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Tuesday, June 6, 2023

Ankle Arthokinematics Do Not Normalize with Improved Dorsiflexion Active Range of Motion Following Acute Ankle Sprain

Brent Brookbush

Brent Brookbush


Research Review: Ankle Arthokinematics Do Not Normalize with Improved Dorsiflexion Active Range of Motion Following Acute Ankle Sprain

By Jinny McGivern, PT, DPT, CFMT, Certified Yoga Instructor

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

Original Citation: 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.


Why is this relevant?: Ankle sprains are a common injury, especially among athletic populations, and this injury is known for having a high rate of recurrence (1-3). Considering the high rate of recurrence, it would seem prudent to investigate the possibility that a component of this injury has not been fully addressed in typical rehab settings. Loss of dorsiflexion range of motion (ROM) is commonly noted following this injury, and stretching programs are typically recommended to increase soft tissue extensibility. This research demonstrates that although dorsiflexion ROM may return (and presumably soft tissue extensibility); arthrokinematics of the talocrural joint may not normalize. It is possible that persisting arthrokinematic dyskinesis may play a role in the rate of recurrence.

Picture of the lateral foot and ankle post inversion ankle sprain. Bruising inferior to the lateral malleolus.
Caption: Picture of the lateral foot and ankle post inversion ankle sprain. Bruising inferior to the lateral malleolus.

Bruising post inversion ankle sprain - By Boldie - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=3564049

Study Summary

Study DesignDescriptive comparative study
Level of EvidenceIII - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
Subject Demographics

Subjects were drawn from volunteer collegiate student athletes who sustained a unilateral ankle sprain, completed a rehabilitation program and returned to unrestricted sport activity

  • Age: women: 19.3 +/- 1.4 years; Men 19.8 +/- 1.3 years (range 18-22 years)
  • Gender: 7 women, 5 men
  • Characteristics: collegiate athletes with a history of unilateral ankle injury
  • Inclusion Criteria: history of unilateral lateral ankle sprain in the past 6 months for which rehabilitation was received; no history of contralateral ankle sprain; no history of fracture or surgery to either ankle; full return to sport/activity prior to participation in the study.
  • Exclusion Criteria: not meeting inclusion criteria.
Outcome Measures 1) Talo-crural and sub-talar ligamentous laxity evaluated via:
  • Anterior Drawer Test
  • Talar Tilt Test
  • Medial Subtalar Glide Test

(Graded 0-4; 0= hypomobile , 1=normal, 4=gross laxity)

2) Ankle Dorsiflexion (DF) range of motion (ROM) measured in the following positions (3 measures per position - mean of  3 used for analysis):

  • Sitting with straight knee (SSK) - ankle passively positioned by examiner
  • Prone with bent knee (PBK) - ankle passively positioned by examiner
  • Standing with Straight Knee (STSK) - lunge with back knee straight - measurement taken when heel started to rise.
  • Standing with Bent Knee (STBK) - single leg squat with upper extremity support - measurement taken when heel starts to rise

3) Posterior Talar Glide - measured in sitting with ankle in sub-talar neutral.  Examiner passively dorsiflexed ankle to a firm capsular end feel. Angle of knee flexion was recorded at the end range of DF (author's rationale was that the knee was unable to flex any further due to limited posterior glide of the talus).


1) Laxity measures

Significant differences were found in laxity between involved and uninvolved ankles for all 3 tests.

  • Anterior Drawer: P=.02
  • Talar Tilt: P=.04
  • Medial Sub-Talar Glide Test: P=.02
  • Only 1 of the uninjured limbs demonstrated any amount of laxity (score of 1 for all tests for most of the sample; 1 case of score of 2 for each test).
  • None of the injured limbs scored a 4 (gross laxity).
  • Most of the injured limbs scored between 2 and 3 with no more than 3 cases scoring a 1 on any single test.

2) DF ROM measures

  • Intra-tester reliability for both involved and uninvolved ankles: .88-.99 (SE .34 deg and 2.0 d
  • There were no significant differences in any of the 4 test positions for dorsiflexion ROM between the injured and uninjured ankles.
  • Values for involved ankle (in degrees): SSK 17.4 +/- 6.7; PBK 16.4 +/- 5.5; STSK 22.8 +/- 6.1; STBK 24.5 +/- 5.6
  • Values for uninvolved ankle (in degrees): SSK 15.2 +/- 5.7; PBK 17.2 +/- 6.4; STSK 22.8 +/- 5.6; STBK 27.4 +/-6.8

3) Posterior Talar Glide Test

There was a significant difference in passive knee flexion  between involved and uninvolved limbs (P <.01) with involved limb demonstrating reduced talar posterior glide.

  • Involved Side: 8.0 deg +/- 5.8
  • Uninvolved Side: 16.6 +/- 3.4
ConclusionsFollowing lateral ankle sprain, ROM measures should not be used in isolation to evaluate the ankle for optimal function. This research demonstrates that restoration of DF ROM does not necessarily indicate optimal arthrokinematics have been restored in the ankle.
Conclusions of the ResearchersFollowing lateral ankle sprain in an athletic collegiate population, joint laxity and restrictions to posterior glide of talus persist, despite the restoration of normal dorsiflexion ROM.

