Ankle sprains are one of the most common ankle injuries in active populations. The most prevalent mechanism of injury is a combination of inversion and adduction of the foot while in plantar flexion.1,2 This mechanism may cause tissue disruption to the lateral ligament complex of the ankle with the increased tension most commonly affecting the anterior talofibular ligament.3,4
Australian physiotherapist Brian Mulligan suggested that this mechanism does not always damage the anterior talofibular ligament tissue. Instead, the resulting tissue tension causes the anterior talofibular ligament to exert an anterior and caudal force on the fibula.5,6 The force may result in a positional fault between the tibia and fibula that could be addressed through a sustained mobilization of the fibula in an obliquely superior and posterolateral direction followed by the patient actively performing his or her previously provocative movement or limited motion.5 It has been recommended to apply the mobilization with movement as soon as possible following a lateral ankle sprain, provided a fracture is not present and pain-free motion is produced by application of the mobilization with movement, to aid in both the differential diagnosis and the healing process.5,7 Minor joint malalignments or positional faults are theorized to be present if a Mulligan concept mobilization with movement successfully eliminates the patient's pain.6 A successful Mulligan concept mobilization with movement may help to confirm a differential diagnosis of a position fault between the tibia and fibula causing tension on the anterior talofibular ligament rather than significant damage of the anterior talofibular ligament.5–7 Applying the lateral ankle sprain mobilization with movement, combined with the fibular repositioning tape, has been found to produce improvement in patient-reported outcomes following ankle sprains7; however, little is known about the potential benefit of the fibular repositioning taping application when a mobilization with movement is not indicated.
Patient-rated outcome measures are used to assess meaningful improvement from the patient's perspective and to evaluate efficacy of care. The Disablement in the Physically Active (DPA) scale is a generic patient-reported outcome measure composed of 16 questions that measure impairments, functional limitations, disabilities, and quality of life on a scale from 1 (no problem) to 5 (severe).8 Sixteen points are subtracted from the final score, resulting in a score range of 0 to 64.8 A 9-point change on the DPA scale for patients with acute injuries has been established as the change significant to the patient, or the minimal clinically important difference.8 The DPA scale was chosen for this case review over a specific patient-reported outcome measure because of the incorporation of multiple dimensions of disablement (ie, functional limitations, impairment, and disability) and consideration of quality of life.
Another generic patient-reported outcome measure is the Global Rating of Change (GRC) scale, which is designed to quantify the improvement or worsening of a patient over a period of time to determine the effectiveness of an intervention or document the course of a condition.9 Patients use the GRC scale to assess their current health status, taking into account their pain, disability, quality of life, and any other factors they believe relevant to their condition and rate how much their health status has improved or worsened since a predetermined time point.9 The predetermined time point used by the clinician in the current case review was at the initial injury. The GRC scale ranges from −5 (condition is much worse) to 0 (condition unchanged) to +5 (condition is completely recovered).9 The minimal clinically important difference of the GRC scale is 2 or more points on an 11-point scale.9
A frequently used measurement of pain intensity is the Numerical Rating Scale (NRS).10 The NRS measures the intensity of pain by having the patient rate the severity of their pain using an 11-point (0 to 10) scale.10 The minimal clinically important difference for the NRS is 2 points.10
A 20-year-old female collegiate middle-distance track athlete reported to the clinic approximately 30 minutes after sustaining an injury. She presented with an antalgic gait and described an acute inversion of her left ankle after stepping off a curb during a run. The patient's primary complaint was pain, rated 3 on the 11-point NRS at rest; pain increased to 6 of 10 on the NRS with plantarflexion and inversion of her ankle. She denied hearing or feeling any abnormal sounds or sensations at the time of injury or any abnormal neurological sensations at the time of the examination. She did not take any medications after the injury. The patient reported a previous history of three lateral ankle sprains, but had not previously sought care for these injuries.
Initial evaluation revealed mild edema and discoloration of the lateral aspect of the left ankle at the sinus tarsi and point tenderness while palpating the anterior talofibular ligament and calcaneofibular ligament. The patient had a mild increase in pain during all ankle active and passive range of motions, with plantarflexion with inversion producing the greatest increase. During isometric break testing (ankle in a neutral position for all directions) her strength was graded 4+ (held test position against moderate to strong pressure) in all directions, with mild pain about the ankle during all motions compared to 5 (normal) bilaterally. The anterior drawer and inversion talar tilt tests (both performed with the patient seated with the knee flexed and ankle in neutral position) were positive for pain and laxity (with a firm-end feel) when compared bilaterally. The Ottawa Ankle Rules were negative for fracture; Kleiger's, Pott's compression, heel percussion, posterior drawer, eversion talar tilt, and wedge tests were also negative. The patient's capillary refill, dermatomes, and reflexes were within normal limits compared bilaterally. The results of the examination were consistent with a lateral ankle sprain and the patient was preliminarily classified as having a Grade I lateral ankle sprain involving the anterior talofibular and calcaneofibular ligaments.
