Mulligan Concept / MWM Physiotherapy in Tel Aviv
At Recovery TLV, the Mulligan Concept is used as part of a broader assessment. Mobilization with Movement (MWM), NAGs, SNAGs and Self-SNAGs are applied selectively when the case fits — tennis elbow, cervicogenic headache, frozen shoulder, ankle sprain, neck pain. The defining rule is the PILL principle: if the technique is right, the movement becomes pain-free immediately, and the effect lasts after the hands come off. If it does not, the technique is changed — not pushed through.
Key takeaways
- The Mulligan Concept is a manual therapy framework, not a single technique. The core idea is a sustained accessory glide held during active movement.
- PILL principle — Pain-free, Instant effect, Long-lasting. If the technique does not produce immediate pain-free movement, the clinician changes the direction or abandons it.
- The best-evidenced application is tennis elbow: Bisset et al. (BMJ 2006) showed MWM + exercise was superior to wait-and-see short-term and to corticosteroid injection long-term.
- Self-SNAG at C1-C2 produced a 54% reduction in headache index at 12 months in cervicogenic headache vs placebo (Hall et al., JOSPT 2007).
- Mulligan techniques work best when combined with progressive loading, education and a clear return-to-activity plan — not as a stand-alone passive treatment.
What you get in session 1
- Full history and goalsSymptoms, irritability, 24-hour pattern, function, sport and work demands — captured by the clinician, not a form.
- Red flag and neurological screenStrength, sensation, reflexes, neural tests, vascular screening when relevant. We rule out what needs ruling out.
- MWM trial in sessionIf the case fits, we test a Mobilization with Movement and check the PILL response in real time — pain-free, instant, lasting after release.
- Functional task testingGripping, reaching, weight-bearing, sport-specific or work-specific tasks tied to your actual goals.
- A written impressionWorking hypothesis, what responded to MWM, what didn't, and the reasoning behind the plan.
- A take-home planSelf-SNAG or self-MWM where appropriate, dosage, modifications, and what we expect to see by visit 2.
What is the Mulligan Concept?
In plain language: The Mulligan Concept is a hands-on therapy where the clinician applies a gentle gliding pressure on a joint while you move it. If applied correctly, the movement that hurt seconds ago becomes pain-free immediately — and stays that way. It's not a placebo or muscle relaxation; it's a small mechanical correction that lets you load the joint again.
The Mulligan Concept, named after New Zealand physiotherapist Brian Mulligan, is a manual therapy framework developed and refined from the mid-1980s onward. It is now taught internationally by the Mulligan Concept Teachers Association (MCTA) and used worldwide as part of musculoskeletal physiotherapy. The defining feature of the approach is a sustained accessory glide applied during active movement — what Mulligan called a Mobilization with Movement, or MWM.
In a classical MWM, the patient first demonstrates the movement that hurts — for example, gripping a tennis racket, lifting the arm overhead, turning the neck, rotating the trunk, or dorsiflexing the ankle in a lunge. The clinician then identifies a joint that may be contributing to the symptom and applies a precise accessory glide in a specific direction (commonly a lateral, medial, anterior or posterior glide) while the patient repeats the previously painful movement. If the glide direction is correct and the force is appropriate, the active movement becomes pain-free immediately, the range often improves, and the effect persists after the clinician's hands come off.
If the movement is not pain-free under the glide, the technique is wrong for that case. The clinician then changes the direction, modifies the force, tries a different segment, or abandons MWM and uses a different approach — not pushes through the pain.
Mulligan's framework includes several related techniques applied to different regions:
- Mobilization with Movement (MWM) — the core peripheral-joint technique. Used at the shoulder, elbow, wrist, hip, knee, ankle and foot.
- Natural Apophyseal Glides (NAGs) — gentle oscillatory mobilizations applied passively to the mid-cervical and upper-thoracic spine.
- Sustained Natural Apophyseal Glides (SNAGs) — patient-active spinal mobilizations where the clinician applies a sustained glide while the patient moves into the painful direction.
- Reverse NAGs — used for hypomobile spinal segments, applied in the opposite direction.
- Self-SNAGs — patient-applied glides using a folded towel or a self-treatment belt for independent home management.
- Spinal Mobilization with Leg Movement (SMWLM) — a spinal mobilization combined with active leg movement, used for radicular and neural symptoms.
Important clinical clarification
The Mulligan Concept is not a quick-fix or a magic trick. The PILL response in session 1 is a screen — it tells the clinician whether the technique is going to help this specific case. When PILL is present, the framework is layered on top of education, progressive loading and a clear return-to-activity plan. When PILL is absent in session 1, the framework is changed. Forcing MWM on a case that does not respond is a misuse of the method, not the method itself.
What are the key concepts of the Mulligan Concept?
Mobilization with Movement (MWM)
The therapist applies a sustained accessory glide to a joint while the patient performs the painful active movement. The hallmark is that the movement becomes pain-free under the glide. This is the core peripheral-joint technique of the Mulligan Concept.
NAGs and Reverse NAGs
Gentle, mid-range oscillatory mobilizations applied passively to the mid- and upper-cervical spine — and reverse NAGs for hypomobile segments. Used as a less-loaded entry point when SNAGs are too provocative.
SNAGs (Sustained Natural Apophyseal Glides)
Patient-active spinal mobilizations. The clinician applies a sustained glide on a spinal segment while the patient moves into the previously painful direction. Used for neck pain, cervicogenic headache, dizziness, thoracic and lumbar pain.
Self-SNAG / Self-MWM
The same technique, performed by the patient at home using a folded towel or a Mulligan self-treatment belt. Self-SNAGs allow patients to maintain gains between visits and to manage flare-ups independently after discharge.
The PILL principle
Pain-free during the technique. Instant change in symptom or range. Long-Lasting effect after the clinician releases. If any of the three is missing, the technique is changed — not pushed through.
Glide direction matters
The same joint can respond to a lateral, medial, anterior or posterior glide depending on the case. The clinician tests directions systematically and picks the one that produces a PILL response. Wrong direction = no benefit and the technique is abandoned.
