THE EFFECTS OF MULTIAXIAL AND UNIAXIAL
UNSTABLE SURFACE BALANCE TRAINING IN
COLLEGE ATHLETES
TRACEY C. EISEN, JEROME V. DANOFF, JAMES E. LEONE,
Department of Exercise Science, The George Washington University Medical Center, Washington,
Downloaded from https://journals.lww.com/nsca-jscr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3dNjRBBAKGODXLWOhfSoGsG5hQ2fuWGxFwKwqXGsq18Zs/e2YGddcTg== on 04/09/2020
District of Columbia
ABSTRACT
Eisen, TC, Danoff, JV, Leone, JE, and Miller, TA. The effects
of multiaxial and uniaxial unstable surface balance training
in college athletes. J Strength Cond Res 24(7): 1740–1745,
2010—The purpose of this study was to compare the effects of
2 different types of unstable surface balance training (uniaxial
on a rocker board [RB] and multiaxial on a dynadisc [DD]) on
balance in division 1 collegiate athletes in sports that are at high
risk for ankle sprains. Subjects (n = 36) consisted of male
soccer players and female volleyball and soccer players who
were equally and randomly assigned to 1 of 3 groups (CON,
DD, and RB). Balance training consisting of balancing on 1 leg
on either the RB or DD, while repeatedly catching a 1-kg ball
was performed 3 times per week for 4 weeks. Balance was
tested with the Star Excursion Balance Test (SEBT) before,
halfway through, and at the completion of the balance training.
Control (CON) subjects also were given the balance test but
did not participate in the training. A 3-way repeated analysis of
variance revealed that no group individually changed SEBT
scores from pre (CON, 0.98 6 0.086; DD, 0.98 6 0.083; RB,
0.97 6 0.085) to post (CON, 1.00 6 0.090; DD, 1.01 6
0.088; RB, 1.02 6 0.068) after balance training. When the 2
treatment groups were combined (DD and RB), the p value
decreased and came closer to significance (p = 0.136). When
all 3 groups were combined, there was a significant difference
in SEBT scores from pretraining (CON + DD + RB; 0.98 6
0.085) to posttraining (CON + DD + RB; 1.01 6 0.082), which
likely indicates low statistical power. The increase in physical
activity the subjects experienced during the return to in-season
activity, may have contributed to the significant differences in
SEBT scores over time but not between DD or RB training.
Address correspondence to Todd A. Miller, tamiller@gwu.edu.
24(7)/1740–1745
Journal of Strength and Conditioning Research
Ó 2010 National Strength and Conditioning Association
the TM
1740 Journal of Strength and Conditioning Research
AND TODD A. MILLER
Therefore, a threshold level of physical activity may exist that is
necessary to maintain balance during the off-season.
KEY WORDS functional ankle instability, star excursion balance
test, proprioception
INTRODUCTION
A
nkle sprains are common in sports involving
running and jumping, particularly when in close
proximity to other players (29). A usual mecha-
nism for such injury is landing on another player’s
foot when jumping, which forces the foot rapidly into
plantarflexion and inversion, stretching and sometimes
tearing the lateral ligaments of the ankle (31). Other risk
factors of ankle injury are numerous, including intrinsic
factors, such as unstable postural sway, muscle weakness and
imbalance, poor flexibility or a hypermobile ankle joint, poor
proprioception, previous predisposing injury, gender, and
anatomical malalignment of the ankle and foot (5,9,17,22,
26,35), and extrinsic risk factors, such as shoe type, taping,
orthotics worn in footwear, and playing surface (37,38).
Functional instability has been defined as ‘‘the occurrence of
recurrent joint instability and the sensation of joint instability
because of the contributions of any neuromuscular deficits,’’
(17) and becomes evident in up to 20–42% of the patients
suffering from an acute ankle injury (4,19).
