Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability

Physical Therapy Intervention Effects on Alteration of Spinal Excitability in Patients With Chronic Ankle Instability: A Systematic Review and Meta-analysis

CONTEXT

Chronic ankle instability (CAI) is a common injury in athletes. Different forms of physical therapy have been applied to the population with CAI to assess their impact on spinal excitability.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to investigate the effectiveness of various physical therapy interventions on the alteration of spinal excitability in patients with CAI.

DATA SOURCES

Four databases (EMBASE, MEDLINE, Cochrane CENTRAL, and Scopus) were searched from inception to November 2022.

STUDY SELECTION

A total of 253 studies were obtained and screened; 11 studies on the effects of physical therapy intervention on the alteration of spinal excitability in patients with CAI were identified for meta-analysis.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 3a.

DATA EXTRACTION

A total of 11 studies that included the maximal Hoffmann reflex normalized by the maximal muscle response (H/M ratio) in the peroneus longus and soleus muscles were extracted and summarized. The quality of the studies was assessed using the PEDro scale.

RESULTS

The extracted studies had an average PEDro score of 4.7 ± 1.4, indicating that most of them had fair-to-good quality. The physical therapy interventions included cryotherapy, taping, mobilization, proprioceptive training, and dry needling. The overall effects showed that the H/M ratios of the peroneus longus (P = 0.44, I2 = 0%) and soleus (P = 0.56,I2 = 22%) muscles were not changed by physical therapy in patients with CAI.

CONCLUSION

The meta-analysis indicated that physical therapy interventions such as cryotherapy, taping, mobilization, proprioceptive training, and dry needling do not alter the spinal excitability in patients with CAI. Given that only 1 study reported ineffective changes in spinal excitability with dry needling, more research is essential to establish and validate its efficacy.

PROSPERO REGISTRATION

CRD42022372998.

What interventions can treat arthrogenic muscle inhibition in patients with chronic ankle instability? A systematic review with meta-analysis

PURPOSE

To identify, critically appraise, and synthesize the existing evidence regarding the effects of therapeutic interventions on arthrogenic muscle inhibition (AMI) in patients with chronic ankle instability (CAI).

MATERIALS AND METHODS

Two reviewers independently performed exhaustive database searches in Web of Science, PubMed, Medline, CINAHL, and SPORTDiscus.

RESULTS

Nine studies were finally included. Five types of disinhibitory interventions were identified: focal ankle joint cooling (FAJC), manual therapy, fibular reposition taping (FRT), whole-body vibration (WBV), and transcranial direct current stimulation (tDCS). There were moderate effects of FAJC on spinal excitability in ankle muscles (g = 0.55, 95% CI = 0.03-1.08, p = 0.040 for the soleus and g = 0.54, 95% CI = 0.01-1.07, p = 0.046 for the fibularis longus). In contrast, manual therapy, FRT, WBV were not effective. Finally, 4 weeks of tDCS combined with eccentric exercise showed large effects on corticospinal excitability in 2 weeks after the intervention (g = 0.99, 95% CI = 0.14-1.85 for the fibularis longus and g = 1.02, 95% CI = 0.16-1.87 for the tibialis anterior).

CONCLUSIONS

FAJC and tDCS may be effective in counteracting AMI. However, the current evidence of mainly short-term studies to support the use of disinhibitory interventions is too limited to draw definitive conclusions.

Effects of H-Reflex Onset Latency on Gait in Elderly and Hemiplegic Individuals

Background and Objectives: The Hoffmann’s reflex (H-reflex) is important in electrodiagnostic testing because it improves sensitivity and specificity in diagnosing radiculopathies. Although quantitative electromyography (EMG) measurements for H-reflex amplitudes during the gait cycle have been performed in both hemiplegic and healthy individuals, research on the H-wave latency in these individuals during the gait cycle is lacking. Materials and Methods: The H-reflex latency of the soleus muscle was investigated in hemiplegic stroke patients and healthy elderly persons in this observational analytical study. Two groups of individuals participated in this study: healthy adults (n = 25) and stroke patients with hemiplegia (n = 25) were compared. An MP150 with Ag-Ag/Cl electrodes was utilized to record and analyse electromyography measurements. All individuals could walk independently indoors. Stimuli were administered to elicit the H-reflex in the four gait phases as the participant walked. Results: Stroke patients had a significantly shorter latency than did healthy patients in the mid-swing, mid-stance, and toe-off phases of the gait cycle; heel-strike latency did not significantly differ. Conclusions: These results can be used as diagnostic data to help account for patient characteristics or measure the recovery extent for treatment planning and gait training in hemiplegic individuals.

