Efficacy of fibular mobilisation with movement and tape for the treatment of ankle inversion sprains: A randomised clinical trial

INTERVENTION: Group 1. Distal fibular mobilisation with movement ‐ This treatment technique involves the application of a posterior‐lateral and superior glide over the distal end of the fibula that is then maintained while the subject actively inverts the ankle to the end of pain‐free range. If full pain‐free range is achieved, overpressure is applied by the therapist (Vicenzino et al., 2011). 3 sets of 10 repetitions have been found to provide an immediate improvement in ROM and function (Merlin, McEwan, & Thom, 2005). In addition to this treatment, a posterior gliding fibular tape will be used. This will be in the form of two diagonal strips of non‐stretch tape at the level of the tibiofibular joint applying a posterior‐superior glide to the fibula. This has been advocated for the prevention and treatment of lateral ankle sprains (Hopper et al., 2009). Moiler, Hall and Robinson (2006) found the posterior gliding fibular tape to reduce the incidence of ankle sprains in basketball players when compared to other forms of prophylactic methods including traditional ankle taping and ankle bracing. Group 2. This group will only have the distal fibular mobilisation with movement and not the posterior gliding fibular tape that is being used in Group 1. The mobilisations and the posterior gliding tape will be applied for a maximum of 3 times per week for 2 weeks. The mobilisations and the posterior gliding tape will be discontinued before the end of week 2 if full pain‐free range of movement has been restored. Discontinuation of mobilisations and posterior gliding tape will be decided by the investigator measuring the outcome measures, who will be blind to the treatment allocation of the subject. The discontinuation of mobilisations and tape will be recorded, and used itself as a measure of the effectiveness of each intervention. Proprioceptive exercises will start in week 3 at the latest. When mobilisations and the posterior gliding tape are discontinued prior to the end of week 2, proprioceptive exercises will start as soon as treatment with mobilisations and tape is discontinued. These exercises involve standing on uneven surfaces while being challenged with environmental and external stimuli/perturbations, starting with less difficult challenges and progressing as balancing ability improves. This is a standard physiotherapy treatment following ankle sprains and is usually done daily and at training sessions as a warm up when returning to sport. The exercises should take about 15‐20 minutes each session. All subjects (in all three intervention groups) will receive 20 minutes of TENS (50‐100Hz, pulse width 150microseconds) and 5 minutes of oedema draining massage. This will be administered after the distal fibular mobilisation with movement treatment and before the application of tape in Group 1. All groups will also receive general advice on self management of their ankle injury (i.e., ice, elevation). Proprioception exercises, which have been found to significantly reduce injury recurrence (Hupperets, Verhagen, & van Mechelen, 2009), will also be included in all groups. Adherence will be monitored through regular physiotherapy visits and interviews in the first 5 weeks (weekly visits in weeks 3, 4, 5) and then by email or phone communication. CONDITION: Grade II sprain of the lateral collateral ligament of the ankle SECONDARY OUTCOME: Ankle and foot range of movement (ROM):‐ ; 3.Inversion and Eversion Range of movement‐ ; ; Pain: ; ; Ankle and foot range of movement (ROM):‐ ; ; ; PRIMARY OUTCOME: Foot and Ankle Ability Measure (FAAM) ‐ The FAAM will be used to assess the participant´s change in function during the treatment. The FAAM has been used previously to assess the effect of treatment on patients with ankle injuries (Gilbreath, Gaven, Van Lunen, & Hoch, 2013), and has been found to be a valid and reliable measurement tool for ankle function (Martin, Irrgang, Burdett, Conti, & Van Swearingen, 2005). The FAAM consists of 29 items separated into two subscales: a 21‐item activities of daily living subscale and a 8‐item sports subscale. Each item is scored on a 5 point Likert scale ranging from “no difficulty” to “unable to do”. Lower scores are indicative of greater levels of functional loss. Global rating of change (GROC) ‐ A Patient Global Impression of Improvement Scale (PGI‐I) will be used to measure the overall change of the patient. The PGI‐I is a seven‐point categorical scale, where the patient can rate their overall change since the start of the treatment (Farrar, Young, LaMoreaux, Werth, & Poole, 2001). Patients will be asked to choose a point in the scale that ranges from “very much improved” to “very much worse. The Spanish version of the scale developed by the Spanish Pain Society (Sociedad Espanola del Dolor) will be used. ; 2. Plantar Flexion Range of Movement: ‐ The protocol described by Nunes et al (2012) will be used to measure plantar flexion ROM. This protocol has shown very good intra‐tester reliability, and greater reliability than other methods such as goniometry and static image analysis. The participant will be positioned in a supine position and instructed to slide the foot on the plinth, whilst extending the knee and maintaining full contact between the sole of the foot and the plinth. The moment the sole of the foot looses contact with the plinth, the patient will be instructed to stop the movement and the measurement