Ankle sprains are very common in the practice of sports physiotherapy. However, unfortunately many patients go on to have long term problems. This has lead to the development of many proposed treatments and rehabilitation programs. This article will discuss new research into the use of manual therapy techniques combined with exercises for the rehabilitation of inversion ankle sprains.
What Do We Know About Ankle Sprains?
Well, as previously mentioned, we know that they are very common. The annual incidence of ankle sprain injuries is 7 per 1000 people (Cleland et al., 2013). Fortunately, they respond well to conservative physiotherapy management. However, ongoing pain and symptoms at long-term followup is reportedly as high as 72% (Braun, 1999). Furthermore, reported re-injury rate is as high as 80% (Cleland et al., 2013)!
Obviously the simple ankle sprain is not as simple as many might suggest!
This means assessment of optimal treatment and rehabilitation still requires refinement! Previous research into recurrent inversion ankle sprains has identified dysfunctions at the following joints:
- Proximal tibiofibular (Beazell et al, 2012; Grindstaff et al., 2011)
- Distal tibiofibular (Hibbard & Hertel, 2008)
- Talocrural (Denegar et al., 2002)
- Subtalar joint (Greenman, 1996)
Therefore, you may suggest that manual therapy techniques aimed at correcting these ‘joint dysfunctions’ may be beneficial in the management of ankle injuries. This is highly warranted given the previous findings of the manual therapy benefit in restoring:
- Ankle dorsiflexion (Cleland et al., 2013)
- Posterior talar glide (Vicenzino et al., 2006)
- Step length (Green et al., 2001)
- Force distribution through the foot (López-Rodríguez et al., 2007)
- Pain (Cosby et al., 2011)
New Research on Manual Therapy for Inversion Ankle Sprains
Cleland et al (2013) randomised 74 patients into 2 groups to compare the effectiveness of a home exercise program (HEP) to an exercise and manual therapy (MTEX) based approach for inversion ankle sprains. Main inclusion criteria included:
- Current ankle symptoms (regardless of acute, subacute, chronic)
- Grade 1 or 2 sprain on the West Point Ankle Sprain Grading System (Gerber et al., 1998; Hockenbury & Sommarco, 2001)
- Age: 16 and 60 years
- Numeric pain rating scale (NPRS) score greater than 3/10 in the last week
- Negative Ottawa ankle rules
- Exhibited no contraindications to manual therapy
- Foot and Ankle Ability Measure (FAAM) ADL subscale (Martin et al., 2005)
- FAAM sports subscale
- Lower Extremity Functional Scale (LEFS) (Binkley et al., 1999)
- NPRS (Jensen et al., 1994)
- 15-point global rating of change (GRC)
Interventions for Inversion Ankle Sprains
7 experienced physical therapists participated in the study, and they all received training and a detailed manual of standard operations and procedures. These therapists implemented the following interventions.
Home Exercise Program
The subjects in the HEP group were seen by a physical therapist for 4 x 30 minute sessions (1 per week), with a focus on the exercise program and appropriate progressions. The exercise program was based on that outlined in previous research by Bassett and Prapavessis (2007). It is worth reading the original source (here) for a full program of exercises which included:
- ROM Exercises (foot and ankle)
- Gentle strengthening
- Band and body-weight resistance exercises
- Proprioception/balance exercises – including single leg stance and balance board
- Functional weight-bearing activities
Exercises were progressed and the discretion of the therapist based on clinical decision making and the individual patient.
Manual Therapy And Exercise Group
The subjects in the MTEX group were treated by a physical therapist twice weekly for 4 weeks, for a total of 8 x 30 minute sessions (yep, twice as many as the HEP). As well as the manual treatments shown below, the patients also performed the home exercise program and 2 additional self-mobilisation techniques at home (ankle eversion and weight- bearing dorsiflexion). The manual treatments included:
Proximal Tibiofibular Joint
Technique Summary: high velocity, end-range anterior force to the head of the fibula on the tibia
Distal Tibiofibular Joint
Technique Summary: low-velocity, mid- to end-range anterior-to-posterior oscillatory force to the distal fibula
Distraction Manipulation Technique Summary: high-velocity, end-range longitudinal traction force
Non-weight Bearing TC Mobilisation
Technique Summary: Low-velocity, mid- to end-range anterior-to-posterior oscillatory force to the talus on the distal tibiofibular joint
Technique Summary: Low-velocity, mid- to end-range medial-to-lateral oscillatory force to the medial side of the talus (or calcaneus)
Weight Bearing Talocrural Mobilisation
Technique Summary: Low-velocity, end-range anterior-to- posterior sustained glide to the talus in a weight-bearing position
Similar technique shown in the great video below!
Results of The Research
The authors found some great results! Of the 74 patients originally included, 65 (87.8%) completed the 6-month follow-up, although this was not significantly different between the two groups. At the 4 week follow-up period, the MTEX group had greater improvements in:
- FAAM ADL (mean difference = 11.7, 95% CI:7.4, 16.1 )
- FAAM Sports (mean difference = 13.3, 95% CI: 8.0, 18.6)
- LEFS (mean difference = 12.8, 95% CI: 9.1, 16.5)
- NPRS/Pain (mean difference = -1.2, 95% CI: -1.5, .-0.90)
At the 6 month follow-up the authors found that the MTEX groups scored better for the following outcomes:
- FAAM ADL (mean difference = 6.2, 95% CI: 0.98, 11.5)
- FAAM Sports (mean difference = 7.2; 95% CI: 2.6, 11.8)
- LEFS (mean difference = 8.1; 95% CI: 4.1, 12.1)
- NPRS/Pain (mean difference = –0.47; 95% CI: –0.90, –0.05)
- Recurrence Rate: whilst not statistically significant, there was a trend in favour of MTEX, with a recurrence of 3/33 (or 9.1%), compared to 5/32 (or 15.6%)
Clinical Implications of This Research
This study demonstrated that patients who underwent a multi-modal rehabilitation approach combining manual therapy and exercises achieved greater improvements in pain and function at both 4 weeks and 6 months when compared to those who performed a progressive home exercise program alone. However, the study authors are quick to point out that despite statistically significant differences the scores have wide 95% confidence intervals. This means that the majority of scores may not be greater than the minimal clinically important difference (worth thinking about).
Whilst you contemplate that, it is worth noting that the results of the current study are strengthened by the conclusions of the previous systematic review by Brantingham et al (2012). Both have concluded that a combined approach of manual therapy and exercise is effective for reducing pain and improving function at short-term follow-up.
Limitations of The Research
There are, as always, limitations to this research. These include:
- No treatment (control) or a placebo intervention group
- No therapist blinding (impossible)
- MTEX subjects spent twice as much time with a therapist than those in the HEP group
- As previously mentioned, wide confidence intervals question the clinical importance of findings
- No assessment or correlation with common objective clinical measures (such as ROM), would have been nifty to know..
- Treatment was not based on assessment findings, and I believe all joints were treated regardless of an identified dysfunction
What Are Your Thoughts On This Research?
Do you routinely use manual therapy in the management of inversion ankle sprains? Are there any techniques here that are new to you? I would love to know so be sure to let me know in the comments or you could:
Promote Your Clinic: Are you a physiotherapist or physical therapist looking to promote your own clinic? Check this out.
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