Journal of Bodywork & Movement Therapies 37 (2024) 202–208

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

The effect of manual therapy on ankle dorsiflexion range of motion: A pilot

crossover randomized trial
Carolyn J. Taylor *, Lisa C. Hanson , Abbey Hayes , Alan Pham , Elliott Taylor , Poppy Attlesey ,
Gemma Stewart , Amy O’Neill , Ilana Karass , Nivan Weerakkody
La Trobe Rural Health School, La Trobe University, Bendigo, Australia

A R T I C L E I N F O A B S T R A C T

Handling Editor: Dr Jerrilyn Cambron Introduction: Restricted ankle dorsiflexion is common after lower limb injury. The aim of this pilot study was to
investigate the effect of passive ankle joint mobilization and calf muscle massage on ankle dorsiflexion range of
Keywords: motion in adults with residual restricted dorsiflexion. The secondary aim was to assess the methodology of the
Ankle dorsiflexion pilot study to inform a larger clinical trial.
Manual therapy
Method: The study design was a randomized crossover trial with assessor blinding. Twenty-five healthy partic­
Pilot study
ipants with a history of lower limb injury were included in the study. Ankle joint mobilization and calf muscle
massage were applied for 5 min in a random order, one to two weeks apart. Ankle dorsiflexion was measured by
using the weight-bearing lunge pre- and post-intervention (cm). Paired t-tests were used to analyze the effect of
the manual therapy interventions on restricted ankles. A minimal detectable difference 95% (MMD95) was
calculated. The pilot study was analyzed for suitability of inclusion criteria, blinding of assessors and the manual
therapist, and the washout period.
Results: A significant increase in dorsiflexion was demonstrated for ankle joint mobilization (change score = 0.51
± 0.76, p = 0.003) and calf muscle soft tissue massage (change score = 0.91 ± 1.07, p < 0.001). There was no
difference in change scores between manual therapy techniques (mobilization 0.51 ± 0.76, massage 0.91 ± 1.07,
p = 0.12). Evaluation of the pilot study revealed limitations to be modified in future studies.
Conclusion: These preliminary data indicate ankle joint mobilization and calf muscle soft tissue massage had
similar effects on increasing ankle dorsiflexion range of motion in ankles with residual dorsiflexion restriction.

1. Introduction Residual restricted ankle dorsiflexion is common following lower

1.1. Background
Adequate ankle dorsiflexion range of motion (ROM) is required for
functional movements such as walking, running, landing, squatting and
stair climbing (Fong et al., 2011). Restricted ankle dorsiflexion has been
identified as a risk factor for lower limb injuries in the athletic popu­
lation (Crossley et al., 2007; Dennis et al., 2008; Gabbe et al. 2004, 2006;
Malliaris et al., 2006). It is proposed that restricted ankle dorsiflexion
ROM prevents the calf muscle from optimally lengthening eccentrically
at ground contact and prevents absorption of ground reaction force
(Prilutsky and Zatsiorsky 1994). The transfer of force through the kinetic
chain may overload proximal structures, either acutely or chronically,
and result in lower limb injury (Kaufman et al., 1999; Malliaris et al.,
2006).
limb injury, such as an ankle ligament sprain or lower limb fracture.
After the injury has resolved, restricted ankle dorsiflexion may persist
due to residual calf muscle tightness (Denegar et al., 2002), biome­
chanical faults leading to poor joint position (Collins et al., 2004;
Vicenzino et al., 2006) or peri-articular stiffness of ankle joint capsular
and ligamentous tissue (Denegar et al., 2002; Hengeveld and Banks
2005).
Clinically, manual therapists use joint mobilization to address
reduced ankle dorsiflexion. Active mobilization with movement (Mul­
ligan techniques) of the talus in the anterior to posterior direction has
been demonstrated to increase ankle dorsiflexion ROM in injured ankles
(Collins et al., 2004; Gilbreath et al., 2014; Landrum et al., 2008; Reid
et al., 2007; Vicenzino et al., 2006). Application of passive joint mobi­
lization (Maitland techniques) to the talocrural joint in the anterior to
posterior direction increased ankle dorsiflexion in participants with

* Corresponding author. La Trobe Rural Health School, PO Box 199, Bendigo, Vic, 3550, Australia.
E-mail address: Carolyn.Taylor@latrobe.edu.au (C.J. Taylor).

