Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study

The effect of manual therapy on ankle dorsiflexion range of motion: A pilot crossover randomized trial

INTRODUCTION

Restricted ankle dorsiflexion is common after lower limb injury. The aim of this pilot study was to investigate the effect of passive ankle joint mobilization and calf muscle massage on ankle dorsiflexion range of motion in adults with residual restricted dorsiflexion. The secondary aim was to assess the methodology of the pilot study to inform a larger clinical trial.

METHOD

The study design was a randomized crossover trial with assessor blinding. Twenty-five healthy participants with a history of lower limb injury were included in the study. Ankle joint mobilization and calf muscle massage were applied for 5 min in a random order, one to two weeks apart. Ankle dorsiflexion was measured by using the weight-bearing lunge pre- and post-intervention (cm). Paired t-tests were used to analyze the effect of the manual therapy interventions on restricted ankles. A minimal detectable difference 95% (MMD95) was calculated. The pilot study was analyzed for suitability of inclusion criteria, blinding of assessors and the manual therapist, and the washout period.

RESULTS

A significant increase in dorsiflexion was demonstrated for ankle joint mobilization (change score = 0.51 ± 0.76, p = 0.003) and calf muscle soft tissue massage (change score = 0.91 ± 1.07, p < 0.001). There was no difference in change scores between manual therapy techniques (mobilization 0.51 ± 0.76, massage 0.91 ± 1.07, p = 0.12). Evaluation of the pilot study revealed limitations to be modified in future studies.

CONCLUSION

These preliminary data indicate ankle joint mobilization and calf muscle soft tissue massage had similar effects on increasing ankle dorsiflexion range of motion in ankles with residual dorsiflexion restriction.

Evaluation of arthrokinematics and posterior soft tissues of the ankle during ankle dorsiflexion using ultrasound

BACKGROUND

Arthrokinematics (caudal and posterior movements of the talus) and posterior soft tissues of the ankle during ankle dorsiflexion have not been objectively evaluated in detail. This study aimed to investigate the characteristics of arthrokinematics and posterior soft tissues of the ankle during ankle dorsiflexion using ultrasound.

METHODS

Thirteen healthy adults participated in the study. Participants whose passive dorsiflexion range of motion (ROM) of the ankle joint was <35° were classified as the restricted group (n = 6), and participants whose passive ankle dorsiflexion ROM was ≥35° were classified as the control group (n = 7). Passive ankle dorsiflexion was performed to measure the ankle arthrokinematics. Strain elastography was performed to measure the elasticity of the flexor hallucis longus (FHL) and Kager's fat pad (KFP) at each dorsiflexion angle.

RESULTS

A significant difference in the posterior movement of the talus at the ankle dorsiflexion of 30° was observed between the two groups (P = 0.04). The elasticity of the restricted group was increased at all angles in both FHL and KFP (P < 0.05).

CONCLUSION

This study showed that it is possible to objectively evaluate the direction of ankle arthrokinematics and posterior ankle soft-tissue restrictions using ultrasound.

Talus mobilization-based manual therapy is effective for restoring range of motion and enhancing balance in older adults with limited ankle mobility: A randomized controlled trial

BACKGROUND

The ankle plays a key role in balance, but ankle range of motion decreases with ageing.

RESEARCH QUESTION

To establish whether a talus mobilization-based manual therapy intervention may be effective for increasing range of motion and balance in older adults with limited ankle mobility due to the ageing process.

METHODS

Randomized clinical trial in which 42 community-dwelling older adults with limited ankle mobility were allocated to an experimental or a control group. The experimental intervention consisted of six sessions of anteroposterior talus mobilization, whereas the control intervention was a sham treatment. Baseline change in weight and non-weight bearing ankle range of motion (ROM), balance outcome in terms of the Timed up and go (mobility and dynamic balance), Single-leg stand (static balance and stability), Functional reach (margins of stability) and Romberg tests (static balance) were assessed. Analysis of variance based on a mixed-linear model of repeated measures looked for group interactions.

RESULTS

Forty participants completed the study. Participants who received six sessions of manual therapy showed greater improvements in the Timed up and go, Functional reach and Single-leg stand tests than participants who received a sham intervention (p < 0.001). Both groups presented similar performance in post-treatment static balance measures (p > 0.05).

