Immediate Effect of Ankle Mobilization on Range of Motion, Dynamic Knee Valgus, and Knee Pain in Women With Patellofemoral Pain and Ankle Dorsiflexion Restriction: A Randomized Controlled Trial With 48-Hour Follow-Up

in Journal of Sport Rehabilitation

Context: Restriction in ankle dorsiflexion range of motion (ROM) has been previously associated with excessive dynamic knee valgus. This, in turn, has been correlated with knee pain in women with patellofemoral pain. Objectives: To investigate the immediate effect of 3 ankle mobilization techniques on dorsiflexion ROM, dynamic knee valgus, knee pain, and patient perceptions of improvement in women with patellofemoral pain and ankle dorsiflexion restriction. Design: Randomized controlled trial with 3 arms. Setting: Biomechanics laboratory. Participants: A total of 117 women with patellofemoral pain who display ankle dorsiflexion restriction were divided into 3 groups: ankle mobilization with anterior tibia glide (n = 39), ankle mobilization with posterior tibia glide (n = 39), and ankle mobilization with anterior and posterior tibia glide (n = 39). Intervention(s): The participants received a single session of ankle mobilization with movement technique. Main Outcome Measures: Dorsiflexion ROM (weight-bearing lunge test), dynamic knee valgus (frontal plane projection angle), knee pain (numeric pain rating scale), and patient perceptions of improvement (global perceived effect scale). The outcome measures were collected at the baseline, immediate postintervention (immediate reassessment), and 48 hours postintervention (48 h reassessment). Results: There were no significant differences between the 3 treatment groups regarding dorsiflexion ROM and patient perceptions of improvement. Compared with mobilization with anterior and posterior tibia glide, mobilization with anterior tibia glide promoted greater increase in dynamic knee valgus (P = .02) and greater knee pain reduction (P = .02) at immediate reassessment. Also compared with mobilization with anterior and posterior tibia glide, mobilization with posterior tibia glide promoted greater knee pain reduction (P < .01) at immediate reassessment. Conclusion: In our sample, the direction of the tibia glide in ankle mobilization accounted for significant changes only in dynamic knee valgus and knee pain in the immediate reassessment.

Patellofemoral pain (PFP) is a clinical condition characterized by retropatellar or peripatellar pain that is aggravated by activities that increase the compressive forces in the patellofemoral joint.1 The PFP is the most common overuse injury of the lower limb2; its prevalence is around 20% in the general population, and women are more likely to develop PFP compared with men.3 Its recurrence rate is very high (around 70%–90%),4 and those with persistent PFP can present abnormal pain processing,5 impaired physical and sensorimotor function,6 and altered psychological factors (eg, catastrophizing and kinesiophobia).7

In some individuals, PFP may develop as a result of increased pressure and joint stress due to a reduction in the contact area in the patellofemoral joint.8 The excessive dynamic knee valgus, an abnormal movement pattern during weight-bearing activities, has been cited as one of the main factors associated with contact area reduction.911 The excessive hip adduction and internal rotation, 2 components of dynamic knee valgus, are important contributors to patella misalignment and for the increase of laterally directed forces on the patella, thus contributing to PFP.12,13 Regarding the factors associated with excessive dynamic knee valgus, it has been proposed that the restriction of ankle dorsiflexion in a closed kinetic chain can lead to excessive tibia internal rotation and excessive hip adduction and internal rotation.11,14,15 Together, these kinematic events contribute to excessive dynamic knee valgus. Lima et al16 carried out a systematic review with meta-analysis and found a strong association between limited dorsiflexion ROM and excessive dynamic knee valgus during squat and jump landing tasks. Rabin et al17 observed that women with PFP who had decreased dorsiflexion range of motion (ROM) showed excessive dynamic knee valgus during a single-leg squat task, and Almeida et al18 observed that excessive dynamic knee valgus was associated with greater knee pain intensity in women with PFP.

From the aforementioned information, we hypothesized that the use of ankle mobilization techniques could be beneficial for individuals with PFP who display ankle dorsiflexion restriction. Based on the Kaltenborn convex–concave rule,19 the tibia rolls and glides forward during ankle dorsiflexion in a closed kinetic chain. Thus, it makes sense to think that an ankle mobilization technique with anterior tibia glide could improve dorsiflexion by correcting ankle arthrokinematics. Previous studies demonstrated that ankle mobilization with an anterior tibia glide has resulted in statistically significant increases in the dorsiflexion ROM in individuals with recurrent lateral ankle sprain or chronic ankle instability.2022 However, to our knowledge, no randomized controlled trial has investigated: (1) the effect of ankle mobilization with different tibia glide directions on dorsiflexion ROM and (2) the effect of ankle mobilization on dorsiflexion range of motion, dynamic knee valgus, and knee pain in women with PFP who display ankle dorsiflexion restriction. Therefore, this study aimed to investigate the immediate effects of ankle mobilization with 3 different tibia glide directions on ankle dorsiflexion ROM, dynamic knee valgus, knee pain, and patient perceptions of improvement in women with PFP who display ankle dorsiflexion restriction.

