THE EFFECTS OF JOINT MOBILIZATION AND MUSCLE ENERGY TECHNIQUE
ON ANKLE DORSIFLEXION RANGE OF MOTION AMONG
ASYMPTOMATIC INDIVIDUALS
39 Pages
Context: Decreased ankle dorsiflexion range of motion (ROM) is both a predictor and a
consequence of lateral ankle sprains. Many clinical interventions exist to increase range of
motion with varied protocols. Objective: To determine the effectiveness of two interventions,
joint mobilization and muscle energy technique (MET) on ankle dorsiflexion ROM compared to a
control. Design: Single-blinded randomized controlled trial. Setting: Laboratory. Participants:
Forty-six asymptomatic off-season high school football players (16.5 ± 1.0 years, 83.1 ± 17.3 kg,
180.2 ±7.4 cm). Interventions: One ankle of each participant was randomly assigned to either
the joint mobilization or MET group, while the contralateral ankle was assigned to serve as a
control. The ankle which received either the joint mobilization or MET intervention was treated
two times per week for four weeks. Main Outcome Measures: Non-weightbearing and
weightbearing dorsiflexion ROM (°) in both knee flexion and knee extension. Results: No
significant findings were found for any of the post-intervention ROM variables between groups
(p > .11). Conclusions: Based on our results, using MET or joint mobilizations to increase ankle
dorsiflexion ROM among asymptomatic individuals.
THE EFFECTS OF JOINT MOBILIZATION AND MUSCLE ENERGY TECHNIQUE
ON ANKLE DORSIFLEXION RANGE OF MOTION AMONG
ASYMPTOMATIC INDIVIDUALS
ii
CONTENTS
Page
ACKNOWLEDGMENTS
i
CONTENTS
ii
TABLES
iv
FIGURES
v
CHAPTER
I. INTRODUCTION: PURPOSE OF RESEARCH
1
II. REVIEW OF RELATED LITERATURE
5
Introduction
5
Ankle Anatomy Review
5
Bone
Static Restraints
Dynamic Stability
Functional Activity
6
6
7
9
Incidence of Ankle Sprains
9
Pathoanatomy and Sequelae of Lateral Ankle Sprains
Anterior Displacement of the Talus
Muscular Tightness
10
11
12
Muscle Stiffness and Loss of Range of Motion
14
Clinical Treatment to Increase Dorsiflexion to Prevent and Rehabilitate
Lateral Ankle Sprains
15
iii
Joint Mobilization
Muscle Energy Technique
15
18
III. METHODS
21
Participants
21
Instrumentation
22
Dorsiflexion Range of Motion Measurements
22
Calf Stiffness Measurement
26
Procedures
26
Joint Mobilization Technique
Muscle Energy Technique
Statistical Analysis
26
27
27
IV. RESULTS
29
Dorsiflexion Range of Motion
29
V. CONCLUSION AND DISCUSSION
32
Discussion
Conclusion
32
35
REFERENCES
APPENDIX A:
33
Activity and Injury Questionnaire
iv
39
TABLES
Table
Page
1.
Participant Characteristics (means ± standard deviations)
22
2.
Descriptive Statistics for non-weight-bearing ankle dorsiflexion
range of motion (degrees).
30
Descriptive Statistics for weight-bearing ankle dorsiflexion
range of motion (degrees).
31
3.
v
FIGURES
Figure
Page
1.
Dorsiflexion ROM in non-weight-bearing with knee extended measurement.
21
2.
Dorsiflexion ROM in non-weight-bearing with knee flexed measurement.
21
3.
Dorsiflexion ROM in weight-bearing with knee extended measurement
22
4.
Dorsiflexion ROM in weight-bearing with knee flexed measurement
22
5.
Joint Mobilization Technique
23
6.
Muscle Energy Technique: Subtalar neutral and passive dorsiflexion
24
7.
Muscle Energy Technique: Beginning of isotonic contraction
25
vi
CHAPTER I
INTRODUCTION: PURPOSE OF RESEARCH
In the United States, about 23,000 ankle sprains occur each day.1 In sports, ankles are
the most common joint injured,2 with approximately 85% of these injuries diagnosed as ankle
sprains.3,4 More specifically, it has been estimated that over 272, 000 ankle sprains occur every
year in high school athletics,5 corresponding to about 15% of all athletic injuries.6 Almost half of
injured athletes with ankle sprains miss at least one week of activity7 with a recurrence rate as
high as 80%.8 Furthermore, more than 80% of ankle sprains involve the lateral ligament
complex.3
While decreased dorsiflexion range of motion (ROM) can be a predictor of ankle
sprains9, it also can be a result of ankle sprains. Hubbard and Hertel10 reported that injury to the
lateral ligaments caused increased glide of the talus in the neutral zone, which is an area of
movement without ligamentous restriction. If this motion occurs, the axis of rotation moves
anteriorly, limiting dorsiflexion ROM. Muscular tightness of the gastrocnemius-soleus complex
has also been shown to occur in patients with functional ankle instability.8 This prohibits full
ankle dorsiflexion ROM during gait, thus altering kinematics in the entire lower extremity. Not
only is the ankle more plantarflexed throughout the entire gait cycle,8 but the hip and knee
compensate with more flexion, especially in midstance.11
1
Many clinical techniques are available to increase dorsiflexion, including passive
stretching,12 acupuncture,13 and high velocity manipulation14. Two techniques that have been
recently investigated include joint mobilization of the talocrural joint15,16, and muscle energy
technique (MET)17 in an attempt to increase ankle dorsiflexion ROM. Both interventions share
the similar intended clinical outcome of to increasing ankle dorsiflexion. While joint
mobilization primarily targets the static structures of the articulating surfaces and surrounding
joint, the implication on surrounding muscular tissue is unknown. MET, in contrast, targets the
musculature by using a voluntary contraction by the patient against a directly executed
counterforce applied by the operator.18
Specific to the ankle, there has only been one study to examine the effects of joint
mobilization and MET on pain, ankle dorsiflexion and plantarflexion, proprioception, and
functional measures.17 They found that both techniques were effective in all measures over a
three-week period. In this study a grade V joint mobilization was used, but lower grade
mobilizations are more clinically relevant. Grades I - IV can be performed by a variety of
clinicians. Therefore, the purpose of this study was to determine the impact of a four week MET
or grade IV posterior joint mobilizations to the talocrural joint intervention on dorsiflexion ROM
compared to a control group among asymptomatic individuals.
