










































MANUSCRIPT TYPE


CLINCAL OUTCOMES RESEARCH  

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 
 

Using the Mulligan Mobilization with Movement and Fibular 
Repositioning to Treat High School Patients with a Grade One Lateral 
Ankle Sprain 
Alexander Zettlemoyer, DAT, LAT, ATC *; Rich Patterson, DAT, LAT, ATC†; Russell Baker PhD, DAT, ATC‡; 
Alan Nasypany, EdD, LAT, ATC‡ 
*Mechanicsburg Area School District, Mechanicsburg, PA; †Clarion University, Clarion, PA; ‡ University of Idaho, Moscow, ID 

  

 
ABSTRACT 
Ankle injuries are common among high school athletics with 
the highest incidence rates in boys and girls basketball and 
boys football. Novel treatment paradigms like the Mulligan 
Mobilization with Movement (MWM) in conjunction with 
fibular repositioning tape have shown promising results in 
reducing pain, disability, and time lost due to lateral ankle 
sprains (LAS). However, research focusing on Mulligan 
treatment strategies and ankle swelling following a LAS is 
limited. Therefore, the purpose of this case series was to 
evaluate the combined effects of the MWM and fibular 
repositioning taping on swelling, function, and pain in high 
school patients with an acute grade 1 LAS. A convenience 
sample of seven (4 females, 3 males, 5 right ankle, 2 left 
ankle injuries) consecutive high school patients (15.9± 1.4 
years of age; range = 14-18 years) were evaluated 
following an acute LAS and treated with the MWM and 
fibular repositioning tape. Subjective evaluation of pain, self-
report function and disability were assessed throughout the 
treatment process utilizing PROMs. Specifically, the Numeric 
Pain Rating Scale, Disablement in the Physically Active scale, 
Foot and Ankle Ability Measure and the Foot and Ankle 
Ability Measure Sport Subscale were included throughout the 
treatment protocol along with the figure-of-eight ankle girth 
measurement to assess the amount of swelling following each 
treatment session. All seven patients returned to unrestricted 
participation following an average of 2.9±0.8 treatments 
(range 2-4 treatments) and presented an average decrease 
in ankle girth of 24.7±13.7mm from baseline to return to 
participation. Overall, the MWM and fibular repositioning 
tape produced an immediate change in pain, disability, 
function and swelling following an acute grade 1 LAS. 
Key Phrases 
Manual techniques, clinician-rated outcomes, patient-
reported outcomes 
 
Correspondence 
Mechanicsburg Area Senior High School, 500 South Broad 
Street, Mechanicsburg, PA 17055 
E-mail: SZettlemoyer@mbgsd.org  
Twitter: @realneal35 
 
Full Citation 
Zettlemoyer A, Patterson R, Baker R, Nasypany A. 
Using the Mulligan mobilization with movement and 
fibular repositioning to treat high school patients with 
a grade one lateral ankle sprain. Clin Pract Athl Train. 
2022;5(3): 22-30. 
https://doi.org/10.31622/2021/0005.01.4.    
 
Submitted: January 17, 2021 Accepted: April 14, 2021. 

 
INTRODUCTION 
 
With a peak ankle incident rate between the ages 
of ten and nineteen, high school athletes are 
specifically susceptible to ankle sprains, 
accounting for 22.6% of all sports related 
musculoskeletal injuries.1,2 The highest incidence in 
high school sports of ankle sprains occurs in boys 
basketball (7.74 per 10,000 exposures), 
followed by girls basketball (6.93 per 10,000 
exposures) and boys’ football (6.52 per 10,000 
exposures).2 Approximately 85% of ankle injuries 
occur after excessive inversion and plantarflexion 
of the foot combined with external rotation of the 
distal leg, which results in damage to the lateral 
ligament complex.3 Of the three lateral ligaments, 
the anterior talofibular ligament (ATFL) is the 
weakest and is more frequently involved in ankle 
sprains than the calcaneofibular ligament or the 
posterior talofibular ligament.3,4  

