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The Effects of Caudal Mobilisation with Movement (MWM) and Caudal Self-
Mobilisation with Movement (SMWM) in Relation to Restricted Internal
Rotation in the Hip: A Randomized Contro...

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DOI: 10.1016/j.math.2016.01.007

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 Manual Therapy 22 (2016) 9e15

Contents lists available at ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The effects of caudal mobilisation with movement (MWM) and caudal

self-mobilisation with movement (SMWM) in relation to restricted
internal rotation in the hip: A randomised control pilot study
Riche Walsh*, Sharon Kinsella
Department of Science and Health, Institute of Technology Carlow, Carlow, Ireland

a r t i c l e i n f o a b s t r a c t

Article history: Background: A loss of internal rotation (IR) of the hip is associated with hip pathology. Improving IR may
Received 2 July 2015 improve hip range of motion (ROM) or prevent hip pathology.
Received in revised form Objectives: The purpose of this study was to compare the immediate effects of caudal mobilisation with
18 December 2015
movement (MWM) and caudal self-mobilisation with movement (SMWM) on young healthy male
Accepted 19 January 2016
subjects with reduced IR of the hip.
Design: A randomised controlled trial was performed. Twenty-Two subjects were randomised into a
Keywords:
MWM group (n ¼ 6), SMWM group (n ¼ 8) or a control group (n ¼ 8).
Hip internal rotation
Mobilisation with movement
Method: The primary outcome measures included the functional internal rotation test (FIRT) for the hip
Self-mobilisation with movement and the passive seated internal rotation test (SIRT) for the hip. Outcomes were captured at baseline and
immediately after one treatment of MWMs, SMWMs or control.
Results: A two-way analysis of variance (ANOVA), group  time interaction was conducted. The ANOVA
revealed the only significant improvement was in the MWM group for the FIRT (p ¼ 0.01), over the
control group. Subjects with reduced IR of the hip who receive a single session of MWMs exhibited
significantly improved functional IR of their hip than the control group.
Conclusions: From the data presented, it can be suggested that caudal MWMs of the hip appear to have a
positive effect on functional IR of healthy young hips. This may be due to addressing the positional fault
theory or the arthrogenic muscular inhibition theory. SMWMs may be effective in augmenting treat-
ments for patients waiting for hip operations.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction which may be a precursor to osteoarthritis (Nogier et al., 2010).

Hip and groin injuries amongst professional English soccer
players account for 12.0% of injures (Hawkins et al., 2001). Diag-
nosing hip pain in young adults continues to be a challenge and is
most common in males (Casartelli et al., 2011). Boykin et al. (2013)
suggests soft tissue injuries are believed to predispose patients to
adaptive bony changes of the hip such as femoral acetabular
impingement (FAI). Limited hip ROM is believed to be a predis-
posing factor in lower limb and trunk pain (Barbee Ellison et al.,
1990; Almeida et al., 2012). Restriction in hip flexion and or inter-
nal rotation (IR) is strongly associated with FAI (Boykin et al., 2013).
Patents with osteoarthritis (OA) often present with altered pelvic-
femur alignment (Grimaldi et al., 2009). Hip and groin pain/posi-
tive impingement tests are a common finding in young active males
* Corresponding author.
E-mail address: mail2richiewalsh@gmail.com (R. Walsh).
Freeman et al. (2013) suggests that the phenomenon of arthrogenic
muscular inhibition (AMI) of the glutaeus maximus is present in hip
pathology. AMI is believed to inhibit muscle activation at the site of
acute injury as a defence reflex, but may itself lead to a chronic
cause of re-injury. Experimentally induced effusion of the hip joint
has been shown to inhibit glutaeus maximus activation (Freeman
et al., 2013). Poor proprioceptive awareness of the hip may inhibit
the glutaeus maximus muscle which is a major component of
propulsion and stability (Yerys et al., 2002).
The proposed mechanism behind MWMs is the positional fault
hypothesis (Abbott, 2001). MWMs involve an accessory glide in
conjunction with a physiological movement, performed by the
therapist or patient. MWMs should be performed pain free and the
effects should be long lasting (Hing and Mulligan, 2011). Small ad-
justments, “tweakology”, can be used to maximise the effect of
MWMs (Hing et al., 2008). Kachingwe et al. (2009) suggests that
MWMs should be performed in the position that causes the most
agitation. The anterior impingement test (AIT) as described by

