Review article

Effectiveness of proprioceptive exercises for ankle ligament injury in adults:

A systematic literature and meta-analysis
q
K. Postle
a,
*
, D. Pak
b
, T.O. Smith
a
a
School of Allied Health Professions, Faculty of Medicine and Health Science, University of East Anglia, Queens Building, Norwich NR4 7TJ, UK
b
Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich NR4 7TJ, UK
a r t i c l e i n f o
Article history:
Received 18 November 2011
Received in revised form
4 February 2012
Accepted 22 February 2012
Keywords:
Talocrucial
Sprain
Joint position sense
Kinaesthesia
a b s t r a c t
The purpose of this study was to assess the effectiveness of such proprioceptive exercise following ankle
ligament injury. A systematic review of the databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane
library database and the PEDro database, in addition to unpublished literature databases was conducted
to July 2011. When appropriate, meta-analysis was conducted to pool results from homogeneous studies.
The methodological quality of the literature was reviewed using the Critical Appraisal Skills Programme
tool. The results indicated that there is no statistically signicant difference in recurrent injury between
the addition of proprioceptive exercises during the rehabilitation of patients following ankle ligament
injury (p 0.68). The addition of proprioceptive training demonstrated a signicant reduction in
subjective instability and functional outcomes (p < 0.05). There was no consensus on the advantages of
including proprioceptive training in the rehabilitation of this population for swelling, postural sway, joint
position sense, ankle range of motion or return to sport outcomes. Further study is warranted to develop
the rigour of the evidence-base and to determine the optimal proprioceptive training programme
following ankle ligament injury with different populations.
2012 Elsevier Ltd. All rights reserved.
1. Introduction
Ankle ligament injuries are one of the most commonly seen
musculoskeletal injuries by physiotherapists (Handoll et al., 2001).
It is estimated that per 10,000 people, one ankle ligament sprain
will occur per day (Kannus and Renstrom, 1991). Ankle inversion
injuries particularly affect the sporting population with a high
incidence in sports such as basketball, football and volleyball
(Handoll et al., 2001). Re-injury rate can be as high as 70e80%,
frequently leading to the development of chronic ankle instability
(CAI) as receptive ankle injury lead to irreparable ligament laxity
(Webster and Gribble, 2010).
Proprioception relates primarily to the position sense of mech-
anoreceptives (Laskowski et al., 1997; Lephart et al., 1997; Olsson
et al., 2004). It encompasses two aspects of position sense, static
and dynamic. Static sense is thought to provide conscious orien-
tation of one body part to another, while dynamic sense facilitates
a neuromuscular feedback system related to the rate and direction
of movement (Laskowski et al., 1997; Stillman, 2002; Olsson et al.,
2004). Proprioception can therefore be considered a complex
neuromuscular process that involves both afferent and efferent
signals to maintain stability and orientation during activities
(Laskowski et al., 1997; Stillman, 2002). However proprioceptive
decit and loss of joint position sense are associated with occur-
rence or re-occurrence of ankle ligament injury (Lentell et al., 1995;
Willems et al., 2002; de Noronha et al., 2007).
Rehabilitation has been advocated to improve proprioception.
Literature has suggested that proprioceptive training post-ankle
ligament injury may improve peroneal muscle reaction time, kin-
aesthetic and postural sway decits (Osborne et al., 2001; Hughes
and Rochester, 2008; McKeon and Hertel, 2008; Mitchell et al.,
2008). Eight systematic literature reviews have been previously
undertaken to assess the value of rehabilitation in the management
of ankle ligament sprain (Handoll et al., 2001, 2011; Kerkhoffs et al.,
2002a,b; Loudon et al., 2008; McKeon and Hertel, 2008; Hbscher
et al., 2010; Webster and Gribble, 2010). None have examined the
effectiveness of proprioceptive exercise following ankle ligament
injury. The purpose of this review was therefore to specically
assess the literature pertaining to the use of proprioceptive exercise
in the rehabilitation of patients following ankle ligament injury.
q
This study was conducted at the Faculty of Medicine and Health Science,
University of East Anglia, Norwich NR4 7TJ, UK.
