












































DISABLEMENT MODEL CASE STUDY 

 

48 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 
 

The Mulligan Concept in the Treatment of Anterior Knee Pain  
Karla S. Judge, DAT, LAT, ATC1; Alan Nasypany, Ed.D., LAT, ATC2; Russell T. Baker, PhD, LAT, ATC2; and 
James May, DAT, LAT, ATC2  
1Idaho State University, Pocatello ID; 2University of Idaho, Moscow, ID   
 

 
ABSTRACT 

The purpose of the disablement model case study was to 
describe the case of a collegiate basketball player suffering 
from anterior knee pain (AKP). The patient had been 
experiencing AKP while participating in pre-season 
basketball related activities (playing, weight lifting, and 
conditioning) for approximately six weeks.  As the intensity 
increased, the pain became intolerable. Previously, the 
patient had missed a significant amount of off-season 
workouts due to surgery for an upper extremity injury 
sustained during the competitive season. The patient reported 
tenderness at the inferior pole of the patella, and at the tibial 
tuberosity. There was no joint line tenderness, swelling, tissue 
temperature change, crepitus, or joint locking identified 
during the initial assessment. Manual muscle testing revealed 
decreased strength and pain at the inferior pole of the 
patella and the tibial tuberosity with the long sitting straight 
leg raise, as well as seated knee extension. Patient reported 
outcome measures were used to establish a baseline of pain 
and function. The Disability of the Physically Active Scale, the 
Numeric Pain Rating Scale, and the Patient Specific Functional 
Scale were used to identify patient-centered, as well as 
clinician-centered changes produced by the treatment 
intervention. Recording of outcome measures took place at 
the initial assessment, after the initial treatment intervention, 
two days after the initial intervention, and one and two weeks 
after the initial intervention. Outcome measures reflected a 
positive result for the decrease of pain with basketball 
activities, as well as activities of daily living. Evidence 
supports the use of mobilizations to treat tendinopathies, joint 
positional faults, and neuromuscular motor control. While 
evaluating and treating patients with the Mulligan Concept 
MWM, the clinician receives immediate feedback regarding 
the efficacy and potential success of the intervention strategy. 
The purpose of this case study was to describe the application 
of the Mulligan MWM philosophy and tibial internal rotation 
(TIR) technique while treating a patient complaining of AKP 
in an intercollegiate athletic training clinic. 
 
Key Phrases 
Manual techniques, patient-reported outcomes, mulligan 
concept, sub-therapeutic dose 
 
Correspondence 
Dr. Karla Judge, Idaho State University, 921 South 8th Ave, 
Pocatello, ID, 83209 
Email: judgkarl@isu.edu 
 
 

Full Citation 
Judge KS, Nasypany A, Baker RT, May J. The Mulligan 
Concept in the Treatment of Anterior Knee Pain. Clin Pract 
Athl Train. 2019;2(3):48-57. 
https://doi.org/10.31622/2019/0003.5.  
 
Submitted: November 29, 2018 Accepted: October 18, 
2019 
 

INTRODUCTION 

Anterior knee pain (AKP) is a common complaint 

in athletics.1 Multiple conditions can produce pain 
at the anterior knee and an accurate assessment 
is necessary to direct proper treatment. Patellar 
tendinopathy, patellofemoral pain syndrome, 
quadriceps tendinopathy, chondromalacia, 
synovial plica, bursa and meniscal lesions can all 
present as AKP.1 Poor motor control of the hip, 
pelvis and knee has also been identified as a 
possible cause of AKP.1-7 Ultimately, loss of 
efficient motor control of hip abductors, 
adductors, extensors and knee flexors may lead 
to poor joint kinematics, resulting in AKP. 2-7,12,14,15  
The Mulligan Concept (MC) was developed on a 
positional fault theory, which is based on the 
belief that minor malalignment of joint surfaces 
may be present, resulting in swelling, stiffness, and 
pain.12-18 The Mobilization with Movement 
(MWM) may address this minor joint 
malalignment, as well as help create a more ideal 
neurophysiological environment for improved 
motor control and pain-free movement 
strategies.15 A MWM has been defined as a 
“sustained passive accessory force/glide to a joint 
while the patient actively performs a task that was 
previously painful”.15 The force is applied parallel 
to the treatment plane and should be a light, 
gentle force, just enough to improve motion and 
reduce pain. During assessment, the clinician will 
identify the direction of the force applied to the 
joint line in order to produce a positive outcome. 

