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Context: Chronic ankle instability (CAI) is associated with motor-behavioral and sensory-perceptual impairments, including reduced balance performance, hip strength, and ankle function, and increased disablement, and injury-related fear. Progressive balance training (BAL) and hip strengthening (HIP) can both improve balance and function, but their comparative effects are unknown. Our objective was to compare the effects of progressive BAL and HIP on balance, hip strength, and patient-reported outcomes in those with CAI., Methods: Forty-five individuals with CAI volunteered for this randomized control study. Participants were randomly allocated to BAL, HIP, and control (CON) groups (n = 15 per group). BAL and HIP each participated in 8-week interventions while CON did not. Participants' involved limbs underwent testing of patient-reported outcomes (Foot and Ankle Ability Measure [FAAM-ADL, FAAM-S], modified Disablement in the Physically Active Scale [mDPA], Tampa Scale of Kinesiophobia-11 [TSK-11], Fear-Avoidance Beliefs Questionnaire [FABQ], and Self-Efficacy of Balance Scale [SEBS]), Star Excursion Balance Test (SEBT), and isometric hip strength (extension [EXT], abduction [ABD], and external rotation [ER]) before and after the intervention. Multiple imputation was used for missing data. Multivariate repeated-measures analyses of variance analyzed effects of the interventions., Results: A significant group × time interaction existed for psychosocial outcomes (P = .008), but not for balance (P = .159), strength (P = .492), or ankle function and disability (P = .128). Time main effects existed for balance (P = .003), strength (P < .001), function and disability (P < .001), and psychosocial outcomes (P = .006). BAL significantly improved in SEBT, EXT, ABD, and all patient-reported outcomes. HIP significantly improved in EXT, ABD, ER, FAAM-S, mDPA, FABQ, and SEBS., Conclusions: Balance training and hip strengthening can both improve motor-behavioral and sensory-perceptual impairments in individuals with CAI; however, balance training remains the most effective option for clinicians.

Clinical Scenario: Individuals with chronic ankle instability (CAI) typically complete balance training protocols to improve postural control and reduce recurrent injury risk. However, the presence of CAI persists after traditional balance training protocols suggesting that such programs may be missing elements that could be beneficial to patients. Visual occlusion modalities, such as stroboscopic goggles, may be able to augment balance training exercises to further enhance postural control gains in those with CAI. However, a cumulative review of the existing evidence has yet to be conducted., Focused Clinical Question: Does wearing stroboscopic goggles during balance training result in greater improvements to postural control than balance training alone in those with CAI?, Summary of Key Findings: All 3 studies indicated that the stroboscopic goggles group had statistically significant improvements in either a measure of static or dynamic postural control relative to the standard balance training group. However, significant improvements were not consistent across all postural control outcomes assessed in the included studies., Clinical Bottom Line: Postural control may improve more in those with CAI when stroboscopic goggles were worn while completing balance training exercises relative to completing balance training exercises alone., Strength of Recommendation: Overall, consistent moderate- to high-quality evidence was present in the 3 studies, suggesting grade C evidence for the use of stroboscopic goggles during balance training in those with CAI.

Context: Shoulder rehabilitation can be a difficult task due to the dynamic nature of the joint complex. Various weight training implements, including kettlebells (KB), have been utilized for therapeutic exercise in the rehabilitation setting to improve shoulder girdle strength and motor control. The KBs are unique in that they provide an unstable load and have been purported to promote greater muscle activation versus standard dumbbells. Recent literature has examined the efficacy of KB exercises for global strengthening and aerobic capacity; however, electromyographic data for shoulder-specific activities are lacking., Objective: To examine muscle activation patterns about the rotator cuff and scapular musculature during 5 commonly-utilized KB exercises., Design: Cross-sectional analysis of a single group., Setting: Clinical biomechanics laboratory., Participants: Ten participants performed all exercises in a randomized order., Main Outcome Measures: Mean electromyographic values for each subject were compared between exercises for each target muscle., Results: Significant differences (P < .05) between exercises were observed for all target muscles except for the infraspinatus., Conclusions: The data in this study indicates that certain KB exercises may elicit activation of the shoulder girdle at different capacities. Physical therapy practitioners, athletic trainers, and other clinical professionals who intend to optimize localized strengthening responses may elect to prescribe certain exercises over others due to the inherent difference in muscular utilization. Ultimately, this data may serve to guide or prioritize exercise selection to achieve higher levels of efficacy for shoulder strength and stability gains.

