November 2021, Volume 71, Issue 11

Original Article

Effects of tibiofemoral mobilization in patients of Patellofemoral pain syndrome

Ishrat Fatimah  ( Department of Rehabilitation Sciences, Ahmed Medical Institute, Peshawar, Pakistan. )
Saira Waqqar  ( Department of Riphah College of Rehabilitation and Allied Health Sciences, Riphah International University, Islamabad, Pakistan. )


Objective: To determine the effects of tibiofemoral joint mobilisation on pain and range of motion in patients with patellofemoral pain syndrome.

Methods: The randomised control trial was conducted at the Lady Reading Hospital and Hayatabad Medical Complex, Peshawar, Pakistan, from July to December 2019, and comprised patellofemoral pain syndrome patients of either gender aged 25-35 years with anterior knee pain for at least one month. The subjects were randomly allocated control group A and experimental group B. Group A received 6 stretching and strengthening exercises of hip and knee muscles with hot pack, while group B additionally received tibiofemoral joint mobilisation. There were 3 sessions per week over 4 weeks for both the groups. Numeric pain rating scale, Kujala scale, algometer and goniometer were used to assess pain and range of motion at baseline and at the end of the last session. Data was analysed using SPSS 20.

Results: Of the 60 individuals initially assessed, 52(86.6%) were enrolled; 26(50%) in each of the two groups. The overall mean age of the sample was 29.63±3.25 years. The experimental group B showed significant improvement in pain, range of motion and pressure pain threshold (p<0.05) compared to the control group A. Group B also showed significant improvement in terms of functional activities (p<0.05). Except patellar instability and weight-bearing activities, the groups showed no significant difference (p>0.05).

Conclusion: Tibiofemoral joint mobilisations with hip and knee stretching and strengthening exercises were found to be more effective in reducing pain, and increasing range of motion as well as pressure pain threshold.

Clinical Trial Number: Identifier: NCT04225000:

Keywords: Kujala anterior knee pain scale, Numerical pain rating scale, Patellofemoral pain syndrome, Pressure pain threshold, Tibiofemoral mobilisation. (JPMA 71: 2506; 2021)





Patellofemoral pain syndrome (PFPS) is a common condition associated with overuse injuries of the lower extremity. It is characterised by anterior knee pain (AKP) which tends to worsen with activity of daily living (ADLs), like prolonged sitting with knee-bend, walking, squatting, running and jumping.1-4 It is caused by abnormal biomechanics and abnormal arrangement of patella.5 Abnormal biomechanics lead to muscle imbalance among vastus medialis oblique (VMO) and vastus lateralis (VL). The VMO muscle works relative to the VL muscle. When it does not work properly, like delayed recruitment of VMO relative to VL, it leads to patellar maltracking.6

PFPS is highly difficult to treat.4 Physical therapy (PT) is the first-line treatment programme as non-operative management.7 PT treatment of PFPS for pain reduction and restoration of muscle balance include manual techniques, therapeutic modalities, exercise therapy and techniques of knee-taping and re-establishment of functional activities.8 Exercise therapy of PFPS include muscle strengthening, stretching, isometric and resisted exercises.9 Mobilisation is low-amplitude passive movements that produce traction and gliding at the joint surface, i.e. joint play movements.10 The therapeutic purpose of this technique is improving range of motion (ROM), pain relief, reduction of muscle guarding, and effusion reduction.11 According to a study, afferent inputs from the surrounding tissues alter motor regulation at joint dysfunction which can be responsible for the weakness of the muscle.12 Mobilisation of dysfunctional and restricted joint generates arthrokinetic reflex which removes the inhibition and improves the strength of the muscle.13 As such, joint mobilisation and manipulation reduce pain and activate the weak muscle  in PFPS patients by stimulating sensory receptors within and around the joint.14

There is limited literature on the effects of tibiofemoral joint (TFJ) mobilisation in patients with PFPS. A search on PubMed, PEDro, Cochrane library and Google Scholar databases revealed no randomised controlled trial (RCT) determining the effects of TFJ mobilisation in PFPS.

The current study was planned to determine the effects of TFJ mobilisation on pain and ROM in PFPS patients.


