Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral

“Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral
Pain: A Randomized Placebo-Controlled Trial” by Nunes GS et al.

Journal of Sport Rehabilitation
© 2019 Human Kinetics, Inc.
Note: This article will be published in a forthcoming issue of

the Journal of Sport Rehabilitation. The article appears here
in its accepted, peer-reviewed form, as it was provided by the
submitting author. It has not been copyedited, proofed, or
formatted by the publisher.
Section: Original Research Report
Article Title: Acute Effects of Hip Mobilization With Movement Technique on Pain and
Biomechanics in Females With Patellofemoral Pain: A Randomized Placebo-Controlled Trial
Authors: Guilherme S. Nunes a, Débora Faria Wolf a, Daniel Augusto dos Santos a, Marcos
de Noronha b, and Fábio Viadanna Serrão a
Affiliations: a Department of Physiotherapy, Federal University of São Carlos, São Carlos,

São Paulo, Brazil. b Department of Community and Allied Health, La Trobe University,
Bendigo, Victoria, Australia.
Running Head: Hip mobilization for patellofemoral pain
Journal: Journal of Sport Rehabilitation
Acceptance Date: May 12, 2019
©2019 Human Kinetics, Inc.
DOI: https://doi.org/10.1123/jsr.2018-0497
Title page
ACUTE EFFECTS OF HIP MOBILIZATION WITH MOVEMENT TECHNIQUE ON
PAIN AND BIOMECHANICS IN FEMALES WITH PATELLOFEMORAL PAIN: A
RANDOMIZED PLACEBO-CONTROLLED TRIAL
Hip mobilization for patellofemoral pain
Guilherme S. Nunes a, Débora Faria Wolf a, Daniel Augusto dos Santos a,

Downloaded by BETHEL UNIVERSITY on 05/29/19
Marcos de Noronha b, Fábio Viadanna Serrão a
a
Department of Physiotherapy, Federal University of São Carlos, São Carlos, São Paulo,
Brazil.
b
Department of Community and Allied Health, La Trobe University, Bendigo, Victoria,
Australia.
Acknowledgment: The authors would like to acknowledge Sao Paulo Research Foundation -
FAPESP (process 2015/15391-0 and 2015/01704-7).
Declarations of conflict interest: none
Brazilian clinical trials registry (RBR-55kzbn)
Address for correspondence: Guilherme S. Nunes

Rod. Washington Luis, km 235 - São Carlos - SP - Brazil - CEP 13565-905
Email: nunesguilherme@live.com
ABSTRACT
Context: People with patellofemoral pain (PFP) present altered lower limb movements during
some activities. Perhaps, joint misalignment in the hip is one of the reasons for altered
movement patterns in people with PFP. Some mobilization techniques have been designed to
address joint misalignments.
Objective: To investigate the acute effects of hip mobilization-with-movement (MWM)

technique on pain and biomechanics during squats and jumps in females with and without PFP.
Design: Randomized placebo-controlled trial.
Setting: Movement analysis laboratory.
Patients: Fifty-six physically active females (28 with PFP and 28 asymptomatic) divided into
four groups: PFP experimental and sham, and asymptomatic experimental and sham.
Intervention(s): The experimental groups received MWM for the hip and the sham groups
received sham mobilization.
Main Outcome Measures: Pain, trunk and lower limb kinematics, and hip and knee kinetics
during single-leg squats and landings.
Results: After the interventions, no difference between groups was found for pain. The PFP
experimental group decreased hip internal rotation during squats compared to the PFP sham
group (p=0.03). There was no other significant difference between PFP groups for kinematic
or kinetic outcomes during squats, as well as for any outcome during landings. There was no
difference between asymptomatic groups for any of the outcomes in any of the tasks.
Conclusions: Hip mobilization was ineffective to reduce pain in people with PFP. Hip MWM
may contribute to dynamic lower limb realignment in females with PFP by decreasing hip
internal rotation during squats. Therefore, hip MWM could be potentially useful as a
complementary intervention for patients with PFP.
Keywords: Knee, Mulligan, Manual therapy, Squat, Jump.

