# Early osteopathic treatment delivered to patients with an acute lateral ankle sprain improves recovery: an investigative study

Claire Bournon, Dominique Prin-Conti, Jimmy Douay, Pierre-Alexandre Montfajon, Lukshe Kanagaratnam, Stéphane Gennai

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## To cite this version:

Claire Bournon, Dominique Prin-Conti, Jimmy Douay, Pierre-Alexandre Montfajon, Lukshe Kanagaratnam, et al.. Early osteopathic treatment delivered to patients with an acute lateral ankle sprain improves recovery: an investigative study. Journal of Osteopathic Medicine, 2026, 10.1515/jom-2025-0096. hal-05481166

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Claire Bournon, DO, Dominique Prin-Conti, DO, PhD, Jimmy Douay, MD, Pierre-Alexandre Montfajon, DO, Lukshe Kanagaratnam, MD, PhD and Stéphane Gennai*, MD, PhD

# Early osteopathic treatment delivered to patients with an acute lateral ankle sprain improves recovery: an investigative study

https://doi.org/10.1515/jom-2025-0096

Received May 15, 2025; accepted November 19, 2025;

published online January 22, 2026

## Abstract

**Context:** Acute lateral ankle sprain (ALAS) is responsible for short-term disability, increased risk for future acute ankle sprain, and chronic ankle instability. Several studies highlighted that manipulative therapy may reduce pain and increase the range of motion (ROM) of the injured ankle, but not all of them targeted acute injuries. Some studies focused their interest on a specific manipulative technique or utilized either physiotherapy or chiropractic techniques.

**Objectives:** The objectives of this study were to evaluate the effectiveness of osteopathic care in ALAS, to assess pain, edema, and functional stability of the injured ankle, and to assess and comparing mobility between the injured and noninjured ankle.

**Methods:** We conducted an interventional randomized controlled trial (RCT) in the emergency department (ED) of a French University Hospital. Fifty patients were enrolled in this study. They had to be ≥18 years old, consulting in the ED for a single ALAS (<72 h) stage 1 or 2, and must have had preliminary consultation with an emergency physician. Patients with an ALAS stage 3 or fractured, or with history of homolateral ankle surgery, were excluded. Patients were randomized either in the medical treatment (MT) group or in the medical and osteopathic treatment (MOT) group and had a 3-week follow-up. In the MOT group, the intervention

consisted of a single osteopathic treatment (manual intervention) at Day 0, depending on the tissue affected and on the intensity of the tissular tension found, and individualized advice provided at Days 0, 7, and 21. Comparisons between groups were investigated utilizing the chi-square or Fisher's exact test, or Student's t-test or Mann Whitney U-test, as appropriate.

**Results:** Forty-five patients completed the study. The patients' median age was 29.5 years old (23–40 years). At Day 21, 95.7 % of patients in the MOT group had equivalent capacity of unloaded dorsal flexion between the injured and non-injured ankle, vs. 50.0 % of patients in the MT group (p=0.0005). Between Day 0 and Day 21, the pain with the injured ankle loaded and unloaded decreased more significantly in the MOT group (p=0.001 and p=0.0007, respectively), while the loaded and unloaded dorsal flexion, and the unloaded plantar flexion, increased (p=0.003, p<0.0001 and p=0.02, respectively). Between Day 0 and Day 0 post-osteopathic treatment, all judgment criteria showed improvement in the MOT group. At Day 7, all the functional stability tests were performed better by patients in the MOT group.

**Conclusions:** Early osteopathic treatment associated with usual MT, delivered to patients with an ALAS, may improve mobility and functional stability, and may reduce pain and edema, in the 3 weeks postintervention. These promising findings require confirmation in a larger controlled trial.

**Keywords:** lateral ankle sprain; osteopathic treatment; randomized controlled trial

Acute ankle sprain (AAS) is characterized by the stretching or tearing of the ankle ligaments. It is one of the most common musculoskeletal injuries [1]. Even if it often occurs during the practice of nearly all sports, half of patients consulting in the emergency department (ED) for AAS do not report a sport activity when the injury occurred [2]. Approximately three-quarters of all AASs are lateral [3]. AAS is responsible for short-term disability, increased risk for future AAS, and chronic

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<footnote>*Corresponding author: Stéphane Gennai, MD, PhD, Université de Reims Champagne-Ardenne, CHU Reims, Reims, France, E-mail: sgennai@chu-reims.fr</footnote>

<footnote>Claire Bournon, DO, Dominique Prin-Conti, DO, PhD and Pierre-Alexandre Montfajon, DO, Institut Supérieur d'Ostéopathie de Paris (ISOP), Lognes, France</footnote>

<footnote>Jimmy Douay, MD, Université de Reims Champagne-Ardenne, CHU Reims, Reims, France</footnote>

<footnote>Lukshe Kanagaratnam, MD, PhD, Université de Reims Champagne-Ardenne, VieFra, CHU Reims, Unité d'aide Méthodologique, Reims, France</footnote>
ankle instability for up to 70 % of patients [4]. Therefore, there
is interest in exploring ways to better treat AAS for improving
patients' musculoskeletal health and reducing the burden of
this injury and its associated complications.

