Lateral Ankle Sprain
Conditions
Keywords
Acute Lateral Ankle Sprain, Mulligan Mobilization With Movement, Manual Therapy, Ankle Dorsiflexion, Weight-Bearing Lunge Test, Posterior Talar Glide, Foot and Ankle Ability Measure, Ankle Rehabilitation
Brief summary
This randomized controlled trial evaluates the effects and clinical specificity of Mulligan Mobilization With Movement (MWM) in adults with grade I or II lateral ankle sprains occurring less than 6 weeks before enrollment. The primary study population consists of participants enrolled within 2 weeks of the index lateral ankle sprain. Participants with an injury occurring between 2 and less than 6 weeks before enrollment are also eligible. Approximately 110 participants will be allocated to a Mulligan MWM intervention group or a control group receiving usual-care rehabilitation without Mulligan treatment. In the intervention group, three MWM techniques targeting the inferior tibiofibular, talocrural, and cubometatarsal joints are tested in a randomized order and adapted according to the participant's immediate pain-free response. Treatment includes up to six sessions provided twice weekly. Clinical outcomes are assessed at baseline, 3 weeks, and 3 months. The primary outcomes are ankle dorsiflexion range of motion, ankle joint arthrokinematics, and pain during weight-bearing dorsiflexion.
Detailed description
This prospective pragmatic randomized controlled trial investigates the effects and clinical specificity of Mulligan Mobilization With Movement techniques in adults with grade I or II lateral ankle sprains occurring less than 6 weeks before enrollment. The primary study population consists of participants enrolled within 2 weeks of the index lateral ankle sprain. Participants enrolled between 2 and less than 6 weeks after the index injury are also eligible. Participants undergo a standardized clinical assessment including ankle dorsiflexion range of motion, pain during weight-bearing dorsiflexion, ankle joint arthrokinematics, static and dynamic balance, ankle muscle strength, self-reported foot and ankle function, and peripheral neurodynamic sensitivity. Participants allocated to the intervention group receive Mulligan Mobilization With Movement delivered by physiotherapists trained in the Mulligan Concept. Three MWM techniques targeting the inferior tibiofibular, talocrural, and cubometatarsal joints are tested according to a randomized sequence. Treatment follows the Mulligan pain-free immediate-response principle. If the response criterion is not met with the first technique, the next technique in the randomized sequence is tested. Participants allocated to the control group receive usual-care rehabilitation for lateral ankle sprain without Mulligan Concept treatment. Treatment is provided for up to six sessions, twice weekly. Outcome measures are collected at baseline, 3 weeks, and 3 months after enrollment.
Interventions
A physiotherapist trained in the Mulligan Concept applies Mobilization With Movement while the participant actively performs ankle dorsiflexion. Three techniques targeting the inferior tibiofibular, talocrural, and cubometatarsal joints are tested according to a randomized sequence. The intervention is performed without pain and is evaluated for an immediate response. According to the protocol, an immediate clinically relevant response is defined as a 2-point improvement in pain on the numerical rating scale or an improvement greater than 1.9 cm in ankle dorsiflexion measured with the Weight-Bearing Lunge Test. If the response criterion is not met, the next MWM technique in the randomized sequence is tested. Up to six treatment sessions are provided twice weekly.
OTHERUsual-Care Rehabilitation for Lateral Ankle Sprain
Participants receive traditional rehabilitation for lateral ankle sprain without Mulligan Mobilization With Movement. Rehabilitation is adapted to the participant's clinical presentation and is documented by the treating physiotherapist.
Sponsors
Université Catholique de Louvain
The Mulligan Concept Teachers Association (MCTA) : 2023 Mulligan Concept Award (Grant).
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Outcomes Assessor)
Masking description
Participants and outcome assessors are blinded to treatment allocation. Participants are not informed whether they are assigned to the Mulligan Mobilization With Movement intervention group or the control group. Outcome assessors performing the clinical measurements are blinded to treatment allocation and do not participate in treatment delivery. Treating physiotherapists are not blinded because they deliver the allocated intervention. They have access to the clinical assessment results to guide the individualized background rehabilitation provided to participants in both groups.