SIGNIFICANCE

An anteroposterior talus mobilization-based manual therapy intervention is effective for increasing ankle ROM, with a positive effect on dynamic balance, mobility and stability in community-dwelling older adults with limited ankle mobility.

Increased Ankle Range of Motion Reduces Knee Loads During Landing in Healthy Adults

Decreased dorsiflexion range of motion (DROM) can be modified using static stretching and joint mobilizations and may attenuate known knee anterior cruciate ligament injury risk factors. It is not known how these interventions compare to each other and how they improve knee landing mechanics. This study's purpose was to determine the immediate effects of static stretching and joint mobilization interventions on DROM measurement changes and right-leg drop jump knee landing mechanics. Eighteen females and 7 males, all recreationally active, completed 2 study sessions. Active and passive DROM, the weight-bearing lunge test, the anterior reach portion of the Star Excursion Balance Test, and a right-leg drop jump landing task were completed before and after the intervention. Change in DROM (ΔDROM) was calculated for DROM assessments between preintervention and postintervention. Pairwise dependent t tests determined no differences in ΔDROM between interventions, and statistical parametric mapping determined increased knee flexion (P = .004) and decreased anterior shear force (P = .015) during landing after both interventions. Increased DROM improves sagittal plane displacement and loading at the knee. Stretching may be a more feasible option in a healthy population for those wanting to maintain range of motion and decrease knee injury risk without physical therapist involvement.

The Implementation of Therapeutic Alliance in the Rehabilitation of an Elite Pediatric Athlete with Salter-Harris Fracture: A Case Report

BACKGROUND/PURPOSE

Although research on the value of therapeutic alliance is prominent in other areas of health care, physical therapy research is limited. The purpose is to describe the incorporation of therapeutic alliance concepts throughout the rehabilitation of an elite pediatric athlete with a complicated recovery following a fracture to the distal femoral epiphysis.

CASE DESCRIPTION

A 14-year-old male was referred to physical therapy following an open reduction and internal fixation to address a type IV Salter-Harris fracture of the right distal femoral epiphysis. Post-operative care included immobilization in a brace for six weeks and he initiated physical therapy for four weeks (post-op weeks 6-10). At 10-weeks post-injury his range of motion and strength were severely limited compared to expected post-operative milestones. Due to these deficits an arthroscopic debridement of the subject's right knee, hardware removal, and manipulation under anesthesia was performed. The subject then reported to the physical therapist on post-operative day three for evaluation and treatment without bracing or weight-bearing restrictions.

OUTCOMES

The episode of care spanned 17 weeks and included 25 physical therapy sessions. To facilitate therapeutic alliance with the subject, clear communication and easily measurable goals were established and connected to the subject's relevant needs as an athlete. The plan of care was divided into three phases using "chunking" techniques to establish the rehabilitation priorities. The subject demonstrated improved range of motion, strength and was able to return to hydroplane racing and won a national championship in his age group.

DISCUSSION

The unique aspect of this case was the incorporation of therapeutic alliance concepts and techniques into the rehabilitative management of a subject with a complicated fracture to the distal femoral epiphysis. The physical therapist built trust with the subject and facilitated a successful return to elite hydroplane boat racing.

LEVEL OF EVIDENCE

4.

STUDY DESIGN

Case Report.

Back foot influence on dorsiflexion using three different positions of the weight bearing lunge test

OBJECTIVES

To determine whether back foot (BF) position influences dorsiflexion range of motion (DFROM) during three different positions of the weight bearing lunge test (WBLT).

DESIGN

Randomised, repeated measures design.

SETTING

Sports clubs.

PARTICIPANTS

52 athletes participating in cutting and pivoting sports.

MAIN OUTCOME MEASURES

DFROM was obtained using a WBLT in three different BF positions: BF heel in full contact with the floor, BF heel raised off the floor and BF was non weight bearing (NWB). All measurements were obtained using three methods: inclinometer at the tibial tuberosity, toe to wall distance and goniometer angle from the lateral malleolus to the fibula head. Differences between testing positions were determined using a repeated measures one-way ANOVA and reliability analysis was performed using the Intraclass Correlation Coefficient (ICC).

