Adding Neural Mobilization to Mulligan Technique for Treatment of Patients with Chronic Tennis Elbow

The study aimed to assess the combined effect of neural mobilization and mulligan technique on pain ,functional disability and grip strength in patients with tennis elbow

Tennis elbow, known as lateral epicondylitis (LE) describes an overuse injury secondary to an eccentric overload of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon. Tennis elbow primarily results from the repetitive strain caused by activities that involve loaded and repeated gripping and/or wrist extension. It is common in individuals who play tennis, squash, badminton, or any activity involving repetitive wrist extension, radial deviation, and/or forearm supination.

Patients with tennis elbow usually report pain or tenderness at the lateral epicondyle of the humerus, decreased gripping strength, and weakness when turning their palms up and straightening their wrists. Pain and inflammation of make it difficult to move the elbow joint through its full range of motion because of the pain and affect function of joint (ECRB)

Radial nerve mobilization exercises, has been used to treat musculoskeletal problems, including LE. Nerve mobilization or neurodynamic mobilization, defined by David Butler, is aimed at restoring homeostasis in and around the nervous system through facilitating movement between neural structures and their surroundings. It is stated that neural shifting reduces adhesions between the nerve and surrounding tissue, improves neural vascularity, and improves the axoplasmic flow Mulligan mobilization with movement (MWM) is a form of manual therapy that includes a sustained lateral glide to the elbow joint with concurrent physiological movement. This mobilization technique is often used to correct the faulty position of the elbow joint. It is the primary modality for the correction of positional fault of the elbow joint complex mimicking a contractile element pathology of the common extensor bundle." Which result in reducing pain, improvement of pain-free grip strength (PFGS), and increased ability to tolerate resisted isometric wrist extension

Eligibility Criteria:
Inclusion Criteria:

* Patient aged 20-60 years old

  * . Diagnosed with chronic tennis elbow
  * experienced discomfort in their dominant arm, tenderness over the lateral epicondyle of the elbow joint, and exhibited signs and symptoms of tennis elbow persisting for three months
  * Increased pain with resistant elbow extension, wrist extension, gripping, and supination
  * ULTT 2 b (radial nerve) should be positive ) pain referral throughout the dorsal and radial aspect of the forearm and, sometimes, an "electrical shock-like" pain on the radial side of the right wrist (

Exclusion Criteria:

* patients who had a history of or were suffering from psychogenic stress

  * acute strain, fractures of the humerus, radius, and ulna,
  * History of Rheumatoid diseases
  * Subjects on steroids or any other medications for pain at present were excluded
  * severe edema, infection
  * malignancy
  * osteoporosis
  * unstable joints
  * severe neck or shoulder pain, neurological conditions \\ impacting the upper extremity Cervical radiculopathy
  * Bilateral Symptoms of Tennis elbow