Can Therapeutic Exercises Improve Proprioception in Chronic Ankle Instability? A Systematic Review and Network Meta-analysis



      To assess exercise therapies that aim to enhance proprioception in individuals with chronic ankle instability (CAI).

      Data Sources

      Five databases (PubMed, Embase, Cochrane Library, Web of Science, and EBSCO) were searched in October 2021.

      Study Selection

      Randomized controlled trials involving exercise therapy conducted on individuals with CAI were included.

      Data Extraction

      Data were extracted by 2 independent reviewers using a standardized form. Methodological quality and risk of bias were assessed with the Physiotherapy Evidence Database scale.

      Data Synthesis

      The end trial weighted mean difference and standard deviations were analyzed, and the synthetic value for the improvement in error scores of ankle joint position sense in multiple directions was evaluated.


      Eleven trials with 333 participants were eligible for inclusion in this systematic review and were included in the network meta-analysis. Foot and ankle muscle strengthening exercise showed the highest probability of being among the best treatments (surface under the cumulative ranking [SUCRA]=74.6%). The next 2 were static balance exercise only (SUCRA=67.9%) and corrective exercise (SUCRA=56.1%). The SUCRA values of proprioceptive exercise, dynamic balance exercise only, aquatic exercise, rehabilitation exercise with brace, mixed static/dynamic balance exercise, and control were at relatively low levels and scored at 49.6%, 48.8%, 47.8%, 47.7%, 44.0%, and 13.5%, respectively.


      Foot and ankle muscle strengthening exercise may have a good effect when used to improve joint position sense in individuals with CAI. The more complex balance exercise intervention becomes, the less effective the proprioceptive outcome.


      List of abbreviations:

