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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients

October 03, 2017

RESEARCH COMMENTARY

Ejona (Ona) Jeblonski DPT, COMT
Fellow in Training MAPS Accredited Fellowship in Orthopedic Manual Therapy

Chris R. Showalter PT, COMT, OCS, FAAOMPT
Fellowship Program Director


Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients

Ankle sprains are one of the most frequently incurred musculoskeletal injuries (1), and as such, are commonly thought of as an innocuous injury that will likely heal without the need for intervention. However, the literature suggests that a substantial proportion of individuals who experience an ankle sprain will continue to report residual symptoms including pain, persistent swelling, perception of ankle joint instability and subsequent re-injury (2,3,4,5). These patient reports are considered to be due to interactions of numerous mechanical and functional insufficiencies (6).


Background

One factor commonly considered to contribute to an initial ankle sprain injury, and subsequent reinjury, is an inappropriate positioning of the foot in excessive plantarflexion and/or inversion at the point of initial contact (IC) with the ground during gait, landing from a jump and other sporting activities (7, 22). Decreased dorsiflexion is a common finding following acute ankle sprain (7), and in individuals with chronic ankle instability (CAI) during jogging, and immediately after jumping (22).

Joint positional deficits have been shown in both muscle-driven computer simulations (8) and cadaveric models (9) showing an increased plantarflexion angle at the point of initial contact (IC) with the ground. Therefore, increasing sagittal plane dorsiflexion may provide increased reliance upon bony stability and less reliance upon the lateral ligaments for stability, thus ultimately decreasing the risk of the initial ankle sprain and potential for reinjury (10,8).

This Research Commentary examines a 2013 paper that investigated the role of joint mobilization in changing angles of plantarflexion and dorsiflexion. The paper “Joint mobilization acutely improves landing kinematics in chronic ankle instability” by Delahunt et al, 2013 (7) evaluated the functional improvement following manual therapy provided to individuals with Chronic Ankle Instability (CAI).

·    The authors evaluated 15 adults with CAI who participated in a drop-landing protocol.

·         A maximum of five practice drop landings on the test leg were allowed before testing began.

·         The test leg was held in non-weight bearing position.

·         The participants stood on a 0.40m (15.8”) high platform in front of a force plate, and they were required to step forward with the test leg to land on the force plate using their own landing style and mechanics.

·         Upon landing, participants were required to balance as quickly as possible on the test leg in the center of force plate and hold this position for approximately 4-6 seconds.


Method

Test sequence:

·         3 single leg drop landings on the test ankle premobilization, followed by

·         3 joint mobilization techniques (a total of 30 glides of each technique) and again

·         3 single leg drop landings on test ankle post mobilization (7).

A combination of 3 joint mobilizations were performed by the same investigator on each participant, as follows:

1.    non-weight bearing dorsiflexion MWM (Vincenzino, 11)
2.    AP glide of the inferior tibiofibular joint (Mulligan, 12)
3.    AP accessory glide of the Talus (Maitland, 13).

The above mobilizations were applied with the intent of facilitating a reduction of any anterior positional faults at the talocrural and at the inferior tibiofibular joints. Subjects with CAI have been shown to exhibit both of these faults (14, 15). Therefore, the specific mobilizations in Delahunt et al 2013 (7) paper aimed to enhance sagittal plane ankle joint kinematics during more demanding tasks replicating sporting activities, including landing from a jump.


Measurements

Kinematic data was derived using affixed joint marker positions and calculated using vector algebra and trigonometry utilizing CODA software (CODA, Charnwood Dynamics Ltd.).  


Results

The results from Delahunt et al 2013 showed that there was a statistically significant (P <0.05) decrease in angle of ankle joint plantarflexion at initial contact from pre-mobilization to post-mobilization with a mean decrease of 2.98o.


Conclusion

The authors concluded “the results indicate that mobilization acted to immediately reduce the angle of joint plantarflexion at IC during single leg drop landing” and “Mobilization applied to participants with CAI has a mechanical effect upon the ankle joint, and thus facilitates a more favorable positioning of the ankle joint in dorsiflexion when landing from a jump”.

The conclusion of the authors of Delahunt et al 2013 support the mechanical theory concepts associated with joint mobilization.


