Manual Therapy
Passive accessory & physiological movements · MWM · Wk 8
Grade → Use When
Grade I & II
Pain is the predominant symptom. Small/large amplitude, short of resistance. Also for catching pains and to relieve treatment soreness.
Grade III & IV
Stiffness is the predominant symptom. Large/small amplitude into resistance. Applied at or near end of available ROM.
Indication
Restricted dorsiflexion, ankle stiffness post-immobilisation or sprain.
Technique
- Stabilise distal tibia underneath with one hand
- Web space of moving hand over anterior talus
- Glide talus posteriorly
- Therapist's thigh can position ankle in varying degrees of DF
- For tissue extensibility: must be at end of available ROM
Reassessment
Reassess active or passive ankle DF range. Compare to pre-treatment baseline.
Technique
- Stabilising hand placed anteriorly over tibia
- Moving hand grasps posterior calcaneus → anterior glide
- Maintain ankle in neutral with thigh or forearm
- Prone variation: stabilise anterior proximal ankle, glide calcaneus anteriorly; can do with knee at 90° F
- Stabilise distal tibiofibular joint above subtalar joint
- Moving hand holds rearfoot, applies medial or lateral glide through calcaneus
PFJ Medial Glide
- Supine: thumbs on lateral patella border, index fingers on medial border → medial/lateral translation
- Side-lying: for stronger grades with knee flexion added
- Indication: painful or restricted patellar movement
TFJ AP Glide (posterior tibia) — assoc. flexion restriction
- Grades I–II: stabilise distal femur, hand on tibial tuberosity → posterior glide
- Grades III–IV: supine, hip/knee 90°, cup tibial tuberosity, glide posteriorly
TFJ PA Glide (anterior tibia) — assoc. extension restriction
- Grades I–II: stabilise distal femur, hand behind tibial plateau → anterior glide
- Grades III–IV: prone, palm glides tibia anteriorly parallel to joint line
Hip Lateral Glide (Grades III–IV)
- 90° hip flexion; mobilisation belt around proximal thigh (close to joint line, towel layer under belt)
- Control knee with body/arms; apply lateral glide via belt by pushing bottom out, leaning slightly forward
- Indications: capsular tightness, medially migrated hip OA, painful/stiff hip
Hip Inferior Glide (Grades III–IV)
- Same setup: 90° hip flexion, mobilisation belt
- Face head of bed; direct glide towards patient's feet
Key MWM Principles
- Accessory glide applied while patient performs impaired movement
- Must be pain-free — ask repeatedly
- If improvement: 6–10 reps × 2–3 sets
- Not graded I–IV
- If no change: adjust direction or force
Ankle DF MWM — NWB (Talocrural AP Glide)
- Supine, foot off end of bed. Get baseline pain/ROM for DF.
- Wrap web space around talus close to joint margin. Glide talus posteriorly.
- Sustain glide → patient actively dorsiflexes. Release after they return to start.
- Reassess — expect significant improvement in pain-free ROM.
Weight-Bearing Progression
Affected foot on chair/step. Patient lunges forward keeping heel on ground. Belt variation: pull tibia/fibula anteriorly as patient lunges.
Fibular AP Glide Variant (NWB)
Hand wrapped over lateral ankle, fingers posterior to Achilles. Thenar eminence applies AP glide. Patient actively dorsiflexes.
Hip Flexion MWM — Lateral Glide
Patient supine near edge of plinth, hip at 90° F. Belt around proximal thigh (towel under). Stabilise ASIS. Apply lateral glide via belt (pelvis away from bed) → patient actively flexes hip. 6–10 reps. Reassess hip flexion ROM.
Therapeutic Exercise
ACL rehab · Patellar tendinopathy · PFPS · Ankle rehab · Wk 10
- Prescribe as exercise as medicine — not generic "strengthening"
- Match to: impairments → activity limitations → patient goals
- Apply FITT-VP principles (Frequency, Intensity, Time, Type, Volume, Progression)
- Justify each exercise with clinical reasoning
- Modify based on pain response and safety
Pre-op
Eliminate swelling, full ROM, 90% quad/hamstring strength. Ice, ROM ex, low-impact cardio, progressive strengthening.
Phase 1 — Post-op recovery
Regain extension/flexion, settle swelling, quadriceps activation. Quad sets, gentle ROM, ice + compression.
Phase 2 — Strength & NM control
SL balance, muscle strength, SL squat technique. Lunges, step-ups, squats, bridging, calf raises, hip abduction, core, balance.