The Effects of Therapeutic Exercise With and Without Mobilization in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

Context: Manual therapy (MT) is reported to increase range of motion (ROM), improve balance, and decrease pain in individuals with chronic ankle instability (CAI). Additional literature is needed to examine the effectiveness of the addition of MT to a therapeutic exercise regimen in individuals with CAI. Objective: To examine the combined effects of thrust joint manipulation (TJM) and exercise on function in participants reporting CAI. Design: Randomized controlled trial. Setting: Research laboratory. Participants: A convenience sample of 30 participants (mean age 23.7 [3.65] y; mean height 169.50 [9.50] cm; mean mass 66.48 [10.64] kg). Intervention: Participants were randomly allocated to the exercise (n = 15) or exercise + TJM group (n = 20) and completed an exercise program. The exercise + TJM group also received MT at the talocrural, proximal, and distal tibiofibular joints in the first 3 sessions. Main Outcome Measures: Self-reported outcomes were recorded at baseline and follow-up using the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport (FAAM-S) subscale, and the Ankle Joint Functional Assessment Tool (AJFAT). The side-hop test, figure-of-8 hop test, 3 directions of the Star Excursion Balance Test, and dorsiflexion ROM were also assessed at baseline and follow-up. Results: Only the exercise + TJM group demonstrated an improvement in weight-bearing dorsiflexion with the knee flexed following treatment (P = .02). For all outcome measures, except ROM, subjects improved significantly at follow-up regardless of group assignment (P ≤ .01). Conclusions: Our data suggest that rehabilitation of patients with CAI is related to improved ROM, function, and self-reported outcomes. This provides evidence that the addition of MT to exercise may enhance improvements in ROM as compared with exercise alone. Additional research is needed to identify optimal parameters to maximize therapeutic benefit.

Treatment of Posttraumatic Osteoarthritis Secondary to a Chronic Plafond Fracture: A Case Report

Objective

The purpose of this case report is to describe the treatment of a 3-year-old plafond fracture that developed posttraumatic osteoarthritis in a patient with chronic left ankle pain.

Clinical Features

A 65-year-old woman presented with daily anterior, posterior, medial, and lateral left ankle pain. Her initial pain level was 7 of 10 on weight bearing. She had trouble working and walking. She was previously treated with a walking boot, crutches, exercises, nonsteroidal anti-inflammatory drugs, and a steroid injection. She consulted our office approximately 3 years post-injury, at which point her initial disability score was 55 of 104 on the Foot and Ankle Disability Index.

Interventions and Outcome

The patient was subsequently treated with low-level laser, kinesio taping, exercise, and toggle board manipulation of the ankle. After a total of 6 visits, she was able to return to work and was walking with marked reduction of pain. Her pain level was 1 of 10 on weight bearing 1.5 years after her last treatment.

Conclusion

In this case report, a patient presented with 3-year-old ankle pain with an original etiology of plafond fracture. Her pain and disability resolved with a combination of low-level laser, exercises, kinesio taping, and toggle board manipulation. Her disability score after 6 visits was 18 of 104 on the Foot and Ankle Disability Index. This is a possible treatment option for posttraumatic osteoarthritis secondary to plafond fractures.

Effects of Tibiofibular and Ankle Joint Manipulation on Hip Strength and Muscle Activation

OBJECTIVES

The purpose of this study was to determine whether high-velocity, low-amplitude ankle region manipulations could increase force output and muscle activation of hip musculature in individuals with a history of ankle sprain and unilateral tensor fascia latae (TFL) weakness during muscle testing.

METHODS

This investigation used a single-arm repeated measures design. Twenty-five participants' force outputs were tested at three time points (before manipulation, immediately after manipulation, and 48 hours after manipulation), and muscle activation of the rectus femoris, gluteus medius, and TFL was measured before and immediately after manipulation. Manipulations were applied to the talocrural, subtalar, proximal, and distal tibiofibular joints of the weaker limb. No contralateral manipulations were applied. Two-way repeated measures analysis of variance was used to compare maximal and average force production for each limb. In addition, paired t tests were used to compare muscle activation before and after manipulations.