Context: Although taping has been proven effective in reducing ankle sprain events in individuals with chronic ankle instability, insight into the precise working mechanism remains limited., Objectives: To evaluate whether the use of taping changes ankle joint kinematics during a sagittal and frontal plane landing task in subjects with chronic ankle instability., Design: Repeated measure design., Setting: Laboratory setting., Participants: A total of 28 participants with chronic ankle instability performed a forward and side jump landing task in a nontaped and taped condition. The taping procedure consisted of a double "figure of 6" and a medial heel lock., Main Outcome Measures: 3D ankle joint kinematics was registered. Statistical parametric mapping was used to assess taping effect on mean ankle joint angles and angular velocity over the landing phase., Results: For both the forward and side jump, a less plantar flexed and a less inverted position of the ankle joint were found in the preparatory phase till around touchdown (TD) in the taped condition (P < .05). In addition, for both jump landing protocols, a decreased dorsiflexion angular velocity was found after TD (P < .05). During the side jump protocol, a brief period of increased inversion angular velocity was registered after TD (P < .05)., Conclusions: Taping is capable of altering ankle joint kinematics prior to TD, placing the ankle joint in a less vulnerable position at TD.

Clinical Scenario: Patients with chronic ankle instability (CAI) commonly display lower levels of self-reported function and health-related quality of life. Several rehabilitation interventions, including manual therapy, have been investigated to help CAI patients overcome these deficits. However, it is unclear if the addition of manual therapy to exercise-based rehabilitation is more effective than exercise-based rehabilitation alone. Clinical Question: Does incorporating manual therapy with exercise-based rehabilitation improve patient-reported outcomes when compared with exercise-based rehabilitation alone? Summary of Key Findings: The literature was searched for articles that examined the difference in outcomes for patients with CAI between manual therapy with exercise-based rehabilitation and exercise-based rehabilitation alone. A total of 3 peer-reviewed randomized controlled trials were identified. Two articles demonstrated improved patient-reported outcome scores following the incorporation of manual therapy with exercise-based rehabilitation, whereas one study found no statistically significant differences between interventions. Clinical Bottom Line: The current evidence suggests that incorporating manual therapy in addition to exercised-based rehabilitation may improve patient-reported outcome scores in patients with CAI. Strength of Recommendation: In accordance with the Strength of Recommendation Taxonomy, the grade of A is recommended due to consistent evidence from high-quality studies.

Context: Manual perturbation training improves knee functional performance and mitigates abnormal gait in patients with anterior cruciate ligament (ACL) rupture. However, manual perturbation training is time- and labor-intensive for therapists., Objective: To investigate whether perturbation training administered using a mechanical device can provide effects similar to manual training on clinical measures and knee biomechanics after ACL rupture., Design: Prospective cohort (therapeutic) study. A 2 × 2 analysis of variance was used for statistical analysis., Setting: A clinical and biomechanical laboratory., Patients: Eighteen level I/II patients with acute ACL ruptures participated in this preliminary study., Intervention: Nine patients received mechanical perturbation training on an automated mechanical device (mechanical group), and 9 patients received manual perturbation training (manual group)., Outcome Measures: Patients completed performance-based testing (quadriceps strength and single-legged hop tests), patient-reported questionnaires (Knee Outcome Survey-Activities of Daily Living Scale, Global Rating Score, and International Knee Documentation Committee 2000), and 3-dimensional gait analysis before (pretesting) and after (posttesting) training., Results: There was no significant group-by-time interaction found for all measures (P ≥ .18). Main effects of time were found for International Knee Documentation Committee 2000 (pretesting: 69.10 [10.95], posttesting: 75.14 [7.19]), knee excursion during weight-acceptance (pretesting: 16.01° [3.99°]; posttesting: 17.28° [3.99°]) and midstance (pretesting: 14.78° [4.13°]; posttesting: 16.92° [4.53°]) and external knee-flexion moment (pretesting: 0.43 [0.11] N m/kg/m; posttesting: 0.48 [0.11] N m/kg/m) (P ≤ .04). After accounting for pretesting groups' differences, the mechanical group scored significantly higher on triple hops (mechanical: 96.73% [6.65%]; manual: 84.97% [6.83%]) and 6-m timed hops (mechanical: 102.07% [9.50%]; manual: 91.21 [9.42%]) (P ≤ .047) compared with manual group., Conclusion: The clinical significance of this study is the mechanical perturbation training produced effects similar to manual training, with both training methods were equally  effective at improving patients' perception of knee function and increasing knee excursion and external flexion moment during walking after acute ACL rupture. Mechanical perturbation training is a potential treatment to improve patients' functional and biomechanical outcomes after ACL rupture.

