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Tuesday, June 6, 2023

The Effect of Joint Mobilizations on Acute Inversion Ankle Sprains

Brent Brookbush

Brent Brookbush


Research Review: Randomized Controlled Trial of Joint Mobilization on Acute Inversion Ankle Sprains

By Erik Korzen, DC, NASM CES

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

Original Citation: 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. FULL TEXT

Why is this relevant? Inversion ankle sprains are a common occurrence in the athletic and general populations. The RICE (rest, ice, elevate, compress) protocol became very well-known and utilized as the standard treatment for such conditions. This study compares the use of the RICE protocol with joint mobilizations to the use of RICE protocol alone. The passive joint mobilizations were performed by physical therapists. The findings of this study indicate that passive joint mobilizations are beneficial in the treatment of acute inversion ankle sprains.

Study Summary

Study DesignRandomized Controlled Trial
Level of Evidence Level IB
Subject Demographics
  • 38 volunteer subjects
    • Patients diagnosed w/ acute  inversion ankle sprains
    • 19 subjects in each of the Control and Experiment groups

  • Radiograph (x-ray) performed on each subject prior to study to rule-out other diagnoses
  • Subjects entered trial within 72 hours of injury
  • Bruising, swelling and tenderness of lateral ankle ligaments
Outcome Measures
  • ALL subjects received a standardized RICE protocol
    • Rest: avoidance of pain-provoking activities
    • Ice: crushed ice to anterolateral ankle for 20 minutes twice per day
    • Compression: daily use of elastic tubular bandage
    • Elevation: raise affected foot above heart level for at least 25% of the day

  • Experiment group received Anterior-Posterior (A-P) mobilizations of the talo-crural joint, prior to the RICE protocol
    • 60 second oscillatory period w/ approximately 60 oscillations, performed a total of 3 times with a 10 second rest between sets

  • ALL subjects were treated every other day, within a 2 week period (total of 6 possible treatment sessions)
  • Force applied and angle of dorsiflexion at which subjects first experienced pain were recorded (Lidcombe template)
  • Video Gait analysis (7 walks per subject)
    • double and single leg support stances were calculated for injured and non-injured extremities
    • Stride speed = stride length/stride time

  • Subjects discharged from trial when 100-N force led to full pain-free range of movement in dorsiflexion
  • Dorsiflexion ROM from trial entry to 2nd treatment session
    • Experiment group: improved 10.9 degrees
    • Control group: improved 5.8 degrees

  • Stride speed increased for both groups
  • Step length symmetry improved for both groups
  • Symmetry of single support time improved for both groups
  • Return to Normal Activity
    • Experiment group: walking at 7.7 days, running at 12.6 days, sports at 12.2 days
    • Control group: walking at 9.2 days, running at 13.3 days, sports at 13.4 days

  • At the 4th treatment session 13/19 subjects in Experiment group were discharged
  • Completion of Trial (2 weeks): Only one subject remained in experimental group and four subjects remained in the control group
Conclusions of the Researchers
  •  Anterior to Posterior (A-P) mobilizations of the talo-crural joint added to a conventional RICE protocol reduced the number of required treatment sessions to achieve pain free dorsiflexion.
  • Although both groups improved overall, the experiment group improved quicker than the control group.
  •  Joint Mobilizations added to the RICE protocol of acute inversion ankle sprains allows subjects to return to normal activities quicker than just RICE treatment alone

Review & Commentary:

The use of a randomized control trial (RCT) design provides strong evidence that the addition of passive joint mobilizations to an intervention designed to treat the common condition of ankle sprains will enhance outcomes.

The researchers use of dorsiflexion range of motion, 3 gait variables (stride speed, step length and single support time), and time to recovery for various tasks (walking, running and sport) provides us with multiple measurable outcomes to consider. This is an important contribution to the results of this study as a return to previous activity likely requires improvement of various attributes including, mobility, stability, strength, speed and performance of functional tasks. Further, the use of multiple assessments had the potential to show improvements that may not have been seen if only a single assessment was used, although in this study all outcomes were better in the experimental group.

A potential weakness of the study is the use of a single manual technique when the condition may have indicated the use of an integrated approach and multiple techniques. However, the authors of this review note this is actually a weakness of research itself as a tool, and not an over-site by the researchers and clinicians who designed the study. Despite an integrated approach potentially enhancing outcomes, it would have also added confounding variables. Further research including release techniques and mobilization, self-administered mobilizations , or mobilizations and activation techniques may provide additional evidence for a more optimal approach to treating ankle sprains.

The lack of an arthrokinematic assessment (passive accessory joint mobility) may have been a weakness of the study. Although some studies have showed low reliability with these assessments, further correlations could have been added that would potentially highlight how effective mobilizations are when applied to the appropriate population.

Why is this study important?

This study compares RICE to RICE with joint mobilizations. There are many ways to view the importance of this study, starting with the effectiveness of joint mobilizations for acute inversion ankle sprains. However, this study also provides evidence that passive therapy (RICE) is not superior to active therapeutic intervention with a human movement professional. More and more research is being published showing that rest is not optimal treatment for orthopedic injury, and more should be done to promote referral and education about the benefits of continued treatment with a human movement professional post physician's diagnosis.

How does it affect practice?

This study implies that human movement professionals should include joint mobilizations in their therapeutic and corrective exercise programs, especially those programs involving ankle injury. Further, the REST protocol, even when used during the acute phase of injury may not be optimal intervention.

Passive anterior to posterior tibiotalor ankle mobilization - http://www.physio-pedia.com/online-courses/online-courses/images/4/48/Passive_joint_mobilisation.jpg

How does it relate to Brookbush Institute Content?

The Brookbush Institute advocates the use of joint mobilizations (and specifically the use of anterior posterior mobilizations for ankle dysfunction) as part of an integrated approach to correcting movement impairments and rehabilitating injuries. The arthrokinematic dyskinesis, changes in ROM, and decrease in performance noted in the beginning phases of this study are described in the Brookbush Institute's predictive model of Lower Leg Dysfunction (LLD). Further, the use of multiple assessments to clarify the variations between individuals regardless of injury, and keep accurate records of the effective of interventions via outcome measures is important to the Brookbush Institute and education is provided on many of the assessment used in this study - (for example, Introduction to Goniometry)

Self-administered Anterior to Posterior Talus Mobilization with Dosiflexion

  • Note: This is not a passive mobilization and may be more aggressive than the techniques used in this study. Please use caution and professional judgement if applying this technique to an acute ankle injury. It is generally sound practice to only perform this technique if it can be done pain free or a pain free ROM)

© 2015 Brent Brookbush

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