Balance Measures for Discriminating between

Functionally Unstable and Stable Ankles

SCOTT E. ROSS1, KEVIN M. GUSKIEWICZ2, MICHAEL T. GROSS2, and BING YU2
1
Virginia Commonwealth University, Richmond, VA; and 2University of North Carolina, Chapel Hill, NC

ABSTRACT
ROSS, S. E., K. M. GUSKIEWICZ, M. T. GROSS, and B. YU. Balance Measures for Discriminating between Functionally Unstable
and Stable Ankles. Med. Sci. Sports Exerc., Vol. 41, No. 2, pp. 399–407, 2009. Purpose: To identify force plate measures that
discriminate between ankles with functional instability and stable ankles and to determine the most accurate force plate measure for
enabling this distinction. Methods: Twenty-two subjects (177 T 10 cm, 77 T 16 kg, 21 T 2 yr) without a history of ankle injury and 22
subjects (177 T 10 cm, 77 T 16 kg, 20 T 2 yr) with functional ankle instability (FAI) performed a single-leg static balance test and a
single-leg jump-landing dynamic balance test. Static force plate measures analyzed in both anterior/posterior (A/P) and medial/lateral
(M/L) directions included the following: ground reaction force (GRF) SD; center-of-pressure (COP) SD; mean, maximum, and total
COP excursion; and mean and maximum COP velocity. COP area was also analyzed for static balance. A/P and M/L time to
stabilization quantified dynamic balance. Greater values of force plate measures indicated impaired balance. A stepwise discriminant
function analysis examined group differences, group classification, and accuracy of force plate measures for discriminating between
ankle groups. Results: The FAI group had greater values than the stable ankle group for A/P GRF SD (P = 0.027), M/L GRF SD
(P = 0.006), M/L COP SD (P = 0.046), A/P mean COP velocity (P = 0.015), M/L mean COP velocity (P = 0.016), A/P maximum
COP velocity (P = 0.037), M/L mean COP excursion (P = 0.014), M/L total COP excursion (P = 0.016), A/P time to stabilization
(P = 0.011), and M/L time to stabilization (P = 0.040). M/L GRF SD and A/P time to stabilization had the greatest accuracy scores of
0.73 and 0.72, respectively. Conclusion: Although 10 measures identified group differences, M/L GRF SD and A/P time to sta-
bilization were the most accurate in discriminating between ankle groups. These results provide evidence for choosing these GRF
measures for evaluating static and dynamic balance deficits associated with FAI. Key Words: CHRONIC INSTABILITY, CENTER
OF PRESSURE, FORCE PLATE, FUNCTIONAL INSTABILITY, POSTURE, STABILITY

I
njuries to the lateral ligaments of the ankle are common
among physically active individuals (13,33). Approxi-
mately 25% of all injuries in athletics are ankle sprains,
and 85% of these injuries involve lateral ligament sprains
(13). A functional instability at the ankle joint might persist
after initial injury, and anywhere from 30% to 78% of in-
jured individuals may suffer recurrent sprains (1,3,10,11,
31,34,36). Although the exact casual factor is unknown,
functional ankle instability (FAI) is believed to occur from a
combination of mechanical instability, ankle strength def-
icits, and ligament deafferentation (10,11,21).
Address for correspondence: Scott E. Ross, Ph.D., ATC, Department of
Health and Human Performance, Virginia Commonwealth University,
PO Box 842020, 1015 W. Main St., Richmond, VA 23284-2020; E-mail:
seross@vcu.edu.
Submitted for publication January 2008.
Accepted for publication July 2008.
0195-9131/09/4102-0399/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2009 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e3181872d89
APPLIED SCIENCES
Freeman et al. (10,11) originally proposed ligament
deafferentation as a causal factor of FAI. The damaged
ankle ligament sensory receptors were thought to disrupt
sensorimotor function by diminishing proprioceptive mes-
sages related to joint movement and position to afferent
pathways. The resulting proprioceptive deficits could also
lead to diminished postural reflex responses and conse-
quently contribute to balance deficits. Thus, sensorimotor
deficits were one potential contributing factor to recurrent
ankle sprains (10,11).
Although Freeman et al. (10,11) used single-leg Romberg
tests to identify balance impairments, other researchers have
used instrumented force plates to identify balance deficits
associated with ankle instability (2,6,7,12,14,16,18,20,21,
23–26,35,37,38). Center-of-pressure (COP) force plate
measures and ground reaction force (GRF) measures that
have been used to quantify balance in the ankle instability
literature included the following: COP SD; mean, maxi-
mum, and total COP excursion; COP velocity; COP area;
and ground reaction force (GRF) SD (2,6,7,12,14,16,18,
20,21,23–26,35,37,38). In our review of literature, we
found that 55% of static force plate measures used in re-
search studies detected balance deficits in subjects with
ankle instability (2,6,7,12,14,16,18,20,21,23–26,35,37,38).

