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Ankle Instability Is Associated with Balance Impairments: A Meta-Analysis


Medicine & Science in Sports & Exercise: May 2009 - Volume 41 - Issue 5 - p 1048-1062
doi: 10.1249/MSS.0b013e318192d044
Basic Sciences

Purpose: Our primary purpose was to determine whether balance impairments were associated with functional ankle instability (FAI).

Methods: Our literature search consisted of four parts: 1) an electronic search of PubMed, CINAHL, pre-CINAHL, and SPORTDiscus; 2) a forward search of articles selected from the electronic search using the Science Citation Index; 3) a hand search of the previously selected articles; and 4) a direct contact with corresponding authors of the previously selected articles. We initially identified 145 articles and narrowed these to 23 for inclusion in the meta-analysis. Identified outcomes were categorized by measurement units and balance task type (i.e., dynamic or static). Each study was coded based on whether inclusion or exclusion criteria were identified. Our statistical analysis included fixed, random, or mixed effect analyses based on the presence of within study heterogeneity and whether categories were being compared.

Results: FAI was associated with poorer balance (standard difference of the mean [SDM] = 0.455, 95% confidence interval = 0.334-0.577, Z = 7.34, P < 0.001), but no difference existed between dynamic and static measure categories (Q = 3.44, P = 0.063). However, there was a significant difference between the dynamic measures (Q = 6.22, P = 0.013) with both time to stabilization and the Star Excursion Balance Test producing significant SDM and between static measures (Q = 13.00, P = 0.012) with the linear, time, velocity, and other measurement categories (but not area) producing significant SDM. Examination of individual outcomes revealed that time in balance and foot lifts produced very large SDM (3.3 and 4.8, respectively).

Conclusion: FAI is associated with impaired balance. Due to the relatively large effect sizes and simplicity of use of time in balance and foot lifts, we recommend that further research should establish their clinical validity and clinical cutoff scores.

1Department of Health and Human Performance, Virginia Commonwealth University, Richmond, VA; 2Uniformed Service University of Health Sciences, Bethesda, MD

Address for correspondence: Brent L. Arnold, Ph.D., A.T.C., F.N.A.T.A., Department of Health and Human Performance, Virginia Commonwealth University, Richmond, VA 23284-2020; E-mail:

Submitted for publication September 2008.

Accepted for publication October 2008.

©2009The American College of Sports Medicine