RESULTS

There was a significant limb × time interaction. The involved limb average force increased from before manipulation (65.7 N) to 48 hours after manipulation (77.8 N; P = .014), maximal force increased (76.9 N) 48 hours after manipulation (87.8 N; P = .030), and gluteus medius activation increased (9.8% maximum, 12.2% average) immediately after manipulation. No significant differences were found in the uninvolved limb.

CONCLUSION

The results of this study suggest that high-velocity, low-amplitude ankle region manipulations might improve hip abductor strength in individuals with a history of ankle sprain and unilateral weakness during a TFL muscle test.

The immediate effects of passive joint mobilisation on local muscle function. A systematic review of the literature

BACKGROUND

Passive joint mobilisation is popular among healthcare providers and their patients; however, its effectiveness for improving muscle function is not well researched and the mechanisms of action involved are unclear.

OBJECTIVES

To assess the effect of passive joint mobilisations on the function of muscles surrounding the targeted joints in symptomatic as well as asymptomatic individuals.

SELECTION CRITERIA

Controlled experimental trials assessing the immediate effect of passive joint mobilisation on outcomes associated with local muscle function.

DATA COLLECTION

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

A total of seventeen studies were included, of which ten studies reported data on asymptomatic individuals and seven studies reported data on symptomatic individuals with various conditions. There is a moderate level of evidence that joint mobilisation immediately decreases the activation of superficial muscles during low load conditions in symptomatic individuals. For asymptomatic individuals, there is a low level of evidence that passive joint mobilisation improves maximum muscle strength when compared to sham mobilisation, opposed to a very low level of evidence suggesting no effect in symptomatic individuals. The five studies reporting data on both, changes in muscle function as well as changes in pain, suggest that other, not pain-related mechanisms may play an important role regarding the reported improvement in muscle function.

CONCLUSION

Current best evidence suggests that passive joint mobilisation has the ability to immediately alter muscle function. The specific mechanisms of action involved require further basic science investigations. Registration number (PROSPERO): CRD42018117033.

Surgical management of chronic lateral ankle instability: a meta-analysis

Background

A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The purpose of this meta-analysis was to compare different surgical techniques for management of chronic lateral ankle instability.

Methods

We searched the Cochrane Library, MEDLINE, and EMBASE. All identified randomized and quasi-randomized controlled trials of operative treatment for chronic lateral ankle instability were included. Two review authors independently extracted data from each study and assessed risk of bias. Where appropriate, results of comparable studies were pooled.

Results

Seven randomized controlled trials were included for analysis. They fell in five clearly distinct groups.

One study comparing two different kinds of non-anatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: better clinical satisfaction and fewer subsequent sprains.

Two studies compared non-anatomic reconstruction versus anatomic repairment. In one study, nerve damage was more frequent in non-anatomic reconstruction group; the other one reported that radiological measurement of ankle laxity showed that non-anatomic reconstruction provided higher reduction of talar tilt angle.

Two studies comparing two anatomic repairment surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time.

One study compared two different anatomic repairment techniques. They found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique.

One study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at 2 years post-surgery, than the modified Brostrom procedure.

Conclusions

There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions: (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. (2) Non-anatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compare with anatomic repairment. (3) Multiple types of modified Brostrom procedures could acquire good clinical results. (4) Anatomic reconstruction is a better procedure for some specific patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0870-6) contains supplementary material, which is available to authorized users.

The immediate effect of talocrural joint manipulation on functional performance of 15-40 years old athletes with chronic ankle instability: A double-blind randomized clinical trial

OBJECTIVE

To evaluate the immediate effect of talocrural joint manipulation (TCJM) on functional performance of athletes with chronic ankle instability (CAI).

PARTICIPANTS

Forty athletes (18males, 22females) with CAI divided into TCJM group (n = 20) and sham manipulation group (n = 20).

INTERVENTION

TCJM was performed as a quick thrust on the involved talus, in the posterior direction. Sham manipulation was maintaining the same position, without any thrust.

