Journal o f Sport Rehabilitation, 1997, 6 , 21-29

0 1997 Human Kinetics Publishers. Inc.

The Role of Ankle Strength in Functional

Ankle Instability

Cynthia M. McKnight and Charles W. Armstrong

The .purpose of this study was to determine if there were any differences in ankle
-

range of motion, strength, or work between persons with normal ankles (Nor-
mal, n = 14), those with functional ankle instability (FAI, n = 15), and those with
a history of FA1 who have been through formal proprioceptive rehabilitation
(Rehab, n = 14).A second purpose was to determine normative values for ankle
strength and work measurements using the Biodexe isokinetic system. There
were no significant differences between groups for ankle range of motion or for
any strength or work measurements. The overall strengthlwork averages were
11.7513.42 for plantar flexion, 3.3911.48 for dorsiflexion, 3.3012.40 for inver-
sion, and 2.6211.79 for eversion. Dorsiflexion torque overall was 31.43% of plantar
flexion, and the evertorsproduced 75.42% of the torque produced by the invertors.
It is recommended that clinicians continue to rehabilitate ankles with strength
and proprioceptive exercises but do not rely on ankle strengthlwork testing as the
only criteria for determining an athlete's readiness to return to full activity

Researchers have concluded that the ankle is the most commonly injured
joint in sport, with the sprain being the predominant injury (4,5). The most com-
mon injury mechanism is plantar flexion with inversion (1-3,8, 12), and the most
commonly injured ligament is the anterior talofibular ligament (3, 12). Mack (16)
reported that the ankle sprain constituted 25% of all time-loss injuries in running
and jumping sports. Garrick and Requa (8) had similar findings, reporting that
25% of 12,681 injuries occurring over a 7-year span involved the foot and ankle,
50.4% of which were sprains. The relatively high frequency of ankle injuries has
compelled researchers to investigate the incidence of first-time injuries as well as
the reasons for functional ankle instability (FAI).
Freeman originally defined FA1 as subjective "giving way" (7). Tropp et al.
(21) expanded the original definition by including in the FA1 population persons

Cynthia M. McKnight is with the Department of Exercise and Sport Sciences, Colby-
Sawyer College, 100 Main St., New London, NH 03257. Charles W. Armstrong is with the
Department of Health Promotion and Human Performance, University of Toledo, Toledo,
OH 43606.
 22 McKnight and Armstrong

reporting recurrent ankle sprains. Staples (20) identified four possible causes for
FAI: mechanical instability, peroneal weakness, tibiofibular sprain, and proprio-
ceptive deficits. Less observable problems could be present in a chronically un-
stable ankle even if there is full range of motion and no measurable instability (4).
These include muscle imbalances, inadequate proprioceptive feedback, and lack
of neuromuscular coordination.
There is an abundance of information concerning ankle strength and pro-
prioception for ankle rehabilitation. However, there have been few studies com-
paring the strength of ankles with varying histories. Most studies report only bilateral
comparisons, not comparisons between groups of subjects with normal ankles,
subjects with FAI, and those with a history of FA1 who have been through formal
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proprioceptive rehabilitation. Also, since the emphasis in ankle rehabilitation is

moving toward proprioceptive training, information is needed to ensure that ankle
strength is maintained. Therefore, the purpose of this study was to determine if
there were any ankle strength or work differences between persons with normal
ankles, those with FAI, and those with a history of FA1 who had been through
formal proprioceptive rehabilitation. A second purpose was to determine norma-
tive values for ankle strength and work measurements, as a percentage of body
weight, using the BiodexBisokinetic system.

Methods
For the purpose of this study, functional ankle instability was defined as recurrent
ankle sprains (minimum of two) or multiple episodes of subjective "giving way,"
either of which had occurred within the 12 months prior to testing (14). Formal pro-
prioceptive rehabilitation was defined as rehabilitation with instruction from a physi-
cal therapist or athletic trainer that included a minimum of four supervised sessionsof
proprioceptivelbalance training within the 12 months prior to testing (10). Proprio-
ceptivelbalancetraining was defined as training or rehabilitation that included BAPSB
board, balancetteeter board, andlor single-leg stance exercises. Strength was defined
as the amount of torque produced in one maximal contraction, and work represented
the interaction of force production and range of motion (8).