RESULTS

DFROM was statistically significantly different for all three positions of the WBLT for each measurement technique (P < .001). These results were associated with large effect sizes for all BF positions and measurement techniques. Reliability ICC values were excellent for all measurements (ICC 0.94-0.99).

CONCLUSIONS

Results show that DFROM differs depending upon the position of the BF during the WBLT. Further research is needed to establish the reproducibility of these three BF positions due to the variability observed.

Acute Effects of Increased Joint Mobilization Treatment Duration on Ankle Function and Dynamic Postural Control in Female Athletes With Chronic Ankle Instability

Background:

Chronic ankle instability (CAI) is linked to mechanical and functional insufficiencies. Joint mobilization is purported to be effective at treating these deficits.

Purpose:

To examine the effect of different treatment durations of a grade IV anterior-to-posterior ankle joint mobilization on weightbearing dorsiflexion range of motion (WB-DFROM), posterior talar glide (PG), and dynamic postural control in individuals with CAI.

Study Design:

Controlled laboratory study.

Methods:

A total of 48 female athletes (mean age, 22.8 ± 4.8 years) with unilateral CAI participated in this study. Participants were randomly assigned to 1 of 3 treatment conditions: 30 seconds, 60 seconds, and 120 seconds. Treatment was provided to the injured limb on 3 separate occasions 48 hours apart and consisted of a Maitland grade IV anterior-to-posterior talar joint mobilization based on the participant’s initial group assignment. WB-DFROM; PG; and the anterior (ANT), posteromedial (PM), and posterolateral (PL) reach directions of the Star Excursion Balance Test were measured bilaterally before and after each treatment. The uninjured limb acted as a control. Data were analyzed using 2-way mixed-model analyses of variance, and effect sizes were calculated through use of Hedges g.

Results:

Significant differences were detected after all treatment sessions for all outcome measures (P ≤ .001) and between treatment groups after sessions 1, 2, and 3 for all outcome measures (P ≤ .001). Effect sizes were very large or huge for all treatment groups for WB-DFROM, PG, and ANT reach direction. Substantial variation was found in effect sizes for PM and PL measures.

Conclusion:

Accessory mobilization is an effective treatment to induce acute changes in ankle motion and dynamic postural control in patients with CAI, with longer treatment durations conferring greater improvements.

Clinical Relevance:

This study adds clarity to the use of joint mobilization treatments and will add to the current clinical practice strategy for patients with CAI.

A Randomized Controlled Trial Assessing the Evolution of the Weight-Bearing Ankle Dorsiflexion Range of Motion Over 6 Sessions of Talus Mobilizations in Older Adults

BACKGROUND

Ankle range of motion declines with age, affecting mobility and postural control.

OBJECTIVE

The objective of this study was to investigate the effects of a talus mobilization-based intervention among healthy community-dwelling older adults presenting with limited weight-bearing ankle dorsiflexion range of motion and determine how ankle mobility evolved over the treatment.

DESIGN

This was a randomized clinical trial.

SETTING

This study was conducted in an outpatient clinic.

PARTICIPANTS

Community-dwelling, older adults over 60 years of age who had limited ankle mobility participated in this study.

INTERVENTIONS

The experimental intervention consisted of 6 sessions of manual therapy applied in the ankle joint. The control group received the same volume of sham treatment.

MEASUREMENTS

The primary outcome was the weight-bearing ankle dorsiflexion range of motion as measured using the lunge test. Data were collected at 9 time points: baseline, after each session, and follow-up.

RESULTS

A total of 36 participants were analyzed. A single session of mobilization increased ankle range of motion by 8 degrees (95% confidence interval = 6 to 11). At the end of the sixth session, this effect had increased slightly to 11 degrees (95% confidence interval = 9 to 13). Significant between-group differences were found throughout the intervention.

LIMITATIONS

Optimal dose and effects from follow-up evaluations for treatment volumes of fewer than 6 sessions remain unknown.

