Clin Orthop Relat Res (2020) 478:359-377
DOI 10.1097/CORR.0000000000000946
Meta-analysis
Do External Supports Improve Dynamic Balance in Patients with
Chronic Ankle Instability? A Network Meta-analysis
Konstantinos Tsikopoulos MD, MSc, Konstantinos Sidiropoulos MD, Dimitrios Kitridis MD, MSc,
Spencer M. Cain ATC MSc, PhD, Dimitrios Metaxiotis MD, PhD, Ashique Ali MD
Received: 13 April 2019 / Accepted: 8 August 2019 / Published online: 14 October 2019
Copyright © 2019 by the Association of Bone and Joint Surgeons
Each author certifies that neither he, nor any member of his im-
mediate family, have funding or commercial associations (con-
sultancies, stock ownership, equity interest, patent/licensing
arrangements etc) that might pose a conflict of interest in con-
nection with the submitted article.
Each author certifies that his institution waived approval for the
reporting of this investigation and that all investigations were
conducted in conformity with ethical principles of research.
This work was performed at the 424 Army General Training Hos-
pital, Thessaloniki, Greece.
K. Tsikopoulos, D. Kitridis, 424 Army General Training Hospital,
Thessaloniki, Greece
K. Tsikopoulos, Orthopedic Department, University Hospitals of
North Midlands, Stoke-on-Trent, UK
K. Sidiropoulos, Orthopaedic Department, General Hospital of
Serres, Serres, Greece
D. Kitridis, First Orthopedic Department of Aristotle University, G.
Papanikolaou General Hospital, Exohi, Thessaloniki, Greece
S. M. Cain, Department of Exercise and Sports Science, University of
North Carolina at Chapel Hill, Chapel Hill, NC, USA
D. Metaxiotis, Second Orthopedic Department, Papageorgiou
General Hospital, Thessaloniki, Greece
A. Ali, Orthopedic Department, University Hospitals of North
Midlands, Stoke-on-Trent, UK
K. Tsikopoulos (✉), Orthopaedic Department, University Hospitals
of North Midlands, Newcastle Rd, Stoke-on-Trent UK ST4 6QG,
Email: kostastsikop@gmail.com
All ICMJE Conflict of Interest Forms for authors and Clinical Or-
thopaedics and Related Research® editors and board members are
on file with the publication and can be viewed on request.
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Abstract
Background To improve ankle stability in patients who
have experienced an ankle sprain with residual symptoms
of instability and/or objective joint laxity, external supports
(such as taping, bracing, and orthotic insoles) are used
sometimes. However, available randomized trials have
disagreed on whether restraints improve balance in those
individuals. In this situation, a network meta-analysis can
help because it allows for comparing multiple treatments
simultaneously, taking advantage not only of direct but
also indirect evidence synthesis.
Questions/purposes The aim of this network meta-
analysis was to assess (1) the impact of taping and or-
thotic devices on dynamic postural control in individuals
with ankle instability and (2) the presence of a placebo
effect in participants treated with sham taping and com-
plications resulting from the administered treatments.
Methods We searched the PubMed, Scopus, and CEN-
TRAL databases up to February 13, 2019 for completed
studies. Randomized trials assessing the results of real
and/or sham taping, wait-and-see protocols, ankle bracing,
and foot orthotics for ankle instability as determined by one
or more ankle sprains followed by ongoing subjective
symptoms and/or mechanical laxity were included. We
evaluated dynamic postural control in terms of the Star
Excursion Balance Test in the posteromedial direction
(SEBT-PM), which is considered the most representative
of balance deficits in patients with ankle instability. Stan-
dardized mean differences were re-expressed to percentage
differences in SEBT-PM, with higher scores representing
possible improvement. Subsequently, those data were
checked against the established minimal detectable change
of 14% for this scale to make judgements on clinical
 360 Tsikopoulos et al.
importance. We also assessed the presence of a placebo
effect by comparing the results of sham taping with no
treatment and complications resulting from the adminis-
tered treatments. Additionally, we judged the quality of
trials using the Cochrane risk of bias tool and quality of
evidence using the Grading of Recommendations, As-
sessment, Development, and Evaluations (GRADE) ap-
proach. A total of 22 trials met our inclusion criteria, 18 of
which were deemed to be at a low risk of bias. A network of
treatments consisting of 13 studies was created, and the
level of evidence was judged to be high. As far as partic-
ipants’ allocation to treatment arms, 85 patients followed a
wait-and-see protocol, 29 received placebo taping, 99 were
treated with taping, 16 were treated with bracing, 27 were
administered insoles, and six individuals were offered a
combination of insoles with bracing. Of note, with statis-
tical power set at 80%, a minimum of 16 patients per
treatment group was required to provide sufficient statis-
tical power and detect a SEBT-PM percentage difference of
14%.
Results A network meta-analysis did not demonstrate a
benefit of taping or bracing over no treatment (percentage
difference in SEBT-PM between taping and bracing versus
control: -2.4 [95% CI -6 to 1.1]; p = 0.18, and -7.5 [95% CI
-15.9 to 1]; p = 0.08, respectively). This was also the case
for sham taping because the measurement increase failed to
exceed the minimal detectable change (percentage differ-
ence in SEBT-PM between sham taping and untreated
control: -1.1 [95% CI -6.9 to 4.7]; p = 0.72). Importantly,
there were no reported adverse events after treatment
application.
Conclusions Evidence of moderate strength indicated that
external supports of any type were no more effective than
controls in improving dynamic postural control in patients
with at least one ankle sprain and residual functional or
mechanical deficits. Therefore, implementing those tools
as a standalone treatment does not appear to be a viable
strategy for the primary management of ankle instability. It
is conceivable that combinations of rehabilitation and ex-
ternal supports could be more effective than external sup-
ports alone, and future trials should evaluate the potential
of such combinations in enhancing not only clinician-
reported but also patient-oriented outcomes using long-
term follow-up measurements.
Level of Evidence Level I, therapeutic study.
Introduction
It is believed that as many as 74% of individuals with an
initial ankle sprain will experience either a subsequent
ankle sprain injury or residual symptoms such as pain,
weakness, and giving-way episodes [5, 21, 27]. Those
chronic symptoms are commonly designated as “chronic
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
ankle instability” [13] and are associated with decreased
levels of physical activity [37]. Importantly, the incidence
of posttraumatic osteoarthritis resulting from instability of
this sort can be as high as 78% [34, 56]. Rehabilitation
emphasizing balance has been shown to effectively reduce
the symptoms of ankle instability [53, 54]. The addition of
external supports such as bracing, taping, and orthotic
insoles in shoes could both yield better outcomes and re-
duce the time and effort required. In evaluating treatment
outcomes in ankle instability patients, postural control
deficit is one of the major modifiable impairments clini-
cians and researchers should focus on [6, 46].
However, given the discrepant results reported in
multiple randomized controlled trials (RCTs) assessing
the impact of taping and orthotic devices on dynamic
postural control in patients with chronic lateral ankle in-
stability [7, 12, 22, 39, 52, 58], we considered that pooling
data to elucidate this research topic would be of the es-
sence. Furthermore, earlier authors have failed to draw
safe conclusions on the existence of a placebo effect of
ankle taping in patients with ankle instability [12, 51].
Therefore, whether patients’ performance is affected by
their belief or expectations that taping prevents injury
remains unclear.
A network meta-analysis allows readers to assess the
relative efficacy of multiple competing treatments and
potentially rank them even if they have not been previously
compared in head-to-head RCTs. This approach could help
us gain a more complete understanding of the role of tap-
ing, bracing, and orthotic devices in the care of patients
with chronic ankle instability by critically appraising key
comparisons drawn from randomized trials in a robust way
[9, 19].
Therefore, in the current network meta-analysis, we
sought to assess (1) the impact of taping and orthotic
devices on dynamic postural control in individuals with
ankle instability and (2) the presence of a placebo effect in
