Impaired muscle function/dynamic balance in chronic ankle instability – does mobilization of the foot make sense?
Isabelle Werner
Chronic ankle instability
Ankle sprain is a very common injury, with a prevalence of 11-12%, most common are lateral ankle sprains, typically during sports in females, children and young adults [1]. In athletes 70% experience injuries of the lateral ligament complex, 20% syndesmotic injuries and 8% acute osteochondral lesions of the talus [2]. After ankle sprains, up to 70% of the patients develop persistent symptoms like giving-way, pain, recurrent injuries, weakness and reduced range of motion (ROM) – known as chronic ankle instability (CAI) [1], [3], [4], [5]. Therefore, every ankle sprain has to be examined thoroughly – pain, gait, swelling, range of motion, arthrokinematics, sensorimotor control and strength are recommended in a recent consensus paper [6] – and adequately treated [3] according a sound clinical reasoning, with the goal to prevent recurrence. Risk for re-injury is 3.5x higher after a first-time ankle sprain [5].
In patients with CAI altered balance was found due to altered corticospinal inhibition and excitability of the soleus muscle [7]. Altered arthrogenic muscle response is described to be present in CAI [8], [9], [10].
Nitz et al. evaluated electromyographically peroneal and tibial nerve injuries in ankle sprains; in patients with injuries of the lateral complex and deltoid ligament 17% had a peroneal nerve injury, 10% the tibial nerve; in more severe sprains (affected lateral complex, deltoid ligament and anterior tibiofibular ligament) 86% had a delayed nerve conduction of the peroneal nerve, in 83% the tibial nerve was affected [11]. Slight nerve injures might probably be masked by the symptoms in the ankle [12], [13], [14], [15].
Subjects with history of ankle sprain showed an increased mechanosensitivity (palpation, pressure pain threshold) in the tibial and peroneal nerve as well as in the tibialis anterior and peroneal muscles [16]. A similar study found significantly lower pressure pain threshold over the peroneal nerve only, in soccer players with chronic ankle instability compared to healthy controls, interestingly, the physical performance did not differ between groups [17].
If a peroneal nerve involvement is suspected [14] nerve function has to be evaluated in patients with a history of ankle sprain [12], [13]. Minor affections of the nerve might not be recognized by the patient himself, as they might be masked by initial symptoms [11], [12], [13], [18], but can be a crucial factor for recurrence and CAI [11], [12], [16]. Peroneal nerve injury may present clinically as follows: often delayed [11], [12], [13], [14], [15], [19]) foot drop/weakness of ankle and toe dorsiflexors and ankle evertors, gait impairment and diminution or loss of sensation in the supply area of the peroneal nerves [12], [15], [20]. Dysesthesia in the foot or lateral leg can be provoked by tapping on the nerve at the fibular head (Tinel sign) [12], reflexes are typically unaffected [20].
In the management of CAI regaining stability is the main objective. Pain-free exercises – specifically to the impairments of the patient – are important [4], [6], [21], [22], [23]. As often ROM is reduced in Dorsiflexion, [4], [6], [21], [22], [23] mobilization might be used in the management of a patient suffering from CAI. The question is now, does mobilization not only have an effect on ROM, but also on motor activity, which might enhance training efficiency?
What does research say?
If clinicians add mobilization, they may not only improve range of motion but also dynamic balance [24], [25], [26], [27], [28], [29] or activity of the medial part of M. gastrocnemius [30]. Training can become more efficient, if mobilization is added [27], [28], [31], compared to training alone [29], [31].
It is important to emphasize, that mobilization can be one piece of the puzzle of the overall management. First of all, the patient has to be examined thoroughly, including pain, gait, active weightbearing and non-weightbearing ROM, strength, dynamic balance, functional activities [21], ankle swelling, sensorimotor control [6], [23] sensory-perceptual [4], arthrokinematics with a special focus on talar translation, talar inversion [22] using the biopsychosocial model of health care as a foundation [4], to provide individual and specific intervention [23]. In case of a hypothesis concerning N. peroneus involvement, nerve function has to be evaluated additionally [12], [16], [17].