      CAI (chronic ankle instability), CI (confidence interval), JPS (joint position sense), SUCRA (surface under the cumulative ranking)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Delahunt E
        • Bleakley CM
        • Bossard DS
        • et al.
        Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium.
        Br J Sports Med. 2018; 52: 1304-1310
        • Witchalls J
        • Blanch P
        • Waddington G
        • et al.
        Intrinsic functional deficits associated with increased risk of ankle injuries: a systematic review with meta-analysis.
        Br J Sports Med. 2012; 46: 515-523
        • Hubbard TJ
        • Kramer LC
        • Denegar CR
        • et al.
        Correlations among multiple measures of functional and mechanical instability in subjects with chronic ankle instability.
        J Athl Train. 2007; 42: 361-366
        • Gribble PA
        • Delahunt E
        • Bleakley C
        • et al.
        Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium.
        J Athl Train. 2014; 49: 121-127
        • Han J
        • Anson J
        • Waddington G
        • et al.
        The role of ankle proprioception for balance control in relation to sports performance and injury.
        Biomed Res Int. 2015; 2015842804
        • Han J
        • Anson J
        • Waddington G
        • et al.
        Proprioceptive performance of bilateral upper and lower limb joints: side-general and site-specific effects.
        Exp Brain Res. 2013; 226: 313-323
        • Witchalls J
        • Waddington G
        • Adams R
        • et al.
        Chronic ankle instability affects learning rate during repeated proprioception testing.
        Phys Ther Sport. 2014; 15: 106-111
        • Witchalls J
        • Waddington G
        • Blanch P
        • et al.
        Ankle instability effects on joint position sense when stepping across the active movement extent discrimination apparatus.
        J Athl Train. 2012; 47: 627-634
        • Han J
        • Waddington G
        • Adams R
        • et al.
        Assessing proprioception: a critical review of methods.
        J Sport Health Sci. 2016; 5: 80-90
        • Han J
        • Yang Z
        • Adams R
        • et al.
        Ankle inversion proprioception measured during landing in individuals with and without chronic ankle instability.
        J Sci Med Sport. 2021; 24: 665-669
        • de Vries JS
        • Krips R
        • Sierevelt IN
        • et al.
        Interventions for treating chronic ankle instability.
        Cochrane Database Syst Rev. 2011 Aug 10; CD004124
        • Cruz AL
        • Oliveira R
        • Silva AG.
        Exercise-based interventions for physically active individuals with functional ankle instability: a systematic review of the literature.
        J Sports Med Phys Fitness. 2019; 59: 666-675
        • Tsikopoulos K
        • Mavridis D
        • Georgiannos D
        • et al.
        Efficacy of non-surgical interventions on dynamic balance in patients with ankle instability: a network meta-analysis.
        J Sci Med Sport. 2018; 21: 873-879
        • Wright CJ
        • Linens SW
        • Cain MS.
        A randomized controlled trial comparing rehabilitation efficacy in chronic ankle instability.
        J Sport Rehabil. 2017; 26: 238-249
        • Luan L
        • Adams R
        • Witchalls J
        • et al.
        Does strength training for chronic ankle instability improve balance and patient-reported outcomes and by clinically detectable amounts? A systematic review and meta-analysis.
        Phys Ther. 2021; 101 (pzab046)
        • Hall EA
        • Chomistek AK
        • Kingma JJ
        • et al.
        Balance- and strength-training protocols to improve chronic ankle instability deficits, part II: assessing patient-reported outcome measures.
        J Athl Train. 2018; 53: 578-583
        • Hutton B
        • Salanti G
        • Caldwell DM
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • Herbert R
        • Moseley A
        • Sherrington C.
        PEDro: a database of randomised controlled trials in physiotherapy.
        Health Inf Manag. 2016; 28: 186-188
        • Moseley AM
        • Herbert RD
        • Maher CG
        • et al.
        Reported quality of randomized controlled trials of physiotherapy interventions has improved over time.
        J Clin Epidemiol. 2011; 64: 594-601
        • Armijo-Olivo S
        • Saltaji H
        • Da Costa BR
        • et al.
        What is the influence of randomisation sequence generation and allocation concealment on treatment effects of physical therapy trials? A meta-epidemiological study.
        BMJ. 2015; 5: e8562
        • Moseley AM
        • Rahman P
        • Wells GA
        • et al.
        Agreement between the Cochrane risk of bias tool and Physiotherapy Evidence Database (PEDro) scale: a meta-epidemiological study of randomized controlled trials of physical therapy interventions.
        PLoS One. 2019; 14e0222770
        • Li L
        • Tian J
        • Tian H
        • et al.
        Network meta-analyses could be improved by searching more sources and by involving a librarian.
        J Clin Epidemiol. 2014; 67: 1001-1007
        • Thorlund K
        • Mills EJ.
        Sample size and power considerations in network meta-analysis.
        Syst Rev. 2012; 1: 41
        • Hutton B
        • Salanti G
        • Chaimani A
        • et al.
        The quality of reporting methods and results in network meta-analyses: an overview of reviews and suggestions for improvement.
        PLoS One. 2014; 9: e92508
        • Bagherian S
        • Rahnama N
        • Wikstrom EA.
        Corrective exercises improve movement efficiency and sensorimotor function but not fatigue sensitivity in chronic ankle instability patients: a randomized controlled trial.
        Clin J Sport Med. 2019; 29: 193-202
        • Lee E
        • Cho J
        • Lee S.
        Short-foot exercise promotes quantitative somatosensory function in ankle instability: a randomized controlled trial.
        Med Sci Monit. 2019; 25: 618-626
        • Anguish B
        • Sandrey MA.
        Two 4-week balance-training programs for chronic ankle instability.
        J Athl Train. 2018; 53: 662-671
        • Ha SY
        • Han JH
        • Sung YH.
        Effects of ankle strengthening exercise program on an unstable supporting surface on proprioception and balance in adults with functional ankle instability.
        J Exerc Rehabil. 2018; 14: 301-305
        • Lazarou L
        • Kofotolis N
        • Malliou P
        • et al.
        Effects of two proprioceptive training programs on joint position sense, strength, activation and recurrent injuries after ankle sprains.