INTRODUCTION
Patellofemoral pain (PFP) is a common knee disorder that affects people of both sexes
in different ages and levels of physical activity.1,2 The prevalence of PFP in the general
population is around 20%, and the prevalence in females has been reported to be as high as
30%.1 PFP is characterized by diffuse pain in the anterior region of the knee and is more evident
in activities that overload the patellofemoral joint (PFJ), such as squatting, climbing and
descending stairs.3
Poor control of dynamic knee valgus during weight-bearing activities may be a trigger
factor for PFP.4,5 Excessive hip adduction and internal rotation (components of dynamic knee
valgus) observed in people with PFP5 are likely to overload the PFJ due to the increased forces
acting laterally on the patella, causing greater stress on the lateral patellar cartilage.4
Theoretically, excessive hip adduction and internal rotation in people with PFP5 is a sign of
decreased control around the hip, as it shows decreased muscle strength and function.6–9
However, previous studies investigating the relations between hip muscle strength and PFP
onset have not established such relationship.9,10 Furthermore, little is known about the
relationship between kinematic changes and hip muscle function.11 Therefore, other factors
could be the reason for the excessive movements observed in people with PFP.
One possible factor might be changes in hip arthrokinematics due to possible
misalignment between the femoral head and the acetabulum. Possibly, a hip joint misalignment
could explain changes in hip movement patterns, as joint alignment may influence muscle
function.12,13 Thus, mobilization or manipulation techniques aimed at correcting hip
arthrokinematics could be beneficial for people with PFP.14 Potential corrections from hip
mobilization may improve movement control related to dynamic knee valgus in people with
PFP, which consequently may decrease stress and pain in the patellofemoral joint. For example,
the mobilization-with-movement (MWM) technique has been reported to be beneficial for