* Corresponding author. Tel.: 44 01603 593087; fax: 44 01603 593166.
E-mail addresses: K.Postle1@uea.ac.uk (K. Postle), toby.smith@uea.ac.uk
(T.O. Smith).
Contents lists available at SciVerse ScienceDirect
Manual Therapy
j ournal homepage: www. el sevi er. com/ mat h
1356-689X/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2012.02.016
Manual Therapy 17 (2012) 285e291
2. Methods
2.1. Review question
The review question was to determine the clinical effectiveness
of proprioceptive exercises for ankle ligament injury in adults?
2.2. Search strategy
A PRISMA compliant methodology was undertaken (Moher
et al., 2009). The primary search was conducted of the electronic
databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane library
database and the PEDro database, searched from their inception to
July 2011. A secondary search was performed of unpublished
literature and ongoing trials using the database: OpenGrey (System
for Information on Grey Literature in Europe), WHO International
Clinical Trials Registry Platform, Current Controlled Trials, UKCRN
Portfolio Database, National Technical Information Service and the
UK National Research Register Archive. The reference lists of all
included papers were reviewed and all corresponding authors from
these papers were contacted to identify any additional papers. The
MeSH and search terms and Boolean operators used are presented
inTable 1. The search strategy was independently performed by one
reviewer (KP) and veried by a second (TS).
2.3. Eligibility criteria
All randomised control trials assessing the clinical and func-
tional outcomes of proprioceptive exercise were included. Partici-
pants who sustained any grade of injury, acute or chronic ankle
ligament injury were eligible. Both male and female participants
and athletic and non-athletic populations were included to allow
the generalisation of results to different populations. Participants
who had experienced a rst-time and recurrent ankle inversion
injuries were included.
Studies were excluded if they recruited participants following
ankle surgery. Animal studies and trials solely assessing children
(those under 16 years of age) were excluded. Studies published in
languages other than English were excluded to ensure accurate and
complete interpretation.
2.4. Identication of studies
Titles and abstracts from the search strategy were indepen-
dently assessed by two reviewers (KP, DP) and veried by a third
(TS). Full-text version of each potentially eligible paper was
obtained. Eligibility was then re-assessed by the two reviewers
based on this full-text, until consensus was agreed on the nally
included studies.
2.5. Data extraction
Data was independently extracted by two reviewers (KP, DP),
with verication by a third reviewer (TS). Data extracted included:
participant age, gender, duration of injury, classication of injury;
interventions including concurrent non-proprioceptive interven-
tions and details on the proprioceptive exercises including type of
exercises, frequency, intensity, compliance; outcome measure-
ments; follow-up period; and results.
2.6. Outcome measures
The primary outcome was recurrent injury at twelve months, to
provide insight into the potential effectiveness of proprioceptive
exercise as a preventative measure for future injury. Secondary
outcomes included:(1) functional outcomes such as: the Foot and
Ankle Disability Index (FADI; Martin et al., 1999) which is a region-
specic self-reported measure of function based on 2 components:
activities of daily living, and the more difcult sport-related tasks,
and has been shown to be reliable in the ankle-sprain population
(Hale and Hertel, 2005; Eechaute et al., 2007); and the Star
Excursion Balance Test (SEBT) which is a functional test of dynamic
stability which requires the participant to reach as far as possible
with one leg each of 8 prescribed directions whilst maintaining
balance on the contralateral leg, and has demonstrated reliability
and validity (Olmsted et al., 2002; Plisky et al., 2009); (2) return to
sports, dened as a return to previously performed sport at the
same level; (3) subjective ankle instability indicative of the rela-
tionship between improved stability and proprioception; (4)
swelling measured by girth measurement or water volumetry,
since these have been demonstrated to be reliable in assessment
ankle swelling and oedema (Petersen et al., 1999; Brodovicz et al.,
2009); (5) and (6) postural sway/joint position sense as an indi-
cator of proprioceptive capability which has also demonstrate
reliability in this population (Halasi et al., 2005; Sekir et al., 2008).
