ARTICLE IN PRESS

Manual Therapy 9 (2004) 77–82

www.elsevier.com/locate/math

Original article
The initial effects of a Mulligan’s mobilization with movement
technique on dorsiflexion and pain in subacute ankle sprains
Natalie Collins, Pamela Teys, Bill Vicenzino*
Department of Physiotherapy, The University of Queensland, St. Lucia, Brisbane, QLD 4072, Australia
Received 17 December 2002; received in revised form 25 July 2003; accepted 21 August 2003

Abstract

Physiotherapists frequently use manipulative therapy techniques to treat dysfunction and pain resulting from ankle sprain. This
study investigated whether a Mulligan’s mobilization with movement (MWM) technique improves talocrural dorsiflexion, a major
impairment following ankle sprain, and relieves pain in subacute populations. Fourteen subjects with subacute grade II lateral ankle
sprains served as their own control in a repeated measures, double-blind randomized controlled trial that measured the initial effects
of the MWM treatment on weight bearing dorsiflexion and pressure and thermal pain threshold. The subacute ankle sprain group
studied displayed deficits in dorsiflexion and local pressure pain threshold in the symptomatic ankle. Significant improvements in
dorsiflexion occurred initially post-MWM (Fð2;26Þ ¼ 7:82; P ¼ 0:002), but no significant changes in pressure or thermal pain
threshold were observed after the treatment condition. Results indicate that the MWM treatment for ankle dorsiflexion has a
mechanical rather than hypoalgesic effect in subacute ankle sprains. The mechanism by which this occurs requires investigation if we
are to better understand the role of manipulative therapy in ankle sprain management.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Manipulation; Ankle; Pain; Movement

1. Introduction
The lateral ligament complex of the ankle, described
as the body’s ‘‘most frequently injured single structure’’
(Garrick, 1977), is mechanically vulnerable to sprain
injury. At extremes of plantarflexion and inversion,
influenced by the shorter medial aspect of the ankle
mortise, the relatively weak anterior talofibular ligament
(ATFL) and calcaneofibular ligament (CFL) are prone
to varying grades of rupture, often via minimal force
(Hockenbury and Sammarco, 2001).
Immediate inflammatory processes produce acute
anterolateral pain and oedema, with avoidance of
movement and weight bearing (Wolfe et al., 2001).
Subsequent losses of joint range, particularly dorsiflex-
ion, and muscle strength results in significant gait
dysfunction. Recent data from our laboratory highlights
the presence of a dorsiflexion deficit not only in the
*Corresponding author. Tel.: +61-7-3365-2781; fax: +61-7-3365-
2775.
E-mail address: b.vicenzino@mailbox.uq.edu.au (B. Vicenzino).
acute stage, but also in the subacute stage (Yang and
Vicenzino, 2002).
Early physiotherapy intervention consists of rest, ice,
compression, elevation (RICE) and electrotherapy
modalities to control inflammation, as well as manip-
ulative therapy and therapeutic exercise techniques to
address impairments of movement and strength (Wolfe
et al., 2001; Hockenbury and Sammarco, 2001). Green
et al. (2001) investigated the impact of combining non-
weight-bearing talocrural anteroposterior (AP) passive
mobilisations, believed to restore dorsiflexion range,
with the RICE protocol in the treatment of acute ankle
sprains. The experimental group ðn ¼ 19Þ demonstrated
a more rapid improvement in pain-free dorsiflexion and
function than the control group ðn ¼ 19Þ who were
treated solely with RICE. This provides important
evidence substantiating the role of passive joint mobi-
lizations in an acutely injured population.
The mobilization with movement (MWM) treatment
approach for improving dorsiflexion post-ankle sprain
combines a relative posteroanterior glide of the tibia
on talus (or a relative anteroposterior glide of the talus
on the tibia) with active dorsiflexion movements,

