The shoulder joint complex (SJC), a structurally intricate joint, provides articulation between the upper extremities and the axial skeleton. Owing to its unique anatomical configuration, the SJC has the maximum range of motion (ROM) among all joints in the human body. However, poor joint congruency, along with the demands of strength, stability, and flexibility placed on the SJC in everyday tasks, makes it particularly susceptible to musculoskeletal disorders (Chang, Anand & Varacallo 2025). Shoulder joint complex disorders constitute a very frequent problem in the general population, with an estimated prevalence ranging from 0.7% to 55.2%, being higher in women than in men and especially prevalent in high-income countries (Lucas et al. 2022). Symptoms can be persistent and disabling, leading to pain, functional limitations, and reduced quality of life, and interfering with daily activities at home and work, with significant economic costs in terms of increased healthcare demands and impaired work (Espahbodi et al. 2017).

Several overlapping medical conditions can lead to painful shoulders, including rotator cuff disorders, biceps tendinopathy, acromioclavicular joint abnormalities and adhesive capsulitis (Linaker & Walker-Bone 2015). A wide range of treatments has been proposed, including joint rest, pharmacological treatment with anti-inflammatory or analgesic drugs, active and passive mobilisation, electrotherapy, capsular distension, and manipulation under anaesthesia or arthroscopy (Crookes et al. 2023; Lucas et al. 2022).

Physiotherapeutic interventions focused on restoring joint mobility and function occupy a central role among numerous therapeutic strategies available for painful shoulder conditions. Manual therapy-based techniques aim to relieve pain and improve ROM through specific mobilisation procedures, while exercise-based techniques emphasise restoring muscular strength, endurance and motor control. Within this spectrum, two commonly employed interventions are Maitland mobilisation (MAIT), a structured manual therapy method based on graded oscillatory movements (Yaver 2007), and kinesiotherapy (KINE), a method that employs active and passive exercises to optimise recovery of shoulder function (Ansari, Mohammad Rahimi & Aminzadeh 2025).

Maitland mobilisation represents a structured and evidence-informed manual therapy approach, integrating clinical reasoning with graded passive movements to the spinal and peripheral joints. Based on the patient’s presentation, oscillatory techniques are applied at varying amplitudes and ranges. These techniques are classified into grades I to V, with grade V indicating the option of a small-amplitude, high-velocity thrust. Lower-grade techniques primarily address pain modulation through neurophysiological mechanisms, whereas higher-grade techniques reduce stiffness and restore mobility by targeting end-range restrictions, with the goal of increasing ROM and decreasing pain (Gutierrez-Espinoza et al. 2023). However, the efficacy of the MAIT method in painful shoulder pathologies remains poorly understood (Do Moon et al. 2015; Haider et al. 2018; Piekarz & Perry 2016).

Kinesiotherapy involves movement of some parts of the body or the whole body using exercises to maintain, establish, develop and change the functions of the locomotor apparatus and organs of locomotion. Kinesiotherapy aims to achieve optimal recovery of damaged locomotor function by using all the potential of the patient undergoing treatment. Kinesiotherapy includes both active and passive exercises. Active exercises are divided into those with assistance, without assistance, and with resistance (Ansari et al. 2025).

Recent evidence suggests that a therapeutic exercise constitutes a central element in managing shoulder pain, with additional modalities such as laser therapy demonstrating meaningful benefits. Manual therapy and educational interventions may also contribute to symptom improvement, although their effects appear less consistent and generally inferior to exercise-based interventions (Aguilar Garcia et al. 2024). Heat therapy, often delivered through shortwave diathermy (SWD), is well established to enhance multimodal treatment outcomes by increasing blood flow and metabolic activity and promoting pain relief, and it is therefore frequently combined with other physiotherapeutic interventions to mitigate shoulder pain and functional limitations (Sung, Lee & Kim 2022; Zanoli et al. 2024). Emerging evidence also suggests a likely contribution to skeletal muscle mass gain, although current findings remain preliminary (Rodrigues et al. 2020). Alongside these treatment strategies, transcutaneous electrical nerve stimulation (TENS) is commonly employed as a non-invasive analgesic tool to reduce symptomatic pain (Johnson et al. 2022).

Despite wide clinical use of both MAIT and KINE, their relative effectiveness within the context of multimodal shoulder rehabilitation remains poorly established. Addressing this gap is essential for guiding evidence-based decision-making in non-traumatic shoulder disorders. Therefore, we aimed to compare the effectiveness of these two commonly implemented approaches as an adjunctive treatment to TENS, SWD, and therapeutic exercise in the rehabilitation of painful shoulders, to determine which intervention yields greater improvements in pain, function, and shoulder mobility.

Our study cohort comprised 34 women and 25 men aged 23–83 years (mean 55.6 ± 14.8 years). No significant differences were observed between the two groups in terms of age distribution, sex ratio or frequency of specific shoulder pathologies, indicating adequate sample comparability. Across both groups, rotator cuff tendinosis was the most frequently diagnosed condition, followed by other common non-traumatic shoulder pathologies (Table 1). These findings suggest that the allocation of patients resulted in two balanced cohorts, thereby allowing subsequent comparisons between the intervention groups to be interpreted with greater validity.

