Balance Capabilities after Lateral Ankle

Trauma and Intervention: A Meta-analysis

ERIK A. WIKSTROM1, SAGAR NAIK2, NEHA LODHA2, and JAMES H. CAURAUGH2
1

Biodynamics Research Laboratory, Kinesiology Department, University of North Carolina at Charlotte, Charlotte, NC;
and 2Applied Physiology and Kinesiology Department, University of Florida, Gainesville, FL

ABSTRACT

ized reductions in injury rates after completing various

sensorimotor training programs (15,36,48).
One of the most commonly examined sensorimotor
outcome measures is single leg postural control. Impaired
postural control is associated with an increased risk of ankle
injury (78,82) and is an hypothesized potential mechanism of CAI (77,79). Due to this strong association, balance
and coordination training are common components of intervention programs used by allied health care practitioners
to treat patients with a history of both acute ankle trauma
and CAI. Despite the common implementation of balance
training, the literature reveals no consensus regarding the
clinical evidence that postural control is impaired after an
acute ankle sprain or the development of CAI (50).
However, one systematic review provides strong evidence
that postural control is impaired after an acute ankle sprain
when the injured limb is compared with a healthy reference
group (50). The lack of consensus is most likely due to a)
the myriad of postural control methods and measures used,
making direct comparison of the existing literature difficult
(61), and b) the potential for bilateral impairments in postural control after a lateral ankle sprain (50).

ateral ankle sprains are the most common lower

extremity injury in collegiate athletics (5,37) and
occur at an estimated incidence of 25,000 a day in
the United States (5) and have greater than 70% recurrent
rate (22). In addition, up to 75% of the people who sprain
their ankle will develop chronic residual symptoms that are
defined as chronic ankle instability (CAI) (22). These
statistics are inherent in the multiple investigations characterizing the effects of both acute ankle injury and CAI on
numerous measures of the sensorimotor control system
(36,56). Moreover, multiple investigations have character-

Address for correspondence: Erik A. Wikstrom, Ph.D., ATC, Department

of Kinesiology, University of North Carolina at Charlotte, 9201 University
City Blvd, Charlotte, NC 28223; E-mail: ewikstrom@uncc.edu.
Submitted for publication July 2008.
Accepted for publication November 2008.
0195-9131/09/4106-1287/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2009 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e318196cbc6

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APPLIED SCIENCES

WIKSTROM, E. A., S. NAIK, N. LODHA, and J. H. CAURAUGH. Balance Capabilities after Lateral Ankle Trauma and Intervention:
A Meta-analysis. Med. Sci. Sports Exerc., Vol. 41, No. 6, pp. 12871295, 2009. Despite the high incidence of lateral ankle sprains,
the issue about whether postural control is impaired after acute or chronic injury is still unresolved. In addition, the literature is
unclear if balance training, a commonly prescribed intervention, improves postural control after a history of lateral ankle
trauma. Purpose: To conduct a meta-analysis on studies reporting the effects of lateral ankle trauma on postural control and how
balance training affects postural control after acute and chronic lateral ankle trauma cumulatively and separately as moderating variables. Methods: Thirty-seven postural control studies qualified for inclusion in the meta-analysis. Twenty-five
studies investigated postural control independent of an intervention, and 15 studies administered balance-training interventions.
Separate analyses on the two types of studies calculated Hedges g individual effect sizes (ES). Further, we explored
moderating variables for both the postural stability and the intervention studies. Results: A significant cumulative effect size
(ES) indicated that postural stability is impaired after a history of ankle injury (ES = 0.492, P G 0.0001). Moderator analysis
revealed that both acute and chronic lateral ankle trauma negatively affected balance: a) acute: ES = 0.419, P G 0.0001, and b
chronic, ES = 0.570, P G 0.0001. A third meta-analysis showed that balance training improves postural control (ES = j0.857,
P G 0.0001). In addition, moderator variables indicated large ES for both types of ankle trauma. Conclusions: Postural control
impairments are present in patients with a history of lateral ankle trauma. However, clinicians should exercise caution
when using the uninjured contralateral limb as a reference of normal postural control. In addition, balance training improves
postural control scores after both acute and lateral ankle trauma. However, further research should determine the optimal
dosage, intensity, type of training, and a risk reduction/preventative effect associated with balance training after both acute and
chronic ankle trauma. Key Words: ANKLE SPRAIN, CHRONIC ANKLE INSTABILITY, POSTURAL CONTROL,
SYSTEMATIC REVIEW

