Knee Mobilisations

Original Editor - David Drinkard

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This article is currently under review and may not be up to date. Please come back soon to see the finished work! (9/02/2024) 

Introduction

Knee joint mobilisations are manual physical therapy interventions, also known as nonthrust manipulation. 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.

There are 4 types of mobilisation grades whose application is based on the amount of resistance and magnitude of movement that depend on the aim of treatment.

• 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.

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

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.  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. 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.

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

Tibiofemoral articulations

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

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

Indications

• Initial treatment and general mobility of the patient
• Pain control

Tibiofemoral Distraction (High sitting position, Supine lying, and Prone lying )

Patient position/Hand placement/Mobilising force

The patient is positioned in prone with thigh fixated to the table via the use of a stabilising belt. 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. This technique is particularly effective for pain control; other positions may be more beneficial for higher-grade mobilisations to increase general joint play and flexion. An alternative position is performed with the patient sitting with the leg hanging off a table or in supine lying position.

Anterior Glide

The indication for anterior glide is to increase knee extension. The patient is positioned in crook lying which is the drawer test position. The mobilising force comes from the fingers on posterior tibia.as the therapist lean 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 /medially over the tibial plateau.

Posterior Glide

The patient is positioned in supine lying with the knee slightly flexed and a prop placed under the distal femur. The stabilising hand is used to prop the distal femur and the mobilising hand is placed over the proximal tibia just below the tibial tuberosity. The mobilisation itself is performed by a force perpendicular to the line of the tibia. This technique is useful for obtaining joint play necessary for knee flexion. 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.

Rotational Glides

Internal and external rotation glides are useful for gaining joint play for knee flexion and extension, respectively. These glides can be performed at various points in the normal ROM of the knee with the patient positioned in supine. 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

Patellofemoral glides are used when restriction of the patellofemoral joint causes pain or decreased overall knee ROM/function.

Medial/lateral glides are utilised for knee rotation improvement. The patient is in supine position with the knee slightly flexed. 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. 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.