Knee Mobilisations

Introduction[edit | edit source]

Knee joint mobilisations are manual physical therapy interventions, also known as nonthrust manipulation. [1] When mobilising, an oscillatory manual force may be applied to the tibiofemoral, proximal tibio-fibular, or patellofemoral joints, in a variety of directions and positions based on the patient’s presentation, and with several different hand positions or grips. [1]

There are 4 types of mobilisation grades (Maitland's Mobilisations) whose application is based on the amount of resistance and magnitude of movement that depend on the aim of treatment. [2]

  • Grade I: In this grade, mobilizations are of small amplitude and of slow oscillations at the beginning of the joint range of motion. These mobilizations are done with light pressure.
  • Grade II: In this grade, mobilizations are of large amplitude and of slow oscillations within the joint's entire available range of motion.

Grades I and II refer to movements before reaching joint resistance. The goal of these two grades is pain modulation.

  • Grade III: In this grade, mobilizations are large in amplitude and of slow oscillations that're focused on middle to end of range of motion.
  • Grade IV: In this grade, mobilizations are small in amplitude and of slow oscillations at the end of the range of motion.

Grades III and IV refer to movements reaching resistance. The goal of these two grades is increase range of motion and reduce joint stiffness.

Indications[edit | edit source]

Knee mobilisations may be beneficial for individuals with a variety of conditions. Although they are commonly used in post-operative rehabilitation [3] and knee osteoarthritis (OA), they can also be applied in other circumstances where therapy of the knee joint is necessary such as knee stiffness, pain and hypomobility.

Several studies have used knee mobilisations for the treatment of knee pathology. In OA, the two with the longest follow-up, out to one year, include:

  • Knee OA - Deyle et al. 2000.[4]  Manual therapy and exercise were compared to placebo ultrasound in 83 patients with knee OA. Patients underwent treatment twice a week for 4 weeks and were followed up for one year. There was a clinically and statistically significant greater improvement in the manual therapy and exercise group compared to the placebo ultrasound group at four weeks and the improvements were maintained at one year. The authors used an impairment-based approach that included mobilisations of the tibiofemoral joint, patellofemoral joint, proximal tibiofibular joint, and surrounding soft tissue. Mobilisations to the lumbar spine, hip, and ankle were also applied as required.
  • Knee OA - Deyle et al. 2005.[5] Manual therapy and home exercise were compared to a home exercise program in 134 patients with knee OA. Both interventions provided an improvement in pain and function but at the one-year mark, the manual therapy and exercise group were less likely to be taking medications for their OA and were more satisfied with the overall outcome of their treatment. They used the same techniques as in the first trial.[4]

The effectiveness of knee mobilisations in knee OA have also been lately investigated in a systematic review by Weleslassie et al. [6] 15 RCTs with 704 participants were included.Pain reduction and functional improvement were significantly better than the control groups in most studies.

In addition to that, several studies also used knee mobilizations for Patellofemoral Pain Syndrome (PFPS).

  • According to one randomized study done on 50 patients with PFPS, results showed that there was a significant decrease in pain and a significant improvement of functional outcome of the knee in patients who received patellar mobilizations and patellar tapping. The study states that a 12 session treatment of both patellar mobilization and tapping in addition to conventional therapy is effective in alleviating pain and improving knee function in PFPS[7].
  • According to another study, results showed that joint mobilizations have been associated with decreasing aberrant pain mechanism and combined with its biomechanical effects could serve as an adjunctive intervention in the management of PFPS[8].

Contraindications[edit | edit source]

Some of the contraindications of joint mobilization include:[9]

  • Joint replacement arthroplasties
  • Any fracture adjacent to the the joint that has not properly healed
  • Acute inflammatory or septic arthritis
  • Bone disease (Osteomylitis)
  • Bacterial infection
  • Malignancy and neoplastic disease
  • Physiologically unstable joint

Tibiofemoral Articulation[edit | edit source]

The tibial plateau is concave and it articulates with convex femoral condyles.

Resting position: 25 degrees of knee flexion

Treatment plane: It is along the tibial plateaus

Stabilisation: The femur bone is stabilised.

Tibiofemoral joint distraction[edit | edit source]

The tibiofemoral joint distraction is done in three different positions: Prone lying, Supine lying, and high sitting position.

Indications: Initial treatment, general mobility of the patient and pain control.

Patient position: The patient is positioned in prone with thigh fixated to the table via the use of a stabilising belt.

Hand placement and mobilising force: The therapist grasps the involved leg just proximal to the malleoli and provides a distraction force (along the long axis of the tibia) by leaning backward along the line of the tibia.

An alternative position is performed with the patient sitting with the leg hanging off a table or in supine lying position.

[10]

Anterior Glide[edit | edit source]

Indication: increase knee extension.

Patient Position: The patient is positioned in crook lying which is the drawer test position.