APPLIED SCIENCES

Moreover, evidence is accumulating that implicates

various sensorimotor training programs in reducing the
recurrence of ankle injuries (15,36,47,48). Although the
underlying mechanism of why these programs are effective
is still not completely understood, the restoration of
proper or normal postural control has been hypothesized (3,21,47,81). Although the restoration of normal
postural control has been postulated, no consensus exists
regarding the clinical evidence that balance training restores
normal postural control to patients with either an acute
lateral ankle sprain or CAI (51). Most likely, this lack of
consensus is due to a) the myriad of multiple balance
training programs, b) the varying lengths of programs, and
c) the multiple postural control measures used in the
existing literature (51,61). Thus, to date, reviews and
systematic reviews have attempted to summarize the
postural control literature because it relates to lateral ankle
sprains and CAI and have had limited success in drawing
decisive conclusions about the impairment and the restoration of normal postural control (50,51,61).
A comprehensive meta-analysis provides a quantitative
solution to the concerns that emerged from previous studies and systematic reviews. Indeed, determining an overall
effect size (ES) in an area of study is convincing evidence
considering the frequency of meta-analyses reported in
evidence-based medicine. A cumulative assessment of
the evidence found in our meta-analyses would provide a
valuable source of information. Indeed, health care practitioners would be able to use such an informative comprehensive and quantitative review to make better clinical
decisions regarding acute lateral ankle sprains, CAI, and
balance training. Therefore, the purposes of this metaanalysis were to answer the following clinical questions: a)
Does a history of either acute ankle injury or CAI result in
impairments of postural control? and b) Does balance
and coordination training improve postural control in
individuals with a short or long history of ankle trauma?

METHOD
Subjects: study selection and inclusion/exclusion criteria. Conducting an exhaustive search for ankle
stability and balance-training studies began with two
computerized databases (19802008): a) PubMed and b)
Cochrane Database of Systematic Reviews. Six key words
dictated our search: ankle sprain, ankle instability, ankle
injuries/trauma, balance training, postural control, and rehabilitation. Additional search techniques included examining
reference lists of retrieved articles.
Our search identified 51 potential articles on stability after
ankle injury and balance training (1,2,4,68,1214,
1621,2325,27,28,3033,36,38,4042,4446,4953,55,57
60,62,6872,76,77,79). Further review confirmed what
articles met inclusion criteria for answering our research
questions about a history of ankle trauma, postural control,
and balance training. Only studies assessing static postural

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Official Journal of the American College of Sports Medicine

control measures in patients with a history of lateral ankle

trauma were included. We only included studies that used
static measures for two reasons: a) to compare our results
with previous systematic reviews and b) because studies
assessing dynamic postural control are as of yet not common
in the ankle trauma literature. Furthermore, all studies needed
to address at least one of the two questions stated above.
Consistent with conventional meta-analysis techniques, 14
studies were excluded from our list of 51 articles for the following reasons: a) 7 review articles (2,16,30,44,50,51,60);
b) 1 case study (45); and c) 6 insufficient data (1820,24,
38,42). The 37 remaining studies examined postural control
after ankle injury and/or used various types of balancetraining protocols during ankle injury recovery as an intervention for improving/restoring postural control.
Table 1 shows the specific details about each study. The
authors unanimously agreed on the 37 postural control
articles as well as balance-training studies included in the
meta-analysis. Data were extracted by two authors and
separately confirmed by two other authors.
Establishing outcome measures. Specific outcome
measures varied across acute/chronic ankle injuries and
rehabilitation conditions. To avoid bias in our meta-analysis,
only one outcome measure per study, a common postural
control measure, was selected and the results of each measure
were standardized. For our primary question concerning
postural control after acute or chronic injuries (trauma), the
three most frequent outcome measures were a) center of
pressure excursion, b) reach distance during a star excursion
balance test, and c) postural sway. However, the direction of
the change in postural control measures, either an increase or a
decrease, directly impacts postural stability interpretations.
Indeed, two different situations indicate an increase in postural
control deficit: a) a positive value (sign) on the center of
pressure excursion and postural sway and b) a negative value
on the star excursion balance test, time to boundary, and limits
of stability. Consequently, our data were entered into the
meta-analysis program with the same sign in relation to an
increase in postural control deficit.
Two predominant outcome measures in the balancetraining studies were postural sway and center of pressure
excursion. Our second research question determined the
effect of balance-training intervention contributions to
postural control performances with acute or chronic ankle
injury/trauma. Both analyses were consistent with conventional meta-analytic techniques (29,34,64,65).
Data synthesis and analysis. According to Rosenthal
(64), two functions are inherent in a meta-analysis: a)
synthesis and b) analysis. First, the synthesis function
includes describing the relevant properties of the collection
of studies including ES as a whole. Second, the analysis
function involves calculating a weighted ES in a collection
of common studies and identifying moderator variables
that may explain the standardized mean differences (65,66).
In line with conventional meta-analysis purists, we computed Hedges adjusted g for individual ES of the studies that

