Case of the Week 2-25-13: KISS the Ankle | Modern Manual Therapy Blog

Case of the Week 2-25-13: KISS the Ankle

Here is a case for you regular readers, what would you do in this situation?

Subjective: The patient is a mid 30s border patrol agent who has been working out regularly. About two months ago, he slipped, and slightly rolled his right ankle inward. There was no swelling, and he rested for a few weeks. Since then he has been unable to exercise regularly, cut left or right and perform any lunging like activities. He complains of pain in the lateral border of his right talus.  At first I thought he was pointing to his sinus tarsi area, but it was his talocrural joint.


FN in MSR, Hip mobility, tibial IR, and his ankle df test could bash his knee right through the wall. This says, not a mobility issue.
SLS and SL Swing tests were also FN.
The patient was FP with ankle pain on the right with DS and SL Squat

I did not check rolling as he was a patient last year for left hip and knee issues, and it was FN then, plus he has been keeping up with that HEP.

No tenderness to touch. All MMT were strong and pain free.

I'll ask you the first thing I asked my current intern who was observing the evaluation. Pop quiz hotshot, what would you look at next? Please, no special test suggestions!


  1. Neurodynamics
    I would also do a AP of the fibula head during any painful ankle movements to see the effect.

  2. Good suggestion Jon! I didn't even get a chance to look at either neurodynamics or fibular head - the second because tibial IR was FN. The solution was even easier.

  3. Being a "Mckenzie" guy I would instantly go to repeated movement testing. Obviously loaded DF was painful so I would do repeated DF to see if it improved, worsened or was Increased/Not Worsened (aka MDT exam). Likely a TCJ derangement which are very common and usually reduced with loaded DF and sometimes DF in Everted position. If it worsened then I would go to unloaded repeated DF or partial loading DF on the TG progressing back to full WB loading.

    Ben Ness, PT, MS, Cert. MDT
    Austin, Tx.

  4. Ben, you're close! I find the DP for the ankle is not normally df, however.

  5. Interesting, that's what is taught at the courses and the consensus among most of the diplomats when their comparing patterns they have been seeing. Will be interested to hear your thoughts.

  6. I'll cheat and piggy-back off your conversation with Ben and assume that you did repeated PF, and biased it into either inversion or eversion based on response...maybe with distal tib-fib mob?

  7. check posterior glide of the distal tib-fib joint and it commonly get stuck anterior with inversion ankle sprains

  8. i would try repeated movement--i too find derangements at TC joint most often reduced with end range PF. If sx are decreased, use as treatment and give rep end range PF with overpressure (make sure patient truly understands end range!)
    as HEP.

  9. I've trained 6 DIPs in mentorship at my practice, pretty sure most of them found pf worked more than df in most instances. I rationalize it just like the cervical and lumbar spines. Most pts repeatedly stretch into df, like they would for flexion, end range pf is easier obtained than df, which is often limited and/or painful. Since the "magic" happens at end range, pf reduces the derangement better than df.

  10. I may have checked that if repeated end range plantarflexion did not work so well!

  11. Could possibly assess it tib-fib by McConnell taping distal tib-fib posterior, having him squat/lunge and assess for sx's. Also mulligan AP glides in standing. Proximal tib-fib also needs to be assessed to check its mobility. Glute medius would also be important to assess dynamically since there is a possibility of mild IR of hip with squatting maneuvers that would force IR of tibia and possible pain at TCJ.

  12. Not familiar with McConnel taping outside of the knee, and I gave that up years ago. Your other suggestions are great, but the point of the case it that it fell into a rapid responder category and all he needed was repeated end range loading into plantarflexion for HEP. He even canelled his follow up visit!