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This is to certify that the

thesis entitled

THE EFFECT OF TWO MASSAGE TREATMENTS ON GRADE
ONE AND GRADE TWO LATERAL ANKLE SPRAINS

presented by

Shawn Raye Cradit

has been accepted towards fulfillment
of the requirements for

M.S. Kinesiology

degree in

 

 

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Major professor

 

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PLACE IN RETURN BOX to remove this chedtout from your record.
TO AVOID FINE return on or before date due.
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THE EFFECT OF TWO MASSAGE TREATMENTS ON
GRADE ONE AND GRADE TWO LATERAL ANKLE SPRAINS

By

Shawn Raye Cradit

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Kinesiology

1998

ABSTRACT

THE EFFECT OF TWO MASSAGE TREATMENTS ON
GRADE ONE AND GRADE TWO LATERAL ANKLE SPRAINS

By

Shawn Raye Cradit

The purpose of this study was to determine if efllerage massage was more effective
than cross fiiction massage in returning an athlete to activity afier sustaining a grade one
or grade two lateral ankle sprain. Twenty high school athletes participated in a control
group that was used to determine the accuracy of the assessments used in the study. The
treatment groups, cross fi'iction massage and efllerage massage, were comprised of 27
high school athletes who were participating in a winter and/or spring sport and sustained a
grade one or two lateral ankle sprain. The cross fiiction group included seven males and
six females, while the efllerage group contained eight males and six females. The injured
athletes were alternatively placed in the treatment groups following random selection of
the first assignment. The success of the treatment was measured by how many days it
took an athlete to return to activity and by how many total days of treatment were
necessary for the injured ankle to return to the same girth measurement as that of the non-
injured ankle. The results of this study established that both treatments were equally
effective in achieving these two criteria, and were better than the estimates for

rehabilitation of injured ankles reported in the literature.

To my dad who left this world much earlier than expected,
but left me with many memories, love, and valuable lessons.
He has and always will inspire me to never quit and to fight
and work hard for what I believe in.

To my mom, Tammy, Paula, John, and Aaron (each of whom has
inspired me as I admire many of their qualities) and anyone
else who never thought I would be finished with my Master’s
degree...

Well, here is the proof. I thank you all for your help and
support!

ifi

.ACflGWDWIIHXEHEWHNS

First of all, I would like to thank my three member
thesis committee which consisted of my academic advisor and
thesis committee chairman John Haubenstricker, Ph.D., Jeff
Kovan, M.D., and Jeff Monroe, M.S., ATC. Dr. Haubenstricker
provided extensive guidance with the analysis of the data
and the preparation of the thesis. Dr. Kovan and Mr. Monroe
contributed vital information and many useful suggestions
for the design and treatment phases of the study.

Second, I want to thank Dave Bertie, ATC, Lisa Slater,
PTA, and Karen Sauve, MMT, for their assistance with the
instrumentation, recommending the procedures, and teaching
the proper techniques of goniometry, cross friction and
efflerage massage. I am grateful to Kevin Wolfram, ATC, and
Jennifer Chowaneiec, ATC, for their assistance in the data
collection process.

A special thanks to student athletes Michael Baird,
Jr., Christopher Couitcher, Christopher Phillips, Jessica
Hartung, and Julie Kern who let me take pictures of their
feet at various stages and positions to enhance the visual
aspect of this thesis and for their additional support.
Also, to Brian O’Rourke for scanning the pictures and
putting them on a diskette in my computer’s format.

I would like to give credit and thanks to all

of the high school athletes who participated willingly as

iv

subjects in this study. It was an experience I am sure that
they will remember for a long time. Without their co-
operation and assistance, this thesis would not have been
possible.

Lastly, I would like to thank Constance Cradit, Tamara
Cradit, Paula Pretzer, John Pretzer, and Aaron Pretzer for
all of their love, support and for just being there. I
would not have been able to finish this long project with
out them.

If I have been remiss in recognizing anyone, I
apologize, because I would like to thank and recognize
everyone who assisted in the long process of this degree,

especially my family and friends.

TABLE OF CONTENTS

LIST OF TABLES ..................................................

LIST OF FIGURES .................................................

LIST OF ABBREVIATIONS ..........................................

CHAPTER ONE
THE PROBLEM ...................................................

Purpose of the Study ...........................................
Significance of the Study ........................................
Hypothesis ..................................................
Assumptions .................................................
Delimitations .................................................
Limitations ..................................................
Terms and Definitions ..........................................

CHAPTER TWO
REVIEW OF LITERATURE ..........................................

Modalities ...................................................
Duration Time ................................................
Rehabilitative Techniques .......................................
Measurement Devices ..........................................
The Injury and Subjects .........................................
Study Design ................................................
Conclusion ..................................................

CHAPTER THREE
RESEARCH METHODS .............................................

Research Design ..............................................
Subjects ....................................................
Assessments .................................................
Treatments ..................................................
Procedures ..................................................
Instruments ..................................................
Data Collection ...............................................
Data Analysis ................................................

vi

6

l l
1 1
19
20
22
26
28

30
3O

CHAPTER FOUR

RESULTS AND DISCUSSION ........................................ 53
Purpose .................................................... 53
Results ..................................................... 53
Discussion ................................................... 58
Effectiveness ................................................. 64
Comments ................................................... 65

CHAPTER FIVE

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ............... 68
Summary ................................................... 68
Conclusions ................................................. 69
Recommendations ............................................. 70

APPENDICES ..................................................... 74
Appendix A: Consent Form ...................................... 74
Appendix B: Research Data Sheet ................................. 75
Appendix C: Table 7- Control group Data ........................... 76
Appendix D: Figure 7. Treatment Data ............................. 77
Appendix B: Table 8- Data for the Treatment Group ................... 78
Appendix F: Progression of Sensations During Ice Water Immersion ....... 79
Appendix G: Graphic Pain Rating Scale ............................ 80
Appendix H: Table 9- Treatment Protocols .......................... 81
Appendix I: Table 10- Frequency Table Report ....................... 82
Appendix J: Table 11- Cross Friction Treatment Figure-of-Eight Results . . . . 83
Appendix K: Table 12- Efllerage Treatment Figure-of-Eight Results ....... 84
Appendix L: Figure 8. Treatment, Degree of Sprain and RTP ............ 85
Appendix M: Figure 9A. Frontal Ligament View of a Normal Ankle ....... 86

Figure 9B. Lateral Ligament View of a Normal Ankle ....... 86

REFERENCES .................................................... 87

vii

LIST OF TABLES

Table 1- Means and Standard Deviations for Injured
and Non-Injured Ankles for Control Group Two ............... 55

Table 2- Distribution of Subjects by Gender, Type of Sprain
and Treatment Type .................................... 56

Table 3- Means and Standard Deviations for Return To Play
Following an Injury ..................................... 57

Table 4- Means and Standard Deviations for Days of
Treatment Following an Injury ............................. 58

Table 5- Total Number of Days Before an Athlete Returned

To Activity and Discontinued Treatment ..................... 61
Table 6- Massage Treatment Compared to Strapping Treatment .......... 62
Table 7- Data for the Control Groups .............................. 76
Table 8- Data for the Treatment Groups ............................ 78
Table 9- Treatment Table Protocols ............................... 81
Table 10- Frequency Table Report ................................ 82
Table 11- Cross Friction Treatment Figure of

Eight Results ......................................... 83
Table 12- Efllerage Treatment Figure-of-Eight Results ................. 84

viii

LIST OF FIGURES

Figure l- Edema In Right Ankle Due to a Lateral Inversion Sprain ........ 37
Figure 2- Figure of Eight Measurement on a Non-Injured Ankle .......... 37
Figure 3- Goniometer Alignrnent- Prior to Normal Goniometer
Position ............................................ 38
Figure 4- Normal Goniometer Position ............................. 38
Figure 5- Proper Positioning for Dorsi F lexion Measurement ............ 39
Figure 6- Proper Positioning for Plantar Flexion Measurement ........... 39
Figure 7- Treatment Data (Appendix D) ............................ 77
Figure 8- Treatment, Degree of Sprain and RTP
(Appendix L) ......................................... 85
Figure 9A- Frontal Ligament View of a Normal Ankle
(Appendix M) ....................................... 86
Figure 9B- Lateral Ligament View of a Normal Ankle
(Appendix M) ....................................... 86

ATC

ATF

CF

CFL

CM

DF

DTR

EM

PF

PNF

RICE

ROM

RTP

LIST OF ABBRE VIA T IONS

Certified Athletic Trainer

Anterior Talofibular Ligament

Cross Friction Massage

Calcaneal Fibular Ligament
Centimeters

Dorsi Flexion

Days of Treatment

Eiflerage Massage

Plantar Flexion

Proprioceptive Neuromuscular Facilitation
Rest, Ice, Compression, and Elevation
Range of Motion

Return to Play

CHEAPGIHR CDHB

11D? EERJBLID!

First and second degree lateral ankle sprains are the
most common sprains involved in athletics (l,2,3,4,5,l6,
18,30,32,4l,52). Ankle sprains in sports are caused by the
vulnerability of the ankle joint and the position of the
foot while participating in athletic activities. Sports
that involve running and jumping hold the greatest amount of
susceptibility for an ankle sprain. If the foot is not
properly positioned for landing, such as when landing on
someone else’s foot, then an ankle sprain will likely occur.
The incidence of ankle sprains in athletics is high due to
the hours of interaction during practice and competition. A
primary concern of athletic trainers is the effective
treatment of ankle sprains to accelerate the return of the

athlete to activity.
Purpose of the Study

The purpose of this study was to determine the
effectiveness of two different massage treatments on the
rehabilitation of high school athletes who had sustained a
first or second degree lateral ankle sprain. The massage
treatments combined with exercises and Rest, Ice,
Compression, and Elevation (RICE)were hypothesized to

expedite the healing process to allow a prompt recovery and

expedite the healing process to allow a prompt recovery and
return to competition within a ten day limit. Efflerage
massage has been shown to reduce edema as well as enhance
blood flow to the area being manipulated (11, 27, 28, 29,
31, 32, 33). Cross friction massage has been used to assist
making mobile, strong scar development which can prevent

perpendicular scarring (ll, 28, 36).
Significance of the Study

A primary objective of an athlete is to return to
activity as soon as possible following an initial injury.
The role of the athletic trainer is to facilitate this
return. Thus, any treatment protocol that is safe and
reduces recovery time is important. Massage treatment
should be incorporated into the athletic training room
setting if the evidence shows that an athlete can heal
rapidly from an ankle sprain using this procedure.
Electrical stimulation facilitates edema reduction and is
beneficial to the healing and rehabilitative process
(1,7,12,42). However, many high schools are not allowed to
use modalities such as electrical stimulation, unless
directed to do so by a physician. Athletic trainers rely on
their hands in settings where electrical stimulation is not
permitted or can not be afforded. If the athletic trainer’s
use of massage can decrease an athlete’s time off due to

injury, then this protocol should be implemented. If one

 

treatment is more conducive to getting the athlete back to
the athletic activity more quickly, then that treatment
should be administered to the injured athlete on a regular

basis for a first or second degree ankle sprain.
Hypothesis

Hypothesis: Efflerage massage will be more effective in
moderate edema reduction than cross friction massage in a

grade one (first degree) or grade two (second degree)

lateral ankle sprain.
Assmnptions

The following assumptions were made in this study:
1) The researcher is competent in classifying the severity
of ankle sprains. The researcher is a certified athletic
trainer who has passed a board certification as well as
taken courses to educate herself on evaluation techniques.
These techniques allow the athletic trainer to make a
competent interpretation as to the type and degree of sprain
that an athlete has sustained.
2) Reduction in edema and ecchymosis formation will enable
the athlete to return uninhibited to competition. The
athletes must successfully complete a return to play
protocol (within a 10 day time limit) before returning to
active participation. The protocol was implemented to
verify that the sprain has healed indicating no obvious

pain, discomfort, or evidence of instability while

performing the exercises and that the athlete was “ready” to

return.

3) The athletes were willing to participate and follow

protocol due to their personal desire to return to activity

as soon as possible.