CONCLUSIONS

Six sessions of a talus mobilization-based intervention in healthy community-dwelling older adults found that the greatest mobility gain in terms of the weight-bearing ankle dorsiflexion range of motion is produced after the first session. Additional sessions produce smaller improvements with a slight upward trend. Importantly, the restoration of joint mobility is enhanced over time after the end of the intervention.

Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial

BACKGROUND

Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients.

OBJECTIVES

To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture.

METHODS

In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling.

RESULTS

There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -86.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%.

CONCLUSION

A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation.

LEVEL OF EVIDENCE

Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310-319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864.

Physical Impairments in Adults With Ankle Osteoarthritis: A Systematic Review and Meta-analysis

Study Design Systematic review with meta-analysis. Background Lower-limb osteoarthritis (OA) is associated with pain and reduced function. Most research focuses on hip and knee OA- related impairments; consequently, impairments that characterize ankle OA are not well understood. Objective To systematically review available evidence of physical impairments in individuals with ankle OA. Methods A comprehensive search of electronic databases was conducted from their inception to July 2017. Studies were screened using predefined inclusion/exclusion criteria. Studies that compared physical measures (excluding gait) between individuals with ankle OA and healthy controls or the unaffected ankle were included. Two reviewers rated studies for quality. Meta-analyses with random effects were conducted when appropriate. Results Of 4565 identified studies (563 participants), 8 satisfied the inclusion criteria and 3 studies were included in meta-analyses. All studies evaluated a range of impairments at end-stage OA, and exhibited poor reporting of missing data, assessor blinding, and measurement validity. Meta-analyses revealed large impairments of ankle sagittal plane motion and strength. Evidence from single studies indicated large deficits of ankle frontal plane motion and strength, talar translation and rotation on arthrometry, balance, and electromyography of ankle joint muscles. There were also abnormal bony alignments and greater fatty infiltrate in all calf muscle compartments. Conclusion The results of this literature review suggest significant ankle motion, strength, and functional impairments in individuals with ankle OA. The strength of the conclusions is limited, due to the small number and methodological limitations of published studies. Level of Evidence Symptom prevalence, level 1a. J Orthop Sports Phys Ther 2018;48(6):449-459. Epub 7 Apr 2018. doi:10.2519/jospt.2018.7569.

Effects of central and unilateral posteroanterior mobilization on cervical lordosis, muscle stiffness and ROM in patient with ankylosing spondylitis: case study

[Purpose] The aim of this study was to determine the effects of central and unilateral posteroanterior (PA) mobilization on cervical lordosis, muscle stiffness and range of motion in a patient with ankylosing spondylitis (AS). [Subject and Methods] The subject of this case study was diagnosed with AS in 1997. At baseline, variance was measured without any intervention during the first 3 days (2016.6.13-2016.6.15). Cervical PA mobilization was applied to each segment from C2-C7 from the 4th to the 11th day for 8 days. Intervention was not performed from the 12th to the 15th days for 4 days. Variances were measured a final time without intervention on the 16th day (2016.6.28). [Results] Cervical lordosis was seen to have increased. Muscle stiffness was significantly decreased after intervention and the effect of treatment lasted for five days without any additional intervention. The cervical flexion and extension angles were increased. However these increases were not statistically significant. Both the lateral flexion and left rotation angle were significantly increased and the effects of treatment lasted for five days without any additional intervention. [Conclusion] These results suggest that central and unilateral PA mobilization is effective in increasing cervical lordosis and range of motion, and decreasing muscle stiffness in patients with AS.

JOINT MOBILIZATION IN THE MANAGEMENT OF PERSISTENT INSERTIONAL ACHILLES TENDINOPATHY: A CASE REPORT

BACKGROUND & PURPOSE

Insertional Achilles tendinopathy (IAT) can be a challenging condition to manage conservatively. Eccentric exercise is commonly used in the management of chronic tendinopathy; however, it may not be as helpful for insertional tendon problems as compared to mid-portion dysfunction. While current evidence describing the physical therapy management of IAT is developing, gaps still exist in descriptions of best practice. The purpose of this case report is to describe the management of a patient with persistent IAT utilizing impairment-based joint mobilization, self-mobilization, and exercise.