2.7. Methodological quality assessment
All included studies were assessed for methodological quality
using the Critical Appraisal Skills Programme (CASP) appraisal tool
for randomised control trials (CASP, 2011). This tool was selected
primarily as it has been widely adopted for the review of muscu-
loskeletal clinical trials (Reilly et al., 2006; Smith et al., 2007). All
included papers were appraised by one reviewer (KP) and veried
by a second (TS).
2.8. Analysis of results
An assessment of the methodological heterogeneity was made
by examining the inter-study variation in population characteris-
tics, interventions, concurrent interventions as part of the standard
rehabilitation programme, and outcome measurements. When
substantial heterogeneity was demonstrated, a meta-analysis was
not conducted. In such a case, a narrative review of the data was
presented for the specic outcome measurements. When there was
limited heterogeneity, statistical heterogeneity was assessed using
the X
2
and I
2
statistics. If X
2
was greater than p 0.10 and the I
2
greater than 20%, higher levels of statistical heterogeneity were
denoted and a random effects model was adopted. When X
2
was
less than 0.10 and I
2
less than 20%, a xed-effects model was
adopted.
Each outcome measurement was assessed for a mean difference
(MD) between the groups i.e. rehabilitation with or without the
addition of proprioceptive exercises. A standard mean difference
(SMD) was adopted when different measurement methods were
Table 1
Table of the search terms lter used for MEDLINE search.
Classication Terms and boolean operators ($ truncation)
Anatomy Ankle OR Subtalar OR Talocrural
AND
Injury Soft tissue injury OR sprain OR inversion adj2 injury
AND
Treatment Exercis$
AND
Propriocept$ OR sensory re-educat$ OR Joint position
sense OR Balance OR Physiotherapy OR Physical therapy
OR Rehabilitation
AND
Study design Random$ OR Controlled trial
K. Postle et al. / Manual Therapy 17 (2012) 285e291 286
reported evaluating the same domain. A statistically signicant
difference was denoted as p < 0.05. The presentation of 95%
condence intervals (CI) was made.
All statistical analyses were conducted using the Review
Manager 5.0 for Windows (The Nordic Cochrane Centre, Copen-
hagen, The Cochrane Collaboration, 2008).
3. Results
3.1. Search results
A summary of the search results is presented in Fig. 1. This
demonstrated that 67 papers were identied from the search
strategy. After reviewing the titles, abstracts and eventually full-
texts, eight studies were eligible and included in the review.
3.2. Methodological quality assessment
The results of the CASP appraisal are summarised in Table 2. All
studies scored ve or more out of a ten point scale of methodo-
logical quality with the exception of Ross et al.s (2007) study. The
principal strengths of the studies were that participants in all
groups were followed-up throughout the study, and that the data
was appropriately presented with descriptive and inferential
statistical tests to assess between-group differences. The main
weaknesses were that it was not possible to ascertain if partici-
pants, staff or study personnel were blinded to participants study
group allocation. Only one study justied their sample size using
a power calculation (Hupperets et al., 2009a,b). Ross et al. (2007)
did not provide sufcient information to determine the outcomes
for all participants entered into the trial. However in most cases this
information was more explicit, with Wester et al. (1996), Bernier
and Perrin (1998), Holme et al. (1999), Eils and Rosenbaum
(2001), Hale et al. (2007), Han et al. (2009) and Hupperets et al.
(2009a,b) providing information on all participants at the end of
each study. In the case of Hale et al. (2007) and Han et al.s (2009)
studies, six out of 48 and ve out of 40 participants were lost to
follow-up respectively. Wester et al. (1996) reported a larger
attrition rate where 13 out of 48 participants were lost.
