Physical Therapy Treatment of Ankle Injuries using Joint Mobilization

The ankle joint is susceptible to sprains or fractures which often result in restricted movement.  Mobilization with movement is a treatment technique which can be used to try and restore range of motion (ROM) at a joint. It is used in the rehabilitation of ankle injuries with reported positive results.

Anatomy of the Ankle Joint

The ankle joint consists of four bones, the tibia, fibula, talus and calcaneus. These four bones have three ‘articulations’ which are contained within the ankle joint. The three articulations are:

Talocrural Joint

This is a hinge joint formed by the distal (far) ends of the fibula and tibia and the talus. It allows dorsiflexion (pulling the toes up towards you) and plantarflexion (pointing the foot).

Inferior tibiofibular Joint

This is strong joint between the lower surfaces of the tibia and fibula. This is re-enforced by a ligament (ligaments attach bone to bone) called the inferior tibiofibular ligament.

Subtalar Joint

The subtalar joint is the joint between the talus and the calcaneus.  It provides shock absorption and the movements of inversion and eversion (inward and outward ankle movements respectively) occurs here.

Ankle Injury and the use of MWM

The ankle is fairly susceptible to injury, sprains and fractures are commonly seen at the ankle joint. Both these types of injury can result in a restriction of dorsiflexion. A limited ability to dorsiflex the ankle has many implications for normal function and can lead to chronic pain and instability. It has been suggested that following such injuries positional faults can occur within the articulations of the ankle joint (1).

Mobilization with movement (MWM) techniques can be used to help restore dorsiflexion. MWM is a manual therapy technique where a manual force is applied to a part of the body and sustained while a previously restricted and/or painful movement is performed. The aim of MWM is to restore normal range of motion, and reduce pain (2) by correcting positional faults.

The exact mechanism of how MWM’s help to improve range of motion and levels of pain are not fully understood; however what is clear is that by stabilizing one joint or body part whilst allowing another to move, appears to correct positional faults which have occurred as a result of injury. Several studies have shown MWM has a positive effect on ankle range of motion (particularly dorsiflexion) (3) (4). Due to the success of MWM to restore full range of motion at a joint, MWM’s are recommended as part of a thorough treatment plan for ankle sprains or fractures (5).

References

1. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Kavanagh, J. 1, 1999, Manual Therapy, Vol. 4, pp. 19-24.

2. Mobilisations with movement (MWM's). Mulligan, B R. 4, 1993, The journal of manual and manipulative therapy, Vol. 1, pp. 154-156.

3. The initial effects of a Mulligan's mobilization with movement technique on osiflexion on dorsiflexion and pain in subacute ankle spraind. Collins, N, Teys, P and Vicenzino, B. 2, 2004, Manual Therapy, Vol. 9.

4. Mulligan's mobilization-with-movement, poistional faults and pain relief: Current concepts from a critical review of literature. Vicenzino, B, Paungmali, A and Teys, O. 2, 2007, Manual Therapy, Vol. 12, pp. 98-108.

5. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Vicenzino, B, Branjerdporn, M and Teys, P. 7, 2006, Journal of orthopaedic and sports physical therapy, Vol. 36, pp. 464-471.

Useful Manual Therapy Techniques to Improve Shoulder Impingement Outcomes

The shoulder gives the most degrees of freedom of any joint in the body. The rotator cuff is an extremely important structure in providing a vital balance between mobility and stability. The rotator cuff consists of the tendons (a tendon is an extension of a muscle which attaches that muscle onto a bone) of 4 different muscles: Infraspinatus, Teres minor, Supraspinatus and Subscapularis. These structures are vulnerable to injury. One of the most common of all shoulder injuries is impingement.

Impingement occurs when the rotator cuff tendons get pinched in the space between the arm bone and the arch of the shoulder blade, which is known as the sub acromial space, as they pass from their muscle to their attachment at the front of the shoulder. This causes a mechanical stress to the tendon which results in swelling and/or damage. This pain is usually felt when lifting the arm up straight in front of you or out to the side as this is when the sub acromial space is at its smallest.

Rotator cuff impingement can be difficult to cure. Stretching or strengthening exercises and non steroidal anti inflammatory (NSAID's) are often prescribed as treatments for impingement. Another valuable treatment option is manual therapy. Manual therapy has been shown to improve the outcomes for rotator cuff impingement treatment ⁽¹⁾. Manual therapy helps to relieve the mechanical stress on the tendon which causes the damage and helps the damaged tendon to recover more quickly.

What is Manual Therapy?

Manual Therapy is a term used to describe a ‘hands on' treatment approach where joints, muscles ligaments and other soft tissues are mobilized or manipulated by a therapist to achieve a therapeutic benefit.  The benefits for the shoulder and rotator cuff muscles in using these techniques includes increased flexibility, increased tissue healing, improved muscle function without impingement, and a patient's increased tolerance to performing functional activities without impingement pain following treatment.