The lateral ankle sprain mobilization with movement was applied initially to evaluate for efficacy and appropriateness for subsequent treatment. During mobilization with movement application, the patient immediately reported pain over the distal fibula due to the clinician's hand placement. Pain with mobilization is a contraindication for mobilization with movement use,5,6 so the clinician adjusted the mobilizing hand and attempted to adjust the force of application; however, the patient again reported pain with the application of the mobilization. The clinician also attempted a modified lateral ankle sprain mobilization with movement, approximately 2 inches proximal to the lateral malleolus, but it too was painful.7 Within the Mulligan concept, a pad may be used to decrease pain/pressure associated with clinician hand placement, but in this case, a pad was unavailable, so this modification could not be attempted. Thus, the clinician decided to perform the fibular repositioning tape in an effort to mobilize the distal fibula in a pain-free manner without the associated force of hand placement during the mobilization with movement.
According to the Mulligan concept, a fibular repositioning taping is applied at the same time the clinician performs a pain-free posterolateral-superior glide of the fibula (in relationship to the tibia).11 However, in this case, only the fibular repositioning taping was used to provide the mobilization of the fibula due to an increase in pain experienced by the patient with clinician hand placement. The clinician applied Leukotape P Sports Tape (BSN Medical, Hamburg, Germany), starting obliquely at the distal fibula, wrapping diagonally around the Achilles tendon, and anchoring it above the initial tape attachment (Figures 1–2).11 With the exception of mobilization with movement application, the Mulligan concept fibular repositioning taping guidelines were followed. The tape pulled the patient's foot into eversion and dorsiflexion, which demonstrated effective application. A second piece of tape was applied directly over the first to reinforce the mobilization. The patient did not report experiencing any pain or tenderness during the tape application.
Application of Mulligan concept fibular repositioning taping demonstrating posterolateral-superior glide of the fibula with Leukotape P Sports Tape (BSN Medical, Hamburg, Germany).
Applied Mulligan concept fibular repositioning taping.
After fibular repositioning taping application, the patient reported being pain free during active ankle range of motion (all motions). She indicated an improvement in her condition (GRC score of +2 on an 11-point scale) in terms of her perception of pain, movement, and function after fibular repositioning taping application. Because the fibular repositioning taping application produced immediate clinically meaningful results and resolved pain with motion, the clinician determined that treatment was indicated.
The following day, the patient's active ankle range of motion was equal bilaterally and strength (all motions) was normal (5). She reported a score of 2 of 10 on the NRS at worst over the past 24 hours with motion and at rest. The patient reported continued improvement on the GRC scale and a total score of 9 on the DPA scale, which was within the reported range for the healthy population.8 Given the improvement on the patient-reported outcome measures, the patient was cleared to return to full activity as long as her pain did not worsen. The fibular repositioning taping was continued as treatment during and after activity, and was applied when the patient reported a decrease in tape effectiveness (5 times) over a 2-week period (provided there was no skin irritation). The patient did not miss any activity during the course of treatment. The NRS, DPA, and GRC scales were administered approximately every 2 days over the next 2 weeks and at discharge. Initially, the patient reported a 9 on the DPA scale and a 3 of 10 on the NRS. Without any other treatment, the patient was discharged 11 days after injury and reported a score of 0 of 10 on the NRS, 1 on the DPA scale, and +4 on the GRC scale (Table 1). The reported changes represent minimal clinically important differences for each of the scales after initial treatment and over the course of care.
