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Lateral Ankle Sprain and Chronic Ankle Instability: A Critical Review

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Ankle Specialist

Lateral Ankle Sprain and Chronic Ankle Instability: A Critical Review

Takumi Kobayashi and Kazuyoshi Gamada
Foot Ankle Spec 2014 7: 298 originally published online 24 June 2014
DOI: 10.1177/1938640014539813

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539813
research-article2014
FASXXX10.1177/1938640014539813Foot & Ankle SpecialistFoot & Ankle Specialist

298 Foot & Ankle Specialist August 2014

〈 Review
〉
Lateral Ankle Sprain and
Chronic Ankle Instability Takumi Kobayashi, PhD, PT, and Kazuyoshi
Gamada, PhD, PT

A Critical Review
Abstract: Many studies investigated
the contributing factors of chronic
ankle instability, but a consensus
has not yet been obtained. The
objective of this critical review is to
provide recent scientific evidence on
chronic ankle instability, including
the epidemiology and pathology of
lateral ankle sprain as well as the
causative factors of chronic ankle
instability. We searched MEDLINE
Levels of Evidence: Therapeutic
Level IV: Review of Level IV studies
Keywords: lateral ankle sprain;
chronic ankle instability; functional
ankle instability; mechanical ankle
instability
Epidemiology
Lateral ankle sprain (LAS) is one of the
the incidence of LAS between males and
females.4-9 A previous report
summarizing 16 years of National
Collegiate Athletic Association injury
surveillance data for 15 sports indicated
that basketball, soccer, volleyball, and
gymnastics had high injury rates
(1.01-1.30/1000 athlete-exposure),
whereas baseball, softball, and ice
hockey had low injury rates (0.23-
0.32/1000 athlete-exposure).10 Many LAS

from 1964 to December 2013 using the
terms ankle, sprain, ligament, injury,
chronic, functional, mechanical,
and instability. Lateral ankle sprain
shows a very high recurrence rate
and causes considerable economic
loss due to medical care, prevention,
and secondary disability. During
the acute phase, patients with ankle
sprain demonstrate symptoms such as
pain, range of motion deficit, postural
control deficit, and muscle weakness,
and these symptoms may persist,
leading to chronic ankle instability.
Although some agreement regarding
the effects of chronic ankle instability
with deficits in postural control and/
or concentric eversion strength exists,
the cause of chronic ankle instability
remains controversial.
“
most common injuries in
competitive sports and
recreational activities. LAS often occurs in persons less than
Ankle injuries account
for 10% to 30% of all 50 years old because it is frequently
athletic injuries and 40%
to 56% of injuries in sustained during sports activity, but
certain sports.1 Ankle
sprains comprise 70% or quite a few LAS are reported in the
more of ankle injuries in
many sports,1 and LAS elderly as well.”
accounts for about 80%
of ankle sprains.2,3 One ankle sprain occur on landing or turning during
occurs per 10 000 person-days, and an sports activity with or without contact.3
estimated 2 million acute ankle sprains LAS often occurs in persons less than 50
occur each year in the United States (an years old because it is frequently
incidence of 2.15 per 1000 person-years).4 sustained during sports activity, but quite
The peak incidence of ankle sprain a few LAS are reported in the elderly as
occurs between 15 and 19 years of age,4 well.11 LAS is often caused by relatively
but there is no significant difference in minor events such as “falls,” “slipping,”

DOI: 10.1177/1938640014539813. From the Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Hokkaido, Japan (TK); Department
of Rehabilitation, Hiroshima International University, Hiroshima, Japan (KG). Address correspondence to: Kazuyoshi Gamada, PhD, PT, Hiroshima International University,
555-36 Kurose Gakuendai, Bldg 1, Rm 705, Higashi Hiroshima, Hiroshima 739-2695, Japan; e-mail: kazgamada@ortho-pt.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2014 The Author(s)