1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S1356-689X(03)00101-2
 ARTICLE IN PRESS
78 N. Collins et al. / Manual Therapy 9 (2004) 77–82
preferentially in weight bearing (Mulligan, 1999).
Claims of rapid restoration of pain-free movement are
associated with MWM techniques generally (Mulligan,
1993, 1999; Exelby, 1996). Through examination of the
effects of MWM on ankle dorsiflexion in asymptomatic
mildly restricted ankle joints, Vicenzino et al. (2001)
found that both the weight bearing and non-weight-
bearing variations of the dorsiflexion MWM technique
produced significant gains in dorsiflexion range. How-
ever, weight-bearing treatment techniques are widely
believed to be superior to non-weight-bearing techni-
ques, as they replicate aspects of functional activities
(Mulligan, 1999). Acute ankle sprains, whilst having
marked reduction in dorsiflexion range of motion, are
frequently painful in full weight bearing, and weight-
bearing techniques are not clinically indicated. The
subacute ankle sprain is characterized by significant
residual deficits in dorsiflexion (Yang and Vicenzino,
2002) and the capacity to fully weight bear, making it a
good model on which to study the initial effects of
weight-bearing MWM on dorsiflexion.
The mechanism of action of manipulative therapy has
been the focus of several reports in recent times,
however spinal manipulative therapy appears to be the
common subject of research. A synopsis of current
evidence for the initial mechanism of action of
manipulative therapy indicates in part a neurophysiolo-
gical basis (Vicenzino et al., 1996, 1998, 2000).
Manipulative therapy treatment techniques studied have
exhibited non-opioid hypoalgesia to mechanical but not
thermal pain stimuli (Vicenzino et al., 1995, 1998).
The primary objective of this study was to test the
hypothesis that application of Mulligan’s MWM tech-
nique for talocrural dorsiflexion to subacute lateral
ankle sprains produces an initial dorsiflexion gain, and
simultaneously produces a mechanical but not thermal
hypoalgesia.
2. Methods
The double-blind randomized controlled trial incor-
porated repeated measures into a cross over design, in
which each participant served as their own control.
2.1. Participants
Sixteen participants, eight males and eight females
aged 18–50 (average 28.25 years and standard deviation
9.33 years), were recruited through the University
Physiotherapy Clinic, local physiotherapy practices
and sporting clubs, and University advertising. The
primary criterion for inclusion was a grade II ankle
lateral ligament sprain that was sustained on average 40
days (724 days standard deviation) prior to testing. We
defined this sprain as ‘‘an incomplete tear of the
ligament with mild laxity and instability (and) slight
reduction in functiony’’ (Safran et al., 1999); A
minimum pain-free dorsiflexion asymmetry of 10 mm
on weight-bearing measure (Vicenzino et al., 2001),
anterolateral ankle tenderness, and full pain free weight-
bearing capacity were also required. Acute ankle sprains
were excluded due to the potential for exacerbation of
pain with repeated testing on the outcome measures.
Exclusion also occurred if fracture or intra-articular
ankle effusion were clinically detectable, or if there was a
recent history of other lower limb or lumbar spine
conditions. Physiotherapists and physiotherapy students
were excluded to remove a potential source of bias from
the participants.
Ethical clearance was obtained from the relevant
Institution Review Board for ethics at the University of
Queensland, and all participants provided informed
consent.
2.2. Outcome measures
2.2.1. Dorsiflexion
Weight-bearing dorsiflexion (DF), found to have
excellent inter- and intra-rater reliability (Bennel et al.,
1998), was measured using the knee-to-wall principle.
The participant stood in front of a wall, with the test
foot’s second toe and midline of the heel and knee
maintained in a plane perpendicular to the wall. The
participant slowly lunged forward into talocrural dorsi-
flexion until the knee contacted the wall, and progres-
sively moved the foot back to the point where the knee
could just touch the wall with the heel sustained on the
ground. This represented end of range dorsiflexion, and
the distance between the wall and second toe was
measured in millimetres using a tape measure. The
examiner ensured maintenance of heel contact via verbal
instructions and manual contact with the calcaneum.
Vicenzino et al. (2001) found this measure to be more
sensitive in detecting treatment effects than an angular
weight-bearing measure and a non-weight-bearing
measure.
2.2.2. Pain
Quantitative measures of pain were obtained via
pressure and thermal pain threshold. Pressure algome-
try, which has demonstrated reliability (Pontinen, 1988),
was used to measure pressure pain threshold (PPT) at
three lower limb sites: (1) over the proximal third of the
tibialis anterior muscle belly; (2) directly distal to the
lateral malleolus over the CFL; (3) directly anterior to
the lateral malleolus over the ATFL. A digital pressure