Methods

Design

This was a randomized controlled trial with a blind evaluator, 3 parallel groups, and a balanced distribution (1:1:1). The included participants were randomly assigned to 3 treatment groups: (1) anterior mobilization group (AMG), (2) posterior mobilization group (PMG), and (3) anterior and posterior mobilization group (APMG). The randomization codes (AMG, PMG, and APMG) were computer-generated in Random Allocation Software (version 1.0.0, Mahmood Saghaei  [MD], Isfahan, Iran) by a researcher who was not involved in the data collection and analysis. The codes were placed in sealed opaque envelopes and consecutively numbered to ensure anonymity. The assessor and the therapist did not communicate during or after treatment administration.

Participants

One hundred seventeen women with PFP and ankle dorsiflexion restriction were recruited from the general community of the city of Fortaleza (Ceará, Brazil). The eligibility criteria was based on previous studies.1,23 The inclusion criteria were as follows: (1) women; (2) ages 18–35 years; (3) presence of anterior knee pain for at least 3 months, unrelated to any traumatic knee event and reproducible by performing at least 2 of the following activities: sitting for a long time, squatting, kneeling, ascending or descending stairs, walking or running long distances, and performing jump landing tasks; (4) anterior knee pain in the previous week with an intensity of at least 3 points on a numeric pain rating scale (NPRS); and (5) limited ankle dorsiflexion ROM in closed kinetic chain, identified by a weight-bearing lunge test in which the distance between the foot and wall was ≤10 cm.24 Participants were excluded if they had: (1) a history of surgery or fracture in the lumbar spine, hip, knee, ankle, or foot; (2) referred pain from the lumbar spine, hip, ankle, or foot; (3) a history of patellar subluxation; (4) knee swelling; (5) presence of meniscal, ligament, or tendon injury (confirmed by specific tests and imaging exams); or (6) Osgood–Schlatter or Siding–Larsen–Johansson syndrome.

For those who met all eligibility criteria and presented bilateral pain, the lower limb that was most painful (ie, the limb with greater knee pain intensity on NPRS in the last week) was selected for evaluation. Women were chosen for the sample because they are more likely to develop PFP3 and to exhibit greater dynamic knee valgus during functional tasks compared with men.25

The sample size was calculated a priori based on a between-group mean difference of 2.0 cm26 in the weight-bearing lunge test and SD of 3.1 cm.27 Considering a power of 80%, an alpha of 5%, and a possible 10% sample loss, 39 participants were needed in each group. The study was approved by the São Paulo University Faculty of Medicine Research Ethics Committee (protocol number: 146/16), prospectively registered in the Clinical Trials Registry (protocol number: NCT03281421), and reported in accordance with the Consolidated Standards of Reporting Trials. Written informed consent was obtained from all the subjects prior to their participation.

Procedures

All procedures (assessments and interventions) were performed at the Biomechanics Laboratory of the Physical Therapy Department at the Federal University of Ceará. Prior to recording the outcome measures, the demographic and anthropometric characteristics and subjective functional capacity of the knee were recorded in order to characterize the sample. The subjective functional capacity of the participants were recorded with the translated and validated Portuguese-language version of the anterior knee pain scale. The scores for this scale, 0 to 100, represent the lowest to the highest levels of functional capacity, respectively.28 Then, primary and secondary outcome measures were collected. Following the recording of the outcome measures, the included participants received the interventions according to randomization and were reassessed immediately and 48 hours posttreatment. The order of recording the outcome measures was standardized as follows: ankle dorsiflexion ROM, dynamic knee valgus, knee pain intensity, and participant perception of received treatment.

Interventions

The mobilization with movement (MWM) technique was the chosen intervention for the ankle joint because it is a low-cost, easy to apply technique that tends to produce immediate effects on ROM improvement, function restoration, and pain reduction.29,30 According to randomization, each included participant received a single session of ankle MWM technique, applied in 4 sets of 5 repetitions, with 1 minute of rest between sets. A therapist with 3 years of manual therapy experience applied the intervention for the included participants in each treatment group.