CASE DESCRIPTION

A 51-year-old male was seen in physical therapy for complaints of posterior heel pain and reduced running capacity. He was seen by multiple physical therapists previously, but reported continued impairment, and functional restriction. Joint-based non-thrust mobilization and self-mobilization exercise were performed to enhance his ability to run and reduce symptoms.

OUTCOMES

The subject was seen for four visits over the course of two months. He made clinically significant improvements on the Foot and Ankle Activity Measure and Victorian Institute of Sport Assessment-Achilles tendon outcomes, was asymptomatic, and participated in numerous marathons. Improvements were maintained at one-year follow-up.

DISCUSSION

Mobility deficits can contribute to the development of tendinopathy, and without addressing movement restrictions, symptoms and functional decline related to tendinopathy may persist. Joint-directed manual therapy may be a beneficial intervention in a comprehensive plan of care in allowing patients with chronic tendon changes to optimize function.

LEVEL OF EVIDENCE

Therapy, Level 4.

Relationships between mechanical joint stability and somatosensory function in individuals with chronic ankle instability

BACKGROUND

Individuals with chronic ankle instability (CAI) have demonstrated alterations in ankle mechanics and deficits in sensory function. However, relationships between mechanical stability and somatosensory function have not been examined, nor have those between somatosensory function and injury history characteristics. Therefore, the objective of this study was to examine relationships between (1) somatosensory function and mechanical stability and (2) somatosensory function and injury history characteristics.

METHODS

Forty adults with CAI volunteered to participate. In a single testing session, participants completed mechanical and sensory assessments in a counterbalanced order. Dependent variables included anterior/posterior displacement (mm), inversion/eversion rotation (°), SWM index values, JPS absolute error (°), number of previous ankle sprains, and number of "giving way" episodes in the previous 3 months. Spearman's Rho correlations examined the relationships between somatosensory function and (1) mechanical stability and (2) injury history characteristics (p<0.05).

RESULTS

No significant correlations were identified between any variables (p>0.11), and all r-values were considered weak.

CONCLUSIONS

These results revealed somatosensory function was not significantly correlated to mechanical stability or injury history characteristics. This indicates peripheral sensory impairments associated with CAI are likely caused by factors other than mechanical stability and injury history characteristics.

The influence of gastrocnemius stretching combined with joint mobilization on weight-bearing ankle dorsiflexion passive range of motion

[Purpose] The purpose of this study was to investigate the effect of gastrocnemius stretching combined with talocrural joint mobilization on weight-bearing ankle dorsiflexion passive range of motion. [Subjects] Eleven male subjects with bilateral limited ankle dorsiflexion passive range of motion with knee extended participated in this study. [Methods] All subjects received talocrural joint mobilization while performing gastrocnemius stretching. Ankle dorsiflexion passive range of motion was measured using an inclinometer under weight-bearing conditions before and immediately after intervention. A paired t-test was used to analyze the difference between weight-bearing ankle dorsiflexion passive range of motion pre- and post-intervention. [Results] A significant increase in weight-bearing ankle dorsiflexion passive range of motion was found post-intervention compared with pre-intervention. [Conclusion] These findings demonstrate that gastrocnemius stretching combined with joint mobilization is effective for increasing weight-bearing ankle dorsiflexion passive range of motion.

Immediate combined effect of gastrocnemius stretching and sustained talocrural joint mobilization in individuals with limited ankle dorsiflexion: A randomized controlled trial

BACKGROUND

Although gastrocnemius stretching and talocrural joint mobilization have been suggested as effective interventions to address limited ankle dorsiflexion passive range of motion (DF PROM), the effects of a combination of the two interventions have not been identified.

OBJECTIVE

The aim of the present study was to compare the effects of gastrocnemius stretching combined with joint mobilization and gastrocnemius stretching alone.

DESIGN

A randomized controlled trial.

METHODS

In total, 24 individuals with limited ankle DF PROM were randomized to undergo gastrocnemius stretching combined with joint mobilization (12 feet in 12 individuals) or gastrocnemius stretching alone (12 feet in 12 individuals) for 5 min. Ankle kinematics during gait (time to heel-off and ankle DF before heel-off), ankle DF PROM, posterior talar glide, and displacement of the myotendinous junction (MTJ) of the gastrocnemius were assessed before and after the interventions. The groups were compared using two-way repeated measures analysis of variance.