Balance is an individual’s ability to maintain his or her
center of gravity within the base of support (39). Stabilization
of postural equilibrium is maintained by continuous afferent
and efferent signals within the sensorimotor system with
feedback from somatosensory, vestibular, and visual inputs
(3). Of the 3 classes of afferent nerves responsible for provid-
ing proprioceptive feedback (nerves in the ligaments and
joint capsule, skin, or muscle tissue), muscle afferents are
thought to play the most important role (33). Motor skill
training, which includes balance training, promotes the
neuromuscular mechanisms responsible for the co-contrac-
tion of agonist and antagonist muscles that enhance joint
stability by increasing the sensitivity of feedback pathways
and shortening the onset time of these muscles; this increased
joint stiffness results in less joint displacement and thus less

strain on joint structures (3,21). The ability to involuntarily
increase joint stiffness when in an unstable situation has been
shown on multiple occasions to reduce the rate of ankle
sprains in athletes (3,4,12,21,26–28,30,38). For example,
implementation of balance board training in Dutch volleyball
players resulted in a significantly lower incidence of ankle
sprains per 1,000 playing hours, when compared to a control
group that did no balance training (36).
To stimulate reflex joint stabilization, some believe that
activities should focus on sudden alterations in joint
positioning (26). Unstable surfaces provide these sudden
alterations and make training more dynamic, and possibly
more applicable to a sporting context (21). A commonly used
unstable surface is a rocker board (RB), which is a flat,
wooden surface, typically placed on a half cylinder or a dowel
to allow for uniaxial movement along 1 axis of the ankle.
With this type of device, the direction of training is
determined by the position of the foot relative to the dowel
beneath the board. In contrast, an ankle disc, that is,
a dynadisc (DD), is a flexible plastic pillow filled with air that
allows for multiaxial ankle movement in all axes of the ankle,
regardless of foot position on the disc. The muscles that
stabilize the ankle to prevent any unwanted motion are the
invertors and evertors (such as the tibialis posterior and
peroneal muscles) and plantarflexors and dorsiflexors (such
as the gastrocnemius and the tibialis anterior) (31). Although
uniaxial balance training and multiaxial balance training have
both been shown to be effective at increasing balance, no
studies have been found that compare the effects of uniaxial
vs. multiaxial balance training. Therefore, the purpose of this
study was to determine whether mulit vs uniaxial balance
training lead to differences in measured balance.
METHODS
Experimental Approach to the Problem
As stated earlier, some researchers argue that a sudden
alteration in joint positioning is effective at stimulating reflex
joint stabilization (26). If this is in fact the case, one might
expect that a device designed to induce these alterations in
joint position multiaxially, such as the DD (Fitball brand,
Allegro Medical, Scottsdale, AZ, USA) (Figure 1) might be
more effective at stimulating reflex joint stabilization than
a device designed to induce these alterations uniaxially, such
as the RB (Exertools, Rohnert Park, CA, USA) (Figure 2),
which allows for 12.5° of inversion and eversion only.
To date, no research has been performed that compares the
effects of uniaxial vs. multiaxial balance training on balance.
For this reason, the DD and RB were selected as the balance
training devices in this study. With respect to balance testing,
a dynamic test may be more sports specific than a purely
static test because athletes are exposed to situations where
balance is dynamically challenged every time they step,
run, or jump (21). For this reason, a dynamic test, the
Star Excursion Balance Test (SEBT) was used to test balance
the TM
Journal of Strength and Conditioning Research | www.nsca-jscr.org
Figure 1. Dynadisc provides multiaxial movement of the ankle.
before, during, and after 12 sessions of multiaxial or uniaxial
balance training.
Subjects
Subjects were athletes from the George Washington University
(GWU) in Washington, DC, USA. Subjects were informed of
the experimental risks and signed an informed consent
document before the investigation. The investigation was
approved by the Institutional Review Board for use of Human
subjects at GWU. Subjects were members of the women’s
volleyball, men’s soccer, and women’s soccer teams, ages
ranged from 18 to 22 years. Subjects were all athletes who at the
start of data collection were resuming athletic team practice
and strength and conditioning sessions after an 8-week break
from regularly scheduled physical activity. Data collection
occurred throughout the late winter and early spring months,
simultaneous with the start of the spring playing season for all
subjects in this study. Subjects were attending regular practices
and organized strength and conditioning sessions 2–3 times per
week. Soccer and volleyball were chosen because of 16 college
sports observed between 1988 and 2004 by Hootman et al.
(20); these had the highest rates of ankle sprains, according to
the National Collegiate Athletic Association Injury Surveil-
lance System (20). All of these teams were out of season during
data collection, so outside training was easily controlled,
because it consisted mainly of strength and conditioning and
agility sessions.
The subject pool of 44 participants was reduced to 36 after
multiple participants were excluded because of existing or
new injuries incurred during the time of data collection.