participants treated with sham taping and complications
resulting from the administered treatments.
Materials and Methods
We registered the present systematic review in advance
with PROSPERO (CRD42016037849), and abided by the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines for network meta-
analyses [38].
Inclusion and Exclusion Criteria
We considered randomized trials investigating the results
of real and/or sham taping, ankle bracing, and foot
 Volume 478, Number 2
orthotics, or a combination of the above in individuals with
chronic ankle instability. Patients with functional ankle
instability and/or mechanical ankle instability were eligible
for inclusion [33]. We discarded trials dealing with acute
ankle sprains. For qualitative synthesis, we considered
parallel-group and crossover trials assessing dynamic bal-
ance; whereas for quantitative synthesis, we narrowed our
criteria to studies evaluating the aforementioned outcome
using the Star Excursion Balance Test (SEBT) only. Also,
to achieve homogeneity in the treatment arms, we excluded
trials considering adjuvant therapies from quantitative
synthesis.
Information Sources and Search
We performed electronic database and manual searching to
identify completed published and unpublished trials until
February 13, 2019. For the database search, we included
the databases of PubMed, Web of Science, Scopus, and
Cochrane Central Register of Controlled Trials, whereas
for the manual search, we considered the trial registries of
International Standard Randomized Controlled Trial
Number, ClinicalTrials.gov, and the Australian New
Zealand Clinical Trials Registry. Reference lists of
pertinent systematic reviews were also examined.
In particular, we searched for the following terms in
PubMed to identify potentially relevant studies:
Fig. 1 A flowchart of the study selection procedure is shown; SEBT = Star Excursion Balance
Test.
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External Supports for Ankle Instability 361
“controlled trial,” “random*,” “comparative study,” “ankle
sprain,” “ankle,” “chronic lateral ankle,” “instability,”
“mechanically unstable,” “functional ankle instability,”
“mechanical ankle instability,” “functionally unstable,”
“chronic complaint,” “ankle strain,” “re-injury,” “ankle
injury,” “tapping,” “bracing,” “passive restraints,” “tape,”
“taping,” and “strap*” (see Table, Supplemental Digital
Content 1, http://links.lww.com/CORR/A219).
Study Selection
Two review authors (DK, KT) performed the search in-
dependently without language restrictions to identify po-
tentially relevant records. Thereafter, duplicates were
removed, and the titles and abstracts of the retrieved articles
were screened for eligibility. Subsequently, for the re-
mainder of the articles, the full-text articles were assessed
for inclusion. Any discrepancies in the aforementioned
study selection procedure were resolved through
discussion.
Our search yielded 744 potentially relevant studies. We
deleted duplicates and screened the remaining 680 records
for inclusion. Fifty-two articles met our eligibility criteria,
based on information provided in the abstract and title. Of
these, 31 studies were excluded following full-text
screening. Ultimately, 13 studies were included in the
meta-analysis (Fig. 1).
 362 Tsikopoulos et al.
Data Extraction
Two investigators (DK, KT) independently extracted in-
formation from the included full-text articles. More spe-
cifically, details about the comparators in the treatment
groups, countries in which the studies took place, anthro-
pometrics and activity level of the enrolled patients,
outcome and follow-up measurements, and losses to
follow-up were gathered. They also extracted information
about potential side effects resulting from the administered
treatments, inclusion criteria, and diagnosis of chronic
lateral ankle instability. When there were insufficient data
for quantitative synthesis or missing information, these
data were requested by the author(s) of the included source
studies.
Study Characteristics
In the current systematic review, we included 21 trials
published between 2006 and 2019 with a total of 469 un-
stable ankles (Table 1). Thirteen of those studies were
crossover studies and another three referred to nested trials
in prospective cohort studies with ankle instability patients
and healthy controls. In terms of geographic locations, five
investigations were conducted in North or South America
[10, 20, 39, 57, 58], three in Australia [24, 35, 51], seven in
Asia [1, 7, 22, 23, 43, 52, 55], and six in Europe [3, 4, 12,
14, 15, 28]. The mean age of participants ranged from 14 to
24 years, and the mean height of the participants ranged
from 156 cm to 192 cm. In addition, the mean weight of the
patients varied between 47 kg and 80 kg (see Table, Sup-
plemental Digital Content 2, http://links.lww.
com/CORR/A220). There was only one loss to follow-
up [57].
Outcome Assessment
For outcome analysis, we chose the Star Excursion Balance
Test because it is a cost- and time-effective test that can be
completed in a straightforward manner. On top of that, it is
evidenced that the SEBT is a valid and reliable dynamic
balance quantification tool with satisfactory intra- and
intertester reliability [16, 26]. To perform this particular
test, the individual stands on the involved leg and reaches
as far as possible in the prespecified test direction while
maintaining their balance. Of the eight different reach
directions (anterior, anteromedial, anterolateral, medial,
lateral, posterior, posteromedial, posterolateral) of the
SEBT, we only focused on the posteromedial direction
because it is the most representative of balance deficits in
patients with ankle instability [25]. Possible scores vary
between 0 and 100 with higher scores denoting more
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
stability. We gathered and analyzed data pertaining to pa-
tient performance with the external supports. In particular,
85 patients did not receive any particular treatment (that is,
they followed the wait-and-see protocol), 29 were allocated
to the placebo group, 99 were treated with taping, 16 with
bracing, 27 were administered insoles, and six participants
were offered a combination of insoles with bracing (see
Figure, Supplemental Digital Content 3, http://links.lww.
com/CORR/A221). We also assessed for the presence of a
placebo effect by comparing the results of sham taping with
no treatment and reported complications.
Statistical Analysis
We conducted not only pairwise analyses but also a net-
work meta-analysis using the effect measure of standard-
ized mean differences, with the Star Excursion Balance
Test- posteromedial reach as the dependent outcome vari-
able. In addition, a p value < 0.05 denoted statistical
significance.
Furthermore, we used Cohen’s rule of thumb to classify
the effect sizes. Accordingly, a standardized mean differ-
ence value of 0.2 denoted a small effect, a value of 0.5
indicated a moderate effect, and a value of 0.8
demonstrated a large effect [11]. Additionally, for a more
clinically relevant interpretation of the results, we back-
transformed standardized mean differences to SEBT-PM
actual scores by multiplying standardized mean differences
with the percentage baseline SDs reported in an included 3-
arm trial [10]. Subsequently, to enable judgements on
clinical meaningfulness, we considered the minimal de-
tectable change of 14% [10], which represents the estab-
lished smallest amount of change in SEBT-PM score that
ensures the change is not a result of a measurement error.
Of note, the above change of 14% corresponds to a large
effect size (that is, standardized mean difference of more
than 1.2). Importantly, with statistical power and proba-
bility of type I error set at 80% and 0.05, respectively, a
minimum of 16 patients per treatment group was needed to
provide sufficient statistical power and detect a SEBT-PM
percentage difference of 14%.
For pairwise quantitative synthesis, we considered a
random-effects model, and we used the Review Manager
software, version 5.3 (The Nordic Cochrane Center,
Cochrane Collaboration, Copenhagen, Denmark) [47]. To
incorporate the results of two-arm crossover trials, we
performed approximate analyses [29] and, depending on
the available information, we either imputed or assumed
that the required correlation coefficients were 0.5. For
three-arm crossover trials, we considered data from the
final period of assessment in the analyses. We also com-
bined treatment subgroups when the same type of external
support was implemented [30].
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Table 1. Treatment-related characteristics of the enrolled studies