The current study aimed primarily to evaluate the effectiveness of MAIT and KINE in improving joint mobility and quality of life. Therefore, participants were assessed at baseline, after 5 weeks of treatment (first control), and at a 2-week follow-up after the completion of treatment (second control), using ROM measures and the DASH, ASES, VAS and SF-36 scales. In the KINE group, remarkable improvements in flexion, abduction and external rotation ROMs, and in all four clinical scales (DASH, ASES, VAS and SF-36) post-treatment (Table 2). These gains were generally maintained at the 2-week follow-up, although flexion improvement lost statistical significance. In contrast, the MAIT group exhibited significant improvements in all ROMs and all clinical scales both at both post-treatment and follow-up, demonstrating more consistent and sustained effects of these interventions.

After confirming that both MAIT and KINE groups supported functional recovery, their relative efficacy was directly compared. For this purpose, percentage changes relative to baseline were calculated for each outcome variable at the two assessment points, as described in the statistical analysis. Results reveal key between-groups differences. At the first control, the MAIT group showed significantly greater improvements than KINE in flexion, external rotation, DASH and ASES scores (Figure 1; Online Appendix 1 – Table 1). Furthermore, at the second control, the superiority of MAIT became more pronounced with significantly better results observed across nearly all variables, including ROM and clinical scales, except internal rotation and SF-36. The Cliff’s δ effect size estimates further reinforce these findings (Online Appendix 2 – Table 2), suggesting consistent differences between groups.

Absolute change scores were calculated for DASH, ASES, and VAS at post-treatment and follow-up and were compared with their established MCIDs (10.83 for DASH, 12 for ASES, and 3 cm for VAS) to evaluate the proportion of patients achieving clinically meaningful improvement. Proportion analyses revealed that, at post-treatment, significantly more patients in the MAIT group met the MCID thresholds for DASH and ASES, whereas no between-group differences were observed for VAS. At follow-up, and in line with the patterns observed in previous analyses, MAIT achieved a higher MCIDs on all three scales at follow-up (Figure 2; Online Appendix 3 – Table 3). Overall, these findings indicate that, while both treatment modalities are beneficial, MAIT provides broader, more sustained and clinically meaningful improvements in shoulder mobility, pain, and function compared with KINE.

Our study provides novel evidence that MAIT represents a valuable therapeutic alternative for patients with non-traumatic shoulder pathology. The global expansion of computer use may contribute to the rising prevalence of arm, neck, and shoulder disorders. Painful shoulder conditions frequently cause disability worldwide, substantial health care utilisation, prolonged sick leave and decreased quality of life (Kang et al. 2024). Resultantly, identifying cost-effective, clinically applicable and sustainable interventions remains a priority in musculoskeletal rehabilitation.

Both interventions proved effective in improving pain, shoulder function, and quality of life, validating their therapeutic relevance in non-traumatic shoulder rehabilitation. However, participants treated with MAIT demonstrated significantly better outcomes post-treatment, and these improvements were not only maintained but, in most cases, enhanced at follow-up (Figure 1). Notably, the fact that most patients who underwent MAIT exceeded the MCID thresholds across all functional and pain-related scales highlights the clinical relevance of these improvements (Figure 2). From a clinical perspective, these findings suggest the potential for sustained benefit and support incorporating MAIT into routine management strategies, although future studies with extended follow-up are needed to determine whether these effects persist over time and confirm its longer-term superiority.

To date, no previous study has directly compared MAIT with KINE. Furthermore, the evidence supporting KINE for conservative shoulder rehabilitation remains scarce. Sumariva-Mateos et al. (2022) compared KINE with myofascial techniques in 44 patients with immobilised shoulders and found improvements in function, mobility, and pain in both groups, though clinically meaningful pain reduction was achieved only with myofascial therapy (Sumariva-Mateos et al. 2022). This suggests that although KINE is beneficial for shoulder rehabilitation, its effect may be less consistent in shoulder pathology than other approaches.

The body of evidence for MAIT in shoulder rehabilitation is limited but promising. Another study compared the Maitland method with the Kaltenborn technique in 20 patients with frozen shoulder, reporting significant improvements in both groups without between-group differences (Do Moon et al. 2015). However, the exclusive focus on frozen shoulder limits the generalisability of those results to other pathologies.

Haider et al. demonstrated that the Maitland technique combined with conservative exercise was superior to exercise alone for patients with subacromial syndrome, yielding significant reductions in pain and improved function and mobility (Haider et al. 2018). Importantly, however, in that trial, MAIT was applied to the thoracic region rather than directly to the shoulder, which may have influenced the results. A similar approach was adopted by Elgendy et al., who compared conventional exercise with Maitland and Mulligan thoracic mobilisations in men with subacromial impingement syndrome, reporting improvements across all interventions. However, Mulligan mobilisation achieved the greatest gains in pain reduction, abduction and external rotation ROM, and kyphosis correction (Elgendy et al. 2024). Together, these studies suggest that spinal manual therapy may contribute to symptomatic improvement in shoulder disorders, although the indirect application limits conclusions regarding its specific efficacy at the shoulder joint. The current research extends this evidence by demonstrating the efficacy of MAIT when applied directly to the shoulder in a broader population with heterogeneous non-traumatic shoulder pathologies.

