Manual Therapy for Inversion Ankle Sprains -The Sports Physiotherapist

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)

The short term benefits of this approach have been identified in a previous systematic review by Brantingham et al (2012), however, no long-term support could be identified. This is where new research from Cleland et al (2013) comes in.

Sports Physiotherapist | Sports Physiotherapy | Physical Therapy

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
Outcomes Assessed

The outcome measures were assessed at baseline and at 4-week and 6-month follow-up:
  • 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

Talocrural Joint

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

Subtalar 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.


Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc 1999;31:1176-1182

Bassett SF, Prapavessis H. Home-based physical therapy intervention with adherence-enhancing strategies versus clinical-based management for patients with ankle sprains. Phys Ther. 2007;87:1132-1143

Beazell JR, Grindstaff TL, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2012;42:125-134

Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79:371-383.

Brantingham JW, Bonnefin D, Perle SM, et al. Manipulative therapy for lower extremity conditions: update of a literature review. J Manipulative Physiol Ther. 2012;35:127-166

Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med. 1999;8:143-148.

Cleland JA, Mintken P, McDeviit A, Bieniek M, Carpenter K, Kulp K, Whitman JM. Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: A multicenter randomized clinical trial. J Orthop Sports Phys Ther 2013;43(7):443-455.

Cosby NL, Koroch M, Grindstaff TL, Parente W, Hertel J. Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain. J Man Manip Ther. 2011;19:76-83.

Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32:166-173.

Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examina- tion of an athletic population. Foot Ankle Int. 1998;19:653-660

Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive acces- sory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81:984-994.

Greenman P. Principles of Manual Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.

Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability. J Electromyogr Kinesiol. 2011;21:652-658.

Hockenbury RT, Sammarco GJ. Evaluation and treatment of ankle sprains: clinical recommendations for a positive outcome. Phys Sportsmed. 2001;29:57-64.

Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008;13:63-67.

Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994;58:387-392.

López-Rodríguez S, Fernández-de-las-Peñas C, Alburquerque-Sendín F, Rodríguez-Blanco C, Palomeque-del-Cerro L. Immediate ef- fects of manipulation of the talocrural joint on stabilometry and baropodometry in patients with ankle sprain. J Manipulative Physiol Ther. 2007;30:186-192.

Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26:968-983.

Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. J Orthop Sports Phys Ther. 2006;36:464-471

Photo CreditMarc Di Luzio