3.3. Study characteristics
The results of each studys cohort characteristics are summar-
ised in Table 3. In total, 840 participants were included: 390 males
and 402 females, with a mean age of 24 years. Weight was pre-
sented in all but two studies (Wester et al., 1996; Holme et al.,
1999), indicating a mean participant weight of 72.5 kg. Four
studies characterised their populations as having chronic or
recurrent ankle instability or sprains (Bernier and Perrin, 1998;
Holme et al., 1999; Eils and Rosenbaum, 2001; Hale et al., 2007;
Han et al., 2009), whilst four studies described their cohorts as
having experiences an ankle sprain (Wester et al., 1996; Holme
et al., 1999; Ross et al., 2007; Hupperets et al., 2009a,b). In
respect to participation in sports, the frequency of exercise partic-
ipation was not stated in Bernier and Perrin (1998), Eils and
Rosenbaum (2001), Han et al. (2009) or Ross et al.s (2007)
studies. The cohort was described as recreational athletes in
Hale et al. (2007) and Holme et al.s (1999) studies, whilst
Records identified through database
searching
(n = 48)
Additional records identified
through other sources
(n = 19)
Records after duplicates removed
(n = 67)
Records screened
(n = 67)
Records excluded
(n = 56)
Full-text articles assessed
for eligibility
(n = 11)
Full-text articles excluded,
with reasons
(n = 3)
Clark et al
(2005):unsuitable
outcome measures
Mohammadi
(2007):
prophylactic
aspect to study
Verhagen et al
(2004):
asymptomatic
study population
Studies included in
qualitative synthesis
(n = 8)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 2)

Fig. 1. PRISMA ow diagram to depict the results of the search strategy.

K. Postle et al. / Manual Therapy 17 (2012) 285e291 287
Hupperets et al. (2009a,b) described their participants as being
athletes. Wester et al. (1996) dened athletic participation as
participants who engaged in sport for at least 2 h per week.
Study follow-up procedures varied; no two studies followed the
exact same protocol. The most frequently chosen follow-up period
was four weeks, used by three studies (Hale et al., 2007; Ross et al.,
2007; Han et al., 2009). However follow-up times ranged from four
weeks (Hale et al., 2007; Ross et al., 2007; Han et al., 2009) to one
year (Eils and Rosenbaum, 2001) study for injury re-evaluation.
3.4. Proprioceptive interventions
All studies included proprioceptive input for one arm of their
randomised controlled trials. However there was some variety in
terms of the precise exercise type. The specic type and detailed
prescription of each proprioceptive intervention is presented in
Table 4. For example Wester et al. (1996) primarily used a balance
board to provide proprioceptive input whilst Han et al. (2009)
provided proprioceptive input through the use of elastic tubing.
Four studies implemented proprioceptive input through an exer-
cise programme consisting of a number of different individual
proprioceptive exercises (Holme et al., 1999; Eils et al., 2007; Hale
et al., 2007; Hupperets et al., 2009a,b). Two studies specically
described coordination or balance, and coordination training as
their form of proprioceptive input (Bernier and Perrin, 1998; Ross
et al., 2007).
The frequency of training for these exercise interventions also
varied between studies (Table 4). This ranged from once a week
(Eils and Rosenbaum, 2001) to seven times per week (Wester et al.,
1996). The total duration of the proprioceptive training ranged from
four weeks (Hale et al., 2007; Han et al., 2009) to twelve weeks
(Wester et al., 1996).
3.5. Primary outcome measures
3.5.1. Recurrent injury
Two studies examined recurrent injury rates (Wester et al.,
1996; Hupperets et al., 2009a,b). Whilst neither study presented
data on this outcome twelve months after commencing rehabili-
tation, data was available for analysis at 8e12 weeks.