MAIN OUTCOME MEASURES

Functional performance of athletes was assessed with single leg hop; speed and Y balance tests, before and after the interventions.

RESULTS

All functional tests evaluated in this study improved significantly after TCJM (p-value<0.05). These findings were not seen in the control group. Between-group comparisons also showed significant changes for all the measurements after the interventions (p < 0.05).

CONCLUSIONS

TCJM can significantly increase the functional performance of athletes with CIA and can be an effective supplementary treatment for these subjects. However, this was a pre-post study and future studies with long-term follow-ups may provide more reliable results about the long-term effectiveness of this type of treatment.

Neural Excitability and Joint Laxity in Chronic Ankle Instability, Coper, and Control Groups

CONTEXT

Neuromuscular and mechanical deficiencies are commonly studied in participants with chronic ankle instability (CAI). Few investigators have attempted to comprehensively consider sensorimotor and mechanical differences among people with CAI, copers who did not present with prolonged dysfunctions after an initial ankle sprain, and a healthy control group.

OBJECTIVE

To determine if differences exist in spinal reflex excitability and ankle laxity among participants with CAI, copers, and healthy controls.

DESIGN

Case-control study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-seven participants with CAI, 30 participants categorized as copers, and 26 healthy control participants.

MAIN OUTCOME MEASURE(S)

We assessed spinal reflex excitability of the soleus using the Hoffmann reflex protocol. Participants' ankle laxity was measured with an instrumented ankle arthrometer. The maximum Hoffmann reflex : maximal muscle response ratio was calculated. Ankle laxity was measured as the total displacement in the anterior-posterior directions (mm) and total rotation in the inversion and eversion directions (°).

RESULTS

Spinal reflex excitability was diminished in participants with CAI compared with copers and control participants (P = .01). No differences were observed among any of the groups for ankle laxity.

CONCLUSION

Changes in the spinal reflex excitability of the soleus that likely affect ankle stability were seen only in the CAI group, yet no mechanical differences were noted across the groups. These findings support the importance of finding effective ways to increase spinal reflex excitability for the purpose of treating neural excitability dysfunction in patients with CAI.

The Consequence of a Medial Ankle Sprain on Physical and Self-reported Functional Limitations: A Case Study Over a 5-Month Period

STUDY DESIGN

Case report.

BACKGROUND

Little evidence exists about impairments and perceived disability following eversion injury to the deltoid ligament. This case study prospectively examined the neuromuscular, biomechanical, and psychological consequences of a case of a medial ankle sprain.

CASE DESCRIPTION

A recreationally active man with a history of a lateral ankle sprain (grade I) was participating in a university Institutional Review Board-approved research study examining the neuromuscular and mechanical characteristics associated with chronic ankle instability. Twenty-two days after the testing session, the participant sustained an eversion injury to his left ankle while playing basketball. Outcomes The outcomes of this case are presented using the International Classification of Functioning, Disability and Health model. Outcome variables were assessed at preinjury (medial ankle sprain), 3 months postinjury, and 5 months postinjury. Measurements included neural excitability of the soleus, balance assessment, joint stability, and psychological assessments. Data from this case study revealed that a medial ankle sprain reduces joint mobility and alters neural excitability of the soleus, with concurrent deficits in balance and self-reported function. These impairments forced the participant to downgrade his physical activity lifestyle up to 5 months postinjury.

DISCUSSION

These data suggest the need for the development of intervention strategies to address impairments in neural excitability and joint mobility at the ankle to help patients meet the goal of maintaining long-term joint health.

LEVEL OF EVIDENCE

Prognosis, level 4.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

STUDY DESIGN

Case series.

BACKGROUND

Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures.

CASE DESCRIPTION

Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline.

OUTCOMES

Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks.

DISCUSSION

Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population.

LEVEL OF EVIDENCE

Therapy, level 4.

Fibular taping does not alter lower extremity spinal reflex excitability in individuals with chronic ankle instability

OBJECTIVE

To determine changes in spinal reflex excitability of the soleus and fibularis longus muscles before and after fibular taping intervention.

