Jospt.2015.5981 Tornozelo

MANUAL PHYSICAL THERAPY FOLLOWING IMMOBILIZATION FOR STABLE
ANKLE FRACTURE: A CASE SERIES
Elizabeth E. Painter, PT, DSc1

Gail D. Deyle, PT, DSc1
Christopher Allen, PT, DSc1
Evan J. Petersen, PT, DSc2
Theodore Croy, PT, PhD3
Kenneth P. Rivera, PA-C, DSc4
Downloaded from www.jospt.org at New York University on July 23, 2015. For personal use only. No other uses without permission.
1 Brooke Army Medical Center, Army-Baylor University Doctoral Fellowship in

Orthopaedic Manual Physical Therapy, Fort Sam Houston, TX, USA
2University of the Incarnate Word, School of Physical Therapy, San Antonio, TX, USA
3US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston,
TX, USA
4Brooke Army Medical Center, US Army-Baylor University Physician Assistant
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Postgraduate Doctoral Program in Orthopaedics, Fort Sam Houston, TX, USA
The Institutional Review Board at Brooke Army Medical Center, Fort Sam Houston, TX
approved the protocol for this study.
The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest organization or entity with a direct
financial interest in the subject matter or materials discussed in the article.
Journal of Orthopaedic & Sports Physical Therapy®
The opinions and assertions contained herein are the private views of the authors and
are not to be construed as official or as reflecting the views of the Departments of the
Army or Defense.
Address correspondence to Dr. Elizabeth Painter, Physical Therapy Service, Fort Sam
Houston Primary Health Clinic, 3551 Roger Brooke Drive, Ft. Sam Houston, TX 78234
Email: Elizabeth.e.painter@gmail.com or elizabeth.e.painter.mil@mail.mil
1
1 STUDY DESIGN: Case series.
2 BACKGROUND: Ankle fractures commonly result in persistent pain, stiffness, and
3 functional impairments. There is insufficient evidence for any particular rehabilitation
4 approach after ankle fracture. The purpose of this case series was to describe an
5 impairment-based manual physical therapy approach to treating patients with

6 conservatively managed ankle fractures.
7 CASE DESCRIPTION: Patients with stable ankle fractures post immobilization were
8 treated with manual physical therapy and exercise targeted at associated impairments
9 in the lower limb. The primary outcome measure was the Lower Extremity Functional
10 Scale (LEFS). Secondary outcome measures included the Ankle Lunge Test (ALT),
11 Numeric Pain Rating Scale, and Global Rating of Change. Outcomes measures were
12 collected at baseline (performed within 7 days of immobilization removal), and 4 and 12
13 weeks post-baseline.
14 OUTCOMES: Eleven patients (mean age 39.6 years, range 18-64; 2 male), post ankle
15 fracture related immobilization (mean duration 48 days, range 21-75) were treated for
16 an average of 6.6 sessions (range 3-10) over a mean of 46.1 days (range 13-81).
17 Compared to baseline, statistically significant and clinically meaningful improvement
18 were observed in the LEFS (P=.001; mean change, 21.9 points; 95% confidence
19 interval [CI] 10.4, 33.4) and ALT (P=.001; mean change 7.8 cm; 95% CI: 3.9, 11.7) at 4
20 weeks. These changes persisted at 12 weeks.
21 DISCUSSION: Statistically significant and clinically meaningful improvements in self-
22 reported function and ankle range of motion were observed at 4 and 12 weeks following
2
23 treatment based on impairment-based manual physical therapy. All patients tolerated
24 treatment well. Results suggest this approach may have efficacy in this population.
25 LEVEL OF EVIDENCE: Therapy, level 4.
26 KEY WORDS: clinical reasoning, lower extremity, manipulation, mobilization
27
28 BACKGROUND
29 Ankle fracture is a common lower limb injury requiring orthopaedic management.40
30 While many patients have good to excellent clinical outcomes after a surgically or
31 conservatively treated ankle fracture,32 ankle fracture has long-term consequences on
32 physical, psychological, and social functioning, comparable to hip and vertebral

33 fractures.48 Insufficient rehabilitation is a possible cause of persistent disability after
34 ankle fracture.41
35
36 Prognostic indicators for successful return to sport after ankle fracture include younger
37 age, male gender, overall good health, and absence of syndesmosis injury.6 Greater
38 dorsiflexion range of motion (ROM) at the time of immobilization removal predicts better
39 long-term outcome, suggesting that addressing limited dorsiflexion ROM immediately
40 after immobilization may be important.19,35 In addition to impaired ankle dorsiflexion
41 ROM,7 immobilization after ankle fracture results in calf muscle atrophy, reduced peak
42 plantar flexion torque, and reduced central activation of the calf musculature.51,52
43 Manual physical therapy techniques applied to the foot and ankle have been shown to
44 improve ankle dorsiflexion,25,50,53,54 increase soleus muscle activation,9,18 and improve
45 single limb balance.25
3
46
47 Currently, there is insufficient evidence for any particular rehabilitation intervention after
48 ankle fracture.33 The authors of a randomized controlled trial (RCT) investigating the
49 use of manual physical therapy techniques in addition to exercise in those with
50 surgically or conservatively treated ankle fracture found no additional benefit over
51 exercise alone.34 However, the manual physical therapy intervention was artificially
52 constrained by standardizing treatment to a single predetermined joint mobilization
53 technique regardless of the movement limitations demonstrated by each patient. This
54 prescriptive treatment regimen is not reflective of actual clinical practice and may have
55 reduced the potential treatment effectiveness of manual physical therapy.

56
57 Given the complexity of joint movement at the foot and ankle required for daily activities
58 and gait,15,39 an impairment-based manual physical therapy approach may be well
59 suited for finding and addressing reduced ROM and muscle strength occurring after
60 immobilization for ankle fracture. An impairment-based manual physical therapy
61 approach includes a comprehensive evaluation identifying impairments to movement,
62 relevant muscular weakness, painful structures, and functional limitations.13,21,31 This
63 approach incorporates clinical reasoning and careful judgments on expected symptom
64 response to examination and treatment procedures to ensure that sessions are well
65 tolerated. Manually applied treatment and related exercises are tailored in scope and
66 dose to each patient’s identified impairments.13,14 This treatment approach has
67 demonstrated efficacy in improving short and long-term outcomes for other lower
4
68 extremity disorders, including inversion ankle sprain,11 plantar heel pain,10 and knee12,14
69 and hip osteoarthritis.1,27
70
71 Impairment-based manual physical therapy for ankle fracture has been described in a
72 small case series54 of 5 patients, treated for 5 weeks after the end of the immobilization
73 period, with good short term results. However, functional improvement was
74 documented with an outcome tool that has no demonstrated validity or reliability37 which
75 limits application of results. Additionally, 2 case reports23,47 describe good results with
76 impairment-based manual physical therapy for chronic pain after ankle fracture. Both
77 patients were initially managed with immobilization and a rehabilitation exercise

78 program but reported persistent pain, reduced ankle ROM, and functional limitations
79 that subsequently responded well to a manual physical therapy intervention. These
80 case reports illustrate the chronic disability that can result from stable, uncomplicated
81 ankle fractures treated with immobilization, as well as the potential benefit of an