4) The athletic trainer was competent in administering the

massage treatments. The athletic trainer was taught the

correct techniques of efflerage and cross friction massage

by a massage therapist technician. She also had previous .
knowledge of these techniques from previous job—related

experience.
Delimi ta tions

The following were delimitations in this study:
1) Only high school athletes who were participating in an
in—season sport will be monitored and used as subjects
(including the control groups).
2) Massage techniques included only cross friction and
efflerage massage treatment.
3) Only athletes with first and second degree lateral ankle
sprains were to be involved in the study.
4) The athletes had to be injured for a minimum of three
days to be included in this study. This is done because the
first three days of treatment consists of Rest, Ice,
Compression, Elevation, (RICE) and Exercises. The massage

treatment was implemented following RICE on day three.

5) All sprains were weight bearing. An ace bandage was

essential and applied for the first three days.
Limi ta tions

There were some warranted limitations in this study:
1) Duration of treatment may not be long enough to
significantly reduce edema.
2) Edema formation may not be consistent with the severity
of the injury.
3) Ankle size may not decrease after treatment as well as
between sessions.
4) The athletes may not want their coach to know about the
injury and may wait to tell the athletic trainer, making the
determination of the sprain more difficult.
5) The return to play criteria may be too long.
6) The goniometer only measures in five degree increments,
therefore some precision in assessment of range of motion is
lost.
7) Athletes may not be honest during pain measurement
because they feel that the injured area has to hurt a lot in
order for them to heal faster.
8) There is no long term measurement of the athletes' ankles
to determine if swelling returned.
9) Ten days may not be an appropriate time duration for the
athletes to be able to perform the return to play protocol

and have no obvious instability. It may be to much or not

enough time depending upon the degree of the lateral ankle

sprain sustained by the athlete.
Terms and Definitions

Ace bandage- An elastic and nylon wrap that is applied
distal to proximal to an injury for prevention of excessive
edema, ecchymosis and effusion from occurring.

Ankle qirth— the measurement of effusion and edema that
had accumulated in the ankle joint due to an ankle sprain.
This measurement was performed with a tape measure using the
figure of eight method and centimeters as the predetermined
increment.

Cross friction massaqe- "Small, deep movements
performed vertically across the involved tissue. The
movement of the massage is transverse to the fiber direction
producing a small, controlled inflammatory response" (28).

Days Lg return- Total number of days from the initial
injury before an athlete could participate and complete the
return to play criteria successfully and no noticeable
instability in the injured ankle. This was determined when
the athlete informed the Certified Athletic Trainer (ATC)
that he/she felt stable enough to perform the protocol.

Days 9f treatment— Total number of days (from the
initial injury to the conclusion of treatment) of
treatment(s) received until athlete’s ankle size was

“normal” or less than normal.

Degree of laxity- The amount of movement in the ankle
joint while performing drawer and talor tilt tests. If the
ligament(s) is (are) damaged, there will be a certain amount
of movement in the capsular region of the ankle joint where
the ligament(s) is (are) attached. Evaluated by the ATC.

Drawer test- A special test that determines the

 

stability of the anterior talofibular ligament (1,3,30).

Ecchvmosis— "Black and blue skin discoloration caused
by hemorrhage" (39).

Edema- "Swelling as a result of the collection of fluid
in connective tissue" (39).

Efflerage massaqe- "A gliding stroke that is applied
horizontally in relationship to the tissues involved" (28).
It is important that the movement starts distal to the
injury and heart and works proximally over the injury
towards the heart using a circular motion.

Effusion- An accumulation of fluid (interstitial or
blood) in the ankle joint.

gigs; degree sprain— One that "involves microscopic
tearing of the ligament with no loss of function. The
sprain will show minimal functional loss, little swelling,
localized tenderness, and mild pain in response to stress.
Pathologically, there is functional integrity with a minor
ligamentous injury” (4). This sprain involves the anterior
talofibular ligament (30), which is indicated with a

positive drawer test (1,3,30).

Goniometer- A device that has a stationary arm and an
arm that is fully moveable. A goniometer is used to measure
joint range of motion from O to 180 degrees (39). This
device is used over the joint where movement occurs.

Initial evaluation- The observation, palpation,
measurement of range of motion, measurement of ankle girth,
and the interpretation of what type of sprain has occurred
using special tests (drawer and talor tilt tests).

Light tissue stimulus— A light gliding horizontal
stroke above and below the injury sight which stimulates the
subjects injury and prepares for or relieves the athlete
from a more abrasive technique (efflerage or cross friction
massages).

Mild edema- Swelling which is l centimeter or less
during the figure of eight measurement.

Mild sprain- Determined by control group and were out
of activity 1 day or less (as recalled by control group
two).

Milking- The gliding motion (similar to “milking” a
cow) administered while performing efflerage massage.

Moderate edema- Swelling which is 1.1 - 2.4 centimeters

 

during the figure of eight measurement.

Moderate Sprain- Swelling that lasted up to 14 days and
were out of full activity during that time, a minimum of
three days absent from activity (which is recalled by

control group two).

gain rating- A composite ranking consisting of sensory
(pertaining to the actual sensation), affective (emotional
responses influenced by the pain), evaluative (examining the
present sensation and comparing it with a past experience),
and miscellaneous (describing in words) components that
result from the athlete's estimation. This estimation will
be verbalized to the athletic trainer during the massage
treatments. This is done for the comfort of the athlete.

Palpation- The evaluation of the injury by using the
sense of touch.

Range 9f motion— “Active movement from the beginning
point to the end point of joint movement that occurs because
of muscle contraction" (39).

Return Lg play protocol— An extensive battery of tests
given to and performed with no pain by the athlete before
being allowed to participate in activity.

Second degree sprain- “One that has partial disruption
or stretching of the ligament with some loss of function,
showing moderate functional loss with difficulty on toe
raise and walking, diffuse tenderness and swelling.
Pathologically, there is a near complete lateral complex
injury" (4). This sprain involves the anterior talofibular
and calcaneofibular ligaments (30), as well as a positive
drawer and talor tilt tests (1,3,30).

Severe edema— Swelling which is 2.5 centimeters or more

during the figure of eight measurement.

Severe sprain— Some crutch use and were out of activity

4 or more days

(recollected by control group two). This

type of sprain was not used in this study due to the amount

of damage that has occurred to the ligaments and time

involved for rehabilitation of this injury.

Successful
size and active
or practice.

Talor tilt
determining the
talofibular and

the ankle while

rehabilitation- The return to normal ankle

participation of the athlete in competition

tests— Two separate tests used for
stability of the calcaneal fibular, anterior
deltoid ligaments by inverting and everting

relaxed at 90 degrees.

10

(HflURZERIIWKD

IUEVIEWItWF.LIflHflRAITHUE

Many studies have been conducted on the various methods
and instruments used in the treatment of sprains. This
review begins with a discussion of various treatment
modalities and the protocols associated with each. Next,
rehabilitative approaches such as weight bearing,
proprioceptive, and strengthening and stretching exercises
are examined for possible use in this study. Then,
measurement devices for the evaluation of ankle sprains,
treatment protocol and success are reviewed. Ankle
injuries, why they occur, and what subjects were studied are
discussed next. Finally, the design for this investigation
will be proposed.

Modeli ties

Research has been conducted to determine the
effectiveness of individual modalities. The modalities
utilized in the current study were ice and ice baths, and
efflerage and cross friction massage. Cryotherapy is one of
the most widely used modalities in the sports medicine and
athletic training fields (l,2,3,7,1l,28,30,35). This is the
introductory step of treatment for any injury, and was also
used in this study for treatment of first or second degree

lateral ankle sprains. This modality assists with the

11

reduction of swelling that may occur as a result of the
athlete’s body responding to the injury. When initially
treating an ankle sprain, the use of Rest, Ice, Compression,
and Elevation (RICE) will help limit swelling of the soft
tissues (l,2,3,30,37,47). This treatment is given three to
five times a day after the primary injury occurs. Early
treatment decreases edema which can hinder the healing
process (10,15,37,40).

The preliminary cryotherapy treatment occurred within
minutes after the athlete was evaluated following the
injury. Ice was included in the protocol of this study
because it is an easily acquired modality and is highly
beneficial in reducing edema and effusion formation. Ice
has an anti—inflammatory, analgesic affect on an injury. To
expedite the reduction in edema and ecchymosis formation,
ice bags and ice baths were utilized (1,2,3,29,41). The
temperature of the ice baths during the 4 to 11 day
treatment cycle was between 10 and 15 degrees Celsius.

"12.8 degrees Celsius to 15.6 degrees Celsius water curbed
edema formation after blunt trauma in rats” (15). An
athlete can reap the beneficial effects of cryotherapy, such
as pain reduction, vasoconstriction and edema control,
without compromising eccentric force production or endurance
(17,28,47). Ice has the capacity to lower the temperature
in the area of application, and the sensations from the

superficial nerves are hindered by this modality. "When

12

reductions in intramuscular tissue temperature occur, the
neuronal discharge and sensitivity of the muscle spindles
are impeded” (14).

Therapeutic muscle massage is a common modality used to
reduce the pain resulting from an injury, as well as to
disperse edema and reduce ecchymosis (10,19,22,23,24,29).
This treatment has been used for centuries, but has not been
researched in the athletic training field. All athletic
trainers work with their hands making this the ultimate
modality available. This treatment also was chosen because
not all high schools have the funding for other treatment
modalities.

The treatment is available to athletic trainers who are
willing to be taught by a massage therapist technician or
physical therapist. The techniques must be learned and
performed several times under strict supervision before
applying them to an injured person. "Massage produced a
significant reduction in patients' perceptions of pain over
a twenty-four hour period"(35). This modality is “hands-on”
for the athletes’ comfort and reduction of pain. The massage
is done over the affected ligaments, but the treatment is
not done right after the injury occurs because it is
ineffective during the acute phases of an injury.

Therefore, massage is introduced on the third day following

an injury.

13

Efflerage massage is commonly assumed to enhance muscle
blood flow when associated with long term muscle recovery
from intense exercise, or from edema formation from an acute
injury that is in the restorative phase (19,24,28,31,49).
This massage is relaxing for the athlete. The fluid motion
that is performed by the certified athletic trainer is
easing to the apprehensions of the athlete. The athlete can
feel the treatment and in most instances observe the
immediate results. Efflerage massage is more effective than
other treatments in enhancing material transport out of the
interstitium into the initial lymphatics which is the goal
of the treatment (22,23,31). If the coagulated blood and
interstitial fluid stay in the ligaments and area
surrounding the ankle, the range of motion can take many
days or weeks to be restored to normal. With application of
the gliding upward stroke, the edema formation will
dissipate from the injured area. As a result of the
efflerage massage technique, it is hypothesized that range
of motion will be restored at an accelerated pace.

Reducing swelling, restoring shape and preventing
inflammatory episodes are objectives of treatment for
lymhedema (7,10,31). The faster an athlete can regain range
of motion (ROM) the sooner the athlete will return to the
playing field. Lactate and Interleukin-6 concentrations in
plasma were increased in groups of rats who had single or

bilateral fractures in their hind limbs (36). Pasquale, in

14

his inflamation and injury correlation study involving rats,
recognized that “Plasma lactate is affected by an injury,
however does not correlate with the severity of injury"
(36). This study supports the idea that edema response does
not correlate with the severity of injury. Some rats who
had minor fractures had more fluid retention than did those
with severe fractures. Fluid was aspirated from the rats
hind legs to determine what composition was present. This
was done to see if the composition varied in severe or minor
fractures, which it did not.

There were no aspiration measurements of ankle fluid
taken in the current study because of the risk it posed to
the athletes. The athletes could recognize the effect of
their treatment by observing the figure of eight measurement
as the ankle size decreased.

Massage can stimulate the release of endorphins;
decrease anxiety, pain, spasm and increase the production of
cortisol; and enhance relaxation, cytotoxic capacity and
blood flow (l9,24,31,49). These results are all beneficial
to the athlete. Ikomi and Schmid-Schonbein observed that
slow massage frequency caused a significant increase in
lymph flow rates compared to the resting state (23).

