Effect of Static Stretching and Joint Mobilization in Patients with - PowerPoint PPT Presentation

Effect of Static Stretching and Joint Mobilization in Patients with Chronic Ankle Instability Jay Hertel, PhD, ATC, FACSM,FNATA Exercise & Sport Injury Laboratory Orthopedic Summit Las Vegas, NV December 8, 2017

Disclosures  Textbook Royalties – Wolters Kluwer  Grant Support:  National Institutes of Health

Ankle Sprains: Public Heath Issue  Ankle sprains are the most common injury in sports  Also common in military personnel & the general population  Societal burden includes direct costs, indirect costs, & long term consequences Gribble et al, Br J Sports Med, 2016

Ankle Sprains as a Public Heath Issue  Chronic ankle instability (CAI)  Repetitive sprains and “giving way”  Persistent symptoms  Diminished self-reported function  Prevalence = 40% of 1 st time sprainers at 12 month follow-up (Dohertry et al, AJSM, 2016)  College students with CAI take ~2000 less steps per day than their healthy counterparts ( Hubbard et al, JAT, 2015)  Relationship between ankle sprain history and development of osteoarthritis ( Valderrabano et al, AJSM, 2006 )

Hertel & Corbett (in press)

Donovan & Hertel, Chronic Ankle Instability Physician & Sports Med, Assessment & Treatment Algorithm 2012 Assess ROM Treat ROM Re-assess ROM Assess Strength Treat Strength Re-assess Strength Assess Balance Treat Balance Re-assess Balance Assess Treat Functional Re-assess Functional Activities Functional Activities Activities

Donovan & Hertel, Physician & Sports Med, 2012 ROM Treatment Treat with Mobilizations and Stretching Assess ROM Arthrokinematic Deficit No Re-assess ROM Osteokinematic Deficit Treat with Stretching

Joint Motion Algorithm Physiological Movement (Osteokinematics) Hypomobile Hypermobile Normal Strengthening & Neuromuscular Accessory Movement Control Exercises (Arthrokinematics) Limited = Capsular Restriction Evaluate at each relevant joint & Grade III/IV/V Mobs assess functional movement of the Normal = Contractile Restriction lower extremity Stretch Contractile Tissue

Osteokinematic Assessment

STRETCHING WORKS, BUT…  Stretching of the triceps surae muscles results in increased ankle dorsiflexion ROM, but it is unlikely to address arthrokinematic restrictions

Joint Mobilizations: Indications & Contraindications Contraindications: Indications:  Hypermobility  Pain  Joint effusion (Grade I-II OK)  Joint  Intra-articular fixation hypomobility  Osteoporosis  Muscle inhibition  Healing fracture  Malignancy in spine or limb  Osteomyelitis  Rheumatoid Arthritis

Talocrural Distraction  Grades I-II:  Pain relief  Grades III-V:  Increase general motion  No research on isolated use of this technque

Anterior-Posterior Talar Glides  Talus must glide posteriorly on tibia during ankle dorsiflexion  By far, the most researched joint mobilization concept at the ankle  Dorsiflexion deficits commonly reported after ankle sprain – WHY?

RESTRICTED POSTERIOR TALAR GLIDE  Posterior talar glide restricted 12 weeks after ankle sprain (Denegar et al, JOSPT, 2002)  Patients treated with posterior talar mobilization regained dorsiflexion ROM quicker after acute sprain  7° more dorsiflexion after 3 treatment sessions (Green et al, Phys Ther., 2001)  Patients with CAI treated with posterior talar mobilization had immediate increases in:  Dorsiflexion ROM (26%)  Posterior talar glide (50%) (Vicenzino et al, JOSPT, 2006)

Anterior-to-Posterior Talar Glide

J Orthop Res . 2012 During each session, each subject received 2, 2-min sets of Maitland Grade II talocrural joint traction and 4, 2-min sets of Maitland Grade III talocrural joint mobilization with 1 min of rest between sets.

 Direct comparison of talocrural joint mobilizations, calf stretching, & plantar massage

Tibiofibular Joints  Distal fibula is “stuck” Tibia anteriorly and inferiorly  Proximal fibula stuck posteriorly (Mulligan)  Mounting evidence supports this phenomenon in some Talus patients with lateral ankle instability Calcaneus

Anterior to Posterior Distal Fibula Mobilization

Proximal Fibula Mobilization

J EMG Kines, 2011 Proximal tib-fib manipulation caused immediate increase in soleus motorneuron pool excitablility

Manual Therapy , 2013  Significant increase in soleus motorneuron pool excitability in the soleus fibular reposition taping  No change found in the peroneus longus

DISTAL JOINTS  Subtalar*  Calcaneocuboid (Jennings & Davies, 2005)  Tarsometarsal*  Lateral  1 st ray *No evidence for these techniques in isolation

Whitman et al, JOSPT 2009 6 manipulations –mobilizations  4 significant predictors of  success:  Talocrural lateral glides  Proximal tib-fib manipulation  Symptoms worse when standing  Distal tib-fib manipulation  Symptoms worse in evening  Talocrural AP glides  Navicular drop >5 mm  Talocrural distraction manipulation  Distal tib-fib hypomobility  Rear foot distraction manipulation  If 3 of 4 predictors present:  (+) LR = 5.9  Clinical Predictor Rule  95% probability of success developed to predict success with manual therapy  Success = GROC of +5 to +7  Limitation: Shotgun  Not Success = GRPC of -7 to approach to manual therapy +4

Current Status of Evidence to Support Joint Mobilizations in Lateral Ankle Sprain/Instability Patients  Very little research that assesses what most skilled clinicians routinely do in clinical practice  Assess osteokinematics & arthrokinematics at multiple joints & treat appropriately  Decent evidence to support use of AP talar mobilization to increase DF ROM  Long term follow-up studies do not exist

Conclusions  Patients with ankle pathology may have osteokinematic & arthrokinematic restrictions  If you don’t assess for them, you won’t find them  Calf stretches will improve dorsiflexion ROM  Joint mobilizations & manipulations should be used with specific treatment goals in mind at joints with arthrokinematic restrictions  Neither should be use in isolation, but rather as part of a comprehensive treatment plan that includes therapeutic exercise

THANK YOU Jhertel@virginia.edu @Jay_Hertel