International Journal of Physiotherapy and Research, Int … nisha , nijhawan a. megha, p. paresh. efficacy of weight bearing distal tibiofibular joint mobilization with movement (mwm)

Int J Physiother Res 2014;2(3):542-48. ISSN 2321-1822 542

Original ArticleEFFICACY OF WEIGHT BEARING DISTAL TIBIOFIBULAR JOINTMOBILIZATION WITH MOVEMENT (MWM) IN IMPROVING PAIN,DORSIFLEXION RANGE AND FUNCTION IN PATIENTS WITHPOSTACUTE LATERAL ANKLE SPRAINKumari Nisha *1, Nijhawan A. Megha 2, P. Paresh 3.*1 Research Student, ISIC Institute of Rehabilitation Sciences, New Delhi, India.2 MPT (Musculoskeletal), Assistant Professor, ISIC Institute of Rehabilitation Sciences, New Delhi,India.3 MPT (Musculoskeletal), Consultant Physiotherapist, New Delhi, India.

Background: Various treatments in physiotherapy are available for ankle sprain with no consensus like taping,bracing, splinting, cryotherapy, electrotherapy modality like ultrasound, laser therapy, interferential therapyand HVGS, joint mobilization. Mulligan’s mobilizations-with movement (MWM) have been proposed as novelmanual therapy technique to improve joint ROM by combining physiological and accessory joint movements.He developed a suite of treatment techniques on the basis of his theory of positional faults and altered jointkinematics following injuries affecting spinal and peripheral joints.Objective: To find out the efficacy of distal tibiofibular joint MWM in conjunction with conventional treatmentover conventional treatment alone for improving pain , dorsiflexion range and lower extremity function inpatients with post acute lateral ankle sprain.Subject and methods: 30 lateral ankle sprain subjects were randomized into 2 groups:- Group 1(n=15) werereceived distal tibiofibular joint MWM along with conventional treatment and Group 2 (n=15) subjects werereceived conventional treatment only. Treatment consist of 3 sessions spread over 1 week, each session 48hours apart and data is recorded at beginning and end of treatment regimen.Results: Independent t-test showed statistical significant improvement in only weight bearing lunge measurefor dorsiflexion (p=0.008) in group 1 over group 2 and paired t-test was used for within group analysis whichshowed significant improvement in both the groups in all the outcome variables (p=0.000)Discussion and conclusion: Both the groups demonstrated significant improvement in pain, range and lowerextremity function in lateral ankle sprain and distal tibiofibular joint mobilization with movement in conjunctionwith conventional treatment will be significantly more effective than conventional treatment alone in improvingweight bearing ankle dorsiflexion range (Weight bearing lunge measure) in post acute lateral ankle sprain. Sodistal tibiofibular joint mobilization with movement is worth considering for further exploration in lateral anklesprain patients.KEYWORDS: Lateral ankle sprain, Distal tibiofibular joint MWM, Weight bearing lunge measure of dorsiflexion.

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International Journal of Physiotherapy and ResearchISSN 2321- 1822

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Received: 05-05-2014 Accepted: 16-05-2014

Published: 11-06-2014

ABSTRACT

INTRODUCTION

Address for correspondence: K. Nisha, Research Student, Department of physiotherapy, ISIC Institute ofRehabilitation Sciences, Indian Spinal Injuries Centre, New Delhi – 110070, India.Email: [email protected], [email protected]

International Journal of Physiotherapy and Research,Int J Physiother Res 2014, Vol 2(3):542-48. ISSN 2321-1822

Peer Review: 05-05-2014

The lateral ligament complex of the ankle,described as the body’s ‘‘most frequently injuredstructure’’ (Garrick, 1977), is mechanically vul-nerable to sprain injury. At extremes of plantar-

flexion and inversion, influenced by the shortermedial aspect of the ankle mortise, the relativelyweak anterior talofibular ligament (ATFL) andcalcaneofibular ligament (CFL) are prone to vary-ing grades of rupture, often via minimal force. 1


METHODS

Kumari Nisha , Nijhawan A. Megha, P. Paresh. EFFICACY OF WEIGHT BEARING DISTAL TIBIOFIBULAR JOINT MOBILIZATION WITH MOVEMENT(MWM) IN IMPROVING PAIN, DORSIFLEXION RANGE AND FUNCTION IN PATIENTS WITH POSTACUTE LATERAL ANKLE SPRAIN.