Context: Ideal rehabilitation method following arthroscopic capsulolabral repair surgery for anterior shoulder instability has not been proven yet. Although rapid or slow protocols were compared previously, home- or hospital-based protocols were not questioned before., Objective: The aim of this prospective unrandomized controlled clinical trial is to compare the clinical outcomes of home-based and hospital-based rehabilitation programs following arthroscopic Bankart repair., Design: Nonrandomized controlled trial., Setting: Orthopedics and physical therapy units of a single institution., Patients: Fifty-four patients (49 males and 5 females) with an average age of 30.5 (9.1) years, who underwent arthroscopic capsulolabral repair and met the inclusion criteria, with at least 1-year follow-up were allocated into 2 groups: home-based (n = 33) and hospital-based (n = 21) groups., Interventions: Both groups received identical rehabilitation programs. Patients in the home-based group were called for follow-up every 3 weeks. Patients in the hospital-based group admitted for therapy every other day for a total of 6 to 8 weeks. Both groups were followed identically after the eighth week and the rehabilitation program continued for 6 months., Main Outcome Measures: Clinical outcomes were assessed using Disabilities of Arm Shoulder Hand, Constant, and Rowe scores. Mann-Whitney U test was used to compare the results in both groups. Wilcoxon test was used for determining the progress in each group., Results: Groups were age and gender matched (P = .61, P = .69). Average number of treatment sessions was 13.8 (7.3) for patients in the hospital-based group. Preoperative Disabilities of Arm Shoulder Hand (27.46 [11.81] vs 32.53 [16.42], P = .22), Constant (58.23 [14.23] vs 54.17 [10.46], P = .13), and Rowe (51.72 [15.36] vs 43.81 [19.16], P = .12) scores were similar between groups. Postoperative scores at sixth month were significantly improved in each group (P = .001, P = .001, and P = .001). No significant difference was observed between 2 groups regarding clinical scores in any time point., Conclusions: We have, therefore, concluded that a controlled home-based exercise program is as effective as hospital-based rehabilitation following arthroscopic capsulolabral repair for anterior shoulder instability.

Context : Patients with chronic ankle instability (CAI) have demonstrated atrophy of foot and ankle musculature and deficits in ankle strength. The effect of rehabilitation on muscle morphology and ankle strength has not previously been investigated in patients with CAI. Objective : Our objective was to analyze the effect of impairment-based rehabilitation on intrinsic and extrinsic foot and ankle muscle volumes and strength in patients with CAI. Design : Controlled laboratory study. Setting : Laboratory. Patients : Five young adults with CAI. Intervention : Twelve sessions of supervised impairment-based rehabilitation that included range of motion, strength, balance, and functional exercises. Main Outcome Measures : Measures of extrinsic and intrinsic foot muscle volume and ankle strength measured before and after 4 weeks of supervised rehabilitation. Novel fast-acquisition magnetic resonance imaging was used to scan from above the femoral condyles through the entire foot. The perimeter of each muscle was outlined on each axial slice and then the 2-dimensional area was multiplied by the slice thickness (5 mm) to calculate muscle volume. Plantar flexion, dorsiflexion, inversion, and eversion isometric strength were measured using a hand-held dynamometer. Results : Rehabilitation resulted in hypertrophy of all extrinsic foot muscles except for the flexor hallucis longus and peroneals. Large improvements were seen in inversion, eversion, and plantar flexion strength following rehabilitation. Effect sizes for significant differences following rehabilitation were all large and ranged from 1.54 to 3.35. No significant differences were identified for intrinsic foot muscle volumes. Conclusion : Preliminary results suggest that impairment-based rehabilitation for CAI can induce hypertrophy of extrinsic foot and ankle musculature with corresponding increases in ankle strength.

Context: Tennis induces a decreased internal rotation range of motion at the dominant glenohumeral joint. The effects of self-myofascial release have not yet been investigated to restore glenohumeral range of motion., Objective: This study aimed at investigating the effects of self-myofascial release on shoulder function and perception in adolescent tennis players., Design: Test-retest design., Setting: Tennis training sport facilities., Participants: Eleven male players participated in this study (age: 15 [3] y; height: 173.1 [11.1] cm; mass: 56.0 [15.1] kg; International Tennis Number: 3)., Intervention: During 5 weeks, the players performed their regular tennis training. During 5 additional weeks, self-myofascial release of the infraspinatus and pectoralis muscles was implemented 3 times per week after the warm-up of the regular training session., Main Outcome Measures: The primary outcome was glenohumeral internal rotation range of motion. The secondary outcomes were perceived shoulder instability and tennis serve accuracy and velocity., Results: Adding self-myofascial release allowed an increase of 11° (2°) of internal rotation range of motion at the dominant glenohumeral joint (P < .001) and a decreased perception of shoulder instability (P = .03), while maintaining tennis serve velocity and accuracy., Conclusions: Implementing self-myofascial release on infraspinatus and pectoralis muscles 3 times per week during 5 weeks improved dominant glenohumeral internal rotation range of motion in tennis players. It can be used as a strategy to preserve the mobility of this joint.

