Reference: Feldbrugge CM, Pathoomvanh MM, Powden CJ, Hoch MC. Joint mobilization and static stretching for individuals with chronic ankle instability: A pilot study. J Bodyw Mov Ther. 2019; 23(1): 194-201.
Abstracted by: Ryan Lasley PT, MPT, AT/L, COMT, NASM-CES/PES, Phoenix, AZ – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.
Context: Ankle sprains are prevalent in society and can be simple or complex in severity. Often ankle sprains evolve into chronic ankle instability (CAI) with long lasting negative effects on ankle range of motion (ROM), function, and quality of life. Numerous studies have touted both calf stretching and manual therapy as ways to improve on all limitations and impairments. Further research is needed to determine if one or both interventions are necessary for positive improvement. There is also a need to investigate the amount of time in which these interventions should be utilized in order to experience the positive gains desired.
Objective: The main focus of this study was to research the effect of talocrural joint dorsal mobilization and static calf stretching on dorsiflexion range of motion (DROM), health related quality of life reports (HRQL), and static and dynamic postural control via the star reach task.
Design: A randomized, non-control group, two-group pretest-posttest design.
Setting: A large public university.
Patients or Other Participants: Ten subjects (5 men, 5 women) voluntarily presented for the study. Demographic information included age of 24.4 ± 4.7years, height 172.1 ± 11.3 cm and weight 76.2 ± 17.1 kg.
Intervention(s): Static calf stretching was utilized daily for 4 weeks to address the soleus and gastrocnemius muscles. These stretches were performed once daily via a descriptive home exercise program (HEP) with the parameters 3 x 30 seconds hold for each stretch. Ankle talocrural anterior-posterior (AP) joint mobilizations were performed over the same 4-week period with either early implementation (first 2 weeks) or late implementation (last 2 weeks). First a 1-minute session of talocrural joint traction was applied to each ankle. Second, four 2-minute sessions of Maitland (grade III) AP joint mobilizations were performed. Between each set of Maitland AP mobilizations there was a 1-minute rest break.
Main Outcome Measure(s): Patient reported outcome (PRO) measures included the Disablement in the Physically Active Scale (DPA), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (FAAM-ADL) and Sport (FAAM-Sport) subscales, and the Fear Avoidance Belief Questionnaire (FABQ). DROM was measured using weight-bearing lunge technique (WBLT), in which the patient was placed into a lunge position with the patella touching the wall. The participants foot was moved posterior, away from the wall, in 1cm increments until the patella could not be maintained on the wall while the same heel sustained contact with the floor. Single-limb stance with eyes open and closed was used to assess static postural control while standing on a force plate for 10-seconds. The static postural control measure focused on Time To Boundary (TTB) calculations, which are based off of changes in participants’ foot Center of Pressure (COP) values while standing on the force plate. TTB values are basically changes in foot COP force values that are then broken down into sagittal and frontal plane vectors. These are used to help quantify a participant’s baseline, pre-intervention, and post-intervention balance capabilities. The researchers also calculated the means and standard deviations for the anterior-posterior and medial-lateral directions with the TTB calculations. Lastly, the star excursion balance test (SEBT-AR) was used to measure dynamic postural control. During this test the participants performed four practice trials and then three analysis trials in which reach distance was measured in centimeters and normalized to the participants leg length.
Results: There was no findings between the early- and late-mobilization groups at the end of this study. The WBLT score did demonstrate a significant improvement at post-intervention (baseline: 9.80 ± 4.16 cm, pre-intervention: 9.80 ± 3.60 cm, post-intervention: 11.20 ± 3.05 cm). The patient reported outcome measures FAAM-ADL (baseline – 88.45 ± 8.10, pre-intervention – 89.64 ± 5.59, post-intervention – 93.69 ± 5.24), DPA (baseline – 14.50 ± 9.57, pre-intervention – 16.00 ± 6.99, post-intervention – 11.80 ± 4.66), and FABQ-PA (baseline: 10.50 ± 2.55, pre-intervention: 10.4 ± 4.50, post-intervention: 7.7 ± 4.14) scores significantly improved at post-intervention. In the case of static and dynamic postural control, no significant differences were found in the post-intervention groups or between the early- and late-mobilization groups.
Conclusions: Patient’s experiencing chronic ankle instability (CAI) were found to experience significant improvement in self-reported ankle function, global well-being, and fear of re-injury when measured through numerous patient-reported outcome measures including the FAAM-ADL, DPA, and FABQ-PA. Significant improvement was also noted with ankle ROM from baseline measurements to post-intervention measurements regardless of the manual therapy intervention timing.
Clinical Impression: Patients following acute untreated ankle sprains may or may not eventually regain complete function.1 These types of patients may eventually develop CAI with a reduction in osteokinematic and arthrokinematic motion at the talocrural joint along with a reduction in neuromotor control with both static and dynamic balance activities. This reviewed article highlights the fact that rehabilitating the CAI patient is a complex endeavor. The use of manual therapy is effective at improving motion and self-reported quality of life and function as is seen through the WBLT and FAAM-ADL, DPA, and FABQ-PA, however neuromotor control was not positively impacted in this study. This contradicts other research that reported marked improvement in neuromotor control with the performance of single leg balance training in those with CAI.2 Consumers of this research article should make it a point to implement manual therapy into their treatment protocols with the purpose of improved osteokinematic and arthrokinematic motion only with no positive effect on neuromotor control.
Consistency of the Content: This article elaborates on the positive effect that manual therapy has on both osteokinematic and arthrokinematic motion when delivered to the talocrural joint by a licensed professional. This type of information is commonly taught in physical therapy curriculum along with continuing education courses and seminars. The article makes an interesting point that manual therapy alone is not enough to generate positive neuromotor control changes. The implementation of neuromotor control exercises is necessary to see positive static and dynamic postural control responses in patients experiencing CAI. This too, is consistent with physical therapy teachings.
- Anandacoomarasamy A., Barnsley L. Long term outcomes of inversion ankle injuries. Br. J. Sports Med. 2005; 39(3): e14.
- Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J. Orthop. Sports Phys. Ther. 2007; 37(6): 303e311.
Talocrural Joint Manual Physical Therapy Interventions