https://doi.org/10.1016/j.jbmt.2023.11.027
Received 8 September 2022; Received in revised form 22 September 2023; Accepted 14 November 2023
Available online 25 November 2023
1360-8592/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
C.J. Taylor et al.
ankle injuries in randomized controlled trials (Green et al., 2001; Silva
et al., 2017; Yeo and Wright 2011) and a prospective cohort trial (Hoch
et al., 2012). Maitland also described passive mobilization techniques
for mobilizing the talocrural joint in the posterior to anterior direction,
and lateral and medial mobilization of the subtalar joint (Hengeveld and
Banks 2005). While the latter Maitland techniques are used clinically, no
published research was found on the effectiveness of these techniques
for increasing restricted ankle dorsiflexion and investigation is
warranted.
Soft tissue massage to the calf muscles is another method manual
therapists use to restore ankle dorsiflexion ROM. One randomized
controlled trial was identified that investigated the effect of trigger point
therapy to the calf muscles on ankle dorsiflexion (Grieve et al., 2011).
Manual release of trigger points in the soleus muscle increased ankle
dorsiflexion in healthy participants with unilateral restriction in active
ankle dorsiflexion. From the published literature, it is unknown the ef­
fect of other soft tissue massage techniques to the calf muscle, such as
effleurage, kneading and stroking, on restricted ankle dorsiflexion.
Previous findings suggest that both passive ankle joint mobilization
and soft tissue massage to the calf muscle are effective for increasing
ankle dorsiflexion, further suggesting that residual restricted ankle
dorsiflexion may be caused by either biomechanical changes at the ankle
joint, or shortening of the calf muscle. However, it is not clear whether
the ankle joint or calf muscle is more important to address clinically to
resolve residual restriction.
1.2. Objectives
The primary aim of this study was to determine and compare the
effect of passive ankle joint mobilization and calf muscle massage on
ankle dorsiflexion range of motion in adults with residual restricted
dorsiflexion. The secondary aim was to assess the methodology of the
pilot study.
The main hypothesis was that mobilization of the ankle joint would
have a greater effect on increasing residual ankle dorsiflexion than soft
tissue massage to the calf muscles. It was expected that improvements to
the methodology of the pilot study would be revealed after completion
of the trial.
2. Method
2.1. Trial design
The study design was a single-blind crossover randomized trial and
the participants acted as their own control. A crossover trial design was
chosen to reduce the number of participants required as this was a pilot
study to test the proof of concept. The study was retrospectively regis­
tered with the Australian New Zealand Clinical Trials Registry (Clinical
Trial no: ACTRN12623001243606) and the full protocol can be found at
https://www.anzctr.org.au/ACTRN12623001243606.aspx
A 2x2 allocation ratio was employed, where 25 participants received
both interventions: 1) a single session of mobilization on both ankles and
2) a single session of soft tissue massage to both calf muscles. In­
terventions were administered in a randomized order one to two weeks
apart (Reid et al., 2007).
2.2. Participants
2.2.1. Recruitment
Twenty-five healthy participants with a history of lower limb injury
in either or both limbs were recruited from a university staff and student
cohort. Potential participants were recruited through advertisements.
Volunteers contacted a project investigator and were initially screened
for eligibility by interview. Recruitment occurred between August 2017
and October 2018.
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Journal of Bodywork & Movement Therapies 37 (2024) 202–208
2.2.2. Sample size
The sample size was calculated using an effect size of 0.59 derived
from a previous crossover design study (Collins et al., 2004). The
required sample size of 25 participants was calculated by using G*Power
software (Version 3.0.10, University of Dusseldorf, Dusseldorf, Ger­
many) to determine the effect size with a two-sided 5% significance level
and power of 80%.
2.2.3. Eligibility
Participants were eligible if they were adults between the age of 18
and 65 years of age, fluent in English, and had a previous lower limb
injury, including ankle sprains and fractures. There were no limitations
placed on the type or severity of injury.
In order to assess residual restricted ankle dorsiflexion after a lower
limb injury had healed, participants were excluded if the lower leg soft
tissue injury occurred within the last 3 months, a lower limb fracture
within the last 12 months, or if they had pins, plates or screws in situ as a
result of a lower limb fracture. No other time limits were placed on when
the injury had occurred. Participants were excluded if they were taking
antithrombotic medication, had a lower limb neurological condition
that caused a loss of sensation or were allergic to low-allergy massage
cream.
2.2.4. Ethical approval and consent
This trial complied with the Declaration of Helsinki and received
ethical approval from the La Trobe University Human Ethics Committee
(HEC17-046). All participants provided written informed consent before
commencing.
2.3. Randomization
All eligible participants were randomly allocated by an independent
researcher into one of two groups. A coded randomization table was
created by the flip of a coin and was provided to the manual therapist.
The manual therapist performing the intervention was blind to all
assessment ankle range measurements. The assessors performing the
pre- and post-assessment measurements were blind to which manual
therapy intervention the participant received. It was not possible to
blind the participants, but they were asked not to tell the manual ther­
apist which was their restricted ankle and not to tell the assessors which
intervention they had received during the post-intervention
measurements.
2.4. Procedure
2.4.1. Setting and location
The research was performed in a controlled environment in an ex­
ercise laboratory at a regional university in Bendigo, Australia.
2.4.2. Procedure
Group 1 received ankle joint mobilization in the first session, fol­
lowed by calf massage in the second session; Group 2 received calf
massage in the first session, followed by ankle joint mobilization in the
second session. Participants continued with normal activities between
sessions. Both groups completed the sessions under the same conditions
in the same laboratory. The second session occurred one to two weeks
after the first session at the same time of day, allowing for a washout of
at least one week (Reid et al., 2007).
All participants completed a pre-intervention (T1 and T3) and post-
intervention assessment (T2 and T4), immediately before and after the
intervention. Ankle dorsiflexion ROM was measured, then the partici­
pants were moved to a room where the manual therapist applied the
intervention, then returned to the assessors’ room to have the ankle
dorsiflexion re-measured.
C.J. Taylor et al. Journal of Bodywork & Movement Therapies 37 (2024) 202–208