algometer (Somedic AB, Farsta, Sweden) was used to
measure the pressure applied to the test site by a rubber-
tipped probe (area 1 cm2), which was positioned
perpendicular to the skin. The pressure was applied at
a rate of 40 kPa/s. Activation of a button by the
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N. Collins et al. / Manual Therapy 9 (2004) 77–82
participant at the precise moment that the pressure
sensation changed to one of pain and pressure, signalled
cessation of pressure application, and froze the mea-
surement onscreen for manual recording.
The Thermotest System (Somedic AB, Farsta,
Sweden) measured hot and cold thermal pain threshold
(TPT). A rectangular contact thermode was manually
positioned over two sites: (i) the proximal third of the
tibialis anterior muscle belly, and (ii) over the ATFL,
extending from the anteroinferior border of the lateral
malleolus toward the toes at an angle that allowed
maximal contact with the foot contours. The hot or cold
stimuli were increased at a rate of 1 C/s from a baseline
of 30 C. Participants pressed a button at the precise
moment that the thermal sensation changed to one of
pain and heat for heat pain threshold, and one of pain
and cold for cold pain threshold. At this point,
stimulation ceased and the temperature reached was
manually recorded. Automatic cut-off points of 52 C
and 2.5 C were adopted to ensure safe stimulus
application.
2.3. Treatment conditions
Three treatment conditions, consisting of MWM for
dorsiflexion, placebo and a no-treatment control, were
studied. During the treatment condition, the dorsiflex-
ion MWM technique was performed on the sympto-
matic talocrural joint, as described by Mulligan (1999).
With the participant in relaxed stance on a bench, a non-
elastic seatbelt was placed around the distal tibia and
fibula and the therapist’s pelvis, with foam cushioning
the Achilles tendon (Fig. 1). A backward translation by
the therapist imparted tension on the seatbelt and a
posteroanterior tibial glide, while the talus and forefoot
were fixated with the webspace of one hand close to the
Fig. 1. The weight-bearing mobilization with movement technique in
which the therapist applies a posteroanterior force to the distal leg
through a treatment belt while manually stabilizing the foot and talus.
79
anterior joint line. The other hand was positioned
anteriorly over the proximal tibia and fibula to direct the
knee over the second and third toes to maintain a
consistent alignment of the distal leg and foot. The glide
was sustained during slow active dorsiflexion to end of
pain-free range, with the seatbelt kept perpendicular to
the long axis of the tibia throughout movement, and
released after return to the starting position. Three sets
of 10 repetitions were applied, with one minute between
sets (Exelby, 1996). Pain experienced during treatment
resulted in immediate cessation of the technique and
exclusion from the study.
The placebo condition replicated the treatment
condition, with the following exceptions. The seatbelt
was placed over the calcaneum, and only minimal
tension imparted to take up the slack. One hand
remained on the proximal tibia and fibula, however
the other hand was positioned across the metatarsal
bases. Instructions were given to produce a small inner
range dorsiflexion while the seatbelt was maintained
perpendicular to the tibia. An identical number of
repetitions, sets and interval period were used.
In the control condition, the participant assumed the
same relaxed stance position as for treatment and
placebo, and maintained this for five minutes. No
manual contact occurred between the therapist and
participant.
2.4. Procedure
A preliminary session, during which a clinical
examination and the three outcome measures were
performed on both ankles, was conducted initially to
determine the participant’s suitability for inclusion. This
session also served to familiarize participants with
testing procedures. Suitable participants returned for
three testing sessions within one week of the initial
appointment. These were scheduled at similar times of
the day to prevent diurnal variations in joint range and
pain, and allow a 24-h interval for wash-out of any
treatment effects. Testing was conducted in an environ-
ment-controlled laboratory, with constant temperature
and humidity.
Each testing session began with the asymptomatic
then symptomatic ankles undergoing each of the three
outcome measures. With the participant in side lying, a
splint was applied to the testing ankle to maintain a
standardized 10 of plantarflexion. PPT and TPT
measures were then conducted in an order randomized
by the toss of a coin, followed by weight-bearing
dorsiflexion. Three repetitions of each measure were
taken. The examiner then left the laboratory while the
therapist then entered and applied one of the treatment
conditions (MWM, placebo, control) to the sympto-
matic ankle. Following treatment, outcome measures
were repeated on the symptomatic ankle by the
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80 N. Collins et al. / Manual Therapy 9 (2004) 77–82

