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research report
SEBASTIÁN TRUYOLS-DOMÍNGUEZ, PT, PhD1 • JAIME SALOM-MORENO, PT2 • JAVIER ABIAN-VICEN, PT, PhD1
JOSHUA A. CLELAND, PT, PhD3-5 • CÉSAR FERNÁNDEZ-DE-LAS-PEÑAS, PT, PhD2
Efficacy of Thrust and Nonthrust
Manipulation and Exercise With or
Without the Addition of Myofascial
Therapy for the Management
of Acute Inversion Ankle Sprain:
A Randomized Clinical Trial
TTSTUDY DESIGN: Randomized clinical trial.
TTOBJECTIVE: To compare the effects of thrust
and nonthrust manipulation and exercises with
and without the addition of myofascial therapy for
the treatment of acute inversion ankle sprain.
TTBACKGROUND: Studies have reported that
thrust and nonthrust manipulations of the ankle
joint are effective for the management of patients
post–ankle sprain. However, it is not known whether
the inclusion of soft tissue myofascial therapy could
further improve clinical and functional outcomes.
TTMETHODS: Fifty patients (37 men and 13 wom-
en; mean  SD age, 33  10 years) post–acute
inversion ankle sprain were randomly assigned to 2
groups: a comparison group that received a thrust
and nonthrust manipulation and exercise intervention, and an experimental group that received the
same protocol and myofascial therapy. The primary
outcomes were ankle pain at rest and functional
ability. Additionally, ankle mobility and pressure
pain threshold over the ankle were assessed by
a clinician who was blinded to the treatment
allocation. Outcomes of interest were captured at
baseline, immediately after the treatment period,
and at a 1-month follow-up. The primary analysis
was the group-by-time interaction.
TTRESULTS: The 2-by-3 mixed-model analyses of
variance revealed a significant group-by-time interaction for ankle pain (P<.001) and functional score
(P = .002), with the patients who received the combination of nonthrust and thrust manipulation and myofascial intervention experiencing a greater improvement in pain and function than those who received the
nonthrust and thrust manipulation intervention alone.
Significant group-by-time interactions were also observed for ankle mobility (P<.001) and pressure pain
thresholds (all, P<.01), with those in the experimental
group experiencing greater increases in ankle mobility
and pressure pain thresholds. Between-group effect
sizes were large (d>0.85) for all outcomes.
L
TTCONCLUSION: This study provides evidence
that, in the treatment of individuals post–inversion
ankle sprain, the addition of myofascial therapy to a
plan of care consisting of thrust and nonthrust manipulation and exercise may further improve outcomes compared to a plan of care solely consisting
of thrust and nonthrust manipulation and exercise.
However, though statistically significant, the difference in improvement in the primary outcome
between groups was not greater than what would
be considered a minimal clinically important difference. Future studies should examine the long-term
effects of these interventions in this population.
TTLEVEL OF EVIDENCE: Therapy, level 1b–.
J Orthop Sports Phys Ther 2013;43(5):300-309.
Epub 13 March 2013. doi:10.2519/jospt.2013.4467
TTKEY WORDS: manual therapy, pressure pain
threshold, triceps surae
ateral ankle sprains account
for 85% of all ankle sprains,
are common in individuals
who participate in athletic
activities, and result in substantial
societal burden.13,23 These injuries
frequently occur when a person lands on a
plantar-flexed and inverted foot.17 Typical
symptoms of lateral ankle sprain include
swelling, pain on palpation, and functional impairment.18 Despite the assumption of good prognosis, many individuals
continue to report pain and disability 1
month after lateral ankle sprain.1 Though
conservative management is the initial
treatment option for these patients, the
most appropriate treatment strategies to
prevent chronicity have yet to be established.15 Among ankle sprains, grades 1
and 2 are more likely to recur.21
Current evidence indicates that manual therapy interventions, such as joint
mobilization and manipulation, and exercises are often used by physical therapists
to manage patients who have sustained
an ankle sprain.2,29,30 The authors of sev-
Department of Physical Therapy, Universidad Camilo José Cela, Madrid, Spain. 2Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine,
Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. 3Department of Physical Therapy, Franklin Pierce University, Concord, NH. 4Rehabilitation Services, Concord Hospital,
Concord, NH. 5Manual Therapy Fellowship Program, Regis University, Denver, CO. The study protocol was approved by the Institutional Review Board of the Universidad Rey Juan
Carlos. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials
discussed in the manuscript. Address correspondence to Dr César Fernández-de-las-Peñas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas
s/n 28922 Alcorcón, Madrid, Spain. E-mail: cesarfdlp@yahoo.es t Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy ®
1
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eral studies have shown that manual
interventions directed at the ankle-foot
region result in improved mobility of the
ankle8,9,16,36 and weight bearing through
the foot.20 Additionally, 2 randomized
clinical trials have demonstrated that,
in patients post–lateral ankle sprain,
manual therapy directed at the ankle
is superior to a placebo or rest, ice, and
compression, along with nonsteroidal
anti-inflammatory drugs, for improving
range of motion, pain, and function.11,24
However, the authors of a relatively recent systematic review34 concluded that,
though manual mobilization has an initial positive effect on ankle dorsiflexion
range of motion, the clinical relevance
may be limited (level 2 evidence).
Whitman et al,38 using a cohort study
design, developed a clinical prediction
rule to help identify individuals with subacute inversion ankle sprain who would
be likely to benefit from manual therapy
interventions and a general exercise protocol targeted to the ankle/foot. In this
study, 75% of all patients exhibited a successful outcome.38 Hence, it is possible
that the majority of individuals with lateral ankle sprain may benefit from such
a treatment approach. However, a causeand-effect relationship, in the absence of
a comparison group, cannot be directly
inferred from this cohort study.