2.4.3. Interventions of the inclusion criteria, the blinding of assessors and manual therapist,
The manual therapy interventions were Maitland techniques of and the suitability of the washout period.
passive accessory mobilization of the sub-talar joint and talocrural joint
(Hengeveld and Banks 2005) and soft tissue massage of the calf muscles
2.5. Statistical analysis
(lateral and medial gastrocnemius muscles and soleus muscles). The
manual therapy interventions were performed by a physiotherapist with
For primary outcomes, analysis was conducted by grouping ankles
more than 20 years of musculoskeletal physiotherapy experience. As the
into restricted and non-restricted; the ankle with the least dorsiflexion
physiotherapist was blinded to which was the restricted ankle, manual
was considered restricted. The data were assessed for normality via the
therapy interventions were applied to both limbs.
Shapiro-Wilks test. For normally distributed data, means and standard
For the passive accessory mobilization techniques, participants sat in
deviations were analyzed. For skewed data, medians and interquartile
a reclined supine position with their foot over the end of the plinth and
range were analyzed and for categorical data, frequencies and per­
the therapist applied a rhythmic mobilization to the talocrural joint in a
centages. The mean change (change scores) in ROM between the pre-
posterior to anterior direction (the talus was moved anteriorly in rela­
and post-assessments for both groups were calculated. Paired t-tests
tion to the tibia and fibula) (Hengeveld and Banks 2005). For the sub­
were used to analyze the differences between change scores for both
talar mobilization, the participant laid on one side with the lateral aspect
interventions and differences between interventions. Effect size was
of the ankle uppermost at the edge of the plinth. A medial glide of the
calculated by the formula: mean difference divided by the pooled
calcaneus with respect to the talus was applied. The participant then laid
standard deviation (d = MD/SDpooled) (Field 2009). An effect size of 0.2
on their other side with the medial aspect of the ankle uppermost and a
was considered small, 0.5 was considered medium and 0.8 was consid­
lateral glide of the calcaneus was applied with respect to the talus
ered large (Cohen 1988). Minimal detectable difference 95% (MDD95)
(Hengeveld and Banks, 2005). Grade III mobilizations were applied to
was calculated using the formula MDD95 = 1.96 x √2 x SEM. All data
joints and in directions of stiffness (hypomobility). Grade II mobiliza­
were analyzed using IBM SPSS (Version 26) (IBM, N.Y.) and significance
tions were applied to joints where no restriction was felt, or joints were
was set at p < 0.05.
hypermobile. These grades of mobilization were chosen as they have
The findings of the secondary outcomes were summarized descrip­
similar amplitude of movement as to blind the participant to the tech­
tively. Wilcoxon signed ranks tests were used to analyze the effective­
nique used; Grade III was aimed at reducing restriction and Grade II is
ness of the washout period by comparing the first pre-intervention
performed through a similar range, but not into joint restriction. The
results (T1) with the second pre-intervention results (T3).
intervention consisted of 2–4 sets of 30 s each at approximately one
mobilization per second, with an interval of 10 s between sets. For
hypermobile joints, 2 sets of 30 s using a Grade II was applied and for 3. Results
restricted joints, 3–4 sets of 30 s using a Grade III was applied (Henge­