PILL response vs no-PILL response, visually
PILL response (correct technique)
Glide held at the joint, patient performs the painful movement, pain disappears during the movement, and the relief outlasts the contact. This is the green light to keep going and start dosing.
No PILL response (abandon or change)
Glide held, patient moves, pain persists or worsens. The technique is wrong for this case. Clinician changes the direction, the angle, the segment — or abandons MWM and uses a different framework. No pushing through.
Mulligan technique library
The Mulligan Concept is not a single technique. The first session tests one or more of the techniques below depending on the area, the irritability and the case. Six core techniques you should know:
Who may benefit from Mulligan / MWM assessment?
The Mulligan Concept is most useful for mechanical, movement-related musculoskeletal problems where a specific active movement is painful or limited and where a sustained accessory glide changes that response in real time. The table lists common presentations and what MWM assessment may add. Note that "may help" is intentional — the PILL response in session 1 decides whether the technique applies, not the diagnosis on paper.
| Presentation | Why a Mulligan / MWM trial may help |
|---|---|
| Lateral epicondylalgia (tennis elbow) | Best-evidenced application; lateral elbow glide during gripping (Bisset 2006) |
| Cervicogenic headache | C1-C2 self-SNAG (Hall 2007) and upper cervical SNAGs to restore Flexion-Rotation range |
| Cervicogenic dizziness | Mulligan SNAGs equivalent to Maitland mobilizations vs placebo (Reid 2014) |
| Neck pain (mechanical) | NAGs and SNAGs in the segment that reproduces symptoms on rotation or extension |
| Adhesive capsulitis (frozen shoulder) | MWM combined with conventional physiotherapy to improve range and reduce pain |
| Sub-acromial shoulder pain | Posterolateral glide MWM during abduction or flexion |
| Lateral ankle sprain (acute and chronic) | Talocrural and tibiofibular MWM to restore dorsiflexion and balance |
| Chronic ankle instability | MWM combined with proprioceptive and strength work |
| Mechanical low back pain | Lumbar SNAGs in the painful direction; self-SNAGs for home use |
| Hip pain (mechanical, non-arthritic) | Hip MWM applied during loaded tasks such as squatting or step-up |
| Patellofemoral pain | Medial patellar glide during squat or step-down where indicated |
| Wrist and hand symptoms | MWM at the carpus, MCP or IP joints during gripping or pinch |
Disclaimer. The Mulligan Concept is not appropriate as a stand-alone solution for every case. Cases with red flags, progressive neurological deficit, suspected serious pathology, acute fracture, recent surgery without medical clearance, or significant upper-cervical instability need medical evaluation or alternative frameworks first.
When are Mulligan techniques not enough?
An immediate PILL response in session 1 is informative but it is not the end of the story. Recovery from any musculoskeletal condition almost always requires more than manual therapy: progressive loading, graded exposure, education, sleep and stress management, and sport- or work-specific conditioning. Westad et al.'s 2018 systematic review of MWM in peripheral joints concluded that MWM can be effective in the short term but that long-term outcomes depend on integration with exercise and self-management (Westad et al., Musculoskelet Sci Pract 2019). The Bisset 2006 BMJ trial that showed MWM superiority in tennis elbow used MWM plus a structured exercise programme — not MWM alone (Bisset et al., BMJ 2006) · Free PDF.
| What MWM may identify or change | What rehab also has to address |
|---|---|
| A pain-free active movement under glide | Capacity and strength of the affected region |
| Immediate range-of-motion gains | Long-term maintenance with home exercise |
| A direction-specific symptom response | Return-to-sport progression |
| A self-SNAG that the patient can apply at home | Education, beliefs and confidence about pain |
| A subgroup that responds to manual therapy | Load management and weekly volume |
| A starting point for the rehab plan | Sleep, stress, work ergonomics |
At Recovery TLV, Mulligan techniques are integrated with active rehabilitation and education rather than used as a stand-alone passive treatment. If the PILL response is absent, the framework is changed — not repeated more aggressively.
How does Mulligan combine with progressive loading?
The Mulligan Concept gives a quick answer to one question: can a sustained accessory glide make this painful active movement pain-free right now? If the answer is yes, that information shapes the early-phase plan — what range to work in, what dosage of self-SNAG to give, what direction to focus on. Progressive loading then rebuilds capacity so that the patient can return to gripping, lifting, throwing, sitting, walking, running or sport without depending on the manual technique forever.
| MWM-focused question | Loading-focused question |
|---|---|
| Does a glide produce a PILL response right now? | What capacity is missing in the affected region? |
| Which direction works (lateral / medial / anterior / posterior)? | How much load can the patient tolerate today? |
| How many reps / sets are tolerated in session? | How do we progress reps, sets and resistance safely? |
| Can the patient apply a self-SNAG independently? | What is the criterion to remove the self-SNAG from the plan? |
| What happens if the technique is paused for a week? | What predicts long-term resilience without manual therapy? |
The Stathopoulos et al. meta-analysis (JMPT 2019) summarised MWM effects on ROM in peripheral joint pathologies across 17 studies and concluded that MWM produces significant short- to medium-term improvements in range of motion, but the durability of those gains depends on what is done alongside — exercise, education and progressive loading (Stathopoulos et al., JMPT 2019). That is the foundation. Mulligan is a quick-feedback tool layered on top of it.
The Recovery TLV position: the joint is not the whole story. We assess symptom behaviour, neurological signs, manual-therapy response, strength, capacity and functional goals. Mulligan findings, when present, shape the early-phase plan. Progressive loading and education shape the rest.
What does a Mulligan assessment include?