Despite all the aforementioned studies that included manual therapy interventions, none incorporated myofascial
techniques. An example of the potential
effectiveness of adding myofascial techniques to a manual therapy approach
was demonstrated in a randomized controlled trial on patients with plantar fasciosis.28 In that study, the patients who
received myofascial therapy in addition
to a best-evidence treatment approach
experienced greater improvements in
function and pain compared to those who
were treated with a best-evidence treatment approach alone.20 The contribution
of soft tissues to the etiology of chronic
painful conditions like plantar fasciosis is
based on alterations in soft tissue function over time. However, the need to ad-
dress muscle tissues in individuals with
acute conditions is still speculative. One
can speculate that post–ankle sprain, the
musculature surrounding the ankle (eg,
gastrocnemius, tibialis anterior, fibularis) may attempt to protect the ligaments
from further trauma by creating a protective soft tissue response.27
Acute injuries have been proposed as
a potential mechanism of activation of
myofascial trigger points (TrPs).31 As yet,
no studies have examined the efficacy of
myofascial techniques combined with
thrust and nonthrust manipulation and
exercises for patients post–acute lateral
ankle sprain. Therefore, the purpose of
this randomized clinical trial was to compare the effects of thrust and nonthrust
manipulation and exercise combined with
myofascial therapy to thrust and nonthrust manipulation and exercise alone,
using outcomes of pain, function, mobility, and pressure pain sensitivity in individuals with acute lateral ankle sprain.
METHODS
Participants
P
atients who presented to a
physical therapy clinic in Madrid,
Spain from January 2011 to June
2012 with a primary report of unilateral
inversion ankle sprain were screened for
inclusion in this study. To be included in
the study, patients had to be between 18
and 50 years of age, to report that this
was their first inversion ankle sprain in
the injured ankle, to have an inversion
ankle sprain grade of 1 or 2, and to have
been injured for less than 5 days. The diagnosis of an ankle sprain was made by
each patient’s physician. Potential participants were excluded if they exhibited
any of the following criteria that could
have altered their pain perception: previous trauma, fracture, or surgery to the
lower extremity; any concomitant lower
extremity pathology, for example, vascular disease or osteoarthritis; pregnancy;
any painful medical syndrome, such as
fibromyalgia, rheumatoid arthritis, whiplash, or carpal tunnel syndrome; the use
of pain or other medication within 7 days
prior to the study; or previous physical
therapy interventions provided for the
foot region. The study protocol was approved by the Institutional Review Board
of the Universidad Rey Juan Carlos and
was conducted according to the Helsinki
Declaration. All participants signed an
informed consent form prior to their inclusion in the study.
Outcome Measures
The primary outcome measure, intensity
of ankle pain at rest, was assessed with an
11-point numeric pain rating scale, where
0 represented the absence of pain and 10
represented maximum pain.19 In patients
with neck pain, the minimal detectable
change and the minimal clinically important difference (MCID) have been reported to be 1.3 and 2.1 points, respectively.6
However, in patients post–inversion ankle sprain, there are no available data for
minimal detectable change and MCID.
Secondary outcomes in this study
included ankle function, active range of
motion, and pressure pain sensitivity.
Function was assessed using the Functional Score for Assessment of Acute
Lateral Ankle Sprains, as described by
de Bie et al.10 The score on this tool is
based on a functional evaluation of the
following 5 items: pain (0-35), instability
(0-25), weight bearing (0-20), swelling
(0-10), and walking pattern (0-10). The
maximum total score is 100, with higher
values indicating better functional status.
Active range of motion of the ankle
was measured using a standard goniometer.22 The patient was seated with the
knee bent to 90°. The therapist aligned
the axis of the goniometer over the lateral malleolus, the proximal arm with
the midline of the fibula, and the distal
arm parallel to the fifth metatarsal. The
patient performed active plantar flexion
and a measurement was recorded. Next,
the patient performed active dorsiflexion
and a measurement was recorded.22 The
reliability of goniometric measurements
of ankle plantar flexion and dorsiflexion
ranges from poor to good.12,35,39
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FIGURE 3. Anterior/posterior nonthrust manipulation
applied to the distal tibiofibular joint.
FIGURE 2. Lateral glide/eversion rearfoot nonthrust
manipulation technique.
FIGURE 1. Anterior/posterior nonthrust manipulation
of the subtalar joint.
Pressure pain threshold (PPT), the
amount of pressure (kg/cm2) at which the
sensation of pressure changes to pain,33
was assessed with a mechanical pressure
algometer (Pain Diagnosis and Treatment, Inc, Great Neck, NY). Participants
were instructed to notify the tester when
the pressure first changed to a pain sensation. The device consists of a round rubber disc (1 cm2) attached to a force gauge
(kg). The pressure was applied at a rate
of approximately 0.1 kg/cm2/s. The mean
of 3 trials was calculated for each tested
location and used for the main analysis.
A 30-second rest was provided between
each trial. The reliability of pressure algometry has been found to be high (intraclass correlation coefficient = 0.91; 95%
confidence interval: 0.82, 0.97) when the
testing is performed on healthy people.5
Walton et al37 recently reported the minimal detectable change for PPT measured
over the cervical spine and tibialis anterior muscle in patients with acute neck
pain; however, no normative data for
PPT assessed over the locations used for
patients post–inversion ankle sprain have
been reported in the literature.
To investigate the hypoalgesic effects
of both treatment protocols, consistent
with a previous study,26 PPT was assessed at 4 predetermined locations on
the affected leg: anterior to the lateral
malleolus over the anterior talofibular
ligament, distal to the lateral malleolus
over the calcaneofibular ligament, over
the lateral malleolus, and over the medial malleolus.
FIGURE 4. Talocrural joint distraction thrust
manipulation technique.