There are a range of techniques which fall into the category of manual therapy, those most commonly used for the treatment of rotator cuff impingement are:

• Soft Tissue Massage
• Friction massage
• Manipulation
• Mobilization

Soft Tissue Massage

Soft tissue massage is the systematic application of pressure and movement on the soft tissues of the body with the intention of facilitating normal range of movement.

Friction Massage

Deep  tissue friction massage is the application of a massage technique whereby superficial tissues are rubbed against deeper tissues. It is useful in assisting the body's own healing mechanisms and as such can help to speed up the healing of injured tendons.

Manipulations

Manipulation is a passive joint movement performed with the aim of increasing joint mobility. It incorporates a small amplitude quick thrust movement at the end of the available joint range.

Mobilizations

Joint mobilization involves the application of a passive force to increase joint range of motion. Mobilizations are performed up to the end of available joint range, but always within that range.

Although manual therapy has been proven to improve rotator cuff impingement recovery, it is not clear which of these manual therapy interventions is better ⁽²⁾. It would seem logical to assume that a combination of these treatments would prove to be of benefit in promoting recovery from rotator cuff impingement.

References

1. The effect of manipulation on the structures of the shoulder girdle as additional treatment for symptom rekief and for prevention of chronicity or recurrence of shouder symptoms. Bergman, GJD, Winters, JC and G, Heijden. 2002, Physical Therapy, Vol. 25, pp. 543-549.

2. Comparison of conservative treatment with and without manual physical therapy for patients wth shoulder impingement syndrome: a prospevtive, randomized clinical trial. G, Senbursa., Baltaci, G and Atay, A. 2007, Knee surgery sports traumatology and arthroscopy, pp. 915-921.

How the Use of Joint Mobilization to Treat Injured Shoulders Will Improve Patient Outcomes.

One of the treatment strategies we often incorporate here at All-Access Physical Therapy to treat shoulder injuries pre and post surgery is joint mobilization.  Use of joint mobilization techniques in treatment depend on ROM limitations combined shoulder capsule restriction that a patient may present with at initial evaluation.  Two of the most common diagnoses for which we incorporate joint mobilization into our treatment plans are adhesive capsulitis and shoulder impingement syndrome.  Two common joint mobilization techniques we utilize are posterior glides or mobilizations that decrease posterior capsule restriction, and mobilization with movement. We recently investigated the research behind use of joint mobilization for treatment of these conditions. 

A study by Johnson et. al. compared the effect of anterior joint mobilization glides versus posterior glides to increase shoulder external rotation in patients with adhesive capsulitis.  Their results showed the 10 patients in both groups had a significant reduction in pain, but the posterior glide group showed a mean increase of 31 degrees of external rotation versus a 3 degree increase for the anterior glide group over the course of 6 therapy sessions. (1)

Another study by Yang et. al. compared use of mid-range mobilization, end-range mobilization, and mobilization with movement when treating adhesive capsulitis.  They concluded that end-range mobilizations and mobilization with movement techniques provided better functional scores and shoulder kinematics in patients versus using mid-range mobilization techniques.  They also reported mobilization with movement significantly improved scapulohumeral rhythm after 3 weeks.(2) 

Finally, two different studies conducted by Bang et. al.(3) and Senbursa et. al. (4) compared use of manual therapy and exercise versus exercise alone when treating shoulder impingement syndrome.  Results from both studies showed patients receiving manual therapy treatment along with exercise showed greater improvements in function, ROM, and strength along with decreased pain, as compared to the patients receiving exercise treatment alone. 

Presenting this research is not to say we are absolutely correct in our approach to using the joint mobilization techniques we use to treat the shoulder, but rather to show that we are utilizing effective evidence based techniques when treating the patients here.  As research is ongoing in all health care fields, we may find that we may need to change our approach at some point.   In the end for us, it is how patients respond to our treatment that matters most. 

References:

• 1. Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. Department of Physical Rehabilitation, Beaver Medical Group, Redlands, CA, USA. ajohnson@epiclp.com. J Orthop Sports Phys Ther. 2007 Mar;37(3):88-99.
• 2. Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ. Mobilization techniques in subjects with frozen shoulder syndrome: randomized multiple-treatment trial. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan. Phys Ther. 2007 Oct;87(10):1307-15. Epub 2007 Aug 7.
• 3. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. Department of Medicine, Kaiser Permanente Medical Center, Vallejo, Calif. 94590, USA. Mbang96@aol.com. J Orthop Sports Phys Ther. 2000 Mar;30(3):126-37.
• 4. Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. School of Physiotherapy and Rehabilitation, Hacettepe University, 06100 Ankara,Turkey. Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):915-21. Epub 2007 Feb 28.