Subjects
Forty-three healthy male and female volunteers, ranging in age from 14 to 28 years,
participated in this study. Descriptive data on the subjects are in Table 1. The group
mean and the standard deviation are given for each characteristic. The subjects were
divided into three groups: no history of ankle problems (Normal) (n = 14), history of
functional ankle instability with no formal rehabilitation (FAI) (n = 15), and history of
previous functional instability with formal rehabilitation (Rehab) (n = 14). Subjects
had no history of knee, hip, or foot injuries or of ankle fractures. All subjects were
screened for ankle instability using standard talar tilt and anterior drawer tests, and
there were no differences between groups.
 Ankle Strength

Table 1 Demographic Characteristics of the Subjects With Means and

Standard Deviations

Normal FA1 Rehab

M SD M SD M SD

Age (years) 21.13 3.18 19.60 1.72 18.47 2.95

Height (cm) 170.84 9.37 171.70 10.87 172.90 11.07
Weight (kg) 67.68 14.29 68.55 16.10 71.16 10.09
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The FA1 subjects reported an average of 7.5 previous ankle sprains and the
Rehab subjects reported an average of 2. The average time since the last injury was
+ +
9.55 11.54 months for the FA1 group and 6.36 3.91 months for the Rehab
group. This difference was not statistically significant. Sixty percent of the FA1
subjects complained of "giving way" in their ankles, while only 28% of the Rehab
subjects had the same complaint after completing their rehabilitation.
Assembled information concerning the subjects' histories of ankle rehabili-
tation included modalities and specific exercises used. This information, surnma-
rized in Tables 2 and 3, is reported as percentages of subjects receiving a particular
treatment or performing a specific exercise. The Rehab subjects were in formal
rehabilitation for an average of 7.89 visits over 3.78 weeks. The final rehabilita-
tion sessions occurred, on average, 4 months prior to testing.
In addition, activity level was documented for each subject. At the time of
testing, subjects in the Normal group participated in some form of aerobic, weight-
bearing activity an average of 2.5 times per week, the FA1 group averaged 3 times
per week, and the Rehab group averaged 3.5 times per week.

Procedures
Plantar flexion, dorsiflexion, inversion, and eversion were measured
goniometrically by the primary author using the methods described by Norkin
and White (17). The concentric strength and work of each subject was tested
using an isokinetic strength-assessment system (Biodexa). Plantar flexion, dorsi-
flexion, inversion, and eversion were included in the strength assessment. Posi-
tioning of the equipment and the subjects was as follows. For plantar flexion and
dorsiflexion, the powerhead was tilted upward at 16" and the plantar flexion1
dorsiflexion footplate was attached. Each subject was positioned in the accessory
chair so that the tibia was horizontal and the knee was extended in a long sitting
position when the foot was in the footplate (6). The limb was supported with the
multisupport pad positioned under the distal thigh and secured with a strap. A
low-cut shoe was worn for all testing to allow for full range of ankle motion. The
 24 McKnight and Armstrong

Table 2 Percentages of Subjects Having Used a Particular Modality for Ankle

Problems Prior to Testing

Rehab

Ice
Heat
Ultrasound
Warm whirlpool
Cold whirlpool
Electrical stimulation
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Jobsta Cryotemp

Table 3 Percentages of Subjects Using a Particular Type of Therapeutic

Exercise Prior to Testing

FA1 Rehab

Stretching 3 86
Toe raises 13 78
Heel raises 0 71
BAPSmboard 0 100
Balance training 0 86
Elastic resistance 0 93
Manual resistance 0 64

axis of rotation in neutral position was a line passing through the body of the talus,
through the fibular malleolus, and through or just below the tibia1 malleolus.
For inversion and eversion, the powerhead was rotated to 35' and the footplate
was attached and tilted to 45". Each subject was seated in the accessory chair with
the knee flexed to 10" (9, 15). The limb was supported by positioning the
multisupport pad just distal to the knee and securing it with a strap. The chair was
positioned facing the powerhead, and the axis of rotation with the foot in neutral
position was aligned with the powerhead shaft. The axis used was a line through
the fibular malleolus and the body of the talus. The subjects were secured for both
testing conditions with straps across the distal foot, the proximal foot, and the
waist, with two crossing straps to hold the upper body secure against the chair. The
chair casters were locked in place.
The primary author gave complete instructions to each subject and ran all tests.
A three-repetition w m - u p occurred after initial instructions, followed by 2 min of
 Ankle Strength 25

rest prior to data collection. Two speeds were used in the analysis. Three repetitions
were performed at 30°/s followed by 15 repetitions at 240°/s. The 30°/s speed mea-
sured strength, and 240'1s measured total work.