https://doi.org/10.31622/2019/0003.5


The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

49 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

Two acronyms help guide and define proper 
application of the MC MWM.12-18 First, identified 
in Table 1 is the PILL acronym. Pain free, 
Immediate, and Long Lasting identifies the desired 
result of the mobilization technique. The most 
important part of the PILL acronym is the pain free 
aspect of the mobilization. If pain is not 
eliminated, then small changes in direction 
(addition of a minor rotation) or force (increase or 
decrease) can be made to improve symptoms. An 
immediate improvement of pain-free range of 
motion (ROM) is expected at the time of the 
mobilization.    If the results are not long lasting, 
changes should be made regarding the number of 
sets or repetitions used during the mobilization.15   
 
Table 1. The Mulligan Concept PILL Acronym 
for Performing a Mobilization with 
Movement12-18,21 

P Pain free: the immobilization should be 
pain free 

I Immediate: reduction of pain and increase 
of functional activity  

LL Long Lasting: the result of the mobilization 
should have a long lasting effect in 
reduction of pain   

 
Second, Table 2 identifies the CROCKS acronym, 
“Contraindications, Repetitions, Overpressure, 
communication, Knowledge, 
Sustain/sense/skills/success”, which guides the 
technique and expectations of the mobilization for 
both the clinician and patient.12-18 The clinician 
should possess knowledge of the indications and 
contraindications of joint mobilization techniques, 
in general, as well as specific knowledge 
regarding the MWM technique to ensure a safe 
intervention.12-18  Joint health and any underlying 
pathology also need to be clearly understood to 
avoid exacerbating any existing condition, such as 
fractures, rheumatoid arthritis, or poor skin 
integrity. Sets and repetitions may vary 
depending on treatment area, length of 
dysfunction, and treatment calendar.12-18 For 
example, spinal manipulations are treated with 
fewer repetitions than peripheral joints or in 
patients presenting in severe pain.12-18 One set of 
three repetitions would be used for the first 
intervention for a spinal mobilization, while a 

peripheral joint may be treated with three sets of 
six to ten repetitions.12-18 Overpressure added to 
the end of the active mobilization is believed to 
aid in providing optimal recovery.12-18 
Communication between the clinician and the 
patient is imperative. The clinician must explain the 
process of the mobilization, and the patient must 
be able to communicate if any pain is 
experienced during the mobilization.12-18 Finally, 
a clinician possessing proper skills will sustain the 
mobilization through the entire ROM in order to 
have a successful treatment intervention.12-18 

 

A common mobilization used for AKP is the tibial 
internal rotation (TIR) MWM. The TIR MWM is 
often the first technique clinicians will utilize to 
treat reported pain and/or dysfunction at the 
knee.12-15, 17, 18 The TIR MWM technique includes a 
clinician-directed rotational mobilization force 
added to the patient-directed flexion and 
extension movement across the treatment plane 
(the tibial plateau).12-15 The TIR MWM can be 
reinforced with a tape application that may be 
worn until the patient’s return to the clinic in 24-48 
hours (standard precautions for tape application 
must be considered).12,14,15 The desired effect of 
the tape is to sustain the mobilization effect and 

Table 2: Mulligan Concept “CROCKS” acronym for 
guidelines and expectations of a mobilizations with 
movement.12-18,21 

C Contraindications: do any conditions exist that 
would limit the use of joint mobilization 

R Repetitions: three sets of ten repetitions are 
used for treating the extremity joints 

O Overpressure: passive overpressure is applied 
by either the patient or the clinician at the end 
range of movement 

C Communication: between the clinician and the 
patient about the treatment, techniques and 
expectations before the intervention begins.  
During the intervention the patient should 
report any pain. 

K Knowledge: the clinician should possess 
knowledge of joint planes of motion being 
treated 

S Sustain, sense, skills, and success: using common 
sense and clinical skills, the mobilization should 
be sustained throughout the movement in order 
to attain success.  



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

50 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

apply continual neurological input for more ideal 
motor control.15 The mobilization and tape 
application are intended to enable pain free 
movement and motor control by addressing the 
malalignment of tibial external rotation, 
decreasing medial hamstring inhibition, and 
decreasing pain.15 Short term re-training of 
motor control can have a prolonged positive 
effect on pain and therefore is important to 
facilitate pain free movements, while treating 
painful and restricted joints.7  
 
The MC MWM can also be incorporated into the 
patient assessment as well as an intervention 
tool.15 Along with observation, palpation, 
functional and special tests, the application of a 
single set of six repetitions (“sub-therapeutic 
dose”) of the MWM can provide valuable 
information. A decrease of pain during the sub-
therapeutic dose of MWM can indicate to the 
clinician that the MWM could produce a successful 
outcome.15 A decrease of pain with the knee 
flexion movement will indicate the MWM is 
clinically indicated to treat the AKP and assist in 
re-establishing joint alignment and motor control. 
 