RESULTS/FINDINGS

Greater increases in the time to heel-off and ankle DF before heel-off during gait and posterior talar glide were observed in the stretching combined with joint mobilization group versus the stretching alone group. Ankle DF PROM and displacement of the MTJ of the gastrocnemius were increased significantly after the interventions in both groups, with no significant difference between them.

CONCLUSIONS

These findings suggest that gastrocnemius stretching with joint mobilization needs to be considered to improve ankle kinematics during gait.

Increased treatment durations lead to greater improvements in non-weight bearing dorsiflexion range of motion for asymptomatic individuals immediately following an anteroposterior grade IV mobilisation of the talus

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.

Three-dimensional analysis of foot motion after uphill walking with mobilization with movement using tape applied to the talocrural joint in women with limited ankle dorsiflexion

BACKGROUND

Previous studies that investigated mobilization with movement (MWM) treatment assessed only improvements in passive range of motion (ROM). No information is currently available regarding the efficacy of modified MWM by application of tape. Therefore, we investigated the effect of uphill walking with modified MWM using tape applied to the talocrural joint (uphill walking with MWM taping) in women with limited ankle dorsiflexion.

METHODS

Twelve feet of 12 women with ankle dorsiflexion < 8 degrees were studied. Passive ROM measured using a goniometer was used to select participants. Participants walked on a level walkway under 3 conditions: before exercise, after uphill walking, and after uphill walking with MWM taping. The Oxford Foot Model using 3D motion analysis system was used to examine dynamic foot kinematics, and statistical significance was determined by 1-way repeated-measures analysis of variance.

RESULTS

After uphill walking with MWM taping, peak hindfoot dorsiflexion relative to the tibia was significantly greater than that before exercise and after uphill walking. Furthermore, peak forefoot plantarflexion relative to the hindfoot, peak hindfoot plantarflexion relative to the tibia, and backward tilt of the tibia were greater than those before exercise.

CONCLUSIONS

Uphill walking with MWM taping resulted in an immediate alteration in foot motion during walking, increasing hindfoot dorsiflexion in particular.

CLINICAL RELEVANCE

Further studies are needed to investigate the long-term effects of uphill walking with MWM taping and its potential use in rehabilitation training.

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.

Active ankle motion may result in changes to the talofibular interval in individuals with chronic ankle instability and ankle sprain copers: a preliminary study

INTRODUCTION

Alterations in talocrural joint arthrokinematics related to repositioning of the talus or fibula following ankle sprain have been reported in radiological and clinical studies. It is unclear if these changes can result from normal active ankle motion. The study objective was to determine if active movement created changes in the sagittal plane talofibular interval in ankles with a history of lateral ankle sprain and instability.

METHODS

Three subject groups [control (n = 17), ankle sprain copers (n = 20), and chronic ankle instability (n = 20)] underwent ultrasound imaging of the anterolateral ankle gutter to identify the lateral malleolus and talus over three trials. Between trials, subjects actively plantar and dorsiflexed the ankle three times. The sagittal plane talofibular interval was assessed by measuring the anteroposterior distance (mm) between the lateral malleolus and talus from an ultrasound image. Between group and trial differences were analyzed with repeated measures analysis of variance and post-hoc t-tests.

RESULTS

Fifty-seven subjects participated. A significant group-by-trial interaction was observed (F4,108 = 3.5; P = 0.009). The talofibular interval was increased in both copers [2.4±3.6 mm; 95% confidence interval (CI): 0.73-4.1; P = 0.007] and chronic ankle instability (4.1±4.6 mm; 95% CI: 1.9-6.2; P = 0.001) at trial 3 while no changes were observed in control ankle talar position (0.06±2.8mm; 95% CI: -1.5-1.4; P = 0.93).

DISCUSSION

The talofibular interval increased only in subjects with a history of lateral ankle sprain with large clinical effect sizes observed. These findings suggest that an alteration in the position of the talus or fibula occurred with non-weight bearing sagittal plane motion. These findings may have diagnostic and therapeutic implications for manual therapists.

