Joint Mobilization Acutely Improves Landing Kinematics in Chronic Ankle Instability

Joint Mobilization Acutely Improves LandingKinematics in Chronic Ankle Instability

EAMONN DELAHUNT1,2, KIM CUSACK1, LAURA WILSON1, and CAILBHE DOHERTY1

1School of Public Health, Physiotherapy and Population Science, University College Dublin, Dublin, IRELAND;and 2Institute for Sport and Health, University College Dublin, Dublin, IRELAND

ABSTRACT

DELAHUNT, E., K. CUSACK, L. WILSON, and C. DOHERTY. Joint Mobilization Acutely Improves Landing Kinematics in Chronic

Ankle Instability. Med. Sci. Sports Exerc., Vol. 45, No. 3, pp. 514–519, 2013. Purpose: The objective of this study is to examine the

acute effect of ankle joint mobilizations akin to those performed in everyday clinical practice on sagittal plane ankle joint kinematics

during a single-leg drop landing in participants with chronic ankle instability (CAI).Methods: Fifteen participants with self-reported CAI

(defined as G24 on the Cumberland Ankle Instability Tool) performed three single-leg drop landings under two different conditions:

1) premobilization and, 2) immediately, postmobilization. The mobilizations performed included Mulligan talocrural joint dorsiflexion

mobilization with movement, Mulligan inferior tibiofibular joint mobilization, and Maitland anteroposterior talocrural joint mobiliza-

tion. Three CODA cx1 units (Charnwood Dynamics Ltd., Leicestershire, UK) were used to provide information on ankle joint sagit-

tal plane angular displacement. The dependent variable under investigation was the angle of ankle joint plantarflexion at the point of

initial contact during the drop landing. Results: There was a statistically significant acute decrease in the angle of ankle joint plantar-

flexion from premobilization (34.89- T 4.18-) to postmobilization (31.90- T 5.89-), t(14) = 2.62, P G 0.05 (two-tailed). The mean

decrease in the angle of ankle joint plantarflexion as a result of the ankle joint mobilization was 2.98- with a 95% confidence interval

ranging from 0.54 to 5.43. The eta squared statistic (0.32) indicated a large effect size. Conclusion: These results indicate that mobili-

zation acted to acutely reduce the angle of ankle joint plantarflexion at initial contact during a single-leg drop landing. Mobilization

applied to participants with CAI has a mechanical effect on the ankle joint, thus facilitating a more favorable positioning of the ankle joint

when landing from a jump. Key Words: ANKLE SPRAIN, JUMP LANDINGS, KINEMATICS, LOWER EXTREMITY, JOINT

MANIPULATION

Injury to the lateral ligament complex of the ankle jointin the form of ankle sprain is one of the most frequentlyincurred musculoskeletal injuries (14). It has previously

been estimated that approximately 23,000 and 5000 anklesprain injuries are incurred per day in the United States andthe United Kingdom, respectively (4,24). It is likely thatthese reported figures do not represent the true incidenceof ankle sprains, because the injury statistics are likely to beconfounded by the fact that many individuals who spraintheir ankle joint will not seek treatment from a health careprofessional (29).

Ankle sprain is often regarded as an innocuous injury.However, recent literature suggests that a large proportionof individuals who incur an ankle sprain will continue to

report residual symptoms, including pain, persistent swelling,feelings of ankle joint instability, and resprain (15,38,39,44).Chronic ankle instability (CAI) is the generic term used toclassify a set of residual symptoms that are persistent fora minimum of 1 yr postsprain (5). The well-accepted para-digm of Hertel (18) suggests that the development of CAIis dependent on the interaction of numerous mechanical andfunctional insufficiencies. Mechanical insufficiencies includepathological joint laxity, arthrokinematic restrictions, degen-erative changes, and synovial changes (18). Functional in-sufficiencies include impairments in neuromuscular control,proprioception, muscle strength, and postural stability (18).