Following an acute lateral ankle sprain (LAS), 
ankle joint ligamentous and muscular dynamic 
stability are compromised to varying degrees 
based on the extent of the injury. One factor that 
may contribute to increased dysfunction 
associated with LAS is the anatomical position of 
the fibula in relation to the tibia within the ankle 
mortise.5–7 This post-injury variation was first 
hypothesized by Brian Mulligan, founder of the 
Mulligan Concept (MC), as a positional fault in 
which the distal fibula is displaced in the anterior, 
inferior and medial direction.8 Following LAS, the 
fibula may become stuck anteriorly resulting in an 
increase in accessory movements such as gliding 
and rolling of talus in the ankle mortise.9 These 

mailto:SZettlemoyer@mbgsd.org
https://doi.org/10.31622/2021/0005.01.4


Using the Mulligan MWM and Fibular Repositioning to Treat High School Patients with Grade One Lateral Ankle Sprain 
 

 

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altered arthrokinematic motions lead to abnormal 
physiological motions which increase ligamentous 
stress and when left untreated may lead to 
delayed healing and chronic ankle instability.10  

Immediate conservative treatment of LAS 
commonly includes protection, optimal loading, 
ice, compression and elevation (POLICE)11 in 
conjunction with early mobilization and non-
steroidal anti-inflammatory medication.12 This 
intervention is recommended based on the tissue-
healing model that clinicians believe must occur 
post-LAS. However, given the previous research 
on the presence of positional faults post-LAS,5,10,13 
it appears that commonly used conservative 
methods fail to address the position of the fibula 
which may lead to delayed recovery and the 
development of ankle instability. The early 
application of MC Mobilization with Movement 
(MWM) and the fibular repositioning taping 
technique, which are designed to provide an 
immediate and long-lasting correction of the 
previously mentioned positional fault, may 
improve patient outcomes following LAS. If a Pain-
free, Immediate, and Long-Lasting (P.I.L.L) 
mobilization applied to the distal fibula in a 
posterior, superior and lateral direction while 
active or passive range of motion is performed 
with overpressure at the end-range, resolves 
patient-reported pain and improves range of 
motion, then the clinician should continue to utilize 
the technique as part of the treatment protocol 
following MC guidelines.8  

The majority of the evidence on this technique 
includes description studies, but initial reports 
have documented positive effects of the MWM 
and fibular repositioning tape on pain and 
dysfunction in patients suffering from acute LAS.14–

17 Studies evaluating patient outcomes for 
swelling or edema reduction post MWM or fibular 
repositioning taping application post-LAS were 
not identified. Thus, there is a paucity of research 
on the effects of MWMs in patients who have 
suffered acute LAS. Therefore, the purpose of this 

case series was to evaluate the combined effects 
of the MWM and fibular repositioning taping on 
swelling, function, and pain in high school patients 
with an acute grade 1 LAS. 

PATIENT POPULATION 

A convenience sample of seven (4 females, 3 
males, 5 right ankle, 2 left ankle injuries) 
consecutive high school patients (15.9± 1.4 years 
of age; range = 14-18 years) were evaluated by 
an Athletic Trainer following an acute inversion 
ankle injury. Initial examination occurred within 72 
hours of the acute LAS. Prior to beginning the 
study, each patient agreed to complete the LAS 
treatment protocol, as well as the associated 
patient reported outcome measures (PROMs). 
Patients were included if they suffered an acute 
(i.e., must report within 72 hours of initial onset) 
inversion ankle sprain as well as self-reported 
functional limitations resulting from the injury. 
Patients were excluded if they had any 
concomitant injuries or contraindications to manual 
therapy such as: systemic or local infection, 
fracture, malignancy, acute circulatory conditions, 
pregnancy, or hyper joint mobility. Patient history 
of LAS was not controlled for during the study. All 
patients completed the approved consent process 
(i.e., minor participant assent and parental 
consent) prior to participation in the study. The 
study was approved by the high school’s 
institutional review board.  