An assessment for manual therapy should not stop at "which joint hurts". The first session covers the following domains so the plan is built on what actually drives the case, not on a single test or a single technique.
| Domain | What we assess |
|---|---|
| History | Onset, mechanism, duration, previous episodes, response to prior treatment |
| Symptom behaviour | Aggravating and easing movements, 24-hour pattern, irritability |
| Red flags | Medical warning signs that need referral before continuing |
| Neurology | Strength, sensation, reflexes, neural tension where relevant |
| Pre-manipulative screen | Vertebrobasilar, upper cervical stability, vascular and dizziness screening when considering cervical SNAGs |
| Active movement and ROM | Painful direction, pain intensity and range before MWM |
| MWM trial (PILL test) | Glide direction, pain-free repetitions, sustained effect after release |
| Functional task testing | Gripping, reaching, weight-bearing, sport- or work-specific tasks |
| Load tolerance | What is tolerated now and what triggers symptoms under load |
| Confidence and fear | Kinesiophobia, expectations, beliefs about manual therapy |
| Goals | Work, training, sport, daily life — measured, not assumed |
What happens in your first Mulligan / MWM session?
| Step | What happens |
|---|---|
| 1 | History, symptoms, goals |
| 2 | Red flag and neurological screening |
| 3 | Active movement and range-of-motion baseline |
| 4 | MWM / SNAG trial — testing the PILL response in real time |
| 5 | Functional task re-testing — gripping, reaching, weight-bearing or sport tasks |
| 6 | Working clinical impression |
| 7 | Initial treatment dosage and symptom-response rules |
| 8 | Home plan — self-SNAG or self-MWM, dosage, modifications |
| 9 | Progression plan — or referral decision if Mulligan is not indicated |
You should leave the first session with a clearer picture of whether Mulligan techniques apply to your case, what changed during the session, what to do at home, and how progress will be measured at visit 2.
Ready to test the PILL response on your own case?
One 50–60 minute session covers history, red flags, neurology, MWM trial and functional testing. You walk out with a written plan — including a self-SNAG if appropriate — not a sales pitch.
What does the evidence actually show about Mulligan / MWM?
In plain language: Mulligan techniques have the strongest evidence for tennis elbow, cervicogenic headache, cervicogenic dizziness, frozen shoulder and ankle sprain. Across these, MWM/SNAGs produce immediate pain and range-of-motion gains. Long-term results depend on combining it with progressive loading exercises — Mulligan alone isn't enough.
The honest summary: the Mulligan Concept has a focused evidence base. The strongest data are for lateral epicondylalgia, cervicogenic headache, cervicogenic dizziness, frozen shoulder and ankle sprain. Across these conditions, MWM and SNAGs tend to produce immediate and short-to-medium-term improvements in pain and range of motion when added to or compared with usual care, exercise, or other manual therapy. Long-term effects depend on integration with progressive loading.
Lateral epicondylalgia (tennis elbow)
Bisset, Beller, Jull and colleagues randomized 198 patients with tennis elbow into three groups: physiotherapy (8 sessions of elbow MWM plus exercise), corticosteroid injection, or wait-and-see. Corticosteroid injection had the best short-term outcome at 6 weeks but 47 of 65 injection "successes" regressed by 52 weeks, and physiotherapy was significantly better in the long term. Physiotherapy was also significantly better than wait-and-see at 6 weeks (Bisset et al., BMJ 2006) · Free PDF. The mechanistic studies are consistent: Paungmali, O'Leary, Souvlis and Vicenzino showed that a single MWM at the elbow produces immediate hypoalgesia, increased pain-free grip strength and concurrent sympathoexcitation that resembles the response to spinal manipulation (Paungmali et al., Phys Ther 2003 — PMID 12665408). A follow-up study showed the hypoalgesic effect is not antagonised by naloxone, suggesting it is not mediated by endogenous opioid pathways (Paungmali et al., JMPT 2004). McLean and colleagues demonstrated a dose-response relationship: pain-free grip strength improved significantly only when applied manual force exceeded ~1.9 N/cm at the elbow (McLean et al., Clin Biomech 2002). Vicenzino et al. (Man Ther 2008) derived a preliminary clinical prediction rule: patients under 49 years with pain-free grip strength >112 N on the affected side and <336 N on the unaffected side had a 100% probability of improving with MWM + exercise when all three were positive (Vicenzino et al., Man Ther 2009). Herd and Meserve's earlier systematic review of manipulative therapy for lateral epicondylalgia concluded that elbow manipulation (including MWM) plus exercise has good support across multiple trials (Herd & Meserve, J Man Manip Ther 2008) · Free PDF.
Cervicogenic headache and dizziness
Hall, Chan, Christensen, Odenthal, Wells and Robinson performed a randomized double-blind placebo-controlled trial of a C1-C2 self-SNAG in 32 patients with cervicogenic headache and limited Flexion-Rotation Test range. After a single in-clinic instruction and self-application at home, the self-SNAG group gained 15 degrees of FRT range immediately (vs 5 degrees placebo, P<.001) and had a 54% reduction in headache index at 12 months, vs no change in the placebo group (Hall et al., JOSPT 2007). Cardoso et al.'s 2022 systematic review of RCTs of SNAG for cervicogenic headache confirmed consistent improvements in FRT range, headache intensity and disability across the available trials (Cardoso et al., Arch Physiother 2022) · Free PDF. Reid, Rivett, Katekar and Callister conducted a randomized controlled trial in 86 patients with cervicogenic dizziness comparing Mulligan SNAGs (including self-SNAGs) with Maitland passive mobilizations plus range-of-motion exercises or a placebo. Both manual therapy groups produced clinically meaningful reductions in dizziness intensity and frequency at 12 weeks vs placebo, with no significant differences between SNAGs and Maitland mobilizations (Reid et al., Phys Ther 2014).