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vol. 7 / no. 4
“tripping,”11 and there are many hidden
risks of LAS in the routine activities of
daily life.
The economic cost of treating and
preventing LAS is large because the
incidence of LAS is quite high.12-14 The
indirect annual medical cost of treating
LAS was $1.1 billion in United States
high school soccer and basketball
players.13 Furthermore, the annual cost in
the Netherlands was estimated as €84
240 000,12 and Verhagen et al14 calculated
that the cost of preventing one ankle
sprain was approximately €444.03.
Because the LAS recurrence rate is very
high, symptoms often persist. After 6.5
years of follow-up among athletes with
ankle sprain, 5% had to change and 4%
had to stop their sport activities due to
residual symptoms.15 Similarly, among
nonathletes with ankle sprain, 6% were
not able to continue their previous
occupation and 15% required external
support to continue their original
occupation.15
Injury Mechanism
LAS commonly occurs during plantar
flexion and inversion with excessive
ankle supination because the ankle joint
is more unstable in plantar flexion when
ankle inversion and internal rotation are
thought to occur.16-18 Wright et al19
indicated that increased ankle inversion
during foot contact might promote LAS
based on a mathematical model.
Konradsen and Voigt20 also showed that
ankle inversion before foot contact in
unstable ankles.
However, recent case reports using a
3-dimensional motion analysis technique
suggested that LAS occurs even during
excessive ankle internal rotation with
slight dorsiflexion.21-24 Fong et al21
indicated that LAS occurred during large
ankle internal rotation with slight inversion
on analysis of foot position at injury in
tennis players. They considered that ankle
internal rotation rather than ankle plantar
flexion could also be one of the factors
promoting LAS, especially when the foot is
planted on the sports ground, preventing
further plantar flexion into the ground
during horizontal sideward movement as
in tennis. A similar finding was obtained
from 3-dimensional motion analysis during
the sidestep cutting.22,23 Based on these
studies, excessive ankle inversion or
internal rotation occurs in the noncontact
LAS development, whereas the role of
excessive plantar flexion remains
uncertain.
Pathology and Prognosis
Various tissues are damaged by LAS.25
The anterior talofibular ligament (ATFL)
sustains the most damage, and to merge
the calcaneofibular ligament (CFL)
damage.26,27 In patients with LAS, the
ATFL and CFL were injured in 73% to
96% and 80%, respectively.3,28,29 The
diagnosis of LAS is primarily based on
physical findings such as tenderness,
hematoma, and anterior drawer test
(ADT), but ATFL damage was confirmed
by arthrogram in 52% of patients
demonstrating tenderness of the ATFL,
and CFL damage was confirmed in 72%
of patients demonstrating tenderness in
CFL.28,30 Although tenderness may have
low specificity, van Dijk et al31 showed
that a combination of tenderness,
hematoma discoloration, and ADT in the
subacute phase (5 days after injury)
demonstrated a sensitivity of 96% and a
specificity of 84% in 160 LAS patients.
Although high intertester reliability was
shown on stress X-rays,32 this
examination often exacerbates pain in
the acute phase. In addition, none of the
reports indicated a high sensitivity or
specificity of this examination. On
magnetic resonance imaging after LAS, a
high percentage of patients demonstrated
injury to the posterior tibialis tendon,
peroneus brevis, or peroneus longus in
addition to ATFL and CFL damage.28
Thus, various combinations of these
injuries may be the cause of symptoms,
but identifying the damaged tissue in
individual patients is difficult.
On in vitro studies, the maximal load on
ATFL and CFL was considered to be 231
to 297 N and 307 to 598 N,
respectively.33,34 Using a simulation model,
Leardini et al35 assumed that the ATFL
extended in plantar flexion, whereas the
CFL length showed little change during
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Foot & Ankle Specialist 299
dorsiflexion-plantar flexion. However, it is
impossible to speculate on the load and
direction of damage to each ligament,
because varying degrees of excessive
3-dimensional load are added to each
ligament during LAS occurrence. ATFL
excision increased talar anterior
translation during ankle plantar flexion
and increased talar inversion/internal
rotation during ankle rotation; these
movements were further increased by
resecting the CFL.36-41
Various symptoms such as swelling,
pain, and range of motion (ROM) deficit
occur in the acute or subacute phase of
LAS. Ten days after LAS injury, swelling
significantly decreases compared to that
after 3 days, but there is no significant
improvement in ROM deficit.42 Ankle
dorsiflexion ROM deficit is associated with
abnormal gait pattern due to decreases in
step and single leg support time.43 In
addition, proprioceptive function might
be deficient because mechanoreceptors
are damaged by LAS. Konradsen et al44
indicated that position sense in the ankle
inversion direction was decreased
compared to that on the uninjured side 12
weeks after LAS, whereas neuromuscular
reaction time and ankle evertor strength
were not significantly different between
the injured and uninjured sides 3 to 12
weeks after LAS.44 However, many
researchers have suggested that
neuromuscular deficit and evertor strength
weakness occur in chronic ankle
instability (CAI) patients, and these
functions might show progressive deficits
over time. Postural control deficit after
LAS was also suggested.45-51 Although
these studies used different measurement
methods, significant postural control
deficits were noted on both the injured
and uninjured sides 1 day after LAS.46
However, the center of gravity
displacement was larger than that on the
uninjured side 6 weeks after LAS.51 A
recent meta-analysis52 has suggested that
there is a significant decrease in static
postural control in injured and uninjured
sides at acute phase but failed to find
significance in the uninjured side for CAI
patients.
Symptoms of LAS often persist, which
may be because athletes with LAS often
300 Foot & Ankle Specialist
return to sports without consulting a
medical care provider. Hubbard et al53
suggested that mechanical instability
resulting from LAS persisted 8 weeks after
injury. In a study reporting 6.5 years of
follow-up data after LAS, 17% to 22% of
patients complained of pain, 35% to 48%
of patients reported an unstable feeling,
and 26% to 33% of patients demonstrated
persistent swelling.15 In addition, among
patients with tenderness in the ATFL
during the acute phase, 32% showed
tenderness at the same point 7 years after
injury.54 A high recurrence rate is
considered one of the causes of
persistent symptoms. The recurrence rate
of LAS is reportedly as high as 56% to
74%.55-58 Predominant symptoms are pain
and crepitus in the ankle with 1 to 3
reinjuries, and an unstable feeling in the
ankle with 4 or more reinjuries.55 Thus,
repetition of LAS leads to CAI.16
Chronic Ankle Instability
A diagnosis of CAI is based on a
history of multiple sprains and repeated
episodes of an unstable feeling or giving-
way. Freeman et al59,60 first described
functional instability in 1965 when they
attributed CAI to proprioceptive deficits
after LAS. Several decades later, Hertel et
al16 defined the cause of CAI is either
mechanical ankle instability (MAI) or
functional ankle instability (FAI). MAI is,
by definition, caused by ligament laxity,
whereas FAI is caused by other factors,
including proprioceptive deficits,
neuromuscular deficits, postural control
deficits, and muscle weakness. Recently,
Hiller et al61 updated of Hertel’s CAI
model16 that suggests there may be as
many as 7 different subsets, which are
dependent on the complex interaction of
mechanical instability, perceived
instability, and frequency of recurrent
sprain. Furthermore, selection criteria for
CAI were unified by the International
Ankle Consortium in 2013.62
Mechanical Instability
Structural instability after LAS is caused
by “looseness” resulting from
ligamentous collagen sequence changes
that occur during the healing process,63
and it might be further induced by
physical limitations due to joint
degeneration and synovial changes.16
There are few studies describing the
association between MAI and CAI. In CAI
patients, mechanical instability of the
talocrural and subtalar joints was found
in 24% to 68%64-67 and 58%,68
respectively.
In MAI patients, talocrural anterior
translation and internal rotation on the
injured side were increased compared to
those in the healthy ankle.36,37,39,41,69
Therefore, MAI might be the greatest
contributor to CAI, making it important
to distinguish subjects with MAI when
conducting a study of CAI.70 Although
such distinction would be difficult
because most of the current MAI
evaluation techniques are 1-dimensional
methods such as manual testing or stress
X-rays, Kobayashi et al71,72 demonstrated
increased talocrural anterior translation
and subtalar internal rotation during
weightbearing ankle internal rotation in
CAI subjects using 3-dimensional
evaluations.
Several reports have investigated the
relationship of fibular malposition to
CAI.73-77 Some studies suggested that CAI
ankles showed a more posterior fibula
position than the healthy side,73,74,78 but
other studies suggested that CAI ankles
showed a more anterior fibula position75
or no significant difference.76,77 Although
these findings were not consistent, it was
suggested that some kind of fibular
malposition occurs in CAI. The
inconsistent fibular position findings are
due to the landmark that the position is
compared to. Some studies compared
fibula position to the tibia,9,43,168 and
some studies compared the fibula
position to the talus.76,77 Dikos et al79
indicated the presence of individual
specificity in anteroposterior or
mediolateral translation and rotation of
the fibula. In future studies, it will be
necessary to perform 3-dimensional
evaluation, because these previous
studies evaluated the fibula position
using only 2-dimensional techniques (eg,
lateral X-ray or computed tomography
[CT]).
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August 2014
Proprioception
Studies of proprioceptive deficits have
examined 3 distinct components: joint
position sense, kinesthesia, and force
sense (Tables 1 and 2). Glencross and
Thornton80 first indicated the lack of joint
position sense, and similar findings
obtained with a goniometer or computer
control systems were later published.81-83
In recent years, various joint angles were
measured using an isokinetic
dynamometer.84-92 Sekir et al91 compared
the error of the joint position sense
between CAI and the uninjured side in
24 subjects with unilateral CAI. In 10°
and 20° of ankle inversion (1° per
second angular speed), the error on the
CAI side was significantly greater than
that on the uninjured side in both
positions. There are many studies
suggesting that joint position sense in
CAI ankles is significantly decreased
based on similar measurements.85,87-89,92,93
However, some studies indicated
contradictory findings,84,86,90 and a
consensus has not yet been obtained
(Table 1). The cause of this controversy
is considered to involve differences in
the inclusion criteria for CAI and the lack
of standardized measurement systems.94
A recent meta-analysis95 has suggested
that CAI subjects display consistent
deficits in joint position sense when
compared with people without CAI.
Garn and Newton96 compared the error
frequency during passive plantar flexion
between CAI and the uninjured side in
30 unilateral CAI subjects, and they
showed that kinesthesia was significantly
decreased on the CAI side. Although
similar findings have been reported,64,97,98
recent studies using motor control
equipment suggested that there was no
significant difference between CAI and
the uninjured side regardless of
movement direction (Table 2).99-101
However, definitive conclusions cannot
be drawn because the number of reports
is still limited.
Force sense deficit was also
investigated102-104 by measuring the
degree of error when subjects
reproduced a predetermined evertor
torque (eg, 10% maximum voluntary
isometric contraction [MVIC]). Based on
 vol. 7 / no. 4

Table 1.
Studies Investigating Joint Position Sensea.

Time Side of
History of Since Instability
Number of Indicate CAI, Presence Giving- Last (Unilateral/
Author Subjects FAI, or Other of MAI History of Sprain Way Sprain Bilateral) Control Group Outcome Measurement Results

Boyle and 17 males, 8 Ankle ≥2 sprains ≥3 months Normal Pedal goniometer (active and Significantly
Negus females (19-25 instability subjects passive, 30%/60%/90% per decreased in normal
(1998)81 years) (N = 67) maximum inversion, 5°/s) subjects (active,
30%; passive, all)

Brown 10 FAI ≥2 sprains/year (the + ≥3 months Normal Isokinetic dynamometer Not significant
(2004)84 past less than 1 subjects (passive, dorsiflexion/
year) (N = 10) plantar flexion, inversion/
eversion, 2-20°/s)

Docherty 43 (22.4 ± 4.9 Multiple ankle + Unilateral Normal Electric goniometer (active, No correlation error
(2006)103 years) sprains subjects 10° inversion/20° eversion) and FAI
(N = 13)

Fu and 19 males (19-26 Multiple ankle ≥2 sprains/2 years ≥3 months Bilateral Normal Isokinetic dynamometer Significantly
Hui-Chan years) sprains subjects (active and passive, 5° decreased
(2005)85 (N = 20) plantar flexion, 1° and 5°/s)

Glencross and 13 males, 11 Group A: severe; ≥8 months Healthy ankles Goniometer (15°/30°/40°/50° Significantly
Thornton females (18-25 group B: plantar flexion) decreased (vs
(1981)80 years) moderate; group healthy); Not

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C: mild significant (among
group)

Gross (1987)86 11 males, 3 CAI ≥2 sprains Unilateral Healthy ankles Isokinetic dynamometer Not significant
females (18-35 and normal (active and passive, 10°
years) subjects eversion,10°/20° inversion,
(N = 7) 5°/s)

