The Effects of Joint Manipulation vs.

Non-manipulative Manual Therapy to Treat Ankle

Hypomobility in Patients with a History of Ankle Sprains

Submitted by: Allison Wierda

 Ankle sprains are the most common injury during sports activities.1 Over 23,000 people

sprain their ankle each day in the United States and 30% experience persistent symptoms lasting

at least 6 months post injury.2 Following an ankle sprain patients can experience chronic ankle

instability. Chronic ankle instability is a set of residual symptoms that can occur after an ankle

sprain and include chronic pain, episodes of giving way, recurrent sprains, and swelling.1

Patients may also experience ankle hypomobility in dorsiflexion which can commonly affect

daily activities such as walking, running, stair-climbing and squatting.1

Various methods of physical therapy have been applied to treat patients with chronic

ankle instability such as bracing, kinesio taping, strengthening exercises, balance training, and

manual therapy.3 Manual therapy techniques are frequently applied by physical therapists to help

improve range of motion, alleviate pain, and facilitate return to function.1 Manual therapy

techniques are typically applied to the talocrural joint and commonly include joint mobilization,

mobilization with movement, and/or joint manipulation.2

Joint mobilizations are delivered as low-velocity sustained or oscillatory motions, while

joint manipulations are defined often as high velocity thrusts. The distinguishing factor between

mobilizations and manipulations is the speed of their application.2

Improving the understanding of the processes responsible for the clinical effects of these

techniques is important so treatments can be selectively incorporated into patient care.2 This

literature review seeks to compare previous studies to help determine if high velocity, low

amplitude (HVLA) manipulations are more effective than non-manipulative techniques to

increase mobility in the talocrural joint in patients with a history of an ankle sprain.
 In a study by Fisher et al., twenty-seven participants with a history of an ankle sprain

were randomly assigned to a control, joint mobilization, or thrust manipulation group. The

subtalar neutral dorsiflexion and weight-bearing composite ankle dorsiflexion were assessed on

two separate occasions at least 5 days apart. Individuals in the intervention groups received a 30

second sustained caudal talocrural mobilization or a thrust manipulation and those in the control

group received the hand placement used for the manipulation only with no long-axis distraction

or other forces. Results showed there was no significant change in ankle dorsiflexion amongst all

three groups. This may have been due to the study population and the lack of sensitivity of the

measures to detect any small changes. The population consisted of participants who were largely

asymptomatic and did not have significantly impaired range of motion.2

Marrón-Gómez et al., conducted a randomized, double-blind, repeated measures, parallel

control design. The aim of the study was to compare the effects of a mobilization with movement

vs. talocrural manipulation, for improvement of ankle dorsiflexion over a 48 hour period. 19

Nineteen participants we assigned to the HVLA group, 18 to the weight bearing-mobilization

with movement group, and 15 were in the placebo group. Statistical analysis showed a

significant increase in ankle dorsiflexion in both treatment groups with respect to the placebo

group, but no differences between the treatment groups. Within-group effect sizes between pre

and 48 hours post-intervention for dorsiflexion were small for the HVLA group, moderate for

weight bearing-mobilization with movement group and the placebo group had insignificant

effect size. Overall there was no significant differences between the two manual techniques over

time, but weight bearing-mobilization with movement showed greater within-group effect sizes

than HVLA between pre and post measurements.1

 Similarly, in a study done by Kamali et al., 40 participants were equally randomly

assigned to the treatment group and the control group. The treatment group received a

manipulation performed by a physical therapist and the control received “treatment” in the same

position for 1 minute without any thrust as the sham manipulation. The interventions were

carried out once a day for 3 consecutive days. All participants completed a timed speed test, hop

test distance, and Y-balance test distance in all directions pre and post treatment. In the treatment

group there was a significant change observed in all 3 tests and none of them altered

meaningfully in the control group. Although ankle dorsiflexion was not specifically measured,

the improvement in dynamic balance can be primarily attributed to an increase in ankle

dorsiflexion range of motion.3

After thoroughly analyzing the aforementioned three articles, it was noted that there was

some discrepancies among the study designs, treatment methods, and independent variables. The

studies were short in duration and varied with how often participants received treatment and

when measurements were taken. The long term effects of treatment were not observed in any of

the studies. Understanding the best long term treatment options for ankle hypomobility due to

history of ankle sprains is important for physical therapists because of the high prevalence of the

injury. Ankle hypomobility can have a long lasting effect on daily activities such as walking and

stair climbing so it is crucial to be able to effectively and efficiently treat patients with this

problem.

The review of literature resulted in no definitive conclusion as to whether talocrural joint

manipulation is more effective than other forms of treatment to treat ankle hypomobility in

patients with a history of ankle sprains. However, two of the studies did conclude that some form

of treatment is better than no treatment. Therefore, one would conclude that more research needs
to be completed in order to determine if manipulation to the talocrural joint is more effective

long term than other forms of treatment for dorsiflexion hypomobility due to history of ankle

sprain.

References
1. Marrón-Gómez D, Rodríguez-Fernández ÁL, Martín-Urrialde JA. The effect of two
mobilization techniques on dorsiflexion in people with chronic ankle instability. Physical
Therapy in Sport. 2015;16(1):10-15. doi:10.1016/j.ptsp.2014.02.001
2. Fisher BE, Piraino A, Lee Y-Y, et al. The Effect of Velocity of Joint Mobilization on
Corticospinal Excitability in Individuals With a History of Ankle Sprain. Journal of
Orthopaedic & Sports Physical Therapy. 2016;46(7):562-570. doi:10.2519/jospt.2016.6602
3. Kamali F, Sinaei E, Bahadorian S. The immediate effect of talocrural joint manipulation on
functional performance of 15–40 years old athletes with chronic ankle instability: A double-
blind randomized clinical trial. Journal of Bodywork and Movement Therapies.
2017;21(4):830-834. doi:10.1016/j.jbmt.2017.01.010

PTH 661 – Manual Therapy I EBM Literature Review Paper 2019

Student: Allison Wierda Faculty Initials: JTZ

Scoring Criteria
1. Clearly describes the clinical question or purpose 1/1
2. Provides brief description of materials reviewed 1/1
3. Provides synopsis of conclusions/discussion 2/2
4. Assessed the quality of the evidence provided 1/1
5. Identifies why article(s) is/are appealing/interesting 1/1
6. Clinical implications (relevance to practice?) 2/2
7. Grammar/spelling/punctuation 1/1
8. Clarity, organization, conciseness 1/1 Excellent!!

Total Score 10/10

Percent Score 100%
Additional Feedback: Allison, wonderful job with reviewing multiple pieces of
evidence to come to a clinical conclusion to inform your future clinical practice.
Your writing style was well organized and concise, and your conclusions based on
the evidence or substantiated. Nice job with the review! Dr. Zipple