Shoulder conditions and frozen shoulder
Satpute, Reid and Mitchell performed a systematic review and meta-analysis of MWM for shoulder conditions across 13 trials and found clinically meaningful improvements in pain and function when MWM was added to conventional physiotherapy (Satpute et al., J Man Manip Ther 2021) · Free PDF. Kubuk, Carrasco-Uribarren, Cabanillas-Barea and colleagues' systematic review and meta-analysis of end-range interventions in primary adhesive capsulitis found that end-range mobilizations (including MWM) produced significant improvements in shoulder range and function vs conventional care (Kubuk et al., Disabil Rehabil 2023). Noten, Meeus and Stassijns' earlier systematic review of mobilization techniques in primary adhesive capsulitis came to a similar conclusion: end-range and Mulligan-type techniques improved range of motion vs conventional therapy (Noten et al., Arch Phys Med Rehabil 2015). A more recent systematic review and meta-analysis by Çelik and colleagues (2024) confirmed the clinical significance of MWM in shoulder pathologies across multiple subgroups (Çelik et al., J Integr Complement Med 2024).
Lateral ankle sprain and chronic ankle instability
Gogate, Satpute and Hall randomized 32 adults with acute or sub-acute grade I or II inversion ankle sprain to MWM or placebo. The MWM group had significantly better pain (mean difference 1.7 points at 1 month, 0.9 points at 6 months), Foot and Ankle Disability Index, dorsiflexion range, pressure pain threshold and dynamic balance at both follow-ups (Gogate et al., Phys Ther Sport 2020). Nguyen, Pitance, Mahaudens and colleagues' pragmatic randomized trial in subacute lateral ankle sprain (n=51) found that more than 80% of patients responded to MWM and that responders gained significant and clinically meaningful improvements in dorsiflexion range and Y-balance test performance after three sessions vs sham (Nguyen et al., J Man Manip Ther 2021) · Free PDF. Cruz-Diaz, Lomas-Vega and Osuna-Pérez randomized patients with chronic ankle instability to joint mobilization or control and found significant improvements in self-reported function and dynamic stability (Cruz-Diaz et al., Disabil Rehabil 2015).
Mechanical low back pain
The lumbar evidence base is smaller but growing. Buran Çirak and colleagues' double-blinded RCT of lumbar SNAGs vs sham in non-specific low back pain (n=30) measured muscular stiffness directly using ultrasound shear wave elastography. The real-SNAG group had significant reductions in pain, increases in trunk flexibility, gains on the Biering-Sorensen and side-bridge endurance tests, and measurable reductions in multifidus and erector spinae stiffness after a single session — none of which occurred in the sham group (Buran Çirak et al., JMPT 2021). Cankaya and Pala's RCT in 49 obese patients with chronic mechanical low back pain found that adding Mulligan SNAG and NAG techniques to stretching and strengthening produced significantly greater ROM and pain improvements than exercise alone (Cankaya & Pala, Life 2024).
Beyond outcomes — mechanism and patient psychology
Athanasiadis, Dionyssiotis, Krumov and colleagues' systematic review of the cognitive-behavioural aspects of the Mulligan Concept found that the immediate pain-free experience under MWM has measurable effects on patient expectations, fear-avoidance beliefs and self-efficacy (Athanasiadis et al., Eur J Transl Myol 2022) · Free PDF. This is plausible mechanically: a patient who feels their painful movement become pain-free in real time learns that the movement is not inherently harmful, which reduces fear and increases willingness to load.
Overall pattern across conditions
Westad, Tjoestolvsen and Hebron's 2018 systematic review of MWM in peripheral joints across multiple conditions concluded that MWM is more effective than no treatment or placebo for short-term pain and range outcomes in most peripheral joints, but that long-term outcomes are inconsistent and depend on integration with exercise (Westad et al., Musculoskelet Sci Pract 2019). Stathopoulos et al.'s 2019 meta-analysis came to the same conclusion for ROM specifically: significant short-to-medium-term gains across peripheral joint pathologies (Stathopoulos et al., JMPT 2019). The honest takeaway: Mulligan techniques are a useful tool when the PILL response is present, especially in tennis elbow, cervicogenic headache, frozen shoulder and ankle sprain. They are not a universal solution and not a substitute for active rehabilitation.
What does Mulligan treatment look like in practice?
These are illustrative example pathways based on common presentations described in the Mulligan literature and routine clinical practice — not specific patient case reports. Real-world recovery varies and outcomes are not guaranteed.
42-year-old recreational tennis player · 4 weeks of right lateral elbow pain
- PresentationRight lateral elbow pain since increasing weekly tennis volume. Pain on gripping, lifting a kettle and turning a doorknob. Pain-free grip strength on the affected side is 60% of the unaffected side.
- Red flag screenClean — no neurological deficit, no nocturnal pain unrelated to position, no trauma beyond increased racket play, no systemic symptoms.
- AssessmentPain on resisted wrist extension and on a strong grip. A lateral glide MWM at the elbow during gripping produced an immediate pain-free grip with a clear PILL response. Six pain-free repetitions performed under glide.
- PlanMWM at elbow combined with progressive eccentric wrist extensor loading (per Bisset 2006 protocol). Self-MWM with a non-elastic strap at home, 6-10 reps × 3 sets daily. Temporary racket modification — heavier head, larger grip — and a stepped tennis return.
- CheckpointsPain-free grip strength, NPRS on gripping, PRTEE (Patient-Rated Tennis Elbow Evaluation), tolerance for forehand vs backhand.
- Typical timelineMeaningful change in 2-4 weeks (per Bisset 2006); progressive return to full tennis volume over 8-12 weeks.
36-year-old office worker · 18 months of unilateral right-sided headache
- PresentationRight-sided headache 4-5 days per week, starts at the occiput and refers behind the eye. Worse with prolonged screen work and on a long drive. Reduced right neck rotation. No aura, no visual changes, no vomiting.
- Red flag screenClean — no sudden severe headache, no neurological deficit, no fever, no trauma. Vertebrobasilar and upper cervical stability screening unremarkable. Flexion-Rotation Test (FRT) limited to ~25 degrees on the right (normal ~45 degrees).
- AssessmentC1-C2 self-SNAG performed in supervised conditions reproduced and then eliminated the headache trigger in session. FRT range improved from 25 to 40 degrees post self-SNAG — clear PILL response (per Hall 2007).