Table 1 application. Any significant interaction effects were

Intraclass correlation coefficient (standard error of measurement) for followed up with tests of simple effects. Post hoc tests
the pressure, heat and cold pain threshold measures
of main effects were performed in the absence of
Pain stimulus ATFL CFL TA an interaction. A Bonferroni adjustment ðaadjusted ¼
Pressure 0.98 (5.57 kPa) 0.95 (8.93 kPa) 0.95 (12.00 kPa) 0:05=3 ¼ 0:017Þ was used to interpret results of the pair
Heat 0.99 (0.40 C) 0.97 (0.22 C) wise tests of simple effects and to adjust for any type I
Cold 0.98 (0.64 C) 0.99 (0.74 C) error resulting from multiple comparisons.

examiner to evaluate the effect of treatment. This

5. Results
procedure facilitated blinding of the examiner. The
participant was unaware of the aim of the study and
5.1. Pre-experiment deficits in outcome measures
which treatment condition was under investigation.
Over the 3 days of involvement in the primary study,
Pre-experiment values for dorsiflexion and pain
each participant experienced all three treatment condi-
measures of the affected and unaffected ankles are
tions in a randomised order as determined by the roll of
displayed in Table 2. Statistical analysis of side-to-side
a dice by the therapist.
differences revealed a deficit only for dorsiflexion (DF)
(t ¼ 5:689; Po0:001) and pressure pain threshold over
the anterior talofibular ligament (PPT ATFL)
3. Reliability
(t ¼ 2:570; P ¼ 0:025). No such deficits in thermal pain
threshold (TPT) were found.
Acceptable intrarater reliability was determined
through analysis of pre-treatment data from the three
testing sessions. The intraclass correlation coefficient 5.2. Primary study
(ICC) and standard error of measurement (SEM) data
for the pain measures are presented in Table 1. The ICC 5.2.1. Dorsiflexion
and SEM for the dorsiflexion measure were 0.99 and A significant interaction time by condition effect for
3.50 mm, respectively. The ICC for the pain measures the dorsiflexion outcome measure was detected by the
ranged from 0.95 to 0.99. The SEM for pressure pain ANOVA (Fð2;26Þ ¼ 7:817; P ¼ 0:002). The interaction
threshold ranged from 5.57 to 12.00 kPa, and the plot is shown in Fig. 2. Post hoc analysis revealed
thermal pain threshold SEM ranged from 0.22 to a significant treatment effect for dorsiflexion from
0.74 C. Note that both the size of the error (SEM) pre- to post-application (t ¼ 2:870; P ¼ 0:013). The
and the ICC are indicative of reliable measures. post hoc analysis for the pre- and post-application
data showed no significant differences between the
placebo (t ¼ 1:343; P ¼ 0:202) and control (t ¼ 1:324;
4. Data management and analysis P ¼ 0:208) conditions. Table 3 presents the dorsiflexion
data.
Two independent variables were incorporated into the
research design; TREATMENT (MWM, placebo, con-
trol), and TIME of application (pre- and post-interven- Table 2
tion). Three dependent variables, measures of pressure Pre-experiment mean (standard deviation) values of the outcome
pain threshold (PPT), thermal pain threshold (TPT) and measures for asymptomatic and symptomatic sides
dorsiflexion (DF), were evaluated. Prior to analysis, Outcome measure Region Asymptomatic Symptomatic
triplicate DF, PPT and TPT data were averaged.
Dorsiflexion (mm) 100.93 (41.04) 58.57 (36.25)
Data pertaining to two of the participants were
Pressure pain ATFL 212.61 (73.52) 154.82 (55.89)
excluded from analysis; subject 4 who had a post-testing threshold (kPa)
MRI that revealed an osteochondral lesion of the talus CFL 348.28 (93.23) 323.46 (95.09)
and ankle joint effusion, and subject 7 who experienced TA 378.78 (115.46) 348.29 (107.93)
pain during the MWM technique.
Heat pain threshold ( C) ATFL 43.48 (2.45) 43.39 (3.57)
Pre-experiment differences between sides (sympto-
TA 43.83 (2.97) 44.26 (2.14)
matic–asymptomatic) were evaluated by paired t-tests
ða ¼ 0:05Þ: Cold pain threshold ( C) ATFL 10.74 (7.07) 11.07 (6.39)
A two-factor analysis of variance (ANOVA) was then TA 8.24 (8.30) 8.85 (7.59)
performed on each of the three dependent variables to Abbreviations: ATFL=anterior talofibular ligament; CFL=calcaneo-
test the hypothesis that MWM produced changes in fibular ligament; TA=tibialis anterior.
excess of placebo and control from pre- to post-  Denotes statistically significant difference ðPo0:05Þ:
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N. Collins et al. / Manual Therapy 9 (2004) 77–82 81