2
CHAPTER II
REVIEW OF RELATED LITERATURE
Introduction
Ankle sprains are the most common injury in sports.2 A common sequela of this injury is
a loss of ROM at the talocrural joint. Normal gait requires a minimum of 10° ankle dorsiflexion
during the stance phase.19 It has also been reported that 20° to 30° of dorsiflexion is needed for
functional and athletic activities.19 Rehabilitation of ankle sprains often targets the decrease in
dorsiflexion in a variety of ways. One method is joint mobilization, which aims to increase the
accessory gliding motion of one articular surface in relation to the subsequent articular
surface.20 Another approach is MET. This maneuver uses low force muscle contractions to draw
the joint into proper position enabling full motion and function to occur.18 Therefore, the
purpose of this literature review is to explain the anatomy of the ankle, the pathology and
sequelae of lateral ankle sprains, and the current research on joint mobilization and MET as
clinical interventions.
Ankle Anatomy
The ankle is a complicated joint comprised of four bones: the fibula, tibia, talus, and
calcaneus. The shapes of the bony infrastructure allow for specific and intricate movements at
each articulation: the subtalar, talocrural, and distal tibiofibular joints. These joints work in
3
combination to allow dorsiflexion, plantarflexion, inversion, eversion, and internal and external
rotation of the ankle.21 These motions work in conjuction to cause the gross movement seen in
the ankle: pronation and supination. Pronation is caused by eversion, external rotation, and
dorsiflexion. Supination is caused by inversion, internal rotation, and plantarflexion.22 Despite
the large amount of potential movement, the talocrural joint is a stable joint. This stability is
due to good bony congruency, ligamentous and joint capsule support, and the surrounding
musculotendinous structure.
Bone
The talocrural joint is comprised of the talar dome, medial malleolus, tibial plafond, and
lateral malleolus.21 The medial and lateral malleoli run inferiorly on each side of the talar dome
to create the ankle mortise. They work in combination and act as a unified concave structure in
which the talus sits. The talus sits snugly in the ankle mortise due to its wedge-shape. It
decreases in width anterior to posterior, increasing the bony stability.23 In this case, the talus is
considered to be a convex shape, in relation to the mortise.20
Static Restraints
Ligamentous structures also provide support to the talocrural joint. The three main
lateral ligaments are the anterior talofibular ligament, posterior talofibular ligament, and
calcaneofibular ligament. The anterior talofibular ligament attaches the lateral malleolus to the
talus at a 45° angle to the frontal plane, preventing anterior translation of the talus and
excessive inversion and internal rotation of the talus on the tibia. The calcaneofibular ligament
attaches on the lateral malleolus and runs posteriorly and inferiorly to the lateral aspect of the
calcaneus preventing excessive inversion and internal rotation of the talocrural joint. Although
the main attachments of this ligament are on bones surrounding the talus, some fibers may
4
attach directly to the talus, increasing the ligamentous stability. The posterior talofibular
ligament runs posteriorly from the lateral malleolus to the posterolateral talus and fibula
preventing inversion and internal rotation of the talus.21
Anterior displacement of the talus when manually stressed has been found to be about
6 mm in healthy cadavers. After division of the anterior talofibular ligament, these authors
found up to 14 mm of anterior displacement of the talus. These findings were consistent
whether they divided the anterior talofibular ligament alone, or in conjunction with the
calcaneofibular ligament. The additional division of the anterior capsule was found to increase
anterior translation further.24
Joint stability is enhanced in the closed-pack position, which is defined as the maximal
contact between joint surfaces where the joint capsule and ligaments are maximally tensed
reducing articular surface gliding.20 In this case, maximal dorsiflexion of the ankle is considered
to be the closed-pack position.
The mechanoreceptors in the joint capsule, as well as the lateral ligaments allow for
proper neuromuscular control and proprioception by sending sensory information about joint
positioning and movement to the central nervous system. This is especially important in the
anterior-posterior direction due to the importance of soft tissue stability in those directions.25
Dynamic Stability
An important factor in the increased severity of lateral ankle sprains is the amount of
plantarflexion the ankle is in during the mechanism of injury. Therefore the muscles that
doriflex the ankle are an important part of dynamic stability. These include tibialis anterior,
extensor digitorum longus, extensor digitorum brevis, and peroneus tertius.21 The tibialis
anterior originates on the lateral condyle of the tibia and inserts on the plantar surface of the
5
base of the 1st metatarsal and medial cuneiform.26 In conjunction with ankle dorsiflexion, it also
inverts the foot. Extensor digitorum longus also originates on the lateral condyle of the tibia,
but inserts on the phalanges of the lateral four toes. It assists ankle dorsiflexion as well as
extends the lateral four toes at the metatarsal-phalange joint. Peroneus tertius originates on
the anterior distal fibula and inserts on the base of the 5th metatarsal.26 This muscle assists
dorsiflexion and everts the foot.
