Lateral ankle sprains are common injuries in sports and the general population, occurring with an annual incidence of 7 injuries per 1000 people. The majority of people with ankle sprains feel they are improving after the first 30 days post-injury, but continue to have some residual symptoms and lack of full function. Most people respond great to conservative therapy for ankle sprains, but some continue to have issues, such as pain, stiffness, sense of weakness, swelling, and laxity with frequent re-sprains of their ankle. Another group of individuals may have no lingering symptoms in their ankle but actually have stiffness in their ankle which they compensate for, potentially jeopardizing other areas in their body and cause pain in areas far away from the ankle. This is known as regional interdependence, or the ability of dysfunctions in the kinetic chain to affect other areas away from that dysfunction.

A recently published case study in the Journal of Manual & Manipulative Therapy (JMMT), the author describes a case of a 40 year-old runner and cyclo-cross athlete with a one year history of anterior knee pain of insidious onset (no known cause of knee pain). During questioning, the patient stated a history of ipsilateral (same side) lateral ankle sprain two-years prior, with apparent full recovery months after the initial sprain. After examination, the clinical diagnosis of her knee was patellofemoral pain syndrome (PFPS), or pain around the kneecap. She demonstrated significant stiffness in her ankle which affected the biomechanics around the knee during weight-bearing activities, possibly leading towards compensatory strategies and the onset of her anterior knee pain one year after the initial ankle injury. The clinician treated the patellofemoral pain through manipulation of her ankle (to help restore normal range of motion at the ankle), and mobilization of her knee, all while re-teaching her how to restore normal movement patterns during functional activities (such as standing, squatting, performing stairs). Once her range of motion was restored in the kinetic chain, she was progressed back to full functioning, which included running and cyclo-cross. She was able to return back to full activities, with no complaints of knee pain.

This case study highlights the importance of a detailed physical therapy assessment which includes questions about past history of injuries, and examination of areas away from the spot of pain to see if other areas are contributing to the patient’s pain complaint (regional interdependence). Even though pain may go away after certain injuries, such as ankle sprains, there may be lingering issues which have not fully resolved, which may cause future issues (possibly in areas remote from the actual injury) as the athlete returns back to full function. Below is the abstract of the JMMT case study, which is currently online only to JMMT members.


Lower extremity thrust and non-thrust joint mobilization for patellofemoral pain

syndrome: a case report

Brad G. Simpson1, Corey B. Simon2

1Life’s Work Physical Therapy, Portland, OR, USA, 2Department of Physical Therapy, College of Health andHuman Professions, University of Florida, Gainesville, FL, USA


A 40-year old female presented to physical therapy with a one-year history of insidious right anteromedial and anterolateral knee pain. Additionally, the patient had a history of multiple lateral ankle sprains bilaterally, the last sprain occurring on the right ankle 1 year prior to the onset of knee pain. The patient was evaluated and given a physical therapy diagnosis of patellofemoral pain syndrome (PFPS), with associated talocrural and tibiofemoral joint hypomobility limiting ankle dorsiflexion and knee extension, respectively. Treatment included a high-velocity low amplitude thrust manipulation to the talocrural joint, which helped restore normal ankle dorsiflexion range of motion. The patient also received tibiofemoral joint non-thrust manual therapy to regain normal knee extension mobility prior to implementing further functional progression exercises to her home program (HEP). This case report highlights the importance of a detailed evaluation of knee and ankle joint mobility in patients presenting with anterior knee pain. Further, manual physical therapy to the lower extremity was found to be successful in restoring normal movement patterns and pain-free function in a patient with chronic anterior knee pain.

Keywords: Patellofemoral pain syndrome, Knee extension, Talocrural stiffness, High-velocity low-amplitude manipulation, Physical therapy, Regional interdependence