Normal sensory and range of motion (ROM) responses during Thoracic Slump Test (ST) in asymptomatic subjects

The purpose of the study was to determine the normal sensory and range of motion (ROM) responses during the movement components of Thoracic Slump Test (Thoracic ST) in asymptomatic subjects. Sixty asymptomatic subjects were included in the study. Thoracic ST was performed in two sequences, proximal initiation, which was proximal to distal and distal initiation, which was distal to proximal. Subjects were randomized into four groups depending on the order of sequences and sides. Outcome measures of sensory responses (intensity, type, and location) and ROM responses were recorded after each sequence. Friedman's test was done to compare between sensory responses of the subjects. Between-component comparison for prevalence of sensory responses within each sequence was done using Kruskal-Wallis test and Wilcoxonsigned ranks test was used for between-component comparisons of intensity of symptoms within each sequence of testing. Independent t test was used to assess the ROM responses. Results show the prevalence of sensory responses, its nature, area and intensity. These sensory and ROM responses may be considered as normal response of Thoracic ST. The intensity of the symptoms of proximal initiation sequence (1.09±1.35 cm) was significant (P<0.05) when compared to distal initiation sequence (0.08±1.26 cm). The change in the ROM was significant (P<0.05) for distal initiation (7.55±4.51 degrees) when compared to proximal initiation (4.96±3.76 degrees). These normal responses may be used as a reference when using the Thoracic ST as an assessment technique.

Therapeutic interventions for increasing ankle dorsiflexion after ankle sprain: a systematic review

CONTEXT

Clinicians perform therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, authors of previous studies have not determined which intervention or combination of interventions is most effective.

OBJECTIVE

To determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain.

DATA SOURCES

We performed a comprehensive literature search in Web of Science and EBSCO HOST from 1965 to May 29, 2011, with 19 search terms related to ankle sprain, dorsiflexion, and intervention and by cross-referencing pertinent articles.

STUDY SELECTION

Eligible studies had to be written in English and include the means and standard deviations of both pretreatment and posttreatment in patients with acute, subacute, or chronic ankle sprains. Outcomes of interest included various joint mobilizations, stretching, local vibration, hyperbaric oxygen therapy, electrical stimulation, and mental-relaxation interventions.

DATA EXTRACTION

We extracted data on dorsiflexion improvements among various therapeutic applications by calculating Cohen d effect sizes with associated 95% confidence intervals (CIs) and evaluated the methodologic quality using the Physiotherapy Evidence Database (PEDro) scale.

DATA SYNTHESIS

In total, 9 studies (PEDro score = 5.22 ± 1.92) met the inclusion criteria. Static-stretching interventions with a home exercise program had the strongest effects on increasing dorsiflexion in patients 2 weeks after acute ankle sprains (Cohen d = 1.06; 95% CI = 0.12, 2.42). The range of effect sizes for movement with mobilization on ankle dorsiflexion among individuals with recurrent ankle sprains was small (Cohen d range = 0.14 to 0.39).

CONCLUSIONS

Static-stretching intervention as a part of standardized care yielded the strongest effects on dorsiflexion after acute ankle sprains. The existing evidence suggests that clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions. Investigators should examine the relationship between improvements in dorsiflexion and patient progress using measures of patient self-reported functional outcome after therapeutic interventions to determine the most appropriate forms of therapeutic interventions to address ankle-dorsiflexion limitation.

Bilateral tarsal coalition in a National Collegiate Athletic Association Division I basketball player: a case report

OBJECTIVE

To present a case of bilateral subtalar joint coalition in a National Collegiate Athletic Association Division I basketball player and the treatment plan that was used to manage the coalition from the beginning of conference play through the postseason.

BACKGROUND

A 20-year-old male basketball athlete (height = 182.8 cm, mass = 83.4 kg) presented with bilateral subtalar joint tarsal coalition that became symptomatic in 2006 and resulted in constant pain with any form of activity.

DIFFERENTIAL DIAGNOSIS

Traumatic injury of the talocalcaneal joint.

TREATMENT

Nonsurgical intervention of conservative therapy was elected.