Context: Deficits in ankle and hip strength and lower-extremity postural control are associated with chronic ankle instability (CAI). Following strength training, muscle groups demonstrate increased strength. This change is partially credited to improved neuromuscular control, and many studies have investigated ankle protocols for subjects with CAI. The effects of isolating hip musculature in strength training protocols in this population are not well understood., Objective: To examine the effects of hip strengthening on clinical and self-reported outcomes in patients with CAI., Design: Prospective randomized controlled clinical trial., Setting: Athletic training facility., Participants: Twenty-six participants with CAI (12 males and 14 females; age = 20.9 [1.5] y, height = 170.0 [12.7] cm, and mass = 77.5 [17.5] kg) were randomly assigned to training or control groups., Intervention: Participants completed either 4 weeks of supervised hip strengthening (resistance bands 3 times a week) or no intervention., Main Outcome Measures: Participants were assessed on 4 clinical measures (Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions; Balance Error Scoring System; hip external rotation strength; and hip abduction strength) and a patient-reported measure (the Foot and Ankle Ability Measure activities of daily living and sports subscales) before and after the 4-week training period., Results: The training group displayed significantly improved posttest measures compared with the control group for hip abduction strength (training: 446.3 [77.4] N, control: 314.7 [49.6] N, P < .01); hip external rotation strength (training: 222.1 [48.7] N, control: 169.4 [34.6] N, P < .01); Star Excursion Balance Test reach in the anterior (training: 93.1% [7.4%], control: 90.2% [7.9%], P < .01), posteromedial (training: 96.3% [8.9%], control: 88.0% [8.8%], P < .01), and posterolateral (training: 95.4% [11.1%], control: 86.6% [9.6%], P < .01) directions; Balance Error Scoring System total errors (training: 9.9 [6.3] errors, control: 21.2 [6.3] errors, P < .01); and the Foot and Ankle Ability Measure-sports score (training: 88.0 [12.6], control: 84.8 [10.9], P < .01)., Conclusion: Improved clinical and patient-reported outcomes in the training group suggest hip strengthening is beneficial in the management and prevention of recurrent symptoms associated with CAI.

Context: Specific muscle-stabilization training can be relevant to patients with clinical spinal instability symptoms. The authors hypothesized that performing sling exercise using an elastic band in patients with clinical spinal instability would lead to pain reduction and improved lumbar spine stability., Objective: To compare supervised sling exercise with an elastic band with traditional stabilizing exercise in chronic lower back pain (LBP) patients with clinical spinal instability., Design: Randomized assessor-blind controlled trial., Setting: University rehabilitation hospital., Main Outcome Measures: The participants were evaluated thrice at baseline, immediately after, and 3 mo after the last treatment session with the Numeric Pain Rating Scale (NPRS) and by the Oswestry Disability Index (ODI)., Interventions: Participants were randomly assigned to 1 of 2 treatment groups: a traditional trunk-muscle-stabilizing exercise group or a sling-exercise with elastic bands group. The participants in all treatment groups attended treatment twice a week for 12 wk., Results: The NPRS at immediately and 3 mo after treatments showed significantly higher improvement in the sling-exercise with elastic bands group than in the traditional trunk-muscle-stabilizing exercise group, respectively (P < .05). The ODI at immediately and 3 mo after treatment showed a significantly higher improvement in the sling-exercise with elastic bands group than in the traditional trunk-muscle-stabilizing exercise group, respectively (P < .05)., Conclusion: A sling exercise with elastic bands leads to a reduction in pain and disability compared with a traditional stabilizing exercise, although traditional stabilizing exercise also shows good results in chronic LBP patients with clinical spinal instability. A sling exercise with an elastic band could be a useful treatment for chronic LBP with clinical spinal instability.

Context: Both balance training and selected interventions meant to target sensory structures (STARS) have been shown to be effective at restoring deficits associated with chronic ankle instability (CAI). Clinicians often use multiple treatment modalities in patients with CAI. However, evidence for combined intervention effectiveness in CAI patients remains limited., Objective: To determine if augmenting a balance-training protocol with STARS (BTS) results in greater improvements than balance training (BT) alone in those with CAI., Design: Randomized-controlled trial., Setting: Research laboratory., Patients: 24 CAI participants (age 21.3 ± 2.0 y; height 169.8 ± 12.9 cm; mass 72.5 ± 22.2 kg) were randomized into 2 groups: BT and BTS., Interventions: Participants completed a 4-week progression-based balance-training protocol consisting of 3 20-min sessions per week. The experimental group also received a 5-min set of STARS treatments consisting of calf stretching, plantar massage, ankle joint mobilizations, and ankle joint traction before each balance-training session., Main Outcome Measures: Outcomes included self-assessed disability, Star Excursion Balance Test reach distance, and time-to-boundary calculated from static balance trials. All outcomes were assessed before, and 24-hours and 1-week after protocol completion. Self-assessed disability was also captured 1-month after the intervention., Results: No significant group differences were identified (P > .10). Both groups demonstrated improvements in all outcome categories after the interventions (P < .10), many of which were retained at 1-week posttest (P < .10). Although 90% CIs include zero, effect sizes favor BTS. Similarly, only the BTS group exceeded the minimal detectable change for time-to-boundary outcomes., Conclusions: While statistically no more effective, exceeding minimal detectable change scores and favorable effect sizes suggest that a 4-week progressive BTS program may be more effective at improving self-assessed disability and postural control in CAI patients than balance training in isolation.