Massage generated lymph flow rates in neighboring areas of
the skin which is cumulative to this study. Deformation of
the surrounding tissues in combination with brief

compression and expansion is an essential requirement for

15

lymph fluid collection (23). Passive lymph pumping may be
promoted by tissue manipulation, however the lymph formation
is dependent on interstitial fluid. This was the primary
reason for choosing this treatment modality. There are
many benefits of applying therapeutic massage to an injured
ankle. “It has been our experience that the extent of edema
or ecchymosis does not serve as a good indicator of the
extent of ligamentous injury” (30,41). Some athletes swell
more than others. A sprain resulting in a large amount of
swelling does not indicate that the sprain is more severe.
Each individual’s body responds differently to an injury.
The control group was measured before exercise or activity
began because of evidence demonstrating increases in extra
vascular volume during exercise (11). The probability of
thickening tissues and fibrosis in an ankle sprain is
problematic. This results in stiffness to the joint, pain,
inadequate nutrition to the tissues and dysfunction to the
joint which is why massage treatment was chosen over other
modalities. It is hoped that efflerage massage will assist
in edema and effusion reduction in grade one and grade two
lateral ankle sprains.

Applying friction massage can effect normal passive
range of motion, a reduction in pain and swelling with
improvement in active range of motion (7,19,28,33,45). The
loss of range of motion , ligament instability , and failure

of an ankle to return to “normal” size is detrimental to an

16

athlete’s return to activity. Pain management is important
to the athlete and athletic trainer. If the athlete is
experiencing a high pain rating then the athletic trainer is
pressing too hard. The pain rating was moderate to high,
but not severe. "Deep friction massage is a therapeutic
modality for tendinitis, muscle strains, ligamentous
sprains..."(7,10,13,l9). This therapy can be uncomfortable
to the athlete, however the advantages of this treatment are
worth the temporary discomfort the athlete may experience.

Massage treatments using deep friction massage can
range in duration from five to twenty minutes and can be
fatiguing to the administrator of the massage (l3,l9,28,45).
The administrator had to position his or her hands and
fingers so not to place pressure in more than two places at
the same time on the same ligament. A lot of pressure must
be placed on each finger and the technique must be taught
properly, or the athlete may be too uncomfortable to return
to future treatment sessions.

The pressure should be forceful, but not increase the
athlete’s pain. The purpose of cross friction massage is to
produce the formation of a movable, concentrated scar that
is not painful when resumption of normal activity takes
place. According to Steward, Woodman, and Hurlburt “A daily
five minute cross friction massage assists in the healing
process by “tweezing” apart the muscle fibers to prevent

perpendicular scarring. This is accomplished by passively

17

moving the ligament to and fro to prevent its adherence to
the underlying bone” (45). This suggests conformity of
treatment duration and technique involved with this study.
The patient's skin and athletic trainer’s fingers must move
simultaneously, in a perpendicular position to the tissue
fiber. This is what will cause the formation of the scar.
The massage should be intense but within the athlete’s pain
tolerance. The ligament should be adequately exposed and a
full glide must be provided for the technique to be
performed properly. The exactness of the procedure was
taught by the massage therapist and, in turn, would enhance
scar build up while healing the injured ligament(s). Many
studies on the evaluation of massage and massage techniques
have been conducted, however there is still much to be
learned about the application and success of this modality
(7,10,19,45).

Only one other study combined the use of the
cryotherapy modalities with the addition of strapping or
wrapping techniques(40). In a comparative study, Scotece
and Guthrie had the purpose of quantifying the adequacy or
influence of specific treatment protocols on the patient’s
pain relief, return to full duty status, and in identifying
which treatment was most successful treating grade one and
two ankle sprains. The Scotece study did not use a control
group, which is an important distinction between these two

studies. The use of a control group is crucial to the

18

researcher’s results. The control group provides results
for determining if the treatments are effective or why they

may not be effective.
Duration Time

Duration of the treatment time varies with research
protocols and what the researchers are attempting to find.
The thirty minute approach comes from three different
sources (29,35,44) from which a mean duration of treatment
was decided. For this research project, the ice application
over the ace bandage was the determining factor as to
duration time. The protocol states that the ace bandage was
to be applied resulting in longer ice therapy time. The ice
would penetrate to the injury site sufficiently as a result
of the longer treatment time. The three treatment sessions
were chosen because of results from previous research. The
durations of the treatments ranged from 20 to 40 minutes,
and the number or sessions ranged three to five a day. The
injured ankle was examined for edema, ecchymosis,
tenderness, range of motion, and weight bearing ability for
the current study. There is no single recommended protocol
or treatment method that predominates regarding ankle
sprains, which supports the selection and implementation of
the procedures use in the current study. Early mobilization
enables patients to return to work faster (6-18 days) than

patients who are immobilized (16—47 days), (l6).

l9

This was why an ace wrap and range of motion exercises
were utilized for the current study. Taping or bracing also
replaced the ace wrap on the third day, because it was not
believed that there would be enough support with the ace
wrap.

Rehabilitative Techniques

Rehabilitative techniques that have been used for the
treatment of ankle sprains are weight bearing,
proprioceptive exercises, strengthening exercises and muscle
stretching. One of the measurements for treatment success
was the amount of time it took for the athlete to return to
full activity and to complete a return to play protocol
(16,26,36,40). This measurement informs the evaluator as
well as the athlete as how the treatment is progressing.
This also gives the athletes a positive attitude when they
see improvements.

In addition to cryotherapy in the treatment for the
current study, a series of exercises were performed to
address flexibility, low-loads, static stretching for
prolonged duration, muscle strengthening, muscle re-
education or proprioceptive training (16,26,37,40,46,52).
These exercises supplemented the massage treatments and help
to re-educate the muscles that were involved in the ankle’s
range of motion. With the muscles being re-taught, and the

ligaments being massaged, the athlete should recover from

20

the injury at a faster rate. Range of motion was rated as

normal or limited and swelling and ecchymosis were rated as
mild, moderate or severe (16) in the control group for this
study.

Active and passive ROM are assessed before performing
stress tests (drawer and talor tilt). Evaluating ROM
immediately following the injury is more valuable than if
time has passed (14,17,40,4l,42). The ankle sprain is
limited by the degree of ligamentous damage. The control
group was used to determine if the goniometer and figure of
eight measurements were valid and reliable.

“Weak Muscles and poor proprioception predispose the
athlete to further injury” (9). This was the foremost
reason for including the proprioceptive exercises in this
study. The final goal of treatment is the restoration of
movement and function to pre—injury status. The goniometer
measurement was also helpful in measuring what the treatment
protocols and exercises offered (21). This assists in
comparing the range of motion of the normal ankle with the
injured ankle to determine if improvement is occurring. The
exercises in the “take home" and “training room” therapies
were assessed by using this device.

Proprioception of the ankle is usually impaired after
an ankle injury. Balance which is affected by lack of
proprioception must be incorporated into a rehabilitative

program. Inadequate joint motion can result in a non-

21

successful outcome as well as a reduction in functional
athletic performance. The limited functional range of
motion disrupts the athletes' activities throughout daily
living and hinders participation in their sport. The use of
proprioceptive exercises enable the athlete to return to
activity at a faster rate than if they were not used.
Proprioceptive Neuromuscular Facilitation exercises are
becoming a standard among athletic trainers but were not

used in the current study because of time restraints.
Measurement Devices

"Measurement of ankle size is necessary to evaluate
the effectiveness of treatment procedures" (4,26,36,40,48).
If there is no initial measurement, it is difficult to
determine how much an athlete is improving. There are many
methods of measuring the edema in an ankle. Fluid volume
measurements and various tape measurement methods are the
most popular, however none were found to be more reliable
than the figure of eight tape measurement. With the use of
a figure of eight measurement, an inter-tester reliability
of 0.99 was established (40,48). The figure of eight
measurement also was utilized because of the accessibility
and inexpensive cost of tape measures, as well as their
simplicity. Most high schools can afford to purchase a tape
measure. The figure of eight was the most crucial

measurement of treatment success. Treatment concluded when

22

this measurement of the injured ankle was less than or equal
to that of the non—injured ankle.

A pain rating scale, given verbally by the athlete, was
used to evaluate pain from the pressure of the massage
(12,29,40). The scale was used so that the evaluator could
determine the severity of pain the athlete was experiencing.
This scale is a graphic rating scale which describes the
intensity of the athlete’s pain (see Appendix G). It is
based on a ratio scale from zero to ten. The athlete
verbalizes the number indicating the severity of pain
resulting from the massage. The athlete was not to go above
a rating of seven, however if he or she does, the massage
force would be decreased. If the athlete was experiencing
too much pain, he or she would not want to return for future
treatment.

This scale was to inform the evaluator as to how the
athlete was responding to the increase in pressure and force
for the efflerage or deep cross friction massage. This
scale allows the researcher to conclude whether the athlete
was ready to advance from the protocol stage they were in to
a more advanced stage. The importance of knowing how to
rank what pain was essential to the athlete. This would
make their number more accurate. Pain was be referred to as
“an unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms

of such damage” (29). Pain can have varying degrees of

23

distress or sensations and is interpreted differently by
each individual. Sensory (discriminative), affective
(motivational), evaluative (cognitive), and miscellaneous
(nagging or penetrating) are the four multifaceted
components of pain. These components were discussed with
the athletes so they could individually determine their own
interpretation of pain using the graphic rating scale.

A goniometer was used to evaluate range of motion (ROM)
of the ankle joint due to the low random error of
measurement (12,39,40,42,43,51). This device has an
immovable end and a movable end. Its use can be easily
taught to an athletic trainer by a physical therapist
assistant (PTA). It is also easily learned and repeated
after many practice trials. In this study, inter-tester
reliabilities of 0.90 to 0.99 were obtained by the athletic
trainer for goniometer applications. The athletic trainer
was taught by the PTA and performed many measurements prior
to executing the protocol. A goniometer is also an
inexpensive device that any high school can afford.

The standard of measurement was taken from the Academy
of Orthopaedic Surgeons, which was suggested by the physical
therapy assistant (34). Dorsi flexion would be measured
from zero to twenty degrees and plantar flexion measured
from zero to fifty degrees. The goniometer was used because

of its ability to measure ankle ROM accurately.

24

When performing an ankle evaluation, palpation should
begin distal from the most apparent ligamentous injury and
work gently towards it. The head and neck of the fibula and
tibia is where the palpation should commence and proceed
distally towards the phalanges (1,2,3,21,34,52). Palpation
of the injury sight assists in the recognition of the
location of sight and the degree of the sprain. Gaps,
inspection of the joint, elicitation of pain, edema
formation, ecchymosis and distortions encompass what
palpation is capable of determining. Palpation must first
begin with the uninjured extremity joint followed by the
bilateral comparison. This was how a baseline for
determining the extent of the injury was determined.

A subjective protocol was executed to evaluate if the
athlete was ready to return to practice or activity. This
was accomplished by measuring the recovery of the ankle,
balance, strength, stability, joint laxity and joint
movement. Five distinct studies that used various exercises
and tests were examined to establish the rehabilitative and
return to activity protocols (2,8,9,26,46). Each of these
five had different tests that were either eliminated or
acquired for this study. The return to play test battery
does not require extra apparatuses and was uncomplicated to
perform. The rehabilitative protocol required additional
equipment, but was also undemanding. “Once the athlete has

successfully progressed through the (treatment and return to

25

play protocols) therapy they were to begin sport specific
activities and return to practice” (9). The rehabilitative
protocol follows the “Rehabilitation Protocol After Stable
Open Reduction and Internal Fixation of Bimalleolar or
Trimalleolar Ankle Fracture” (8). In this protocol the
patient was instructed to begin active range of motion and
dorsi flexion and plantar flexion exercises. The protocol
also states that full muscular control, no swelling, full
range of motion and taping or bracing should accompany the
athlete when returning to competition. In all of the
research designs it was noted that any bracing or strapping
should not be used as a substitute for weak muscles. Each
research study was examined and referred to while compiling
the rehabilitation exercises and the return to play

protocol.
The Injury and Subjects

The most common injury in any sport is the ankle sprain
(l,2,3,4,5,l6,18,30,32,41,52). The ankle is a vulnerable
joint when playing basketball, volleyball, and participating
in running and jumping sports. Twenty five percent of all
time loss injuries in running and jumping sports are a
result of ankle sprains (16). The majority of ankle
injuries occur while the foot and ankle are in plantar
flexion, adduction and inverted positions. The joint is

most vulnerable in these positions due to the susceptible

26

location of the anterior talofibular ligament (ATF),
(1,2,3,5,21,32,41,50). The ATF is usually injured first
followed by the calcaneofibular ligament or anterior and
posterior inferior tibial fibular ligaments if the ankle is
in the dorsi flexion stance (4,10,18,25,27,4l) (see Appendix
M). There is a frequency of 3.7 to 4.0 injuries per 1000
exposures during participation, which equals about two
players per season minimum receiving an ankle sprain
(4,5,18,27,30,32,41,52). The mechanism of injury is most
frequently ball scrambles for ball sports and the stepping
on an opponent’s foot for any sport. Basketball and
volleyball are the two sports with the highest incidence of
ankle sprains (5,18,25,32,41).

