Lower Extremity


  • A 2018 consensus statement recommended exercise (especially combining hip and knee), combined interventions and foot orthoses. Patellofemoral, knee or lumbar mobilizations in isolation, or electrophysical agents, were not recommended. There is uncertainty regarding patellar taping/bracing, acupuncture/dry needling, manual soft tissue techniques, and gait retraining.1
  • A 2017 systematic review which included 5 randomized controlled trials of manual and physical therapy for patellofemoral pain syndrome concluded that giving more emphasis to proximal stabilization and full kinetic chain treatments in PFPS will better alleviate symptoms.2
  • A 2016 randomized controlled trial (n=300) explored the effect of booster sessions on manual therapy for knee OA. Exploratory interaction analysis suggested knee pain decreased for participants receiving boosters and increased for participants not receiving boosters from 9 weeks to 1 year.3


  • A 2017 overview of systematic reviews on acute and recurrent ankle sprain concluded that for acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilization, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of chronic ankle instability.4
  • A 2019 systematic review of manual therapy for chronic ankle instability (CAI) concluded that 6 sessions of manual therapy improves ankle functional performance more than one session.5
  • A 2017 randomized controlled trial of talus mobilization for subacute and chronic ankle injuries found that articular grade III mobilization improved ankle dorsiflexion ROM, when compared with the sham group, receiving manual contact only. Changes in pain and function were similar in both groups.6
  • A 2018 randomized controlled trial compared a single session of compressive myofascial release (CMR) or Graston Technique (GT) on closed chain ankle-restricted dorsiflexion. It concluded that compressive myofascial release increased ankle dorsiflexion after a single treatment.7
  • A 2018 meta-analysis of nonsurgical treatments for ankle instability that included 21 trials concluded that a supervised impairment-based program after chronic ankle instability was superior to control, although followup in the included trials tended to be short and inconsistent.8
  • A 2018 systematic review of mobilization for ankle sprains that included 23 trials concluded that joint mobilization appears to be beneficial for improving dynamic balance immediately after application, and dorsiflexion range in the short-term. Long-term benefits have not been adequately investigated.9


  • A 2018 systematic review of manual therapy (MT) for plantar fasciitis that included 7 randomized controlled trials concluded that inclusion of MT in treatment yielded greater improvement in function and algometry from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Pain improvement was equivalent to comparison interventions.10
  • A 2019 randomized controlled trial of manual therapy, foot orthoses and combined therapy for plantar fasciitis (PF) found that all 3 treatments improved pain and function at 1 month but the MT group showed greater improvements.11
  • A 2017 systematic review of manual physical therapy for plantar heel pain that included 8 articles, with only 2 of high quality, which showed improve pain and function in the manual therapy group.12
  • A 2018 review including 6 trials of manual therapy (deep massage, myofascial release or joint mobilization) for plantar heel pain. It concluded that soft tissue mobilization is an effective modality for treating plantar heel pain. Outcomes of joint mobilizations were equivocal.13


  1. Collins NJ, Barton CJ, van Middelkoop M, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170-8. FREE FULL TEXT
  2. Espí-López GV, Arnal-Gómez A, Balasch-Bernat M, Inglés M. Effectiveness of manual therapy combined with physical therapy in treatment of patellofemoral pain syndrome: Systematic review. J Chiropr Med. 2017;16(2):139-146. FREE FULL TEXT
  3. Fitzgerald GK, Fritz JM, Childs JD, et al. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial. Osteo Cartilage. 2016;24(8):1340-1349. FREE FULL TEXT
  4. Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British J Sports Med. 2017;51(2):113-125. FREE FULL TEXT
  5. Shi X, Han J, Witchalls J, et al. Does treatment duration of manual therapy influence functional outcomes for individuals with chronic ankle instability: A systematic review with meta-analysis. Musculoskelet Sci Pract. 2019;40:87-95.
  6. Silva RD, Teixeira LM, Moreira TS, Teixeira-Salmela LF, de Resende MA. Effects of anteroposterior talus mobilization on range of motion, pain, and functional capacity in participants with subacute and chronic ankle injuries: a controlled trial. J Manipulative Physiol Ther. 2017;40(4):273-283.
  7. Stanek J, Sullivan T, Davis S. Comparison of compressive myofascial release and the Graston technique for improving ankle-dorsiflexion range of motion. J Athl Train. 2018;53(2):160-167. FREE FULL TEXT
  8. Tsikopoulos K, Mavridis D, Georgiannos D, et al. Does multimodal rehabilitation for ankle instability improve patients’ self-assessed functional outcomes? A network meta-analysis. Clin Orthop Relat Res. 2018;476(6):1295-1310. FREE FULL TEXT
  9. Weerasekara I, Osmotherly P, Snodgrass S, Marquez J, de Zoete R, Rivett DA. Clinical benefits of joint mobilization on ankle sprains: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2018;99(7):1395-1412.e1395.
  10. Fraser JJ, Corbett R, Donner C, Hertel J. Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. J Man Manipulative Ther. 2018;26(2):55-65. FREE FULL TEXT
  11. Grim C, Kramer R, Engelhardt M, John SM, Hotfiel T, Hoppe MW. Effectiveness of manual therapy, customised foot orthoses and combined therapy in the management of plantar fasciitis—an RCT. Sports (Basel). 2019;7(6). FREE FULL TEXT
  12. Mischke JJ, Jayaseelan DJ, Sault JD, Emerson Kavchak AJ. The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review. J Man Manipulative Ther. 2017;25(1):3-10. FREE FULL TEXT
  13. Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. Foot (Edinb). 2018;34:11-16.