UNIQUENESS

Less than 13% of the overall population is affected with tarsal coalition, so it is safe to assume that very few athletes competing at the collegiate or elite level suffer from this condition. This is the first report in the literature to document conservative manual therapies used to manage the symptoms of subtalar joint tarsal coalition in a Division I basketball player.

CONCLUSIONS

After the intensive treatment program for tarsal coalition was implemented, the patient experienced pain relief and was able to continue to compete at a competitive level. This case represents the need to further explore and document a conservative treatment protocol for tarsal coalition.

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.

Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain

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.

Immediate effects of bilateral grade III mobilization of the talocrural joint on the balance of elderly women

OBJECTIVE

The purpose of this study was to evaluate the immediate effects of a single treatment session of bilateral grade III mobilization of the talocrural joint on the balance of elderly women.

METHODS

Thirty-two elderly women (age, 65-80 years) with low physical activity levels completed balance evaluation using baropodometry, the Functional Reach Test and the Timed Up and Go Test, and plantar flexion and dorsiflexion range of motion (ROM), before and immediately after the mobilization (n = 16) or sham (n = 16). Each subject was submitted to a total of twelve 30-second grade III mobilizations, 6 for each ankle, in a single treatment session.

RESULTS

No significant difference was found for intragroup and intergroup comparisons in the balance of elderly women during the following evaluations: Functional Reach Test (P = .851), Timed Up and Go Test (P = .653), anteroposterior oscillation with eyes opened (P = .333) and with eyes closed (P = .652), and mediolateral oscillation with eyes opened (P = .486) and with eyes closed (P = .602). In addition, no significant difference was observed in right (P = .881) and left (P = .060) plantar flexion ROM and in right (P = .540) and left (P = .341) dorsiflexion ROM.

CONCLUSION

The results of this study suggest that a single session of bilateral grade III mobilization of the talocrural joint does not immediately improve balance and ROM in elderly women with low physical activity levels.

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-.

Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability

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.

Dorsiflexion range of motion significantly influences dynamic balance

The purpose of this study was to examine the relationships between dorsiflexion range of motion on the weight-bearing lunge test (WBLT) and normalized reach distance in three directions on the Star Excursion Balance Test (SEBT). Thirty-five healthy adults (14 males, 21 females, age: 25.9±6.7 years, height: 166.7±22.9 cm, weight: 76.7±22.8 kg) participated. All subjects performed three trials of maximum lower extremity reach in the anterior, posteromedial, and posterolateral directions of the SEBT on each limb to assess dynamic balance. Subjects performed three trials of the WBLT to measure maximum dorsiflexion range of motion. Dependent variables included the means of the SEBT normalized reach distances in the anterior, posteromedial, and posterolateral directions and the mean of the WBLT. Only the anterior direction (mean: 79.0±5.8%) of the SEBT was significantly related to the WBLT (mean: 11.9±2.7 cm), r=0.53 (p=0.001). The r² for this simple linear regression was 0.28, indicating that the WBLT explained 28% of the variance in the anterior normalized reach distance. The WBLT explained a significant proportion of the variance within the anterior reach distance signifying this direction of the SEBT may be a good clinical test to assess the effects of dorsiflexion range of motion restrictions on dynamic balance.

Ankle sprain: pathophysiology, predisposing factors, and management strategies

With the high percentage (up to 75%) of initial lateral ankle sprains (LAS) leading to repetitive sprains and chronic symptoms, it is imperative to better understand how best to treat and rehabilitate LAS events. The purpose of this paper is to review LAS pathophysiology, predisposing factors, and the current evidence regarding therapeutic modalities and exercises used in the treatment of LAS. Functional rehabilitation, early mobilization with support, is the current standard of care for LAS. However, the high percentage of reinjury occurrence and development of chronic symptoms (up to 75%) after a LAS, suggests the current standard of care may not be effective. Recent evidence has shown the need for more stringent immobilization to facilitate ligament healing and restoration of joint stability and function after a LAS. Additionally, the importance of adding adjunctive therapies, specifically joint mobilizations and balance training have been shown to improve function and decrease the incidence of reinjury after a LAS. Modifying current rehabilitation protocols to include protecting the ankle joint with stringent immobilization, and including joint mobilizations and balance training may be the first step to decreasing the incidence of short and long term ankle joint dysfunction.