Recurrent injury was the only outcome which was suitable for
meta-analysis since all other outcomes presented with either
insufcient data to analysis or considerable methodological
heterogeneity in respect to interventions or methodological
approached. The meta-analysis indicated that the odds of recurrent
ankle injury for people not prescribed proprioceptive exercises was
twice as high as those prescribed proprioceptive exercises.
However this was not a statistically signicant nding between the
interventions (Odds Ratio 2.27; 95% CI: 0.08, 66.31; p 0.63;
Fig. 2). This is further re-enforced by the wide 95% condence
intervals indicating little precision for this non-statistically signif-
icant nding. Furthermore, the I
2
nding of 81% indicated that
statistical heterogeneity was evident suggesting caution should be
made when interpreting these results.
3.6. Secondary outcome measures
3.6.1. Subjective instability
One study examined patient-reported subjective ankle insta-
bility (Wester et al., 1996). They reported a reduced incidence of
subjective ankle instability following a proprioceptive
Table 2
CASP methodological appraisal results.
Critical appraisal skills programme (CASP) Bernier and
Perrin (1998)
Eils and
Rosenbaum (2001)
Hale et al.
(2007)
Han et al.
(2009)
Holme et al.
(1999)
Hupperets
et al. (2009a,b)
Ross et al.
(2007)
Wester
et al. (1996)
1. Did the study ask a clearly focused question? U U U U U U U U
2. Was this a randomised controlled trial (RCT)
and was it appropriately so?
U U U U U U U U
3. Were participants appropriately allocated to
intervention and control groups?
NC NC U NC U U NC U
4. Were participants, staff and study personnel
blind to participants study group?
NC NC NC NC NC NC NC NC
5. Were all of the participants who entered the
trial accounted for at its conclusion?
U U X X X U NC X
6. Were the participants in all groups followed-up
and data collected in the same way?
U U U U U U U U
7. Did the study have enough participants to
minimise the play of chance?
X X X X X U X X
8. How were the results presented and what is
the main result?
U U U U U U U U
9. How precise are these results? X X U U X U X X
10. Were all important outcomes considered so the
results can be applied?
X U U U X U X U
Total score out of 10 5 6 7 6 5 9 4 6
Table 3
Population characteristics of included studies.
Study Numbers Male/female Mean age (years) Mean weight (Kg) Presenting condition Level of sporting participation
Bernier and Perrin (1998) 48 N/S 22.5 71.7 Chronic ankle instability N/S
Eils and Rosenbaum (2001) 30 12/18 26.7 72.6 Repeat ankle inversion sprain N/S
Hale et al. (2007) 51 23/28 21.4 73.8 Chronic ankle instability Recreationally active individuals
Han et al. (2009) 40 20/20 21.3 68.2 Chronic ankle instability N/S
Holme et al. (1999) 71 44/27 26.5 N/S Ankle sprain All subjects recreational athletes
Hupperets et al. (2009a,b) 522 248/274 28.3 72.6 Ankle sprain Athletes
Ross et al. (2007) 30 14/16 21 76 Ankle sprain N/S
Wester et al. (1996) 48 29/19 25 N/S Ankle sprain Subjects active in sport at least
2 h/week
K. Postle et al. / Manual Therapy 17 (2012) 285e291 288
rehabilitation program compared to not performing propriocep-
tive exercises (p 0.05). None of the 24 patients reported
subjective instability of the ankle joint after completing the
rehabilitation program, whilst six out of 24 patients (25%) in the
non-proprioception exercise group reported instability of the
ankle during the follow-up period (Wester et al., 1996).
3.6.2. Functional outcomes
Hale et al. (2007) assessed Star Excursion Balance Test (SEBT),
FADI and the FADI-Sports subscale (FADI-Sport) score. They
reported a statistically signicantly greater SEBT result, FADI and
FADI-Sports scores in the proprioceptive group compared to the
non-proprioceptive intervention group at four weeks follow-up
(p < 0.01).
3.6.3. Swelling
Wester et al. (1996) additionally looked at speed of reduction of
swelling. They reported no statistically signicant difference in
swelling and the resolution of swelling at six weeks between the
non-proprioceptive training group (p < 0.05).
