ARTICLE IN PRESS

Manual Therapy 13 (2008) 63–67

www.elsevier.com/locate/math

Original article

Anterior positional fault of the fibula after sub-acute

lateral ankle sprains
Tricia J. Hubbarda,, Jay Hertelb
a
Department of Kinesiology, University of North Carolina, 9201 University City Blvd., Charlotte, NC 28223, USA
b
Kinesiology Program, University of Virginia, Charlottesville, VA 22904, USA
Received in revised form 5 July 2006; accepted 26 August 2006

Abstract

Recent evidence has suggested a positional fault of the fibula exists in chronically unstable ankles. However, there has been little
research examining positional faults after a sub-acute lateral ankle sprain (LAS). Our purpose was to measure the position of the
distal fibula in relation to the distal tibia in subjects with sub-acute LASs and to determine if there is a relationship between the
amount of swelling and fibular position. Eleven subjects with a unilateral sub-acute LAS and 11 healthy controls participated. The
Wilcoxon signed rank test revealed a significant ðp ¼ 0:008Þ difference within the ankles of the injured group. The sprained ankles
had a mean fibular position of 14.2+3.4 mm and were positioned significantly more anteriorly than the contralateral uninjured
ankles (17.0+3.2 mm). The Mann–Whitney test revealed a significant difference ðp ¼ 0:045Þ between the sprained ankle and the
side-matched limbs of the controls (16.8+2.3) Pearson product moment correlations revealed a strong positive correlation between
fibular position and swelling (r ¼ 0.793, p ¼ 0:004). Those ankles with more swelling had the most anteriorly positioned fibulae. The
fibulae in sub-acutely sprained ankles appear to be positioned more anteriorly compared to the contralateral ankles. This positional
fault may be maintained acutely by swelling.
Published by Elsevier Ltd.

Keywords: Ankle sprain; Fibula; Fluoroscopy; Tibiofibular joint

1. Introduction After an acute LAS, attention is typically paid to the

Lateral ankle sprains (LASs) are among the most
common injuries suffered during athletic activities
(Garrick, 1977). The anterior talofibular ligament
(ATFL) is reported to be the weakest and first ligament
injured in an ankle sprain (Brostrom, 1964). This is
followed by the calcaneofibular ligament (CFL) and the
posterior talofibular ligament (PTFL). Rupture of the
ATFL occurs as an isolated injury in 66% of all ruptures
of the ankle ligaments and in combination with a
rupture of the CFL in another 20% (Brostrom, 1964).
Corresponding author. Tel.: +1 704 687 6202;
fax: +1 704 687 3350.
E-mail address: thubbar1@uncc.edu (T.J. Hubbard).
lateral ligamentous structures. However, in addition to
injury of the ligamentous structures of the ankle,
hypomobility may develop after injury (Denegar and
Miller, 2002; Hertel, 2002). This hypomobility has been
often been demonstrated in the form of a positional
fault (Mulligan, 1995). The relative void in the literature
regarding positional faults gives the impression they do
not contribute to residual symptoms or to increasing the
risk for reinjury.
Mulligan (1995) has proposed that some individuals
diagnosed with LASs experience an anterior positional
fault of the distal fibula on the tibia. Since the original
hypothesis proposed by Mulligan (1995), several studies
have examined fibular position in subjects after an
acute ankle sprain or with chronic ankle instability
(Kavanagh, 1999; Mavi et al., 2002; Eren et al., 2003;

1356-689X/$ - see front matter Published by Elsevier Ltd.