Patients and Methods


The RCT was conducted at the Lady Reading Hospital and Hayatabad Medical Complex, Peshawar, Pakistan, from July to December 2019. After approval from the ethics review committee of Riphah College of Rehabilitation Sciences, Rawalpindi, the sample size was calculated using OpenEpi version 3.0115 by applying a two-group means comparison, post  t-test values of control and treatment groups while keeping power at 0.90 or 90%, mean difference of Numeric pain rating scale (NPRS) ascending stairs 2±0.8 and level of significance 0.05.16 The study trial was registered at with registry number NCT04225000 .The sample was raised using non-probability purposive sampling technique from among PFPS patients of either gender aged 25-35 years with AKP intensity level of 3≥ on NPRS during stepping up and down a 25-cm height for at least one month Reported knee pain had to be on anterior peripatellar or retropatellar site during at least two of the following activities: stairs climbing, kneeling, prolonged sitting, running, squatting and jumping. Patients with spinal referred pain, history of medication, or those who had undergone any PT or acupuncture treatment for the knee joint within the preceding 30 days  were excluded, and so were those with history of knee surgery, arthritis, patellar subluxation or dislocation, malalignment, ligament laxity, or other irregularities, such as leg length discrepancy 2 cm.

For clinical assessment, the following criteria was used: pain during patellar compression test, apprehension test and crepitation on compression test.3,16,17

After taking written informed consent, the patients were randomised into control group A and experimental group B using sequence generation through opaque sealed envelope as allocation concealment.

Patient in group A received 3 sessions per week over 4 weeks. Each session consisted of hip and knee stretching and strengthening exercises along with hot-pack. Exercises included semi-squatting, straight leg raise (SLR) and hamstring stretch, quadriceps isometrics, terminal knee extension with elastic band, adductor squeeze and hip abduction in standing position with elastic band. Each set consisted of 15 repetitions of stretching and strengthening exercises with 10 sec hold three times a day.17,18 Each session lasted approximately 25-30 minutes.

Patient in group B also received the same number of sessions over the same duration. The treatment consisted of of TFJ mobilisation through anterior-posterior (AP) glide, which is the Kaltenborn technique, along with exercises and hot-pack provided to the other group.18

According to concave on convex rule, grade II or III AP tibial glide was performed. TFJ mobilisation was performed in supine position with knee flexion in approximately 45º or 90º according to patient comfort. Knee was mobilised at 45º  with limited knee flexion when <100º and the knee was mobilised at 90º in patients with knee flexion >100º.9,19

The primary outcome variables were changes in pain intensity and ROM of the knee joint. For pain intensity, 11-item NPRS scale ranging 0-10 was used; 0 = the least pain, and 10 = extreme pain.20 Algometer was used to determine the pressure-pain threshold (PPT).21

Universal goniometer was used to measure ROM of the knee joint extension. It is a universal tool and is most commonly used for evaluating ROM in hospitals and clinics.22

As a secondary outcome measurement, the 13-item Kujala questionnaire  with 3-5 options22 for pain severity, symptoms and specific activities was used. The scale was used to determine the functional activity level of patients at baseline and at the end of the last session. The total sum of the scale ranges 0-100; 0 = greatest limitation of the knee function, and 100 = the greatest ability to perform most knee functions.23

Data was analysed using SPSS 20. Kolmogorov was used to check data normality. For non-normally distributed data, non-parametric Mann Whitney U (two-related-sample) test was used to check the intergroup significance, and Wilcoxon signed rank test for intragroup analysis. Median and inter-quartile range (IQR) values was used to express the data that was ordinal-ranked, like limping, walking, stair climbing, squatting, weight-bearing, running, jumping, and sitting with prolonged knee-bend. Parametric independent-sample t test for intergroup and paired-sample t test for intragroup analyses were used for normally-distributed variables. P<0.05 was considered statistically significant.




Of the 60 individuals initially assessed, 52(86.6%) were enrolled; 26(50%) in each of the two groups. The overall mean age of the sample was 29.63±3.25 years, and there were 39(75%) females and 13(25%) males. Further, 41(78.8%) patients reported pain in the right knee, and 28(53.8%) had pain in the anterior location (Table 1).

There was significant improvement in terms of NPRS score, PPT, ROM Kujala score in group B compared to group A (p<0.05) (Table 2).

Group B also showed significant improvement in functional activities, like limping, walking, squatting, prolonged sitting with flex knee, walking, stairs climbing, running and jumping (p<0.05), while no significant difference was observed in terms of weight-bearing and patellar instability across the 4 weeks of intervention (p>0.05) (Table 3).