In usual practice, initial medical management of an AAS combines a clinical examination with the search for Ottawa criteria that may indicate an X-ray, and the treatment consists of applying the acronym RICE (Rest, Ice, Compression, Elevation) as well as painkillers, nonsteroidal anti-inflammatory drugs (NSAIDs), a functional support such as an ankle brace, and physiotherapy sessions [5]. However, there is no evidence that RICE alone, cryotherapy or compression alone, has any positive influence on pain, edema, or patient recovery after an acute lateral ankle sprain (ALAS) [5]. Also, although NSAIDs may be efficient in reducing pain and edema, they may suppress or delay the natural healing process [5]. On the other hand, the use of functional support and physiotherapy may improve patients' recovery [5].

Several studies highlighted that manipulative therapy performed in patients with an ankle sprain may reduce pain and increase the range of motion (ROM) of the injured ankle [6, 7]. However, not all of them targeted acute injuries. Some focused their interest on a specific manipulative technique (e, manipulation of a particular joint) or utilized either physiotherapy or chiropractic techniques.

In recent years, osteopathic recognition has taken a
huge step forward, and there is growing evidence that an
osteopathic approach reduces medical care costs and im-
proves outcomes and patient satisfaction [8]. The guideline
for osteopathic treatment is the holistic approach of the
patient (e, for ALAS: postural rebalancing, body stress
redistribution, harmonization of musculoskeletal tensions),
utilizing a range of techniques (muscular, articular, neuro-
logical, cranial, myofascial, visceral), to restore both mobility
and function, in one consultation.

To date, there is very little data about osteopathic care in AAS. One study indicates that an osteopathic treatment may reduce pain and edema and improve the ROM in AAS but lacks details in terms of the type of sprain or joint movement measurements [9], and there is no study evaluating the interest of osteopathic care precisely in ALAS. To this end, in our ED, we implemented free osteopathic consultations offered to patients with an ALAS, and we evaluated the effectiveness of osteopathic care in conjunction with the usual medical treatment (MT), in improving patients' recovery.

Methods

We conducted an interventional monocentric randomized
controlled trial (RCT) in the ED (50,000 visits per year) of the

Reims University Hospital (2,300 beds) from November 28,
2021, to March 3, 2022. The study was previously recorded on
ClinicalTrials.gov under the number NCT04999254.

Ethics

The study was approved by the Ethics Committee South-
Mediterranean II on November 5, 2021 (assigned number:
2021-A02056-35/SI:21.02054.000026). A written informed
consent was obtained, and an information letter was pro-
vided for each patient willing to participate. No funding
supported this study.

Sampling determination

In the absence of data in the literature, and based on our
inclusion capabilities, we planned to include 50 patients: 25
in the MT group and 25 in the medical and osteopathic
treatment (MOT) group.

Eligibility criteria

Included

Patients accepted to participate were ≥18 years old, consul-
ting in the ED for a single ALAS (<72 h) stage 1 or 2, and with
edema and/or hematoma but no fever. They must have had
preliminary consultation with an emergency physician,
understand French, and be affiliated to social security.

Not included

Patients were not included if they had an ALAS stage 3 or
fractured, a history of homolateral ankle surgery, active
neoplasia, or altered mental status, were under alcoholic or
drug use, were deprived of liberty, or presented with oste-
opathic care contraindications.

Randomization

Patients were randomly assigned in a 1:1 ratio to receive MT or MOT. Randomization was performed in blocks of varying size, determined by a computer sequence.

Investigation plan

At Day 0 (ED visit), each eligible patient willing to participate
was randomized in either the MT group or the MOT group,
utilizing the online software CleanWeb™. In either group, an allopathic treatment was implemented, and a first osteopathic evaluation was conducted. Allopathic treatment was not standardized, as it was left to the emergency physician discretion. The osteopathic evaluation consisted of the following assessments and measurements over a 20-min period:

(1) Pain assessment with the injured ankle loaded: patient asked to stand, to face a wall, and to squat – unloaded – and patient asked to lie with a 30-degree knee flexion and a cushion under the knee, utilizing a 10-point linear visual analogue scale (VAS).

