Acute ankle sprain is the most frequent orthopedic injury in intercollegiate athletics, accounting for 10% to 25% of all sports injuries.1,2 Approximately 28.3% of those initial ankle sprains reoccur within 1 year.3 Chronic ankle instability (CAI) is a constraining condition that is encountered frequently after an ankle injury and is characterized by a recurring “giving way” of the ankle joint.4–7 In addition to giving way, individuals with CAI usually complain of repetitive acute ankle injuries, consistent inflammation, and discomfort.1–3,8–10 Several obstinate complications (eg, a high frequency of chronic symptoms, decreased physical activity, recent injury, and functional abnormalities) can obstruct an individual's ability to successfully complete daily tasks or even participate in physical activity.1,10–12 Due to the high percentage of patients who develop CAI, more research is needed to better understand the most effective treatments and rehabilitation strategies.
Recently, manual therapy techniques have been examined as potential treatment options to address both mechanical and neuromuscular changes in individuals with CAI.1,13–16 One manual therapy technique, instrumented soft tissue mobilization (ISTM), is used to assist with the release of soft tissue adhesions and fascial restriction.1 The method employs a collection of six stainless steel instruments of a particular size and contour that are used to manipulate a variety of soft tissue regions. Specific stroke patterns are used with the instruments to detect and relieve adhesions located in the muscles and tendons.1,15,16 Studies have reported that ISTM could reduce inflammation and scar tissue build up and increase flexibility in a healthy population.1,15,16 Because research has reported mechanical changes in patients with CAI, ISTM could be an effective treatment option.8,12
One concern with ISTM is the limited research examining its efficacy, especially in younger patients with musculoskeletal injuries such as CAI. Further, the majority of ISTM research has not explored rehabilitation strategies that incorporate manual therapy in improving neuromuscular and functional dysfunction in individuals with CAI.1,16 Thus, further research is needed to explore the isolated effects of soft-tissue techniques on neuromuscular outcomes in individuals with CAI. ISTM may be another method to improve neuromuscular function. The first goal of this study was to assess the effects of a 4-week ISTM treatment on balance, subjective function, and range of motion in patients with CAI relative to a sham treatment. The second aim was to assess subjective function, balance, and range of motion 2 weeks after treatment ended to determine how long the treatment effects last. We hypothesized ISTM would result in significantly improved subjective function, balance, and range of motion compared to the sham treatment. We also hypothesized the ISTM group would have continued improvement in all dependent variables 2 weeks after treatment ended.
This was a randomized control trial in which 16 student athletes were recruited from the University of North Carolina at Charlotte's athletic department. The recruited athletes participated in the following sports: football, baseball, women's soccer, and volleyball. All participants were randomly allocated via a hat drawing to receive ISTM (4 men, 4 women, weight: 73.43 ± 18.18 kg; height: 177.8 ± 7.68 cm; age: 20.0 ± 1.07 years) or sham treatment (4 men, 4 women, weight: 80.25 ± 28.81 kg; height: 177.53 ± 11.30 cm; age: 19.75 ± .886 years). The athletes continued participating in normal athletic practices and competitions. The author who collected all of the data (JAJ) was not blinded to group allocation. The patients were not informed of the purpose of the study or the group allocation differences.
To classify a patient as having CAI, he or she was required to have had a history of at least one significant ankle sprain.17 The initial sprain had to occur at least 12 months prior to study enrollment, be associated with pain and swelling, and be significant enough to interrupt at least 1 day of preferred physical activity. Participants had to report at least two incidents of the ankle giving way in the past 6 months. Finally, participants had to score less than 24 on the Cumberland Ankle Instability Tool (CAIT).17,18 Exclusion criteria were an ankle sprain (or any acute musculoskeletal injury to the lower limb) within the past 3 months, a history of previous surgery to either lower extremity, a history of fracture in either limb, or any neuromuscular disease/impairments.17 All participants reviewed and signed an informed consent form prior to participating in the study. Our inclusion criteria were based on recommendations by the International Ankle Consortium for identifying younger adults with CAI.17 The institutional review board of the University of North Carolina at Charlotte approved this study.
