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

September 2, 2026 updated by: Labib Mousa Labib Ghali, Cairo University

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.

Study Overview

Status

Status

Indicates the current recruitment status or the expanded access status.
Not yet recruiting

Conditions

Conditions

The disease, disorder, syndrome, illness, or injury that is being studied. On ClinicalTrials.gov, conditions may also include other health-related issues, such as lifespan, quality of life, and health risks.

Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.

Detailed Description

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.

Study Type

Study Type

Describes the nature of a clinical study. Study types include interventional studies (also called clinical trials), observational studies (including patient registries), and expanded access.
Interventional

Enrollment (Estimated)

Enrollment

The number of participants in a clinical study. The "anticipated" enrollment is the target number of participants that the researchers need for the study.
90

Phase

Phase

The stage of a clinical trial studying a drug or biological product, based on definitions developed by the U.S. Food and Drug Administration (FDA). The phase is based on the study's objective, the number of participants, and other characteristics. There are five phases: Early Phase 1 (formerly listed as Phase 0), Phase 1, Phase 2, Phase 3, and Phase 4. Not Applicable is used to describe trials without FDA-defined phases, including trials of devices or behavioral interventions.
  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact

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Study Contact Backup

Study Locations

  • Jordan
      • Amman, Jordan, 11733
        • Al-Zaytoonah University of Jordan
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Eligibility Criteria

The key requirements that people who want to participate in a clinical study must meet or the characteristics they must have. Eligibility criteria consist of both inclusion criteria (which are required for a person to participate in the study) and exclusion criteria (which prevent a person from participating). Types of eligibility criteria include whether a study accepts healthy volunteers, has age or age group requirements, or is limited by sex.

Ages Eligible for Study

  • Adult

Accepts Healthy Volunteers

No

Description

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.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm

Participant Group / Arm

A group or subgroup of participants in a clinical trial that receives a specific intervention/treatment, or no intervention, according to the trial's protocol.
Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.
Experimental: Group A: Foot segment Milligan mobilization group
mobilization with movement for talonavicular and talocrural joint + Hip-knee focused exercises
Other: mobilization with movement of the foot segment

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

Other Names:
  • Mulligan mobilization of the foot segment
Other: Hip-knee focused exercises

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.

Other Names:
  • conventional hip-knee focused exercises
Experimental: Group B: Ilium Milligan mobilization group
mobilization with movement of ilium + Hip-knee focused exercises
Other: Hip-knee focused exercises

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.

Other Names:
  • conventional hip-knee focused exercises
Other: Mobilization with movement of the Ilium
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.
Active Comparator: Group C: Control group
Hip-knee focused exercises only
Other: Hip-knee focused exercises

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.

Other Names:
  • conventional hip-knee focused exercises

What is the study measuring?

Primary Outcome Measures

Primary Outcome Measures

In a clinical study's protocol, the planned outcome measure that is the most important for evaluating the effect of an intervention/treatment. Most clinical studies have one primary outcome measure, but some have more than one.
Outcome Measure
Measure Description
Time Frame
Function measured by Anterior Knee Pain Scale
Time Frame: baseline and after 4 weeks
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.
baseline and after 4 weeks
Pain measured by Numeric pain rating scale (NPRS)
Time Frame: baseline and after 4 weeks
Numeric pain rating scale (NPRS) The numeric pain rating scale ranges from 0 to 10 points, where 0 represents no pain and 10 represents the worst possible suffering. Its ICC which measures the reliability of test-retests, has been 0.76, indicating that it is a reliable measure of pain intensity.
baseline and after 4 weeks

Secondary Outcome Measures

Secondary Outcome Measures

In a clinical study's protocol, a planned outcome measure that is not as important as the primary outcome measure for evaluating the effect of an intervention but is still of interest. Most clinical studies have more than one secondary outcome measure.
Outcome Measure
Measure Description
Time Frame
Muscle strength by hand-held dynamometer
Time Frame: baseline and after 4 weeks

This device is valid and reliable in assessment of muscle strength during the dynamic movement and also during the isometric contraction of the muscles with intra-rater correlation coefficient (ICC ≥0.75).

It used to assess the isometric muscle strength of hip and knee joint in patient with PFPS by using a calibrated Nicholas hand-held dynamometer (Lafayette Instrument Company, Lafayette, IN, USA) which characterized by good to excellent interrater and intra-rater reliability
baseline and after 4 weeks
Pelvic tilt angle by Palpation Meter device (PALM)
Time Frame: baseline and after 4 weeks
Palpation meter (PALM) is a pelvic leveling tool that blends inclinometer and caliper functions, it's made by performance Attainment Associates (Performance Attainment Associates, 3600 LaBore, Suite 6, Saint Paul, MN 55110 - 4144 USA). It's developed to measure pelvic torsion, pelvic tilting and leg length discrepancy (LLD). The body of the PALM contains a bubble level in a semi-circular arc with one-degree graduations that range from zero degree to thirty degrees on either side of the midline. The caliper arms are placed in bony landmarks and the degree of deviation from horizontal is read from the inclinometer. Interclass correlation coefficient suggests that intratester reliability was high for frontal plane measure (0.84) and sagittal plane measures (0.98) and intertester reliability was high for sagittal plane measures (0.89) but moderate for frontal plane measures (0.65).
baseline and after 4 weeks
foot pronation by Foot Posture Index (FPI)
Time Frame: baseline and after 4 weeks