Implications

The results of Delahunt et al 2013 indicate that mobilization results in changes in joint mechanics, and thus supports the mechanical effect of mobilization techniques. Other research papers have shown that joint mobilization effectively reduces pain via the neurophysiological effect and effectively restores movement via the mechanical effect:

Joint mobilization has been shown to effect pain modulation and reduction using pressure pain thresholds (PPT):

  • Lateral Epicondylalgia (16)
  • Rheumatoid Arthritis (17)
  • Cervical Spine Pain (18)
  • Thoracic Spine Pain (19)

Joint mobilization effects pain modulation - using SNS markers in patients with:

  • Cervical Spine Pain (18)
  • Asymptomatic Upper Limbs (20)
  • Asymptomatic Lumbar Spines (21)

Joint mobilization also has mechanical effects:

  • Ankle - utilizing early joint mobilization leads to improved mobility and decreased symptoms (22).
  • Knee - effectively increase joint motion in one single session for participants with knee OA who exhibited restricted knee extension ROM. (23)
  • Hip - mobilization of the hip for patients that presented with knee OA and painful hip, significantly improved: ROM of hip flexion; ROM with functional squat test; Pain with tests (hip flexion, functional squat, FABER, hip scour test) (24)


Clinical Significance

In summary, evidence-based research supports the concept that manual therapy has positive results in changing mechanical, neurophysiological and pain responses in individuals with or without symptoms.

·         Joint mobilizations at the ankle, and other joints, should therefore be used based upon an accurate clinical assessment and clinical reasoning, while respecting irritability per the stiffness dominance and irritability concepts, as described initially by Maitland (25).

·         The Delahunt et al (2013) paper further reinforces the Maitland concept that there is a strong need for the clinician to fully assess the clinical features of the specific patient being examined.

Detailed, patient-centric clinical assessment leads to clinical reasoning, and the inclusion of evidence-based research to guide appropriate utilization of manual therapy. Joint mobilization can be used for pain modulation, and addressing stiffness and other mechanical faults with the intent to improve function, stability, proprioception and motor recruitment.


Cheers, and Enjoy

Ona Jeblonski FIT

© Maitland-Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website (www.ozpt.com) is permissible.


References:

1. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. Systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37(1):73–94.

2. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10): 653–60.

3. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008;121(4):324–31

4. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995; 114(2):92–6.

5. Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med. 1994;28(2):112–6.

6. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37(4):364–75.

7. Delahunt E, Cusack K, Wilson L, Doherty, C. Joint mobilization acutely improves landing kinematics in chronic ankle instability. Med Sci Sports Exerc. 2013 Mar;45(3):514-9.

8. Wright IC, Neptune RR, van den Bogert AJ, Nigg BM. The influence of foot positioning on ankle sprains. J Biomech. 2000;33(5):513–9.

9. Konradsen L, Voigt M. Inversion injury biomechanics in functional ankle instability: a cadaver study of simulated gait. Scand J Med Sci Sports. 2002;12(6):329–36

10. Brown C, Padua D, Marshall SW, Guskiewicz K. Individuals with mechanical ankle instability exhibit different motion patterns than those with functional ankle instability and ankle sprain copers. Clin Biomech (Bristol, Avon). 2008;23(6):822–31

11. Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. J Orthop Sports Phys Ther. 2006;36(7):464–71.

12. Mulligan BR. Manual Therapy: ‘‘NAGS’’, ‘‘SNAGS’’, ‘‘MWMS’’ etc. 3rd ed. Wellington (New Zealand): Plane View Services Ltd.; 1995. p. 98

13. Hengeveld E, Bank K. Maitland’s Peripheral Manipulation. 4th ed. Philadelphia (PA): Elsevier Butterworth Heinemann; 2005. p. 549.

14. Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Arch Phys Med Rehabil. 2010;91(8):1267–71

15. Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008;13(1):63–7.

16. Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther. 1998 Sep;21(7):448-53.

17. Dhondt W, Willaeys T, Verbruggen LA, Oostendorp RA, Duquet W. Pain threshold in patients with rheumatoid arthritis and effect of manual oscillations. Scand J Rheumatol. 1999;28(2):88-93.

18. Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001 May; 6(2): 72-81

19. Fryer G, Carub J, McIver S. The effect of manipulation and mobilization on pressure pain thresholds in the thoracic spine. J of Osteopathic Medicine 2004; 7(1):8-14

20. Moulson A, Watson T. A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Man Ther. 2006 Aug;11(3):214-24

21. Perry J, Green A. An investigation into the effects of a unilaterally applied lumbar mobilization technique on peripheral sympathetic nervous system activity in the lower limbs. Man Ther. 2008 Dec;13(6):492-9.

22. Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001 Apr;81(4):984-94.

23. Taylor AL, Wilken JM, Deyle GD, Gill NW. Knee extension and stiffness in osteoarthritic and normal knees: a videofluoroscopic analysis of the effect of a single session of manual therapy. J Orthop Sports Phys Ther. 2014 Apr;44(4):273-82

24. Cliborne AV, Wainner RS, Rhon DI, Judd CD, Fee TT, Matekel RL, Whitman JM. Clinical Hip Tests and a Functional Squat Test in Patients with knee Osteoarthritis: reliability, Prevalence of Positive Test Findings, and Short-Term Response to Hip Mobilization. JOSPT 2004;34 (11):676-685.

25. Maitland G, Hengeveld E, Banks K, English K. Maitland's Vertebral Manipulation, 6th ed. Boston: Butterworth-Heinemann; 2001   

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