PATIENT INFORMATION  

The patient was a 19-year old male 
intercollegiate basketball player. He was a 6’1”, 
point guard weighing 205 pounds. During the past 
off-season, this patient had undergone surgery for 
an upper extremity injury which limited his ability 
to participate in summer conditioning activities. He 
reported to the athletic training clinic with a 
primary complaint of intermittent AKP pain for 
approximately six weeks.  Low level knee pain 
began shortly after the start of fall semester 
workouts. Initially, the patient had been able to 
participate in basketball activity, weight lifting, 
and conditioning.  As the intensity of conditioning 
increased, the patient became unable to 
participate in basketball-related activities. The 
patient had been self-treating with patellar 
strapping and ice, which is a treatment he used 
previously when he experienced AKP. 

DIFFERENTIAL DIAGNOSIS AND 
EVALUATION 

The patient presented with point tenderness to 
palpation at the tibial tuberosity and the inferior 
pole of the patella with his knee resting in 
extension. The patient denied complaints of 
tenderness, locking, or popping of the joint line. 
The patient also denied any previous Osgood-
Schlatter or Sinding-Larson-Johansson diagnosis 
by a medical professional. No crepitus was 
present. There was no point tenderness or 
temperature changes along the length of the 
patellar tendon. All passive and active ROM were 
within normal limits (WNL) at the hip, knee, and 
ankle bilaterally. Trunk flexion, extension, and 
rotation motions were WNL and pain free. 
Bilateral lower extremity manual muscle testing 
resulted in 3/5 with pain reported at the inferior 
pole of the patella during the long sitting straight 
leg raise and seated knee extension, while all 
other muscle tests resulted in 5/5. The patient 
presented with normal patellar alignment, and 
both Clarke’s sign for patellofemoral irritation 
and the patellar apprehension tests were 
negative. At the completion of the assessment, the 
differential diagnosis included: patellar 
tendinopathy, dysfunctional patellar tracking, 
Hoffa’s fat pad irritation.  

BODY STRUCTURE AND FUNCTION 

The long sitting straight leg test was used as the 
client specific impairment measure (CSIM).15 The 
CSIM is a baseline test that is easily and safely 
reproducible in the clinic, prior to any functional 
or dynamic movement based testing. The CSIM is 
used to assess the treatment effects regarding 
pain or function. The test should be patient-
centered and meaningful to the patient.15 The long 
sitting straight leg test was used for the CSIM for 
this patient due to the painful result of the manual 
muscle testing during the initial assessment. 

After completion of the functional and special 
tests, the clinician included a “sub therapeutic 
dose” (1x6 repetitions) of the MC TIR MWM to 



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

51 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

identify if the joint mobilization could produce a 
positive effect on the patient reported pain.15 
Incorporating a sub-therapeutic dose of the 
mobilization into the assessment allows the 
clinician to determine if a MWM is clinically 
indicated.15 During the sub-therapeutic dose, the 
patient reported a pain-free MWM and 
immediate decrease in painful knee flexion.  As 
the sub-therapeutic MWM dose matched the PILL 
response, the clinician determined the MC TIR 
MWM was clinically indicated to treat the 
patient’s AKP. 

The patient had been self-treating his AKP over 
the preceding four days with no improvement of 
symptoms. He experienced pain at 110˚ of knee 
flexion, as well as seated knee extension and 
while performing a straight leg raise. After the 
positive result of the sub therapeutic dose of TIR 
MWM, the clinician was encouraged to proceed 
with a full intervention before scheduling further 
diagnostic testing. 