It is a clinical tool that measures foot posture in multiple planes and anatomical segments. Its correlation coefficient showed excellent intra-rater reliability (ICC = 0.89-0.96) which indicates a very good FPI-6 reliability in the foot assessment. The FPI-6 is a valid cheap non-invasive instrument which in a fast and simple way allows one to conduct a comprehensive evaluation of many parameters of the foot's construction without the need to apply complex and time-consuming measurement methods.

Foot posture index determined either the foot was pronated or not based on the scores of its six items (talar head palpation curves above and below the lateral malleoli, calcaneal angle, talonavicular bulge, medial longitudinal arch, and forefoot to rearfoot alignment). Each of the six items of FPI-6 was evaluated on a scale from -2 to +2. The neutral position of the foot is classified as 0, a positive score is foot pronation and negative score is foot supination
baseline and after 4 weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Sponsor

The organization or person who initiates the study and who has authority and control over the study.
Cairo University

Collaborators

Collaborators

An organization other than the sponsor that provides support for a clinical study. This support may include activities related to funding, design, implementation, data analysis, or reporting.
Al-Zaytoonah University of Jordan

Investigators

Investigators

A researcher involved in a clinical study. Related terms include site principal investigator, site sub-investigator, study chair, study director, and study principal investigator.
  • Principal Investigator: Labib M Ghali, PhD, Cairo University
  • Study Chair: Samah H Nagib, PhD, Al-Zaytoonah University of Jordan

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

Study Start

The actual date on which the first participant was enrolled in a clinical study. The "anticipated" study start date is the date that the researchers think will be the study start date.
October 1, 2026

Primary Completion (Estimated)

Primary Completion

The date on which the last participant in a clinical study was examined or received an intervention to collect final data for the primary outcome measure. Whether the clinical study ended according to the protocol or was terminated does not affect this date. For clinical studies with more than one primary outcome measure with different completion dates, this term refers to the date on which data collection is completed for all the primary outcome measures. The "anticipated" primary completion date is the date that the researchers think will be the primary completion date for the study.
November 1, 2027

Study Completion (Estimated)

Study Completion

The date on which the last participant in a clinical study was examined or received an intervention/treatment to collect final data for the primary outcome measures, secondary outcome measures, and adverse events (that is, the last participant's last visit). The "anticipated" study completion date is the date that the researchers think will be the study completion date.
December 1, 2027

Study Registration Dates

First Submitted

First Submitted

The date on which the study sponsor or investigator first submitted a study record to ClinicalTrials.gov. There is typically a delay of a few days between the first submitted date and the record's availability on ClinicalTrials.gov (the first posted date).
September 2, 2026

First Submitted That Met QC Criteria

First Submitted That Met QC Criteria

The date on which the study sponsor or investigator first submits a study record that is consistent with National Library of Medicine (NLM) quality control (QC) review criteria. The sponsor or investigator may need to revise and submit a study record one or more times before NLM's QC review criteria are met. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
September 2, 2026

First Posted (Actual)

First Posted

The date on which the study record was first available on ClinicalTrials.gov after National Library of Medicine (NLM) quality control (QC) review has concluded. There is typically a delay of a few days between the date the study sponsor or investigator submitted the study record and the first posted date.
September 8, 2026

Study Record Updates

Last Update Posted (Actual)

Last Update Posted

The most recent date on which changes to a study record were made available on ClinicalTrials.gov. There may be a delay between when the changes were submitted to ClinicalTrials.gov by the study's sponsor or investigator (the last update submitted date) and the last update posted date.
September 8, 2026

Last Update Submitted That Met QC Criteria

Last Update Submitted That Met QC Criteria

The most recent date on which the study sponsor or investigator submitted changes to a study record that are consistent with National Library of Medicine (NLM) quality control (QC) review criteria. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
September 2, 2026

Last Verified

Last Verified

The most recent date on which the study sponsor or investigator confirmed the information about a clinical study on ClinicalTrials.gov as accurate and current. If a study with a recruitment status of recruiting; not yet recruiting; or active, not recruiting has not been confirmed within the past 2 years, the study's recruitment status is shown as unknown.
August 1, 2026

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

Other Study ID Numbers

Identifiers or ID numbers other than the NCT number that are assigned to a clinical study by the study's sponsor, funders, or others. These numbers may include unique identifiers from other trial registries and National Institutes of Health grant numbers.
  • IRB # 30/8/2025 2026

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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