Participants (n = 36) were recruited via an informational
session at a regularly scheduled strength and conditioning
session for each of the participating teams. Subjects
completed a preparticipation data form solely to identify
issues that could affect the outcome of the investigation,
and to determine which leg was usually used as the support
for a single limb activity such as kicking. Exclusion criteria
VOLUME 24 | NUMBER 7 | JULY 2010 | 1741
Surface Balance Training

Figure 2. Rocker board provides uniaxial movement of the ankle.
included anyone who had any lower back injury, leg injury,
or a concussion as recently as 4 weeks before data collection,
hypertension, recurrent fainting, or was simultaneously
involved in an outside balance training program. Any
subjects who experienced a leg, back, or head injury during
the course of the investigation also were excluded.
To achieve stratified randomization, subjects first com-
pleted the baseline balance test and were then ranked by the
investigator from the lowest to the highest %maxd (this
outcome measure is explained in the testing procedures).
Each subject was assigned a number depending on pretest
score, sequentially from highest to lowest (1–36). Based on
ranking, scores were classified as top third (numbers one
through 12), middle third (numbers 13–24), and lowest third
(numbers 25–36). Individuals in each of these sections were
randomly assigned to 1 of the 3 experimental conditions:
control (CON), RB, and DD.
Procedures
Balance Testing. Balance testing consisted of the SEBT, as
previously described by Bressel et al. (5), Buckley et al. (6),
Gribble et al. (14), Hertel (18), Kinzey (25), Plisky (32), and
Robinson (34). Briefly, the SEBT consisted of 8 lines of cloth
measuring tape adhered to the floor with clear packing tape
45° apart from each other, in the shape of an asterisk. Before
testing, the lengths of both lower extremities of each subject
were measured by the investigator from the anterior superior
iliac spine of the hip to the distal end of the medial malleolus
(14). While testing, subjects stood on one leg in the middle of
the star and reached as far as possible with their toes of the
opposite leg, holding their hands on their hips, and keeping
the heel of the stance leg on the ground. A mark on the tape
was made by the investigator with an erasable marker and the
distance was read from the center of the star to the mark (14).
After each reach, the distance was recorded and the mark
erased so that the subject did not use that mark as a target for
the next trial. Subjects performed only the posteromedial
reach, because this component of the SEBT is highly repre-
sentative of the performance of all 8 components of the test in
limbs with and without chronic ankle instability (14). The
subject first practiced the test 3 times, waited 5 minutes, and
then performed the test 3 times. The 3 lengths were averaged
to find the reach length that was used in the analysis. Hertel
et al. (18) also used the averages of 3 reach lengths to
determine balance. They applied factor analysis and analysis
of variance (ANOVA) to compare the reach directions
and concluded that there was sufficient redundancy in the
test procedure for any single direction to suffice as a valid
representation of lower extremity functional performance.
To normalize the reach length, the investigator divided the
reaching distance by the length of the stance lower extremity,
then multiplied by 100. This number, abbreviated as %maxd,
represents the reach distance as a percent of limb length
(14,18). Testing was performed for both limbs and occurred
on the initial day of data collection and after the 6th and 12th
training sessions. Testing was conducted when the subjects
reported to their sport’s scheduled strength and conditioning
session before any other activities began.
Balance Training. Subjects in each testing group reported at
their scheduled time to participate in their regular strength

TABLE 1. Test scores on the star excursion balance test.*†

Group Pre Post Change p Value

DD (n = 12) 0.98 6 0.083 1.01 6 0.088 0.031 6 0.080 0.337

RB (n = 12) 0.97 6 0.085 1.02 6 0.068 0.046 6 0.076 0.348
CON (n = 12) 0.98 6 0.086 1.00 6 0.090 0.021 6 0.059 0.215
DD + RB (n = 24) 0.98 6 0.084 1.02 6 0.078 0.041 6 0.078 0.136
DD + RB + CON (n = 36) 0.98 6 0.085 1.01 6 0.082‡ 0.033 6 0.072 0.007
*DD = dynadisc; RB = rocker board; CON = control.
†Values are given as mean 6 SE.
‡Denotes significant difference from pretest (p , 0.001).

