Reep NC, Leverett SN, Heywood RM, Baker RT, Barnes DL, Cheatham SW.

The Efficacy
of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review. IJSPT.
2022;17(7):1219-1235.

Systematic Review/Meta-Analysis

The Efficacy of the Mulligan Concept to Treat Meniscal Pathology:

A Systematic Review
a
Nathan C. Reep 1 , Sydney N. Leverett 1 , Rebecca M. Heywood 1 , Russell T. Baker 1,2 , Darren L. Barnes 1 ,
Scott W. Cheatham 3
1 Department of Movement Sciences, University of Idaho, 2 WWAMI Medical Education, University of Idaho, 3 Department of Kinesiology, California
State University Dominguez Hills
Keywords: lesion, manual therapy intervention, Mobilization with Movement (MWM), rehabilitation, knee injury
[Link]

International Journal of Sports Physical Therapy

Vol. 17, Issue 7, 2022

Background
Meniscal pathologies are common knee injuries and arthroscopic surgery is the current
accepted gold standard for treatment. However, there is evidence to support the use of
the Mulligan Concept (MC) Mobilization with Movement (MWM) for meniscal
pathologies including the ‘Squeeze’ technique, tibial internal rotation (IR), and tibial
external rotation (ER).

Hypothesis/Purpose
The purpose of this systematic review was to critically appraise the literature to
investigate the effectiveness of MC MWMs for meniscal lesions on patient reported pain,
function, and multi-dimensional health status in patients with clinically diagnosed
meniscal pathologies.

Study Design
Systematic Review

Methods
A literature search was completed across multiple databases using combinations of the
words “knee, function, mobilization with movement, MWM, mulligan concept, MC,
meniscal pathology, meniscal derangement, and meniscal tear.” Studies written within
the prior 10 years that examined MC MWM techniques to treat knee meniscal injury were
included. Articles that met the inclusion criteria (used MC MWM ‘Squeeze’ technique,
tibial IR, or tibial ER for treatment of clinically diagnosed meniscal pathologies; Patient
reported outcome [PRO] measures had to be used in the assessment of knee pain or
function) were analyzed for quality. Randomized control trials were analyzed using the
PEDro scale and the Downs & Black (D&B) checklist, case series were analyzed using the
Joanna Briggs Institute (JBI) checklist, and case reports were analyzed using the CARES
checklist.

Results
Six articles met the inclusion criteria and were included in this review, two randomized
controlled studies, two case series, and two case reports consisting of 72 subjects. All six

a Corresponding author:
Nathan R. Reep MAT, LAT, ATC, CSCS
Department of Movement Sciences
University of Idaho
875 Perimeter Drive
Moscow, ID 83844
Fax: 765-677-1676
Email: reep2529@[Link]
Phone: 765-677-3034
 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

papers included reports of improvements in pain and function that were either
statistically significant or met the minimal clinically important difference (MCID). Five
studies reported the Disablement in the Physically Active (DPA) scale that also
demonstrated statistically significant differences or met the MCID. The MC MWM
‘Squeeze’ technique, tibial IR, or tibial ER demonstrated the ability to reduce pain,
improve function, and improve patient perceived disability following treatment of a
clinically diagnosed meniscal pathology. These studies demonstrated short term results
lasting from one week to 21 weeks.

Conclusion
Treatment interventions incorporating MC MWM techniques demonstrated reduction of
pain and improvement in function in the short term in patients with clinically diagnosed
meniscal pathologies.

Level of Evidence
2a

INTRODUCTION toms indicate meniscal injury, non-operative or conserva-

tive treatment is recommended.2,18
Meniscal injuries are diagnosed through clinical evaluation, Thus, there is a need to consider other treatment options
magnetic resonance imaging (MRI), or diagnostic for patients who present with the signs and symptoms of a
arthroscopy.1,2 Arthroscopy, which is reported to have an meniscal pathology due to the prevalence of meniscal in-
accuracy of 90-95% and has the benefit of immediate surgi- juries, potential undesired surgical outcomes (e.g., adverse
cal correction being able to be performed, is considered the long-term outcomes), and recommendations for conserva-
gold standard diagnostic technique; however, arthroscopy tive care.2,12,19,20 The Mulligan Concept (MC), introduced
has drawbacks such as unnecessary surgical costs and by Brian Mulligan, is an innovative conservative treatment
risks.1,3 The reported diagnostic accuracy of MRI has been approach used to address common issues (e.g., joint pain,
as high as 88%,4 but MRI also has drawbacks, such as high decreased ROM, movement dysfunction, etc.) associated
prevalence of findings in asymptomatic uninjured knees,5 with knee joint pathology.21,22 The MC incorporates move-
increased healthcare costs,6 and challenges with accessing ment with mobilization by combining the patient’s active
imaging.7 Thus, accurate diagnosis with a physical exam range of motion (AROM) with a clinician’s joint glides to at-
is valuable; comprehensive physical examination and test- tempt to produce immediate changes in the patient’s com-
ing batteries (i.e., positive McMurray’s, Thessaly’s, and Ap- plaints and impairment measures. While consensus on the
ley’s tests) have been associated with high diagnostic ac- mechanism of action has not been reached, application of
curacies of 90% and 81%, respectively.8 Similarly, a clinical the MC is thought to alter the mechanoreceptive and noci-
prediction rule of a history of catching or locking, pain with ceptive responses to promote immediate improvements in
forced hyperextension, pain with maximum knee flexion, the patient’s impairment.23,24
joint line tenderness, and pain or clicking while performing Specific MC mobilizations with movement (MWMs)
McMurry’s test has been reported to have a positive predic- techniques have been proposed as effective conservative
tive value of 92.3% and a positive likelihood ratio of 11.45 non-surgical interventions for meniscal pathology.25 Re-
when all five signs are present in a clinical exam.9 searchers have recently begun to examine the effects of
Once diagnosed, meniscal injuries are often treated sur- the proposed MC MWM techniques (i.e., ‘Squeeze’ tech-
gically in combination with conservative therapy or after nique, tibial IR, and tibial ER) in patients with clinically di-
conservative therapy has failed to produce the desired im- agnosed meniscal lesions.24,26–29 A synthesis of the avail-
provement.2,10,11 In fact, arthroscopic partial meniscec- able literature to assess the effectiveness of the proposed
tomy (APM), which addresses meniscal injury by removing meniscal MC MWM techniques in the treatment of clini-
the damaged meniscal tissue, is one of the most commonly cally diagnosed meniscal lesions has not been conducted.
performed orthopedic surgeries.12,13 Surgical approaches, Examining the effects of these MC MWMs in clinically diag-
however, have often failed to have the desired result. For nosed meniscal lesions would provide an update on the ev-
example, APM has not been found to outperform sham idence and help inform practitioners on an evidence-based
surgery or conservative management, and surgery has re- method for incorporating MC MWMs ‘Squeeze’, tibial IR,
sulted in patients who were more susceptible to developing and tibial ER into clinical practice. Therefore, the purpose
osteoarthritis.11,12,14 Arthroscopic repair, which has a rep- of this systematic review was to critically appraise the lit-
utation as the “gold standard” for meniscal injuries in cases erature to investigate the effectiveness of MC MWMs for
where it is feasible to repair the specific meniscal tear pre- meniscal lesions on patient reported pain, function, and
sent,10,15 has high rates of failure (e.g., patients often re- multi-dimensional health status in patients with clinically
develop symptoms, patients require additional corrective diagnosed meniscal pathologies.
operations, etc.).16,17 When patient history, physical exam-
ination, current pain, and dysfunction or mechanical symp-

