Ankle Sprain: Is joint manipulation appropriate?

Manipulations improve mobility.
Ankle sprains need stability.
Is manipulation appropriate?

The talocrural joint is commonly hypomobile in many individuals with knee pain or low back problems. In addition to hypomobility, the ankle often lacks adequate dorsiflexion range of motion and plantar flexion strength. A simple intervention to improve the joint mobility is a talocrural joint manipulation (see video below). We know manipulation is safe and effective in certain situations. However, many students question if manipulating an acute ankle sprain is appropriate.

An 'ankle sprain,' which is often an injury to the Anterior Talofibular Ligament (ATFL), is one of the most commonly treated injuries in Orthopedic physical therapy clinics. Following an acute ankle sprain, patients often present with pain, swelling, decreased strength, decreased range of motion, poor neuromuscular control, and joint mobility deficits. From a purely biomechanical approach, manipulating a region that is hypermobilie is not indicated. However, improving the joint mobility is a necessary component of the treatment plan to restore function.  

Joint manipulations are high velocity, low amplitude techniques directed at the joint

When performing joint manipulation, there are only a few absolute contraindications. As with most aspects of physical therapy (and healthcare), the indication depends on a variety of factors. Regarding acute ankle sprains, the clinician must decide if the benefits of the technique outweigh the risks. If the individual has low to moderate irritability, minimal swelling, and decreased joint mobility, I choose to manipulate the talocrural joint following an ankle sprain. If the patient has excessive pain and guarding, I will use lower grade mobilizations to improve the joint motion. Personally, I am not too concerned with the grade (1-3) of ankle sprain (A grade 3 sprain will likely present with more pain and swelling. Therefore, the appropriate treatment is a lower grade mobilization.)  The manipulation is a high velocity, low amplitude technique focused on the joint. Additionally, the distraction technique demonstrated above is performed in a mid-range of motion, not an end-range stress similar to the mechanism of injury. Overall, joint manipulation is a safe and appropriate technique following an acute ankle sprain. 

*Disclaimer: Always use clinical judgement and evaluate each patient on a case-by-case basis. ​When performing any manual technique, the practitioner needs to assess the patient's irritability level and use the appropriate differential diagnosis to rule out other possible diagnosis.
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​-Jim Heafner PT, DPT, OCS

Absolute Contraindications
​to Manipulation
-Neoplasm
-Fracture
-Acute RA episode
-Empty end-feel
-No working hypothesis 
(...plus a few others)

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