Effectiveness of exercise therapy on chronic ankle instability: a meta-analysis

Key points

1. 01Long-term exercise therapy (over 4 weeks) significantly improved daily function (FAAM-A) and sports function (FAAM-S) scores
2. 02Dynamic balance improved across most Star Excursion Balance Test directions, especially posterior reaches
3. 03Joint mobilization was most effective for anterior balance deficits; strength training and proprioceptive training were most effective for posterolateral and posteromedial deficits
4. 04Short-term programs (4 weeks or less) did not significantly improve daily function or anterior balance
5. 05Overall GRADE evidence quality was low to moderate, mainly due to high heterogeneity and small sample sizes

How it was conducted

Design

Systematic review and meta-analysis of randomized controlled trials

Participants

586 adults diagnosed with chronic ankle instability across 15 RCTs

Databases searched

PubMed, EMBASE, Cochrane Library, and Web of Science, from inception to September 13, 2024

Intervention

Exercise therapy (strength training, neuromuscular activation, proprioceptive training, or joint mobilization) vs. no intervention control

Primary outcomes

Foot and Ankle Ability Measure (FAAM-A and FAAM-S) and Star Excursion Balance Test (SEBT) in 8 directions

Quality assessment

Cochrane RoB 2 tool for risk of bias; GRADE approach for evidence quality

What they found

• Exercise therapy significantly improved FAAM-S (MD = 7.98, 95% CI: 4.11 to 11.86, p < 0.0001, I2 = 30%)
• Overall FAAM-A improvement was significant but heterogeneous (MD = 4.95, 95% CI: 0.06 to 9.85, p = 0.05, I2 = 68%)
• Programs longer than 4 weeks significantly improved FAAM-A (MD = 10.95, 95% CI: 6.60 to 15.29, p < 0.00001, I2 = 0%) while programs of 4 weeks or less did not (MD = 1.4, 95% CI: -2.10 to 4.89, p = 0.43)
• Exercise therapy significantly improved SEBT-A (MD = 3.59, 95% CI: 1.05 to 6.13, p = 0.006, I2 = 75%), SEBT-M (MD = 5.42, 95% CI: 3.86 to 6.97, p < 0.00001, I2 = 43%), SEBT-P (MD = 8.36, 95% CI: 2.93 to 13.78, p = 0.003, I2 = 72%), SEBT-PM (MD = 7.55, 95% CI: 4.89 to 10.22, p < 0.00001, I2 = 70%), and SEBT-PL (MD = 7.01, 95% CI: 4.22 to 9.81, p < 0.0001, I2 = 80%)
• No significant effects on SEBT-AL (MD = 5.06, 95% CI: -5.06 to 10.69, p = 0.08) or SEBT-L (MD = 11.29, 95% CI: -2.03 to 24.61, p = 0.10)
• Long-term programs (over 4 weeks) improved all three key SEBT directions: SEBT-A (MD = 4.83, 95% CI: 1.04 to 8.63, p = 0.01), SEBT-PM (MD = 6.93, 95% CI: 2.37 to 11.48, p = 0.003), and SEBT-PL (MD = 8.98, 95% CI: 2.66 to 15.29, p = 0.005)
• Joint mobilization was most effective for SEBT-A (MD = 7.65, 95% CI: 4.93 to 10.37, p < 0.00001, I2 = 0%); proprioceptive training for SEBT-PM (MD = 10.46, 95% CI: 5.27 to 15.65, p < 0.0001, I2 = 33%); strength training for SEBT-PL (MD = 8.15, 95% CI: 6.09 to 10.21, p < 0.00001, I2 = 0%)
• GRADE evidence was rated high for FAAM-S, moderate for FAAM-A and SEBT-PM, low for SEBT-A and SEBT-PL, and very low for SEBT-AL, SEBT-AM, and SEBT-L

Limitations

• Overall GRADE evidence quality was low to moderate due to high heterogeneity (I2 > 50% in most SEBT outcomes) and small sample sizes (n < 200 for FAAM, n < 180 for several SEBT outcomes)
• Patients inevitably knew which treatment they were receiving, potentially introducing bias in self-reported function scores
• Most included studies provided no follow-up data, leaving the durability of treatment effects unclear
• Only RCTs with a no-intervention control were included, limiting conclusions about how exercise therapy compares to other active treatments such as conventional physiotherapy

Why it matters

For patients

People with chronic ankle instability can expect meaningful improvements in function and balance from exercise programs, particularly when those programs last more than 4 weeks and combine different exercise types.

For clinicians

Clinicians should tailor exercise prescriptions using SEBT results: prioritize joint mobilization for anterior deficits, and combine strength and proprioceptive training for posterolateral and posteromedial deficits.

For readers

This meta-analysis provides a framework for personalized rehabilitation in chronic ankle instability, though high heterogeneity and low GRADE ratings for balance outcomes mean results should be interpreted with caution.