Study Protocol
Participants were assigned by concealed
random allocation, using random numbers generated by online software (www.
randomization.com), to 1 of the 2 groups.
The comparison group received the same
thrust and nonthrust manipulation and
exercise protocol as that used by Whitman et al.38 The experimental group was
treated with myofascial manual therapy
techniques in addition to the protocol
that was also provided to the comparison group. Both groups were treated by
a clinician with 5 years of postgraduate
orthopaedic manual therapy training and
more than 10 years of clinical experience
in the management of musculoskeletal
disorders. All participants were treated
for 4 sessions, once per week, for 4 weeks.
The treatment was applied to the affected
ankle only.
Outcome measures were captured at
baseline, after the last treatment session,
and at a 1-month follow-up. PPT and ankle mobility were assessed by a clinician
blinded to group assignment. Patients
were not informed of the true objective of
the study, hence they did not know which
intervention was being evaluated.
FIGURE 5. Proximal tibiofibular joint thrust
manipulation technique.
Nonthrust (Mobilization) and Thrust
Manipulation Interventions Both groups
received the same manual therapy protocol as that used by Whitman et al,38 which
included ankle and foot nonthrust (mobilization) and thrust manipulation, general exercises, and instruction to elevate
and ice the ankle. Nonthrust manipulation techniques included an anterior-toposterior subtalar joint technique (FIGURE
1), a lateral glide/eversion rearfoot technique (FIGURE 2), and an anterior/posterior technique applied to the distal
tibiofibular joint (FIGURE 3). Each mobilization was applied at grade 3 or 4 and
was delivered for 20 to 30 seconds. The
thrust manipulations included a talocrural joint distraction (FIGURE 4) and a proximal tibiofibular joint technique (FIGURE 5).
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Patients with lateral ankle sprain
screened for eligibility criteria, n = 56
Excluded, n = 6:
• Repetitive ankle sprain, n = 3
• Ankle sprain grade 3, n = 1
• Ankle fracture, n = 2
FIGURE 6. Pressure-release technique over the
myofascial tissues of the gastrocnemius muscle.
Baseline measurements, n = 50
• Pain
• Function
• Ankle range of motion
• Pressure pain thresholds
Randomized, n = 50
FIGURE 7. Static stroke over the myofascial tissues of
the fibularis muscles.
FIGURE 8. Cross-hand technique over the
gastrocnemius myofascial tissue.
More specific details of the interventions
can be found in the article by Whitman et
al.38 Patients also performed Achilles tendon stretching, general range-of-motion
exercises, and self-mobilization of the
ankle at the end of each session. In addition, patients were advised to maintain
usual activity within the limits of pain. 38
Both groups received the same amount of
therapy, but the intervention order was
left to the therapist’s discretion, based on
the findings of the clinical examination.
Myofascial Therapy The myofascial intervention targeted the soft tissues of the
lower leg and was not based solely on the
presence of myofascial TrPs.27 Patients
Allocated to the comparison
group, n = 25:
• 1 weekly therapy session for 4
weeks
Allocated to the experimental
group, n = 25:
• 1 weekly therapy session for 4
weeks
Postintervention, n = 25
• Pain
• Function
• Ankle range of motion
• Pressure pain thresholds
Postintervention, n = 25
• Pain
• Function
• Ankle range of motion
• Pressure pain thresholds
1-month follow-up, n = 25
• Pain
• Function
• Ankle range of motion
• Pressure pain thresholds
1-month follow-up, n = 25
• Pain
• Function
• Ankle range of motion
• Pressure pain thresholds
FIGURE 9. Flow diagram of patients throughout the course of the study.
received pressure-release techniques
over the different myofascial structures,
for example, the gastrocnemius and fibularis muscles (FIGURE 6). With this technique, pressure was progressively applied
over the tissue until an increase in muscle
resistance (tissue barrier) was perceived.
The pressure was then maintained until
the therapist perceived release of the tissue. At this stage, the pressure was increased to return to the previous level of
soft tissue tension, and the process was
repeated 3 times. If the clinician identified a myofascial TrP (sensitive spot
eliciting referred pain), the pressure was
applied over the TrP. Patients were also
treated with static strokes (FIGURE 7) and
cross-hand interventions (FIGURE 8), applied over the gastrocnemius and tibialis
anterior muscles.4 Again, with these techniques, manual pressure was maintained
at the soft tissue barrier. The myofascial
techniques were applied slowly and without producing pain.
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Sample-Size Calculation
TABLE 1
Baseline Demographics for Both Groups*
Comparison Group (n = 25)
Experimental Group (n = 25)
P Value
19/6
18/7
.747
Gender (male/female), n
Age, y
32  11 (28, 38)
33  9 (30, 38)
.757
Height, cm
173  8.4 (170, 179)
173  8.8 (170, 178)
.961
Weight, kg
66.9  11.7 (62.1, 71.8)
68.4  6.6 (65.7, 71.1)
.675
Time from injury, d
3.1  0.7 (2.8, 3.4)
3.2  0.7 (2.9, 3.5)
.837
Pain (0-10)
5.1  1.0 (4.4, 5.8)
5.4  2.0 (4.8, 6.1)
.641
Functional score
Total (0-100)
40.9  18.0 (35.2, 46.6)
38.9  8.8 (33.2, 44.6)
.621
Pain (0-35)
13.2  5.5 (11.1, 15.2)
12.2  4.5 (10.1, 14.2)
.591
Instability (0-25)
10.6  6.3 (8.3, 12.8)
9.6  4.7 (7.3, 11.8)
.532
Weight bearing (0-20)
8.8  4.3 (7.2, 10.3)
8.6  3.0 (7.1, 10.1)
.853
Swelling (0-10)
3.6  2.4 (2.8, 4.4)
3.2  1.1 (2.4, 4.0)
.561
Walking pattern (0-10)
2.4  2.2 (1.4, 3.4)
2.3  2.4 (1.4, 3.3)
.906
Ankle mobility, deg
Plantar flexion
26.6  10.0 (22.8, 30.5)
25.8  8.9 (22.0, 30.0)
.760
Dorsiflexion
12.8  6.2 (10.4, 15.1)
11.9  5.5 (9.5, 14.2)
.583
Anterior talofibular ligament
4.9  1.2 (4.5, 5.3)
4.6  0.9 (4.3, 5.1)
.606
Calcaneofibular ligament
5.8  1.2 (5.1, 6.4)
5.5  1.8 (5.0, 6.2)
.694
Lateral malleolus
6.2  1.8 (5.5, 6.9)
5.9  1.8 (5.1, 6.6)
.627
Medial malleolus
5.9  1.9 (5.2, 6.7)
6.1  1.9 (5.3, 6.8)
.836
Pressure pain threshold, kg/cm2
*Values are mean  SD (95% confidence interval), except for gender.