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TABLE 1. Characteristics of the ankle injury studies in the present meta-analyses.

Control Ankle
Study
Akbari et al. (1)
Baier and Hopf (4)
Bernier et al. (7)
Bullock-Saxton (8)
Cornwall and Murrell (12)
Docherty et al. (13)
Evans et al. (17)
Goldie et al. (23)
Gribble and Hertel (25)
Guskiewicz and Perrin (27)
Hale et al. (28)
Hertel et al. (32)
Hertel et al. (31)
Hertel and Olmsted-Kramer (33)
McKeon and Hertel (49)
Nakagawa and Hoffman (55)
Olmsted et al. (57)
Perrin et al. (58)
Perron et al. (59)
Rose et al. (62)
Ross and Guskiewicz (69)
Rozzi et al. (71)
Ryan (72)
Tropp et al. (77)
Tropp and Odenrick (79)
Bernier and Perrin (6)
Eils and Rosenbaum (14)
Gauffin et al. (21)
Hale et al. (28)
Holme et al. (36)
Kidgell et al. (40)
Laufer et al. (41)
Matsusaka et al. (46)
McKeon et al. (52)
Michell et al. (53)
Ross et al. (68)
Rotem-Lehrer et al. (70)
Rozzi et al. (71)
Tropp and Askling (76)
Tropp et al. (77)

Injured Ankle

Total N

Mean Age, Yr

Total N

Mean Age, Yr

Ankle Trauma Type

22
9

30
30

24
16
12

39
9
32
19
20
50
36
18
14
13

15
9
10

42
7

21

12
NA

13
30

25
26.22 T 2.34

24.9 T 5.06
18.7 T 0.8

21.7 T 6.3
22.5 T 2.4
25.7 T 6.6

20.7 T 2.4
22.7 T 2.6
21.25 T 3.85
21.7 T 2.1
20.2 T 1.4
2030
30 T 7
21.2 T 1.6
22 T 1.92
21.2 T 2.5

22.1 T 3.9
26.22 T 2.34
26.4 T 4.9

27.4 T 4.6
25.4 T 4.2

23 T 3.2

NA
NA

21.2 T 2.5
NA

30
22
9
20
20
30
28
24
14
13
13
17
48
15
32
19
20
15
34
19
14
13
45
25
15
9
20
10
13
29
6
40
22
31
16
NA
16
13
25
25

22.8 T 4.8
26
22.89 T 3.18
1835
22.63 T 3.14
20.0 T 1.5
19.7 T 1.4
20.9 T 4.8
21.9 T 2.9
18.1 T 5.8
22.2 T 4.6
21.8 T 5.9
20.9 T 3.2
19.7 T 1.3
22.25 T 2.85
21.5 T 2.6
19.8 T 1.4
24.4
26 T 6
20.4 T 1.5
21.71 T 2.64
21.9 T 3.1
23
23.8
22.1 T 3.9
22.89 T 3.18
27.0 T 7.7
24 T 3
22.2 T 4.6
25.5 T 3.8
25.4 T 4.2
20.8
20.9 T 2.1
22.2 T 4.5
20 T 3
21 T 2
20.6 T 1.9
21.9 T 3.1
NA
23.8

Acute
Chronic
Chronic
Acute
Acute
Chronic
Acute
Acute
Chronic
Acute
Chronic
Acute
Chronic
Chronic
Chronic
Chronic
Chronic
Chronic
Acute
Acute
Chronic
Chronic
Chronic
Acute
Chronic
Chronic
Chronic
Chronic
Chronic
Acute
Chronic
Acute
Chronic
Chronic
Chronic
Chronic
Acute
Chronic
Chronic
Acute

The 25 studies above the bold line are postural control deficit studies. The 15 studies below the bold line are balance-training intervention studies.

