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| Q: |
Are balance and strengthening exercises effective in reducing the incidence
of re-injury among adults with acute or chronic ankle sprain?
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A: |
To answer this question, we performed a comprehensive search of the PubMed database for randomized, controlled trials that addressed this specific research question.
1
Overall, five studies met the criteria for inclusion in this review:
Three studies evaluated the effectiveness of balance training
(2,3,5);
one study evaluated both balance training and strength training
(1); and one study utilized a program that
combined balance and strength exercises (4).
Of the three balance training studies, two found significant effects
of the intervention in preventing ankle sprain among those with a
history of ankle sprain (3,5).
The remaining study found that while balance training reduced the
incidence of sprain, the result was not significant (2).
A low compliance rate with the intervention likely contributed to
this lack of significance. In the study that compared balance and
strength training, only balance training was found to significantly
reduce injury compared to controls (1).
While the strength component resulted in fewer injuries, the effect
did not reach statistical significance. Finally, in the study that
combined balance and strength into one program, the risk of ankle
sprain was lower in the intervention group but was not statistically
significant (4).
Based on this review, both strength and balance exercises can be
effective at reducing the risk of ankle sprain among those with
a history of sprain. However, of the five studies that we evaluated,
balance training was the only intervention that resulted in a
significant reduction in the risk of ankle injury. Details pertaining
to the exercises used in the evaluated studies are below (Table 1).
As the theoretical rationale for the effectiveness of the above
exercises is based on progressively challenging the neuromuscular
system (i.e. proprioception, motor response), additional sample
exercises were selected from VHI PC-Kits
that met this same criteria (Table 2). While not all of these exercises were directly included in the above research studies they would in all likelihood achieve a similar outcome.
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Balance board exercise from VHI PC-Kits: Closed Chain, Lower Extremity #33
Single-leg balance exercise with eyes closed from VHI PC-Kits: Balance & Vestibular, Static Standing #20
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Table 1: Overview of Research Studies1
| Study2 | Overview | Description of Intervention | Results & Conclusions3 |
| Mohammadi, 2007 ++ |
Study subjects included 80 male soccer players with ankle inversion sprain. Study duration was one soccer season after the previous sprain. Groups included: Proprioceptive training (n=20); Strength training (n=20); Orthoses (n=30); Control (n=20)
| Proprioceptive training: Ankle disk was used for 30 minutes per day. Subject stood on the injured leg and shifted body weight so that the disk moved in a circle. Disk exercise was progressed by closing the eyes and/or placing the disk on softer surfaces. Strength training: Everter muscles were targeted with isometric exercises against an immovable object. Exercises were progressed to dynamic exercises with ankle weights and resistive bands. Subjects completed 10 sets of 20 reps with a 9 seconds hold. | Proprioceptive training was the only intervention that resulted in a significantly lower incidence of ankle sprain when compared to the control group (RR=0.13, p=0.02). There was a potential clinical effect seen with strength training (RR=0.5, p=0.27) and orthoses (RR=0.25, p=0.06). |
| Emery, 2007 + | Study subjects included 920 male (464) and female (456) high school basketball players. Study duration was one basketball season (18 wks) with follow up to one year. Groups included: Sport specific balance training program (n=494); Control (n=426). | Balance training: 5 minute sport specific balance training was completed at practice and a 20 minute exercise program using a 16" wobble board was completed at home. Details of the home exercise program were not provided in the article. | The wobble board training program did not significantly reduce ankle sprain injury. The authors reported a "clinically relevant trend" in reducing ankle sprain injury (RR=0.71, p=0.15). Poor compliance with the home program may be responsible for the lack of significance: Only 60% of the intervention group was compliant with the program. |
| McGuine, 2007 ++ | Subjects included 765 male (242) and female (523) high school basketball and soccer players. About 24% had a history of ankle sprain. The study duration was one season plus 4 wks preseason. Groups included: Balance training program (n=373); Control (n=392). |
Balance training:
1) Single leg stance on floor
2) #1 w/opposite leg swinging
3) Single leg squat (30-45°) on floor
4) Single leg stance with sport activities (dribbling, catching, kicking) on floor
5) #1-#4 on balance board
5) Double leg stance on board while rotating board
6) #5 with single leg stance
* 30 seconds per leg with 30 sec rest
* 5 sessions per week for 4 weeks during preseason; 3 sessions per week for 10 minutes during season.
