The Combined Effect of Mulligan Technique and Scapular Mobilization in Shoulder Adhesive Capsulitis

The Combined Effect of Mulligan Technique and Scapular Mobilization in Shoulder Adhesive Capsulitis

The shoulder joint capsule is a fibrous sheath that encloses and stabilizes the structures of the shoulder joint, extending from the anatomical neck of the humerus to the rim of the glenoid fossa. It is normally lax, allowing a wide range of motion. Shoulder adhesive capsulitis, or frozen shoulder, is a common musculoskeletal condition characterized by pain and restricted movement due to thickening and contraction of this capsule. Proper coordination between the scapula and humerus-known as the scapulohumeral rhythm-is essential for normal shoulder motion. Disruption of this rhythm contributes to movement limitation and pain in adhesive capsulitis.

This randomized, single-blind clinical trial aims to investigate the combined effect of the Mulligan technique and scapular mobilization on improving shoulder range of motion, pain, disability, and scapulohumeral rhythm in patients with adhesive capsulitis. Thirty-eight participants aged 30 to 60 years, diagnosed with unilateral adhesive capsulitis, will be randomly assigned to two groups. Group A will receive Mulligan mobilization techniques for shoulder elevation, internal and external rotation, along with scapular mobilization. Group B will receive conventional physical therapy consisting of hot packs, ultrasound, stretching, and range-of-motion exercises. Both groups will undergo treatment three times per week for four weeks.

Primary outcomes include changes in shoulder range of motion (measured using a digital goniometer), pain and disability (measured by the Shoulder Pain and Disability Index [SPADI]), and scapulohumeral rhythm (assessed using tape measurement). The study is expected to provide clinical evidence on whether combining Mulligan and scapular mobilization techniques yields superior functional recovery compared with conventional physiotherapy alone in patients with shoulder adhesive capsulitis.

The shoulder joint capsule is a fibrous structure that surrounds the shoulder joint and connects the anatomical neck of the humerus to the rim of the glenoid fossa. It provides stability to the joint while allowing extensive mobility. In adhesive capsulitis, also known as frozen shoulder, the capsule becomes inflamed, thickened, and contracted, leading to pain, stiffness, and a progressive loss of both active and passive range of motion. This condition is most common in middle-aged individuals and can significantly limit daily function.

Normal shoulder motion depends on a coordinated movement pattern between the scapula and the humerus, known as the scapulohumeral rhythm. During shoulder elevation, approximately two degrees of glenohumeral motion are accompanied by one degree of scapulothoracic movement. Disruption of this rhythm contributes to movement dysfunction, altered biomechanics, and pain. Rehabilitation approaches that restore this coordination are therefore critical for effective management of adhesive capsulitis.

The Mulligan mobilization technique involves the application of sustained accessory glides by the therapist concurrent with the patient's active movement. This technique aims to correct positional faults, reduce pain, and improve joint mobility without provoking discomfort. Scapular mobilization is a manual therapy approach designed to restore normal motion of the scapula on the thoracic cage and to improve the scapulohumeral rhythm during shoulder elevation.

This study is designed as a randomized, single-blind clinical trial to evaluate the combined effect of Mulligan mobilization and scapular mobilization in patients with adhesive capsulitis. Thirty-eight participants aged between 30 and 60 years with unilateral adhesive capsulitis will be randomly assigned into two groups. Group A will receive Mulligan techniques for shoulder elevation, internal rotation, and external rotation in addition to scapular mobilization. Group B will receive conventional physical therapy consisting of hot packs, pulsed ultrasound at 1 MHz and 0.8 W/cm² for five minutes, posterior capsule stretching, and range-of-motion exercises. Both groups will receive therapy three times per week for four weeks.

Outcome assessments will include shoulder range of motion using a digital goniometer, pain and disability using the Shoulder Pain and Disability Index (SPADI), and scapulohumeral rhythm using a tape measurement method. Measurements will be taken before and after the four-week intervention period. It is hypothesized that the combined Mulligan and scapular mobilization protocol will produce greater improvements in pain reduction, joint range, and scapulohumeral coordination compared to conventional physiotherapy alone.

Inclusion Criteria:

• Medically stable and willing to provide informed consent to participate in the study.
• Age between 30 and 60 years.
• Both male and female participants.
• Unilateral shoulder involvement with pain and limited active and passive range of motion in lateral rotation, abduction, and internal rotation for more than three months compared with the unaffected side.
• Clinically diagnosed with adhesive capsulitis (frozen shoulder).

Exclusion Criteria:

• History of shoulder surgery.
• History of radiotherapy or chemotherapy.
• Presence of acute infection in the area to be treated.
• History of skin disease.
• History of cervical radiculopathy within the past six months.
• Secondary adhesive capsulitis, rotator cuff tears, shoulder fractures, or dislocations.