MANUAL THERAPY ROUNDS

II Mobilisations with Movement (MWMS) for the Hip Joint to Restore

Internal Rotation and Flexion
Brian R. Mulligan, MNZSp, DipMT

Abstract: The techniques discussed in this paper are used to restore hip internal rotation and
hip flexion. The suitability of these techniques can be quickly ascertained. When indicated and
applied correctly, mobilisations with movement cause no pain and immediate improvement in
the range of movement is apparent.

Key Words: Manual Therapy, Mobilisation, MWMS, Hip Joint

W hen pain and capsular signs are present in the hip

joint, and x-rays show little or no degenerative
changes, mobilisations with movement (MWMS) to re-
will also require a plinth for the patient to lie on and it
helps if it is height adjustable. In describing in detail the
procedure I am presuming that you, the reader, are aware
store movement losses should be considered. It can quickly of the contraindications to manual therapy.
be established if MWMS are of value if the patient expe- The patient lies supine on the bed with the hip and
riences no pain during the technique and an immediate knee, on the side to be treated, flexed and foot just off
improvement in the range of movement is apparent. I have the bed. Let us assume that we are treating a right hip.
presented the indications for MWMS in my earlier articles You stand facing the right hip and place the clasped belt
in this J ournaI1-3• around the patient's upper thigh as proximal as it will go
When hip joint movement is restricted, and MWMS and just below your hip joints. You will be standing within
are indicated, at the top of my list is the technique for the belt of course (Fig. 1). The bed should be adjusted in
restoring internal rotation in the joint. This can be re- height so that the belt is virtually horizontal when
ally spectacular as was witnessed by 30 colleagues on one
of my Australian courses two years ago. On that occa-
sion, the patient, in his thirties, regained virtually full
hip internal rotation after fifteen years of marked limi-
tation. The patient also reported that his new active range
of movement was not painful when undertaken. This was
in marked contrast to the pain and limited movement
which he experienced before MWMS were applied.
To carry out the technique successfully you require
a belt that can be altered in length. It should be about
2.6 meters long, made of material like that used for car
seatbelts and with a suitable easily released clasp. You

Address all correspondence and request for reprints to:

Brian R. Mulligan
37 Courtenay Place
Wellington 1
New Zealand Fig. 1 Starting position for applying a MWMS to the
right hip.

The Journal of Manual & Manipulative Therapy

Vol. 4 No.1 (1996),35 - 36 Manual Therapy Rounds / 35
positioned. Now place the heel of your left hand on the
patient's right lateral iliac crest and the elbow of this
arm should lie in the crease of your hip joint (groin).
Your left arm should lie within the belt which is very
important as iliac fixation is paramount. This position-
ing is critical for the success of the MWMS as your fore-
arm stabilizes the pelvis of the patient when you slightly
extend your hips to distract the head of the femur later-
ally from the acetabulum. Through the belt you are lat-
erally distracting the hip joint because of your left forearm's
fixation of the ilium. Just prior to applying this lateral
traction wrap your right arm around the patient's right
flexed leg and secure the patient's mid thigh with your
wrapped around hand (Fig. 2). While the traction is being
maintained you rotate the right hip using your right arm
and body movement. By this I mean you rotate your trunk.
When this MWM is indicated no pain is felt by the
Fig. 2 Technique for the right hip.
patient and you will feel the range of movement increas-
ing as you carry out this technique. If the technique is
painful then it should not be used. The patient plays a
passive role throughout and must tell you if they feel
discomfort. Sometimes, of course, the discomfort is present
REFERENCES
1. Mulligan BR. Mobilisations with Movement (MWM'S). The Jour-
nal of Manual & Manipulative Therapy. 1993; 1(4): 154-156
2. Mulligan BR. Spinal Mobilisations with Arm Movement (Further
Mobilisations with Movement). The Journal of Manual & Manipu-
36 / The Journal of Manual & Manipulative Therapy, 1996
because the direction of the distracting force is incor-
rect and a small alteration in the pull will immediately
allow pain free movement. One should always with MWMS
make subtle direction changes when mild pain is expe-
rienced to see if it allows the pain free movement to take
place. Another technique fault that often happens is that
the belt around the thigh is not placed proximally as far
as it will go and it "digs" painfully into the thigh's ad-
ductor muscle. If this happens just "shove" it up a little
higher. Perhaps "shove" is not an appropriate word to
use as discretion and care must be used to avoid trap-
ping sensitive male parts within the belt!
As with all MWMS three sets of 10 repetitions would
be undertaken and the hip joint reassessed. Follow up
exercises, pain relieving modalities and other therapies
can be given concurrently.
The MWM technique set up to increase hip flexion is
identical to the above. You stand as for internal rotation
with the belt positioned in the same way. You now apply
the distraction laterally using your hips and with fore-
arm fixation on the ilium. Maintaining this distraction
you take the hip up passively in flexion provided there is
no pain. Whilst the hip is being flexed you should slightly
side flex to the left to ensure that the distraction is being
maintained in the way it was in the starting position.
On a course in the United Kingdom last year I was
able to successfully restore most of a thirteen year loss
of hip flexion in a colleague. However, and this is impor-
tant to remember when using MWMS, it took three or
four slight directional changes to get the distraction right
to enable the pain free movement increase to occur. When
it did, almost in unison, most of those present said, "What
about adaptive shortening?" This statement has been repeated
many times in my courses and, oh dear, what a question.
With a movement loss of many years standing the text-
books would tell us that adaptive shortening must hap-
pen. My experience is showing that this is generally not
the case or if it does occur it is small and of no signifi-
cance. Now, this is an exciting avenue for our research-
ers to travel. Once you have mastered these techniques
you will have the same enthusiasm for them that I have
and they will, often as not, ensure that you attain your
quota of one "miracle" a day using MWMS .•
lative Therapy. 1994; 2(2): 75-77
3. Mulligan BR. Spinal Mobilisations with Leg Movement (Further
Mobilisations with Movement). The Journal of Manual & Manipu-
lative Therapy. 1995; 3(1): 25-27