as existing study designs limit the generalization of findings. Literature on other tendinopathies such as medial elbow tendinopathy, de Quervain’s disease, and Achilles tendinopathy is also very limited since the analgesic effect of these techniques has been sparsely identified in a few retrospective case-series and case studies. Despite these limitations, joint mobilization and manipulation may potentially contribute to the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

Acknowledgments

Open Access funding provided by the Qatar National Library.

None declared

Biographies

Dr. Christos Savva is an Assistant Professor in Musculoskeletal Physiotherapy at the Department of Health Sciences of the European University Cyprus. He studied physiotherapy (2004–2008) at the Technological Educational Institute of Athens and continued with an MSc in Manipulative Physiotherapy (2009–2011) at the University of Birmingham. In 2014, he completed his PhD in the area of Neural Mobilization. Dr. Savva’ areas of interest include tendinopathies and neural mobilization

Dr. Christos Karagiannis is a Lecturer in Physiotherapy at the Department of Health Sciences of the European University Cyprus. He studied physiotherapy (2004–2008) at the Technological Educational Institute of Athens and continued with an MSc in Cardiopulmonary Resuscitation (2009–2011) at the Medical School of the National and Kapodistrian University of Athens. In 2020, he completed his PhD in the area of respiratory physiotherapy. Dr. Karagiannis’ areas of interest include cardiac rehabilitation, pulmonary rehabilitation, evaluation of musculoskeletal dysfunctions, and treatment of musculoskeletal dysfunctions.

Vasileios Korakakis is a specialist spine and sports physiotherapist working as Clinical Leader at Aspetar Sports Medicine Hospital. He has worked as a physiotherapist in elite football teams and has several years of experience in spinal and orthopedic rehabilitation. He is a senior lecturer in Orthopaedic Manipulative Therapy in IFOMPT certified programmes, has a diploma in Mechanical Diagnosis and Therapy from the University of Otago (NZ). After gaining his MSc in Health and Exercise from the University of Thessaly in 2012, he continued to gain his PhD in biomechanics (2020). He has published more than 50 original publications and book chapters. His recent research interest is focused on blood flow restriction training, tendinopathies, spinal biomechanics, sports rehabilitation, systematic reviews, and clinimetrics.

Michalis Efstathiou holds a bachelor degree in Physiotherapy form the Technological Educational Institute (TEI) of Athens where he graduated in 2008. Two years after he completed his Master’s Degree (MSc) in Advancing Practice – Specialist in Manual Therapy at the University of Birmingham in the UK. Currently he is a PhD candidate in Neuromusculoskeletal Physiotherapy at the University of Nicosia. He has published studies in per reviewed journals and has given oral presentations at scientific conferences concerning musculoskeletal physiotherapy disorders. Michalis has worked as a musculoskeletal physiotherapist at private physiotherapy clinics in Greece, UK and Cyprus. Since 2013 he holds the title ″Associate Lecturer″ of Physiotherapy and teaches musculoskeletal courses for the Physiotherapy programme of the University of Nicosia.

Sources of funding

None declared

Disclosure statement

All authors declare that there is not any interest or relationship, financial or otherwise that might be perceived as influencing an author’s objectivity is considered a potential source of conflict of interest.

Data availability statement:

None declared

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Data Availability Statement

None declared

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