* Training program progressed from eyes open to closed and from floor to board
| Balance board training significantly reduced the risk of ankle sprain (RR=0.56, p=0.03). Athletes in the intervention group that had a prior ankle sprain also had a significantly reduced rate of sprain (risk ratio and p value not provided). |
| Olsen, 2005 + | Subjects included 1837 male (150) and female (808) high school age handball players. The study duration was one season (8 months). Groups included: Balance and Strength training (n=958); Control (n=879). |
Balance and strength training:
1) Warm up exercises for 30 seconds each: Jogging, backward running with sidesteps, forward running with knee lifts and heel kicks, grapevine, sideways running with arms lifted, forward running with trunk rotations, forward running with intermittent stop, speed running.
2) Technique exercises for 5x30 seconds and one exercise per session: Planting and cutting movements; jump shot landings.
3) Balance exercises on a balance mat or wobble board for 2x90 seconds and one exercise per session: Passing the ball with one or two leg stance; Squats with one or two leg stance; Bouncing ball with eyes closed; Perturbation.
4) Strength and power exercises for 3x10 reps and two exercises per session: Squats, bounding strides, forward jumps, or jump shot; and Nordic hamstring lowers.
*Every day for 15 days and then once/week
| Risk of acute ankle injury was lower in the intervention group, but was not statistically significant (RR=.63; p=0.09). |
| Verhagen, 2004 ++ | Subjects included 1127 male (483) and female (644) volleyball players. About 65% had a previous ankle injury. The study duration was one season (36 wks). Groups included: Balance board (n=641); Control (n=486). |
Balance training:
1) One-leg stance w/ opp knee flexed
2) One-leg stance w/opp hip and knee flexed
3) #1 & #2 while throwing/catching a ball 5x
4) #1 & #2 on balance board for 30 sec
5) Both legs on board & throw/catch ball 10x
6) #5 with one leg and knee flexed
7) #6 & throw/catch ball 10x
8) One-leg stance on board while slowly stepping over the board with opposite leg 10x and keeping board in horizontal position
9) Both legs on balance board with 10 squats
10) #9 with one-legged stance
11) Both legs on board w/ upper hand technique 10x
12) #11 with one leg and knee flexed
* One exercises per session (5 minutes)
*Variations included combinations of the following with the above exercises: standing leg is stretched or flexed; eyes are open or closed; upper or lower hand technique (sport specific) is added.
| Balance exercises reduced the risk of ankle sprain among those with a history of ankle sprain (RR=0.4, CI=0.2-0.8). |
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References
- Mohammadi F.
Comparison of 3 preventive methods to reduce the recurrence of
ankle inversion sprains in male soccer players.
Am J Sports Med. 2007 Jun;35(6):922-6. Epub 2007 Mar 22.
- Emery CA, Rose MS, McAllister JR, Meeuwisse WH.A prevention strategy to reduce the incidence of injury in
high school basketball: a cluster randomized controlled trial.
Clin J Sport Med. 2007 Jan;17(1):17-24.
- McGuine TA, Keene JS.The effect of a balance training program on the
risk of ankle sprains in high school athletes.
Am J Sports Med. 2006 Jul;34(7):1103-11. Epub 2006 Feb 13.
- Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R.Exercises to prevent lower limb injuries in youth sports:
cluster randomised controlled trial.
BMJ. 2005 Feb 26;330(7489):449. Epub 2005 Feb 7.
- Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W.The effect of a proprioceptive balance board training program
for the prevention of ankle sprains: a prospective controlled trial.
Am J Sports Med. 2004 Sep;32(6):1385-93. Epub 2004 Jul 20.
Animations were created as part of a Phase I SBIR grant from the National Institutes of Health (NIH)
"Internet Delivery of Animated Rehabilitation Exercises"
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