3.6.4. Postural sway/joint position sense
Three studies assessed postural sway and joint position sense
as outcome measurements (Bernier and Perrin, 1998; Holme et al.,
1999; Eils and Rosenbaum, 2001). Ross et al. (2007) examined
single leg postural stability and static postural stability on a force
plate. Han et al. (2009) assessed total travel distance which can be
interpreted as a measurement of postural sway.
Bernier and Perrin (1998) reported improvements in postural
sway following proprioceptive input but could not attribute the
same affect for joint position sense. Eils and Rosenbaum (2001)
also found improvement in postural sway and joint position
sense and within the proprioceptive exercise group. This was
denoted as a signicant improvement in the proprioceptive
compared to the non-proprioceptive training group (p <0.05). Eils
and Rosenbaum (2001) also identied signicant changes in
muscle reaction times in response to proprioceptive rehabilitation
as opposed to the non-proprioceptive training group (p < 0.01).
Ross et al. (2007) demonstrated improved postural stability with
proprioceptive input with reduced centre of pressure measures
signicantly higher compared to the non-proprioceptive training
group (p < 0.05). However, these ndings were contrary to Holme
et al.s (1999) results which reported identical normalisation of
postural control at four months follow-up in the proprioceptive
and non-proprioceptive training groups.
4. Discussion
The ndings of this study indicate no statistically signicant
difference in the occurrence of recurrent injury between those
provided with proprioceptive exercises. The addition of proprio-
ceptive training did however demonstrate a reduction in subjec-
tive instability (Wester et al., 1996), and functional outcomes as
assessed through the SEBT and FADI (Hale et al., 2007). There was
no consensus on the advantages of including proprioceptive
training following ankle ligament injury for the assessment of
swelling, postural sway or joint position sense. No studies have
reported on the affects of ankle range of motion or return to sports
with or without the addition of proprioceptive training in the
rehabilitation of patients following ankle ligament injury.
This study has identied a number of major methodological
limitations to the current evidence. These have included not
blinding assessors to participant treatment allocation potentially
causing assessment biases (Furberg and Furberg, 2007). The
included studies demonstrated losses to follow-up within their T
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cohorts, little allowance was made for managing missing data, such
as multiple imputation or strategies to estimate missing data values
(Furberg and Furberg, 2007) and the poor description of cohort
characteristics, particularly in the diagnosis and denition of ankle
inversion injury. Furthermore the severity of the injury was rarely
categorised within the literature (Kannus and Renstrom, 1991). By
providing limited information, it is therefore more difcult to
generalise the study ndings to a specic population. Future study
is required to address these and the other methodological limita-
tions to begin to more rigorous answer the research questions
posed.
The results identied that a supervised proprioceptive program
is most commonly delivered over six weeks. However, the use of
more lengthy programmes was demonstrated in two studies
(Wester et al., 1996; Hupperets et al., 2009a,b). The frequency of
such a programme has been reported as occurring between one and
seven times weekly, and varies in duration from10 min to up to 1 h.
Where resources are limited, there is evidence that unsupervised
home exercise may be as effective, although may need to be
completed over a longer time period, i.e. eight weeks (Hupperets
et al., 2009a,b). Whilst this provides an indication as to how
proprioceptive exercise programmes may be delivered, this may
not be typical of current health service practice.
