Individuals with inversion ankle sprains have been shown to improve from manual therapy, exercise, or even just rest depending on the severity of the sprain.  The important thing to consider is the potential for recurrence which is high after the initial incident (about 80% according to Cleland et al.).  So how can we improve that statistic?

Studies have shown that manual therapy techniques (thrust and nonthrust) improved ankle dorsiflexion, posterior talar glide, stride speed, step length, the distribution of forces through the foot, and pain level.  I came across a couple articles that talked about mobilization and manipulation treatments to improve physical performance after an inversion ankle sprain.  The article by Whitman et al. developed a Clinical Prediction Rule to identify individuals who would benefit from manual therapy (mobilizations and manipulations) and exercise.  There are 4 variables that they have clustered together; 1. If the symptoms are worse with standing, 2. If symptoms are worse in the evening, 3. A navicular drop greater than or equal to 5mm, and 4. The presence of distal fibular joint hypomobility.  The success rate for individuals with 1/4 variables is 50%, 2/4 variables is 78%, 3/4 variables is 95%, and 4/4 variables is 56%.

CPR

(Whitman JM, Cleland JA, Mintken P, Keirns M, Bieniek ML, Albin SR, et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Phys Ther. 2009; 39(3):188-200.)

The other two articles showed the benefit of using mobilizations and manipulations for inversion ankle sprains.  The first article by Wassinger et al. assessed the benefit of using a rearfoot distraction manipulation for improving balance.  They found that the individuals receiving the manipulation had significant improvement with single leg stance and reach with the contralateral leg with the greatest improvement in a posterior-medial direction.

rearfoot manipulation

(Wassinger CA, Rockett A, Pitman L, Murphy MM, Peters C. Acute effects of rearfoot manipulation on dynamic standing balance in healthy individuals. Man Ther. 2014; 19: 242-245.)

The second article by Cleland et al. had a more comprehensive intervention protocol and will be the primary focus of this post.  They treated subjects with Manual Therapy and Exercise for 8 sessions (2x/week for 4 weeks) and sessions lasted for about 30 minutes.  They used:

1. High-velocity mobilization to the proximal tibiofibular joint

Proximal fibular mob

2. High-velocity longitudinal traction force to the dorsum of the foot

longitudinal manipulation

3. Low-velocity mobilization to the distal fibula

Distal fibular mob

4. Low-velocity mobilization at the talus on the distal tibiofibular joint in supine

talocrural mob

5. Low-velocity mobilization to the talus in a weight bearing position

talocrural active mob

6. Low-velocity mobilization to the medial side of the talus/calcaneus

Calcaneal glides

(Click the link below for access to the article)

Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients with Inversion Ankle Sprain

Purpose: To investigate the effects of manual therapy and exercise compared to home exercise program for the management of patients with inversion ankle sprains.

Methods: This was a randomized controlled trial that consisted of 74 participants.  They only assessed individuals with Grade 1 and 2 ankle sprains.  Two key exclusion criteria were a positive Ottawa Ankle Rule and prior ankle surgeries.  They compared two groups; one group received a Home Exercise Program (HEP) alone and another group received Manual Therapy and the same Home Exercise Program (MTEX) plus two self ankle mobilizations.  The HEP group received 4 sessions (1x/week) for 30 minutes and they were expected to complete the HEP 1 time daily.  The HEP was progressed at each visit.  The MTEX group received 8 sessions (2x/week) for 30 minutes.  The MTEX group received either low-velocity (Grade III and IV) mobilizations for 5 bouts of 30 seconds or a high-velocity mobilization at end-range joint motion.  The manual therapy consisted of:

1. A high-velocity mobilization at end-range with an anterior force to the head of the proximal fibula on the tibia at end-range knee flexion and external rotation in supine and a high-velocity mobilization at end-range with a longitudinal traction force to the dorsum of the foot on the lower leg in supine with the ankle dorsiflexed and everted.

2. Low-velocity mobilizations at mid to end-range with an anterior to posterior oscillatory force to the distal fibular head in supine with slight ankle plantar flexion, to the talus in supine with varying amounts of ankle dorsiflexion, and sustained at the talus in weight bearing with active ankle dorsiflexion and knee flexion.  They also used a low-velocity mobilization at mid to end-range in the medial to lateral direction to the medial side of the talus/calcaneus in side-lying.

Results: The researchers found that the MTEX group showed statistically significant improvement at 4-weeks and at the 6 month follow up for Foot and Ankle Ability Measure activities of daily living (FAAM ADL), Foot and Ankle Measure sports subscale (FAAM Sports), the Lower Extremity Functional Scale (LEFS), and the Global Rating of Change (GRC) when compared to the HEP group.  They did not find  statistical significance in change of pain rating or recurrence of ankle sprains (even though the HEP group had double the recurrence of ankle sprains compared to the MTEX group) but both groups did show improvement in pain and function.

Limitations: The researchers stated that there were 3 limitations.  They did not have a comparison group that did not receive treatment.  The MTEX group had twice as much treatment time as the HEP group.  They also did not assess smoking in the participants which could affect healing time.

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