CLINICAL EVALUATION AND INTERVENTION 

Initial evaluation consisted of a standardized 
bilateral physical examination of the ankle, which 
included a detailed history, physical exam, the 
Ottawa Ankle Rules to rule out ankle fracture, 
girth measurement (figure-of-eight), and baseline 
PROMs. Pre- and post-intervention PROMs 
included the Numeric Pain Rating Scale (NPRS), 
the Disablement in the Physically Active (DPA) 
scale, Foot and Ankle Ability Measure (FAAM) and 
the Foot and Ankle Ability Measure Sport 
Subscale (FAAM-S). A second Athletic Trainer, who 



Using the Mulligan MWM and Fibular Repositioning to Treat High School Patients with Grade One Lateral Ankle Sprain 
 

 

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was blinded to the results of the primary 
investigator, performed a secondary examination 
to confirm the original diagnosis and verify 
patient inclusion criteria. Diagnosis of a Grade 1 
LAS was defined by mild swelling along the distal 
lateral malleolus, tenderness on palpation, pain 
along the ATFL during the anterior drawer test 
with the patient seated and the foot in neutral, 
and inversion stress testing with a firm end-feel 
(i.e., without ligament laxity).18  

Following the initial evaluation and 
acknowledgment of consent, patients completed 
the baseline PROMs and were treated using the 
Mulligan distal fibular anterior-posterior (A-P) 
MWM followed by the fibular repositioning 
taping technique. This technique was carried out 
by placing the patient supine with the involved 
ankle off the end of the treatment table. The 
MWM technique required a pain-free sustained 
anterior to posterior, slightly superior and lateral 
glide of the distal fibular in relation to the ankle 
mortise (Figure 1), which was performed by 
placing the thenar eminence of the clinician on the 
patient’s fibula just anterior to the distal, lateral 
malleolus. In conjunction with the sustained glide, 
the patient actively plantar-flexed and inverted 
the foot for 3 sets of 10 repetitions to the end of 
active range, followed by pain-free overpressure 
by the clinician. Immediately following the MWM, 
fibular repositioning tape was applied to 
maintain the corrected positional fault.8 Two-inch 
(5.0cm) BSN Medical Cover-Roll® was loosely 
applied anterior to the distal fibula and continued 
in a posterior-superior direction, wrapping 
around the distal tibia ending approximately one-
inch (2.5cm) superior to the starting position along 
the anterior aspect of the tibia. One and one- half 
(3.84cm) inch Leukotape® was then applied 
directly to the Cover-Roll in the same direction as 
the glide to maintain the position of the fibula until 
the next scheduled treatment (Figure 2).8  

 

Figure 2. MC lateral fibular repositioning taping technique 

Each patient was seen for a minimum of two 
visits, with one day between visits. During each 
follow-up visit the patient was re-evaluated for 
change in ankle girth measurements (figure-of-
eight) as described by Tatro-Adams et al19 by 
both clinicians which were blinded to the results 
followed by completion of the NPRS. The patient 
was again treated with the Mulligan distal 
fibular A-P MWM in the same method as 
previously described. The fibular repositioning 
tape remained in place for the duration of the 
study but was reinforced if slippage was 
identified. The use of standard conservative 
treatment such as POLICE was not controlled by 
the investigators. The patients were instructed to 
continue activities of daily living (ADLs) as 
tolerated but refrain from participation in sports. 

Figure 1. Mulligan Technique: anterior to posterior, slightly 
superior and lateral glide of the distal fibular 



Using the Mulligan MWM and Fibular Repositioning to Treat High School Patients with Grade One Lateral Ankle Sprain 
 

 

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Following the treatment intervention, each patient 
completed the DPA scale, FAAM and the FAAM-S 
outcome measures. Patients were monitored 
throughout the study for signs warranting 
additional medical care, but no such patient 
existed during the duration of the study. As a 
condition of discharge, each patient had to 
perform functional non-standardized sports-
specific activities evaluated by the original 
clinicians. The activities were performed with the 
Mulligan fibular repositioning tape applied and 
included running, cutting/lateral movement, 
jumping and single-leg hop on the involved 
extremity. 