PFPS is a common knee joint problem associated with AKP and limited ROM. Patellar maltracking is a major feature due to weak adjunct hip and knee muscle strength. The PFPS syndrome restricts the functional activities of patients.24 Different PT treatment approaches have been reported to be effective in the PRFPS management, but no one technique has been proven to be superior over the rest.25

In the current study, TFJ mobilisation produced great improvement through significant reduction in pain, enhancement in PPT and knee-joint ROM and restoration in functional activities except weight-bearing and patellar instability.

The current study showed that females were more affected with PFPS than males, which is in line with literature.26,27 One study concluded that females are at high incidence of developing PFPS due to difference in anatomical and biomechanical factors, like q angle (increased static measure in females), lower extremity muscle strength (weaker in females, i.e. quadriceps, hip external rotators, hip extensors and hip abductors) and dynamic frontal plan alignment (increased knee valgus angle, valgus movement, hip internal rotation angle and decreased knee flexion angle).28

The repetitive passive joint gliding movement improves nutrition, blood flow, and joint lubrication further restores mobility. It also helps to normalise the joint kinematic, gliding and rolling movement.29

Studies concluded that both six-week exercise programmes focussing on the hip and the knee were equally effective to improve functional activities and muscle strength, and in reducing pain of PFPS patients.1,30 The current study found remarkable improvement in pain, ROM and functional activities within 4 weeks of TFJ mobilisation along with exercises which is in accordance with literature.1 A case  of PFPS patient managed with TFJ mobilisation (AP glide III) with home plan exercises increased PPT due to decreased active nociceptive pathways and eliminated central sensitisation of pain.19 These findings are in support of the results of the current study.

One study compared knee manipulation with the patellar medial glide with local lateral retinacular massage, and concluded that knee mobilisation indicated remarkable improvement in  pain and ROM compared to patellar medial glide with lateral retinacular massage treatment.17

The current study has limitations as it had a short duration which was not enough to rule out long-term effects of the intervention. Also, the study did not assess the physical activity level of the patients that might have indicated the association between physical activity and PFPS development. Further studies should focus on long-term effects of TFJ mobilisation (Kaltenborn) along with strengthening and stretching exercises and its effects on physical activity levels in patients with and without PFPS.




TFJ mobilisation with hip and knee stretching and strengthening exercises effectively reduced pain intensity, improved ROM with improvement in PPT in PSPF patients compared to conventional PT. TFJ mobilisation with hip and knee joint exercises were also effective in improving functional activities except weight-bearing and patellar instability.


Disclaimer: The text is based on an academic thesis.

Conflict of interest: None.

Source of Funding: None.




1.      Hott A, Brox JI, Pripp AH, Juel NG, Paulsen G, Liavaag S. Effectiveness of isolated hip exercise, knee exercise, or free physical activity for Patellofemoral pain: a randomized controlled trial. Am J Sports Med. 2019; 47:1312-22.

2.      Collins NJ, Barton CJ, Van Middelkoop M, Callaghan MJ, Rathleff MS, Vicenzino BT, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018; 52:1170-8.

3.      Briani RV, Pazzinatto MF, Silva DDO, Azevedo FM. Different pain responses to distinct levels of physical activity in women with patellofemoral pain. Braz J Phys Ther. 2017; 21:138-43.

4.      Crossley KM, van Middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med. 2016; 50:844-52.

5.      Décary S, Fallaha M, Pelletier B, Frémont P, Martel-Pelletier J, Pelletier J-P, et al. Diagnostic validity and triage concordance of a physiotherapist compared to physicians’ diagnoses for common knee disorders. BMC Musculoskelet Disord. 2017; 18:445.

6.      Smith BE, Selfe J, Thacker D, Hendrick P, Bateman M, Moffatt F, et al. Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis. PloS One. 2018; 13:e0190892.

7.      Powers CM, Witvrouw E, Davis IS, Crossley KM. Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3. Br J Sports Med. 2017; 51:1713-23.

8.      Logan CA, Bhashyam AR, Tisosky AJ, Haber DB, Jorgensen A, Roy A, et al. Systematic review of the effect of taping techniques on patellofemoral pain syndrome. Sports Health. 2017; 9:456-61.

9.      Alba-Martín P, Gallego-Izquierdo T, Plaza-Manzano G, Romero-Franco N, Núñez-Nagy S, Pecos-Martín D. Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: a systematic review. J Phys Ther Sci. 2015; 27:2387-90.