Objective: To track the patient-reported efficacy of a 4-wk intervention (wobble board [WB] or resistance tubing [RT]) in decreasing symptoms of chronic ankle instability (CAI) at 6 mo postintervention (6PI) as compared with immediately postintervention (IPI)., Design: Randomized controlled trial., Participants: Fourteen of 21 participants (66.7%) responded to an electronic 6-m follow-up questionnaire (age 19.6 ± 0.9 y, height 1.63 ± 0.18 m, weight 70.5 ± 16.3 kg; 2 male, 12 female; 5 WB, 9 RT). All participants met CAI criteria at enrollment, including a history of ankle sprain and recurrent episodes of giving way., Interventions: Participants completed either RT or WB protocols, both 12 sessions over 4 wk of progressive exercise. WB sessions consisted of five 40-s sets of clockwise and counterclockwise rotations. RT sessions consisted of 30 contractions against resistance tubing in each of 4 ankle directions., Main Outcome Measurements: Patient-reported symptoms of "giving way" preintervention and at 6PI, global rating of change (GRC) frequencies at IPI and 6PI, and resprains at 6PI were reported descriptively. Changes in global rating of function (GRF) and giving way were compared using Wilcoxon tests, while GRC was compared with Fisher exact test., Results: All participants reported giving way preintervention, only 57.1% reported giving way at 6PI. Resprains occurred in 21.4% of participants. Giving-way frequency (P = .017), but not GRF or GRC (P > .05), was significantly different at IPI vs 6PI., Conclusions: Simple 4-wk interventions maintained some but not all improvements at 6PI. At least 42.9% of participants would no longer meet the current study's CAI inclusion criteria due to a reduction in giving way.

Objective: To determine whether a neuromuscular rehabilitation program can improve postural stability and ankle-evertor strength and to examine the temporal changes and persistence of the rehabilitation effects in athletes with chronic ankle instability (CAI)., Design: A total of 21 national women field hockey players participated in this study (CAI, n = 12; control, n = 9)., Main Outcome Measures: Isokinetic ankle-evertor strength (peak torque [PT], total work [TW]) at 30°/s, 60°/s, 90°/s, and 120°/s, mediolateral stability index (MSI), and dynamic stability test (TCT). Data were recorded at baseline, 6 wk, and 24 wk., Results: At baseline, isokinetic evertor strength was comparable between groups. At 6 wk, the CAI group demonstrated significantly increased eccentric PT and TW at 30°/s and 60°/s and increased concentric/eccentric TW at 90°/s. The control group showed significantly increased concentric TW at 30°/s and increased concentric PT and TW at 90°/s. At 24 wk, except for eccentric PT at 60°/s and 120°/s, concentric/eccentric PT and TW were significantly increased in the CAI group. The control group showed significantly increased TW at all angular velocities regardless of contraction mode. The CAI group exhibited significant increases in concentric/eccentric evertor PT and TW at 120°/s in comparison with the control group. MSI and TCT decreased in both groups at 6 wk; however, the CAI group demonstrated significant increases in both measures at 24 wk, whereas the control group showed no significant change., Conclusions: The results suggest that the neuromuscular rehabilitation program had an immediate effect on gaining eccentric evertor strength and improving postural control and appeared to contribute to enhancing the evertor strength of unstable ankles in the longer term. On the other hand, improved postural stability did not seem to persist.