(2) Peri-malleolar measurement of the injured ankle (in cm) reflecting the edema, utilizing a measuring tape.

(3) Mobility assessment of the injured and noninjured ankle, measuring the loaded and unloaded dorsal flexion, and the unloaded plantar flexion (in degree), utilizing a goniometer positioned on the outer malleoli, and conducting a squat test; the patient was asked to squat and to try to touch their heels with their buttocks, testing positive when buttocks touch heels.

(4) Functional stability assessment of the injured ankle: patient asked to stand on tiptoe, to hop on one foot to another alternatively, to hop on the ipsilateral foot, to trot, to jump on two feet and then to jump on the ipsilateral foot, testing positive when gesture executed in harmony, half-positive when gesture executed without harmony, and negative when not executed.

In the MOT group, an osteopathic treatment was conducted at Day 0 over a 40-min period and followed by a Day 0 post-osteopathic-treatment (POT) evaluation (same assessments and measurements as before osteopathic treatment).

At Day 7 (±3) and Day 21 (±3), systematic follow-up queries were asked about some potential adverse events, and new osteopathic evaluations were conducted in both groups. The day before each osteopathic evaluation, a reminder was sent on patients' phones.

## Intervention

The intervention consisted of a single osteopathic treatment (manual intervention) at Day 0, following global and specific tests, and correcting restricted anatomical areas. The choice of treatment depended on the tissue affected and on the intensity of the tissular tension found. Individualized advice was also provided to patients in the MOT group at Day 0, Day 7, and Day 21. Applying ice or doing some quick daily physical exercises may have been suggested. The intervention and the evaluations occurred in a dedicated consultation room in

the ED and were carried out by a single practitioner, an osteopath having followed a 5-year complete course at the "Institut Supérieur d'Ostéopathie de Paris."

## Osteopathic treatment

Osteopathic treatment was based on the holistic approach of the patient, adapted to their specific restrictions, not only related to the actual AAS but also to previous physical or emotional trauma. In the case of an ALAS, the principal areas of identified restrictions include the pelvis (mostly the posterior mobility) [10], the dorso-lumbar region (mostly T12, L1, and L3 joints), the craniofacial area (temporo-mandibular joint) [11], and the foot. Once the postural structure is restored and balanced, specific work is carried out at the ankle, including precise manipulations of the slope and the lower tibiofibular joint. The most employed techniques were myofascial, muscular, and/or structural. A more comprehensive description of the decision-making process and the most applied osteopathic techniques is available as Supplementary Material.

## Data collection

Characteristics of the patients were collected at Day 0 and included: age, body mass index (BMI), sex, relevant medical history and ongoing treatments, sport level (amateur if ≤1 sports activity per week, regular practice if ≥2 sports activities per week, top athlete if professional athlete), education level, and information about a possible previous osteopathic consultation in the year before the ED visit. Characteristics of ALAS were also collected at Day 0 and included: context, laterality, symptoms, and information about a potential previous ankle sprain. Data from the assessments and measurements at each osteopathic evaluation, and potential adverse events, were also collected.

## Judgment criteria

The primary judgment criteria was to obtain an equivalent capacity of unloaded dorsal flexion between the injured and noninjured ankles at Day 21, with a difference in amplitude of ≤5°.

The secondary judgment criteria were the pain assessment with the injured ankle loaded and unloaded, the peri-malleolar perimeter (reflecting edema), the loaded and unloaded dorsal flexion, the unloaded plantar flexion, and results from the squat test and the functional stability test at
<figure><img src="image_6.png" /><figcaption>**Figure 1:** Flow chart.</figcaption></figure>

Day 0, Day 0 POT (functional stability tests excluded), Day 7, and Day 21.

To measure the perimalleolar perimeter, the ankle was placed in a 90-degree dorsal flexion without rotation. The tape was simply placed on the skin, without pulling or being loose. Anatomical landmarks of the ribbon were: a) mid-distance between the lateral malleolus and the tendon of the anterior tibial muscle; b) distal position of the navicular tuber; c) passage in the plantar, lateral edge just behind the base of the 5th metatarsal; d) cross on the tendon of the anterior tibial muscle, then under the internal malleolus; and e) cross with the Achilles tendon, then return to the lateral malleolus until the point of departure.

## Potential side effects related to the osteopathic treatment

Weakness, headache, joint pain, aches, and digestive disorders are potential side effects rarely encountered POT. They may persist up to 3 days and are considered normal, because they participate in the osteopathic concept of the body's self-regulation process.