5.2.2. Pain
The data for pain thresholds for pressure, cold and
heat stimuli are expressed as mean and standard
deviation in Table 4. Statistical analysis of the pain
related data revealed no interaction effects (see Fig. 2 for
plots). However, there were main effects for time for
PPT ATFL (Fð1;13Þ ¼ 6:401; P ¼ 0:025) and PPT TA
(Fð1;13Þ ¼ 9:17; P ¼ 0:010). Post hoc tests of simple
effects demonstrated significant pre- to post-differences
for PPT ATFL in the placebo condition (t ¼ 2:774;
P ¼ 0:016) (Fig. 3), but no significant change in PPT
TA. No significant time or condition effects were evident
for PPT CFL, or the TPT measures.

Fig. 2. The Treatment condition (MWM, Placebo, Control) by Time 6. Discussion

interaction plot for dorsiflexion (squares, significant interaction
Fð2;26Þ ¼ 7:817; P ¼ 0:002), pressure pain threshold (PPT) at the Application of the dorsiflexion mobilization with
anterior talofibular ligament (ATFL) test site (circles) and over the
movement (MWM) technique to patients with subacute
tibialis anterior muscle belly (Tib Ant) test site (triangles). Closed
figures (squares, circles and triangles) indicate pre-treatment condition
lateral ankle sprains produced a significant immediate
and open figures indicate post-treatment. The  indicates a significant improvement in dorsiflexion, but had no significant
difference after treatment when compared to before treatment initial effect on mechanical and thermal pain threshold
ðPadjusted o0:017Þ: measures. This dorsiflexion gain following manipulative
therapy parallels findings by Green et al. (2001) in acute
ankle injuries, and Vicenzino and colleagues’ (2001)
study of asymptomatic minimally restricted ankles.
Table 3
Mean and standard deviation for dorsiflexion (mm) under the three
Current and previous research findings suggest that
treatment conditions the predominant mechanism of action for the dorsiflex-
ion MWM technique is most likely mechanical, rather
Time MWM Placebo Control
than a direct hypoalgesic effect. An excessive anterior
Pre 57.27 (41.00) 60.17 (38.49) 58.29 (32.67) displacement of the talus is believed to occur during
Post 68.93 (45.44) 62.07 (38.97) 56.42 (33.48) plantarflexion/inversion injury and persist with residual
There were no significant differences between conditions in the pre- laxity of the anterior talofibular ligament (ATFL)
application data. (Mulligan, 1999). Denegar et al. (2002) reported
 Denotes significant change ðPo0:017Þ:
increased ATFL laxity and restricted posterior talar

Table 4
Mean and standard deviation for the pain measures under the three treatment conditions before and after their application