Phase 3 — Running, agility, landings
Hop performance (technique/distance/endurance), agility, full strength. Slalom, shuttles, ladders, scissor jumps → box jumps, SL landings with perturbation.
Phase 4 — Return to sport
Athlete confident and eager. ACL injury prevention discussed.
Phase 5 — Prevent re-injury
Long-term prevention program.
Goal (per notes): progressively develop load tolerance of the tendon, the musculoskeletal unit and the kinetic chain, while addressing biomechanical and other risk factors. Progression criteria are individualised, based on pain, strength and function.
Stage 1 — Isometric
Isometric exercises. (Notes give the stage name; specific loading details are not specified.)
Stage 2 — Isotonic
Isotonic exercises. (Stage name only in notes.)
Stage 3 — Energy Storage
Jumping (2-leg jumps, hops, forward hops, split jumps); acceleration (sprinting from standing start); deceleration (running and stopping on 2 then 1 limb); cutting (~70°).
Stage 4 — Return to Sport
Sport-specific training, gradual training resumption.
From the Week 10 PFPS case (19 yo, R anterior knee pain). The notes give the examination findings; treatment is built by mapping each treatable impairment to a technique using the prescription framework (exercise as medicine, FITT-VP, justified by reasoning).
Findings the notes provide
- Reduced R quad and VMO bulk; swelling
- Patella: lateral displacement and tilt
- Gait: excessive pronation R > L; Trendelenburg R hip
- Tender R lateral patella border; PFJ hypomobile (pain 2/10)
- Positive McConnell's test (pain at 90°)
- SL squat: R hip adduction and IR, contralateral hip drop
Notes-supported treatment links
- PFJ hypomobility → PFJ medial glide (notes manual therapy technique)
- Patella position / tracking → McConnell PFJ taping, individualised to correct tilt / displacement / rotation per assessment
- SL squat hip adduction/IR + Trendelenburg → hip/gluteal impairment to target with exercise (select via the framework — notes don't prescribe the specific exercises)
Use the notes' framework
- Prescribe "exercise as medicine" — not generic strengthening
- Match exercise to the patient's impairments, activity limitations and goals
- Justify choices with clinical reasoning; apply FITT-VP
- Modify based on pain response, safety and progression; consider contraindications/precautions
Planning sequence (from notes)
Assessment → Impairment → Functional Goal → Exercise Selection → Dosage → Progressions.
Reason from the case (e.g. recurrence goal = target the relevant functional deficit) and progress toward the demands of the patient's activity/sport.
Therapeutic Taping
38mm rigid tape · Ankle anti-inversion / anti-pronation · PFJ · MCL/LCL · Wk 9
Before Taping
- Informed consent — ask about allergy, skin conditions, precautions
- Contraindications: allergy, open wounds, skin infection/dermatitis, fragile skin, sensory loss
- Caution: circulatory/vascular disorders, diabetes, steroid use, cognitive loss
- Dry, clean skin; remove/shave hair if needed; hypoallergenic underlay for sensitive skin
- Apply tape ends slightly diagonal — avoids tourniquet effect
After Taping — Check
- Comfortable, no restriction/tightness/pain
- No pins and needles, numbness, circulation signs (pallor, cyanosis, oedema, reduced pulse)
- No creases or folds
Patient Advice
Remove immediately if: increased discomfort, increased symptoms, pins/needles, skin itch/irritation, temperature changes. Remove after 48h if no adverse effects.
Position
Supine, foot over edge of plinth. Rolled towel under knee if gastroc tight. Ankle in plantigrade, neutral inversion/eversion.
Sequence
- Anchor — 5–6 cm above malleoli. Ask patient to contract muscles during anchor only.
- Stirrups (×2–3) — Medial to lateral, posteromedial → posterolateral aspect of anchor. Overlap by half each.
- 6s (×2–3) — Medial to lateral, direct over dorsum of foot as it reaches lateral ankle, lock on itself forming a '6'.
- Reverse 6s — Start lateral malleolus, over dorsum, under foot, proximally along lateral ankle to finish at lateral aspect of anchor.
- Heel lock — Start medial malleolus, over anterior TCJ laterally, under lateral malleolus, around calcaneus, up around Achilles, back toward start. Do NOT tension over Achilles.
- Lock-offs (×3) — Overlap each by half.
Position
Supine, foot over edge of plinth, subtalar joint neutral, slight supination at midfoot.