http://dx.doi.org/10.1016/j.math.2016.01.007
1356-689X/© 2016 Elsevier Ltd. All rights reserved.
10 R. Walsh, S. Kinsella / Manual Therapy 22 (2016) 9e15
Ratzlaff et al. (2013) incorporates adding adduction, and then IR, to a
hip flexed to 90.0 . Often MWMs are performed in functional weight
bearing positions (McDowell et al., 2014). The prevalence of OA of the
hip is becoming a considerable problem for modern society espe-
cially as the incidence of OA of the hip increases with the ageing
population (Grimaldi et al., 2009). It has been recognised that self-
management is an important aspect to patient management in hip
pathology clinical presentations (Cowan et al., 2010). Self-
Management is an important consideration, in an Irish context,
due to waiting lists in the free public sector (French, 2007). In the
United Kingdom, the National Health System continues to have long
waiting lists for surgical management for patients presenting with
end stage hip pathology. Therefore self-management of these pa-
tients is crucial to minimise healthcare cost associated with surgical
wait lists. Caudal self-mobilisation with movement may offer an
alternative pain management strategy to exercise and pharmacology.
The body of research in to MWMs is in relation to the immediate
effect of MWMs (Teys et al., 2008; Katchingwe et al., 2009). Hing
and Mulligan (2011) state that the effect of MWMs are long last-
ing. However the research in to establishing the time frame of the
benefits of MWM are sparse, the literature would suggest that if
there is an instantaneous improvement the benefits of MWM can
last up to 3 months (Doner et al., 2013; Teys et al., 2013). This is
especially pertinent if there is an effective way to supplement
MWM treatments with SMWMs.
This is the first randomised study that investigates the effects of
MWMs in relation to the hip joint (Hing et al., 2009). Wright and
Hegedus (2012) reported the use of home mobilisations using a
heavy elastic resistance band. Using a resistance band would allow
the subject to maintain an accessory glide throughout the SMWM
which is a crucial aspect of the MWM concept (Teys et al., 2013).
Many of the recent investigations involving MWMs (Katchingwe
et al., 2009; Doner et al., 2013; Teys et al., 2008, 2013) are associ-
ated with the shoulder joint and show promising results. There are no
studies to date that investigate the use of home exercises to replicate
MWM. However, there are positive effects of using taping to augment
MWMs (Djordjevic et al., 2012; Teys et al., 2013; Yoon et al., 2014). The
use of home exercises may improve self-management which is a key
goal to rehabilitation (French, 2007; Cowan et al., 2010).
This pilot study aims to assess whether MWMs and SMWMs can
be implemented into the management of hip pain in young males
to improve hip internal rotation. Thus it was hypothesised that a
caudal MWM with adduction as the movement would increase IR
ROM in a healthy restricted hip. Also that SMWMs would be as
effective as therapist induced MWMs.
2. Methodology
2.1. Study design
The Study was a parallel-group single blind randomized pilot
study (Fig. 1). Patients were blinded to the treatment technique
received. The randomisation schedule was prepared using random
function in Excel® 2010 (Microsoft Corp., Redmond, Washington,
USA) for windows® 7 (Microsoft Corp., Redmond, Washington, USA).
Subjects were randomly assigned into the order in which the
outcome measures would be recorded thus avoiding any sequencing
effect using random function in Excel® 2010 for windows® 7. Ethical
approval was sought in line with Institute of Technology Carlow's
Ethics Board. Subjects completed an informed consent form.
2.2. Subject selection
Forty-six male subjects aged 20 ± 1.80 were recruited using
