Manipulation is a generally accepted, well-established and widely used therapeutic intervention for lower extremity injuries. Manipulative treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury.

Osteopathic manipulation, such as high velocity, low amplitude (HVLA) technique, muscle energy techniques, counter strain, myofascial release, and non-force techniques are all types of manipulative treatment.

Different types of manipulation exist:

  • Direct techniques – a forceful engagement of a restrictive/pathologic barrier;

  • Indirect techniques– a gentle/non-forceful disengagement of a restrictive/pathologic barrier;

  • The patient actively assists in the treatment;

  • The patient relaxing, in allowing the practitioner to move the body tissues.

When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed.

There is some evidence that, in patients with plantar fasciitis, six sessions of individually tailored manual therapy with exercise is more effective in improving foot function six months later than six sessions of a standardized program of exercise with ultrasound, dexamethasone iontophoresis, and ice.

There is some evidence that, for ankle sprains, a four week program of twice weekly manual physical therapy, plus home exercise, provides benefits in addition to home exercise alone at the end of treatment.


Time to Produce Effect (for all types of manipulative treatment): 1 to 6 treatments.

Frequency: Up to 3 times per week for the first 3 weeks as indicated by the severity of involvement and the desired effect.

Optimum Duration: 10 treatments.

Maximum Duration: 12 treatments. Additional visits may be necessary, in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and co-morbidities. Functional gains, such as decreased pain and increased ROM, demonstrate response to treatment.

Eric Vanzura