Prior to the examination, three patient-oriented 
outcome measures were administered to establish 
a baseline to measure the effect of patient care. 
First, the disability of the physically active scale 
(DPAS)23 was used to identify physical 
impairments, functional limitations, and quality of 
life changes that have taken place due to the 
injury.23 It has been designed to provide 
descriptive themes that are clinically meaningful 
to athletes. The DPAS has shown to be reliable, 
valid and responsive in the evaluation and 
monitoring of physically active patients.24 Second, 
the patient rated his pain on a 0-10 scale “least 
pain to most pain” using the numeric pain rating 
scale (NRS).25 The NRS has shown to be a sensitive 
and valid instrument in detecting changes in 
pain.25 Third, the patient completed the patient 
specific functional scale (PSFS)26 to identify 
movements that are important to him in daily or 
sport activities (descending stairs, single leg 
landing, weight lifting, kneeling).  The patient 
graded his ability to perform each activity on a 
scale of 0-10 “poor ability to best ability”. The 

PSFS has shown to have excellent test-retest 
reliability and is sensitive to changes.26 The 
treating clinician compared initial and follow-up 
scores at pre-determined intervals (initial, two 
days, one week, two weeks). The results at the 
initial and follow-up intervals are listed in Table 
3. 

Table 3: Initial Assessment and Follow-Up 
Scores of AKP 
 Initial 2 

days 
1 

week 
2 

weeks 
DPAS 19 8 0 0 
NRS 5 0 0 0 
PSFS:     
1)descending 
stairs 4 9 9 10 

 2)single leg 
landing 4 9 9 10 

 3)weight 
lifting 4 10 10 10 

 4)kneeling 4 8 8 10 
DPAS-Disability Of Physically Active Scale; 
NRS-Numeric Pain Rating Scale; PSFS-Patient 
Specific Functional Scale 
 

Results of the outcome measures were used to 
assess if changes have met minimal clinically 
important difference (MCID) standards.27 An 
MCID is considered the minimum change that takes 
place as a result of the intervention that is 
important to both the patient and the clinician.27 
To be considered MCIDs, changes include a pain 
decrease of six points for chronic pain (pain 
present for more than 6 weeks) or nine points for 
acute pain (pain present for less than 6 weeks) on 
the DPAS, a decrease of two points on the NRS 
and a three point change on the PSFS.23-27 

ACTIVITY AND PARTICIPATION 

The patient had been participating in pre-season 
individual workouts, weight lifting, conditioning, 
and playing unsupervised basketball for four 
weeks with AKP until the pain became unbearable 
the day prior to reporting for assessment. The 
patient did not feel the AKP was affecting his 



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

personal relationships or limiting his social 
activities. 

ENVIRONMENTAL AND PERSONAL 
FACTORS 

The patient was, however, very concerned about 
missing more team activities, as he had been 
unable to participate in any activities during the 
summer months. He had been the starting point 
guard and was anxious that he would lose his role 
on the team. His AKP was also affecting his ability 
to sit in class comfortably and to walk up and 
down stairs to his apartment.  

INTERVENTION 
 
To perform the MWM, the patient’s left foot was 
placed on a non-rolling stool with the knee and 
hip flexed to 90˚. A chair may be placed near the 
patient for balance if he/she feels uncomfortable 
standing on unaffected limb. Figure 1 illustrates 
the starting position for the MWM. 

Prior to the mobilization, the patient reported 
7/10 pain at the tibial tuberosity with the knee 
flexed to 110˚. To complete the MWM, the 
clinician placed one hand medially around the 
superior tibia close to the joint line without 
contacting the tender tibial tuberosity and the 
other hand grasped the lateral portion of the 
proximal tibiofibular joint. Figure 2 illustrates the 
starting hand position to perform the TIR MWM. 

The clinician applied internal rotation of the tibia 
and maintained the rotation throughout the entire 
ROM as the patient moved through available 
pain-free knee flexion and returned to the 
starting position    (Figure 3). 

During the MWMs, the clinician communicated with 
the patient regarding any discomfort that may 
have occurred guided by the CROCKS acronym. 
The intervention continued with two more sets of 
the MWM, following the treatment 
recommendation of three sets of 10 repititions.11-

19 After the completed treatment, the patient 

reported 0/10 pain at both the inferior pole of 
the patella or tibial tuberosity. The CSIM, long 
sitting straight leg raise, was also reassessed with 
the patient reporting a NRS score of 0/10 (MCID 
for pain) and the MMT was assessed as 5/5. Pain 
scores and knee flexion ROM changes are 
described in Table 4. 

