The use of manipulation in a patient with an ankle... respondingto conventional management: a case report

Manual Therapy 10 (2005) 224–231
Case report
The use of manipulation in a patient with an ankle sprain injury not
responding to conventional management: a case report$
J.M. Whitmana,b,, J.D. Childsc, V. Walkerd
Affiliate Faculty, Regis University, Denver, CO, USA
US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic and Manual Physical Therapy, USA
Department of Physical Therapy, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX, USA
West Texas Rehab Center, Abilene TX, USA
Received 12 January 2004; received in revised form 13 September 2004; accepted 14 October 2004
1. Introduction
Ankle sprains are common among physically active
individuals, (Almeida et al., 1999) with a reported
incidence of seven injuries per 1000 persons over a 1year period. (Holmer et al., 1994). The primary
environments in which these injuries occurred were
during sports (45%), play (20%), and work (16%)
activities, with inversion ankle sprains accounting for
over 60% of the sprains. (Holmer et al., 1994). In a
study of 547 patients with ankle sprains, Fallat et al.
(1998) found that the anterior talofibular ligament
(ATFL) was most frequently injured, followed by the
calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). A combination of injury to the
ATFL and the CFL accounted for 34.2% of the ankle
sprains, and involvement of all three ligaments was
found in 31.3% of the injuries (Fallat et al., 1998).
Inversion ankle sprains are typically classified as
Grades I, II, or III based on a pathoanatomical model
Previous Presentation: This case was presented as a Sports Section
Research Platform Presentation at the 2002 Combined Section
Meeting of the American Physical Therapy Association in Boston,
MA. This study was exempt from review by the Wilford Hall Medixcal
Center Institutional Review Board (IRB) and the University of
Pittsburgh IRB based on the study being a case report.
Corresponding author. Regis University, Rueckert-Hartman School
for Health Professionals, Mail Code G-9, 3333 Regis, Blvd, Denver, CO
80221-1099, USA. Tel.: +1 303 458 4340; fax: +1 303 964 5474.
E-mail address: [email protected] (J.M. Whitman).
1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
that consists of a combination of factors detected during
the physical examination. These factors include the
location of tenderness, the presence of oedema/ecchymosis, reduced weight-bearing ability, ligament damage,
reaction to ligamentous stability testing, and the
presence of instability (Gerber et al., 1998). Grade I
sprains have been reported to account for 71.3% of
injuries, with Grade II and III sprains accounting for
9.5% and 2.9% of the injuries, respectively (Fallat et al.,
Conventional management of Grade I ankle sprains
incorporates the RICE principles (Rest, Ice, Compression, and Elevation) combined with early motion and
full weight bearing (Wolfe et al., 2001). Its success in
improving mobility, pain, and disability has been well
documented in the literature (Linde et al., 1971; Dettori
et al., 1994; Eiff et al., 1994; Dettori and Basmania,
1994; Karlsson et al., 1996). Further, this approach has
been shown to lead to greater improvements in motion
and decreased pain and swelling than a program that
includes immobilization (Dettori et al., 1994).
The generally accepted prognosis is that a Grade I
ankle sprain treated with conventional management will
resolve within 7–14 days (Safran et al., 1999). However,
there appears to be a subgroup of patients who continue
to experience pain and functional limitations substantially longer than 2 weeks, (Dettori and Basmania, 1994;
Gerber et al., 1998), with some patients remaining
symptomatic even 1 year after injury (Dettori and
Basmania, 1994). Perhaps one reason that some
individuals continue to experience prolonged pain and
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
functional limitations even after completing a traditional rehabilitation program is that the conventional
management approach does not adequately address the
potential for underlying hypomobility in joints that are
susceptible to injury during an inversion ankle sprain.
Joints that may become injured and contribute to the
pain, limited motion, and functional limitations associated with an inversion ankle sprain include the
proximal and distal tibiofibular, talocrural, and the
subtalar joints. The talocrural joint is primarily responsible for the motions of dorsiflexion and plantar flexion,
and limited dorsiflexion is a common impairment in
individuals with an inversion ankle sprain (Denegar
et al., 2002).
It is possible that an individual with a Grade I ankle
sprain may exhibit decreased passive accessory motion
of this joint which may not be addressed by conventional management. Passive accessory motion is defined
as movements that a patient cannot perform himself but
which can be performed on the patient by someone else
(Maitland, 1991). For example, gliding the talus in an
anterior to posterior direction on a fixed distal tibia and
fibula would be considered an accessory motion that is
required for normal ankle physiologic dorsiflexion.
