Are ankle mobilizations effective in treatment of CAI?

As I progress through my fellowship training, I have been busier than ever (sorry for the infrequent updates to the site).  It has also forced me to read even more literature on manual therapy and its effectiveness in the treatment of musculoskeletal conditions.  One article, in particular caught my eye this afternoon so I thought I would review it:
Beazell JR, Grindstaff TL, et al. Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals with Chronic Ankle Instability. JOSPT 2012: 42; 125-134.
This randomized clinical trial assessed the effects of joint mobilization in 43 individuals classified with chronic ankle instability (CAI).
CAI was defined as a history of at least one ankle sprain followed by additional episodes of ankle instability/giving way, and an 85% of greater on the Foot and Ankle Ability Measure (FAAM) sport subscale. Additionally all participants had to have an ankle dorsiflexion ROM deficit of at leat 5 degrees compared to the opposite side.
After baseline data was taken, the subjects were randomized into one of three groups: proximal tibiofibular manipulation, distal tibiofibular manipulation or no treatment. Once the subjects were randomized, outcome measures were taken including: ankle dorsiflexion ROM, single-limb stance on foam, the step-down test and the FAAM sport subscale. The intervention was then performed and the same data was recollected.  Data was then taken during three follow-up visits 1,2, and 3 weeks post initial intervention.  The participants would recieve the same intervetion during these subsequent sessions.
The results in this study indicated that there was not a significant difference between participants who recieved ankle manipulation vs. no intervention.
Bottom Line: “So what.  This study tells me that ankle manipulation as an isolated intervention is likely not effective.  But how many therapists treat CAI with manipulation only for one session per week for three weeks?  None.”
“The subjects included in this study were not seeking care for CAI but were instead subjects of convenience who were recruited for participation. Does this represent a patient who seeks our services? No. Expectations have a large effect on results and patients who seek our services have an expectation for recovery. This group lacked that variable.”
“The sample size was very small (Proximal tibfib group: n=15, distal tibfib group: n=15, control = 13).  To extract information from a study which includes such a small sample size should be done with caution. This must have been picked up in the peer review because the authors included a power analysis in the methods portion of the published version.  They said they needed 12 subjects per group to have an 80% chance of detecting a significant difference in ankle dorsiflexion ROM (which they are stating would yield the smallest effect size among the outcome variables) but I question that ankle dorsiflexion would demonstrate the smallest effect size.”
“Overall, no offense to the authors, but this study just wasted my past hour.”

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All Comments

  • Great post!
    Not to mention is ROM really the best measure for this population?? I can think of many, many other variables that are more important!
    Not a very applicable or useful study for everyday practice IMO.

    Kyle J. Ridgeway, DPT April 3, 2012 5:25 pm Reply
  • Thanks man. I agree…obviously.

    josephbrence April 3, 2012 8:21 pm Reply
  • I agree that this study does not use the standard practice of how we would treat CAI in the clinic, performing only manipulation and then having the patient attempt to get back full function without re-training them. I do disagree, however, with the first response with ankle ROM not being an important measure in this population. In my experience, the majority of CAI patients present with DF AROM loss, which has significant changes in gait pattern, standing pattern, squatting technique, as well as other activities such as running and stairs. This deficit has huge implications to the rest of the kinetic chain, from the mid-foot/forefoot/big toe, to the knee/hip/SIJ/lumbar spine. Why the loss is there, however, is the big question, and I find significant restrictions in talocrural mobility, tibiofibular hypomobility, as well as mortise instability, with all three treated in a different manner. As a fellowship student myself, the ability to understand the mechanism of their sprains, obtain a good history, and then rely on our objective tests to pick up hypo vs hypermobilities/instabilities in this area and use our manual skills as needed by our findings is the biggest thing. There is a lot of research and reasoning to say talocrural manipulation is beneficial in treating CAI secondary to the loss of posterior glide and subsequent ER at the talus with DF, and there is ample research stating decreased DF at the ankle changes the kinetic chain, leading to PFPS, weak hips, toe out gait, weak calf musculature, etc.

    Brad Simpson, DPT, CMPT April 4, 2012 10:09 am Reply
    • Hi,
      I agree that ROM is likely an important to look at clinically. But for research purposes it is absolutely not the best measure for a study to be powered on as a primary outcome.
      I am familiar with the research showing a lack of DF is correlated with dynamic knee valgus and femoral IR.
      I am not familiar with the research that a lack of DF directly leads or is even correlated with calf weakness, hip weakness, or lumbopelvic pain. I think a causative link is likely quite tenuous, but would be curious to see any data showing an association or correlation in symptomatic individuals.
      I am also not familiar with data that limited DF is a primary risk factor for PFPS AND that when corrected reduces the risk or incidence of PFPS.
      Now, if there had been strong previous literature that showed that a lack of DF was a very common impairment AND that resolution of that impairment was associated with improved clinically outcomes OR that failure of that impairment to resolve was associated with a poorer outcome then this study MAY be slightly more applicable clinically. Still good info to have if analyzed and put in context appropriately as Joe has done.
      Would appreciate your comments or any references. Cheers.

      Kyle J Ridgeway, PT, DPT April 4, 2012 12:25 pm
  • I didn’t read the article yet (sorry), but am curious if there was immediate change in DF after manip.
    If so, obviously I would send the patient home with self mobs/ROM to be done every 2 hours or so to see if we can maintain the gains. I wouldn’t expect retention of gains after one week with no other interventions.

    Magnus April 4, 2012 2:22 pm Reply

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