altering joint movement, leading to a decrease in pain.15 A recent systematic review has
summarized the results of studies investigating the effects of mobilizations and manipulations
applied as a treatment modality for PFP.16 This systematic review provides evidence that
manual therapy applied to the knee and lumbopelvic region may decrease pain and improve
function in people with PFP.16 However, no study has investigated the effects of joint
mobilizations applied to the hip for PFP treatment.
Thus, the objective of the present study was to evaluate the effects of a technique of
mobilization-with-movement applied to the hip on pain, trunk and lower limb kinematics, and
hip and knee kinetics during single-leg squats and jumps in females with PFP. A subgroup of
asymptomatic individuals was also included as a control situation to investigate whether the
mobilization technique could influence kinematics and kinetics of people without PFP.
METHODS
Design
This was a randomized placebo-controlled trial in which participants were allocated
either to the experimental groups, in which they received a MWM technique on the hip, or the
sham groups, in which they received a sham hip mobilization technique. Thus, four groups
were formed: experimental group with PFP, sham group with PFP, experimental group without
PFP and sham group without PFP (Figure 1). Randomization was performed using individual
allocation codes by a person not involved in the any intervention and assessment, with the use
of sealed and opaque envelopes opened after the eligibility and initial assessments.
Participants
Fifty-six females (28 with PFP and 28 asymptomatic), aged 18 to 35 years, physically
active (engaged in aerobic or athletic activities at least three times a week for at least 30
minutes),17,18 recruited from the community of the Federal University of São Carlos
participated in the study (Table and Figure 1). For participants with PFP the inclusion criteria
were: a) insidious onset of PFP symptoms not related to traumatic events; b) presence of
retropatellar or peripatellar pain; c) minimum pain level of 3/10 in visual analogue scale (VAS)
in at least three of the following situations: stair climbing/descending, running, kneeling,
squatting, prolonged sitting, jumping, isometric contraction of the quadriceps and palpation of
the medial or lateral facet of the patella; d) presence of pain for at least two months.8,19
Asymptomatic participants could not have a history of knee injury or pain.8,19 Participants were
excluded if they had a history of knee surgery, hip injury or pain, patellar instability, pain at
palpation of the patellar tendon region, Hoffa fat, iliotibial band, pes anserinus tendon or knee
joint line. They were also excluded if they presented signs or symptoms of meniscal or knee
ligament injury, presence of Osgood-Schlatter or Sinding-Larsen-Johansson syndromes.8,19
The sample size was predetermined based on a between group mean difference of 2.0
cm in VAS for pain and standard deviation of 1.5 cm.20 Considering a power of 80% and an
alpha of 5%, a minimum sample size of 10 participants for each group was required. The study
was approved by the Federal University of São Carlos Human Research Ethics Committee
(registration number 40428514.6.0000.5504), registered in the Brazilian Clinical Trials
Registry (RBR-55kzbn) and consent was obtained from all participants.
Procedures
Assessments and interventions were performed at the Movement Analysis Laboratory
of Federal University of São Carlos. After data on pain was collected, we assessed kinematics
and kinetics of squatting and jumping. Following the assessments, participants received the
interventions according to randomization (experimental or sham) and were immediately
reassessed for pain, kinematics and kinetics of squatting and jumping. For participants with
PFP, the affected lower limb or the most painful lower limb (when both limbs were affected)
was assessed. For the asymptomatic participants, the limb assessed was paired to the PFP group
according to dominance.
Intervention
A hip MWM technique was used with the aim to realign the hip joint for optimum
function and position.14 The mobilization followed the principles proposed by Dr. Mulligan in
which a force is applied to one of the joint axes and maintained during active movement, to
improve performance of the sliding surfaces.21,22
For the interventions (TIDier checklist – supplementary material 1), the participant
stood on a box with a height of 31 cm. The therapist (physiotherapist with five years of
experience in manual therapy) stood next to the participant, facing the hip to be treated and
stabilized the participant’s pelvis with both hands. A rigid belt was placed on the participant's
inguinal region and around the therapist's lumbar region (Figure 2). From this position, the
participant was asked to perform two sets of 10 double-leg squats (up to approximately 60º
knee flexion), of four seconds per squat and one minute interval between sets.23,24 For the
experimental groups, the therapist projected his body in order to move away from the
participant, producing a non-painful lateral glide of the hip. Throughout the squats, the therapist
kept the glide force constant with the technique described above.23,24 For the sham groups, a
sham technique was applied using the same procedures, however the force applied by the
therapist was the minimal needed to keep tension in the belt and to promote a pressure
sensation.15,23,24
The forces applied to the experimental and sham groups were assessed through a pilot
study. Twenty-four participants received the experimental intervention (12 participants) or the
sham intervention (12 participants) with a handheld dynamometer (Lafayette Instruments, IN,
USA) positioned between the therapist's lumbar region and the belt (Supplementary material
2). The force applied during the experimental intervention (82.7 ± 12.7N) was approximately
four times greater than the sham intervention (19.7 ± 6.5N; independent t test p<0.01, 95%CI
54.5-71.6).
Assessments
All participants were assessed before and after the intervention by the same blind
assessor.
Pain assessment
The VAS was used to assess pain (primary outcome). Participants were asked to
indicate the knee pain level on a line 10 cm long where 0 indicated no pain and 10 the worst
possible pain.25,26 The pain level was measured prior and immediately after the interventions.
For the initial pain assessment, the participants performed 10 double-leg squats and then
recorded pain level.
Biomechanical assessment
Kinematic and kinetic analyzes were performed during single-leg squats and single-leg
drop vertical jumps (secondary outcomes). Kinematics were collected using the Qualisys
motion capture system with seven cameras (Qualisys Medical, AB, SE) at a sampling rate of
