Ankle is a complex joint which is categorized as a hinge joint.It is one of the important component for ambulation in humans.Ankle sprains are one of the commonest injuries in athletics.It accounts for 20% of all sports injuries(Bergfeld J;2004).In India,incidence rate of ankle sprain accounts for 0.31% of the population(Statistics for ankle sprain;2003).The chances of re-injury is seen high as 78-80% despite the continued research in this field.
The pathomechanics for ankle inversion injury is inversion and plantar flexion of the ankle joint.There is loss of range which is attributed to pain and swelling(Denegar CR et al;2002),(Collins et al;2004).Talocrural joint is primary responsible for the dorsiflexion and plantar flexion movement.
The conventional treatment for acute ankle sprain is RICE (rest,ice,compression,elevation).The conventional treatment with early motion is suggested to be more effective for improving pain,swelling and mobility(dettori et al;1994).This shows that the chances of re-injury is high because of the ineffectiveness of conventional treatment for treating the positional dysfunction caused due to acute ankle inversion injury which makes the joint for susceptible to injury(Denegar et al,1994).
Manual Therapy focus on the correction of the postural and movement dysfunction due to ankle sprain This method of intervention includes Maitland grades of mobilization,it is stated that maitland grades of mobilization improves the ankle dorsiflexion(green t et al;2001). .Mulligan's mobilization with movement technique is stated to be effective in reducing pain and improves dorsiflexion of ankle joint(Collins et al;2004). This study was conducted on subjects with subacute ankle sprain. The studies done on Mulligan's mobilization with movement technique in acute ankle sprain are very rare one of the study done is the effect of Mulligan's mobilization with movement for the treatment of acute lateral ankle sprain(T O Brien,B.Vincenzino;1998).The study showed improvement in range of motion and functional outcome and reduction in pain. However the design of this study was single case study design leading to limitations of generalization of its findings effect of Mulligan's mobilization with movement technique on temporal and spatial parameters of gait showed limitations in study design, sample design and statistical analysis (John-Mark Chesney, Erin Morris)
The need for study arises due to the limitation of the previous studies done on the treatment of acute ankle sprain y Mulligan's mobilization technique with movement. Hence the aim of the study is to find the effect of Mulligan's anterior-to-posterior talar mobilization with movement technique in acute ankle inversion sprain and compare the results with effect of maitland grades of mobilization for treatment of acute ankle inversion sprain.
Review of literature.
The review of literature focuses on following topics.
1. Anatomy of ankle and pathomechanics of inversion injuries.
2. Risk factors of injury.
3. Conventional Management of ankle sprain.
4. Manual therapy to ankle inversion sprain.
Anatomy of ankle and Pathomechanics of ankle injuries.
Ankle joint is a complex joint due to its articles, ligamentous and tendinous anatomy. The anterior talofibular ligament restricts anterior translation and internal rotation of talus inside the mortise. The coupled motion during plantar flexion happens as internal rotation and anterior translation of talus aided by deltoid ligament. The calcaneofibular ligament restricts inversion of the talocrural and subtalar joint. The posterior talofibular ligament restricts inversion and internal rotation after calcaneofibular ligament and anterior talofibular ligament undergo injury.
Konradsen and Voight (2002) quoted that an inversion torque was produced on loading a cadaveric leg, when the unloaded foot was positioned in 30 degree inversion, full plantar flexion and 10 degree internal tibial rotation. They also stated that collision with 20 degree inverted foot in swing phase follow through forced the foot into full limit of inversion, plantar flexion and internal tibial rotation.
Denegar CR et al (2002) stated that in normal biomechanics the instantaneous axis of rotation of talocrural joint translates posteriorly during dorsiflexion, but in anterior malaligned talus or with restricted posterior talar glide the axis of rotation is shifted anteriorly leading to joint dysfunction.
Risk factors of injury
Various risk factors, both intrinsic and extrinsic have been attributed to predispose to inversion injury and re-injury.