Previous studies demonstrated that a single session of ankle mobilization with anterior tibia glide (performed with at least 1 or up to 4 sets that account for a maximum of 20 repetitions of the ankle mobilization) promotes a significant increase in ankle dorsiflexion ROM and produces a statistically superior effect to placebo, sham intervention, and inactive treatment (ie, wait and see) in ROM increase.2022 Thus, we considered the AMG to be the comparison group, and we chose not to include a placebo, sham-intervention, or inactive treatment in present study.

Anterior Mobilization Group

To perform the MWM technique with anterior tibia glide, the participant was instructed to place the involved limb in a weight-bearing position on the treatment table while maintaining a vertical tibia position on the ankle joint. The therapist stood in front of the patient’s involved limb and used the hands to stabilize the patient’s foot as close as possible to the anterior region of the talus. A rigid belt was placed on the patient’s tibia and around the therapist’s hip. From this position, the therapist projected his hip backwards, producing a nonpainful anterior tibia glide. The participant was asked to perform a forward lunge as far as possible without raising the heel off the table and without reproducing knee symptoms. After achieving the maximum forward lunge, the participant was instructed to hold this position for 5 seconds and then return to the starting position to repeat the procedure according to the previously informed protocol (Figure 1A and B).

Figure 1
Figure 1

—Intervention and assessment procedures. (A) MWM technique with anterior tibia glide: initial position, (B) MWM technique with anterior tibia glide: final position, (C) MWM technique with posterior tibia glide: initial position, (D) MWM technique with posterior tibia glide: final position, (E) WBLT: initial position, (F) WBLT: final position, (G) FSDT: initial position, and (H) FSDT: final position. AMG indicates anterior mobilization group; APMG, anterior and posterior mobilization group; FSDT, forward step-down test; MWM, mobilization with movement; PMG, posterior mobilization group; WBLT, weight-bearing lunge test.

Citation: Journal of Sport Rehabilitation 30, 5; 10.1123/jsr.2020-0183

Posterior Mobilization Group

To perform the MWM technique with posterior tibia glide, the participant was instructed to place the involved limb on the treatment table, as was described for the AMG. The therapist stood behind the patient’s involved limb and used the hands to stabilize the patient’s foot as close as possible to the posterior region of the talus. A rigid belt was placed on the patient’s tibia and around the therapist’s trunk. From this position, the therapist projected his trunk backwards, producing a nonpainful posterior tibia glide. The participant was asked to perform a forward lunge as far as possible without raising the heel off the table and without reproducing knee symptoms. After achieving the maximum forward lunge, the participant was instructed to hold this position for 5 seconds and then return to the starting position to repeat the procedure according to the previously informed protocol (Figure 1C and D).

Anterior and Posterior Mobilization Group

To perform the MWM technique with anterior and posterior tibia glide, the participant received both the MWM technique with anterior tibia glide (Figure 1A and B) and the MWM technique with posterior tibia glide (Figure 1C and D). To standardize the number of mobilizations and the application sequence, the participant also received 4 sets of 5 repetitions (with 1 min of rest between series), in which the first 2 series consisted of the MWM technique with anterior tibia glide and the last 2 series consisted of the MWM technique with posterior tibia glide.

Outcome Measures

The primary outcome measure was the ankle dorsiflexion ROM in a closed kinetic chain, as assessed with the weight-bearing lunge test. The secondary outcome measures were the following: dynamic knee valgus, as assessed by the frontal plane projection angle during the forward step-down test; knee pain intensity, as assessed with the NPRS during the forward step-down test; and participant perception of received treatment, as assessed with the global perceived effect scale (GPES).

The ankle dorsiflexion ROM, dynamic knee valgus, and knee pain intensity were collected at 3 time points: in pretreatment (baseline), immediate posttreatment (immediate reassessment), and 48 hours posttreatment (48-h reassessment). The participant perception of received treatment was collected at 2 time points: immediate reassessment and 48-hour reassessment. An assessor with 8 years of experience in the clinical and functional evaluation of the lower limbs recorded the outcome measures. The assessor was blind regarding the treatment conditions.

Weight-Bearing Lunge Test

The weight-bearing lunge test is a valid and reliable measurement of ankle dorsiflexion ROM in a closed kinetic chain.31 The weight-bearing lunge test was performed in accordance with previous recommendations.27 The participants were instructed to place the foot of the involved limb on a measuring tape on the floor. The second toe and heel center were aligned with the tape so that the foot was 10 cm from the wall. From this position, the participant was instructed to perform a forward lunge with the involved limb. The knee was projected forward until it touched the wall without the heel lifting off the ground (Figure 1E and F). If the participant could not reach the wall with the knee, the foot was moved 1 cm forward, and the procedure was repeated until the maximum distance between the foot and the wall could be reached while the participant touched the wall with the knee without lifting the heel off the ground.

