1

!"#$%&'(") "+ ,-&+"&#%).- ') /0- 1/%& 23.4&('") 5%6%).- 7-(/

8-/9--) !"$-&( %): ;):'<':4%6( 9'/0 !0&")'. =)>6- ;)(/%8'6'/?



By
}ustin E. King
Webei State 0niveisity Athletic Tiaining Nastei's Stuuent














2
7%86- "+ !")/-)/(

Section

Abstiact
S
Intiouuction
4
Bypotheses
S
Assumptions
6
LimitationsBelimitations
6
0peiational Befinitions
6
Nethous
7
Paiticipants
7
IuFAI
7
SEBT
8
Statistical Analysis
9
Results
9
Biscussion
11
Conclusion
12
Refeience List
1S


Appenuix A
14
Chaits anu Tables
14
Appenuix B
18
Liteiatuie Review
18
Chionic Ankle Instability
18
IuFAI
19
Stai Excuision Balance Test
2u
Refeience List
2S

S
=8(/&%./
!")/-3/@ A laige amount of ieseaich on the functional ability of inuiviuuals with Chionic
ankle instability (CAI) exists. Bowevei, the neeu to look at Copeis, inuiviuuals who have
hau ankle spiains but not uevelopeu instability who have not uevelopeu CAI, iemains.
Exploiation of why copeis aie able to cope will help unueistanuing anu tieatment of CAI
giow. A8B-./'<-@ The puipose of this stuuy is to compaie inuiviuuals with CAI anu Copeis
in peifoimance on the stai excuision balance test (SEBT). The hypothesis is that
inuiviuuals with CAI have a scoie lowei on the SEBT. 1-//')C@ Laboiatoiy ,%&/'.'$%)/(@ 4S
subjects (Age 2SS, Beight 1.8 m18, Weight 7Skg14). All paiticipants weie active,
exeicising at least Su minutes a uay anu S times a week. Paiticipants weie classifieu into
foui gioups: Contiol (no histoiy of ankle instability); Copei (a histoiy past ankle spiains
but no iesiuual symptoms); CAI (ankle spiains with instability anu a scoie of 11+ on the
Iuentification of Instability Questionnaiie; Collegiate Athlete (inuiviuuals who weie fiom
the 0niveisity's collegiate athletic team anu paiticipateu in a seasonal stiuctuieu stiength
piogiam). Inuiviuuals with a histoiy of lowei extiemity fiactuie oi suigeiy weie excluueu.
;)/-&<-)/'")(@ The SEBT was auministeieu in thiee uiiections (anteiioi, posteiioi meuial,
anu posteiioi lateial). D%') A4/."#- D-%(4&-(@ The stai excuision balance test was
measuieu in cm. The SEBT consisteu of S completeu tiials in each uiiection. Each tiial was
given a noimalizeu scoie by uiviuing the uistance achieveu by leg length anu multiplying by
1uu. An aveiage scoie foi each uiiection was computeu as well as a combineu scoie fiom
all uiiections. The statistical analysis useu was a iepeateu AN0vA at foui levels as well as a
Post-Boc Analysis compaiing each gioup within each uiiection scoieu. E-(46/(@ Theie
significant iesults between subject gioups scoies on the SEBT foi Posteiioi Neuial
(F=S.S87, p=.u22), Posteiioi Lateial (F=2.964, p= .u4S), anu Combineu (F=S.678, p=.u2u).
The Post-Boc analysis hau significant iesults in the posteiioi meuial uiiection between the
contiol anu CAI gioup (p=. u44) anu boiueiing significance between the copei anu CAI
gioup (p=.uS1). Post-Boc of the Combineu scoie also founu significance between CAI anu
Copei (p=.uSu) anu again boiueiing significance this time between Contiol anu CAI
(p=.uSS). !").64('")(@ Thiough the iesults of this ieseaich anu othei suppoiting ieseaich
a conclusion that theie is a functional uiffeience between Contiols anu CAI as well as
Copeis anu CAI can be maue. Scoies of Contiols anu Copeis fall within noimal ianges founu
in othei stuuies. The Collegiate athlete gioup, while containing inuiviuuals with CAI,
ieflecteu similai peifoimance means on the SEBT as the Contiol anu Copei gioups. Noie
ieseaich shoulu be obtaineu to see Collegiate Athletes weie able to peifoim functionally as
well as Copeis anu Contiol.





4
;)/&":4./'")
Ankle Injuiies aie some of the most common injuiies among athletes. Some estimate
2S,uuu ankle spiains occui uaily in the 0niteu States.
1,2
Ankle injuiies aie even moie a
gieatei concein among collegiate athletic tiaineis. A stuuy fiom 1998 to 2uu4 showeu that
ankle spiains weie the most common injuiy among collegiate athletes.
S,4
0f all inuiviuuals
suffeiing fiom an ankle spiain, Su% will uevelop chionic ankle instability anu be theiefoie
subject to even moie ankle instability.
2,S
Chionic ankle instability (CAI) has been uefineu as
having iepetitive bouts of ankle instability that iesults in numeious ankle spiains.
6