There are many factors that go into determining how,
when and why an ankle sprain occurs. Exposures and previous
injury are the more important predictors of sports injuries
(5,50). This factor was important due to the amount of time
the high school athlete is practicing. This is why high
school athletes were chosen as subjects. The high school
athletes’ practices range from 2.5 to 3.0 hours, three to
five times a week. They also participate in competitive
events which could last from 3 to 14 hours depending upon
their sport. Their seasons conclude every three to four
months. The average season consists of a minimum of 1000
participation hours based on an average mean score of

practice and competition hours (10 x 10 x 10). Results of

27

these studies corroborate that exposure time is an important
prognosticator of sport injury occurrence (5,32,50). High
school athletes are not required to wear ankle protection
devices. If they choose to wear ankle braces they must
purchase them on their own. This ensures the high school
athletes would be an optimal group to investigate. Most of
the research compiled pertains to military personnel or
sport specific athletes (4,5,32,35,38,40,4l,52). This study
focuses on winter and spring sport high school athletes.

Study Design

Three essential requirements are needed for the
completion of an experimental design. Application of an
intervention, use of a control group and randomization of
subjects are requirements for a successful project. Cross
friction and efflerage massage are the interventions, there
are two control groups and an every other injury occurrence
was the randomization used in this study. The first injured
athlete was placed in the efflerage massage treatment group,
the second placed in the cross friction treatment group and
so on. The intervention determines if a cause and effect
relationship exists in this study. The massage treatments
were parallel with regard to the strokes, the timing, the
athletic trainer who administers the massage, and the area
of the ankle massaged. Only two studies on ankle massage

were found. These two studies were used to determine if

28

efflerage massage reduces anxiety states and increases well
being. Although this study did not examine these concepts
the information provided was helpful. Both studies formed
experimental and control groups and ascertained that massage

reduced anxiety and improved overall well being (10).
conclusion

This study was researched in every aspect from modality
selection, rehabilitative techniques, measurement devices,
the type of injury considered and the design of the study.
High school athletes were used in this study because there
is not much information available on adolescents. Most of
the research that was found pertained to college athletes,
soldiers or geriatric patients. The use of each instrument
was given careful consideration before incorporated into the
study. This study was successful due to the attention given

to every detail of the procedures presented.

29

CEHUHZERIIIHUEE

IUESEAEKHIIMEHIKflWS

The athletic trainer has the responsibility to expedite
an athlete's return to activity following an injury. This
study was designed to determine if efflerage or cross
friction massage, in conjunction with RICE and
rehabilitative techniques, has relevance in getting an
athlete who has sustained a first or second degree ankle

sprain to return to competition in 10 days or less.
Research design

The heart of any research design is the components that
compose the independent and dependent variables.

Independent variables. The independent variable in this
study is the type of massage [Efflerage (EM) or Cross
Friction (CF)] administered to the first or second degree
ankle sprains as prescribed by the treatment protocol.

Dependent variables. The dependent variables in this
study are days until return to play and total days of
treatment (days until total edema reduction). Criteria for
determining total days of treatment included figure of eight
girth measurements, and dorsi and plantar flexion range of
motion measurements as well as noticeable instability.

A Quasi-experimental one by two design was used in this

study. Convenience samples were utilized due to

30

accessibility to athletes with grade one or grade two ankle
injuries. Athletes from one class B high school and one
certified athletic trainer were involved in this study.
Other professional personnel included a massage therapist
technician, who taught the certified athletic trainer the
correct methods for performing each massage technique, and a
physical therapist assistant, who taught the figure of eight
and goniometer measurements to assure the accuracy and
reliability of the assessments. A measurement of both
ankles was taken after an injury and the difference in girth
measurement was recorded by the athletic trainer for data
analysis. The degree of ankle sprain also was recorded by

the athletic trainer.
Subjects

High school male and female athletes participating in
winter and/or spring sports were the subjects in this study.
The athletes participating in the study signed an informed
consent form and parents of athletes under the age of 18
also signed the consent form before any massage treatment
began. The informed consent form was previously approved by
the University Committee on Research Involving Human or
Animal Subjects at Michigan State University before the
initiation of the study (Appendix A).

The athletes were selected as a convenient sample

because only high school athletes who suffered ankle sprains

31

during athletic practice or competition could participate in
the treatment groups. The athletes were assigned to
treatment groups, One (CF) and Two (EM), on an every other
injury basis. Prior to the first assignment, it was
randomly determined that the first athlete who sprained an
ankle would be placed into the EM treatment group, and the
second injured athlete into the CF treatment group so that
no one was placed into either treatment group on the basis
of ecchymosis, effusion, edema, or degree of sprain. The
individuals in the treatment groups had no knowledge as to
which group they were assigned. Once an ankle sprain
occurred and the athlete was placed into treatment group CF
or EM, an initial evaluation by the athletic trainer took
place.

The control groups consisted of 20 volunteer athletes.
Ten were athletes who had sprained an ankle but not within
nine months of the current study (C1), while ten had never
sprained their ankles (C2). Five males and five females
were included in each of the control groups. The sprains of
the control group athletes were first or second degree in
nature and were ranked by the athletes as mild (1), moderate
(2) or severe (3). The athletes' rankings were used because
no record could be obtained to verify the extent of the
athletes' injuries. The athletes received various
treatments for these sprains, none of which involved

massage. Members of the control group were measured on two

32

separate occasions, at the beginning and conclusion of their
seasons. A series of three goniometer and figure of eight
measurements were taken for each ankle and the average score
for each series was recorded on their personal data sheet
(Appendix B). These measurements preceded exercise or
activity for consistency. A summary of the measurements for
the control subjects (Cl and C2) is displayed in Appendix C.

This summary is practical for exhibiting the
differences in ankle sizes for the 10 control athletes who
had sustained a previous ankle sprain. These data are
helpful for demonstrating that the measurements used in
determining when the treatment for the lateral ankle sprain
would conclude are warranted.

Treatment Group One (CF) consisted of eight males and
six females who received cross friction massage as treatment
for an ankle sprain. Treatment Group Two (EM) consisted of
six males and seven females who received efflerage massage
as their treatment for an ankle sprain. A summary of the
data for the treatment groups is located in Appendices D and
E. Only those athletes who had a lateral ankle sprain and
reported it immediately following the injury were used as
subjects. Immediate reporting was important because edema
and effusion as well as testing of ligament instability can
be altered if evaluated hours after an injury has occurred.
Delayed assessment could influence the results of this study

for comparing the initial assessments to the final results.

33

Assessments

Assessments were taken to determine the end point of
the treatment and the toleration of the athlete to the
aggressiveness of the treatment protocols. For the current
study, the treatment end point was when the athlete’s ankle
returned to the same size as the non-injured ankle or
smaller than the non-injured ankle. Mild, moderate and
severe edema were assessed in the current study to determine
the success of each treatment. The severity of edema an
athlete sustained was recorded on the research data sheet
under the athletic trainer's comment section, but was not
given a specific category for the research data sheet. An
example of moderate edema concentration in a second degree
lateral ankle sprain can be found in Figure 1. During the
initial evaluation, two special tests were used to determine
ligamentous instability (drawer test-anterior talofibular
ligament and talor tilt tests-calcaneal fibular and anterior
talofibular or deltoid ligaments).

Iigure of eight measurements were taken to determine

ankle size and to measure the amount of edema present in the
injured ankle. The procedure for taking the figure of
eight measurement is as follows: 1) place the beginning of
the tape between the tibialis anterior tendon and lateral
malleolus; 2) draw the tape medially across the instep and
just distal to the tuberosity of the navicular; 3) pull the

tape across the arch and up just proximal to the base of the

34

fifth metatarsal; 4) pull the tape across the tibialis
anterior tendon; 5) pull tape around the ankle joint
distally to the distal tip of the medial malleolus; 6) pull
the tape across the Achilles tendon; 7) place tape to the
distal tip of the lateral malleolus; 8) end the measurement
where the tape started. Please refer to Figure 2 for a
completed figure of eight measurement. This measurement was
done two or three times (a third measurement was not taken
if the same score occurred on the first two measurements)
and a mean score was recorded from the combined scores.

The measurements were taken on a daily basis on the
injured ankle before and after each treatment. This
measurement was taken only one time on the non-injured ankle
to serve as a control criterion for the injured ankle. The
non-injured ankle was measured before the injured ankle to
put the athlete’s mind at ease for what it would feel like
on the injured ankle. The injured and non-injured ankle
were measured using enough tension so that no loops or
excess tape bulges were noticeable which would create
inaccuracies. The centimeter was the pre-established unit
of measurement. The centimeter is used worldwide and was
the obvious choice for this reason. The figure of eight
gives the certified athletic trainer an accurate profile of
how much progress an athlete is making on a daily basis.
This was the primary measurement to determine the end point

for each treatment.

35

Range offlmotion was measured with a goniometer. The
goniometer was aligned with the proximal arm of the
goniometer on the lateral side of the lower leg, using the
head of the fibula as a reference point. The distal arm of
the goniometer was parallel to the fifth metatarsal. The
goniometer was positioned at 90 degrees, which was read as
zero degrees (Figures 3 and 4). During the dorsi flexion
measurement, the researcher was in a seated position and
read the goniometer at eye level. The athlete was
instructed to actively (performed entirely by the athlete)
dorsi flex the ankle and the measurement at maximum dorsi
flexion was recorded. Dorsi flexion has a standard range of
0—20 degrees(34). See Figure 5 for proper positioning of
the goniometer for dorsi flexion measurement. The same
starting position (at 90 degrees) and placement was used for
the plantar flexion measurement. The athlete was instructed
to actively plantar flex at which time the maximum
measurement was read and recorded. Plantar flexion has a
standard of 0-50 degrees(34). For the positioning of the
goniometer for plantar flexion measurement, refer to Figure
6.

While the goniometer measurements were being taken, the
athlete sat using correct posture, with the knee bent, and
the leg dangling over the edge of the table. This
disengaged the gastrocnemius for total relaxation of the

ankle joint. No assistance was given to the athlete

36

 

Figure l. Edema In Right Ankle Due
to a Lateral Inversion Sprain.

 

Figure 2. Figure-of—Eight Measurement on a
Non—Injured Ankle.

37

 

Figure 3. Goniometer Alignment- Prior to
Normal Goniometer Position.

 

Figure 4. Normal Goniometer Position.
Zero (Ninety) degrees to begin
the range of motion assessment.

38

 

Figure 5. Proper Positioning for
Dorsi Flexion Measurement.

 

Figure 6. Proper Positioning for
Plantar Flexion Measurement.

39

(as demonstrated by the athletic trainer's hand placement in
figures 2-5) giving an accurate active measurement. The
measurements for dorsi and plantar flexion were compared to
the measurements of the non—injured ankle. When the injured
ankle had the same range of motion as the non-injured ankle,
full range of motion was considered to have been restored.
Pain.measurement based on a graphic rating scale was
verbalized by the athlete informing the athletic trainer of
how tolerant the athlete was of the treatment. The scale
consisted of numbers ranging from zero (no pain) to ten
(unbearable pain). The athlete then would write the number
down on his or her personal data sheet. The athlete was
asked to rate his or her pain after the first, third and
fifth minute of massage treatment. The pain rating scale is
an integration of the "Borg Scale of Perceived Pain” and
Talig’s scale (19). See Appendix G for a copy of the scale.
This scale was visible to the athlete receiving treatment
and was posted next to the treatment table. The athlete was
also asked, "How did the pain change during the session?",
and was given a choice of three answers— continuous,
periodic or brief. A new data sheet was filled out daily by
the athletic trainer with the assistance of the athlete.
This was done so that the athlete did not experience
intolerable pain without the athletic trainer’s knowledge.
The pain ratings were not included in statistical analyses

because the purpose was to assist in the athlete's comfort.