Intervention model description
Participants are randomized in parallel to a Mulligan Mobilization With Movement intervention group or a usual-care rehabilitation control group. Within the Mulligan intervention group, the order in which three MWM techniques are tested is also randomized.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Grade I or II lateral ankle sprain Index lateral ankle sprain occurring less than 6 weeks before enrollment Age 18 years or older No fracture associated with the index lateral ankle sprain No immobilization in a plaster cast Able to provide written informed consent
Exclusion criteria
* Grade III lateral ankle sprain Index lateral ankle sprain occurring 6 weeks or more before enrollment Additional lower-limb musculoskeletal disorder or injury incompatible with study participation Neurological disorder Severe hypertension Renal disease Cardiorespiratory disorder Sickle cell disease Arterial calcification Varicose veins Current anticoagulant treatment Current risk of or history of deep-vein thrombosis Fragile skin Previous surgery affecting sports performance
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Ankle Dorsiflexion Range of Motion Measured With the Weight-Bearing Lunge Test | Throughout the entire study, during approximately 24 months | Ankle dorsiflexion range of motion is measured in centimeters (hallux-to-wall distance) and degrees (tibial inclination) using the Weight-Bearing Lunge Test performed against a wall. Higher values indicate greater weight-bearing ankle dorsiflexion. |
| Posterior talar glide range of motion | Throughout the entire study, during approximately 24 months | Posterior talar glide range of motion is assessed using the Posterior Talar Glide Test (tibial inclination in degrees). Higher values indicate greater posterior talar glide range of motion. |
| Patient-Reported Sensations During the Weight-Bearing Lunge Test | Throughout the entire study, during approximately 24 months | Patient-reported sensations are assessed using the Weight-Bearing Lunge Test sensory-mapping process. During the end-range Weight-Bearing Lunge Test position, participants report the type(s) and anatomical localization(s) of the sensation(s) perceived. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Static Postural Control During Single-Leg Stance | Throughout the entire study, during approximately 24 months | Static postural control is assessed during a 20-second single-leg stance task by counting balance errors. The test is performed under two surface conditions: a stable surface and an unstable foam surface (Airex). A higher number of errors indicates poorer static postural control. |
| Dynamic postural control using the Modified Y-Balance Test | Throughout the entire study, during approximately 24 months | Dynamic postural control is assessed using the modified Y-Balance Test. Reach performance is measured in the anterior, posteromedial, and posterolateral directions and expressed in centimeters. |
| Eversion strength | Throughout the entire study, during approximately 24 months | Eversion strength is measured in Newtons using a hand-held dynamometer. |
| Inversion strength | Throughout the entire study, during approximately 24 months | Inversion strength is measured in Newtons using a hand-held dynamometer. |
| Dorsiflexion strength | Throughout the entire study, during approximately 24 months | Dorsiflexion strength is measured in Newtons using a hand-held dynamometer. |
| Plantar Flexor Endurance Assessed With the Heel Raise Test | Throughout the entire study, during approximately 24 months | Plantar flexor endurance is assessed using the single-leg Heel Raise Test recorded with the Calf Raise application. |
| Foot and Ankle Ability Measure Score | Throughout the entire study, during approximately 24 months | Self-reported foot and ankle function is assessed using the Foot and Ankle Ability Measure (FAAM Activities of Daily Living Subscale Score and FAAM Sports Subscale Score). |
| Fibular Nerve Neurodynamic Test Angle | Throughout the entire study, during approximately 24 months | Peripheral neurodynamic sensitivity is assessed in degrees using a fibular nerve straight leg raise test. |
| Side Hop Test Performance | Throughout the entire study, during approximately 24 months | Functional hopping performance is assessed using the Side Hop Test. Participants hop laterally and medially as fast as possible for 10 repetitions between two parallel lines positioned 30 cm apart. The first hop is performed toward the lateral side. Performance is recorded as the time required to complete the test, in seconds. Feelings of ankle instability during the task are also recorded. |
| Figure-of-8 Hop Test Performance | Throughout the entire study, during approximately 24 months | Functional hopping performance is assessed using the Figure-of-8 Hop Test. Participants complete two consecutive figure-of-eight laps around two posts positioned 5 m apart, corresponding to a total distance of 20 m, as fast as possible. Performance is recorded as the time required to complete the test, in seconds. Feelings of ankle instability during the task are also recorded. |
| Ankle-GO Score | Throughout the entire study, during approximately 24 months | Overall functional recovery and readiness to return to sport are assessed using the Ankle-GO composite score. The score integrates functional performance tests and patient-reported outcome measures, including single-leg stance, modified Star Excursion Balance Test, Side Hop Test, Figure-of-8 Hop Test, Foot and Ankle Ability Measure activities of daily living and sport subscales, and the Ankle Ligament Reconstruction-Return to Sport after Injury questionnaire. The total score ranges from 0 to 25 points, with higher scores indicating better functional status and greater readiness to return to sport. |
| Ankle Joint Swelling Measured With the Figure-of-Eight Method | Throughout the entire study, during approximately 24 months | Ankle joint swelling is quantified using the figure-of-eight measurement method. A tape measure is positioned around standardized anatomical landmarks of the ankle and foot following a figure-of-eight path. The resulting circumference is recorded in centimeters, with higher values indicating greater ankle swelling. |
| Psychological Readiness to Return to Sport Assessed With the ALR-RSI | Throughout the entire study, during approximately 24 months | Psychological readiness to return to sport is assessed using the Ankle Ligament Reconstruction-Return to Sport after Injury questionnaire (ALR-RSI). The questionnaire contains 12 items scored from 0 to 10, with 0 indicating no confidence and 10 indicating full confidence. The total score is converted to a percentage, with higher scores indicating greater psychological readiness to return to sport. |
| Perceived Ankle Instability Assessed With the Cumberland Ankle Instability Tool | Throughout the entire study, during approximately 24 months | Perceived ankle instability is assessed using the Cumberland Ankle Instability Tool (CAIT), a patient-reported questionnaire evaluating symptoms and functional ankle instability. The total score ranges from 0 to 30 points, with higher scores indicating better perceived ankle stability and lower scores indicating greater ankle instability. |
Countries
Belgium
Contacts
CONTACTHugo Bogaerts, MSc
PRINCIPAL_INVESTIGATORAnh Phong Nguyen, PhD
CIRRIS ULaval
Outcome results
None listed