Research Review By Dr. Brynne Stainsby©


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Date Posted:

November 2018

Study Title:

Clinical benefits of joint mobilization on ankle sprains: A systematic review and meta-analysis


Weerasekara W, Osmotherly P, Snodgrass S et al.

Author's Affiliations:

School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, Australia.

Publication Information:

Archives of Physical Medicine and Rehabilitation 2018; 99: 1395-1412.

Background Information:

A common injury in sport and the general population, the incidence of ankle sprains has been reported to be between 2.5 to 7 per 1000 person-years (1-5). While typically an acute injury, ankle sprains may eventually lead to chronic pain, physical limitations and disability (1, 2).

Manual therapy, including joint mobilizations, manipulation and mobilization with movement (MWM), has been recommended for the management of acute ankle sprains and in the progressive loading stage of rehabilitation (6). It has been reported that these techniques may have both biomechanical (such as stretching tissue, reducing hypertonicity or stiffness) and neurophysiological (proprioception, spinal cord-related or supraspinal-mediated) benefits (7, 8).

Given the large body of research relating to the treatment of ankle sprains, the purpose of this systematic review was to address the specific role of ankle joint mobilizations (including high velocity thrust manipulation) in grade I or grade II medial or lateral ankle sprains in the acute, subacute and chronic stages of rehabilitation.

Pertinent Results:

Literature Search Results and Included Studies:
  • A total of 1530 titles and abstracts were screened for eligibility and 56 potentially relevant articles were identified for full-text screening.
  • Twenty-three studies were ultimately included in the review, and 11 were appropriate for meta-analysis.
  • Three studies evaluated subacute ankle sprains and 21 studies evaluated chronic ankle sprains.
  • Outcome measures included: range of motion, proprioception, stability/balance, pain threshold, pain intensity, function, talar stiffness, postural sway, and patient confidence.
  • Interventions included: mobilization with movement (MWM); anteroposterior talocrural mobilization; high velocity, low amplitude axial elongation; Mulligan ankle taping; distal tibiofibular joint manipulation or mobilization; combined mobilization and traction of the talocrural joint.
  • Immediate effects were studied in 17 studies, short-term effects in 10 studies and long-term effects in one study.
  • Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the overall level of evidence was considered to be of moderate quality.
Immediate Effects of Mobilization:
  • The immediate effects on dorsiflexion ROM were assessed in 14 outcome evaluations, and 11 reported improvement following mobilization.
  • In the 10 studies that measured stability and balance, 3 demonstrated improvement.
  • The other outcomes (pain, talar stiffness and function) were inconsistent following mobilization.
  • In the meta-analysis, pooled data from a total of 180 participants demonstrated a significant difference in the posteromedial direction on the Star Excursion Balance Test (MD = 3.22, 95% CI 1.43-5.01, p = 0.0004), however all other directions were not significant. Pooled data for static balance, pain intensity and dorsiflexion ROM demonstrated no significant differences immediately following mobilization.
Short-Term Effects of Mobilization:
  • Improvement was reported following mobilization in dorsiflexion ROM, stability/balance, pain intensity, function, talar stiffness, proprioception and pain threshold.
  • Pooled data from 94 participants indicated mobilization was effective for improving dorsiflexion ROM (MD = 2.56, 95% CI 0,89-4.23, p = 0.003).
Long-Term Effects of Mobilization:
  • Only one study evaluated the long-term effects of mobilization and found improvement in dorsiflexion ROM and stability/balance.

Clinical Application & Conclusions:

This review identifies a potential role for joint mobilization in the management of subacute and chronic grade I or II medial or lateral ankle sprains. It is important to note that no studies evaluated the role of mobilization in the acute phase, as this may be a more relevant intervention after initial pain and inflammation have been addressed (this is also when many clinicians employ mobilization or manipulation in their offices!).

Though a systematic review (and meta-analysis) is not intended to determine the merits of individual techniques, it is helpful to note that as a whole, ankle joint mobilizations appear to have some benefit in the short- and long-term, but do not appear to offer consistent benefit in the period immediately following treatment (this is understandable if the outcome in question is pain, as acute sprains are painful for a while regardless of intervention).

Importantly, the reviewers noted that little information was provided regarding the optimal frequency and duration of interventions. This highlights the need for high quality research regarding of effectiveness of individual and combined therapies, and the optimal dosage and timing for providing them efficiently and effectively.