Worldwide approximately 1 ankle sprain occursper 10000 persons /day, and an estimated 2million acute ankle sprains occur each year inthe United States. Three-quarters of ankleinjuries involve the lateral ligamentous complex,with an equal incidence between males andfemales. 2, 3

Subsequent losses of joint range, particularlydorsiflexion and muscle strength results insignificant gait dysfunction, descending stairs,kneeling and running. Inadequate rehabilitationof dorsiflexion range is proposed to lead to longterm pain and ankle instability.1,4 Recent data byyang and vicenzino highlights the presence ofdorsiflexion deficit not only in the acute stage,but also in the subacute stage and one reasonfor continued pain and elevated risk for reinjurymay be limited ankle joint mobility and isobserved in 20-40% of patients after anklesprain.1,5

In ankle sprain Mulligan advise talocrural anddistal tibiofibular joint mobilization withmovement. Efficacy of talocrural jointmobilization with movement has been provenin weight bearing position in lateral ankle sprainin subacute stage as well as in recurrent anklesprain.1, 2, 4, 6.

Mulligan 1995 suggested that 2/3rd of all ‘lateralligament’ injuries solely involve the tibiofibularjoint and hypothesized that the distal fibulasubluxes anteriorly and caudally duringplantarflexion- inversion injury of the ankle.7

Mulligan suggested basis for distal tibiofibularjoint mobilization with movement that apositional fault of the ûbula (movement of thelateral malleolus anteriorly during dorsiûexion)often occurred after ankle sprains and claimsthat a posterosuperior mobilization performedon the distal tibioûbular joint could be expectedto improve dorsiûexion and regain normal ûbularmotion and may increase functional ability. 8

Need of the Study

Despite preliminary evidence on efficacy ofdistal tibiofibular positional fault there ispaucity of literature on efficacy of distal tibiofibu-lar joint MWM in lateral ankle sprain. Results ofthe present study may help us to formulate acomprehensive and more effective treatmentplan in patients of lateral ankle sprain.

30 male and female patients diagnosed withlateral ankle sprain by an orthopaedician whoare in their postacute phase , who volunteer toparticipate in the study, meeting the inclusionand exclusion criteria would sign aninstitutionally approved informed consent formafter understanding the procedure as explainedin figure 1. Patients are assessed for pain (VAS),dorsiflexion range (weight bearing lungemeasure, NWB universal goniometer), andlower extremity function (LEFS).Inclusion criteriawas diagnosed cases of lateral Ankle sprain, agebetween 15-45 years, postacute phase (2-6weeks), Unilateral lateral ankle sprain,anterolateral ankle tenderness less than equalto grade 2, patients who can read andunderstand english. Exclusion criteria washistory of previous ankle sprain and giving way,influence of pain killer during the study, anyabnormal sensation or radiation of pain in lowerlimbs, patient on anticoagulant medications,patients with skin problems like infection,blisters, ulcers, haematoma, Any ankle and footdeformity, ankle instability, grade 3 sprain andother systemic illness.Pain assessed using a 10 cm visual analoguescale, marked “no pain” at one end and “worstpain imaginable” at the other of 10 cm line. Apatient is asked to indicate his/her perceivedpain intensity.9 In Weight bearing lunge measureof dorsiflexion, patient is required to place theirfoot perpendicular to the wall and lunge theirknee toward the wall. The foot is progressivelymoved away from the wall until the maximumrange of dorsiflexion is reached without the heellifting. The most frequent measurement takenat this point is distance from the foot to the wallby tape.10

The Lower Extremity Functional Scale (LEFS) is aquestionnaire containing 20 questions about aperson’s ability to perform everyday tasks. TheLEFS can be used by clinicians as a measure ofpatients’ initial function, ongoing progress andoutcome, as well as to set functional goals. TheLEFS can be used to evaluate the functionalimpairment of a patient with a disorder of oneor both lower extremities. It can be used tomonitor the patient over time and to evaluatethe effectiveness of an intervention.11



Fig. 1: Flowchart of procedure.