veld and Banks 2005; Silva et al., 2017). Total time for the intervention Twenty-five participants (median age = 25.54 (IQR = 9.45) years,
was 5 min. range = 19–57), completed both manual therapy interventions. All
The calf muscle massage involved the participant lying prone on the participants self-reported they had sustained at least one injury to at
treatment table and the manual therapist applied soft tissue massage least one lower limb; 40 injuries were reported to 50 lower limbs (mean
techniques of effleurage, kneading and stroking to the calf muscles in a
standardised manner. Care was taken to apply consistent manual ther­ Table 1
apy interventions with regard to the sequence of massage movements Participant demographic characteristics.
and the forces applied. To target the gastrocnemius muscles, the knee Characteristics
was positioned in a relatively extended position with a rolled towel Age (years) (median (IQR), range) 25.54 (9.45) range =
placed under the foot and the soleus was targeted by bending the knee to 19-57
approximately 90◦ . Time for the calf muscle massage was 5 min. Gender (no.)
Male 11
Female 14
2.4.4. Outcomes
Side injured (no. (%))
The primary outcome was change in ankle dorsiflexion as measured Right 8 (32%)
by the weight-bearing lunge. The smaller the score on the weight- Left 7 (28%)
bearing lunge, the more restricted the ankle dorsiflexion is. This Bilateral 7 (28%)
Not stated/could not recall 3 (12%)
assessment of ankle dorsiflexion has demonstrated high validity and
Ankle dorsiflexion ROM (cm) (mean ± SD)
high reliability (ICC = 0.99, 95%CI = 0.97–0.99) (Bennell et al., 1998). Restricted ankles (n = 24) 9.46 ± 3.86
The ankle dorsiflexion ROM was assessed by allied health students who Non-restricted ankles (n = 24) 11.34 ± 3.79
received training in conducting the standardized test procedure. A steel Type of injury (no. (%))
1-m ruler was taped to the floor, perpendicular to a wall. The participant Lateral ankle sprain 21 (52.5%)
Lateral ankle sprain with tendon injury 1 (2.5%)
placed the great toe and heel on the steel ruler and lunged forward so the
Lateral ankle sprain with associated bone fracture 3 (7.5%)
knee touched the wall over the ruler, without the heel leaving the Lateral ankle ligament rupture with dislocation and 1 (2.5%)
ground. If the heel lifted, the participant repositioned the foot forward fibula fracture
on the ruler. The assessor ensured this was the limit of the ankle range Tibia stress fracture 2 (5.0%)
and the pelvis did not rotate during the test. The participant remained in Tibialis posterior tendinopathy/shin splints 4 (10%)
Tibia and fibula fracture 1 (2.5%)
position while the distance from the wall to the great toe was measured Fibular growth plate fracture 1 (2.5%)
in centimetres, to the nearest half centimetre. Single measurements were Calcaneal surgical fracture and reset 1 (2.5%)
taken for the left and right legs. Ankle dorsiflexion was assessed only Patellofemoral pain syndrome 1 (2.5%)
once pre- and post-intervention due to the high reliability of the Anterior cruciate ligament and lateral collateral 1 (2.5%)
ligament injury
weight-bearing lunge and to reduce the potential influence of the test on
Anterior cruciate ligament and medial collateral 1 (2.5%)
outcomes by stretching contractile or non-contractile structures during ligament injury
the testing procedure. Meniscal injury and associated bone bruising 1 (2.5%)
The secondary outcome of the study was to evaluate the methodol­ Hamstring injury 1 (2.5%)
ogy of the pilot study for a potential future randomized controlled trial. Not stated 1 (2.5%)