TABLE 2
Experimental Group (n = 25)
Pain intensity (0-10)
Pretreatment
5.1  1.0
5.4  2.0
Posttreatment
3.2  1.5
2.1  1.4
Follow-up
2.0  1.2
Pre/post within-group change scores
–1.9 (–2.4, –1.3)
Pre/post between-group change scores
Pre/follow-up within-group change scores
Pre/follow-up between-group change scores
0.7  0.5
–3.4 (–4.3, –2.5)
1.5 (1.0, 2.2)
–3.1 (–3.7, –2.4)
–4.7 (–5.5, –4.0)
1.6 (1.1, 2.1)
Total functional scores (0-100)
Pretreatment
40.9  18.0
38.9  8.8
Posttreatment
64.0  17.8
78.6  13.9
Follow-up
82.2  11.8
97.1  4.6
Pre/post within-group change scores
23.1 (16.1, 30.0)
39.7 (33.2, 46.1)
Pre/post between-group change scores
16.6 (7.3, 25.8)
Pre/follow-up within-group change scores
41.3 (31.5, 51.0)
Pre/follow-up between-group change scores
16.9 (6.4, 27.3)
Adverse Events
All participants were asked to report
any adverse events experienced after the
intervention and during the 1-month
follow-up period. An adverse event was
defined as sequelae of medium-term duration of any symptom perceived as distressing and unacceptable to the patient
and that required further treatment.
Statistical Analysis
Outcome Data for Pain Intensity and Total Functional Score*
Comparison Group (n = 25)
The sample-size calculations were performed with the ENE 3.0 software
(Universitat Autònoma de Barcelona,
Barcelona, Spain). The calculations were
based on detecting a mean difference of
2.1 points (MCID) on an 11-point numeric pain rating scale,6 assuming a standard
deviation of 2.1, a 2-tailed test, an alpha
level of .05, and a desired power of 90%.
The estimated desired sample size was 22
patients per group. To accommodate expected dropouts before study completion,
a total of 25 participants were included in
each group.
58.2 (53.6, 63.0)
Abbreviations: Pre/follow-up, pretreatment to 1-month follow-up; Pre/post, pretreatment to immediately posttreatment.
*Values are mean  SD, except for change scores, which are mean (95% confidence interval).
Data were analyzed with SPSS Version
18.0 (SPSS Inc, Chicago, IL), and the
analysis was conducted following an
intention-to-treat analysis. When any
postintervention data were missing,
previous scores that would reflect a conservative approach to handling missing
data were used. Means, standard deviations, and 95% confidence intervals were
calculated for each variable. The Kolmogorov-Smirnov test showed a normal
distribution of quantitative data. Potential differences in baseline demographic
and clinical variables between the 2
groups were analyzed using independent Student t tests for continuous data
and chi-square tests of independence
for categorical data. Separate 2-by-3
mixed-model analyses of variance were
used to examine the effects of treatment
on pain intensity, functional score, ankle
plantar flexion and dorsiflexion range of
motion, and PPTs as the dependent variables, with group (experimental, control)
as the between-subject variable and
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time (baseline, posttreatment, 1-month
follow-up) as the within-subject variable. Between-group effect sizes were
calculated using the Cohen d coefficient
(between-group differences divided by
mean standard deviation).7 An effect size
greater than 0.8 was considered large,
around 0.5 moderate, and less than 0.2
small.7 The finding of interest was the
group-by-time interaction at an a priori
alpha level equal to .05.
RESULTS
F
ifty-six consecutive individuals
with acute inversion ankle sprain
were screened for eligibility criteria.
Fifty patients (mean  SD age, 33  10
years; 26% female; weight, 68  9 kg;
height, 173  8 cm) satisfied all eligibility
criteria, agreed to participate, and were
randomized to either the comparison (n
= 25) or experimental (n = 25) group.
The reasons for ineligibility are found in
FIGURE 9, which provides a flow diagram
of patient recruitment and retention.
Baseline features between groups were
similar for all variables (TABLE 1). No patient reported any adverse event during
the study period.
The 2-by-3 mixed-model analysis of
variance revealed significant group-bytime interactions for pain (F = 11.727,
P<.001) and functional score (F = 10.466,
P = .002), with the patients who received
the combined treatment of myofascial
manual therapy, nonthrust (mobilization)
and thrust manipulation, and exercises
experiencing a greater reduction in pain
and a greater improvement in function
than those who received the intervention
of nonthrust and thrust manipulation
and exercises. These outcomes were observed both immediately after the 4-week
intervention (P<.001) and at 1-month
follow-up (P = .003). Between-group effect sizes were large (d>1.3) for both outcomes at the end of the intervention and
1 month postintervention (TABLE 2).