doi:10.1016/j.math.2006.09.008
 ARTICLE IN PRESS
64 T.J. Hubbard, J. Hertel / Manual Therapy 13 (2008) 63–67
Berkowitz and Kim, 2004; Hubbard et al., 2006).
Results have suggested both anterior (Kavanagh, 1999;
Mavi et al., 2002; Hubbard et al., 2006) and posterior
(Eren et al., 2003; Berkowitz and Kim, 2004) positional
faults although measurement difference likely contribute
to those contradicting findings. Our purpose was to
examine the position of the distal fibula in relation to the
distal tibia in subjects with sub-acute LASs and to
determine if a relationship exists between the amount of
swelling and fibular position.
2. Methods
2.1. Subjects
Eleven recreationally active subjects with sub-acute
LASs (5 males and 6 females, age ¼ 20.170.94 yr,
mass ¼ 75.5721.5 kg, ht ¼ 172.1714.1 cm) and 11 sub-
jects with no previous history of ankle injury (five males
and six females, age ¼ 20.070.89 yr, mass ¼ 71.47
11.2 kg, ht ¼ 170.678.6 cm), participated in this study.
A certified athletic trainer initially examined the injured
subjects. Subjects with a LAS were then referred to the
researchers and offered the opportunity to participate in
the study. The mean grade of ankle sprain suffered by
subjects was 1.9+0.53 on a 3-category scale. Fluoro-
scopic images were taken between 2 and 10 days after
injury (mean ¼ 4.7+2.5 days). All healthy subjects were
recruited from undergraduate courses until we had an
equal number of males and females in both the injured
and healthy groups. The sides were assigned so that
there were an equal proportion of right and left involved
ankles in the sub-acute LAS and control groups.
2.2. Instrumentation
The position of the distal fibula in relationship to the
distal tibia was determined by taking a lateral image of
both ankles. A Mini 6600 Fluoroscope with a digital
mobile C-arm (OEC Medical Systems Inc., Salt Lake
City, UT) recorded images.
2.3. Procedures
The position of the fibula was measured with fluoro-
scopy. Using previously reported methods (Hubbard et al.,
2006). Test–retest reliability (ICC (3, 1) ¼ 0.98, SEM ¼
0.64 mm) and intratester reliability (ICC (3, 1) ¼ 0.92,
SEM ¼ 0.72 mm) were also previously reported (Hubbard
et al., 2006). Subjects were positioned side lying on the
treatment table. The subject’s posterior thigh was posi-
tioned against a bolster to ensure the hip was maintained
in a neutral position in the sagittal plane. Additionally, a
fluid inclinometer was placed on the lateral joint line of the
knee to ensure the leg was kept in neutral and not in
abduction or adduction in the frontal plane. The subject’s
knee was in full extension. Towels were then placed under
the leg to maintain neutral position. The foot of the top leg
was then placed on the image intensifier of the fluoroscope.
The foot was passively positioned in maximum dorsiflex-
ion for testing (Hubbard et al., 2006). Subjects were
observed to ensure that no rotations of the lower extremity
occurred during testing. The order of which ankle was
tested first was randomly assigned by 1 examiner. The
same examiner positioned and made measurements on all
subjects.
A lateral image was then recorded. The same
procedure was then followed for the opposite leg. A
radiographic marker (4.5 mm long) was placed on all
ankles to correct for variances in magnification. After
the images were printed, measurements were made to
determine the position of the fibula (Fig. 1). A tape
measure was used to measure the distance between the
anterior margin of the fibula and the anterior margin of
the tibia in millimetres. Measurements were made
perpendicular to a line drawn vertically from the most
anterior point of the tibia.
To measure swelling, the figure-of eight method was
used. High intratester and intertester reliability have
been reported (ICC ¼ 0.99 for both) (Tatro-Adams
et al., 1995). Subject’s ankles were positioned in neutral.
The beginning of the tape measure was placed midway
between the anterior tibialis tendon and the lateral
malleolus. The tape measure was then placed around the
foot, distal to the navicular tuberosity, across the arch
proximal to the base of the fifth metatarsal, across the
Fig. 1. Fibular position was measured by the distance between the
anterior edge of the distal fibula and the anterior edge of the distal tibia
was measured in centimeters and then converted to millimetres.
Reprinted from Hubbard TJ, Hertel J, Sherbondy P. Fibular position
in Individuals With Self-Reported Chronic Ankle Instability. J Orthop
Sports Phys Ther. 2006; 36(1):3–9, with permission of the Orthopaedic
and Sports Physical Therapy Sections of the American Physical
Therapy Association.
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T.J. Hubbard, J. Hertel / Manual Therapy 13 (2008) 63–67 65

anterior tibialis tendon, and back around the heel. The fibular position difference was explained by variance in
measurement was recorded in centimeters for both the ankle girth difference.
right and left ankles.