BALANCE AFTER ANKLE TRAUMA META-ANALYSIS

evaluates the consistency of evidence beyond a statistical

chance occurrence, represents heterogeneity as a percentage, and displays increased heterogeneity as larger values
(low = 25%; moderate = 50%; high = 75%). Ideally, this
magnitude of variability test will produce low values so that
we are confident that the selected studies are similar.
Fail-safe analysis. Classic fail-safe N analysis determines the stability of meta-analytic results by calculating the
number of nonsignificant studies required to nullify an
overall effect (63). The technique uses the probability value
of the overall (pooled) ES to compute the number of studies
required to negate the effect.
Given that only published studies on postural stability
after ankle injury and balance training were included in
the present meta-analysis, we conducted a classic fail-safe
analysis to determine whether there was publication bias
(29,64,74). Typically, positive ES are reported in published
studies, so we are trying to avoid any potential bias in
our data.
Quality assessment. Further, consistent with recommendations by Higgins and Green (34), we evaluated the
quality of each study (39,54). Three quality assessment criteria included a) randomization (i.e., subject and treatment
assignments), b) double blinding (i.e., knowledge of balancetraining treatments), and c) dropouts or withdrawals (34).

Medicine & Science in Sports & Exercised

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APPLIED SCIENCES

investigated postural stability after ankle injury as well as

balance-training intervention. Computing Hedges adjusted g
is a robust and conventional meta-analysis technique for
determining individual ES and incorporating the adjusted
pooled variance (6467,75). Further, we selected a randomeffects model for our meta-analysis to ensure consistency in
examining heterogeneity of the 25 postural control studies
and 15 ankle rehabilitation studies (34,35,74). Indeed, the ES
were weighted by the inverse variances to avoid inflated ES
and to derive the overall corrected mean ES (29,34,64,65,74).
Further, weighting ES by an inverse of the variances reduces
the potential bias from studies with disparities in sample size.
This technique is conventional and highly recommended by
meta-analysis experts (34,64).
Measuring the contribution of moderator variables on
individual ES is the third standardized meta-analytic
technique recommended (29,74). Given that most participants in our balance after ankle injury and balance-training
studies are categorized as either acute or chronic trauma, we
explored the possibility that individual ES varied depending
on these two specific conditions.
Measuring heterogeneity. Additional meta-analytic
techniques included computing a heterogeneity test known
as I2. This technique measures the degree of inconsistency
across studies in a meta-analysis (29,64,65). Moreover, I2

TABLE 2. Quality assessments for each study included in the meta-analyses.

Random
Not
Single Double
Research
Assignment Described Blind Blind Dropouts Design

APPLIED SCIENCES

Study

A. Postural stability studies

Akbari et al. (1)
0
1
Baier and Hopf (4)
1
0
Bernier et al. (7)
0
1
Bullock-Saxton (8)
0
1
Cornwall and
0
1
Murrell (12)
Docherty et al. (13)
0
1
Evans et al. (17)
0
1
Goldie et al. (23)
0
1
Gribble and Hertel (25)
0
1
Guskiewicz and
0
1
Perrin (27)
Hale et al. (28)
1
0
Hertel and Olmsted1
0
Kramer (33)
Hertel et al. (32)
0
1
Hertel et al. (31)
0
1
McKeon and Hertel (49)
0
1
Nakagawa and
0
1
Hoffman (55)
Olmsted et al. (57)
0
1
Perrin et al. (58)
0
1
Perron et al. (59)
0
1
Rose et al. (62)
0
1
Ross and
0
1
Guskiewicz (69)
Rozzi et al. (71)
0
1
Ryan (72)
0
1
Tropp and
0
1
Odenrick (79)
Tropp et al. (77)
0
1
B. Balance-training intervention studies
Bernier and Perrin (6)
1
0
Eils and
0
1
Rosenbaum (14)
Gauffin et al. (21)
0
1
Hale et al. (28)
1
0
Holme et al. (36)
1
0
Kidgell et al. (40)
1
0
Laufer et al. (41)
1
0
Matsusaka et al. (46)
1
0
McKeon et al. (52)
1
0
Michell et al. (53)
1
0
Ross et al. (68)
1
0
Rotem-Lehrer
1
0
et al. (70)
Rozzi et al. (71)
0
1
Tropp and Askling (76)
0
1
Tropp et al. (77)
0
1