Before the study began, 4 weeks after treatment, and 2 weeks after treatment ended, all participants completed the Foot and Ankle Ability Measure (FAAM) assessing subjective function, Balance Error Scoring System (BESS) assessing balance, and a weight-bearing lunge test assessing dorsiflexion range of motion.
The FAAM questionnaire consisted of a 21-item daily living activities and an 8-item sport subscale questionnaire that asked specific questions about the ankle and the athlete's perceived difficulty with certain activities.19 The FAAM has been reported as a reliable, responsive, and valid measure of physical function for individuals with a musculoskeletal pathology of the lower leg, foot, and ankle.19
The BESS included a three-stance variation of double leg, single leg, and tandem stance performed by the participant with his or her eyes closed. Each stance was performed on a firm surface and a foam surface, with each trial lasting 20 seconds. Errors that were relevant to insufficient balance included moving hands off of the hip, opening eyes, stepping or stumbling, overabduction or flexion of the hip, or remaining out of the proper position for more than 5 seconds. The BESS was used because it was a reliable, cost-efficient, and objective method of assessing static postural stability in individuals with CAI and is sensitive to CAI-associated postural impairments.13
The weight-bearing lunge test was used to quantify dorsiflexion range of motion.8,20 The weight-bearing lunge test is accomplished by first marking the ground with a piece of tape. The participant places his or her toes on the edge of the tape and flexes the knee until it comes in contact with the wall. If the heel is comfortably resting against the ground the toes can be placed further away from the wall or tape to achieve a greater dorsiflexion range of motion. The weight-bearing lunge test is valid and reliable when calculating ankle dorsiflexion in patients with CAI.8,20
Participants were randomly placed into one of two groups: ISTM or sham treatment. Both groups reported three times per week for a total of 4 weeks. For the ISTM group, the treatment consisted of the application of Graston Technique to the involved ankle. To begin, the ankle and lower leg were cleaned, and lubrication emollient was applied to the treatment area. In the current study, we used three of six Graston instruments (GT2, GT3, and GT4 [Graston Technique, LLC, Indianapolis, IN]), which were administered over specific muscles (Figure 1). Graston Technique instrument GT2 was used through the framing stroke on the muscles and tendons of the gastrocnemius, soleus, tibialis anterior, and posterior tibialis (Figure 2). The framing stroke consists of applying instrument GT2 to a muscle or tendon in close relation to the bone. The instrument is applied with constant framing stroke alongside the bone. Graston Technique instrument GT3 was used through the strumming stroke around the lateral malleolus and the peroneus longus, brevis, and tertius muscles (Figure 3). The strumming stroke consists of applying the instrument GT3 to a muscle or tendon in the action of strumming a string. Graston Technique instrument GT4 was used through the fanning stroke on the muscles and tendons of the gastrocnemius, soleus, tibialis anterior, and posterior tibialis (Figure 4). The fanning stroke consists of applying the instrument GT4 to a muscle while applying pressure with a fanning motion. The fanning stroke is used in areas of the muscle belly. All stroke patterns were performed in an anterior, posterior, medial, and lateral direction with a total of 10 strokes. This way, the treatment group received treatment similar to what would be received in a clinical practice. The sham treatment group participants completed the 4-week treatment 3 days a week for 15 minutes just like the treatment group. The same stroke patterns were performed with very light pressure applied to the skin. ISTM was performed on the participants by the same medical professional certified in the Graston Technique M1 course.
Graston Technique instruments GT2, GT3, and GT4 with lubricant. GT2, GT3, and GT4 are manufactured by Graston Technique, LLC, Indianapolis, IN.
Graston Technique instrument GT2 with framing method. GT2 is manufactured by Graston Technique, LLC, Indianapolis, IN.
Graston Technique instrument GT3 with strumming method. GT3 is manufactured by Graston Technique, LLC, Indianapolis, IN.
Graston Technique instrument GT4 with fanning method. GT4 is manufactured by Graston Technique, LLC, Indianapolis, IN.