The particular features of this trial that were evaluated were suitability SD = standard deviation, ROM = range of motion.

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C.J. Taylor et al.
= 1.7, ±1., range = 1–5) of which, 31 were soft tissue injuries, four were
bone injuries and five were a combination of soft tissue and bone injury
(Table 1). The mean time since injury was 4.14 (±6.56) years (range = 4
months to 37 years). There were no dropouts. No adverse events were
reported. The participant flow diagram is presented in Fig. 1.
Forty-eight ankles were included in the analysis. One participant was
excluded due to equal dorsiflexion on each ankle and neither ankle could
be considered restricted. Baseline dorsiflexion measures demonstrated a
significant difference between restricted ankles and non-restricted an­
kles (mean difference = 1.88 ± 1.45 cm, 95%CI = 1.27–2.50, p <
0.001). For restricted ankles, an increase in dorsiflexion ROM was
demonstrated for both ankle joint mobilization and calf muscle soft
tissue massage (Table 2). There was no difference in change scores be­
tween interventions for restricted ankles (mean difference between
change scores = 0.40 ± 1.19 cm, 95%CI = − 0.11 to 0.91, p = 0.12).
The results of the feasibility of the trial found issues with the inclu­
sion criteria, the blinding of the assessor and with the washout period.
The inclusion criteria did not restrict the length of time since the injury
and some participants could not remember which leg they had injured or
how long ago. Further, 28% of participants had bilateral injuries and
both ankles may have been restricted. The blinding of the manual
therapist was successful as they did not know which was the restricted
ankle during the interventions. Blinding of the assessors had a problem
related to the application of massage cream during the massage inter­
vention. Massage cream was applied to the lower leg of the participants
during the massage intervention and not during ankle joint mobiliza­
tion. While care was taken to remove the massage cream, in some cases
the assessors could tell when the massage intervention had been applied
due to residual massage cream. Assessment of the washout period found
for the group who received ankle mobilization first, dorsiflexion ROM
was maintained between interventions and did not return to baseline
after the washout period. (Fig. 2). The group who received calf muscle
massage first returned to baseline after the washout period.
4. Discussion
To our knowledge, this is the first study to investigate and compare
the relative effects of ankle joint mobilization and calf muscle soft tissue
massage on ankle dorsiflexion ROM in restricted ankles. The hypothesis
was that ankle mobilization would be more effective than calf muscle
massage; however, a single session of ankle joint mobilization and calf
muscle massage resulted in equivalent increase in ROM. The results of
this study suggest that a larger trial to investigate the effect of manual
therapy on ankle joint dorsiflexion ROM may be feasible; however,
changes to the method are proposed.
4.1. Primary outcomes
The present study demonstrated ankle joint mobilization increased
ankle dorsiflexion ROM in restricted ankles. This finding is consistent
with the findings of Collins et al. (2004); however, the magnitude of the
change is different. The current study demonstrated an increase of 0.51
cm, whereas Collins et al. (2004) reported an increase in dorsiflexion of
1.17 cm. The difference may be due to inclusion criteria, baseline
measures, the duration of time the mobilization was applied, and/or the
different techniques used. The current study recruited participants with
any lifetime lower limb injury and no limitations were placed on nature
or severity of injury, time since the injury had occurred or minimum
level of asymmetry between ankles. Collins and colleagues recruited
participants with a relatively recent ankle sprain and a minimum of 10
mm asymmetry between restricted and non-restricted ankles. The
baseline difference between ankles for the current study was 1.88 cm, in
comparison to Collins et al. (2004), which was 4.24 cm. The greater
restriction may have seen greater change due to the intervention. While
the current study applied mobilization techniques for 3–4 sets of 30 s for