convenience sampling for this pilot study between September 2014
and December 2014. The recruitment pool consisted of volunteers
from Science and Health Department and Sports Development
Courses at Institute of Technology Carlow. Subjects were included in
the pilot study provided that they participated in multidirectional
sports. Hip and groin injuries have a high prevalence in young active
males who participation in multidirectional sport such as soccer
(Boykin et al., 2013). Subjects also had to have had an IR ROM in the
hip of 30.0 or less in prone. Burns et al. (2011) used IR of less than
30.0 as an inclusion criterion in a study in hip mobilisation.
Subjects were excluded (n ¼ 6) from the study if they reported
having had a lower extremity injury in the past six months; having
undergone surgery on the hip in the past year; having being
diagnosed with rheumatoid arthritis, osteoarthritis or any neuro-
logical conditions. Subjects were also excluded if they had a posi-
tive AIT (Fig. 2) as described by Ratzlaff et al. (2013). The AIT is
performed in supine. The tested leg was passively brought into
90.0 of flexion, fully adducted, and internally rotated. The test was
considered positive if any of the movements elicit pain. Twenty-
Two eligible subjects presented to the Institute of Technology
Carlow's Physiology Laboratory for assessment of baseline mea-
sures, having abstained from vigorous activity for 24 h prior to
initial testing. Subjects presented themselves no more than seven
days after baseline testing, again having abstained from vigorous
activity for 24 h for pre-test measurements. Post-Test measures
were completed immediately after the interventions.
2.3. Interventions
2.3.1. MWM Group
The subject was set up in four-point-kneeling on a plinth. To
ensure the subject's hips stayed in 90.0 of flexion the tester posi-
tioned their hands on the subject's greater trochanters. All MWMs
were administered by a single undergraduate with 1 year clinical
experience. The MWM was performed with a caudal glide to the
femur applied with a Mulligan® mobilisation belt (Mulligan Products
and Tape, Vught, the Netherlands) modified from Hing and Mulligan
(2011). The mobilisation belt was positioned as proximally on the
femur as was comfortable for the subject. The subject was instructed
to inform the tester if there was any pain or discomfort, thus
allowing for minor adjustments (Hing et al., 2008). MWM's should
be performed with sufficient over pressure to effect the joint. The
MWM must also be performed pain free, requiring communication
between subject and tester (Abbott, 2001). To produce adduction
the subject leaned their hips ipsilaterally to the affected side (Fig. 3).
2.3.2. SMWM Group
All SMWMs were supervised by the same undergraduate stu-
dent with 1 year clinical experience. For the SMWMs, the subjects
were in four-point-kneeling on the floor. The tester gave verbal
feedback to the subject to ensure the subject's hips maintained
90.0 of flexion. A caudal glide was produced with a level 3
Crossmaxx® elasticated resistance band (Lifemaxx Fitness Acces-
sories, Rotterdam, the Netherlands) which was tethered to a secure
vertical beam of a squat rack. The resistance band was comfortably
positioned as proximally on the femur as possible. The subject was
instructed to inform the tester if there was any pain or discomfort,
minor adjustments were made to ensure pain free movement. The
subject leaned towards the affected leg to produce adduction. There
is no literature in relation to using resistance bands to replicate
MWMs, Reiman and Matheson (2013), however, offer clinical sug-
gestions for self-mobilisations that could be easily adapted to
simulate MWMs (Fig. 4).
 R. Walsh, S. Kinsella / Manual Therapy 22 (2016) 9e15 11