Ankle dorsiflexion ROM can be impaired by the inflexibility of the plantarflexors, which
are primarily the gastrocnemius and soleus. The gastrocnemius originates on the medial and
lateral epicondyles of the femur and inserts on the calcaneus via the Achilles tendon. The soleus
shares the Achilles tendon insertion, but originates distal to the knee on the soleal line of the
tibia and the posterior head and shaft of the fibula. Plantaris, peroneus longus, peroneus brevis,
tibialis posterior, flexor hallicus longus, and flexor digitorum longus also assist in ankle
plantarflexion.26
Dynamic stability of the talocrural joint against lateral ankle sprains depends on the eccentric
contraction of the evertors of the foot, which include the peroneus longus, peroneus brevis, and
peroneus tertius. The peroneus longus originates on the head and lateral shaft of the fibula and
inserts on plantar surface of the base of the first metatarsal and the first cuneiform. Peroneus
brevis originates lower on the shaft of the fibula and inserts on the base of the 5th metatarsal.26
The prompt eccentric contraction of these muscles is necessary to reduce the amount of
inversion stress on the lateral ankle ligaments.21
Functional Activity
Full ROM in any joint requires both proper arthrokinematics as well as appropriate soft
tissue length. During ankle dorsiflexion, the talocrural joint moves in a combination of
6
directions. To acquire the normal ROM of 30° physiological dorsiflexion in a loaded ankle, 23° of
motion occurs in the dorsiflexion direction, 9° in external rotation, and 2° in eversion.21 During
dorsiflexion, the axis of the talocrural joint is not fixed horizontally, but tilted inferiorly and
laterally. The talus glides posteromedially on the tibia while the fibula moves superiorly and
laterally on the tibia. This movement is caused by the talus’ increasing width from posterior to
anterior.27 The amount of fibular movement is correlated to the steepness of the inclincation of
the axis of the talus due to the talar alignment in the mortise. While the medial side of the talus
maintains its plane throughout the ROM, the lateral side externally rotates in order to maintain
the axis of rotation. The fibula must rotate laterally to make ample space for the talus.23, 10
Incidence of Ankle Sprains
Lateral ankle sprains are one of the most common injuries seen in emergency
departments. In sports, ankles are the most common joint injured.2 Eighty-five percent of all
ankle injuries are ankle sprains.3,4 Kannus and Renstrom1 report that about 23,000 ankle sprains
occur in the United States each day. Hootman and colleagues6 estimated that over 11,000 ankle
sprains occur every year in collegiate athletics, corresponding to about 15% of all athletic
injuries.6 It has been shown that almost half of injured athletes miss at least one week of
activity7 with a recurrence rate as high as 80%.8 Garrick3 reported that more than 80% of all
ankle sprains involve the lateral ligament complex.
Pathoanatomy and Sequelae of Lateral Ankle Sprains
Injury to the lateral ankle ligament complex is commonly caused by excessive inversion
with internal rotation.21 The lateral malleolus extends farther inferiorly than the medial
malleolus allowing for a tendency toward inversion due to the decreased bony stability on the
7
medial side.3,28 More extensive damage may be caused when the ankle is also in a plantarflexed
position.21 Ankle supination (inversion with internal rotation) with plantarflexion is the most
unstable position for the ankle29 because it lacks bony, ligamentous, and capsular stability
during gait.30 Since the talus glides anteriorly during plantarflexion,31 this position causes the
most strain on the lateral ligament complex.21 Wright et al.32 found that the more plantarflexion
at contact, the greater incidence of increased supination. They also found that the greater the
degree of plantarflexion, the greater the severity of sprains.32
Ligament injuries, including ankle sprains are graded from I to III. A grade I sprain
stretches the lateral ligaments without tearing. It involves little swelling and minimal functional
loss and instability. A grade II sprain is a partial macroscopic tear with swelling, pain, and point
tenderness over the lateral ligaments. A grade III ankle sprain is a complete ligament rupture of
the lateral complex. It is indicated by severe swelling, tenderness, loss of function, and
instability.33 The anterior talofibular ligament is the first ligament in the complex to be damaged
with the inversion in plantarflexion mechanism, followed by the calcaneofibular ligament. Injury
to the posterior talofibular ligament is generally found in severe ankle sprains, fractures or
dislocations of the ankle, or an ankle injury from a different mechanism of injury.21
In the acute phase, the injured athlete often experiences swelling,34 instability,8 pain,34
balance deficits,35 and a decrease of ROM after injury.8 The loss of motion after injury,
specifically, a loss of ankle dorsiflexion36,37 has been attributed to a number of factors. The two
main causes of this decreased dorsiflexion are arthrokinematic changes and a tight
gastrocnemius-soleus complex.
Anterior Displacement of the Talus
8
Reduced dorsiflexion ROM has also been linked to increased incidence of ankle
sprains.32 This can be due to altered arthrokinematics of the ankle joint or muscle imbalances.
Both a fibular positional fault and talar malposition have been implicated in altering
arthrokinematics. The distal fibula may become positioned more anteriorly and inferiorly in a
laterally sprained ankle. Kavanagh38 found that there was more fibular movement per unit of
force in acutely sprained ankles. The author concluded that the results proved a positional fault
of the fibula. Another possible explanation, however, is the recent injury to the anterior
talofibular ligament, which allows for more joint play, instead of a positional fault.38 However,
Hubbard et al.31,39 did not find a difference in fibular position in subjects with chronic ankle
instability thereby adding to the confusion surrounding this topic.
A hypomobile or anteriorly positioned talus due to restricted posterior glide also has
been implicated as the cause of decreased ankle dorsiflexion ROM. Hubbard and Hertel10
reported that injury to the lateral ligaments caused increased glide of the talus in the neutral
zone, or the area of movement without ligamentous restriction. If this motion occurs, the axis
of rotation would move anteriorly increasing dysfunction. This deviant axis of rotation puts
unusual stress on the surrounding tissue changing sensory input to the central nervous system
and an ensuing abnormal motor response.10 Freeman et al,40 proposed that functional
instability, including a decrease in dorsiflexion ROM, may be caused by a decrease in the
sensitivity of mechanoreceptors after injury, leading to this proprioceptive alteration. In
contrast, Hertel et al.35 proposed that posterior swelling due to injury pushes the talus
anteriorly, causing altered arthrokinematics that lead to decreased postural control.