For intervention according to the findings a targeted management is appropriate. If there is hypomobility, mobilization of the restricted area is indicated. Always an important part of rehabilitation is retraining stability of the foot with pain-free exercises – specifically chosen to the impairments of the patient [4], [6], [21], [22], [23]. It is important to reduce the modifiable risk factors for lateral ankle sprain which are higher body mass index, decreased slow eccentric INV strength and fast concentric PF strength, diminished passive INV joint position sense, prolonged reaction time of M. peroneus brevis [32], reduced hip and ankle strength and postural balance [33].
One possible explanation for improved dynamic balance could be, that the increased DF mobility also improved the SEBT especially in anteromedial direction. The SEBT is recommended by recent guidelines [22] and a valid and reliable functional tool to evaluate the lower limb concerning dynamic postural balance [34]. Patients stand on 1 leg and try to reach as far as possible with the non-weight-bearing leg into anteromedial, posteromedial, and posterolateral directions without losing balance. In the spine, there is evidence, that mobilization enhances deep neck flexor motor activity [35], [36], [37], [38], [39]. In the foot the results are not as clear as in the neck. A reason could be, that in the SEBT the whole leg is involved and needs to keep stability, the hypothesis arises, that dynamic balance can’t improve that much, as the knee and hip have an impact on foot stability [33]and therefore on the results too. If the foot improves in balance, but for example the hip is not able to stabilize, only a very small effect can be achieved. Martin et al. 2021 recommend to test the hip strength in abduction, extension, and external rotation [22] especially if 2 or more ankle sprains occurred, as the whole lower limb is important for a stable foot.
Another mechanism might be arthrogenic muscle inhibition [8], [9], [10] which is described to follow pain, effusion or joint dysfunction. These limiting factors have to be addressed to decrease inhibition and provide adequate training [40], [41]. Pain and dysfunction can be treated with mobilization, at least a short-term time-window can be used for more efficient active exercises. Current evidence says, passive joint mobilizations may immediately alter the ability of muscle function [42].
To explain the effect of manual techniques we can use the brick wall [43], [44] which is well-known in the Maitland concept. On the left/theoretical side pain might be inhibited due to systemic neurophysiological responses initiated by a mechanical force such as mobilization [45], [46]. Research in neurophysiological effects of for example spinal manipulation is still in progress. Neurophysiological responses could be central neuroplastic alterations, changes in motor neuron excitability, enhanced muscle strength, improved cortical drive, activation of the descending pain modulation circuit and central sensitization [47].
On the right/clinical side of the brick wall [43], [44] we examine a region for stiffness or pain – where we could apply mobilization. Moreover, we look for loss of strength and/or power, decreased endurance or proprioception to which impairment we could specify a training program. In case of fear of movement, the patient will need education.
Conclusion
There is moderate evidence, that mobilization not only improves mobility, but also sometimes dynamic balance or strength, which leads to a more efficient training. If there really was an effect on motor activity, in every patient an adequate reassessment before and after the mobilization is needed to confirm the hypothesis [48].
Further studies are recommended to examine mid- and long-term effects.
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Key points To prevent recurrence in patients with CAI, a specific, patient-centered training is essential. There is moderate evidence, that mobilization on talus, cuboid, tarsal or metatarsal joints is a useful treatment option to enhance motor activity of the foot and provide a more efficient training. Effects have to be confirmed in an adequate reassessment. Adding mobilization to training can be more efficient than training alone. Mobilization is never a stand-alone-treatment and has to be combined with targeted training to improve stability. |
REFERENCES
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Comments
3. It is logical, that a patient is not becoming stronger with mobilization. However, there is evidence, for short-term neurophysiological changes - in AMI it is recommended to address the underlying pathology (pain, effusion, dysfunction). It is more about better activation than \"strength\", but in re-assessments “strength tests” are used - this could lead to misunderstandings. These so-called “strength tests” test the patient’s capacity, which can be affected by different factors including inhibition, pain anticipation, fear, beliefs, lack of sleep, lack of motivation… and so on. These re-assessments have to be interpreted within a clinical reasoning – like all other parameters.