Fig. 1. Flow diagram of study design.

Fig. 2. Anterior impingement test. Where a is passive flexion to 90 , where b is passive Fig. 3. Caudal MWM (a) with adduction (b).
adduction, where c is passive internal rotation.
2.4. Outcome measures

2.3.3. Control Group 2.4.1. The SIRT

The Control Group was set up the same as the SMWM For the SIRT, subjects were secured to a plinth with a Mulligan®
Group, but without elasticated resistance band. All subjects per- mobilisation belt in a seated position. The leg to be tested was
formed three sets of ten repartitions with 30 s rest (Hing et al., passively internally rotated to the full ROM determined by the first
2008). firm resistance, ensuring the pelvis stayed in neutral. The angle was
12 R. Walsh, S. Kinsella / Manual Therapy 22 (2016) 9e15
Fig. 4. Caudal SMWM (a) with adduction (b).
measured with a Baseline® bubble inclinometer (Fabrication Enter-
prises Incorporated, New York City, New York, USA) positioned 5 cm
distally from the tibial tuberosity on the anterior border of the tibia.
There are a multitude of methods of measuring hip IR. These mea-
surements include active IR, passive IR, point of first resistance and
passive resistance torque. Hip IR can also be measured in different
positions: prone, supine and seated. The SIRT is the method most
often use to measure passive ROM (Gulgin et al., 2010). Almeida et al.
(2012) and Charlton et al. (2015) reported high intra-class reliability
(p < 0.05). Increases in seated IR measurement may be due to liga-
ment release or the role the piriformis as an internal rotator at
60.0e90.0 , as opposed to being an external rotator at less than
60.0 (Uritani and Fukumoto, 2012). Measurement errors for hip IR
using bubble inclinometers have been reported to be 2.3e3.3
(Charlton et al., 2015) The only consistency in the literature is that
passive IR is greater than active IR (Gulgin et al., 2010) (Fig. 5).
Fig. 5. Seated internal rotation (a) test.
2.4.2. The FIRT
The FIRT (Jordan, 2013) was performed in standing. Subjects
were positioned in front of a horizontal bar that was the same dis-
tance from the floor as the subjects' posterior superior iliac spines.
The weight of the subject was distributed on to the leg to be tested.
The other leg was used for support only. A dowel was positioned
across both of the subject's anterior superior iliac spines so that it
was parallel to the horizontal bar. The subjects actively internally
rotated from the tested hip. The subjects were instructed to ensure
that there was no additional movement from the supporting leg,
thus potentially inadvertently increasing the angle of rotation. The
assessor monitored the dowel to ensure it stayed in contact with
both anterior superior iliac spines. The outcome measure was the
angle of intersection of the bar and the dowel using a True-Angle®
goniometer (Gaiam-Pro, Boulder, Colorado, USA). Hip ROM is nor-
mally measured in a non-weight bearing position, while most ac-
tivities and sports are performed in weight bearing positions (Gulgin
et al., 2010). Restricted IR ROM is especially significant if the subject
needs IR for their activity. The pathology may only manifest when
the hip is brought repeatedly, with force, into its limit of IR in load
bearing activities (Van Dillan et al., 2008). Therefore measuring
functional hip IR should also be considered when measuring ROM
(Souza et al., 2014). Hip ROM can be effected by satellite structure
such as the lumber spin (Almeida et al., 2012). Normative values for
the FIRT have been reported as 60.2 (Jordan, 2013). Goniometry
measurement error has been reported to range from 10.0 to 15.0
(Barbee Ellison et al., 1990; Cibulka et al., 2010).
2.5. Statistical analysis
If the subject had two restricted hips the most restricted hip was
used. The mean of three measurements was used for each data
Fig. 6. Functional internal rotation (a) test.
 R. Walsh, S. Kinsella / Manual Therapy 22 (2016) 9e15
point. IBM SPSS Statistics® 20 (International Business Machines
Corp., Armonk, New York, USA) for windows® was used to analyse
the data. Means, SDs and 95% confidence intervals (CIs) were
calculated. The ShapiroeWilk test showed a normal distribution of
all quantitative data (P > 0.05). The baseline SIRT had a skew
of 2.33 to 0.49 and a Kurtosis ranged from 0.83 to 0.95 . The
skewness of the baseline FIRT was 0.46 e4.91, whereas the Kur-
tosis spanned from 0.06 to 0.95 . A 2  3 analysis of variance
(ANOVA) with time (pre-test and post-test) as the within subject
factor and group (MWM, SMWM and Control Group) as the
between-subject factors was used to determine the effects of the
intervention on FIRT and the SIRT. Independent ANOVAs were used
for each outcome. Intra-Rater reliability was conducted using intra-
class reliability test between baseline-test and the pre-test. The
main hypothesis of interest was the group  time interaction. The
statistical analysis was conducted at 95% confidence level, and
p < 0.05 was considered statistically significant.
3. Results
3.1. Subjects
The subjects had a mean age of 20.0 ± 1.8 (±SD) years, a mass of
76.4 ± 9.8 kg and a stature of 177.8 ± 6.6 cm as illustrated in Table 1.
3.2. SIRT
The Primary analysis for passive ROM was the SIRT and involved