The research pertaining to talar movement in subjects with a history of ankle sprains has
been conflicting. Hubbard et al.31,39 found no decrease in posterior talar glide in patients with
9
chronic ankle instability, although they did not investigate ROM differences. Denegar et al.41
found that there was a decrease in posterior talar glide in subjects within six months of a lateral
ankle sprains. They also found that there was no difference in dorsiflexion when comparing the
injured ankle with the contralateral uninjured ankle. The difference in these two studies may
show that such a positional fault may only be clinically seen in acute injury. Wikstrom and
Hubbard42 took radiographic images to compare talar position in an uninjured control group to
subjects with chronic ankle instability. They found that the talus sat an average of 1 mm more
anterior in the involved side of the unstable patients when compared to the contralateral ankle
as well as the case-control subjects.
Muscular Tightness
Muscular tightness of the gastrocnemius-soleus complex has also been shown to occur
in patients with functional ankle instability.8 This prohibits full ankle dorsiflexion ROM during
gait, altering kinematics in the entire lower extremity. Not only is the ankle more plantarflexed
through the entire gait cycle,8 but the hip and knee compensate with more flexion, especially in
midstance.11 Delahunt et al.43 studied three-dimensional gait patterns in people with functional
chronic instability versus control. They found a decrease in vertical floor clearance in subjects
with functional ankle instability. While this finding was not directly attributed to a cause,
impaired dorsiflexion ROM could cause this decrease. Tabrizi et al.44 noted that children treated
for an acute ankle sprain had a significantly tighter triceps surae than an uninjured control
group. In a review by de Noronha et al.,45 decreased flexibility of ankle plantarflexors was
shown to be a strong predictor of ankle sprains. Furthermore, Pope et al.9 found that average
flexibility of the calf musculature increased the risk of injury by 2.5 times and up to 8 times with
poor flexibility.
10
Regardless of cause, the reduction of dorsiflexion ROM has unfavorable implications. It
has been shown that a decrease in dorsiflexion ROM, whether due to muscular tightness or
altered arthrokinematics, may increase the risk for lateral ankle sprain due to being in an openpack position, which decreases static stability. Denegar et al.,41 however, found normal
dorsiflexion ROM in conjunction with an anteriorly translated talus. These findings may indicate
an increased flexibility of the posterior musculature to compensate for the displaced talus. In a
plantarflexed ankle, the talus inverts and internally rotates at heel strike.21,27 Hertel et al.35
explained that a more plantarflexed ankle would cause the center of gravity to be more
posterior than in a normal ankle. Since it is farther from the closed-pack position and more
unstable, the person would have increased postural deviations. This may be caused by a
reduction in dorsiflexion ROM, resulting in a more plantarflexed ankle during the swing phase of
gait.
Lateral ankle sprains are often debilitating and may have lengthy symptoms. With the
consistent stress of weight-bearing activities, it is unknown the time precisely needed for the
lateral ligament complex to fully heal. In a review by Hubbard et al.46 improvements were found
in ligament stability ranging from six weeks to three months. The seven articles reviewed
included patients with recurrent and acute ankle sprains with or without fracture in the general
population. They further reported that 30% of subjects still complained of instability for up to a
year. Braun34 found an alarming rate of residual symptoms in a follow up survey of the general
population 6-18 months after injury. Forty percent of subjects reported ankle instability and an
inability to walk a mile without antalgic gait.
Clinical Treatment to Increase Dorsiflexion to prevent and rehabilitate lateral ankle sprains
11
Many clinical techniques are available to increase dorsiflexion ROM, including passive
stretching,12 acupuncture,13 high velocity manipulation,14 muscle energy technique,47–49 and joint
mobilization of the tibiofibular50 and talocrural joints.15,16 Despite static stretching being one of
the most commonly used techniques, research has shown that the results may be clinically
insignificant.12 When used in the treatment of lateral ankle sprains, the increases in ROM may
be simply due to a reduction in edema within the acute stage.51 Early mobilization is considered
standard of care in ankle sprains.1,52 In a study by Eiff et al.52, mobilization was correlated with
quicker return to play, as well as less pain at three weeks. They did not find a difference in any
outcome measure at the one-year follow up.
Joint Mobilization
Joint mobilization is defined as “passive movements performed in such a way that at all
times they are within control of the patient so that he can prevent the movement if he so
chooses.” 53 A widely-used system created by Maitland categorizes joint mobilization into five
grades. Grade I is a small amplitude passive movement at the beginning of ROM. A Grade II
mobilization is a large amplitude movement in the mid-range of motion. A Grade III
mobilization is a large amplitude oscillation up to the first barrier at the end-range. A Grade IV
mobilization is a small amplitude oscillation at the end-range of motion.53 A grade V
mobilization is also known as a manipulation. This technique involves a small-amplitude thrust
at the end-range of motion.
