Year: 2025

Proprioception and Postural Control: Clinical Insights from Recent Research

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Blog Post Author Biography: Dr. Brice Picot currently works at the Sciences et Technologies des Activités Physique et Sportives (STAPS), Université Savoie Mont Blanc and in the French association of Sports Physical Therapy. Brice does research in Traumatology, Rehabilitation Medicine and Physiotherapy. His current projects are focused on injury rehabilitation and prevention of Chronic Ankle Instability and ACL among athletes.

Citation: Sagnard T, Picot B, Forestier N. Proprioceptive acuity, proprioceptive weighting and balance in individuals with chronic ankle instability. Gait Posture. Published online March 15, 2025. doi:10.1016/j.gaitpost.2025.03.006

Take-to-the-Clinic Message:

  • Not all patients suffering from CAI exhibits postural impairments or proprioceptive acuity and reweighting deficits.
  • Poorer proprioceptive acuity is associated with increases postural sway, only in CAI patients.
  • Higher proprioceptive reweighting is observed when proprioception is disrupted in healthy individuals only.

Background: Chronic ankle instability (CAI) is a common consequence of repeated ankle sprains, often leading to impaired postural control and proprioception. Understanding the impact of these deficits is crucial for improving rehabilitation strategies.

Purpose: The purposes of this study were to evaluate proprioceptive and postural control deficits among CAI and healthy control individuals, and to assess whether these parameters were correlated among those two groups.

Methods: The study assessed 13 participants with chronic ankle instability (CAI) and 15 healthy controls to examine proprioception and balance deficits. Joint position sense (JPS) was evaluated in dorsiflexion and plantarflexion by calculating absolute and constant repositioning errors. Unipedal balance was measured using center of pressure (CoP) ellipse area and velocity to assess postural stability. Relative proprioceptive weighting (RPW) was determined by analyzing postural responses to triceps surae and lumbar multifidus tendinous vibrations.

Results: This study found nodifferences in proprioception or balance between CAI patients and healthy controls. However, within the CAI group, poorer accuracy in proprioceptive acuity was linked to greater difficulty maintaining balance, as shown by increased body sway. In contrast, for the control group, a different relationship emerged—those with greater proprioceptive errors tended to rely more on other sensory inputs for balance.

Rolling the field forward: Contrary to previous belief, not all CAI patients exhibited poor postural control or impaired proprioception. However, results from the present study suggests that contrary to healthy individuals, people with CAI still maintain an ankle steered strategy when proprioceptive signals are inaccurate. This could explain why CAI patients with unreliable acuity (i.e. high errors in JPS) exhibit poorer postural control while healthy control individuals do not. These findings highlight the importance of assessing both proprioception and balance in CAI patients to better address potential deficits in rehabilitation programs.

Question for the researchers:

  • How can we easily evaluate postural control deficits in CAI patients?
  • What are the normative values in errors of repositioning among healthy individuals?

External Ankle Support and Ankle Biomechanics in Chronic Ankle Instability

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Blog Post Author Biography: Patrick Rowe is a Physiotherapist, Lecturer & PhD Candidate in the College of Sport, Health & Engineering at Victoria University and the Centre of Health, Exercise & Sports Medicine at the University of Melbourne. Patrick has research expertise in the biomechanics of lateral ankle sprains and chronic ankle instability by using musculoskeletal modeling to explore how footwear and external ankle supports influence the lateral ankle ligament complex.

Citation: Rowe, P. L., Bryant, A. L., Egerton, T. & Paterson, K. L. External ankle support effects on ankle biomechanics in chronic ankle instability: systematic review and meta-analysis. Journal of Athletic Training (2022) doi:10.4085/1062-6050-0208.22.

Take-to-the-clinic message: This review found that ankle supports (taping and bracing) reduce inward motion but not inward position at ground contact in people with unstable ankles during landing. This may help prevent ankle sprains or lessen injury severity by limiting excessive inward movement. However, while ankle supports also reduce forward ankle motion, this could shift forces to the knee and hip, potentially increasing injury risk at these joints.

Background: Lateral ankle sprains are common among youth and adolescent athletes in high-demand, multidirectional sports, with up to 70–80% experiencing repeated sprains and chronic ankle instability (CAI). Biomechanical alterations in CAI, such as reduced plantarflexion and higher ground reaction forces during landing, contribute to instability. Athletes often use ankle supports (taping and bracing) to reduce sprain risk, but research is limited to non-randomized studies and lower-demand tasks. Therefore, we must explore whether external ankle supports influence ankle biomechanics during higher demand tasks (running, landing, and cutting), particularly in athletes at higher risk of sustaining a lateral ankle sprain and CAI.

Purpose: This systematic review aimed to compare the effects of external ankle supports compared to no support on ankle biomechanics in individuals with CAI during sports-related tasks.