Arthrokinematics refers to the movement of articular sur-faces during the physiological motion of that joint. Normalphysiological motion at the talocrural joint is primarily dor-siflexion and plantarflexion (27). Accessory joint movementsare an integral component of normal physiological joint mo-tion (10). Both the accessory joint movements occurring atthe inferior tibiofibular joint and the talocrural joint contri-bute to optimal arthrokinematics of the ankle joint complex(27). It has been hypothesized that alterations in accessoryjoint movements of the inferior tibiofibular and talocruraljoints may produce aberrant movement patterns of theinstantaneous axis of rotation of the ankle joint complexduring physiological motion (10), thus contributing to thedevelopment of CAI (10).

Address for correspondence: Eamonn Delahunt, Ph.D., School of Public Health,Physiotherapy and Population Science, University College Dublin, Health Sci-ences Center, Belfield, Dublin 4, Ireland; E-mail: [email protected] for publication April 2012.Accepted for publication September 2012.

0195-9131/13/4503-0514/0MEDICINE & SCIENCE IN SPORTS & EXERCISE�Copyright � 2013 by the American College of Sports Medicine

DOI: 10.1249/MSS.0b013e3182746d0a

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Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

A deficit in ankle joint dorsiflexion is a common findingpost–acute ankle sprain (16,43). It has also been reportedthat individuals with CAI exhibit a deficit in dorsiflexionduring jogging (12) and immediately after landing from ajump (9). Landing from a jump is a common athletic activitythat has been associated with a high risk of ankle sprain (1).Ideally, the joint of the lower extremity function in concertin the sagittal plane to attenuate landing forces, such thatgreater motion at one joint is typically accompanied bygreater motion at adjacent joints (13). It has been suggestedthat an error in ankle joint and foot positioning will increasethe potential for ankle joint injury (26,42). Both a muscle-driven computer simulation (42) and a cadaveric model (26)have shown that an increased plantarflexion angle at thepoint of initial contact (IC) with the ground increases therisk of ankle joint sprain. Thus, it is plausible that a deficit inankle joint dorsiflexion may be a contributory factor to thisspecific ankle joint injury mechanism. Therefore, increasingsagittal plane dorsiflexion may provide increased relianceon bony stability and decreased reliance on lateral liga-ments for stability, ultimately decreasing the risk of anklesprain (2,42).

It has been hypothesized that alterations in accessory jointmovements of the inferior tibiofibular and talocrural jointsmay produce aberrant movement patterns of the instanta-neous axis of rotation of the ankle joint complex duringphysiological motion, thus contributing to the developmentof CAI (10). During dorsiflexion, the talus glides in a pos-terior medial direction on the tibia (27). A potential con-tributing factor to this observed dorsiflexion deficit is ananterior positional fault of the talus (11). Denegar et al. (11)reported a reduction in posterior glide of the talus in partic-ipants 6 months postankle sprain. Further evidence to sup-port an anterior positional fault of the talus has been reportedby Wikstrom and Hubbard (41), who observed an ante-rior positional fault of the talus in the involved limb ofindividuals with CAI relative to their uninvolved limb andcompared with the matched limb of a noninjured controlgroup. Joint mobilization is a common treatment undertakenby clinicians when treating individuals with ankle sprains.Several studies have indicated that a particular joint mobi-lization originally advocated by Mulligan (36), called thedorsiflexion mobilization with movement (MWM), producesa mechanical effect at the talocrural joint as evidenced byan immediate increase in dorsiflexion range of move-ment (3,40).

Similar to a positional fault of the talus, Mulligan (36)proposed that an anterior positional fault may also occur atthe inferior tibiofibular joint. The presence of an anteriorpositional fault at the inferior tibiofibular joint has beenconfirmed by Hubbard and Hertel (22) in individuals withsubacute ankle sprains and by Hubbard et al. (23) in indi-viduals with CAI. A recently published study has providedpreliminary data regarding the prophylactic effects of fibu-lar repositioning tape in preventing ankle joint injury in malebasketball players (31). Specifically, it was hypothesized that

this ankle joint taping technique improves arthrokinematicefficiency at the inferior tibiofibular joint by preventing ex-cessive anterior excursion of the fibula relative to the tibia(31) and thus preventing excessive slackness of the ante-rior talofibular ligament (18). Consequently, it is possiblethat an anteroposterior glide of the inferior tibiofibularjoint may function in a similar manner (35).