GIII techniques (90–120 s), Collins et al. do not specify the time, but
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Journal of Bodywork & Movement Therapies 37 (2024) 202–208
instead describe ‘3 sets of 10 repetitions of slow active dorsiflexion to
end of pain-free range’; therefore, it is difficult to make a direct com­
parison. The differences in techniques used (active weight-bearing
mobilization vs passive non-weight bearing mobilization) may also ac­
count for differences in magnitude of the results.
This study appears to be the first to assess a combination of passive
posterior to anterior glide of the talocrural joint, and passive lateral and
medial glides of the subtalar joint (Hengeveld and Banks 2005). Previ­
ous research has investigated mobilization with movement in the ante­
rior to posterior direction only (Collins et al., 2004; Gilbreath et al.,
2014; Reid et al., 2007; Vicenzino et al., 2006) or passive accessory
movement of the talus in the anterior to posterior direction only (Green
et al., 2001; Hoch et al., 2012; Landrum et al., 2008; Silva et al., 2017;
Venturini et al., 2007; Yeo and Wright 2011). No studies were identified
that have investigated the passive mobilization techniques used in this
study, either in isolation or combination, which makes direct compari­
sons difficult.
Calf muscle massage increased ankle dorsiflexion ROM. This finding
is consistent with results reported by Grieve et al. (2011), although there
were differences in the study protocols. Grieve et al. (2011) used trigger
point release on the soleus muscle for a maximum of 3 min, while the
current study used a combination of effleurage, kneading and stroking
applied to the gastrocnemius and soleus muscles for 5 min. Although the
techniques are different, both interventions target the calf muscles and
appear to have the effect of lengthening the skeletal muscle to allow
greater range at the joint.
The findings of the current study suggest changes in joint arthro­
mechanics are a factor in reduced ankle ROM. The interventions that
targeted the non-contractile elements of the ankle joint (ligaments and
joint capsule) increased ankle dorsiflexion in restricted ankles suggest­
ing these structures are at fault. A possible mechanism is that ligamen­
tous and joint capsule tightness prevents accessory joint movement,
which is required for full physiological movement (Hengeveld and
Banks 2005). Passive mobilization stretches the non-contractile joint
structures, the talus is reseated in the mortice and allows accessory
posterior gliding, and physiological movement is restored.
Calf muscle shortening also appears to be a factor in restricted an­
kles. When a lower limb injury occurs, there is a period of immobiliza­
tion and calf muscle tightness can persist (Denegar et al., 2002; Shaffer
et al., 2000). Calf muscle massage appeared to restore muscle length and
increase ankle dorsiflexion.
4.2. Secondary outcomes
The results of this study suggest that a larger trial to investigate the
effect of manual therapy on ankle joint dorsiflexion ROM is feasible;
however, the findings suggest some modifications to the protocol are
required to improve future studies.
4.2.1. Inclusion criteria
The inclusion criteria did not limit time since injury and some par­
ticipants could not remember which leg had sustained an injury;
therefore, it could not be confirmed if the injured leg was the most
restricted. A suggestion for future studies is to put a time limit (i.e. 2
years) on when injury had occurred in order to confirm the restricted
ankle is the injured ankle.
Type and severity of injury were not standardized, nor was the
amount of asymmetry between restricted ankles. Future studies could
limit the type and severity of injury to reduce possible confounders.
Potential participants should be screened to ensure at least a 2 cm dif­
ference between restricted and unrestricted ankles (Vicenzino et al.,
2006).
The inclusion criteria allowed seven participants with bilateral in­
juries to be included, and baseline measurements showed a significant
difference between their restricted and non-restricted ankles; therefore,
the non-restricted group included both uninjured and injured ankles.
C.J. Taylor et al. Journal of Bodywork & Movement Therapies 37 (2024) 202–208