Frontal Plane Projection Angle

Frontal plane projection angle during the forward step-down test (FSDT) was evaluated by 2D kinematics in Kinovea video editor software (version 0.8.15, open source project available for download at: http://www.kinovea.org). The intrarater reliability for the FSDT has been reported as moderate to high.32 The 2D kinematic evaluations are feasible and low-cost movement analysis methods, and have satisfactory correlations with 3D kinematics.33,34 The Kinovea is a valid and reliable 2D motion analysis software that enables the analysis of joint angles from a video recording.35,36 To record the FSDT, we used a digital camera (Sony Cyber-shot DSC-W35, 7.2 megapixels).

The FSDT was performed in accordance with previous recommendations.18 Three markers were placed on the participant’s involved limb: one at the midpoint between the medial and lateral malleoli, another at the center of the patella, and another on the proximal thigh along a line from the anterior superior iliac spine to 30 cm above the knee marker. The participant was instructed to stand with the involved limb on a step, keeping the trunk straight, and place the hands on the waist. The participant was asked to bend the knee on the involved limb until the heel of the uninvolved limb touched the ground and then immediately reextend the knee of the involved limb to return to the starting position. All participants performed a maximum of 5 practice trials, rested for 2 minutes, and then performed 3 measured trials. The FPPA mean of the 3 measured trials was calculated for each participant. The step height was standardized at 10% of each participant’s height, and the digital camera was positioned 2 m from the step at the same height as the participant’s knee.

The FPPA was manually recorded when the heel of the uninvolved limb touched the ground during the test, through the intersection between the line connecting the ankle and patella markers and the line connecting the patella and thigh markers (Figure 1G and H). The knee marker in a medial position to the thigh and ankle markers were assigned positive FPPA (dynamic knee valgus), while the knee marker in the lateral position was assigned a negative FPPA (dynamic knee varus).

Numeric Pain Rating Scale and Global Perceived Effect Scale

The NPRS is a valid and reliable instrument that is recommended for use in studies that address chronic pain.37 A 10-cm long line was used (0, no pain; 10, worst possible pain) to quantify the participant’s knee pain intensity during the FSDT. The GPES is a valid instrument that is recommended for quantifying participant perception of received treatment.38 The GPES ranges from −5 (perception of great worsening) to +5 (perception of great improvement).

Statistical Analysis

Statistical analysis was performed in IBM SPSS Statistics for Windows, (version 24.0; IBM Corp, Armonk, NY). The normality of the data distribution was verified with the Kolmogorov–Smirnov test. The continuous variables are described by the mean and SD. In the baseline, the between-groups differences were tested with a one-way analysis of variance (for continuous variables) and chi-square tests (for categorical variables).

A mixed methods analysis of variance with “group by time” interaction terms was used to analyze the effects of the treatment conditions over time for each outcome measure. In all outcome measures, the treatment conditions were “AMG,” “PMG,” and “APMG.” The time points were “baseline,” “immediate postintervention,” and “48 hours postintervention” for the ankle dorsiflexion ROM, dynamic knee valgus, and knee pain intensity, and “immediate postintervention” and “48 hours postintervention” for the participant perception of received treatment. Bonferroni post hoc analysis was used to perform pairwise comparisons within-groups and between-groups. The significance level adopted was P ≤ .05 for all comparisons. Effect sizes were calculated for significant differences (in between-group analysis) according to Cohen d, in which d = 0.2 is considered a small effect, 0.5 as moderate, and 0.8 as large.39 The statistical analysis was conducted in accordance with the intention-to-treat analysis for patients in the group to which they were allocated.40 In the case of missing data at the 48-hour reassessment, multiple imputation was applied.41

Results

Between September 2017 and September 2018, 190 women were screened for eligibility. Seventy-three women were excluded, and 117 met all the eligibility criteria and were included. All participants underwent immediate reassessment, and only 9 (7.7%) did not participate in the 48-hour reassessment. The details regarding the motives of those who were excluded and those who did not participate in the 48-hour reassessment are presented in the flow diagram of the study (Figure 2). The 3 treatment groups were homogeneous on all variables and outcome measures in the baseline (Table 1).

Figure 2
Figure 2

—Flow diagram of the study.

Citation: Journal of Sport Rehabilitation 30, 5; 10.1123/jsr.2020-0183

Table 1

Demographic and Anthropometric Variables and Outcome Measures in the Baseline

VariableAMG (n = 39)PMG (n = 39)APMG (n = 39)P value
Age, y25.25 (5.34)24.56 (4.33)25.59 (5.05).64
Weight, kg64.59 (12.69)61.37 (11.22)63.82 (12.64).47
Height, m1.60 (0.06)1.60 (0.05)1.61 (0.05).69
BMI, kg/cm225.06 (5.16)23.78 (3.97)24.52 (5.33).50
Involved limbRight 18 (46.2%); left 21 (53.8%)Right 17 (43.6%); left 22 (53.4%)Right 18 (46.2%); left 21 (53.8%).96
AKPS, 0–10068.92 (9.80)68.56 (10.63)66.51 (11.53).56
WBLT, cm8.12 (1.59)8.17 (1.86)8.19 (1.79).98
FPPA, deg7.25 (8.78)5.94 (8.51)4.93 (6.90).45
NPRS, 0–102.74 (2.90)1.69 (2.58)3.02 (3.03).09

Abbreviations: AKPS, anterior knee pain scale; AMG, anterior mobilization group; APMG, anterior and posterior mobilization group; BMI, body mass index; FPPA, frontal plane projection angle; NPRS, numerical pain rating scale; PMG, posterior mobilization group; WBLT, weight-bearing lunge test. Note: Categorical variables are presented as frequencies and percentages, and continuous variables are expressed as mean (SD).

Primary Outcome Measure

For the weight-bearing lunge test, no significant differences were observed between the 3 treatment groups in the immediate and 48-hour reassessment (Table 2). In the within-group analysis, all 3 groups produced a statistically significant increase in the immediate and 48-hour reassessment (Table 2).

Table 2

Within-Groups and Between-Groups Analysis for the WBLT and FPPA

Outcome measuresGroupTimeWithin-groups differenceBetween-groups difference
WBLT, cmImmediate reassessment
BaselineImmediate reassessment48-h reassessmentΔ2 − Δ1 differenceΔ3 − Δ1 differenceAMG less PMGAMG less APMGPMG less APMG
AMG8.12 (7.51 to 8.73)9.07 (8.46 to 9.68)9.21 (8.60 to 9.82)0.94 (0.61 to 1.28) P < .01*1.08 (0.74 to 1.41) P < .01*−0.01 (−0.87 to 0.85)

P = .97
−0.42 (−1.28 to 0.43)

P = .33
−0.41 (−1.27 to 0.45)

P = .34
PMG8.19 (7.58 to 8.80)9.50 (8.89 to 10.11)9.52 (8.91 to 10.13)1.30 (0.97 to 1.64) P < .01*1.33 (0.99 to 1.66) P < .01*48-h reassessment
APMG8.19 (7.58 to 8.80)9.50 (8.89 to 10.11)9.52 (8.91 to 10.13)1.30 (0.97 to 1.64) P < .01*1.33 (0.99 to 1.66) P < .01*AMG less PMGAMG less APMGPMG less APMG
0.23 (−0.62 to 1.09)

P = .59
−.31 (−1.17 to 0.54)

P = .47
−.54 (−1.41 to 0.31)

P = .20
FPPA, degImmediate reassessment
BaselineImmediate reassessment48-h reassessmentΔ2 − Δ1 differenceΔ3 − Δ1 differenceAMG less PMGAMG less APMGPMG less APMG
AMG7.25 (4.71 to 9.78)9.13 (6.59 to 11.66)7.82 (5.28 to 10.35)1.87 (0.27 to 3.48) P = .02*0.56 (−1.03 to 2.17) P = .480.97 (−2.60 to 4.56) P = .594.01 (0.43 to 7.60) P = .02*3.04 (−0.54 to 6.62) P = .09
PMG5.94 (3.41 to 8.48)8.15 (5.62 to 10.69)7.12 (4.59 to 9.66)2.20 (0.60 to 3.80) P < .01*1.17 (−0.42 to 2.77) P = .1448-h reassessment
APMG4.93 (2.40 to 7.47)5.11 (2.58 to 7.65)4.48 (1.95 to 7.02)0.17 (−1.42 to 1.78) P = .82−0.44 (−2.05 to 1.15) P = .58AMG less PMGAMG less APMGPMG less APMG
0.69 (−2.88 to 4.28) P = .703.33 (−0.24 to 6.92) P = .062.63 (−0.94 to 6.22) P = .14

Abbreviations: Δ2 − Δ1 difference, immediate reassessment less baseline; Δ3 − Δ1 difference, 48-hour reassessment less baseline; AMG, anterior mobilization group; APMG, anterior and posterior mobilization group; CI, confidence interval; FPPA, frontal plane projection angle; PMG, posterior mobilization group; WBLT, weight-bearing lunge test. Note: In time moments, the values are presented as mean (95% CI). Both in within-groups and between-groups difference, the values are presented as mean difference (95% CI) and statistical significance (P value).