One factor commonly reported to contribute to the anklesprain injury mechanism and particularly in the case of in-dividuals with CAI is an inappropriate positioning of thefoot (excessive plantarflexion and/or inversion) at IC withthe ground during gait, landing from a jump and other sport-ing activities (7–9,26,28,32,33,34,42). Thus, it is plausiblethat aberrant arthrokinematics in the form of an anteriorpositional fault of the talus and/or an anterior positional faultat the inferior tibiofibular joint could contribute to the anklesprain injury mechanism, particularly in individuals withCAI. A recent critically appraised article has suggested thatfurther research is required to investigate the effects of multi-component mobilization interventions on functional tasks inindividuals with CAI (21). To the author’s knowledge, nostudy that examines the effect of acute ankle joint mobili-zation on the angle of ankle joint plantarflexion during land-ing from a jump has been published.

The aim of the present study was to investigate theacute effect of a combination of ankle joint mobilizationsapplied at the talocrural and inferior tibiofibular joints (non–weight-bearing dorsiflexion MWM, anteroposterior glideof the inferior tibiofibular joint, and anteroposterior ac-cessory talar glide) on sagittal plane ankle joint kinematicsin participants with CAI during a functional landing task. Itwas hypothesized that the application of the aforementionedmobilizations would increase physiological dorsiflexion,producing a more favorable sagittal plane ankle joint posi-tion at IC in participants with CAI during a single-leg droplanding task.

METHODS

Participants. Fifteen adults with CAI (nine males, sixfemales, age = 21.66 T 1.23 yr, height = 1.71 T 0.10 m, bodymass = 68.15 T 13.78 kg) volunteered to participate. Thestudy protocol was approved by the university Human Re-search Ethics Committee, and all subjects signed a consentform before testing. Inclusion criteria consisted of a scoreof G24 on the Cumberland Ankle Instability Tool (19).The average Cumberland Ankle Instability Tool score was18.40 T 3.20.

Jump landing. Each participant was given a maximumof five practice drop landings on the test leg before testingbegan. During the test, the participants stood on a 0.40-m-high platform in front of a force plate. The test leg was ini-tially held in a non–weight-bearing position with the kneeflexed. Participants were required to step forward with thetest leg to land on the force plate in front of the platform in

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their own natural landing style/mechanism. Thus, participantswere allowed to adopt their own specific natural landing style.Upon landing, participants were required to balance as quicklyas possible on the test leg in the center of the force plateand hold this position for approximately 4–6 s. A similardrop landing protocol has been previously described in thestudy of Delahunt et al. (6). No participants reported feel-ings of pain or discomfort during the drop landing proce-dure. The test sequence was as follows: each participantperformed three single-leg drop landings on the test anklepremobilization and again postmobilization. After the pre-mobilization single-leg drop landings, each participant un-derwent a treatment of ankle joint mobilization (describedin the next section—Joint mobilization). On average, thistook 5 min to complete, with the participants then beingrequired to perform another three single-leg drop landings(postmobilization).

Joint mobilization. A combination of three mobilizationswas performed by the same investigator on each participant.The first mobilization consisted of a non–weight-bearing dor-siflexion MWM as described in Vicenzino et al. (40). A total of30 such glides were applied. The second mobilization appliedwas an anteroposterior glide of the inferior tibiofibular jointas described in Mulligan (35). A total of 30 of these glideswere performed on each participant. The third mobilizationperformed was an anteroposterior accessory talar glide as de-scribed inMaitland’s Peripheral Manipulation (17). A total of30 of these glides were performed. There was approximately7 min between the final premobilization drop landing and thefirst postmobilization drop landing. This is accounted for asfollows: Immediately after the final premobilization drop land-ing, subjects were placed on a treatment plinth and rested for1 min. The three specific mobilizations were then administered(taking approximately 5 min). The subjects then rested for1 min before commencing the set of three postmobilizationdrop landings.