All participant descriptive data (height, weight, age, number of ankle sprains, and CAIT score) were analyzed using independent t tests between the ISTM and sham treatment groups. A 2 × 3 (group × time) repeated measure analysis of variance was used to analyze all dependent measures (balance, subjective function, and range of motion). Post hoc comparisons of between time means were performed using Tukey's HSD tests. A P value of less than .05 was used to determine the significant effects for each analysis. Hedge's g measures of effect sizes were calculated to determine the magnitude of the effect. The strength of effect sizes was determined as small (0.02 to 0.49), moderate (0.5 to 0.79), and large (≥ 0.80).21
Means and standard deviations for all dependent variables are presented in Table 1. Effect sizes are presented in Table 2. There were no significant differences in patient demographic data. The average number of ankle sprains reported by the ISTM treatment group was 3 ± 0.866 with a mean CAIT score of 16.63. The average number of ankle sprains reported by the sham treatment group was 2.75 ± 0.968 with a mean CAIT score of 17.38.
Treatment Effect Sizes
There were no group by time interactions for the FAAM (P = .593) or the FAAM sport (P = .682). There was a main effect for time, with no main effect for group (P = .069). The pretest and posttest patients in both groups showed significant improvements in the FAAM (P = .014) and FAAM sport (P = .001) scores. There were no significant differences between the posttest and the 2-week follow-up for either the FAAM (P = .600) or FAAM sport (P = .481). However, there was a significant difference between the pretest measurement and the 2-week follow-up for both the FAAM (P = .012) and FAAM sport (P = .005). Patients in the ITSM and sham treatment groups maintained improvements in subjective function (FAAM and FAAM sport) 2 weeks after treatment ended. The ISTM group had large effect sizes between before and after treatment, whereas the sham treatment group had moderate to large effect sizes.
There were no group by time interactions for the BESS measurements (P = .213). There were significant main effects for time for the firm single-leg stance (P = .002), firm tandem stance (P = .014), foam single-leg stance (P = .001), and foam tandem stance (P = .002). There were no significant group differences (P = .12). Between the pretest and the posttest measures, patients in both groups had significantly fewer errors comparing the pre-measurement to the post-measurement. For the firm single-leg stance (P = .921), firm tandem stance (P = .837), and foam tandem stance (P = .631), there were no significant differences for either group between the 4-week posttest and the 2-week follow-up. The foam single-leg stance (P = .010) had fewer errors at the 2-week follow-up compared to the 4-week posttest. The patients in both groups maintained the improvements in balance 2 weeks after treatment ended. Additionally, the balance scores for all measures were significantly better than the pretest measurement. Effect sizes were large for the ISTM group and small for the sham treatment group.
There were no significant group by time interactions for the weight-bearing lunge test (P = .654). There was a main effect for time. Patients in both groups had significantly more dorsiflexion motion between the pretest and the posttest (P = .001). There was no significant difference between posttest and the 2-week follow-up (P = .828). The patients in both groups maintained improvements in range of motion 2 weeks after treatment ended. Effect sizes were large for both groups.
The results from this study suggest that the participants with CAI had significant improvements in subjective function, balance, and range of motion during a 4-week soft tissue intervention regardless of the treatment (ISTM or sham) they received. We were surprised that there were no differences between the sham treatment and ISTM groups because we hypothesized participants receiving the ISTM treatment would have significant improvements in outcome variables over the 4-week treatment period when compared to the sham treatment. Interestingly, there were no statistically significant differences between the posttest and 2-week follow-up measurements for subjective function, balance, and range of motion between the groups. This implies that both the ISTM and sham treatment groups improved in subjective function, balance, and motion during the 4-week treatment period and maintained those improvements 2 weeks after treatment ended.