82 impairment-based manual physical therapy approach.
83
84 The purpose of this case series was to observe and describe changes over the course
85 of treatment in patients with conservatively managed ankle fractures treated with an
86 impairment-based manual physical therapy approach. Changes over the course of
87 treatment were documented using functional outcome tools with demonstrated content
88 and construct validity, reliability, and responsiveness to change, easily administered in a
89 clinical setting. Recording the number of manual techniques, bouts performed, and
90 application into resistance for each technique provided a record of treatment dose for
5
91 each patient. Results of this study may guide clinicians in providing and dosing manual
92 physical therapy interventions following ankle fracture to minimize disability and
93 enhance function.
94
95 CASE DESCRIPTION
96 Patients
97 Consecutive patients presenting to the Orthopaedic Service at Brooke Army Medical
98 Center, Fort Sam Houston, TX, between March and September 2014, with stable ankle
99 fractures involving the distal tibia, distal fibula, or talus and treated conservatively with
100 immobilization were screened for eligibility criteria. Providers within the Orthopaedic
101 Service screened patients for enrollment, cleared all patients for partial or full weight
102 bearing and appropriateness for physical therapy treatment and ensured timely referral
103 to physical therapy. Inclusion criteria consisted of stable ankle fractures treated
104 conservatively with immobilization and start of intervention no more than 7 days post-
105 removal of immobilization device.
106
107 Additional inclusion criteria were: age of 18-65 years and no concurrent injuries or
108 pathology such as neurological injury or other fractures. Patients with surgical fixation,
109 fracture malunion or nonunion, syndesmosis injury, or any standard contraindication to
110 manual physical therapy were excluded. All patients who met inclusion criteria and
111 agreed to participate underwent a formal informed consent process and signed a
112 consent form approved by the Institutional Review Board at Brooke Army Medical
6
113 Center, Fort Sam Houston, TX, prior to collection of baseline measurements or physical
114 therapy evaluation.
115 Therapists
116 The single physical therapist who examined and treated all patients was a fellow in
117 training in a manual physical therapy fellowship program. This physical therapist was
118 board certified in both orthopaedic and clinical electrophysiological physical therapy with
119 15 years of clinical experience in orthopaedic physical therapy.
120 Evaluation Procedure
121 Patients received the initial evaluation appointment within 7 days of immobilization
122 removal.19,35 All patients completed a standard medical history questionnaire including
123 questions on medication usage. The treating physical therapist conducted a thorough
124 neuromusculoskeletal evaluation primarily focused on the foot and ankle. Other
125 potential areas and structures, such as the knee, hip, and lumbar spine, that could
126 potentially contribute to functional limitations were examined as indicated. This

127 sequential evaluation process focused on identifying impairments to movement,
128 relevant muscular weakness, painful structures, and functional limitations. Examination
129 components included active and passive joint ROM, passive joint accessory motion, soft
130 tissue mobility, muscle strength, neural mobility, and balance.
131 Outcome Measures
132 Patients completed the Lower Extremity Functional Scale (LEFS), Numeric Pain Rating
133 Scale (NPRS), and the Ankle Lunge Test (ALT) at baseline, which was within 7 days of
134 immobilization removal, and at 4 and 12 weeks post-baseline evaluation, regardless of
7
135 duration of treatment. Patients rated their perceived change in condition using the
136 Global Rating of Change (GROC) at 4 and 12 weeks post-baseline evaluation.
137
138 The primary outcome measure was the patient’s perceived level of pain and disability as
139 measured by the LEFS. The LEFS is a valid, responsive, and reliable 20-item
140 questionnaire covering a variety of functional tasks. It is commonly used for lower
141 extremity pathologies,5 including ankle fracture.36,37 Scores on the LEFS range from 0 to
142 80, with higher scores indicating better function. The LEFS has a minimal clinically
143 important difference (MCID) of 9 points,5,36,37 with score differences of 12 and 16 points
144 indicating medium and large changes in patient perceived change in condition. 2
145
146 Secondary outcome measures included the NPRS, GROC, and ALT. The NPRS is an
147 11-point, 0-10 scale, for patients to self-rate their perceived pain intensity. The NPRS
148 has demonstrated reliability, responsiveness, and validity.8,29 A difference of 2 points on

149 this scale is considered clinically meaningful.17 The GROC is a valid measure of a
150 patient’s overall perceived change in quality of life assessed through a 15-point Likert
151 scale ranging from −7 (“a very great deal worse”) to +7 (“a very great deal better”). 28
152 The MCID is a change greater than 3 points,28 with scores of +4 and +5 indicating
153 moderate changes in patient status and scores of +6 and +7 indicating large changes in
154 patient status.28,30 Although the GROC is commonly used in clinical settings, correlation
155 with functional change may be limited for longer recall periods. 45
156
157 The ALT utilizes a simple linear measure to evaluate weight bearing ankle dorsiflexion
8
158 ROM. This technique uses inexpensive, readily available equipment, does not rely on
159 identification of bony landmarks and avoids errors associated with goniometric
160 measurement.46 It is often used as an outcome measure in the ankle disorder
161 literature3,24,53 and is considered more functionally relevant than a non weight bearing
162 measurement.46 Weight bearing dorsiflexion ROM measurements have good intra and
163 interrater reliability in both healthy individuals26,43 and those with ankle fracture after
164 immobilization.46 The MCID in the ankle fracture population is 1.38 centimeters,46 and
165 each additional centimeter from the wall represents 3.6 degrees of ankle/subtalar
166 dorsiflexion.26 Clinically, a side to side asymmetry of greater than 1.5 cm may be
167 relevant.26 Scores can be positive or negative with lower measurements reflecting less
168 ankle dorsiflexion. Performance of the ALT has been previously described in the ankle
169 fracture population46 and is depicted in FIGURE 1.
170
171 The principal investigator performed all data collection at Brooke Army Medical Center,
172 Physical Therapy Clinic, Fort Sam Houston, TX.
173
174 Intervention
175 Manual physical therapy intervention addressed impairments identified during the
176 evaluation and was tailored to likely patient tolerance using clinical reasoning.13,49
177 Treatment consisted of joint mobilization, soft-tissue mobilization, muscle stretching,
178 and neural tension/mobility techniques22 depending on evaluation findings (APPENDIX
179 A). The physical therapist focused treatment primarily at the leg, ankle, and foot,10,11
180 with additional techniques provided at the knee14 for identified, relevant impairments. To
9
181 ensure manual techniques were well tolerated, the physical therapist tailored the grade
182 and duration for each technique, assessed the patient’s symptoms post-intervention and
183 continued or modified the treatment plan based on patient response.
184
185 Each patient received a similarly tailored, impairment-based therapeutic home exercise
186 program reinforcing the objectives of the manual physical therapy techniques. The
187 home program primarily consisted of exercises targeting deficits in joint ROM, muscle
188 flexibility and strength, and balance (APPENDIX B). Progressive integration of home
189 exercises occurred over the course of several treatment sessions with the physical
190 therapist modifying or adding exercises based on patient response and progression.
191 Patients completed an exercise log to track their compliance with the home exercise
192 program. At the conclusion of treatment, patients were instructed to continue exercises
193 to further improve or maintain gains if deemed necessary by the treating physical
194 therapist.
195
196 The physical therapist documented the dosage of manual physical therapy provided at
197 each visit by recording the technique, quantity, and grade of manual treatment
198 performed on each body region, as well as the exercises provided. We operationally
199 defined a unit of manual treatment as 1 bout of 30 seconds of joint mobilization (grades
200 I-IV) or soft tissue mobilization, 1 thrust manipulation (grade V), or 10 repetitions of
201 mobilization with movement. The physical therapist progressed the manual physical
202 therapy dosage by increasing the number of bouts of a technique, progressing the
203 technique further into restricted movement, or adding additional techniques per patient
10
204 tolerance.22
205
206 Patients received treatment once or twice per week for 6 to 8 visits of 30 to 45 minutes
207 duration. The physical therapist could continue treatment as clinically indicated. Visits
208 were more frequent early in the episode of care and typically less frequent later as focus
209 shifted from manually applied treatment to exercise progression.

