Short-Term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial
Albin SR, Koppenhaver SL, Marcus R, Dibble L, Cornwall M, Fritz JM. J Orthop Sports Phys Ther. 2019. doi: 10.2519/jospt.2019.8864. [Epub ahead of print]
https://www.jospt.org/doi/abs/10.2519/jospt.2019.8864
Take Home Message: After surgical fixation of an ankle/hindfoot fracture, people who received joint mobilizations during 3 sessions had similar improvements in ankle range of motion, balance, and gait compared to people receiving only light soft-tissue mobilization.
Patients with fractures to the ankle/hindfoot commonly undergo operative fixation. These patients often experience post-operative deficits in range of motion and balance as well as gait alterations that increase the risk for long-term consequences if not fully addressed during rehabilitation. Typical post-surgical treatment requires long periods of immobilization that results in talocrural and subtalar joint stiffness. Unfortunately, only 1 in 5 patients will be able to fully recover from the increased stiffness. Manual therapy may improve outcomes after surgical fixation but there is little evidence to support this hypothesis. Thus, the authors conducted a randomized controlled trial to determine the short-term effects of manual therapy on ankle and foot mobility, muscle stiffness, gait, and static and dynamic balance. Seventy-two people between 18 and 70 years of age and who underwent an open reduction internal fixation of the ankle or hindfoot participated. At the time of enrollment, participants were full weight bearing with limited ankle dorsiflexion range of motion according to the ankle lunge test. Participants were randomly assigned to the manual therapy group, which received 3 treatment sessions within 7-10 days of enrollment. Each participant received individualized manual therapy according to the type of fracture and fixation method. The control group received a light soft-tissue mobilization and grade I-II mobilizations of the proximal tibiofibular joint. Three physical therapists with 3-15 years of experience delivered all treatments. The following outcome measures were collected pre- and post-treatment sessions to compare between groups:
- Range of motion (Ankle Lunge Test)
- Mid-foot mobility (Foot Assessment Platform)
- Gastrocnemius stiffness (MyotonPRO)
- Gait analysis (GAITRite)
- Static balance (single Limb Stance test)
- Dynamic balance (Star Excursion Balance Test)
The authors observed no group differences for balance, gait, or range of motion. However, on average the manual therapy group had almost no changes in muscle stiffness, while the control group had a 9% increase in muscle stiffness following treatment. Both groups improved on the ankle lunge test, although only the MT group exceed minimal detectable changes.
The main conclusion to draw from this study is that 3 sessions of manual therapy may be inadequate to restore ankle range of motion deficits following 3 to 4 months of immobilization after fixation surgery. These results are primarily applicable to people who present with ankle range of motion deficits after they completed supervised physical therapy without manual therapy. Perhaps including manual therapy earlier in the rehabilitative process or offering more treatment sessions may have elicited greater improvements. Clinicians working with patients following operative fixation of the ankle/hindfoot should avoid delaying the start of manual therapies and start them earlier in the rehabilitative process, which is supported by previous work summarized in an earlier post.
Questions for Discussion: If you incorporate manual therapies to treat post-surgical ankle fractures, do you consider the type of fracture when applying joint mobilizations? How early should you include joint mobilizations in your rehabilitation of operative ankle fixations?
Written by: Danielle M. Torp
Reviewed by: Jeffrey Driban
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As a student, I often use manual therapies on patients that have suffered from some type of foot injury, often resulting in them being immobilized. I think this article gives a lot of think about in terms of utilization of these skills in the clinic, especially post-operation. When it comes to fractures I feel there is a lot of fear, especially ORIF with screws in solved there maybe be a need to be more conservative with treatment. I have sometimes not even seen any of joint mobilizations if the they are post surgical. Seeing the results in the control group, however, that without this treatment there can be an increase in muscle stiffness is concerning in regards to the delay or return to play (or every day activity). I do believe there is more damage done not using lower grade mobilization. Personally I have seen more success in patients that receive joint mobilizations along with lower extremity massage in addition to their rehabilitation program, especially when done right at the transition from non weight bearing to weight bearing. In general it was encouraging to see that with the control group results stayed within the same ROM, gait, and balance in the ankle which can be seen a testament to the importance of “hands-on” patient care.
Hi Jolene,
Thank you for the comment. There is more and more evidence suggesting joint mobilizations are beneficial at improving range of motion specifically at the ankle. It is important to understand the underlying physiological response that occurs when a joint, post-surgical or not, is immobilization and the effects this has on a range of motion. As athletic trainers’ we do have the skills and capabilities of providing hand-on patient care and joint mobilizations are another way of achieving that. In surgical cases, especially complicated ones like ORIF you mentioned, it is important to consult with the treating surgeon about their recommendations for joint mobilizations following surgery.