In compaiison to CAI, a gioup of inuiviuuals who have hau ankle spiains in theii
histoiy, anu yet uo not have iecuiient episoues of ankle spiains oi functional symptoms
common with chionic ankle instability such as "giving way". These inuiviuuals aie
classifieu as copeis.
7
. Eviuence on why Copeis aie able to avoiu functional symptoms founu
among CAI is lacking. 0sing the Stai Excuision Balance Test (SEBT) as a ieseaich tool we
can isolate anu measuie functional mechanisms of neuiomusculai stiength anu balance.
8

With the SEBT we can take these peifoimance ueficits of CAI anu test them against Copeis.
To be able to paiticipants into test gioups of Contiol, Copeis, anu CAI we useu the ieliable
Iuentification of Functional Ankle Instability Questionnaiie (IuFAI).
9
We auueu a foui
gioup, Collegiate Athletes, once consistent uisciepancies in peifoimance on the SEBT was
seen only fiom inuiviuuals fiom the univeisity's collegiate athletic teams.
The puipose of this stuuy is to compaie Copeis anu inuiviuuals with CAI, founu
using the IuFAI, thiough the SEBT. The ieseaich goal is to finu functional ueficits between
the test gioups thiough compaiison of peifoimance on the SEBT. The ieseaich hopes to
suppoit the hypothesis that Copeis will peifoim bettei on the SEBT than the CAI gioup.
S

F?$"/0-(-(
Inuiviuuals with CAI will have a lowei scoie on SEBT anteiioi uiiection than copeis
Inuiviuuals with CAI will have a lowei scoie on SEBT posteiioi lateial uiiection than
copeis
Inuiviuuals with CAI will have a lowei scoie on SEBT posteiioi meuial uiiection
than copeis.
Inuiviuuals with CAI will have a lowei scoie on SEBT in the combineu scoie.
G466 F?$"/0-(-(
Inuiviuuals with CAI will have an the same scoie on the IuFAI as copeis
Inuiviuuals with CAI will have the same scoie as copeis on SEBT anteiioi uiiection
Inuiviuuals with CAI will have the same scoie as copeis on SEBT posteiioi lateial
uiiection
Inuiviuuals with CAI will have the same scoie as copeis on SEBT posteiioi meuial
uiiection
=((4#$/'")(
All inuiviuuals tiuly have symptoms on IuFAI
Paiticipants will give a constant effoit uuiing STEB
Paiticipants aie honest about activity level
H'#'/%/'")(
College age population
Active inuiviuuals Su minuay x S timesweek
0nilateial ankle spiains
6
Nechanical ankle instability not iuleu out
A$-&%/'")%6 I-+')'/'")(
CAI - Tenuency foi the foot to 'give way' aftei an initial ankle spiain.
6
0i test gioup
classifieu into the categoiy suffeiing fiom IuFAI.
Copei - A gioup of inuiviuuals with a histoiy of pievious initial spiain but no
complaints of instability.
1S

College Athlete- Inuiviuuals
Active - Su minutes of exeicise at least S times a week
SEBT - Test foi uynamic postuial contiol that consists of ieaching with the leg in the
anteiioi uiiection, posteiioi meuial uiiection (1SS fiom anteiioi), anu posteiioi
lateial uiiection (1SS fiom anteiioi in opposite uiiection)

D-/0":(
,%&/'.'$%)/(
4S paiticipants weie ieciuiteu fiom the stuuent bouy of a miu-sizeu westein
univeisity subjects (24 males, 21 females, Age 2SS, Beight 176cm18, Weight 7Skg14).
Paiticipants weie oiganizeu into gioups baseu on theii scoie on the IuFAI. Those who
scoieu a 1u+ weie classifieu as the CAI gioup (inuiviuuals who suffeieu fiom chionic ankle
instability), anu those who scoieu 1u oi less weie the Copei gioup (inuiviuuals with a past
ankle spiain but no iesiuual symptoms oi known functional ueficits). We auueu a fouith
gioup, Collegiate Athletes, once consistent uisciepancies in peifoimance on the SEBT weie
seen only in inuiviuuals fiom the univeisity's collegiate athletic teams. With cieation of
foui gioups the gioup numbeis weie 1u Contiols, 1u Copeis, 1S CAI, 1u Collegiate Athletes.
7
The paiticipants weie scieeneu foi activity, which was uefineu as Su minutes of exeicise at
least S times a week. They must have at least one ankle spiain in theii life, anu shoulu be
fiee fiom othei majoi past lowei extiemity injuiies anu suigeiies. The ieciuitment of
paiticipation anu methous of expeiimentation was appioveu by Webei State 0niveisity
IRB.
;:J=;
The IuFAI is a seiies of 1u questions useu to iuentify chionic ankle instability as it
has been pieviously uefineu.
11
To become moie accuiate in instability iuentification, IuFAI
was cieateu by combining the two questionnaiies, the CAI anu AII.
9
Examples of these time
peiious questions aie incluue how long ago was the pievious ankle spiain, last time it gave
way, anu how often uoes it feel unstable. Paiticipants will complete the IuFAI anu be
gioupeu accoiuing to scoie into the CAI gioup oi Copei gioup. 0pon completion, the
questionnaiie is scoieu by auuing the points fiom all the questions. Inuiviuuals with
chionic ankle instability weie founu to have a scoie of at least 1u+ on the questionnaiie.
1u