Low Dye
- Calcaneal spur — Below 1st MTP, tension around calcaneus, finish below 5th MTP.
- Mini-stirrups (×5–6) — Start laterally over distal spur, finish medially lifting medial arch. Finish in line with middle of medial malleolus.
- Repeat spur — as lock-off over mini-stirrups.
- Lock-off — Patient stands; check comfort. Apply lock-off on distal dorsum to secure.
Augmented Low Dye (adds)
- Anchor — 5–6 cm above malleoli (patient contracts muscles).
- Reverse 6s (×2–3) — Start medial malleolus, over dorsum and under foot, finish in line with middle of medial malleolus. Ensure navicular tuberosity covered.
- Calcaneal sling (optional) — Tape around calcaneus into supination, tension both sides to anchor simultaneously. 2nd sling optional (used if patient heel-strikes in pronation).
- Lock-offs (×3) — Superior, over anchor.
McConnell PFJ — Assessment First
Identify: provocative functional test (e.g. step-down), patella position (tilt, lateral displacement, rotation). Taping must be individualised.
Technique
- Apply hypoallergenic underlay over patella (3–4 cm each side)
- Correct tracking: Tape on lateral side; thumb applies medial glide, fingers lift medial tissue up; tension tape to medial side
- Correct tilt: Tape mid-patella; lift medial tissue upward and hold while placing tape (don't compress patella in trochlea)
- Correct rotation: Inferior lateral border for medial rotation; inferior medial border for lateral rotation
- After taping: patient actively flexes knee (pain-free range); physio supports tape on both sides
MCL / LCL Taping
- Patient standing, heel on 2–3 cm raise (knee in 20–30° F)
- Superior anchor (distal quads/hams) and inferior anchor (proximal gastrocs) — patient contracts during anchors
- MCL: 1st strip posterior on inferior → anterior on superior; 2nd strip anterior on inferior → posterior on superior = X pattern over MCL
- Lock-offs superiorly and inferiorly. Tape must not cross over patella.
The exam question asks you to describe how you will assess effectiveness. The notes direct you to use "appropriate outcome measures" — so reassess the provocative task or complaint that justified the tape, comparing before vs after:
- Anti-inversion: The provocative functional task from the case — e.g. hopping tasks and single-leg landing stability/confidence
- Anti-pronation: Pain or symptoms on the aggravating task (e.g. gait/running), reassessed before vs after taping
- McConnell: Repeat the provocative functional test identified at assessment (e.g. step-down), compare pain/symptoms before vs after
Neural System Treatment
Neurodynamics · Sliders vs tensioners · SLR / Slump · Wk 11
Sliders
Increase tension at one end, decrease at other → nerve slides with low strain.
Use when: high irritability, acute presentations. Alternating movements (e.g. cervical F + knee F → cervical E + knee E). 2–3 sets × 10–15 reps.
Tensioners
Increase tension across multiple joints → greater mechanical load.
Use when: lower irritability, later-stage rehab. Elongation at multiple joints simultaneously. 1–2 sets × 5–10 reps.
Treatment of Interface
Also address structures restricting nerve movement: inferior tibiofibular joint, lumbar spine, hip. Use joint mobilisations + soft tissue techniques. Often combined with neurodynamic techniques.
Standard SLR
- Supine without pillow. One hand distal thigh (control/feel for knee movement), other hand under Achilles
- Slow hip flexion with knee extended. Note range + symptom onset
- When symptoms reproduced: lower until symptoms just disappear → structural differentiation
Structural Differentiation
- Cervical flexion (increases proximal neural tension)
- Dorsiflexion — if proximal symptoms (e.g. buttock)
- Hip adduction or internal rotation — if distal symptoms
Foot Position Biases
Tibial Nerve
Ankle dorsiflexion + eversion
Peroneal Nerve
Ankle plantarflexion + inversion
Sural Nerve
Ankle dorsiflexion + inversion
Slump Test
- Sitting well back on plinth, hands behind back
- Flex thorax + lumbar spine → then flex neck
- Monitor neck position with one hand (do not force)
- Patient slowly extends unaffected leg (foot relaxed) → note symptoms
- When symptoms reproduced: guide patient to lift head (release cervical F) → structural differentiation
Slump Knee Bend (Femoral Nerve Slump Test)
- Side-lying; spine flexed, head/neck neutral, bottom leg in 90-90 position held by hands
- Patient flexes neck (chin to chest)
- Therapist: stabilise pelvis, extend hip through available range (prevent lumbar extension / pelvic rotation), then flex knee through range
- Structural differentiation: release cervical flexion
Application
- Start in non-provocative position (reduced neural tension)
- Low amplitude, controlled movements initially
- Monitor: symptom reproduction during movement; symptoms should ease on release
Safety Rules
- Do not sustain end-range positions that reproduce symptoms
- Avoid worsening or prolonged symptoms after treatment
- Modify technique if highly irritable
- Continuous communication with patient throughout
Posterior thigh pain after hamstring strain
Tibial nerve (via SLR/slump). SLR + slump positive; symptoms increase with ankle DF, which is the tibial-biasing position in the notes' table. Symptoms change with structural differentiation (Csp F / DF), confirming a neural component. At 12 weeks, lower irritability → progress toward tensioner.
