Comparison Between Foot Segment Mulligan Mobilization and Ilium Mulligan Mobilization in Treatment Patellofemoral Pain Patients With Flatfeet: a Randomized Controlled Comparative Study

N/ANot Yet RecruitingNCT07806929

Cairo University90 enrolled

Overview

This three-arm, parallel-group randomized controlled trial will investigate the comparative effects of adding Mulligan foot-segment mobilization or Mulligan ilium mobilization to a standardized hip-knee focused exercise program in patients with patellofemoral pain and foot pronation. The study will compare these interventions with hip-knee focused exercises alone over a 4-weeks intervention period. The primary outcomes will be pain intensity and functional status, while secondary outcomes will include lower-limb muscle strength, dynamic knee valgus, pelvic tilt angle, and foot pronation.

Patellofemoral pain is a common musculoskeletal condition characterized by pain around or behind the patella that is aggravated by activities such as squatting, stair negotiation, running, and prolonged sitting. Although local knee impairments may contribute to symptoms, factors throughout the lower-limb kinetic chain may also influence patellofemoral mechanics and clinical presentation. Foot pronation may alter lower-limb biomechanics during weight-bearing activities and may contribute to changes in tibial and femoral movement. Proximal factors, including pelvic alignment and dynamic knee valgus, may also influence lower-limb loading and patellofemoral joint mechanics. Exercise therapy targeting the hip and knee is commonly used for the management of patellofemoral pain; however, it may not fully address kinetic-chain impairments in patients presenting with concomitant foot pronation. This study will evaluate whether adding Mulligan mobilization directed toward either the distal foot segment or the proximal ilium/pelvic segment provides additional clinical and biomechanical benefits when combined with a standardized hip- and knee-focused exercise program. Participants with patellofemoral pain and clinically relevant foot pronation will be screened according to predefined eligibility criteria and randomly allocated to one of three parallel groups: Foot Mulligan Mobilization Group: Participants will receive standardized hip- knee focused therapeutic exercises combined with Mulligan mobilization directed toward the foot segment. Ilium Mulligan Mobilization Group: Participants will receive the same standardized hip- knee focused therapeutic exercises combined with Mulligan mobilization directed toward the ilium/pelvic segment. Control Group: Participants will receive the standardized hip- knee focused therapeutic exercise program alone. The intervention period will last 4 weeks. Outcome measures will be assessed at baseline and immediately after completion of the intervention. The primary outcomes will be pain intensity, assessed using the Visual Analogue Scale (VAS), and functional status, assessed using the Anterior Knee Pain Scale (AKPS). Secondary outcomes will include hip and knee muscle strength assessed using a handheld dynamometer, dynamic knee valgus assessed using photogrammetric analysis and Kinovea motion-analysis software, pelvic tilt angle assessed using a PALM/pelvic inclinometer, and foot posture assessed using the Foot Posture Index (FPI). The study will primarily examine changes over time and differences among the three treatment groups, with particular attention to the group-by-time interaction. Appropriate statistical analyses will be performed based on the distribution and characteristics of the collected data, with statistical significance set at p \< 0.05. The study aims to determine whether targeting the distal or proximal segment of the lower-limb kinetic chain provides greater additional benefit when combined with hip-knee focused exercises in patients with patellofemoral pain and foot pronation.

Interventions

mobilization with movement of the foot segmentOTHER

Mobilization with movement of the foot segment First, a dorsal glide of the talonavicular joint will be combined with plantarflexion and inversion of the foot. Second, a posterior glide of the talocrural joint will be applied in combination with the corresponding active ankle dorsiflexion. Both mobilization techniques will be applied for 10 repetitions/ 3 sets

Mobilization with movement of the IliumOTHER

the patients will be in prone position with their hands at shoulder level, and the therapist will stand on the opposite side of the mobilized ilium. The therapist will stabilize the sacrum with the medial aspect of one hand, place the fingers of the other hand under the anterior superior iliac spine, and then will pull the ilium in posterior translation and rotation in relation to the sacrum. Next, the patient will be asked to perform 10 pain-free press-ups by extending the elbows. The mobilization included 3 sets with 10 repetitions for each set and a 30-s rest in between.

Hip-knee focused exercisesOTHER

Stretching exercises will include hamstring dynamic stretching from a supine position, soleus muscle stretching from a step-down position and standing the iliotibial band stretches first with arms at the side and then with arms extending overhead. Stretching exercises were performed 3 times, with a 30-s hold and a 1- in rest between each set and each muscle. The hip exercises will consist of bridging with an isometric hip abduction exercise from a supine position for hip extensors, side-lying hip abduction and clamshell at 30° hip flexion for hip external rotators. The knee exercises will involve mini wall squatting from 0-45° with a band around the distal thigh to engage hip abductors and external rotators, terminal knee extension exercise from a standing position and seated knee extension exercise from 90° to 45° knee flexion.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 35 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Age of the subjects between 18-35 years 2. BMI was from 18.5 to ≤ 29.5 Kg/m² . 3. Anterior or retro patellar knee pain for at least 6 weeks duration. 4. Foot posture index score from +6 to + 12. 5. Sagittal plane innominate tilt angle more than 8 degrees. 6. Pain elicited at least by two of the following four screening tests; (i) isometric muscle contraction with slight bent knee,(ii) palpation of the patella, (iii) patellar compression against the femoral bone (iv) active resisted knee extension. 7. Pain provoked by at least two of the following activities: running, walking, hopping, squatting, stair negotiation, kneeling, or prolonged sitting Exclusion Criteria: 1. Meniscal or other intra-articular pathologic conditions; cruciate or collateral ligament involvement. 2. A history of traumatic patellar subluxation or dislocation.. 3. Previous surgery in the knee, ankle and hip joints. 4. Knee, ankle and hip joints osteoarthritis. 5. Taking non-steroidal anti-inflammatory drugs or corticosteroids within 24 hours before the test. 6. History of brain injury or vestibular disorder within the last 6 months. 7. Pregnant female.

Outcomes

Primary Outcomes

Function measured by Anterior Knee Pain Scale

Anterior Knee Pain Scale (AKPS) It is a self-administered, weighted questionnaire that examines 13 different items including pain and functionality and a maximum score of 100 points, with higher scores indicating better lower extremity function. It documents response to six activities associated specifically with AKPS (walking, running, jumping, climbing stairs, squatting and sitting for prolonged period with knee bent). This scale has demonstrated high test-retest reliability and is considered a good and valid detector for significant changes after treatment of patients with PFPS.