Restricted ankle accessory motions could contribute
to a slower improvement in pain and function than that
typically observed in individuals who sustain a Grade I
ankle sprain. The subtalar joint, which has also been
implicated in ankle sprain injuries, is primarily responsible for inversion and eversion and contributes to the
tri-planar motions of supination and pronation. The
subtalar joint is important for functional movement of
the talus, as a restriction in this joint can restrict ankle
motion, thus possibly contributing to the recalcitrant
nature of some inversion ankle sprains (Beirne et al.,
It seems reasonable to suggest that manipulation/
mobilization techniques for joints that exhibit limited
passive accessory motion may be helpful in the management of ankle sprains that do no respond to conventional management. The Guide to Physical Therapist
Practice (American Physical Therapy Association
(APTA), 2001) defines manipulation/mobilization as a
‘‘manual therapy technique comprising a continuum of
skilled passive movements to the joints and/or related
soft tissues that are applied at varying speeds and
amplitudes, including a small-amplitude/high-velocity
therapeutic movement.’’ Unfortunately, there is little
evidence on the efficacy of these types of interventions
for patients with ankle sprains not responding to
conventional management. Thus, the purpose of this
case report is to describe the use of manipulation/
mobilization for a patient after an inversion ankle
sprain who did not demonstrate any improvements
in pain or function after 3 weeks of conventional
2. Methods
2.1. History
The patient was a 27-year old volleyball player who
had suffered from an ankle sprain three weeks prior to
her first visit to physical therapy. The patient clearly
recalled and described an inversion mechanism of injury
that occurred while returning to the ground after
jumping to hit a volleyball. She had administered selftreatment with rest, ice, compression with self-ankle
taping, and elevation. This individual also reported that
she had been consistently doing strengthening exercises
with resistive tubing (dorsiflexion, plantarflexion, inversion, and eversion) per instruction by a therapist after a
previous ankle sprain injury. The patient noted no
change in symptoms over the 3 weeks of self-treatment,
although she had forced herself to stop using the
crutches approximately 1 week prior to her visit to the
The patient reported having a history of 6–7 inversion
ankle sprains of the involved ankle over the last 10–15
years. For previous injuries, symptoms typically resolved in 1 week, occasionally in up to 2 weeks, with
self-treatment of rest, ice, compression, and elevation.
This patient decided to seek medical care because this
injury was not responding to self-treatment using
conventional management. Although very active prior
to the injury, to include playing volleyball 2–3 days per
week and running 6–10 miles weekly, she was currently
completely unable to participate in exercise or sports.
The patient’s current symptoms included a constant
ache to the medial calcaneal region that varied based on
activity and an intermittent, burning pain extending
along the medial leg up to approximately 10 cm below
the medial tibial plateau (Fig. 1). On a numeric pain
rating scale (Downie et al., 1978; Jensen et al., 1994) the
patient reported a range of pain from 5 to 9 out of 10
over the last 24 h (Table 1). Interestingly, the patient’s
current symptoms were not characteristic of those from
previous injuries. Previous episodes involved only
symptoms localized to the lateral aspect of the ankle,
without any pain in the leg. The patient reported
increased pain with running, squatting, going up and
down steps, and prolonged weight-bearing. Non-steroidal anti-inflammatory medications and non-weightbearing positions temporarily eased her symptoms and
there were no other reported lower extremity symptoms
or low back pain (LBP).
Her baseline scores for several self-report measures of
function can be seen in Table 1. For the Foot and Ankle
Ability Index (FAAI), higher numbers represent greater
functional ability (Pugia et al., 2001). The Patient
Specific Functional Scale (PSFS) was used to help
quantify the patient’s specific functional limitations
(Stratford et al., 1995; Chatman et al., 1997). In this
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
scale, patients select a score for 3–5 specific activities
that they are having difficulty with as a result of their
problem. The range of available scores is 0–10, with 0
representing an inability to perform the activity and 10
representing an ability to perform activity at same level
as before the injury or problem. The patient identified
difficulty with negotiating stairs, squatting, prolonged
standing, and running. Her average score for the PSFS
was 5.5 and her score on the FAAI was 68.3%. The
patient’s primary goal was to quickly return to highlevel physical activity, including running without pain.