240Hz. Kinetics were assessed using a Bertec force platform (4060-08, Bertec Corporation,
OH, USA) at a sampling rate of 2400Hz. Both collection systems were integrated using the
Qualisys Track Manager 2.3 acquisition software (Qualisys Medical, AB, SE). Participants
were assessed wearing sports clothes and footwear provided by the researchers (Asics Gel-
Equation 5, Asics, ID). Eighteen reflective markers were positioned on the following
landmarks: spinous process of the 7th cervical vertebra, sternum, right and left acromion,
interarticular space between 5th lumbar vertebra and sacrum, right and left iliac crest, right and
left posterosuperior iliac spine, right and left major trochanter, lateral and medial femoral
epicondyle (right and left), lateral and medial malleoli (right and left), 1st and 5th metatarsal
heads and distal phalanx of the second toe (right and left). Five clusters were positioned as
follows: on the spinous process of the 4th thoracic vertebra, on the spinous process of the 2nd
lumbar vertebra, on the posterolateral region of the thigh (right and left), on the posterolateral
region of the shank (right and left) and on the calcaneus (right and left). All markers and
clusters remained in place throughout the interventions.
For the single-leg squat assessment, the participant was positioned on the force platform
with a single-leg support (on the lower limb under analysis), the contralateral hip in neutral
position and contralateral knee in 90º of flexion. With arms crossed over the chest, the
participant performed the squat until she reached at least 60º of knee flexion and returned to
the initial position.19,27 The 60º angle was indicated by an adjustable height stand positioned
next to the participant. The complete squat movement was performed in about four seconds
(two seconds descending and two seconds ascending), controlled by a metronome.19,27
For the single-leg drop vertical jump, the participant remained in a single-leg support
position on a 31 cm high box, with arms crossed over the chest. The participant was then
instructed to drop from the box and land on the force platform with the assessed limb, and upon
landing, to jump vertically as high and as fast as possible.
Participants familiarized themselves with the tasks at least twice before data collection.
Five valid attempts, before and after the interventions were collected for each task. A minimum
one minute rest was adopted between attempts.
Data analysis
Kinematics and kinetics data were processed using the Visual 3D software (version 3.9;
C-motion Inc., USA). Cardan angles were calculated using the joint coordinate system in
relation to a static anatomical position collected prior to the tasks, as recommended by the
International Society of Biomechanics.28 Hip and knee angles were calculated as the movement
of the distal segment relative to the proximal segment; and pelvic and trunk angles were
calculated as the movement of these segments relative to the laboratory (global coordinate
system). Internal joint moments for the knee and hip were calculated according to standard
inverse dynamics.29 Kinematics and kinetics data were filtered using a low-order, low-pass,
fourth-order Butterworth filter with zero-phase delay and with cutoff frequencies of 12Hz and
50Hz, based on residue analysis.29
The software Matlab (version 2008b, Mathworks, Natick, USA) was used for data
reduction. Outcomes of interest were analyzed at peak knee flexion for both tasks. This is
because PFJ load seems to increase with increased knee flexion in weight-bearing activities.30
The outcomes were: a) angles for knee, hip, pelvis and trunk, and knee joint moment in the
frontal plane; b) trunk angle and joint moments for knee and hip in the sagittal plane; c) hip
angle in the transverse plane. The average of the five trials of each task, pre and post-
intervention, were used for analysis. Kinematics data are presented in degrees and kinetics data
in Nm normalized by body mass (Nm/kg).
Prior to data collection, eight participants (four with PFP and four asymptomatic) were
assessed on two separate occasions to verify intra-rater reliability of biomechanical measures,
using intraclass correlation coefficient (ICC3,1) and standard error of the measurement (SEM).
ICCs ranged from 0.89 to 0.93 and SEMs ranged from 0.7 to 2.4 degrees for joint angles and
0.1 to 0.2 Nm/kg for joint moments, indicating adequate reliability31 (Supplementary material
3).
Statistical Analysis
The change in the outcomes was considered for analysis (post minus pre). The data
normality was verified using the Shapiro–Wilk test; only pain data for the asymptomatic groups
presented non-normal distribution. Independent t-tests were used to compare the effects of
mobilization on pain (PFP groups) and biomechanical outcomes. A Mann–Whitney test was
used to compare the pain level between the asymptomatic groups to verify if the hip
mobilization induced pain. The PFP groups and asymptomatic groups were analyzed
separately. The significance level adopted was p≤0.05 for all comparisons. No statistical
adjustment was applied to prevent potential clinically relevant differences from being
undetected due to strict statistical corrections.32 Effect sizes (ES) were calculated for significant
differences according to Cohen's d, in which d = 0.2 is considered a small effect, d = 0.5
moderate, and d = 0.8 large.33 Data were analyzed using SPSS version 17.0 (SPSS Inc.,
Chicago, IL, USA).
RESULTS
A total of 76 volunteers were screened for eligibility, 56 met the inclusion criteria and
were included in the study. All included participants followed the established protocol (Figure
1).
Participants with PFP
The experimental and sham groups were homogeneous regarding age, mass, height and
onset of symptoms (Table 1). There was no difference between the experimental and sham
groups regarding pain (p=0.89) (Table 2).
During the single-leg squat, the experimental group presented a moderate reduction
(ES=0.77) in hip internal rotation compared to the sham group (p=0.03; Table 3). There was
no difference between groups for any other kinematic and kinetic outcomes during the single-
leg squat (Table 3), as well as for any outcome during the single-leg drop vertical jump (Table
3).
Asymptomatic participants
The experimental and sham groups were homogeneous regarding age, mass and height
(Table 1). All participants scored pain as 0 during all the evaluations, except one participant
who presented a minimal increase in pain after the mobilization (0.1 cm). There was no
difference between groups for pain (p = 0.32) and for any of the biomechanical outcomes
analyzed in any of the tasks (Table 4).
DISCUSSION
Our results present that MWM technique was able to moderately decrease hip internal
rotation during single-leg squats in females with PFP. Hip mobilization had no effects on pain