It is important to communicate to the patient, that this is a short-term improvement of activation, to train more efficiently – because becoming stronger is only possible with training.
We always have to examine each patient individually, within the bio-psycho-social context. Targeted to his goals and our findings we plan the rehab, for an efficient management continuous assessment/re-assessment is crucial, to not be stuck with ineffective mobilizations or exercises. If doing so, we can accompany the patient gradually back to activity and participation, and if we act smart enough, we also keep an eye on prevention.
2. Yes, there are always some asymmetries in the human body, some could be a contributing factor, some not. As long as the patient is limited in his/her activities due to decreased dorsiflexion, it should be addressed during therapy and integrated into self-management. If missing dorsiflexion is impairing tests for return-to-sports, it still has to be in the treatment plan – as prevention is a very important factor. Risk factors are for example previous ankle sprains, poor rehab, poor dynamic balance/strength, therefore, the modifiable factors have to be kept in mind. As dorsiflexion is just one out of many tests – for example there are also endurance, balance, strength, jump and agility tests - the patient will not only be focused on mobility. If the patient has reached his goals, if has no participation limits anymore, there is no need to address mobility anymore.
Part 3 will follow in the next comment
1. As already written, mobilization can be ONE part of the puzzle. If we have a puzzle with 20 pieces, it becomes a very small part of the management! We have to examine the patient thoroughly, to decide if we start with mobilization in our management or with an active approach only - it depends always from the findings and is individual in every patient. Mobilization can be used as long as there is a meaningful short-term effect in the re-assessment. As soon as there is no change anymore in the re-assessment, we don’t need to apply mobilizations anymore. Active exercises are prescribed from day 1. Every patient will be asked about the main problem and goals. These goals are on participation level such as hiking with friends, playing football or taking part at a gymnastics competition. Therefore, exercises and management are targeted to these goals, and of course therapy will be sport-specific or participation-specific. So, every patient will have an individualized approach directed to her/his needs. Usually, the frequency of therapy sessions decreases during the rehabilitation time, in the end phase we adapt their exercise programme during therapy and they are training individually and know strategies for training and load variations, which leads them back into autonomy. Participation is an important goal, but also prevention to avoid recurrence should be present during rehab.
Part 2 follows in the next comment
1. Mobilization as part of the puzzle
I agree that mobilization, in the presence of hypomobility or pain, can open a temporary window to enable more efficient loading. However, in clinical practice, this “window” too often becomes the room we stay locked in — a strategy that risks fostering therapeutic dependency. Given the evidence showing comparable outcomes between active exercise and manual techniques, one might argue that our goal should be to make the patient as independent from us as possible.
2. The focus on ROM risks becoming a clinical fetish
I’m struck by how much attention is placed on joint range of motion, without considering that many patients can be “fully functional despite limited dorsiflexion.” This is a key concept: functional performance (running, jumping, walking) does not necessarily require full ROM restoration. From this perspective, shifting the focus toward function and perceived disability, as international guidelines recommend, is often more meaningful for the patient.
3. The idea that a passive intervention “increases strength” should be treated cautiously
You suggest that mobilization may improve strength or muscle activity. While short-term neurophysiological changes may occur, I find it unlikely that a passive input can lead to a clinically meaningful increase in muscle strength. Strength is built through progressive loading, effort, adaptation, and active engagement. Confusing “activation” or “cortical excitability” with true strength gains may be misleading—especially for less experienced clinicians.
In summary, I appreciate the intention to present a nuanced and updated view of mobilization. But I believe it’s always worth asking ourselves:
“Does this intervention truly enhance the person’s autonomy and partecipation?
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