Group 1: Distal tibiofibular joint mobilizationwith movement (Weight bearing) + Conventionaltreatment:Patient places affected foot on stool or chairwhile standing. Application of posterosuperiorglide on distal end of fibula and while this posi-tioning is maintained, allow the patient to leanforward over his foot to force dorsiflexion(figure2). It is given as 10 repetitions 3 sets with 1minute rest between sets for 3 sessions, 48hours apart for 1 week. 1,12

Fig. 2: Distal tibiofibular MWM – Weight bearing.

Group 2: Conventional treatment only:Talocrural joint mobilization - Patient placesaffected foot on stool or stool while standing.Belt is placed around therapist’s hips and thepatient ’s lower leg about 4cms above theinsertion of tendoachiliis. Between the belt andtendoachiilis, a small folded towel placed forcomfort. Wrap the web between the thumb andindex finger of one hand, reinforced by the otheraround talus as close to the joint as possible. Pullthe tibia and fibula forward with the belt as thepatient holding the back of chair, flexes forwardover his foot.1,13

Exercises - Range of motion exercises i.e. achillisstretching in non weight bearing and weightbearing positions, Alphabet exercises (3 times/day, 15-30 sec hold). Muscle strengtheningexercises (isometric and concentric) usingcontralateral foot for dorsflexors, plantar flexors,invertors and evertors (3sets 5-10 reps 3times/day).Toe curls and marble pickups (2 sets 10 reps2times/day). Toe raises, heel walk and toe walk(3 sets 10 reps 2times/day).14,15

Data Analysis

Data were managed on a Microsoft excel spreadsheet.The analysis was done using SPSS version19. Means and standard deviation of pre andpost values of pain (VAS), Dorsiflexion range(weight bearing lunge measure and universalgoniometer) and Lower extremity function(LEFS) for both experimental group and controlgroup were computed. Paired t-test was usedfor within group analysis and independent t- testfor between group analyses for all the outcomevariables.



RESULTS AND TABLESIn this section, the results of the present studyare presented, In all there were 7 males, 8females in both group 1 and group 2 (14 malesand 16 females). Basic demographiccharacteristics of both groups did not show anysignificant difference at baseline values of age,weight, height, BMI, VAS, WBLM, DF(goniometer) and LEFS. In between groupanalysis, there were no significant improvementsin pain on VAS (pd”0.352), lower extremityfunction (pd”0.062).There was significantimprovement in dorsiflexion range on WBLM(pd”0.008) and no significant improvement onuniversal goniometer in non weight bearingposition. (table1)However there wasimprovement on mean difference of pre andpost values between the two groups.In within group analysis there was significantdifference between pre and post values of pain(VAS), dorsiflexion range (WBLM and DF) andlower extremity function (LEFS) in both group 1and group 2(p=0.00) as shown in table 2.

Graph 1: Within group analysis of Group 1.

Graph 2: Between group analysis of VAS, WBLM, DF.

Table 1: Between Group analysis.Group Mean ±SD t-value Sig

VAS 0.946 .352NS

WBLM 2.849 0.008**

DF 1.993 0.05NS

LEFS 1.942 0.062NS

2.56±1.09 2.23±0.76

1 2

24.91±10.76 16.91±11.77

4.13±3.52 2.13±1.64

4.29±1.93 2.34±1.80

1 2

1 2

1 2

NS – Non significant, ** Significant

Graph 3: Between group analysis of LEFS.

Table 2: Within group analysis.