International Journal of Sports Physical Therapy

 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

METHODS STUDY SELECTION

STUDY DESIGN One author (NR) conducted the initial search, while a sec-
ond author (SL) repeated the search to ensure the accuracy
The systematic review was registered on the International
and repeatability of the search results (Figure 1). The two
Prospective Register of Systematic Reviews (PROSPERO), a
search authors (NR and SL) were blinded to the initial re-
database for tracking the quality of systematic reviews in
view of titles and abstracts and met to ensure final inclu-
health professions (CRD42021278025). The 13-item PROS-
sion was consistent. Four of the authors (NR, SL, RH, and
PERO checklist for the creation of systematic reviews was
DB) independently completed a full text review of the stud-
followed for accuracy of study design and reporting.30 The
ies that met inclusion and exclusion criteria and met to
Preferred Reporting Items for Systematic Reviews and
reach consensus for inclusion; a fifth author (RB) was con-
Meta-Analysis (PRISMA) 27 item checklist was also used in
sulted to confirm inclusion in the event of an impasse. All
the creation of the systematic review to ensure the quality
the authors agreed that the studies selected met the criteria
of the study design.31
for inclusion after review (Table 2).

SEARCH STRATEGY
DATA COLLECTED
An electronic search of the literature was conducted in
The studies included were graded with the following scales
May 2022. The following databases were used for the lit-
to assess and measure the study quality (e.g., study type,
erature search: PubMed, SportDiscus, CINHAL, MEDLINE,
internal validity, level of evidence; (Table 3). The PEDro
the University of Idaho library, and the indexed reference
scale was used to assess the internal validity of the random-
of published works listed on the Mulligan Concept website.
ized control trials (RCTs); scores of seven or higher were
The search was limited to the last ten years with an addi-
considered high methodological quality, five to six were fair
tional filter to specify academic articles or journal articles
quality, and zero to four were poor quality.32 The Downs
depending on the database. The search terms used were
and Black (D&B) Checklist for randomized studies exam-
"menisc* AND mulligan AND pain (Figure 1). Other search
ining health care interventions was also utilized to evalu-
terms (i.e., knee, function, mobilization with movement,
ate included RCTs.33 The 27 item D&B Checklist was scored
MWM, mulligan concept, MC, meniscal pathology, menis-
out of 32 total points where ranges of corresponding scores
cal derangement, and meniscal tear) were used to find ad-
were given: excellent (26-32); good (20-25); fair (15-19);
ditional studies, but no additional studies were identified
and poor (≤ 14).34 Any identified case series was assessed
with these terms. A hand search of the references of iden-
with the Joanna Briggs Institute (JBI) checklist for case se-
tified articles was also performed; however, no additional
ries. A 6/10 or greater indicated a low risk of bias.35 Iden-
studies were identified with this process, while one addi-
tified case studies were assessed with the CARES checklist
tional study was identified on the Mulligan Concept website
and were scored out of twelve.36 The CARES checklist was
that was published in the Journal of Sports Medicine and
scored on a 0-12 scale by giving a point to any question
Allied Health Sciences, which is the official journal of the
within a category when answered “yes” by the reviewer. The
Ohio Athletic Trainers Association.
last question (Question 13) was not scored because it is in-
tended for the completion of a case study by the original
ELIGIBILITY CRITERIA
author and is not always reported in the study. Each study
Each study had to meet the following inclusion criteria to was assigned a level of evidence in accordance with the Ox-
be eligible for this review. A clinical diagnosis of a menis- ford Center of Evidence-Based Medicine.37 This system of
cal pathology consisting of a minimum of three of the fol- assessment was designed to quickly assess the best liter-
lowing items during the physical exam: 1) a positive test ature based on the study’s design. Each study design falls
for McMurray’s, Thessaly’s, or Apley’s Compression tests; within a specific level that can be graded up or down based
2) pain at end range of knee flexion; 3) pain at end range of on the quality of the study.37
knee extension; 4) joint line tenderness; and 5) a history of
DATA EXTRACTION
painful popping or clicking (Table 1). Additionally, the use
of the MC MWM ‘Squeeze’ technique, tibial IR, or tibial ER
The total number of participants and general demographic
for treatment of clinically diagnosed meniscal pathologies
information were extracted from each qualified study. The
had to be present. Finally, PRO measures had to be used in
primary data extracted from each article were study charac-
the assessment of knee pain or function. Studies were ex-
teristics (e.g., publication data, study design, etc.), method-
cluded if a non-MWM MC technique or alternative forms
ology (e.g., treatment protocol, inclusion/exclusion criteria,
of manual therapy were utilized or if the included partic-
etc.), and results. Patient reported pain was assessed by the
ipants had any other clinically diagnosed knee pathology,
Numeric Pain Rating Scale (NRS). Patient-reported func-
hyperalgesia, or a previous history of knee surgery. Stud-
tion was assessed by the Patient-Specific Functional Scale
ies were also excluded if they were not published in Eng-
(PSFS), while multi-dimensional (e.g., impairment, quality
lish, not published within the last 10 years, or did not
of life, etc.) patient-reported assessment of health status
meet the expectations for blinded peer-review (e.g., disser-
was assessed with the Disablement in the Physically Active
tations, poster presentations,).
(DPA) and Knee Osteoarthritis Outcome Score (KOOS). The

