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Principles of Joint Mobilisation

Original Editor - Ewa Jaraczewska based on the course by Shala Cunningham

Top Contributors - Ewa Jaraczewska, Vidya Acharya and Stacy Schiurring  

Introduction

Joint mobilisation is a treatment of passive movements at the joint interface. [1] Joint manipulation and mobilisation can be used interchangeably, and they combine neurophysiological mechanisms with biomechanical principles to restore optimal joint function.[2]

Guide to Physical Therapy Practice defines joint mobilisation and manipulation as “a continuum of skilled passive movements to joint and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement." [2]

This article explores the theoretical foundations and practical applications that guide clinical decision-making in joint mobilisation.

Neurophysiological Mechanisms of Pain Relief

“Diffuse noxious inhibitory control (DNIC), also known as conditioned pain modulation (CPM) in humans, is a paradigm wherein the heterotopic application of a noxious stimulus results in the attenuation of another spatially distant noxious input.“[3]

One of the primary therapeutic effects of joint mobilisation involves pain modulation through neurophysiological mechanisms. [4] Much of the research on pain modulation has been conducted in animal models and it has demonstrated that joint mobilisation triggers the release of endogenous opioids such as beta-endorphin, which contribute significantly to pain reduction. Studies conducted on rats have shown that joint mobilisation decreases hyperalgesia in acute and chronic pain conditions. In acute scenarios, joint mobilisation following tissue injury produced measurable endogenous opioid responses. In chronic conditions, such as those involving nerve compression, mobilisation inhibited pain and increased myelin sheath thickness, suggesting potential regenerative effects.[5] Nerve mobilisation techniques, including tensioners and sliders, have also demonstrated the ability to increase endogenous opioid production, and to help with pain reduction.[5] [6]

When a clinician performs joint mobilisation, it initiates a cascade of analgesic responses within the nervous system. The mobilisation provides alternative sensory input that augments and modulates the pain sensations travelling to the spinal cord.

Kinesiological Foundations

To apply joint mobilisation effectively, clinicians must understand the difference between osteokinematic and arthrokinematic movements:[7]

Osteokinematic movements refer to the observable movements of bones through space. These movements include flexion, extension, abduction, and adduction. Clinicians measure them during active and passive range of motion testing.

Roll and glide

Arthrokinematic movements represent the accessory motions occurring within the joint, including roll, glide, and spin. These movements are not under voluntary control and cannot be achieved through active muscular contraction alone, however they are essential for a full, pain-free range of motion:

  • A roll is a rotary movement when one bone is rolling on another (like a wheel rolling along the ground).
  • A spin is a rotary movement around a longitudinal axis with one point of contact when one body spinning on another.
  • A glide is a translatory movement with one joint surface sliding over another.

In the human body, all joint movements involve combinations of roll and glide co-occurring in various proportions. The relationship between roll and glide becomes important when selecting appropriate mobilisation techniques. If a joint would move through pure roll without glide, the moving bone would eventually roll off the joint surface. The body prevents this through simultaneous gliding that keeps the articulating surfaces appropriately aligned throughout the range of motion.

The Kaltenborn’s Convex-Concave Rules

To apply a correct mobilisation technique, a clinician must understand joint morphology. Joint surfaces are classified as either convex, resembling a rounded or arched component, or concave, representing a hollowed or shallow component. The Kaltenborn rules define the direction of therapeutic gliding forces:[8]

Concave-on-convex glide

In concave-on-convex glide, a concave surface moves on a stationary convex surface. The glide occurs in the same direction as the bone movement.[9] For example, the concave proximal phalanx moves on the convex metacarpal head during finger flexion. The therapist would perform a palmar glide of the phalanx to improve flexion, pushing in the same direction as the desired movement.

Convex-on-concave glide

The convex-on-concave rule indicates that when a convex surface moves on a stationary concave surface, the glide occurs opposite to bone movement.[10] For example, during shoulder abduction, the convex humeral head moves superiorly on the concave glenoid fossa, but the therapeutic glide must be directed inferiorly to facilitate this motion.

The treatment plane rests in the concave articular surface, parallel to the joint surface and perpendicular to the axis of the convex surface. Mobilisation forces are applied parallel to this treatment plane for gliding techniques and perpendicular to distraction techniques.[11]

Joint Positions

Joint position influences mobilisation effectiveness:

The resting position, or an open-packed position, defines the joint position where surrounding tissues are maximally relaxed and the intracapsular space is largest. [12] This position allows maximum joint play and provides the most comfortable starting point for mobilisation. It is the standard position for assessing joint mobility.

