Low frequency anteroposterior mobilization of the talus was found to be more effective at increasing ankle dorsiflexion range of motion than high frequency mobilization in healthy subjects. The low frequency technique allowed more time for plastic deformation of the connective tissues to occur, in line with their viscoelastic properties. Future studies should investigate these mobilization techniques in patients with acute, subacute, or chronic ankle conditions.

1. Italian Journal of Physiotherapy 2012; 2(1):3-11
INFLUENCE OF HIGH AND LOW
FREQUENCY ANTEROPOSTERIOR
MOBILIZATION OF THE TALUS ON ANKLE
DORSIFLEXION: A DOUBLE-BLIND
RANDOMIZED CONTROLLED TRIAL
M. Zambaldi, F. Capra, I. Gardenghi, P. Pillastrini

2. INTRODUCTION
• Ankle dorsiflexion: talus rolls anteriorly and slides posteriorly
• Anteroposterior (AP) mobilization of the talus demonstrated to
increase ankle dorsiflexion (level B evidence)
Brantingham et al. J Manipulative Physiol Ther 2009; 32:53-71
• High frequency technique not congruous with connective
tissues’ (CT) viscoelastic properties
Threlkeld. Phys Ther 1992; 72(12):61-70
Chaudhry et al. J Bodiw Mov Ther 2007; 1:159-67
AIM
• Low frequency more effective in elongating the CT?

3. BACKGROUND
• Proposed mechanisms of action
– Pain modulation
Wright. Man Ther 1995; 1:11-16
Bialosky et al. Man Ther 2009; 14:531-8
– Articulating bones realignment
Denegar et al. JOSPT 2002; 32:166-73
– Periarticular connective tissues elongation
Loudon et al. J Athl Train 1996; 31(2):173-8
Threlkeld. Phys Ther 1992; 72(12):61-70
• Connective tissue viscoelasticity
– The faster the loading, the stiffier the behaviour
Threlkeld. Phys Ther 1992; 72(12):61-70
• Authors’ recommendations
– 7 up to 60 seconds for plastic deformation
Loudon et al. J Athl Train 1996; 31(2):173-8
Threlkeld. Phys Ther 1992; 72(12):61-70
Chaudhry et al. J Bodiw Mov Ther 2007; 1:159-67
Kaltenborn. Manual Mobilization of the Joints 2002; 73.
Lower frequency of AP
oscillation of the talus

4. METHODS
• Setting: Physiotherapy Outpatient Clinic
Azienda Provinciale per i Servizi Sanitari, Trento, Italy
• 30 healthy male volunteers, randomized into 3 groups
•Exclusion criteria:
−Previous lower limb fracture or joint dislocation;
−History of lower limb surgery;
−History of ankle or foot injury in the last year;
−Signs or symptoms of ankle instability;
−Ankle or foot tenderness;
−Beighton and Horan Joint Mobility Index ≥4.
Kyndall et al. J Athl Train 2003; 38(4):281-5
• Assessed by CONSORT standards, except for items 23, 24
Schulz et al. BMJ 2010; 340:c332

6. OUTCOMES
• Ankle dorsiflexion ROM
• Digital inclinometer (range: 360°, resolution: 0.1°)
Mini-Pro Digital Protractor, Level Developments LTD, Surrey, UK
• Blinded assessor
• Weight-bearing
measurement before (T0)
and after (T1) treatment.
• Mean of 5 consecutive
relevation was taken as the
true value
– Maximum error: 0.53%
Bennell et al. Aust J Physiother 1998; 44(3):175-9 A: digital inclinometer. B: midpoint of
Munteanu et al. J Sci Med Sport 2009; 12:54-9
Collins et al. Man Ther 2004; 9:77-82
the tibia. C: ankle dorsiflexion angle.

7. LOW FREQUENCY MOBILIZATION
• Low frequency AP mobilization of the talus:
-2’ treatment
-5 series grade III AP
mobilization, 20’’ each
-Talus maintained at the end
of its posterior glide
-5’’ break between series

8. HIGH FREQUENCY MOBILIZATION
• High frequency AP mobilization of the talus:
-2’ treatment
-5 series grade III AP
mobilization, 20’’ each
-10 AP talus oscillation each
series
-5’’ break between series

10. RESULTS

11. DISCUSSION
CONNECTIVE TISSUE
• Healthy subjects
• AP talus mobilization tightens connective tissues that limit posterior glide
• Strain vs. time curve (creep)
Chaudhry et al. J Bodiw Mov Ther 2007; 1:159-67
• HFM results in accordance with previous studies conducted on
healthy subjects
- Tissues warming up
- Improved lubrification
Venturini et al. J Manipulative Physiol Ther 2007; 30(8):593-7
De Souza et al. J Manipulative Physiol Ther 2008; 31(4):285-92
Greater treatment effect of the LFM depends
specific action on the connective tissues

12. CLINICAL IMPLICATIONS
• Oscillation frequency determines therapeutic effect
• Greater ROM improvement with LFM
• Other mechanisms are not excluded
• Tissue load capacity
Clinical conditions
Treatment
Treatment goals
Mobilization technique
CT wound healing

13. STUDY LIMITATIONS
• Small sample
• Follow-up
• Time vs. ROM relationship
FUTURE STUDIES
• Acute/subacute/chronic conditions
• Sub-groups classification (clinical prediction rules?)
• Other joints

14. References
Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy for lower extremity conditions: expansion of literature
review. J Manipulative Physiol Ther 2009; 32:53-71.
Venturini C, Penedo MM, Peixoto GH, Chagas MH, Ferreira ML, de Resende MA. Study of the force applied during anteroposterior articular mobilization
of the talus and its effect on the dorsiflexion range of motion. J Manipulative Physiol Ther 2007; 30(8):593-7.
De Souza MVS, Venturini C, Teixeira LM, Chagas MH, de Resende MA. Force-displacement relationship during anteroposterior mobilization of the
ankle joint. J Manipulative Physiol Ther 2008; 31(4):285-92.
Wright A. Hypoalgesia post-manipulative therapy: a review of potential neurophysiological mechanisms. Man Ther 1995; 1:11-16.
Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a
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individuals with recurrent ankle sprain. J Orthop Sports Phys Ther 2006; 36(6):464-71.
Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle
sprains. Man Ther 2004; 9:77-82.
Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute inversion ankle sprains.
Phys Ther 2001; 81(4):984-94.
Kyndall LB, Philip W, Cheryl RK. Intrarater and interrater reliability of the Beighton and Horan Joint Mobility Index. J Athl Train 2003; 38(4):281-5.
Bennell KL, Talbot R, Wajswelner H, Techovanich W, Kelly DH, Hall AJ. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle
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Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised
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