210
211 Data analysis
212 Data from the outcome measures obtained on 11 patients were primarily analyzed
213 through descriptive statistics including frequency counts for categorical variables and
214 measures of central tendency and dispersion for continuous variables. We evaluated
215 time as the independent variable with 3 levels (baseline, and 4 weeks and 12 weeks
216 post-baseline) and the LEFS, ALT, NPRS, and GROC values as dependent variables.
217 We calculated frequency distributions and a mean value for the GROC. In addition,
218 after assessing for normality and sphericity of the data, and using the Greenhouse-
219 Geisser correction for data found to violate the assumption of sphericity, we examined
220 changes in the LEFS, ALT, and NPRS over time with 1-way repeated measures
221 analysis of variance (ANOVA). Time (baseline and 4 and 12 weeks post-baseline) was
222 the within-subjects factor and alpha level was set at .05. The Sidak correction was used
223 for planned pairwise comparisons to examine the differences over time with 95%
224 confidence intervals (CIs) calculated for mean differences. All data were analyzed
225 using SPSS Version 22 for Windows software (SPSS Inc, Chicago, IL).
226
11
227 OUTCOMES
228 An orthopaedic physician assistant (KPR), screened 19 consecutive patients with
229 conservatively managed ankle fractures for eligibility criteria. Of the 19 patients
230 screened, 2 declined due to preference for care at a closer facility, 2 were already
231 receiving physical therapy, 2 had additional concurrent injuries (syndesmosis injury, 5th
232 metatarsal fracture), 1 exceeded the age for inclusion (83 years old), and 1 elected
233 surgical stabilization after 1 month of conservative care provided prior to potential
234 enrollment in the study. Eleven patients met the inclusion criteria and consented to
235 participate in the study.
236
237 Eleven patients (mean age 39.6 years, range 18-64 years; 9 female) with stable ankle
238 fractures, immobilized with removable immobilization or a combination of cast and
239 removable immobilization (mean duration 48 days, range 21-75 days), were treated for
240 an average of 6.6 visits (range 3-10) over a mean of 46.1 days (range 13-81 days).
241 Treatment was initiated a mean of 2.4 days (range 1-7 days) after immobilization was
242 removed (TABLE 1).
243
244 All patients stated good compliance with the prescribed home exercise program by
245 indicating at 4 weeks that they performed the prescribed exercises 5 days per week or
246 better. By the 12-week follow-up visit, 45% (5 of 11) had stopped the exercises for a
247 variety of reasons including no longer feeling that exercises were needed, perceived
248 return to pre-injury ankle function, or forgetting to do the exercises. Of those who
249 continued their home exercise program, ankle ROM exercises were most commonly
12
250 performed for relief of intermittent ankle stiffness.
251
252 Changes over time demonstrated a rapid and similar rate of improvement in self-
253 reported function as measured by the LEFS and ankle dorsiflexion ROM as measured
254 by the ALT. These changes were both clinically meaningful and statistically significant
255 at 4 and 12 weeks (FIGURE 2). Compared to baseline, at 4 weeks, the score on the
256 LEFS was improved by an average of 21.9 points (95% CI: 10.4, 33.4; P=.001; range 3-
257 48) and ALT by 7.8 cm (95% CI: 3.9, 10.9; P=001; range 1.5-16.5). All patients met the
258 MCID for the ALT and LEFS at 4 weeks except patient 7 who demonstrated a 3 point
259 improvement on the LEFS. Improvement in the LEFS and ALT at 12 weeks, compared
260 to baseline, was 30.5 points (95% CI: 19.3, 41.6; P<.001; range 17-50) and 9.6 cm
261 (95% CI: 4.3, 15.0; P=.001; range 2-21), respectively. All patients for whom data was
262 available met the MCID for the LEFS and ALT at 12 weeks as compared to baseline.
263 We were unable to collect 2 data points at the 12-week follow up visit due to military
264 moves (patient 7, LEFS; patient 10, ALT), and last known values were carried forward
265 for data analysis.
266
267 At 4 weeks, all patients indicated they were at least “quite a bit better” (range 5+ to 7+)
268 on the GROC. At 12 weeks, all patients rated their overall change in condition as at
269 least “a great deal better” (GROC ≥ 6+; TABLE 2).
270
271 Patients’ rating of worst pain as measured by the NPRS demonstrated statistically
272 significant and clinically meaningful improvement from baseline to 4 weeks (mean
13
273 difference, 2.9; 95% CI: 1.1, 4.7; P=.003; range 0-7) and 12 weeks (3.3; 95% CI: 1.2,
274 5.4; P=.003; range 0-7) (FIGURE 3). Nine of 11 patients met the MCID of a 2 point
275 reduction in worst pain or reported no pain at 4 and 12 weeks as compared to baseline.
276
277 Of the manual techniques performed, the majority (65%) were provided at the talocrural
278 joint through either non-thrust or thrust techniques (FIGURE 4). The most frequent
279 techniques performed included anterior to posterior and distraction mobilizations applied
280 at the talocrural joint. 11 Between baseline and the 12-week follow-up visit, none of the
281 patients required further immobilization, surgical intervention for the ankle fracture, or an
282 increase in medication used for ankle pain. The patients did not report any adverse
283 events during the period of care.
284
285 We characterized the manual physical therapy dosage progression and corresponding
286 exercise prescription for the 8 patients who had the greatest movement impairments,
287 arbitrarily designated as those with a baseline ALT of 0 centimeters or less (patients 1,
288 3, 4, 5, 6, 8, 10, 11). These were the patients who received the most manual therapy
289 techniques and made-up a more homogeneous group potentially more likely to benefit
290 from these techniques (FIGURE 5).
291
292 A smaller dose of treatment and fewer exercises were used at the initial visit to ensure
293 the session was well tolerated. The initial sessions included a greater number of bouts
294 of treatment performed at 50% or less resistance, typically quantified as a grades III or
295 IV or less by Maitland.22 These techniques are considered gentler and can be used to
14
296 treat pain or provide a gentle stretch at initial joint resistance. At subsequent visits, the
297 dosage was increased, with peak manual therapy dosage observed at the third visit with
298 most techniques applied at greater than 50% of joint resistance, typically quantified as a
299 grade IV+ or III+ or greater by Maitland.22 These techniques are considered more
300 vigorous and are used primarily to treat joint stiffness. As visits progressed and
301 impairments amenable to manual therapy resolved, emphasis shifted to the use of
302 exercise with a smaller dosage of manual techniques being applied.
303
304 DISCUSSION
305 We observed a positive and clinically meaningful improvement in self reported function,
306 ankle motion, and pain in patients with stable ankle fractures post immobilization
307 following an average of 6.6 treatment sessions combining impairment-based manual
308 physical therapy and exercises. The major portion of these benefits occurred within the
309 first 4 weeks with slower additional improvement by 12 weeks. All patients except 1
310 (patient 7, 4 week LEFS) met or exceeded the MCID for ALT and LEFS at 4 and 12
311 weeks as compared to baseline. Nine of 11 patients reported exceeding the MCID of a
312 2-point or greater reduction in worst pain experienced by 12 weeks post-baseline.
313
314 The observed patient improvements could likely be attributed to a combination of
315 expedited physical therapy referral, early movement intensive therapy including manual
316 physical therapy with reinforcing exercise, healing due to the passage of time, and
317 patient unique factors. The exact contribution of each of those factors to the recovery
318 process cannot be determined from this case series. In addition, how factors such as
15
319 the specific type of ankle fracture and the length and method of immobilization
320 influenced outcomes is unknown based on the current literature.4,6,32,41
321
322 This case series provides support that manual physical therapy techniques for the lower
323 extremity10,11,14,20,27 can be safely performed after immobilization for patients with
324 conservatively treated ankle fractures. Between baseline and the 12-week follow-up
325 visit, none of the patients in this case series required further immobilization, surgical
326 intervention for the ankle fracture, or increased medication usage for ankle pain. There
327 were no reports of increased pain associated with treatment, and all patients had
328 ceased taking medication for ankle pain at the 12-week follow-up visit.
329
330 The described physical therapy approach captures the possible effects of expedited
331 referral and relatively early impairment-based treatment strategies in the ankle fracture
332 population. The manual examination may be particularly well suited to identifying motion
333 impairments and symptom producing structures. The majority of the techniques used in
334 these patients addressed perceived movement impairments at the talocrural joint and
335 the various articulations of the foot. We believe that careful clinical reasoning is
336 important to tailoring the interventions to each patient, both in scope and dose, with on-
337 going reassessment of symptoms after each technique, and contributes to safety and
338 patient tolerance.13 Treatment was continued or modified based on each patient’s
339 response. In addition, exercises were selected to reinforce the intended effects of the
340 manual therapy techniques performed in the clinic and were dosed to ensure tolerance.
341
16
342 Similar to the findings of previously published reports,4,34 patients demonstrated rapid
343 improvement in the first 4 weeks. However, many still demonstrated functional
344 impairments as documented by the LEFS at 12 weeks, particularly with higher-level
345 activities and sports. It is unknown whether these functional impairments persisted or
346 improved beyond this point.
347
348 The persistent functional impairments we observed may be related to a number of
349 factors. Of the patients treated, 3 of the 11 (patients 2, 5, 11) were not able to do
350 running activities prior to sustaining an ankle fracture because of other musculoskeletal
351 or medical conditions (patient 2: diabetes mellitus, obesity; patient 5: previous

