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Picture

Ankle Sprain: Is joint manipulation appropriate?

10/2/2016

3 Comments

 

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.
​
​-Jim Heafner PT, DPT, OCS

Absolute Contraindications
​to Manipulation

-Neoplasm
-Fracture
-Acute RA episode
-Empty end-feel

-No working hypothesis 
(...plus a few others)

Picture
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3 Comments
Glenn
10/3/2016 10:05:01 pm

Agree with this post.

My mulligan course instructor once made the golf reference:

tee off bring out big bertha (manipulation) and follow up with chip/putt (MWM). *In appropriate patients of course.

Good trick question I ask other PT's: "name me a muscle that attaches to the talus." .. It makes sense that joint play may be more warranted with the TC than to others, and thus bringing more benefit along the chain.

Glenn

Reply
Natalie
10/9/2016 05:44:01 pm

Was curious about thoughts for using an ankle manip for chronic ankle issues where ROM is restricted

Reply
http://www.findauthoritypill.net link
10/10/2016 07:41:52 am

Concur with this post.

My mulligan course teacher once made the golf reference:

Reply



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  • Home
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  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
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    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test