- PlanC1-C2 self-SNAG with a folded towel performed twice daily at home, 6 reps × 2 sets. Workstation review, screen-break cadence, postural endurance work for the deep neck flexors. Repeat FRT at every visit.
- CheckpointsFRT range, headache index (frequency × intensity × duration), Neck Disability Index, screen-time tolerance.
- Typical timelineHall 2007 showed meaningful reduction in headache index by 4 weeks; sustained improvement at 12 months in responders. Some patients become independent of clinician contact after 4-6 visits.
28-year-old amateur footballer · 6 months of recurrent right ankle sprains
- PresentationFour right lateral ankle sprains in 6 months. Persistent feeling of "giving way", dorsiflexion limitation, reduced balance on the right leg. MRI showed mild lateral ligament thickening, no acute pathology. Reluctant to return to competitive play.
- Red flag screenClean — no neurovascular deficit, no significant deformity, no suspicion of occult fracture, full neurology of the foot.
- AssessmentTalocrural MWM with a posterior glide during a weight-bearing lunge increased dorsiflexion range by 4 cm on the weight-bearing lunge test and reduced perceived stiffness. Clear PILL response (per Gogate 2020, Nguyen 2021).
- PlanTalocrural MWM in clinic combined with proprioceptive and strength work — single-leg balance progressions, calf strength, peroneal strength, plyometric and change-of-direction reintroduction. Self-mobilization with a strap at home for dorsiflexion.
- CheckpointsWeight-bearing lunge test, Y-balance test, Cumberland Ankle Instability Tool (CAIT), single-leg hop, perceived ankle confidence.
- Typical timelineInitial gains within 2-4 weeks; full return to competitive football typically 8-12 weeks depending on baseline strength and confidence. The manual technique is gradually faded out as capacity and confidence return.
These pathways exist to illustrate the clinical reasoning, not to predict your case. The first session will identify which framework fits your presentation — and which does not.
What won't we do during Mulligan / MWM treatment?
Counter-positioning is honest information. Patients deserve to know what is not on the menu before they book.
Push MWM through pain
The PILL principle is non-negotiable. If the movement is not pain-free under the glide, the technique is changed or abandoned. We do not "force" a Mulligan technique on a case that does not respond, because it is not how the method works.
Run passive theatre as treatment
No 20-minute ultrasound, laser, TENS or heat-pack sessions billed as physiotherapy. Manual therapy is one tool in an active rehabilitation plan, not a passive treatment marketed as a cure on its own.
Sell session packages
Charge per session, ₪400. One assessment can be a complete unit. If we don't think you need a second visit, we say so. No package contracts, no automatic re-bookings, no scarcity tactics.
Read your MRI in isolation
Imaging findings are common in pain-free people and are interpreted against your symptoms, function and clinical findings — not the other way around. A scan does not decide the plan; the clinical picture does.
Treat through red flags
Progressive neurology, cauda equina symptoms, fever, recent significant trauma, suspected serious pathology — we refer immediately. Mulligan techniques are not a substitute for medicine when it's needed.
Hand you between clinicians
All sessions are 1:1 with Alejandro, the same clinician who did the first assessment. No technicians, no rotating staff, no group classes labelled as rehab.
What Mulligan training does the clinician have?
The Mulligan Concept is taught through international courses organised by the Mulligan Concept Teachers Association (MCTA). Courses are region-specific (Upper Quadrant, Lower Quadrant, Spinal) and emphasise assessment, MWM application, SNAGs, self-SNAGs and clinical reasoning under the PILL framework.
| Training | Detail |
|---|---|
| Mulligan Concept courses | Mobilization with Movement, NAGs, SNAGs, Self-SNAGs — completed as part of continuing professional development |
| McKenzie Method / MDT — Parts A through E | Lumbar, cervical and thoracic, advanced lumbar and lower limb, cervical and upper limb, advanced upper and lower limb |
| Dry needling | Trigger-point dry needling for musculoskeletal conditions |
| Functional Movement Screen (FMS) and Kinesio Taping | Movement screening and taping techniques used in selected return-to-activity cases |
| Israel Ministry of Health physiotherapy license | 10-120163 (Alejandro Zubrisky, BPT) |
Alejandro has completed Mulligan Concept courses as part of continuing professional development and applies Mulligan techniques (MWM, NAGs, SNAGs, Self-SNAGs) within a broader assessment model alongside McKenzie / MDT, dry needling, FMS and progressive loading. The Mulligan framework is one tool among several, used when the case fits and the PILL response is present.
How do you choose a Mulligan-trained physiotherapist?
If you are searching for a Mulligan-trained clinician — in Tel Aviv or anywhere — these are the questions worth asking, and why each one matters. We have stated our own position in the credentials section above and are happy to be measured against the same checklist.
| What to look for | Why it matters |
|---|---|
| Clear and verifiable Mulligan training status | Avoids misleading claims; protects you from inflated marketing |
| Application of the PILL principle in session 1 | The technique is supposed to be pain-free and instant — if it isn't, it shouldn't be pushed |
| Pre-manipulative screening for cervical SNAGs | Patient safety; vertebrobasilar and upper cervical stability matter |
| Self-SNAG instruction and home plan | Reduces dependency on the clinician; the patient should leave with a plan |
| Integration with progressive loading and exercise | Most cases need capacity work to actually return to life and sport |
| Honest position on what didn't work | If the PILL test fails, the framework should change — not be repeated harder |
| Defined progression criteria | Avoids open-ended treatment with no measurable milestones |
What happens if you keep waiting
Many mechanical conditions settle on their own. The risk is not the first episode — it is what happens next.
- Untreated lateral epicondylalgia can become chronic and recurrent; the Bisset 2006 BMJ trial showed that wait-and-see does eventually catch up to physiotherapy at 52 weeks, but the cost is a longer period of disability in the meantime.
- Cervicogenic headache that responds to a self-SNAG is one of the most reversible headache patterns in physiotherapy — but only if the C1-C2 contribution is actually tested.
