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

Targeting the Lower-Limb Kinetic Chain in Patellofemoral Pain: A Randomized Comparison of Foot and Ilium Mulligan Mobilization Combined With Hip-Knee Focused Exercises

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.

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.