Research Review By Gary Maguire©

Date Posted:

July 2010

Study Title:

Does distal tibiofibular joint mobilization decrease limitation of ankle dorsiflexion?

Authors:

Fujii M, Suzuki D, Uchiyama E et al.

Author's Affiliations:

Graduate School of Health Sciences, Sapporo Medical University, School of Health Science, Sapporo, Japan.

Publication Information:

Manual Therapy 2010; 15: 117-121.

Background Information:

Restricted ankle dorsiflexion becomes a serious problem during activities of daily living, not to mention athletic tasks (e.g. normal gait requires at least 10° of dorsiflexion and kneeling or descending stairs requires more ankle motion). Ankle sprains and fractures are common orthopedic injuries that restrict ankle mobility and depending on the extent of the injury the use of a brace or plate fixation may be required for several weeks.

This can result in limited mobility and pain even when prudent treatment guidelines are followed (evidence suggests this involves 20-40% of patients). Women who often wear high heeled shoes can also have limited dorsiflexion (although this is often due to shortening of the Achilles tendon and gastroc group versus loss of ankle joint mobility).

There are three types of physical therapy approaches to address restricted dorsiflexion: range of motion (active and/or passive) to increase mobility, joint mobilization to improve accessory joint movements and stretching to improve flexibility of muscles, fascia and connective tissue.

Joint mobilization (JM) is effective in improving joint dysfunction and providing pain relief (1). JM for ankle dorsiflexion focuses on three joints: the talocrural, subtalar and distal tibiofibular. The use of gliding interventions targeting both the anterior and posterior tibiofibular ligaments improves ankle dorsiflexion but the use of JM for the tibiofibular joint has not been used very frequently.

The focus of this cadaveric study was to investigate how the distal tibiofibular joint should be moved; how much it moves; and how much dorsiflexion improves if JM is provided to the distal tibiofibular joint mechanism.

Emphasis was on studying the movement of the joint during gliding on the lateral malleolus, the technique’s effect on displacement of the lateral malleolus and the dorsiflexion angle (utilizing a cyclic load-simulating oscillatory gliding technique). Electromagnetic sensors were applied to frozen fresh cadavers (5M and 2F, mean age of 79.4) to accurately measure the above parameters.

Pertinent Results:

  • Joint mobilization techniques were based on Maitland’s gliding theory and involved oscillatory movement.
  • Results of the study suggest that cyclic loading to the distal fibula is effective for increasing the range of ankle dorsiflexion and that JM should be utilized to improve limitations of dorsiflexion. The use of a posterosuperior glide is beneficial to improve an anterior positional fault (movement of the lateral malleolus anteriorly during dorsiflexion) of the distal fibula.
  • The lateral malleolus was loaded cyclically with a 30N force, 1000 times at a speed of 15/Ns in a direction 45° posterosuperiorly to vertical (as in a JM)...the purpose was to examine the relationship of oscillations and movement of the lateral malleolus during dorsiflexion.
  • Performing a joint mobilization involving posterosuperior gliding of the fibula appears to be an effective treatment technique to improve limited ankle dorsiflexion (at least in a cadaveric model – naturally, further research is required on live human subjects to verify this).
  • There is a relationship between the number of cycles and displacement which approximates a logarithmic curve. The initial increase in lateral malleolus displacement was modest due to the distal fibula being firmly attached at the fibular notch of the tibia and the four supporting ligaments (anterior tibiofibular, interosseous, superficial posterior tibiofibular and deep posterior tibiofibular).
  • The average dorsiflexion angle increased from 14.36 ± 7.51° to 16.74 ± 7.21° after cyclic loading (P < 0.05).
  • It should also be noted that a variation exists in the direction of fibular motion depending on the shape of the fibular incisura on the tibia.

Clinical Application & Conclusions:

Joint mobilization for the distal tibiofibular joint is used to reduce both chronic pain and improve ankle ROM. A positional fault often occurs following acute or chronic ankle injuries in that the movement of the lateral malleolus is shifted anteriorly during dorsiflexion.