10.    Espí-López GV, Arnal-Gómez A, Balasch-Bernat M, Inglés M. Effectiveness of manual therapy combined with physical therapy in treatment of patellofemoral pain Syndrome: Systematic review. J Chiropr Med. 2017; 16:139-46.

11.    Neal BS, Lack SD, Lankhorst NE, Raye A, Morrissey D, van Middelkoop M. Risk factors for patellofemoral pain: a systematic review and meta-analysis. Br J Sports Med. 2019; 53:270-81.

12.    Page P, Frank C, Lardner R. Assessment and treatment of muscle imbalance: the Janda approach. J Orthop Sports Phys Ther. 2011; 41:799-800.

13.    Holden S, Rathleff MS, Jensen MB, Barton CJ. How can we implement exercise therapy for patellofemoral pain if we don’t know what was prescribed? A systematic review. Br J Sports Med. 2018; 52:385.

14.    Bolgla LA, Boling MC, Mace KL, DiStefano MJ, Fithian DC, Powers CM. National Athletic Trainers' Association Position Statement: Management of Individuals With Patellofemoral Pain. J Athl Train. 2018; 53:820-36.

15.    Dean A, Sullivan K, Soe M. OpenEpi: Open source epidemiologic statistics for public health, version 3.01. [Online] [Cited 2020 May 21]. Available from: URL: http://www openepi com

16.    Fukuda TY, Rossetto FM, Magalhães E, Bryk FF, Garcia Lucareli PR, de Almeida Carvalho NA. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther. 2010; 40:736-42.

17.    Altmış H, Oskay D, Elbasan B, Düzgün İ, Tuna Z. Mobilization with movement and kinesio taping in knee arthritis-evaluation and outcomes. Int Orthop. 2018; 42:2807-15.

18.    ŞAHİN M, Ayhan FF, Borman P, ATASOY H. The effect of hip and knee exercises on pain, function, and strength in patientswith patellofemoral pain syndrome: a randomized controlled trial. Turk J Med Sci. 2016; 46:265-77.

19.    Lantz JM, Emerson-Kavchak AJ, Mischke JJ, Courtney CA. Tibiofemoral joint mobilization in the successful management of patellofemoral pain syndrome: a case report. Int J Sports Phys Ther. 2016; 11:450-61.

20.    Chuang LL, Lin KC, Hsu AL, Wu CY, Chang KC, Li YC, et al. Reliability and validity of a vertical numerical rating scale supplemented with a faces rating scale in measuring fatigue after stroke. Health Qual Life Outcomes. 2015; 13:91.

21.    Ko SJ, Kim H, Kim SK, Park K, Lee J, Lee BJ, et al. Reliability and validity of modified algometer in abdominal examination. Evid Based Complement Alternat Med. 2016; 2016:3052954.

22.    Wellmon RH, Gulick DT, Paterson ML, Gulick CN. Validity and reliability of 2 goniometric mobile apps: device, application, and examiner factors. J Sport Rehabil. 2016; 25:371-9.

23.    Lankhorst N, van Middelkoop M, Crossley K, Bierma-Zeinstra S, Oei E, Vicenzino B, et al. Factors that predict a poor outcome 5–8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2016; 50:881-6.

24.    Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral pain syndrome. Am Fam Physician. 2019; 99:88-94.

25.    Crossley K, Bennell K, Green S, McConnell J. A systematic review of physical interventions for pattellofemoral pain syndrome. Clin J sport Med.2001; 11:103-10.

26.    Vora M, Curry E, Chipman A, Matzkin E, Li X. Patellofemoral pain syndrome in female athletes: a review of diagnoses, etiology and treatment options. Orthop Rev (Pavia). 2017; 9:7281.

27.    Selhorst M, Rice W, Degenhart T, Jackowski M, Tatman M. Evaluation of a treatment algorithm for patients with patellofemoral pain syndrome: a pilot study. Int J Sports Phys Ther. 2015; 10:178-88.

28.    Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sport. 2010; 20:725-30.

29.    Alsulaimani B. Effectiveness of patellar mobilization in patellofemoral pain syndrome. MOJ Orthop Rheumatol. 2019; 11:31-3.

30.    Santos TR, Oliveira BA, Ocarino JM, Holt KG, Fonseca ST. Effectiveness of hip muscle strengthening in patellofemoral pain syndrome patients: a systematic review. Braz J Phys Ther. 2015; 19:167-76.


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