The group-by-time interaction was
statistically significant for all domains
of the functional score (pain: F = 6.826,
TABLE 3
Outcome Data for Each Domain
of the Functional Score*
Comparison Group (n = 25)
Experimental Group (n = 25)
Pretreatment
13.2  5.5
12.2  4.5
Posttreatment
22.2  8.3
27.7  11.4
Follow-up
28.4  7.2
35.6  12.1
Pain (0-35)
Pre/post within-group change scores
9.0 (5.5, 12.4)
Pre/post between-group change scores
6.5 (1.7, 12.2)
Pre/follow-up within-group change scores
15.2 (11.2, 19.2)
Pre/follow-up between-group change scores
8.2 (2.9, 14.5)
15.5 (10.7, 20.3)
23.4 (18.3, 28.5)
Instability (0-25)
Pretreatment
10.6  6.3
9.6  4.7
Posttreatment
17.2  8.2
19.6  5.2
Follow-up
19.6  7.5
24.4  2.2
Pre/post within-group change scores
6.6 (4.0, 9.2)
10.0 (7.8, 12.3)
Pre/post between-group change scores
3.4 (1.0, 5.7)
Pre/follow-up within-group change scores
9.0 (5.8, 12.2)
Pre/follow-up between-group change scores
5.8 (2.1, 9.6)
14.8 (12.5, 17.1)
Weight bearing (0-20)
Pretreatment
8.8  4.3
8.6  3.0
Posttreatment
11.8  6.8
17.0  3.8
Follow-up
16.8  4.7
20.2  2.3
Pre/post within-group change scores
3.0 (1.0, 6.9)
Pre/post between-group change scores
5.4 (1.0, 9.7)
Pre/follow-up within-group change scores
8.0 (5.0, 10.9)
Pre/follow-up between-group change scores
3.6 (1.3, 5.9)
8.4 (6.4, 10.3)
11.6 (10.0, 13.1)
Swelling (0-10)
Pretreatment
3.6  2.4
Posttreatment
6.6  2.5
3.2  1.1
7.6  2.2
Follow-up
8.2  2.0
10.2  1.0
Pre/post within-group change scores
3.0 (2.1, 3.9)
Pre/post between-group change scores
1.4 (0.2, 2.6)
Pre/follow-up within-group change scores
4.6 (3.5, 5.7)
Pre/follow-up between-group change scores
2.4 (1.1, 3.5)
4.4 (3.7, 5.2)
7.0 (6.5, 7.4)
Walking pattern (0-10)
Pretreatment
2.4  2.2
2.3  2.4
Posttreatment
6.5  2.5
6.8  2.4
Follow-up
7.3  2.1
9.2  1.9
Pre/post within-group change scores
4.1 (3.2, 4.9)
4.5 (3.2, 5.7)
Pre/post between-group change scores
0.4 (–1.2, 1.8)
Pre/follow-up within-group change scores
4.9 (3.8, 6.0)
Pre/follow-up between-group change scores
2.0 (0.3, 3.6)
6.9 (5.6, 8.2)
Abbreviations: Pre/follow-up, pretreatment to 1-month follow-up; Pre/post, pretreatment to immediately posttreatment.
*Values are mean  SD, except for change scores, which are mean (95% confidence interval).
P = .012; instability: F = 4.570, P = .013;
weight bearing: F = 4.890, P = .010;
swelling: F = 7.961, P = .001; walking pat-
tern: F = 4.221, P = .017), with patients
who received the combined-treatment
approach experiencing greater improve-
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[
ment on each domain compared to those
in the comparison group. These outcomes
were observed both immediately after
the last therapy session and at 1-month
follow-up (P<.01). Between-group effect
sizes ranged from moderate (d = 0.65) to
large (d = 1.0), depending on the domain
(TABLE 3).
The 2-by-3 mixed-model analysis of
variance also revealed significant groupby-time interactions for plantar flexion (F
= 18.394, P<.001) and dorsiflexion (F =
19.009, P<.001) range of motion and for
PPTs (anterior talofibular ligament: F =
45.601, P<.001; calcaneofibular ligament:
F = 7.954, P<.001; lateral malleolus: F =
16.339, P<.001; medial malleolus: F =
8.599, P = .005), with patients who received the combination of nonthrust
and thrust manipulation, exercises, and
myofascial manual therapy experiencing
greater increases in ankle mobility and
PPTs compared to those who received
the comparison intervention, both immediately after the last therapy session and
at 1-month follow-up (P<.01). Betweengroup effect sizes were large (d>0.85) for
all secondary outcomes (TABLES 4 and 5).
DISCUSSION
T
he results of this study suggest
that the combination of myofascial
manual therapy techniques and joint
nonthrust and thrust manipulation techniques and exercises to treat individuals
with acute ankle sprains may result in
better outcomes after 4 weeks of therapy
and 1 month after the end of therapy than
joint nonthrust and thrust manipulation
and exercises alone. It should be noted
that although between-group change
scores were statistically significant, they
did not surpass the previously reported
MCID for the primary outcome measure (pain). Additionally, for the muscles
tested in the present study, there are no
reported values for the MCID of PPT in
individuals after ankle inversion sprain;
however, the present study showed large
effect sizes for PPT. Therefore, the benefit
of adding myofascial treatment may be
research report
TABLE 4
]
Outcome Data for Ankle Mobility*
Comparison Group (n = 25)
Experimental Group (n = 25)
Ankle plantar flexion, deg
Pretreatment
26.6  10.0
25.8  8.9
Posttreatment
34.7  8.8
39.6  8.3
Follow-up
37.1  8.5
47.9  9.5
Pre/post within-group change scores
8.1 (4.2, 11.9)
13.8 (10.8, 16.8)
Pre/post between-group change scores
5.7 (1.9, 10.5)
Pre/follow-up within-group change scores
10.5 (6.2, 14.8)
Pre/follow-up between-group change scores
11.6 (6.2, 17.1)
22.1 (18.6, 25.7)
Ankle dorsiflexion, deg
Pretreatment
12.8  6.2
11.9  5.5
Posttreatment
15.7  5.3
23.2  5.2
Follow-up
20.2  8.3
28.8  6.1
Pre/post within-group change scores
2.9 (0.4, 5.4)
Pre/post between-group change scores
8.4 (5.2, 11.7)
Pre/follow-up within-group change scores
7.4 (4.3, 10.6)
Pre/follow-up between-group change scores
9.5 (5.1, 13.8)
11.3 (9.2, 13.5)
16.9 (13.8, 20.1)
Abbreviations: Pre/follow-up, pretreatment to 1-month follow-up; Pre/post, pretreatment to immediately posttreatment.