Although it was not statistically significant, one of the most important clinical findings was the changes in the weight-bearing lunge test. The ISTM group showed an average change of 4 cm and the sham group saw an improvement of approximately 3 cm on the weight-bearing lunge test. The weight-bearing lunge test has been reported as a valid measure of dorsiflexion range of motion.8 It has also been reported the average minimal detectable change is 1.9 cm. Therefore, ISTM may be the slightly more appropriate treatment option to improve dorsiflexion range of motion in patients with CAI compared to soft tissue massage.22 The clinical importance of the two interventions is further demonstrated in the group effect size calculations. The effect sizes for each group from the pretest to the posttest were moderate to high for most dependent variables, and the 95% confidence intervals were small. This demonstrates the clinical importance of using either ISTM or sham treatment to improve subjective function, static balance, and range of motion in patients with CAI. There were small effect sizes for most group variables between the posttest and 2 weeks after treatment ended. This demonstrates the lack of change 2 weeks after receiving the treatment. Clinically, this is important because it demonstrates that the effects of both ISTM and sham treatment last after treatment ends, further demonstrating the need to include one of the two treatments in the rehabilitation plan for individuals with CAI.
Schaefer et al.1 also reported improvements in subjective function, dynamic postural control, and range of motion during a 4-week treatment period with ISTM. The results reported by Schaefer et al.1 were similar to the results in the current study in that we saw improvements in both the ISTM and sham treatment groups. ISTM showed no more improvement when compared to a basic sham treatment. Schaefer et al.1 used the same sham technique as the current study, but used an additional instrument (GT5) and measured range of motion through a non-weight–bearing method. Both Schaefer et al.1 and the current study reported improvements in subjective function, balance, and range of motion (both weight-bearing and non-weight–bearing), but the sham treatment was equally effective.1 Although there are no other studies to which we can make direct comparisons, based on the results from Schaefer et al.1 and the current study, both ISTM and sham treatment improve outcomes in patients with CAI, and therefore should be incorporated as a supplement to their rehabilitation plan.
Recurring ankle sprains can be caused by arthrokinematic impairments, pathologic laxity, synovial changes, and neuromuscular control deficits.2,4,5,23,24 The improvement in subjective function, balance, and range of motion reported in the current study may have been due to consistent breaking up of small adhesions in the ligament and muscle, lengthening of the muscle belly and tendons, and repetitive sensory interaction. Research studies have demonstrated that ISTM can help loosen adhesions in the muscle belly and ligaments.5,25 Releasing adhesions can improve range of motion by elongating the muscle, resulting in an increase in dorsiflexion of the ankle. In the current study, the sham treatment included a light massage, which could also show improvements in adhesions in the muscle belly, tendons, and ligaments. ISTM may have re-educated neuromuscular control deficits by improving firing patterns and postural control. Consistent manipulation of the muscles and ligaments with the instruments may have improved balance through stimulation of the mechanoreceptors. Mechanical insufficiencies were not measured in this study, making the impairments of our patients unknown; however, all of the positive attributes may have contributed to the improvement of the outcome measures.
The most significant limitation of the current study is the small sample size. Further research is needed to determine if similar results are found in a larger population. This study demonstrates the need for further research and use of manual therapy in the treatment of patients with CAI.
Implications for Clinical Practice
Because both the ISTM and sham treatment groups improved in the current study, it can be concluded that light massage of the lower leg and ankle is a clinically efficient treatment and rehabilitation protocol. To perform the Graston Technique, clinicians must be certified in the proper use of the instruments. The instruments are expensive and can only be ordered if a health care provider is certified after taking a 12-hour course; however, the Graston Technique instruments typically save clinicians' hands due to the number of patients treated in one day. A sham treatment or a roller massage is more cost-effective and more easily available in a clinical environment.26 If ISTM and sham treatments have the same outcome, sham treatment is more efficient, cost-effective, and applicable to clinical practice. However, because both treatments reportedly work, clinicians can select the technique that works best for them and for their patients.
The 4-week ISTM and sham treatments showed significant improvements in subjective function, balance, and range of motion in collegiate athletes with CAI. There were no statistically significant differences between posttest and the 2-week follow-up. This indicates that ISTM and sham treatment can be beneficial in the CAI population. Although both groups showed improvements with treatment, several improvements were maintained after treatment ended. Clinical soft tissue massage was as effective as ISTM, and thus should be used to help treat patients with CAI.