The oveiall accuiacy of using the IuFAI was founu to be 89.6%.
9

1/%& 23.4&('") 5%6%).- 7-(/
The SEBT is able to successfully test a subjects' uynamic postuial contiol by having
the them maintain a stable base of balance on one leg while ieaching as fai as they can in a
specific uiiection without allowing theii base ankle 'give way' anu compiomise the
integiity of theii base.
11
The SEBT consisteu of a paiticipant stanuing on theii uominant
foot wheie lines of a "Y" conveigeu fiom anteiioi, posteiioi lateial, anu posteiioi angle.
The paiticipant stoou in the miuule of the "Y" facing the infeiioi base. These uiiections
8
consisteu of anteiioi (stiaight out fiom wheie the toes of the base leg aie pointeu),
posteiioi lateial (1SS fiom the anteiioi uiiection), posteiioi meuial (opposite siue, also
1SS fiom anteiioi position) (See Pictuie 1).
12
The paiticipant took theii non-stanuing leg
(oi nonCAI ankle) anu attempteu to ieach as fai away fiom his stanuing foot along those
lines without losing balance. Thiee successful iepetitions weie peifoimeu in thiee
uiffeient uiiections. Paiticipants of the stuuy hau S-4 piactice iuns befoie measuiement so
that the SEBT tiuly testeu theii piopiioception anu not theii ability to uo something new.
Befoie attempting oi piacticing an inuiviuual was tolu what woulu qualify as a successful
attempt. Each uiiection was coveieu by cleai tape anu touches weie iecoiueu with a
maikei so it was easily maikeu, iecoiueu, anu then wipeu away. In oiuei to contiol the
confounuing vaiiable of longei ieaching uistances uue to longei leg lengths, uistances
ieacheu weie noimalizeu by uiviuing each attempt by leg length. Leg length was measuieu
fiom the ASIS to the meuial malleolus of each subject.

1/%/'(/'.%6 =)%6?('(
Statistical analysis consisteu of an AN0vA at foui levels; Contiol, CAI, Copeis, anu
Collegiate Athlete, the uepenuent vaiiable was ieach uistance (SEBT). A post hoc analysis
was also uone to see uiffeiences between the foui gioups within the uiffeient uiiections of
ieach in the SEBT: Anteiioi, Posteiioi Neuial, Posteiioi Lateial, anu a Combineu Composite
scoie of the thiee uiffeient uiiections.
E-(46/(
An AN0vA was iun to see if theie weie significant uiffeiences between the gioups
(Figuie 2). Compaiisons between gioups founu significant uiffeiences in posteiioi meuial
9
(F=S.S87, p= .u22), posteiioi lateial (F=2.964, p=.u4S), anu combineu (F=S.678p=.u2u)
scoies. Figuie S iepiesents the uistiibution of gioups in the posteiioi meuial scoies anu
Figuie 4 iepiesents the uistiibution of combineu scoies. In both figuies similai
uistiibutions aie founu between the Copei gioup anu Collegiate Athlete gioup.
Specific ielationships between gioups anu ieach scoies weie analyzeu thiough a
post-hoc analysis (Figuie S). The significant compaiisons occuiieu between specific test
gioups in the posteiioi meuial uiiection anu the combineu scoie in the compaiison
between the Contiol anu CAI as well as the Copei anu CAI gioup. In the PN uiiection theie
was significant uiffeiences between contiol anu CAI (p=.u44), anu boiueiing significance
between the Copei anu CAI gioup (p=.uS1). The Combineu scoie also founu significance
between CAI anu Copei (p=.uSu) anu again boiueiing significance this time between
Contiol anu CAI (p=.uSS). Theie was no significance in scoies between gioups in the
Anteiioi uiiection between any of the gioups.
The only othei ielationship that was founu between othei tests associateu with the
stuuy was a coiielation of meuium stiength between anteiioi ieach of the SEBT anu iange
of uoisiflexion in the Stanuing Boisiflexion Test (SBFT). A iegiession analysis uone
between aveiage uegiees achieveu in the SBFT anu anteiioi scoie ieach of the SEBT
iesulteu in i= .4u9. It must be noteu that neithei the aveiage uegiees noi anteiioi scoie
weie founu to be significant in an intiagioup compaiisons.
Nean iesults foi the Stai Excuision Balance Test aie iepiesenteu in Figuie 1. The CAI
gioup hau the smallest mean ieach scoie in each uiiection (ANT:81.SS, PN: 84.78,
PL:77.26, Combineu: 81.19) when compaieu to the thiee othei gioups. The Copei gioup
1u
hau the gieatest scoies of each uepenuent measuie (ANT: 86.17, PN: 9S.79, PL: 89.4S,
Comb: 9u.48).
I'(.4(('")
The iesults of this investigation showeu that Copeis weie able to peifoim bettei on
the functional SEBT when compaieu to the CAI gioup. This suppoits theoietical stances,
clinical finuings, anu othei ieseaich that inuiviuuals with CAI have less neuiomusculai anu
postuial contiol while Copeis have been able to oveicome those symptoms associateu with
instability.
7
Not only uiu they peifoim statistically bettei, but they weie also exhibiteu
similai iesults in most of the tests to the collegiate athletes anu the contiol gioup.
The gieatest uiffeience in peifoimance on the SEBT between the gioups was in the
posteiioi-meuial uiiection. Scoies achieveu by CAI anu Contiol gioups also ieflecteu
pievious ieseaich in the posteiioi-meuial uiiection (CAI:8S.S-88, Contiol: 91-9S).
11,1S,14