In a close-packed position articular surfaces are maximally congruent, surrounding tissues are under maximum tension, and the intracapsular space is minimal. [13] In this locked position, there is no room for therapeutic gliding, and joint mobilisation may be harmful.

Therapists should initiate mobilisations in the resting position, though they may progress into other ranges as treatment advances and capsular extensibility improves. [8]

Joint Mobilisation Grading Systems for Assessment and Treatment

Two primary grading systems guide joint mobilisation practice: the grading system for assessment and the grading system for treatment.

Joint Mobilisation Grading Systems for Assessment

When assessing joint mobility, clinicians use zero to six point scale:[8]

  • 0-the joint is ankylosed (fused)
  • 1-extremely hypomobile
  • 2-slightly hypomobile
  • 3-normal joint mobility
  • 4-slightly hypermobile
  • 5-extremely hypermobile
  • 6-pathologically unstable

However, research indicates clinicians reliably distinguish only three categories: hypomobile, normal, and hypermobile. A hypomobile joint demonstrates restricted capsular movement, normal joints show expected mobility, and hypermobile joints exhibit excessive laxity. [8]

Joint Mobilisation Grading Systems for Treatment

For treatment, two major grading systems exist: Kaltenborn and Maitland.

Kaltenborn's system uses three mobilisation grades with hold (I to III). Each category has specific objectives and outcomes:[9]

  • Grade I (Loosen) involves small-amplitude pressure within joint limits, producing no appreciable joint separation. It cancel the regular compressive forces acting on the joint and provides little or no resistance. The focus is on pain relief, soft tissue relaxation, and increasing joint fluid viscosity through oscillation.
  • Grade II (Tighten) uses stronger glide pressure within joint limits, progressing from feeling slight resistance to definite tissue tightening. It has similar goals to Grade I.
  • Grade III (Stretch) aims to elongate the joint at the point of restricted movement, addressing shortened soft tissue or joint hypomobility.

Maitland's system uses four mobilisation grades with oscillatory movements: [9]

  • Grades I-II offer neurophysiological pain relief
  • Grades III-IV aim to increase the range of motion by reducing soft tissue stiffness. They are also indicated for joint conditions with muscle tension or spasms, providing analgesic benefits.

Oscillation is performed at a rate of one oscillation every 1 to 2 seconds. It is a slow, rhythmic speed. For higher-grade mobilisations (Grade IV), faster rates are typically associated with treating stiffness, but slower rates can also be used. It involves small amplitude movements sustained beyond the initial resistance point, maintaining constant tension on the tissues.[9] [14]

Precautions and Contraindications in Joint Mobilisation

The "do no harm" principle guides all mobilisation practice.[8]

Therapists must conduct thorough subjective and objective examinations, identifying any contraindications before initiating treatment. When uncertain, consultation with physicians or specialist colleagues ensures patient safety. Additionally, mobilisation should never cause pain beyond mild discomfort. If mobilisation produces sharp pain, muscle guarding, or symptom exacerbation, the therapist must immediately modify or discontinue the technique. Continuous monitoring of patient response guides treatment progression, adjusts intensity, direction, or technique based on individual tolerance and response.

Clinicians must understand the absolute contraindications and relative contraindications in joint mobilisation. The following paragraphs provide examples of absolute and relative contraindications and red flags.

Absolute Contraindications

Absolute contraindication defines conditions where mobilisation must never be performed because it poses a significant risk of harm:

When malignancy in the treatment area is present, the mechanical forces could potentially spread cancerous cells or cause a pathological fracture through weakened bone.[15][16][17] Septic arthritis contraindicates mobilisation due to the risk of rapid chondrolysis and joint destruction.[18] Metabolic bone diseases such as osteoporosis create fragile skeletal structures that cannot withstand mobilisation forces, risking fracture even with gentle techniques. [19] Neoplastic disease affecting bone integrity makes mobilisation dangerous regardless of grade or technique used. Osteomyelitis may be a contraindication for joint mobilisation due to risks of further bone destruction. However, a case study presented by Prall et al. describes a rib manipulation technique in a patient recovering from osteomyelitis of the thoracic spine. [20] Fractures or complete ligament ruptures require healing time before mobilisation can be safely introduced, as premature mechanical stress disrupts the healing process and may worsen the injury. In case of joint fusion or ankylosis, there is no mobile joint to treat, making mobilisation potentially harmful to surrounding structures.

