Research in Focus: Does Strength Training for Chronic Ankle Instability Improve Balance and Patient-Reported Outcomes?

  •   March 4, 2021
  •  Leanne Loranger, PT

Full Citation: Luan L, Adams R, Witchalls J, Ganderton C, Han J.  Does Strength Training for Chronic Ankle Instability Improve Balance and Patient-Reported Outcomes and by Clinically Detectable Amounts? A Systematic Review and Meta-Analysis. Physical Therapy, 2021; pzab046,


Ankle sprain is the most common sports injury and is associated with chronic ankle instability (CAI) and recurring ankle injuries. Common interventions to manage CAI include strength training and neuromuscular control training. Neuromuscular control training has been found to result in improved balance and function. The effectiveness of strength training in CAI and its relative effectiveness compared with neuromuscular control training is unclear.

The purpose of this systematic review and meta-analysis was to “assess the effects of strength training compared with no exercise or neuromuscular control training on balance and patient-reported function in individuals with CAI.”


  • Systematic Review with meta-analysis
    • Databases searched: PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, CNKI, and WanFang
    • No restriction on publication year
    • English and Mandarin Chinese publications only
    • Two reviewers screened titles and abstracts for inclusion and completed data extraction
  • Inclusion
    • Randomized controlled trials
    • Population - Individuals with CAI
    • Intervention - Strength training
    • Comparison – no exercise or neuromuscular control training
    • Outcomes of interest:
      • Star Excursion Balance Test (SEBT) measures dynamic postural control
      • Foot and Ankle Ability Measure (FAAM), self-report questionnaire of ADL and sprot performance
      • Cumberland Ankle Instability Tool (CAIT) used to assess subjective symptoms of CAI
  • Exclusion
    • Animal, in vitro, or cadaver studies
    • Simulators or prosthesis
    • Acute ankle sprain
    • Case report or detection studies or surveys
    • Not published in peer-reviewed journal (book chapter, conference abstract)
  • Quality evaluation used the PEDro scale.
  • GRADE used to determine strength of evidence.
  • 554 studies identified from the literature search, from which 11 RCTs (published 2009-2018) met the inclusion criteria. 8 of these were included in the meta-analysis.


  • Comparison: strength training vs no-exercise control
    • Statistically significant improvement in SEBT with strength training, did not reach the level of minimal detectable change (MDC)
    • No statistically significant difference in self-report function (FAAM)
  • Comparison: strength training vs neuromuscular control training
    • Strength training was inferior to neuromuscular control training in SEBT scores
    • Similar effects for both interventions on FAAM
    • Neuromuscular control training was significantly better than strength training on improving CAIT scores

“Strength deficits of the main ankle stabilizers have been thought to represent weakness and predispose individuals to recurrent injuries… However, previous research has also indicated that improving strength may not be an important factor in the improvement of self-reported function in patients with CAI. This is consistent with the findings of the current review, which show that the changes after strength training in self-reported activities of daily living and sport performance, were statistically insignificant…”


  • Studies included in this review were limited to English and Mandarin Chinese language publications.
  • Included several small study samples.
  • Participants demonstrated heterogeneity in terms of study inclusion criteria for diagnosis of CAI.
  • Differences in the parameters of strength training, with limited duration of 4-6 weeks of strength training in included studies.

Relevance to physiotherapy practice in Alberta

The results of this study suggest that strength training provides modest, statistically significant benefit on dynamic postural control outcomes for people with CAI, but that neuromuscular control training demonstrates better outcomes for dynamic postural control and patient reported symptoms.

Physiotherapists who work with individuals experiencing CAI should be aware of the findings of this systematic review and may wish to consider including neuromuscular control training in rehabilitation programs in addition to, or instead of strength training.

Disclaimer: The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.