The earlier grades (I and II) of joint mobilization assist in decreasing pain and relaxing
the surrounding structures.54 The later grades (III – V) of joint mobilization intend to increase
accessory motion54 by decreasing adhesions and contractures, increasing extensibility in the
targeted ligaments and capsules, and restoring normal joint position.20 In regards to the load12
deformation curve, grades III and IV target the linear region allowing for the tissue to incur no
permanent changes, yet stretch the intended viscoelastic structures.55,56 In doing so, the
clinician is stimulating mechanoreceptors in these tissues allowing for greater proprioceptive
properties.20 By stretching the tissue and activating the afferent transmission of sensory
information, the CNS is able to increase joint position sense and postural control.25
Maitland’s joint mobilization techniques have also been shown to be beneficial in
rehabilitation of lateral ankle sprains.25,54–56 The talus is mobilized posteriorly in order to
increase the glide during dorsiflexion. This direction is utilized due to the “Kaltenborn ConvexConcave Rule.” Since the talus is considered to be convex, it is mobilized in the direction
opposite to the movement.20 More specifically, dorsiflexion is considered to be motion in an
anterior direction in anatomical position, therefore, the talus is mobilized in the posterior
direction to increase ankle dorsiflexion. Despite the fact that both Grade III and Grade IV
mobilizations are used to increase ROM, most studies have used only grade III joint
mobilizations. Both Hoch and McKeon25 and Landrum et al.54 used a crossover method to
determine that a Grade III mobilization increased dorsiflexion25,54 and static postural control.25
Both studies applied the mobilization and control in a random order to all subjects. Green et
al.16 determined that a grade IV joint mobilization improved outcomes in patients with an acute
(<72 hours) ankle sprain when compared to rest, ice, compression, and elevation (RICE) alone.
After three treatment sessions, these researchers found that stride speed increased and ankle
dorsiflexion ROM returned to normal earlier than those treated simply with RICE. However,
similar to other studies16,25,56–59, this study measured only the acute effects of the treatment,
with no long-term follow up.
13
Grade V mobilizations, or manipulations, have also been shown to be beneficial in the
rehabilitation of ankle injuries.30,60,61 In a case series presented by Dananberg et al.,60 mortise
traction and posterior talar adjustment in conjunction with an anterior fibular head
manipulation was shown to be effective in returning from disability after a lateral ankle sprain.
Pellow and Brantingham30 validated these results in a randomized control trial. Furthermore,
they found that this manipulation decreased pain and increased ankle function.30 Despite these
results advocating for manipulation in the treatment of ankle sprains, Fryer et al.14 found that
manipulation to the talocrural joint does not increase ROM. The participants in this study,
however, were asymptomatic individuals.
Yang et al.59 combined multiple mobilizations in a single study to determine if one grade was
superiorly effective. In this crossover study, Grade II, Grade IV, and a mobilization-withmovement were compared. They determined that both the mobilization-with-movement and a
Grade IV mobilization were useful to increase shoulder ROM in subjects with frozen shoulder
syndrome. Based on these findings and the lack of supporting evidence for Grade IV
mobilizations to increase dorsiflexion, this study will use Grade IV in order to further validate or
refute the effectiveness of this level of mobilization.
Muscle Energy Technique
Greenman47 defines MET as “manual medicine treatment procedure which involves
voluntary contraction by the patient against a directly executed counterforce applied by the
operator.” The goals of METs are to mobilize restricted joints, increase extensibility of fascia
and muscles, strengthen weak musculature, and improve local circulation.62 MET uses inherent
properties in the muscle to aid in these goals. The golgi tendon organs are stimulated during the
“counterforce” making the muscle relax immediately after contraction.18 This refractory
14
inhibition allows for further stretch of the muscle. It also employs the muscle spindles, resulting
in contraction of the target muscle and inhibition of the antagonist muscle, which is known as
reciprocal inhibition.18 The technique also uses inspiration and ocular movements to increase
the stretch during relaxation.18 During relaxation, the patient is to exhale and look towards the
direction of movement to further promote the intended result.18
There are many different methods of MET employed in clinical and research settings.
Clinicians employ various different types of contractions, including isometric contractions and
isotonic contractions, both eccentric and concentric. The strength of the contraction also
differs. Research has shown that 40% of the particpant’s maximum effort63 and 75% of the
participant’s maximal effort49 are effective in increasing ROM. The number of repetitions also
varies across the literature. Schenk et al47,48 used 4 repetitions of the intervention on a study on
the lumbar spine47 while they used 3 repetitions in a study on the cervical spine.48
Most research on MET has been completed on the spine.47,48,64–68 In an unblinded
randomized control trial, Schenk et al.47 treated asymptomatic participants with seven MET
treatments over 4 weeks. In this experiment, the neck was brought to the ROM limitation in all
planes for each participant. The clinician then resisted only rotation, in accordance with the
usual parameters of MET. In follow up testing, these authors found that the group treated with
MET had an increase in only cervical rotation, despite bringing the patient to the end-range of
flexion-extension, lateral flexion, and rotation. Fryer and Ruszkowski65 found similar results
when comparing the length of contraction to increased rotation at the atlanto-axial joint.
Lenehan et al.66 built of previous research by using a larger sample size and blinding the tester in
their study of the effects of MET on trunk rotation ROM. They found that after a single bout of
MET, the experimental group increased gross thoracic ROM, specifically to the restricted side in
15
asymptomatic subjects. Another study by Schenk et al.48 found that MET increased ROM in the
lumbar spine, specifically extension in an asymptomatic sample with less than 25° of extension.
Some researchers have shown the efficacy of MET to increase muscle flexibility,
particularly in the hamstrings.49,69,70 In a randomized control trial, Waseem et al.49 treated
healthy subjects for five consecutive days with MET. Upon follow-up on the eighth day, they
found that hamstring flexibility increased significantly as compared to a control group that
received no intervention. Smith and Fryer70 compared two METs that differed in stretch time
after relaxation. They found that there was no difference between the two treatments, but
both increased flexibility when compared to baseline. While MET has been shown to be
effective, Shadmehr et al.69 found no difference in hamstring flexibility after treatment with MET
compared to passive stretching. In the only other published study of MET in the extremities,
Moore et al.71 reported that a single application of MET for the glenohumeral joint horizontal
abductors increased ROM of the posterior shoulder among asymptomatic baseball players.