Relative Contraindications

Relative contraindications require careful clinical reasoning and may allow modified mobilisation approaches depending on individual circumstances:

Excessive pain or swelling indicates acute inflammation, and aggressive mobilisation could increase symptoms and delay healing. However, gentle grade one or two mobilisations may help manage pain and promote fluid movement.[21] Following arthroplasty or joint replacement surgery, mobilisation must respect surgical precautions and healing timelines. Mobilisation may be appropriate in later stages of rehabilitation but requires coordination with the surgical team regarding allowed movements and forces. [22] Pregnancy presents special considerations. While peripheral joint mobilisation generally remains safe, therapists must use caution with spinal techniques and avoid positioning that compromises maternal or foetal wellbeing.[23] In hypermobility syndrome therapists should identify and address hypomobile segments while avoiding mobilisation of hypermobile joints. Spondylolisthesis requires special consideration, as mobilisation forces could worsen vertebral slippage. However, gentle mobilisation may be appropriate when carefully selected and monitored.[24] During acute flares of rheumatoid arthritis, mobilisation should be minimal or avoided, though gentle movements during remission phases may help maintain mobility. [25] Vertebrobasilar Insufficiency (VBI) is a critical precaution for cervical spine mobilisation, as certain positions or forces could compromise blood flow to the brain, potentially causing stroke.[26]

Red Flags

Therapists must remain attentive to several red flag presentations. Empty end feel during passive movement testing suggests serious pathology such as tumour, infection, or fracture, requiring immediate medical referral rather than mobilisation. Severe night pain unrelieved by position changes often indicates serious pathology. Progressive neurological deficits, unexplained weight loss, fever, or systemically unwell patients all require medical evaluation before mobilisation consideration.

This optional article, An Introduction to Red Flags in Serious Pathology, discusses signs and symptoms related to screening for serious underlying pathologies.

Clinical Application and Treatment Planning

Selecting appropriate mobilisation techniques requires consideration of multiple factors, which include:[8]

  • location and nature of dysfunction
  • joint morphology
  • treatment goals
  • tissue irritability
  • whether the condition is acute or chronic.

Treatment Goals and the Choice of Mobilisation Technique

Goal: Pain inhibition

Treatments should remain in lower grades within comfortable ranges for acute conditions with significant pain and muscle guarding. Grade one and two mobilisations prove most effective through neuromodulation of joint mechanoreceptors. They stimulate articular mechanoreceptors that gate pain transmission at the spinal cord and brainstem levels. [8] These lower-grade techniques can be applied daily.

Oscillatory movements generally manage pain by stimulating type one and two mechanoreceptors.

Goal: Increase joint mobility

Chronic conditions with established capsular restrictions require end-range stretching techniques to restore mobility. Sustained holds more effectively stretch collagen to increase the range of motion. When addressing restricted mobility from capsular tightness, grade three and four mobilisations become necessary. [8] These higher-grade techniques mechanically stretch shortened tissues through plastic deformation, typically applied three to five times weekly.

Conclusion

Applying joint mobilisation requires understanding the neurophysiological mechanisms underlying pain relief and the biomechanical principles governing joint movement. It is also important to recognise when mobilisation is inappropriate or requires modification to ensure patient safety. By integrating knowledge of arthrokinematics, joint morphology, appropriate positioning, grading systems, and safety considerations, therapists can make informed clinical decisions that optimise patient outcomes while minimising risk.