The literature was largely based on sporting populations,
whether these were regarded as recreational or professional
athletes (Wester et al., 1996; Holme et al., 1999; Hale et al., 2007;
Hupperets et al., 2009a,b). However four studies did not docu-
ment whether their participants regularly engaged in sporting
pursuits or not (Bernier and Perrin, 1998; Eils and Rosenbaum,
2001; Ross et al., 2007; Han et al., 2009). Furthermore, the litera-
ture was predominantly based on younger aged groups, with the
mean age the review cohort being 24 years. Given this, it is not
possible to determine whether there is a difference in possible
treatment benet for those patients who participate or not in
sporting activities, or whether there is a difference in age and
treatment effect. This may be important as those who participate in
sporting activities, particular multidirectional exercises performed
on uneven activities, may require superior proprioceptive control
compared to more sedentary people (Fong et al., 2009; Hoch and
McKeon, 2011). Similarly, joint position sense has been demon-
strated to be poorer in older people (Goble et al., in press; Wright
et al., 2011). Accordingly, the age of the patient may be a key
prognostic indicator for proprioceptive retraining which should be
considered when designing future trails assessing typical ankle
instability populations.
Although not assessed in this study, Hupperets et al. (2010)
assess the cost-effectiveness of including a proprioceptive
training element in their rehabilitation of 522 recreational athletes.
They reported that there was a statistically signicant differences in
total costs per participant (mean difference, V69; 95% condence
interval, V200 to V2) and per injured participant
(V332; V741 to V62) in favour of the proprioception group
(p < 0.05). The effect of the intervention was larger with lower
overall costs for those who were provided with proprioceptive
training as opposed to not (p < 0.05). Further examination of the
cost-effectiveness of the addition of a proprioceptive exercise
programme with different populations is warranted to further
consider the appropriateness of this intervention in health service
provision.
Ongoing research is needed in this area to further investigate
the capacity for benecial effect that proprioceptive exercises have
in the treatment of ankle ligament injury re-occurrence. There
appeared to be some variability in the type of proprioceptive
exercises prescribed to patients following this injury. Accordingly
investigation into the type and duration of proprioceptive inter-
vention post-ankle ligament injury is warranted as there is current
a dearth of literature answering this question. Furthermore, it
remains unclear when proprioceptive rehabilitation should begin
after injury. Further evidence is needed regarding the efcacy of
proprioceptive input in the stages of rehabilitation and the benets
it has on functional and clinical outcomes. In addition greater focus
could be given to the physiological mechanisms of proprioception
and impaired proprioception post-injury to aid identication and
promotion of the most effective training components.
No studies reported the ndings of ankle range of motion or
return to sports post-ankle ligament injury and proprioceptive
training. The existing literature also demonstrates a paucity of
evidence assessing the benets of proprioceptive exercise in rela-
tion to swelling and functional outcomes. Further assessment of
these outcome measures specically in relation to proprioceptive
exercise post-ankle ligament sprain is warranted to address the
unanswered questions surrounding the precise potential benets
of proprioceptive exercise.
5. Conclusions
Proprioceptive exercises may reduce subjective instability, and
improve functional outcomes when included as part of the reha-
bilitation of people following ankle ligament injury. There was no
consensus on the advantages of including proprioceptive training
for the assessment of swelling, postural sway, joint position sense
or recurrent injury rates. Given this, proprioceptive training may be
an important part of this populations rehabilitation. Further study
is nowwarranted to develop the rigour of the evidence-base and to
determine the optimal proprioceptive training programme
following this injury.
Study or Subgroup
Hupperets, 2009
Wester, 1996
Total (95% CI)
Total events
Heterogeneity: Tau = 4.98; Chi = 5.35, df = 1 (P = 0.02); I = 81%
Test for overall effect: Z = 0.48 (P = 0.63)
Events
56
6
62
Total
256
24
280
Events
89
0
89
Total
266
24
290
Weight
59.0%
41.0%
100.0%
M-H, Random, 95% CI
0.56 [0.38, 0.82]
17.22 [0.91, 325.37]
2.27 [0.08, 66.31]
Proprioceptive exercise No proprioceptive ex's Odds Ratio Odds Ratio
M-H, Random, 95% CI
0.01 0.1 1 10 100
Favours experimental Favours control
Fig. 2. Forrest plot depicting pooled odds ratio for recurrent ankle sprain after rehabilitation with or without proprioceptive training.
K. Postle et al. / Manual Therapy 17 (2012) 285e291 290
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