*Values are mean  SD, except for change scores, which are mean (95% confidence interval).
clinically relevant, as indicated by moderate to large between-group effect sizes
and by between-group differences in all
outcomes.
Because the addition of myofascial
manual therapy resulted in statistically
greater and potentially greater clinical
improvements in pain and function, we
hypothesize that soft tissues may perpetuate symptoms associated with lateral ankle sprains. It is plausible that the
muscles surrounding the ankle, in an attempt to protect the ankle from further
trauma, go into a protective state. The
exact mechanism by which the treatment
of soft tissues, including TrPs, is effective
remains to be elucidated. However, it
is possible that the treatment results in
a restoration of the length of the sarcomeres, resulting in a reduction of pain. 31
The restoration of sarcomere length may
also be related, at least in part, to the
greater improvements in ankle mobility
observed in those patients who received
the soft tissue myofascial approach.
Another explanation may be that the
treatment of myofascial soft tissue struc-
tures results in segmental antinociceptive
effects.32 It has also recently been demonstrated that localized mechanical pain
hypersensitivity over ankle ligaments and
the lateral malleolus exists in individuals
with lateral ankle sprains.26 This suggests
that the peripheral sensitization secondary to the acuteness of the injury post–
lateral ankle sprain may be positively
affected by myofascial techniques.26 We
also found significantly greater increases
in PPTs over the affected leg in the experimental group. Again, effect sizes were
large, supporting a clinical effect of the
intervention over mechanical sensitivity
in those points previously found to be
hypersensitive. Our results would, therefore, support the antinociceptive effect of
myofascial interventions.
Whitman et al38 found that 75% of
individuals who received nonthrust and
thrust manipulation interventions, Achilles tendon stretching, general range-ofmotion exercises, and self-mobilization
of the ankle experienced a successful
outcome with 2 physical therapy sessions.
It is possible that a greater percentage of
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TABLE 5
Outcome Data for Pressure Pain Sensitivity*
Comparison Group (n = 25)
Experimental Group (n = 25)
Pretreatment
4.9  1.2
4.6  0.9
Posttreatment
5.7  1.3
7.9  1.0
Follow-up
6.3  1.2
9.1  0.8
Pre/post within-group change scores
0.8 (0.4, 1.3)
3.3 (2.6, 3.9)
Pre/post between-group change scores
2.5 (1.7, 3.2)
Anterior talofibular ligament, kg/cm2
Pre/follow-up within-group change scores
1.4 (0.9, 1.9)
Pre/follow-up between-group change scores
3.1 (2.4, 3.8)
4.5 (4.0, 5.0)
Calcaneofibular ligament, kg/cm2
Pretreatment
5.8  1.2
5.5  1.8
Posttreatment
7.5  1.8
8.3  1.5
Follow-up
8.2  1.5
9.4  0.6
Pre/post within-group change scores
1.7 (1.1, 2.2)
2.8 (2.1, 3.3)
Pre/post between-group change scores
1.1 (0.3, 1.8)
Pre/follow-up within-group change scores
2.4 (1.8, 2.9)
Pre/follow-up between-group change scores
1.5 (0.6, 2.2)
3.9 (3.2, 4.5)
Medial malleolus, kg/cm2
Pretreatment
5.9  1.9
6.1  1.9
Posttreatment
7.1  2.0
8.3  1.3
Follow-up
8.0  1.8
9.6  0.7
Pre/post within-group change scores
1.2 (0.5, 1.8)
2.2 (1.5, 2.9)
Pre/post between-group change scores
1.0 (0.1, 1.9)
Pre/follow-up within-group change scores
2.1 (1.2, 2.7)
Pre/follow-up between-group change scores
1.4 (0.5, 2.6)
3.5 (2.7, 4.4)
Lateral malleolus, kg/cm2
Pretreatment
6.2  1.8
5.9  1.8
Posttreatment
7.4  1.6
8.1  1.3
Follow-up
8.0  1.5
9.6  0.7
Pre/post within-group change scores
1.2 (0.6, 1.6)
2.2 (1.6, 2.8)
Pre/post between-group change scores
1.0 (0.2, 1.8)
Pre/follow-up within-group change scores
1.8 (1.1, 2.4)
Pre/follow-up between-group change scores
1.9 (1.0, 2.9)
3.7 (2.9, 4.4)
Abbreviations: Pre/follow-up, pretreatment to 1-month follow-up; Pre/post, pretreatment to immediately posttreatment.
*Values are mean  SD, except for change scores, which are mean (95% confidence interval).
patients would experience a successful
outcome if the current myofascial treatment were added as an intervention;
although future studies are needed to
confirm this assumption. Additionally,
Whitman et al38 used patient-perceived
improvement as an outcome measure to
determine success. As the current study
did not use such a self-report measure,
its success rate cannot be directly compared to theirs. However, it is interest-
ing to note that patients in the study by
Whitman et al38 experienced a decrease
in ankle pain very similar to the pain
decreases measured in our comparison
group, which was expected, given the use
of the same nonthrust and thrust manipulation protocol. It is suggested that
thrust manipulation induces presynaptic
inhibition of segmental pathways, reflex
pain inhibition, reflex muscle relaxation,
or changes in proprioceptive afferences.25
The most current accepted theory is that
manual therapy in general, including
soft tissue myofascial interventions, acts
over central pain control by stimulating descending inhibitory pain mechanisms, particularly the periaqueductal
gray area.3 It is possible that the effects
of nonthrust and thrust manipulation interventions are complementary to the application of myofascial interventions for
the management of acute ankle sprain.