To correct this positional fault and improve ankle dorsiflexion, clinicians could apply a posterosuperior mobilization performed on the distal tibiofibular joint. Although preliminary, this approach is supported by the findings in this study. To complement this technique a distraction of the distal tibiofibular joint has also been thought to increase space and decrease impingement in the talocrural joint to allow full ankle dorsiflexion (3).

When considering the treatment of ankle dysfunction and pain a talocrural joint mobilization with the RICE protocol (Rest, Ice, Compression and Elevation) provides a positive change in pain-free dorsiflexion and improves stride speed compared to RICE alone (4). Combined with additional joint mobilizations such as the one studied here, clinicians may advance their results and better serve their patients.

EDITOR’S NOTE - Technique for Posterior-Superior Distal Tib-Fib Mobilization:

Although not detailed in the paper, readers could use the following technique. Below are two pictures showing a single and backed-up thumb contact for this type of mobilization. Line of force is indicated on the first picture. Grade of mobilization is up to the practitioner.

Single Thumb Contact
Double Thumb Contact

Study Methods:

The cadaver specimens were cut through the distal third of the femur without disrupting the soft tissue about the leg and foot and mounted on a wooden fixture. Fixation of the foot was through the calcaneus and the metatarsal bones and the knee joint was fixed into extension.

The authors used a machine to apply a 1000 times cyclic loading of 15/Ns (15-30N force). Two electromagnetic sensors were attached and placed on the tibial and fibular shafts. The tibial sensor provided 6 anatomical points (higher and lower tibial shaft, medial malleolus, medial and lateral condyles and the tip of the lateral malleolus) while the fibular sensor had four (anterior and posterior edge of the lateral malleolus fibular head and the tip of the lateral malleolus). As each sensor was moved, each motion of the anatomical points was recorded as a series of coordinated values.

The experimental procedure was designed to replicate the force of a Grade III JM based on the Maitland method of a slow, large-amplitude movement that takes the joint up to and slightly through the limit of available joint motion and into tissue resistance.

Application of a posterosuperior force to the lateral malleolus of the fibula caused both the fibula and the tibia to move slightly. As the number of cyclic loadings increased differences between the displacement of the tibia and fibula occurred with the largest displacement at 1000 cycles. The external rotation angle of the fibula increased as the number of cyclic loadings increased approximating a logarithmic curve. Fifty percent of the total rotation was reached in the first 200 cycles of loading and 80% at the 500th cycle.

All statistical analyses were performed with SPSS for Windows ver. 11.5 and a paired t-test was performed to verify cyclic loading and comparison of maximum ankle dorsiflexion before and after cyclic loading was performed (significance level setting was 0.05).

Study Strengths / Weaknesses:

The study acknowledged that the mechanical properties of the ligaments being tested might not be the same for patients with ankle injuries requiring JM due to the fact that the study utilized aged cadavers (mean age of 79.4). The other limitation was that normal specimens were utilized that did not exhibit ankle dorsiflexion positional faults. The study was also not able to take into consideration the neuromuscular control over the tibiofibular motion with the in vitro model.

Overall the study does provide baseline evidence that a positional fault restricting dorsiflexion in acute or chronic ankle injuries can be improved with JM techniques using a posterosuperior mobilization as well as distraction of the distal tibiofibular join to increase space and decrease impingement in the talocrural joint.

Evidence from this study suggests that the average movement of the distal tibiofibular joint can be significantly increased in the range of ankle dorsiflexion and that these JM techniques should be considered in the care of patients with ankle injuries.

Additional References:

  1. Kaltenborn F. The extremities. In: Manual mobilization of the joint: the Kaltenborn method of joint examination and treatment. 5th ed., (1) Oslo: Olaf Norlis Bokhandel; 1999: 21-28.
  2. Hsu et al. Immediate response of glenohumeral abduction range of motion to a caudally directed translational mobilization: A fresh cadaver simulation. Archives of Physical Medicine and Rehabilitation 2000; 81: 1511-1516.
  3. Close J. Some applications of the functional anatomy of the ankle. The Journal of Bone and Joint Surgery (Am) 1956: 38A: 761-781.
  4. Green et al. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprain. Physical Therapy 2001; 81: 984-994.