2.2. Physical examination
Based on a visual observation of the patient’s gait, the
patient was judged to exhibit a slightly antalgic gait,
with pain primarily occurring during the late stance
phase of gait when maximal talocrural dorsiflexion
range of motion (ROM) is required. Active dorsiflexion
ROM on the involved lower extremity, both with the
knee flexed and the knee fully extended, was limited to
51 and was painless with overpressure. Active ankle
ROM on the uninvolved lower extremity was normal.
ROM measurements were performed with a universal
goniometer, both in sitting with 901 knee flexion (as
described by Norkin and White, 2003), as well as in
supine with full knee extension. The patient’s strength
was essentially normal and pain free. Mild laxity was
present with the inversion talar tilt and anterior drawer
tests. No swelling or ecchymosis was present. Specific
pain scores were obtained during walking, squatting,
and with a step-up at baseline (Table 2). Based on the
patient’s self-report of limited oedema and ability to
fully bear weight soon after the initial injury, the patient
was judged to have a Grade I ankle sprain that was not
responding to conventional management. The presence
of slight laxity with the talar tilt and anterior drawer
tests was judged to be a sequela of previous ankle sprain
Based on our clinical experience and the suggestion of
others (Greenman 1996), patients with ankle sprains not
responding to conventional management and those with
a history of recurrent ankle sprains frequently demonstrate decreased passive accessory motion of the
proximal and distal tibiofibular joint, talocrural joint,
and the subtalar joint. As a result, the authors of this
manuscript routinely examine these joints in the management of all ankle sprain injuries. Passive accessory
motion testing revealed decreased mobility at the
proximal and distal tibio-fibular joints and the talocrural and subtalar joints relative to the opposite lower
extremity. All passive accessory motion testing was
performed as described by Maitland (1991). Radiographs
of the tibia, fibula, and foot and ankle were negative for
fracture or any other abnormalities, and the dorsiflexion/
external rotation and ‘‘squeeze tests’’ to rule out a
syndesmosis injury were negative (Alonso et al., 1998).
2.3. Treatment
Fig. 1. Patient’s pain diagram.
Based on the patient’s failure to respond with selftreatment utilizing conventional management and the
presence of decreased passive accessory motion in
several joints of the leg and ankle, the decision was
made to utilize manipulation/mobilization techniques
that targeted the underlying joint hypomobility identified in the examination. The techniques that were used
Table 1
Self-report measures of pain and function
Four-day follow-up
Six week follow-up
Average NPRS value for past 24 h
Patient specific functional scale
Foot and ankle ability index score
Running activity
Two miles (one time) without pain
Two miles, 4–6 times weekly without pain
NPRS ¼ Numeric Pain Rating Scale (0 ¼ no pain; 10 ¼ worst pain imaginable).
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
Table 2
Impairment and physical performance measurements
Immediately after initial
treatment (first visit)
Four-day follow-up
Six-week follow-up
Ankle active ROM
Total ankle ROM
NPRS with gait
NPRS with squat
NPRS with step-up
Not assessed
Not assessed
NPRS ¼ Numeric Pain Rating Scale (0 ¼ no pain; 10 ¼ worst pain imaginable).
are outlined in Table 3 with pictures that illustrate the
direction of movement. The proximal tibio-fibular joint
manipulation and the rearfoot distraction manipulation
were performed one time each. The talocrural joint
lateral glide mobilizations, subtalar joint eversion
mobilizations, and the talocrural joint anterior to
posterior joint mobilizations were each performed for
approximately 3–4 bouts of 30 oscillations.
Immediate improvements were noted after the manipulation/mobilization interventions. The patient demonstrated increased dorsiflexion ROM and experienced an
immediate decrease in pain during gait, negotiating
stairs, and squatting (Table 2). Additionally, when retested, passive accessory joint motion appeared to be
equal to the opposite ankle and foot except for some
remaining limitation in mobility in the rearfoot with
lateral glides.
visit and the patient was instructed in proprioception
and agility training exercises. In a telephone follow-up
call 11 days after the initial treatment, the patient
reported a return to full participation in volleyball and
running without limitation or pain (Tables 1 and 2).
2.6. Longer-term follow-up
All improvements in pain and function persisted 6
weeks after treatment, with a return to running 2 miles
4–6 days per week without pain. Her scores on the PSFS
and the FAAI remained stable (Table 1). Based on the
patient having achieved her goals and the absence of any
impairments or functional limitations, the therapist
reviewed the patient’s exercise program with her and
discharged her from physical therapy.
