Article Full Title
Effects of Tibiofibular and Ankle Joint Manipulation on Hip Strength and Muscle Activation
Author Names
Lawrence, M., Raymond, J., Look, A., Woodard, N., Schicker, C., Swanson, B.
Reviewer Name
Alyssa Bush, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
The purpose of this study was to determine whether high-velocity, low-amplitude (HVLA) ankle region manipulations could increase force output and muscle activation of hip musculature in individuals with a history of ankle sprain and unilateral tensor fascia latae (TFL) weakness during muscle testing. This investigation used a single-arm repeated measures design. Twenty-five participants’ force outputs were tested at three time points (before manipulation, immediately after manipulation, and 48 hours after manipulation), and muscle activation of the rectus femoris, gluteus medius, and TFL was measured before and immediately after manipulation. Manipulations were applied to the talocrural, subtalar, proximal, and distal tibiofibular joints of the weaker limb. No contralateral manipulations were applied. Two-way repeated measures analysis of variance was used to compare maximal and average force production for each limb. In addition, paired t tests were used to compare muscle activation before and after manipulations. There was a significant limb × time interaction. The involved limb average force increased from before manipulation (65.7 N) to 48 hours after manipulation (77.8 N; P = .014), maximal force increased (76.9 N) 48 hours after manipulation (87.8 N; P = .030), and gluteus medius activation increased (9.8% maximum, 12.2% average) immediately after manipulation. No significant differences were found in the uninvolved limb. The results of this study suggest that high-velocity, low-amplitude ankle region manipulations might improve hip abductor strength in individuals with a history of ankle sprain and unilateral weakness during a TFL muscle test.
Was the study question or objective clearly stated?
Yes
Were eligibility/selection criteria for the study population prespecified and clearly described?
Yes
Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?
Yes
Were all eligible participants that met the prespecified entry criteria enrolled?
No
Was the sample size sufficiently large to provide confidence in the findings?
Yes
Was the test/service/intervention clearly described and delivered consistently across the study population?
Yes
Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?
Yes
Were the people assessing the outcomes blinded to the participants’ exposures/interventions?
No
Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?
Yes
Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?
Yes
Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?
Yes
If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?
Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Average gluteus medius activity in the involved limb increased by 12.2% immediately following ankle manipulation, and maximal force production for the gluteus medius increased by 9.8%.
Key Finding #2
The study found that a combination of talocrural, subtalar, distal tibiofibular, and proximal tibiofibular joint manipulations increased average force of MVIC in the TFL in MMT testing position in the involved limb by 18.5% and increased the maximal force production by 14.2%.
Please provide your summary of the paper
The study found that 48 hours after high-velocity, low-amplitude (HVLA) manipulations of the talocrural, subtalar, proximal tibiofibular and distal tibiofibular joints, average force production of the TFL increased by 18.5% in the involved limb of subjects. Additionally, the study found that gluteus medius activation increased in the involved limb by 12.2% immediately following ankle manipulation. These findings are significant, as previous studies have not suggested that ankle manipulation could impact force production and activation of the hip musculature. However, the increase in gluteus medius activation could be a contributor to the increased force produced by the TFL 48 hours after manipulation since the anterior fibers of the gluteus medius are tested in the same manual muscle testing (MMT) position as the TFL. These findings highlight a limitation of the study and the need to consider synergistic muscles during the physical examination. Despite this noted limitation, the study ultimately suggests that ankle region HVLA manipulations can increase force production in hip region musculature, which is a notable finding. Importantly, increased gluteus medius activation was measured immediately after manipulation, while maximal force production did not occur until 48 hours after manipulation. Due to the short time frame for strength testing immediately after manipulation, it is possible that the hip musculature was fatigued, which is a possible explanation for the lack of significant change in force production immediately following ankle manipulation. Although more research is needed in this area due to limitations of the study, this research presents a notable finding that manipulation of the talocrural, subtalar, proximal tibiofibular and distal tibiofibular joints may increase force production of the hip musculature in subjects with a history of ankle sprain.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study suggests that HVLA manipulation of the talocrural, subtalar, proximal tibiofibular and distal tibiofibular joints may be an effective intervention for patients with a history of ankle sprains who also present with weakness in the hip musculature, specifically TFL, upon MMT. This is a notable finding for clinical practice because patients with a history of chronic ankle sprains often have weakness in the hip abductors, which puts these patients at a higher risk of injury due to a lack of closed chain stability in the lower extremity. The results of this study suggest that HVLA manipulations at the ankle joint in the involved limb may be an effective intervention to increase force production at the hip musculature in patients with chronic ankle sprains, and can potentially decrease risk of ankle injury by improving closed chain stability in the affected lower extremity.