OUTCOME MEASURES 

Subjective evaluation of pain, self-report function 
and disability were assessed throughout the 
treatment process utilizing PROMs. Specifically, 
the NPRS, DPA scale, FAAM and the FAAM-S were 
included throughout the treatment protocol. 
Clinician oriented evidence included the figure-of-
eight ankle girth measurement to assess the 
amount of swelling following each treatment 
session.  

Numeric Pain Rating Scale and Disablement in 
the Physically Active Scale 

Patient oriented evidence including pain and 
global disablement was collected utilizing the 
NPRS and DPA scale. The NPRS is an 11-point 
self-report pain scale ranging from 0-10, where 
0 is “no pain” and 10 is the “worst pain 
imaginable.” The patient indicates intensity of 
current pain, worst pain and best pain over the 
last 24-hours which is averaged to identify a pain 
score.20 The DPA scale is a 16 item, 
multidimensional, outcome instrument based on the 
disablement model which uses a 5-point Likert 
Scale where 0 represents “no problem” and 4 
represents “severe” disability.21 With a scoring 
range of 0-64, the higher the score the higher the 
level of disability.21 The minimally clinically 
important difference (MCID) represents the ability 

of the instrument to reflect the patient’s perception 
of change in the disease process over time. The 
MCID for the NPRS and DPA scale has been 
previously calculated as a 2-point change22 and 
9-points in acute participants respectively.21 These 
instruments were chosen because they have 
demonstrated consistent validity among patients 
with similar musculoskeletal conditions such as 
acute LAS.21,23  

Foot and Ankle Ability Measure 

The FAAM is a region-specific PROM divided into 
the FAAM-ADL (activities of daily living) and the 
FAAM-S subscales. The FAAM evaluates activity 
limitations and patient disability on a 5-point 
Likert scale (0-4, 0=no difficulty and 4=unable to 
do). Scores range from 0-84 (FAAM-ADL) and 0-
28 (FAAM-S) which are written as a percentage 
with 100% representing no functional loss. The 
MCID for the FAAM-ADL and FAAM-S is an 8-
point and 9-point change 
respectively.24  Similarly, the FAAM-ADL and 
FAAM-S have shown reliability and validity for 
patients with a broad range of lower limb, ankle 
and foot dysfunctions.24  

Ankle Girth Measurements - Figure-of-Eight  

Ankle girth was measured by applying the figure-
of-eight method while each foot was maintained 
in a neutral position. Tatro-Adams et al19 
described the figure-of-eight as the following 
procedure; with the ankle in a neutral dorsiflexion 
position, a flexible 1-centimeter tape starts 
midway between the tibialis anterior tendon and 
the lateral malleolus and is then drawn medially 
across the instep and placed just distal to the 
tuberosity of the navicular and then pulled across 
the arch and up just proximal to the base of the 
5th metatarsal. The tape is then placed across the 
tibialis anterior tendon and continues around the 
ankle joint just distal to the distal tip of the medial 
malleolus, crosses the Achilles tendon, and is 
placed just distal to the distal tip of the lateral 
malleolus ending at the starting position.19  The 



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ICC was previously determined to be 0.99 for 
both inter-tester and intra-tester reliability for this 
method of measuring ankle swelling.19 Ankle girth 
measurements were in millimeters and taken three 
times during the initial treatment and following 
each subsequent treatment with the average of 
the three measures recorded.  

RESULTS   

Patient demographic data was analyzed using 
mean and standard deviation (Table 1). All seven 
patients were evaluated and treated for LAS and 
returned to unrestricted participation following an 
average of 2.9±0.8 treatments (range 2-4 
treatments). Figure-of-eight measurements were 
taken at baseline and following each treatment. 
Baseline figure-of-eight measures for the involved 
ankle were 587.5±15.0mm compared to the 
uninvolved ankle 559.9±11.3mm. Between 
baseline treatment and final figure-of-eight 
measures, patients demonstrated a decrease in 
ankle girth of 24.7±13.7mm (Table 2) and 
presented a final ankle girth of 562.7±11.6mm. 
All seven patients also reported changes across all 
PROM taken between baseline and final measure 
which met the MCID for the NPRS (2-points), DPA 
(9-points), FAAM (8-points) and FAAM-S (9-
points) (Table 3). 