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Figure 1. PRISMA flow diagram

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 1. Study Participants

Study Participant Demographics Clinical Diagnosis of Meniscal Pathology

Kasturi N=40 (32M, 8F) Each participant had all the following findings:
(2020)28 Control (N=20) • Joint line tenderness
Intervention (N=20) • Restricted AROM
Average age of all participants 28.87y • Pain with terminal knee flexion, knee extension, and internal/external
(SD 7.09) rotation
• Feeling of locking and instability in the knee joint

Hudson N=23 (11M, 12F) Inclusion: Participants presented with at least three of the
(2018)21 Both athletic and general populations following findings:
Age range: 14-62 y • Positive McMurray’s test
Average Age 24.91y (SD 12.09) • Pain with maximal knee flexion
Control (N=11) • Pain with maximal knee extension
Acute: 3 | Chronic: 8 • Joint line tenderness
Intervention (N=12) • History of clicking and/or popping
Acute: 6 | Chronic: 6
Generally healthy Positive finding on at least one of the following rotational tests:
• Apley’s compression and distraction
• Thessaly’s at 20°

Sanchez N=1 • Insidious right knee stiffness and swelling

(2017)24 26-year-old physically active female • History of locking and popping
• Pain with terminal knee extension and flexion
• Positive Thessaly’s test at 5º and 20º of knee flexion
• Positive Apley’s compression test
• Joint line tenderness

Hudson N=5 (4M, 1F) Inclusion: Participants presented with at least three of the
(2016)27 All acute meniscal injury following:
Age range: 15-24 years • Positive McMurray’s test
Average age: 19.6 (SD 3.2) • Pain with terminal knee flexion
• Pain with terminal knee extension
• Joint line tenderness
• History of clicking and/or popping
Positive finding on at least one of the following rotational tests:
• Apley’s compression and distraction
• Thessaly’s at 20°

Brody N=2 (1M, 1F) Inclusion:

(2015)26 Healthy college students and • Joint line knee pain
recreational athletes • History of catching or locking
• Pain with knee flexion or extension
Positive finding on at least one or more of the following
orthopedic special tests:
• McMurray
• Apley’s
• Thessaly

Rhinehart N=1F Clinical diagnosis of meniscal pathology due to the following

(2015)29 20-year-old female soccer player examination findings:
DX: lateral meniscus pathology • Inability to fully flex or extend knee
• Pain with stairs
• Sporadic giving out of knee
• Joint line tenderness
• Positive McMurray and Thessaly test for pain
Moderate swelling at both medial and lateral joint lines

M-Male; F- Female; y – years; SD-Standard Deviation; DX-diagnosis; AROM-active range of motion

Lower Extremity Functional Scale (LEFS), Global Rating of PRIMARY OUTCOMES

Change (GRoC), Range of motion (ROM), and Client Spe-
cific Impairment Measures (CSIM) were assessed as sec- PAIN
ondary outcomes when reported. Lastly, follow-up results
were collected to determine the long-term effectiveness of The NRS is an outcome measure designed to assess pain
the treatment intervention. intensity.38 All six studies utilized the NRS, which is a
single-item measure that ranges from 0 (no pain) to 10
(most severe pain) and is used to assess the best, current,
and worst pain the patient has experienced over the past

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 2. Characteristics of Included Studies

Author Study Participants Intervention Comparison Outcome

(Year) Design Measures
Kasturi Experimental N=40 (32M, 8F) MC ‘Squeeze’ technique along Conventional NRS
(2020)28 Randomized Control (N=20) with conventional therapy Therapy PSFS
Control Trial Intervention Knee ROM
(N=20)
Hudson Experimental N=23 (11M, Mulligan with Movement Sham Mulligan NRS
(2018)21 Randomized 12F) ‘Squeeze’ technique Treatment PSFS
Control Trial Control (N=11) DPA
Intervention KOOS
(N=12)
Sanchez Case Study N=1F Tibial IR Mobilization with None DPA
(2017)24 Movement PSFS
And MC ‘Squeeze’ technique NRS
Hudson Case Series N=5 (4M, 1F) MC ‘Squeeze’ technique None NRS
(2016)27 PSFS
DPA
KOOS
Brody Experimental N=2 (1M, 1F) MC ‘Squeeze’ technique None DPA
(2015)26 Case Series PSFS
Knee ROM
NRS
Rhinehart Case Study N=1F MC ‘Squeeze’ technique None DPA
(2015)29 NWB tibial IR NRS
WB tibial IR glide LEFS
WB tibial IR glide combined GRoC
with a distal anterior PSFS
tibiofibular glide lateral tibial CSIM
glide Knee ROM
MC tibial IR glide taping
technique

M – male; F – female; MC-Mulligan Concept; NRS – Numeric Pain Rating Scale; PSFS – Patient-Specific Functional Scale; DPA – Disablement in the Physically Active Scale; KOOS –
Knee injury and Osteoarthritis Outcomes Score; ROM – Range of Motion; LEFS – Lower Extremity Functional Scale; GRoC – Global Rating of Change; CSIM – Client Specific Impair-
ment Measure; NWB – Non-weight bearing; WB – Weight-bearing; IR – Internal rotation

Table 3. Assessment of Included Studies

Study Author (Date) Study Design Scale Used Scale Score Level of Evidence
Kasturi (2020)28 RCT PEDro Scale / D&B 4/10 / 22/32 Level 2
Hudson (2018)21 RCT PEDro Scale / D&B 6/10 / 26/32 Level 2
Hudson (2016)27 Case Series JBI Checklist 8/10 Level 4
Brody (2015)26 Case Series JBI Checklist 9/10 Level 4
Sanchez (2017)21 Case Study CARES Checklist 10/12 Level 4
Rhinehart (2015)29 Case Study CARES Checklist 9/12 Level 4