Table 4: Pain Level and ROM Available Prior 
to, During and After The MWM was 
Performed 

Test Intervals NRS Knee Flexion 
ROM 

Before MWM 7 110˚ 
After sub-
therapeutic dose 
of  MWM 

4 110˚ 

After 1st set of 
MWM 4 120˚ 

After 3rd set of 
MWM 0 128˚ 

NRS-Numeric Pain Rating Scale; ROM-Range 
of Motion 

 

The MC guidelines recommend applying tape to 
reinforce the mobilization, assisting 
proprioceptive accommodations to the length 
and load of the new joint position created 
through the MWM intervention.12-15,17,18 The tape 
application is intended to mimic the MWM as the 
patient goes about their daily activities. While 
standing, the knee is placed in slight flexion (10˚) 
and full internal tibial rotation. The clinician 
applies the tape by starting laterally at the 
proximal fibular head, matching the MWM 
direction and force, and crossing to the medial 
aspect of the tibia in a spiral fashion. The tape 
application continued superiorly, on the posterior 
knee to the lateral thigh.12-15, 18 The patient 
reported the tape application resulted in the 
same joint position sensation as the hands-on 
mobilization. Figure 4 illustrates the completed 
tape application. 

OUTCOMES 

BODY STRUCTURE AND FUNCTION 



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

The patient returned after the weekend (two days 
after the initial intervention) for a follow-up visit 
to assess the changes to the MWM and the PILL  

Figure 1: Starting Position for TIR MWM 

 

 

Figure 2: Clinician’s Hand Placement to Perform 
TIR MWM.  
Right hand is encompassing the head of the 
fibula while the left hand contacts the medial 

tibia. Both hands avoid contacting the tender 
tibial tuberosity. 
 

Figure 3: Maintaining Manual Contact 
Throughout the Mobilization 

 

Figure 4: Tape Application Following TIR MWM. 
Small wrinkles of the tape may arise as the skin 
shifts under the adhered tape. 
  



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

response, as well as monitor any adverse effects 
the tape may have had on his skin. 12-20 At the first 
follow-up, the patient reported 0/10 pain during 
daily activity over the preceding two days, and 
reported a score of eight on the DPAS (MCID). The 
clinician repeated bilateral manual muscle testing 
resulting in 5/5 for all motions, including seated 
knee extension, which had previously been 
recorded at 3/5 with pain at the inferior pole of 
the patella. The clinician performed another 
intervention of 3x10 mobilizations followed by a 
new tape application and the patient was 
advised to return to the athletic training clinic for 
follow-up care as needed. To continue to collect 
patient centered outcomes, the patient was asked 
to return at one week intervals, unless there was a 
return of painful activity sooner. At the first one 
week interval, the patient reported 0/10 
tenderness at the inferior pole of the patella and 
at the tibial tuberosity. A TIR MWM was not 
performed at the one week interval due to the 
patient reporting pain-free activity. At the final 
outcome collection two weeks after the initial 
intervention, the patient remained pain-free. Both 
the patient-reported DPAS and NRS were 
recorded at 0/10, while the PSFS activities all 
were recorded at 10/10. Due to the patient 
reported responses on the outcome measures, TIR 
MWM was not performed at the second week 
follow-up visit. The patient was discharged with 
the understanding he should return to the athletic 
training clinic if there was a return of either pain 
or dysfunction. 

ACTIVITY AND PARTICIPATION 

The patient had not participated in any physical 
activity for two days following the initial 
intervention. He reported pain-free activities of 
daily living, which included walking up and down 
stairs and sitting in class. At the follow up visit two 
days after the initial intervention, the clinician 
recommended modified return to basketball 
activity, suggesting he participate in individual 
workouts, weight lifting and half the volume of 
each running workout as pain permitted. The 

patient determined that he would increase his 
activity as long as he was pain free and had 
returned to full basketball activities and reported 
0/10 pain with all activity. 

ENVIRONMENTAL AND PERSONAL 
FACTORS 

The patient was very anxious to return to activity 
due to his extended time away previously. His 
non-basketball painful activities (descending 
stairs and sitting in class) had decreased 
immediately and were completely eliminated 
within two days. While it was recommended he 
slowly return to activity through modified 
workouts, he felt he could fully participate as he 
remained pain free. He reported for follow up 
visits as scheduled, was truthful about his activity 
level and was responsive to completing the 
patient-based outcome forms. 