The present study results align with those of previous studies in evaluating the effectiveness of MAIT when applied directly to the shoulder joint. Celik and Menek (2025) conducted a study of 45 individuals with rotator cuff lesions, showing that both Mulligan and MAITs produced greater improvements in pain, function, and ROM than conventional exercise, with Mulligan yielding the most pronounced gains in quality-of-life domains (Celik & Menek 2025). Additionally, Khandaloo et al. investigated the effects of Mulligan and Maitland shoulder mobilisation techniques combined with contemporary physical therapy on acromiohumeral distance in 51 overhead athletes with primary subacromial impingement syndrome. Both techniques significantly increased acromio-humeral distance at three static angles of passive scapular abduction, while no changes were observed in the control group. The Mulligan approach produced greater improvements than the Maitland technique, suggesting that both mobilisations are effective adjuncts to physical therapy, with Mulligan providing superior outcomes (Khandaloo et al. 2025).

Maitland mobilisation has also been compared with other techniques. A randomised controlled trial investigated the effects of muscle energy technique (MET) and MAIT on shoulder pain and disability in 30 patients following neck dissection surgery. Both interventions, combined with conventional physiotherapy, significantly improved pain, disability, and shoulder ROM. However, MET demonstrated superior efficacy compared to MAIT, suggesting that MET is a more effective approach for restoring shoulder function and quality of life in the postoperative period (Elhameed et al. 2024).

Lastly, Singh et al. compared the immediate effects of kinesio taping (K-taping) and Grade IV MAIT on glenohumeral internal rotation deficit in 32 asymptomatic overhead athletes. Even though both interventions produced significant improvements in internal rotation, no differences were detected between groups or among different sports. These findings indicate that K-taping is equally effective for enhancing shoulder internal rotation in overhead athletes with glenohumeral internal rotation deficit (Singh et al. 2023).

Collectively, the extant literature supports the effectiveness of different mobilisation techniques, such as Maitland, Mulligan, and MET in improving shoulder pain, function, and ROM across various populations. While Mulligan mobilisation demonstrates superior outcomes compared to other techniques and MET shows promise, more studies involving larger, more heterogeneous cohorts with comprehensive patient data are required to elucidate the specific clinical scenarios to optimally indicate each technique.

Our study has important methodological strengths. The interventions were delivered in a standardised manner; outcomes were assessed with validated scales and objective kinematic measures; and our study design included both post-treatment and short-term follow-up assessments. Moreover, incorporating MCID thresholds also strengthens the clinical relevance of the results, helping to contextualise the observed changes beyond statistical significance. Such a multidimensional evaluation supports the robustness of our findings and enhances their clinical interpretability.

Our study suffers from some limitations. Firstly, the wide age range of the participants may have introduced variability in treatment response, as younger and older patients may differ in tissue elasticity, recovery potential, and adherence. Secondly, the inclusion of a heterogeneous sample of shoulder pathologies could have impacted outcome variability. However, the absence of significant differences in baseline age or diagnosis distribution between groups alleviates concerns about bias. Thirdly, the follow-up period was limited to 2 weeks, precluding conclusions about long-term effects. Fourthly, observer and performance bias might have been introduced as the same physiotherapist administered all interventions and performed all assessments. Finally, although the sample size was sufficient to detect differences between groups, larger multicentre trials are needed to confirm and extend our findings.

Future research should address these limitations by focusing on specific pathologies, stratifying patients by age, and incorporating longer follow-up periods. Comparative studies with other manual therapy approaches, such as Mulligan or Kaltenborn, as well as multimodal rehabilitation programmes, would also be informative. In addition, cost-effectiveness analyses and studies assessing patient satisfaction could further support the integration of MAIT into clinical practice guidelines. Future studies should also investigate whether patient-specific factors, such as baseline symptom duration, physical activity levels, or occupational demands, modify the response to MAIT, thereby helping identify subgroups most likely to benefit from this intervention. Additionally, examining the neurophysiological mechanisms underlying MAIT through imaging, electromyographic, or biomechanical approaches could provide valuable insight into its therapeutic effects and inform more targeted clinical applications.

Overall, MAIT demonstrated superior improvements in pain, function, and ROM compared with KINE in patients with non-traumatic shoulder pathology. Because of its comparable workload for patients and physiotherapists and its favourable clinical profile, MAIT should be considered within clinical decision-making. These findings not only contribute to the growing body of evidence supporting manual therapy but also underline the need for future trials to consolidate Mailand’s role within shoulder rehabilitation programmes.