RCT - Randomized Control Trial; CARE - Case Report guidelines; JBI - Joanna Briggs Institute; PEDro Physiotherapy Evidence Database; D&B - Downs and Black Checklist

24 hours.38,39 The minimal clinically important difference MULTI-DIMENSIONAL HEALTH STATUS

(MCID) on the NRS is 2 points or a 33% reduction indicating
a “much better” improvement in symptoms.40 Five studies used the DPA scale to assess the patient’s per-
ception of disablement as a result of their injury.42 The DPA
FUNCTION scale consists of 16 items scored from 1 (no problem) to
5 (the problem(s) severely affect me).42,43 The scores for
The PSFS was used to assess function. All six studies uti- each item are totaled and then 16 is subtracted from the to-
lized the PSFS, where patients choose and rate functional tal score to provide the DPA score; scores range from 0-64,
or personally important tasks from 0 (unable to perform with high scores indicating more severe disablement.42 The
activity) to 10 (able to perform activity at pre-injury MCID value for the DPA scale is a change of 9 points in
level).34,35,41 The MCID for the PSFS is 3 points in orthope- acute injuries and a change of 6 points in chronic injuries.42
dic knee conditions.41 Two studies used the KOOS, which is a self-administered
outcome measure used to assess a patient’s perception of

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

their knee injury and ability to complete usual activities.44 QUALITY ASSESSMENT
The KOOS assesses five different subscales specific to knee
injury: pain, symptoms, activities of daily living, sport and Six studies were included in the final analysis covering mul-
recreational function, and knee-related quality of life over tiple designs and levels of evidence.21,24,26–29 Two RCTs,
the past week.44 The KOOS includes 42 items across the five two case series, and two case studies were evaluated for
subscales with each item scored on a Likert scale from 0 quality using the appropriate measurements (Table 3). The
(no problem or never) to 4 (extreme problem or always); the two RCTs were graded down to Level 2 because of quality:
score is then converted to a 0-100 scale with a lower score both were scored as six or less on the PEDro scale indicating
representing more severe problems.44 concerns with methodological quality. However, in the D&B
checklist the Hudson RCT21 fell in the “excellent” range
SECONDARY OUTCOMES (26/32) while Kasturi28 fell in the “good” range (22/32). The
case series were graded above a 6/10 demonstrating low risk
One study used the LEFS to assess a patient’s perceived dis- of bias. Both case studies were assessed with the CARES
ablement with a 20-item questionnaire designed to assess checklist used for the reporting of a case study; both were
a patient’s perceived level of difficulty completing different able to answer “yes” to 75% or higher of the questions in
activities due to lower extremity injury.45 The LEFS items the checklist. Table 1 details the assessment of each article
are scored on a Likert scale from 0 (extreme difficulty or un- included.
able to perform) to 4 (no difficulty) and the score for each
is summed together for a total score; the maximum score INTERVENTION PROTOCOL AND GENERAL FINDINGS
on the LEFS is 80 points and indicates no functional limita- ASSESSMENT
tions.45
One study used the GRoC which is a single-item measure The total number of treatments used varied between stud-
to assess the patient’s perceptions of their overall improve- ies. Kasturi28 was the only study without the total number
ment since the initial treatment.46 The GRoC is scored on of treatments reported; however, data was reported at three
a 15-point Likert Scale ranging from -7 (a very great deal time points during the study. The number of treatments
worse) to +7 (a very great deal better).47 A change in score reported in the other studies varied between two and
of 5 points or greater on the 15-point GRoC scale represents six.21,24,26,27,29 The time between treatments varied across
a clinically meaningful change.48 all six studies ranging from 24 hours to 14 days.21,26 The
Three studies used range of motion (ROM) as a clinician- specific intervention protocols and study timelines are de-
reported outcome measure used to assess joint motion. The scribed in Table 4.
normative ROM for knee flexion and extension ranges from Some of the patients were allowed to continue participa-
132.9° to 142.3° and 0.5° to 2.4° respectively.49 tion during treatment while other authors did not specify
One study used the CSIM, which is a specific movement the amount of participation or restriction during treatment.
or muscle contraction that causes pain or is difficult for a Kasturi28 did not report on the level of activity before, dur-
patient to perform; the CSIM is rated on a scale from 0 (no ing, or after treatment. Hudson et al21 only reported on dis-
difficulty or pain) to 10 (maximum difficulty or pain).50 The charge criteria and did not specify participation parame-
CSIM is used in the Mulligan Concept to identify what is ters. Sanchez24 reported that all the patients returned to
painful for the patient and help the clincian use the ap- participation but did not describe participation during the
propriate directional force or glide to relieve pain through- intervention. In the case series, Hudson et al27 reported
out the previously painful movement. No validation of the that the patients were able to continue participation
CSIM has been done to date. throughout treatment and returned to previous levels of ac-
tivity. Brody et al26 and Rhinehart29 only reported that pa-
tients were able to return to previous levels of participation
RESULTS
following the MC MWM treatment. No researcher reported
any adverse reaction to the treatment or worsening of the
A total of 139 articles were initially identified from the
symptoms following treatment.
search and 133 articles were excluded due to either being
Similar results were reported across the two RCTs.21,28
duplicates or not meeting the inclusion and exclusion cri-
Kasturi28 reported both groups improved with rehabilita-
teria (Figure 1). A total of six articles met the inclusion and
tion; however, the treatment group with MC MWM had
exclusion criteria for full-text review and were included in
a statistically significant improvement in comparison to
the analysis (Table 2). All eligible articles yielded a total
the control group consisting of conventional rehabilitation.
of 72 subjects (Male=48, Female=24) ranging in age from
Hudson et al21 also demonstrated statistically significant
14-62 years. All patients were clinically diagnosed with a
results for those in the treatment group and crossover
meniscal pathology through a physical exam; participant
group compared to the sham treatment.
demographics and physical exam diagnostic criteria are
presented in Table 1.

