The effectiveness of mobilization with movement on pain, balance and function following acute and sub acute inversion ankle sprain: a randomized, placebo controlled trial

Key points

1. 01MWM group showed significantly greater improvement than sham group at all follow-up points (2 weeks, 1 month, 6 months) for every outcome measured.
2. 02Large effect sizes favored the MWM group for pain, functional dorsiflexion ROM, FADI score, and dynamic balance immediately after the intervention.
3. 03More than half of MWM-group subjects surpassed the minimally clinically important difference for pain, FADI, and dorsiflexion ROM after treatment, a rate higher than in the control group.
4. 04Mechanical hypoalgesia was recorded both locally at the ankle and remotely at the shoulder, and was significantly greater in the MWM group, suggesting a possible central pain inhibitory mechanism.
5. 05Exercise alone was also beneficial but appeared to take longer to produce clinically meaningful improvement above the MCID.

How it was conducted

Design

Parallel-group, assessor-blind, placebo-controlled randomized clinical trial

Setting

Physiotherapy outpatient department of a general hospital in India

Participants

Adults of either sex with acute (up to a defined early post-injury period) or sub-acute grade I or II inversion ankle sprain, referred by an orthopedic surgeon

Groups

Experimental: MWM at inferior tibiofibular joint + rigid taping + usual care and exercise; Control: sham MWM + sham tape + usual care and exercise

Treatment duration

Multiple sessions over 2 weeks; outcomes assessed at post-intervention, 1 month, and 6 months

Primary outcome

Worst pain intensity in the previous 24 hours on a Numeric Rating Scale (NRS); secondary: FADI score, functional ankle dorsiflexion ROM (weight-bearing lunge test), Y Balance Test, pressure pain threshold at ankle and ipsilateral deltoid

What they found

• Thirty participants completed the study (32 recruited); 2 participants in the control group had adverse events (pain increase not settling within 5 minutes) and all experimental-group participants but 2 demonstrated increased pain-free ROM to MWM on the first session.
• Between-group analysis revealed a statistically significant effect of MWM in favor of the experimental group for all outcome measures at post-intervention, 1-month, and 6-month follow-up.
• Pain intensity: mean difference between groups was statistically significant at all time points; the mean difference values relative to the previous assessment point exceeded the MCID at the 2-week and 1-month follow-up only (specific numeric values not recoverable from extracted text).
• Effect sizes were large in favor of the experimental group for all outcomes except pressure pain threshold immediately after the intervention; moderate to large effect sizes were maintained at subsequent follow-up points.
• Within-group analysis showed significant improvement in both groups for all outcomes from baseline to each follow-up point, with large effect sizes in both groups.
• Mechanical hypoalgesia was significantly greater in the experimental group at both the local (ankle) and remote (shoulder deltoid) sites.

Limitations

• No untreated natural history control group was included, so the contribution of spontaneous healing cannot be quantified.
• Small sample size, despite adequate power calculation, increases the risk of false-positive findings.
• Home exercise programme adherence was self-reported and unsupervised, introducing potential bias.
• Ankle sprain recurrence rate was not measured over the follow-up period, which could affect the validity of 6-month outcomes; results are also limited to patients who responded to a trial MWM on initial assessment.

Why it matters

For patients

People with a recent ankle sprain who receive MWM from a physiotherapist in addition to exercise and standard care can expect faster, greater, and longer-lasting reductions in pain and improvements in mobility and balance than with exercise alone.

For clinicians

This RCT provides preliminary evidence supporting the Mulligan inferior tibiofibular MWM technique combined with rigid taping as a beneficial adjunct to exercise for acute and sub-acute grade I-II ankle sprain, with large effect sizes persisting to 6 months.

For readers

This was the first RCT specifically targeting the inferior tibiofibular joint with MWM in acute ankle sprain; findings support a biomechanical or neurophysiological rationale but the small sample and missing natural-healing control limit certainty.