Blood Flow Restriction Training Versus Mulligan Technique in Treatment of Lateral Epicondylitis

Lateral epicondylitis (LE) is a work-related musculoskeletal disorder caused by the tendon's inflammation of either one or both of the extensor carpi radialis longus and extensor carpi radialis brevis. It is often referred to tennis elbow. It manifests as pain on the lateral side of the elbow and reduced range of motion, which results in weakening and impairment in the forearm muscles (Ahmad et al., 2013).With no sex predisposition, LE is a widespread ailment that affects up to 3% of the population (Vaquero-Picado et al., 2017). Etiological factors of LE include overuse, repetitive movements, physically forceful occupational activities, exercise errors, misalignments, flexibility problems, ageing, muscle imbalances and psychological (e.g. job strain) factors. The estimated incidence of LE ranges from 2.0-11.3 per 100 worker-years in specific activity sectors (Herquelot et al., 2013; Bongers et al., 2002).

• blood flow restriction (Device): The physical therapist will apply the occlusive cuff on the upper arm (brachium) with a pressure of 0.5 times of patient's systolic blood pressure. The physiotherapist will use the BFR cuffs from SAGA
• Mulligan's with mobilization (Other): First, the pain-free angle of application will be determined for each patient. The lateral condyle of the humerus will be fixed by the first bar space of the physiotherapist. The elbow joint will be glided until no pain will be felt in the elbow joint and the hand will be in the contracted position.
• Exercise (Other): Eccentric training for the extensor carpi radialis brevis muscle, the most affected wrist extensor tendon, and static stretching exercises for the extensor carpi radialis brevis muscle will be provided as a home exercise program.

Primary outcomes

• Grip strength [4 weeks]: The patients' maximal grip strength will be measured with a hand dynamometer dynamometer.
• Pain intensity [4 weeks]: Measured using an 11-point numeric rating scale.
• Elbow pain and intensity [4 weeks]: Measures pain and disability by Patient-Rated Elbow Evaluation （PREE） Score (0-100 scale, with 100 = worst pain \& disability).

Sex: All, ages: 18 Years to 50 Years

Inclusion Criteria:

1\) 36 subjects of both gender aged between 18 and 50 years with a positive test of LE (Positive Cozen's, Maudsley's, and/or Mill's test), which has been determined based on physical therapy assessment procedures; 2) the presence of pain in the lateral epicondyle of the humeral bone; and 3) show decreased muscle strength and functional ability.

Exclusion Criteria:

While the exclusion criteria of this study will be 1) refusal to be a sample in this study; 2) presences of bilateral symptoms; 3) presences of sensory and motor impairment of the upper extremities; 4) samples with systemic disease and metabolic disorders; 5) history of trauma and surgery on the elbow; 6) having a history of malignancy and peripheral vascular disorders.

• Study Protocol, Statistical Analysis Plan, and Informed Consent Form (PDF, 2025-09-02)

• Prof.Dr.Nasr A Abdelkader, professor, Principal investigator, Cairo Univesity