0
0
0
0
0

0
0
0
0
0

0
0
4
0
0

3
3
3
3
3

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

3
1
3
3
3

0
1

0
0

6
0

3
3

0
0
0
0

0
0
0
0

0
0
0
0

3
3
3
3

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

3
3
3
3
3

0
0
0

0
0
0

0
4
0

3
3
3

0
0

0
0

3
0

3
1a

0
0
0
0
0
0
0
0
1
0

0
0
0
0
0
0
0
0
0
0

0
6
0
0
0
0
0
0
0
0

1a
1a
2
1a
1a
1a
1a
1a
1a
1a

0
0
0

0
0
0

0
0
0

1a
1a
1a

same participants and b) between an injured group and a

control group are readily apparent in the Forest plot of the
individual ES (Fig. 1).
Moderating variable analysis. Our initial meta-analysis
indicated postural control impairments in patients with a
history of lateral ankle trauma. However, more imporantly,
what is the cumulative effect of postural control when
considering the histories of ankle trauma as moderating
variables? Thus, acute and chronic injuries were analyzed as
moderating variables in the 25 postural control studies.
This second meta-analysis on moderating variables used
a random-effects model and revealed a medium, significant
cumulative effect of 0.494 (SE = 0.052; P G 0.0001) with
lower and upper limits for the 95% confidence interval
of 0.393 to 0.596. The number of subjects for each type
of ankle trauma study is as follows: acute = 230 and
chronic = 324. Additional analysis of the studies focused
on each type of ankle injury history revealed a similar
pattern. The acute ankle sprain studies (N = 10) indicated a
medium effect with an ES = 0.419 (SE = 0.073; P G 0.0001),
with a confidence interval of 0.275 to 0.563. Similarly, the
CAI studies (N = 15) indicated a cumulative effect = 0.570
(SE = 0.074; P G 0.0001), and the 95% confidence interval
for the chronic studies was 0.426 to 0.714.
Measuring heterogeneity. Variability calculations on
the combined studies revealed an I2 = 8%. This indicates
that the moderating variables have a relatively high amount
of consistency in the studies (35).
Fail-safe analysis. The fail-safe analysis determined
that 707 null effect findings were necessary to lower the
cumulative ES to an insignificant level. Specifically, 707
null studies are required to reduce our cumulative effect to a

Research design numbers: 1 = prospective investigation; 2 = retrospective investigation;

3 = cross-sectional/time series
a
Preinjury postural control measures were not identified

Tables 2A and B display the quality assessment values of

our postural stability and rehabilitation/intervention studies
in addition to the type of experimental design.

RESULTS
Postural Control Deficit and Ankle Trauma (Acute
and Chronic) Meta-Analysis
Mean ES. A random-effects model meta-analysis of the
25 postural control studies indicated a significant overall
Hedges g mean effect size (ES) of 0.492 (SE = 0.048;
P G 0.0001) with a 95% confidence interval of 0.397 to
0.587. This ES is a medium, positive effect (e.g., small =
0.20, medium = 0.50, and large = 0.80) that indicates a
postural control deficit (11,64,65). Individual-weighted ES
ranged from 0.128 to 1.905. Moreover, the combined effect
on postural stability across two types of comparisons a)
between the injured leg and the sound leg (control) in the

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Official Journal of the American College of Sports Medicine

FIGURE 1Forest plot of the 25 individual ES analyzed in the

postural stability studies. The order from top to bottom matches the
alphabetical list in Table 3A. The numbers on the far right correspond
to the reference numbers for studies included in the analysis, and the
diamond labeled at the bottom of the plot represents the overall ES.