Although ieseaich on the compaiison between Copeis anu CAI is spaise, iesults aie in
accoiuance with the othei finuings. Plante anu Wikstiom founu in theii compaiison using
all thiee gioups that the posteiioi-meuial scoie was the only statistically significant scoie
among the thiee uiffeient attempteu uiiections.
1S
With posteiioi-meuial scoies being
significant in both stuuies, it becomes eviuence that inuiviuuals who oveicome the
symptoms of CAI uo so in pait by ueveloping coping mechanisms associateu with
impaiiment that occuis in a posteiioi-meuial ieach. 0thei ieseaich has shown inuiviuuals
with CAI having latent peioneal activation, which is the piimaiy stabilizei on the ankle
uuiing the posteiioi-meuial ieach of the SEBT.
16

Though the peioneal muscles aie essential stabilizeis in the posteiioi-meuial ieach,
it uoes iequiie postuial contiol fiom many muscles thioughout the lowei extiemity.
17
It
11
must be taken into consiueiation that the SEBT is a static postuial test anu not a uynamic
test. To bettei unueistanu copeis it is impoitant to stuuy both static anu uynamic testing
as iecuiient injuiy usually occuis uuiing movement.
18
Bopkins has also stateu that
although coping occuis anu uecieases symptoms of CAI, coping mechanisms aie not always
biomechanically sounu anu coulu inciease vulneiability to injuiy of othei aieas of the
lowei extiemity.
19

It is impoitant to note the uevelopment of the colligate athlete gioup within the
stuuy. Initially the stuuy began with thiee gioups: Contiol, Copeis, anu CAI. With the
exclusion ciiteiia foi paiticipants being only that they weie active foi Su minutes a uay S
times a week collegiate athletes in the uepaitment weie ieciuiteu. As ieseaich pioceeueu a
tienu with almost all of the athletes showeu enhanceu peifoimance in the SEBT, so a fouith
gioup was analyzeu. 0pon ieview of the iesults, we founu that iegaiuless of scoie on the
IuFAI that athletes uemonstiateu similai iesults on the SEBT as the copei gioup. As stateu
pieviously, although the athletes weie able to oveicome CAI, it uoes not mean that all
coping methous aie biomechanically sounu. Fuithei ieseaich is neeueu to see if stiength
tiaining iegiments, which all the collegiate athletes weie paiticipating in, coulu help
oveicome postuial anu neuiomusculai ueficits founu in CAI. 0thei ieseaich can be
fuitheieu to see if these "coping" athletes have uevelopeu sounu biomechanics.
!").64('")
The ability to cope with postuial anu neuiomusculai ueficiencies founu in CAI can
be uue to many uiffeient factois. Biffeiences founu in between CAI anu the Copei gioup in
the meuial ieach anu combineu scoie of the SEBT show that theie aie insufficiencies in
12
postuial balance. Although biomechanics may be uiffeient, theie is no statistical uiffeience
between Copeis, Contiols, anu Collegiate Athletes in the peifoimance in the SEBT.