DISCUSSION  

Application of the MWM treatment protocol in 
combination with the fibular repositioning tape on 
patients presenting with an acute grade 1 LAS 
demonstrated improvement across all outcome 
instruments and a reduction in swelling as 
measured by the figure-of-eight girth method 
over approximately 3 treatments. As we 
hypothesized, restoring the normal relative 
position of the distal fibula through the MWM and 
fibular repositioning tape was an effective 
intervention for the treatment of pain and 
disability in high school patients with acute grade 
1 LAS. All seven patients also met or exceeded 
the MCID on the included outcome instruments 
indicating clinically significant improvements from 
baseline to discharge for pain, measured by the 
NPRS, disablement measured by the DPA scale, 
and function which was measured by the FAAM 
and FAAM-S (Table 3). These meaningful 
improvements in PROMs are consistent with 
patient measures reported in previous studies.14–

17, 25–28  

Acute LAS are frequently accompanied by 
swelling around the ankle joint and foot.12 The 
figure-of-eight ankle girth measurement is a 
reliable and cost-effective method for measuring 
ankle swelling regardless of ankle position.5,29 
Hubbard and Hertel5 found a correlation between 
the anterior position of the fibula and the amount 
of swelling in individuals with sub-acute ankle 
sprains using fluoroscopy. However, it should be 
noted that the amount of swelling does not directly  

Table 1. Patient demographic information 
Patient Days from Initial Injury to 

Evaluation and Treatment 
Patient 

Age  
Sex  Sport  Involved 

Ankle 
Number of 
Treatments 
to discharge 

1 1 15 F WBB R 3 
2 1 17 F WBB R 4 
3 1 15 M MBB L 2 
4 3 18 M SOC L 3 
5 2 15 F WP R 2 
6 1 17 M SOC R 2 
7 1 14 F VB R 4 

* WBB= Women’s Basketball, MBB= Men’s Basketball, SOC= Men's Soccer,   
    WP= Women’s Water Polo, VB= Women’s Volleyball   



CLINCAL OUTCOMES RESEARCH  

 

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Table 2: Figure-of-eight measures 
 Injured  Uninjured 

Patient Baseline Girth 
(mm) 

Girth at Discharge 
(mm) 

Change in Girth 
(mm) 

Baseline Girth 
(mm) 

1 581.6 556.2 25.4 555.2 
2 582.8 546.6 36.2 544.8 
3 595.5 580.3 15.2 576.7 
4 588 565.7 22.3 566 
5 564.9 553.2 11.7 548 
6 585.2 572.1 13.1 567.4 
7 614.3 565.3 49 561.3 
Average 587.5 562.8 24.7 559.9 
SD (±) 15.0 11.6 13.7 11.3 

Table 3. Patient-rated outcome measure results: initial, discharge and mean change 

Patient # 1 2 3 4 5 6 7 Mean change and 
SD MCID 

NPRS 
Baseline  6.00 8.00 4.33 5.00 4.00 6.33 5.00   

NPRS 
Discharge  1.33* 1.67* 3.00 2.33 2.00* 1.00* 0.33* 3.86±1.86 2 

FAAM 
Baseline  40 28 47 35 42 13 54   

FAAM 
Discharge  80* 79* 79* 64* 64* 84* 83* 39.12±16.87 8 

FAAM-S 
Baseline  1 7 7 0 12 3 7   

FAAM-S 
Discharge  22* 21* 19* 18* 24* 24* 22* 16.14±3.89 9 

DPA 
Baseline  37 36 27 29 42 57 30   

DPA 
Discharge  3* 6* 7* 12* 3* 4* 14* 29.86±13.48 9 

*Achieved MCID  

correlate with the self-reported function following 
an ankle injury.30  Therefore, measures of swelling 
may not represent a functional outcome but could 
be useful in establishing a baseline which can be 
tracked throughout the rehabilitation process.  