2.4. Data analysis

4. Discussion
The data did not fit a normal distribution so nonpara-
There was a statistically significant difference in
metric statistics were calculated. The Wilcoxon signed
fibular position for the subjects with sub-acute LAS.
rank test was used to test for side-to-side differences
Our findings suggest an anterior positional fault was
within both the sub-acute LAS group and the control
group. Mann–Whitney tests were used to test for
Table 2
differences between the injured ankle of the sub-acute Fibular position (mm) for all 22 subjects
LAS group and the side matched ankle of the control
group, and the uninjured ankle of the sub-acute LAS Sub-acute LAS group Control group
group and the side-matched ankle of the control group. Sub-acute ankle Opposite ankle Matched ankle Opposite ankle
Bivariate correlations using Pearson product moment
calculations were made between the amount of side-to- 12.00 12.00 15.00 14.40
side difference in swelling and the corresponding 9.50 20.50 14.20 15.90
17.00 20.80 17.60 15.00
difference in fibular position for the sub-acute LAS 19.00 19.00 13.50 13.30
group. The level of significance was set a priori at 17.20 21.10 15.10 13.80
po0:05 for all analyses. 15.00 17.00 20.20 20.70
13.30 14.40 15.00 14.50
8.10 13.50 19.30 20.70
16.70 19.40 17.60 17.20
3. Results 15.00 15.30 18.90 16.50
13.00 14.70 18.60 19.40
The Wilcoxon signed rank test revealed significant
differences within the ankles of the sub-acute LAS
group ðp ¼ 0:008Þ. The injured ankle of the sub-acute 8
LAS group had a mean fibular position of 14.2+3.4 mm 7
Ankle Girth Difference

posterior to the anterior edge of the tibia compared to 6

17.0+3.2 mm for the contralateral uninjured ankle.
There were no significant side-to-side differences within 5
the healthy group ðp ¼ 0:563Þ. The Mann–Whitney test 4
revealed a significant difference between the injured 3
ankle of the sub-acute LAS group and the matched side
of the control group ðp ¼ 0:045Þ, there were no 2
significant differences between the uninjured ankle of 1
the sub-acute LAS group and the matched side of the 0
control group ðp ¼ 0:438Þ (Table 1). Fibular position for 0 2 4 6 8 10 12
all 22 subjects is listed in Table 2. Fibular Position Difference
Pearson product moment calculations revealed a
Fig. 2. Pearson product moment calculations* between the difference
statistically significant positive correlation between the
in ankle circumference and fibular position difference for the sub-acute
side-to-side differences in fibular position and swelling lateral ankle sprain group ðn ¼ 11Þ. Girth measures are in cm, and
ðr ¼ 0:793; p ¼ 0:004Þ. (Fig. 2) 63% of variance in the fibular position measures are in mm.

Table 1
Means, standard deviations, and range of fibular positiona for a group with a sub-acute lateral ankle sprain (LAS) ðn ¼ 11Þ and a control group
ðn ¼ 11Þ