Volume 478, Number 2

Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up
Study Study design ankles Treatment groups chronicity Outcomes measurement
Abbasi et al. Randomized 30 WFO $ one major ankle sprain (at least 12 SEBT normalized reach After completion of
[1] crossover trial months before the study) distances in AM, medial, and each session
PM directions
PFO (Slimflex; Algeos UK Ongoing instability and/or ankle giving
Ltd., Liverpool, UK) way
CFO (3-mm-thickness $ two giving-way episodes during the
polyethylene) past 6 months
CTFO (layer of 3-mm-thick Last ankle sprain at least 3 months
EVA foam [shore A50]) before the study
CAIT score of # 24
Alguacil- Randomized 28 Elastic bandage Non- $ one acute LAS that resulted in Postural sway (composite Pre-bandage
Diego et al. parallel group standardized tape swelling, pain, and temporary loss of SOT score and its strategy, application
[3] trial function (but none in the prior 3 SOT condition 2 and its
months) strategy, unilateral stance
test)
Multiple “giving-way” episodes in the Center of gravity sway Post-bandage
past 6 months velocity with open and application
closed eyes during the
unilateral stance test
CAIT score of # 27 1 week after
application
Mechanical instability assessed by
a 10-mm difference in anterior drawer

External Supports for Ankle Instability

test compared with the contralateral
ankle
Alves et al. Randomized 16 Mulligan’s fibular taping $ one ankle sprain resulting in an 15s of unipedal stance with Before treatment
[4] crossover trial Placebo taping interrupted day of physical activity eyes closed in force platform
First sprain occurring at least 12 Figure-of-eight, lateral hop Immediately after
months prior and the most recent one test taping application
at least 3 months prior
Giving way and/or instability feeling Peroneal longus latency time After a running test
in sudden inversion with taping
CAIT score # 25