and also did not modify kinematics or kinetics of single-leg drop vertical jump in females with
PFP. Also, hip mobilization had no influence on pain, kinematics or kinetics during single-leg
squats or single-leg drop vertical jumps in asymptomatic females. This was the first study to
verify the effects of joint mobilizations applied to the hip of people with PFP.
Previously, Nakagawa et al.34 reported the existence of a correlation between the peak
of hip internal rotation angle during a step-down task and pain in females with PFP (r = 0.63).
Thus, it would be expected that a reduction in hip internal rotation could lead to a decrease in
pain, which was not observed in the present study. Possibly, the small reduction in hip internal
rotation seen in the current study (–1.2 degrees) is insufficient to generate any significant pain
reduction. Furthermore, the estimates of the effect on hip internal rotation had confidence
intervals that extended to include an effect as small as 0.1 degree, which suggests that the effect
may be too small to be clinically sufficient to generate pain reduction. However, the technique
was applied only one single time, raising the question on whether the results would be the same
had the intervention been applied over several sessions. Similar results were obtained in the
study by Collins et al.23. People with subacute ankle sprains were treated in a single session
using ankle MWM and presented an increase in ankle dorsiflexion without any improvements
in pain.23 Researchers should consider future investigations involving multiple treatment
sessions of hip mobilization for people with PFP.
Interventions that decrease hip internal rotation in people with PFP may be important,
as the excess of this movement can influence PFJ stress.5,6 Also, excessive hip internal rotation
during jump landing may be a risk factor for the development of PFP.35 A study by Souza et
al.36 reported that females with PFP had greater internal rotation of the femur compared to
asymptomatic females during single-leg squats, and this excessive rotation was associated with
an excessive lateral displacement of the patella.36 Thus, there is possibly a decrease in contact
area in the PFJ which can lead to an increase in PFJ stress.36,37 This suggests that patellar
kinematics may be closely related to movements of the femur; perhaps more than previously
assumed, particularly in activities with body weight support.36
Current literature suggests that the effects of MWM techniques could correct joint
positional failure occurring secondary to an injury,22,38 however, it is unclear whether these
positional failures actually occur.21 Nevertheless, it can be hypothesized that chronic pain
experienced by females with PFP could lead to compensatory movements that alter the
mechanics of the hip. Thus, the decrease in hip internal rotation observed in the present study
may have occurred due to a possible realignment of hip joint surfaces favoring somatosensory
control of hip mechanics. During squatting, the femur head rolls within the acetabulum, which
is a movement involving sliding and pivoting.39 When we performed the mobilization that
aimed at increasing joint space, it is possible that this mobilization facilitated the repositioning
of the joint which reestablished the normal joint mechanics. The results from a study
investigating the effects of ankle MWM in people with chronic ankle instability showed a
decrease in ankle plantar flexion range of motion during a jump landing task.40 This suggests
that joint repositioning through joint mobilization may favor movement control.
The results from the asymptomatic participants also support this theory. Hip MWM did
not modify any kinematics and kinetics variables during the squats and jumps of the
asymptomatic participants. This indicates that the effects of the mobilization may be limited to
when there is in fact a positional problem in the joint. Also, the results from the asymptomatic
participants indicate that the mobilization is a safe technique, as it did not induce pain and did
not cause any changes in healthy participants.
In the present study, hip MWM did not affect the biomechanics of single-leg drop
vertical jump in females with PFP. Possibly, the order in which the assessment after the
intervention took place could explain the lack of significant differences in the jump analyses.
These post-assessments occurred after the squat post-assessments and possibly the effects of
the mobilization verified in the squat were dissipated over time. Another possible explanation
may be related to the fact that the jump is a higher impact activity and any correction of
positional failure could have been reversed by the intensity and absorption of the impact.
Perhaps, to observe further changes to the biomechanics of females with PFP, the mobilization
needs to be applied more than once, to create a cumulative effect. Another possibility is that
hip mobilization, as applied in the current study, is unable to modify biomechanics during
activities of large impact.
Three key factors may have limited the results of the present study. First, we only
looked at the immediate effects of mobilization and the dose of the treatment may have been
insufficient to improve pain and decrease other potential excessive movements. Second, the
force applied through the mobilization was performed only in the lateral direction and perhaps
forces in other directions could have an effect on other hip movements. Third, the technique
was applied only in females and, thus, other populations with PFP, such as adolescents and
males, may present different results from those presented in the present study. Nevertheless,
the present study indicates that hip MWM may be a useful complementary intervention in the
treatment of females with PFP when the aim is to correct joint position and improve control of
internal rotation of the hip. Furthermore, our results seem to be trustworthy as we used strong
methods (adequate randomisation, allocation and assessor blinding), and used standardized and
controlled evaluations and interventions.
CONCLUSION
The results of the present study indicate that hip MWM decreases hip internal rotation
during single-leg squats suggesting that the mobilization may contribute to a better dynamic
alignment of the lower limb in females with PFP. Hip MWM applied in a single session does
not decrease pain and also does not influence movements of the hip, knee, trunk and pelvis in
females with PFP during single-leg vertical jumps. Furthermore, hip mobilization does not
change knee, hip, pelvis and trunk biomechanics in asymptomatic females. Future studies
should be performed to evaluate the effects of multi-sessions of hip mobilization on pain,
function and biomechanics in people with PFP. Also, future research could investigate the
effects of mobilization in combination with exercise protocols.

