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Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain
Abstract
Objective:
Distal fibula mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques.
Methods:
In this double-blind randomized controlled trial, 45 amateur soccer players with acute (<72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3 per week within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation (TENS), edema draining massage. and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure (FAAM) and Patient Global Impression of Improvement Scale (PGI-I) were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength.
Results:
Participants receiving MWM and MWMtape were equally effective and demonstrated greater function on FAAM at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for PGI-I or any of the secondary outcomes.
Conclusion:
There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibula MWM is most effective to achieve activities of daily living (ADL) and sport function, when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit.
Impact:
Distal fibula mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long term ADL and sport function. In the short term, antero-posterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibula mobilization with movement.
... Clinically, most patients with AAS experience their condition due to the initial impact on the lateral and anterior aspects of the foot, which stimulates a chronic biomechanical imbalance in the posterior and lateral muscle groups of the lower leg, subsequently inducing aseptic inflammatory responses in the muscles and ligaments of the ankle region [47][48][49]. ...
Background
Micro-needle knife (MNK) therapy releases the superficial fascia to alleviate pain and improve joint function in patients with acute ankle sprains (AAS). We aimed to evaluate the efficacy and safety of MNK therapy vs that of acupuncture.
Material/Methods
This blinded assessor, randomized controlled trial allocated 80 patients with AAS to 2 parallel groups in a 1: 1 ratio. The experimental group received MNK therapy; the control group underwent conventional acupuncture treatment at specified acupoints. Clinical efficacy differences between the 2 groups before (time-point 1 [TP1]) and after treatment (TP2) were evaluated using the visual analogue scale (VAS) and Kofoed ankle score. Safety records and evaluations of adverse events were documented. One-month follow-up after treatment (TP3) was conducted to assess the intervention scheme’s reliability.
Results
VAS and Kofoed ankle scores significantly improved in both groups. No patients dropped due to adverse events. At TP1, there were no significant differences between the 2 groups in terms of VAS and Kofoed scores (P>0.05). However, at TP2, efficacy of MNK therapy in releasing the superficial fascia was significantly superior to that of acupuncture treatment (P<0.001). At TP3, no significant differences in scores existed between the groups (P>0.05).
Conclusions
This study demonstrates that 6 sessions of MNK therapy to release the superficial fascia safely and effectively alleviated pain and enhanced ankle joint function in patients with AAS, surpassing the efficacy of conventional acupuncture treatment. Future studies should increase the sample size and introduce additional control groups to further validate the superior clinical efficacy of this intervention.
... Twenty-five studies did not address all discrepancies. Of these 25, 4 registered studies (11.8%) addressed some of the discrepancies 49,62,65,72 and 21 registered studies (61.8%) did not address any discrepancies. 43 ...
Rationale:
The physiotherapy profession strives to be a leader in providing quality care and strongly recognizes the value of research to guide clinical practice. Adherence to guidelines for research reporting and conduct is a significant step towards high-quality, transparent and reproducible research.
Aim/objective:
Assess integrity between planned and conducted methodology in randomized controlled trials (RCTs) and systematic reviews (SRs) published in physiotherapy journals.
Methods:
Eighteen journals were manually searched for RCTs and SRs published from 1 July 2021 through 31 December 2021. Studies were included if the journal or specific study was indexed in PubMed and published/translated in English. Descriptive statistics determined congruence between preregistration data and publication.
Results:
Forty RCTs and 68 SRs were assessed. Forty-three SRs included meta-analysis (MA). Of the 34 registered RCTs, 7 (20.6%) had no discrepancy between the registration and publication. Two trials (5.9%) addressed all discrepancies, 4 (11.8%) addressed some and 21 (61.8%) did not address any discrepancies. Of the 36 registered MAs, 33 (91.7%) had discrepancies between the registration and publication. Two (5.6%) addressed all discrepancies and three (8.3%) had no discrepancies. Eight SRs without MA published information not matching their registration, and none provided justification for the discrepancies.
Conclusion:
Most RCTs/SRs were registered; the majority had discrepancies between preregistration and publication, potentially influencing the outcomes and interpretations of findings. Journals should require preregistration and compare the submission with the registration information when assessing publication suitability. Readers should be aware of these inconsistencies and their implications when interpreting and translating results into practice.
Zusammenfassung
Das Supinationstrauma ist eine der häufigsten Sportverletzungen weltweit. Die Betroffenen klagen oft über persistierende Beschwerden mehrere Jahre nach dem ersten Supinationstrauma. Bewegungsmangel sowie eine verminderte gesundheitsbezogene Lebensqualität können die Folge sein. Manuelle Therapie ist eine effektive Interventionsform bei muskuloskelettalen Erkrankungen und hat möglicherweise eine positive Wirkung bei Patient*innen mit Supinationstrauma.
Eine systematische Literaturübersichtsarbeit und Meta-Analyse wurden durchgeführt. Mittels einer systematischen Literatursuche auf PubMed, Embase, OVID, PEDro sowie Google Scholar wurden 14 RCTs in die qualitative Auswertung eingeschlossen und anhand der PEDro-Skala und des Risk-of-Bias-Tools der Cochrane Collaboration (RoB 2.0) bewertet. Danach wurden die Ergebnisparameter „Bewegungsausmaß der Dorsalextension“, „Schmerz“ und „Funktion“ extrahiert und miteinander verglichen.
Die 14 eingeschlossenen Studien verfügten über eine gute methodologische Qualität und hatten ein geringes Bias-Risiko. Zwölf Studien wurden in die quantitative Auswertung eingeschlossen. Für das Bewegungsausmaß der Dorsalextension ergab sich ein gepoolter Effekt (g) von 1,08 (KI=0,20; 1,96), für den Schmerz ein statistisch nicht-signifikanter Effekt (g) von 1,00 (KI=− 2,01; 0,01) und für die Funktion ein statistisch nicht-signifikanter Effekt (g) von 0,36 (KI=− 0,32; 1,03).
Manuelle Therapie hat eine positive Wirkung auf das Bewegungsausmaß der Dorsalextension. Keine Aussage kann über deren Wirkung auf die Funktion und Schmerzen bei Patient*innen mit Supinationstrauma getroffen werden. Es gibt Hinweise dafür, dass manuelle Therapie eine langfristige Wirkung auf das Bewegungsausmaß der Dorsalextension bei Patient*innen mit Supinationstrauma haben könnte.
Objective
To observe the efficacy of contralateral needling combined with Maitland ankle mobilization in the treatment of chronic ankle sprain.MethodsA total of 106 patients with chronic ankle sprain were included in the study. They were numbered according to their order of visit, with odd numbers assigned to the control group and even numbers assigned to the observation group, with 53 cases in each group. Patients in the control group were treated with Maitland ankle mobilization, while those in the observation group were given additional contralateral needling treatment. After treatment, we observed the indicators including, ankle circumference, range of motion (ROM) of dorsiflexion, ROM of plantar flexion, thickness of ankle ligaments, and the changes in Baird-Jackson ankle score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and visual analog scale (VAS) score to compare the efficacy between the two groups.ResultsAfter treatment, the total effective rate of the observation group was 94.3% and was significantly higher than that of the control group (81.1%), indicating statistical significance (P<0.05). After treatment, the ankle circumference of both groups decreased, and the ROM of dorsiflexion and the ROM of plantar flexion increased (P<0.05). The changes in the observation group were more significant, indicating inter-group statistical significance (P<0.05). After treatment, the thickness of the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament, as well as the VAS scores decreased in both groups; the changes in the observation group were more significant, indicating inter-group statistical significance (P<0.05). After treatment, the Baird-Jackson ankle score and the AOFAS ankle-hindfoot score increased in both groups, and the scores in the observation group were higher than those in the control group, indicating inter-group statistical significance (P<0.05).Conclusion
The efficacy of contralateral needling combined with Maitland ankle mobilization in the treatment of chronic ankle sprain is superior to that of Maitland ankle mobilization alone.