METHODS

Twenty-one individuals (age = 23.4 ± 2.7 y, height = 171.0 ± 12.8 cm, mass = 69.7 ± 11.8 kg) with chronic ankle instability (CAI) and at least 5° ankle dorsiflexion asymmetry volunteered for this randomised crossover design study. Each participant received a fibular taping with tension or fibular taping without tension during separate sessions. Spinal reflex excitability of the soleus and fibularis longus was determined by obtaining maximum values for H-reflex (Hoffmann reflex) and maximum compound muscle action potential (Mmax), which was expressed as a ratio (H/M ratio). Measures were obtained immediately before and after a fibular taping intervention.

RESULTS

The application of tape to the fibula, regardless of tension, did not produce a change in spinal reflex excitability for the soleus (F1,39 = .01, P = .91) or fibularis longus (F1,39 = .001, P = .99).

CONCLUSIONS

Fibular taping with and without tension did not result in an immediate change in spinal reflex excitability of the soleus or fibularis longus in individuals with CAI. Although fibular taping has been shown to reduce recurrent ankle sprains in individuals with CAI, the mechanism of effectiveness may not involve an immediate increase in spinal reflex excitability.

Alterations in neuromuscular control at the knee in individuals with chronic ankle instability

CONTEXT

Few authors have assessed neuromuscular knee-stabilization strategies in individuals with chronic ankle instability (CAI) during functional activities.

OBJECTIVE

To investigate the influence of CAI on neuromuscular characteristics around the knee during a stop-jump task.

DESIGN

Case-control study.

SETTING

Research laboratory. Participants or Other Participants: A total of 19 participants with self-reported unilateral CAI and 19 healthy control participants volunteered for this study.

INTERVENTION(S)

Participants performed double-legged, vertical stop-jump tasks onto a force plate, and we measured muscle activation around the knee of each limb.

MAIN OUTCOME MEASURE(S)

We calculated the integrated electromyography for the vastus medialis oblique, vastus lateralis, medial hamstrings, and lateral hamstrings muscles during the 100 ms before and after initial foot contacts with the force plate and normalized by the ensemble peak electromyographic value. Knee sagittal-plane kinematics were also analyzed during a stop-jump task.

RESULTS

Compared with control participants, the CAI group demonstrated greater prelanding integrated electromyographic activity of the vastus medialis oblique (CAI = 52.28 ± 11.25%·ms, control = 43.90 ± 10.13%·ms, t36 = 2.41, P = .021, effect size = 0.78, 95% confidence interval = 0.11, 1.43) and less knee-flexion angle at the point of initial foot contact (CAI = 7.81° ± 8.27°, control = 14.09° ± 8.7°, t36 = -2.28, P = .029, effect size = -0.74, 95% confidence interval = -1.38, -0.07) and at 100 ms post-initial foot contact (CAI = 51.36° ± 5.29°, control = 58.66° ± 7.66°, t36 = -3.42, P = .002, effect size = -1.11, 95% confidence interval = -1.77, -0.40). No significant results were noted for the other electromyographic measures.

CONCLUSIONS

We found altered feed-forward patterns of the vastus medialis oblique and altered postlanding knee sagittal-plane kinematics in the CAI group. These observations may provide insight regarding sensorimotor characteristics that may be associated with CAI.

Chiropractic care for foot drop due to peroneal nerve neuropathy

Peroneal nerve palsy is the most common entrapment neuropathy in the lower extremity, and the presentation of foot drop is a frequent initial manifestation of this disorder. This condition can have a marked influence on the patient's activities of daily living, and is classified as 'Impairment of Body Structure.' Current literature provides little direction to its evaluation and management, and the importance to differentially diagnose the causes of foot drop. Therefore, the purpose of this case report is to describe the application of chiropractic manipulative therapy, for a 14-year-old female with an insidious onset of foot drop.

Immediate effects of talocrural and subtalar joint mobilization on balance in the elderly

BACKGROUND AND PURPOSE

The aim of the present study was to evaluate the immediate effects of therapeutic mobilization of the talocrural and subtalar joints on ankle mobility and postural control in elderly subjects.

METHODS

Nineteen subjects (83.1 ± 6 years, 159 ± 1 cm; 56.1 ± 9.7 kg - mean ± standard deviation) participated in this study. The centre of pressure (COP) displacements along the anterior-posterior and medial-lateral axes was recorded in static and dynamic conditions on a force platform before and after therapeutic mobilization of the feet and ankles without blinding the subjects.