Jerosch and 16 (20-31 years) Ankle 4 months Unilateral Healthy ankles Isokinetic dynamometer Significantly
Bischof instability to 13 (passive, 5°/15°/20° decreased
(1996)87 years inversion, 5°/s)

(continued)
Foot & Ankle Specialist
301
 302

Table 1. (continued)

Time Side of
Foot & Ankle Specialist

History of Since Instability

Number of Indicate CAI, Presence Giving- Last (Unilateral/
Author Subjects FAI, or Other of MAI History of Sprain Way Sprain Bilateral) Control Group Outcome Measurement Results

Konradsen and 23 (22-37 years) FAI − (manual ≥7 sprains/year Healthy ankles Computer control (passive, Significantly
Magnusson test; and normal 10°/15°/20° inversion) decreased (absolute
(2000)82 ADT) subjects error); Not significant
(N = 15) (real error)

Lee (2006)88 8 (19.21 ± 1.34 FAI ≥1 sprain (the past + Unilateral Normal Isokinetic dynamometer Significant decreased
years) less than 1 year) subjects (active and passive, 15° (only passive motion)
(N = 8) inversion/neutral/10°
eversion, 2°/s)

Lee and Lin 8 males, 4 females FAI − (manual ≥1 sprain (the past + Unilateral Healthy ankles Isokinetic dynamometer Significantly
(2008)89 (20.08 ± 1.38 test; less than 1 year) (active and passive, 15° decreased
years) ADT) inversion/neutral/10°
eversion, 2°/s)

Nakasa 6 males, 6 females Recurrent +/− ≥4 sprains Unilateral Healthy ankles Foot plate (passive, inversion Significantly
(2008)83 (16-35 years) ankle sprain (Stress at 20° plantar flexion) decreased (no
X-ray) correlation with MAI)

Santos and Liu 6 males, 15 FAI ≥2 sprains (less + Unilateral Healthy ankle Isokinetic dynamometer Not significant
(2008)90 females (30 ± 11 than 6 months) and normal (passive, 30° inversion,
years) subjects 5°/s)

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(N = 16)

Sekir (2007)91 24 (21 ± 2 years) FAI − (manual ≥2 sprains + Unilateral Healthy ankles Isokinetic dynamometer Significantly
test) (passive, 10°/20° inversion, decreased
1°/s)

Willems 4 males, 6 females CAI ≥3 sprains + ≥3 months 6 unilateral, Normal subjects Isokinetic dynamometer Significantly
(2002)92 (18.3 ± 1.1 years) 4 bilateral (N = 53) and (active and passive, 15°/ decreased (only
coper maximum minus 5° maximum minus 5°
(N = 16) inversion, 5°/s) inversion)

Witchalls 5 males, 8 females Unstable ankle 1.62 ± 1.61 45.9 ± Stable ankles The Active Movement Extent Significantly
(2012)93 (25.75 ± 9.72 41.8 (N = 8) Discrimination Apparatus decreased
years) months footplate (inversion)

Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test.
a
A blank cell indicates that data were not provided.
August 2014
 vol. 7 / no. 4

Table 2.
Studies Investigating Kinesthesiaa.

Side of
Indicate History of Instability
Number of CAI, FAI, or Presence Giving- Time Since (Unilateral/
Author Subjects Other of MAI History of Sprain Way Last Sprain Bilateral) Control Group Outcome Measurement Results

de Noronha 16 males, 4 FAI ≥1 sprain (once Both Healthy ankles Motor control No correlation with
(2007)101 females (18-40 within 1 year) (N = 13) and footplate (passive CAIT score
years) normal subjects inversion/eversion,
(N = 20) 0.1°/0.5°/2.5°/s)

Forkin 2 males, 9 Multiple ≥1 sprain 1-12 months 8 unilateral, 3 Healthy ankles Platform (passive Significantly
(1996)97 females (16-22 ankle bilateral inversion, 0.33°/s) decreased
years) sprain

Garn and 24 males, 6 CAI ≥2 sprains (2-20 1-60 months Unilateral Healthy ankles Platform (passive Significantly
Newton females (18-24 times) inversion, 0.33°/s) decreased
(1988)96 years)

Hubbard and 8 males, 8 FAI − (manual Unilateral Healthy ankles Threshold-to-detection of Not significant
Kaminski females (21.6 test; passive motion (passive
(2002)100 ± 1.7 years) ADT/ inversion and eversion,
talar tilt) 0.5°/s)

Lentell 30 males, 12 CAI ≥1 sprain Unilateral Healthy ankles and Platform (passive Significantly
(1995)65 females (18-27 (protected normal subjects inversion, 0.3°/s) decreased

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years) weightbearing (N = 7)
and/or
immobilization)

Refshauge 25 (18-41 years) Recurrent ≥3 sprains (the ≥3 weeks Normal subjects Motor control footplate Not significant
(2000)99 inversion past less than 2 (N = 18) (passive dorsiflexion
sprain years) and plantar flexion,
0.1°/0.5°/2.5°/s)

Refshauge 39 (21.3 ± 3.5 Recurrent ≥3 sprains/2 ≥3 weeks Both Normal subjects Motor control footplate Significantly
(2003)98 years) inversion years (N = 30) (passive inversion decreased (only
sprain and eversion, eversion)
0.1°/0.5°/2.5°/s)

Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; CAIT, Cumberland Ankle Instability Tool.
a
A blank cell indicates that data were not provided.
Foot & Ankle Specialist
303
304 Foot & Ankle Specialist
these studies, there was a correlation
between the error in evertor torque (10,
30% MVIC) and CAI.102-104 It has also
been reported that the peroneus longus
resting motor threshold is higher in
CAI.105 However, further examination of
this issue is necessary to obtain more
substantive evidence.
Neuromuscular
The association between
neuromuscular deficits and CAI has been
considered based on neuromuscular
reaction time, H:M ratio, and muscle
activation (Tables 3-5). Most studies
investigating neuromuscular reaction
time used a trapdoor and measured the
reaction time of the peroneus longus or
tibialis anterior when the ankle was
suddenly inverted.106-112 Some studies
indicated that muscle reaction time was
significantly delayed in CAI
subjects,108-111,113 whereas other studies
reported that there was no significant
difference compared to that in healthy
subjects.90,106,111,112 Furthermore, a recent
meta-analysis has determined that there
is a significant delayed in reaction time
of the peroneus muscles in subjects with
a previous ankle sprain.114 However, it is
unknown in CAI subjects (Table 3). One
of the causes of this controversy is that
there was great variation in the CAI
inclusion criteria among these studies.
The unified CAI criteria were published
by the International Ankle Consortium62;
thus, future studies will be required to
comply with these selection criteria.
Furthermore, some studies have
suggested that the H:M ratio of the
peroneus longus or soleus is decreased
in CAI subjects (Table 4).115-117
Muscle activities during various
movements were also described.84,90,117-123
In CAI subjects, peroneus longus activity
was decreased,122 whereas tibialis
anterior activity was increased124 in the
stance phase during gait. In jump
landing, activities of the peroneus longus
before initial contact and those of the
soleus after landing were significantly
decreased.84,118,119 Additionally, Lin et al125
indicated that tibialis anterior/peroneus
co-contraction during prelanding and
peroneus longus activity during
postlanding were decreased in CAI. In
contrast, activity increased in the rectus
femoris, tibialis anterior, and soleus on
initial contact during side hop.120 It was
suggested that abnormal muscle activity
patterns in CAI subjects occur during
various movements (Table 5).126
Postural Control
Postural control deficit in CAI subjects
has been extensively investigated. In
recent years, not only static stability but
also dynamic stability has been
evaluated (Tables 6 and 7). Postural
control deficit was first reported by
Freeman et al,60 who found that of 33
unilateral CAI patients examined by
Romberg test, 25% showed significant
postural control deficits on the injured
side compared to that on the uninjured
side. Thereafter, many studies
examining static stability in CAI subjects
using techniques such as stabilometry
or force plate were
published.66,67,76,85,87-91,96,97,127-153 In these
studies as well, the inclusion criteria of
CAI showed great variability, and the
results were not conclusive. However,
recent studies described the inclusion
criteria of CAI in greater detail (eg,
histories of multiple sprains and giving-
way, disappearance of acute symptoms),
and these studies have suggested
decreased static stability in CAI (Table
6).90,91,129,144,146,148,149,154,155 Recent meta-
analyses52,156,157 have suggested that
there is a significant decrease in static
postural control in CAI subjects.
To examine dynamic stability, the Star
Excursion Balance Test (SEBT) as a test
of dynamic postural control suggested
decreased dynamic stability in CAI
subjects.76,135,158-162 Other studies using
other evaluation techniques (eg, the
quantity of center of gravity
displacement and time to regain stability
after jump landing,77,148,149,163-166
unplanned gait termination,167 or
multiple hop test168) reported similar
results. Therefore, it was suggested that
dynamic postural control in CAI subjects
is significantly decreased based on a
recent meta-analysis.156
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August 2014
Muscle Strength
It has long been reported that there is
an association between muscle weakness
and CAI (Table 8).169 Many studies
measured ankle inversion/eversion and
plantar flexion/dorsiflexion peak torque
using an isokinetic dynamometer, but
these studies demonstrated great
variation in joint angle and angular
velocity. Regarding eversion strength,
some studies demonstrated a significant
decrease in CAI subjects,90,92,170,171
whereas other studies did not detect
significant differences between CAI and
healthy subjects.64,76,91,128,143,172-178
Although a recent meta-analysis
suggested that concentric eversion
strength is decreased in CAI subjects
regardless of angular velocity,179 there is
not yet a consensus regarding the results
of inversion and plantar flexion strength.
Significant decreases in hip joint
adduction, abduction, and extension
strength in CAI subject were also
described in some studies (Table
9).76,180,181 Among these, 2 studies
obtained measurements using a handheld
dynamometer (HHD),76,181 and 1 study
used an isokinetic dynamometer.180
Although decreased hip abduction
strength was shown in all studies, findings
regarding extension strength were not
consistent. Further examination of this
issue is required due to the limited
amount of research conducted to date.
Kinematics of Chronic
Ankle Instability
Talocrural and subtalar joint kinematics
combine to form ankle joint kinematics.
Most of the ankle joint plantar flexion/
dorsiflexion occurs in the talocrural joint,
whereas similar amounts of ankle joint
inversion/eversion and internal rotation/
external rotation occur in the talocrural
and subtalar joints similarly.182-186
Maximal dorsiflexion of the ankle is
considered stable due to the bony
conformity known as the close-packed
position.187,188 Therefore, the subtalar
joint shows relatively greater mobility in
dorsiflexion. On the contrary, the ankle
is considered more unstable in plantar
 Table 3.
vol. 7 / no. 4

