Mobilisation: the answer for ankle stiffness

Ankle sprains are considered the most common sporting injury, with high re-injury rates (up to 80%) and often encompass persistent symptoms. Sports involving cutting and agility such as basketball also have high rates of chronic instability (up to 70%) after an initial ankle injury, with a considerable impact on ones ability to train and compete. The Ankle Mobility Matters blog covered the effects of persistent ankle stiffness and the associated foot, leg and knee conditions that can develop as a result of injury with significant functional deficits for those involved.

HOW CAN PHYSIOTHERAPY HELP?

Limitations in dorsiflexion range can be caused by a lack of calf flexibility or posterior capsule tightness (at the back), however ankle sprains commonly present with impingement and pain at the front of the ankle. Physiotherapists can employ several different manual therapy techniques to improve ankle range of motion. Joint mobilisation is a specific treatment approach to improve range of motion, alleviate pain and improve ankle function. The most common type of technique is an antero-posterior (AP) accessory joint mobilisation of the talus on the tibia in non-weight bearing (NWB) or weight bearing (WB) positions.

HOW DOES MOBILISATION WORK?

The mechanism of injury with an ankle sprain may change the position of the talus (foot bone) in relation to the mortise (shin bones) when the ligaments are damaged or stretched. The positional fault theory describes an anterior subluxation of the talus where it remains slightly out of place, with a resultant restriction in posterior glide and compromised ankle function remaining. Without mobilisation, the ankle can remain significantly restricted or range of motion may actually be restored by compensatory mechanisms such as excessive stretching of the plantar flexors (calf muscles), excessive motion at surrounding joints, or through an abnormal axis of rotation at the ankle. These compensatory mechanisms predispose people to injury recurrence and/or degeneration over time at the foot and ankle or throughout the other joints of the lower limb such as the knee or hip.

Mobilisation as a treatment aims to restore the normal joint motion, improving the position of the talus deeper within the ankle joint and improving the axis of rotation to avoid compensation. Techniques can be applied by physiotherapists in NWB or WB positions depending on the stage of recovery and individual symptoms. The essential component is that it is a pain free technique, which alleviates pain during the once-painful tasks (walking, squatting, lunging or descending stairs).

Combinations of techniques can be completed over a number of treatment sessions resulting in a lasting change in dorsiflexion range of motion, a reduction in pain and significantly increased function for patients with normalised ankle movement and a successful rehabilitation and return to sport.

CLINICAL EVIDENCE:

• Acute Ankle Sprains: Addition of AP talocrural mobilisation to the RICE protocol in the early management of acute ankle inversion injuries (<72 hours), required fewer treatments to achieve pain-free dorsiflexion range and improved stride speed, compared to RICE alone (Green et al., 2001).
• Ankle Stiffness: After a single application of AP talocrural joint mobilisation, dorsiflexion range was significantly increased in patients who had been immobilised post lower limb injury (Landrum et al., 2008).
• Sub-Acute Ankle Sprains: Application of the dorsiflexion mobilisation with movement (MWM) technique to patients with subacute lateral ankle sprains produced a significant immediate improvement in dorsiflexion range (Collins et al., 2004).
• Chronic Recurrent Ankle Sprains: The application of MWM treatment techniques improved posterior talar glide and talocrural dorsiflexion immediately after application in subjects with chronic recurrent lateral ankle sprain (Vincenzino et al., 2006).
• Chronic Ankle Instability: A single application of WB MWM improved ankle dorsiflexion greater than manipulation or placebo, in people with Chronic Ankle Instability (CAI), and the effects lasted at least two days (Marrón-Gómez et al., 2015).
• Ankle Stiffness: Ankle self-stretching using a strap is an independent technique used to improve active and passive ankle-dorsiflexion range of motion and lunge ability. It is more effective than stretching alone and can be performed independently without a practitioner present in patients with reduced ankle range (Jeon et al., 2015). However, this technique can often be difficult to do at home as it requires specialist equipment such as an incline board and a non-elastic strap for completion.

For ankle sprains, pain or stiffness early assessment, accurate diagnosis and appropriate treatment including joint mobilisation are all key components to a successful outcome.

Without this vital intervention one risks a delayed and impaired recovery, persistent symptoms that can last a lifetime and a significantly increased chance of re-injury to the same ankle and damage to other joints in the lower limb. The best practice for ankle injury requires multiple physiotherapy sessions during the healing process to provide mobilisation along with a progressive rehabilitation program and a home based program completed for some time post injury.

Daniel has received additional training in ankle injury assessment and management as part of his Masters in Sports Physiotherapy course. He is passionate about providing a concise diagnosis and specific rehabilitation plan to help you safely resume your sport or leisure activities comfortably. For an appointment please book online here or contact our Claremont clinic today.

July 21, 2017

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, 77–82. doi:10.1016/S1356-689X(03)00101-2

Denegar, C., 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.

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, 81, 984–994.

Jeon, I., Kwon, O., Yi, C., Cynn, H., Hwang, U. (2015). Ankle-Dorsiflexion Range of Motion After Ankle Self-Stretching Using a Strap. Journal of Athletic Training, 50(12), 1226–1232. doi: 10.4085/1062-6050-51.1.01

Landrum, E., Kelln, B., Parente, W., Ingersoll, C., & Hertel, J. (2008). Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. The Journal Of Manual & Manipulative Therapy, 16(2), 100-105.

Marrón-Gómez, D., Rodríguez-Fernández, A., & Martín-Urrialde, J. (2015). The effect of two mobilization techniques on dorsiflexion in people with chronic ankle instability. Physical Therapy in Sport 16, 10-15 . doi: http://dx.doi.org/10.1016/j.ptsp.2014.02.001

Vincenzino, B., Branjerdporn, M., Teys, P., & Jordan, K. (2006). Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals With Recurrent Ankle Sprain. Journal of Orthopaedic & Sports Physical Therapy, 36(6), 464-471. doi:10.2519/jospt. 2006.2265