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 4. Intervention Protocol

Author Intervention Protocol Timeline Number of Treatments

(Year)
Kasturi IG: MC ‘Squeeze’ technique with conventional Treatment was conducted for 6 weeks; frequency of treatment sessions Not provided
(2020)28 therapy (e.g., 1/week, 2/week) was not reported.
• 3x10 in one session
Conventional therapy:
• Static quadriceps, vastus medialis obliques, and
hamstring strengthening
• Active hip, knee, ankle ROM exercises
• Seated multiple angle isometric exercises
• AROM and strengthening for the unaffected lower
limb
• Gait training given on parallel bar in front of the
mirror
• All exercises were repeated ten times with 10 sec
hold and relaxed each time.
Control Group: conventional therapy only
Hudson Intervention Group: 14-days ≤6
(2018)21 • MWM: MC ‘Squeeze’ technique
• 3 x 10 with a minimum of 30 seconds of rest in be- 24-72 hours in between each Tx Crossover group had an additional 1-6 treatments
tween each set with the ‘Squeeze’ technique after the sham
Crossover group had an additional 14-day treatment period with the treatment
Control Group:
‘Squeeze’ technique after the sham treatment if they had not recovered
• Used same protocol as IG, but with a sham Mulli-
gan using a different hand placement and amount
of force
• No activity restriction
Crossover Group:
• Received MC ‘Squeeze’ treatment after not reach-
ing discharge criteria in the sham group

Sanchez • MWM - MC ‘Squeeze’ technique 11-days 3

(2017)24
Visit 1:
• Tibial IR MWM with squat 3 x 10
Visit 2:
• MC ‘Squeeze’ 3 x 10
Visit 3:
• MC ‘Squeeze’ 2 x 10
• Tibial IR MWM with terminal knee extension 3 x 10

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Author Intervention Protocol Timeline Number of Treatments

(Year)
Hudson • MC ‘Squeeze’ technique was administered accord- Average 14.2 days (SD = 5.68 days) Ranged from 2 to 6 treatment sessions
(2016)27 ing to Mulligan Concept principles.
• All participants were treated until discharged Ranged from 2 to 21 days

Brody • MC ‘Squeeze’ Tx given by same Mulligan Patient 1: 21 days Both patients: 2

(2015)26 trained clinician Patient 2: 15 days
• 3 sets of 10 reps in PWB during 1st Tx.
• 3 sets of 10 in squat during 2nd Tx.

Rhinehart Visit 1: 9-days 4

(2015)29 • 3x10 NWB tibial IR MWM flexion/extension
• 3x10 WB tibial IR MWM knee flexion
• 3x10 WB tibial IR MWM with anterior tib/fib glide
for dorsiflexion
• Taped the tibial IR glide using Coverall and Leuko-
tape
Visit 2:
• 1x10 NWB tibial IR MWM flexion/extension
• 2x10 WB tibial IR MWM knee flexion
Visit 3:
• 2x10 lateral tibial glide while walking up steps
• 2x10 tibial IR with lateral tibial glide while walking
up steps
• 2x10 MC ‘Squeeze’ technique while walking up
steps
• Taped the tibial IR glide using Coverall and Leuko-
tape
Visit 4:
• 2x10 MC ‘Squeeze’ technique while lunging 3x10
standing forward lunge with medial tibial glide

MWM - Mobilization with Movement; MC – Mulligan Concept; ROM - Range of Motion; AROM - Active Range of Motion; IG – Intervention Group; Tx – Treatment; CG – Control Group; SD – Standard Deviation; IR – Internal Rotation; PWB – Partial weight bearing; NWB -
Non-weight bearing; WB – Weight bearing

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 5. Numeric Pain Rating Scale Results

Intake Discharge Change

Kasturi (2020)28 IG: 7.35 ± 1.18 IG: 1.1 ±0.79 IG: 6.25 pt ↓*
CG: 7.2 ±0.15 CG 3.05 ±1.23 CG: 4.15 pt ↓*
Hudson (2018)21 IG: 2.64 ±0.89 IG: 0.44 ± 0.44 IG: 2.2 pt ↓*
CG: 3.67 ±2.50 CG 2.42 ±1.96 CG: 1.25 pt ↓
COG: 3.40 COG: 0.66 COG: 2.73 pt ↓*
Sanchez (2017)24 3 (Worst score) 0 (worst) 3 pt ↓*
Hudson (2016)27 4.32 (Average) 0.07 (average) 4.25 pt ↓*
Brody (2015)26 Patient 1: 4 (average) Both patients: 0 (average) Patient 1: 4 pt ↓*
Patient 2: 8 (average) Patient 2: 8 pt ↓*
Rhinehart (2015)29 4.7 0.83 3.87 pt ↓

* Denotes minimal clinically important difference; IG – Intervention Group; CG – Control Group; COG – Crossover Group; pt – point