Context: There is minimal patient-oriented evidence regarding the effectiveness of interventions targeted to reduce symptoms associated with chronic ankle instability (CAI). In addition, clinicians aiming to prioritize care by implementing only the most effective components of a rehabilitative program have very little evidence on comparative efficacy., Objective: To assess the comparative efficacy of 2 common ankle rehabilitation techniques (wobble-board [WB] balance training and ankle strengthening using resistance tubing [RT]) using patient-oriented outcomes., Design: Randomized controlled trial., Setting: Laboratory., Patients: 40 patients with CAI randomized into 2 treatment groups: RT and WB. CAI inclusion criteria included a history of an ankle sprain, recurrent "giving way," and a Cumberland Ankle Instability Tool (CAIT) score ≤25., Interventions: Participants completed 5 clinician-oriented tests (foot-lift test, time-in-balance, Star Excursion Balance Test, figure-of-8 hop, and side-hop) and 5 patient-oriented questionnaires (CAIT, Foot and Ankle Ability Measure [FAAM], Activities of Daily Living [ADL] and FAAM Sport scale, Short-Form 36 [SF-36], and Global Rating of Function [GRF]). After baseline testing, participants completed 12 sessions over 4 wk of graduated WB or RT exercise, then repeated baseline tests., Main Outcome Measures: For each patient- and clinician-oriented test, separate 2 × 2 RMANOVAs analyzed differences between groups over time (alpha set at P = .05)., Results: There was a significant interaction between group and time for the FAAM-ADL (P = .04). Specifically, the WB group improved postintervention (P < .001) whereas the RT group remained the same (P = .29). There were no other significant interactions or significant differences between groups (all P > .05). There were significant improvements postintervention for the CAIT, FAAM-Sport, GRF, SF-36, and all 5 clinician-oriented tests (all P < .001)., Conclusions: A single-exercise 4-wk intervention can improve patient- and clinician-oriented outcomes in individuals with CAI. Limited evidence indicates that WB training was more effective than RT., Level of Evidence: Therapy, level 1b.

Context: Chronic ankle instability (CAI) describes the residual symptoms present after repetitive ankle sprains. Current rehabilitation programs in the high school population focus on a multistation approach or general lower-extremity injury-prevention program. Specific rehabilitation techniques for CAI have not been established., Objective: To determine the effectiveness of a 4-wk biomechanical ankle platform system (BAPS) board protocol on the balance of high school athletes with CAI., Design: Randomized control trial., Setting: Athletic training facility., Patients: Twenty-two high school athletes with "giving way" and a history of ankle sprains (ie, CAI) were randomized into a rehabilitation (REH) (166.23 ± 0.93 cm, 67.0 ± 9.47 kg, 16.45 ± 0.93 y) or control (CON) (173.86 ± 8.88 cm, 84.51 ± 21.28 kg, 16.55 ± 1.29 y) group., Interventions: After baseline measures, the REH group completed a progressive BAPS rehabilitation program (3 times/wk for 4 wk), whereas the CON group had no intervention. Each session consisted of 5 trials of clockwise/counterclockwise rotations changing direction every 10 s during each 40-s trial. After 4 wk, baseline measurements were repeated., Main Outcome Measures: Dependent measures included longest time (time-in-balance test), average number of errors (foot lift test), average reach distance (cm) normalized to leg length for each reach direction (Star Excursion Balance Test [SEBT]), and fastest time (side hop test [SHT])., Results: Significant group-by-time interactions were found for TIB (F 1,20 = 9.89, P = .005), FLT (F 1,20 = 41.18, P < .001), SEBT-anteromedial (F 1,20 = 5.34, P = .032), SEBT-medial (F 1,20 = 7.51, P = .013), SEBT-posteromedial (F 1,20 = 12.84, P = .002), and SHT (F 1,20 = 7.50, P = .013). Post hoc testing showed that the REH group improved performance on all measures at posttest, whereas the CON group did not., Conclusion: A 4-wk BAPS rehabilitation protocol improved balance in high school athletes suffering from CAI. These results can allow clinicians to rehabilitate in a focused manner by using 1 rehabilitation tool that allows benefits to be accomplished in a shorter time.

Context: Lateral ankle sprain (LAS) is one of the most common injuries in active individuals. Chronic ankle instability (CAI) is a condition that commonly occurs after LAS and is associated with long-term disability and a high risk of multiple ankle sprains. Ankle taping is a commonly used intervention for the prevention of ankle sprains., Objective: To analyze the ankle-joint coupling using vector coding during walking and jogging gait with the application of ankle tape and without ankle tape in young adults with and without CAI., Design: Observational laboratory study design. Patients walked and jogged on an instrumented treadmill while taped and not taped. Fifteen strides for each subject were collected and analyzed using a vector-coding technique to compare magnitude coupled motion, ratio of coupled motion, and the variability (VCV) within groups. Within-group means and 90% confidence intervals (CI) were compared between the taped and nontaped condition, and where the CIs did not overlap was considered significant., Setting: A 12-camera 3D motion-capture system with instrumented treadmill., Patients: 12 patients with CAI and 11 healthy controls., Main Outcome Measures: Magnitude to coupled motion, ratio of coupled motion, and the VCV of shank-rear-foot joint coupling., Results: Magnitude of coupled motion and VCV were significantly lower in the taped condition than in the nontaped condition in both groups. Magnitude differences were identified near initial contact during walking and during swing phase of jogging. VCV differences were identified throughout the gait cycle at both walking and jogging. No differences were identified in theta between tape and nontaped conditions., Conclusions: A decrease in the magnitude of coupled motion and VCV may represent a protective mechanism of ankle taping in CAI and healthy patients during gait.