the TM

1742 Journal of Strength and Conditioning Research


and conditioning session, and the balance training was
included at the end of the warm-up. Balance training occurred
3 times each week for 4 weeks, as 12 sessions have been
shown to be the minimum number needed to result in balance
improvement (16). No balance training was performed by
subjects in the CON group. Subjects in the experimental
groups paired up, and one partner balanced on the assigned
surface, RB or DD. Balancing only was done on the
predetermined stance leg. If the subject was on a DD, the
stance foot was in the middle of the pillow. If the subject was
on an RB, the stance foot was in the middle of the board
aligned parallel to the dowel on the underside and the board
was balanced so that neither the medial nor the lateral edge
touched the ground. The partner stood 10 ft back (marked
by tape on the ground) and tossed a 1-kg weighted ball
underhanded directly to the balancing partner. When
catching and then throwing the ball back to his or her
partner, the participant attempted to stay on 1 leg on the
given unstable surface, and if balancing on the RB, he or
she attempted to keep the board balanced. Each partner
performed 3 sets of 12 catches on the unstable surface. The
athlete’s rest between sets was when the partner was doing
the balancing. Throughout the data collection, subjects were
asked not to practice the SEBT or perform any additional
or other type of balance training outside of their sport or
strength and conditioning.
Statistical Analyses
Power analysis based on preliminary data established that
with a sample size of 36 subjects, statistical power was
approximately 30%. A 3-way repeated ANOVA was con-
ducted with group as a between subjects independent variable
(the 3 groups were CON, RB, and DD) and time and limb
as within subjects (repeated) dependent variables. Outcome
measures were recorded as %maxd and change in %maxd
throughout the testing. Significant F values, set at a p value of
p # 0.05, were subject to Tukey post hoc analysis. In addition,
injuries were tracked to compare to national rates in these
sports previously determined through a surveillance system
(20). Intraclass correlation coefficient (2,1) of the SEBT was
previously established at 0.87 (25).
RESULTS
With a starting subject pool of 44 and a final n = 36,
the adherence rate was 81.8%. Five of the subjects excluded
had previous injuries that disqualified them from par-
ticipation and 3 of the subjects were excluded because of
new injuries incurred during athletic team practices during
the study period. None of these injuries were at the ankle
joint. Performance on the SEBT was significantly different
from the pretest to the posttest when all groups and
sides were combined, p = 0.007 (Table 1). There was no
difference for each group individually, though, and no differ-
ence between trained and untrained legs within subject (data
not shown).
the TM
Journal of Strength and Conditioning Research | www.nsca-jscr.org
DISCUSSION
The results of this study show that individually, no group
showed a significant increase in SEBT score over time. When
the experimental groups are compared together against the
CON group, the p score comes closer to significance. When
all groups are combined, there was a significant difference
pre to post. The lack of a significant difference in SEBT score
for individual treatment groups could be the result of several
possible factors. First, both Impivaara et al. (23) and Davlin
(11) found that athletes have superior performance in
dynamic balance tasks than do nonathletes. From this, one
could speculate that the regular, high levels of physical
activity that these athletes were exposed to could be an
important contributor to improved dynamic balance. Sub-
jects in this study were all athletes who at the start of data
collection were resuming athletic team practice and strength
and conditioning sessions after an 8-week break from
regularly scheduled physical activity. Possibly the decreased
level of activity preceding this study represented a detraining
condition with respect to balance. As a result, the increased
level of physical activity that occurred upon resumption of
regularly scheduled sport participation may have lead to
significantly improved scores on the SEBT.
The reporting of improvements in balance among a control
group of subjects is not without precedent. Chaiwanichsiri
et al. (8) used the SEBT as a balance training method for
athletes for 3 d
wk21 for a 4-week period. Single leg stance
time assessed at pre and posttraining improved for both the
training group and the control group, but the training group
demonstrated significantly greater improvement (p # 0.015)
than the control group. This suggests that there is either
a treatment effect or practice effect with repeated execution
of the SEBT. Because the Chaiwanichsiri study did not test
midway through the training, it is difficult to determine
if the SEBT score improvements were from the subjects
getting better at performing the task, which would represent
a practice effect or if the task actually increased subjects’
balance ability, which would represent a treatment effect.
Therefore, it is difficult to determine if improvements on the
SEBT in the current study were because of a practice or
training effect. If it were a training effect, then this study
suggests that the SEBT only needs to be performed once
every 2 weeks for 1 month to improve balance ability.
Statistical power for the sample size in the current study
was low (approximately 30%) because of a small subject pool,
and the probability of a type 2 error is consequently high.
Estimates based on preliminary data indicated that a subject
pool of about 400 people would have been necessary to
achieve a power of 70–80%. The changes in SEBT score
measured were small compared with the overall variability of
the scores. Therefore, true improvements might have been
obscured resulting in a type 2 error.
A possible contributor to the high variability in this study
was sport selection. The SEBT is different from other
VOLUME 24 | NUMBER 7 | JULY 2010 | 1743
Surface Balance Training
dynamic balance tests because it requires the subject to
perform a maximal reach while balancing. Some sports may
have a greater requirement for increased reach ability than
others, so it might be practiced more; for example, one would
expect a gymnast to be able to reach farther than a volleyball
player because of the demands of the sport, though this has
not been studied. A future study may have smaller SD, and
possibly significant findings, if all subjects compete in the
same sport.
The subjects used in this current study did not have
an ankle injury in the 4 weeks before commencement of
data collection, but functional ankle instability is a lingering
complication of previous ankle injury (2) and not identifying
people with a history of ankle sprains prevented the detection
this disability. In an earlier study, people with functional
instability in 1 limb yielded significantly lower scores when
performing the SEBT on that limb when compared with their
other, healthy limb (7). This presents the possibility
of a nonhomogenous subject pool that could have contributed
to the high variability in this study. In future research, subjects
should have a similar injury history, increasing the chance that
they will start with similar scores on the SEBT.
As discussed, physical activity contributes to increased
balance ability (11,23). One would expect that if persons are
already skilled at something, they do not have as much
potential for growth with training as would persons who are
new to that skill. Another group of individuals who have
not shown to benefit from balance training are subjects
who have uninjured ankles (10,21), as was the case with
the current study. A possibility for future research would be
to use inactive or recently injured subjects, because they have
been shown to benefit from balance training programs (4,15).
Injuries incurred during the data collection period consisted
of a contact-related concussion, a contact-related low back
muscular strain, and lower leg compartment syndrome.
Ankle injury rate during this study was 0. National rates of
ankle injuries per 1,000 athlete exposures from 1988–1989
to 2003–2004 according to the National Collegiate Athletic
Association Injury Surveillance System for men’s soccer,
women’s soccer, and women’s volleyball were 1.24, 1.30, and
1.01, respectively (20). One could deduce from this that this
study’s training program was a contributing factor to ankle
injury prevention, but further research is needed to decide
this conclusively.
Twelve training sessions may have been sufficient in
previous research (16), but it needs to be recognized that this
protocol was different from others shown to help improve
balance. Each training session only consisted of 1 exercise.
One program proven to help balance involved 12 exercises
on an assortment of different unstable surfaces (12). Another
program involved a periodization scheme, which at times
involved up to 13 different tasks on just 2 different surfaces,
the floor and an RB (4). For a training program to contribute
to improvements in balance, it needs to challenge the
participant.
the TM
1744 Journal of Strength and Conditioning Research
As previously stated, balance is an individual’s ability to
maintain his or her center of gravity within the base of support
(39). Dynamic balance is the ability to perform a task while
maintaining a stable position (5). If performed correctly, the
SEBT tests just that. The SEBT also may train dynamic
balance; this needs to be further investigated. As mentioned,
considerations for future research also include making subject
pools more specific; however, using other populations could
be used to determine if the same protocol could have
different effects. Younger athletes, nonathletes, other sports,
and different injury statuses should be explored.
PRACTICAL APPLICATIONS
Because physical activity often results in an improvement in
balance (11,23), the authors feel that the physical activity
level of the subjects was an independent predictor of balance
ability. Preseason balance ability is a significant independent
predictor of ankle ligament injury (22), so physical activity, be
it balance training or otherwise, needs to be maintained
during any break in athletic participation to keep a high level
of balance. Activities need to challenge the athlete enough to
actually garner improvements in balance. Postural control
appears to correlate with anaerobic and aerobic capacity (13),
so activities that stress these components should be sufficient.
The subjects in the current study participated in conditioning
sessions 3 times per week, which included agility training,
3 or 4-mile-long runs, and strength training sessions 3 times
per week that usually lasted for 1 hour. This level of activity
was likely much higher than that which the subjects
voluntarily performed during the off-season and is likely
partially responsible for the improved balance in the control
group. Because of the important role that general physical
activity may play in maintaining balance, physical activity
should be kept high during the off-season. Conventional
training programs that focus on general fitness (i.e., strength,
flexibility, power, and endurance) are likely to be adequate for
maintaining balance. Finally, injury rates are significantly
higher in the competitive preseason than in- or postseason
(1,20,24), so the off-season is just as important as any other
time in the athletic year to maintain physical activity.
ACKNOWLEDGMENTS
The authors would like to thank the subjects who donated
their time and effort into the completion of this study.
REFERENCES
1. Agel, J, Evans, TA, Dick, R, Putukian, M, and Marshall, SW.
Descriptive epidemiology of collegiate men’s soccer injuries:
National collegiate athletic association injury surveillance system,
1988–1989 through 2002–2003. J Athl Train 42: 270–277, 2007.
2. Anandacoomarasamy, A and Barnsley, L. Long term outcomes of
inversion ankle injuries. Br J Sports Med 39: e14, 2005.
3. Anderson, K and Behm, DG. The impact of instability resistance
training on balance and stability. Sports Med 35: 43–53, 2005.
4. Bernier, J and Perrin, NDH. Effect of coordination training on
proprioception of the functionally unstable ankle. J Orth Sports Phys
Ther 27: 264–275, 1998.

5. Bressel, E, Yonker, JC, Kras, J, and Heath, EM. Comparison of static
and dynamic balance in female collegiate soccer, basketball, and
gymnastics athletes. J Athl Train 42: 42–46, 2007.
6. Buckley, WE, Denegart, CR, Gribble, PA, and Hertel, J. The effects
of fatigue and chronic ankle instability on dynamic postural control.
J Athl Train 39: 321–330, 2004.
7. Carcia, CR, Hertel, J, Olmsted, LC, and Shultz, SJ. Efficacy of the star
excursion in balance tests in detecting reach deficits in subjects with
chronic ankle instability. J Athl Train 37: 501–506, 2002.
8. Chaiwanichsiri, D, Lorprayoon, E, and Noomanoch, L. Star
excursion balance training: Effects on ankle functional stability after
ankle sprain. J Med Assoc Thailand 88: S90–S94, 2005.
9. Coughlan, G and Caulfield, B. A 4-week neuromuscular training
program and gait patterns at the ankle joint. J Athl Train 42: 51–59,
2007.
10. Cox, ED, Irrgang, JJ, and Lephart, SM. Unilateral balance training of
noninjured individuals and the effects on postural sway. J Sport
Rehab 2: 87–96, 1993.
11. Davlin, CD. Dynamic balance in high level athletes. Percep Motor
Skills 98: 1171–1176, 2004.
12. Eils, E and Rosenbaum, D. A multi-station proprioceptive exercise
program in patients with ankle instability. Med Sci Sports Exerc
33: 1991–1998, 2001.
13. Era, P and Heikkinen, E. Postural sway during standing and
unexpected disturbance of balance in random samples of men of
different ages. J Gerontol 40: 287–295, 1985.
14. Gribble, PA, Hertel, J, and Denegar, CR. Chronic ankle instability
and fatigue create proximal joint alterations during performance
of the star excursion balance test. Int J Sports Med 28: 236–242,
2007.
15. Hale, SA, Hertel, J, and Olmsted-Kramer, LC. The effect of a 4-week
comprehensive rehabilitation program on postural control and
lower extremity function in individuals with chronic ankle instability.
J Orth Sports Phys Ther 37: 303–311, 2007.
16. Heitkamp, HC, Horstmann, T, Mayer, F, Weller, J, and
Dickhuth, HH. Gain in strength and muscular balance after
balance training. Int J Sports Med 22: 285–290, 2001.
17. Hertel, J. Functional instability following lateral ankle sprain. Sports
Med 29: 361–371, 2000.
18. Hertel, J, Braham, RA, Hale, SA, and Olmsted-Kramer, LC.
Simplifying the star excursion balance test: Analyses of subjects with
and without chronic ankle instability. J Orth Sports Phys Ther 36:
131–137, 2006.
19. Hintermann, B. Biomechanics of the unstable ankle joint and clinical
implications. Med Sci Sports Exerc 31: S459–S469, 1999.
20. Hootman, JM, Dick, R, and Agel, J. Epidemiology of collegiate
injuries for 15 sports: Summary and recommendations for injury
prevention initiatives. J Athl Train 42: 311–319, 2007.
21. Hrysomallis, C. Relationship between balance ability, training and
sports injury risk. Sports Med 37: 547–556, 2007.
22. Hrysomallis, C, McLaughlin, P, and Goodman, C. Balance and
injury in elite Australian footballers. Int J Sports Med 28: 844–847,
2007.
the TM
Journal of Strength and Conditioning Research | www.nsca-jscr.org
23. Impivaara, O, Karppi, SL, and Raty, HP. Dynamic balance in former
elite male athletes and in community control subjects. L’equilibre
dynamique chez les anciens athletes masculins de haut niveau et
chez les sujets d ’un groupe de controle. Scand J Med Sci Sports
(Copenhagen). 12: 111–116, 2002.
24. Kellis, E, Kofotolis, ND, and Vlachopoulos, SP. Ankle sprain injuries
and risk factors in amateur soccer players during a 2-year period. Am
J Sports Med 35: 458–466, 2007.
25. Kinzey, SJ and Armstrong, CW. The reliability of the star-excursion
test in assessing dynamic balance. J Orth Sports Phys Ther 27: 356–
360, 1998.
26. Lephart, SM, Pincivero, DM, Giraldo, JL, and Fu, FH. The role of
proprioception in the management and rehabilitation of athletic
injuries. Am J Sports Med 25: 130–137, 1997.
27. Lync, SA and Renstrom, PA. Treatment of acute lateral ankle
ligament rupture in the athlete. Conservative versus surgical
treatment. Sports Med 27: 61–71, 1999.
28. Mcguine, TA and Keene, JS. The effect of a balance training program
on the risk of ankle sprains in high school athletes. Am J Sports Med
34: 1103–1111, 2006.
29. Nelson, AJ, Collins, CL, Yard, EE, Fields, SK, and Comstock, RD.
Ankle injuries among united states high school sports athletes,
2005–2006. J Athl Train 42: 381–387, 2007.
30. Nilsson, G, Ageberg, E, Ekdahl, C, and Eeneroth, M. Balance in
single-limb stance after surgically treated ankle fractures: A 14-
month follow-up. BMC Musculoskel Dis 7: 35, 2006.
31. Oatis, CA. Kinesiology: The Mechanics and Pathomechanics of Human
Movement. Philadelphia, PA: Lippincott Williams & Wilkins, 2004.
32. Plisky, PJ, Rauth, MJ, Kaminiski, TW, and Underwood, FB. Star
excursion balance test as a predictor of lower extremity injury in high
school basketball players. J Orth Sports Phys Ther 36: 911–919, 2006.
33. Refshauge, KM, Kilbreath, SL, and Raymond, J. The effect of
recurrent ankle inversion sprain and taping on proprioception at the
ankle. Med Sci Sports Exerc 32: 10–15, 2000.
34. Robinsion, RH and Gribble, PA. Support for a reduction in the
number of trials needed for the star excursion balance test. Arch Phys
Med Rehab 89: 364–370, 2008.
35. Troijian, TH and Mckeag, DB. Single leg balance test to identify risk
of ankle sprains. Br J Sports Med 40: 610–613, 2006.
36. Verhagen, EA, Van Tulder, M, Van Der Beek, AJ, Bouter, LM, and
Van Mechelen, W. An economic evaluation of a proprioceptive
balance board training programme for the prevention of ankle
sprains in volleyball. Br J Sports Med 39: 111–115, 2005.
37. Waddington, G and Adams, R. Football boot insoles and sensitivity
to extent of ankle inversion movement. Br J Sports Med 37: 170–174,
2003.
38. Wang, HK, Chen, CH, Shiang, TY, Jan, MH, and Lin, KH. Risk-
factor analysis of high school basketball-player ankle injuries: A
prospective controlled cohort study evaluating postural sway, ankle
strength, and flexibility. Arch Phys Med Rehab 87: 821–825, 2006.
39. Yaggie, JA and McGregor, SJ. Effects of isokinetic ankle fatigue on
the maintenance of balance and postural limits. Arch Phys Med Rehab
83: 224–228, 2002.
VOLUME 24 | NUMBER 7 | JULY 2010 | 1745