Patient-Reported Outcomes Measures Posttreatment
Conservative management for acute lateral ankle sprains remains the standard care provided to an athletic population, consisting of rest, ice, compression, and elevation (RICE), protective taping or bracing, and functional rehabilitation to improve range of motion, strength, and proprioception.12,13 Traditional functional rehabilitation and management of acute lateral ankle sprains is based on the three stages of biological ligament healing, which include the inflammatory phase (until 10 days post-trauma), the proliferation phase (4 to 8 weeks post-trauma), and the maturation phase (until 1 year post-trauma).1,3 During the inflammatory phase, RICE is performed to protect from further injury, limit pain and swelling, and decrease the risk of secondary hypoxic injury occurring due to the inflammatory reaction.1,13 Treatment using the RICE process is often performed for 4 to 5 days post-injury.1,3 However, RICE may not be the optimal treatment because the clinical reasoning behind the procedure is based on lower-quality trials and laboratory studies with uninjured individuals or animals.13 Following the acute, protective rehabilitative period, conservative care often involves peroneal muscle and general leg strengthening, combined with proprioceptive training for the foot and ankle.3 The proprioceptive training is thought to be pivotal in reestablishing postural control, which may reduce the occurrence of another injury.14 Patients who are treated with RICE and functional rehabilitation have been reported to have improved function at 1 to 2 weeks. Immobilization, using either elastic wraps or casts, has resulted in patients returning to normal stair climbing between 5.5 and 28 days after a Grade I or II lateral ankle sprain.13 Most patients return to full activity within 6 weeks of an ankle injury, but many report repeated injury and lasting symptoms up to 4 years post-injury.13
Despite the prevalence of lateral ankle sprains, few research studies have been conducted examining Mulligan's hypotheses regarding the positional fault as the cause of patient complaint following injury. However, the available literature does provide some evidence supporting the hypothesis that a positional fault may occur with a sprain of the anterior talofibular ligament. A positional fault between the fibula and tibia has been found in patients with subacute ankle sprains and chronic ankle instability through the use of fluoroscopy15,16; it has also been confirmed following an ankle sprain using an external measuring device17 and magnetic resonance imagining.18 Although evidence exists for a positional fault existing after lateral ankle sprains, it is not known whether the positional fault occurs immediately after an acute injury.
There is moderate evidence available on the effectiveness of lateral ankle sprain mobilization with movement techniques and the fibular repositioning taping application when treating lateral ankle sprains acutely. Hetherington19 reported that lateral ankle sprain mobilization with movements and fibular repositioning taping application improved pain, range of motion, gait patterns, and single-leg balance with eyes closed in patients who suffered an acute ankle sprain who had been treated with 5 to 10 days of immobilization. Similarly, O'Brien and Vicenzino20 reported immediate and rapid improvements in pain, range of motion, and function following lateral ankle sprain mobilization with movement and fibular repositioning taping application in patients treated 2 to 3 days after acute lateral ankle sprains. In contrast, Mau and Baker7 reported an inability to apply the lateral ankle sprain mobilization with movement at the distal fibula 10 days after the injury occurred due to tenderness with mobilization with movement application. A modified lateral ankle sprain mobilization with movement, approximately 2 inches proximal to the lateral malleolus, was applied and produced immediate pain-free movement for the patient. In conjunction with a modified fibular repositioning taping at the site of the modified mobilization with movement, their patient was able to return to competitive basketball activity the next day and did not suffer reinjury throughout the follow-up period (60 days post-injury).7
The current report examines patient-reported outcomes when using Mulligan concept principles applied immediately (ie, within 1 hour) after an acute ankle sprain. The clinician was unsuccessful in producing a pain-free mobilization due to continued tenderness with the clinician's hand placement, but was able to achieve a clinically and patient-oriented significant improvement with fibular repositioning taping application. The patient was able to return to sport in 1 day with the use of fibular repositioning taping without mobilization with movements, indicating that the taping technique may be indicated for use for acute lateral ankle sprains as an alternative when mobilization with movement is not tolerated. The patient may have benefited from application of the lateral ankle sprain mobilization with movement later in the course of treatment once clinician hand placement was tolerated; however, fibular repositioning taping was continued as the sole intervention for this patient because it continued to be effective and produce meaningful change.
Based on the positive patient outcomes in this case, future research is needed to evaluate the effectiveness of an immediate fibular repositioning taping without mobilization in patients who report pain and/or tenderness with application of a traditional Mulligan concept lateral ankle sprain mobilization with movement. Research should also be conducted to determine the efficacy of care when the lateral ankle sprain mobilization with movement, once tolerated by a patient, is added to the rehabilitative protocol. Finally, given the body of literature on the lateral ankle sprain mobilization with movement, a full-scale randomized controlled trial is necessary to compare the effectiveness of this intervention to traditional lateral ankle sprain treatment protocols.