Objective:
The purpose of this case study was to report the chiropractic management of a teenage athlete who had chronic pain after a lateral ankle sprain.
Clinical features:
A 15-year-old male patient presented with persistent ankle pain due to an inversion sprain while playing soccer approximately 8.5 months prior. Emergency department records noted a left lateral ankle sprain, including the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The examination revealed ankle tenderness upon palpation, limited active and passive dorsiflexion range of motion, restricted talocrural joint posterior glide, and moderate lateral compartment muscular hypertonicity.
Intervention and outcome:
Chiropractic management included high-velocity, low-amplitude chiropractic ankle manipulation and education on home-based ankle dorsiflexion stretching. After 4 treatments, the athlete returned to unencumbered athletic participation. Follow-up evaluation at 5 months revealed no pain or functional complaints.
Conclusion:
This teen athlete's chronic pain from a lateral ankle sprain resolved with a short course of chiropractic manipulation coupled with home-based stretching.
Introduction:
Patients classified with ankle sprains are commonly treated with a multimode intervention approach. Currently, protection and tissue healing are the most accepted forms of care for these patients.
Case presentation:
Six patients (4 male, 2 female) 20.2 ± 1.3 years of age were classified with acute grade I lateral ankle sprains (LAS). Each patient was treated with either the Fibular Mobilization with Movement (FMWM) or Modified Fibular Mobilization with Movement (MFMWM).
Management and outcome:
The clinical outcomes for the patients treated with both fibula MWM improved and patients returned to activity levels at about three days after three treatments.
Discussion:
As medicine continues to advance and explore new theories for rehabilitative clinical practice it is necessary to assess interventions on patients. This prospective exploratory case series was written to share a clinical intervention, Mulligan Concept, and the outcomes that occurred in the patients with a lateral ankle sprain.
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Background
Up to 40% of individuals who sprain their ankle develop chronic ankle instability (CAI). One treatment option for this debilitating condition is joint mobilisation. There is preliminary evidence that Mulligan’s Mobilisation With Movement (MWM) is effective for treating patients with CAI, but the mechanisms by which it works are unclear, with Mulligan suggesting a repositioning of the fibula. This randomised controlled trial aims to determine the effects of MWM on anatomical and clinical characteristics of CAI.
Methods
Participants 18 years or over with CAI will be accepted into the study if they satisfy the inclusion and exclusion criteria endorsed by the International Ankle Consortium. They will be randomised into the experimental group (MWM) or the placebo group (detuned laser) and will receive the assigned intervention over 4 weeks. General joint hypermobility and the presence of mechanical instability of the ankle will be recorded during the first visit. Further, position of the fibula, self-reported function, ankle dorsiflexion range, pressure pain threshold, pain intensity, and static and dynamic balance will be assessed at baseline, and at the conclusion of course of intervention. Follow-up data will be collected at the twelfth week and at the twelfth month following intervention.
Discussion
Effectiveness of MWM on clinically relevant outcomes, including long term benefits will be evaluated. The capacity of MWM to reverse any positional fault of the fibula and the association of any positional fault with other clinically important outcomes for CAI will be explored. Proposed biomechanical mechanisms of fibular positional fault and other neurophysiological mechanisms that may explain the treatment effects of MWM will be further explored. The long term effectiveness of MWM in CAI will also be assessed.
Trial registration
Australian New Zealand Clinical Trials Registry; ACTRN12617001467325 (17/10/2017).
Objective:
To explore and identify the predictors of ankle sprain after an index (first) lateral ankle sprain.
Design:
Prospective cohort study, Level of evidence II.
Setting:
Musculoskeletal research laboratory at the University of Sydney.
Participants:
A sample of convenience (70 controls, 30 with an index sprain) was recruited.
Methods:
Potential predictors of ankle sprain were measured including: demographic measures, perceived ankle instability, ankle joint ligamentous laxity, passive range of ankle motion, balance, proprioception, motor planning and control, and inversion/eversion peak power. Participants were followed up monthly and the number of ankle sprains was recorded over 12 months.
Results:
Ninety-six participants completed the study; 10 participants sustained an ankle sprain. A combination of 10 predictors including: a recent index sprain, younger age, greater height and weight, perceived instability, increased laxity, impaired balance, and greater inversion/eversion peak power explained 27 to 56% of the variance in occurrence of ankle sprain (χ211,95=30.67, p=0.001). The regression model correctly classified 90% of cases. The strongest independent predictors were history of an index sprain (odds ratio (OR)=8.23, 95% confidence interval (CI)=1.66 to 40.72) and younger age (OR=8.41, 95%CI=1.48 to 47.96).
Conclusion:
A recent index ankle sprain and younger age were the only independent predictors of ankle sprain. The combination of greater height or weight, feeling of instability, peak power and impaired balance predicted the occurrence of ankle sprain in almost 90% of participants. These findings could form the basis for intervention targeted at reducing recurrence of sprain after an index sprain.
Background
One-third of individuals who sustain an acute lateral ankle ligament sprain suffer significant disability due to pain, functional instability, mechanical instability or recurrent sprain after recovery plateaus at 1 to 5 years post injury. The identification of early prognostic factors associated with poor recovery may provide an opportunity for early-targeted intervention and improve outcome.
Methods
We performed a comprehensive search of AMED, EMBASE, Psych Info, CINAHL, SportDiscus, PubMed, CENTRAL, PEDro, OpenGrey, abstracts and conference proceedings from inception to September 2016. Prospective studies investigating the association between baseline prognostic factors and recovery over time were included. Two independent assessors performed the study selection, data extraction and quality assessment of the studies. A narrative synthesis is presented due to inability to meta-analyse results due to clinical and statistical heterogeneity.
Results
The search strategy yielded 3396 titles/abstracts after duplicates were removed. Thirty-six full text articles were then assessed, nine of which met the study inclusion criteria. Six were prospective cohorts, and three were secondary analyses of randomised controlled trials. Results are presented for nine studies that presented baseline prognostic factors for recovery after an acute ankle sprain. Age, female gender, swelling, restricted range of motion, limited weight bearing ability, pain (at the medial joint line and on weight-bearing dorsi-flexion at 4 weeks, and pain at rest at 3 months), higher injury severity rating, palpation/stress score, non-inversion mechanism injury, lower self-reported recovery, re-sprain within 3 months, MRI determined number of sprained ligaments, severity and bone bruise were found to be independent predictors of poor recovery. Age was one prognostic factor that demonstrated a consistent association with outcome in three studies, however cautious interpretation is advised.
Conclusions
The associations between prognostic factors and poor recovery after an acute lateral ankle sprain are largely inconclusive. At present, there is insufficient evidence to recommend any factor as an independent predictor of outcome. There is a need for well-conducted prospective cohort studies with adequate sample size and long-term follow-up to provide robust evidence on prognostic factors of recovery following an acute lateral ankle sprain.
Trial registration
Prospero registration: CRD42014014471
Electronic supplementary material
The online version of this article (10.1186/s12891-017-1777-9) contains supplementary material, which is available to authorized users.
Objective: The purpose of this study was to examine the effect of the Mulligan Concept (MC) Mobilization with movement (MWM) in the treatment of clinically diagnosed acute lateral ankle sprains in competitive athletes.
