Comparison of Mulligan’s MWM and Ultrasound Therapy

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 SETTING

The study was conducted at Department of Physiotherapy, PSG Hospitals Coimbatore, an 810 bed multispecialty hospital with fully equipped physiotherapy department.

3.3 POPULATION AND SAMPLING

Subjects referred from the Department of Orthopedics with lateral epicondylitis were chosen as population and total of 30 participants were randomly assigned into two groups.

3.4 CRITERIA FOR SAMPLE SELECTION

3.4.1 INCLUSION CRITERIA

Age group 30- 60 yrs (Both male and female).

History of localized pain and tenderness at anterior inferior aspect of lateral epicondyle aggravated by gripping and wrist extension activities and relieved by rest with the diagnosis of lateral epicondylitis.

Positive Mill’s test /Cozen’s test.

Full elbow ROM.

3.4.2. EXCLUSION CRITERIA

History of local steroid infiltration in the last 6 months .

Analgesics in preceding six hours to the treatment.

Cervical spine pain or neurological involvement.

Osteoporosis

Past history of fractures around the elbow joint.

Rheumatoid arthritis.

Malignancies.

STUDY DURATION:

6 months.

TREATMENT DURATION:

Group A: Ultrasound therapy + MWM (20mins/session, total 10 sessions within 3 weeks)

Group B: Ultrasound therapy (10 mins/session,3 sessions/week, total 10 sessions within 3 weeks)

3.5 INSTRUMENT & TOOL FOR DATA COLLECTION

Visual Analogue Scale – for pain intensity.

Hand held Dynamometer – for pain free grip strength.

Patient Rated Tennis Elbow Questionnaire.

3.6 TECHNIQUE OF DATA COLLECTION

Participants were selected randomly and assigned to Group A and Group B. Group A will be receiving Ultrasound therapy alone. Group B will be given Ultrasound therapy along with Mulligan’s MWM. Base line values and the values after the treatment intervention i.e after 3 weeks are taken for analysis. The pre test and post test values will be taken for interpretation of pain by VAS, grip strength by HHD and functional ability of the participants by PRTEQ.

TECHNIQUES OF DATA ANALYSIS AND INERPRETATION

Data collected from both group subjects were analyzed using paired ‘t’ test to measure the changes between the pre and post test values within the group and Independent ‘t’ test to measure the changes between the groups.

Paired‘t’ test:

tet

d = Calculated Mean Difference of pre test & post test values

SD = Standard Deviation

N = Number of samples

d = Difference between pre test & post test values

Independent‘t’ test:

Where,

X1 = Mean difference in Group A

X2 = Mean difference in Group B

SD = Combined standard deviation of Group A and Group B

n1 = Number of patients in Group A

n2 = Number of patients in Group B

SD1 = Standard Deviation of Group A

SD2 = Standard Deviation of Group B

CHAPTER –IV

DATA ANALYSIS AND INTERPRETATION

Data analysis is the systemic organization and synthesis of research data and testing of research hypothesis using these data. Interpretation is the process of making sense of the results of a study and examining the implication (Polit & Belt, 2004). Interpretation means examining the results from data analysis forming conclusion, exploring the significance of the findings and suggesting further studies.

The pretest and posttest values for both Group A & Group B were obtained before and after Mulligan’s MWM alongwith Ultrasound therapy & Ultrasound therapy only. The improvement in pain, grip strength and functional outcome was assessed using Visual Analogue Scale, Hand held Dynamometer and Patient Rated Tennis Elbow Questionairre.

The mean, standard deviation and Paired “t” test values were used to find out whether there was any significant difference between pretest and posttest values within the groups. The Independent “t” test was used for finding out the significant difference between the groups.

