Manual Therapy: Knee


The primary goals of manual therapy are[1][2][3]:

  • Modulate pain
  • Increase range of motion
  • Reduce soft-tissue inflammation
  • Improve contractile & non-contractile tissue repair, extensibility, or stability
  • Facilitate movement

Manual therapy is defined as the application of manual forces of the therapist, to change/improve the quality and the range of motion of joints and soft tissues[1]. Mobilisation is a manual technique that through repeated passive motion at low speed replicates normal joint glides at varying amplitudes, while manipulation is defined as fast with a small force, small amplitude and high speed of movement of a joint[3].

It is hypothesised that manual therapy improves function of the kinetic chain (joints and sot tissue) by a combination of mechanical and neuromuscular mechanisms. In particular in the knee, techniques are aimed at increasing the extensibility of collagen, optimising joint lubrication and reduction of muscle tone which all result in improved joint function and joint mobility[2].

Read more about manual therapy


The use of manual therapy is supported in the knee[4].  Indications for the use of manual therapy include[5]:

  1. painful neuromusculoskeletal joint disorder
  2. pain in or from palpation of bony joint surfaces
  3. pain in of from palpation of joint soft tissues
  4. decreased or altered range of quality of motion
  5. pain on joint movement.

When there is pain in combination with joint restriction, it is recommended to apply manual therapy together with exercise therapy. There is a consensus that manual therapy can be considered as a preparation for exercise therapy by having an effect on pain and joint limitations[6], and muscle activity[7].

Clinical application

A commonly used form of manual therapy applied to joints are oriented mobilisations called ‘joint glides’, these are performed in specific planes of movement and are intended to restore specific movements. Research has demonstrated increased range of movement and function following tibiofemoral mobilisations but these positive effects are only for a short duration and cannot be considered effective for long term outcomes[2][8].  This would suggest that mobilisations may be effectively used to promote exercise performance.

Manual therapy is often used in clinical practice for osteoarthritis. Although it is often used, there is little research on the effects of the treatment of knee osteoarthritis independently of other interventions, such as exercise therapy[3]. Studies have shown that manual therapy has a positive effect on the modulation of pain in knee osteoarthritis[9][10][3].  A combination of manual therapy and guided exercises has functional benefits for patients with knee osteoarthritis[11].  Manual therapy and a guided exercise program can reduce the burden of complaint and postpone the need for surgery therefore reducing cost[12].

Manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy improves patellofemoral pain syndrome[5][13] Anterior knee pain is associated with the loss of strength and decreased activity of the knee extensors, which refers to a muscle inhibition. Muscle co-contraction around the knee has been shown to improve after joint mobilisations to the knee[7].  Spinal manipulation may also be regarded as an effective treatment to reduce muscle inhibition in the lower limb musculature[14][15]

There is little or no evidence of the use of manual therapy at acute knee injury, like ligaments or meniscus injury. For such persons, other appropriate measures in their therapy should be taken such as a supervised exercise programme[16][17].

Manual therapy combined with an appropriate exercise therapy seems to be more effective for improving the muscle strength, proprioception and functional performance than exercise therapy alone.


Grading scales

The intensity of the mobilisation is determined by the grading scale.


  1. 1.0 1.1 J Haxby Abbott et Al., ’Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee: a factorial randomized controlled trial protocol’, trial journal, February 2009 (Level of evidence: 1B )
  2. 2.0 2.1 2.2 Michael A. Hunt et al., ‘Effect of Anterior Tibiofemoral Glides on Knee Extension during Gait in Patients with Decreased Range of Motion after Anterior Cruciate Ligament Reconstruction’, Physiother Can. 2012, 235-241 (Level of evidence: 1B)
  3. 3.0 3.1 3.2 3.3 Carolyn J. et al, ‘Physiotherapy management of knee osteoarthritis.’, International Journal of Rheumatic Disease 2011, 145-151 (Level of evidence: 1A)
  4. Salamh P, Cook C, Reiman MP, Sheets C. Treatment effectiveness and fidelity of manual therapy to the knee: A systematic review and meta‐analysis. Musculoskeletal Care. 2016 Jan 1.
  5. 5.0 5.1 James W. brantighal et al., Manipulative therapy for lower extremity conditions: Expansion of literature review, National University of Health sciences 2009, 53-71 (Level of evidence: 2A)
  6. Peter WF et al.,’ Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.’ Acta Reumatol Port 2011, 268-281 (Level of evidence: 1A )
  7. 7.0 7.1 Cruz-Montecinos C, Flores-Cartes R, Montt-Rodriguez A, Pozo E, Besoaín-Saldaña A, Horment-Lara G. Changes in co-contraction during stair descent after manual therapy protocol in knee osteoarthritis: A pilot, single-blind, randomized study. Journal of Bodywork and Movement Therapies. 2016 Apr 27.
  8. Fitzgerald GK, Fritz JM, Childs JD, Brennan GP, Talisa V, Gil AB, Neilson BD, Abbott JH. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial. Osteoarthritis and Cartilage. 2016 Mar 10.
  9. Courtney CA, Steffen AD, Fernández-De-Las-Peñas C, Kim J, Chmell SJ. Joint mobilization enhances mechanisms of conditioned pain modulation in individuals with osteoarthritis of the knee. journal of orthopaedic & sports physical therapy. 2016 Mar;46(3):168-76.
  10. Deyle GD, Henderson NE, Matekel RL, et al. ‘Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: A randomized, controlled trial.’ Ann Intern Med 2000 Feb, fckLR173–81. (Level of evidence: 1B)
  11. Abbott JH, Chapple CM, Fitzgerald GK, Fritz JM, Childs JD, Harcombe H, Stout K. The incremental effects of manual therapy or booster sessions in addition to exercise therapy for knee osteoarthritis: a randomized clinical trial. journal of orthopaedic & sports physical therapy. 2015 Dec;45(12):975-83.
  12. Deyle GD et al.,’ 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’ Physical therapy, December 2005, 1301-1317 (Level of evidence: 1B)
  13. Paul A. Van den Dolder et al., ‘Six sessions of manual therapy increase knee flexion and improve activity in people with anterior knee pain: a randomized controlled trial’, Australian journal of physiotherapy 2006 vol.52 (Level of evidence: 1B )
  14. Jayaseelan DJ, Courtney CA, Kecman M, Alcorn D. Lumbar manipulation and exercise in the management of anterior knee pain and diminished quadriceps activation following acl reconstruction: A case report. International journal of sports physical therapy. 2014 Dec;9(7):991.
  15. Esther Sutel; PhD et al., ‘Conservative Lower Back Treatment Reduces Inhibition in Knee-Extensor Muscles: A Randomized Controlled Trial’, Journal of manipulative and physiological therapeutics, February 2000 (Level of evidence: 2B)
  16. Deyle G. et al. A Preliminary clinical prediction rule: knee osteoarthritis patients who are unlikely to benefit from manual physical therapy and exercise, The journal of manual and manipulative therapy 2009
  17. Carol A Courtney et al, ‘Clinical presentation and manual therapy for lower quadrant musculoskeletal conditions.’, Journal of Manual and Manipulative Therapy 2011, 212-222