E-+-&-).-(
1. Kannus P, Renstiom P. Tieatment foi acute teais of the lateial ligaments of the
ankle. 0peiation, cast, oi eaily contiolleu mobilization. !"# %&'()*+ &, -&)# *). /&0)1
2'(3#(4 56#(07*) 8&+'6#. 1991;7S(2):SuS-S12.
2. Beitel }, Kaminski TW. Seconu inteinational ankle symposium summaiy statement.
!"# %&'()*+ &, &(1"&9*#.07 *). 29&(12 9"4207*+ 1"#(*94. 2uuS;SS(S):A2.
S. Bootman }N, Bick R, Agel }. Epiuemiology of collegiate injuiies foi 1S spoits:
summaiy anu iecommenuations foi injuiy pievention initiatives. % 51"+ !(*0).
2uu7;42(2):S11-S19.
4. Zhang S. Recent uevelopments on mouels anu inclusion ciiteiia foi chionic ankle
instability. %&'()*+ &, :9&(1 *). ;#*+1" :70#)7#. 2u12. Available at:
http:u.wanfanguata.com.cnpeiiouical_yuyjkkx-e2u12uSuu6.aspx. Accesseu Naich 29,
2u1S.
S. Soboioff SB, Pappius EN, K0NAR0FF AL. Benefits, iisks, anu costs of alteinative
appioaches to the evaluation anu tieatment of seveie ankle spiain. <+0)07*+ &(1"&9*#.072
*). (#+*1#. (#2#*(7". 1984;18S:16u-168.
6. Beitel }. Functional Anatomy, Pathomechanics, anu Pathophysiology of Lateial
Ankle Instability, Functional Anatomy, Pathomechanics, anu Pathophysiology of Lateial
Ankle Instability. % 51"+ !(*0). 2uu2;S7, S7(4, 4):S64, S64-S7S.
7. Wikstiom EA, Tillman NB, Chmielewski TL, Cauiaugh }B, Naugle KE, Boisa PA.
Bisciiminating between copeis anu people with chionic ankle instability. %&'()*+ &, *1"+#107
1(*0)0)3. 2u12;47(2):1S6.
8. uiibble PA, Beitel }, Plisky P. 0sing the Stai Excuision Balance Test to assess
uynamic postuial-contiol ueficits anu outcomes in lowei extiemity injuiy: a liteiatuie anu
systematic ieview. % 51"+ !(*0). 2u12;47(S):SS9-SS7. uoi:1u.4u8S1u62-6uSu-47.S.u8.
9. Bonahue N, Simon }, Bocheity CL. Reliability anu valiuity of a New Questionnaiie
Cieateu to Establish the Piesence of Functional Ankle Instability: The IuFAI. 51"+#107
!(*0)0)3 = :9&(12 ;#*+1" <*(#. 2u1S;S(1):S8-4S. uoi:1u.S9281942S864-2u121212-u2.
1u. Simon }, Bonahue N, Bocheity C. Bevelopment of the Iuentification of Functional
Ankle Instability (IuFAI). >&&1 5)?+# @)1. 2u12;SS(9):7SS-76S. uoi:B0I:
1u.S11SFAI.2u12.u7SS.
1S
11. Beitel }, Biaham RA, Bale SA, 0lmsteu-Kiamei LC. Simplifying the stai excuision
balance test: analyses of subjects with anu without chionic ankle instability. %&'()*+ &,
A(1"&9*#.07 = :9&(12 B"4207*+ !"#(*94. 2uu6;S6(S):1S1-1S7.
12. uiibble PA, Beitel }. Consiueiations foi noimalizing measuies of the stai excuision
balance test. C#*2'(#6#)1 0) 9"4207*+ #.'7*10&) *). #D#(702# 270#)7#. 2uuS;7(2):89-1uu.
1S. Linens SW, Ross SE, Ainolu BL, uayle R, Piucoe P. Postuial-Stability Tests That
Iuentify Inuiviuuals With Chionic Ankle Instability. %&'()*+ &, 51"+#107 !(*0)0)3.
2u1S;49(1):1S-2S. uoi:1u.4u8S1u62-6uSu-48.6.u9.
14. Wikstiom EA, Plante }. Bisciiminating Between Copeis anu those with Chionic
Ankle Instability with Clinical 0utcomes. In: @)1#()*10&)*+ %&'()*+ &, ED#(702# :70#)7#F
<&),#(#)7# B(&7##.0)32.vol S.; 2u11:S6. Available at:
http:uigitalcommons.wku.euuijesabvolSiss2S6. Accesseu Apiil 18, 2u14.
1S. Plante }E, Wikstiom EA. Biffeiences in clinician-oiienteu outcomes among contiols,
copeis, anu chionic ankle instability gioups. B"4207*+ !"#(*94 0) :9&(1. 2u1S;14(4):221-
226.
16. Bopkins }T, Biown TN, Chiistensen L, Palmieii-Smith RN. Beficits in peioneal
latency anu electiomechanical uelay in patients with functional ankle instability. %&'()*+ &,
A(1"&9*#.07 G#2#*(7". 2uu9;27(12):1S41-1S46.
17. 0lmsteu LC, Caicia CR, Beitel }, Shultz S}. Efficacy of the Stai Excuision Balance
Tests in Betecting Reach Beficits in Subjects With Chionic Ankle Instability. % 51"+ !(*0).
2uu2;S7(4):Su1-Su6.
18. Teiaua N, Pfile KR, Pietiosimone Bu, uiibble PA. Effects of Chionic Ankle Instability
on Eneigy Bissipation in the Lowei Extiemity: C#.070)# = :70#)7# 0) :9&(12 = ED#(702#.
2u1S;4S(11):212u-2128. uoi:1u.1249NSS.ubu1SeS1829aSuub.
19. Bopkins }. Notoi Stiategies of Self-Repoiteu Ankle Instability: Consequences anu
Possible Inteiventions. 2u14.






14
=$$-):'3 =
,'./4&- K@ Pait 1 is Anteiioi, Pait 2 is Posteiioi Lateial, anu Pait S Posteiioi Neuial ieach.
Both PL anu PN aie 1SS uegiees fiom the anteiioi uiiection.

J'C4&- K@ These aie the Neans of each gioup pei the uiiectional scoies measuieu.


1S
J'C4&- L@
The AN0vA stats foi uiffeiences between the gioups. Biffeiences weie statistically
significant foi all uepenuent vaiiables except foi anteiioi aveiage scoie.

=GAM=@ I'++-&-).-( 5-/9--) N&"4$(
I'&-./'") 1."&- J 1'CO
=)/-&'"& =<-&%C- 1."&- KOPQR OKQL
,"(/-&'"& D-:'%6 1."&- SOQPT OULL
,"(/-&'"& H%/-&%6 1."&- LOVRS OUWS
!"#8')-: 1."&- SORTP OULU

J'C4&- S
This box-plot shows gioup similaiities anu uiffeiences in the Posteiioi Neuial Biiection.

16

J'C4&- W
This box-plot shows gioup similaiities anu uiffeiences in the Combineu Scoie.















17
J'C4&- Q
The significant statistics foi the Post-Boc compaiison between gioups fiom the Posteiioi
Neuial Aveiage Scoie anu Combineu Scoie.

