Sports Medicine Research: In the Lab & In the Field: Balancing Chronic Ankle Instability (Sports Med Res)
Wednesday, July 8, 2015

Balancing Chronic Ankle Instability

Effects of 6 Weeks of Balance Training on Chronic Ankle Instability in Athletes: A Randomized Controlled Trial.

Cruz-Diaz D, Lomas-Vega R, Osuna-Perez MC, Contreras FH, and Martinez-Amat A. Int J Sports Med. 2015; E pub ahead of print. DOI: 10.1055/s-0034-1398645.

Take Home Message: A 6-week lower-extremity training program that incorporates progressive balance exercises is effective in reducing feelings of instability and improving dynamic balance in athletes with chronic ankle instability.

Ankle sprains are very common within the athletic and physically active populations and can lead to chronic issues such as chronic ankle instability (CAI).  CAI results in residual symptoms and “giving way”, which can leave someone susceptible to further injury, decreased quality of life, and potential degenerative joint changes.  Balance training may help mitigate some of these short- and long-term issues.  The authors of this randomized clinical trial investigated whether a 6-week balance training program helped improve feelings of instability, pain, and dynamic balance in athletes with CAI.  One of the main study outcome measures was the Cumberland Ankle Instability Tool (CAIT), which is a self-reported measure of a patient’s perception of ankle instability.  Seventy participants with a history of a unilateral ankle sprain that had residual pain, instability, and a CAIT score less than 27 were randomly assigned and completed a 6-week strength-training workout routine, while the intervention group completed additional balance training (balance group).  The balance exercises consisted of a progression through unstable surfaces (e.g., exercise mat to minitramp to foam roller) while progressing in difficulty (e.g., double leg to single leg to dynamic activities).  Participants were assessed with the CAIT, star excursion balance test, and pain symptoms pre and post program.  Athletes in the balance group improved three times as much as the control group, which just did a strength-training routine, in CAIT and star excursion balance test scores. There were no differences between groups for pain. 

The authors of this study found that balance training can be effective at improving dysfunction, specifically CAIT and balance scores among individuals with CAI. The improved CAIT scores indicate that participants felt more stable after completing the 6-week program.  It would be interesting to continue to follow these patients longer than 6 weeks to see if there were any cumulative effects of the training program that resulted in long-term pain reduction. Furthermore, a longer follow-up would let us know if the balance training reduced the number of episodes of “giving way” and the number of ankle re-injuries.  The authors provide great examples of a balance training progression but unfortunately provided little information about the lower-extremity exercises in the strengthening program.  As clinicians, it is important to incorporate some balance training for patients reporting ankle instability or residual symptoms after a lateral ankle sprain because it can help improve the patient’s balance and perception of their ankle stability. 

Questions for Discussion:  Are there certain balance activities that you typically incorporate into post-ankle sprain rehabilitation?  Are there certain things that you use as “red flags” (e.g., repetitive sprains, chronic pain) that make you choose to intervene for CAI athletes?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:
Cruz-Diaz, D., Lomas-Vega, R., Osuna-Pérez, M., Contreras, F., & Martínez-Amat, A. (2015). Effects of 6 Weeks of Balance Training on Chronic Ankle Instability in Athletes: A Randomized Controlled Trial International Journal of Sports Medicine DOI: 10.1055/s-0034-1398645

7 comments:

Christina Hollis said...

Balance exercises are key to restoring full functional ability after an ankle sprain. Often times there are only 2-3 balance exercises when there could be more because they are not extremely fatiguing and may help to restore central nervous system function. It is important to continue with balance exercises even after the athlete has return to play in order to have more beneficial long term outcomes. Repetitive ankle sprains and constant external stabilization(bracing or taping) is a red flag for chronic ankle instability which could necessitate further intervention and treatment.

Nicole Cattano said...

Thank you Christina for your comment! I agree that balance is key. Have you ever considered doing balance activities AFTER the athlete has fatigued? Ankle sprains tend to happen towards the end of practice/game, and I sometimes find that this is much more challenging for the athlete to do in a rehabilitation program.

Although I am not sure that I would allow athletes with lax ankles to not have external bracing, regardless of function/balance. How do you decide when they no longer need external stabilization?

Stephan Bodkin said...

I agree with Christina on the point made about continuing the balance and proprioception rehabilitation even after the patient has returned to activity. Especially in the CAI population, where the deficits addressed during a rehabilitation phase do not carry over to functional activity.

On the point about external bracing, I agree with Nichole, where I do not think I would return a lax athlete back to participation without external bracing. Muscle activation patterns in CAI patients have shown to be more comparable to a healthy population when the CAI patients are taped/braced. I think this is an important factor to address when returning these CAI patients back to participation.

Interesting article!!

Ryan Eddy said...

I love the idea of a balance component after fatiguing exercise. I think that adds a dimension to rehab that challenges the athlete as well as allows them to see where they are in comparison to their functional sport. If they could witness how good or bad their balance is after being fatigued, they might understand how they will react better when they are returning to sport.

Matt Kneece said...

Great article and ideas, everyone. In my experience, it may never be appropriate for an individual with CAI to engage in their esired level of activity without external bracing and this is absolutely acceptable. However, it is crucial that continuously progressive and challenging rehabiliation exercises persist throughout return to play. I love the idea of performing exercises with a component of fatigue. The danger of this is that it inherits a higher risk of re-injury during these exercises. It is crucial that the most imporant thing during this protocol is perfect form and activation patterns. If the individual can only perform 1 perfect repition, then that is all you do. The hope is you can progress to doing more and more after fatigue and maintain perfect form, which should decrease the risk of injury late in competition.

Nicole Cattano said...

Great comments everyone! I am in agreement that post fatigue balancing activities could be beneficial, but I think it is really important to proceed with caution as Matt as indicated regarding reinjury.

Personally I still externally stabilize my CAI patients, which seems similar to what others have done.

That is a good question for this discussion though...how many continue with external stabilization and who progresses athletes to no stabilization? And how do you decide this clinically?

Chris Donner said...

Balance training is one of the most useful interventions with ankle sprains. If an athlete cannot balance on one foot, then how could they be expected to balance when they are running? Many clinicians limit their use of proprioception and focus more on strengthening. While strengthening is important, I would argue that propriocention is more important, because it is more dynamic and can help the athlete stabilize their ankle better.

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