2.4. Home exercise program
3. Discussion
To reinforce the manipulation/mobilization techniques, the patient was taught to self-mobilize her ankle
into dorsiflexion and eversion. A weight bearing on/off
self-mobilization technique was used to increase dorsiflexion ROM, and a seated self-mobilization technique
was used to increase eversion ROM (Table 3).
Most patients who sustain a Grade I ankle sprain
improve rapidly with conventional management utilizing an RICE approach that emphasizes early motion
and full weight bearing. However, there appears to be a
subgroup of patients who continue to have symptoms
even at 1 year post-injury (Dettori and Basmania, 1994).
It seems reasonable to suspect that some of these
individuals may have decreased passive accessory joint
motion that is not addressed by conventional management and may benefit from interventions that utilize
manipulation/mobilization techniques.
There is little published evidence on the efficacy of
manipulation/mobilization for patients with any diagnoses involving the ankle or foot. A recent literature
search revealed a total of five randomized controlled
trials (Wilson, 1991; Dettori and Basmania, 1994; Green
et al., 2001; Pellow and Brantingham, 2001; Coetzer et
al., 2001) and a limited number of case–control studies,
case series, or case reports (Marshall and Hamilton,
1992; Nield et al., 1993; Mooney and Maffey-Ward,
2.5. Short-term follow-up
Four days after treatment, the patient reported
resolution of pain with squatting, standing, and
negotiating stairs and demonstrated no pain and normal
mobility with gait, squatting, and performing a step-up
during the physical exam (Table 2). The patient’s score
on the PSFS improved to a 10 and both subscales of the
FAAI improved substantially (Table 1). Additionally,
the patient returned to running up to 2 miles without
pain. Based on the presence of normal passive accessory
motion in the follow-up examination, no further
manipulation/mobilization was performed during this
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
Table 3
Description of mobilization/manipulation techniques
Reprinted with kind permission from Wainner R, Flynn T, Whitman J. Spinal and Extremity Manipulation: The Basic Skill Set for Physical
Therapists [book on CD-ROM]. San Antonio, TX; 2001. Copyright 2001, Manipulations Inc.
1994; O’Brien and Vicenzino, 1998; Menetrey and
Fritschy 1999; Dananberg et al., 2000). The populations
in these studies included normal subjects, (Nield et al.,
1993) individuals with acute (Dettori and Basmania,
1994; O’Brien and Vicenzino, 1998; Green et al., 2001;
Coetzer et al., 2001) and chronic ankle sprains (Pellow
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
and Brantingham, 2001) status post cast immobilization
secondary to fracture (Wilson, 1991) and with various
foot and ankle diagnoses such as ankle equinus
(Dananberg et al., 2000) cuboid subluxation (Marshall
and Hamilton, 1992; Mooney and Maffey-Ward, 1994)
and subtalar joint subluxation (Menetrey and Fritschy,
Only one study was identified with a patient population and treatment regimen similar to ours (Pellow and
Brantingham, 2001). Chronicity for this study was
defined as the persistence of pain for more than 5 days
after the initial injury. Patients in the experimental
group received an ‘‘ankle mortise separation technique’’,
similar to the rearfoot distraction technique that was
used in this patient. The control group received a
placebo treatment. Patients in the manipulation group
demonstrated a significant reduction in pain and
increased function compared to the control group both
immediately after treatment and at a 1-month followup. Although there are limitations in the study’s
methodology, the results seem to support the use of
manipulation in patients with persistent symptoms after
an ankle sprain injury.
In our experience, many clinicians avoid manipulation in acute and subacute injuries of the periphery
because of a belief that tissue damage has occurred, and
the notion that manipulation will contribute to further
tissue damage. In other areas, such as the lumbopelvic
region, the literature generally supports the use of
manipulation in the management of acute injuries (Koes
et al., 2001). Perhaps the pathoanatomical model that is
currently utilized to determine the severity of ankle
sprains (Grade I vs. Grade II vs. Grade III) biases
clinicians to inappropriately assume that manipulation/
mobilization may be harmful, when in fact some
individuals with recalcitrant ankle sprains may exhibit
decreased passive accessory joint motion that, if
adequately addressed, will lead to dramatic improvements in pain and function. Its interesting to note that a
pathoanatomical model (Waddell, 1996) based on a
‘‘tissue damage’’ model has been largely unsuccessful in
explaining pain and disability in LBP. Because of the
difficulty in sub-grouping patients with LBP based on
this model, attempts have been made to subgroup, or
classify, patients based on findings from the history and
physical examination (Flynn et al., 2002). Perhaps the
treatment of ankle sprains would benefit if clinicians and
researchers explored an alternate treatment-based classification scheme that is based on an individual patient’s
response to treatment rather than on a pathoanatomical
model that often fails to explain the pain and functional
limitations associated with recalcitrant ankle sprains.
