Manual Therapy: Knee

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The primary goals of manual therapy are:

• Modulate pain
• Increase range of motion
• Reduce soft-tissue inflammation
• Improve contractile & non-contractile tissue repair, extensibility, or stability
• Facilitate movement

Manual therapy is defined as the application of manual forces of the therapist, to change/improve the quality and the range of motion of joints and soft tissues. Mobilisation is a manual technique that through repeated passive motion at low speed replicates normal joint glides at varying amplitudes, while manipulation is defined as fast with a small force, small amplitude and high speed of movement of a joint.

It is hypothesised that manual therapy improves function of the kinetic chain (joints and sot tissue) by a combination of mechanical and neuromuscular mechanisms. In particular in the knee, techniques are aimed at increasing the extensibility of collagen, optimising joint lubrication and reduction of muscle tone which all result in improved joint function and joint mobility.

Indication

The use of manual therapy is supported in the knee.  Indications for the use of manual therapy include:

1. painful neuromusculoskeletal joint disorder
2. pain in or from palpation of bony joint surfaces
3. pain in of from palpation of joint soft tissues
4. decreased or altered range of quality of motion
5. pain on joint movement.

When there is pain in combination with joint restriction, it is recommended to apply manual therapy together with exercise therapy. There is a consensus that manual therapy can be considered as a preparation for exercise therapy by having an effect on pain and joint limitations, and muscle activity.

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Clinical application

A commonly used form of manual therapy applied to joints are oriented mobilisations called ‘joint glides’, these are performed in specific planes of movement and are intended to restore specific movements. Research has demonstrated increased range of movement and function following tibiofemoral mobilisations but these positive effects are only for a short duration and cannot be considered effective for long term outcomes.  This would suggest that mobilisations may be effectively used to promote exercise performance.

Manual therapy is often used in clinical practice for osteoarthritis. Although it is often used, there is little research on the effects of the treatment of knee osteoarthritis independently of other interventions, such as exercise therapy. Studies have shown that manual therapy has a positive effect on the modulation of pain in knee osteoarthritis.  A combination of manual therapy and guided exercises has functional benefits for patients with knee osteoarthritis.  Manual therapy and a guided exercise program can reduce the burden of complaint and postpone the need for surgery therefore reducing cost.

Manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy improves patellofemoral pain syndrome Anterior knee pain is associated with the loss of strength and decreased activity of the knee extensors, which refers to a muscle inhibition. Muscle co-contraction around the knee has been shown to improve after joint mobilisations to the knee.  Spinal manipulation may also be regarded as an effective treatment to reduce muscle inhibition in the lower limb musculature

There is little or no evidence of the use of manual therapy at acute knee injury, like ligaments or meniscus injury. For such persons, other appropriate measures in their therapy should be taken such as a supervised exercise programme.

Manual therapy combined with an appropriate exercise therapy seems to be more effective for improving the muscle strength, proprioception and functional performance than exercise therapy alone.

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