399

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 Some researchers have reported greater COP excursions
and greater GRF SD in ankles with functional instability
compared with stable ankles,(14,18,21,23,37,38), and
others have reported contrary results (2,14,18,20,24,26).
Thus, this discrepancy suggests that selected force plate
measures may be more sensitive than others at discriminat-
ing between ankles with functional instability and stable
ankles.
Although balance deficits can exist with single-leg stance,
the functionality of this test has been questioned (26). Dy-
namic single-leg hopping tests that challenge postural con-
trol greater than single-leg stance have been recommended
as alternative assessment techniques to single-leg static bal-
ance tests (26). Anterior/posterior (A/P) and medial/lateral
(M/L) time to stabilization force plate measures have been
used to evaluate single-leg jump-landing dynamic balance
of subjects with FAI (4,26–28,39). Subjects with FAI take
longer to stabilize than subjects with stable ankles after a
single-leg jump landing (4,26–28,39). This stabilization mea-
sure has been theorized to have greater sensitivity than static
measures for discriminating between ankles with functional
instability and stable ankles (26,27).
The sensitivity of static and dynamic force plate measures
for discriminating between ankles with functional instability
and stable ankles has not been established. Determining force
plate measures that accurately discriminate between ankles
with functional instability and stable ankles might assist
researchers in identifying balance impairments that might
otherwise go undetected with less accurate measures. There-
fore, the objectives of this study were 1) to identify force plate
measures that discriminate between ankles with functional
APPLIED SCIENCES
signs and symptoms of injury included pain, loss of function,
mild point tenderness, swelling, and abnormal range of
motion. Subjects with stable ankles with a history of ankle
sprain injury were excluded from this study.
Informed written consent was obtained from all subjects
before participation in this study. The Committee for the
Protection of the Rights of Human Subjects granted approval
for this project. All subjects completed the Ankle Joint
Functional Assessment Tool to assess ankle stability (30).
Possible scores on this instrument range from 0 to 48, and
greater scores indicate greater functional instability. A
certified athletic trainer (SER) tested the subjects’ ankle
laxity by performing the anterior drawer and talar tilt
orthopedic tests before balance testing.
Single-leg balance test. Subjects were instructed to
remain as motionless as possible while standing with their
test leg on a force plate. Subjects kept their eyes open, their
hands on their hips, and their non–weight-bearing leg slightly
flexed at the hip and knee. The weight-bearing leg was
slightly flexed at the knee, and the foot was in a neutral toe in/
out position with the tips of their shoes pointed straight ahead.
All subjects wore athletic shoes during testing; however, we
did not control for the type of athletic shoes. Our rationale for
testing subjects while wearing athletic shoes was to keep
contact surfaces consistent between static and dynamic tests.
Additionally, this single-leg balance protocol has been used in
previous ankle instability studies (28,29). Subjects performed
one 10-s practice trial, followed by three 20-s testing trials.
Subjects rested 20 s between each trial. Trials were repeated

TABLE 1. Charateristics of subjects with and without FAI.

instability and stable ankles and 2) to determine the most ac-
Stable Ankle Group FAI Group
curate force plate measure for enabling this distinction be- (10 males, 12 females) (10 males, 12 females)
tween ankles with functional instability and stable ankles. The
Dominant test limb, n 13 13
identification of these force plate measures might assist re- Nondominant test limb, n 9 9
searchers in detecting individuals at risk for sprains or help Height (cm), mean (SD) 177 (10) 177 (10)
Weight (kg), mean (SD) 77 (16) 77 (16)
researchers determine the efficacy of an injury prevention Age (yr), mean (SD) 21 (2) 21 (2)
program. Sprains in the past year Number of Subjects Number of Number of
No subjects reported a Sprains Subjects
history of ankle sprain 2 8
injury. 3 4
4 3
METHODS 5 1
6 1
Subjects. Subject characteristics are reported in Table 1. 7 2
9 1
Twenty-two control subjects with stable ankles were matched 10 2
by height, mass, age, sex, and leg tested to 22 subjects with Giving way sensations Number of Subjects Number of Number of
clinically diagnosed FAI. Subjects with stable ankles were the past year No subjects reports Give Ways Subjects
reported a history of giving 2 1
tested on the same leg (dominant or nondominant) as their way sensations. 3 1
match. Dominance was defined as the preferred leg used to 4 4
5 2
kick a ball. Inclusion criteria for FAI included 1) self-report of 7 3
a history of one sprain followed by at least 3 d of immobi- 10 2
lization and 2) self-report of at least two ankle sprains and at 15 5
20 4
least two episodes of ‘‘giving way’’ sensations during physical Special Test Number of Subjects Number of Give Ways
activity within the year before the subjects’ enrollment in this Drawer Talar Tilt Drawer Talar Tilt
Positive 4 4 11 12
study. Potential subjects were excluded if they displayed acute Positive 18 18 11 10
signs and symptoms of injury or reported an ankle sprain AJFAT score, mean (SD) 22.60 (1.22) 33.05 (4.02)
within 6 wk before their participation in the study. Acute AJFAT, Ankle Joint Functional Assessment Tool.

