Posterior Talus Mobilizations Improve Ankle Pain, Dorsiflexion and Functional Capacity

Research Review: Posterior Talus Mobilizations Improve Ankle Pain, Dorsiflexion and Functional Capacity

By Nicholas Rolnick PT, DPT, MS, CSCS

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, H/FS

Original Citation: Silva RD, Teixeira LM, Moreira TF, Teixeira-Salmela LF, and de Resende MA. (2017). Effects of anteroposterior talus mobilization on range of motion, pain, and functional capacity in participants with subacute and chronic ankle injuries: A controlled trial. J Manipulative Physiol Ther. 40(4): 273-283. ABSTRACT

Why the Study is Relevant: Loss of ankle dorsiflexion is a common impairment in those exhibiting lower extremity dysfunction (1-10). Human movement professionals use a variety of soft-tissue techniques, joint-based interventions, and self-administered exercises to address this issue (1-10). This 2017 study investigated the short- and long-term effects of posterior talar mobilizations  (joint based intervention) on ankle pain, functional capacity and dorsiflexion range of motion in 19 participants with a history of ankle dysfunction. The results suggest that ankle dorsiflexion improves immediately following application of posterior talar mobilizations , and effects last a minimum of two weeks. Human movement professionals should consider incorporating this technique into treatments for individuals lacking ankle dorsiflexion.

Caption: Posterior talar glides are effective at improving ankle dorsiflexion range of motion.

Posterior talar mobilizations are effective at improving ankle dorsiflexion range of motion. (Courtesy of BrentBrookbush.com)

Study Summary

Normal dorsiflexion range of motion is between 15-20 degrees. (Courtesy of BrentBrookbush.com)

Review & Commentary:

To our knowledge, this study is one of the few to compare the short and long-term effects of posterior talus mobilizations on ankle pain, perceived function and dorsiflexion range of motion in participants with a history of ankle dysfunction. The results provide evidence that posterior talus mobilizations alone can improve ankle dorsiflexion with effects lasting at least two weeks.

The study had many methodological strengths, including:

• The clinical relevancy of the intervention improves generalizability. In practice, posterior talar mobilizations are commonly used to improve ankle dorsiflexion range of motion.
• The homogeneity between groups at baseline increases internal validity, allowing outcomes to be attributed to the mobilization intervention itself and not other factors.
• The authors performed an a priori power analysis prior to data collection to determine the minimum number of participants needed to produce a clinically significant treatment effect. This strengthens the reliability of the results of the study.
• The use of a follow-up evaluation to determine good carry-over highlights an attribute of this technique that is often under-emphasized in research on physical interventions.

Weaknesses that should be noted prior to clinical integration of the findings include:

• Reliability of the applied force from the practitioner used in the joint mobilization was not measured.
• The examiner was not blinded to the group allocation which may increase confirmation bias.
• Release or lengthening techniques were not applied to the gastrocnemius , soleus or long toe flexors prior to the intervention, which may have further improved dorsiflexion range of motion.
• Both groups improved in perceived pain and functional capacity over time, suggesting that natural history may play a role in recovery. Further investigation is warranted to determine if this perception of increased functional capacity and reduction in pain is the result of avoidance, adoption, or modification of activities of daily living.
• More research is needed to investigate the short and long-term effects of posterior talar mobilizations on balance and strength in individuals with ankle dysfunction.

How This Study is Important:

This study adds to the body of research on the efficacy of joint mobilizations. The addition of pain and functional ability to measurements of dorsiflexion demonstrate that both movement impairment and the patients perception of pain and ability improved. Although most clinicians would agree that impairment and pain are closely correlated, some recent research has called that "clinical belief" into question. More studies on both manual techniques and self-administered interventions should consider the addition of validated pain and functional ability questionnaires as used in this study. Further, the addition of a follow-up evaluation demonstrated carry-over from one session to the next (and in this study carry-over for at least 2 weeks), which is an under-emphasized but important attribute of any technique deemed effective, especially for long-term pain relief.