*Statistically significant difference (P < .05).

Secondary Outcome Measures

For the FPPA, the AMG produced a greater increase (small effect size: 0.22 [−0.23 to 0.66]) on dynamic knee valgus when compared with the APMG in the immediate reassessment (P = .02; Table 2). In the within-group analysis, the AMG and PMG produced a statistically significant increase in the immediate reassessment (AMG, P = .02; PMG, P < .01; Table 2). For the NPRS, the AMG and PMG produced greater knee pain reduction (AMG, small effect size: −0.40 [−0.85 to 0.05]; PMG, small effect size: −0.21 [−0.65 to 0.24]) when compared with the APMG in the immediate reassessment (AMG less APMG, P = .02; PMG less APMG, P < .01; Table 3). In the within-group analysis, the AMG produced a statistically significant reduction in the immediate (P < .01; Table 3) and 48-hour (P < .01; Table 3) reassessment, and the APMG produced a statistically significant reduction in the 48-hour reassessment (P < .01; Table 3). For the GPES, no significant differences were observed between the 3 treatment groups in the immediate and 48-hour reassessment (Table 3).

Table 3

Within-Groups and Between-Groups Analysis for the NPRS and GPES

Outcome measuresGroupTimeWithin-groups differenceBetween-groups difference
NPRS (0–10)Immediate reassessment
BaselineImmediate reassessment48-h reassessmentΔ2 − Δ1 differenceΔ3 − Δ1 differenceAMG less PMGAMG less APMGPMG less APMG
AMG2.74 (1.96 to 3.52)1.66 (0.89 to 2.44)1.37 (0.59 to 2.14)−1.07 (−1.79 to −0.35) P < .01*−1.37 (−2.09 to −0.65) P < .01*0.43 (−0.66 to 1.53) P = .43−1.23 (−2.32 to −0.13) P = .02*−1.66 (−2.76 to −0.56) P < .01*
PMG1.69 (0.91 to 2.46)1.23 (0.45 to 2.00)1.20 (0.42 to 1.98)−0.46 (−1.18 to 0.26) P = .20−0.48 (−1.20 to .23) P = .1848-h reassessment
APMG3.02 (2.24 to 3.80)2.89 (2.12 to 3.67)1.82 (1.04 to 2.59)−0.12 (−0.85 to 0.59) P = .72−1.20 (−1.92 −0.48) P < .01*AMG less PMGAMG less APMGPMG less APMG
0.16 (−0.93 to 1.26) P = .76−0.44 (−1.54 to 0.64) P = .42−0.61 (−1.71 to 0.48) P = .27
GPES (−5/+5)Immediate reassessment
BaselineImmediate reassessment48-h reassessmentΔ2 − Δ1 differenceΔ3 − Δ1 differenceAMG less PMGAMG less APMGPMG less APMG
AMG−0.30 (−0.92 to 0.31)0.34 (−0.27 to 0.96)0.56 (−1.44 to 0.31) P = .20−0.41 (−1.28 to 0.46) P = .350.15 (−0.72 to 1.02) P = .73
PMG0.25 (−0.36 to 0.87)0.54 (−0.07 to 1.16)48-h reassessment
APMG0.10 (−0.51 to 0.72)0.58 (−0.03 to 1.20)AMG less PMGAMG less APMGPMG less APMG
−0.19 (−1.07 to 0.67) P = .65−0.23 (−1.11 to 0.63) P = .59−0.03 (−0.91 to 0.83) P = .93

Abbreviations: Δ2 − Δ1 difference, immediate reassessment less baseline; Δ3 − Δ1 difference, 48-hour reassessment less baseline; AMG, anterior mobilization group; APMG, anterior and posterior mobilization group; CI, confidence interval; GPES, global perceived effect scale; NPRS, numeric pain rating scale; PMG, posterior mobilization group. Note: In time moments, the values are presented as mean (95% CI). Both in within-groups and between-groups difference, the values are presented as mean difference (95% CI) and statistical significance (P value).