        Isokinet Exerc Sci. 2017; 25: 289-300
        • Lee HJ
        • Lim KB
        • Jung TH
        • et al.
        Changes in balancing ability of athletes with chronic ankle instability after foot orthotics application and rehabilitation exercises.
        Ann Rehabil Med. 2013; 37: 523-533
        • Nualon P
        • Piriyaprasarth P
        • Yuktanandana P.
        The role of 6-week hydrotherapy and land-based therapy plus ankle taping in a preseason rehabilitation program for athletes with chronic ankle instability.
        Asian Biomed. 2013; 7: 553-559
        • Anguish BM.
        The effects of a randomized four-week dynamic balance training program on individuals with chronic ankle instability [dissertation].
        West Virginia University, Morgantown2010
        • Eils E
        • Rosenbaum D.
        A multi-station proprioceptive exercise program in patients with ankle instability.
        Med Sci Sports Exerc. 2001; 33: 1991-1998
        • Bernier JN
        • Perrin DH.
        Effect of coordination training on proprioception of the functionally unstable ankle.
        J Orthop Sports Phys Ther. 1998; 27: 264-275
        • Docherty CL
        • Moore JH
        • Arnold BL.
        Effects of strength training on strength development and joint position sense in functionally unstable ankles.
        J Athl Train. 1998; 33: 310-314
        • Han J
        • Waddington G
        • Anson J
        • et al.
        Level of competitive success achieved by elite athletes and multi-joint proprioceptive ability.
        J Sci Med Sport. 2015; 18: 77-81
        • Liu B
        • Witchalls J
        • Waddington G
        • et al.
        Vibration of calf muscles has reverse effects on right and left ankle proprioception in high and low proprioceptive performer groups.
        Somatosens Mot Res. 2020; 2020: 1-7
        • Hall EA
        • Docherty CL
        • Simon J
        • et al.
        Strength-training protocols to improve deficits in participants with chronic ankle instability: a randomized controlled trial.
        J Athl Train. 2014; 50: 36-44
        • Melam GR
        • Alhusaini AA
        • Perumal V
        • et al.
        Effect of weight-bearing overload using elastic tubing on balance and functional performance in athletes with chronic ankle instability.
        Sci Sport. 2018; 33: e229-e236
        • Han K
        • Ricard MD
        • Fellingham GW.
        Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains.
        J Orthop Sport Phys. 2009; 39: 246-255
        • Witchalls J
        • Newman P
        • Waddington G
        • et al.
        Functional performance deficits associated with ligamentous instability at the ankle.
        J Sci Med Sport. 2013; 16: 89-93
        • Rios JL
        • Gorges AL
        • dos Santos MJ.
        Individuals with chronic ankle instability compensate for their ankle deficits using proximal musculature to maintain reduced postural sway while kicking a ball.
        Hum Mov Sci. 2015; 43: 33-44
        • Youssef NM
        • Abdelmohsen AM
        • Ashour AA
        • et al.
        Effect of different balance training programs on postural control in chronic ankle instability: a randomized controlled trial.
        Acta Bioeng Biomech. 2018; 20: 159-169
        • Cruz-Diaz D
        • Lomas-Vega R
        • Osuna-Pérez MC
        • et al.
        Effects of 6 weeks of balance training on chronic ankle instability in athletes: a randomized controlled trial.
        Int J Sports Med. 2015; 36: 754-760
        • O'Driscoll J
        • Delahunt E.
        Neuromuscular training to enhance sensorimotor and functional deficits in subjects with chronic ankle instability: a systematic review and best evidence synthesis.
        Sports Med Arthrosc Rehabil Ther Technol. 2011; 3: 19
        • Minoonejad H
        • Ardakani MK
        • Rajabi R
        • et al.
        Hop stabilization training improves neuromuscular control in college basketball players with chronic ankle instability: a randomized controlled trial.
        J Sport Rehabil. 2019; 28: 576-583
        • Ardakani MK
        • Wikstrom EA
        • Minoonejad H
        • et al.
        Hop-stabilization training and landing biomechanics in athletes with chronic ankle instability: a randomized controlled trial.
        J Athl Train. 2019; 54: 1296-1303
        • Shi X
        • Han J
        • Witchalls J
        • et al.
        Does treatment duration of manual therapy influence functional outcomes for individuals with chronic ankle instability: a systematic review with meta-analysis?.
        Musculoskelet Sci Pract. 2019; 40: 87-95
        • Schaefer JL
        • Sandrey MA.
        Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument–assisted soft-tissue mobilization for chronic ankle instability.
        J Sport Rehabil. 2012; 21: 313-326
        • Long Z
        • Wang R
        • Han J
        • et al.
        Optimizing ankle performance when taped: effects of kinesiology and athletic taping on proprioception in full weight-bearing stance.
        J Sci Med Sport. 2017; 20: 236-240
        • Smyth E
        • Waddington G
        • Witchalls J
        • et al.
        Does ankle tape improve proprioception acuity immediately after application and following a netball session? A randomised controlled trial.
        Phys Ther Sport. 2021; 48: 20-25
        • Pintsaar A
        • Brynhildsen J
        • Tropp H.
        Postural corrections after standardised perturbations of single limb stance: effect of training and orthotic devices in patients with ankle instability.
        Br J Sports Med. 1996; 30: 151-155
        • Han J
        • Waddington G
        • Adams R
        • et al.
        A proprioceptive ability factor underlying all proprioception tests? Response to Tremblay (2013).
        Percept Mot Skills. 2014; 119: 301-304
        • Rivera MJ
        • Winkelmann ZK
        • Powden CJ
        • et al.
        Proprioceptive training for the prevention of ankle sprains: an evidence-based review.
        J Athl Train. 2017; 52: 1065-1067
        • Yang N
        • Waddington G
        • Adams R
        • et al.
        Joint position reproduction and joint position discrimination at the ankle are not related.
        Somatosens Mot Res. 2020; 37: 97-105
        • Han J
        • Adams R
        • Waddington G.
        Imposed” and “obtained” ankle proprioception across the life span—commentary on Djajadikarta et al.
        J Appl Physiol. 2020; 129: 533-534
        • Yang N
        • Waddington G
        • Adams R
        • et al.
        Age-related changes in proprioception of the ankle complex across the lifespan.
        J Sport Health Sci. 2019; 8: 548-554