Fig. 1. Participant flow diagram.

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C.J. Taylor et al. Journal of Bodywork & Movement Therapies 37 (2024) 202–208

Table 2
The effect of ankle joint mobilization and calf muscle massage on ankle dorsiflexion range of motion.
Intervention Pre-intervention ankle DF Post-intervention ankle DF Mean difference 95% CI p-value Effect MDD95
ROM (cm) ROM (cm) (cm) size
Mean (SD) Mean (SD) Mean (SD)

Restricted ankles (n Ankle joint 9.78 (±3.75) 10.29 (±3.75) 0.51 (±0.76) 0.19 to 0.003 0.14 0.43
= 24) mobilization 0.83
Calf muscle 9.79 (±4.24) 10.70 (±3.59) 0.91 (±1.07) 0.46 to <0.001 0.23 0.60
massage 1.36

Fig. 2. Ankle dorsiflexion range of motion after washout period.

This could lead to difficulty when making clear comparisons between
ankles when not all participants had an uninjured control limb. In future
studies, it is suggested participants be restricted to those with unilateral
injuries.
The eligibility criteria did not exclude participants who were
receiving or had recently received physical therapy treatment. Regular
lower limb strength and/or flexibility exercise training during partici­
pation in the study may have introduced errors in the effectiveness of the
participant’s response to the manual therapy. In future, it is suggested
eligibility criteria should specify participants must not have had physical
therapy treatment in the previous 3 months before their involvement.
The participants were university staff and students, who were easily
accessible and possibly more active and healthier than a potential pa­
tient population. Therefore, this may have introduced a convenience
sampling bias, which could be a possible source of error in the study
(Sim and Wright 2000). Future recruitment should target a broader
sample of the population.
4.2.2. Blinding
Massage cream was only applied to the lower leg of the participants
during the massage intervention and not the ankle joint mobilization.
While care was taken to remove the massage cream, when the assessors
reassessed the ankle range of motion, at times they could tell which
intervention had been applied as residual massage cream was evident.
Future studies should apply, then remove massage cream at the end of
the joint mobilization session.
4.2.3. Washout period
The change in ankle dorsiflexion ROM for the restricted ankles that
received ankle mobilization first persisted during the washout period,
with the effects on ROM from the first intervention carrying over to the
second intervention. This result is consistent with previous findings
where increased ankle dorsiflexion ROM was maintained for one (Yeo
and Wright 2011) to two (Silva et al., 2017) weeks. This may have led to
errors in the effect size observed from the second intervention, possibly
reducing the observed magnitude of ROM changes. This carry-over ef­
fect may be positive from a clinical perspective, but detrimental to the
strength of the study findings. In future it is suggested the washout
period be longer; however, based on currently available evidence, it is
unclear how long this should be. In the future, it is suggested that
follow-up weight-bearing lunge measurements be made one, two, three,
and four weeks after each intervention to give insight into the clinical
persistence and effectiveness of a single manual therapy session on ankle
dorsiflexion ROM. This will inform an appropriate washout period for
future research.
4.2.4. Study design
A limitation of the current study was the study design. This pilot
study was a crossover trial design, without a true control group. It is
suggested that future randomized controlled study designs have three
arms; where one group receives ankle joint mobilization, one group
receives calf massage and one group receives a sham intervention. The
introduction of a sham control would strengthen any findings that
suggest the clinical effectiveness of manual therapy.

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C.J. Taylor et al.
5. Conclusion
The findings indicate for ankles with restricted dorsiflexion ROM,
joint mobilization and soft tissue massage to the calf muscles both have
equal effects on increasing ROM. This further suggests both the ankle
joint arthrokinematics and calf muscle tightness play a role in restricting
ankle dorsiflexion, and both should be considered when clinically
assessing and treating restricted dorsiflexion ankle ROM. The results of
this trial suggest a larger trial is feasible, with modifications.
Clinical relevance
• A single session of ankle joint mobilization and a single session of calf
muscle massage increased ankle dorsiflexion range of motion in
restricted ankles
• Both interventions should be considered when rehabilitating ankle
dorsiflexion restriction after lower limb injury
Funding
Carolyn J. Taylor, Lisa C. Hanson and Nivan Werrakkody were
supported by La Trobe University to conduct this research.
CRediT authorship contribution statement
Carolyn J. Taylor: Conceptualization, Data curation, Formal anal­
ysis, Investigation, Methodology, Supervision, Writing – original draft,
Writing – review & editing. Lisa C. Hanson: Formal analysis, Writing –
review & editing. Abbey Hayes: Data curation, Methodology, Investi­
gation. Alan Pham: Data curation, Methodology, Investigation. Elliott
Taylor: Data curation, Methodology. Poppy Attlesey: Data curation,
Investigation, Methodology. Gemma Stewart: Data curation, Investi­
gation, Methodology. Amy O’Neill: Data curation, Investigation,
Methodology. Ilana Karass: Data curation, Investigation, Methodology.
Nivan Weerakkody: Formal analysis, Supervision, Writing – original
draft, Writing – review & editing.
Declaration of competing interest
Declarations of interest: none.
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