## Statistics

Quantitative variables were presented as mean and standard deviation or median and interquartile range according to the distribution of the variable, and qualitative variables

as number and percentage. Comparisons between groups were investigated utilizing the chi square or Fisher's exact test, or the Student's *t*-test or Mann Whitney U-test, as appropriate. Comparison between D0 and D0 POT was performed with the Wilcoxon or paired Student's *t*-test, as appropriate. Cohen's *d* and its 95 % confidence interval (95 % CI) were calculated for quantitative variables, while odds ratios (ORs) with 95 % CI were calculated for qualitative variables. A p value of 0.05 was considered statistically significant. All analyses were performed utilizing SAS, version 9.4 (SAS Institute, Inc., Cary, NC, USA).

## Results

### Population

Fifty patients were included, randomized either in the MT or the MOT group (25 patients per group). In the end, 45 patients (90 %) completed the study (Figure 1).

### Characteristics of patients and acute lateral ankle sprains

The patients' median age was 29.5 years old (23-40 years), and their BMI was 25.1 kg/m<sup>2</sup> (21.7-27.9 kg/m<sup>2</sup>) (Table 1). Most patients had an amateur sport level and a high education level.
<table><caption>**Table 1:** Characteristics of patients and acute lateral ankle sprains (ALASs).</caption><thead><tr><th></th><th>MT group</th><th>MOT group</th><th>p-Value</th></tr></thead><tbody><tr><td colspan="4"><strong>Characteristics of patients</strong></td></tr><tr><td>Age, years<sup>a</sup></td><td>33</td><td>[28–40]</td><td>[23–36]</td><td>0.06</td></tr><tr><td>Body mass index, kg/m<sup>2a</sup></td><td>25.5</td><td>[23.1–27.9]</td><td>[21.7–27.0]</td><td>0.56</td></tr><tr><td>Sex</td><td></td><td></td><td></td><td>0.78</td></tr><tr><td>Male</td><td>11</td><td>(44 %)</td><td>(48 %)</td><td></td></tr><tr><td>Female</td><td>14</td><td>(56 %)</td><td>(52 %)</td><td></td></tr><tr><td>Medical history</td><td></td><td></td><td></td><td></td></tr><tr><td>Cardiac</td><td>3</td><td>(12 %)</td><td>(12 %)</td><td>1.00</td></tr><tr><td>Pulmonary</td><td>6</td><td>(24 %)</td><td>(16 %)</td><td>0.48</td></tr><tr><td>Traumatism</td><td>12</td><td>(48 %)</td><td>(52 %)</td><td>0.78</td></tr><tr><td>Lower limbs</td><td>20</td><td>(80 %)</td><td>(92 %)</td><td>0.42</td></tr><tr><td>Dental</td><td>22</td><td>(88 %)</td><td>(72 %)</td><td>0.16</td></tr><tr><td>Ongoing treatment</td><td></td><td></td><td></td><td></td></tr><tr><td>None</td><td>21</td><td>(84 %)</td><td>(88 %)</td><td>1.00</td></tr><tr><td>NSAID</td><td>2</td><td>(8 %)</td><td>(8 %)</td><td>1.00</td></tr><tr><td>Cardiologic</td><td>1</td><td>(4 %)</td><td>(0 %)</td><td>1.00</td></tr><tr><td>Sport level</td><td></td><td></td><td></td><td>0.39</td></tr><tr><td>Amateur</td><td>16</td><td>(64 %)</td><td>(60 %)</td><td></td></tr><tr><td>Regular practice</td><td>7</td><td>(28 %)</td><td>(40 %)</td><td></td></tr><tr><td>Top athlete</td><td>2</td><td>(8 %)</td><td>(0 %)</td><td></td></tr><tr><td>Education level</td><td></td><td></td><td></td><td>0.54</td></tr><tr><td>Elementary school</td><td>1</td><td>(4 %)</td><td>(4 %)</td><td></td></tr><tr><td>High school</td><td>9</td><td>(36 %)</td><td>(20 %)</td><td></td></tr><tr><td>Graduate studies</td><td>15</td><td>(60 %)</td><td>(76 %)</td><td></td></tr><tr><td>Osteopathic consultation &lt;1 year</td><td>14</td><td>(56 %)</td><td>(32 %)</td><td>0.09</td></tr><tr><td colspan="4"><strong>Characteristic of acute lateral ankle sprains</strong></td></tr><tr><td>Context</td><td></td><td></td><td></td><td>0.12</td></tr><tr><td>Sport</td><td>7</td><td>(28 %)</td><td>(40 %)</td><td></td></tr><tr><td>Domestic</td><td>15</td><td>(60 %)</td><td>(32 %)</td><td></td></tr><tr><td>Professional</td><td>3</td><td>(12 %)</td><td>(28 %)</td><td></td></tr><tr><td>Laterality right</td><td>17</td><td>(68 %)</td><td>(40 %)</td><td>0.047</td></tr><tr><td>Initial symptoms</td><td></td><td></td><td></td><td></td></tr><tr><td>Crack</td><td>12</td><td>(48 %)</td><td>(32 %)</td><td>0.25</td></tr><tr><td>Pain</td><td>24</td><td>(96 %)</td><td>(96 %)</td><td>1.00</td></tr><tr><td>Oedema</td><td>25</td><td>(100 %)</td><td>(100 %)</td><td>1.00</td></tr><tr><td>Perceived functional impairment</td><td>24</td><td>(96 %)</td><td>(92 %)</td><td>1.00</td></tr><tr><td>Perceived functional instability</td><td>22</td><td>(88 %)</td><td>(92 %)</td><td>1.00</td></tr><tr><td>Initial associated symptoms</td><td></td><td></td><td></td><td></td></tr><tr><td>Neck pain</td><td>6</td><td>(24 %)</td><td>(20 %)</td><td>0.73</td></tr><tr><td>Back pain</td><td>2</td><td>(8 %)</td><td>(20 %)</td><td>0.42</td></tr><tr><td>Low-back pain</td><td>11</td><td>(44 %)</td><td>(48 %)</td><td>0.78</td></tr><tr><td>Pelvic pain</td><td>4</td><td>(16 %)</td><td>(12 %)</td><td>1.00</td></tr><tr><td>Gonalgia (knee pain)</td><td>5</td><td>(20 %)</td><td>(16 %)</td><td>1.00</td></tr><tr><td>Recurrence</td><td>16</td><td>(64 %)</td><td>(88 %)</td><td>0.047</td></tr><tr><td>Ipsilateral recurrence</td><td>12</td><td>(48 %)</td><td>(84 %)</td><td>0.007</td></tr><tr><td>Practitioner consulted</td><td></td><td></td><td></td><td></td></tr><tr><td>General practitioner</td><td>13</td><td>(52 %)</td><td>(72 %)</td><td>0.15</td></tr><tr><td>Physiotherapist</td><td>8</td><td>(32 %)</td><td>(60 %)</td><td>0.047</td></tr><tr><td>Osteopath</td><td>3</td><td>(12 %)</td><td>(8 %)</td><td>1.00</td></tr></tbody></table>