Two studies have researched subjective patient outcomes after the use of MET. Wilson
et al.68 compared MET in addition to neuromuscular reeducation and strength training to a
group undergoing neuromuscular reeducation and strength training. They found that spinal
MET decreases Oswestry Disability Index scores in patients with low back pain. Selkow et al.67
used a double-blinded randomized control trial to compare a single bout of MET to a sham
condition. The MET included four 5-second hold/relax periods of the iliopsoas and hamstrings.
They found a decrease in pain over 24 hours in the MET group, with no change in the sham
group.
In a thesis undertaken by Joseph and de Busser,17 MET was compared to a Grade V
mobilization, or manipulation, in patients with chronic ankle instability. Two groups of 20
16
subjects both underwent six treatments over a three-week period. Outcome measures included
both subjective and objective measures. Subjective measures included numerical pain rating
scale, McGill Pain Questionnaire, and Functional Evaluation Scale. Objective measurements
included plantarflexion and dorsiflexion ROM and the modified Rhomberg’s test for
proprioception. Both techniques were shown to be effective in all measures. While MET caused
a faster decrease in the numeric pain scale when compared to manipulation, no other outcome
measures differed over the course of the study. The researchers concluded that both therapies
are effective in the treatment of chronic ankle sprains.
Both joint mobilization and MET are common practices in the rehabilitation of
orthopedic-related injuries. The two interventions have only been compared once in the ankle
by Joseph and de Busser17 despite suggestions that both increase ROM. While this study used a
Grade V joint mobilization, a more clinically-universal, but less studied lower grade mobilization
will be used in this study. The lasting effects of both therapies were not addressed and are
unknown, requiring further research. Therefore, the purpose of this study is to determine the
effectiveness of multiple treatments of MET or Grade IV posterior joint mobilization of the talus
on ankle dorsiflexion and muscle stiffness.
17
CHAPTER III
METHODOLOGY
Participants
Forty-two high school male football players voluntarily participated in this study (Table
1). A participant’s limb was excluded if it met criteria including history of lower extremity
surgery or an injury during the course of a study. Based on these criteria a total of 80 ankles
were used for data analysis with 40 ankles in the control group, 22 ankles in the MET group, and
18 ankles in the joint mobilization group.
Table 1. Participant Characteristics (means ± standard deviations)
Group
Muscle Energy Technique (n
= 22)
Joint Mobilization
(n = 18)
Control (n = 40)
Age (yrs)
16.5 ± 1.0
Height (cm)
183.6 ± 6.9
Mass (kg)
87.6 ± 19.7
16.3 ± 1.4
176.0 ± 6.3
77.9 ± 13.6
16.5 ± 1.2
180.1 ± 7.5
82.4± 17.3
Instrumentation
Ankle dorsiflexion ROM was measured in both non-weight-bearing and weight-bearing
positions. Non- weight-bearing motion was measured with a standard goniometer. For
weight-bearing measurements, we used a digital inclinometer (SPI-Tronic, Garden Grove, CA).
This device provides a real-time digital reading of all angles in a 360º circle with respect to either
a horizontal or vertical reference and is accurate up to 0.1º as reported by the manufacturer.
The digital inclinometer was modified with a reference line positioned along the midline of the
device, which was used for proper alignment of anatomical landmarks.
18
Procedures
Informed assent and consent were obtained by all participants and their guardians prior
to any testing as approved by the university institutional review board. All testing was
conducted in a high school athletic training room. After admission into the study, one randomlyassigned ankle of each participant was randomly assigned to receive either joint mobilization or
MET treatments, while the contralateral ankle served as a control. Each participant participated
in a pre-test and post-test data collection sessions. Bilateral ankle dorsiflexion ROM with the
knee flexed and extended in both weight bearing and non-weight bearing positions were
recorded in a counterbalanced order. All dorsiflexion ROM measurements were conducted in a
subtalar neutral position with a total of 3 measurements recorded for each position and the
average of the 3 measurements being used for data analysis. To put the ankle in subtalar
neutral, the investigator grasped the calcaneous and moved the ankle into eversion and
inversion, while palpating the talar dome with the other hand. The investigator who performed
the ROM measurements was blinded to the group of each ankle. An additional investigator,
unblinded to the intervention groups, positioned the goniometer and read the measurements.
Investigators were the same for all measurements throughout the course of the study. The
interventions were completed twice per week for a total of four weeks by the same investigator.
Activity and injury questionnaires were filled out weekly by the participant to monitor any
changes, which may have affected ROM. Post-test occurred about 72 hours after final
treatment which included all ROM measurements consistent with pre-test measurement
protocol. The control limbs did not receive any intervention between testing sessions.
19
Dorsiflexion Range of Motion Measurement
For the non-weightbearing measurement in knee extension, each participant was
positioned supine with the ankle off the edge of a standard treatment table (Figure 1). For both
non-weight-bearing measurements, the axis of rotation of the goniometer was placed inferior to
the lateral malleolus. The stationary arm was placed parallel to the long axis of the fibula
pointing toward the fibular head. The movable arm was placed parallel to the sole of the heel
with the starting position equaling 90°, which was recorded as 0° of dorsiflexion. The
investigator then passively moved the ankle to the first point of resistance in dorsiflexion (Figure
1). At this position the angle created by the goniometer was recorded. The same procedures
were used to measure non-weight bearing dorsiflexion ROM with the knee flexed, but each
participant was seated on the table with the test knee flexed to 90° (Figure 2). The use of a
standard goniometer to measure ankle dorsiflexion has been shown to have good intra-tester
reliability among asymptomatic individuals (intraclass correlation coefficient = .74-.99)72
For the weight-bearing with the knee extended measurements, the participant was
asked to lunge forward with the non-test limb forward. The test side knee remained in terminal
extension and the ankle was adjusted to subtalar neutral. The participant was instructed to lean
forward until the back heel started to lift off the table. The digital inclinometer was then placed
just proximal to the lateral malleolus in alignment with the fibula to determine the angle
between lower limb and a horizontal reference as determined by the inclinometer (Figure 3).
