Knee Joint Anterior to Posterior (Femur on Tibia) Manual Mobilization

Set-Up

1. The patient should be supine, with a rolled-up towel or half foam roll under the patient's lower leg, and the practitioner standing on the patient's affected side.
2. The table should be at a height that allows the practitioner to have elbows extended when the practitioner's chest is over the patient's knee.

Anterior to Posterior Mobilization (Femur on Tibia)

1. If the practitioner is less familiar with knee palpation:
   1. Start by identifying the patella
   2. Then allow the index fingers and thumb to sink posteriorly beyond the patella to the medial and lateral aspects of the knee.
   3. Identify the large round bumps of the femoral condyles that comprise the proximal half of the knee
   4. Then identify the bumpy thick ridge of bone at the top of the tibia that is the tibial plateau and comprises the distal half of the knee.
   5. Once the femoral condyles and tibial plateau have been identified, identify the linear depression between these two landmarks that is the joint line. Identifying the joint line is an important component of this technique.
2. The practitioner will then position the hands as if grasping the knee around the patella. Both thumbs over the lateral joint line, both index fingers over the medial joint line, the patella between the webs space of both hands, the palm of one hand firmly on top of the distal femur, and the palm of the other hand firmly over the proximal tibia.
3. The thumb and index fingers will serve as guides to aid in identifying arthrokinematic motion during the mobilization.
4. The palm over the femur will be used to apply the anterior to posterior oscillations used in this technique; try to use as much of the surface area of the palm as possible to reduce patient discomfort. The other hand is only aiding in stabilizing the tibia and leg.
5. Force will be generated using body weight by rocking the torso.

Mobilization:

1. Once you are comfortable with hand position, start with small test oscillations to identify articular motion and any exquisite tenderness.
2. When satisfied with the feel of the technique, identify the amount of pressure needed to feel the first resistance barrier just prior to articular motion, and then press harder to identify the most pressure that can be used and still result in articular motion. The point at which any further pressure fails to increase articular motion is the end of the articular range and no additional pressure should be used.
3. Identify the mid-point between the first resistance barrier and articular end-range; approximately 50% resistance.
   • Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
     • Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.
   • Grade IV - Small oscillations at 50% resistance or more.
4. Oscillate at 1 - 2 pulses per second.
5. Continue oscillating until you feel a change in tissue resistance/joint stiffness.