Methods: A prospective case series of 5 adolescent patients, ages ranging from 14 to 18 years (mean = 15.8 ± 1.64), that suffered an acute lateral ankle sprain (LAS). Patients were treated with the MC lateral ankle MWM. Mobilization was directed at the distal fibula or, using a modified MWM, 2–3 inches proximal to the distal fibula. Using paired t-tests and descriptive statistics (mean and standard deviation) results were analyzed.
Results: Treatment lasted an average of 9 days (mean = 9.2, ±SD 3.96) from intake to discharge. During that time frame, patients reported decreases in pain on the numeric pain rating scale (NRS), disability on the Disablement in the Physically Active (DPA) scale and an increase in function on the patient-specific functional scale (PSFS); and an immediate decrease in pain on the NRS within the first treatment. The minimal detectable change for the PSFS and NRS were exceeded from intake to discharge. Additionally, the minimally clinical important differences were exceeded on the NRS and DPA scale.
Discussion: The evidence presented in this Level-4 case series supports the use of the MC lateral ankle MWM to treat patients diagnosed with acute grade II LAS. Patients in this case series reported immediate decreases in pain and immediate increases in function. Therefore, further investigation of the MC lateral ankle MWM is warranted.
Objective:
The purpose of this study was to measure the acute (1 session) and chronic effects (6 sessions) and the follow-up (2 weeks) of anteroposterior articular mobilization of the talus, grade III of Maitland, on the dorsiflexion range of motion (ROM), pain, and functional capacity of individuals with subacute and chronic traumatic injuries of the ankle.
Methods:
Thirty-eight volunteers, men and women, with a mean age of 40.8 years, with subacute and chronic ankle injuries participated. The volunteers were blinded to the study purpose and were allocated into the experimental group (EG) or sham group (SG). Dorsiflexion ROM, pain, and functional capacity were measured using the universal goniometer, visual analog scale, and Foot and Ankle Ability Measure, respectively. Measurements were taken on 4 different occasions: (1) baseline, (2) after the first session, (3) after the sixth session, and (4) at follow-up. Articular anteroposterior mobilization of the talus grade III of Maitland was applied to the EG, whereas manual contact was applied to the SG. Three series of 30 seconds each with a 30-second rest interval between the series were conducted.
Results:
Significant increases in ankle dorsiflexion ROM were observed only for the EG after the first (EG: 9.5 ± 1.1; SG: 7.6 ± 1.1) and sixth (EG: 12.8 ± 1.2; SG: 8.4 ± 1.2) sessions and were maintained at follow-up (EG: 13.2 ± 1.1; SG: 9.3 ± 1.3). Decreases in pain and improvements in functional capacity (FC) were identified for both groups after the first and sixth sessions (Pain, EG: 1.3 ± 0.5; SG: 1.8 ± 0.6 and EG: 0.7 ± 0.3; SG: 0.7 ± 0.3; FC, EG: 64.6 ± 3.5; SG: 67.4 ± 4.4 and EG: 79.9 ± 3.3; SG: 86.2 ± 3.3) and remained at follow-up (Pain, EG: 0.3 ± 0.2; SG: 0.5 ± 0.3; FC, EG: 86.8 ± 2.7; SG: 89.8 ± 3.7).
Conclusion:
Articular grade III mobilization improved ankle dorsiflexion ROM, when compared with the SG. Changes in pain and functional capacity were similar in both groups.
Background
Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports.
Objective
To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.
Design
Overview of intervention systematic reviews.
Participants
Individuals with acute ankle sprain/CAI.
Main outcome measurements
The primary outcomes were injury/reinjury incidence and function.
Results
46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.
Conclusions
For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.
Background:
Impairments in motor control may predicate the paradigm of chronic ankle instability (CAI) that can develop in the year after an acute lateral ankle sprain (LAS) injury. No prospective analysis is currently available identifying the mechanisms by which these impairments develop and contribute to long-term outcome after LAS.
Purpose:
To identify the motor control deficits predicating CAI outcome after a first-time LAS injury.
Study design:
Cohort study (diagnosis); Level of evidence, 2.
Methods:
Eighty-two individuals were recruited after sustaining a first-time LAS injury. Several biomechanical analyses were performed for these individuals, who completed 5 movement tasks at 3 time points: (1) 2 weeks, (2) 6 months, and (3) 12 months after LAS occurrence. A logistic regression analysis of several "salient" biomechanical parameters identified from the movement tasks, in addition to scores from the Cumberland Ankle Instability Tool and the Foot and Ankle Ability Measure (FAAM) recorded at the 2-week and 6-month time points, were used as predictors of 12-month outcome.
Results:
At the 2-week time point, an inability to complete 2 of the movement tasks (a single-leg drop landing and a drop vertical jump) was predictive of CAI outcome and correctly classified 67.6% of cases (sensitivity, 83%; specificity, 55%; P = .004). At the 6-month time point, several deficits exhibited by the CAI group during 1 of the movement tasks (reach distances and sagittal plane joint positions at the hip, knee and ankle during the posterior reach directions of the Star Excursion Balance Test) and their scores on the activities of daily living subscale of the FAAM were predictive of outcome and correctly classified 84.8% of cases (sensitivity, 75%; specificity, 91%; P < .001).
Conclusion:
An inability to complete jumping and landing tasks within 2 weeks of a first-time LAS and poorer dynamic postural control and lower self-reported function 6 months after a first-time LAS were predictive of eventual CAI outcome.
http://www.ncbi.nlm.nih.gov/pubmed/26751060/
Objectives. To conduct a systematic review comparing the effects of Kinesio taping with McConnell taping as a method of conservative management of patients with patellofemoral pain syndrome (PFPS). Methods. MEDLINE, PUBMED, EMBASE, AMED, and the Cochrane Central Register of Control Trials electronic databases were searched through July 2014. Controlled studies evaluating the effects of Kinesio or McConnell taping in PFPS patients were retrieved.
Results. Ninety-one articles were selected from the articles that were retrieved from the databases, and 11 articles were included in the analysis. The methods, evaluations, and results of the articles were collected, and the outcomes of patellar tapings were analyzed. Kinesio taping can reduce pain and increase the muscular flexibility of PFPS patients, and McConnell taping also had effect in pain relief and patellar alignment. Meta-analysis showed small effect in pain reduction and motor function improvement and moderate effect in muscle activity change among PFPS patients using Kinesio taping. Conclusions. Kinesio taping technique used for muscles can relieve pain but cannot change patellar alignment, unlike McConnell taping. Both patellar tapings are used differently for PFPS patients and substantially improve muscle activity, motor function, and quality of life.