,"(/XF". =)%6?('(
Bepenuent vaiiable I-uioup }-uioup Sig
Posteiioi Neuial
Aveiage Scoie
Contiol CAI
Copei
Athlete
1.uuu
.u44
.924
CAI Contiol
Copei
Athlete
.u44
.uS1
.186
Athlete Contiol
Copei
CAI
.924
.94S
.186
Combineu Scoie Contiol Copei
CAI
Athlete
.99S
.uSS
.8Su
Copei Contiol
CAI
Athlete
.99S
.uSu
.S11
























18
=$$-):'3 5
E-<'-9 "+ H'/-&%/4&-

;)/&":4./'")
Ankle Injuiies aie some of the most common injuiies among athletes. Some estimate
2S,uuu ankle spiains occui uaily in the 0niteu States.
1,2
Ankle injuiies aie even moie a
gieatei concein among collegiate athletic tiaineis. A stuuy fiom 1998 to 2uu4 showeu that
ankle spiains weie the most common injuiy among collegiate athletes.
S,4
Theie aie
iecuiience iates that exceeu 7u% in spoits such as basketball.
2u
Bistoiy of an ankle spiain
is one of the most common pieuispositions foi moie ankle spiains. 0f all of these injuiies
Su% will uevelop chionic ankle instability anu be theiefoie subject to even moie ankle
instability.
2,S
Chionic ankle instability (CAI) has been uefineu as having iepetitive bouts of
ankle instability that iesults in numeious ankle spiains.
6

!0&")'. =)>6- ;)(/%8'6'/?
Fieeman, one of the fiist to uiagnose ankle instability, uesciibeu it as the ankle
'giving away' uue to a tempoiaiy uncontiollable sensation oi iolling ovei one ankle.
21

Beitel uesciibeu chionic ankle instability as having both mechanical anu functional paits.
Nechanical instability consisteu of pathologic laxity, aithiokinematics iestiictions,
uegeneiative changes, anu synovial changes within the bouy. The functional aspect chionic
instability consists of impaiieu piopiioception, impaiieu neuiomusculai contiol, stiength
ueficits, anu impaiieu postuial contiol.
6
0thei ieseaicheis have incluueu iecuiiant spiains
as a majoi contiibutoi to ueveloping chionic ankle instability.
22
Although it has been
vaguely iuentifieu, Chionic Ankle instability has no cleai set clinical uefinition, oi golu
stanuaiu foi iuentification.
2S
Fuitheimoie, iuentification of copeis, inuiviuuals with
19
pievious spiains but no complaints of instability, is even less cleai.
24
In oiuei to help claiify
the uefinition of Chionic ankle instability anu assisteu towaius bettei uiagnosing anu
theiefoie tieating the pathology, oui ieseaich has planneu to apply two vaiiables to
inuiviuuals with Chionic ankle instability. Thiough the use of the Iuentification of
Functional Ankle Instability Questionnaiie anu Stai Excuision Balance Test ieseaich
shoulu pioviue clinicians with a cleaiei unueistanuing of what uefines inuiviuuals
suffeiing fiom chionic ankle instability anu how to uiffeientiate them fiom copeis.

;:J=;
Questionnaiies have been useu by many clinicians to assist in uiagnosing injuiies
causeu by chionic ankle instability. Recently stuuies have been uone to asceitain which of
these questionnaiies was most ieliable in establishing that an inuiviuual hau chionic ankle
instability. Seven of the most populai questionnaiies to iuentify ankle instability, the Ankle
Instability Instiument (AII), Ankle }oint Functional Assessment Tool (A}FAT), Chionic
Ankle Instability Scale (CAIS), Cumbeilanu Ankle Instability anu Ankle Instability
Questionnaiie (CAIT), anu Foot anu Ankle Ability Neasuie (FAAN), Foot anu Ankle
Instability Questionnaiie (FAIQ), Foot anu Ankle 0utcome Scoie (FA0S), weie all compaieu
anu assesseu in theii ability to iuentify functional components of chionic instability anu
none weie founu to significantly iuentify instability.
2S
The Iuentification of Functional
Ankle Instability was fiom two uiffeient existing questionnaiies, the CAIT anu AII, when it
was uiscoveieu that the moie effective iuentification occuiieu when combining them.
2S
By
using the IuFAI in oui ieseaich we will be able to cleaily uefine inuiviuuals with CAI anu
then see how they function in they function in the Stai Excuision Balance Test.
2u
Fuitheimoie, ieseaich hopefully will asceitain whethei oi not the IuFAI is able to
accuiately to iuentify copeis, as it has yet only been accuiate in its ability to confiim CAI.

;:J=; D-/0":( %): D-%(4&-#-)/(
The IuFAI is a seiies of 1u questions useu to iuentify chionic instability as uefineu
by Fieeman.
9
Questions consist mostly of time peiious ievolving aiounu ankle injuiies.
Examples of these time peiious questions incluue how long ago was the pievious ankle
spiain, last time it gave way, anu how often uoes it feel unstable. Time peiious fiom nevei
to 2 yeais to less than a month to a few uays can be chosen uepenuing on the question.
Each question ieceives a specific point value uepenuing on the uegiee oi seveiity of the
answei. 0pon completion, the questionnaiie is scoieu by auuing the points fiom all the
questions.
9
Inuiviuuals with chionic ankle instability weie founu to have a scoie of at least
1u+ on the questionnaiie.
1u
The oveiall accuiacy of using the IuFAI was founu to be
89.6%.
1u
As stateu pieviously, the IuFAI only accuiate in iuentification of inuiviuuals with
CAI, howevei when using the othei chionic tests to uefine a copei gioup, it is possible that
a coiielation scoie between copeis functional testing (SEBT anu SBFT) anu IuFAI coulu be
founu. If so, the ieseaich coulu bettei assist clinicians in using the IuFAI to iecognize anu
tieat copeis anu inuiviuuals with CAI.