Stimulus Region Time MWM Placebo Control

Pressure (kPa) ATFL Pre 154.19 (48.64) 155.38 (68.69) 175.12 (89.03)
Post 166.74 (78.68) 179.05 (75.33) 187.66 (101.55)
CFL Pre 327.44 (83.15) 318.43 (96.31) 346.68 (148.70)
Post 335.04 (76.56) 341.13 (135.58) 325.28 (146.88)
TA Pre 371.85 (115.43) 372.43 (144.57) 385.55 (160.20)
Post 394.79 (147.81) 385.01 (144.12) 420.94 (185.79)

Heat ( C) ATFL Pre 43.14 (2.49) 43.20 (2.24) 43.78 (3.26)

Post 42.57 (2.29) 44.14 (3.36) 43.76 (2.61)
TA Pre 44.74 (2.46) 44.73 (2.40) 44.63 (2.43)
Post 44.46 (2.21) 44.14 (2.42) 44.77 (2.72)

Cold ( C) ATFL Pre 10.80 (5.87) 11.06 (6.13) 9.07 (5.41)

Post 9.86 (5.54) 10.77 (6.56) 8.93 (6.26)
TA Pre 8.25 (6.23) 8.18 (7.11) 7.25 (6.10)
Post 8.04 (5.85) 7.95 (7.19) 7.62 (6.72)

There were no significant differences between conditions in the pre-application data. Abbreviations: ATFL=anterior talofibular ligament;
CFL=calcaneofibular ligament; TA=tibialis anterior.
 ARTICLE IN PRESS
82 N. Collins et al. / Manual Therapy 9 (2004) 77–82
glide in twelve athletes who had sustained an ankle
sprain 6 months earlier and had since returned to sport.
The clinical rationale given for the anteroposterior glide
component of the weight-bearing dorsiflexion MWM
technique is to reduce any residual anterior displace-
ment of the talus (Mulligan, 1999). Mulligan (1993,
1999) proposed that correction of the restricted poster-
ior glide, via repetitions of DF with a sustained
anteroposterior talar mobilization (mechanically similar
to posteroanterior tibial glide on talus), restores the
normal joint kinematics even after release of the glide.
The mechanism by which this occurs in the presence of
ATFL laxity requires further examination.
Despite the presence of a reduction in pressure pain
threshold (PPT) over the ATFL, the MWM technique
did not produce a significant change in local PPT in the
initial post-treatment period. The dorsiflexion MWM’s
mechanism of action therefore appears to be mechan-
ical, and not directly via changes in the pain system. The
conduct of further research is required to identify a
precise mechanism.
While small but non-significant increases in pressure
pain threshold occurred following treatment and control
application, it was the placebo condition that produced
a statistically significant improvement in pressure pain
threshold over the ATFL. It is possible that the gentle
inner range dorsiflexion movement performed during
the placebo condition was more successful at altering the
local pathophysiology peripherally at the ankle or via
central neurophysiological mechanisms than the sus-
tained end of range glide and larger range movement of
the MWM technique. The application of small ampli-
tude accessory glides of joints in an acute and painful
state has been previously advocated (Maitland, 1985)
and their benefits in the subacute population requires
further investigation.
The reasonably small sample size should also be
considered to have influenced the results of the statistical
analysis. It is possible that the pain measures have a
lower sensitivity to change than the dorsiflexion
measure, yet the significant dorsiflexion improvement
seen post-treatment indicates that range gains are the
predominant effect. In addition the failure to elicit pre-
study deficits in thermal pain thresholds most likely
lessened the likelihood of detecting a change with
treatment. Research using a larger sample size and
possibly acute ankle sprains with deficits in thermal
pain, should they exist, may reveal differences not
detected in this study.
7. Conclusion
Mulligan’s dorsiflexion mobilization with movement
technique significantly increases talocrural dorsiflexion
initially after application in subacute ankle sprains. The
absence of hypoalgesia post-application suggests a
predominant mechanical rather than hypoalgesic effect
behind the technique’s success. Further research using a
larger sample is required to determine the exact
mechanism behind this.
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