Hand Placement and mobilising force: The mobilising force comes from the fingers on posterior tibia as the therapist leans backward.

Alternately, position the patient in prone lying. The knee joint is initially kept in resting position and progressed later on till the end available range. A small pad is placed on the patella to avoid its compression. The distal tibia is grabbed with one hand and the palm of the proximal hand is placed over the proximal tibia on one side. The force is directed laterally and medially over the tibial plateau.

[11]

Posterior Glide[edit | edit source]

Indication: to increase knee flexion.

Patient Position: The patient is positioned in supine lying with the knee slightly flexed and a prop placed under the distal femur.

Hand placement and mobilising force: The mobilisation itself is performed by a force perpendicular to the line of the tibia.

Although this technique is often used in the closed-packed position, it can also be performed with the knee flexed near the level of restriction, similar in position to the posterior drawer test for the PCL.

[12]

Patellofemoral Joint[edit | edit source]

The patella has the ability to glide distally on the the femur for normal knee flexion and glide proximally for normal knee extension.

Rotational Glides[edit | edit source]

Indication: Internal increases knee flexion. External rotation glides increases knee extension.

Patient Position: These glides can be performed at various points in the normal ROM of the knee with the patient positioned in supine.

Hand placement and mobilising force: The stabilising hand grasps the distal femur and the mobilising hand grasps the heel of the patient's foot. The ankle is maximally dorsiflexed so that rotational motion is applied to the rotating tibia and not at other joints more distally. The foot is either rotated medially or laterally, depending on the mobilisation preferred (internal or external rotation) and at the range where restriction may be apparent.

Patellofemoral Glides[edit | edit source]

Indication: Increase patellar mobility.

Patient position: The patient is in supine position with the knee slightly flexed.

Hand placement and mobilising force: To provide a medial glide, the therapist utilises both hands to press on the inferior and superior aspects of the medial patella and deliver a force to glide the patella in a lateral direction. Conversely, contact points on the lateral patella are used to produce a medial glide.

Superior and inferior glides are used for joint play and patellar motion necessary for extension and flexion, respectively. [13] Similar to the medial/lateral glides, joint surfaces on the side of the patella opposite the direction of mobilisation are used. For example, inferior surfaces are used to mobilise the patella in a superior direction and vice versa.


References[edit | edit source]

  1. 1.0 1.1 Silvernail J., Gill N.,Teyhen D., Allison S. Biomechanical measures of knee joint mobilization. J Man Manip Ther 2011; 19(3):162-171.
  2. Maitland G., Hengeveld E., Banks K, (eds). Maitland’s peripheral manipulation. 4th ed. Oxford: Butterworth-Heinemann, 2005.
  3. Dailey K., McMorris M., Gross M. Tibiofemoral joint mobilizations following total knee arthroplasty and manipulation under anesthesia. Physiotherapy Theory and Practice 2018; 36(7): 863-870.
  4. 4.0 4.1 Deyle G., Henderson N., Matekel R., Ryder M., Garber M., Allison S.. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000 Feb 1;132(3):173-181.
  5. Deyle G., Allison S., Matekel R., Ryder M., Stang J., Gohdes D., Hutton J., Henderson N., Garber M. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther 2005 Dec;85(12):1301-1317.
  6. Weleslassie G., Temesgen M., Alamer A., Tsegay G., Hailemariam T., Melese H. Effectiveness of Mobilization with Movement on the Management of Knee Osteoarthritis: A Systematic Review of Randomized Controlled Trials. Pain Res Manag. 2021 May 3;2021:8815682.
  7. Khuman R, Devi S, Anandh V, Kamlesh T, Satani K, Nambi G. Patello-Femoral Pain Syndrome: A comparative Study ofMobilization Verses Taping.
  8. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009 Oct 1;14(5):531-8.
  9. Edmond SL. Joint Mobilization/Manipulation, 3rd Edition: Extremity and Spinal Techniques. St. Louis, MO: Mosby; 2017.
  10. Dr. Dania Qutishat. Knee Traction | Assessment & Treatment. Available from: https://www.youtube.com/watch?v=IUWWoxy3ANA (accessed 10/8/2022)
  11. Daney20. Anterior Glide to Increase Knee Extension Available from:https://www.youtube.com/watch?v=X74_lGuNyJc (accessed 10/08/2022)
  12. Physical Therapy Nation. Posterior to Anterior Mobilization at the Tibiofemoral Joint and the Scoop Technique. Available from: https://www.youtube.com/watch?v=RcusJUIDhp4(accessed 10/08/2022)
  13. Wise C., Gulick D. (eds). Mobilization Notes: A Rehabilitation Specialist's Pocket Guide. McGraw Hill; 2009. Available online: https://fadavispt.mhmedical.com/content.aspx?bookid=2595&sectionid=213634252 (accessed 11/08/2022.