Kinematics. Three CODA cx1 units were used to pro-vide information on ankle joint sagittal plane angular dis-placement. Infrared light-emitting diode markers wereattached to specific anatomical positions on the lower limbas outlined in the gait analysis setup of the CODA mpx30users manual (Charnwood Dynamics Ltd., Leicestershire,UK). Markers were positioned on the lateral malleolus, theheel, and the fifth metatarsal head. Wands with anterior andposterior markers were positioned on the shank. All markerswere attached to the skin using double-sided adhesive tape.Markers were attached unilaterally on CAI subjects. Markerpositions were sampled at a frequency of 200 Hz. An AMTI(Watertown, MA) force plate was used for the identificationof IC (sampled at 1000 Hz). Vertical ground reaction forcewas used to identify IC, and the threshold for determinationof IC was set at 10 N (30). The CODA cx1 units and forceplate were time synchronized and triggered by the one ofinvestigators. The angle of ankle joint sagittal plane (plantar-flexion/dorsiflexion) angular displacement was measured atIC with the ground.

Kinematic analysis. Kinematic data were calculated bycomparing the angular orientations of the coordinate sys-tems of adjacent limb segments using the angular couplingset ‘‘Euler angles’’ to represent clinical rotations in threedimensions. Marker positions within a Cartesian frame areprocessed into rotation angles using vector algebra and tri-gonometry (CODA mpx30 User Guide, Charnwood Dynam-ics Ltd.). Joint angular displacement was calculated for theankle joint sagittal plane only. A neutral stance trial was usedto align the participant with the laboratory coordinate sys-tem and to function as a reference position for subsequentkinematic analysis as recommended in previously publishedliterature (30,37). Kinematic data were analyzed using theCODA software. The angle of ankle joint plantarflexionat IC was extracted from each test trial for each partici-pant. The three trials for each participant were combined tocreate an average value for each participant, with condi-tion profiles then being calculated (i.e., premobilization vspostmobilization).

Data analysis. A paired-samples t-test was conductedto evaluate the impact of ankle joint mobilization on theangle of ankle joint sagittal plane angular displacement atIC during a single-leg drop landing. The independent vari-able was condition (i.e., premobilization vs postmobiliza-tion), with the dependent variable being ankle joint sagittalplane angular displacement at IC. All values are presented asmean T SD. All data were analyzed using Predictive Ana-lytics SoftWare (Version 18; SPSS Inc., Chicago, IL).

RESULTS

There was a statistically significant decrease in the an-gle of ankle joint plantarflexion at IC from premobiliza-tion (34.89- T 4.18-) to postmobilization (31.90- T 5.89-),t(14) = 2.62, P G 0.02 (two-tailed) (Fig. 1). The mean de-crease in the angle of ankle joint plantarflexion at IC asa result of the ankle joint mobilization was 2.98- with a95% confidence interval ranging from 0.54 to 5.43. Theeta squared statistic (0.32) indicated a large effect size. No

FIGURE 1—Angle of ankle joint plantarflexion at IC.

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progression in dorsiflexion because of the premobilizationdrop landings was observed.

DISCUSSION

The primary finding of the present study was that theapplication of a combination of ankle joint mobilizations(non–weight-bearing dorsiflexion MWM, anteroposteriorglide of the inferior tibiofibular joint, anteroposterior ac-cessory talar glide) resulted in an acute reduction in theangle of ankle joint plantarflexion at IC during a single-legdrop landing.

Several previous studies have investigated the effects ofjoint mobilization on clinical outcomes post–acute anklesprain and in the presence of CAI (3,16,20,40). Green et al.(16) reported that the addition of anteroposterior talar mo-bilizations to a traditional rest, ice, compression, and eleva-tion (RICE) protocol after acute ankle sprain required fewertreatments to achieve pain-free dorsiflexion and to improvestride speed compared with the group who received an iso-lated RICE protocol. Collins et al. (3) reported a significantimprovement in ankle joint dorsiflexion after the applica-tion of a Mulligan’s weight-bearing dorsiflexion MWM ina group of participants with subacute lateral ankle sprain.The authors also reported no immediate change in pressureor thermal pain threshold, thus concluding that the applica-tion of a dorsiflexion MWM may be attributable to a me-chanical rather than a hypoalgesic effect. Vicenzino et al. (40)reported a significant increase in posterior talar mobility andweight-bearing dorsiflexion in a group of participants withrecurrent ankle sprain after treatment applied in the form of adorsiflexion MWM. A similar finding was also reported byHoch and McKeon (21). The results of the aforementionedstudies support the idea that joint mobilization may induce apositive mechanical effect after ankle joint injury. However,a recent critically appraised topic has suggested that furtherresearch is necessary to investigate the effects of multi-component mobilization interventions on functional tasks inindividuals with CAI (21).