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point that various types of ankle trauma would not affect

postural control.
Quality assessment. As shown in Table 3A, the 25
postural control studies displayed a relatively low quality.
Few studies described the randomization procedure used
nor conducted single/double blind experiments.
Postural Control Deficit and Balance-Training
Intervention Meta-Analysis
Mean ES. A random-effects meta-analysis of the 15
postural control and balance-training intervention studies
revealed a large significant cumulative Hedges g effect =
j0.857 (SE = 0.097; P G 0.0001), with a 95% confidence interval of j1.047 to j0.667 (11,64,65). Individual-weighted
ES ranged from j1.848 to j0.42. The overall ES shown in
the Forest plot clearly demonstrates postural control differentiation according to rehabilitation treatments (Fig. 2).
Moderating variable analysis. Again, a potential
moderating variable is whether the subjects represented
acute or chronic ankle traumas. Analysis of the type of
ankle injury history as a moderating variable on postural

stability in rehabilitation studies indicated a large significant overall effect = j0.865 (SE = 0.099; P G 0.0001) with
lower and upper limits for the 95% confidence interval of
j1.059 to j0.671. Separate analyses of the acute (N = 110)
and chronic (N = 165) histories revealed two significant
cumulative ES: a) acute, ES = j0.824 (SE = 0.198; P G
0.0001), with lower and upper confidence interval limits =
j1.212 to j0.437; and b) chronic, ES = j0.879 (SE =
0.115; P G 0.0001), with lower and upper confidence
interval limits = j1.103 to j0.654.
Measuring heterogeneity. Variability calculations on
the 4 acute and 11 chronic ankle trauma postural control
studies revealed an I2 = 36%. This indicates a low level of
heterogeneity in the balance-training intervention studies.
Fail-safe analysis. The fail-safe analysis calculated the
number of studies required to lower the cumulative effect to
an insignificant level. Specifically, 494 null studies are
necessary to reduce the effect of various rehabilitation
interventions on postural stability for participants who
experienced acute and chronic ankle injuries.
Quality assessment. As with the postural control studies, the 15 balance-training interventions and ankle trauma

Table 3. Summary statistics for the 25 studies included in the postural control deficit meta-analysis.
Study

Primary Outcome Measure

Hedges g

Model
Random

Overall Weighted Effect Size

j0.857

BALANCE AFTER ANKLE TRAUMA META-ANALYSIS

SE
0.097

Confidence Interval (95%)

j1.047 to j0.667

Confidence Interval (95%)

0.420
0.571
1.905
0.473
0.128
1.026
0.380
0.412
0.723
0.809
0.406
0.495
0.318
0.844
0.371
0.708
0.454
0.773
0.363
0.748
0.401
0.345
0.517
0.342
1.069

0.056
0.111
0.827
0.028
j0.430
0.494
0.007
0.008
0.162
0.017
0.010
0.012
0.032
0.011
j0.117
0.065
0.010
0.187
j0.104
0.095
j0.326
j0.406
0.210
j0.049
0.322

to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to

0.785
1.030
2.982
0.919
0.685
1.559
0.754
0.816
1.280
1.600
0.801
0.977
0.603
1.677
0.859
1.351
0.897
1.358
0.831
1.402
1.128
1.095
0.823
0.733
1.816

I2
8.00%

Classic Fail-Safe N
707
Confidence Interval (95%)
j1.387 to j0.316
j1.076 to j0.152
j2.212 to j0.553
j1.553 to 0.022
j1.853 to j0.699
j3.092 to j0.604
j0.737 to j0.102
j2.634 to j0.823
j1.074 to j0.064
j2.735 to j0.664
j1.428 to 0.087
j1.539 to j0.393
j1.386 to j0.200
j1.327 to j0.340
j1.155 to j0.296

I2
36.00%

Classic Fail-Safe N
494

Hedges g
j0.851
j0.614
j1.382
j0.766
j1.276
j1.848
j0.420
j1.729
j0.569
j1.670
j0.671
j0.966
j0.793
j0.834
j0.725

