Tag Archives: inversion

The Ice-less Management of Acute Ankle Sprains

I’ve written several articles on the use of ice on injuries, the need for inflammation, and the intricate physiological process of tissue healing.  Despite the mounds of evidence that ice is not all it is cracked up to be, there still exists a dogmatic polarization that it has magical tissue-healing properties. I often get told “Prove to me that ice does not work.” No; that is not how evidence-based practice works. You need to prove that ice does work for the reasons you use it.

Read the comments I receive, and you will recognize our ice dependency. “If I don’t ice, then what do I replace it with?” That statement screams dependency. When we take away ice, we feel that a void must be filled. It doesn’t! The treatment decision is multifactorial; the injury type, severity, tissues involved, the person, etc., all play a role in how you treat that specific injury.

A 2013 position statement made by the National Athletic Trainers’ Association on the management of ankle sprains found ice therapies had a C-level of evidence 1. Meaning little or poor evidence exists. In an interview, the author of that article said: “I wish I could say that what we found is what is really being done in a clinical setting…. Maybe our European colleagues know 20151221_102243_resizedsomething we don’t…there is very little icing over there.”

The blog shows how I treated an acute ankle sprain without ice by using all of the fun little tools learned through school and further honed with clinical experiences, trial, and error. I did what I thought was best. This protocol should not be used for every ankle injury. My treatment and rehabilitation plan changed daily. Everything I did was based on my ankle needs. I did NOT use any biophysical or electromagnetic modalities. Everything I did was manual. This is not to say that I would not use other modalities, I just chose not to. My only rule? No ice. Continue reading

Prevent Dysfunctional Movement by Improving Ankle Mobility – A Research Review of Manual Therapy Techniques

Topic Overview:

A single joint with altered arthrokinematics can precipitate a kinetic chain domino effect that will wreck havoc on functional human movement.  One such joint is the ankle, where altered arthrokinematics has been linked to several forms of human movement dysfunction and subsequent musculoskeletal injury. Specifically, limited ankle dorsiflexion, has been associated with patellar tendionopathy, ipsilateral gluteus medius weakness, plantar fasciitis, medial tibial stress syndrome, contralateral shoulder pathologies, sacroiliac joint dysfunction, recurrent ankle sprains, chondromalacia, ACL tears, Iliotibial band syndrome, increasing frontal plane motion of the knee, external snapping hip syndrome and osteitis pubis (just to name a few).  In addition to the aforementioned injuries athletes ware at risk of significant performance declines in overall power, agility, and speed.  I am not saying that these are all caused from limited ankle dorsiflexion, but I am saying that limited ankle dorsiflexion can cause these issues.

These issues can create a huge headache for the athlete, health care practitioner, personal trainer or performance coach. So, the question is what can we do that to prevent or treat these dysfunctional patterns or injuries? Simple, increase ankle dorsiflexion. But how? There are several treatment methods so I began thinking what is the single best way to improve ankle dorsiflexion; static stretching, manual therapy, soft tissue release, dynamic flexibility? I could come up with only one solid, and universal one stop treatment option – manual therapy, specifically Movement with Mobilization (MWM). So I found a good research article to review that talks about MWM and the effect it has on ankle dorsiflexion.

Complete Reference: Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals With Recurrent Ankle Sprain. J Ortho Sports Phys Ther Jul 2006;36(7):464-71.

Introduction to the Study:

Mobilization with Movement  (MWM) techniques are commonly utilized to improve joint range of motion and reduce pain. Recent evidence indicates posterior glide of the talus and ankle dorsiflexion is deficient in patients suffering from recurrent ankle sprains. Clinicians have used MWM techniques as an effective tool to increase posterior talar glide and increase talocrural dorsiflexion. The purpose of this study is to evaluate effectiveness of two MWM techniques (weight-bearing and non-weight bearing) for treatment of recurrent ankle inversion ankle sprains.

Study Limitations:

  • Imaging studies have not been done to validate assessment of posterior talar glide.
  • Age range was limited to University’s student population age range of 18-27.
  • Time from injury only  9.4 months (mean) since most recent injury



  • 16 subjects (8 male, 8 female) age 18-27 from University of Queensland student population. Subjects must have history of recurrent unilateral ankle sprains, must not have had injury on contralateral side and must not have had injury within the past 6 months.

Dependent Variables:

  • Posterior Talar Glide – Posterior glide was applied while passively dorsiflexing at the ankle and flexing the knee.  Posterior talar glide measured with use of tibial inclinometer.
  • Weight-Bearing Ankle Dorsiflexion – Standing lunge until anterior knee touches wall. Measurement taken via tape measurement of toe to wall distance was taken.

Independent Variables:

  • Weight Bearing  Mobilization with Movement (MWM-WB)
  • Non-Weight Bearing Mobilization With Movement (MWM-NWB)
  • Control Group               


  • Randomized, double-blind, repeated-measures, cross over control design.

Statistical Analysis:

  • Three repeated trials of posterior talar glide and dorsiflexion taken pre and post treatment.
  • Omnibus 3×2 repeated-measures ANOVA
  • Paired t tests to determine pretreatment differences of affected and unaffected limbs for intrastudy use.