Introduction Inversion injuries that occur at the ankle have been suggested to cause an antero-inferior displacement of the distal fibula or a "positional fault" (1). Mulligan (3), and others have shown that range of movement, function and pain have all been affected after the Mulligan's mobilisation with movement (MWM) technique. However, only Kavanagh (2) showed that a proportion of patients had a "positional fault" at the inferior tibiofibular joint. The aim of this study was to verify if the antero-inferior displacement of the distal fibula or "positional fault" in ankle injuries can be confirmed using magnetic resonance imaging (MRI). Methods Thirty-eight participants, 26 males and 12 females, aged 26.9 ± 6.9 years (range 19-45 years) volunteered for this study. Thirty of the participants were healthy with no history of ankle injury. The other 8 participants had recently had a sprain of the lateral ligament complex of the ankle. Ankle dorsiflexion was measured on both legs using the knee to the wall principle. Pain was measured at the point of maximum dorsiflexion using a visual analogue scale. Balance was measured using the Rhomberg single leg stance criteria with the eyes open and repeated with the eyes closed. MRI scans were taken in 3 plans, sagittal, coronal and axial using a fixed 0.2-T MRI scanner in 26 participants. The ankle was strapped to a brace that fixed the ankle at 90 degrees and two external water based markers were placed on the skin for accuracy of analysis. These tests were repeated 30 minutes later. In between the tests the injured participants underwent the treatment technique. The treatment technique glided the lateral malleolus in a posterior and cephalad direction whilst the participant performed active plantar-flexion and inversion. Three sets of 10 repetitions were performed. A repeated measure ANOVA was used to determine significance. Results The control group showed no significant difference in balance, pain and range of movement scores in the repeated tests or in the position of the fibular from the MRI scans. In the injured group there was a significant increase in range of movement (Pre: 5.2 ± 1.0 cm; Post: 6.8 ± 1.0 cm; P<0.01) and an increase in balance ability with eyes closed (Pre: 6.9 ± 1.8 s; Post: 16.5 ± 4.0 s; P<0.05) after the MWM intervention, with no change in the pain score. The MRI results of the injured group showed significance displacement in the sagittal plane only, with an increase in the distance of the tip of the fibula from the sole of the foot (Pre: 6.19 ± 0.28 cm; Post: 6.54 ± 0.13 cm; P<0.05). No displacement of the fibula was observed in the non-injured participants. Thus showing that the fibula had been relocated in a superior direction with the MWM technique.
Introduction and background:
Lateral ankle sprains (LAS) are common in sports medicine and can result in a high rate of re-injury and chronic ankle instability (CAI). Recent evidence supports the use on mobilizations directed at the ankle in patients who have suffered a LAS. The Mulligan Concept of Mobilization-with-Movement (MWM) provides an intervention strategy for LASs, but requires pain-free mobilization application and little literature exists on modifications of these techniques.
Purpose:
To present the use of a modified MWM to treat LASs when the traditional MWM technique could not be performed due to patient reported pain and to assess outcomes of the treatment.
Case description:
The subject of this case report is a 23 year-old female collegiate basketball player who had failed to respond to initial conservative treatments after being diagnosed with a lateral ankle sprain. The initial management and subsequent interventions are presented. After re-examination, the addition of a modification of a MWM technique produced immediate and clinically significant changes in patient symptoms. The use of the modified-MWM resulted in full resolution of symptoms and a rapid return to full athletic participation.
Outcomes:
After the initial application of the modified-MWM, the patient reported immediate pain-free ankle motion and ambulation. Following a total of 5 treatments, using only the modified MWM and taping technique, the patient was discharged with equal range of motion (ROM) bilaterally, a decreased Disablement in the Physically Active (DPA) Scale score, and an asymptomatic physical exam. Follow-up exam 6 weeks later indicated a full maintenance of these results.
Discussion:
Recent evidence has been presented to support the use of mobilization techniques to treat patient limitations following ankle injury; however, the majority of evidence is associated with addressing the talar and dorsiflexion limitations. Currently, little evidence is available regarding the use of the MWM technique designed for LASs and the expected outcomes. This case adds to the emerging evidence supporting the use for MWMs to treat ankle pathology and introduces a modification that may be applied in cases where patient reported pain prevents traditional application.
Level of evidence:
Level 5; Single case report.
Altered neuromuscular function and decreased dorsiflexion range of motion (DFROM) have been observed in patients with chronic ankle instability (CAI). Joint mobilizations are indicated for restoring DFROM and dynamic postural control; yet, it remains unknown if a mobilization can alter neuromuscular excitability in muscles surrounding the ankle.
To determine the immediate effects of a Maitland grade III anterior-to-posterior joint mobilization on spinal reflex and corticospinal excitability in the fibularis longus (FL) and soleus (SOL), DFROM, and dynamic postural.
Single-blinded randomized control trial.
Research Laboratory.
Thirty patients with CAI were randomized into a mobilization (n=15) or control (n=15) group.
Maitland grade III anterior-to-posterior joint mobilization.
Spinal reflex excitability was measured with the Hoffmann reflex, while corticospinal excitability was evaluated with transcranial magnetic stimulation. DFROM was measured seated with the knee extended, and dynamic postural control was quantified with the star excursion balance test. Separate 2x2 repeated measures ANOVAs were performed for each outcome measure. Dependent t-tests were used to evaluate individual differences within groups in the presence of significance.
Spinal reflex and corticospinal excitability of the SOL and FL were not altered in the mobilization or control group (P>0.05). DFROM increased immediately following the mobilization (P=0.05), but not in the control group; while dynamic postural control was unchanged in both groups (P>0.05).
A single joint mobilization treatment was efficacious at restoring DFROM in participants with CAI, however, excitability of spinal reflex and corticospinal pathways at the ankle and dynamic postural control were unaffected.
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to ankle ligament sprain.
J Orthop Sports Phys Ther 2013;43(9):A1–A40. doi:10.2519/jospt.2013.0305
Ankle sprain is one of the most common musculoskeletal injuries, yet a contemporary review and meta-analysis of prospective epidemiological studies investigating ankle sprain does not exist.
Our aim is to provide an up-to-date account of the incidence rate and prevalence period of ankle sprain injury unlimited by timeframe or context activity.
We conducted a systematic review and meta-analyses of English articles using relevant computerised databases. Search terms included Medical Search Headings for the ankle joint, injury and epidemiology. The following inclusion criteria were used: the study must report epidemiology findings of injuries sustained in an observed sample; the study must report ankle sprain injury with either incidence rate or prevalence period among the surveyed sample, or provide sufficient data from which these figures could be calculated; the study design must be prospective. Independent extraction of articles was performed by two authors using pre-determined data fields.
One-hundred and eighty-one prospective epidemiology studies from 144 separate papers were included. The average rating of all the included studies was 6.67/11, based on an adapted version of the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines for rating observational studies. 116 studies were considered high quality and 65 were considered low quality. The main findings of the meta-analysis demonstrated a higher incidence of ankle sprain in females compared with males (13.6 vs 6.94 per 1,000 exposures), in children compared with adolescents (2.85 vs 1.94 per 1,000 exposures) and adolescents compared with adults (1.94 vs 0.72 per 1,000 exposures). The sport category with the highest incidence of ankle sprain was indoor/court sports, with a cumulative incidence rate of 7 per 1,000 exposures or 1.37 per 1,000 athlete exposures and 4.9 per 1,000 h. Low-quality studies tended to underestimate the incidence of ankle sprain when compared with high-quality studies (0.54 vs 11.55 per 1,000 exposures). Ankle sprain prevalence period estimates were similar across sub-groups. Lateral ankle sprain was the most commonly observed type of ankle sprain.
Females were at a higher risk of sustaining an ankle sprain compared with males and children compared with adolescents and adults, with indoor and court sports the highest risk activity. Studies at a greater risk of bias were more likely to underestimate the risk of ankle sprain. Participants were at a significantly higher risk of sustaining a lateral ankle sprain compared with syndesmotic and medial ankle sprains.
Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes.
Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains.
This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination 'ankle', 'sprain', 'injuries', 'lateral', 'manual therapy', and 'joint mobilisation'. The methodological quality of individual studies was assessed using the PEDro scale.
After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed.
For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function.
The International Ankle Consortium is an international community of researchers and clinicians whose primary scholastic purpose is to promote scholarship and dissemination of research-informed knowledge related to pathologies of the ankle complex. The constituents of the International Ankle Consortium and other similar organizations have yet to properly define the clinical phenomenon known as chronic ankle instability (CAI) and its related characteristics for consistent patient recruitment and advancement of research in this area. Although research on CAI and awareness of its impact on society and healthcare systems have grown substantially in the last 2 decades, the inconsistency in participant/patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalize this evidence to the target patient population. Therefore, there is a need to provide standards for patient/participant selection criteria in research focused on CAI, with justifications using the best available evidence.