Medicine & Science in Sports & Exercised

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APPLIED SCIENCES

A. Postural Control Deficit Studies

Akbari et al. (1)
Star excursion balance test
Baier and Hopf (4)
Total horizontal sway velocity
Bernier et al. (7)]
Sway index
Bullock-Saxton (8)
Balance in one leg standing
Cornwall and Murrell (12)
Mediolateral postural sway frequency
Docherty et al. (13)
Total balance error score
Evans et al. (17)
Center of pressure excursion velocity
Goldie et al. (23)
Mediolateral force variability
Gribble and Hertel (25)
Reach distance as a percentage of leg lengthposterior direction
Guskiewicz and Perrin (27)
Sway index
Hale et al. (28)
Star excursion balance test
Hertel et al. (32)
Center of pressure excursion in frontal plane
Hertel et al. (31)
Posteromedial star excursion balance test
Hertel and Olmsted-Kramer (33)
Center of pressure anteriorposterior velocity
McKeon and Hertel (49)
Time-to-boundary in anteroposterior absolute minimum
Nakagawa and Hoffman (55)
Total excursion of the center of pressure
Olmsted et al. (57)
Distance reached
Perrin et al. (58)
Center of pressure area
Perron et al. (59)
Overall dynamic limit-of-stability score
Rose et al. (62)
Sway index
Ross and Guskiewicz (69)
Anteroposterior mean sway
Rozzi et al. (71)
Stability
Ryan (72)
Uniaxial balance evaluator
Tropp et al. (77)
Stabilometry
Tropp and Odenrick (79)
Area of confidence ellipse
B. Balance-Training Intervention Studies
Study
Overall Weighted Effect Size
SE
Confidence Interval (95%)
Random
0.492
0.048
0.397 to 0.587
Study
Primary Outcome Measure
Bernier and Perrin (6)
Postural sway
Eils and Rosenbaum (14)
Total sway distance
Gauffin et al. (21)
Area of confidence ellipse
Hale et al. (28)
Center of pressure velocity
Holme et al. (36)
Postural sway
Kidgell et al. (40)
Postural sway
Laufer et al. (41)
Overall stability index
Matsusaka et al. (46)
Mean rectangular area
McKeon et al. (52)
Center of pressure velocity
Michell et al. (53)
Center of pressure excursion
Ross et al. (68)
Center of pressure area
Rotem-Lehrer et al. (70)
Overall stability index
Rozzi et al. (71)
Stability
Tropp and Askling (76)
Stabilometry
Tropp et al. (77)
Stabilometry

FIGURE 2Forest plot of the 15 individual ES analyzed in the

balance-training intervention studies. The order from top to bottom
matches the alphabetical list in Table 3B. The numbers on the far left
correspond to the reference numbers for studies included in the
analysis, and the diamond labeled at the bottom of the plot represents
the overall ES.

studies demonstrated a relatively low quality. Although 10

(67%) of the studies described randomization procedures,
only 1 (7%) conducted a single or double blind experiment.

APPLIED SCIENCES

DISCUSSION
Postural control deficit after later ankle trauma. This
comprehensive meta-analysis clearly indicates that postural
control deficits are present in those with a history of lateral
ankle trauma. These postural control deficit results of 25
studies provide a representative sample of ankle injury
severity and gender. Specifically, the meta-analyses indicated that both moderating variables support postural control
impairments present in acute lateral ankle sprains and CAI.
A previous systematic review by McKeon and Hertel (50)
demonstrated postural control deficits in patients with an
acute lateral ankle sprain when compared with a healthy
control group. However, the authors were unable to determine whether side-to-side deficits existed, most likely due to
a bilateral impairment in postural control. The current metaanalysis determined if postural control was impaired after
lateral ankle trauma and did not conduct a separate analysis
like McKeon and Hertel (50). Therefore, a bilateral impairment of postural control present in the investigations using
side-to-side comparisons (i.e., injured limb relative to
uninjured limb) may have affected our results. Indeed, visual
inspection of Figure 1 (i.e., individual ES for each study,
cumulative ES, and lower/upper confidence intervals) illustrates a more distorted result for the within-subject comparisons (injured to uninjured) relative to the between-subjects
comparisons (injured to control group).
The idea of a bilateral impairment suggests that central
changes occur after a lateral ankle sprain in addition to the
peripheral alterations traditionally noted. Central changes