How the Findings Apply to Practice:

This study demonstrated that posterior talus mobilizations improves ankle dorsiflexion range of motion (ROM), pain and functional ability in those with chronic ankle dysfunction, and improvements may last for 2 weeks or more. Human movement professionals with a scope of practice that includes manual joint-based interventions should consider the inclusion of manual posterior talar mobilizations as part of a integrated approach to addressing ankle  dysfunction. Practitioners whose scope does not include manual therapy can recommend self-administered ankle joint mobilizations  to accomplish similar outcomes. Note: self-administered ankle joint mobilizations  should also be recommended by manual therapists for home exercise programs.

How does it relate to Brookbush Institute Content?

This study supports the Brookbush Institute recommendation of posterior talus mobilization  as part of an integrated approach to addressing ankle dorsiflexion deficits in those exhibiting signs of lower extremity dysfunction (LED) . Further, the study supports the direction of mobilization recommended in the LED  model. The integrated model of addressing postural dysfunction  includes a sequential approach of release, mobilization and lengthening techniques to enhance mobility, followed by activation and integration techniques for under-active muscles with the intent of optimizing motion and posture. The additional benefit that may be attained via an integrated approach should be investigated in future studies.

Effectiveness of any technique recommended by the BI is determined by reliable assessments using an “assess, address, re-assess” approach. Ankle dorsiflexion goniometery  is a reliable and commonly performed assessment when determining the efficacy of posterior talus mobilizations  in practice.

Human movement professionals (DPTs, DCs, ATCs, DOs) whose scope of practice includes manual therapy should consider adding manual posterior talus mobilizations  to their practice and self-administered ankle joint mobilizations  for home exercise programs. Human movement professionals whose scope does not include manual joint-based techniques (CPTs, LMTs) can accomplish similar results self-administered ankle joint mobilizations .

The following videos illustrate the techniques discussed above:

Ankle Dorsiflexion Goniometry

Posterior Talar Mobilizations

Self-Administered Ankle Dorsiflexion Mobilization

Bibliography:

1. Denegar, C. R., Hertel, J., & Fonseca, J. (2002). The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity.Journal of Orthopaedic & Sports Physical Therapy, 32(4), 166-173
2. Hubbard, T. J., Olmsted-Kramer, L. C., Hertel, J., & Sherbondy, P. (2005). Anterior–posterior mobility of the talus in subjects with chronic ankle instability. Physical Therapy in Sport, 6(3), 146-152.
3. Wikstrom, E. A., & Hubbard, T. J. (2010). Talar positional fault in persons with chronic ankle instability. Archives of physical medicine and rehabilitation, 91(8), 1267-1271.
4. Green, T., Refshauge, K., Crosbie, J., Adams, R. (2001). A Randomized Controlled Trial of a Passive Accessory Joint Mobilization on Acute Ankle Inversion Sprains. Physical Therapy, 2001. 81: 984-994
5. Cosby, N. L., Koroch, M., Grindstaff, T. L., Parente, W., & Hertel, J. (2011). Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain. Journal of Manual & Manipulative Therapy, 19(2), 76-83.
6. Hoch, M. C., & McKeon, P. O. (2011). Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. Journal of Orthopaedic Research, 29(3), 326-332.
7. Delahunt, E., Cusack, K., Wilson, L., & Doherty, C. (2013). Joint mobilization acutely improves landing kinematics in chronic ankle instability. Med Sci Sports Exerc, 45(3), 514-519.
8. Cruz-Díaz, D., Lomas Vega, R., Osuna-Pérez, M. C., Hita-Contreras, F., & Martínez-Amat, A. (2015). Effects of joint mobilization on chronic ankle instability: a randomized controlled trial. Disability and rehabilitation, 37(7), 601-610
9. Collins, N., Teys, P., & Vicenzino, B. (2004). The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Manual therapy, 9(2), 77-82.
10. Pellow, J. E., & Brantingham, J. W. (2001). The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. Journal of manipulative and Physiological therapeutics, 24(1), 17-24.

© 2017 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged