The use of manipulation in a patient with an ankle sprain injury not responding to conventional management
A 27-year old volleyball player presented with an ankle sprain associated with a constant ache to the medial calcaneal region that varied based on activity and an intermittent, burning pain extending along the medial leg up to approximately 10 cm below the medial tibial plateau three weeks prior to her first visit to physical therapy. She had an injury while returning to the ground after jumping to hit volleyball. She had self treatment with rest, ice, compression with self-ankle taping, and elevation and consistently doing strengthening exercises with resistive tubing (dorsiflexion, plantar flexion, inversion, and eversion) per instruction by a therapist after a previous ankle sprain injury. There was no change in symptoms over 3 weeks of self-treatment, although she had forced herself to stop using the crutches approximately 1 week prior to her visit to the physiotherapist. On a numeric pain rating scale 1,2 the patient reported a range of pain from 5-9 out of 10 over the last 24 hour. The patient reported increased pain with running, squatting, going up and down steps, and prolonged weight-bearing. Non-steroidal anti-inflammatory medications and non-weight-bearing positions temporarily eased her symptoms and there were no other reported lower extremity symptoms or low back pain (LBP).
The most likely diagnosis of this presentation is
- Muscle spasms
- Broken toe
- Ankle sprain
- Joint fractures
Ankle sprains are common among physically active individuals,3 with a reported incidence of seven injuries per 1000 persons over a 1- year period.4 The primary environments in which these injuries occurred were during sports (45%), play (20%), and work (16%) activities, with inversion ankle sprains accounting for over 60% of the sprains. 4 In a study of 547 patients with ankle sprains, Fallat et al (1998) found that the anterior talofibular ligament (ATFL) was most frequently injured, followed by the calcaneo fibular ligament (CFL) and posterior talofibular ligament (PTFL). A combination of injury to the ATFL and the CFL accounted for 34.2% of the ankle sprains, and involvement of all three ligaments was found in 31.3% of the injuries.5
Conventional management of Grade I ankle sprains incorporates the RICE principles (Rest, Ice, Compression, and Elevation) combined with early motion and full weight bearing. 6 Its success in improving mobility, pain, and disability has been well documented in the literature. 7-10
The patient has a history of 6–7 inversion ankle sprains of the involved ankle over the last 10–15 years.
The patient had slightly antalgic gait, with pain primarily occurring during the late stance phase of gait when maximal talocrural dorsiflexion range of motion (ROM) is required. Active ankle ROM on the uninvolved lower extremity was normal. No swelling or ecchymosis was present. The presence of mild laxity with the talar tilt and anterior drawer tests was judged to be a sequela of previous ankle sprain injuries. Passive accessory motion testing revealed decreased mobility at proximal and distal tibio-fibular joints and talocrural and subtalar joints relative to the opposite lower extremity.
Based on the patient’s failure to respond with self treatment utilizing conventional management and the presence of decreased passive accessory motion in several joints of the leg and ankle, the decision was made to utilize manipulation/mobilization techniques that targeted the underlying joint hypomobility identified in the examination. The techniques used included proximal fibrio-fibular joint manipulation, rearfoot distraction manipulation, lateral glides and expression mobilization/manipulation, tab-crural joint anterior to posterior mobilization, ankle eversion mobilization, dorsiflexion self mobilization. The proximal tibio-fibular joint manipulation and the rearfoot distraction manipulation were performed one time each. The talocrural joint lateral glide mobilizations, subtalar joint eversion mobilizations, and the talocrural joint anterior to posterior joint mobilizations were performed for approximately 3–4 bouts of 30 oscillations. The patient demonstrated increased dorsiflexion ROM and experienced an immediate decrease in pain during gait, negotiating stairs, and squatting. The patient was also counseled on home exercise program and short-term or long-term follow-up.
Most patients who sustain a Grade I ankle sprain improve rapidly with conventional management utilizing an RICE approach that emphasizes early motion and full weight bearing. However, there appears to be a subgroup of patients who continue to have symptoms even at 1 year post-injury. 9 Many clinicians avoid manipulation in acute and subacute injuries of the periphery due to belief that tissue damage has occurred, and the notion that manipulation will contribute to further tissue damage. In other areas like lumbopelvic region, the literature supports the use of manipulation in managing acute injuries. Perhaps, the pathoanatomical model, currently utilized to determine the severity of ankle sprains (Grade I vs. Grade II vs. Grade III) biases clinicians to inappropriately assume that manipulation/mobilization may be harmful, when in fact some individuals with recalcitrant ankle sprains may exhibit decreased passive accessory joint motion that, if adequately addressed, will lead to dramatic improvements in pain and function. The pathoanatomical model 12 based on a ‘‘tissue damage’’ model has been largely unsuccessful in explaining pain and disability in LBP. Because of the difficulty in sub-grouping patients with LBP based on this model, attempts have been made to subgroup patients based on findings from the history and physical examination.13 Perhaps the treatment of ankle sprains would benefit if clinicians and researchers explored an alternate treatment-based classification scheme that is based on an individual patient’s response to treatment rather than pathoanatomical model that often fails to explain the pain and functional limitations associated with recalcitrant ankle sprains. Without the ability to match patients to specific treatments, clinicians are left without evidence for their decision-making in selecting treatments for a particular patient.
Supplementing conventional management strategies with manipulation/ mobilization techniques may improve treatment effectiveness by decreasing pain and improving function in shorter time periods.
- Downie WW, Leatham PA, Rhind VM, et al. Studies with pain rating scales. Annals of the Rheumatic Diseases 1978;37(4):378–81
- Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement Pain 1994;58(3):387–92
- Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Medicine & Science in Sports & Exercise 1999;31(8):1176–82
- Holmer P, Sondergaard L, Konradsen L, et al. Epidemiology of sprains in the lateral ankle and foot. Foot & Ankle International 1994;15(2):72–4
- Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. Journal of Foot Ankle Surgery 1998;37(4):280–5
- Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. American Family Physician 2001;63(1):93–104
- Linde F, Hvass I, Juergensen U, Madsen F. Early mobilizing treatment of ankle sprains. A clinical trial comparingthree types of treatment. Scandinavian Journal of Sports Sciences 1986;8(2):71–4
- Dettori JR, Pearson BD, Basmania CJ, Lednar WM. Early ankle mobilization, Part I: the immediate effect on acute, lateral ankle sprains (a randomized clinical trial). Military Medicine 1994;159(1):15–20.
- Dettori JR, Basmania CJ. Early ankle mobilization, Part II: a one-year follow-up of acute, lateral ankle sprains (a randomized clinical trial). Military Medicine 1994;159(1):20–4
- Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. American Journal of Sports Medicine 1994;22(1):83–8
- Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scandinavian Journal of Medicine and Science in Sports 1996;6(6):341–5
- Waddell G. Low back pain: a twentieth century health care enigma. Spine 1996;21(24):2820–5
- Flynn T, Fritz J, Whitman J, Wainner R, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short term improvement with spinal manipulation. Spine 2002;27(24): 2835-43