Group Mean ±SD t-value Sig

-4.29± 1.93 -8.60 0.00**

-4.13± 3.52 -4.54 0.00**

-24.91± 10.76 -8.96 0.00**

WBLM1-WBLM2

DF1-DF2

LEFS1-LEFS2

1.56±1.09 2.23 ± 0.76

1 2

9.02 11.36

0.00** 0.00**

VAS1-VAS2

-16.91 ± 11.77

-2.13 ± 1.64

-2.34 ±1.80

1 2

1 2

1 2

-5.56 0.00**

0.00**

0.00**-5.02

-5.03

** Significant

DISCUSSIONIn between group analysis results of presentstudy show that distal tibiofibular jointmobilization with movement group significantlyimproved weight bearing Dorsiflexionrange(weight bearing lunge measure) of motionin patients with post acute lateral ankle sprainover conventional therapy alone i.e. controlgroup.Mulligan has hypothesized positional fault at



distal fibula that subluxes anteriorly and caudallyduring plantar flexion and inversion injury of theankle. There is preliminary evidence of Radio-graphic positional faults in sub-acute and chronicankle sprain that supports this hypothesis. 16

Kavanagh (1999) measured change in boneposition with application of the anteroposteriorglide MWM of the inferior tibiofibular joint. Theauthor claimed that the data supported theproposal of anterior-caudal positional fault of theinferior tibiofibular joint in ankle sprainpatients.7, 16

Hubbard et al in his two successive studiesassessed the position of distal fibula in individualwith chronic ankle instability and sub-acutelateral ankle sprain respectively usingfluoroscopy imaging and distance from anteriormargin of distal fibula in relation to the distaltibia was measured in millimeters. He concludedthat fibula was positioned more anterior inrelation to tibia on their involved ankle in relationto their uninvolved limb. 17.18

In a lab study, limitation of ankle Dorsiflexion wasdecreased in cadavers by distal tibiofibular jointmobilization in which fibula was displaced bycyclic loading postero-superiorly and thenmaximum dorsiflexion pre and post wascompared which came effective for increasingthe range of dorsiflexion.19

In a single case study of 1998 by O’Brien, thetechnique involved the physiotherapistsustaining a non weight bearing posterior glideto the distal fibula for acute ankle sprain, whilethe patient actively inverted the ankle severaltimes. There were rapid improvements in rangeof motion of inversion and dorsiflexion range inweight bearing, and immediate decreases in painand also improvement in function.20

The ûbula has been found to function in weightbearing approximately 6.4% of the applied loads,according to Takebe et al. Hence correction ofits positional fault might have attributed toweight bearing dorsiflexion range of motionimprovement. 21

Although there was no statistical significantimprovement in pain (on VAS) and lowerextremity function (LEFS) in the experimentalgroup over the control group but mean scoresof pain and LEFS were better in experimental

group over control group.The minimal detectable change (MDC) andminimal clinically important difference (MCID)of the LEFS is 9 scale points. In the present studyall patients could achieve the MDC & MCID inthe experimental group where as only 9 patientscould achieve MDC & MCID in the control group.Thus, experimental group is showing an edgeover the conventional physiotherapy alone inLEFS scores. 11

Mulligan hypothesizes that 2/3rd of all lateralligament injuries solely involve the tibiofibularjoint or are due to combination of damage todistal tibiofibular joint and to ATFL ligamentwhich was supported by Kavanagh (1999) whodid a lab study to measure positional fault atdistal tibiofibular joint in acute or chronic anklesprains and found positive results in 1/3 rd ofthe patients. But in the present study by nomeans we could check for positional fault atdistal tibiofibular joint in each group and hencethere might be an uneven distribution ofpatients having distal tibiofibular joint positionalfault.In the present study, within group analysisshowed significant improvement in all theoutcome variables namely pain (VAS),dorsiflexion range (WBLM & universalgoniometer) and lower extremity function (LEFS)in both the experimental and conventionaltherapy group ie control group.In the experimental group the significantimprovement, apart from the positional faultcorrection can be attributed to the hypoalgesiceffects of manual therapy which was given inform of MWM.The effect of Mulligan’s mobilisation withmovement technique at talocrural joint wasstudied by Collins et al (2004) with sub acuteankle sprains on dorsiflexion range of motion forpre- to post-application in one session wasfound, compared to placebo and control group.1