4O

The "Progression of sensation during'ice-water
immersion" was also presented to the athletes (Appendix F).
This was done so that the athletes knew what feelings could
and did occur during the ice baths. Athletes who never had
an ice bath before were informed in great detail about the
progression of sensations. The addition of this information
is worth mentioning because some athletes injured in prior
seasons had not been informed of the phases of ice
immersion. This had resulted in the discontinuation of
their treatment protocols. However, the current athletes
understood what was happening and continued their treatment
until they returned to activity. This information also
enabled the athletes to recognize if they were having an
allergic reaction to the ice.

Treatments

Efflerage.massage is a gliding stroke that is applied
horizontally in relationship to the tissues. This treatment
began on day three after the RICE treatment had been
completed. Baby oil is applied to the ankle joint as a
lubricant to avoid friction. The palm of the hand and
fingers are used in circular strokes that use moderate
pressure from the toes in an upward motion toward the heart.
Light to moderate pressure extends through the subcutaneous
layer to reach muscle tissue, but not so deep as to compress

the tissue against the underlying bony structure. The long

41

broad movement can be used repetitively while gradually
increasing the depth of pressure. Because of the distal to
proximal manipulation of this massage method, the flow
pattern adjusts easily from one body part to another. This
makes it easy to move from the toes up to the ankle, up to
the tibial shaft, moving the tissues, and fluid (effusion
and edema) toward the heart. This is done so that the
ecchymosis will not settle in the joint which will hinder
movement in the joint. The pressure is increased as the
athlete can tolerate it. The massage is started at the toes
and the tissues are milked in an upward direction. Then the
palm of the hand is used to glide from the toes to the heel,
and with added pressure using the knuckles to glide from the
toes to the heel. While using the thumbs and fingers,
circular strokes are used from the toes to mid-calf. The
circular motion of the massage distributes the pressure
evenly throughout the ankle joint (29).

cross friction massage was initiated on the third day
after the RICE treatment had been completed. The massage
consisted of small deep movements performed opposite the
tissue structure (vertically) across a tissue. The skin
moves with the fingers and no lubricant is applied during
this massage. The movement of the massage is transverse
to the fiber direction, which initiates a small, controlled
inflammatory response. Movement is produced by beginning

with a specific and moderate to deep compression using the

42

thumbs or index fingers with the middle finger on top of the
index finger for more pressure or support. This is done
over the anterior talofibular ligament, calcaneal fibular
ligament, posterior talofibular ligament and/ or lateral
talocalcaneal ligament. As the tissue responds to the
friction, one is able to gradually stretch the area and
increase the pressure. The feeling for the athlete may be
intense, however it should be tolerable. The feeling should
replicate a mild after exercise soreness. If the athlete
complains of soreness the following day, a modification of
lighter cross friction massage is given. The athlete should
gradually increase his or her tolerance throughout the
treatment session which resumes during the continuation of
the protocol (29). The athlete was given every opportunity
to inform the certified athletic trainer of discomfort so
that a modification of the massage could be administered.
Procedures

An athlete who sustained an ankle sprain reported to
the athletic trainer, who then assigned the athlete to
treatment group CF or EM. Immediately following this, an
evaluation of the ankle joint took place to determine which
degree ankle sprain the athlete had sustained and recorded.
The drawer and talor tilt tests were conducted to determine
the stability of the ligament(s).

Drawer tests are used to determine if the anterior

talofibular ligament is torn due to the ankle sprain. It

43

was performed while the athlete sat on the treatment table
with legs and feet relaxed. The ATC then gripped the lower
tibia in one hand and the calcaneus in the palm of the
other. The tibia was then pushed back as the calcaneus
brought forward. If the foot slid forward or a clunk was
heard or felt at the end of the movement a positive drawer
Sign was documented. This indicates a tear to the anterior
talofibular ligament.

Talor tilt tests are used for determining calcaneal
fibular ligament (CFL) and anterior talofibular ligament
(ATF) tears (inverted) or deltoid ligament (everted). The
foot was positioned at 90 degrees to the lower leg and
stabilized as the heel is inverted. If the talus rocks
there are torn CFL and ATF ligaments. In the same position
everting the heel and noticing or palpating a gap between
the medial malleolus and calcaneus is characteristic of a
deltoid tear (this type of sprain was not used in the
current study).

The figure of eight and goniometer measurements
followed the evaluation to determine the degree of edema.
After a series of three measurements were performed on each
ankle (for comparison of the injured and non-injured ankle)
and recorded, the treatment commenced. After the athletic
trainer had evaluated the injury and the figure of eight and
goniometer measurements were taken, a sheet describing the

take home therapy protocol was provided to the athlete.

44

The injured subjects were involved in the study until
the volume in the injured ankle returned to normal, or full
range of motion was restored, and a return to play protocol
was fully completed for return to activity. If an athlete
felt any kind of slight, abnormal discomfort or twinge in
the ankle, he or she was to notify the certified athletic
trainer. Treatment was implemented upon receipt of a
complaint from the athlete. Measurements were taken before
and after every treatment session after the occurrence of
the injury. The control group also had three measurements
taken and an average was recorded. X-Rays were suggested
when deemed appropriate, but not mandatory due to the
parent’s or guardian’s insurance requirements.

Take home therapy was performed the first three days
and consisted of Rest, Ice, Compression, and Elevation
(RICE). The athlete used an ace bandage and placed ice over
the bandage for 40 minutes at least three times each day (on
for 40 minutes, off for 40 minutes). While the ice was off
the athlete performed range of motion (ROM) exercises, dorsi
flexion and plantar flexion and circles without any pain.
The exercises progressed to doing the alphabet and towel
exercises. The athlete also was instructed to sleep with a
pillow under the affected ankle to keep it elevated
throughout the night. The ace wrap was to be left on unless
the swelling in the ankle led to discoloration and numbness

in the toes. If that occurred, the athlete was to first

45

loosen the bandage and if no improvement occurred reapply
the bandage. Compression over the injured site was desired
while the athlete was sleeping to prevent excessive
swelling. The ace wrap was applied beginning at the base of
the toes circularly progressing to a figure of eight method
upward proximally to the tibial shaft. There were to be no
gaps or open areas. The toes are left uncovered for
determining if the bandage was too tight and that
circulation was normal.

Training roan treatment CF consisted of RICE and the
take home therapy for the first three days. On the third
day, the ace bandage was removed and tape or bracing took
its place for support. The athlete had a choice of
purchasing a brace or to receive tape purchased by the high
school. The brace or tape was applied after conclusion of
the massage treatment. Advanced treatment (days 3—10)
consisted of ice baths (10 degrees Celsius for seven
minutes) followed by light tissue stimulus for two minutes
generally decreasing to one minute, continuing into cross
friction massage over the affected ligament(s) for four
minutes and increasing to five minutes, and ending with one
minute of light tissue stimulus. The range of motion (ROM)
exercises were implemented. These included: 1) dorsi
flexion using active ROM — releasing a gas pedal; 2) plantar
flexion exercises using active ROM - stepping on a gas

pedal; 3) writing the alphabet using the big toe as a pen.

46

 

As pain and effusion decreased, the athlete started a
progression of towel stretches and isometrics. Towel
stretches included pulling the foot into plantar flexion,
pulling the foot into dorsi flexion, pulling the foot out
and up into eversion, and pulling the foot up and into
inversion. These exercises were done in three sets of ten
for each exercise. Isometric exercises using a pillow to
resist the normal ankle movements of dorsi flexion, plantar
flexion, eversion and inversion were implemented at this
point. These were done for five sets and held in 10—15
second increments per set, each exercise.

General weight bearing exercises combined with
proprioceptive neuromuscular facilitation (PNF) exercises
involved: l)balancing on the injured leg for 10 seconds
working up to 15 seconds with eyes open. 2) balancing on
the injured leg for 10 seconds working up to 15 seconds with
eyes closed using the athletic trainer or wall nearby for
assistance with balance, if needed. This was repeated 5
times. 3) walking heel-to-toe for 10 yards 5 times with
eyes open then repeating with eyes closed using the athletic
trainer or wall for lack of balance if needed (27). These
PNF exercises were to be done with strict supervision, so
that no further injury occurred. This enabled the athlete
to gain confidence in their injured ankle's ability.

Walking, jogging or running for five minutes was then

introduced. As pain tolerated, increments of five minutes

47

were added until the athlete could run pain free for 20
minutes. These activities were applied to assist the
athlete in anticipation of the lengthy return to play
protocol. Finally, the return to play protocol was executed
by the athlete, which if completed successfully meant return
to activity and competition.

Training room.treatment EM involved RICE and the take
home therapy for the first three days. On the third day ice
bags were replaced with an ice bath (10 degrees Celsius for
seven minutes), and the ace bandage was replaced with tape
or an ankle brace. Advanced training room treatment (days
3-10) consisted of ice baths followed by l to 2 minutes of
light tissue stimulus, followed by an abrasive efflerage
technique (4-5 minutes), and concluding with one minute of
light tissue stimulus.

This was followed by the ROM exercises and progression
toward the return to play protocol as stated in training
room treatment for group CF. The athlete’s return after
completion of the return to play protocol before the 10 day
limit was the goal of this study. Efflerage massage
progressing to a more aggressive level was provided to the
athlete as tolerated.

Take home therapy and training room therapy protocols for
both treatments are reported in Appendix H.
Return to.play'criteria consisted of: l) jogging one

mile or 18 laps around the gym; 2) six 80-yard sprints at h

48

speed or 15 lengths of gym; 3) six 80-yard sprints or 15
lengths at 3/4 speed; 4) six 80-yard sprints or 15 lengths
at full speed; 5) six 80—yard sprints or 15 lengths while
cutting zig zags at 3/4 speed; 6) six 80-yard sprints or 15
lengths while cutting zig zags at full speed; 7) ten minutes
of running and jumping drills that are sport-related. Steps
1-7 must be done pain free. If any pain persisted or
instability was noticed, the discontinuation of the protocol
was enforced and icing the ankle for 20 minutes took place.
The criteria could be attempted again the next day, but had
to be completed before return to activity was approved (40).
There was to be no observable instability in the ankle or
return to activity was not permitted. The athlete was then
released to compete in practice or competition under strict
supervision and had to wear tape or bracing when doing so.
Instruments

In the current study, other instruments and techniques
were used but not considered when performing the statistical
analyses. Each instrument or technique is meaningful and
was supportive to both treatment procedures.

Ice baths consisted of a whirlpool or tub of water at
10—18 degrees Celsius. The temperature of water was
recorded daily. Providine Iodine was added to the water to
deter contamination of the athlete’s foot. The athlete was

to be seated inside the whirlpool on a bench or seat so that

49

the ankle was free to do the range of motion exercises
(dorsi flexion, plantar flexion, eversion and inversion,
etc.). If a tub was used a chair was used for the athlete
to sit on and the same format applied.

Position of the athlete for the massage treatment
consisted of the athlete sitting on the table with the ankle
off the edge of the table and the leg resting at mid-calf.
This was done so that the foot was relaxed and movement
around the foot and ankle was maximal. The athlete sat up
to avoid falling asleep or getting too comfortable. This
position also made it easier to hear an athlete make
comments about the treatment. The placement of the calf was
important so that no extra movement came from the knee while
doing the massage.

Paper towels were available to the athletes to wipe
off water or lubricant after a treatment session. This was
done to avoid contamination of the athletes’ feet.

