Ankle inversion sprains: the added benefits of manual therapy combined with stabilization exercises
Ankle inversion sprains occur commonly in physical active people, with an annual incidence rate of 7 injuries per 1000 people. It occurs when the foot rolls inward, causing damage to the ligaments on the outer portion of the ankle. Not only does this cause pain and limited tolerance to everyday activities, but damage to ligaments can negatively impact proprioception, or awareness of joint positioning, which can decrease performance in balance and set the stage for recurrent injuries.
The following study compares the effects of manual therapy with exercise versus exercise alone, when treating an ankle inversion sprain.
The study:
Cleland et al performed a randomized controlled trial in 2013, where patients with ankle inversion injuries underwent a four-week intervention program. The study randomly allocated subjects into two groups:
Group 1 was given exercise alone.
Group 2 was given the same exercise program as Group 1, plus a manual therapy regime. The manual therapy regime consisted of mobilizations to the proximal and distal tibiofibular joints, talocrural and subtalar joints.
Outcome measures were the Foot and Ankle Ability Measures (ADL and Sports), Lower Extremity Functional Scale (LEFS), Numeric Pain Rating Scale (NPRS) and Global Rating of Change (GRC). Post-intervention measures were taken after the 4-week intervention and at 6-months.
The results:
The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P⩽.001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group.
There was no statistically significant difference in the recurrence of ankle sprain rate between the both groups.
Limitations of the study: 1.) subjects were not blinded to group assignment, 2.) all outcome measures were questionnaires, and there were no objective outcome measures, such as improvements in range of motion, strength, 3.) there was no control group, so improvements cannot be attributed to the treatment intervention or that of placebo effect, and 4.) participants of Group 2 (exercise + manual therapy) spent more time with a physical therapist, which may encourage bias.
What this means:
According to the results of this study, a multimodal approach integrating both ankle stability exercises and manual therapy improves pain and increased tolerance to activities of daily living and return to sport. The nature of improvement is still unknown, and there are several explanations that may account for results favoring manual therapy intervention:
1.) manual therapy may help restore motion in the joints, consequently improving function and decreasing pain. This is the primary intention of manual therapy.
2.) the effects of manual therapy may be neurophysiological. That is, it may play a role in undoing a disrupted neural feedback system to the dynamic stabilizers of the ankle via stimulation of mechanoreceptors in the ankle.
3.) manual therapy may result in reduction of inflammatory cytokines, an increase in beta endorphins, and hypoalgesia.
No matter the case, manual therapy seems to play a role in improving pain and perceived tolerance to activities of daily living. Below are the manual therapy techniques used in the appraised study.
REFERENCES:
Cleland JA, Mintken P, McDevitt A, Bieniek M, Carpenter K, Kulp K, Whitman JM. Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy. 201343:7,443-455