PRIMARY OUTCOMES statistically significant or met the MCID.21,24,26–29 In both

RCTs,21,28 a statistically significant difference in the PSFS
PAIN scores of the participants in the intervention group com-
pared to the control group were found across each of the
In the six included papers, the researchers reported de- measured time points.21,28
creases in pain that were either statistically significant or Additionally, in a case series by Hudson et al.,27 each
met the MCID of a two-point change on the of the participants had an increase of at least 3 points on
NRS21,24,26–29,40All of the participants who received MC their PSFS by the time of discharge, meeting the MCID of
MWMs had a complete or near-complete resolution of pain 3.27,51 Furthermore, changes in patient reported function
(Table 5). Kasturi28 reported no significant difference after were reported to be statistically significant (p = 0.003) and
day one of treatment (p = 0.698) but a significant difference a large effect size (d = 3.01) was reported.27,52 The other
in NRS scores between the control group and the interven- case series by Brody et al26 did not include inferential sta-
tion group at four weeks with a mean difference of 1.65 (p = tistical analysis; however, both patients reported PSFS im-
< 0.001), six weeks post intervention with a mean difference provements which met the MCID value for the PSFS.
of 1.95 (p = < 0.001). Both groups had a reduction in pain on In a case study by Rhinehart,29 the participant had an in-
the NRS that exceeded the MCID. In their RCT, Hudson et crease in their average PSFS score by 4.75 points from ini-
al.21 did not report a statistically significant difference be- tial visit to discharge (nine days), which also met the MCID
tween the sham-control group and the intervention group for the PSFS. In another case study,24 the participant im-
after the final treatment for pain; however, the interven- proved 2 points on their PSFS to reach the maximum 10
tion group had over a two-point average reduction on the points from initial visit to discharge.
NRS and met the MCID, while the sham-control group did
not meet the MCID for the NRS after the final treatment. MULTIDIMENSIONAL HEALTH STATUS
Additionally, all the participants in the intervention group
scored a two or less on the NRS scale following the final DISABLEMENT IN THE PHYSICALLY ACTIVE SCALE (DPA)
treatment.21
In the two included case series26,27 the researchers re- In each of the five studies that reported on the DPA scale,
ported decreases in pain in as little as two treatments26 either the MCID was met or a statistically significant
to an average of five treatments.27 In both cases, pain was change in DPA scores was reported (Table 7) indicating
reduced to near zero at discharge on the NRS.26,27 The the patient’s perceived disability improved with treat-
total number of patients treated between the two-case se- ment.21,24,26,27,29 The DPA scale was utilized in one RCT
ries was seven with five of them from the Hudson et al.27 and a statistically significant difference (mean difference of
study. Two additional patients have been reported in the 8.78 points; p = 0.013) was found between the MC MWM
literature through two case studies.27,29 Both patients re- treatment group and the sham group.21 In the case series
ported decreased pain in as few as three treatments.27,29 by Hudson et al.,27 each of the five participants had an im-
Both studies met the MCID with a greater than two-point provement in their DPA scale at discharge: three of the five
change at discharge.27,29 In addition, both authors reported participants reported changes exceeding the MCID crite-
that the patients had less than 1/10 on the NRS at dis- rion, while the other two participants reported DPA scale
charge.27,29 scores within the reported ranges of healthy people prior to
starting treatment.27,42 Brody et al.26 reported that the DPA
FUNCTION score increased from intake to discharge for one participant
and noted that the increase was due to increased life stress.
Patient reported improvement in function was found on the In the two case studies, both patients reported a decrease
PSFS (Table 6) in all six studies and the results were either in their DPA score with each visit.24,29

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 6. Patient-Specific Functional Scale Results

Intake Discharge Change

Kasturi (2020)28 IG: 3.39 ± 1.18 IG: 8.49 ± 0.61 IG: 5.1 pt ↑*
CG: 3.89 ±0.81 CG 7.11 ±0.84 CG: 3.22 pt ↑*
Hudson (2018)21 IG: 3.67 ±1.72 IG: 9.50 ±1.85 IG: 5.83 pt ↑*
CG: 6.45 ±1.57 CG 7.00 ±2.07 CG: 0.55 pt ↑
COG: 5.80 COG: 9.00 COG: 3.20 pt ↑*
Sanchez (2017)24 8 (average) 10.0 (average) 2 pt ↑
Hudson (2016)27 3.4 (average) 10.0 (average) 6.6 pt ↑*
Brody (2015)26 Patient 1: 5.33 (average) Patient 1: 8.67 (average) Patient 1: 3.34 pt ↑*
Patient 2: 2.0 (average) Patient 2: NT Patient 2: N/A
Rhinehart (2015)29 4.0 8.75 4.75 pt ↑*

* Denotes minimal clinically important difference; IG – Intervention Group; CG – Control Group; COG – Crossover Group; Tx – treatment; pt – point; NT – not tested; N/A – Not ap-
plicable

Table 7. Disablement in the Physically Active Scale Results

Intake Discharge Change

Kasturi (2020)28 N/A
Hudson (2018)21 IG: 23.92 ±10.05 IG: 9.00 ±8.12 IG: 14.92 pt ↓*
CG: 24.91 ±11.96 CG 18.55 ±14.05 CG: 6.36 pt ↓
COG: 26.6 COG: 10.4 COG: 16.2 pt ↓*
Sanchez (2017)24 16 6 10 pt ↓*
Hudson (2016)27 25.6 (Average) 7.4 (average) 18.2 pt ↓*
Brody (2015)26 Patient 1: 10 Patient 1: 13* Patient 1: 3 pt ↑†
Patient 2: 40 Patient 2: NT Patient 2: N/A
Rhinehart (2015)29 46 0 46 pt ↓*

* Denotes minimal clinically important difference; IG – Intervention Group; CG – Control Group; COG – Crossover Group; Tx – treatment; pt – point; NT – not tested; N/A – Not ap-
plicable; † Increase in DPA score was attributed to other aspects of the patient’s life causing them stress

KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE points, which is the highest score possible indicating no
perceived functional limitations were identified by the pa-
Two of the studies included the KOOS outcome measure to tient on the LEFS.29 Additionally, this patient maintained
assess the patient’s perception of their knee injury and dys- this score at both the one-week and one-month follow up
function.21,27 In a case series, Hudson et al.27 found the av- after discharge.29
erage change on the KOOS across participants was a 28.56
± 5.68 point increase (i.e., improvement) from the initial GLOBAL RATING OF CHANGE
exam to discharge, which was an average of 14.2 days across
the five participants. In a randomized controlled trial, Hud- The GRoC was used as an outcome measure in the case re-
son et al.21 observed an average increase (i.e., improve- port by Rhinehart.29 The patient reported a score of +6 (A
ment) of 13.82 ± 10.94 points on the KOOS in participants great deal better) following the first treatment session.29
in the MC ‘Squeeze’ treatment group, while there was only The discharge exam for this patient occurred nine days af-
a 9.07 ± 11.13 average increase in the sham group. Five ter initial treatment, and a GRoC score of +7 (A very great
participants crossed over and completed the MC ‘Squeeze’ deal better) was reported. The GRoC score was maintained
treatment and reported a mean increase of 21.28 ± 11.38 at both the one-week and one-month follow-up appoint-
from completion of sham trial to completion of MC ments.29
‘Squeeze’ trial.
RANGE OF MOTION
SECONDARY OUTCOMES
Three of the studies included knee ROM as an outcome
LOWER EXTREMITY FUNCTIONAL SCALE measure (Table 8).26,28,29 In two of the studies, the patients
had full knee range of motion by discharge.26,29 Addition-
The LEFS was included as an outcome measure in a single ally, in their case report, Rhinehart29 found improvements
case report.29 Researchers reported the patient had an ini- in ROM were maintained through the one-month follow-
tial score of 55. After four treatment sessions over the up. In an RCT, the researchers found a statistically signifi-
course of 9 days, the patient had attained a score of 80