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Official Journal of the American College of Sports Medicine

would alter motor control patterns (i.e., feed-forward

neuromuscular control), which control both limbs, thus
causing a bilateral impairment of postural control. Because
the idea of central changes was first proposed, postural
control impairments have been noted in both the injured and
the uninjured limbs of acute ankle sprain patients relative to
a control group (17,19). For example, Evans et al. (17)
identified a bilateral impairment in postural control but also
revealed that resolution of the impairment did not occur at
the same time. Specifically, the impairment seen in the
uninjured limb resolved 7 d postinjury whereas resolution
of postural control deficits in the injured limb did not take
place until at least 4 wk after injury. These results suggest
that bilateral postural control impairments exist but the
severity of the impairment is not equal. Thus, side-to-side
differences may exist but are difficult to determine due to a
bilateral impairment. The current findings, which demonstrate a combined impairment of postural stability across a
within- and a between-group comparison does not support
or refute the possibility that side-to-side differences exist.
Yet, anecdotal evidence, Figure 1, and the existing literature
seem to support the conclusions drawn by McKeon and
Hertel (50). Specifically, bilateral alterations have been
reported both at the ankle joint itself (17) and more
interestingly at joints proximal to the ankle in acute lateral
ankle sprains (9,10) and in patients with CAI (26,73).
Future meta-analyses should attempt to determine whether a
bilateral impairment in postural control exists and how
much this impairment contributes to ankle instability.
Postural control deficits were found in both types of
patients, acute trauma as well as CAI. Moreover, these
novel findings have not been identified in previous reports.
Granted our findings are cumulative values of individualweighted ES inherent in the meta-analysis technique.
Unfortunately, a scarcity of knowledge exists regarding
the underlying neurophysiologic mechanisms involved in
acute ankle sprains and CAI. Thus, the present investigation
cannot comment on the cause of the postural control
impairments due to the retrospective study design.
Although our findings indicate deficits in postural
control, the results do not challenge previously asserted
recommendations for evaluating postural control in patients
with a history of lateral ankle sprain(s). Like previous investigations, the current results imply that a bilateral
impairment in postural control may exist, and therefore
extreme caution must be taken by the clinician when
considering the use of an uninjured limb as a criterion for
normal postural control (50). Using the uninjured limb as a
reference may lead to inappropriate conclusions about the
patients ability to balance and therefore may result in a
hasty return to play. Indeed, research indicates an association between an impaired postural control and an increased
risk of sustaining a lateral ankle sprain (47,78,82). In
addition, patients have an elevated risk of recurrent injury
for 12 months after a lateral ankle sprain (81). Therefore, clinicians should use a healthy reference group or

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Therefore, we are confident that balance training improves

postural control after lateral ankle trauma, but we cannot be
certain that balance training restored preinjury levels of
postural control.
Ultimately, the exact dosage, the type of exercise, and the
level of intensity will most likely be determined by several
variables, including, but not limited to, injury severity, concomitant injuries, demands of the activity/sport and position
played, experience with balance training, motor ability levels,
and physical conditioning. Regardless of the balance-training
parameters, the current findings support the position that
patients with a history of lateral ankle trauma complete a
balance/coordination training program for three reasons.
First, balance-training programs improve postural control, a
measure associated with an increased risk of sustaining a
lateral ankle sprain (47,78,82). Second, these programs
reduce the recurrence of ankle injuries (15,36,47,48), which
is the primary symptom of CAI, and finally, the development of CAI compromises the talar articular surface (43) and
is a common cause of posttraumatic osteoarthritis (80).

CONCLUSIONS
Postural control impairments are present in patients with
both a short and a long history of lateral ankle sprains.
However, we urge caution when using the uninjured limb as
a reference for normal postural control because bilateral
deficits may mask postural control impairments. Balance/
coordination training programs improve the postural control
scores of patients with an acute lateral ankle sprain and with
CAI. Further research needs to determine the optimal dosage,
intensity, and type of training needed to maximize postural
control improvements and to reduce recurrent ankle injuries
as well as to evaluate a risk reduction/preventative effect
associate with balance training after both acute and chronic
ankle trauma. In addition, future meta-analyses should
investigate the presence of a bilateral impairment in postural
control and/or other sensorimotor control measures after an
acute lateral ankle sprain and the development of CAI.

The only external funding that partially supported this work was
an AHA grant to JHC.
The authors of this investigation do not have any professional
relationships with companies or manufacturers who may benefit
from the results of the present study. In addition, the results of the
present study do not constitute endorsement by the American
College of Sports Medicine.

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APPLIED SCIENCES

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