will be performed. The distance between the highest point on the knee and the plinth, and the horizontal distance between the most posterior aspect of the calcaneus and the projection of the vertical distance will be recorded. Ankle plantar flexion angle will be calculated by trigonometry. Ankle and foot range of movement (ROM):‐ ; 1. Visual analogue scale ‐ The visual analogue scale, a 10cm line with the two end points representing ‘no pain’ and ‘worst pain imaginable’ will be used as a measure of pain. The patients will be asked to rate the average and the maximum pain in the last 24 hours. Patients will be asked to make a mark representing their pain. The distance in cm from the “no pain” marker to the mark drawn by the patient will be used as the measure of the participant´s pain (Hawker, Mian, Kendzerska, & French, 2011). ; Weight bearing Dorsiflexion ‐ Weight bearing ankle dorsiflexion ROM will be measured using the knee‐to‐wall measurement. This measurement has been widely used to measure ankle ROM (Collins, Teys, & Vicenzino, 2004) and has been reported to have very good intra‐rater reliability (Konor, Morton, Eckerson, & Grindstaff, 2012). ; The participant will stand with their foot perpendicular to a wall and will be instructed to gradually dorsiflex their foot to a position where the knee touches the wall whilst maintaining the heel in contact with the floor. Participants will be asked to dorsiflex their foot to the point permitted by their symptoms. No attempts will be made to control or limit foot pronation or supination. The distance between the first toe and the wall will be used as a measure of the participant's ankle dorsiflexion ROM. ; Inversion and eversion ROM will be measured in prone using a hand‐held goniometer as described by Menadue et al (2006). This measurement protocol has been shown to have moderate to good between‐session within‐observer reliability. With the foot over the edge of the plinth, the ankle will be allowed to rest in plantar flexion. The participant will be instructed to move the foot to maximum ankle eversion and then inversion, and the ROM in each direction will be measured. The axis of the goniometer will be positioned at the midpoint between the malleoli. The angle formed between a line bisecting the posterior aspect of the lower leg and a line bisecting the posterior aspect of the calcaneus will be used to measure eversion and inversion ROM. Ankle and foot volume ‐ A volumeter will be used to measure ankle and foot volume. The measurement will be taken in sitting for patient comfort and safety. Foot and ankle water volumetry has been to shown to have very good reliability (Petersen et al., 1999), and offer a higher responsiveness to change than other methods of volume measurement (Henschke, Boland, & Adams, 2006). Ankle eversion muscle strength ‐ Strength of the ankle evertors will be measured using a hand‐held dynamometer (HHD). A systematic review by (Stark, Walker, Phillips, Fejer, & Beck, 2011) found hand‐held dynamometry to be both valid and reliable for the measurement of muscle strength. Participants will be positioned in a long sitting position with their feet over the edge of the plinth, and the HHD will be positioned against the lateral border of the 5th metatarsal head. Participants will be instructed to perform an isometric ankle eversion against the HDD for 5 seconds. An average of 3 repetitions separated by two 10‐second rest periods will be used as a measure of ankle eversion strength. The participants will be allowed a submaximal familiarisation contraction prior to testing (Carroll, Joyce, Brenton‐Rule, Dalbeth, & Rome, 2013). Balance ‐ With the subject standing on one leg over a stabilometer (force platform), the displacement of the centre of pressure will be used to assess the balance (Hopper et al., 2009). Pain: INCLUSION CRITERIA: Amateur football players with a Grade II sprain of the lateral collateral ligament of the ankle presenting to the Vizcay Association of Football following an acute inversion injury (maximum 72 hours post injury) will be invited to take part in the study. (A Grade II sprain is defined as a partial tear of the ligaments with moderate pain, swelling and tenderness over the involved structures with some loss of motion and mild or moderate instability of the joint (Kaikkonen, Kannus, & Jarvinen, 1994)). ; 2. Pressure pain threshold (PPT) ‐ PPT will be measured at two sites: directly distal to the lateral malleolus over the calcaneofibular ligament, and directly anterior to the lateral malleolus over the anterior talofibular ligament (Collins et al., 2004). The test will be performed first (twice) on the anterior talofibular ligament of the unaffected ankle in order to first familiarise the participant with the procedure. PPT will be defined as the amount of pressure required to elicit the first onset of a sensation of pain that is distinct from pressure or discomfort. Pressure with the algometer will be increased at a rate of 5 Newtons per second. An average of three measurements performed 15 seconds apart will be calculated to reflect PPT at each measured site (Chesterton, Sim, Wright, & Foster, 2007). Recurrence rate will be recorded by medical staff attending to any of the participants who re‐sprain their ankle within the study period. This data will be collected on a questionnaire. When a treatment is applied, all measurements will be performed at the beginning of the treatment session. Measurements will be performed by an investigator blind to the group allocation of the participant.