Data Analysis
Comparisons were made bilaterally and between groups of subjects.The independent
variable was group, and the dependent variables were active range of motion, strength,
and work values for inversion, eversion, plantar flexion, and dorsiflexion.The SPSS
program was used to analyze the data. Analysis of variance (ANOVA) and Scheffk's
post hoc test were used in the analysis at the p < .05 level of significance.
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Results
The subjects' active range of motion measurements are in Table 4. There were no
significant differences between groups for any range of motion measurements,
and the overall means fell within normal parameters for ankle range of motion
(17). Strength and work information, reported as percentages of body weight, can
be found in Tables 5 and 6. We found no significant differences in any strength or
work measurements between the groups. Dorsiflexion torque overall was 3 1.43%
of plantar flexion. The evertors produced 75.42% of the torque produced by the
invertors.

Discussion
In an effort to determine factors leading to FAI, researchers have discussed the roles
of many proprioceptors in conjunction with ankle injuries. These include pressure
receptors, joint receptors, Golgi tendon organs, and muscle spindle fibers, which are

Table 4 Means and Ranges for Active Range of Motion

Normal FA1 Rehab Overall

Plantar flexion

Dorsiflexion

Inversion

Eversion
 26 McKnight and Armstrong

Table 5 Means and Standard Deviations of Peak Torque (Strength) Recorded

as Percentages of Body Weight

Normal FA1 Rehab Overall

M SD M SD M SD M SD

Plantar flexion 36.26 12.94 33.14 9.84 36.88 13.84 35.22 11.75
Dorsiflexion 10.79 4.69 10.71 2.95 11.91 2.06 11.07 3.39
Inversion 15.20 3.49 12.90 3.43 12.69 3.40 13.63 3.30
Eversion 10.43 2.64 10.67 2.97 9.57 2.25 10.28 2.62
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Table 6 Means and Standard Deviations of Work Recorded as Percentages

of Body Weight

Nomd FA1 Rehab Overall

M SD M SD M SD M SD

Plantar flexion 8.76 3.74 7.88 2.62 6.79 4.07 7.88 3.42
Dorsiflexion 2.00 1.00 3.07 1.69 1.93 1.49 2.38 1.48
Inversion 6.63 2.55 5.60 4.53 4.53 1.03 5.66 2.40
Eversion 3.78 1.92 3.64 1.52 3.36 2.18 3.68 1.79

all important in maintaining posture and balance (2, 3, 6, 11). Closed kinetic chain
proprioceptive exercises have become very popular in ankle rehabilitation. Lattanza
et al. (13) emphasized the importance of closed kinetic chain ankle exercises, stating
that if only open chain rehabilitation exercises were used, much of the normal range
of motion, strength, function, and proprioceptive feedback of the ankle would be
missing. Vegso and Harmon (22) agreed that proprioceptive training is important in
ankle rehabilitation,noting that ankles which are not proprioceptively trained prior to
activity resumption could have an increased risk of reinjury.
Balduini and Tetzlaff (5) noted that there is no consensus regarding the reha-
bilitation of lateral ankle ligament sprains, but the goal should be to decrease FAI.
Most general ankle rehabilitation programs include some form of strengthening
for all major muscle groups related to ankle movement. Exercises include isomet-
rics, manual resistance, toe and heel raises, elastic band resistance for inversion
and eversion, and some form of progressive resistance exercises or isokinetics (1,
2,4,8, 15). Staples (20) reported, however, that bilateral strength was not a deci-
sive factor in symptoms of instability or function. Lentell et al. (15) did not see
significant differences in strength bilaterally in subjects with unilateral ankle in-
stability. They did, however, report a trend toward evertor weakness.
 Ankle Strength 27