Methods: This systematic review followed the Cochrane Handbook, PICOT framework, and PRISMA 2020 guidelines and was registered with PROSPERO in August 2020. A comprehensive search of MEDLINE, SPORTDiscus, and CINAHL in November 2021 identified randomized controlled or crossover studies on ankle biomechanics in individuals with CAI using external supports during landing, running, and directional changes. Studies were independently assessed for eligibility, appraised using the Cochrane risk-of-bias tool, and analyzed using random-effects meta-analysis with 95% confidence intervals.

Results: The literature search identified 162 studies, with 13 meeting inclusion criteria, totaling 248 CAI participants. Most studies had low to moderate risk of bias and examined various ankle supports, including non-elastic taping, semi-rigid bracing, soft bracing, and elastic taping. Landing (7 studies) and running (5 studies) were most commonly investigated, while change of direction tasks lacked homogenous data for meta-analysis. External ankle supports did not reduce inversion angle at initial contact during landing or running but showed very low-grade evidence of reducing frontal-plane and sagittal-plane excursion. These findings suggest ankle supports may influence some biomechanical aspects but with limited evidence supporting their overall effectiveness.

Rolling the field forward: This novel review provides further insight into how external ankle supports influence ankle biomechanics during high demand tasks, and the current literature suggests that external ankle support do not influence ankle inversion position prior to ground contact during running and landing. This challenges the current perception of the mechanical function of external ankle supports which is traditionally thought to adjust ankle inversion position during the pre-landing phase. In contrast, frontal plane excursion was found to be significantly reduced, which may be an important consideration for a typical lateral ankle sprain mechanism by limiting excessive inversion kinematics. Another major finding was the significant reduction in sagittal plane kinematics during running and landing. This may be considered either beneficial or detrimental due changes in ankle position (close-packed) or proximal loading at the hip and knee joints. However, it is difficult to determine this effect based on the limited evidence currently available. Future research should consider validated musculoskeletal, multi-segmental foot and ankle models to accurate measures to quantify joint kinematics, kinetics, joint contact, muscle, and ligament forces during high-demand sporting tasks. Adopting more sophisticated laboratory-based biomechanical approaches for CAI research will provide better translation to clinical and sporting environments and assist in reducing the burden of lateral ankle sprains.

Question for researchers: Based on the kinematic alterations of external ankle supports, does this lead to changes in tissue-based strains and forces at the lateral ankle ligament complex? In turn, do ankle-spanning musculotendinous structures perform differently during higher demand tasks when frontal and sagittal plane kinematics are limited? As a consequence of sagittal plane restrictions, do external ankle supports have negative implications to proximal structures (ie. knee) such as joint contact (tibiofemoral) and ligament (ACL) forces?

Do ankle braces affect functional performance?

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Blog Post Author Biography: Dr. Tomas Megalaa is a researcher and clinician, with expertise in sports injury prevention and rehabilitation. He has recently completed his PhD degree at the University of Sydney. Tomas has published multiple peer-reviewed articles and has extensive clinical and academic experience in Allied Health in Australia.

Citation: Megalaa T, Le PL, Fong Yan A, Beckenkamp PR, Hiller CE. Do ankle braces affect functional performance? A randomised double-blinded cross-over trial. JSAMS Plus. 2024;4:100061. DOI: 10.1016/j.jsampl.2024.100061.

Take-to-the-clinic message: Clinicians and sports practitioners can confidently prescribe ankle braces without concern of having a negative impact on functional performance. This study demonstrated that neither the KISS® nor Aircast ankle brace negatively affected objective measures of functional performance or balance in individuals with and without chronic ankle instability (CAI). Further, participants perceived greater stability and reassurance when they were wearing the KISS® ankle brace compared to no brace during the functional tasks.

Background: Ankle braces are effective in managing and preventing lateral ankle sprains. A new ankle brace, the Kinetic Impulse Suppression System® (KISS®), was developed to allow unrestricted ankle and foot movement within normal ranges while preserving subtalar joint motion in the frontal plane (inversion/eversion) and restricting only end-range joint motion. Despite the known protective benefits of ankle braces, concerns persist regarding their potential impact on functional performance.

Purpose: We aimed to compare the effects of two different ankle braces (KISS® and Aircast) with a no-brace condition on functional performance and perceptions of stability, confidence, and reassurance in individuals with and without CAI. The primary hypothesis was that wearing the KISS® brace would not impair functional performance compared to the no brace condition and participants would present a superior performance compared to the Aircast brace.

Methods: A randomised double-blinded cross-over trial was conducted in people (18-65 years) with and without CAI (determined using the International Ankle Consortium criteria). Participants completed an array of functional performance tests under three conditions: wearing the KISS® ankle brace, the Aircast A60 ankle brace, and no brace (control). The order of condition was randomly allocated, a researcher not involved in data collection applied the braces and the ankle was covered with a black sleeve to keep the assessor blinded to condition. Tests included the side hop test, Star Excursion Balance Test (SEBT), triple hop test, modified T-agility test, and vertical jump test. Perceptions of stability, confidence, and reassurance were also recorded on a 10-point numerical rating scale. Statistical analyses included linear mixed models to assess performance and subjective measures across conditions.

