ARTICLE IN PRESS Manual Therapy 10 (2005) 224–231 www.elsevier.com/locate/math 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 a Affiliate Faculty, Regis University, Denver, CO, USA US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic and Manual Physical Therapy, USA c Department of Physical Therapy, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX, USA d West Texas Rehab Center, Abilene TX, USA b 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. doi:10.1016/j.math.2004.10.003 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., 1998). 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 ARTICLE IN PRESS 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., 1984). 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 management. 225 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 physiotherapist. 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 ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231 226 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 injuries. 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 Measurement Baseline 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 7/10 5.5 68.30% None 1/10 10 96.30% Two miles (one time) without pain 0/10 10 95.60% Two miles, 4–6 times weekly without pain NPRS ¼ Numeric Pain Rating Scale (0 ¼ no pain; 10 ¼ worst pain imaginable). ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231 227 Table 2 Impairment and physical performance measurements Measurement Baseline Immediately after initial treatment (ﬁrst visit) Four-day follow-up Six-week follow-up Ankle active ROM Plantarﬂexion Dorsiﬂexion Inversion Eversion Total ankle ROM NPRS with gait NPRS with squat NPRS with step-up 541 51 401 151 1141 2/10 4/10 3/10 601 131 421 151 1301 1/10 2/10 0/10 Not assessed Not assessed 0/10 0/10 0/10 0/10 0/10 0/10 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 ARTICLE IN PRESS 228 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 ARTICLE IN PRESS 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, 1999). 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 229 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- ARTICLE IN PRESS 230 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. Disclaimer 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. References 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 1998;27(4):276–84. American Physical Therapy Association (APTA). Guide to physical therapist practice. Physical therapy, Issue No. 81. 2nd ed. 2001. p. 9–744. Beirne DR, Burckhardt JG, Peters VJ. Subtalar joint subluxation. Journal of the American Podiatry Association 1984;74(11): 529–32. 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 2002;32(4):166–73. 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 1994;159(1):15–20. 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): 2835–43. 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 1998;19(10):653–60. 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 1994;58(3):387–92. 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 1986;8(2):71–4. 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. ARTICLE IN PRESS 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. 231 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.