Resources

References

  1. ↑ Manske RC, Lehecka B, Reiman M, Loudon J. Orthopedic joint mobilization and manipulation: an evidence-based approach. Human Kinetics; 2019.
  2. ↑ 2.0 2.1 American Physical Therapy Association. Guide to Physical Therapist Practice. Third Edition. American Physical Therapy Association 2017.
  3. ↑ Pereira-Silva R, Neto FL, Martins I. Diffuse Noxious Inhibitory Controls in Chronic Pain States: Insights from Pre-Clinical Studies. Int J Mol Sci. 2025 Jan 5;26(1):402.
  4. ↑ Keter DL, Bialosky JE, Brochetti K, Courtney CA, Funabashi M, Karas S, Learman K, Cook CE. The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews. PloS one. 2025 Mar 18;20(3):e0319586.
  5. ↑ 5.0 5.1 da Silva JT, Santos FM, Giardini AC, de Oliveira Martins D, de Oliveira ME, Ciena AP, Gutierrez VP, Watanabe IS, Britto LR, Chacur M. Neural mobilization promotes nerve regeneration by nerve growth factor and myelin protein zero increased after sciatic nerve injury. Growth Factors. 2015 Feb;33(1):8-13.
  6. ↑ Baptista FM, Nery E, Cruz EB, Afreixo V, Silva AG. Effectiveness of Neural Mobilisation on Pain Intensity, Functional Status, and Physical Performance in Adults with Musculoskeletal Pain–A Systematic Review with Meta-Analysis. Clinical rehabilitation. 2024 Feb;38(2):145-83.
  7. ↑ Norasteh AA, Zarei H. Methods Used for the Assessment of Knee Joint Arthrokinematics: A Review of Literature. Journal of Research in Orthopedic Science. 2021 Aug 10;8(3):117-26.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Cunningham S. Principles of Joint Mobilisation. Plus course 2025
  9. ↑ 9.0 9.1 9.2 9.3 Anggiat L, Altavas AJ, Budhyanti W. Joint Mobilization: Theory and evidence review. International Journal of Sport, Exercise and Health Research. 2020;4(2):86-90.
  10. ↑ Schomacher J. The convex-concave rule and the lever law. Man Ther. 2009 Oct;14(5):579-82.
  11. ↑ Kaltenborn FM. Orthopedic manual therapy for physical therapists Nordic system: OMT Kaltenborn-Evjenth concept. Journal of Manual & Manipulative Therapy. 1993 Jan 1;1(2):47-51.
  12. ↑ Hsu AT, Chang JH, Chang CH. Determining the resting position of the glenohumeral joint: a cadaver study. J Orthop Sports Phys Ther. 2002 Dec;32(12):605-12.
  13. ↑ Kopack JK, Cascardi KA. Range of Motion and Manual Therapy Techniques. In Principles of Therapeutic Exercise for the Physical Therapist Assistant 2024 Jun 1 (pp. 43-62). Routledge.
  14. ↑ Pozsgai M, Péter IA, Farkas N, Than P, Nusser N. End-range Maitland mobilization decreasing pain sensitivity in knee osteoarthritis: randomized, controlled clinical trial. Eur J Phys Rehabil Med. 2022 Jun;58(3):442-451.
  15. ↑ Tse JM, Cheng G, Tyrrell JA, Wilcox-Adelman SA, Boucher Y, Jain RK, Munn LL. Mechanical compression drives cancer cells toward invasive phenotype. Proc Natl Acad Sci U S A. 2012 Jan 17;109(3):911-6
  16. ↑ Graziani V, Crosas-Molist E, George SL, Sanz-Moreno V. Organelle adaptations in response to mechanical forces during tumour dissemination. Curr Opin Cell Biol. 2024 Jun;88:102345.
  17. ↑ Altsitzioglou P, Tsukamoto S, Errani C, Tanaka Y, Mavrogenis AF. Predicting the Risk for Pathological Fracture in Bone Metastases. Current Oncology. 2025 May 28;32(6):309.
  18. ↑ Chabaud A, Tetard M, Descamps S, Nguyen C, Rannou F, Tournadre A, Lesens O, Coudeyre E. Early rehabilitation management strategy for septic arthritis of the knee. Infectious Diseases Now. 2022 May 1;52(3):170-4.
  19. ↑ LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022 Oct;33(10):2049-2102.
  20. ↑ Prall J, Dunning J, Young I, Ross M, Escaloni J, Bliton P. Pain and Disability Reduction Following Rib Manipulation in a Patient Recovering from Osteomyelitis of the Thoracic Spine. Healthcare (Basel). 2025 Jun 6;13(12):1355.
  21. ↑ Nweke CV. Joint Mobilization and Its Resultant Effects. Cross Curr. Int. J. Med. Biosci. 2023;5:72-7.
  22. ↑ Courtney CA, Witte PO, Chmell SJ, Hornby TG. Joint compression and mobilisation modulate heightened flexor withdrawal response in individuals with knee osteoarthritis. The Journal of Pain. 2010 Feb 1;11(2):179-85.
  23. ↑ Sharma A, Sharma S, Steiner LA, Brudvig TJ. Identification and effectiveness of physical therapy interventions for sacroiliac joint dysfunction in pregnant and nonpregnant adults: a systematic review. The Journal of Women's & Pelvic Health Physical Therapy. 2014 Sep 1;38(3):110-7.
  24. ↑ Nedelea DG, Vulpe DE, Gherghiceanu F, Capitanu BS, Dragosloveanu S, Stoica IC. Surgical and non-surgical management of spondylolisthesis: a comprehensive review. J Med Life. 2025 Mar;18(3):196-207.
  25. ↑ Peter WF, Swart NM, Meerhoff GA, Vliet Vlieland TP. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical therapy. 2021 Aug 1;101(8):pzab127.
  26. ↑ Thomas L, Treleaven J. Should we abandon positional testing for vertebrobasilar insufficiency?. Musculoskeletal Science and Practice. 2020 Apr 1;46:102095.
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