Lateral ankle electric pain, history of sprains
Peroneal nerve. SLR with PF/inv bias positive. Interface: inferior tibiofibular joint stiffness. High vs lower irritability guides slider vs tensioner.
Marking Criteria
100 marks · 4 weighted columns · Pass/Fail gateways
| Level | Position | Communication | Effectiveness | Clinical Reasoning |
|---|---|---|---|---|
| Excellent 100 | Safe, supported, comfortable always. Optimal exposure. Therapist position safe, effective, efficient. | Clear, comprehensive, succinct. Informed consent. Optimal symptom info at every appropriate time. | Skill & precision. Excellent manual handling. Reassessment efficient & effective. | Comprehensive knowledge in selection, interpretation, and responses to examiner questions. |
| Very Good 75 | Safe, comfortable. Adequate exposure. Therapist safe & effective. | Clear with appropriate terminology. Consent gained. Sufficient symptom info, responsive mostly. | Effective & accurate with minor errors. Good handling & sequencing. Reassessment at appropriate times. | Good knowledge in selection & interpretation. Good responses to examiner. |
| Satisfactory 50 | Patient safe. Adequate position. Less than optimal exposure. Therapist adequate. | Some explanation. Some attempt at consent. Some symptom info with gaps. | Satisfactory with some errors. Manual handling or sequencing needs practice. Reassessment with prompt. | Good selection & interpretation with prompting. Satisfactory responses. |
| Poor 25 | Safe but uncomfortable/unsupported. Position precludes effective technique. | Poor explanation. No consent. No adequate symptom info. Not responsive. | Unlikely to elicit accurate response. Poor handling/sequencing. Reassessment only with significant prompting. | Limited knowledge despite prompting. Limited responses. |
| Fail 0 | Unsafe, unsupported, uncomfortable. Unsafe or ineffective technique. | No explanation. No consent. No symptom info. | Unsafe or ineffective. No reassessment. | Not sufficient to ensure safe & effective technique. |
Hygiene — −10 marks
Hand sanitiser before/after patient contact (5 moments). Short nails, no nail polish, no rings/jewellery/watches (bare below elbows).
Safety — Score = 0 for that question
Patient left unattended in dangerous position. Wheeled chair/stool. Failing to check contraindications. Unsafe or reckless technique.
Professional — Score = 0 for that question
Inappropriate behaviour, unprofessional conduct, prompting / assisting / obstructing other students during the exam.
Level Rule
Must achieve ALL criteria in a level to be marked at that level. Otherwise: the level below.
Communication is 10% and among the easiest marks to secure. Use a consistent opening for every technique:
Opening (purpose + expectation + consent)
During (responsive monitoring)
- "How does that feel?" / "Is this comfortable?"
- "Any change in your symptoms compared to before?"
- "Can you rate the pain now, out of 10?"
Close (reassess + explain)
Saying the reassessment out loud captures Communication, Effectiveness AND Clinical Reasoning marks in one move.
- Consent first — always explain purpose + expectations before touching patient
- Baseline before treatment — measure pain/ROM before technique, then reassess after
- Talk out your reasoning — clinical reasoning is 30%; verbalise grade selection, position choice, why this technique
- Check in constantly — "Is this comfortable?" "Any change in symptoms?" = big communication marks
- Don't skip reassessment — one of the most penalised omissions
- Hygiene is automatic — hand sanitiser in, hand sanitiser out. Bare below elbows.
- Read the question — note which side, the symptom (pain vs stiffness), and the functional goal
Practice Questions
Viva-style reasoning questions — reveal the model answer when ready
Model Answer
Pre-Exam Checklist
Exam day prep — click to mark items complete