Studies Investigating Muscle Reaction Timea.

History Side of
Indicate of Time Instability
Number of CAI, FAI, or Presence Giving- Since Last (Unilateral/ Outcome
Author Subjects Other of MAI History of Sprain Way Sprain Bilateral) Control Group Measurement Results
106
Ebig (1997) 5 males, 8 FI 1-6 sprains ≥2 months Unilateral Trap door (plantar Not significant
females (19.2 flexion and
± 1.51 years) inversion; PL/TA)

Karlsson and 10 males, 10 FAI + (stress Unilateral Healthy ankles Trap door (30° Significantly delayed
Andreasson females (19- X-ray) inversion; PL/PB)
(1992)107 28 years)

Kavanagh 6 males, 6 CAI ≥1 sprain (the Unilateral Normal subjects Active eversion Significantly delayed (only
(2012)113 females (26 past less than 2 and dorsiflexion eversion)
± 5 years) years) (eversion; PL,
dorsiflexion; TA)

Konradsen and 30 (21-32 FI Multiple sprains + Healthy ankles Trap door (30° Significantly delayed
Ravn (1990)108 years) inversion; PL/PB)

Lofvenberg 4 males, 9 Chronic 11 unilateral, 2 Healthy ankles and Trap door (PL/TA) Significantly delayed (vs
(1995)109 females (24- lateral bilateral normal subjects healthy ankles); not
49 years) instability (N = 15) significant (vs normal
subjects)

Mitchell 19 males (25.1 FAI ≥2 sprains (the + ≥6 months Unilateral Healthy ankles and Tilt platform (20° Significantly delayed (PL, PB,
(2008)110 ± 1.9 years) past less than 2 normal subjects plantar flexion and and TA) (vs healthy/normal)

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years) (N = 19) 3° inversion; PL/PB/
TA/EDL)

Santos and Liu 6 males, 15 FAI ≥2 sprain (the + Unilateral Healthy ankles and Isokinetic Not significant
(2008)90 females (30 past less than 6 normal subjects dynamometer
± 11 years) months) (N = 16) (reaction time to
120°/s inversion)

Vaes (2001)112 3 males, 6 FAI +/− (talar 2 unilateral, 7 Normal subjects Trap door (40° Not significant
females (20- tilt) bilateral (N = 8) plantar flexion and
41 years) 15° inversion; PL)

Vaes (2002)111 18 males, 22 Unstable ≥2 sprains + ≥3 months Normal subjects Trap door (40° Not significant
females (18- ankle (N = 41) plantar flexion and
23 years) 15° inversion; PL)

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; PL, peroneus longus; PB, peroneus brevis; TA, tibialis anterior; EDL, extensor digitorum longus.
a
A blank cell indicates that data were not provided.
Foot & Ankle Specialist
305
 306
Foot & Ankle Specialist

Table 4.
Studies Investigating Muscle H:M Ratioa.

History Side of
Indicate of Instability
Number of CAI, FAI, or Presence of History of Giving- Time Since Last (Unilateral/ Control Outcome
Author Subjects Other MAI Sprain Way Sprain Bilateral) Group Measurement Results

Kim 10 males, 6 CAI ≥1 sprain + ≥6 weeks Unilateral Normal Stimulator Significant

(2012)115 females (the past subjects module decreased
less than 1 (N = 15) (SOL/PL) (only SOL)
year)

Mcvey 8 males, 7 females FAI Healthy Stimulator Significant

(2005)116 (26.5 ± 6.5 ankles module decreased
years) and (SOL/PL/TA) (only SOL/
normal PL, vs
subjects healthy

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(N = 14) ankles)

Palmieri- 3 males, 18 FAI − Normal Stimulator Significant

Smith females (21 ± 2 subjects module (PL) decreased
(2009)117 years) (N = 21)

Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; PL, peroneus longus; TA, tibialis anterior; SOL, soleus.
a
A blank cell indicates that data were not provided.
August 2014
 vol. 7 / no. 4

Table 5.
Studies Investigating Muscle Activitya.
Time Side of
Since Instability
Indicate CAI, Presence History of Last (Unilateral/
Author Number of Subjects FAI, or Other of MAI History of Sprain Giving-Way Sprain Bilateral) Control Group Outcome Measurement Results

Brown 10 FAI ≥2 sprains/year (the + ≥3 Normal subjects Landing (SOL/PL/TA/GL) Significantly decreased SOL
(2004)84 past less than 1 months (N = 10) activity (post landing)
year)

Caulfield 6 males, 6 females FI ≥2 sprains + (in sports) Normal subjects Single leg landing (drop Significantly decreased PL activity
(2004)118 (26.4 ± 4.6 years) (N = 10) jump) and forward hop (pre landing; both attempts)
(SOL/PL/TA)

Delahunt 15 males, 9 females FI ≥2 sprains + (in sports) Normal subjects Single leg landing (drop Significantly decreased PL activity
(2006)119 (25 ± 1.3 years) (N = 24) jump) (PL/RF/TA/SOL) (pre initial contact)

Delahunt 16 males, 10 FI ≥2 sprains + (in sports) Normal subjects Lateral hop (PL/RF/TA/ Significantly increased RF, TA, and
(2007)120 females (N = 24) SOL) SOL (during 200 ms pre- and
(25.6 ± 6.1 years) post-initial contact)

Larsen 17 males, Chronically + (manual + ≥5 Unilateral Post-surgery Foot plate (dorsiflexion/ Significantly increased post-
and Lund 16 females unstable test/ months plantar flexion/inversion/ surgery (only plantar flexion)
(1991)121 (17-52years) ankle stress eversion; PB/GM)
X-ray)

Lin 6 males, 9 females CAI +/− ≥2 sprains + ≤6 Unilateral Normal subjects Running and stop-jump Significantly decreased TA/PL co-
(2011)125 (21.6 ± 2.4 years) (manual months (N = 15) landing (TA/PL, TA/GL) contraction during pre-landing

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test; ADT/ (stop-jump landing); significantly
PDT/talar decreased PL during post-
tilt) landing (stop-jump landing)