363
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Table 1. continued

364
Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up

Tsikopoulos et al.
Study Study design ankles Treatment groups chronicity Outcomes measurement
Bicici et al. Randomized 15 Placebo taping $ three prior ankle sprains Hopping test After completion of
[7] crossover trial each session
No taping CAIT score # 27 Single Limb Hurdle Test
Standard athletic taping Standing Heel Rise test
Kinesiotaping Vertical Jump Test
SEBT
Kinesthetic Ability Trainer
Test
Cline et al. Randomized 24 No treatment $ one major lateral ankle sprain that SEBT (Anterior, PM, and PL Before and after
[10] crossover trial occurred at least 12 months before directions) treatment
study enrollment application
Nonelastic taping $ two giving way episodes in the 6 COP
months before study enrollment
Kinesiotaping IdFAI score of $ 11, FAAM of 54 TTB (ML, AP)
(85.66% 6 11.92%), and FAAM-S
(76.3% 6 15.69%)
VAS
de-la-Torre- RCT 30 KT $ one acute LAS that resulted in Composite SOT score and Pre-intervention
Domingo swelling, pain, and temporary loss of composite SOT strategy
et al. [12] function (but none in the 3 months
before the beginning of the trial)
Sham taping Multiple giving way episodes in the last Partial score for SOT Immediately after
6 months condition 2 and its strategy treatment

Clinical Orthopaedics and Related Research®

application
< 27 on CAIT After 7 days of use
Evidence of MAI (anterior drawer
difference of 10 mm compared with
the contralateral ankle using the
anterior drawer test)
The LASs in the treatment limbs of the
included participants occurred at least
3 months prior to the beginning of the
trial
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Table 1. continued

Volume 478, Number 2

Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up
Study Study design ankles Treatment groups chronicity Outcomes measurement
Delahunt Randomized 16 No treatment $ two inversion sprains SEBT (anterior, PM, and PL After completion of
et al. [14] crossover trial directions) each session
Lateral subtalar sling “Giving way” episodes of the affected Perceived stability; patients’
taping condition ankle joint reassurance and confidence
(during SEBT assessment
using two different taping
conditions)
FRT condition Feelings of joint instability in the
affected ankle during sporting
activities
CAIT score of # 24
De Ridder Randomized 25 Untaped Severe ankle sprain that resulted in DPSI After completion of
et al. [15] crossover trial prohibiting participation in sports or each task
other activities for $ 3 weeks
Τaped Episodes of giving way Subjective feelings of
instability and perceived
difficulty level (VAS)
Repetitive ankle sprains Mechanical effectiveness of
the tape on the ankle joint
(using 3-D kinematics)
Feeling of weakness and instability of
the affected ankle

External Supports for Ankle Instability

Being recreationally active (defined as
$ 1.5 hours of cardiovascular activity/
week)
Gehrke et al. Randomized 21 No treatment Episodes of subjective sensation of SEBT (all eight directions) After completion of
[20] crossover trial instability in the past 6 months each session
Rigid taping CAIT score of # 24 Figure-of-eight hopping test
Elastic athletic taping

365
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Table 1. continued

366
Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up

Tsikopoulos et al.
Study Study design ankles Treatment groups chronicity Outcomes measurement
Hadadi and Nested 22 Without orthosis $ one major ankle sprain (at least 12 Single-limb stance on a force After completion of
Abbasi [22] randomized months before the study) platform for static balance each session
trial in assessment (COP
a prospective parameters)
cohort study CMAS Ongoing instability and/or ankle giving SEBT in the AM, medial, and
with ankle way PM directions
instability SAS $ two giving-way episodes at 6
patients and months before participating in the
healthy controls study. The last ankle sprain at least 3
months before the study
CFO FAI: CAIT score of < 24,
< 90% on the ADL-S,
< 80% on the FAAM-S
MAI: positive talar tilt and anterior
drawer test results
Hadadi et al. Randomized 16 No treatment $ one unilateral inversion sprain of SEBT (AM, medial, and PM After completion of
[23] crossover trial each ankle but not within one year of directions) each session
study enrollment
Soft ankle orthosis $ one episode of recurrent sprain or
feeling of ankle instability or giving
way in the past 6 months
Semirigid ankle orthosis
Halim- Randomized 25 Taped condition One inversion ankle sprain (at least 1 Figure-of-eight hopping test After completion of

Clinical Orthopaedics and Related Research®

Kertanegara crossover trial month prior) resulting in pain and each session
et al. [24] swelling over the lateral ligament and
limping
Untaped condition Score of < 25 on CAIT Hopping obstacle course
Participants needed to be experienced SEBT (anterior, posterior and
with wearing rigid ankle tape PM)
The ankle sprain(s) occurred at least 4 Single-leg stance and stair
weeks before the beginning of the trial descent test
Self-efficacy perception
measures (17-item
confidence questionnaire)
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Table 1. continued

Volume 478, Number 2

Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up
Study Study design ankles Treatment groups chronicity Outcomes measurement
Hettle [28] Randomized 16 Taped condition Repeated going over on or giving way SEBT (AM, medial, and PM After completion of
crossover trial episodes directions) each session
Untaped condition $ one ankle sprain within 1 year (not
within the last 3 months before
testing)
Screening questions were used
The ankle sprain(s) occurred at least 3
months before the beginning of the
trial
Hopper et al. Nested 20 Mulligan ankle tape Recurrent ankle sprains due to lateral Static balance (10 s) Post-treatment
[35] randomized ankle instability which may resulted measurements
trial in from neural (that is, proprioception
a prospective reflexes, muscular reaction time),
cohort study muscular (such as, strength, power)
with ankle and mechanical mechanisms (like
instability ligamentous laxity)
patients and No tape FADI and FADI-S screening for Postural sway recovery
healthy controls instability patterns after a 30 s
functional hop test
(immediately, 30 and 60 s)
Presence of one uninjured and another Dynamic tracking balance
unstable ankle tasks (wandering, target
overshoot and reaction-time)