The three groups in this study (Normal, FAT, and Rehab) did not differ sig-
nificantly for any active range of motion, strength, or work measurements. The
lack of significant differences between groups in strength suggests that strength
may play a less significant role in minimizing functional ankle instability than
many clinicians previously believed. Lentell et al.'s (14) findings are consistent
with this. These authors used a Cybex II+@Isokinetic Dynamometer at speeds of 0
and 30'1s for testing; however, they compared only bilaterally, not between groups
of subjects. We cannot compare the actual torque findings, since Lentell et al.
reported mean peak torque values rather than values normalized by body weight.
Because symptoms of FAT continue after strength has returned, muscle weak-
ness does not appear to be an important factor in FAT. Therefore, proprioceptive train-
ing may be important not only in preventing ankle injuriesbut also in the rehabilitation
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of those injuries to prevent future problems (22). Proprioceptive exercises are now
widely used by physical therapists and athletic trainers in clinics and schools world-
wide. Exercises used to assist in proprioceptive training include heel and toe walking,
bilateral and unilateral balance, uni- and multiaxial teeter boards, B A P S boards, and
other balance devices (1,2,4,8, 15,18). Many clinicians, however, still rely on open
kinetic chain strength assessments in determining readiness for competition.
The traditional emphasis on strength training as the primary component of
ankle rehabilitation and the determinant for return to participation may be mis-
placed. In addition, most sport activities place the ankle in a closed kinetic chain.
Therefore, if the only assessment of an athlete's readiness to return to play is an
open kinetic chain strengthlwork assessment, the ankle may be at risk for reinjury.
Beyond a requisite level of strength, present in all three groups in this study, other
factors become critical for ankle stability and prevention of reinjury. These factors
may include such things as motor control and joint proprioception. Therefore, in
order to safely return an athlete to optimal performance and reduce the risk of
reinjury, the proprioceptive and neuromuscular systems must be trained and evalu-
ated through the use of closed kinetic chain exercises, balance training, and func-
tional progression exercises.
Proprioceptive rehabilitation does need to be emphasized; however, a requi-
site amount of strength must also be maintained. In order to provide easily compa-
rable data, we reported all ankle strength and work findings in the current study as
percentages of body weight. Sepic et al. (19) reported that torque values for all
muscle groups of the ankle were significantly related to height, weight, and lean
body mass; age and gender were not significant factors. Normalizing by body
weight is an important consideration for future researchers in creating a database
for comparisons of ankle strength and work.
Lentell et al. (14).did report eversion to inversion ratios, which averaged
87.5% for the population at 30'1s. In the current study, the finding of 75.42% for
this ratio was lower than that of Lentell et al. but was consistent with a study by
Sepic et al. (19), who reported an eversion to inversion ratio of 73% for an isomet-
ric test. For the dorsiflexion to plantar flexion ratio, we found a ratio of 3 1.43%,
 28 McKnight and Armstrong

which is consistent with Giove (9) at 3044% but lower than that reported by
Sepic et al. (19). They reported that the plantar flexors produced almost twice the
torque as the dorsiflexors. Giove's findings are perhaps more relevant to the cur-
rent study since a Biodexa isokinetic device was used for both. Collectively, these
data indicate that the ankle musculature strength of the subjects in the current
study was comparable to that reported for similar populations in previous studies.
The finding of no significant differences between the Normal, FAI, and Rehab
groups in ankle strength in this study suggests that ankle strength is not a major
factor influencing functional ankle instability.
For ankle work, which represents the interaction of force production and
range of motion, the body weight percentages were lower than for strength. This
was expected, since less torque can be generated at higher speeds. However, the
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ratio of dorsiflexion to plantar flexion for work (30.20%) was nearly identical to
that for strength (31.43%). The eversion to inversion ratio was not as close, with
work at 65.02% and strength at 75.42%. This may be due to the nature of the work
test and the increased fatigue of the evertor muscles in all groups. Ankle work, as
measured in this study on an isokinetic device, has not been previously docu-
mented in the literature, so comparisons cannot be made.

Conclusions
We found no significant differences in ankle active range of motion, strength, or
work measurements in subjects with normal ankles, those with functional ankle
instability, and those with histories of functional ankle instability who had been
through formal proprioceptive rehabilitation. Our recommendations are that clini-
cians continue to rehabilitate ankles with strength and proprioceptive exercises
but do not rely on ankle strengthlwork testing as the only criteria for determining
an athlete's readiness to return to full activity. Future research directions include
continued studies to form a database for normative ankle strengthlwork reported
as percentages of body weight, and determining the best methods for clinically
evaluating proprioceptive readiness.

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