.A digital or.bell timer was used by the athletic
trainer for keeping time. The timer was started as soon as
the athlete's ankle was fully submerged in the ice bath or
ice was placed over the compression bandage. As soon as the
lubricant was applied or the placement of the athletic
trainer’s fingers had taken place, the timer was initiated a
second time. This provided consistency for all treatments.

The timer was set for seven minutes during the massage and

50

ice immersions and for six minutes during the ROM exercises.
The timer was set for 40 minutes if an ice bag was used over
an ace bandage.

.Athletic dress consisted of shorts, a t-shirt and no
socks or shoes. This was standard dress for the training
room setting. It also allowed for easy accessibility to the
athlete’s injury, and was comfortable to the athlete.

Data Cbllection

Data on the injured athletes were collected on a daily
basis. Individual data sheets were developed on which to
record the data (see Appendix B). Completed sheets were
kept in a secure place while the study was underway and
during the data analysis. Because a detailed description of
data collection procedures was presented in the assessments
section, only a summary will be provided here.

Range of motion for the ankle was measured by the
degrees registered on the goniometer. The goniometer was
placed on the joint angle while dorsi flexing and plantar
flexing the ankle. The results were then recorded on the
data sheet.

Girth was measured as the total number of centimeters
observed on the measuring tape using the figure—of-eight
technique. This measurement took place before and after
each treatment session. This assessment was also made on

the control groups (at the beginning and end of the season).

51

 

The range of motion and the girth measurements were
practiced by the athletic trainer until her measurements

were the same as those of the physical therapist assistant
at least 90% of the time. The measurements were taken

independently and then compared to insure the accuracy of
the measurements.
Duta.Analysis

Analysis was achieved through descriptive and
inferential statistics. Means, standard deviations and t-
tests were calculated to describe the data and determine the
effectiveness of the treatment groups.

A quasi-experimental design with convenient samples was
used in this study. Only students attending the involved
class B high school and sustaining first or second degree
ankle sprains while participating in their athletic activity
could be used as subjects. No third degree or medial
(eversion) sprains were included due to the complexity of
their composition. Comparison of the injured limb to the
non-injured limb was used for the both the control and
treatment groups. The appropriateness of each measurement
device was determined after results from the control groups
were analyzed. The control group was used to verify
measurements being used were appropriate in determining the

conclusion of the treatment sessions.

52

'1‘-

 

(flifiiflflflk FTNflR

RESULTS and DISCUSSION

Purpose

The purpose of this study was to determine the
effectiveness of cross friction massage compared to
efflerage massage on first and second degree lateral ankle
sprains. These two methods of treatment were chosen because
they are easily learned and can be performed when more
expensive modalities are unavailable. Massage has been used
successfully with patients in a long term hospital setting
(10,24,33), therefore it was chosen as the preferred
treatment for this study on an acute short term injury to
determine its effectiveness. The relative effectiveness of
the two treatments will be reported and discussed in this

chapter.
Results

Two control groups (One and Two) were used to determine
the appropriateness of the measurement methods used in this
study. There were no differences in Control Group One from
the first measurement (pre—season) to the final measurement
(end of season) for each ankle, and no discrepancies between
the right or left ankles were discovered (see Appendix C).
The athletes in this group had never experienced an ankle

sprain, therefore no differences were expected.

53

Control Group Two, however, showed differences between
the two ankles. These athletes had sustained a previous
ankle injury (nine months or longer prior to the current
study). The means and standard deviations for the
differences between the ankles are presented in Table 1.
These differences are assumed to be the result of a previous
first or second degree ankle sprain that the athlete had
sustained nine months or earlier prior to this study. In
this group, three athletes had a severe (3) second degree
sprain, four athletes had a moderate (2) first or second
degree ankle sprain, and three athletes had a mild (1) first
or second degree sprain. These numbers were associated with
how many days the athlete missed practice (1 = one day or
less with 7 days of treatment, 2 = three days or less with
two weeks of treatment, 3 = four days or longer with 3 or
more weeks of treatment). These athletes ranked their
injury on a 1 (mild), 2 (moderate) or 3 (severe) grade,
because no documentation could be found to determine the
type and severity of the sprain the athlete had sustained.

In general, the differences between the injured and
non-injured ankles increase with the severity of the sprain
in all three measurements, with the greatest difference
noted for plantar flexion for athletes who experienced
severe ankle sprains. If the differences between the ankles
were significant on one or more of the measurements, the

these measurements would not be useful for determining when

54

the treatment should conclude. Therefore t-tests were

performed for each measurement.

 

 

 

 

 

tuna: 1—1gagszum1summuumbnrmnuugmsgggugggIgggflgznnn
ImmkiumnumgggggsJflntggmggn.g&zgzzflg
Degree Degrees lunpuuns Figure of 8
of Dorsi- Plantar Centimeters
Sprain N Flexion Flexion *INJ-NI
*INJ-NI *INJ-NI
14 SD 1! SD in an
m 3 -3.33 2.31 -17.0 3.0 0.83 0.29
mDERATE 4 —2.25 2.06 —3.09 6.18 0.50 0.00
MILD 3 ~1.50 1.00 -2.50 1.91 0.53 0.33
TOTAL 10 -2.27 1.79 -9.27 7.14 0.60 0.26

 

 

 

 

 

 

 

 

 

 

*INJ-NI= Injured ankle minus non-injured ankle.

The results for dorsi flexion revealed a significant

difference in ROM between the injured and the non-injured
ankle (TLg = 8.46, P< 0.007) favoring the non-injured ankle.
The same result occurred when plantar flexion in the injured
and non-injured ankle was compared (TLg = 697.2, P< 0.00).
However, the results for the figure of eight measurement
were not significant (TL9 = 2.53, P< 0.063). Therefore, the
figure of eight measurement was the criterion used for
determining when the treatment should be concluded.

Using the dorsi flexion, plantar flexion and figure of

eight measurements, the injured athletes in both treatment

55

groups were evaluated on each ankle. The comparisons were

then reported on the individual data sheets and used in the
statistical analyses. The gender, and type of sprain, for

each treatment group are presented in Table 2.

TABLE 2- DISTRIBUTION OF SUBJECTS BY GENDER, TYPE 9?
SPRAIN’AND TREATMENT TYPE

 

 

 

 

 

 

 

GFUUIE GEUUIE EKXEAL
TREATMENT GENDER. ONE TWO
CHADSS ITALE 4 3 7
FTC! TI I!
C C) ETDTALE 3 3 6
EFTTJMENGE bflKLE 3 4 7
.A E
IQASS G; FERHUHE 3 4 7
PARTICIPANT 13 14 27
TOHTJJB

 

 

 

 

 

 

Table 2 provides an overview of the total number of
subjects used in the current study and which type of sprain
and treatment they received (which is equally distributed).

The means and standard deviations for the number of
days before returning to play following an injury were
calculated next (see Table 3). The results provide an idea
of how long athletes require treatment, as well as which
treatment appears to return the athlete to his or her

activity more quickly.

56

TABLE 3- MEANS and STAEQARD DEVIATIONS POR.RETURN'TQ PLAT

 

FOLLQEEEG'AN'INJURX
Type of N Cross Friction N Efflerage
Sprain Days Days
M SD M SD

 

Grade One 7 2.43 0.79 7 3.00 0.63
Grade Two 6 2.83 1.33 7 3.13 1.36
TOTAL 13 2.62 1.04 14 3.07 1.07

 

 

 

 

 

 

 

 

 

 

 

The results show that cross friction treatment has a
slight advantage in getting the athletes back to the playing
field faster than does efflerage treatment (M: 0.45).
However, when a t—test was conducted to compare the CF
treatment to the EM treatment, there was no significant
difference between the two treatment groups (TL%,= -0.19,

P< 0.43). Cross friction and Efflerage massage show no
significant difference in the number of days it takes an
athlete to return to their activity. Therefore, the
hypothesis that EM would be more effective than CF in
returning an athlete to activity was rejected.

The means and standard deviations for days of treatment
following injury are presented in Table 4. This table
indicates how many days of treatment an athlete received
before the injured ankle returned to the same size as the

non-injured ankle using means and standard deviations.

57

TABLE 4- MEANS AND STANDARD DEVIATIONS FOR DAIS OF TREAEEENT
FOLLOWING AN INJURY

 

 

 

 

Type of N Cross N Efflerage
Sprain Friction Massage
Days Days
M SD M SD
Grade One 7 5.43 0.79 7 6.17 0.98
Grade Two 6 6.17 1.72 7 6.88 2.70
TOTAL 13 5.77 1.30 14 6.57 2.10

 

 

 

 

 

 

 

 

 

The results suggest that CF treatment is faster than EM
in number of days of treatment required (M= 0.80).
However, a t—test using days of treatment as the dependent
variable revealed that this difference was not significant
(TL% =-0.25, P< 0.41). Therefore the hypothesis that EM
would be more effective that CF in reducing days of
treatment was also rejected.

Discussion

A third treatment group using only RICE was not
included in this study because of the uncertainty of the
number of subjects that would be available. The total
number of athletes participating in a winter or spring sport
was taken into consideration in estimating the number of
ankle injuries that might occur. Due to the small number of
projected injuries and the previous experience of the
athletic trainer, the decision was made to have only two

treatment groups.

58

The control groups were helpful in determining which
measures were best for judging when treatment should be
terminated. The figure of eight measurement was the only
one in which differences between the injured and non-injured
ankles were not significant for the two control groups,
therefore, it was used in determining when treatment should
cease.

Some of the sprains that the athletes sustained were
not severe enough to keep them out of activity for more than
one day before the RTP was completed. The edema and
effusion may not have affected ROM, and functional returns
were possible even though articular fluid was present. The
athletes were the judge of when they thought they were ready
to complete the RTP protocol.

The results of the current study, when compared to
Arnheim’s protocol for a second degree lateral ankle sprain
(3 weeks for the acute phase to the repair phase), were much
faster. Arnheim however does not give specific days for
total treatment, he just states what exercises and
rehabilitative techniques to use (3). Many of the same

exercises suggested by Arnheim were used in the current
study, however, Arnheim's goal for the repair phase is 5096

pain free motion and restoration of full muscle contraction
without pain. The athletes in the current study did not

indicate experiencing pain after returning to activity

59

unless they were to slightly re-sprain the injured ankle
(basketball players landing wrong). The athletes were taped
or braced on a daily basis to insure that a worse sprain
should not occur.

The current study obtained more beneficial results when
compared to the Scotece and Guthrie’s military study (40).
Eighty-one percent of the athletes in this study were
participating in their activity three days or less from the
initial injury as compared to 60 percent of the soldiers
(returned to active duty) in the military study (40). It is
possible that the motivation for returning to activity was
not equal in the two studies. Perhaps the soldiers were
less motivated to return to active duty than were the
athletes to return to their sport. Cross friction massage
on a first degree sprain was 100 percent successful in
returning an athlete to activity in three days or less, and
80 percent successful on a second degree sprain. Efflerage
massage had a 67 percent success rate for a first degree
sprain and a 73 percent success rate for a second degree
sprain (see Table 5). The combined results for the
treatment groups reveal that massage treatment was more
effective in returning the athlete to activity than were the
strapping and rehabilitative exercises used in combination
with various modalities in the military study (40). The
military study had 43 percent (80 of 184) return for duty

within three days (40).

60

. 1 ‘5. 1.1"—

 

With cross friction treatment, 92 percent of the
athletes returned to activity in three days or less.
Efflerage massage was 71 percent successful in returning the
athletes to activity in three days or less. Seventy-eight
percent of the athletes completed treatment (RICE + Massage)
in six days or less.

TABLE 5- TOTAL NUMBER of DAIS BEFORE ATHLETE RETURNED TO
ACTIVITY AND DISCONTINUED TREATMENT

 

 

 

     

 

   

 

   

‘_nr 1 mm

 

   

Errata .t
3 6
Cr”/;. 2 . 5
m ' 1 4
rrrctinn
Lgsear; n: 8
5 9 n=1
3 7 n=1
1 6 ch xs L=2
4 rigs r=l
Eir‘t 1 9
(;::53 P*:) 3 5
a r.)
‘— an
6 13 Gays 1:1
4 8 ' -1
3 7 ~11
11 2 ‘5‘
— E. 3

 

 

 

 

 

 

No athlete exceeded a 13 day period for total

treatment and all athletes returned to activity within six

61

 

days. However,
percent)
percent)

days.

play within six days

in the Scotece study,

(see Table 5).

