Research Review By Dr. Jeff Muir©


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Date Posted:

May 2014

Study Title:

The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review


Loudon JK, Reiman MP, Sylvain J

Author's Affiliations:

Department of Physical Therapy Education, Rockhurst University, Kansas, USA; Department of Physical Therapy, Duke University Medical Center, North Carolina, USA.

Publication Information:

British Journal of Sports Medicine 2014; 48: 365–370.

Background Information:

Lateral ankle sprains are common in active people and the ankle is one of the most commonly injured joints in sports, accounting for up to 30% of all sports-related injuries (1, 2). The mechanism of injury responsible for the majority of these sprains is forced ankle inversion and plantarflexion. These injuries occur most frequently during athletic activities that require jumping, running or explosive lateral or cutting movements (2-6).

Symptoms of lateral ankle sprains normally last for 6-8 weeks depending on severity, treatment administered etc., but can persist for up to 18 months after injury in some patients (7). Clinicians should be concerned with restoring muscle strength and function, joint and general proprioception, as well as dorsiflexion range of motion. If a motion restriction remains, the ankle joint is thought to be at higher risk of developing osteoarthritic changes (8).

The clinical evidence regarding the use of manual therapies in lateral ankle sprains is generally supportive, although recent systematic reviews have shown mixed results (9-11). The purpose of the current study was to update our knowledge on the state of clinical evidence regarding the use of manual therapies in the treatment of lateral ankle sprains.

Pertinent Results:

The initial literature searches yielded 54 potentially eligible studies. Eighteen studies were assessed in full text and 8 studies (including only 244 total participants) investigating manual therapies in the treatment of lateral ankle sprains were chosen for inclusion in the review.

Study Quality:
Study methodological quality was evaluated using the PEDro scale (12). Scores ranged from 5/11 to 10/11, with an average score of 8.1. The most common weakness among these studies was the lack of long-term follow-up.

Effect of manual joint techniques for acute lateral ankle sprains:
Three studies (7, 13, 14) (minimum PEDro score=6) investigated manual therapies for acute lateral ankle sprains. The use of anteroposterior mobilization of the talus was associated with an increase in pain-free dorsiflexion following a single treatment and in general at 8-10 days post-injury. The authors proposed that manual mobilization has an initial pain altering effect on ankle sprains, but does not have a mechanical effect. More work is required in this area.

Effect of manual joint techniques for subacute/chronic lateral ankle sprains:
Five studies (15-19) investigated manual therapies for subacute or chronic lateral ankle sprains. The specific techniques utilized were more heterogeneous than those employed in acute ankle sprains. One study (17) investigated the changes in pressure pain threshold (PPT), ankle ROM and performance following a Maitland A-P talar mobilization. They noted significant improvements in ankle dorsiflexion ROM and PPT only.

Two studies (16, 18) utilized a Mulligan mobilization with movement (MWM) technique where an A-P mobilization is applied to the talus while the standing participant actively dorsiflexed. In both studies, an improvement was noted in ankle dorsiflexion ROM but no change was noted in pain sensitivity.

Finally, two studies (15, 19) utilized thrust manipulation interventions. These studies employed a talocrural distraction manipulation and noted a positive effect on the dorsiflexion ROM, pain and functional score resulted at the 1-month follow-up.

Clinical Application & Conclusions:

Eight studies investigated the effect of mobilization/manipulation on lateral ankle sprains. Manual joint mobilization appears to help to diminish pain, at least temporarily, for patients with an acute ankle sprain. Mobilization appears also to have a positive effect on dorsiflexion ROM, but the clinical relevance of these findings is unknown.

For treatment of subacute/chronic lateral ankle sprains, some form of joint manual therapy appears to help with ankle ROM (especially dorsiflexion) and pain reduction. No detrimental effects were noted in any of the studies.

While the lack of long-term follow-up in any of the eligible studies makes extrapolation of the findings to the long-term difficult, clinicians should feel confident in utilizing manual mobilization/manipulation techniques in acute and subacute lateral ankle sprains as a method of decreasing pain and increasing mobility. These manual techniques are useful additions to a comprehensive treatment plan icing, modalities, soft tissue therapy, proprioception/balance rehabilitation, and eventual progression to sport or task-specific training.