For the weight-bearing measurement with the knee flexed, the participant was asked to
perform a forward lunge by flexing both the hip and knee joints (Figure 4). The amount of
dorsiflexion ROM was measured using the same digital inclinometer placement at the point
directly before the participant’s heel began to rise or he could not lower any further. These
20
measurements were consistent with those by Denegar et al.41 Intra-tester reliability for this
device has been shown to be reliable (intraclass correlation coefficient = .077).73
Figure 1: Dorsiflexion ROM in non-weight-bearing with knee extended measurement.
Figure 2: Dorsiflexion ROM in non-weight-bearing with knee flexed measurement.
21
Figure 3: Dorsiflexion ROM in weight-bearing with knee extended measurement.
Figure 4: Dorsiflexion ROM in weight-bearing with knee flexed measurement.
22
Joint Mobilization Technique
Joint mobilization was applied while the participant was supine with the intervention
ankle over the edge of a standard treatment table. The investigator found subtalar neutral, and
then passively brought the participant’s ankle to the first point of resistance by grasping the
metatarsals and bringing the foot anteriorly until the first point of resistnace was felt. This
position was maintained with the investigator’s torso while the tibia and fibula were stabilized
against the table with the investigator’s one hand. A posterior force was then applied to the
talus using the thumb and webspace of the other hand. The magnitude of force was consistent
with a grade IV mobilization as defined by Maitland.53,74 This grade involves oscillations
performed just beyond the first point of resistance in an effort to mobilize the soft tissue.
Oscillations were performed at a rate of approximately one oscillation per second for one
minute. This process was completed a total of 3 times with 10 seconds of rest between each
set.
Figure 5: Joint Mobilization Technique
23
Muscle Energy Technique
The participant was supine with the intervention ankle over the edge of the treatment
table with the knee in an extended position. The investigator first found subtalar neutral. Once
the talus was in the neutral position, the investigator stabilized the tibia and fibula just proximal
to the malleoli with one hand and then passively moved the ankle into dorsiflexion to the first
point of resistance with the other hand and held in that position for 10 seconds. The participant
then plantarflexed through a full ROM against resistance provided by the investigator. The
investigator verbally described the contraction of each participatint to be approximately 25% of
the participant’s maximum effort. At the end of this isotonic contraction, the investigator again
passively moved the participant’s ankle into dorsiflexion until the first point of resistance and
held the position for 10 seconds. This cycle was completed 3 times with 10 seconds of rest
between each set.
Figure 6: Muscle Energy Technique: Subtalar neutral and passive dorsiflexion
24
Figure 7: Muscle Energy Technique: beginning of isotonic contraction
Data Analysis
Separate 1-way analyses of covariance (ANCOVAs) were performed for the dorsiflexion
ROM. Post-intervention dorsiflexion ROM was the dependent variable and pre-intervension
ROM was the covariate. Post-hoc tests were conducted for significant findings. Statistical
significance was set a priori at p < 0.05. All data were analyzed using Predictive Analytics
SoftWare (Version 18.0, International Business Machines Corp. Armonk, New York).
25
CHAPTER IV
RESULTS
Dorsiflexion Range of Motion
Descriptive statistics for pre-treatment and post-treatment ankle dorsiflexion ROM for
all three groups are reported in Tables 2 and 3. Non-weight-bearing dorsiflexion with knee
extension and knee flexion were not significantly different among the groups at post-treatment
(p = .535 in knee extension, p = .584 in knee flexion). Weight-bearing dorsiflexion ROM with
knee extension and knee flexion were not significantly different among groups at posttreatment (p = .445 in knee extension, p = .110 in knee flexion). .
26
Table 2
Descriptive Statistics for non-weight-bearing ankle dorsiflexion range of motion (degrees).*
Group (N=80)
Knee Extension
Control (n = 40)
Pre-treatment
Posttreatment
Difference
p value
p = .535
-1.16 ± 4.04
-3.11 ± 3.86
-1.95
Muscle Energy
Technique
( n = 22)
-1.62 ± 4.45
-3.35 ± 3.88
-1.73
Joint
Mobilization
(n = 18)
Knee Flexion
Control (n = 40)
-0.57 ± 3.26
-1.89 ± 2.91
-1.32
0.05 ± 4.28
-3.19 ± 4.79
-3.24
Muscle Energy
Technique
( n = 22)
-0.80 ± 5.96
-2.77 ± 6.56
-1.97
Joint
Mobilization
(n = 18)
-0.44 ± 3.24
-2.93 ± 5.10
-2.49
p = .584
* Values are Mean ± Standard Deviation in Degrees
27
Table 3
Descriptive Statistics for weight-bearing ankle dorsiflexion range of motion (degrees).*
Group (N=80)
Knee Extension
Control (n = 40)
Pre-treatment
Posttreatment
Difference
p value
p = .445
30.34 ± 6.54
28.93 ± 6.81
-1.41
Muscle Energy
Technique
( n = 22)
29.57 ± 5.89
30.37 ± 9.30
0.80
Joint
Mobilization
(n = 18)
Knee Flexion
Control (n = 40)
29.95 ± 6.42
28.39 ± 6.59
-1.56
30.46 ± 7.48
30.44 ± 7.28
-0.02
Muscle Energy
Technique
( n = 22)
28.72 ± 9.68
31.81 ± 9.38
3.09
Joint
Mobilization
(n = 18)
32.04 ± 7.23
29.48 ± 7.28
-2.56
p = .110
* Values are Mean ± Standard Deviation in Degrees
28
CHAPTER V
DISCUSSION AND CONCLUSION
Discussion
This study aimed to determine the effectiveness of two clinical interventions, joint
mobilization and MET, for increasing ankle dorsiflexion compared to a control limb. Our results
show that neither a grade IV posterior mobilization of the talus or MET increases dorsiflexion
ROM among asymptomatic individuals.