all subjects that were randomly assigned (n ¼ 22). The 2  3 ANOVA
revealed no significant group  time interaction for the SIRT
measurement (F (2, 38) ¼ 2.28; p ¼ 0.12). Table 2 and Fig. 7 provides
pre-test and post-test data.
3.3. FIRT
The primary analysis for functional ROM was the FIRT and
involved all subjects that were randomly assigned (n ¼ 22 ). The
2  3 ANOVA revealed a significant group  time interaction for the
FIRT measurement (F (2, 38) ¼ 5.21; p ¼ 0.01). Table 2 and Fig. 8
provides pre-test and post-test data. There was a significant
within subject effect for time (F (2, 38) ¼ 0.32, p ¼ 0.01, h2p ¼ 0.22).
With all interventions showing an increase in the SIRT and the FIRT
scores across the two time points (Table 2). Between group effect
was in favour of the MWM group (F (2, 38) ¼ 5.21, p ¼ 0.01,
h2p ¼ 0.97).
3.4. Reliability
The tester was found to be reliable for both outcome measures.
The intra-class coefficients (ICC), measured between the baseline
and pre-test for both outcome measures, for the SIRT was 0.93
(Cronbach's a). The standard error of the measurement (SEM) for
the SIRT was 0.71, whereas the minimal detectable change
(MDC95) was 1.97. The results for the reliability of the FIRT had an
ICC of 0.89 (Cronbach's a). The SEM for the FIRT was 3.32 , whereas
the MDC95 was 9.19 .
Table 1
Physiological measurements (n ¼ 22).
Group Age, years ±SD Mass, kg ±SD Stature, cm ±SD
Control (n ¼ 8) 20.6 ± 2.3 71.6 ± 7.9 179.4 ± 7.2
MWM (n ¼ 6) 19.0 ± 1.3 73.7 ± 10.1 176.1 ± 7.5
SMWM (n ¼ 8) 20.1 ± 1.4 76.7 ± 11.9 177.4 ± 5.9
13
4. Discussion
The purpose of the present pilot study was to establish if a caudal
MWM would improve IR in a non-functional and functional posi-
tion. As well as determining if SMWMs were as effective in treating
restricted IR of the hip as MWMs. Both the SMWM Group and the
MWM Group showed some improvement in the SIRT and FIRT after
one session. These findings are similar to two case studies of
different types of hip mobilisations. Ferreira et al. (2013), who found
increased ROM in a 21 year old female ballet dancer after grade three
posterior accessory glides. The finding are also collaborated by the
findings of Crow et al. (2008) who reported reduced pain and
increased passive range of motion after posterior mobilisation in
neutral, as well as the hip in a medially and laterally rotated position,
respectively, in a 43 year old male patient post-hip arthroplasty.
Doner et al. (2013) and Kachingwe et al. (2009) both found that
MWMs insignificantly increased shoulder ROM (p < 0.05).
There was a statistical significant improvement (p < 0.05) in the
MWM Group in relation to the FIRT. These findings are consistent
with Teys et al. (2008) who used the MWM technique on the
shoulder joint.
There was an improvement in the SMWM Group vis-a
-vis the
FIRT but this was found not to be significant (p > 0.05). Yerys et al.
(2002) reported that glutaeal activation increases after pure
accessory glides of the hip joint. Improved activation of the gluta-
eus muscle may account for the increase of functional ROM, which
may explain the statistical significance of the FIRT but not the SIRT.
The results of this study suggest that using caudal MWM of the
hip joint could have a positive effect on hip internal rotation range.
MWMs require the subject to give constant feedback in relation
to pressure to ensure that MWMs are administered pain free.
Therefore identifying a method of measuring the force of a MWM
glide such as a spring balance (Green et al., 2001) or flexible force
mat (McLean et al., 2002) may result in greater inter-clinician
reliability. This identified method could also be applied to aid in
the accurate replication of force of SMWMs.
5. Limitations
In the present pilot study the sample size was twenty-two.
Considering that there was a significant improvement in func-
tional ROM but not passive ROM after therapist induced MWMs
would suggest that there was a type I error committed. Using
G*Power: Statistical Power Analyses™ 3 (Universia €t Kiel, Kiel,
Germany) for Windows® it was determined that a sample size of
more than 128 would ensure a power of 0.80 thus reducing the
probability of a type I error.
The weight bearing position in 90 of hip flexion during the SIRT
may negate any positive benefits of the caudal glide as prolonged
sitting can be a problematical position associated with hip pa-
thology (Emara et al., 2011).
The role of assessing outcomes as well as administering and
supervising the interventions was carried out by the same person.
Blinding the administering of a MWM is inherently difficult (Doner
et al., 2013). Having all parties blinded would have made the study
more robust and should be considered in further investigations.
6. Clinical applications
Caudal MWMs and SMWMs may improve IR of the hip. As there
are long wait lists for surgical intervention for end stage hip pa-
thology in public health services having treatment options in the
interim could be of benefit. Having a possible home exercise to
complement such treatments could allow self-management thus
being advantageous to the patient and the therapists in the public
14 R. Walsh, S. Kinsella / Manual Therapy 22 (2016) 9e15