External Supports for Ankle Instability

Jackson et al. RCT 30 No treatment $ one lateral ankle sprain Total BESS errors Pre-treatment
[39] KT (four strips applied to $ one giving way episode within the 48 hours after tape
the foot and lower leg) last 6 months application
$ 11 on IdFAI 72 hours after tape
removal
The ankle sprain/-s occurred at least 1
month before the beginning of the trial

367
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Table 1. continued

368
Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up

Tsikopoulos et al.
Study Study design ankles Treatment groups chronicity Outcomes measurement
Lee and Lee Randomized 9 ABT with kinesiology History of severe ankle sprain in the SEBT (anterior, PM, and PL After completion of
[43] controlled trial taping past 3 months (difficulty in bearing directions) each session
weight or requiring surgery)
Sham taping Ankle joint instability or swaying
No treatment CAIT score of # 27
Absence of ankle swelling
Currently not participating in any
rehabilitation program
Sawkins Randomized 30 Real taping using Endura- CAIT score of # 24 Single-limb hopping test After completion of
et al. [51] crossover trial Fix self-adhesive each session
underwrap
Placebo tape condition Ankle sprains occurred at least 3 weeks Modified SEBT (anterior,
before the beginning of the trial posterior, and PM directions)
No treatment Mean number of seven sprains
Mean duration of 11 6 9 months since
the last sprain
Someeh Nested 16 Taped $ two acute ankle sprains resulting in SEBT (AM, medial, and PM After completion of
et al. [52] randomized pain and swelling directions) each session
trial in Untaped Multiple giving way episodes in the
a prospective past 6 months
cohort study < 90% on FADI and < 75% on FADI
with ankle sport
instability

Clinical Orthopaedics and Related Research®

patients and
healthy controls
Uddin et al. Randomized 30 Treatment with 1.5-inch Unilateral ankle instability SEBT At 1st, 7th, and
[55] controlled trial tape 14th days post-
intervention
Semirigid ankle brace One unilateral ankle sprain with pain FADI
along with 2 weeks of and/or limping for at 1 day
ankle rehabilitation
Rehabilitation three times Chronic ankle weakness, pain, or
weekly for only 2 weeks instability because of the initial injury
Giving way episodes of the affected
ankle in the past 6 months
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Table 1. continued

Volume 478, Number 2

Number of randomly
allocated unstable Criteria for ankle instability/ Follow-up
Study Study design ankles Treatment groups chronicity Outcomes measurement
Wheeler Randomized 22 Fibular taping condition $ 1 ankle sprains Weightbearing ankle Pre- and
et al. [57] crossover trial dorsiflexion ROM posttreatment
measure
Sham taping condition Subsequent recurrent episodes of SEBT (in the anterior,
(tape applied without ankle instability posterolateral, and PM
tension) during two visits directions)
> 85% on FAAM-S or at $ 3 on AII
A minimum dorsiflexion deficit of 5° of
the involved ankle compared with the
contralateral limb.
In case of bilateral ankle instability, the
limb with the greatest restriction to
ankle dorsiflexion ROM was selected.
The ankle sprains occurred at least 6
months before the beginning of the
trial
Wikstrom Randomized 28 No treatment FAI as determined by perceived MLSI After a jump
et al. [58] crossover trial sensations of weakness and episodes landing
of giving way during daily activity
Soft brace Absence of MAI as determined by APSI
anterior drawer and talar tilt tests
Semirigid brace VSI

External Supports for Ankle Instability

DPSI vGRF

ABT = ankle balance taping; ADL-S = Activities of Daily Living Subscale; AII = Ankle Instability Instrument; AL = anterolateral; AM = anteromedial; APSI = Anterior-posterior
Stability Index; BESS = Balance Error Scoring System; CAI = chronic ankle instability; CAIT = Cumberland Ankle Instability Tool; CFO = custom-made foot orthosis; COP = center of
pressure; CMAS = combined mechanism ankle support; CTFO = custom-made with textured surface foot orthosis; DPSI = Dynamic Postural Stability Index; EVA = ethylene-vinyl
acetate; FAAM-S = Foot and Ankle Ability Measure-Sport; FAAM = Foot and Ankle Ability Measure; FADI = Foot and Ankle Disability Index; FRT = fibular repositioning tape; IdFAI
= Identification of Functional Ankle Instability; KT = kinesiotaping; LAS = lateral ankle sprain; ML = mediolateral; MLSI = Medial-lateral Stability Index; PFO = prefabricated foot
orthosis; PL = posterolateral; PM = posteromedial; SAS = soft ankle support; SEBT = Star Excursion Balance Test; SOT= Sensory Organization Test; TTB = time to boundary; vGRF =
Vertical Ground Reaction Force; VSI = Vertical stability index; WFO = without foot orthosis.