The context of the ALAS was primarily domestic in the MT group and occurred mainly during sport practice in the MOT group. Initial symptoms were nearly always pain, edema, a perceived functional impairment, and instability.

Ipsilateral recurrence of ALAS was more observed in the MOT group. Among patients reporting a previous ALAS, very few consulted an osteopath, and a physiotherapist was more frequently consulted in the MOT group.

<footnote><sup>a</sup>In median [Q1–Q3]. MOT, medical and osteopathic treatment; MT, medical treatment; NSAID, nonsteroidal anti-inflammatory drug.</footnote>
<figure><img src="image_7.png" /><figcaption>**Figure 2:** Mobility assessment of the injured ankle in (A) loaded dorsal flexion, (B) unloaded dorsal flexion, (C) unloaded plantar flexion, and (D) the squat test.</figcaption></figure>

## Primary judgment criteria

At Day 21, 95.7 % of patients in the MOT group had equivalent capacity of unloaded dorsal flexion between the injured and noninjured ankles, vs. 50.0 % of patients in the MT group (OR=22, 95 % CI [2.5–192.9], p=0.0005).

## Secondary judgment criteria

Between Day 0 and Day 21, the loaded and unloaded dorsal flexion, and the unloaded plantar flexion, increased more significantly in the MOT group (Cohen's *d*=1.11, 95 % CI [0.46–1.76], p=0.003; Cohen's *d*=1.96, 95 % CI [1.23–2.70], p<0.0001; and Cohen's *d*=0.77, 95 % CI [0.15–1.40], p=0.02, respectively) (Figure 2); moreover, the pain with the injured ankle loaded and unloaded decreased more significantly in the MOT group (Cohen's *d*=1.16, 95 % CI [0.51–1.81], p=0.001; and Cohen's *d*=1.30, 95 % CI [0.64–1.97], p=0.0007, respectively), whereas no between-group difference was observed for edema (Figure 3).