352 contralateral ankle fracture with surgical fixation, poor vision; patient 11: knee
353 osteoarthritis bilaterally, obesity), effectively providing a ceiling on their improvement as
354 documented on the LEFS. The newly developed A-Form is an ankle fracture-specific
355 outcome measure that evaluates aspects of physical, social, and psychological recovery
356 that are relevant to patients with ankle fracture,38 rather than purely assessing physical
357 function, and may have more accurately captured overall changes through the course of
358 care.
359
360 Precisely linking observed outcomes with the type of ankle fracture, type of fracture
361 management, and duration of immobilization may provide improved fracture
362 management strategies and prognostic information. While we had a variety of stable
363 fracture types in our case series, we noted 3 of the 4 patients with avulsion fractures
364 (patients 3, 4, and 6) were particularly challenging to treat. All 3 of these patients had
17
365 delayed diagnosis with subsequent immobilization periods ranging from 21 to 75 days.
366 They were some of the patients with the most limited dorsiflexion ROM at baseline
367 (patients 4 and 6) and the lowest LEFS scores at 12 weeks (patients 3, 4, and 6),
368 despite having lower relative age (36, 31, 19 years) which is often considered a positive
369 prognostic indicator.4,6 Limited research on the treatment and prognosis of this
370 subgroup suggests that patients with avulsion fractures may have a worse prognosis
371 than those with ligamentous injury alone.42
372
373 Consistent with findings of other authors that greater dorsiflexion limitation after removal
374 from immobilization may be related to worse prognosis,19,35 patients with more impaired
375 dorsiflexion were treated with an abundance of manual physical therapy. Patients with
376 most impaired dorsiflexion were provided with as many as 30 bouts of manual physical
377 therapy in a single treatment session, all provided at greater than 50% resistance
378 (patient 11, visit 2). Some patients had minimal movement impairments upon removal of
379 immobilization (patients 7 and 9) and required a smaller overall dosage of treatment,
380 with greater emphasis on exercise. The patient with the least impaired movement
381 required only 6 bouts of manual physical therapy over the entire course of care (patient
382 9). These data reflect the variation in impairments and potentially the amount of
383 treatment needed in this population. If the period of immobilization is a prognostic factor,
384 the use of shorter periods of immobilization could be explored for stable fractures.
385
386 A previous prescriptive randomized clinical trial of manual therapy in individuals with
387 ankle fractures34 targeted restricted talocrural joint dorsiflexion, an impairment that is
18
388 typical of the condition and was the primary focus of many of our interventions, as well
389 as one of our outcome measures. However, this type of prescriptive treatment may
390 produce smaller effect sizes than those obtained with more pragmatic trials where
391 clinicians target individual impairments unique to each patient using a perceived
392 appropriate dose of interventions. In this case series, we treated impairments in ankle
393 dorsiflexion with a variety of techniques customized for each patient, including
394 accessory and physiological joint mobilizations, mobilization with movement, and soft
395 tissue mobilization. We also modified the techniques as needed based on perceived
396 stiffness and amount of discomfort. Technique modifications included small changes in
397 the angle of manual force applied and changes in joint position using single plane or
398 combined physiological and accessory motions.16,22 The benefits of impairment-based
399 manual physical therapy over abundant impairment-based exercise may be subtle, with
400 the additional precision of the manual exam being particularly important with shorter
401 immobilization periods and potentially tenuous fracture healing status. Clinically, we
402 observed that the treatment of the foot and ankle region with manual physical therapy
403 techniques seemed to improve patient tolerance to exercises such as standing calf-
404 strengthening.
405
406 Limitations
407 The outcomes of this study should be interpreted with caution, as a case series cannot
408 establish a causal relationship between the intervention and observed outcomes. While
409 we observed clinically meaningful changes in function and ankle dorsiflexion ROM in a
410 small sample, these changes may be due to the natural improvement of the condition
19
411 over time. In addition, all interventions were provided by a single physical therapist with
412 extensive experience and who was completing a fellowship program in manual physical
413 therapy. Therefore, the results may not be generalizable to all clinicians.44
414
415 CONCLUSION
416 This case series suggest that an impairment-based manual physical therapy approach
417 to treating stable ankle fractures post immobilization provide clinically meaningful
418 improvements in function, pain, and ankle ROM. The description of therapy dosage and
419 these results may provide clinical guidance as preliminary evidence for treating patients
420 with conservatively managed ankle fractures. Future randomized controlled clinical trials
421 are needed to accurately determine the effectiveness of this treatment approach in a
422 larger population as well as understand how factors related to fracture management
423 may influence prognosis.
424
425 REFERENCES
426 1. Abbott JH, Robertson MC, Chapple C, et al. Manual therapy, exercise therapy, or
427 both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized
428 controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage 2013;21(4):525-34.
429 doi:10.1016/j.joca.2012.12.014.
430 2. Abbott JH, Schmitt J. Minimum important differences for the patient-specific
431 functional scale, 4 region-specific outcome measures, and the numeric pain rating
432 scale. J. Orthop. Sports Phys. Ther. 2014;44(8):560-4.
433 doi:10.2519/jospt.2014.5248.
434 3. Beazell JR, Grindstaff TL, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Effects
435 of a proximal or distal tibiofibular joint manipulation on ankle range of motion and
436 functional outcomes in individuals with chronic ankle instability. J. Orthop. Sports
437 Phys. Ther. 2012;42(2):125-34. doi:10.2519/jospt.2012.3729.
438 4. Beckenkamp PR, Lin C-WC, Chagpar S, Herbert RD, van der Ploeg HP, Moseley
439 AM. Prognosis of Physical Function Following Ankle Fracture: A Systematic
20
440 Review With Meta-Analysis. J. Orthop. Sports Phys. Ther. 2014;6129657038:841-
441 851. doi:10.2519/jospt.2014.5199.
442 5. Binkley JM, Stratford PW, Lott SA, Riddle L, Riddle DL, The North American
443 Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional
444 Scale (LEFS): Scale Development, Measurement Properties, and Clinical
445 Application. Phys. Ther. 1999;79(4):371-383.
446 6. Del Buono A, Smith R, Coco M, Woolley L, Denaro V, Maffulli N. Return to sports
447 after ankle fractures: a systematic review. Br. Med. Bull. 2013;106:179-91.
448 doi:10.1093/bmb/lds039.
449 7. Chesworth BM, Vandervoort a a. Comparison of passive stiffness variables and

