Therapeutic interventions for increasing ankle dorsiflexion after ankle sprain: a systematic review

Abstract

Context: Clinicians perform therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, authors of previous studies have not determined which intervention or combination of interventions is most effective.

Objective: To determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain.

Data sources: We performed a comprehensive literature search in Web of Science and EBSCO HOST from 1965 to May 29, 2011, with 19 search terms related to ankle sprain, dorsiflexion, and intervention and by cross-referencing pertinent articles.

Study selection: Eligible studies had to be written in English and include the means and standard deviations of both pretreatment and posttreatment in patients with acute, subacute, or chronic ankle sprains. Outcomes of interest included various joint mobilizations, stretching, local vibration, hyperbaric oxygen therapy, electrical stimulation, and mental-relaxation interventions.

Data extraction: We extracted data on dorsiflexion improvements among various therapeutic applications by calculating Cohen d effect sizes with associated 95% confidence intervals (CIs) and evaluated the methodologic quality using the Physiotherapy Evidence Database (PEDro) scale.

Data synthesis: In total, 9 studies (PEDro score = 5.22 ± 1.92) met the inclusion criteria. Static-stretching interventions with a home exercise program had the strongest effects on increasing dorsiflexion in patients 2 weeks after acute ankle sprains (Cohen d = 1.06; 95% CI = 0.12, 2.42). The range of effect sizes for movement with mobilization on ankle dorsiflexion among individuals with recurrent ankle sprains was small (Cohen d range = 0.14 to 0.39).

Conclusions: Static-stretching intervention as a part of standardized care yielded the strongest effects on dorsiflexion after acute ankle sprains. The existing evidence suggests that clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions. Investigators should examine the relationship between improvements in dorsiflexion and patient progress using measures of patient self-reported functional outcome after therapeutic interventions to determine the most appropriate forms of therapeutic interventions to address ankle-dorsiflexion limitation.

Figure 1.

Flow chart of included and excluded studies.

Figure 2.

Effect sizes with 95% confidence intervals for improvements in ankle- dorsiflexion range of motion immediately after joint mobilization in individuals with acute or subacute ankle sprain. Abbreviations: AP, anteroposterior; MWM, movement with mobilization. ^a Indicates a passive small-amplitude oscillatory talocrual joint mobilization was applied in the AP direction. ^b The group receiving rest, ice, compression, and elevation was considered the control group in the study by Green et al.³¹

Figure 3.

Effect sizes with 95% confidence intervals for improvements in ankle dorsiflexion range of motion immediate after therapeutic modalities in individuals with acute or subacute ankle sprain. Abbreviations: BMS, biomechanical muscle stimulation; CG, conventional treatment group; HVPS (–), negative-polarity high-voltage pulsed-current electrical stimulation; HVPS (+), positive-polarity high-voltage pulsed-current electrical stimulation; HBO, hyperbaric oxygen therapy; and RICE, rest, ice, compression, and elevation.

Figure 4.

Effect sizes with 95% confidence intervals for an improvement in ankle dorsiflexion after static stretching with a home exercise program in individuals with acute ankle sprain (active ankle range of motion; active resistive exercise to the affected ankle in all planes; proprioceptive training; and rest, ice, compression, and elevation). Abbreviation: SS, static stretch.

Figure 5.

Effect sizes with 95% confidence intervals for improved ankle dorsiflexion after psychological intervention in individuals with acute ankle sprain. Abbreviation: PT (physiotherapy) program included hydromassage, ultrasound, laser, range-of-motion exercises, strengthening exercises, proprioceptive training, cycling on a stationary bicycle, forward lunges against a wall, step-ups and down, diagonal hops, and stretching exercises.

Figure 6.

Effect sizes with 95% confidence intervals for improved ankle-dorsiflexion range of motion immediately after movement with mobilization (MWM) in individuals with recurrent ankle sprain. Abbreviations: NWB, nonweight bearing; and WB, weight bearing.