J Orthop Sports Phys Ther 2013;43(8):585–591. doi:10.2519/jospt.2013.0303
Background
The foot and ankle are frequently affected in patients with rheumatoid arthritis (RA). One of the negative consequences of RA on the physical function of patients is a decrease in muscle strength. However, little is known about foot and muscle strength in this population. The aim of the study was to evaluate significant differences in foot and ankle muscle strength between patients with established RA against age and sex-matched controls using hand-held dynamometry.
Methods
The maximal muscle strength of ankle plantarflexion, dorsiflexion, eversion and inversion was assessed in 14 patients with RA, mean (SD) disease duration of 22 (14.1) years, and 20 age and sex-matched control participants using hand-held dynamometry.
Results
Significant differences were observed in muscle strength between the two groups in plantarflexion (p = 0.00), eversion (p = 0.04) and inversion (p = 0.01). No significant difference was found in dorsiflexion (p > 0.05). The patients with RA displayed a significantly lower plantarflexion-dorsiflexion ratio than the control participants (p = 0.03).
Conclusions
The results from this study showed that the RA patients displayed a significant decrease in ankle dorsiflexion, eversion and inversion when compared to the non-RA control group suggesting that foot and ankle muscle strength may be affected by the pathological processes in RA. This study is a preliminary step for the measurement of muscle impairments within the RA population.
Purpose:
The objective of this study is to examine the acute effect of ankle joint mobilizations akin to those performed in everyday clinical practice on sagittal plane ankle joint kinematics during a single-leg drop landing in participants with chronic ankle instability (CAI).
Methods:
Fifteen participants with self-reported CAI (defined as <24 on the Cumberland Ankle Instability Tool) performed three single-leg drop landings under two different conditions: 1) premobilization and, 2) immediately, postmobilization. The mobilizations performed included Mulligan talocrural joint dorsiflexion mobilization with movement, Mulligan inferior tibiofibular joint mobilization, and Maitland anteroposterior talocrural joint mobilization. Three CODA cx1 units (Charnwood Dynamics Ltd., Leicestershire, UK) were used to provide information on ankle joint sagittal plane angular displacement. The dependent variable under investigation was the angle of ankle joint plantarflexion at the point of initial contact during the drop landing.
Results:
There was a statistically significant acute decrease in the angle of ankle joint plantarflexion from premobilization (34.89° ± 4.18°) to postmobilization (31.90° ± 5.89°), t(14) = 2.62, P < 0.05 (two-tailed). The mean decrease in the angle of ankle joint plantarflexion as a result of the ankle joint mobilization was 2.98° with a 95% confidence interval ranging from 0.54 to 5.43. The eta squared statistic (0.32) indicated a large effect size.
Conclusion:
These results indicate that mobilization acted to acutely reduce the angle of ankle joint plantarflexion at initial contact during a single-leg drop landing. Mobilization applied to participants with CAI has a mechanical effect on the ankle joint, thus facilitating a more favorable positioning of the ankle joint when landing from a jump.
Context:
Physical therapists often have to measure ankle range of motion (ROM) to decide on intervention and investigate improvements. The most common method of measurement is goniometry, but it has been questioned due to its unsatisfactory levels of reliability.
Objective:
To investigate the intraobserver and interobserver reliability of a new method of measuring plantar-flexion ROM.
Design:
Prospective and descriptive.
Setting:
Laboratory.
Participants:
20 healthy participants (12 women and 8 men).
Main outcome measurements:
Ankle plantar flexion was measured by 3 observers (A, B, and C) with 3 methods (goniometry, measurement in hook-lying position [MHP], and static-image analysis [SIA]). Observer A was the most experienced therapist, and C, the least. MHP was performed with the participant in the supine position, knees flexed, and first and fifth metatarsals in contact with the treatment table. SIA was recorded and analyzed in the same position. Goniometry was performed with participant seated, lower legs unsupported, and axis positioned on the lateral malleolus.
Results:
For the interobserver analysis, the ICC2,1 was high for the MHP (.88), high for SIA (.87), and moderate for goniometry (.57). For the intraobserver analysis, the ICC2,1 was high or very high for MHP (.91-.92), high for SIA (.79-.83), and low to moderate for goniometry (.18-.60).
Conclusion:
MHP is inexpensive, fast, and more reliable than goniometry for measuring plantar-flexion ROM.
A variety of methods exist to measure ankle dorsiflexion range of motion (ROM). Few studies have examined the reliability of a novice rater. The purpose of this study was to determine the reliability of ankle ROM measurements using three different techniques in a novice rater.
Twenty healthy subjects (mean±SD, age=24±3 years, height=173.2±8.1 cm, mass=72.6±15.2 kg) participated in this study. Ankle dorsiflexion ROM measures were obtained in a weight-bearing lunge position using a standard goniometer, digital inclinometer, and a tape measure using the distance-to-wall technique. All measures were obtained three times per side, with 10 minutes of rest between the first and second set of measures. Intrarater reliability was determined using an intraclass correlation coefficient (ICC(2,3)) and associated 95% confidence intervals (CI). Standard error of measurement (SEM) and the minimal detectable change (MDC) for each measurement technique were also calculated.
The within-session intrarater reliability (ICC(2,3)) estimates for each measure are as follows: tape measure (right 0.98, left 0.99), digital inclinometer (right 0.96; left 0.97), and goniometer (right 0.85; left 0.96). The SEM for the tape measure method ranged from 0.4-0.6 cm and the MDC was between 1.1-1.5 cm. The SEM for the inclinometer was between 1.3-1.4° and the MDC was 3.7-3.8°. The SEM for the goniometer ranged from 1.8-2.8° with an MDC of 5.0-7.7°.
The results indicate that reliable measures of weight-bearing ankle dorsiflexion ROM can be obtained from a novice rater. All three techniques had good reliability and low measurement error, with the distance-to-wall technique using a tape measure and inclinometer methods resulting in higher reliability coefficients (ICC(2,3)=0.96 to 0.99) and a lower SEM compared to the goniometer (ICC(2,3)=0.85 to 0.96).
2b.
Restrictions in ankle dorsiflexion range of motion (ROM) have been associated with decreased posterior talar glide in individuals with an acute lateral ankle sprain. Talocrural joint mobilizations may be used to restore joint arthrokinematics. Our purpose was to examine the effects of a single bout of anterior to posterior (AP) talocrural joint mobilization on self-reported function, dorsiflexion ROM, and posterior talar translation in individuals with an acute lateral ankle sprain. This single-blinded, randomized controlled trial utilized 17 volunteers (nine treatment and eight control) with an acute lateral ankle sprain (grade I/II) who were immobilized for a period of 1-7 days. The treatment group received a single 30-second bout of grade III AP talocrural joint mobilization the day their immobilization device was removed, while the control group did not receive any intervention. Active dorsiflexion ROM and posterior talar translation were assessed before, immediately after, and 24 hours after receipt of the treatment or control interventions. Self-reported function and pain were assessed before and 24 hours after the receipt of the treatment or control interventions using the foot and ankle disability index. Collectively all groups demonstrated improved dorsiflexion ROM and self-reported function. There was a significant decrease in pain perception at 24-hour follow-up for the treatment group. A single bout of AP talocrural joint mobilizations may not have an immediate effect on ankle dorsiflexion ROM, posterior talar translation, or self-reported function; however, they may have an immediate effect on pain perception in individuals with an acute lateral ankle sprain.