The clinical rationale given for anteroposteriorglide component of the weight bearingdorsiflexion MWM is to reduce any residualanterior displacement of the talus. Mulliganproposed that correction of the restrictedposterior glide, via repetitions of dorsiflexionwith a sustained anteroposterior talar mobiliz-



ation (mechanically similar to posteroan-teriortibial glide on talus), restores the normal jointkinematics even after release of the glide.1

It also has been proven that effect ofmobilizations with movement at talocrural jointperformed in weight bearing position inindividuals with subacute and recurrent lateralankle sprain demonstrated a positive effect onimproving pain and dorsiflexion range on weightbearing lunge measure than MWM in nonweight bearing position.2, 4, 22

Early post injury exercise can improve the healingand strength of damaged ligament by increasingcollagen formation and reducing adhesion,improved tissue nutrition, minimized musclewasting, and minimal loss of strength are alsobenefits of early exercise. 14,23

Despite incomplete adherence to home regimestill patients showed statistically significantimprovement in all outcome measure in bothgroups. The present picture is close to the clinicalpractice scenario.In the present study patients were not under theinfluence of pain killers so the improvementcame in both the groups can be attributed tothe therapy given to each group.AcknowledgementI begin by thanking GOD for bringing me up tothe completion of this work. It is a pleasure toacknowledge the gratitude I owe my guide Mrs.Megha Arora Nijhawan (MPT Musculoskeletal),Assistant professor, ISIC Institute of Rehabilita-tion Sciences New Delhi, Department of Physio-therapy, who immensely helped me andrendered her valuable advice, previous knowl-edge and relevant information regarding mywork. I would like to thank especially Dr Harpreet(MBBS MS), Consultant Orthopaedician, ISIC,Department of orthopaedic, who immenselyhelped me to send his patients of lateral anklesprain for my dissertation. I would also like tothank Mr. Sanjoy, Statistician, ISIC Institute ofRehabilitation Sciences for analyzing my data. Iwant to express my loving regards to my family,my batch mates for always being with me. It istheir good wishes and prayers that brought methis far. Last but not the least I would like tothank all the subjects who volunteered toparticipate in the study.

Conflicts of interest: None

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How to cite this article:Kumari Nisha , Nijhawan A. Megha, P. Paresh. EFFICACY OF WEIGHTBEARING DISTAL TIBIOFIBULAR JOINT MOBILIZATION WITH MOVEMENT(MWM) IN IMPROVING PAIN, DORSIFLEXION RANGE AND FUNCTION INPATIENTS WITH POSTACUTE LATERAL ANKLE SPRAIN. Int J Physiother Res2014;2(3):542-48.

20. T. O’Brien, B. V icenzino, A study of the effects ofMulligan’s mobilization with movement treatmentof lateral ankle pain using a case study design,Manual Therapy 1998;3(2):78-84.

21. Susan A. Norkus, R.T Floydt. The Anatomy andMechanisms of Syndesmotic Ankle Sprains Journalof Athletic Training 2001;36(1):68–73.

22. Bill Vicenzino , Michelle Branjerdporn, Pam Teys.Initial Changes in Posterior Talar Glide andDorsiflexion of the Ankle after Mobilization withMovement in Individuals with Recurrent AnkleSprain. Journal of Orthopaedic & Sports PhysicalTherapy 2006;36(7):464-471.

23. Ward Mylo Glasoe, Mary K. Allen, Bruce E Awtry,,H. john Yack; Weight-Bearing Immobilization andEarly Exercise Treatment Following a Grade IILateral Ankle Sprain Journal of Orthopaedic &Sports Physical Therapy 1999;29(7):394-399.

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International Journal of Physiotherapy and Research, Int … nisha , nijhawan a. megha, p. paresh. efficacy of weight bearing distal tibiofibular joint mobilization with movement (mwm)