RESULTS

In static conditions, the sway area is reduced contrarily to dynamic conditions where the sway area is increased. In the two experimental sessions, subjects showed comparable COP displacements and the total length of the oscillations. Results demonstrated a significant improvement immediately after mobilization for ankle range of motion in dorsal flexion (right +4.7°; left +3.2°) and plantar flexion (right 5.2°; left +4.2°).

CONCLUSION

These results suggested that postural control is improved in static conditions and decreased in dynamic conditions. Therapeutic mobilization of feet and ankles in the elderly provides an immediate improvement in joint range of movement in dorsal and plantar flexion.

Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: a multicenter randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain.

BACKGROUND

An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP.

METHODS

Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time).

RESULTS

Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P ≤.001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group.

CONCLUSION

The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368).

LEVEL OF EVIDENCE

Therapy, level 1b-.

Musculoskeletal conditions of the foot and ankle: assessments and treatment options

Musculoskeletal conditions of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients' quality of life. Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle. This review provides a summary of the assessments and non-invasive treatment options based upon available evidence. Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance that may be evident in static and/or dynamic tasks. In addition, both clinical and epidemiological studies support the inter-dependence between the foot and proximal joints. For instance, aberrant foot structure has been linked to foot osteoarthritis (OA), as well as OA and pain at the knee and hip. Most recently, advances in motion capture technology and plantar load distribution measurement offer opportunities for precise dynamic assessments of the foot and ankle. In individuals with musculoskeletal conditions of the foot and ankle, the chief objectives of treatment are to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Given that most patients present with multiple impairments, combinational therapies that target foot-specific as well as global impairments have shown promising results. In particular, in individuals with rheumatoid arthritis and other rheumatic diseases, comprehensive rehabilitation strategies including early detection, foot-based interventions (such as orthoses) and wellness-based approaches for physical activity and self-management have been successful. While significant improvements have been made in the last decade to the assessment and treatment of foot and ankle conditions, few randomised clinical trials specifically have investigated patients with foot or ankle conditions to provide global insights into this area. Consequently, current recommendations vary based upon the scope of studies presented in this review as well as the strength of studies. This review indicates a need for more in-depth investigations into the components of assessment and treatment options for foot and ankle musculoskeletal conditions.

Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability

We examined the effect of a 2-week anterior-to-posterior ankle joint mobilization intervention on weight-bearing dorsiflexion range of motion (ROM), dynamic balance, and self-reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior-to-posterior joint mobilization treatments over 2 weeks. Weight-bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre-intervention), 24-48 h following the final treatment (post-intervention), and 1 week later (1-week follow-up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre-intervention measures or between the post-intervention and 1-week follow-up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week.

Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability.

BACKGROUND

Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function.

METHODS

Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21).

RESULTS

There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores.

CONCLUSIONS

The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing.

LEVEL OF EVIDENCE

Therapy, level 2b-.

Chronic ankle instability: diagnosis and treatment

BACKGROUND

Chronic ankle instability (CAI) is a very common injury but still remains an area of debate.

QUESTIONS

This review aims to define the current diagnosis and treatment of persons with CAI.

METHODS

A PubMed (MEDLINE) search of the years 2010 and 2011 (1 January 2010 to 15 July 2011) was performed using three keywords: ankle and chronic and instability. The number of articles in English language that was identified was 57.

RESULTS

Low reliability has been found in effectively testing CAI in a clinical setting. No single force-plate measure is very effective in predicting if an individual had CAI or not. Availability of a nonradiographic device (ankle arthrometer) to measure ankle instability could improve diagnostic accuracy and facilitate decision making in patients with CAI. The sensitivity of magnetic resonance imaging (MRI) may not be adequate to detect lesions in these patients before surgery. In a symptomatic patient, negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. Conservative treatment (rehabilitation, taping, brace) may reduce the occurrence of recurrent ankle sprains and may be effective in managing CAI. In patients with CAI, strengthening of the muscles around the ankle with well-planned proprioceptive exercises helped the patients return to normal living and sports activities, and prevents unnecessary surgery, especially in cases with functional instability. There is no consensus regarding optimum surgical treatment for CAI, but all of them often have good results.

CONCLUSIONS

Conservative treatment of patients with CAI must be the first-line therapy. Surgical treatment must be indicated only when conservative treatment fails.