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 8. Knee Active Range of Motion (AROM) Results

Intake Discharge Change

Kasturi (2020)28 IG: Flexion: 99° IG: Flexion: 128.5° IG: 29.5° ↑
CG: Flexion: 102.75° CG: Flexion: 121° CG: 18.25° ↑
Hudson (2018)21 N/A
Sanchez (2017)24 N/A
Hudson (2016)27 N/A
Brody (2015)26 Patient 1: Patient 1: Patient 1:
Extension: lacking 2° Extension: lacking 1° Extension: 1° ↑
Flexion: 143° Flexion: 146° Flexion: 3° ↑
Patient 2: Patient 2: Patient 2:
Extension: 0° Extension: -2° Extension: 2° ↑
Flexion: 136° Flexion: 152° Flexion: 16° ↑
*Rhinehart (2015)29 Extension: lacking 20° Extension: 0° Extension: 20° ↑
Flexion: 92° Flexion: 135° Flexion: 43° ↑

IG – Intervention Group; CG – Control Group; N/A – Not applicable; * - Type of ROM measured was not specified

cant mean difference of 7.5 (p = < 0.001) in ROM in the in- tive care protocols and outcomes. The MWM techniques,
tervention group compared to the control group.28 however, have not been critically appraised via a systematic
review. The purpose of this study was to evaluate the effec-
CLIENT SPECIFIC IMPAIRMENT MEASURE tiveness of MC MWMs on patient-reported pain, function,
and multi-dimensional health status in patients with clini-
The Client Specific Impairment Measure (CSIM) outcome cally diagnosed meniscus pathologies.
was included in a case report29 where the patient identified
a body-weight squat and forward lunge as the motions PAIN
causing pain and reported a 4 out of 10 for the squat and
a 6 out of 10 for the lunge before treatment for pain/dif- Pain severity was assessed using the NRS in each of the in-
ficulty.29 Following the first treatment session, the CSIM cluded studies21,24,26–29 The application of MWMs in cases
scores improved to a 2; after the second treatment session, of clinically diagnosed meniscal pathology produced sub-
the reported CSIM scores were a 0 indicating no pain or dif- stantial improvements in pain severity. Improvements in-
ficulty with a body-weight squat or forward lunge. Scores cluded complete or near-complete resolution of pain in as
of 0 on the CSIM were maintained through discharge, one- little as one week of treatment26 or in as few as one or two
week, and one-month follow up.29 treatment sessions.24,26 Asymptomatic meniscal tears are
common among healthy people indicating that the dam-
FOLLOW-UP RESULTS aged meniscus may not need to be removed; thus, when
pain is a primary complaint, conservative pain reduction
Follow-up data collection post-discharge (Table 9) was only therapies that successfully resolve this complaint may be
conducted in two26,29 of the included studies. In the case sufficient.53 The use of MC MWMs, and specifically the MC
report by Rhinehart,29 the patient completed four treat- ‘Squeeze’ technique, were found to be effective interven-
ment sessions over the course of nine days and results were tions for pain reduction in clinically diagnosed meniscal
maintained or improved at follow-up. Brody et al26 ob- pathology over shorter durations (e.g., one month-follow-
tained follow-up results from one participant, 21 weeks (~5 up) in the included literature. The included studies did not
months) post discharge. The participant received two treat- identify evidence to support the long-term effects of these
ment sessions and was discharged three weeks after their interventions (e.g., length of pain resolution, relationship
initial evaluation, also reporting maintained or improved to OA development, etc.), patient-applied application of
scores at follow-up.26 the techniques for symptom management, or outcomes of
the techniques being applied as multimodal rehabilitation
DISCUSSION protocols. Thus, clinicians and researchers should consider
measuring and assessing longer-term outcomes of these
Researchers have reported that appropriate physical ex- technique, outcomes from patient-application of the tech-
amination procedures can result in accurate diagnosis of niques, and how the incorporation of other intervention or
meniscal pathology.6,7 Accurate identification of the con- exercise protocols may influence patient outcomes.
dition, as well as determining if the patient will respond
to conservative therapy, is important for healthcare profes- FUNCTION
sionals and researchers. The MC includes MWMs such as
the ‘Squeeze’ technique, tibial IR, and tibial ER proposed to The PSFS was used in all studies to assess patient-perceived
rapidly restore pain-free, functional ROM for patients with functional improvements. The reported PSFS changes met
suspected meniscal injury which could enhance conserva- the MCID and were statistically significant indicating the

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Table 9. Follow-up Results

Rhinehart (2015)29
Outcome Measure Initial Discharge Follow-up Notes
Evaluation
NRS (0-10) 4.7 (Average) 0.83 0 Follow-up was conducted at both 1-week and
1-month after discharge and the patient had the
PSFS (0-10) 4 (average) 8.75 10
same scores at both time points
DPA 46 0 0
LEFS (0-80) 55 64 80
GRoC N/A +7 +7
CSIM (0-10) Squat; 4/10; 6/10 0/10; 0/ 0/10; 0/
Lunge 10 10
Brody (2015)26
NRS (0-10) 4 (Average) 0 0 Follow-up was at 21 weeks and the patient did not
require any additional treatments following
PSFS (0-10)
discharge and was able to participate in their usual
• Squatting 5 9 9 activities