369
 370 Tsikopoulos et al. Clinical Orthopaedics and Related Research®

Before conducting the random-effects network meta-
analysis, we tested transitivity assumption by assessing
the distribution of effect modifiers across treatment
comparisons [8, 50]. Thereafter, graphical tools were
used (StataCorp LP, Release 13, College Station, TX,
USA) to illustrate the network of treatments by means
of a network meta-analysis plot (Fig. 2) [8]. In this plot,
the thickness of edges was proportional to the number of
studies for each comparison, and the size of nodes was
proportional to the number of participants randomly
assigned to each intervention. Then, the surface under the
cumulative ranking probabilities were calculated to rank
the efficacy of the included treatments, and the percent-
age contributions of each direct evidence to the network
estimates were depicted [8, 41, 50]. Inconsistency (that
is, differences between direct and indirect effect esti-
mates concerning the same comparison [17]) was also
assessed by using a global test [31, 45]. Moreover, we
compared direct and indirect estimates by plotting their
absolute difference and assessed the presence of small
study effects, which served as a proxy for the evaluation
of publication bias. It is worthy of mention that no evi-
dence of small study effects was documented based on
the results of Egger’s statistical test [18] (p = 0.208) and
visual inspection of comparison-adjusted funnel plot for
controlled trials [8] (see Figure, Supplemental Digital
Content 4, http://links.lww.com/CORR/A222). Of note,
one small trial with highly imprecise results was
excluded from this plot [43] because we considered that
it could not reflect either small study effects or
publication bias. Finally, we created an interval plot to
enable predictions on the efficacy of external supports in
future trials [8, 32, 48]. Accounting for the results of this
plot and statistical power, we concluded that the major
finding of this study, which is presented in detail in the
following sections, is unlikely to change even if further
studies are conducted (Fig. 3).
Risk of Bias and Evidence Quality Assessment
Two reviewers (KS, KT) independently assessed the risk of
bias within and across trials using the Cochrane risk of bias
tool. For the risk of bias assessment within trials, we con-
sidered the following elements: sequence generation; al-
location concealment; masking of participants, blinding of
personnel, and outcome assessors; incomplete outcome
data; selective reporting; and “other bias.” Each entry was

Fig. 2 The network meta-analysis plot of the current study is depicted. Nodes represent the
included competing treatments and edges indicate direct comparisons between those
treatments. The size of the former is proportional to the number of patients allocated to
each treatment and the thickness of the latter is commensurate with the number of studies
considered in each comparison.

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 Volume 478, Number 2 External Supports for Ankle Instability 371

Fig. 3 This figure shows an interval plot of standardized mean differences with their 95%
CIs (black solid lines) and predictive intervals (red extensions). The blue line represents the
line of no effect. Wait-and-see policy is considered as reference treatment in this plot; PrI =
predictive interval.

assessed to be at an unclear, low, or high risk of bias. In Sensitivity Analyses

addition, to rate the quality of an included trial, we con-
sidered the domain of randomization to be vitally important
(that is, it was considered the key domain).
For the risk of bias assessment across trials, if more than
half of the information was from randomized controlled
trials at a low risk of bias, we considered the domain to be
at a low risk of bias. If most information was from trials at
an unclear or high risk of bias, we judged the domain to be
at an unclear or high risk of bias, respectively.
The quality of evidence of the present systematic review
was evaluated in terms of the Grading of Recom-
mendations, Assessment, Development, and Evaluations
(GRADE) framework [49]. More precisely, judgments of
the elements of inconsistency, study limitations, impreci-
sion, indirectness, and publication bias were made. Each of
these elements were either maintained at a high-quality
level or downgraded by up to three levels.
In the assessment of the individual trials, 18 studies
were judged to be at a low risk of bias (Table 2). In the
evaluation of the risk of bias across trials, the domains of
randomization and incomplete outcome data were deemed
to be at a low risk of bias. On the contrary, the domains
relating to blinding were considered to be at a high risk of
bias, and this was mainly attributed to the nature of treat-
ments. In addition, the domains of allocation concealment,
selective outcome reporting, and “other bias” data were
considered to be at an unclear risk of bias. The quality of
evidence of the network of interventions was judged to be
robust enough (that is, level A).
To assess for the presence of the carry-over effect, which
occurs when the difference between treatments is affected
by the order in which they were administered [29], we
conducted a sensitivity analysis. In this analysis, only
crossover trials allowing for a time interval between the
alternation in treatment protocols were considered. We also
prespecified a sensitivity analysis on the quality of the
enrolled studies, in which we excluded trials at an unclear
or high risk of bias. In addition, given the importance of
treatment lumping and node-making in network meta-
analyses, we proceeded with a further subanalysis to ac-
count for the established orthotic device classification [36,
40]. Finally, to confirm the statistical validity of our find-
ings, we adjusted the assumed correlation coefficients re-
quired for the SDdif calculation in approximate analysis
and found no difference compared to our original analysis.
Results
Assessment of the Efficacy of External Supports as
Measured by the Star Excursion Balance Test
Statistical pooling showed no differences in favor of real
taping over the watch-and-wait approach and placebo
taping (percentage SEBT-PM difference between taping
versus wait-and-see and placebo: -2.4 [95% CI -6 to 1.1];
p = 0.18 and -1.3 [95% CI -6.8 to 4.1]; p = 0.64,

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Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.