1/%& 23.4&('") 5%6%).- 7-(/
As stateu eailiei, majoi functional factois of chionic ankle instability consist of
impaiieu piopiioception, impaiieu neuiomusculai contiol, stiength ueficits, anu impaiieu
postuial contiol.
6
In oiuei to bettei unueistanu a bettei uiagnosis of chionic ankle
21
instability it is impoitant to use functional testing that coveis those ciiteiia. The most
impoitant thing to assess to iecieate an enviionment wheie the patient might have the
feeling 'giving way' while testing these uiffeient factois. The Stai Excuision Balance Test
(SEBT) has been confiimeu to cleaily assess neuiomusculai contiol anu postuial contiol of
the ankle.
8
The SEBT is able to successfully test a subjects' uynamic postuial contiol by
having them maintain a stable base of balance on one leg while, ieaching as fai as they can
in a specific uiiection without allowing theii base ankle 'give way' anu compiomise the
integiity of theii base.
12,26
As the SEBT is efficient in isolating ankles stiuggling with pooi
postuial contiol, ieseaich hopes to finu a ieinfoice the valiuity of both tests thiough a
coiielation between a high scoie on the IuFAI anu a low scoie on the SEBT. In compaiison
between copeis anu CAI, ieseaich assumes copeis scoies will be somewheie between a
noimal ankle anu CAI.

1257 D-/0":(
The SEBT consists of an inuiviuual stanuing on one foot, his base foot, at the point
wheie thiee lines conveige at 1SS uegiee angles fiom the anteiioi line. The subject will
take his non-stanuing leg anu attempt to ieach as fai away fiom his stanuing foot along
those lines. The measuiement is taken wheie the inuiviuual can ieach fuithest without
losing balance oi having the ankle give way. 0iiginally useu as a iehabilitative exeicise foi
week ankles, the test consisteu of 8 uiffeient uiiections.
27
Reseaicheis founu that not only
coulu the test coulu be use to stiengthen weak ankles, but that it coulu inveisely be useu to
iuentify weak ankles.
12


22
1257 D-%(4&-#-)/(
When an inuiviuual with chionic ankle instability attempts the SEBT they will have a
shoitei ieach than inuiviuuals who uo not.
17
Natuially inuiviuuals who aie tallei will have
a longei ieach. It has also been founu that between boys anu giils, boys will have a longei
ieach. Aftei noimalizing height anu leg length between subjects, ieseaicheis founu that
theie was no statistically significant auvantage the tall subjects hau ovei shoitei ones oi
males subjects hau ovei female.
12
Reseaichei founu that ieliability of the test incieases
when the amount of uiiections testeu is ieuuceu to thiee. These uiiections consist of
anteiioi (stiaight out fiom wheie the toes of the base leg aie pointeu), posteiioi lateial
(1SS fiom the anteiioi uiiection), posteiioi meuial (opposite siue, also 1SS fiom anteiioi
position).
28
The SEBT also founu that testing ieliability was veiy high with intiaiatei
ieliability between u.8S-u.89, anu inteiatei ieliability between u.97-1.uu.
29
Reseaich
expects the high ieliability of the SEBT to uetect inuiviuuals with CAI in compaiison with
the iesults fiom the othei objective anu subjective tests useu alongsiue it. Positive finuings
with the copei gioup shoulu hopefully also establish the SEBT as a functional test able to
uistinguish such inuiviuuals.

!").64('")
Impioving the way chionic ankle instability is uefineu anu uiagnoseu will help the
thousanus of inuiviuuals who suffei fiom ankle injuiies eveiy uay. By combining the IuFAI
anu Stai Excuision Balance Test, this ieseaich hopes to stiengthen the way CAI is uetecteu,
anu gain a gieatei unueistanuing to assisteu in uiagnosis anu tieatment of inuiviuuals with
CAI. Seconuly, the two tests will hopefully auu to existing liteiatuie with ieliable uata to
2S
categoiize copeis in ielation to inuiviuuals with CAI anu theieby stiengthen the uefinition
of CAI itself.