Measurement Sub-acute LAS group Control group

Sub-acute ankle Opposite ankle Matched ankle Opposite ankle

Fibular position (mm) 14.273.4 (8.1–19.0) 17.073.2 (12.0–21.1) 16.872.3 (13.5–20.2) 16.572.7 (13.3–20.7)
a
The position of the fibula is defined as the distance between the anterior edge of the distal tibia and anterior edge of the distal fibula measured with
a fluoroscopic image.
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66 T.J. Hubbard, J. Hertel / Manual Therapy 13 (2008) 63–67
present in those with sub-acute LAS when compared to
their contralateral ankles and the side-matched controls.
Additionally our effect size was high (0.91) within the
ankles of the sub-acute LAS group, and high (1.15)
between the involved ankles of the sub-acute and
matched control ankles. Based on our effect sizes, we
believe the altered position of the fibula was enough for
clinical meaningful effects. It is important to note that
not all subjects had an anteriorly displaced fibula. Two
of the 11 subjects (18%) with a sub-acute ankle sprain
did not have an anteriorly positioned fibula. Anterior
positional fault of the distal fibula may be present in
some but not all subjects after an ankle sprain (Table 2).
Our data also suggests that those participants with
greater differences in fibular position had more swelling
as measured by differences in ankle girth. As the
difference in ankle girth increased the difference in
fibular position between the involved and uninvolved
ankles also increased. Additionally, 63% of the variance
in fibular position difference is explained by the variance
in ankle girth. Swelling immediately after injury may
maintain fibular displacement. However, further re-
search is necessary to examine the relationship of
swelling and fibular position. Those with more swelling
may have had a more severe ankle injury which may also
account for the fibular position measures.
Both anterior and posterior positional faults have been
reported after acute ankle sprains and in those with CAI.
Methodological differences may account for differences
in findings. Kavanagh (1999) examined this hypothesis in
a series of cases. She hypothesized there would be a
greater range of anterior-posterior movement possible at
the distal fibula if a positional fault of the fibula occurred
after an ankle sprain. She reported a significantly greater
amount of movement occurred in one third of the
subjects with acute ankle sprains (Kavanagh, 1999).
More objective methods were used by Mavi et al. (2002)
and Hubbard et al. (2006). Both measured the distance
between the anterior margin of the fibula and the anterior
margin of the tibia on radiographic images. They both
reported the fibula was positioned more anteriorly in the
injured group than in the control group.
Despite this evidence of anteriorly positioned fibula,
three recent studies reported the fibula to be posteriorly
positioned in those with lateral ankle instability.
Scranton et al. (2000), Eren et al. (2003), and Berkowitz
and Kim (2004) examined the position of the fibula in
subjects with acute ankle sprains and ankle instability.
The axial malleolar index was computed from CT scans.
The results from these studies suggest the fibula may be
positioned posteriorly in relation to the medial mal-
leolus after ankle sprain (Scranton et al., 2000; Eren
et al., 2003; Berkowitz and Kim, 2004). The authors
measured the relationship in a transverse plane at the
talocrural joint. The major limitation is that the
measurement of fibular position is based on the position
of the talus. Previous research has reported decreased
posterior mobility of the talus after an ankle sprain
(Denegar et al., 2002). This decreased mobility could
have been caused by an anteriorly positioned talus. If
the talus is positioned anteriorly, the fibula would have
appeared to be positioned posteriorly. Studies (Mavi
et al., 2002 and Hubbard et al., 2006) that reported an
anteriorly positioned fibula have measured fibular
position in relation to the tibia without consideration
of talar position. This may explain the different results
and comparison of these different methods of assessing
distal fibula position is certainly warranted. Addition-
ally, a limitation of using fluoroscopy is we do not
currently know the validity of the measure. The
fluoroscope records a 2-dimentional image, which limits
the ability to identify and measure any rotations of the
fibula that may occur (Hubbard et al., 2006).
Distal fibular mobility and position should be
examined after acute ankle injury. If the distal fibula is
positioned anteriorly, manual therapy techniques such
as fibular mobilization should be utilized. Since the goal
is to increase the range of motion, a grade III or IV
technique is used (Mulligan, 1995). The patient is
positioned supine on a treatment table. The clinician
places the palm of their hand on the lateral malleolus. A
posterior mobilization is then applied to the lateral
malleolus (Mulligan, 1995). Typically 15 impulses are
applied to the joint. Additionally, the posterior fibular
glide can be combined with active ankle inversion
(Greenman, 1996). Treatments typically last until full
physiologic and arthrokinematic motion are regained.
Previous research has demonstrated positive out-
comes with distal fibula and talar mobilization after
ankle sprains. O’Brien and Vicenzino (1998), applied
posterior fibular mobilizations in two subjects after an
acute ankle sprain. They reported immediate reduction
in pain, increases in range of inversion, improved
outcome, and improvements in function. Green et al.
(2001) demonstrated that subjects treated with anterior
to posterior mobilizations of the talus received fewer
treatments to obtain pain-free dorsiflexion range of
motion. These results were later supported by Collins
et al. (2004) who also reported significant immediate
improvement in dorsiflexion range of motion after
mobilization. Further research examining the effect of
mobilization techniques at the distal tibiofibular joint is
needed in larger samples.
5. Conclusion
We identified an anteriorly positioned distal fibula in
individuals with sub-acute LAS. We do not currently
know if altered fibular position was a predisposing
factor to injury. It appears that swelling maintains
fibular displacement acutely.
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