372
Tsikopoulos et al.
Table 2. The risk of bias assessment of the included trials
Blinding of
Allocation Blinding of Blinding of outcome Incomplete Selective
Study Randomization concealment participants personnel assessors outcome data reporting Other bias
Abbasi et al. [1] Low risk Unclear risk High risk High risk High risk Low risk Unclear risk Low risk
Alguacil-Diego et al. [3] Low risk Low risk Low risk Unclear risk Low risk Low risk Low risk Low risk
Alves et al. [4] Low risk Unclear risk Low risk Unclear risk Low risk Low risk Unclear risk Low risk
Bicici et al. [7] Unclear risk Unclear risk Unclear risk Unclear risk Unclear risk Low risk Unclear risk Low risk
Cline et al. [10] Low risk High risk High risk High risk High risk Low risk High risk Unclear risk
De-la-Torre-Domingo et al. [12] Low risk Low risk Low risk High risk Low risk Low risk Low risk High risk
Delahunt et al. [14] Unclear risk Low risk High risk High risk High risk Low risk High risk Unclear risk
De Ridder et al. [15] Low risk Low risk High risk High risk High risk Unclear risk Low risk Unclear risk
Gehrke et al. [20] Unclear risk Unclear risk High risk High risk Low risk Low risk Unclear risk Unclear risk
Hadadi and Abbasi [22] Low risk High risk High risk High risk High risk Low risk High risk Unclear risk
Hadadi et al. [23] Low risk High risk High risk High risk High risk Low risk High risk Low risk
Halim-Kertanegara et al. [24] Unclear risk Unclear risk High risk High risk Unclear risk Low risk Unclear risk Unclear risk
Hettle et al. [28] Low risk Unclear risk High risk High risk High risk Low risk Unclear risk Unclear risk
Hopper et al. [35] High risk Low risk High risk High risk High risk Unclear risk Low risk Unclear risk
Jackson et al. [39] Low risk Unclear risk High risk High risk Unclear risk Unclear risk Unclear risk Unclear risk

Clinical Orthopaedics and Related Research®

Lee and Lee [43] Low risk Low risk High risk High risk Low risk Low risk High risk Unclear risk
Sawkins et al. [51] Low risk Unclear risk Low risk Unclear risk Low risk Low risk Unclear risk Unclear risk
Someeh et al. [52] Unclear risk Unclear risk High risk High risk High risk Low risk Unclear risk High risk
Uddin et al. [55] Unclear risk Unclear risk High risk High risk Unclear risk Low risk Unclear risk Low risk
Wheeler et al. [57] Low risk Low risk High risk High risk Low risk Low risk Low risk Unclear risk
Wikstrom et al. [58] Low risk Unclear risk High risk High risk High risk Unclear risk Unclear risk Unclear risk
 Volume 478, Number 2 External Supports for Ankle Instability 373

respectively) (Table 3). Likewise, orthotic insoles demon-
strated no advantages over wait-and-see at the end of the
treatment protocols (percentage SEBT-PM difference be-
tween orthotic insoles and control: -3.1 [95% CI -10.4 to
4.3]; p = 0.41) (Table 3). Although a combination of orthotic
insoles with bracing had the highest probability of being
among the best modalities (see Figure, Supplemental Digital
Content 5, http://links.lww.com/CORR/A223), this finding
was not clinically relevant because the 95% CIs crossed
unity (percentage SEBT-PM difference between combined
orthotics plus bracing versus the wait-and-see approach: -8.9
[95% CI -20.4 to 2.6]; p = 0.13) (Table 3). Only one study
considered this particular combined treatment. Importantly,
we found no global inconsistency in the network of inter-
ventions (p = 0.9949). This was also the case when the node-
splitting approach was used (see Figure, Supplemental
Digital Content 6, http://links.lww.com/CORR/A224).
Head-to-Head Comparisons
We considered 13 trials with 262 individuals to conduct the
pairwise meta-analyses (Fig. 4). Of note, one trial was ex-
cluded from the aforementioned analysis due to the presence
of adjuvant treatments in the study groups [55]. Real taping
did not provide an additional clinical advantage over no
treatment (n = 9 trials; percentage SEBT-PM difference
between taping and control: -2.7 [95% CI -6.4 to 1]; p =
0.15; I2 = 0%). This was also the case for placebo taping,
which was no more effective than a wait-and-see policy (n =
3 trials; percentage SEBT-PM difference between placebo
and wait-and-see: -1.8 [95% CI -9 to 5.7]; p = 0.64; I2 = 0%).
Likewise, no clinical advantage of bracing to wait-and-see
was documented (n = 2 trials, percentage SEBT-PM dif-
ference between bracing and control: -6 [95% CI -14.9 to
2.8]; p = 0.18). Similarly, we observed no superiority of foot
orthotics to no treatment (n = 2 studies; percentage SEBT-
PM difference between foot orthotics and control: -2.7
[95% CI -10.2 to 4.7]; p = 0.49).
Qualitative Synthesis
It should be noted that most of the included trials that did
not qualify for meta-analysis did not report any difference
in dynamic balance between external supports and control
[3, 4, 12, 15, 35, 58].
Assessment of Placebo Effect and Adverse Events
No evidence of a placebo effect was documented when di-
rect and indirect evidence was synthesized at the same time
(percentage SEBT-PM difference between sham taping and
no treatment in network meta-analysis: -1.1[95% CI -6.9 to
4.7]; p = 0.72). This was also the case when direct evidence
was considered only in the analysis (percentage SEBT-PM
difference between sham taping and no treatment: -1.8 [95%
CI -6.9 to 4.7]; p = 0.55). Of note, there were no reported
complications after treatment administration.
Sensitivity Analyses
For our predetermined sensitivity analysis on the washout
effect, the network meta-analysis indicated that there were
no differences between ankle taping and no treatment (per-
centage SEBT-PM difference: -2.3 [95% CI -6.6 to 2]; p =
0.3). Likewise, neither bracing nor foot orthotics was more
effective than the wait-and-see policy (percentage SEBT-
PM difference: -7.5 [95% CI -15.9 to 1] p = 0.08; and -3.1
[95% CI -10.4 to 4.3]; p = 0.41, respectively). We also did
not observe any differences after controlling for the quality
of the enrolled source studies (see Table, Supplemental