In the present study, we chose to investigate the acuteeffect of ankle joint mobilizations akin to those performed ineveryday clinical practice on the angle of ankle joint plan-tarflexion at IC, in participants with CAI during a functionallanding task. We chose drop landing as the particular func-tional task in the present study. The rationale for utilizingthis specific functional task was based on previous researchthat indicates that an inappropriate positioning of the footat IC with the ground during gait, landing from a jump andother sporting activities (7–9,26,32,33,34,42), is implicatedin the injury mechanism associated with lateral ankle jointsprain. Furthermore, it has been specifically indicated thatan increased angle of ankle joint plantarflexion at the pointof IC with the ground during landing from a jump increasesthe risk of ankle joint sprain (42).

The results of the present study indicated that the com-bined application of three specific commonly used clinical

mobilizations significantly reduced the angle of ankle jointplantarflexion at IC during the performance of a drop land-ing in participants with CAI. The mean decrease in the angleof ankle joint plantarflexion at IC as a result of the anklejoint mobilization was 2.989-. This was associated with alarge effect size (eta squared statistic = 0.329), although the95% confidence interval values ranged from 0.542 to 5.436,they did not cross zero. Consequently, we believe that theobserved results represent a true clinically meaningful effectand support previous research that has indicated that theapplication of ankle joint mobilizations in participants withCAI produces a true mechanical effect at the ankle joint.

Based on an understanding of the arthrokinematics ofthe ankle joint and the reported arthrokinematic disruptionsin subjects with CAI (40,41), we chose to use three specificankle joint mobilizations. These included a non–weight-bearing dorsiflexion MWM, an anteroposterior glide of theinferior tibiofibular joint, and an anteroposterior accessorytalar glide. The use of a combination of ankle joint mobi-lizations has been recently advocated by Hoch and McKeon(21). The non–weight-bearing dorsiflexion MWM and theanteroposterior accessory talar glide were applied with theaim of facilitating a reduction of any anterior positional faultat the talocrural joint. Specifically, it has been reported thatsubjects with CAI exhibit an anterior positional fault at thetalocrural joint (41). An anterior positional fault at the talo-crural joint manifests as an osteokinematic restriction, wherebysagittal plane ankle joint motion is reduced in dorsiflexion.Previous studies have reported that the application of dor-siflexion MWM and anteroposterior talar glide produces asignificant acute increase in dorsiflexion range of motion asmeasured by a weight-bearing lunge (40). The anteropos-terior glide of the inferior tibiofibular joint was used basedon the observation that participants with CAI have beenreported to exhibit an anterior positional fault at the inferiortibiofibular joint (22). Accessory motion at the inferiortibiofibular joint is required to allow normal sagittal planemovement at the talocrural joint, whereby dorsiflexion isaccompanied by superior and external glide of the distalfibula, thus facilitating widening of the ankle joint mortise.The specific mobilizations used in the present investigationaimed to enhance sagittal plane ankle joint kinematics. Pre-vious studies investigating the effects of talocrural andtibiofibular mobilizations have failed to investigate sagittalplane ankle joint kinematics during more demanding tasksreplicating sporting activities. Consequently, we used a single-leg drop landing as a functional task with the dependent vari-able being the angle of ankle joint plantarflexion at IC, becausean increased plantarflexion angle has been implicated in theinjury mechanism associated with acute ankle joint lateralligament complex sprain (42).