Image courtesy of https://firstascentpt.com/2014/08/05/incorporating-mobilizations-and-manipulations-to-inversion-ankle-sprains/

Review & Commentary:

This research utilized a strong methodology. Blinding procedures ensured that examiners were not aware of which side was the involved versus uninvolved ankle. The authors used standardization procedures including requesting that subjects not exercise during the 2 hours prior to data collection. All measurements were taken in the same order for all participants. Assessments of joint laxity and ankle dorsiflexion range of motion (ROM) used methods that were previously validated and shown to be reliable (stress testing confirmed via fluoroscopy and goniometry with fluid filled bubble goniometer). The authors measured dorsiflexion in 4 different positions with varying combinations of non-weight bearing & weight bearing, with knee flexion and extension. This provided insight as to whether unloaded measures corresponded with weight bearing functional postures. It also assessed structures that did and did not cross the knee as possible contributors to limiting dorsiflexion (DF) ROM. The selection of multiple measures of ankle functional mobility (ligament laxity, ROM and joint arthrokinematics) provide the reader with a thorough view of the different components of ankle joint mobility.

There are also limitations to this research. The data was collected from young collegiate athletes with lateral ankle sprains so this may not be generalizable to other populations or types of ankle sprains. The athletes completed a rehabilitation program and returned to their respective sports at the time of data collection. The authors state this program included stretching of the plantar flexors, but did not include joint mobilization. We do not know if achieving a certain DF ROM was a criteria to return to sport; however, it is possible that DF ROM was not fully restored. The authors note that they did not assess the compensations that may have occurred at other joints of the lower extremity when measuring DF ROM. For example, when measuring closed chain DF ROM, the authors did not comment on whether the subject's knee tracked over the second toe of the foot. Finally, the method of assessing posterior glide of the talus was not previously validated in the literature and may not have been an optimal choice for quantifying this motion. The assessment was performed in non-weight bearing; however, it may have been beneficial to include a weight bearing assessment due to the importance of accessory motion of the talus during closed chain activities.

The authors propose three possible compensations by which the subjects were able to demonstrate full dorsiflexion ROM: over-stretching of the plantar flexor muscles, hypermobility at other joints in the foot/ankle and moving into dorsiflexion with an altered axis of rotation. Ideally, as the ankle moves into dorsiflexion, the talus glides posteriorly; thus the axis of rotation changes through range. When posterior glide is limited, the axis of rotation becomes stationary, pivoting around a small surface area, potentially increasing stress on compressed tissues. Further, this may result in compensation of distal segments in the kinetic chain. It would be interesting to note whether joint hypo-mobility observed in the involved limb were treated, would compensations at other segments persist or resolve. Future research should consider this possibility.

Why is this study important?

This study reinforces the importance of considering both osteokinematics (movement of the bones) and arthrokinematics (movement at the joint) when assessing function of the ankle joint following injury. Efficiency in one does not necessarily equal efficiency in both; alluding to the human body's tremendous capacity for compensation. This study may allude to arthrokinematic dyskinesis playing a role in the high rates of re-injury following initial ankle sprain, as well as other injuries up the kinectic chain.

How does it affect practice?

This study supports the use of joint mobilizations to restore optimal arthorkinematics at the talo-crural joint following lateral ankle sprain. Further, it supports the work of Green et al . (4) who found passive joint mobilizations performed within 72 hours following acute ankle sprain restored dorsiflexion ROM and gait mechanics more quickly than RICE procedures alone.

How does it relate to Brookbush Institute Content?

This research supports the integrated approach used by the Brookbush Institute (soft tissue and joint based techniques, as well as fascial and neural techniques), and provides further evidence of the common compensation pattern described in the Brookbush Institute's predictive model of Lower Leg Dysfunction (LLD) . An increased risk of ankle injury, and/or compensation noted post ankle injury seem to be highly correlated to LLD based on clinical observations. The following videos provide a sample, comprehensive self-administered ankle mobility program; please note the multiple structures addressed. The techniques progress from mobility techniques (release, mobilize, lengthen) to activation and integration techniques (isolated activation, stability integration and subsystem integration). Note: various manual therapeutic modalities may be added to optimize this program, in which case, the program below may be viewed as an integrated home exercise program.

Gastroc and Soleus (Calf) SA Static Release

Ankle Mobilization

Ankle Slant Board Calf Stretch:

Tibialis Anterior Isolated Activation

Tibialis Posterior Activation

Tibialis Anterior Reactive Activation

Resisted Single Leg Balance and Reach

Frontal Plane Step-up to Balance


  1. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010 Oct 6;92(13):2279-84
  2. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prespective epidemiological studies. Sports Med. 2014 Jan;44(1):123-40
  3. Yeung MS, Chan KM, So CH, Yaun WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994;28:112-116 doi:10.1136/bjsm.28.2.112
  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

© 2016 Brent Brookbush

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