Table 3. A league table of percentage SEBT-PM differences with their 95% confidence intervals
Wait-and-see
8.9 (-2.6 to 20.4); p = 0.13 Orthotic insoles +
bracing
3.1 (-4.3 to 10.4); p = 0.41 -5.8 (-17.8 to 6); Orthotic insoles
p = 0.34
7.5 (-1 to 15.9); p = 0.08 -1.4 (-13.3 to 10.3); 4.4 (-5.5 to 14.3); Bracing
p = 0.84 p = 0.39
2.4 (-1.1 to 6); p = 0.18 -6.5 (-18.5 to 5.9); -0.66 (-8.8 to 7.6); -4.9 (-14.1 to 4.2); Taping
p = 0.3 p = 0.88 p = 0.3
1.1 (-4.7 to 6.9); p = 0.72 -7.8 (-20.7 to 5.2); -1.97 (-11.4 to 7.5); -6.4 (-16.5 to 3.9); -1.3 (-6.8 to 4.1); Placebo
p = 0.24 p = 0.69 p = 0.21 p = 0.64
The reported changes did not exceed the established minimal detectable change of 13.6% for clinical relevance; SEBT-PM = Star
Excursion Balance Test-posteromedial.

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 374 Tsikopoulos et al. Clinical Orthopaedics and Related Research®

Fig. 4 Illustrations depict the forest plots of standardized mean differences for the assessment of dynamic postural control in terms
of the star excursion balance test in the posteromedial direction. The vertical line demonstrates no difference between the two
treatment groups. No statistical differences between the treatment groups are shown; IV = inverse variance; SEBT= Star Excursion
Balance Test.

Digital Content 7, http://links.lww.com/CORR/A225). This
was also the case when we adjusted for the material from
which the foot and ankle orthotic devices were
manufactured (see Table, Supplemental Digital Content 8,
http://links.lww.com/CORR/A226) as well as correlation
coefficients in approximate analyses.
Discussion
To increase ankle stability in individuals experiencing
ongoing subjective symptoms and/or ankle joint laxity
after one or more severe ankle sprains, external supports
like taping, bracing, and orthotic devices are used some-
times [2], but current evidence on whether external sup-
ports are beneficial in improving dynamic postural control
in those patients is conflicting. On top of that, the role of the
placebo effect of ankle taping in patients with ankle in-
stability has yet to be defined. Because of this, we felt
conducting a network meta-analysis to synthesize the
available evidence stemming from RCTs would be bene-
ficial because relative effects for all treatment pairings can
be considered. Since patients with ankle instability exhibit
postural stability deficits [6], we sought to examine the
therapeutic effects of external supports on dynamic balance
as measured by the Star Excursion Balance Test. Statistical

Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 478, Number 2
pooling did not reveal any differences in favor of taping,
bracing, foot orthotics, and combined bracing and foot
orthotics, indicating that external supports of any type
appear to offer no additional benefit over wait-and-see
treatment protocols. Also, we did not detect any evidence
of placebo effect in patients treated with sham taping.
Limitations
Although the impact of external supports on dynamic
postural control can be assessed reliably shortly after their
application, consideration of long-term follow-up meas-
urements is essential. In particular, most of the studies we
assessed typically evaluated patients before and after
treatment application; future studies should focus on con-
ducting longer term follow-up observations to determine
whether the effect of external supports remains the same
over time. A further study limitation is that blinding the
registration protocol details throughout the peer-review
process prevented peer reviewers from assessing whether
our methodology was defined in advance; it was, and this
can be confirmed by reading our prospective registration
with PROSPERO (CRD42016037849). Finally, the
findings of the current network meta-analysis address
only the primary management of chronic lateral ankle in-
stability and not postoperative protocols for surgically
reconstructed ankles.
Efficacy of External Supports
Our network meta-analysis found no clinically important
benefits to the use of external supports in terms of dynamic
postural control between treatment groups and controls.
Therefore, external stabilizers cannot be recommended as a
standalone treatment in the nonsurgical management of
chronic lateral ankle instability. However, we recommend
that future research focus on high-quality RCTs assessing
external supports in conjunction with rehabilitation. Also,
to achieve homogenous and comparable results in this
field, we advocate a more standardized manner of quanti-
fying clinician-oriented outcomes. For instance, a consid-
erable amount of data stemming from seven randomized
trials [3, 4, 12, 15, 35, 39, 58] was not synthesized in the
current systematic review because of the different instru-
ments used to measure dynamic balance.
Presence of the Placebo Effect and Assessment
of Complications
In the present network meta-analysis, strong evidence
revealed no difference in functional performance between
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
External Supports for Ankle Instability 375
sham taping and no-treatment groups, suggesting that a
placebo effect was absent. In other words, there was no
causal linkage of patients’ belief or expectations for im-
provement with actual dynamic balance amelioration [42].
In light of this finding, implementation of placebo-
controlled study design in future research assessing bal-
ance in patients with ankle instability is not recommended;
instead, we advocate the use of a no treatment group. Im-
portantly, given the absence of carry-over effect in the
results of the current quantitative synthesis, we suggest that
crossover study designs be favored over parallel group
designs. In terms of complications, we emphasize that the
absence of reported side effects in the included studies,
which generally enrolled relatively small numbers of
patients, does not support the conclusion that the assessed
interventions are safe; uncommon complications may not
appear in small studies [44].
Conclusions
The major finding of the current network meta-analysis
was that external supports of any type did not improve
dynamic postural control in patients with ankle instability.
We recommend that large-scale trials addressing patient-
reported and clinician-assessed outcomes on combinations
between rehabilitation and external supports be conducted
in the future.
Acknowledgments We thank Dimitris Mavridis PhD from the Uni-
versity of Ioannina, Greece for the statistical support he provided in this
network meta-analysis.
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