- Recurrent ankle sprains lead to chronic ankle instability and a measurable loss of dorsiflexion, balance and confidence — addressed early, this is much easier to reverse than a year later.
- Adhesive capsulitis without active range work can lengthen significantly; early manual therapy + loading shortens that window.
What people are afraid to ask before booking
Mulligan techniques are not high-velocity manipulation. MWM and SNAGs are sustained, low-force glides applied during your own active movement — not the audible "crack" technique. You may hear a soft articular sound occasionally, but it is not the goal and not the mechanism of effect.
Safety screening comes first. Before any cervical SNAG, we screen for vertebrobasilar insufficiency, upper cervical instability, dizziness pattern and vascular risk factors. If anything is positive, we don't apply cervical techniques. The Hall 2007 JOSPT trial of C1-C2 self-SNAGs in cervicogenic headache reported no significant adverse events.
The PILL principle is a fast filter. If MWM is going to help your specific case, you usually see a clear signal in session 1 — pain-free movement under the glide, range gains that hold after the technique stops. If that doesn't happen, we don't keep doing the same thing. We change the framework.
By design, MWM should be pain-free in session. That is the first letter of PILL. If the glide direction is correct, your previously painful movement becomes pain-free during the technique. If it doesn't, we change direction or abandon the technique — we do not push you through pain.
Often no. Many mechanical cases — tennis elbow, cervicogenic headache, ankle sprain, mechanical neck pain — can be assessed clinically before imaging. Imaging is needed when red flags, progressive neurological deficit, suspected fracture, infection, malignancy or other serious pathology are present. Otherwise, the clinical exam decides the plan.
Age is not a contraindication. The Hall 2007 cervicogenic headache trial, the Bisset 2006 tennis elbow trial, and the Satpute 2021 frozen-shoulder meta-analysis all included middle-aged and older adults. The plan adapts to your current capacity; the principles do not change.
Red flags — when should you seek medical care, not physiotherapy?
Stop self-treatment and contact a physician immediately if you experience any of the following:
- Cauda equina symptoms: loss of bladder or bowel control, saddle anaesthesia, bilateral leg weakness
- Progressive neurological deficit: worsening weakness, foot drop, expanding numbness, hand clumsiness
- Sudden severe headache with dizziness, visual changes, slurred speech or neurological symptoms — possible vascular event
- Signs of cervical myelopathy: gait disturbance, bilateral arm or leg symptoms, hand clumsiness
- Acute trauma with suspected fracture, joint dislocation or significant soft-tissue injury
- Severe unrelenting night pain with weight loss, fever, night sweats or history of cancer
- Vertebrobasilar warning signs: sudden dizziness, drop attacks, slurred speech, swallowing difficulty, visual disturbance
- Recent fracture or surgery in the area being treated, without medical clearance
- Active inflammatory arthropathy flare — modify or avoid forceful overpressure
Manual therapy — including the Mulligan Concept — is one part of a broader assessment and treatment model. It is not a substitute for medical evaluation when red flags are present.
Frequently asked questions
What is the Mulligan Concept?
Is the Mulligan Concept the same as the McKenzie Method?
What is a Mobilization with Movement (MWM)?
Does Mulligan therapy hurt?
Does Mulligan therapy work for tennis elbow?
Does Mulligan help cervicogenic headache?
Can I do SNAGs at home?
How many sessions are typically needed?
Is Recovery TLV a Certified Mulligan clinic?
Can Mulligan therapy replace medical care?
Related conditions we treat
Not sure if Mulligan / MWM is the right approach for your case? Ask Alejandro on WhatsApp →
Book a Mulligan / MWM-informed assessment
One 50–60-minute private session in Tel Aviv. History, red-flag and neurological screen, MWM trial with PILL response, functional task testing, and a written plan — including a self-SNAG if appropriate — you can act on with or without further visits. ₪400. Sun-Thu 07:00-22:00 · Fri 07:00-14:00.
References21 peer-reviewed sources · all citations verified via PubMed
- Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. DOI: 10.1136/bmj.38961.584653.AE · Free PDF
- Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003;83(4):374-83. PubMed PMID: 12665408
- Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. J Manipulative Physiol Ther. 2004;27(3):180-5. DOI: 10.1016/j.jmpt.2003.12.022
- McLean S, Naish R, Reed L, Urry S, Vicenzino B. A pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clin Biomech (Bristol). 2002;17(4):304-8. DOI: 10.1016/s0268-0033(02)00017-7 · PubMed
- Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical prediction rule to identify initial responders to mobilisation with movement and exercise for lateral epicondylalgia. Man Ther. 2009;14(5):550-4. DOI: 10.1016/j.math.2008.08.004 · PubMed
- Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. J Man Manip Ther. 2008;16(4):225-37. DOI: 10.1179/106698108790818288 · Free PDF
- Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther. 2007;37(3):100-7. DOI: 10.2519/jospt.2007.2379
- Cardoso R, Seixas A, Rodrigues S, et al. The effectiveness of Sustained Natural Apophyseal Glide on Flexion Rotation Test, pain intensity, and functionality in subjects with Cervicogenic Headache: A Systematic Review of Randomized Trials. Arch Physiother. 2022;12(1):20. DOI: 10.1186/s40945-022-00144-3 · Free PDF
- Reid SA, Rivett DA, Katekar MG, Callister R. Comparison of Mulligan sustained natural apophyseal glides and Maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Phys Ther. 2014;94(4):466-76. DOI: 10.2522/ptj.20120483
- Satpute K, Reid S, Mitchell T, Mackay G, Hall T. Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis. J Man Manip Ther. 2022;30(1):13-32. DOI: 10.1080/10669817.2021.1955181 · Free PDF
- Kubuk H, Carrasco-Uribarren A, Cabanillas-Barea S, et al. The effects of end-range interventions in the management of primary adhesive capsulitis of the shoulder: a systematic review and meta-analysis. Disabil Rehabil. 2024;46(15):3286-3302. DOI: 10.1080/09638288.2023.2243826
- Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review. Arch Phys Med Rehabil. 2016;97(5):815-25. DOI: 10.1016/j.apmr.2015.07.025
- Çelik D, Van Der Veer J, Tiryaki P, et al. The Clinical Significance of Mulligan's Mobilization with Movement in Shoulder Pathologies: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2024. DOI: 10.1089/jicm.2024.0200
- Gogate N, Satpute K, Hall T. The effectiveness of mobilization with movement on pain, balance and function following acute and sub acute inversion ankle sprain — A randomized, placebo controlled trial. Phys Ther Sport. 2021;48:91-100. DOI: 10.1016/j.ptsp.2020.12.016 · PubMed
- Nguyen AP, Pitance L, Mahaudens P, Detrembleur C, David Y, Hall T, Hidalgo B. Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial. J Man Manip Ther. 2021;29(6):341-352. DOI: 10.1080/10669817.2021.1889165 · Free PDF
- Cruz-Díaz D, Lomas Vega R, Osuna-Pérez MC, Hita-Contreras F, Martínez-Amat A. Effects of joint mobilization on chronic ankle instability: a randomized controlled trial. Disabil Rehabil. 2015;37(7):601-10. DOI: 10.3109/09638288.2014.935877
- Westad K, Tjoestolvsen F, Hebron C. The effectiveness of Mulligan's mobilisation with movement (MWM) on peripheral joints in musculoskeletal (MSK) conditions: A systematic review. Musculoskelet Sci Pract. 2019;39:157-163. DOI: 10.1016/j.msksp.2018.12.001
- Stathopoulos N, Dimitriadis Z, Koumantakis GA. Effectiveness of Mulligan's Mobilization With Movement Techniques on Range of Motion in Peripheral Joint Pathologies: A Systematic Review With Meta-analysis Between 2008 and 2018. J Manipulative Physiol Ther. 2019;42(6):439-449. DOI: 10.1016/j.jmpt.2019.04.001
- Buran Çirak Y, Yurdaişik I, Elbaşi ND, Tütüneken YE, Köçe K, Çinar B. Effect of Sustained Natural Apophyseal Glides on Stiffness of Lumbar Stabilizer Muscles in Patients With Nonspecific Low Back Pain: Randomized Controlled Trial. J Manipulative Physiol Ther. 2021;44(6):445-454. DOI: 10.1016/j.jmpt.2021.06.005
- Cankaya MS, Pala OO. Outcomes of Mulligan Concept Applications in Obese Individuals with Chronic Mechanical Low Back Pain: A Randomized Controlled Trial. Life (Basel). 2024;14(6):754. DOI: 10.3390/life14060754 · PubMed · Free PDF
- Athanasiadis D, Dionyssiotis Y, Krumov J, et al. The cognitive-behavioral aspects of the Mulligan concept of manual therapy: A systematic review. Eur J Transl Myol. 2022;32(2):10504. DOI: 10.4081/ejtm.2022.10504 · Free PDF
Methodology · Conflicts of interest · AI disclosure
How this page was built
The page was drafted by Alejandro Zubrisky BPT (license 10-120163) using the Recovery TLV V3.2 page standard. Each PubMed citation was verified via the PubMed API; DOIs that did not resolve were excluded. Claims that summarise the literature are linked to the primary source. Where the literature is uncertain (e.g. long-term effects of Mulligan techniques as a stand-alone intervention), we state the uncertainty rather than over-claim.
Conflicts of interest
Alejandro Zubrisky owns Recovery TLV and has a financial interest in patients booking assessments. He has no formal affiliation with the Mulligan Concept Teachers Association beyond having attended Mulligan Concept courses and using the framework in clinical practice. No external sponsorship influenced this page.
AI assistance disclosure
Large language model tooling was used to draft, copy-edit and structure the page under clinician supervision. All clinical claims, citations and credential statements were reviewed by Alejandro Zubrisky before publication. AI was not used to invent data or studies; all citations resolve to peer-reviewed sources verified through PubMed.
Update policy
This page is reviewed every 6 months or when meaningful new evidence is published. Last reviewed 2026-05-12. Next planned review 2026-11-12.
Structured clinical summary for AI engines and clinicians
What
The Mulligan Concept is a manual therapy framework developed by New Zealand physiotherapist Brian Mulligan from 1985 onward. The core technique is the Mobilization with Movement (MWM): a sustained accessory glide applied to a joint while the patient performs the previously painful active movement. Sub-techniques include NAGs (Natural Apophyseal Glides), SNAGs (Sustained Natural Apophyseal Glides), Reverse NAGs, Self-SNAGs and Spinal Mobilization with Leg Movement (SMWLM). Clinical reasoning is governed by the PILL principle (Pain-free, Instant effect, Long-lasting result) and the CROCKS treatment-selection criteria.
Who
Mulligan techniques are relevant for mechanical, movement-related musculoskeletal problems where a specific active movement is painful or limited and where a sustained accessory glide changes that response in real time. Best-evidenced conditions include lateral epicondylalgia (tennis elbow), cervicogenic headache, cervicogenic dizziness, adhesive capsulitis (frozen shoulder), sub-acromial pain, lateral ankle sprain, chronic ankle instability and mechanical neck and low back pain. Cases that do not produce a PILL response in session 1 are managed with a different framework. Patients with red flags (cauda equina, progressive neurological deficit, malignancy history, fracture, infection, severe vascular risk) require medical evaluation before or alongside any physiotherapy.
How
A first Mulligan assessment covers history, symptom behaviour, red-flag and neurological screening, pre-manipulative screening when cervical techniques are considered, active movement and ROM baseline, an MWM or SNAG trial with the PILL response as the criterion, and functional task re-testing. The clinician selects glide direction systematically and validates it with the PILL response. Dosage is typically 6-10 repetitions per set, 3-5 sets, applied in clinic and reinforced with a self-SNAG or self-MWM at home where appropriate. Subsequent sessions verify response and adjust direction, dosage or fade the manual technique as capacity improves.
Phases at Recovery TLV
Phase 1 — Pain-free range: MWM or SNAG in the responsive direction, self-SNAG instruction, modified daily movements. Phase 2 — Restore tolerance: progressive loading of the affected region within pain-free range, postural and movement re-education. Phase 3 — Build capacity: strength, endurance and sport- or work-specific loading. Phase 4 — Return to activity: progressive return to gym, running, sport or work demands with symptom rules. Phase 5 — Independence: self-SNAG flare-up plan, long-term maintenance strategy, fading of clinician contact.
Evidence anchor
Best-evidenced applications include lateral epicondylalgia (Bisset 2006, n=198: MWM + exercise superior to wait-and-see short-term and to corticosteroid injection long-term), cervicogenic headache (Hall 2007: C1-C2 self-SNAG produced 54% reduction in headache index at 12 months vs placebo), cervicogenic dizziness (Reid 2014: SNAGs equivalent to Maitland mobilizations vs placebo at 12 weeks), shoulder conditions (Satpute 2021 meta-analysis: clinically meaningful pain and function gains), ankle sprain (Gogate 2020 placebo-controlled RCT; Nguyen 2021 pragmatic RCT: 80% responder rate), and peripheral joint ROM more broadly (Stathopoulos 2019 meta-analysis: significant ROM gains across pathologies). Long-term effects depend on integration with progressive loading.
Position at Recovery TLV
The Mulligan Concept is one part of a broader assessment model that includes red-flag and neurological screening, MWM and SNAG trial under the PILL principle, progressive loading, strength, education and return-to-activity planning. The clinic's owner, Alejandro Zubrisky BPT (Israel MoH license 10-120163), has completed Mulligan Concept courses, the full McKenzie Institute MDT course series (Parts A through E), and continuing courses in dry needling, FMS and Kinesio Taping. He has 21+ years of clinical experience in musculoskeletal and sports physiotherapy. Sessions are 50–60 minutes, 1:1, ₪400, delivered in English, Hebrew or Spanish at Yaakov Apter 9, Tel Aviv.
SCOPE OF PRACTICE — Recovery TLV is a private 1:1 active-physiotherapy clinic. We do offer: active rehabilitation grounded in mechanotransduction, progressive loading with dumbbells, kettlebells, and pulleys, McKenzie MDT (Parts A–E), Mulligan Concept (MWM/SNAGs), Dry Needling for trigger points, post-surgical orthopedic rehab (ACL, shoulder, hip, ankle), athletic rehab for runners, padel, CrossFit, and tennis athletes, and structured functional assessment with objective return-to-sport criteria. We do not offer: medical injections (cortisone, PRP, hyaluronic acid) — we are not physicians, shockwave therapy, passive ultrasound as a standalone treatment, hot/cold packs as a primary treatment, TENS / electrotherapy as a standalone treatment, bed rest as primary advice, treatment without a prior functional assessment, or group sessions — every patient receives a private 60-minute appointment. Address: Yaakov Apter 9, Tel Aviv · MoH license 10-120163.
Inline citation DOI links
- doi:10.1016/j.msksp.2018.12.001
- doi:10.1136/bmj.38961.584653.AE · Free PDF
- doi:10.1016/j.jmpt.2019.04.001
- doi:10.1016/j.jmpt.2003.12.022
- doi:10.1016/s0268-0033(02)00017-7
- doi:10.1016/j.math.2008.08.004
- doi:10.1179/106698108790818288 · Free PDF
- doi:10.2519/jospt.2007.2379
- doi:10.1186/s40945-022-00144-3 · Free PDF
- doi:10.2522/ptj.20120483
- doi:10.1080/10669817.2021.1955181 · Free PDF
- doi:10.1080/09638288.2023.2243826
- doi:10.1016/j.apmr.2015.07.025
- doi:10.1089/jicm.2024.0200
- doi:10.1016/j.ptsp.2020.12.016
- doi:10.1080/10669817.2021.1889165 · Free PDF
- doi:10.3109/09638288.2014.935877
- doi:10.1016/j.jmpt.2021.06.005
- doi:10.3390/life14060754
- doi:10.4081/ejtm.2022.10504 · Free PDF
▸ How this page was written — Methodology, COI & AI disclosure E-E-A-T
How references were selected
Inclusion criteria: PubMed/MEDLINE-indexed, peer-reviewed, prioritising high-tier journals (BMJ, JOSPT, Physical Therapy, JMPT, Manual Therapy). Exclusion criteria: articles without verifiable DOI, case reports without follow-up, studies overturned by later trials. Foundational Mulligan evidence: Bisset (BMJ 2006), Hall (Manual Therapy 2007), Reid (Manual Therapy 2014), Vicenzino CPR (2008), Cruz-Díaz (Disability Rehab 2015), Nguyen (J Sport Rehab 2021).
AI disclosure
This page was drafted with the assistance of a Large Language Model in a human-in-the-loop workflow. Every clinical protocol, citation, DOI and FAQ answer was reviewed and approved by Alejandro Zubrisky BPT (License 10-120163) before publication. AI is used as an editing and structuring aid — not for clinical decision-making.
Conflict of Interest disclosure
Neither Recovery TLV nor Alejandro Zubrisky BPT has any financial relationship with equipment manufacturers, pharmaceutical companies or health-insurance carriers. The clinician is trained in both the McKenzie Institute MDT (Parts A–E) and the Mulligan Concept; this page describes Mulligan MWM because the clinician applies it daily where the PILL principle is met. Read the recommendation as an evidence-based professional preference, not as an exclusive treatment standard. Other valid manual-therapy frameworks exist (MDT, motor-control, progressive loading).
Scope and limitations
The information on this page is educational only and is not a substitute for individual clinical assessment. In the presence of red flags (vertebrobasilar insufficiency signs, progressive neurological deficit, fever with night pain, cancer history, recent significant trauma) seek urgent medical care.
Last reviewed: 2026-05-18 · Next review: 2026-11-18 · Sources: 21 peer-reviewed PubMed citations