450 range of motion in uninvolved and involved ankle joints of patients following ankle
451 fractures. Phys. Ther. 1995;75(4):253-61.
452 8. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in
453 patients with low back pain. Spine (Phila. Pa. 1976). 2005;30(11):1331-4.
454 9. Chou E, Kim K-M, Baker AG, Hertel J, Hart JM. Lower leg neuromuscular
455 changes following fibular reposition taping in individuals with chronic ankle
456 instability. Man. Ther. 2013;18(4):316-20. doi:10.1016/j.math.2012.11.004.
457 10. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise
458 versus electrophysical agents and exercise in the management of plantar heel
459 pain: a multicenter randomized clinical trial. J. Orthop. Sports Phys. Ther.
460 2009;39(8):573-85. doi:10.2519/jospt.2009.3036.
461 11. Cleland JA, Mintken PE, McDevitt A, et al. Manual Physical Therapy and Exercise
462 Versus Supervised Home Exercise in the Management of Patients Status Post
463 Inversion Ankle Sprain: A Multi-Center Randomized Clinical Trial. J. Orthop.
464 Sports Phys. Ther. 2013;43(7):443-455. doi:10.2519/jospt.2013.4792.
465 12. Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness
466 for osteoarthritis of the knee: a randomized comparison of supervised clinical
467 exercise and manual therapy procedures versus a home exercise program. Phys.
468 Ther. 2005;85(12):1301-17.
469 13. Deyle GD, Gill NW. Well-tolerated strategies for managing knee osteoarthritis: a
470 manual physical therapist approach to activity, exercise, and advice. Phys.
471 Sportsmed. 2012;40(3):12-25. doi:10.3810/psm.2012.09.1976.
472 14. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC.
473 Effectiveness of manual physical therapy and exercise in osteoarthritis of the
474 knee. A randomized, controlled trial. Ann. Intern. Med. 2000;132(3):173-81.
21
475 15. Donatelli R. Normal biomechanics of the foot and ankle. J. Orthop. Sports Phys.
476 Ther. 1985;7(3):91-5.
477 16. Edwards BC. Combined movements of the lumbar spine: examination and clinical
478 significance. Aust. J. Physiother. 1979;25(4):147-52. doi:10.1016/S0004-
479 9514(14)61037-0.
480 17. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of
481 changes in chronic pain intensity measured on an 11-point numerical pain rating
482 scale. Pain 2001;94(2):149-58.
483
18. Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J.
484 Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex
485 measurements in individuals with chronic ankle instability. J. Electromyogr.
486 Kinesiol. 2011;21(4):652-8. doi:10.1016/j.jelekin.2011.03.011.
487 19. Hancock MJ, Herbert RD, Stewart M. Prediction of outcome after ankle fracture. J.
488 Orthop. Sports Phys. Ther. 2005;35(12):786-92. doi:10.2519/jospt.2005.2074.
489 20. Hando BR, Gill NW, Walker MJ, Garber M. Short- and long-term clinical outcomes
490 following a standardized protocol of orthopedic manual physical therapy and
491 exercise in individuals with osteoarthritis of the hip: a case series. J. Man. Manip.
492 Ther. 2012;20(4):192-200. doi:10.1179/2042618612Y.0000000013.
493 21. Harris KD, Deyle GD, Gill NW, Howes RR. Manual physical therapy for injection-
494 confirmed nonacute acromioclavicular joint pain. J. Orthop. Sports Phys. Ther.
495 2012;42(2):66-80. doi:10.2519/jospt.2012.3866.
496 22. Hengeveld E, Banks K, eds. Maitland’s Vertebral Manipulation. 8th ed. Edinburgh:
497 Churchill, Livingstone, Elsevier; 2014.
498 23. Hensley CP, Kavchak AJE. Novel use of a manual therapy technique and
499 management of a patient with peroneal tendinopathy: a case report. Man. Ther.
500 2012;17(1):84-8. doi:10.1016/j.math.2011.04.004.
501 24. Hoch MC, Andreatta RD, Mullineaux DR, et al. Two-week joint mobilization
502 intervention improves self-reported function, range of motion, and dynamic
503 balance in those with chronic ankle instability. J. Orthop. Res. 2012;30(11):1798-
504 804. doi:10.1002/jor.22150.
505 25. Hoch MC, McKeon PO. Joint mobilization improves spatiotemporal postural
506 control and range of motion in those with chronic ankle instability. J. Orthop. Res.
507 2011;29(3):326-32. doi:10.1002/jor.21256.
22
508 26. Hoch MC, McKeon PO. Normative range of weight-bearing lunge test
509 performance asymmetry in healthy adults. Man. Ther. 2011;16(5):516-9.
510 doi:10.1016/j.math.2011.02.012.
511 27. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and
512 exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis
513 Rheum. 2004;51(5):722-9. doi:10.1002/art.20685.
514 28. Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the
515 minimal clinically important difference. Control. Clin. Trials 1989;10(4):407-15.
516
29. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels
517 needed in pain intensity measurement? Pain 1994;58(3):387-92.
518 30. Juniper EF, Guyatt GH, Willan A, Griffith LE. Determining a minimal important
519 change in a disease-specific Quality of Life Questionnaire. J. Clin. Epidemiol.
520 1994;47(1):81-7.
521 31. Langendoen J, Maffey L. International Federation of Orthopaedic Manipulative

522 Physical Therapists Educational Standards in Orthopaedic Manipulative Therapy

523 Part A : Educational Standards. 2008.
524 32. Lash N, Horne G, Fielden J, Devane P. Ankle fractures: functional and lifestyle
525 outcomes at 2 years. ANZ J. Surg. 2002;72(10):724-30.
526 33. Lin C-WC, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM.
527 Rehabilitation for ankle fractures in adults. Cochrane Database Syst. Rev.
528 2012;11:CD005595. doi:10.1002/14651858.CD005595.pub3.
529 34. Lin C-WC, Moseley AM, Haas M, Refshauge KM, Herbert RD. Manual therapy in
530 addition to physiotherapy does not improve clinical or economic outcomes after
531 ankle fracture. J. Rehabil. Med. 2008;40(6):433-9. doi:10.2340/16501977-0187.
532 35. Lin C-WC, Moseley AM, Herbert RD, Refshauge KM. Pain and dorsiflexion range
533 of motion predict short- and medium-term activity limitation in people receiving
534 physiotherapy intervention after ankle fracture: an observational study. Aust. J.
535 Physiother. 2009;55(1):31-7.
536 36. Lin C-WC, Moseley AM, Refshauge KM, Bundy AC. The lower extremity
537 functional scale has good clinimetric properties in people with ankle fracture. Phys.
538 Ther. 2009;89(6):580-8. doi:10.2522/ptj.20080290.
539 37. Martin R. A Survey of Self-reported Outcome Instruments for the Foot and Ankle.
540 J. Orthop. Sports Phys. Ther. 2007;37(2):72-84. doi:10.2519/jospt.2007.2403.
23
541 38. McPhail SM, Williams CM, Schuetz M, Baxter B, Tonks P, Haines TP.
542 Development and validation of the ankle fracture outcome of rehabilitation
543 measure (A-FORM). J. Orthop. Sports Phys. Ther. 2014;44(7):488-99, B1-2.
544 doi:10.2519/jospt.2014.4980.
545 39. McPoil TG, Knecht HG. Biomechanics of the foot in walking: a function approach.
546 J. Orthop. Sports Phys. Ther. 1985;7(2):69-72.
547 40. Michelson JD. Fractures about the ankle. J. Bone Joint Surg. Am.
548 1995;77(1):142-52.
549
41. Nilsson G, Nyberg P, Ekdahl C, Eneroth M. Performance after surgical treatment

550 of patients with ankle fractures--14-month follow-up. Physiother. Res. Int.
551 2003;8(2):69-82.
552 42. Noh JH, Yang BG, Yi SR, Lee SH, Song CH. Outcome of the functional treatment
553 of first-time ankle inversion injury. J. Orthop. Sci. 2010;15(4):524-30.
554 doi:10.1007/s00776-010-1481-1.
555 43. O’Shea S, Grafton K. The intra and inter-rater reliability of a modified weight-
556 bearing lunge measure of ankle dorsiflexion. Man. Ther. 2013;18(3):264-8.
557 doi:10.1016/j.math.2012.08.007.
558 44. Rodeghero J, Wang Y-C, Flynn T, Cleland JA, Wainner RS, Whitman JM. The
559 impact of physical therapy residency or fellowship education on clinical outcomes
560 for patients with musculoskeletal conditions. J. Orthop. Sports Phys. Ther.
561 2015;45(2):86-96. doi:10.2519/jospt.2015.5255.
562 45. Schmitt J, Abbott JH. Global ratings of change do not accurately reflect functional
563 change over time in clinical practice. J. Orthop. Sports Phys. Ther.
564 2015;45(2):106-11, D1-3. doi:10.2519/jospt.2015.5247.
565 46. Simondson D, Brock K, Cotton S. Reliability and smallest real difference of the
566 ankle lunge test post ankle fracture. Man. Ther. 2012;17(1):34-8.
567 doi:10.1016/j.math.2011.08.004.
568 47. Slaven EJ, Mathers J. Management of chronic ankle pain using joint mobilization
569 and ASTYM® treatment: a case report. J. Man. Manip. Ther. 2011;19(2):108-12.
570 doi:10.1179/2042618611Y.0000000004.
571 48. Van der Sluis CK, Eisma WH, Groothoff JW, ten Duis HJ. Long-term physical,
572 psychological and social consequences of a fracture of the ankle. Injury
573 1998;29(4):277-80.
574 49. Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal
575 physiotherapists. Man. Ther. 2007;12(1):40-9. doi:10.1016/j.math.2006.02.006.
24
576 50. De Souza MVS, Venturini C, Teixeira LM, Chagas MH, de Resende M a. Force-
577 displacement relationship during anteroposterior mobilization of the ankle joint. J.
578 Manipulative Physiol. Ther. 2008;31(4):285-92. doi:10.1016/j.jmpt.2008.03.005.
579 51. Stevens JE, Walter G a., Okereke E, et al. Muscle Adaptations with
580 Immobilization and Rehabilitation after Ankle Fracture. Med. Sci. Sport. Exerc.
581 2004;36(10):1695-1701. doi:10.1249/01.MSS.0000142407.25188.05.
582 52. Vandenborne K, Elliott M a, Walter G a, et al. Longitudinal study of skeletal

