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Mulligan's mobilisation with

movement technique for lateral
ankle pain and the use of magnetic
resonance imaging to...

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Jeanette M Thom
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 Mulligan’s mobilisation with movement technique for lateral ankle pain
and the use of magnetic resonance imaging to evaluate the “positional
fault” hypothesis
Merlin DJ, McEwan I, Thom JM
Institute for Biophysical and Clinical Research into Human Movement, Manchester
Metropolitan University, Alsager, United Kingdom

Introduction
Inversion injuries that occur at the ankle have been suggested to cause an antero-inferior
displacement of the distal fibula or a “positional fault” (1). Mulligan (3), and others have
shown that range of movement, function and pain have all been affected after the
Mulligan’s mobilisation with movement (MWM) technique. However, only Kavanagh (2)
showed that a proportion of patients had a “positional fault” at the inferior tibiofibular
joint. The aim of this study was to verify if the antero-inferior displacement of the distal
fibula or “positional fault” in ankle injuries can be confirmed using magnetic resonance
imaging (MRI).

Methods
Thirty-eight participants, 26 males and 12 females, aged 26.9 ± 6.9 years (range 19-45
years) volunteered for this study. Thirty of the participants were healthy with no history of
ankle injury. The other 8 participants had recently had a sprain of the lateral ligament
complex of the ankle. Ankle dorsiflexion was measured on both legs using the knee to the
wall principle. Pain was measured at the point of maximum dorsiflexion using a visual
analogue scale. Balance was measured using the Rhomberg single leg stance criteria with
the eyes open and repeated with the eyes closed. MRI scans were taken in 3 plans, sagittal,
coronal and axial using a fixed 0.2-T MRI scanner in 26 participants. The ankle was
strapped to a brace that fixed the ankle at 90 degrees and two external water based markers
were placed on the skin for accuracy of analysis. These tests were repeated 30 minutes
later. In between the tests the injured participants underwent the treatment technique. The
treatment technique glided the lateral malleolus in a posterior and cephalad direction whilst
the participant performed active plantar-flexion and inversion. Three sets of 10 repetitions
were performed. A repeated measure ANOVA was used to determine significance.

Results
The control group showed no significant difference in balance, pain and range of
movement scores in the repeated tests or in the position of the fibular from the MRI scans.
In the injured group there was a significant increase in range of movement (Pre: 5.2 ± 1.0
cm; Post: 6.8 ± 1.0 cm; P<0.01) and an increase in balance ability with eyes closed (Pre:
6.9 ± 1.8 s; Post: 16.5 ± 4.0 s; P<0.05) after the MWM intervention, with no change in the
pain score. The MRI results of the injured group showed significance displacement in the
sagittal plane only, with an increase in the distance of the tip of the fibula from the sole of
the foot (Pre: 6.19 ± 0.28 cm; Post: 6.54 ± 0.13 cm; P<0.05). No displacement of the fibula
was observed in the non-injured participants. Thus showing that the fibula had been
relocated in a superior direction with the MWM technique.

Discussion
The results showed that after sustaining a sprain of the lateral ligament complex and
undergoing the MWM technique an increase in the range of dorsiflexion, an increase in
balance ability and a cephalad movement of the fibula occurred. The result confirms

The Accelerated Rehabilitation of the Injured Athlete 99

 previous findings of an increase in the range of movement following MWM in ankle
injuries and has confirmed the increase in balance ability postulated by Hetherington (1).
However, this is the first study to show that a “positional fault” had occurred using MRI.
This was shown as an increase in the distance from the tip of the fibula to the surface
marker on the sole of the foot, thus supporting the hypothesis that there is a “positional
fault” at the distal tibiofibular joint at the ankle in lateral ankle sprains. The position of the
fibula in the injured group post MWM treatment corresponded with that of the fibular in
the non-injured group. This further supports that the “positional fault” was relocated to that
of an uninjured ankle. An increase in participant numbers may be required to further
validate this innovative therapeutic technique for lateral ankle pain.

Conclusions
The aim of this study was to test Mulligan’s “positional fault” hypothesis and this study
has shown that there was a movement of the tip of the fibula in comparison to the surface
marker on the sole of the foot in a cephalad direction. This falls in line with the MWM
technique performed. Therefore, in this preliminary study, the Mulligan’s “positional fault”
hypothesis was supported.

Bibliography
1. Hetherington, B. (1996) Manual Therapy 1, 274-275
2. Kavanagh, J. (1999) Manual Therapy 4, 19-24
3. Mulligan, B. (1999) Manual Therapy “Nags”, “Snags”, “MWMS” etc, 4th Ed.
Hutcheson, Bowman & Stewart

100 The Accelerated Rehabilitation of the Injured Athlete