Technique Highlight: Functional Mobilization Tibial Internal Rotation for Knee Pain | Modern Manual Therapy Blog

Technique Highlight: Functional Mobilization Tibial Internal Rotation for Knee Pain

One of my favorite and easily applied techniques for knee pain that works wonders with PFS!

  • open chain - supine
  • closed chain, standing, single leg squat, lunge, double leg squat, step up or down
  • the involved LE is the forward leg or the WB LE for treatment.
  • open chain, standing on the pt's involved side LE
  • closed chain, kneeling or squatting on the involved side LE
  • grasp on proximal tibia medially and laterally
  • take up all slack and rotate tibia internally for the entire movement - not just the flexion part
  • pt flexes and extends knee in open chain with PT guidance
    • assist with overpressure at end range 
  • for closed chain have the pt perform a normally limited or painful functional movement such as a squat, single leg squat, step up/down, or lunge
  • usually done in 2-3 sets of 10
  • it should be 100% pain free
  • variations - if not completely pain free - a stretch is ok
    • use more force or less force
    • simultaneously externally rotate the femur (or only)
    • try varus/valgus stress
    • externally rotate the tibia - rare
    • try to change the direction of the rotation slightly superior, slightly inferior
  • any limits in knee flexion/extension due to knee pain or restrictions
  • limits in closed chain function
The pt may be easily taught how to maintain this on their own as long as they can reach their own tibia. This works well in combination with IASTM to the ITB, hip and ankle mobilizations, as well as core and gluteus medius strengthening.


  1. What's your opinion on utilizing this technique with patients following total knee replacement?

  2. Love the video Dr.E. Very well explained.

  3. I have used it before, if they can WB, they can use this technique, and as it's supposed to be 100% pain free, it has very little contraindications unless manual therapy itself would be contraindicated, such as in instability, ligamentous rupture, etc...

  4. what is the mechanism by which there is pain relief and improvement in Range of Motion?

  5. The mechanism may be improving tibial IR, which is often lost as a result of a loss of tibial ER and ankle dorsiflexion. Also the distraction may bombard the CNS with proprioceptive information, thus allowing the lockdown on the joint to be released and the movement improves.

  6. I am a graduate student at utah state. I am working on researching involving shoe type and ITBS. I am in need of implementing a program to which my test group could perform in addition to a change in shoe type in order to offset the effects of ITBS. Could I pick your brain here?

  7. Codi, sure, email me at the contact Dr. E link in the above sidebar on the right!

  8. I like your post and it is so good and I am definetly going to save it. One thing to say the In depth analysis this blog has is trully remarkable.Hip Replacement Surgeon

  9. Hi erson,
    Thanks for video. I was fortunate to learn this technique from Brian Mulligan 18 mos ago and have had success with it for PFP like you. Question... Do you use this with meniscal tears? Pt today with post horn med meniscus ovlique tear 6 mos ago and flexion painful and limited to 100 degrees. I wasn't sure if a tear would be contraindicated.? However, I tried the technique, (pain free of course), closed chain double leg squat, and pain free range improved to 123 degrees.
    Patient does not want have sx and am hoping to get her some offloading with glutes (hers are extremely weak), SErF strap, and perhaps this mWm, teach her and tape her, and some gait retraining for shock absorption as some interventions.
    Thanks for your thoughts on MWm on such a tear.
    Meredith PT, MPT, MBA

  10. Regarding studies showing mobilization forces and body structures, we are only pushing a fraction of what they can handle as a whole. That was when therapists were pushing as hard as they could. This technique is so gentle plus pain free, it is highly unlikely you are injuring the patient. I don't worry about scans.

  11. Sorry, but this technique is useless in my opinion. Except if you would like to prefer a mobilisation on the ventrolateral side of the knee capsule or slight distal streching for ITBS for example. Most of the knee problems are the
    giving way of the knee towards medial (Or valgus) is most of the time due to Ankle dorsiflexion stifness, hip IR stifness and muscle weakness of Vastus medialis obliques, hip abductors & posterior chain muscles. I would prefer to improve those parameters instead of tibial internal rotation mobilisation.
    I apologize for my bad english.

    Greetings from Holland

  12. Hi Eddy, if you consider it useless, you've never used this to improve ankle dorsiflexion or pain with closed chain knee function. It's a Mulligan technique and as such works very well, but not in isolation. The things you listed above are also ones you would work on, but also lead to ankle eversion, knee valgus with closed chain activities, leading to tibial ER. So restoring tibial IR seems to help well as an adjunct.

  13. Hi Dr. Erson,
    Thanks for the reply. I will certainly try to implement the mulligan technique, so i can judge it (clinical expertise). I work a lot with elite soccerplayers who have torn their ACL Ligament. Often you see a biomechanical chain reaction, that increases the risk of an injury.
    Unfortunately there is still no strong evidence in literature for mulligan technique (see link)/ or i couldn't find it.
    So if it works well, maybe some good study would help the (para)medicals. Hopefully i will be as enthusiastic and will certainly write a review..

    Eddy Voeten MSc.
    Master Manualtherapie
    Clinical Health Scientist

  14. Hi Erson,

    My PT just gave me this technique but using external rotation, not internal.

    My question (which my PT did not answer for me) is whats wrong with my knee that this mobilization is helping? I fell while skiing and my knee got hit with a lot of impact. I was having pain while flexing the knee and while crossing my left foot onto my right knee (like when one puts a she or sock on).

    And why external rotation and not internal?

    Many thanks,

  15. Joseph,

    The quick answer is that your PT gave that to you most likely because it helped improve your pain, function and flexibility hopefully. We don't always have a mechanical or simple way to explain why these things work the way they do. They are often thought of as a type of "reset" to your nervous system to give an input to an area that is under constant surveillance. The arm in your brain makes your pain thresholds low, so you cannot tolerate as much. When we reset the area, the alarm goes off, so temporarily you will have more motion etc... You just need to keep the alarm reset enough so that it doesn't come back on and you can then get on with strengthening etc... Does this make sense?