Patient in supine or long sit position with leg to receive treatment fully extended and contralateral leg in slight knee flexion with foot on table
Standing at foot of patient, facing towards the patient’s head
The hands are interclasped over the dorsum of the foot foot, placed just below the neck of the talus
The thumbs on the metatarsals provide firm counter-pressure on the plantar side of the foot
The rearfoot is inverted or everted to find the position of less resistance
The leg is raised to position ankle at best angle for distraction
A long-axis distraction mobilization is imparted on the joint in a caudal direction (can range from slow velocity oscillatory mobilization to high velocity thrust manipulation)
Ensuring that the talocrural joint is in a loose-packed position with minimal joint resistance is key to isolating the movement to that joint
Manual therapy interventions for the foot and ankle have been associated with improvements in pain and function in individuals with ankle sprains, plantar heel pain (PHP), cuboid syndrome (CS), and symptomatic hallux abducto valgus (HAV)
To date, there have no placebo-controlled trials that explore the long-term effectiveness of manual therapy interventions on disability and function for individuals status-post (s/p) lateral ankle sprain. Several studies have shown manual therapy to be effective in improving dorsiflexion range of motion, a common impairment found in individuals s/p ankle sprain.
Green et al. investigated the effect of talo-crural posterior glide mobilizations on dorsiflexion range of motion and 3 gait variables in individuals s/p lateral ankle sprain. Patients receiving talocrural mobilizations in addition to a program of rest, ice, compression and elevation (RICE) demonstrated greater improvements in stride speed and required fewer visits to achieve full, pain-free dorsiflexion range of motion than subjects receiving RICE alone.
Whitman and colleagues developed a clinical prediction rule (CPR) to identify individuals s/p inversion ankle sprain likely to demonstrate a rapid and dramatic response to a management program that included manual therapy interventions and general mobility exercises. Five variables were identified as predictors and together formed the CPR. The variables were:
1. Patient report of symptoms worsening with standing
2. Patient report of symptoms worsening in the evening
3. A navicular drop test greater/equal to 5 mm
4. Distal tibiofibular joint hypomobility
The CPR demonstrated a positive likelihood ratio of 5.9, indicating that individuals who were positive for at least three of the four variables increased their likelihood of a successful outcome with this management strategy from 75% (pre-test probability) to 95% (post-test probability). This CPR must be further tested in a broader patient population with a comparison group and long-term follow up in order to validate the findings of this preliminary study.
Supportive evidence for the role of manual therapy in the management of PHP has been limited, but preliminary evidence has been promising. Cleland et al. compared the effectiveness of two distinct rehabilitative programs for individuals with a diagnosis of PHP. One group received six sessions of ultrasound and iontophoresis (with dexamethasone) treatment as well as a home exercise program of calf stretching and foot intrinsic muslce strengthening exercises. The second group received six sessions of manual therapy interventions directed primarily at the ankle and foot. Treating clinicians in the manual therapy group were also free to treat other joints in the spine and lower quarter as they deemed necessary based on a thorough clinical exam. Subjects receiving manual therapy also performed a home exercise program of calf stretching and soft tissue mobilization of the plantar fascia. At the four week follow up, both groups demonstrated improvements in clinical outcomes, however, individuals receiving manual therapy interventions showed greater improvements in pain, function and disability compared to the group receiving electrophysical agents. These differences were clinically meaningful and were largely maintained at the 6 month follow up.
Young and colleagues reported clinical outcomes in a case series of four subjects with PHP following seven or fewer treatment sessions of manual therapy interventions to the ankle and foot combined with therapeutic exercise. All subjects demonstrated clinically meaningful improvements in pain function.
Cuboid syndrome is also known as “subluxed cuboid”, “dropped cuboid”, “cuboid fault syndrome” and “lateral plantar neuritis”. There have not been any controlled-trials comparing the relative effectiveness of interventions for CS to date. Jennings et al. conducted an observational case-series of seven subjects diagnosed with CS following lateral ankle sprain. All subjects were treated with a “cuboid-whip” manipulation followed by 1 minute of soft-tissue massage to the plantar aspect of the foot. Two of the subjects required repeat manipulations, while the other five subjects only required one treatment. All subjects had complete and long-term resolution of symptoms immediately following treatment.
In a pilot study by du Plessis et. al, 30 patients with complaints of greater toe pain from HAV were randomized to receive either a protocol of manual and manipulative therapy (MMT) or standard care involving the use of a night splint. The MMT consisted of 4 sessions over a two-week period. The outcomes of interest were pain on the visual analog scale, the Foot Function Index, and range of motion of the great toe. Outcomes at 1 week after treatment were significantly better in both groups, but out at one month subjects in the night splint group regressed back to baseline scores whereas the MMT group maintained the same scores they had at 1 week. This is low quality evidence.