Overwhelming evidence shows the quality of reporting of randomised controlled trials (RCTs) is not optimal. Without transparent reporting, readers cannot judge the reliability and validity of trial findings nor extract information for systematic reviews. Recent methodological analyses indicate that inadequate reporting and design are associated with biased estimates of treatment effects. Such systematic error is seriously damaging to RCTs, which are considered the gold standard for evaluating interventions because of their ability to minimise or avoid bias.
To examine the current evidence regarding the reliability and validity of hand-held dynamometry for assessment of muscle strength in the clinical setting.
A search was conducted of the following databases: Cochrane, MEDLINE, PubMed, PEDro, OTseeker, Index to Chiropractic Literature (ICL), and MANTIS, from inception until January 29, 2010.
The MeSH subject heading "muscle strength dynamometer" was searched, in isolation and in combination with the text word phrases "hand-held dynamometer" and "isokinetic." Four hundred fifty-four different studies met this search and were reviewed for possible inclusion.
Two independent reviewers assessed the quality of the included manuscripts. The PEDro data collection system was used in conjunction with the Cochrane Diagnostic Test Accuracy Description. A third reviewer was used when there was disagreement between the primary reviewers.
Seventeen manuscripts met the inclusion criteria for this review, with a total of 19 studies (2 of the manuscripts involved 2 separate studies) that compared hand-held dynamometry with an identified reference standard (isokinetic muscle strength testing). The results demonstrated minimal differences between hand-held dynamometry and isokinetic testing.
Considering hand-held dynamometry's ease of use, portability, cost, and compact size, compared with isokinetic devices this instrument can be regarded as a reliable and valid instrument for muscle strength assessment in a clinical setting.
Structured additive regression models are perhaps the most commonly used class of models in statistical applications. It includes, among others, (generalized) linear models, (generalized) additive models, smoothing spline models, state space models, semiparametric regression, spatial and spatiotemporal models, log-Gaussian Cox processes and geostatistical and geoadditive models. We consider approximate Bayesian inference in a popular subset of structured additive regression models, "latent Gaussian models", where the latent field is Gaussian, controlled by a few hyperparameters and with non-Gaussian response variables. The posterior marginals are not available in closed form owing to the non-Gaussian response variables. For such models, Markov chain Monte Carlo methods can be implemented, but they are not without problems, in terms of both convergence and computational time. In some practical applications, the extent of these problems is such that Markov chain Monte Carlo sampling is simply not an appropriate tool for routine analysis. We show that, by using an integrated nested Laplace approximation and its simplified version, we can directly compute very accurate approximations to the posterior marginals. The main benefit of these approximations is computational: where Markov chain Monte Carlo algorithms need hours or days to run, our approximations provide more precise estimates in seconds or minutes. Another advantage with our approach is its generality, which makes it possible to perform Bayesian analysis in an automatic, streamlined way, and to compute model comparison criteria and various predictive measures so that models can be compared and the model under study can be challenged. Copyright (c) 2009 Royal Statistical Society.
To determine whether Mulligan ankle tape influenced the performance in subjects with unilateral chronic ankle instability (CAI) during static balance; postural sway recovery patterns after hopping and dynamic tracking balance tasks.
A cross-sectional, within-subjects experimental study design between 4 ankle conditions (taped; untaped: injured and uninjured).
20 volunteer recreational athletes with unilateral CAI were recruited. Means and standard deviations highlighted the athletes' characteristics: age =23+/-1 years; height=173.1+/-2.4 cm; weight=69.3+/-3 kg; Functional Ankle Disability Index (FADI)=93.5+/-5.1% and FADI Sport=84.2+/-9.4%.
Mulligan ankle taping.
Static balance (10s); postural sway recovery patterns after a 30s functional hop test (immediately, 30 and 60s); dynamic tracking balance tasks (wandering, target overshoot and reaction-time).
Between the four conditions, static balance showed no significant differences (p=0.792); significant changes occurred in postural sway over time (p<0.001); no significant changes were reported for the dynamic tracking tasks. Wandering was highly correlated with reaction-time and overshooting (p<0.01).
Under resting and fatigued conditions, Mulligan ankle taping did not impact on the neuromuscular control during static and dynamic balance in subjects with healthy and unstable ankles.
To evaluate the effectiveness of an unsupervised proprioceptive training programme on recurrences of ankle sprain after usual care in athletes who had sustained an acute sports related injury to the lateral ankle ligament.
Randomised controlled trial, with one year follow-up.
Primary care.
522 athletes, aged 12-70, who had sustained a lateral ankle sprain up to two months before inclusion; 256 (120 female and 136 male) in the intervention group; 266 (128 female and 138 male) in the control group.
Both groups received treatment according to usual care. Athletes allocated to the intervention group additionally received an eight week home based proprioceptive training programme.
Self reported recurrence of ankle sprain.
During the one year follow-up, 145 athletes reported a recurrent ankle sprain: 56 (22%) in the intervention group and 89 (33%) in the control group. Nine athletes needed to be treated to prevent one recurrence (number needed to treat). The intervention programme was associated with a 35% reduction in risk of recurrence. Cox regression analysis showed significantly fewer recurrent ankle sprains in the intervention than in the control group. This effect was found for self reported recurrent ankle sprains (relative risk 0.63, 95% confidence interval 0.45 to 0.88), recurrent ankle sprains leading to loss of sports time (0.53, 0.32 to 0.88), and recurrent ankle sprains resulting in healthcare costs or lost productivity costs (0.25, 0.12 to 0.50). No significant differences were found between medically treated athletes in the intervention group and medically treated controls. Athletes in the intervention group who were not medically treated had a significantly lower risk of recurrence than controls who were not medically treated.
The use of a proprioceptive training programme after usual care of an ankle sprain is effective for the prevention of self reported recurrences. This proprioceptive training was specifically beneficial in athletes whose original sprain was not medically treated.
ISTRCN34177180.
Question
Can manual therapy improve functional outcomes for individuals with chronic ankle instability?
Design
Systematic review with meta-analysis of randomized controlled trials.
Participants
Individuals with chronic ankle instability.
Intervention
Manual therapy is defined as an intervention that involves joint mobilization, and mobilization with movement.
Outcome measure
The primary outcome is patient reported function (PRF) questionnaires scores, the secondary outcomes are ankle dorsiflexion range of motion (DFROM) and balance control.
Results
Four studies were included (n = 208, mean age = 24.4) in the meta-analysis, with moderate to high quality on the PEDro scale (range 6–8). For patient reported function (PRF) questionnaires, two studies reported significant improvement after six-session manual therapy measured by foot and ankle ability measures sport subscale (FAAMS) and Cumberland ankle instability tool (CAIT), respectively. For DFROM, one session manual therapy had no significant effect on the weight-bearing lunge test (WBLT) (3 studies, n = 147, SMD = 1.24 (95%CI -0.87 to 3.36), I² = 96%) or non-weight-bearing inclinometer test (2 studies, n = 47, MD = 3.41° (95%CI -0.26 to 7.09),I² = 43%), while six-sessions manual therapy showed, a significantly positive effect on WBLT(2 studies, n = 80, SMD = 2.39, (95% CI 0.55, to 4.23), I² = 93%). For the SEBT, one-session manual therapy had no significant effect on overall star excursion balance test (SEBT) score (3 studies, n = 137,MD = 2.05,95%CI (−0.96,5.05), I² = 75%), while qualitative analysis of 2 included studies showed significant improvement both on the SEBT score and single limb balance test (SLBT).
Conclusions
Six sessions rather than one session of manual therapy improves ankle functional performance for individuals with CAI.
Trial registration number
PROSPERO CRD42017054715.
This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4–5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.
New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.