18 soldiers

(10
did not return to duty for 21 days and 86 (47
soldiers did not return to duty before thirteen

All participants in the current study returned to

The military study did not reveal if total treatment

was concluded after the athlete returned to duty (40).

The

current study revealed a more successful result compared to

the military study

(40).

See Table 6.

Each of the two

studies found initial evaluations were essential and only

those subjects who had an initial evaluation were included.

TABLE 6- MASSAGE TREATMENT COMPARED TO STRAPPINE TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

TREATMENT Return Return Return Return
TYPE N 3 6 13 21
Days Days Days Days
Massage
Treatments 27 23 4 0 0
(Current
Study)
PERCENT 85% 15%
Strapping and
Gel Cast 184 80 N/A 86 18
(Military
Study)
PERCENT 43% 47% 10%
*Return = Return to activity or duty.

62

 

The results of other studies using massage treatments
were not very useful in interpreting the results of the
current study (10,24,33). The previous studies were
conducted to determine how patients responded to a massage
treatment, not how long it took for them to recover from an
ailment using a specific massage technique.

It is possible that CF and EM were equally effective in
treating the injured ankle. The sprained ankles in control
group two athletes, who did not receive massage as a form of
treatment, and did not return to the exact size of the non—
injured ankles. Each athlete in the treatment groups was
successful in returning the size of the injured ankle to
that of the non-injured ankle. This suggests that massage
on a grade one or grade two lateral ankle sprain is
successful in treating the injury as well as restoring the
ankle size to that of the non-injured ankle.

An exploratory attempt was conducted to determine if
the grade of sprain and treatment type were distinctive.

For this attempt, the return to play criteria were used in
four separate t—tests. Treatment Group One (cross friction)
athletes compared to Treatment Group Two (efflerage) having
a grade one sprain disclosed no differences (TL10= 1.49, P<
0.437). Nor was there a difference for grade two sprains
comparing Treatment Group One (CF) with Treatment Group Two
(EM) (T‘L15= 1.50, P< 0.435). A comparison of grade one and

grade two sprains within each treatment group also failed to

63

yield any differences (TLH = 1.06, P< 0.490) for CF and
(TL13= 1.05, P< 0.492) for EM. Thus each treatment was
equally effective in treating each grade of sprain. (Refer
to Appendix L for information regarding type of sprain and

treatment success).
Effectiveness

Each treatment group was successful in returning the
athlete to activity within a six-day period, which exceeded
the goal of 10 days. The average number of days for
returning to activity was three treatment days. All but one
athlete concluded their treatments within 10 days. The
athletes continued a daily exercise program at the
conclusion of their treatment to insure that the ankle would
get stronger.

The purpose for early treatment is to hinder edema
formation which can impede the healing process
(10,15,37,40). Massage therapy was chosen because of its
ability to disperse edema formation and reduce ecchymosis
(10,19,22,23,24,29). Cross friction massage and efflerage
massage appear to be effective in reducing the amount of
time an athlete is out of activity because of a grade one or
grade two ankle sprain. The results of this study were
impressive with how effective the massage treatments were.

I did not expect to determine that each treatment would be

equally effective. I had hypothesized that efflerage

64

massage would be more effective than cross friction massage
in getting an athlete to return to activity.

Both techniques are effective in assisting an athlete's
prompt return to activity as well as being equally
successful in restoring an injured ankle to the same size as
the non-injured ankle. All injured ankles (0.5 cm to 3.7 cm
of difference) returned to the same size as or less than
that of the non-injured ankle.

Cross friction massage shows no advantage over
efflerage massage in getting the athlete back to activity
and in concluding overall treatment. Reducing the number of
days an athlete is not participating in his or her activity
was the main goal for performing each of these treatments.
Each treatment is similar in the advantages of returning an
athlete to activity in a short duration, which would warrant
further studies to be conducted using these massage therapy
treatments. This concept should be researched further to
determine if there are other possible benefits from

implementing either massage technique to an injury.
Commen ts

The sample size (N: 27) was small, therefore the
severity of the ankle sprains were not analyzed separately.
The military study had 184 subjects and therefore separated
ankle sprains in three separate treatment groups (40). The

treatment protocol in the current study was followed very

65

 

carefully so not to bias the outcome of this study or
interfere with the results. Control group Two was unique in
that the injured ankles of each athlete had never resumed
normal (non-injured) ankle size. This was, however, helpful
in determining which measurements should be used to
determine when an athlete should be released from treatment.

The cross friction treatment was tiresome when two or
more subjects receiving this treatment were injured at the
same time. When this occurred at least three massage
treatments (2 subjects receiving CF and 1 subject receiving
EM) were completed in a one hour time frame. An assistant
would have been helpful to distribute the treatments. If
more subjects would have been involved, perhaps a more
definitive conclusion could have been made as to which of
the treatments was more successful on a grade one or grade
two ankle sprain. The raw score results suggest that the
cross friction massage treatment may have a slight advantage
(M= 2.62 days) over the efflerage massage treatment (M= 3.07
days) to returning an athlete to activity.

An athlete's rapid return to activity is a certified
athletic trainer’s goal as well as the goal of the coach who
needs the athlete to contribute to the team. The athlete
who sustains the injury also has the desire to return
because he or she does not want to “sit the bench”. The
athletes also must be willing to admit to the coach and

athletic trainer when they are not comfortable participating

66

 

 

 

due to the injury. There must be an understanding between
the certified athletic trainer, coach and athlete regarding
the athlete’s completion of the return to play protocols.
This will assist in the achievement of the treatment and the
well being of the athlete. All but one athlete completed
treatment under the 10—day goal for return to activity.

This was inspiring because this athlete returned to activity
in six days, but did not conclude treatment until the
thirteenth day. Both treatments averaged a 6.57 day
interval for treatment conclusion. More research using
larger numbers of subjects should be conducted to determine
if one technique is the more effective for treating a grade
one or grade two ankle sprain.

The overall success of this study was exciting. Both
treatments combined for an 81 percent success rate (getting
the athlete back to activity in three days or less), and no
research to date has shown such effective results from
performing a specific treatment protocol. The small numbers
involved in this study should not downplay the overall
success of the treatments. The combination of the massage
treatment results when comparing them to the military study
are inspiring. These two massage techniques should be
researched to determine if they are successful in assisting

in the healing process of other athletic injuries.

67

 

(HTEPITHQJFIVII

.SUMDDUTY, CXHWZDUSEIHWS, anmrruacoanammnaruznus

Each year at least two athletes per 1,000 exposures
during activity will sustain an ankle injury (4,5,18,25,
27,41). The goal of every athletic trainer is to return the
athlete to activity as soon as possible. Therefore, various
treatment modalities are tried to facilitate the achievement

of this goal.

 

Summary

The purpose of this study was to determine the
effectiveness of cross friction massage compared to
efflerage massage on first and second degree lateral ankle
sprains.

Twenty-seven athletes attending one mid-Michigan high
school, who experienced a Grade One or Grade Two lateral
ankle sprain, were alternately assigned to one of two
treatment groups, Cross friction (One) and Efflerage (Two).
Effectiveness of the treatment was determined by: 1) the
number of days of treatment required before an athlete
successfully completed a return to play protocol; and,

2) the number of days of total treatment (the return of the
injured ankle size to that of the non-injured ankle) using
the figure of eight measurement and observable ligament

instability as the criteria. The hypothesis that efflerage

68

 

massage would be more effective in moderate edema reduction
than cross friction massage in rehabilitation of lateral
ankle sprains was not supported by the results. The results
established that cross friction massage and efflerage
massage were similar in assisting an athlete’s quick return
to activity. The results were surprising because the
abrasiveness of the cross friction technique and the
constant motion in the efflerage technique are so different,
and yet both techniques generated similar results. Both
massage treatments were found to be successful in assisting
the healing process of a Grade One or Grade Two ankle
sprain, although cross friction massage appeared to have a
slight advantage in the results for the days an athlete was
unable to participate. However, the t-Tests were conclusive
that neither treatment has a statistical advantage over the
other. Both treatments were equally effective in returning
an athlete’s injured ankle to the size of the non-injured
ankle. The implementation of either cross friction or
efflerage massage should be considered when treating a Grade

One or Grade Two lateral ankle sprain.
Cbnclusions

Both the CF and EM treatments were successful in
returning the athlete to activity within the ten-day time

frame. A success rate of 100 percent in returning the

athletes to activity within a six—day time frame exceeded

69

 

the goal of 10 days. Eighty-one percent of the athletes
returned to activity in 3 days or less which should be
inspiring to those in professions that work with the
rehabilitation and treatment of ankle sprains.
Statistically, neither treatment had an advantage over
the other, although cross friction massage showed a slight
advantage over efflerage massage in returning an athlete
back to activity and in total treatment time. Perhaps a
larger number of subjects would have determined that cross
friction has the advantage over efflerage treatment. The
current study was instrumental in introducing the benefits
of using cross friction and efflerage massage treatments in
the training room setting. Additional studies should be
conducted to examine whether or not efflerage massage or
cross friction massage has the advantage in restorative

aspects of an injury.
Recomenda tions

Based on the results of this study, the following
recommendations are made for future studies.

1. Additional research should be done to determine if
cross friction (CF) treatment is more beneficial to first or
second degree lateral ankle sprain than efflerage (EM)
treatment. With the slight advantage that cross friction
massage appears to exhibit over efflerage massage, a more

extensive study should be conducted. The current study

70

 

 

sample size was rather small (27 subjects). A comparison of
their effectiveness on first and second degree sprains
should be completed before implementing one procedure (CF)
over the other (EM) in the training room.

2. A combination treatment group (combining efflerage
and cross friction massage) for equal increments (3 minutes
of cross friction and 3 minutes of aggressive efflerage)
should be examined. In the current study, light tissue
stimulus was performed on the cross friction and efflerage
groups (to ease the athletes into the abrasiveness of the
massage techniques used). Each group received two minutes
of light tissue stimulus gradually decreasing to one minute
and one minute of light tissue stimulus in the concluding
minute of massage treatment to relax the athlete and
stimulate the blood flow to the injured area. The light
tissue stimulus should be decreased to 30 seconds before
treatment and 30 seconds after treatment.

3. A control group that just receives the RICE (Rest,
ice, compression, and elevation) should be included in
future studies to provide a baseline group for comparing the
effectiveness of the massage groups. The use of high
school, university, and clinical patients could reveal
interesting results if included in a study using the CF and
EM treatments. Each of these settings have distinctive

variances in their procedures.

71

 

 

4. A long term measurement of ankle size should be
implemented to determine if the athlete’s injured ankle will
remain less than or the same as the size of the non—injured
ankle. It would be interesting to observe a one-month,
three-month and six-month measurement of ankle size. This
could be done to validate the success of each treatment. A
reassessment of the special tests (drawer and talor tilt)
should also be used at the conclusion and with the long term
measurements.

5. The RTP protocol was cumbersome and had the athlete
doing a lot of extra distance running (one mile) instead of
shorter lengths. A modified protocol should be adopted.
With the current protocol, if an athlete could not finish,
he or she was reluctant to come back the next day to do it
again. An example of shortening the protocol would be
running 20 yard sprints instead of 80 yard sprints. This
would be more conducive to the average sport activity
situation, because few sports have a continuation of running
for a distance of 480 yards. This protocol was helpful, but
at times seemed overly repetitive and interminable.

6. Having an assistant would also have been helpful to
monitor the athletes who were not given adequate supervision
while they were in the ice bath and doing the uncomplicated
range of motion exercises. The assistant could witness
whether the athletes were doing the prescribed exercises or

just sitting in the chair. A setting where two whirlpools

72

are available also would have been beneficial. The
athletic trainer occasionally had one athlete in the
whirlpool and the other athlete on the treatment table
receiving the massage treatment while another athlete was
waiting for a totally different (warm) whirlpool treatment.

7. A goniometer with one degree increments should also
be considered. This would allow for more precise
measurements of ROM than was possible with the goniometer
with five degree increments used in the current study.