Between Day 0 and Day 0 POT, all judgment criteria showed improvement in the MOT group: pain with the injured ankle loaded (Cohen's *d*=1.09, 95 % CI [0.69–1.50], p<0.0001) or unloaded (Cohen's *d*=0.96, 95 % CI [0.55–1.36], p=0.0004), edema (Cohen's *d*=0.49, 95 % CI [0.08–0.90], p=0.03), loaded dorsal flexion (Cohen's *d*=1.13, 95 % CI [0.72–1.54], p<0.0001), unloaded dorsal flexion (Cohen's *d*=1.90, 95 % CI [1.50–2.31], p<0.0001), unloaded plantar flexion (Cohen's *d*=0.57, 95 % CI [0.16–0.98], p=0.01), and squat test (OR=27, 95 % CI [1.59–457], p=0.0002).

At Day 7, all of the functional stability tests, eyes opened or closed, were better performed by patients in the MOT group than patients in the MT group, with this difference fading at Day 21 (Table 2).

## Side effects related to the osteopathic treatment

No side effects were reported by patients in the MOT group during the study period.

## Discussion

We conducted a randomized controlled study evaluating the interest of an early osteopathic treatment delivered in the ED to patients with an ALAS, and we found the following main improvements in the MOT group compared to the MT group: (1) at Day 21, almost every patient had equivalent capacity of unloaded dorsal flexion between the injured and noninjured ankle; (2) between Day 0 and Day 21, dorsal and plantar flexion increased more significantly, although pain
<figure><img src="image_8.png" /><figcaption>**Figure 3:** Pain assessment with the injured ankle (A) loaded and (B) unloaded, and (C) edema. VAS, visual analogue scale.</figcaption></figure>

decreased; and (3) all secondary judgment criteria showed improvement at Day 0 POT.

Osteopathic treatment has already been shown to be effective in many other bone and joint diseases, such as the Achilles tendinopathy [12], knee pathologies [13], and temporomandibular disorders [14]. Those studies showed improvements in mobility, muscular performance, and pain. However, one study was a single case report [12], another showed a decrease in pain and an increase in functionality but focused on athletes [13], and one was a meta-analysis pooling eight studies showing improvements in pain and ROM but with large disparities in the number of osteopathic sessions leading to those results [14]. However, Eisenhart et al. [9] showed an immediate improvement in pain and edema, and an improvement in ROM, after a 1-week follow up, yet no difference was found for pain or edema at 1 week, and there was no further follow-up (vs. 3 weeks in our study). One explanation could be that the osteopathic treatment that they provided was focused on the injured ankle, contrasting with our holistic approach. Rather than focusing on just reducing pain and edema in the injured anatomical area, the techniques of osteopathy provided in our study achieved a balance of the neuromusculoskeletal system that actually improved the ROM of the injured ankle. In addition, we focused on ALAS stage 1 or 2, we utilized precise criteria (ROM of the injured ankle loaded and unloaded, plantar flexion, functional stability tests, systematic comparison

to the contralateral ankle), and we carried out multidimensional and close-up assessments.

Compared to physiotherapy or chiropractic therapy, osteopathy has its own approach as a manipulative treatment. Whereas physiotherapy focuses on re-education and rehabilitation, providing treatment protocols in a local muscular approach, and where chiropractic techniques focuses on the neuromusculoskeletal and nervous systems, providing an individual treatment in a global approach focused on joints, osteopathy considers the whole body divided into functional units. Osteopathy provides an individual treatment in a global approach not only focused on muscles or joints, but also focused on neurological, cranial, myofascial, and visceral aspects. In addition, osteopathy-like chiropractic takes place in one consultation, whereas physiotherapy requires several.

To be more specific, the systemic osteopathy manipulations contributed to local ankle recovery by working on:

(1) Postural regulation, working on the biomechanical and myofascial chains, pelvis and lumbar spine (L3, T12-L1) being identified as major centers of transmission of forces. Restrictions in the pelvis, sacroiliac joints, or symphysis pubis modify the ground support and generate compensations, limiting the ankle rehabilitation.