Implications for Clinical Practice
Although the use of lateral ankle sprain mobilization with movement is supported by the literature, cases may occur in which tenderness with the pressure of the mobilization may prevent application of the traditional mobilization with movement. The use of a pad, adjustment of hand placement, varying the force of application, and modifying the direction of the force application have all been recommended to eliminate the pain associated with applying the mobilization with movement.7 Initiating treatment with fibular repositioning taping rather than the application of a mobilization with movement may be more comfortable and may improve the patient's pain and movement in the short term.6 In the case presented, the lateral ankle sprain mobilization with movement resulted in pain and modification of the technique did not produce a pain-free response. As a result, the Mulligan concept fibular repositioning taping was applied to eliminate pain and tenderness without the painful application of manual mobilization. When a pain-free response is not immediately experienced by the application of the lateral ankle sprain mobilization with movement, fibular repositioning taping application may help alleviate pain and increase function in patients who have suffered an acute lateral ankle sprain. A limitation of this case review is the lack of prior measurement to determine whether the patient had a positional fault of the fibula on the tibia due to previous or current lateral ankle sprains. Further research regarding the effects of fibular repositioning taping application in isolation is needed to investigate the appropriateness of clinical use.
- Petersen W, Rembitzki IV, Koppenburg AG, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013;133:1129–1141. doi:10.1007/s00402-013-1742-5 [CrossRef]
- Lin C-WC, Hiller CE, die Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18:22–28. doi:10.1179/106698110X12595770849524 [CrossRef]
- Van den Bekerom MPJ, Kerkhoffs GMMJ, McCollum GA, Calder JDF, Niek van Dijk C. Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013;21:1390–1395. doi:10.1007/s00167-012-2252-7 [CrossRef]
- Glasgow M, Jackson A, Jamieson AM. Instability of the ankle after injury to the lateral ligament. J Bone & Joint Surg Br. 1980;62:196–200.
- Mulligan B. Manual Therapy: Nags, Snags, MWMs, Etc. Wellington, New Zealand: Plan View Services, Ltd; 2010.
- Hing W, Hall T, Rivett D, Vicenzino B, Mulligan B. The Mulligan Concept of Manual Therapy: Textbook of Techniques. Chatswood: Australia: Elsevier; 2015.
- Mau H, Baker RT. A modified mobilization-with-movement to treat a lateral ankle sprain. Int J Sports Phys Ther. 2014;9:540–548.
- Vela LI, Denegar CR. The Disablement in the Physically Active Scale: Part II. The psychometric properties of an outcomes scale for musculoskeletal injuries. J Athl Train. 2010;45:630–641. doi:10.4085/1062-6050-45.6.630 [CrossRef]
- Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17:163–170. doi:10.1179/jmt.2009.17.3.163 [CrossRef]
- Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on an numerical rating scale. Eur J Pain. 2004;8:283–291. doi:10.1016/j.ejpain.2003.09.004 [CrossRef]
- Someeh M, Norasteh AA, Daneshmandi H, Asadi A. Immediate effects of Mulligan's fibular repositioning taping on postural control in athletes with and without chronic ankle instability. Phys Ther Sport. 2015;16:135–139. doi:10.1016/j.ptsp.2014.08.003 [CrossRef]
- Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis. 2011;69:17–26.
- Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48:528–545. doi:10.4085/1062-6050-48.4.02 [CrossRef]
- McCrisken BJ, Cameron KC, Orr JD, Waterman BR. Management and prevention of acute and chronic lateral ankle instability in athletic patient populations. World J Orthop. 2015;6:161–171. doi:10.5312/wjo.v6.i2.161 [CrossRef]
- Hubbard TJ, Hertel J, Sherbondy P. Fibular position in individuals with self-reported chronic ankle instability. J Orthop Sports Phys Ther. 2006;36:3–9. doi:10.2519/jospt.2006.36.1.3 [CrossRef]
- Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Ther. 2008;13:63–67. doi:10.1016/j.math.2006.09.008 [CrossRef]
- Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normal?Man Ther. 1999;4:19–24. doi:10.1016/S1356-689X(99)80005-8 [CrossRef]
- Mavi A, Yildirim H, Gunes H, Pestamalci T, Gumusburun E. The fibula incisura of the tibia with recurrent sprained ankle on magnetic resonance imaging. Saudi Med J. 2002;23:845–849.
- Hetherington B. Lateral ligament strains of the ankle, do they exist?Man Ther. 1996;1:274–275. doi:10.1054/math.1996.0279 [CrossRef]
- O'Brien T, Vicenzino B. A study of the effects of Mulligan's mobilizations with movement treatment of lateral ankle pain using a case study design. Man Ther. 1998;3:78–84. doi:10.1016/S1356-689X(98)80022-2 [CrossRef]
Patient-Reported Outcomes Measures Posttreatment
|Measure||Day 1 (Initial)||Day 2||Day 4||Day 6||Day 8||Day 11 (Discharge)|