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Figure 1. Flow diagram

Figure 2. MWM technique applied on the hip using a rigid belt.

Table 1: Characteristics of participants – mean (SD).
Patellofemoral Pain* Asymptomatic*

Exp Sham Exp Sham
(n=14) (n=14) (n=14) (n=14)
Age (years) 24.3 (2.7) 24.1 (5.1) 22.3 (2.5) 23.4 (2.8)
Body mass (kg) 59.6 (6.8) 57.3 (8.1) 60.3 (7.9) 59.5 (5.9)
Height (m) 1.62 (0.05) 1.64 (0.07) 1.66 (0.06) 1.63 (0.06)
Pain onset (years) 4.8 (3.6) 4.6 (4.3) na
Exp: experimental group; Sham: sham group; na: not applicable. *no difference between experimental and sham
groups analyzed by independent t-test (p>0.05).
Table 2: Pain results for the participants with patellofemoral pain [mean (SDF)].
Experimental Sham Difference Difference

Group Group within between

groups groups
Pre Post Pre Post Exp Con (CI 95%)
VAS 1.4 1.6 2.2 2.2 0.2 0.0 0.2
(cm) (2.2) (2.0) (2.1) (2.6) (2.9) (1.4) (-1.6 to 1.8)
VAS: visual analogue scale.
“Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral Pain: A Randomized Placebo-Controlled Trial” by Nunes GS et al.
Table 3: Kinematic and kinetic data at the peak of knee flexion for the participants with patellofemoral pain ([Mean (SD)].
Squatting Jumping Difference within groups Difference between groups

Exp Sham Exp Sham Squatting Jumping (CI 95%)
Variables
Pre Post Pre Post Pre Post Pre Post
Exp Sham Exp Sham Squatting Jumping
(n=14) (n=14) (n=14) (n=14) (n=14) (n=14) (n=14) (n=14)
Kinematics (degree)*
6.7 6.3 5.4 5.2 2.2 2.8 1.8 2.5 -0.7 -0.2 0.6 0.8 -0.5 -0.2
Knee abduction (+)
(3.3) (3.1) (2.5) (2.5) (4.6) (4.4) (4.3) (3.4) (1.3) (1.2) (1.8) (2.0) (-1.4 to 0.5) (-1.7 to 1.2)
18.5 17.5 18.2 17.9 10.3 9.3 10.4 9.8 -1.0 -0.3 -1.0 -0.6 -0.7 -0.4
Hip adduction (+)

(5.2) (5.2) (5.8) (6.9) (3.7) (3.2) (3.3) (3.2) (2.5) (2.0) (2.6) (3.0) (-2.4 to 0.9) (-2.4 to 1.7)
9.8 7.8 9.2 8.4 3.3 2.6 3.2 3.2 -2.0 -0.8 -0.7 0.0 -1.2a -0.7
Hip internal rotation (+)
(3.2) (3.1) (3.2) (2.8) (5.2) (4.2) (5.0) (5.3) (1.6) (1.5) (2.1) (2.1) (-2.4 to -0.1) (-2.2 to 0.9)
6.3 6.4 7.1 6.9 -2.3 -2.9 -2.8 -3.0 0.1 -0.2 -0.6 -0.2 0.3 -0.4
Pelvis depression (+)
(3.2) (3.2) (2.7) (3.6) (3.3) (3.4) (4.2) (4.4) (1.5) (1.9) (1.2) (1.6) (-1.0 to 1.6) (-1.6 to 0.6)
7.1 6.5 8.0 7.9 8.1 7.7 9.0 9.1 -0.6 -0.1 -0.4 0.1 -0.5 -0.5
Trunk inclination (+)
(2.8) (2.3) (3.8) (3.8) (4.9) (5.6) (3.6) (3.2) (1.8) (2.3) (1.6) (1.4) (-2.0 to 1.1) (-1.6 to 0.7)
18.4 17.2 17.7 16.3 14.2 12.6 13.8 12.8 -1.2 -1.3 -1.6 -1.0 0.1 -0.6
Trunk flexion (+)
(7.5) (6.1) (8.9) (6.8) (12.7) (12.5) (10.2) (9.3) (2.2) (2.8) (2.1) (3.1) (-1.8 to 2.0) (-2.7 to 1.3)
Kinetics (Nm/kg)*
1.4 1.4 1.5 1.5 2.9 2.8 2.8 2.8 0.0 0.0 0.1 0.0 0.0 0.1
Knee adductor (+)
(0.4) (0.4) (0.5) (0.5) (0.9) (0.8) (0.7) (0.7) (0.1) (0.2) (0.3) (0.2) (-0.2 to 0.1) (-0.2 to 0.1)
0.6 0.6 0.7 0.6 1.4 1.4 1.5 1.6 0.0 0.0 0.0 0.1 0.0 -0.1
Knee extensor (+)
(0.3) (0.3) (0.3) (0.3) (0.3) (0.4) (0.3) (0.4) (0.2) (0.1) (0.2) (0.2) (-0.1 to 0.1) (-0.2 to 0.2)
1.1 1.1 1.1 1.1 3.2 3.1 3.1 3.1 0.0 0.0 -0.1 0.0 0.0 -0.1
Hip extensor (+)
(0.2) (0.2) (0.2) (0.3) (0.5) (0.7) (0.8) (0.8) (0.2) (0.2) (0.3) (0.3) (-0.2 to 0.2) (-0.3 to 0.2)
Exp: PFP experimental group; Sham: PFP sham group. *negative signals indicate the opposite movement. asignificant difference (p=0.03)
“Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral Pain: A Randomized Placebo-Controlled Trial” by Nunes GS et al.
Table 4: Kinematic and kinetic data at the peak of knee flexion for the asymptomatic participants [mean (SD)].
Squatting Jumping Difference within groups Difference between