8. A final recommendation would be to implement the
massage treatments the second day following injury. Some of
the athletes were anxious to start the massage treatment and
were unhappy doing the RICE therapy. There also were a few
athletes who advanced directly from the RICE protocol to
complete the return to play protocol. These athletes should
have begun the massage treatment earlier, however due to the
treatment protocol and the strict adherence to the
procedures, they had to wait. This would also mentally
improve the athletes’ well-being and motivate them in

returning to the activity.

73

O .7 12—.”

Vern"

 

APPENDIX A

CONSENT FORM'

To potential subject and parent or guardian,

The research project you, your son or daughter will be
involved in requires parental or guardian consent if under the
age of 18, or your consent if over the age of 18. It involves
two separate protocol treatments for a first or second degree
ankle sprain. The certified athletic trainer at the
participating high school will be determining the severity of
the athletes ankle sprain, by conducting an evaluation of the
injured limb.

One of two treatment protocols will be given to individuals
whose ankle injury can be categorized as a first or second
degree ankle sprain. The first treatment consists of RICE for
the first three days; efflerage massage (a circular light
massage that will intensify with the athletes tolerance. It is
also called milking - due to the movements of the massage, which
will move the excess fluid out of the injury sight) and ice
baths the following 3—10 days. The second treatment consists of
RICE for the first three days followed by cross friction massage
(an intense massage that has the masseur doing deep movements
that are horizontal over the ligaments in the ankle that are
horizontal over the ligaments in the ankle that are injured.
This breaks up any scar tissue that may form)and ice baths for
3-10 days.

A third group will be involved as well. This group will
consist of non injured subjects to measure the volume of their
non injured ankles. Each participant, injured or not, will have
their ankles measured for swelling. This consists of the
athletes putting their ankles off the edge of a treatment table
at mid calf for a figure of eight tape measurement of each
ankle. The foot will be at 90 degrees of flexion or facing
straight up. They will then have a goniometer measurement of
their range of motion for both ankles. Each procedure will be
fully explained to all participants before any involvement in
this research project.

Each subject will be involved until they have a close to
normal measurement of their ankle, have 80% range of motion,
and have a successful completion of the return to play protocol.
The control or non injured group will be involved until a series
of three measurements are made (beginning, middle and end of
season). This is a voluntary participation and the subject
may exclude them self from participation at any time without
penalty. There is no guarantee of beneficial effects. Each
subjects' identity will be kept confidential. Participation in
this project will not involve any additional cost to your health
care insurer. If you have any questions, you can contact
Shawn R. Cradit, ATC (517) 770—4906.

By signing this form, you are giving consent to participate
in this project.

Parent or Guardian DATE Participant DATE
Signature Signature

74

APPENDIX B

Research Data Sheet

Name Date Sport

 

Activity : PRACTICE GAME EVENT Gender: M F Date of Birth

 

Type of massage treatment given : Cross Friction Efflerage
Classification of ankle sprain : First Second

Whirlpool temperature degrees Celsius

 

Left ankle girth cm Right ankle girth cm (Circle injured ankle)
Pain measurements: First __ Second Third

Ankle measurement before treatment cm

Ankle measurement after treatment cm

Goniometer measurements- Left ankle : Dorsi flexion Plantar flexion

Goniometer measurements- Right ankle : Dorsi flexion Plantar flexion

Comments of the athlete:

 

 

 

Comments of the Certified Athletic Trainer:

 

 

 

 

 

75

APPENDIX C

Table 7: Control Group Data

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DF DF PF PF Fig. Fig. DF DF PF PF Fig.8 Fig.8
G DS R1 L1 R1 1.2 8 R 8 L1 RF LF RF LF RF LF

1 1o 10 42 42 62.5 62.4 10 1o 42 42 62.4 62.4
2 10 1o 40 40 45.5 45.5 10 10 40 40 45.5 45.9
1 4 4 68 68 55.5 55.5 4 4 68 68 55.5 55.3]
2 18 18 28 28 46.8 46.8 18 18 28 28 46.8 46.8]
2 15 15 34 34 46.8 46.8 15 15 34 34 46.8 46.8]
2 12 12 76 76 49.4 49.4 12 12 76 76 49.4 49.4]
2 1o 10 4o 40 51.5 51.5 10 10 4o 40 51.5 51.5]
1 12 12 45 45 55.5 55.5 12 12 45 45 55.5 55$
1 18 18 44 44 52.5 52.5 18 18 44 44 52.5 52.5]
1 1o 10 4o 40 48 48 1o 10 4o 40 48 48]
1 3 14 20 55 38 53.5 54 14 20 55 38 53.5 54]
1 2 10 1o 40 29 54 55 10 1o 40 29 54 55]
1 1 15 13 28 26 55.5 56 15 13 28 26 55.5 56]
1 2 8 6 28 19 66.5 66 8 6 28 19 66.5 66]
1 1 15 15 32 32 54.5 54.5 15 15 32 32 54.5 54.5]
2 2 1o 15 4o 43 48.5 48 10 15 4o 43 48.5 48]
2 2 18 16 20 38 49 48.5 18 16 2o 38 49 48.5]
2 1 16 14 36 32 51.5 51.2 16 14 36 32 51.5 51.2]
2 3 1o 12 16 30 49.5 50.5 10 12 16 30 49.5 50.5]
J 3 18 16 go 40 54.5 55.5 18 16 20 40 54.5 55.5]

 

PF- Plantar Flexion- Measured in degrees; Fig. 8- Measured in Centimeters
R- Right; L- Left; 1- First Measurement; F- Final Measurement

76

* LEGEND: G- Gender; DS- Degree of Sprain; DF- Dorsi Flexion- Measured in degrees;

 

l‘

APPENDIX D

Figure 7: Treatment Data

 

 

 

 

 

 

 

 

 

$1 S4 S7 510 $13 516 $19 522 525
Subjects

RTP Treat

* Treat= Treatment (1= cross fi'iction, 2= efflerage);
RTP= Return to Play (number of days before athlete returned to play);
Day TR= Days of Treatment (total number of days for treatment).

 

77

APPENDIX E

Table 8: Data for the Treatment Group

F-8
as TRT RTP DTR

6 50

—L

_L
W

1
2
2
1
2
2
1
2
1
2
1
2
2
2
2
2
1
1
1
2
1
2
1
2
1
2

M-‘N-‘N-‘N-‘NNN-BN-‘N-‘NAN-‘M-‘N—‘N
roa-mammmwwmwwamwwwmmmwwawww

(II-AU'ICDNUIU’IOQUIOCDQQCDCDCDUI

 

*Legend for Table 8: S-Subject; G-Gender(1-male, 2-female); DS-Degree of sprain (1-
first, 2-second); TRT-Treatment (l-CF, 2EM); RTP-Days to complete return to play
protocol; DTR Days of treatment; F -8-Figure of eight-measured in centimeters; DF- Dorsi
flexion-measured in degrees; PF- Plantar flexion-measured in degrees; (l)-First
measurement; (F )- Final measurement; NI-Non Injured ankle.

78

APPENDIX F

progression of Sensations Dunne
IceL Water Immersion

l. CDLD
2. DEED ACHING DAIN
3. DAIN [EVELS Off DD DECDEASES

4. DINS AND NEEDLES/ TALLING ASLIEIED
SENSATIDN

5. DDSSIDLE ND TEELING SENSATIDN
6. NUMDNESS
7. DDIJTS DI: DAIN TDD SHDDT DEDIDDS
8. “AHED DAIN” —A DEED THDDDDING
DAIN —

DCCIJDDING AHED DEMDVAI. FDDM
CDLD

79

APPENDIX G

Graphic Pain Rating Scale

0.5 - 1.5
Dull Ache

2 - 4
Slight Pain

4.5 - 5.5
> Slight Pain

6 - 7
Painful

7.5 - 8.5
Very Painful

9 - 10
Unbearable
Pain

A feeling of discomfort during
activity

An awareness of pain without

distress

Pain distracts attention during
physical exertion

Pain distracts attention from routine
occupation such as reading or
writing

Pain fills the field of consciousness
to the exclusion of other events

Comparable to the worst pain
one can imagine

80

APPENDIX H

 

 

 

 

Table 9: Treatment Table Protocols
Days I - 3 (*Same for Days 4 and above
both groups EM, CF)
Efflerage Massage *A) Assessment of the 1) Ice baths continue
(EM) ankle sprain severity 2) One minute of light EM
‘3) Figure of eight 3) Five minutes of
measurement (daily, aggressive EM
one time on non 4) One minute of light EM
injured ankle) 5) Advanced ROM
*C) Goniometer 6) Return to Play Protocols
measurement (daily, If not completed
one time on non injured successfully yet
ankle)
*TAKE HOME
THERAPY
1) Ice, Compression,
Elevation, Rest
2) Range of Motion (ROM)
exercises
3) ACE Wrap lefi on at all
times, unless bathing
Continue to TRAINING
ROOM THERAPY (TRT)
Cross Friction Massage *TRT 1) Ice baths continue
(CF) 1) Ice over ACE Wrap 2) One minute of light EM
2) ROM exercises 3) Five minutes of CF over
3) Ifathlete improves, Ice Affected ligament(s)
Baths are to be 4) One minute of light EM
implemented 5) Advanced ROM
4) Complete Return to Play 6) Return to Play Protocols
Protocols if athlete can If not completed
tolerate successfully yet

 

 

 

81

 

APPENDIX I

Table 10: Frgguency T (Lble Report

Frequency Distribution of Type

 

Cumulative Cumulative
lyp_e Count Count Percen_t Percent
1 10 10 37.05 37.05
2 17 27 62.96 100.00
Frequency Distribution of Treatment
Cumulative Cumulative
Type Count Count Percent Percent
1 13 13 48.15 48.15
2 14 27 51.85 100.00
Frequency Distribution of Days RTP Completion
Cumulative Cumulative
mys Count Count Percent Percent
1 2 2 7.41 7.41
2 7 9 25.93 33.33
3 14 23 51.85 85.18
4 2 25 7.41 92.59
5 1 26 3.70 96.29
6 1 27 3.70 100.00
Frequency Distribution of Total Treatment Days
Cumulative Cumulative
Days Count Count Percent Percent
4 2 2 7.41 7.41
5 7 9 25.93 33.33
6 12 21 44.44 77.78
7 2 23 7.41 85.19
8 2 25 7.41 92.60
9 1 26 3.70 96.30
13 1 27 3.70 100.00

82

APPENDIX J

Table 11: Cross Friction Treatment Figure-of-Eight Results

F81-F8F
0.8
1
0.6
1.4
0.3
1
0.1
1.6
2.5
0.5
1.7
0.8

OGNOG¥C¢NA

.a
O

.a.
.5
dawUMNNNW-‘UU

6
6
4
7
5
5
6
9
6
6
6
4

.5
N

 

*Legend for Table 11: F8- Figure-of eight (measured in centimeters); RTP- Return to play
(measured in days); Day Tr- Days of treatment; 1- First, F- Final; NI- Non injured ankle.

83

APPENDIX K

Table 12: Efflerage Treatment Figure-of Eight Results

Figure - 8 Figure-8 Return To Days of Fig.8 first -
T

Final

 

* Figure 8- Measured in Centimeters
Return to Play- Measured in Days

84

APPENDIX L

Figure 8. Treatment, Degree of Sprain, and RTP

 

 

 

.5 ‘/
Days x”
RTP 3 K
2 . 5 , ' ///
2 l/ )/
1. 5 g‘,
// 1‘ ,1
1 )/
/'/ l /
O . 5 / / . /
x// , /
o , / /

First degree Second Degree

Treatment Type

I Efflerage
E] Cross friction

85

1...? 1‘ §

APPENDIX M

 

Figure 9-A. Frontal Ligament View of a Normal Ankle.

 

Figure 9-B. Lateral Ligament View of a Normal Ankle.

= Anterior Tibiofibular Ligament
Calcaneofibular Ligament
Anterior Talofibular Ligament
= Cervical Ligament

= Long Plantar Ligament

= Posterior Talofibular Ligament

'HMUQW)
ll

*Ligaments that are involved with a first or second degree lateral ankle sprain

86

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