Baumhauer JF et al (1995) stated that intrinsic factors like previous history of sprain, limited range of motion and reduced dorsiflexor and plantar flexor strength ratio, elevated eversion to inversion ratio have been attributed to predisposing to inversion injury.
Eren OT et al 92003) stated that high malleolar index (posteriorly positioned fibula) is attributed to predispose to sprain. Average malleolar index was +11.5 degree in subjects with ankle sprain and +5.85 degree in normal controls.
Conventional management of ankle sprain.
The conventional management of ankle sprain is initiated to RICE in acute stage of injury functional treatment procedures with early initiation of weight bearing as tolerated, early mobilization, proprioceptive training, balance training has been advocated to provide early functional rehabilitation to subjects.
The management of sprain concentrates on static and dynamic stability, gaining normal ankle range of motion, optimal strength of peroneal, dorsiflexor, plantar flexor, invertor muscles of ankle, retraining ankle strategy (Bahr R, 2004) Bruce Beynnon B et al, 2004)
Kerkhoffs et al 2002) stated that functional treatment is superior to immobilization and surgical intervention in areas of pain on activity, quality of performance on return to sport/work, objectives instability on x-ray views and patient satisfaction.
Manual therapy in ankle inversion sprain.
Green et al (2001) conducted a randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains.
38 subjects with acute ankle sprain (<72 hours) were randomly assigned to control (RICE) or AP mobilization plus RICE. All had home program.
Treatment every 2 days for maximum 2 weeks was given.
Results showed dorsiflexion is proved earlier in treatment group (11 degree compared to 6 degree from baseline to treatment 2).
This showed that talar anterior-posterior glide speeds up recovery rate.
Collins N et al (2004) conducted a double-blind randomized controlled trial which incorporated repeated measures into cross over design.
14 subjects with grade II ankle sprain (40 +/- 24 days old)
Dorsiflexion in weight bearing, thermal pain threshold were calculated.
3 treatment condition.
Mulligan's mobilization with movement for dorsiflexion.
Placebo
No- treatment control were studied.
The results showed that talar anterior-posterior glide speeds up recovery rate in treatment with Mulligan's mobilization with movement.
The study conducted was done on subjects with subacute ankle sprain only.
T O'Brien, B. Vincenzino (1998) conducted single case study to investigate the effects of movement treatment technique for lateral ankle sprain.
The technique was the posterior glide to distal fibular while patient actively inverted the ankle.
Outcome measures used
Modified Kaikkonen test.
Range of Dorsiflexion and Inversion
VAS for pain and functions.
Two subjects with acute ankle sprain were used to control for natural resolution of ankle sprain.
Subject I underwent ABAC protocol while subject II BABC protocol where A-no treatment phase, B-treatment phase, C-post treatment return to sport phase.
Results showed the immediate effects of Mulligan mobilization with movement technique on acute lateral sprain.
Rapid improvement of ROM (inversion and Dorsiflexion) immediate decrease in pain.
Limitations
The study design leads to limitation of generalization of its findings.
Hence, from above studies we can infer that Mulligan's mobilization with movement technique has a resulting effect on ankle sprain.
The above studies also suggest the immediate effects of Mulligan's mobilization with movement technique in treatment of ankle sprain. However, a few studies have been conducted for the effect of this technique on acute ankle sprain and the studies which are done on acute ankle sprain have limitation in form of study design, samples size, statistical analysis.
The basics of those findings effect of Mulligan's mobilization with movement technique should be investigated in subjects with acute ankle sprain.
Research Proposal Question
Does Mulligan's anterior-to-posterior talar glide improves the dorsiflexion in subjects with acute ankle inversion sprain.
Alternate hypothesis.
Mulligan's anterior-to-posterior talar glide improves dorsiflexion in subjects with acute ankle inversion sprain.
Null hypothesis
Mulligan's anterior-to-posterior talar glide does not improve dorsiflexion in subjects with acute ankle inversion sprain.