  • Pretreatment:
    • Posterior Talar Glide – 2.4° for the affected side and 6.3° for unaffected side.
    • Dorsiflexion – 4.2° affected side and 6.4° unaffected side.
  • Post treatment :
    • Posterior talar glide increased to 4.0° or 55% following MWM-WB.
    • Posterior talar glide increased to 4.1° or 50% following MWM-NWB.
    • Dorsiflexion increased to 4.8° or 26% following MWM-WB.
    • Dorsiflexion increased to 4.8° or 26% following MWM-NWB.
    • Control group increased to 3.3° or 17% following MWM-WB
    • Control group increased to 4.4° or 9% following MWM-NWB


Overall, both weight-bearing and non-weight-bearing MWM demonstrated significant positive effectiveness for improving posterior talar glide and ankle dorsiflexion. Maximum possible effect (MPE) for posterior talar glide utilizing Weight bearing MWM and non weight-bearing MWM was 55% and 50% respectively. MPE for ankle dorsiflexion was 26% for both weight-bearing and non-weight bearing MWM.  There was not a significant difference when comparing weight bearing and non-weight bearing MWM.

If you are an athlete, health care practitioner, personal trainer or performance coach and think that your issue might be associated with limited ankle mobility seek out a qualified practitioner. They will be able to identify if dorsiflexion limitations exist and will be able to treat that limitation properly and restore proper function.

Research Review: Anterior Positional Fault of the Fibula after Sub-acute Lateral Ankle Sprains

Complete Reference: Hubbard TJ, Hertel J. Anterior Positional Fault of the Fibula after Sub-acute lateral Ankle Sprains. Manual Therapy. 2008; 13: 63-67.

Clinical Relevance:

Ankle sprains are the most common sports related injury. Unfortunately rehabilitation can be problematic and recurrent injury is possible. A significant side effect of an ankle sprain is decreased ankle dorsiflexion. Research has linked limited ankle dorsiflexion to recurrent ankle sprains, chronic knee injury, ACL tears, increased knee frontal plane movement and excessive femoral rotation. When implementing a recovery program for ankle sprains it would be conducive to perform distal fibular posterior mobilizations to regain lost ankle dorsiflexion.


Recent studies suggest a positional fault of the distal fibula on chronically injured ankles. Studies have not been done to evaluate fibular translation during sub-acute lateral ankle sprains. Additionally studies have not examined the relationship of ankle inflammation and fibular positional fault. Positional fault of the fibula can increase pain, and decrease talocrural dorsiflexion and sub talar range of motion. The purpose of this study is to examine fibular positional fault during sub-acute lateral ankle sprains and correlate positional fault with ankle swelling.



  • 22 subjects (10 male, 12 female) recreationally active subjects.
    • 11 of 22 subjects (5 male, 6 female) with sub-acute lateral ankle sprains
    • 11 of 22 subjects (5 male, 6 female) with no history of previous ankle injury

Dependent Variables:

  • Fibula displacement measured with fluoroscope in relation to the tibia
  • Figure 8 tape measure method to evaluate swelling.


  • Mini 6600 Fluoroscope with a digital mobile C-Arm


  • Lateral fluoroscopic images taken with on both legs of the lateral ankle sprain (LAS) group and the control group.  Bolsters were added and a fluid inclinometer was utilized to ensure proper positioning.
  • Figure 8 measurement following Tatro-Adams, et al, 1995 to evaluate swelling. This was performed on both ankles of the LAS and control group.

Statistical Analysis:

  • Wilcoxon signed rank test was used to evaluate side-to-side differences within both LAS and control groups
  • Mann-Whitney tests to evaluate injured ankle of LAS group and same ankle of control group.
  • Mann-Whitney tests to evaluate uninjured ankle of LAS group and same ankle of the control group.
  • Pearson product moment calculated side-to-side difference in swelling and the corresponding fibular displacement


  • Wilcoxon signed rank test:
    • Significant differences within the ankles of the sub-acute LAS group (p=.008).
    • No significant difference within ankles of the healthy group (p=.563).
  • Mann-Whitney Test:
    • Significant difference between injured ankle and matched ankle of control group (p=.045)
    • No significant difference between uninjured ankle of LAS group and matched ankle of control group (p=.438)
  • Pearson Product moment:
    • Significant positive correlation of side to side differences in fibular position and swelling (r = 0.793, p = .004)
    • 63% of variance in the fibular position difference was explained by variance in ankle girth measurement.

Study Limitations:

  • Unknown if an altered fibular position existed prior to the injury.
  • Study does not indicate any literature review regarding possible translation of the tibia following ankle injury.
  • Study did not indicate whether subjects in the LAS group were excluded if they had previous injury on contralateral ankle.


Statistically significant outcomes indicate the fibula takes on an anterior positional fault in sub-acute LAS. Effect sizes were .91 within the sub-acute LAS group and 1.15 between sub-acute involved ankle and control group. These indicate clinically meaningful effects. In addition, the greater the swelling, as indicated by ankle girth measurement, the greater the anterior positional fault of the fibula. Previous studies have been done on this topic. Recent studies indicate posterior or no translation of the fibula, however these studies measured fibular movement in relation to the talus. Mulligan, 1995 showed the talus also translates anteriorly following inversion ankle sprain, which can explain the findings of those recent studies.