Objective:
To assess the clinical benefits of joint mobilisation on ankle sprains.
Data sources:
MEDLINE, MEDLINE In Process, Embase, AMED, PsycINFO, CINAHL, Cochrane library, PEDro, Scopus, SPORTDiscus and Dissertations and Thesis were searched from inception to June, 2017.
Study selection:
Studies investigating humans with a grade I or II lateral or medial sprains of the ankle in any pathological state from acute to chronic, who had been treated with joint mobilisation were considered for inclusion. Any conservative intervention was considered as a comparator. Commonly reported clinical outcomes were considered such as ankle range of movement, pain, and function. After screening of 1530 abstracts, 56 studies were selected for full text screening, and 23 were eligible for inclusion. Eleven studies on chronic sprains reported sufficient data for meta-analysis.
Data extraction:
Data were extracted using the participants, interventions, comparison, outcomes and study design approach. Clinically relevant outcomes (dorsiflexion range, proprioception, balance, function, pain threshold, pain intensity) were assessed at immediate, short term and long term follow-up points.
Data synthesis:
Methodological quality was assessed independently by two reviewers and most studies were found to be of moderate quality, with no studies rated as poor. Meta-analysis revealed significant immediate benefits of joint mobilisation compared to comparators on improving postero-medial dynamic balance (p=0.0004), but not for improving dorsiflexion range (p= 0.16), static balance (p = 0.96) or pain intensity (p= 0.45). Joint mobilisation was beneficial in the short term for improving weight-bearing dorsiflexion range (p= 0.003) compared to a control.
Conclusion:
Joint mobilisation appears to be beneficial for improving dynamic balance immediately after application and dorsiflexion range in the short term. Long term benefits have not been adequately investigated.
Context:
While the incidence and re-injury rates of lateral ankle sprain (LAS) continue to persist at high rates across many sporting activities, further exploration of assessment and treatment beyond the traditional ligamentous and strength/proprioceptive model is warranted. Further, assessing and treating both arthrokinematic and osteokinematic changes associated with LAS can provide insight into a more diverse approach to treating ankle pathology.
Objective:
To examine the clinical use of the Mulligan Concept MWM while treating patients diagnosed with an acute grade I or II LAS through authentic patient care.
Design:
An a priori case series.
Setting:
Intercollegiate athletic training clinic.
Patients:
Intercollegiate patients diagnosed with an acute grade I or II LAS.
Intervention:
The Mulligan Concept distal fibular anterior to posterior MWM.
Main outcome measures:
Pain-Intensity Numeric Rating Scale (NRS) with Non-Weight Bearing (NRS-NWB) and Weight Bearing (NRS-WB), Disablement of the Physically Active Scale (DPA-scale), Foot and Ankle Ability Measure (FAAM) with Activity of Daily living (FAMM-ADL) and Sport (FAAM-Sport), Client Specific Impairment Measure (CSIM), Y-Balance Composite (YBC) and Weight Bearing Measure for Dorsiflexion (WBDF).
Results:
Patients who are diagnosed with an acute grade I or II LAS and are treated with the Mulligan Concept report immediate and long-lasting minimal clinically important differences in patient outcome measures.
Conclusions:
Clinicians who examine and utilize the Mulligan Concept MWM to treat acute LAS can expect immediate positive results that are progressively retained over time specific to patient centered outcome measures as well as functional clinician based measures. Based on the immediate and positive results, clinicians should examine associated osteokinematic and arthrokinematic changes beyond that of the traditional ligamentous model.
Lateral ankle sprains (LASs) are the most prevalent musculoskeletal injury in physically active populations. They also have a high prevalence in the general population and pose a substantial healthcare burden. The recurrence rates of LASs are high, leading to a large percentage of patients with LAS developing chronic ankle instability. This chronicity is associated with decreased physical activity levels and quality of life and associates with increasing rates of post-traumatic ankle osteoarthritis, all of which generate financial costs that are larger than many have realised. The literature review that follows expands this paradigm and introduces emerging areas that should be prioritised for continued research, supporting a companion position statement paper that proposes recommendations for using this summary of information, and needs for specific future research.
Manual therapy aims to minimise pain and restore joint mobility and function. Joint mobilisations are integral to these techniques, with anteroposterior (AP) talocrural joint mobilisations purported to increase dorsiflexion range of motion (DF-ROM). This study aimed to determine whether different treatment durations of single grade IV anteroposterior talocrural joint mobilisations elicit statistically significant differences in DF-ROM. Sixteen asymptomatic male football players (age = 27.1 ± 5.3 years) participated in the study. Non-weight bearing (NWB) and weight bearing (WB) DF-ROM was measured before and after 4 randomised treatment conditions: control treatment, 30 s, 1 min, 2 min. NWB DF-ROM was measured using a universal goniometer, and WB DF-ROM using the weight-bearing lunge test. A within-subjects design was employed so that all participants received each of the treatment conditions. A 4 × 4 balanced Latin square design and 1 week interval between sessions reduced any residual effects. Two-way repeated measures ANOVA revealed a significant improvement in DF-ROM following all AP mobilisation treatments (p < 0.001). The within subjects contrasts showed that increases in treatment duration was associated with statistically significant improvements in DF-ROM (NWB DF-ROM control = 0.01%, 30 s = 14.2%, 1 min = 21.6%, 2 min = 32.8%; WB DF-ROM control = 0.01%, 30 s = 5.0%, 1 min = 7.6%, 2 min = 10.9%; p < 0.05). However, WB DF-ROM improvements were below the minimal detectable change scores needed to conclude that improvements were not a consequence of measurement error. This research shows that single session mobilisations can elicit NWB DF-ROM improvements in asymptomatic individuals in the absence of pain, whilst increases in treatment duration confer greater improvements in NWB DF-ROM within this population.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Objective
To determine whether fibular repositioning tape influenced the postural control performance in athletes with and without chronic ankle instability (CAI).
Setting
Research laboratory.
Design
A cross-sectional study, within subjects experimental study design between 4 ankle conditions (taped and untaped: CAI and healthy athletes).
Participants
Sixteen volunteer professional athletes with unilateral CAI (10 men and 6 women; age 23.2±3 y, height 175.4±10.3 cm, and weight 73±14.5 kg) and sixteen volunteer healthy professional athletes (10 men and 6 women; age 22.8±1.7 y, height 173.6±12.2 cm, and weight 66.4±11.4 kg).
Interventions
Fibular repositioning taping (FRT).
Main Outcome Measurements
Star excursion balance test (postural control) in anteromedial (AM), medial (M), and posteromedial (PM) directions were measured for the both group in two conditions: tape and untape.
Results
FRT improved significantly postural control (M, AM and PM) in both groups (p < 0.05).
Conclusion
We observed that FRT can significantly improve postural control in athletes with CAI and healthy athletes. Therefore, FRT can be an effective management for athletes who suffer from CAI. Also, this type of taping can apply immediately prior to activity and sport event to increase joint awareness of ankle.
Background
Chronic ankle instability (CAI) is a term used to identify certain insufficiencies of the ankle joint complex following an acute ankle injury. Acute ankle injuries are often associated with sporting mishaps; however, this review was the first to identify the aspects of CAI (perceived instability, mechanical instability and recurrent sprain), and persisting symptoms following an ankle sprain, that have been reported within sporting cohorts.
Objective
To determine the presence of common aspects of CAI within individual sports.
Methods
A systematic search of the MEDLINE, Web of Science, CINAHL, SPORTDiscus and AMED databases up until 1 October, 2013 produced 88 studies appropriate for review. A calculated weighted percentage of the outcome data allowed the comparison of figures across a range of sports.