Santilli 10 males, 4 females FAI − ≥2 sprains + 17-44 Unilateral Healthy ankles Gait (PL) Significantly decreased (stance
(2005)122 (17-34 years) days phase)

Santos 6 males, 15 females FAI ≥2 sprains (the + Unilateral Healthy ankles Force platform (30° Significantly decreased SOL
and Liu (30 ± 11 years) past less than 6 and normal plantar flexion and 15° activity
(2008)90 months) subjects (N inversion, reaction to
= 18) 20% per pain threshold;
TA/SOL/VM/BF/PL)

(continued)
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307
 308
Foot & Ankle Specialist

Table 5. (continued)

Time Side of
Since Instability
Indicate CAI, Presence History of Last (Unilateral/
Author Number of Subjects FAI, or Other of MAI History of Sprain Giving-Way Sprain Bilateral) Control Group Outcome Measurement Results

Soderberg 10 males, 4 females Chronic ankle ≥2 sprains Unilateral Normal subjects Platform (PL/TA/GM/GL) Not significant
(1991)123 sprain (N = 14)

Ty Hopkins 5 males, 7 females FI − (manual Normal subjects Gait (PL/TA) Significantly increased TA in 15%
(2012)124 (23 ± 4 years) test; ADT/ (N = 12) to 30% and 45% to 70% of
talar tilt) stance; significantly increased
PL in heel contact and toe off

Palmieri- 3 males, 18 females FAI − Normal subjects Trap door during gait (30° Significantly decreased PL activity
Smith (21 ± 2 years) (N = 21) inversion; PL)
(2009)117

Wikstrom 20 (20.5 ± 1.0 years) CAI ≥1 sprain (required + 2.9 ± 1.8 Unilateral Healthy ankles Planned and unplanned Significantly different in SOL
(2010)126 immobilization for months and normal gait termination (SOL/ and TA during unplanned and

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at least 3 days) subjects TA/Gmed) planned gait termination (vs
(N = 20) healthy ankles and normal
subjects)

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; PDT, posterior drawer test; PL, peroneus longus; PB, peroneus brevis; TA, tibialis anterior; EDL, extensor digitorum
longus; SOL, soleus; GM, gastrocnemius medialis; GL, gastrocnemius lateralis; RF, rectus femoris; VM, vastus medialis; BF, biceps femoris; Gmed, gluteus medius.
a
A blank cell indicates that data were not provided.
August 2014
 Table 6.
vol. 7 / no. 4

Studies Investigating Static Postural Controla.

Side of
Indicate Instability
Number of CAI, FAI, or Presence of History of Time Since (Unilateral/
Author Subjects Other MAI History of Sprain Giving-Way Last Sprain Bilateral) Control Group Outcome Measurement Results

Baier and Hopf 10 males, 12 FAI − (manual test; ≥5 sprains/year + 12 unilateral, Normal subjects (N Single leg standing with Not significant
(1998)127 females (19-36 ADT/talar tilt) 10 bilateral = 22) open and closed eyes
years) (force plate; postural sway)

Bernier 9 (22.89 ± 3.18 FI +/− (stress ≥2 sprains + ≥4 months Unilateral Healthy ankles and Double and single leg Not significant
(1997)128 years) X-ray) normal subjects standing with open and
(N = 9) closed eyes (balance
system)

Brown and 10 males, 10 CAI ≥2 sprains/year (the + ≥6 months Unilateral Healthy ankles Standing retention for Significantly longer
Mynark females (21.45 past less than 1 standardized tibial nerve anterior-posterior
(2007)129 ± 3.41 years) year) stimulation (force plate; TTS
postural sway/TTS)

Chrintz 12 males, 17 Chronic + (manual test) ≥3 sprains + 1.5-7 years 28 unilateral, Healthy ankles (N Single leg standing with Significantly
(1991)130 females (16-51 functional 1 bilateral = 28) and normal open and closed eyes decreased
years) instability subjects (N = 41) (balance retention time)

Cornwall 12 males, 8 ≥1 sprain (the past 12.35 months Unilateral Normal subjects Single leg standing with No significant
and Murrell females (24.90 less than 2 years) (average) (N = 30) open and closed eyes sway amplitude;
(1991)131 ± 5.06 years) (force plate; postural sway) significant increase

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sway frequency

Docherty 9 males, 21 FAI ≥1 sprain Normal subjects Double, single, and tandem Significantly decrease
(2006)132 females (20.0 ± (N = 30) leg standing on firm and (single leg standing
1.5 years) foam surfaces (Balance on firm and foam
Error Scoring System; surfaces, in tandem
number of times lost leg standing on foam
balance) surfaces)

Forkin 2 males, 9 Multiple ≥1 sprain 1-12 months 8 unilateral, 3 Healthy ankles Single leg standing with Significantly
(1996)97 females (16-22 ankle bilateral open and closed eyes decreased (only 4
years) sprains (number of times lost subjects)
balance)

(continued)
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309
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Table 6. (continued)

Side of
Foot & Ankle Specialist

Indicate Instability
Number of CAI, FAI, or Presence of History of Time Since (Unilateral/
Author Subjects Other MAI History of Sprain Giving-Way Last Sprain Bilateral) Control Group Outcome Measurement Results

Freeman 33 FI Unilateral Healthy ankles Romberg test with open and Significantly
(1965)60 closed eyes decreased (only 25%
subjects)

Fu and 19 males (19-26 Multiple ≥2 sprains (the past ≥3 months Bilateral Normal subjects (N Double leg standing with Significantly
Hui-Chan years) ankle less than 2 years) = 20) open and closed eyes decreased
(2005)85 sprains (Sensory Organization Test)

Garn and 24 males, 6 CAI ≥2 sprains (2-20 1-60 months Unilateral Healthy ankles Single leg standing with Significantly
Newton females (18-24 times) open and closed eyes decreased (only 20
(1988)96 years) (number of times lost subjects)
balance)

Gauffin 10 males (20-28 FI + (4 subjects) >2 sprains + Both Normal subjects (N Single leg standing (force Significantly
(1988)133 years) (manual test; = 15) and post plate and LED [sternum/ increased COP
ADT) training hip/ankle]; postural sway) and LED (sternum)
displacement (vs
normal subjects);
significantly
increased COP and
LED (sternum and
ankle) displacement

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(vs post training)

Goldie 17 males, 7 ≥1 sprain (42% more 36.6 ± 30.3 Unilateral Healthy ankles Single leg standing with Significantly
(1994)134 females (21.7 ± than 2) months open and closed eyes decreased (lateral
6.3 years) (average) (force plate; postural sway) direction)

Hale (2007)135 29 (21.4 ± 3.5 CAI ≥1 sprain + ≥3 months Unilateral Normal subjects (N Single leg standing with Significantly
years) = 19) open and closed eyes decreased
(force plate; postural sway)

Hertel and 15 females (19.7 CAI ≥1 sprain (1-5 times) + (the past ≥3 months Healthy ankles and Double leg standing (open Significantly lower
Olmsted- ± 1.3 years) 3 months normal subjects and closed eye) (force score for TTB
Kramer more than (N = 9) plate; postural sway and
(2007)136 2) TTB)

(continued)
August 2014
 Table 6. (continued)
vol. 7 / no. 4

Side of
Indicate Instability
Number of CAI, FAI, or Presence of History of Time Since (Unilateral/
Author Subjects Other MAI History of Sprain Giving-Way Last Sprain Bilateral) Control Group Outcome Measurement Results

Hiller (2004)137 11 females (16- FAI ≥1 sprain (protected Normal subjects (N Single leg standing and Significantly
35 years) weightbearing and/ = 10) trap door (foot flat and decreased postural
or immobilization) demi-point) (3Space sway (only demi-
FASTRAK, foot flat: 15° point); significantly
inversion/demi-point: 7.5° longer perturbation
inversion; postural sway time (foot flat and
and perturbation time) demi-point)

Hiller (2007)138 41 (24 ± 7.9 FAI +/− ≥1 month 19 unilateral, Healthy ankles and Single leg standing and trap Significantly increased
years) 22 bilateral normal subjects door (foot flat and demi- postural sway;
(N = 20) point) (3Space FASTRAK, significantly longer
15° inversion; postural perturbation time
sway and perturbation
time)

Hubbard 15 males, 15 CAI + (arthrometer) 5.8 ± 2.7 times + ≥6 weeks Unilateral Healthy ankles and Single leg standing (force Not significant
(2007)76 females (20.3 ± normal subjects plate; postural sway)
1.3 years) (N = 30)

Isakov and 8 females (14-18 Chronically + (manual test; ≥3 sprains ≥4 months Unilateral Healthy ankles Single leg standing with Not significant
Mizrahi years) sprained ADT) open and closed eyes
(1997)139 ankles (force plate; postural sway)

Jerosch and 16 (20-31 years) Ankle 4 months to Unilateral Healthy ankles Single leg standing with Significantly

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Bischof instability 13 years open and closed eyes decreased
(1996)87 (number of times lost
balance)

Knapp 30 males, 33 CAI ≥1 sprain (the past Both Normal subjects Barefoot, quiet, and single- Not significant
(2011)140 females (22.3 ± less than 1 year) (N = 46) limb stance with open and
3.7 years) closed eyes (force plate;
postural sway)

Konradsen 15 (21-32 years) FI +/− (manual 5 unilateral, Normal subjects Single leg standing (force Significantly
and Ravn test; ADT/ 10 bilateral (N = 15) plate; postural sway) decreased (medial-
(1991)141 talar tilt) lateral direction)

(continued)
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311
 312

Table 6. (continued)
Foot & Ankle Specialist

Side of
Indicate Instability
Number of CAI, FAI, or Presence of History of Time Since (Unilateral/
Author Subjects Other MAI History of Sprain Giving-Way Last Sprain Bilateral) Control Group Outcome Measurement Results

Leanderson 34 males (17-43 ≥2 sprains 5 unilateral, Normal subjects (N Single leg standing Significantly
(1993)142 years) 29 bilateral = 9) and control (stabilometry; postural decreased (vs
group (N = 11) sway) control group)

Lee (2006)88 8 (19.21 ± 1.34 FAI ≥1 sprain (protected + Unilateral Normal subjects Single leg standing with Significantly
years) weightbearing; the (N = 8) open and closed eyes decreased
past less than 1 (force plate; postural sway
year) and TTB)

Lee and Lin 8 males, 4 FAI − (manual test; ≥1 sprain/year (the + Unilateral Healthy ankles Single leg standing with Significantly
(2008)89 females (20.08 ADT) past less than 1 open and closed eyes decreased
± 1.38 years) year) (force plate; postural sway)

Lentell 17 males, 16 CAI ≥1 sprain (protected ≥3 months Unilateral Healthy ankles Romberg test with open and Significantly
(1990)143 females (17-54 weightbearing and/ closed eyes decreased (only 18
years) or immobilization) subjects)

Levin 20 (20-24 years) CAI ≥2 sprains/year (the + ≥6 months Unilateral Normal subjects Double to single leg stance Significantly longer
(2012)154 past less than 1 (N = 20) with open and closed eyes TTS

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year) (force plate; postural sway
and TTS)

McKeon 18 males, 14 CAI 7.8 ± 5.7 times 10.3 ± 16.4 Normal subjects Single leg standing with Significantly
and Hertel females (males: months (N = 32) open and closed eyes decreased (only
(2008)144 22.4 ± 5.8 (average) (force plate; postural sway) open eyes)
years; females:
20.1 ± 1.9
years)

Michell 8 males, 8 FAI ≥2 sprains/year (the + (the past ≥6 months Healthy ankles and Single leg standing with Not significant
(2006)145 females (20 ± 3 past less than 1 1 year normal subjects open and closed eyes
years) year) more than (N = 16) (force plate; postural sway)
2)

(continued)
August 2014
 vol. 7 / no. 4

Table 6. (continued)

Side of
Indicate Instability
Number of CAI, FAI, or Presence of History of Time Since (Unilateral/
Author Subjects Other MAI History of Sprain Giving-Way Last Sprain Bilateral) Control Group Outcome Measurement Results

Mitchell 19 (26.5 ± 3.1 FAI ≥2 sprains (the past +/− ≥6 months Unilateral Healthy ankles and Single leg standing with Significantly
(2008)146 years) less than 2 years) normal subjects open and closed eyes decreased (open:
(N = 19) (force plate; postural sway) anterior-posterior
direction; close:
medial-lateral
direction)

Perrin 15 males (18-29 10-15 times Unilateral Normal subjects (N Single leg standing with Significantly
(1997)147 years) = 50) open and closed eyes decreased
(force plate; postural sway)

Pope (2011)155 31 males, 30 CAI ≥1 sprain (mean ≤6 weeks Normal subjects (N Single leg standing with Significantly
females (21.5 ± number; 6.0 ± 3.5) = 50) open and closed eyes greater anterior
4.0 years) (force plate; postural sway displacement of COP
and TTB) and TTB minima

Ross and 7 males, 7 FAI ≥2 sprains + ≥6 weeks Normal subjects (N Single leg standing with Significantly decrease
Guskiewicz females (21.71 = 14) open eyes (force plate;
(2004)148 ± 2.64 years) postural sway)

Ross (2009)149 10 males, 12 FAI +/− (manual ≥2 sprains + (≥2 giving ≥3 weeks Normal subjects (N Single leg standing with Significantly
females (20 ± 2 test; ADT/ ways) = 22) open eyes (force plate; decreased postural

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years) talar tilt) postural sway and TTS) sway; significantly
longer TTS

Rozzi 8 males, 5 Functionally ≥2 sprains + Unilateral Normal subjects (N Single leg standing (Biodex Significantly
(1999)150 females (21.9 ± unstable = 13) and post Stability System; Stability decreased
3.1 years) ankle training Index)

Ryan (1994)66 12 males, 33 Functionally +/− (manual ≥3 sprain (the past + (the past Less than Unilateral Healthy ankles Single leg standing (Uni- Significantly
females (16-35 unstable test; ADT) 18 months more 1 year 2 weeks Axial Balance Evaluator; decreased in healthy
years) ankle than 2, and the past more than (giving-way) balance retention time) ankle
6 months more than 6 times)
once)

(continued)
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313
 314

Table 6. (continued)

Side of
Foot & Ankle Specialist

Indicate Instability
Number of CAI, FAI, or Presence of History of Time Since (Unilateral/
Author Subjects Other MAI History of Sprain Giving-Way Last Sprain Bilateral) Control Group Outcome Measurement Results

Santos and Liu 6 males, 15 FAI ≥2 sprains (the past + Unilateral Healthy ankles and Single leg standing (force Significantly
(2008)90 females (30 ± less than 6 months) normal subjects plate; postural sway) decreased
11 years) (N = 16)

Sekir (2007)91 24 (21 ± 2 years) FAI − (manual test) ≥2 sprains + Unilateral Healthy ankles Single leg standing with Significantly
closed eyes (number of decreased
times lost balance)

Tropp 56 males ≥1 sprain (take a rest Normal subjects (N Single leg standing Not significant
(1984)151 more than 1 week) = 71) (Stabilometry; postural
sway)

Tropp (1985)67 128 males FI + (44%) Both Healthy ankles Single leg standing Not significant
(Stabilometry; postural
sway)

Tropp and 15 males (18-29 FI ≥2 sprains Unilateral Normal subjects (N Single leg standing (force Significantly
Odenrick years) = 15) plate and LED [sternum/ decreased
(1988)152 hip/foot]; postural sway)

Wikstrom 16 (22.1 ± 3.3 CAI ≥1 sprain (required + (5.8 ± 3-6 months Unilateral Normal (N = 16) Single leg standing with Significantly greater
(2010)77 years) immobilization 5.2) and coper (N = open eyes (force plate; mediolateral and

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and/or non- 16) subjects postural sway and TTB) anteroposterior COP
weightbearing for at velocity (vs normal
least 3 days) and coper subjects);
significantly
increased COP-COM
moment arm (vs
coper subjects)

You (2004)153 3 males, 3 CAI − (manual test; ≥1 sprain/year (the + Normal subjects Single leg standing with Not significant
females (23.3 ± ADT) past less than 1 (N = 4) open and closed eyes
4.2 years) year) (force plate; postural sway)

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; TTS, time to stabilization; TTB, time to boundary; COP, center of pressure; COP-COM, center of pressure–center of
mass; LED, light emitting diodes.
a
A blank cell indicates that data were not provided.
August 2014
 Table 7.
vol. 7 / no. 4

Studies Investigating Dynamic Postural Controla.

Side of
Indicate Time Instability
Number of CAI, FAI, Presence of History of Since Last (Unilateral/
Author Subjects or Other MAI History of Sprain Giving-Way Sprain Bilateral) Control Group Outcome Measurement Results

Brown 10 FAI ≥2 sprains/year (the + ≥3 months Normal subjects Landing (force plate; TTS) Significantly longer
(2004)84 past less than 1 year) (N = 10)
Brown 24 females (20.0 CAI ≥1 moderate to severe + (the past 1 Both Normal subjects 50% maximum height Significantly decreased
(2010)163 ± 1.3 years) sprain (the past less year more (N = 24) vertical jump in anterior, in anterior and lateral
than 1 year) than 2) lateral, and medial jumps
directions (ground
reaction force)
Eechaute 17 males, 12 CAI ≥2 sprains (the past + Normal subjects Multiple hop test (number Significantly increased
(2009)168 females (24.9 ± less than 6 months) (N = 29) of times lost balance)
5.5 years)
Gribble 7 males, 7 CAI ≥1 sprain + (the past 6 ≥3 months Unilateral Healthy ankles SEBT Significantly decreased
(2004)158 females (21.9 ± months more and normal in all directions (vs
2.9 years) than 2) subjects healthy ankles)
(N = 16)
Hale 29 (21.4 ± 3.5 CAI ≥1 sprain + ≥3 months Unilateral Normal subjects SEBT Significantly
(2007)136 years) (N = 19) decreased in medial,
posterolateral, and
lateral
Hertel 22 males, 26 CAI ≥1 sprain + (the past 1 ≥6 weeks Healthy ankles SEBT Significantly decreased
(2006)159 females (20.9 ± year more and normal in anteromedial,

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3.2 years) than 3 times) subjects posteromedial, medial
(N = 39) (vs healthy ankles and
normal subjects)
Hoch 13 males, 17 CAI ≥1 sprain + (the past 3 ≤6 weeks Normal subjects SEBT Significantly decreased
(2012)160 females (24.9 ± months more (N = 30) in anterior
5.1 years) than 2)
Hubbard 15 males, 15 CAI + (arthrometer) 5.8 ± 2.7 times + ≥6 weeks Unilateral Healthy ankles SEBT Significantly decreased
(2007)76 females (20.3 ± normal subjects in posteromedial and
1.3 years) (N = 30) anterior
Olmsted 10 males, 10 CAI 1 sprain + (the past 1 ≥6 weeks Unilateral Normal subjects SEBT Significantly decreased
(2002)161 females (19.8 ± year more (N = 20) in all directions
1.4 years) than 2)

(continued)
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Table 7. (continued)

Side of
Indicate Time Instability
Foot & Ankle Specialist

Number of CAI, FAI, Presence of History of Since Last (Unilateral/

Author Subjects or Other MAI History of Sprain Giving-Way Sprain Bilateral) Control Group Outcome Measurement Results

Plante 25 (23.7 ± 4.9 CAI 4.6 ± 2.9 times + (the past 1 3-6 Unilateral Normal (N = 20) SEBT Significantly decreased
(2013)162 years) year at least months and coper (N = in posteromedial
once) 21) subjects
Ross and 7 males, 7 FAI ≥2 sprains + ≥6 weeks Normal subjects Single leg landing (force Not significant
Guskiewicz females (21.71 (N = 14) plate; postural sway)
(2004)148 ± 2.64 years)
Ross 5 males, 5 FAI + (6 subjects) ≥3 sprains (the past + (the past 1 Normal subjects Single leg landing (force Significantly longer
(2005)164 females (22.0 ± (manual test; year more than 2) year more (N = 10) plate; TTS)
2.5 years) ADT) than 2)
Ross 10 males, 12 FAI +/− (manual ≥2 sprains + (more than ≥3 weeks Normal subjects Single leg landing (force Significantly decreased
(2009)149 females (20 ± 2 test; ADT/ 2) (N = 22) plate; postural sway postural sway;
years) talar tilt) and TTS) significantly longer
TTS
Wikstrom 29 (21.8 ± 2.3 FAI − (LigMaster) + ≥3 months Normal subjects Step down and single leg Significantly longer
(2005)165 years) (N = 29) landing (force plate; TTS) anterior-posterior
direction
(both attempts)
Wikstrom 28 males, 26 FAI + ≥3 Normal subjects Single leg landing (force Significantly decreased
2007166 females months (N = 54) plate; postural stability in anteroposterior and

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(21.4 ± 1.7 yr) index) vertical direction
Wikstrom 12 males, 12 CAI ≥1 sprain (required + (5.1 ± 4.6) 3-6 Unilateral Normal (N = 24) Single leg hop stabilization Significantly decreased
(2010)77 females (21.7 ± immobilization and/or months and coper (N = (force plate; postural in mediolateral
2.8 years) non-weightbearing for 24) subjects stability index) direction (vs
at least 3 days) coper subjects);
significantly increased
in anteroposterior
direction (vs normal
subjects)
Wikstrom 20 (20.5 ± 1.0 CAI ≥1 sprain (required + (5.1 ± 4.6) 3-6 Unilateral Normal (N = 20) Planned and unplanned Significantly increased
(2012)167 years) immobilization and/or months and coper (N = gait termination (force in anteroposterior
non-weightbearing for 20) subjects plate; postural stability direction (vs normal
at least 3 days) index) and coper subjects)

Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; TTS, time to stabilization; SEBT, star excursion balance test.
a
A blank cell indicates that data were not provided.
August 2014
 vol. 7 / no. 4

Table 8.
Studies Investigating Ankle Muscle Strengtha.

Side of
Indicate History of Time Instability
Number of CAI, FAI, or Giving- Since Last (Unilateral/
Author Subjects Other Presence of MAI History of Sprain Way Sprain Bilateral) Control Group Outcome Measurement Results

Bernier 9 (22.89 ± 3.18 FI +/− (stress X-ray) ≥2 sprains + ≥4 months Unilateral Healthy ankles Isokinetic dynamometer Not significant
(1997)128 years) and normal (inversion and eversion,
subjects (N = 9) 90°/s)

Bosien 113 42% more than 2 2-49 Both Healthy ankles Manual test (inversion and Significantly
(1955)169 months eversion at 40° plantar decreased in
flexion) eversion (only
29 subjects)

Fox (2008)178 8 males, 12 FAI ≥1 sprain + Normal subjects Isokinetic dynamometer Significantly
females (20.65 (N = 20) (inversion, eversion, plantar decreased in
± 2.64 years) flexion, and dorsiflexion plantar flexion
[Ecc], 90°/s)

Hartsell and 7 males, 7 CAI ≥2 sprains + ≥6 months Normal subjects Isokinetic dynamometer Significantly
Spaulding females (26.6 ± (N = 10) (inversion and eversion [Con/ decreased
(1999)171 4.29 years) Ecc], 60/120/180/240°/s)

Hubbard 15 males, 15 CAI + (arthrometer) 5.8 ± 2.7 times + ≥6 weeks Unilateral Healthy ankles Isokinetic dynamometer Significantly
(2007)76 females (20.3 ± and normal (inversion, eversion, plantar decreased in

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1.3 years) subjects (N flexion, and dorsiflexion, plantar flexion
= 30) 30°/s)

Kaminski 21 males (19.3 ± FAI − (manual test) ≥1 sprain + Unilateral Normal subjects Isokinetic dynamometer Not significant
(1999)174 1.1 years) (N = 21) (eversion [Con/Ecc],
30/60/90/120/150/180°/s)

Lentell 17 males, 16 CAI ≥1 sprain ≥3 months Unilateral Healthy ankles Isokinetic dynamometer Not significant
(1990)143 females (17-54 (protected (eversion, isometric and
years) weightbearing 30°/s)
and/or
immobilization)

(continued)
Foot & Ankle Specialist
317
 318

Table 8. (continued)

Side of
Foot & Ankle Specialist

Indicate History of Time Instability

Number of CAI, FAI, or Giving- Since Last (Unilateral/
Author Subjects Other Presence of MAI History of Sprain Way Sprain Bilateral) Control Group Outcome Measurement Results

Lentell 30 males, 12 CAI ≥1 sprain Unilateral Healthy ankles Isokinetic dynamometer Not significant
(1995)64 females (18-27 (protected and normal (eversion; 30/90/150/210°/s)
years) weightbearing subjects (N = 7)
and/or
immobilization)

McKnight and 15 (19.60 ± 1.72 FAI ≥2 sprains (the + (the past 9.55 ± Normal subjects Isokinetic dynamometer Not significant
Armstrong years) past less than 1 1 year 11.54 (N = 14) and (inversion, eversion, plantar
(1997)172 year) more months rehabilitation flexion, and dorsiflexsion
than 2) group (N = 14) [Con], 30/240°/s)

Munn 9 males, 7 FAI ≥1 sprain (the past ≥4 weeks Unilateral Healthy ankles Isokinetic dynamometer Significantly
(2003)176 females (18-29 less than 1 year) (inversion and eversion [Con/ decreased in
years) Ecc], 60/120°/s) inversion (only
Ecc 60/120°/s)

Pontaga 28 males (18-28 + (manual test) ≥2 sprains 7 unilateral, Healthy ankles (N Isokinetic dynamometer Significantly
(2004)177 years) 9 bilateral = 33) (inversion and eversion, decrease
30/60/90/120°/s) inversion (only
60, 90, and
120°/s)

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Porter 15 (22.1 ± 3.7 Functionally − (manual test; Unilateral Normal subjects Isokinetic dynamometer Not significant
(2002)175 years) unstable ADT/talar tilt) (N = 15) (dorsiflexion and eversion,
ankle 120/240°/s)

Ryan (1994)66 12 males, 33 Functionally +/− (manual test; ≥3 sprains(the past + (the past Less than Unilateral Healthy ankles Isokinetic dynamometer Significantly
females (16-35 unstable ADT) 18 months more 1 year 2 weeks (inversion and eversion, increased in
years) ankle than 2, and the more (giving- 30°/s) inversion
past 6 months than 6 way)
more than once) times)

Santos and Liu 6 males, 15 FAI ≥2 sprains (the + Unilateral Healthy ankles Isokinetic dynamometer Significantly
(2008)90 females (30 ± past less than 6 and normal (eversion, isometric) decreased
11 years) months) subjects (N
= 16)

(continued)
August 2014
 vol. 7 / no. 4

Table 8. (continued)

Side of
Indicate History of Time Instability
Number of CAI, FAI, or Giving- Since Last (Unilateral/
Author Subjects Other Presence of MAI History of Sprain Way Sprain Bilateral) Control Group Outcome Measurement Results
91
Sekir (2007) 24 (21 ± 2 years) FAI − (manual test) ≥2 sprains + Unilateral Healthy ankles Isokinetic dynamometer Significantly
(inversion and eversion [Coc/ decreased in
Ecc], 120°/s) inversion

Tropp 12 males, 3 FI + ≥1.5 years Unilateral Healthy ankles Isokinetic dynamometer Significantly
(1986)170 females (13-31 (dorsiflexion and eversion, decreased in
years) 30/120°/s) eversion

Wilkerson 12 males, 3 Chronic ≥2 sprains + ≥6 months Acute LAS Isokinetic dynamometer Not significant
(1997)173 females (14-19 group patients (N (inversion and eversion,
years) = 15) 30/120°/s)

Willems 4 males, 6 CAI ≥3 sprains + ≥3 months 6 unilateral, Normal subjects Isokinetic dynamometer Significantly

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(2002)92 females (18.3 ± 4 bilateral (N = 53) and (inversion and eversion, decreased in
1.1 years) coper (N = 16) 30/120°/s) eversion

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; Con, concentric; Ecc, eccentric.
a
A blank cell indicates that data were not provided.
Foot & Ankle Specialist
319
 320
Foot & Ankle Specialist

Table 9.
Studies Investigating Hip and Knee Muscle Strengtha.

History Side of
of Instability
Number of Indicate CAI, Presence of History of Giving- Time Since Last (Unilateral/
Author Subjects FAI, or Other MAI Sprain Way Sprain Bilateral) Control Group Outcome Measurement Results
181
Friel (2006) 23 (18-52 Chronic ankle ≥2 ≥3 months Unilateral Healthy ankles HHD (hip abduction and Significantly
years) sprain sprains hip extension) decreased in hip
abduction

Hubbard 15 males, 15 CAI + (arthrometer) 5.8 ± 2.7 + ≥6 weeks Unilateral Healthy ankles HHD (hip abduction and Significantly
(2007)76 females (20.3 times and normal hip extension) decreased
± 1.3 years) subjects (N
= 30)

Nicholas 11 (30 years) Chronic ankle Both Healthy ankles Isokinetic dynamometer Significantly
(1976)180 sprain (knee flexion, knee decrease in hip
extension, hip adduction, adduction and
hip abduction, and hip hip abduction

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flexion, 5/15/30 rpm)

Abbreviations: CAI, chronic ankle instability; HHD, handheld dynamometer.

a
A blank cell indicates that data were not provided.
August 2014
vol. 7 / no. 4
flexion. Thus, if the talocrural joint is not
able to fully dorsiflex, the joint will not
reach the close-pack position and may
more easily show inversion and internal
rotation.16,189
On gait analysis, the talocrural joint
shows internal rotation and the subtalar
joint shows internal rotation plus
eversion during movement from heel
contact to mid-stance.182,190 Then, from
mid-stance to toe-off, the talocrural joint
shows external rotation and eversion,
and the subtalar joint shows external
rotation plus inversion.182,190 During
running, the ankle joint shows smaller
plantar flexion after heel contact than
that during gait, whereas ankle joint
dorsiflexion and eversion in mid-stance
were larger than those during gait.191,192
Several studies indicated a deficit in
ankle joint dorsiflexion ROM in CAI
subjects,160,162,189,193,194 because CAI ankles
demonstrated talus anterior
displacement.69,72,195,196 CAI subjects
showed more ankle inversion than
normal subjects during walking,189,197,198
and the center of pressure during the
stance phase was more lateral.124,199,200 A
similar finding was suggested during
running,189,201-203 and ankle dorsiflexion
was significantly decreased.189 In
addition, the CAI ankle was more
inverted before initial contact during
drop jump landing119,125 and side
hop,120,197 and the center of pressure was
located more laterally from the early to
mid-stance phase during lateral
shuffling.204 In contrast, knee flexion was
decreased before initial contact in the
landing phase during vertical jump.205
However, these studies did not assess
whether subjects had MAI; therefore, it is
unknown whether MAI or FAI
contributes more to these abnormal
kinematics. Among recent studies that
distinguished subjects with MAI, one
study suggested that there was no
significant difference in ankle joint
kinematics during running among
subjects with MAI, FAI, and Coper,206 but
another study detected significant
differences among these 3 groups.207
Thus, consensus on this issue has not yet
been obtained. In drop jump landing, the
MAI group showed significantly more
dorsiflexion at the initial contact and
maximal inversion phase compared to
that in the FAI and Coper groups,208
while subjects with ankle instability
demonstrated less variability at the hip
and knee,209 suggesting that landing
strategies may change in CAI patients.
Therefore, it will be necessary to
distinguish subjects with MAI in future
studies, in order to clarify the
contribution of MAI to abnormal
kinematics in CAI subjects. Some
researchers have also indicated that
persons with histories of multiple sprains
who did not complain of an unstable
feeling would comprise a more suitable
control group than healthy subjects
without sprain history.196,210
Therefore, abnormal ankle kinematics
is present in CAI joints, and joint laxity is
suspected of affecting other degrees-of-
freedom. However, past in vivo
kinematic studies using surface markers
often contained soft tissue artifacts211 and
could not evaluate the kinematics of the
talocrural and subtalar joints separately.
Since a potential combined instability of
the talocrural and subtalar joints is
suspected, it is necessary to obtain
detailed measurements of abnormal
kinematics in each of these joints.69,71,72
Conclusion
LAS is one of the most commonly
occurring injuries, and subsequent
development of CAI is also common. In
the past, many studies have attempted to
identify factors that promote CAI, which
has multiple contributing causes.
However, it is difficult to compare the
findings of these studies due to the lack
of a standardized set of inclusion criteria
as well as the lack of a definitive
consensus on what constitutes ankle
instability.212 In the future, all studies will
be required to comply the position
statement of the International Ankle
Consortium.62 These selection criteria are
based on history of initial injury, history
of ongoing bouts of instability, and
ratings of patient perceived function and
disability gathered from validated survey
instruments. Furthermore, fracture or
surgery and other significant lower
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Foot & Ankle Specialist 321
extremity joint injury should be absent,
and an appropriate amount of time
should have passed since suffering acute,
inflammatory symptoms.62 In addition, a
prospective study is needed to determine
whether repeated LAS and giving-way is
the cause of these abnormalities or
whether persistent abnormalities
predispose the patient toward recurrent
LAS and giving-way.
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