The data also indicated that individuals in both groups experienced statistically and clinically significant improvements
in both pain and function over time, with
the lower bound of the 95% confidence
interval for within-group changes in both
groups being larger than the MCID for
pain, the primary outcome. But the lack
of a control group that did not receive
any intervention precludes determining
how much of that improvement in both
groups was due to the natural resolution
of the condition. Similarly, influence of
the placebo effect in both groups is unknown, as the study did not include a
sham-intervention group.14
There are a number of limitations in
the current study. Only 1 therapist provided the treatment, which may limit the
generalizability of the results. It is also
possible that attention bias occurred, as
the patients receiving myofascial therapy
spent more time with the therapist at
each treatment session. Furthermore,
the final follow-up assessment took place
at 1 month, and it is uncertain whether
the observed differences might remain
beyond that time. In addition, we did
not assess the perspective of the patients about the progress of their ankle
sprain by using a self-report evaluation,
such as the global rating of change. Finally, although statistically significant,
between-group differences were not
clinically meaningful, so the actual clinical relevance of myofascial interventions
requires further study, perhaps with the
addition of self-reported outcome measures such as the global rating of change,
the Lower Extremity Functional Scale,
and the Patient-Specific Functional Scale.
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[
Future clinical trials should include multiple therapists delivering the intervention, a true control group, and long-term
follow-up.
CONCLUSION
T
his study provides evidence
that the addition of myofascial techniques to a treatment protocol of
thrust and nonthrust manipulation and
exercise in individuals with acute ankle
sprains results in statistically significant
improvement in pain and function. These
results should be interpreted with regard
to these differences being smaller than
what would be considered a clinically
important difference, despite the fact
that the effect size of the between-group
difference was considered large. Future
studies should include a true control
group and examine the long-term effects
of these interventions in this population,
in addition to further assessment of the
clinical significance of the changes. t
KEY POINTS
FINDINGS: The addition of myofascial
techniques to an intervention of thrust
and nonthrust joint manipulation and
exercise in the treatment of acute ankle
sprain leads to statistically significantly
greater improvement in pain and function immediately after a 4-week intervention and at 1-month follow-up.
IMPLICATIONS: Physical therapists may
consider incorporating soft tissue myofascial manual techniques in the overall
management of individuals with acute
inversion ankle sprains.
CAUTION: Although statistically significant, the difference in improvement for
pain between groups was less than what
would be considered an MCID. We only
assessed short-term outcomes, and only
1 therapist performed all interventions.
research report
]
REFERENCES
1. A
iken AB, Pelland L, Brison R, Pickett W, Brouwer B. Short-term natural recovery of ankle
sprains following discharge from emergency
departments. J Orthop Sports Phys Ther.
2008;38:566-571. http://dx.doi.org/10.2519/
jospt.2008.2811
2. American Physical Therapy Association. Guide
to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001.
3. Bialosky JE, Bishop MD, Price DD, Robinson ME,
George SZ. The mechanisms of manual therapy
in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14:531-538.
http://dx.doi.org/10.1016/j.math.2008.09.001
4. Chaitow L. Modern Neuromuscular Techniques.
3rd ed. London, UK: Elsevier; 2010.
5. Chesterton LS, Sim J, Wright CC, Foster NE.
Interrater reliability of algometry in measuring pressure pain thresholds in healthy
humans, using multiple raters. Clin J Pain.
2007;23:760-766. http://dx.doi.org/10.1097/
AJP.0b013e318154b6ae
6. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck Disability Index
and numeric pain rating scale in patients with
mechanical neck pain. Arch Phys Med Rehabil.
2008;89:69-74. http://dx.doi.org/10.1016/j.
apmr.2007.08.126
7. Cohen J. Statistical Power Analysis for the
Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
8. Collins N, Teys P, Vicenzino B. The initial effects
of a Mulligan’s mobilization with movement
technique on dorsiflexion and pain in subacute
ankle sprains. Man Ther. 2004;9:77-82. http://
dx.doi.org/10.1016/S1356-689X(03)00101-2
9. Dananberg HJ. Manipulation of the ankle as a
method of treatment for ankle and foot pain. J
Am Podiatr Med Assoc. 2004;94:395-399.
10. de Bie RA, de Vet HC, van den Wildenberg FA,
Lenssen T, Knipschild PG. The prognosis of
ankle sprains. Int J Sports Med. 1997;18:285289. http://dx.doi.org/10.1055/s-2007-972635
11. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic
manipulative treatment in the emergency department for patients with acute ankle injuries. J
Am Osteopath Assoc. 2003;103:417-421.
12. Elveru RA, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting. Subtalar
and ankle joint measurements. Phys Ther.
1988;68:672-677.
13. Ferran NA, Maffulli N. Epidemiology of sprains
of the lateral ankle ligament complex. Foot
Ankle Clin. 2006;11:659-662. http://dx.doi.
org/10.1016/j.fcl.2006.07.002
14. George SZ, Robinson ME. Dynamic nature of the
placebo response. J Orthop Sports Phys Ther.
2010;40:452-454. http://dx.doi.org/10.2519/
jospt.2010.0107
15. Gerber JP, Williams GN, Scoville CR, Arciero
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
RA, Taylor DC. Persistent disability associated
with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int.