Results
Soccer, basketball and volleyball were the most represented sports and recurrent ankle injury/sprain was the most reported aspect of CAI. Soccer had the highest percentage of participants with recurrent sprain (61 %) and mechanical instability (38 %), whilst track and field had the highest percentage of participants with perceived instability (41 %). Gymnasts had the highest percentage of ankles with persisting symptoms following an initial ankle sprain.
Conclusion
This review was the first to assess aspects of CAI within sporting cohorts and has identified limitations to the research reporting these data. The problem of CAI across a range of sports remains unclear and thus advocates the need for further controlled research in the area to ascertain the true extent of CAI within sporting populations.
A single case study design was used to investigate the effects of Mulligan's mobilization with movement treatment technique for lateral ankle sprains. The technique involved the physiotherapist sustaining a posterior glide to the distal fibula, while the patient actively inverted the ankle several times. Passive overpressure at end of range was then applied by the therapist. Outcome measures used in this study were the modified Kaikkonen test, range of dorsiflexion and inversion as well as a visual analogue scale for pain and function. Control for the natural resolution of ankle sprains was facilitated by using two subjects. Subject I underwent an ABAC protocol while subject II underwent an BABC protocol: where A was the no treatment phase, B was the treatment phase and C was the post-treatment return to sport phase. A comparison of the trends for both subjects indicated that the treatment technique produced improvements far in excess of that attributable to the natural history of a sprained ankle. This study provides preliminary evidence of the beneficial effects of this treatment technique, thus providing impetus for further investigations.
Spinal mobilisations are a common form of treatment intervention applied by physiotherapists in clinical practice to manage musculoskeletal pain and/or dysfunction. Previous research has demonstrated that mobilisations cause a hypoalgesic effect. However, there is very little research investigating the optimal treatment dose inducing this effect.
To investigate the effect of the number of sets (up to 5) and different durations (30 vs. 60 s) on pressure pain thresholds (PPTs) at different sites.
This single-blinded, randomised, same subject repeated measures crossover design included 19 asymptomatic healthy volunteers. The participants received 5 sets of either 30 or 60 s of postero-anterior mobilisations to L4 on different days. PPTs were measured immediately before, between and after the intervention at 4 different standardised sites.
A 4-way ANOVA analysis revealed that there was no statistically significant difference between 30 versus 60 s of mobilisations. However, there was a tendency for PPT values to be higher for the 60 s intervention. All PPT measurements after the interventions were significantly higher than the baseline. Only the measurement after the 4th set of mobilisations was significantly higher than the measurement after the 1st set (p = 0.035).
The results suggest that in order to induce the greatest local hypoalgesia, at least 4 sets of mobilisations are required. The different durations of 30 versus 60 s of mobilisation may not change the extent of the hypoalgesic effect.
A randomised, double blind, repeated measures study was conducted to investigate the initial effects of an accessory mobilisation technique applied to the ankle joint in 13 patients with a unilateral sub-acute ankle supination injury. Ankle dorsiflexion range of motion, pressure pain threshold, visual analogue scale rating of pain during functional activity and ankle functional scores were assessed before and after application of treatment, manual contact control and no contact control conditions. There were significant improvements in ankle dorsiflexion range of motion (p = 0.000) and pressure pain threshold (p = 0.000) during the treatment condition. However no significant effects were observed for the other measures. These findings demonstrate that mobilisation of the ankle joint can produce an initial hypoalgesic effect and an improvement in ankle dorsiflexion range of motion.
The purpose of this study was to examine the effects of a single joint mobilization treatment on dorsiflexion range of motion (DF ROM), posterior talar glide, and dynamic and static postural control in individuals with self-reported chronic ankle instability (CAI). In this randomized cross-over study, subjects received a Maitland Grade III anterior-to-posterior joint mobilization treatment and a control treatment of rest for 5 min. Weight-bearing DF ROM, instrumented posterior talar displacement and posterior stiffness, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and time-to-boundary (TTB) single-limb stance static postural control were assessed on both treatment days in 9 males and 11 females with CAI. The results indicated that the joint mobilization treatment was associated with significantly greater DF ROM (p = 0.01) and TTB in the anterior-posterior direction with eyes-open (p < 0.05). Although not significant, trends were identified in posterior talar displacement (p = 0.08) and the mean of TTB in the medial-lateral (ML) direction (p = 0.07). No significant differences were observed in the standard deviation of TTB in the ML direction, the SEBT, or posterior stiffness (p > 0.05). This indicates that a single joint mobilization treatment has mechanical and functional benefits for addressing impairments in sensorimotor function and arthrokinematic restrictions commonly experienced by individuals with CAI.
Most clinicians ask their patients to rate whether their health condition has improved or deteriorated over time and then use this information to guide management decisions. Many studies also use patient-rated change as an outcome measure to determine the efficacy of a particular treatment. Global rating of change (GRC) scales provide a method of obtaining this information in a manner that is quick, flexible, and efficient. As with any outcome measure, however, meaningful interpretation of results can only be undertaken with due consideration of the clinimetric properties, strengths, and weaknesses of the instrument. The purpose of this article is to summarize this information to assist appropriate interpretation of the GRC results and to provide evidence-informed advice to guide design and administration of GRC scales. These considerations are relevant and applicable to the use of GRC scales both in the clinic and in research.
Age-related reduction in lower limb muscle strength has been shown to be related to disability, falls and loss of independence. While there have been a number of studies on age-related changes in muscle strength, they have concentrated on more proximal muscle groups with little research into how ageing affects the muscles of the foot and ankle.
To evaluate the intra- and interrater reliability of hand-held dynamometry for the assessment of foot and ankle strength, and to compare the values obtained between young and older people.
The muscle groups which perform ankle dorsiflexion, plantar flexion, inversion, eversion and plantar flexion of the hallux and lesser digits were recorded for 36 young participants (17 males, 19 females, mean age 23.2 ± 4.3 years) and 36 older people (17 males, 19 females, mean age 77.1 ± 5.7 years) using a Citec hand-held dynamometer. Differences in muscle strength between the groups as well as intrarater and interrater reliability of two assessors were determined.
The reliability of the hand-held dynamometry procedure was excellent for both intrarater (ICC(3,1) = 0.78-0.94) and interrater (ICC(3,1) = 0.77-0.88) comparisons. There were significant differences between the muscle strength of the young and older participants for all muscle groups tested (p < 0.001) with older participants being weaker than the young participants by a magnitude of between 24 and 37%.
Hand-held dynamometry is a reliable instrument to measure the foot and ankle strength of young and older adults. Ageing is associated with a reduction in strength of between 24 and 37% for the muscles responsible for movement of the foot and ankle.
The aim of the study was to introduce and evaluate a standardized test protocol and scoring scale for evaluation of ankle injuries. After evaluation of 11 different functional ankle tests, questionnaire answers, and results of clinical ankle examination, the final test protocol consisted of 3 simple questions describing the subjective assessment of the injured ankle, 2 clinical measurements (range of motion in dorsiflexion, laxity of the ankle joint), 1 ankle test measuring functional stability (walking down a staircase), 2 tests measuring muscle strength (rising on heels and toes), and 1 test measuring balance (balancing on a square beam). Each selected test showed excellent reproducibility when tested with a reference group of 100 uninjured persons. According to the test results of a population of 148 patients with an operatively treated grade III lateral ligament injury of the ankle, each test could significantly differentiate healthy controls and patients with excellent overall healing from those with poor or fair recovery. The final total test score correlated significantly with the isokinetic strength results of the ankle, subjective opinion about the recovery, and subjective-functional assessment. The scale presented is recommended for studies evaluating functional recovery after ankle injury.