Clinical Scenario: Chronic ankle instability (CAI) is a condition commonly experienced by physically active individuals. It has been suggested that foot orthotics may increase a CAI patient's postural control., Clinical Question: For patients with CAI, is there evidence to suggest that an orthotic intervention will help improve postural control?, Summary of Key Findings: The literature was searched for studies of level 2 evidence or higher that investigated the effects of foot orthotics on postural control in patients with CAI. The search of the literature produced 5 possible studies for inclusion; 2 studies met the inclusion criteria and were included. One randomized controlled trial and 1 outcomes study were included. Foot orthotics appear to be effective at improving postural control in patients with CAI., Clinical Bottom Line: There is moderate evidence to support the use of foot orthotics in the treatment of CAI to help improve postural control., Strength of Recommendation: There is grade B evidence that foot orthotics help improve postural control in people with CAI. The Centre of Evidence Based Medicine recommends a grade of B for level 2 evidence with consistent findings.

Context: Ankle-destabilization devices are rehabilitation tools that may improve neuromuscular control by increasing lower-extremity muscle activation. Their effects should be tested in healthy individuals before being implemented in rehabilitation programs., Objective: To compare EMG activation of lower-extremity muscles during walking while wearing 2 different ankle-destabilization devices., Design: Crossover., Setting: Laboratory., Participants: 15 healthy young adults (5 men, 10 women)., Intervention: Surface EMG activity was recorded from the anterior tibialis, peroneus longus, lateral gastrocnemius, rectus femoris, biceps femoris, and gluteus medius as subjects walked on a treadmill shod, with an ankle-destabilization boot (ADB), and an ankle-destabilization sandal (ADS)., Main Outcome Measures: Normalized amplitudes 100 ms before and 200 ms after initial heel contact, time of onset activation relative to initial contact, and percent of activation time across the stride cycle were calculated for each muscle in each condition., Results: The precontact amplitudes of the peroneus longus and lateral gastrocnemius and the postcontact amplitudes of the lateral gastrocnemius were significantly greater in the ADB and ADS conditions. In the ADB condition, the rectus femoris and biceps femoris postcontact amplitudes were significantly greater than shod. The peroneus longus and lateral gastrocnemius were activated significantly earlier, and the anterior tibialis, lateral gastrocnemius, and rectus femoris were activated significantly longer across the stride cycle in the ADB and the ADS conditions. In addition, the peroneus longus was activated significantly longer in the ADB condition when compared with shod., Conclusions: Both ankle-destabilization devices caused an alteration in muscle activity during walking, which may be favorable to an injured patient. Therefore, implementing these devices in rehabilitation programs may be beneficial to improving neuromuscular control.

Context: A single talocrural joint-mobilization treatment has improved spatiotemporal measures of postural control but not ankle arthrokinematics in individuals with chronic ankle instability (CAI). However, the effects of multiple treatment sessions on these aspects of function have not been investigated., Objective: To examine the effect of a 2-wk anterior-to-posterior joint-mobilization intervention on instrumented measures of single-limb-stance static postural control and ankle arthrokinematics in adults with CAI., Design: Repeated measures., Setting: Research laboratory., Participants: 12 individuals with CAI (6 male, 6 female; age 27.4 ± 4.3 y, height 175.4 ± 9.78 cm, mass 78.4 ± 11.0 kg)., Intervention: Subjects received 6 treatments sessions of talocrural grade II joint traction and grade III anterior-to-posterior joint mobilization over 2 wk., Main Outcome Measures: Instrumented measures of single-limb-stance static postural control (eyes open and closed) and anterior and posterior talar displacement and stiffness were assessed 1 wk before the intervention (baseline), before the first treatment (preintervention), 24-48 h after the final treatment (postintervention), and 1 wk later (1-wk follow-up). Postural control was analyzed as center-of-pressure velocity, center-of-pressure range, the mean of time-to-boundary minima, and standard deviation of time-to-boundary minima in the anteroposterior and mediolateral directions for each visual condition., Results: No significant differences were identified in any measures of postural control (P > .08) or ankle arthrokinematics (P > .21)., Conclusions: The 2-wk talocrural joint-mobilization intervention did not alter instrumented measures of single-limb-stance postural control or ankle arthrokinematics. Despite the absence of change in these measures, this study continues to clarify the role of talocrural joint mobilization as a rehabilitation strategy for patients with CAI.