*Statistically significant difference (P < .05).

Discussion

Our results showed that the direction of the tibia glide in the MWM technique had no influence on greater gain in dorsiflexion ROM, contrary to the Kaltenborn rule. Previous studies have shown that ankle mobilization with anterior tibia glide has resulted in significant increases in the dorsiflexion ROM.2022 However, no other study that investigated the effect of different tibia glide directions on dorsiflexion ROM was found. Brandt et al42 performed a systematic review of the validity of the Kaltenborn rule and suggested that changes in arthrokinematic motion might be affected by the tension of the passive tissues (capsule and ligaments). Thus, the direction of the glide could result in gains in ROM by the normalization of the tension of the passive tissues even if the glide is contrary to the Kaltenborn rule. This may explain the absence of between-group differences for the dorsiflexion ROM. However, more studies are needed to confirm this hypothesis.

In addition to ankle arthrokinematic dysfunction, the tightness of the calf muscles can also limit ankle dorsiflexion ROM.43,44 However, there is no information about which of the 2 mechanisms (arthrokinematic dysfunction or tightness muscles) is the main limiting factor for ankle dorsiflexion. Since we did not include a calf muscle stretching group, future studies are needed to investigate whether muscle stretching is more effective than joint mobilization in improving ankle dorsiflexion ROM.

Regarding FPPA, our results showed that AMG produced a greater increase (with small effect size) on dynamic knee valgus when compared with the APMG in the immediate reassessment. The fact that the APMG was submitted to tibia mobilization in 2 directions may have contributed to a greater change in the tension state of the passive ankle tissues. This may have promoted a greater increase in degrees of freedom in the ankle and, consequently, avoided an increase in dynamic knee valgus in the APMG. However, because we did not measure the ankle ROM in other plans, we cannot state that the observed differences occurred because of above described mechanism. Howe45 investigated the immediate effects of a single session protocol with 3 ankle mobilization techniques on the dorsiflexion ROM and 3D kinematics of the lower limb during FSDT. The participants were 8 healthy males with restricted ankle dorsiflexion. The intervention protocol produced a significant increase in ankle dorsiflexion ROM (mean difference: 2.425 cm [0.937], P < .01); however, significant changes in the lower limb kinematics were not observed. Despite the differences between our study and that of the Howe,45 the results of the 2 studies suggest that ankle mobilization might not reduce dynamic knee valgus.

Regarding knee pain intensity, our results showed that the AMG and PMG produced greater knee pain reduction when compared with the APMG in the immediate reassessment. In both comparisons (AMG vs APMG and PMG vs APMG), the effect size was small and the differences was not clinically relevant (ie, <2 points in the NPRS46). According to the principles of the Mulligan concept,29,30 the joint glide preferably should be applied in a specific direction to promote its beneficial effects. The literature also suggests that joint mobilization can minimize the nociceptors’ activation and increase peripheral inhibition,47,48 in addition to producing neurophysiologic effects at the medullary and supramedullary levels, which could influence central pain processing and contribute to pain reduction in the regions adjacent to joint mobilization.49,50 Given that in the APMG the joint glide was applied in 2 different and opposite directions and that each glide direction was performed with half of the number of sets and repetitions performed in the AMG and PMG, this may have decreased the ability of the APMG to reduce knee pain. However, more studies are needed to confirm this hypothesis. Moreover, as we did not use an inactive treatment group, we cannot say if the observed changes in the AMG and PMG occurred as a result of the ankle mobilization or for other reasons (eg, Hawthorne effect and natural history of disease). Anyway, the knee pain reduction observed in the AMG and PMG was not clinically important. This may have occurred due to a low dose of the applied treatments.

Regarding participant perception of received treatment, our results showed that the direction of the tibia glide in the MWM technique had no influence on the greater change in this outcome measure (both in the immediate reassessment and 48-h reassessment). No other study that investigated the effect of different tibia glide directions on participant perception of received treatment was found. Evidence shows that home exercises combined with manual therapy are more beneficial than home exercises combined with sham manual therapy to produce a greater perception of improvement in patients with chronic ankle instability51 and that muscle strengthening and motor control exercises are more beneficial than muscle strengthening alone to produce a greater perception of improvement in patients with PFP.52 In both studies, the treatment protocol had a longer duration time (4 and 8 wk, respectively). Since in our study the treatment protocol was performed in a single session, this may have contributed to the absence of a between-groups difference. More studies are needed to confirm this hypothesis.

