Which Chronic Ankle Instability Patients Benefit from Manual Therapy?

Source: Wikstrom, E.A., McKeon, P.O. (2017) Predicing Manual Therapy Treatment Success in Patients With Chronic Ankle Instability: Improving Self-Reported Function. Journal of Athletic Training, 52(4), 325-331.

Research Conclusion: Based on their secondary analysis of a randomized controlled clinical trial, the authors conclude that each of the three manual therapies tested (plantar massage, joint mobilization, and calf stretching) showed success in improving patient-reported function with unique predictors for success.

Clinical Pearls

  • Joint mobilizations, plantar massage, and calf stretching all seem to improve self-reported function in about half of patients with CAI regardless of predictor variable
  • Ankle joint mobilizations had a 98% chance of improving self-reported function in patients with a combination of ≤5 recurrent ankle sprains AND a Foot and Ankle Ability Measure (FAAM) score ≤ 82.7%
  • Plantar massage had a 99% chance of improving self-reported function in patients with a combination of age < 22 years and weight-bearing lunge test ≤ 9.9 cm
  • For single predictor variables:
    • ankle mobilizations were most useful for patients with ≤5 recurrent sprains, ≥5 errors on the single-limb balance test, a FAAM score ≤ 82.7%, a FAAM score between-limb difference ≥ 8.3%, or a Foot and Ankle Ability Measure – Sport (FAAM-S) score ≤ 67.2%
    • plantar massage was most useful for patients ≤ 22-years-old, with a mass ≤ 78kg (172 lbs), weight-bearing lung test ≤ 9.9 cm, and single-limb balance test between-limbs difference ≥ 2 errors
    • calf stretching was most useful for patients with ≤ 3 sprains or a FAAM-S score ≤ 53.1%
  • These manual therapies saw rapid improvements with just six 5-minute treatments over the course of two weeks and improvements remained at 1-month follow-up

Nerdy Breakdown

Level of Evidence: 1b
Grade of Recommendation: B

I struggled with how to rate this research article because it gets a lot right, but misses some key factors.  This is why I gave it a 1b Level and a B Grade.  This may, in part, be due to the fact that this article is a secondary analysis of a randomized controlled trial, and I don’t think readers should necessarily have to track down the original study for a full picture.  Therefore, the fact that I don’t have a full account of the patients combined with the lack of any blinding drops the JADAD score to 3 and the PEDro score to 7.  The authors note that this is a preliminary study and that there were only 20 subjects in each of the 3 groups (all of whom were physically active young adults recruited at three public universities).   Despite the narrow focus of the study participants, I agree with the authors that this preliminary study shows great promise for improving patient-reported outcomes with simple, cost-effective therapies.

The interventions were performed over a 2-week period, where each participant received six 5-minute treatments.  The treatments were carried out as follows:

  • ankle-joint mobilizations consisted of two 2-minute sets of grade III anterior-to-posterior talocrural joint mobilizations with the patient in long-sitting position and a 1-minute rest between sets
  • plantar massage consisted of two 2-minute massage sets with the patient supine and a 1-minute rest between sets; an unspecific combination of effleurage and pettrisage was applied to the entire plantar aspect
  • calf-stretching consisted of 2 sets of three 30-second stretches with the knee bent; a 10-second rest was taken between stretches, and a 1-minute rest was taken between sets; stretching was performed on an adjustable slant board with an angle “so that the calf was gently stretched”

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