1998;19:653-660.
Green T, Refshauge K, Crosbie J, Adams R. A
randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion
sprains. Phys Ther. 2001;81:984-994.
Hertel J. Functional anatomy, pathomechanics,
and pathophysiology of lateral ankle instability. J
Athl Train. 2002;37:364-375.
Ivins D. Acute ankle sprain: an update. Am Fam
Physician. 2006;74:1714-1720.
Jensen MP, Turner JA, Romano JM, Fisher LD.
Comparative reliability and validity of chronic
pain intensity measures. Pain. 1999;83:157-162.
López-Rodríguez S, Fernández-de-las-Peñas
C, Alburquerque-Sendín F, Rodríguez-Blanco
C, Palomeque-del-Cerro L. Immediate effects
of manipulation of the talocrural joint on
stabilometry and baropodometry in patients
with ankle sprain. J Manipulative Physiol Ther.
2007;30:186-192. http://dx.doi.org/10.1016/j.
jmpt.2007.01.011
Malliaropoulos N, Ntessalen M, Papacostas E,
Longo UG, Maffulli N. Reinjury after acute lateral
ankle sprains in elite track and field athletes.
Am J Sports Med. 2009;37:1755-1761. http://
dx.doi.org/10.1177/0363546509338107
Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. 2nd ed. Philadelphia, PA: F.A. Davis Company; 1995.
O’Loughlin PF, Murawski CD, Egan C, Kennedy
JG. Ankle instability in sports. Phys Sportsmed.
2009;37:93-103. http://dx.doi.org/10.3810/
psm.2009.06.1715
Pellow JE, Brantingham JW. The efficacy of
adjusting the ankle in the treatment of subacute
and chronic grade I and grade II ankle inversion
sprains. J Manipulative Physiol Ther. 2001;24:1724. http://dx.doi.org/10.1067/mmt.2001.112015
Pickar JG. Neurophysiological effects of spinal
manipulation. Spine J. 2002;2:357-371.
Ramiro-González MD, Cano-de-la-Cuerda R,
De-la-Llave-Rincón AI, Miangolarra-Page JC,
Zarzoso-Sánchez R, Fernández-de-las-Peñas C.
Deep tissue hypersensitivity to pressure pain in
individuals with unilateral acute inversion ankle
sprain. Pain Med. 2012;13:361-367. http://dx.doi.
org/10.1111/j.1526-4637.2011.01302.x
Remvig L. Myofascial release; an evidence based
treatment concept? [abstract]. First International Fascia Research Congress; October 4-5,
2007; Boston, MA.
Renan-Ordine R, Alburquerque-Sendín F, de
Souza DP, Cleland JA, Fernández-de-las-Peñas
C. Effectiveness of myofascial trigger point
manual therapy combined with a self-stretching
protocol for the management of plantar heel
pain: a randomized controlled trial. J Orthop
Sports Phys Ther. 2011;41:43-50. http://dx.doi.
org/10.2519/jospt.2011.3504
Safran MR, Benedetti RS, Bartolozzi AR, 3rd,
Mandelbaum BR. Lateral ankle sprains: a
308 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy
43-05 Truyols-Dominguez.indd 308
4/17/2013 3:50:56 PM
30.
31.
32.
33.
comprehensive review part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med
Sci Sports Exerc. 1999;31:S429-S437.
Safran MR, Zachazewski JE, Benedetti RS,
Bartolozzi AR, 3rd, Mandelbaum R. Lateral
ankle sprains: a comprehensive review part
2: treatment and rehabilitation with an emphasis on the athlete. Med Sci Sports Exerc.
1999;31:S438-S447.
Simons DG. Understanding effective treatments
of myofascial trigger points. J Bodyw Mov Ther.
2002;6:81-88.
Srbely JZ. New trends in the treatment and
management of myofascial pain syndrome. Curr
Pain Headache Rep. 2010;14:346-352. http://
dx.doi.org/10.1007/s11916-010-0128-4
Vanderweeën L, Oostendorp RA, Vaes P, Duquet
W. Pressure algometry in manual therapy. Man
Ther. 1996;1:258-265. http://dx.doi.org/10.1054/
math.1996.0276
34. v an der Wees PJ, Lenssen AF, Hendriks EJ,
Stomp DJ, Dekker J, de Bie RA. Effectiveness
of exercise therapy and manual mobilisation in
ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52:27-37.
35. Van Gheluwe B, Kirby KA, Roosen P, Phillips
RD. Reliability and accuracy of biomechanical
measurements of the lower extremities. J Am
Podiatr Med Assoc. 2002;92:317-326.
36. Vicenzino B, Branjerdporn M, Teys P, Jordan
K. Initial changes in posterior talar glide and
dorsiflexion of the ankle after mobilization
with movement in individuals with recurrent
ankle sprain. J Orthop Sports Phys Ther.
2006;36:464-471. http://dx.doi.org/10.2519/
jospt.2006.2265
37. Walton DM, MacDermid JC, Nielson W, Teasell
RW, Chiasson M, Brown L. Reliability, standard
error, and minimum detectable change of clinical pressure pain threshold testing in people
with and without acute neck pain. J Orthop
Sports Phys Ther. 2011;41:644-650. http://
dx.doi.org/10.2519/jospt.2011.3666
38. Whitman JM, Cleland JA, Mintken PE, et al.
Predicting short-term response to thrust and
nonthrust manipulation and exercise in patients
post inversion ankle sprain. J Orthop Sports
Phys Ther. 2009;39:188-200. http://dx.doi.
org/10.2519/jospt.2009.2940
39. Youdas JW, Bogard CL, Suman VJ. Reliability
of goniometric measurements and visual estimates of ankle joint active range of motion
obtained in a clinical setting. Arch Phys Med
Rehabil. 1993;74:1113-1118.
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