Study Methods:

Search Strategy:
MEDLINE, CINAHL, EMBASE, Physiotherapy Evidence Database (PEDro) and OVID databases were searched from inception to March 2013. Search terms relating to “ankle”, “sprain”, “injuries”, “lateral”, “manual therapy” and “joint mobilization” were used alone and in combination in the final search.

Selection Criteria:
Randomized, controlled trials on humans with a lateral ankle sprain were considered eligible if the following criteria were met:

Inclusion Criteria:
  • Joint mobilization or manipulation of the distal tibiofibular (we have a review on this listed below), talocrural, subtalar joint or midfoot,
  • intervention compared with a control group,
  • one of the following outcome measures: ankle joint ROM, pain level, swelling and/or some type of functional outcome, and
  • follow-up times defined as either short term (< 3 months), medium term (3–6 months) or long term (> 6 months).
Exclusion Criteria:
  • Investigated ankle injuries other than lateral ankle sprains such as high ankle sprains or fractures, or
  • other interventions in addition to manual joint techniques.
Study Quality:
The methodological quality of individual studies was assessed using the PEDro scale (12). PEDro uses 11 criteria broadly encompassing patient eligibility, blinding, grouping and intervention and outcome similarity. Reviewed studies were awarded one point for each criterion that was clearly satisfied. The maximum score a paper can achieve is 11.

Study Strengths / Weaknesses

  • The heterogeneity of techniques utilized limited capacity to pool data.
  • Follow-up periods were limited.
  • The participants in most studies were relatively young (< 32 years).
  • A comprehensive search strategy was employed.
  • Study methodology was subjected to rigorous evaluation.

Additional References:

  1. Beynnon BD, Renstrom PA, Alosa DM, et al. PM. Ankle ligament injury risk factors: a prospective study of college athletes. J Orthop Res 2001; 19: 213–20.
  2. Fong DT, Hong Y, Chan LK, et al. A systematic review on ankle injury and ankle sprain in sports. Sports Med 2007; 37: 73–94.
  3. Boyce SH, Quigley MA. Review of sports injuries presenting to an accident and emergency department. Emerg Med J 2004; 21: 704–6.
  4. Grimm DJ, Fallat L. Injuries of the foot and ankle in occupational medicine: a 1-year study. J Foot Ankle Surg 1999; 38: 102–8.
  5. Fernandez WG, Yard EE, Comstrock RD. Epidemiology of lower extremity injuries among US high school athletes. Acad Emerg Med 2007; 14: 641–5.
  6. Bahr R, Karlsen R, Lian O, et al. Incidence and mechanisms of acute ankle inversion injuries in volleyball. A retrospective cohort study. Am J Sports Med 1994; 22: 595–600.
  7. Green T, Refshauge K, Crosbie J, et al. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther 2001; 81: 984–94.
  8. Tibero D. Patho-mechanics of structural foot deformities. Phys Ther 1988; 68: 1841–9.
  9. Ogilvie-Harris DJ, Gilbart M. Treatment modalities for soft tissue injuries of the ankle: a critical review. Clin J Sport Med 1995; 5: 175–86.
  10. Van de Wees PJ, Lennssen AF, Hendriks EJ, et al. Effectiveness of exercise therapy and manual mobilization in ankle sprain and functional instability: a systematic review. Aust J Physiother 2006; 52: 27–37.
  11. Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilization with external support after acute ankle sprain: a systematic review. Aust J Physiother 2008; 54: 7–20.
  13. Cosby NL, Koroch M, Grindstaff TL, et al. Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain. J Man Manip Ther 2011; 19: 76–83.
  14. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. JAOA 2003; 103: 417–21.
  15. Lopez-Rodriguez S, Fernandez de-Las-Penas C, Alburquerque-Sendin F, et al. Immediate effects of manipulation of the talocrural joint on stabilometry and baropodometry in patients with ankle sprain. J Manipulative Physiol Ther 2007; 30: 186–92.
  16. Reid A, Birmingham TB, Alcock G. Efficacy of mobilization with movement for patients with limited dorsiflexion after ankle sprain: a crossover trial. Physio Can 2007; 59: 166–72.
  17. Yeo HK, Wright A. Hypoalgesic effect of a passive accessory mobilization technique in patients with lateral ankle sprain. Man Ther 2011; 16: 373–7.
  18. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprain. Man Ther 2004; 9: 77–82.
  19. Pellow JE, Brantingham JW. The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. J Manip Physiol Ther 2001; 24: 17–24.

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