The Effects of Therapeutic Exercise With and Without Mobilization in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

in Journal of Sport Rehabilitation
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Context: Manual therapy (MT) is reported to increase range of motion (ROM), improve balance, and decrease pain in individuals with chronic ankle instability (CAI). Additional literature is needed to examine the effectiveness of the addition of MT to a therapeutic exercise regimen in individuals with CAI. Objective: To examine the combined effects of thrust joint manipulation (TJM) and exercise on function in participants reporting CAI. Design: Randomized controlled trial. Setting: Research laboratory. Participants: A convenience sample of 30 participants (mean age 23.7 [3.65] y; mean height 169.50 [9.50] cm; mean mass 66.48 [10.64] kg). Intervention: Participants were randomly allocated to the exercise (n = 15) or exercise + TJM group (n = 20) and completed an exercise program. The exercise + TJM group also received MT at the talocrural, proximal, and distal tibiofibular joints in the first 3 sessions. Main Outcome Measures: Self-reported outcomes were recorded at baseline and follow-up using the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport (FAAM-S) subscale, and the Ankle Joint Functional Assessment Tool (AJFAT). The side-hop test, figure-of-8 hop test, 3 directions of the Star Excursion Balance Test, and dorsiflexion ROM were also assessed at baseline and follow-up. Results: Only the exercise + TJM group demonstrated an improvement in weight-bearing dorsiflexion with the knee flexed following treatment (P = .02). For all outcome measures, except ROM, subjects improved significantly at follow-up regardless of group assignment (P ≤ .01). Conclusions: Our data suggest that rehabilitation of patients with CAI is related to improved ROM, function, and self-reported outcomes. This provides evidence that the addition of MT to exercise may enhance improvements in ROM as compared with exercise alone. Additional research is needed to identify optimal parameters to maximize therapeutic benefit.

Bolton and Hale are with the Division of Physical Therapy, Shenandoah University, Winchester, VA, USA. Telemeco is with the Department of Kinesiology, College of Health Sciences, University of North Carolina at Pembroke, Pembroke, NC, USA.

Bolton (Cbolton16@su.edu) is corresponding author.
  • 1.

    Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):22792284. PubMed ID: 20926721 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50(24):14961505. PubMed ID: 27259753 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Hertel J, Corbett RO. An updated model of chronic ankle instability. J Athl Train. 2019;54(6):572588. PubMed ID: 31162943 doi:

  • 4.

    Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653660. PubMed ID: 9801078 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Gribble PA, Bleakley CM, Caulfield BM, et al. 2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50(24):14931495. PubMed ID: 27259750 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Plaza-Manzano G, Vergara-Vila M, Val-Otero S, et al. Manual therapy in joint and nerve structures combined with exercises in the treatment of recurrent ankle sprains: a randomized, controlled trial. Man Ther. 2016;26:141149. PubMed ID: 27598553 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Lubbe D, Lakhani E, Brantingham JW, et al. Manipulative therapy and rehabilitation for recurrent ankle sprain with functional instability: a short-term, assessor-blind, parallel-group randomized trial. J Manipulative Physiol Ther. 2015;38(1):2234. PubMed ID: 25457977 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Shih Y-F, Yu H-T, Chen W-Y, Liao K-K, Lin H-C, Yang Y-R. The effect of additional joint mobilization on neuromuscular performance in individuals with functional ankle instability. Phys Ther Sport. 2018;30:2228. PubMed ID: 29310055 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Burcal CJ, Trier AY, Wikstrom EA. Balance training versus balance training with STARS in patients with chronic ankle instability: a randomized controlled trial. J Sport Rehabil. 2017;26(5):347357. PubMed ID: 27632839 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Arch Phys Med Rehabil. 2010;91(8):12671271. PubMed ID: 20684909 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008;13(1):6367. PubMed ID: 17188923 doi:

  • 12.