A variety of MET interventions have been used in the previous literature and may
account for the difference in findings. Schenk et al.47,48 used 5-second isometric contractions at
the first point of restriction in their studies. One study used 3 repetitions of the intervention48
while the other used 4 repetitions.47 Smith and Fryer63 compared two different methods of
MET. Both employed isometric contractions at 40% of the participant’s maximal effort held for
7-10 seconds, but after 2-3 seconds of stretch, one group maintained the stretched position for
30 seconds, whereas the other moved to a resting position. Furthermore, entering the first
group was treated with 4 repetitions, while the second group only performed 3 repetitions.
Waseem et al.49 also used a 5-second isometric contraction at 75% of the participant’s maximal
effort. This was repeated 3 times during a single treatment. As shown, there is not a universal
method for MET. These studies also had a variety of time periods between treatment and posttreatment testing. Schenk et al.47 tested their participants 24 hours post-treatment, whereas
29
Waseem et al.49 tested 72 hours after their last treatment. Regardless of the specific
method used, the number of repetitions performed, and the number of treatments which were
applied these studies show that MET was an effective treatment for improving ROM. However,
our results do not support these previous investigations and questions the usefulness of this
technique for improving dorsiflexion ROM among asymptomatic individuals. Our study also
used a different technique in comparison to previous research. The used of an isotonic
contraction, not an isometric one may have accounted for the disparity in results. Because the
participants in our study concentrically contracted their plantarflexors through their range of
motion, the contraction only lasted about 2 seconds. This may not have been long enough to
correctly use the physiological adaptations in muscle, including the golgi tendon organs, to the
most appropriate extent.
Another possible explanation for the difference in results is the length of the stretch. In
the study by Smith and Fryer, there was found to have no significant differences between a
group that sustained the stretch for 30 seconds as compared to a group that held the stretch for
2-3 seconds. Both interventions were shown to be effective. The length of stretch, however,
has been shown to impact results in studies comparing simply static stretches. Roberts and
Wilson75 found that a 15-second stretch was more effective in increasing active ROM of the
lower extremity than a 5-second stretch. They did not, however, find a difference between
groups in passive ROM. Therefore, the length of contraction may have had an effect on the
results of this study and should be addressed in future research.
Several studies have shown joint mobilization to be effective in improving ROM in the
extremities.56,76,77 In regards to joint mobilizations for the ankle, researchers have found an
acute increase in dorsiflexion ROM following a single treatment.16,25,56–58 Green et al.16 treated
30
participants within 72 hours of an ankle sprain with either a posterior talar mobilization
described similar to a Grade I mobilization and rest, ice, compression, and elevation (RICE) or
RICE only. Most of the participants (13/19) in the experimental group improved within the first
week of the study by reaching maximum dorsiflexion ROM and were discharged from the study.
Kluding and Zipp78 found an increase in passive ankle dorsiflexion at 2-weeks post-treatment in
patients with hemiplegia after a series of end-range anterior and posterior joint mobilizations on
the proximal and distal tibia-fibular joint and a posterior joint mobilization of the talus. The
results of our study do not support these previous findings for increasing ankle dorsiflexion.
This disparity in findings may be due to the current study’s use of an asymptomatic
population. Hoch and McKeon25 used two, 2 minute sets of grade III posterior joint mobilization
of the talus with 1 minute of rest between sets. Approximately 50 oscillations were performed
for each set. They found that a single treatment of joint mobilization increased weight-bearing
ankle dorsiflexion. They used patients with self-reported chronic ankle instability.
While our joint mobilization technique was consistent with Green et al., our results also
differed. Posterior talocrural joint mobilization aims to address the possibility of anterior
positional fault of the talus. Since our participants were taken from an asymptomatic
population, they may not have this anatomical change as compared to a symptomatic
population. However, future research needs to specifically address the influence of such joint
mobilizations among symptomatic participants who present with or without a talar positional
fault.
As with any investigation, there are limitations to this study. First, our participants were
off-season football players who were involved in a variety of activities that could have altered
ankle dorsiflexion. This makes it difficult to generalize to other useful populations, such as
31
females, adults, participants in other sports, or a symptomatic population. Further research
needs to see the effects of these interventions in different samples.
The lack of ROM changes may be due to the ceiling effect. Because our use of
asymptomatic participants, there may not have been a large enough deficit in dorsiflexion
identify changes in dorsiflexion ROM. Further research needs to address this limitation and use
participants with a deficit in ankle dorsiflexion ROM.
Another limitation to this study is the length of contraction and stretch during the MET.
The short contraction used in our study may have not allowed the physiological properties of
muscle to be used optimally. Also, the stretch after contraction was only 10 seconds. An
increased time in the stretched positions may have provided different results.
Conclusion
Our results suggest that neither MET nor Grave IV posterior joint mobilization of the
talus is effective to increase non-weight-bearing or weight-bearing ankle dorsiflexion ROM
amongst asymptomatic individuals. However, using MET and mobilization techniques on
individuals with chronic ankle instability or acute ankle injuries may produce different results
and should be addressed in future research.
32
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APPENDIX A
ACTIVITY AND INJURY QUESTIONNAIRE
Name:
Date:
Week: 1 2 3 4
Physical Activity
1. Since the last time you participated in this study, have you performed any lower
body exercises or activities? If so, when and which ones?
2. Since the last time you participated in this study, have you experienced any injuries
to your lower body that may affect the results of this study? If so, what injury?
3. Since the last time you participated in this study, have you significantly altered your
physical activity level? If so, how?
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