24
E-+-&-).-(
1. Kannus P, Renstiom P. Tieatment foi acute teais of the lateial ligaments of the
ankle. 0peiation, cast, oi eaily contiolleu mobilization. !"# %&'()*+ &, -&)# *). /&0)1
2'(3#(4 56#(07*) 8&+'6#. 1991;7S(2):SuS-S12.
2. Beitel }, Kaminski TW. Seconu inteinational ankle symposium summaiy statement.
!"# %&'()*+ &, &(1"&9*#.07 *). 29&(12 9"4207*+ 1"#(*94. 2uuS;SS(S):A2.
S. Bootman }N, Bick R, Agel }. Epiuemiology of collegiate injuiies foi 1S spoits:
summaiy anu iecommenuations foi injuiy pievention initiatives. % 51"+ !(*0).
2uu7;42(2):S11-S19.
4. Zhang S. Recent uevelopments on mouels anu inclusion ciiteiia foi chionic ankle
instability. %&'()*+ &, :9&(1 *). ;#*+1" :70#)7#. 2u12. Available at:
http:u.wanfanguata.com.cnpeiiouical_yuyjkkx-e2u12uSuu6.aspx. Accesseu Naich 29,
2u1S.
S. Soboioff SB, Pappius EN, K0NAR0FF AL. Benefits, iisks, anu costs of alteinative
appioaches to the evaluation anu tieatment of seveie ankle spiain. <+0)07*+ &(1"&9*#.072
*). (#+*1#. (#2#*(7". 1984;18S:16u-168.
6. Beitel }. Functional Anatomy, Pathomechanics, anu Pathophysiology of Lateial
Ankle Instability, Functional Anatomy, Pathomechanics, anu Pathophysiology of Lateial
Ankle Instability. % 51"+ !(*0). 2uu2;S7, S7(4, 4):S64, S64-S7S.
8. uiibble PA, Beitel }, Plisky P. 0sing the Stai Excuision Balance Test to assess
uynamic postuial-contiol ueficits anu outcomes in lowei extiemity injuiy: a liteiatuie anu
systematic ieview. % 51"+ !(*0). 2u12;47(S):SS9-SS7. uoi:1u.4u8S1u62-6uSu-47.S.u8.
9. Bonahue N, Simon }, Bocheity CL. Reliability anu valiuity of a New Questionnaiie
Cieateu to Establish the Piesence of Functional Ankle Instability: The IuFAI. 51"+#107
!(*0)0)3 = :9&(12 ;#*+1" <*(#. 2u1S;S(1):S8-4S. uoi:1u.S9281942S864-2u121212-u2.
1u. Simon }, Bonahue N, Bocheity C. Bevelopment of the Iuentification of Functional
Ankle Instability (IuFAI). >&&1 5)?+# @)1. 2u12;SS(9):7SS-76S. uoi:B0I:
1u.S11SFAI.2u12.u7SS.
12. uiibble PA, Beitel }. Consiueiations foi noimalizing measuies of the stai excuision
balance test. C#*2'(#6#)1 0) 9"4207*+ #.'7*10&) *). #D#(702# 270#)7#. 2uuS;7(2):89-1uu.
17. 0lmsteu LC, Caicia CR, Beitel }, Shultz S}. Efficacy of the Stai Excuision Balance
Tests in Betecting Reach Beficits in Subjects With Chionic Ankle Instability. % 51"+ !(*0).
2uu2;S7(4):Su1-Su6.
2S
2u. Fong BT, Chan Y-Y, Nok K-N, Yung PS, Chan K-N. 0nueistanuing acute ankle
ligamentous spiain injuiy in spoits. HC< :9&(12 :70#)7#I C#.070)# *). G#"*-0+01*10&).
2uu9;1(1):14. uoi:1u.118617S8-2SSS-1-14.
22. Billei CE, Kilbieath SL, Refshauge KN. Chionic ankle instability: evolution of the
mouel. % 51"+ !(*0). 2u11;46(2):1SS-141. uoi:1u.4u8S1u62-6uSu-46.2.1SS.
2S. Belahunt E, Coughlan uF, Caulfielu B, Nightingale E}, Lin C-WC, Billei CE. Inclusion
Ciiteiia When Investigating Insufficiencies in Chionic Ankle Instability. C#.070)# = :70#)7#
0) :9&(12 = ED#(702#. 2u1u;42(11):21u6-2121. uoi:1u.1249NSS.ubu1SeS181ue7a8a.
24. Biown C, Pauua B, Naishall SW, uuskiewicz K. Inuiviuuals with mechanical ankle
instability exhibit uiffeient motion patteins than those with functional ankle instability anu
ankle spiain copeis. <+0)07*+ H0&6#7"*)072. 2uu8;2S(6):822-8S1.
uoi:1u.1u16j.clinbiomech.2uu8.u2.u1S.
2S. Bonahue N, Simon }, Bocheity CL. Ciitical ieview of self-iepoiteu functional ankle
instability measuies. >&&1 5)?+# @)1. 2u11;S2(12):114u-1146. uoi:1u.S11SFAI.2u11.114u.
26. Eail }E, Beitel }. Lowei-extiemity muscle activation uuiing the Stai Excuision
Balance Tests. %&'()*+ &, :9&(1 G#"*-0+01*10&). 2uu1;1u(2):9S-1u4.
27. uiay uW. J&K#( ED1(#6014 >')710&)*+ B(&,0+#. wynn Naiketing, Incoipoiateu; 199S.
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<+0)072 0) 29&(12 6#.070)#. 2uu8;27(S):SSS-S7u.
29. Plisky P}, uoiman PP, Butlei R}, Kiesel KB, 0nueiwoou FB, Elkins B. The Reliability
of an Instiumenteu Bevice foi Neasuiing Components of the Stai Excuision Balance Test. L
56 % :9&(12 B"42 !"#(. 2uu9;4(2):92-99.