Results: A total of 42 participants were included (21 with and 21 without CAI), 24 females and18 males, with mean (SD) age of 25.4 (7.8) years. No significant differences were found between the three conditions for any objective functional performance measure, including the side hop test (p=0.96), SEBT (p>0.92), triple hop test (p=0.97), agility test (p=0.21), or vertical jump tests (p>0.97). However, subjective measures showed that participants felt significantly more stable and reassured while wearing the KISS brace compared to no brace (p=0.03 and p=0.046, respectively) after performing the side hop test.

Rolling the field forward: This study provides strong evidence that ankle braces do not impair functional performance, addressing a common concern among clinicians, trainers, and athletes. Future research should explore the long-term effects on perception of brace use and evaluate whether different brace designs influence injury prevention strategies and athletic performance. Studies involving elite athletes may help determine if subtle biomechanical effects of bracing emerge in high-performance settings.

Question for the researchers: Given the subjective preference for the KISS brace over the no-brace condition, do you anticipate that different brace designs could have a greater perceived impact on confidence and injury prevention? Would further testing in high-performance athletes reveal different functional outcomes?

‌Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study

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Blog Post Author Biography: Lauren Forsyth is a Research Associate in the department of Biomedical Engineering at the University of Strathclyde and a Strength and Conditioning Coach. Dr Forsyth’s research aims to develop objective functional assessment techniques and rehabilitation interventions for people with chronic ankle instability.

Citation: Picot B, François Fourchet, Lopes R, et al. Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study. Sports Medicine – Open. 2024;10(1). doi: 10.1186/s40798-024-00693-w

Take-to-the-clinic message: The Ankle-GO score is an objective assessment of functional performance and self-reported function which can be used to guide return to sport (RTS) decisions after lateral ankle sprain (LAS) and inform clinical management. When patients scored low of the Ankle-GO their 2-year risk of ankle sprain recurrence was nine times higher. Women also tended to have a fourfold higher risk of reinjury within two years, despite an initial Ankle-GO score comparable to men. Clinicians should therefore be more cautious of lower scores for women.

Background: Lateral ankle sprain (LAS) reported as the most common sports-related injury, followed by high recurrence and development of CAI. Despite impairments and residual functional deficiencies, research shows that nearly 50% of patients return to sport (RTS) within three days after LAS, and 80% within a week. However, there is no published evidence-based criteria to guide a patient’s return to sport (RTS), which may explain the high recurrence. The Ankle-GO™ is a valid and reliable score which aims to score patients to facilitate a safe RTS, while minimising the risk of recurrent injuries.

Purpose: The aim of this study was to assess the efficacy of the Ankle-GO – a new functional score for LAS – to distinguish patients at risk of recurrent LAS within two years after the initial injury.

Methods: The study recruited 64 patients (36 Male/28 Female) from the same clinic from January-August 2021. All participants were recruited within one month of initial LAS, and, following consultation, each participant received personalised rehabilitation for 8 weeks.  Two months after LAS each participant completed the Ankle-GO score. The Ankle-GO score includes two self-reported questionnaires (The Foot and Ankle Ability Measure and the Ankle Ligament Reconstruction-Return to Sport after Injury) and four functional tests (single-leg stance test, modified star excursion balance test, side hop test, and figure-of-8 test). Each item is scored with a maximum total score of 25 points. A lower score indicates lower function. The rate of reinjury was recorded two years following the initial injury. Fifty-four participants (23 Male/31 Female) reported whether they had suffered a recurrent LAS (ie. a new LAS of the same location and type), and the mechanism of the reinjury (ie. contact or non-contact).

Results: Eighteen participants suffered a reinjury (33.3%) with non-contact mechanisms at the two-year follow up. The Ankle-GO score at two-months post-LAS was lower in patients with a recurrent LAS (by 3.7 points) and predicted the risk of reinjury. An Ankle-GO score of less than eight points indicated a 9-times higher risk of recurrent LAS. The same cut-off score (8 points) identified a return to preinjury level of sports four months after LAS. Women and men reported comparable Ankle-GO scores, however women tended to have a 4-times higher risk of recurrent LAS after two years.

Rolling the field forward: The Ankle-GO score offers a new objective criterion for RTS after LAS. This can aid clinical decision making to address the high recurrence rates of LAS. These recurring injuries are often explained by a lack of informed guidance to RTS.

Recently the PAASS framework was published to inform the RTS decision (PAASS: Pain, Ankle impairments, Athlete perception, Sensorimotor control, Sport/functional performance). The Ankle-GO is a step to establishing a specific objective criterion. It should be noted that the Ankle-GO does not include all items related to the PAASS framework. Thus, to gain a broader perspective during clinical assessment the Ankle-GO score may need to be used in conjunction with other clinical assessments.

Question for the researchers: The ANKLE-GO was conducted on participants two months following initial injury, and after a personalized rehabilitation plan had been administered. Do the researchers know how the personalized programme affected the Ankle-GO scores, and do they have a recommended time point for clinicians of when the Ankle-GO could be used? As a result, how may this affect the reinjury risk for patients?