- Schaefer JL, Sandrey MA. Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument-assisted soft-tissue mobilization for chronic ankle instability. J Sport Rehabil. 2012;21:313–326. doi:10.1123/jsr.21.4.313 [CrossRef]
- Coughlan G, Caulfield B. A 4-week neuromuscular training program and gait patterns at the ankle joint. J Athl Train. 2007;42:51–59.
- Pietrosimone BG, Gribble PA. Chronic ankle instability and corticomotor excitability of fibularis longus muscle. J Athl Train. 2012;47:621–626. doi:10.4085/1062-6050-47.6.11 [CrossRef]
- Gutierrez GM, Kaminski TW, Douex AT. Neuromuscular control and ankle instability. PM R. 2009;1:359–365. doi:10.1016/j.pmrj.2009.01.013 [CrossRef]
- O'Driscoll J, Kerin F, Delahunt E. Effect of a 6-week dynamic neuromuscular training program on ankle joint function: a case report. Sports Med Arthrosc Rehabil Ther Technol. 2011;3:13. doi:10.1186/1758-2555-3-13 [CrossRef]
- Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of a star excursion balance test in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37:501–506.
- Knapp D, Lee SY, Chinn L, Saliba SA, Hertel J. Differential ability of selected postural control measures in the prediction of chronic ankle instability status. J Athl Train. 2011;46:257–262. doi:10.4085/1062-6050-46.3.257 [CrossRef]
- Basnett CR, Hanish MJ, Wheeler TJ, et al. Ankle dorsiflexion range of motion influences dynamic balance in individuals with chronic ankle instability. Int J Sports Phys Ther. 2013;8:121–128.
- Benazzo F, Zanon G, Marullo M, Rossi SM. Lateral ankle instability in high demand athletes: reconstruction with fibular periosteal flap. Int Orthop. 2013;37:1839–1844. doi:10.1007/s00264-013-2049-4 [CrossRef]
- Gribble PA, Hertel J, Denegar CR, Buckley WE. The effects of fatigue and chronic ankle instability on dynamic postural control. J Athl Train. 2004;39:321–329.
- 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]
- Mau H, Baker RT. A modified mobilization-with-movement to treat a lateral ankle sprain. Int J Sports Phys Ther. 2014;9:540–548.
- Docherty CL, Valovich McLeod TC, Shultz SJ. Postural control deficits in participants with functional ankle instability as measured by the balance error system. Clin J Sports Med. 2006;16:203–208. doi:10.1097/00042752-200605000-00003 [CrossRef]
- McKeon PO, Hertel J. Systemic review of postural control and lateral ankle instability, part 1: can deficits be detected with instrumented testing. J Athl Train. 2008;43:293–304. doi:10.4085/1062-6050-43.3.293 [CrossRef]
- Howitt S, Wong J, Zabukovec S. The conservative treatment of Trigger thumb using Graston Technique and Active Release Techniques. J Can Chiropr Assoc. 2006;50:249–254.
- Miners AL, Bougie TL. Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, Graston Technique, ART, eccentric exercise, and cryotherapy. J Can Chiropr Assoc. 2011;55:269–279.
- 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;43:585–591. doi:10.2519/jospt.2013.0303 [CrossRef]
- Hiller CE, Refshauge KM, Bundy AC, Herbert RD, Kilbreath SL. The Cumberland ankle instability tool: a report of validity and reliability testing. Arch Phys Med Rehabil. 2006;87:1235–1241. doi:10.1016/j.apmr.2006.05.022 [CrossRef]
- 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;26:968–983. doi:10.1177/107110070502601113 [CrossRef]
- Calatayud J, Martin F, Gargallo P, García-Redondo J, Colado JC, Marín PJ. The validity and reliability of a new instrument device for measuring ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2015;10:197–202.