Arthrokinematic restrictions at both the talocrural joint andinferior tibiofibular joint have been reported in participantswith CAI (10,22,41). These arthrokinematic restrictionsmay contribute to some deficits observed in participantswith CAI during functional tasks such as jogging (12) and


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immediately after landing from a jump (9), thus increasingthe likelihood of incurring repeated injuries. Thus, it isnecessary for clinicians to maintain an awareness of thosespecific mechanical and functional insufficiencies that con-tribute to the development of CAI as outlined in the well-accepted paradigm of Hertel (18). To maintain the higheststandards of rehabilitation care, physiotherapists and athletictrainers must ensure that they have a correct understandingof those insufficiencies that contribute to the development ofCAI. Recent evidence regarding the mechanical and func-tional insufficiencies present in participants with CAI sug-gests that this may not be the case, with experiencedclinicians displaying a less than satisfactory understandingof those insufficiencies contributing to the development ofCAI (25). Based on the results of the present study, it is ourcontention that clinicians should incorporate an arthrokine-matic evaluation (posterior talar glide and mobility of theinferior tibiofibular joint) into their assessment and treatmentof participants with CAI.

This study was not without limitations. The primary lim-itation of the present study relates to the absence of a con-trol group. The addition of a control group would allow forthe determination of the presence or absence of a learningeffect. Thus, we recommend that future studies examiningthe acute effect of ankle joint mobilizations should include acontrol group, who would receive no intervention or a shamintervention. We did not use a direct quantification of talarmobility or position of the inferior tibiofibular joint. Thus, itis possible that a decrease in talar mobility and an anteriorpositional fault at the inferior tibiofibular joint was not pre-sent in all participants. Future studies investigating the ef-fects of ankle joint mobilization in subjects with CAI shouldaim to evaluate clinically or radiologically the position ofthe talus within the ankle joint mortise as well as the posi-tion of the distal fibula relative to the tibia before the use ofspecific ankle joint mobilizations. In addition, we chose toinvestigate ankle joint sagittal plane angular displacementonly, because the specific mobilizations used were directedspecifically toward improving ankle joint sagittal plane mo-tion. No mobilization was applied to the rear-foot or thesubtalar joint. Thus, future studies should endeavor to quan-tify the effect of mobilizations on rear-foot motion. Further-more, we only examined the acute effects of the appliedmobilizations. Although confining the quantification of an-kle joint kinematics to immediate postmobilization effectsis a limitation of the present study, we believe that the re-sults of the present study are an advance on previous studies

investigating the acute effects of ankle joint mobilization inparticipants with CAI. Specifically, previous studies havetypically quantified ankle joint sagittal plane range of mo-tion using weight-bearing lunges (40), which do not repli-cate higher velocity tasks such as landing from a jump, atask that represents significant risk for injury. Therefore, theresults of the present study provide more information rela-tive to the potential mechanism of action of ankle joint mo-bilization in participants with CAI. However, in the absenceof a repeated-measures follow-up design, it is difficult tounderscore the clinical effectiveness of joint mobilization asa therapeutic method. Thus, future research is warranted toexamine the potential carry-over of such acute treatment, aswell as a specific course of such treatment implemented forseveral weeks until discharge after acute ankle joint sprain.A recent study by Hoch et al. (20) has reported beneficialeffects of a 2-wk joint mobilization intervention in partic-ipants with CAI. In addition to this recommendation, futurestudies should also aim to quantify if the application of anklejoint mobilizations results in specific functional improve-ments such as improved static and dynamic postural stabilityand neuromuscular control as quantified by surface electro-myography, as well as participant subjective reports of con-fidence, stability, and reassurance when performing dynamictasks such as jump landing.

In conclusion, the results of the present study indicate thatthe application of a specific combination of joint mobili-zations produces an immediate significant decrease in theangle of ankle joint plantarflexion at IC during a drop land-ing in participants with CAI. We believe that the presentresults support the mechanical theory concept associated withjoint mobilizations. It is our contention that clinicians shouldmake every effort to thoroughly evaluate potential arthroki-nematic restrictions in participants with CAI, with joint mo-bilization likely to be a key component of an efficacioustreatment protocol for addressing insufficiencies associatedwith CAI. However, much more elaborate testing in theform of a methodologically rigorous randomized controlledtrial is required before definite conclusions regarding theclinical value of such mobilizations can be determined.

No conflicts of interest were associated with the authors and theresults of this research.

The results of the present study do not constitute endorsementby the American College of Sports Medicine.

No funding was received for the present study.

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Joint Mobilization Acutely Improves Landing Kinematics in Chronic Ankle Instability

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