Exp Sham Exp Sham Squatting Jumping groups (CI 95%)
Variables
Pre Post Pre Post Pre Post Pre Post
Exp Sham Exp Sham Squatting Jumping
(n=14) (n=14) (n=14) (n=14) (n=14) (n=14) (n=14) (n=14)
Kinematics (degrees)*
6.0 6.4 5.8 5.7 1.7 1.8 1.3 1.8 0.4 -0.1 0.1 0.5 0.5 -0.4
Knee abduction (+)
(3.5) (3.9) (2.9) (2.6) (4.2) (4.9) (3.7) (3.5) (1.7) (1.9) (2.8) (2.8) (-0.8 to 1.8) (-2.5 to 1.7)
14.8 15.0 13.9 14.6 10.5 9.8 9.6 9.1 0.2 0.7 -0.7 -0.5 -0.5 -0.2
Hip adduction (+)

(6.2) (6.0) (5.1) (5.4) (3.5) (4.4) (4.4) (4.9) (2.5) (2.2) (2.5) (2.4) (-2.2 to 1.3) (-2.0 to 1.7)
7.6 6.8 7.2 7.3 2.2 2.0 2.5 2.8 -0.8 0.1 -0.2 0.3 -0.9 -0.5
Hip internal rotation (+)
(4.0) (3.3) (3.8) (3.3) (4.3) (4.3) (4.8) (5.3) (1.4) (1.5) (1.4) (2.4) (-1.9 to 0.2) (-2.0 to 0.9)
5.6 5.5 5.7 5.8 -3.2 -3.4 -4.0 -4.5 -0.1 0.1 -0.2 -0.5 -0.2 0.3
Pelvis depression (+)
(2.3) (2.7) (3.2) (2.9) (3.0) (3.4) (2.9) (2.9) (1.8) (1.3) (2.7) (1.3) (-1.3 to 1.1) (-1.4 to 1.8)
6.0 6.4 6.4 6.3 6.3 5.5 5.0 4.9 0.4 -0.1 -0.8 -0.1 0.5 -0.7
Trunk inclination (+)
(3.2) (3.2) (3.5) (3.5) (4.2) (3.8) (3.9) (2.5) (1.3) (1.9) (2.4) (2.3) (-0.8 to 1.7) (-2.4 to 1.1)
16.6 17.9 17.2 18.4 18.7 17.9 18.5 17.4 1.3 1.2 -0.8 -1.1 0.1 0.4
Trunk flexion (+)
(9.5) (9.1) (9.1) (9.7) (11.8) (12.3) (10.0) (10.0) (2.2) (2.2) (3.3) (2.9) (-1.6 to 1.7) (-1.9 to 2.7)
Kinetics (Nm/kg)*
1.3 1.4 1.3 1.4 3.1 3.0 2.9 3.0 0.1 0.1 0.1 -0.1 0.0 -0.2
Knee adductor (+)
(0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.5) (0.1) (0.1) (0.3) (0.3) (-0.1 to 0.1) (-0.3 to 0.2)
0.6 0.6 0.6 0.6 1.4 1.4 1.5 1.5 0.0 0.0 0.0 0.0 0.0 0.0
Knee extensor (+)
(0.3) (0.4) (0.2) (0.3) (0.3) (0.3) (0.5) (0.5) (0.1) (0.1) (0.2) (0.3) (-0.1 to 0.1) (-0.1 to 0.3)
1.0 1.0 1.1 1.1 3.4 3.5 3.7 3.7 0.0 0.0 -0.1 0.0 0.0 -0.1
Hip extensor (+)
(0.2) (0.2) (0.2) (0.2) (0.7) (0.7) (1.1) (1.1) (0.2) (0.2) (0.4) (0.4) (-0.1 to 0.2) (-0.4 to 0.2)
Exp: Asymptomatic experimental group; Sham: Asymptomatic sham group. *negative signals indicate the opposite movement.
Supplementary Material 1: The TIDieR Checklist (Template for Intervention Description