TABLE I

PRE TEST & POST TEST VALUES OF PAIN IN GROUP A (MULLIGAN’S MWM WITH ULTRASOUND)

S. No.

PRE TEST

POST TEST

1

9

5

2

8

5

3

7

3

4

8

4

5

6

3

6

5

1

7

5

2

8

9

5

9

7

3

10

8

4

11

9

4

12

10

6

13

7

2

14

6

2

15

8

5

TABLE II

PRE TEST & POST TEST VALUES OF PAIN IN GROUP B (ULTRASOUND)

S. No.

PRE TEST

POST TEST

1

6

3

2

7

4

3

8

5

4

6

3

5

8

5

6

5

2

7

4

2

8

9

5

9

7

4

10

8

5

11

5

1

12

9

5

13

7

3

14

4

1

15

8

5

TABLE III

PRE TEST & POST TEST VALUES OF GRIP STRENGTH IN

GROUP A (MULLIGAN’S MWM WITH ULTRASOUND)

S. No.

PRE TEST

POST TEST

1

12

17

2

19

25

3

18

23

4

13

19

5

14

19

6

14

17

7

16

19

8

18

20

9

16

20

10

15

18

11

16

18

12

17

18

13

15

17

14

13

14

15

20

22

TABLE IV

PRE TEST & POST TEST VALUES OF GRIP STRENGTH IN

GROUP B (ULTRASOUND)

S. No.

PRE TEST

POST TEST

1

12

14

2

19

20

3

18

15

4

13

17

5

14

18

6

16

19

7

16

18

8

18

17

9

16

17

10

15

14

11

16

20

12

17

18

13

15

17

14

13

18

15

20

21

TABLE V

PRE TEST & POST TEST VALUES OF FUNCTIONAL OUTCOME IN GROUP A (MULLIGAN’S MWM WITH ULTRASOUND)

S. No.

PRE TEST

POST TEST

1

49

40

2

54

49

3

68

60

4

49

40

5

35

18

6

57

50

7

39

30

8

41

34

9

35

15

10

68

61

11

52

45

12

36

16

13

46

39

14

44

35

15

38

29

TABLE VI

PRE TEST & POST TEST VALUES OF FUNCTIONAL OUTCOME IN GROUP B (ULTRASOUND)