While our research design does not include 
diagnostic testing, repositioning of the fibula and 
ankle mobilization did demonstrate a decrease in 
swelling over the short treatment duration. The 
reduction in ankle swelling following the 
intervention represents a positive effect on 
mechanical properties, regardless of the influence 

of swelling on self-reported function suggesting 
that pain, rather than swelling is the limiting factor 
in acute LAS.30  

The addition and quantity of swelling during the 
plantarflexion/inversion mechanism for LASs may 
influence the relative position of the fibula on the 
tibia in the ankle mortise.  

Hubbard and Hertel5 found nine of 11 patients 
with subacute ankle injuries to have an anterior 
positioned fibula and suggested that the amount 
of swelling was correlated with the amount of 



Using the Mulligan MWM and Fibular Repositioning to Treat High School Patients with Grade One Lateral Ankle Sprain 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

anterior fibular displacement. These results 
coincide with Mavi et al13 and Kavanagh6 who 
both reported an anterior displacement of the 
distal fibula following ankle injury through 
radiographic imaging. Suggested treatment for 
the anterior fibular displacement includes 
mobilization and has been documented in case 
reports with positive outcomes in ROM, patient 
reported pain and function.15,28 Fibular 
repositioning taping has also been evaluated in 
limited fashion and reported to have no effect on 
static or dynamic balance31 but may help to 
prevent recurrent ankle sprains.32   

Our study demonstrated a decrease in both pain 
and ankle girth, but the limited number of 
participants makes it difficult to draw a statistical 
correlation. This is consistent with Collins, Teys & 
Vicenzino,28  who evaluated the acute effects of 
the dorsiflexion MWM on subacute ankle sprains, 
and found significant improvements in ankle 
dorsiflexion but no change in hypoalgesic effects 
following a single treatment session. In contrast, 
our study included the MWM in conjunction with 
fibular repositioning tape on acute ankle patients 
and included multiple MWM treatments. The 
subtle changes in fibular position combined with 
active movement may have a greater influence on 
the mechanical response to acute injury while pain 
receptors are not inhibited by this technique. 
Additional research is warranted to clarify this 
potential change following the MWM and fibular 
repositioning taping.  

The case series design (level 4) of this study 
presents some limitations. The lack of short-term 
follow-up does not give sufficient insight into the 
long-term consequences of the treatment. All 
patients returned to participation with no 
reported ankle complications for the remainder of 
the competitive season, but no additional PROMs 
were administered as a follow-up. This case series 
included a standardized treatment intervention of 
MWM and fibular repositioning, but the lack of a 
control group does not strictly prove that the 

Mulligan Concept caused an improvement in the 
outcome measures but does indicate that an 
association exists. Since all subjects in the study 
were high school students, the generalizability of 
the results to various age and activity levels also 
has limitations. In addition, clinicians were not 
blinded to the results of their figure-or-eight ankle 
girth measurements which could result in 
measurement bias in subsequent applications. 
Future research should include a longitudinal 
design with larger sample size, inclusion of a 
control group, and a more diverse patient 
population.  

CLINICAL APPLICATION   

The results of this case series demonstrate that the 
inclusion of the MC fibular repositioning tape and 
MWM produce an immediate change in pain, 
disability, function and swelling following an acute 
grade 1 LAS. Over the course of 2-4 treatments, 
patients were returned to unrestricted 
participation with no reported ankle impairments. 
The application of the MC treatment intervention 
early in the acute phase of healing had a 
meaningful impact on patient and clinician 
evidence for patients presenting with acute grade 
1 LAS. By addressing the acute positional fault 
early in the rehab process, the clinician may 
impede the inflammatory response to reduce the 
amount of edema following injury. The reduction 
of edema may lead to improved outcomes and a 
more efficient return to healthy participation. 
Based on the outcome of our study, clinicians 
looking to efficiently treat acute grade 1 LAS may 
benefit from the inclusion of the MC in their 
therapeutic approach. 

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Using the Mulligan MWM and Fibular Repositioning to Treat High School Patients with Grade One Lateral Ankle Sprain 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

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Using the Mulligan MWM and Fibular Repositioning to Treat High School Patients with Grade One Lateral Ankle Sprain 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

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	ABSTRACT