583 muscle adaptations during immobilization and rehabilitation. Muscle Nerve
584 1998;21(8):1006-12.
585 53. Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial changes in posterior talar
586 glide and dorsiflexion of the ankle after mobilization with movement in individuals
587 with recurrent ankle sprain. J. Orthop. Sports Phys. Ther. 2006;36(7):464-71.
588 54. Wilson F. Manual Therapy Versus Traditional Excercises in Mobilisation of the
589 Ankle Post Ankle Fracture: A Pilot Study. NZ J. Physiother. 1991;(19):11-16.
590
591
25
592 TABLES
593
594
595 TABLE 1. Participant demographics and baseline characteristics. Scores on the Lower
596 Extremity Functional Scale range from 0 to 80, with the higher scores indicating better
597 function. A smaller (negative) value on the Ankle Lunge Test indicates worse ankle
598 dorsiflexion.
599
26
600
601 TABLE 2. Outcome measures at baseline, and 4 and 12 weeks post-baseline.

602 Abbreviations: LEFS, Lower Extremity Functional Scale; NPRS, Numeric Pain Rating
603 Scale; NA, not available; GROC, Global Rating of Change: 5+ indicates “quite a bit
604 better;” 6+ indicates “a great deal better;” 7+ indicates “a very great deal better.”
605 Minimal clinically important difference for outcome measures: LEFS=9 points; Ankle
606 Lunge Test =1.38 cm; NPRS =2 points; GROC=4+.
607
27
608 FIGURES
609
610
611 FIGURE 1: Ankle Lunge Test: A. Distance reported as a negative value, reflective of
612 limited ankle dorsiflexion as the knee does not reach the wall. B. Distance reported as
613 a positive value, reflective of greater ankle dorsiflexion requiring the toes to be away
614
from the wall.
615
28
616
617 FIGURE 2. Scores on the Lower Extremity Functional Scale (LEFS) and the Ankle
618 Lunge Test (ALT). Values are means and 95% confidence intervals. LEFS scores are
619 from 0 to 80 with higher scores indicating higher function. Values on the ALT can be
620 negative or positive with higher values indicating more ankle dorsiflexion. *Indicates a
621 statistically significant change compared to baseline, P = or < .001.
622
29
623
624 FIGURE 3. Scores for worst pain as measured by the Numeric Pain Rating Scale
625 (NPRS). Values are means and 95% confidence intervals. Scores range from 0 to 10,
626 with higher scores indicating worse pain. *Indicates a statistically significant change
627 compared to baseline, P=.003 at 4 and 12 weeks.
628
30
629
630 FIGURE 4. Targeted treatment areas as indicated by frequency counts of units of

631 manual physical therapy treatment for all 11 patients. A unit of manual physical therapy
632 treatment was operationally defined as 1 bout of 30 seconds of joint mobilization
633 (grades I-IV) or soft tissue mobilization, 1 thrust manipulation (grade V), or 10
634 repetitions of mobilization with movement. Abbreviation: tib-fib, tibiofibular.
635
31
636
637 FIGURE 5. Manual physical therapy and exercise dose progression by visit. Mean total
638 bouts, application into resistance, techniques, and exercises prescribed as calculated
639 for the 8 patients with a baseline Ankle Lunge Test of 0 centimeters or less (Patients 1,
640 3, 4, 5, 6, 8, 10, 11).
32
Downloaded from www.jospt.org at New York University on July 23, 2015. For personal use only. No other uses without p
Appendix A
Guidelines for Ankle and Foot Manual
Physical Therapy following Ankle
Fracture
• Manual physical therapy techniques should be well
tolerated and consistent with the healing status of the
fracture
• When symptoms are provoked, they should be minimal

to moderate and ease quickly
• Manual physical therapy techniques often provide in
session improvements in function or movement
• Treating movement impairments in joints and soft
tissues may improve tolerance to exercises
• Manual physical therapy techniques should be
reinforced with an exercise that provides a similar
movement (Appendix B)
•
•
•
•
•
•
•
•
•
Gr: Grade
DF: Dorsiflexion
PF: Plantarflexion
WB: weight bearing

ROM: range of motion
PA: Posterior to Anterior

AP: Anterior to Posterior
NWB: non weight bearing
Abbreviations
MWM: Mobilization with Movement

Commonly Used Strategies to Improve

Overall Ankle Stiffness
• Talocrural distraction: mobilization (Gr I-IV),

progressing to manipulation (Gr V)
– Amongst the best tolerated techniques and potentially the
least disruptive to healing ankle fractures

– Add slight eversion to take up up slack in capsule
– Modify grip as needed for patient comfort:
• Both hands clasped over dorsum of foot
• One hand clasped over calcaneus and one hand over dorsum of
foot
• Reinforcing exercise: self distraction using a resistance
band, ankle ROM all planes, stationary bicycle
Ankle Distraction Mobilization/Manipulation:

Talocrural and Subtalar Joints
 Patient position
 Supine with heel off table
 Therapist position
 Grasp the patient’s foot, ensuring your
small or ring fingers lie just distal to

the neck of the talus
 Provide firm pressure with both
thumbs in the middle of forefoot to
provide DF
 Mobilization technique
 Engage restrictive barrier with ankle
dorsiflexion & long axis distraction
 Evert & dorsiflex the forefoot to fine-
tune barrier
 Apply a graded mobilization (I-IV)
 Apply a thrust manipulation in a caudal
and DF direction (scooping motion)
Talocrural and Subtalar Joints
one hand over

dorsum of foot
Ankle Distraction Mobilization/Manipulation:
 Alternate hand positions:
• One hand clasped

over calcaneus and
• Both hands clasped
over dorsum of foot
To Improve Dorsiflexion
• Most commonly treated impairment with both manual physical

therapy techniques and exercises in this case series
• Talocrural Joint Progression to improve DF
– Foot in position of comfort: AP
– Foot in increasing degree of DF: AP

– Add additional inversion or eversion to target greatest perceived
stiffness
– Add slight talocrural distraction with AP mobilization
– In loaded position: MWM technique
• Distal tibiofibular joint AP mobilization
• Physiological dorsiflexion to ease: Gr III
• Soft tissue mobilization of gastrocnemius in stretch position
• Reinforcing exercises: gastrocnemius/soleus stretch in NWB or WB
position, DF/PF slides, self mobilization into DF, standing lunge,
stationary bike
Commonly Used Talocrural Joint Mobilizations

and Lines of Progression to Improve DF
• Talocrural AP Progression (Grades I-IV)

Use combined movements
(additional eversion or
inversion) to target greatest

perceived stiffness
Ankle in
Ankle in position
increasing
of comfort Add talocrural distraction
position of DF
with use of a wedge
Loaded position: MWM
Progression of position and grade of mobilization

Talocrural AP Mobilization
 Supine, heel off table
 Proximal hand stabilizes distal leg by grasping

just proximal to malleoli. Rest your hand on
plinth for added support and stabilization.
 Distal mobilizing hand cups the anterior talus
into the 1st web space
 Thigh may be used to help stabilize the foot
 Mobilize with a posteriorly directed force on
the talus into the restrictive barrier
 Progressively increase ankle DF with your
thigh
 Add slight inversion or eversion with your
thigh to target greatest perceived stiffness
foot in position of comfort