S. No.

PRE TEST

POST TEST

1

49

43

2

54

52

3

64

61

4

49

46

5

35

20

6

57

53

7

39

33

8

41

36

9

35

21

10

68

66

11

52

49

12

36

22

13

46

44

14

44

41

15

38

34

TABLE –VII

PAIRED‘t’ TEST, MEAN, MEAN DIFFERENCE, STANDARD DEVIATION OF PAIN IN GROUP A & B

GROUPS

MEAN

MEAN DIFFERENCE

SD

t VALUE

p VALUE

GROUP A

PRE TEST

POST TEST

7.46

3.6

3.87

0.64

23.412

<0.001

GROUP B

PRE TEST

POST TEST

6.73

3.53

3.20

0.56

22.125

<0.001

GRAPH I

MEAN DIFFERENCE OF PAIN IN GROUP A & B

TABLE –VIII

PAIRED ‘t’ TEST, MEAN, MEAN DIFFERENCE, STANDARD DEVIATION OF GRIP STRENGTH IN GROUP A & B

GROUPS

MEAN

MEAN DIFFERENCE

SD

t VALUE

p VALUE

GROUP A

PRE TEST

POST TEST

15.733

19.066

3.33

1.72

7.495

<0.001

GROUP B

PRE TEST

POST TEST

15.866

17.533

1.67

0.72

8.889

<0.001

GRAPH II

MEAN DIFFERENCE OF GRIP STRENGTH IN GROUP A & B

TABLE –IX

PAIRED‘t’ TEST, MEAN, MEAN DIFFERENCE, STANDARD DEVIATION OF FUNCTIONAL OUTCOME IN GROUP A & B

GROUPS

MEAN

MEAN DIFFERENCE

SD

t VALUE

p VALUE

GROUP A

PRE TEST

POST TEST

47.4

37.4

10

4.84

8

<0.001

GROUP B

PRE TEST

POST TEST

47.13

41.40

5.73

4.64

4.781

<0.001

GRAPH III

MEAN DIFFERENCE OF FUNCTIONAL OUTCOME IN GROUP A & B

TABLE –X

INDEPENDENT‘t’ VALUE, STANDARD DEVIATION OF PAIN, GRIP STRENGTH AND FUNCTIONAL OUTCOME IN GROUP A & B

GROUPS

MEAN DIFFERENCE

SD

‘t’ value

‘p’ value

VAS

0.67

0.64

3.034

<0.01

GRIP

STRENGTH

1.67

1.31

3.462

<0.01

PRTEQ

4.27

4.74

2.465

<0.05

CHAPTER – V

RESULTS AND DISCUSSION

The purpose of this study was to compare the effectiveness of Mulligan’s MWM along with Ultrasound therapy versus Ultrasound therapy alone in pain reduction, increase in grip strength and function in patients with lateral epicondylitis. The outcome measures used were VAS, HHD and PRTEQ.

Among 30 patients, female and male ranging from 30-60 years were selected. .Pre test value was taken prior to the intervention, treatment was given for 3 weeks (3 session / week). A repeat assessment was taken after the intervention. The data was analyzed by using paired t test to measure the changes within the group and & independent t test to measure the changes between the groups.

On analyzing the data within the groups, mean difference in group A for pain, grip strength and function were 3.87, 3.33 and 10 respectively. Whereas, the mean difference in group B for pain, grip strength and function were 3.20, 1.67 and 5.73 respectively. This shows that there was significant difference within the groups for pain, grip strength and function at p<0.001. On analyzing the data between the groups for pain, grip strength and function, the mean differences were 0.67, 1.67 and 4.27 respectively and the t value for pain grip strength were 3.034 and 3.462 resp. which is greater than the table value. This shows that there is significant improvement in pain reduction and increase in grip strength at p<0.01 whereas, t value for functional outcome was 2.465 which is greater than the t value and hence shows that there is significant improvement in functional outcome at p<0.05.

The results showed that there was a significant effect of Mulligan’s MWM alongwith Ultrasound therapy in Lateral epicondylitis than in Ultrasound therapy alone for VAS, HHD and PRTEQ as the calculated t value is greater than the table value. All subject in group A showed a significant improvement in pain reduction, increase in grip strength and function.

Correlating the study results with the literature stated by Moneet Kochar and Ankit Dongra, Vicenzino et al, it is clear that Mulligan’s MWM alongwith Ultrasound therapy is more effective than only Ultrasound therapy. VAS, HHD and PRTEQ have been widely used as diagnostic tools in lateral epicondylitis. In the present study, Group A showed significant improvement in pain reduction, increase in grip strength and functional outcome eventhough there are several studies which suggest that Ultrasound therapy does enhance recovery in lateral epicondylitis (Binder et al).

According to Mulligan’s hypothesis, lateral epicondylitis pain will usually disappear when treated with appropriate elbow joint mobilizations. The reason given to confirm his hypothesis is that MWM is nearly at right angles to the plane of movement and will work in only one direction. Further he suggested that, minor positional faults occur following injury or strain resulting in movement restrictions or pain. But when correctional mobilization is sustained, pain free function is restored and several repetitions bring about lasting improvements (Vicenzino et al)

LIMITATIONS

Number of participants

Only short term effects was being evaluated.

No follow up

5.1 SUGGESTIONS

Future studies needs to be conducted to examine whether these benefits are maintained at a long term follow up.

CHAPTER – VI

CONCLUSION

The study primarily tried to analyze the effects of Mulligan’s MWM techniques in pain reduction, improvement in grip strength and functional outcome in individuals with lateral epicondylitis.

With reference to the statistical analysis and interpretation done for the data collected by VAS, HHD and PRTEQ, this study recommends that Mulligan’s MWM alongwith Ultrasound therapy has significant effect in patient with Lateral epicondylitis than in Ultrasound therapy alone in reducing pain , increasing grip strength and functional outcome. Hence, this study recommends that addition of mulligan’s MWM to a regimen comprising of Ultrasound therapy alone, enhances faster recovery in patients with lateral epicondylitis.

Mulligan’s MWM alongwith Ultrasound therapy has statistically significant improvement in pain, grip strength and functional outcome in patients with lateral epicondylitis.