• Knee extension 7 9 10

• Post-activity 4 8 10

NRS – Numeric Pain Rating Scale; PSFS – Patient-Specific Functional Scale; DPA – Disablement in the Physically Active Scale; LEFS – Lower Extremity Functional Scale; GRoC –
Global Rating of Change; CSIM – Client Specific Impairment Measure

technique not only provided a reduction in pain but also re- found a statistically significant change (i.e., improvement)
stored function, as defined by the patient. The findings are in DPA scores following treatment. Brody,26 however, iden-
valuable because pain and function are the primary symp- tified impaired quality of life (QOL) score on this outcome
toms for which patients seek treatment.11 In Kise et al,11 measure in her case study through the course of treatment.
patients were divided into two groups following diagnosis The case report design allowed patient questioning that
of meniscal injury where one group was given exercise ther- revealed the QOL impairment was perceived to be due to
apy alone while the other group received surgery alone. The other life-related stress independent of knee pain. The im-
exercise therapy group and those who underwent meniscal plications of catching a change in life stress related to or
repair showed no significant difference after two years in- independent of presenting pathologies could have long-
dicating a need for a treatment that will restore function term- treatment implications by informing future care de-
and allow continued activity for otherwise healthy patients. cisions.54 Overall, the MC ‘Squeeze’ technique restored
While the MC ‘Squeeze’ technique seems promising to re- physical and QOL impairments as measured by the DPA
store function in the short term, only two of the studies in- scale, which is expected because physical improvements
cluded any long-term follow-up26,29 with the longest fol- (e.g., pain reduction, increased function) are likely to cor-
low-up point being 21 weeks post-discharge.26 Neither of relate with improved QOL.55
the RCT’s21,28 did any long-term follow-up with the pa- The use of the KOOS could have addressed the lack of
tients to see how long the treatment result lasted. The long-term follow-up data as it has been recommended as a
gold standard of surgical repair is not necessarily a long- long-term outcome measure for three months, six months,
term solution for the treatment of meniscal pathologies and a year.44 However, the researchers who included the
as some patients who have had surgery have needed ad- KOOS did not collect discharge data further than 14 days
ditional surgery in as few as two years, and in the event after intake. The studies21,27 that used the KOOS revealed
of a failed repair that is asymptomatic, it is advisable to meaningful improvement in KOOS scores; however, KOOS
leave the meniscus alone instead of performing resection data collected at wider intervals over a longer duration
or another repair.16 Therefore, alternative treatment ap- would have provided greater insight into long-term inter-
proaches are needed, and the MC ‘Squeeze’ technique could vention effectiveness.
be a valuable tool for the mitigation of symptoms to restore
function when a meniscal pathology is suspected. SECONDARY OUTCOMES

MULTIDIMENSIONAL HEALTH STATUS The secondary outcome measures included in the different
studies were the LEFS, GRoC, ROM, CSIM, and follow-up
The DPA scale assesses physical impairment (e.g., pain, treatment. Only Rhinehart29 reported on the LEFS and
function) and quality of life in unique constructs. The in- GRoC, and both measurements revealed patient improve-
cluded studies provide evidence that the MC ‘Squeeze’ ment during the study. These results were corroborated
technique improved multidimensional health status as with other scales (e.g., DPA KOOS) also used in the study
measured by the DPA scale. Four of the studies21,24,27,29 and revealed improvement in pain, function, and QOL. The

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Rhinehart29 study was the only study to include the CSIM; systematic review should be applied with caution across all
the CSIM data collected supported the PSFS and NRS data populations.
corroborating increased function and decreased pain fol-
lowing treatment. It is not known, however, if CSIM data RECOMMENDATIONS FOR FUTURE RESEARCH
provides unique or redundant information compared to
other measures (e.g., NRS, PSFS). Future research is needed on the MC ‘Squeeze’ technique
Joint ROM was assessed in three of the articles26,28,29 in- along with other MC techniques as indicated by the patient
cluded in this review and was found to have increased fol- case and their effectiveness in the treatment of clinically
lowing treatment. The increase in ROM was supported by diagnosed meniscal pathologies. Long-term follow-up with
patient-reported information found in other measures (e.g., patients from six months to three years would be helpful in
NRS, PSFS, DPA scale) providing disease-oriented evidence better understanding how effective the treatment is at re-
supporting the patient-reported evidence. An advantage of ducing the need for surgery. Higher level RCTs with a con-
assessing ROM in addition to patient reported outcomes is trol or sham treatment group assessing a wider age range
ROM provides quantifiable disease-oriented evidence sup- would also be beneficial. Lastly, studies using diagnostic
porting improvement. The collection of disease-oriented imaging (e.g., MRI) or surgery to confirm the presence,
outcomes, in addition to patient-oriented outcomes, should type, and location of a meniscal pathology would help to
be considered for future studies to further understand the further assess the effectiveness of the MC treatment for
effects of the MC ‘Squeeze’ technique along with tibial IR meniscal lesions and provide insight on types of meniscal
and ER MWM’s. pathology that may not respond to MC intervention.26,29

LIMITATIONS CONCLUSION

Limitations are present in this review. While all studies The results of this systematic review provide initial support
found positive findings for patients treated using the MC for the use of MC MWM techniques for conservative treat-
techniques, the quality of evidence should be considered. ment of patients with a clinically diagnosed meniscal
Only two RCTs were identified,21,28 and case reports and pathology. The MC MWMs reduced pain, increased func-
case series made up two-thirds of the studies included in tion, increased knee range of motion, while decreasing pa-
this review. A meta-analysis was unable to be conducted tient reported symptoms of multidimensional health status
due to the limited number of published studies and the het- impairment related to meniscus pathology. Future research
erogeneity of the included studies. The lack of long-term should focus on using the MC MWM techniques as adjunct
follow-up in the included studies is also a limitation, as or stand-alone interventions, in more diverse patient popu-
only two studies26,29 included follow up visits with partic- lations, in imaging confirmed meniscal pathology, and with
ipants’ post-discharge. The collection of longer-term out- longer-term follow-up to better understand the effective-
comes, including patient-oriented and disease-oriented, ness of the intervention.
would be valuable in redetermining the effectiveness of MC
MWM for the treatment of meniscal pathologies. Thus, fur-
ther high-quality RCTs are needed. The included studies
generally lacked comparison to sham treatments, multi- CONFLICTS OF INTEREST
modal conservative treatment, diagnostic imaging, or sur-
gical intervention. Finally, the included studies generally All authors declare that they do not have any conflict of in-
included adolescent through middle aged adults of a phys- terests with any of the topics discussed in this manuscript.
ically active population. While other studies have success-
fully used the MC for other knee pathologies (e.g., os- Submitted: July 15, 2022 CST, Accepted: September 12, 2022
teoarthritis) in older populations,56 the findings of the CST

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 The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

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