Caution is suggested in the interpretation of the results of this study because of some important limitations. First,  several factors are associated with PFP; thus, a randomized controlled trial that aimed to change one factor (restriction of ankle dorsiflexion) might not have been sufficient to generate greater changes. Second, we analyzed the immediate effects of a single session of ankle mobilization, and the dose of the treatment may have been insufficient to promote greater changes. Third, we did not include an inactive treatment group to investigate if the observed changes occurred as a result of the ankle mobilization or for other reasons (eg, Hawthorne effect and natural history of disease). Lastly, the sample was composed of women only; thus, the results cannot be generalized to males.

Conclusion

The results of the current study indicate that the direction of the tibia glide in the MWM technique influenced the occurrence of greater changes only in the dynamic knee valgus and knee pain intensity (both with a small effect size). The MWM technique with anterior tibia glide led to a greater increase in dynamic knee valgus when compared with the MWM technique with anterior and posterior tibia glide, and the MWM technique with either anterior or posterior tibia glide led to a greater knee pain reduction when compared with the MWM technique with anterior and posterior tibia glide.

Acknowledgments

The authors would like to acknowledge São Paulo University and the Federal University of Ceará.

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Coelho and João are with the Musculoskeletal Evaluation Laboratory, Department of Physical Therapy, Speech Therapy and Occupational Therapy, Faculty of Medicine, São Paulo University, São Paulo, Brazil. Coelho, Rodrigues, and Almeida are with the Knee and Sport Research Group, Department of Physical Therapy, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil.

Coelho (brunolimafisioterapia@outlook.com) is corresponding author.
  • View in gallery

    —Intervention and assessment procedures. (A) MWM technique with anterior tibia glide: initial position, (B) MWM technique with anterior tibia glide: final position, (C) MWM technique with posterior tibia glide: initial position, (D) MWM technique with posterior tibia glide: final position, (E) WBLT: initial position, (F) WBLT: final position, (G) FSDT: initial position, and (H) FSDT: final position. AMG indicates anterior mobilization group; APMG, anterior and posterior mobilization group; FSDT, forward step-down test; MWM, mobilization with movement; PMG, posterior mobilization group; WBLT, weight-bearing lunge test.

  • View in gallery

    —Flow diagram of the study.

  • 1.

    Crossley KM, Stefanik JJ, Selfe J, et al. . 2016. Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. Br J Sports Med. 2016;50(14):839843. PubMed ID: 27343241 doi:10.1136/bjsports-2016-096384

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Davis IS, Powers CM. Patellofemoral pain syndrome: proximal, distal, and local factors, an international retreat, April 30–May 2, 2009, Fells Point, Baltimore, MD. J Orthop Sports Phys Ther. 2010;40(3):A116. PubMed ID: 20195028 doi:10.2519/jospt.2010.0302

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Smith BE, Selfe J, Thacker D, et al. . Incidence and prevalence of patellofemoral pain: a systematic review and meta-analysis. PloS One. 2018;13(1):e0190892. PubMed ID: 29324820 doi:10.1371/journal.pone.0190892

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Stathopulu E, Baildam E. Anterior knee pain: a long-term follow-up. Rheumatology. 2003;42(2):380382. PubMed ID: 12595641 doi:10.1093/rheumatology/keg093

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Rathleff MS, Petersen KK, Arendt-Nielsen L, Thorborg K, Graven-Nielsen T. Impaired conditioned pain modulation in young female adults with long-standing patellofemoral pain: a single blinded cross-sectional study. Pain Med. 2016;17(5):980988. PubMed ID: 26814253 doi:10.1093/pm/pnv017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Yilmaz Yelvar GD, Çirak Y, Dalkilinç M, et al. . Impairments of postural stability, core endurance, fall index and functional mobility skills in patients with patello femoral pain syndrome [published online ahead of print June 30, 2016]. J Back Musculoskelet Rehabil. 30:163–170. doi:10.3233/BMR-160729

    • Search Google Scholar
    • Export Citation
  • 7.

    Doménech J, Sanchis-Alfonso V, Espejo B. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):22952300. PubMed ID: 24691626 doi:10.1007/s00167-014-2968-7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Ho KY, Keyak JH, Powers CM. Comparison of patella bone strain between females with and without patellofemoral pain: a finite element analysis study. J Biomech. 2014;47(1):230236. PubMed ID: 24188973 doi:10.1016/j.jbiomech.2013.09.010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639646. PubMed ID: 14669959 doi:10.2519/jospt.2003.33.11.639

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):4251. PubMed ID: 20118526 doi:10.2519/jospt.2010.3337

    • Crossref
    • PubMed
    • Search Google Scholar
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