Developing effective classification schemes or clinical
prediction rules that assist clinicians in selecting appropriate interventions based on a patient’s historical and
physical examination findings should improve clinical
decision-making and patient outcomes. Thus, if a
researcher wants to assess the efficacy of manipulation/mobilization, the identification of those patients
who actually have decreased passive accessory motion of
the ankle joints may be crucial. Although this may seem
obvious, most studies that have assessed the efficacy of
manipulation/mobilization in patients with an ankle
sprain did not assess passive accessory joint motion,
which is the primary impairment believed to be targeted
by manipulation/mobilization techniques. Without the
ability to match patients to specific treatments, clinicians
are left without evidence for their decision-making in
selecting treatments for a particular patient. Classification methods will also enhance the power of clinical
research by permitting researchers to study more
homogenous groups of patients.
Because this was a single case report, one cannot
conclude that the patient’s improvement in pain and
function was a result of the manipulation/mobilization.
However, given the recalcitrant nature of her injury, the
patient’s rapid response to manipulation/mobilization
suggests that this intervention may have been effective
for this patient. Despite the limited number of clinical
trials that assess the efficacy of manipulation/mobilization in the management of ankle sprain injuries, this
form of intervention seems to have some benefit for
patients with inversion ankle sprains. We believe it may
have the most benefit for patients who are not
responding to conventional management, and who
demonstrate limitations in passive accessory motion.
However, this hypothesis has not been investigated at
this time. Based on our experience with this patient and
others with chronic foot and ankle disorders who have
responded positively to manipulation/mobilization, it
would be helpful to identify those patients who will
respond to conventional management versus those
would benefit from the addition of manipulation/
mobilization. Perhaps this group of patients could even
be identified immediately after injury, which would
provide clinicians with a powerful tool to guide
treatment decisions and facilitate a more rapid improvement in pain and function in individuals who would
otherwise continue to have symptoms for a prolonged
period of time. Eventually, it would be useful to develop
a treatment-based classification system for all foot and
ankle disorders. Such a system would provide clinicians
a treatment-based framework to guide the decisionmaking process rather than relying primarily on a
pathoanatomical model.
4. Conclusion
This case demonstrates the use of manipulation/
mobilization to manage a patient who had pain that
was unresponsive to 3 weeks of conventional manage-
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
ment for her inversion ankle sprain. Supplementing
conventional management strategies with manipulation/
mobilization techniques may improve treatment effectiveness by decreasing pain and improving function in
shorter time periods. Although a causative relationship
cannot be drawn from a case report, it is our hypothesis
that utilization of manipulation/mobilization to address
impairments in joint mobility in the ankle and foot may
restore normal joint motion and allow for a quicker
return to sporting activities. While it is not the authors’
opinion that all patients with inversion sprains need this
treatment approach, perhaps there may be a subgroup
of patients for whom this intervention strategy would be
most effective. Future research is needed to determine
the optimal role of manipulation/mobilization in the
rehabilitation of patients after inversion ankle sprains.
The opinions or assertions contained herein are the
private views of the authors and are not to be construed
as official or as reflecting the views of the US Air Force
or Department of Defense.
Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological
patterns of musculoskeletal injuries and physical training. Medicine
& Science in Sports & Exercise 1999;31(8):1176–82.
Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis
injury: reliability and prediction of return to function.
Journal of Orthopaedic and Sports Physical Therapy
American Physical Therapy Association (APTA). Guide to physical
therapist practice. Physical therapy, Issue No. 81. 2nd ed. 2001. p.
Beirne DR, Burckhardt JG, Peters VJ. Subtalar joint subluxation.
Journal of the American Podiatry Association 1984;74(11):
Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW,
Schomberg A, Stabler M. The Patient-Specific Functional Scale:
measurement properties in patients with knee dysfunction. Physical
Therapy 1997;77(8):820–9.
Coetzer D, Brantingham J, Nook B. The relative effectiveness of
Piroxicam compared to manipulation in the treatment of acute
grades 1 and 2 ankle sprains. Journal of the Neuromusculoskeletal
System 2001;9(1):1–12.
Dananberg HJ, Shearstone J, Guillano M. Manipulation method for
the treatment of ankle equines. Journal of the American Podiatry
Association 2000;90(8):385–9.
Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on
dorsiflexion range of motion, posterior talar glide, and joint
laxity. Journal of Orthopaedic & Sports Physical Therapy
Dettori JR, Basmania CJ. Early ankle mobilization, Part II: a one-year
follow-up of acute, lateral ankle sprains (a randomized clinical
trial). Military Medicine 1994;159(1):20–4.
Dettori JR, Pearson BD, Basmania CJ, Lednar WM. Early ankle
mobilization, Part I: the immediate effect on acute, lateral ankle
sprains (a randomized clinical trial). Military Medicine
Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA,
Anderson JA. Studies with pain rating scales. Annals of the
Rheumatic Diseases 1978;37(4):378–81.
Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. American Journal of
Sports Medicine 1994;22(1):83–8.
Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome:
prevalence and analysis of 639 acute injuries. Journal of Foot
Ankle Surgery 1998;37(4):280–5.
Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Butler B, Rendeiro
D, Garber M, Allison S. A clinical prediction rule for classifying
patients with low back pain who demonstrate short term
improvement with spinal manipulation. Spine 2002;27(24):
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC.
Persistent disability associated with ankle sprains: a prospective
examination of an athletic population. Foot & Ankle International
Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled
trial of a passive accessory joint mobilization on acute ankle
inversion sprains. Physical Therapy 2001;81(4):984–94.
Greenman PE. Principles of manual medicine, 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 1996.
Holmer P, Sondergaard L, Konradsen L, Nielsen PT, Jorgensen LN.
Epidemiology of sprains in the lateral ankle and foot. Foot &
Ankle International 1994;15(2):72–4.
Jensen MP, Turner JA, Romano JM. What is the maximum number
of levels needed in pain intensity measurement? Pain
Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute
ligament injuries of the ankle joint. Scandinavian Journal of
Medicine and Science in Sports 1996;6(6):341–5.
Koes BW, van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical
guidelines for the management of low back pain in primary care: an
international comparison. Spine 2001;26(22):2504–13.
Linde F, Hvass I, Juergensen U, Madsen F. Early mobilizing
treatment of ankle sprains. A clinical trial comparing three types
of treatment. Scandinavian Journal of Sports Sciences
Maitland GD. Peripheral manipulation, 3rd ed. Oxford: ButterworthHeinemann; 1991.
Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers.
American Journal of Sports Medicine 1992;20(2):169–75.
Menetrey J, Fritschy D. Subtalar subluxation in ballet dancers.
American Journal of Sports Medicine 1999;27(2):143–9.
Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations:
assessment and treatment. Journal of Orthopaedic & Sports
Physical Therapy 1994;20(4):220–6.
Nield S, Davis K, Latimer J, Maher C, Adams R. The effect of
manipulation on range of movement at the ankle joint. Scandinavian Journal of Rehabilitation Medicine 1993;25(4):161–6.
Norkin C, White D. Measurements of Joint Motion: a guide to
goniometry, 3rd ed. Philadelphia: FA Davis; 2003.
O’Brien T, Vicenzino B. A study of the effects of Mulligan’s
mobilization with movement treatment of lateral ankle pain using
a case study design. Manual Therapy 1998;3(2):78–84.
Pellow JE, Brantingham JW. The efficacy of adjusting the ankle in the
treatment of subacute and chronic grade I and grade II ankle
inversion sprains. Journal of Manipulative and Physiological
Therapeutics 2001;24(1):17–24.
Pugia ML, Middel CJ, Seward SW, Pollock JL, Hall RC, Lowe L,
Mahony L, Henderson NE. Comparison of acute swelling and
function in subjects with lateral ankle injury. Journal of
Orthopaedic & Sports Physical Therapy 2001;31(7):384–8.
J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231
Safran MR, Benedetti RS, Bartolozzi AR, Mandelbaum BR. Lateral
ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Medicine & Science in
Sports & Exercise 1999;31(Suppl. 7):S429–37.
Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and
change on individual patients: a report of a patient specific
measure. Physiotherapy Canada 1995;47:258–63.
Waddell G. Low back pain: a twentieth century health care enigma.
Spine 1996;21(24):2820–5.
Wilson FM. Manual therapy versus traditional exercises in mobilisation of the ankle post-ankle fracture: a pilot study. New Zealand
Journal of Physiotherapy 1991;19(3):11–6, Dec. (7 ref).
Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of
ankle sprains. American Family Physician 2001;63(1):93–104.