(2) Neuromuscular regulation, working on spinal manipulations influencing segmental and supra-segmental reflexive pathways, inducing reduction of protective contractions around the ankle, and facilitating amplitude of movements.
<table><caption>**Table 2:** Functional stability tests.</caption><thead><tr><th rowspan="2"></th><th rowspan="2"></th><th colspan="2">MT group</th><th colspan="2">MOT group</th><th rowspan="2">p-Value</th></tr><tr><th>0.5<sup>a</sup><br>%</th><th>1<sup>a</sup><br>%</th><th>0.5<sup>a</sup><br>%</th><th>1<sup>a</sup><br>%</th></tr></thead><tbody><tr><td rowspan="3">Stand on tiptoe<br>EO</td><td>Day 0</td><td>27.3</td><td>68.2</td><td>8.7</td><td>43.5</td><td>0.003</td></tr><tr><td>Day 7</td><td>31.8</td><td>63.6</td><td>0</td><td>100</td><td>0.002</td></tr><tr><td>Day 21</td><td>4.6</td><td>81.8</td><td>0</td><td>100</td><td>0.049</td></tr><tr><td rowspan="3">EC</td><td>Day 0</td><td>40.9</td><td>27.3</td><td>26.1</td><td>4.4</td><td>0.03</td></tr><tr><td>Day 7</td><td>59.1</td><td>18.2</td><td>21.7</td><td>73.9</td><td>0.0005</td></tr><tr><td>Day 21</td><td>22.7</td><td>40.9</td><td>4.4</td><td>95.6</td><td>&lt;0.0001</td></tr><tr><td rowspan="3">Hop on one foot to another<br>EO</td><td>Day 0</td><td>9.1</td><td>45.5</td><td>0</td><td>13.1</td><td>0.009</td></tr><tr><td>Day 7</td><td>13.6</td><td>77.3</td><td>0</td><td>100</td><td>0.02</td></tr><tr><td>Day 21</td><td>0</td><td>100</td><td>0</td><td>100</td><td>1</td></tr><tr><td rowspan="3">EC</td><td>Day 0</td><td>4.6</td><td>40.9</td><td>0</td><td>13.0</td><td>0.03</td></tr><tr><td>Day 7</td><td>13.6</td><td>77.3</td><td>0</td><td>100</td><td>0.02</td></tr><tr><td>Day 21</td><td>4.6</td><td>95.4</td><td>0</td><td>100</td><td>1</td></tr><tr><td rowspan="3">Hop on the ipsilateral foot<br>EO</td><td>Day 0</td><td>9.1</td><td>31.8</td><td>8.7</td><td>8.7</td><td>0.2</td></tr><tr><td>Day 7</td><td>27.3</td><td>63.6</td><td>0</td><td>100</td><td>0.002</td></tr><tr><td>Day 21</td><td>0</td><td>100</td><td>0</td><td>100</td><td>1</td></tr><tr><td rowspan="3">EC</td><td>Day 0</td><td>9.1</td><td>31.8</td><td>17.4</td><td>0</td><td>0.01</td></tr><tr><td>Day 7</td><td>18.2</td><td>63.6</td><td>0</td><td>100</td><td>0.002</td></tr><tr><td>Day 21</td><td>9.1</td><td>90.9</td><td>0</td><td>100</td><td>0.2</td></tr><tr><td rowspan="3">Trot<br>EO</td><td>Day 0</td><td>4.6</td><td>45.4</td><td>4.4</td><td>13.0</td><td>0.03</td></tr><tr><td>Day 7</td><td>18.2</td><td>77.3</td><td>0</td><td>100</td><td>0.02</td></tr><tr><td>Day 21</td><td>0</td><td>100</td><td>0</td><td>100</td><td>1</td></tr><tr><td rowspan="3">EC</td><td>Day 0</td><td>9.1</td><td>36.3</td><td>4.4</td><td>13.0</td><td>0.1</td></tr><tr><td>Day 7</td><td>18.2</td><td>77.3</td><td>0</td><td>100</td><td>0.02</td></tr><tr><td>Day 21</td><td>4.6</td><td>95.4</td><td>0</td><td>100</td><td>0.5</td></tr><tr><td rowspan="3">Jump on two feet<br>EO</td><td>Day 0</td><td>9.1</td><td>22.8</td><td>4.4</td><td>8.7</td><td>0.4</td></tr><tr><td>Day 7</td><td>36.4</td><td>45.5</td><td>13.0</td><td>87.0</td><td>0.006</td></tr><tr><td>Day 21</td><td>9.1</td><td>86.4</td><td>0</td><td>100</td><td>0.1</td></tr><tr><td rowspan="3">EC</td><td>Day 0</td><td>9.1</td><td>22.7</td><td>0</td><td>8.7</td><td>0.1</td></tr><tr><td>Day 7</td><td>40.9</td><td>40.9</td><td>13.0</td><td>82.6</td><td>0.01</td></tr><tr><td>Day 21</td><td>13.6</td><td>77.3</td><td>0</td><td>100</td><td>0.02</td></tr><tr><td rowspan="3">Jump on the ipsilateral foot<br>EO</td><td>Day 0</td><td>27.3</td><td>0</td><td>4.4</td><td>0</td><td>0.047</td></tr><tr><td>Day 7</td><td>50.0</td><td>13.7</td><td>26.1</td><td>73.9</td><td>&lt;0.0001</td></tr><tr><td>Day 21</td><td>31.8</td><td>45.5</td><td>4.4</td><td>95.6</td><td>0.0003</td></tr><tr><td rowspan="3">EC</td><td>Day 0</td><td>22.7</td><td>0</td><td>4.4</td><td>0</td><td>0.1</td></tr><tr><td>Day 7</td><td>45.5</td><td>9.1</td><td>30.4</td><td>52.2</td><td>0.007</td></tr><tr><td>Day 21</td><td>22.7</td><td>40.9</td><td>4.4</td><td>95.6</td><td>&lt;0.0001</td></tr></tbody></table>