and Replication).
Brief name: Hip mobilization with movement technique

Why: Realign the hip joint for optimum function and position
What:
Materials: box with a height of 31 cm and rigid belt
Procedures: The therapist facing the hip to be treated and stabilizing the patient’s
pelvis with both hands. An inelastic belt is placed on the patient's inguinal region
and around the therapist's lumbar region. From this position, the patient performs
squats and the therapist projects his/her body in order to move away from the patient,
producing a non-painful lateral glide of the hip.
Who provided: Physiotherapist
How: Face-to-face and individually.
Where: Laboratory
When and how much: In a single session, the therapist kept the glide force constant
during two sets of 10 double-leg squats.
Tailoring: none.
Modifications: none.
How well: not applicable.
Supplementary Material 2: Measurement of the applied force during the interventions (arrow
shows the position of the handheld dynamometer).
Supplementary Material 3: Reliability and error for the biomechanics measures [intraclass
correlation coefficients3,1 (standard error of the measurement)].
Squatting Jumping
Kinematics - degree
Knee abduction 0.91 (0.7) 0.89 (1.2)
Hip adduction 0.93 (1.4) 0.92 (1.1)
Hip internal rotation 0.91 (1.1) 0.92 (1.2)
Pelvis depression 0.89 (1.4) 0.91 (1.1)
Trunk inclination 0.90 (1.1) 0.89 (1.4)
Trunk flexion 0.90 (1.4) 0.91 (2.1)
Kinetics - Nm/kg
Knee adductor moment 0.89 (0.1) 0.90 (0.2)
Knee extensor moment 0.93 (0.1) 0.90 (0.1)
Hip extensor moment 0.88 (0.1) 0.90 (0.2)

Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral

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Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral

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“Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral

Pain: A Randomized Placebo-Controlled Trial” by Nunes GS et al.

Note: This article will be published in a forthcoming issue of

Section: Original Research Report

Affiliations: a Department of Physiotherapy, Federal University of São Carlos, São Carlos,

Running Head: Hip mobilization for patellofemoral pain

Journal: Journal of Sport Rehabilitation

Acceptance Date: May 12, 2019

©2019 Human Kinetics, Inc.

ACUTE EFFECTS OF HIP MOBILIZATION WITH MOVEMENT TECHNIQUE ON

PAIN AND BIOMECHANICS IN FEMALES WITH PATELLOFEMORAL PAIN: A

RANDOMIZED PLACEBO-CONTROLLED TRIAL

Hip mobilization for patellofemoral pain

Guilherme S. Nunes a, Débora Faria Wolf a, Daniel Augusto dos Santos a,

Marcos de Noronha b, Fábio Viadanna Serrão a

FAPESP (process 2015/15391-0 and 2015/01704-7).

Declarations of conflict interest: none

Brazilian clinical trials registry (RBR-55kzbn)

Address for correspondence: Guilherme S. Nunes

Objective: To investigate the acute effects of hip mobilization-with-movement (MWM)

Design: Randomized placebo-controlled trial.

Setting: Movement analysis laboratory.

Keywords: Knee, Mulligan, Manual therapy, Squat, Jump.

One possible factor might be changes in hip arthrokinematics due to possible

function.12,13 Thus, mobilization or manipulation techniques aimed at correcting hip

the mobilization-with-movement (MWM) technique has been reported to be beneficial for

mobilizations applied to the hip for PFP treatment.

This was a randomized placebo-controlled trial in which participants were allocated

in at least three of the following situations: stair climbing/descending, running, kneeling,

ligament injury, presence of Osgood-Schlatter or Sinding-Larsen-Johansson syndromes.8,19

(registration number 40428514.6.0000.5504), registered in the Brazilian Clinical Trials

Registry (RBR-55kzbn) and consent was obtained from all participants.

Assessments and interventions were performed at the Movement Analysis Laboratory

interventions according to randomization (experimental or sham) and were immediately

improve performance of the sliding surfaces.21,22

recorded pain level.

clusters remained in place throughout the interventions.

(two seconds descending and two seconds ascending), controlled by a metronome.19,27

landing, to jump vertically as high and as fast as possible.

one minute rest was adopted between attempts.

50Hz, based on residue analysis.29

in Nm normalized by body mass (Nm/kg).

assessed on two separate occasions to verify intra-rater reliability of biomechanical measures,

differences according to Cohen's d, in which d = 0.2 is considered a small effect, d = 0.5

Chicago, IL, USA).

Participants with PFP

groups regarding pain (p=0.89) (Table 2).

analyzed in any of the tasks (Table 4).

in pain.23 Researchers should consider future investigations involving multiple treatment

sessions of hip mobilization for people with PFP.

assumed, particularly in activities with body weight support.36

positional failure occurring secondary to an injury,22,38 however, it is unclear whether these

not cause any changes in healthy participants.

activities of large impact.

controlled evaluations and interventions.

should be performed to evaluate the effects of multi-sessions of hip mobilization on pain,

effects of mobilization in combination with exercise protocols.

pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus

14. American Physical Therapy Association (APTA) position: Manipulation/Mobilization

Figure 1. Flow diagram

Figure 2. MWM technique applied on the hip using a rigid belt.

Table 1: Characteristics of participants – mean (SD).

Patellofemoral Pain* Asymptomatic*

Experimental Sham Difference Difference