Study Methods:

  • A search of 11 electronic databases from inception to June 2017 was conducted using appropriate search terms related to ‘ankle sprains’ and ‘mobilizations’, alone and in combination. A hand search of the reference lists of the identified studies was also conducted.
  • In order to be included, studies must have been one of the following designs: randomized controlled trial, crossover study, cross-sectional study, cohort study, case series or dissertation.
  • For inclusion, trials must have studied live human subjects with grade I or II lateral or medial ankle sprains at any stage of recovery in an ambulatory setting treated with joint mobilization applied at the talocrural, subtalar or inferior tibiofibular joint. Mobilization must have been performed by a physiotherapist, medical doctor, osteopath, chiropractor or athletic trainer, and compared to any conservative intervention or control. Outcome measures could include any measure of clinical impairment, though measures of ankle range of motion (ROM), pain, quality of life and function were the primary outcomes of interest. The outcome measures were categorized as immediate, short-term (up to three months following intervention) or long-term (measured three months or more following intervention).
  • Two authors independently screened titles and abstracts for inclusion, followed by full text screening for eligibility. Disagreement was resolved by consensus or involvement of a third reviewer.
  • Two independent reviewers assessed the methodological quality of studies using the PEDro Scale for randomized controlled trials and the Quality Assessment Tool for Observational Cohort and Cross-sectional studies (9-11).
  • The overall quality of the evidence was assessed during meta-analysis using the GRADE approach to classify the evidence as high, moderate, low or very low (12, 13).
  • Descriptive data were extracted from moderate or high quality studies and presented in evidence tables.
  • For meta-analysis, standardized mean difference (SMD) was calculated for the outcomes where means and standard deviations were provided for pre- and postintervention values. Effect sizes were interpreted as small (0.2), medium (0.5) or large (0.8).

Study Strengths / Weaknesses:

  • A clearly defined researched question with a thorough and systematic search.
  • Independent screening of titles and abstracts, and full texts.
  • Assessment of risk of biased was performed with two validated, appropriate sets of criteria.
  • Meta-analysis was performed when appropriate.
  • As there is a limited body of evidence available, the reviewers included only moderate quality studies. With future research, it would be optimal to include only high quality research.
  • Due to the study designs included, blinding of therapists was not possible, however, it is concerning that in 40% of the included trials, assessors were not blinded and in over 60% of included trials, allocation was not concealed. These are serious methodological flaws and including only high quality research in future reviews would certainly help move toward eliminating these issues.
  • In all of the included cohort and cross-sectional studies, there were issues regarding the definition of the exposure to intervention and whether the exposure measurements were valid and reliable. Future, more robust research should look to address this.
  • Given the potential for risk of bias combined with the lack of high quality findings, it is not possible to determine the most effective interventions or doses.

Additional References:

  1. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003; 81: 646-56.
  2. Parker R, Jelsma J. The prevalence and functional impact of musculoskeletal conditions amongst clients of a primary health care facility in an under-resourced area of Cape Town. BMC Musculoskelet Disord 2010; 11: 2.
  3. Bridgman SA, Clement D, Downing A et al. Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains. Emerg Med J 2003; 20: 508-510.
  4. Holmer P, Sondergaard L, Konradsen L et al. Epidemiology of sprains in the lateral ankle and foot. Foot Ankle Int 1994; 15: 72-74.
  5. Waterman BR, Owens BD, Davey S et al. The epidemiology of ankle sprains in the United States. J Bone Joint Surg (Am) 2010; 92: 2279-2284.
  6. Martin RL, Davenport TE, Paulseth et al. Ankle stability and movement coordination impairments: ankle ligament sprains. J Orthop Sports Phys Ther 2013; 43: A1-40.
  7. McCarthy C, Bialosky J, Rivett D. Spinal manipulation. In: Jull G, Moore A, Falla D et al, editors. Grieve’s modern musculoskeletal physiotherapy. 4th ed. Chatswood: Elsevier; 2015. p 278-82.
  8. Vicenzino B, Hing W, Rivett DA et al. Mobilisation with movement: the art and the science. Chatswood: Elsevier; 2011.
  9. PEDro scale. University of Sydney. Available at: http://www.pedro. Accessed March 1, 2016.
  10. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.handbook. Accessed October 3, 2017.
  11. National Institutes of Health. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Available at https:// reduction/tools/cohort. Accessed March 1, 2016.
  12. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490.
  13. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924.