(3) Circulation and drainage, the pelvis and spine promoting venous and lymphatic return. Release of diaphragmatic, lumbar, and pelvic tensions improves drainage of the lower extremity and reduces edema.

(4) Craniofacial and sensorimotor integration, working on the autonomic nervous system and the proprioception,

and helping in pain reduction, coordination improvement, and functional rehabilitation optimization.

Furthermore, the edema reduction within the osteopathy group between D0 and D0-POT was not sustained over time, whereas the pain and function outcomes improved. This

<footnote><sup>a</sup>Test half-positive (0.5) when gesture executed without harmony, and test positive (1) when gesture executed in harmony. EC, eyes closed; EO, eyes opened; MOT, medical and osteopathic treatment; MT, medical treatment.</footnote>
phenomenon may be explained by the immediate effect of osteopathic manipulations on venous and lymphatic return, with a transient redistribution of fluids. However, post-traumatic inflammation, immobilization, gravity, and mechanical overload were persistent factors of edema. It questions the clinical significance of edema reduction and highlights the difference between an immediate fluid-shift effect (likely from OMT) and the true resolution of inflammation. On the other hand, sustainability of pain and function outcomes may be due to neuromuscular and proprioceptive mechanisms.

Finally, even if we found statistical significance for several outcomes, the minimal clinically important difference may not have been sufficient to be perceived by some patients (eg, in loaded dorsal flexion measurements or pain evaluations), with some between-group differences being very minimal.

The main strength of this study is the complete assessment implemented to provide an overview of all of the possible impacts of the osteopathic treatment on the injured ankle, and the low rate of patients lost at Day 21. However, some limitations must be recognized.

## Limitations

The two major limitations of this study are: (1) the disparity in MT that may have occurred and have not been traced, such as potential pain killers given by the nurses at the ED entrance, or the potential NSAIDs and physiotherapy sessions, and the type of functional support prescribed by emergency physicians, this unmeasured variability in standard care having probably affected the interpretation of the results; and (2) the lack of blinding (the osteopath carrying on the osteopathic evaluations was not blinded to the intervention, even if she was strictly consistent and accurate in all of the assessments). Also, the effects of the osteopathic treatment may have been limited by the functional support prescribed, although improvements were made regardless. And finally, we did not follow up regarding whether patients consulted another practitioner during the study period, which may have influenced the outcomes. These limitations must lead to cautious interpretation of the study findings.

## Conclusions

In this preliminary RCT, early osteopathic treatment, in addition to the usual MT for patients with an ALAS, may improve mobility and functional stability, and may reduce

pain and edema. These positive effects seem to start just after the osteopathic treatment and remain up until Day 21 for mobility and pain. However, benefits beyond 3 weeks remain uncertain. These promising but preliminary findings require confirmation in a large, more rigorously controlled trial.

**Acknowledgement:** The authors would like to thank Miss Jenny Pirot for help editing the manuscript.

**Research ethics:** The study was approved by the Ethics Committee South-Mediterranean II (#2021-A02056-35/SI:21.02054.000026). The study was registered on ClinicalTrials.gov (#NCT04999254).

**Informed consent:** Written informed consent was obtained from each patient prior to participation.

**Author contributions:** The authors have accepted responsibility for the entire content of this manuscript and approved its submission.

**Use of Large Language Models, AI and Machine Learning**

**Tools:** None declared.

**Conflict of interest:** None declared.

**Research funding:** None declared.

**Data availability:** Raw data may be obtained on request from the corresponding author.

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**Supplementary Material:** This article contains supplementary material (https://doi.org/10.1515/jom-2025-0096).