Table 2
Results of SIRT and FIRT (n ¼ 22), with Bonferoni correction. Where y is a significant difference between MWM Group and Control Group (p ¼ 0.05).

Range of motion Test period Control (n ¼ 8) MWM (n ¼ 6) SMWM (n ¼ 8)

Mean ± SD (95% CI) Mean ± SD (95% CI) Mean ± SD (95% CI)

SIRT ( ) Pre-test 24.9 ± 2.7 (22.6e27.1) 24.0 ± 2.6 (21.2e26.7) 25.4 ± 1.9 (23.9e27.0)
Post-test 25.6 ± 3.0 (23.1e28.1) 29.2 ± 4.2 (24.8e33.6) 29.6 ± 3.4 (26.9e32.2)

FIRT ( ) Pre-test 47.1 ± 8.1 (40.3e53.8) 57.2 ± 8.2 (48.6e65.7) 49.0 ± 13.2 (38.0e60.1)
Post-test 48.3 ± 7.8 (41.8e54.8) 63.0 ± 6.0 (56.7e69.1)y 55.1 ± 13.2 (44.7e66.8)

functional ROM was a result of altered muscular activity (Freeman

et al., 2013).
Using ROM of the hip in a seated position may not be the best
outcome measure as it could cause the forward translation of the
femur and is not a functional position, especially if the subject is in
a standing weight bearing position during sporting or physical
activities. While the FIRT attempts to address this at present there is
not enough evidence to substantiate its reliability, validity or ac-
curacy. Future endeavours should consider addressing this or other
measures of functional ROM.
The use of healthy subjects may have reduced the potential for
improvements, investigating the effects of MWMs and SMWM on
subjects with hip pathologies such as FAI and or OA should be
considered.

8. Conclusion

There are various possible causes of restricted hip ROM which

Fig. 7. Mean SIRT (B) (±SE) over time (n ¼ 22).
sector. The subjects (n ¼ 3) that had major loss of IR (less than 20 )
all had a positive AIT. While investigating pathological hips was
outside of the scope of the present study, there would appear to be
an anecdotal coincidence of less than 20 hip IR and a positive AIT.
7. Future research
Measuring glutaeal muscular strength and activation (Grimaldi,
2011; Semciw et al., 2013) could help to establish if the improved
include abnormal bony morphology, altered joint position and
dysfunctional muscular activity. Literature in relation to mobi-
lisations with movements of the hip is limited but has positive
results in case studies. This pilot study investigated the relation
between MWMs and SMWMs for passive and functional hip ROM
in healthy young males. The findings of the present study suggest
that caudal MWMs may restore functional internal rotation ROM.
SMWMs may be beneficial when used to augment therapist
induced MWMs, when the PILL and CROCKS principles are applied.
SMWMs may even be an effective prophylactic treatment to pre-
vent restricted ROM of hip IR. As this study investigated restricted
ROM in young healthy hips it may not be generalised in relation to
older pathological hips.

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