Talocrural AP mobilization with
foot in DF
Talocrural AP Progression
Talocrural AP mobilization with

Talocrural AP Mobilization with a

Wedge
 Supine, ankle resting on wedge, heel off
table
 Proximal mobilizing hand cups the anterior

talus into the 1st web space
 Distal hand grasps the calcaneus, providing
talocrural distraction in a slight scooping
motion
 Mobilize with a posteriorly directed force on
 Maintain talocrural distraction with the distal
hand
 Progressively increase ankle DF with your
thigh
Ankle DF with Talocrural AP Glide

Mobilization with Movement
 Half kneeling position on the plinth with affected foot
in the forward position
 Stand at end of plinth

 Hands stabilizes foot on plinth as close to talocrural
joint as possible
 Mobilization belt is placed around distal tibia and
fibula proximal to malleoli and around therapist’s
hips
 Therapist uses body weight through the belt to
provide anterior glide of distal tibia and fibula on
talus
 Patient is asked to lunge forward while keeping heel
down into the pain-free restrictive barrier for 3 x 10
reps
 Therapist sustains glide and squats to maintain belt
perpendicular to tibia
Easing Techniques for Dorsiflexion

• Alternating bouts of more vigorous, small

amplitude techniques (Gr IV to IV++) with
bouts of larger amplitude techniques

(Gr III-III++) may improve patient tolerance
– Physiological DF Gr III
– Physiological DF with talocrural distraction
Ankle Dorsiflexion
Grade III
 Prone, knee flexed 90 degrees
 Therapist supports patient’s leg

with thigh
 One hand cups posterior calcaneus
near Achilles insertion
 Other hand grasps midfoot with
forearm placed along plantar foot
 Perform graded mobilizations into
DF with a rocking motion of both
arms with movement into slightly
greater knee flexion
 May add quick “flicks” at end range
for added emphasis
Physiological Dorsiflexion with
Talocrural Distraction
 Supine, heel off table
 Proximal hand stabilizes anterior distal leg by
grasping just proximal to malleoli

 Distal mobilizing hand cups the calcaneus
using the palm
 Mobilize with the distal hand using a
combined movement of talocrural distraction
and physiological DF provided through the
forearm into the restrictive barrier
 Provide an arc of movement from the
position of comfort to the restrictive barrier
of DF
 Patient can assist with DF movement
Soft Tissue Technique for Improving

Dorsiflexion
• Standing, hands on wall, leg to be
stretched in the posterior position
• Sit behind the patient

• Place both hands on gastrocnemius,
heels of hands facing, gentle grip of
gastrocnemius
 Stretching technique
• Assess for areas of perceived soft
tissue restriction by using your hands
to gently spread the gastrocnemius
muscle in a horizontal or diagonal
fashion.
• Provide general or specific
mobilization while patient maintains
a calf stretch
• Static stretch held 30 seconds
To Improve Plantarflexion
• PF techniques most frequently used in those treated with cast

immobilization
• PA talocrural mobilization: in prone
– Progress position of PF
– Add slight inversion or eversion to address greatest perceived stiffness

– Soft tissue mobilization along anterior tibiotalar capsule
• Physiological PF to ease: Gr III
• MWM distraction with PA
• Distal tibiofibular PA
• Addressing impairments to movement in the foot may improve
tolerance to weight bearing PF
• Reinforcing exercises: ROM, resistance band strengthening in PF,
DF/PF slides, heel raise progression, towel curls
Commonly Used Talocrural Joint Mobilizations

and Lines of Progression to Improve
Plantarflexion
• Talocrural PA Progression (Gr I-IV)
Ankle in Use combined movements

Ankle in position (additional eversion or
increasing
of comfort inversion) to target greatest
position of PF
perceived stiffness
Progression of position and grade of mobilization

Talocrural PA Mobilization
 Prone with ankle off table
Ankle in increased just proximal to mortise. Rest hand on plinth

PF (below) for added support and stabilization
 Distal mobilizing hand cups the posterior
talus with the 1st web space
 May use thigh to help DF the foot
 Mobilize with an anteriorly directed force on
 Increase ankle PF by reducing support with
Ankle in position of your thigh
comfort (above)  Add slight inversion or eversion with your
thigh to target greatest perceived stiffness
– Physiological PF Gr III
– PF with talocrural PA MWM
bouts of larger amplitude techniques
• Alternating bouts of more vigorous, small
amplitude techniques (Gr IV to IV++) with
(Gr III-III++) may improve patient tolerance

Easing Techniques for Plantarflexion
Ankle Plantar Flexion

Grade III
 Prone, knee slightly flexed
 Hands grasp the foot with thumbs

over the plantar surface of
calcaneus and fingers wrapped
around the dorsal midfoot
 Extend the knee and PF the ankle
until ankle resistance is felt
 Perform graded mobilizations into
PF by rocking both arms and
slightly extending the knee pulling
the forefoot in a upward plantar
direction and pushing the heel
downward
Ankle Plantarflexion with Talocrural PA Glide

Mobilization with Movement
 Sitting on plinth with knee flexed 90 degrees
 Stand at end of plinth

 Proximal hand stabilizes distal tibiofibular joint
proximal to joint line
 Distal hand grasps anterior talus with web
space, thumb and fingers sloping down
 Using body weight, glide tibia and fibula
posteriorly locking the ankle joint. Without
releasing, glide and roll the talus into plantar
flexion
 Movement must be pain-free
 May need to use padding if patient has
tenderness to pressure
To Improve Inversion and Eversion

• Subtalar joint medial and lateral mobilization:

– Typically well tolerated with vigorous, end range
movements (Gr IV+, Gr IV++)

– Comparison to sound ankle may be helpful in
identifying subtle movement impairments
• Physiological eversion, inversion (Gr III) to ease
• Adding slight inversion or eversion to AP and PA
talocrural mobilizations may be helpful in
improving inversion and eversion
Lateral Subtalar Mobilization

 Side lying on affected side, ankle off plinth
 Proximal hand stabilizes distal leg and talus by
grasping just proximal to malleoli. Rest your

forearm across the patient’s medial leg for
added support
 Distal mobilizing hand grasps the calcaneus
with the heel of the hand
 Position your body so your arm is
perpendicular to the patient’s leg
 Graded lateral mobilization is applied by
pushing the calcaneus downward towards the
floor
 The left subtalar joint is being mobilized in
this picture
Medial Subtalar Mobilization
 Side lying on unaffected side, affected ankle
off plinth

talus just proximal to malleoli. Rest your
forearm across the patient’s lateral leg for
added support
 Distal mobilizing hand grasps the talus with
the heel of the hand over the calcaneus
 Position your body so your arm is
perpendicular to the patient’s leg
 Graded medial mobilization is applied by
pushing the calcaneus downward toward the
floor
 Use thigh to stabilize 5th metatarsal/forefoot
into eversion
 The right subtalar joint is being mobilized in
this picture
Tibiofibular Joint Mobilization

• Distal fibula is a common site of fracture

• Mobilize with caution to provide movement to the
joint, not the healing fracture
• AP mobilization of distal joint often improves DF

• PA mobilization of the distal joint often improves PF
• Combined motion of slight superior glide can be added
• Proximal tibiofibular mobilization may be helpful if
stiffness is perceived here
– May or may not be symptom producing
Distal Tibiofibular Joint AP Mobilization

 Supine with heel off table
 One hand positioned so that heel of hand lies
over the anterior distal fibula at the distal

tibiofibular joint line
 One hand stabilizes the medial malleolus and
ankle
 Apply posteriorly directed mobilization to the
anterior surface of the distal fibula at the joint
line
Distal Tibiofibular Joint PA Mobilization

 Prone with foot off table
 One hand positioned so that heel of hand lies
over the posterior distal fibula at the distal

tibiofibular joint line
 One hand stabilizes the medial malleolus and
ankle
 Apply anteriorly directed mobilization to the
posterior surface of the distal fibula at the joint
line
Manual Physical Therapy Techniques

for the Foot
• Techniques addressing the foot were most frequently

used in those treated with cast immobilization
• Foot mobilizations may also be used as an easing
technique and are generally well tolerated