- Lakens D. Calculating and reporting effect sized to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863. doi:10.3389/fpsyg.2013.00863 [CrossRef]
- Powden CJ, Hoch JM, Hoch MC. Reliability and minimal detectable change of a weight-bearing lunge test: a systematic review. Man Ther. 2015;20:524–532. doi:10.1016/j.math.2015.01.004 [CrossRef]
- Cordova ML, Sefton JM, Hubbard TJ. Mechanical joint laxity associated with chronic ankle instability: a systematic review. Sports Health. 2010;2:452–459. doi:10.1177/1941738110382392 [CrossRef]
- Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364–375.
- Laudner K, Compton BD, McLoda TA, Walters CM. Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther. 2014;9:1–7.
- Ross SE, Guskiewicz KM. Examination of static and dynamic postural stability in individuals with functionally stable and unstable ankles. Clin J Sports Med. 2004;14:332–338. doi:10.1097/00042752-200411000-00002 [CrossRef]
|FAAM pretest||77.6 ± 3.38||73.9 ± 7.62|
|FAAM posttest||81.9 ± 1.73||79.3 ± 6.65|
|FAAM 2-week posttest||83.0 ± 1.60||77.0 ± 10.9|
|FAAMS pretest||21.8 ± 2.76||17.5 ± 6.05|
|FAAMS posttest||26.6 ± 1.41||23.9 ± 5.14|
|FAAM Sport 2-week posttest||26.9 ± 1.55||24.1 ± 5.54|
|BESS (Firm SL) pretest||3.00 ± 1.51||2.50 ± 2.73|
|BESS (Firm SL) posttest||1.38 ± 1.41||.750 ± 1.04|
|BESS (Firm SL) 2-week posttest||1.13 ± 1.36||.750 ± .707|
|BESS (Foam SL) pretest||6.50 ± 1.93||5.38 ± 2.62|
|BESS (Foam SL) posttest||3.25 ± 1.28||4.63 ± 1.60|
|BESS (Foam SL) 2-week posttest||2.50 ± 1.20||4.38 ± .513|
|BESS (Firm TS) pretest||.875 ± 1.25||1.13 ± 1.36|
|BESS (Firm TS) posttest||.375 ± .744||0.00 ± 0.00|
|BESS (Firm TS) 2-week posttest||.375 ± .518||.500 ± .535|
|BESS (Foam TS) pretest||2.50 ± 1.41||2.88 ± 2.30|
|BESS (Foam TS) posttest||1.13 ± 1.55||.750 ± 1.04|
|BESS (Foam TS) 2-week posttest||1.00 ± .926||.875 ± 1.25|
|WBLT pretest (cm)||6.87 ± 3.09||7.75 ± 2.51|
|WBLT posttest (cm)||10.4 ± 3.87||10.2 ± 2.95|
|WBLT 2-week posttest (cm)||9.50 ± 4.85||10.06 ± 4.33|
Treatment Effect Sizesa
|FAAM pretest to posttest||1.51 [.40 to 2.63]||1.09 [.04 to 2.14]|
|FAAM posttest to 2-week posttest||.62 [−.38 to 1.63]||−.24 [−1.22 to .74]|
|FAAMs pretest to posttest||1.92 [.74 to 3.11]||1.66 [.53 to 2.80]|
|FAAMs posttest to 2-week posttest||0.19 [−.79 to 1.17]||0.05 [−.93 to 1.03]|
|BESS SL pretest to posttest||−1.05 [−2.09 to 0.0]||−.80 [−1.82 to .22]|
|BESS SL posttest to 2-week posttest||0.17 [−1.15 to .80]||0.0 [−.98 to .98]|
|BESS TS pretest to posttest||0.96 [.81 to 1.01]||0.94 [.76 to 1.21]|
|BESS TS posttest to 2-week posttest||0.09 [.01 to .19]||0.13 [−.10 to .25]|
|WBLT pretest to posttest (cm)||.95 [−.08 to 1.99]||0.85 [−.18 to 1.87]|
|WBLT posttest to 2-week posttest (cm)||−.19 [−1.02 to .94]||−0.04 [−1.02 to .94]|