DISCUSSION 

Anterior knee pain is a common complaint with 
many causative factors including acute injury, 
congenital malalignment, poor motor control of 
the hip, pelvis, knee and core, as well as poor foot 
posture.1-7 Poor motor control of the hip, knee and 
pelvis may result in an internally rotated femur, 
with an accompanying externally rotated tibia, 
creating joint dysfunction.2-5,14,15  

Utilization of the MC MWM in this specific case 
study produced positive results which are 
consistent with results found in a review of the 
tenets and prescription of MWM by Hing, Bigelow 
and Bremner in the November, 2008 New 
Zealand Journal of Physiotherapy.13  The common 
significant results were reduced pain levels, 
increased strength and functional improvements 
when compared to placebo.13 The application of 
an internal rotation force on the tibia as the 
patient moved the knee through flexion and 
extension resulted in decreased pain and a 
change of faulty joint arthrokinematics. The MC 
TIR MWM is a gentle, pain-free intervention 
strategy for addressing symptoms associated with 



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

55 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

AKP.11-15,17 Proper application of a sub-
therapeutic dose within the initial assessment 
indicated the MWM could be clinically effective 
due to the production of the PILL effect.15 The tape 
application is believed to prolong the mobilization 
effect by providing a constant stimulus on the joint 
proprioceptors.12-15   

The clinician must be well-versed in the 
contraindications for joint mobilization before 
applying any mobilizing force on a joint surface, 
with a complete understanding of 
arthrokinematics and skills to sense changes in joint 
mobility. Application of a MWM allows the 
patient to provide feedback to the clinician 
throughout the treatment. If the patient reports 
pain, the clinician should pause at the starting 
point, reposition the hands, making sure hand 
placement, direction, and pressure is comfortable 
to the patient, however, if the patient reported 
pain persists, the MWM would be discontinued. 
Following the MC guidelines, a MWM treatment 
intervention should be pain-free and the reduction 
of pain should be immediate.11-19,22  
 
Utilization of patient-reported outcome measures 
can provide the clinician with information 
regarding the patient’s pain and function, along 
with the identification of the patient’s quality of 
life that may be overlooked if not specifically 
assessed throughout the patient care process. 
Making a concerted effort to appreciate how the 
injury is impacting the patient’s daily life outside 
their sport (e.g., transportation, food preparation, 
attending classes, personal relationships, 
completing school work) provides the clinician with 
a higher level of understanding of the patient’s 
overall well-being. Pain and disability scales 
provided information regarding improvements 
that were important to the patient (pain-free 
basketball, climbing stairs to apartment), as well 
as to the clinician (decreased pain and increased 
range of motion).23-27 Identifying and testing a 
CSIM prior to and after an intervention is effective 
in determining if important changes have taken 
place that are relevant to both the clinician and 

the patient.15 Continued monitoring of pain and 
dysfunction through patient-reported outcome 
measures is important to determine the immediate 
and lasting effect of the MWM intervention. 
While the outcome measures were collected for 
only two weeks until the patient was released to 
full activity, he was monitored daily for any return 
of pain or dysfunction. Prolonged outcome 
collection would have produced a more viable 
conclusion to the efficacy of the TIR MWM 
technique.  
 
CLINICAL BOTTOM LINE 
 
This case study was produced in an effort to 
highlight a successful intervention for one patient 
reporting AKP. The MC MWM is a treatment 
intervention guided by easy to follow acronyms 
for the desired outcome (PILL) and the technique 
of each intervention (CROCKS). The technique 
allows the patient and clinician to communicate 
throughout the mobilization to ensure a pain-free 
intervention, and the importance of the pain-free 
aspect of the mobilization cannot be understated. 
If the PILL effect had not been produced during 
the sub-therapeutic dose, the MWM would not 
have been clinically indicated.11-17 The tape 
application was used to prolong the mobilization 
and provide continued neurophysiological input to 
aid in the success of the intervention. 
 
Careful assessment and clinical reasoning must 
take place in order to determine the proper 
intervention for each patient. This patient had 
symptoms consistent with those of patellar 
tendinopathy which had not improved with his 
treatment of ice and rest. He did report positive 
initial results during the assessment with the sub-
therapeutic dose of the MC TIR MWM. The 
improvement in pain scale and muscle testing 
results are subjective from both the patient and 
the clinician, and may be a limitation of this case 
study. A change in joint arthrokinematics is 
believed to directly affect both pain and strength 
results of the MC TIR MWM.12-15,17-18,22 Further 
case studies and controlled trials are needed to 



The Mulligan Concept in the Treatment of Anterior Knee Pain 
 

 

56 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

further investigate clinical efficacy. The 
incorporation of the MC MWM into an athletic 
training practice can be a powerful treatment 
paradigm that may produce positive results.   
 
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2. Nguyen A, Schultz S, Schnidtz R, Luecht R, 
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3. Powers C, Landel R, Perry J. Timing and 
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patellofemoral pain. Phys Ther. 
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4. McConnell J. Management of a difficult knee 
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5. Bolga L, Malone T, Umberger B, Uhl T. Hip 
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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

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