The lateral ligament complex of the ankle is a frequently injured structure in sports and recreational activities, which often results in chronic ankle instability (CAI). Balance exercise training has become a common component of clinical rehabilitation for CAI to address postural deficits. To determine the effect of balance training on postural stability, this critically appraised topic presents a summary and analysis of 4 relevant studies that address the effectiveness of balance training in subjects with CAI. Information about the methods and sources used in the article is provided. The findings imply that there is moderate evidence that 4-6 wk of balance training can enhance static and dynamic postural stability in subjects with CAI.

Background: Isolated atraumatic posterior glenohumeral instability is rare. Use of thermal capsulorraphy for glenohumeral instability is considered controversial. This case study describes a modified rehabilitation protocol for a patient who underwent a multistep arthroscopic procedure for isolated posterior glenohumeral instability with a postoperative complication of adhesive capsulitis., Case Description: A 30-y-old man with a 15-y history of bilateral posterior glenohumeral instability related to generalized hypermobility underwent right-shoulder arthroscopy consisting of a combined posterior labral repair, capsular imbrication, and thermal capsulorraphy. A gunslinger orthosis was prescribed for 6 wk of immobilization. Adhesive capsulitis was diagnosed at the 5-wk postoperative visit and immobilization was discontinued. A modified treatment protocol was devised to address both the surgical procedures performed and the adhesive capsulitis. Residual symptoms resolved with release of an adhesion while stretching 10 months postoperatively., Outcomes: Scores of 5 shoulder-assessment tools improved from poor to excellent/good with subjective report of a very good outcome., Discussion: The complication of adhesive capsulitis required an individualized treatment protocol. In contrast to the standard protocol, our modified approach allowed more time to be spent in each phase of the program, was aggressive with restoring range of motion (ROM) without excessively stressing the posterior capsule, and allowed the patient to progress to activities that were tolerated regardless of protocol phase. Shoulder stiffness or frank adhesive capsulitis after stabilization, as in this case, requires a more aggressive modification to prevent permanent ROM limitations. Conversely, patients with early rapid gains in ROM must be protected from overstretching the repaired tissue with a program that allows functional motion to be incorporated over a longer time frame. This study indicates the use of thermal capsulorraphy as a viable surgical modality when it is used judiciously with the proper postoperative restrictions and rehabilitation.

Context: There are contradictory data on optimal muscle-activation strategies for restoring shoulder stability. Further investigation of neuromuscular-control strategies for glenohumeral-joint stability will guide clinicians in decisions regarding appropriate rehabilitation exercises., Objectives: To determine whether subscapularis, infraspinatus, and teres minor (anteroposterior force couple) muscle activation differ between 4 shoulder exercises and describe coactivation ratios and individual muscle-recruitment characteristics of rotator-cuff muscles throughout each shoulder exercise., Design: Crossover., Setting: Laboratory., Participants: healthy, physically active men, age 20.55 ± 2.0 y., Interventions: 4 rehabilitation exercises: pitchback, PNF D2 pattern with tubing, push-up plus, and slide board., Main Outcomes Measures: Mean coactivation level, coactivation-ratio patterns, and level (area) of muscle-activation patterns of the subscapularis, infraspinatus, and teres minor throughout each exercise., Results: Coactivation levels varied throughout each exercise. Subscapularis activity was consistently higher than that of the infraspinatus and teres minor combined at the start of each exercise and in end ranges of motion. Individual muscle-recruitment levels in the subscapularis were also different between exercises., Conclusion: Results provide descriptive data for determining normative coactivation-ratio values for muscle recruitment for the functional exercises studied. Differences in subscapularis activation suggest a reliance to resist anteriorly directed forces.

Context: Functional rehabilitation is often employed for ankle instability, but there is little evidence to support its efficacy, especially in those with chronic ankle instability (CAI)., Objective: To review studies using both functional rehabilitation interventions and functional measurements to establish the effectiveness of functional rehabilitation for both postural control and self-reported outcomes in those with CAI., Evidence Acquisition: The databases of Medline, SPORTDiscus, and PubMed were searched between the years 1988 and 2008. Inclusion criteria required articles to have used a clinical research trial involving at least 1 functional rehabilitation intervention, have at least 1 outcome measure of function and/or functional performance, and to have used at least 1 group of subjects who reported either repeated lateral ankle sprains or episodes of "giving way." The term functional was operationally defined as dynamic, closed-kinetic-chain activity other than quiet standing., Evidence Synthesis: Six articles met the inclusion criteria. The articles reviewed used multiple functional means for assessment and training, with a wobble board or similar device being the most common. Despite effect sizes being inconsistent for measures of dynamic postural control, all interventions resulted in improvements. Significant improvements and strong effect sizes were demonstrated for self-reported outcomes., Conclusions: The reviewed studies using functional rehabilitation interventions and functional assessment tools were associated with improved ankle stability for both postural control and self-reported function, but more studies may be needed with more consistent effect sizes and confidence intervals to make a definitive conclusion.