• Can incorporate soft tissue mobilization of plantar
surface of foot
• Consider AP/PA mobilizations of tarsometatarsal and
intermetatarsal joints, particularly in the first digit, to
improve tolerance to weight bearing PF strengthening
• Reinforcing exercise: self mobilization of metatarsals,
towel curls
Intermetatarsal AP/PA Mobilization

 Prone, knee slightly flexed
 Stand at the end of table
 Place both pads of thumbs at heads or

bases of metatarsal bones
 Fingers grasp around each side of foot
towards the dorsum
 One thumb stabilizes, the other thumb
produces the movement
 Apply graded mobilizations at the
metatarsal base or head in relation to
each other in an anterior or posterior
direction
Appendix B: Exercises
•
•
•
•
•
DF: Dorsiflexion
PF: Plantarflexion
WB: weight bearing

ROM: range of motion
NWB: non weight bearing
Abbreviations
General Guidelines for Ankle and Foot Gait and

Exercise Progression following Ankle Fracture
• Gait Retraining:
– Use crutches to establish a normal gait pattern with weight bearing as
allowed by the fracture healing status, thereby encouraging normal

ROM including a DF challenge with every step
• Movement Exercise:
– Patients instructed to do movement exercises at the beginning of the
day and again later in the day as needed for perceived stiffness
– Use repeated end range of motion challenges with 3 second hold at
end range of DF and any other limited movement
– Progress from non weight bearing to weight bearing movements
– Use cycling to provide motion stimuli to healing capsuloligamentous
structures, and improve mid range quality of ankle movement.
– Foot/ankle position during cycling should be flat to slightly dorsiflexed
or varied throughout cycling session.
General Guidelines for Ankle and Foot Gait and

Exercise Progression following Ankle Fracture
• Strengthening Exercise:
– Patients instructed to perform strengthening
exercise later in the day to avoid fatigue with gait

and daily activities
– Progress from NWB to WB exercises as dictated by
fracture healing stage and patient tolerance
– Demonstrate tolerance to prescribed dosage in
clinic
– Manual physical therapy techniques may make
strengthening better tolerated
Reinforcing Exercises for Dorsiflexion

• Gastrocnemius/soleus stretch in NWB or WB position

• Self mobilization with strap (Figure 1B)
• Standing lunge (Figure 2B)

• DF and PF Slide (Figure 3B)
• Strengthening in NWB: resistance bands
• Strengthening in WB: heel-toe rocking, heel walking
• Stationary bike
Figure 1B: DF self mobilization
standing lunge for L ankle

Figure 2B: Reinforcing MWM:
Reinforcing Exercise for Dorsiflexion
– Heel-toe rocking
– Single leg heel raises

• Strengthening in WB:
– Double leg heel raises

• DF and PF Slide (Figure 3B)
• Strengthening in NWB: resistance bands
– Single leg heel raises with slow eccentric lowering phase

Reinforcing Exercises for Plantarflexion
Reinforcing Exercises for

Dorsiflexion/Plantarflexion
Balance support may be used as needed to maintain motion quality and ROM
Figure 3B: DF/PF Slide. Treated ankle is on towel, allows partial weight bearing.
4B)
– Eyes open
– Eyes closed
– Compliant surface
they perceived muscle fatigue
• Single leg balance progression:

Advanced Exercises
• Patients instructed to perform strengthening exercises until
• Strengthening eversion and inversion in a WB position (Figure

borders of feet. Balance support may be used as needed to maintain motion quality and ROM
Figure 4B: Weight bearing eversion, inversion. Controlled movement with lifting lateral and medial
Strengthening Exercise for Inversion/Eversion

Jospt.2015.5981 Tornozelo

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Jospt.2015.5981 Tornozelo

Uploaded by

Copyright:

Available Formats

MANUAL PHYSICAL THERAPY FOLLOWING IMMOBILIZATION FOR STABLE

ANKLE FRACTURE: A CASE SERIES

Elizabeth E. Painter, PT, DSc1

1 Brooke Army Medical Center, Army-Baylor University Doctoral Fellowship in

Postgraduate Doctoral Program in Orthopaedics, Fort Sam Houston, TX, USA

2 BACKGROUND: Ankle fractures commonly result in persistent pain, stiffness, and

3 functional impairments. There is insufficient evidence for any particular rehabilitation

5 impairment-based manual physical therapy approach to treating patients with

6 conservatively managed ankle fractures.

12 collected at baseline (performed within 7 days of immobilization removal), and 4 and 12

17 Compared to baseline, statistically significant and clinically meaningful improvement

20 weeks. These changes persisted at 12 weeks.

21 DISCUSSION: Statistically significant and clinically meaningful improvements in self-

25 LEVEL OF EVIDENCE: Therapy, level 4.

26 KEY WORDS: clinical reasoning, lower extremity, manipulation, mobilization

29 Ankle fracture is a common lower limb injury requiring orthopaedic management.40

31 conservatively treated ankle fracture,32 ankle fracture has long-term consequences on

32 physical, psychological, and social functioning, comparable to hip and vertebral

33 fractures.48 Insufficient rehabilitation is a possible cause of persistent disability after

39 long-term outcome, suggesting that addressing limited dorsiflexion ROM immediately

40 after immobilization may be important.19,35 In addition to impaired ankle dorsiflexion

44 improve ankle dorsiflexion,25,50,53,54 increase soleus muscle activation,9,18 and improve

45 single limb balance.25

49 use of manual physical therapy techniques in addition to exercise in those with

50 surgically or conservatively treated ankle fracture found no additional benefit over

52 constrained by standardizing treatment to a single predetermined joint mobilization

53 technique regardless of the movement limitations demonstrated by each patient. This

55 reduced the potential treatment effectiveness of manual physical therapy.

58 and gait,15,39 an impairment-based manual physical therapy approach may be well

60 immobilization for ankle fracture. An impairment-based manual physical therapy

61 approach includes a comprehensive evaluation identifying impairments to movement,

62 relevant muscular weakness, painful structures, and functional limitations.13,21,31 This

63 approach incorporates clinical reasoning and careful judgments on expected symptom

66 dose to each patient’s identified impairments.13,14 This treatment approach has

69 and hip osteoarthritis.1,27

77 patients were initially managed with immobilization and a rehabilitation exercise

79 that subsequently responded well to a manual physical therapy intervention. These

81 ankle fractures treated with immobilization, as well as the potential benefit of an

82 impairment-based manual physical therapy approach.

85 of treatment in patients with conservatively managed ankle fractures treated with an

86 impairment-based manual physical therapy approach. Changes over the course of

88 and construct validity, reliability, and responsiveness to change, easily administered in a

92 physical therapy interventions following ankle fracture to minimize disability and

97 Consecutive patients presenting to the Orthopaedic Service at Brooke Army Medical

105 removal of immobilization device.

109 fracture malunion or nonunion, syndesmosis injury, or any standard contraindication to

114 therapy evaluation.

119 15 years of clinical experience in orthopaedic physical therapy.

120 Evaluation Procedure

126 potentially contribute to functional limitations were examined as indicated. This

127 sequential evaluation process focused on identifying impairments to movement,

130 tissue mobility, muscle strength, neural mobility, and balance.

131 Outcome Measures

134 immobilization removal, and at 4 and 12 weeks post-baseline evaluation, regardless of

136 Global Rating of Change (GROC) at 4 and 12 weeks post-baseline evaluation.

148 has demonstrated reliability, responsiveness, and validity.8,29 A difference of 2 points on

160 measurement.46 It is often used as an outcome measure in the ankle disorder

169 fracture population46 and is depicted in FIGURE 1.

172 Physical Therapy Clinic, Fort Sam Houston, TX.

177 Treatment consisted of joint mobilization, soft-tissue mobilization, muscle stretching,

178 and neural tension/mobility techniques22 depending on evaluation findings (APPENDIX

183 continued or modified the treatment plan based on patient response.

209 shifted from manually applied treatment to exercise progression.

211 Data analysis