    Hubbard TJ, Hertel J, Sherbondy P. Fibular position in individuals with self-reported chronic ankle instability. J Orthop Sports Phys Ther. 2006;36(1):39. PubMed ID: 16494068 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability. J Electromyogr Kinesiol. 2011;21(4):652658. PubMed ID: 21546263 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Hoch MC, Staton GS, Medina McKeon JM, Mattacola CG, McKeon PO. Dorsiflexion and dynamic postural control deficits are present in those with chronic ankle instability. J Sci Med Sport. 2012;15(6):574579. PubMed ID: 22575498 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Weerasekara I, Osmotherly P, Snodgrass S, Marquez J, de Zoete R, Rivett DA. Clinical benefits of joint mobilization on ankle sprains: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2018;99(7):13951412.e5. PubMed ID: 28882509 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Evans T, Hertel J, Sebastianelli W. Bilateral deficits in postural control following lateral ankle sprain. Foot Ankle Int. 2004;25(11):833839. PubMed ID: 15574245 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531538. PubMed ID: 19027342 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Coulter ID, Crawford C, Vernon H, et al. Manipulation and mobilization for treating chronic nonspecific neck pain: a systematic review and meta-analysis for an appropriateness panel. Pain Physician. 2019;22(2):E55E70. PubMed ID: 30921975

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Gross A, Miller J, D’sylva J, et al. Manipulation or mobilisation for neck pain: a Cochrane review. Man Ther. 2010;15(4):315333. PubMed ID: 20510644 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4):984994. PubMed ID: 11276181 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Gribble PA, Delahunt E, Bleakley C, et al. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. J Orthop Sports Phys Ther. 2013;43(8):585591. PubMed ID: 23902805 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2007;37(6):303311. PubMed ID: 17612356 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Cruz-Díaz D, Lomas Vega R, Osuna-Pérez MC, Hita-Contreras F, Martínez-Amat A. Effects of joint mobilization on chronic ankle instability: a randomized controlled trial. Disabil Rehabil. 2015;37(7):601610. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Docherty CL, Arnold BL, Gansneder BM, Hurwitz S, Gieck J. Functional-performance deficits in volunteers with functional ankle instability. J Athl Train. 2005;40(1):3034. PubMed ID: 15902321

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability. J Orthop Sports Phys Ther. 2009;39(11):799806. PubMed ID: 19881005 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the star excursion balance tests in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37(4):501506. PubMed ID: 12937574

    • Search Google Scholar
    • Export Citation
  • 27.

    McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008;40(10):18101819. PubMed ID: 18799992 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater reliability of the star excursion balance test. J Athl Train. 2013;48(5):621626. PubMed ID: 24067151 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Hertel J, Miller S, Denegar CR. Intratester and intertester reliability during the star excursion balance tests. J Sports Rehabil. 2000;9:104116. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Gribble PA, Hertel J. Considerations for normalizing measures of the star excursion balance test. Meas Phys Educ Exerc Sci. 2003;7(2):89100. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31.

    Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the foot and ankle ability measure (FAAM). Foot Ankle Int. 2005;26(11):968983. PubMed ID: 16309613 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Carcia CR, Martin RL, Drouin JM. Validity of the foot and ankle ability measure in athletes with chronic ankle instability. J Athl Train. 2008;43(2):179183. PubMed ID: 18345343 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Ross SE, Guskiewicz KM, Gross MT, Yu B. Assessment tools for identifying functional limitations associated with functional ankle instability. J Athl Train. 2008;43(1):4450. PubMed ID: 18335012 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons with functionally unstable ankles. J Orthop Sports Phys Ther. 1999;29(8):478486. PubMed ID: 10444738 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32(4):166173. PubMed ID: 11949665 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2012;7(3):279287. PubMed ID: 22666642

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Linens SW, Ross SE, Arnold BL, Gayle R, Pidcoe P. Postural-stability tests that identify individuals with chronic ankle instability. J Athl Train. 2014;49(1):1523. PubMed ID: 24377958 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Hale SA, Fergus A, Axmacher R, Kiser K. Bilateral improvements in lower extremity function after unilateral balance training in individuals with chronic ankle instability. J Athl Train. 2014;49(2):181191. PubMed ID: 24568231 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Wright C, Linens S, Cain M. A randomized controlled trial comparing rehabilitation efficacy in chronic 1 ankle instability. J Sport Rehabil. 2017;26(4):238249. PubMed ID: 27632874 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40.

    Marrón-Gómez D, Rodríguez-Fernández ÁL, Martín-Urrialde JA. The effect of two mobilization techniques on dorsiflexion in people with chronic ankle instability. Phys Ther Sport. 2015;16(1):1015. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Beazell JR, Grindstaff TL, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2012;42(2):125134. PubMed ID: 22333567 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Bialosky JE, Beneciuk JM, Bishop MD, et al. Unraveling the mechanisms of manual therapy: modeling an approach. J Orthop Sports Phys Ther. 2018;48(1):818. PubMed ID: 29034802 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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