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TABLE 2. Definitions of force plate measures.
Measure Definition
GRF SD Overall SD of the GRF in a given direction in a given
time for a given number of trials
COP SD Overall SD of the COP in a given direction in a given
time for a given number of trials
Mean COP excursion The absolute averaged distance between the
instantaneous COP and the average COP position
in a given direction during a given time
Maximum COP excursion The absolute maximum distance between the
instantaneous COP position and the average COP
position during a given period
Total COP excursion The absolute length of the path movements over the
testing period
Mean COP velocity The absolute mean value of the instantaneous
velocity of the COP in a given direction during a
given period
Maximum COP velocity The absolute maximum value of the instantaneous
velocity of the COP in a given direction during a
given period
COP area A rectangular area defined by the maximum anterior,
posterior, medial, and lateral sways during a
given time
Time to stabilization Time needed to reduce the variation of a smoothed
GRF to the range of vibration of the corresponding
component of the GRF in a stabilized single-leg
stance of individuals with stable ankles
GRF, ground reaction force; COP, center of pressure.
if subjects hopped on the weight-bearing leg or touched
down with the non–weight-bearing leg.
Single-leg jump landing. Methods for performing
single-leg jump-landing tests have been described in previous
reports (26–28). First, subjects performed maximum standing
reach while standing flat footed directly underneath a Vertec
(Sports Imports, Columbus, OH) by flexing their shoulders
jumped using a bilateral foot takeoff technique. Subjects
were allowed to swing their arms while they jumped off of
the floor. Then, subjects flexed their shoulders to 180- and
fully extended their elbows, touched the highest plastic rod
that they could reach with the distal end of their fingers, and
then landed on both feet on the floor. The greatest jump
height of the three vertical jumps for each subject was re-
corded and then subtracted from their respective maximum
standing reach. Thus, the difference between maximum ver-
tical jump height and maximum standing reach was recorded
as the true maximum jump. Next, the plastic rods on the
Vertec were placed in line with the center of a force plate,
and the plastic rods were then set between 50% and 55% of
subjects’ true maximum jump. Subjects stood on the floor
70 cm away from the center of the force plate and performed
a jump using a bilateral foot takeoff technique. Again, sub-
jects were allowed to swing their arms while they jumped off
of the floor. However, subjects were required to reach with
their shoulder flexed at 180- and elbow fully extended after
take off. The reaching arm was the ipsilateral arm of the
ankle with functional instability or the matched testing ankle
of subjects with stable ankles. As subjects jumped vertically,
they touched the plastic rods between 50% and 55% of their
maximum jump with the distal end of their fingers, and then
they landed on a single leg (their test leg) on a force plate.
Subjects were instructed to stabilize as quickly as possible and
remain as motionless as possible in single-leg stance for 20 s.
Three practice trials and seven testing trials were performed
with 30 s of rest between trials. Trials were repeated if subjects
failed to jump within the 50–55% range, hopped on the test
leg, or touched down with the non–weight-bearing leg.

to 180- and touching the highest plastic rod that they could
reach with the distal end of their fingers. The Vertec has
adjustable plastic rods set at different heights that permit
maximum reach and jump height assessments. Subjects were
then assessed for maximum vertical jump height as they
stood on the floor 70 cm away from a Vertec. Three max-
imum vertical jump heights were assessed while subjects
APPLIED SCIENCES
Data collection and reduction. A Bertec force plate
model number 4060-08A (Bertec Corp., Columbus, OH)
collected GRF data at a sampling rate of 180 Hz (4,26–28).
Analog signals were amplified with a Bertec amplifier (AM-
6701). Signals were then passed through a BNC adapter
chassis that was interfaced with an analog-to-digital board
within a personal computer. MotionSoft Balance Assessment

TABLE 3. Mean T SD and ES for force plate measure analyses.

Force Plate FAI Stable Ankle ES ,, F(1,42), P value
A/P GRF SD 0.45 T a
0.18 0.35 T a
0.08 0.72 , = 0.90, F(1,42) = 5.24, P = 0.027*
M/L GRF SD 0.54 T 0.22a 0.39 T 0.07a 0.92 , = 0.84, F(1,42) = 8.23, P = 0.006*
A/P COP SD (cm) 1.01 T 0.38 0.85 T 0.18 0.54 , = 0.93, F(1,42) = 3.26, P = 0.078
M/L COP SD (cm) 0.73 T 0.19 0.64 T 0.10 0.60 , = 0.91, F(1,42) = 4.24, P = 0.046*
A/P mean COP excursion (cm) 0.80 T 0.30 0.67 T 0.12 0.57 , = 0.92, F(1,42) = 3.72, P = 0.061
M/L mean COP excursion (cm) 0.60 T 0.15 0.51 T 0.10 0.71 , = 0.87, F(1,42) = 6.51, P = 0.014*
A/P maximum COP excursion (cm) 3.01 T 1.32 2.41 T 0.52 0.60 , = 0.92, F(1,42) = 3.92, P = 0.054
M/L maximum COP excursion (cm) 2.02 T 0.52 1.82 T 0.33 0.46 , = 0.95, F(1,42) = 2.23, P = 0.143
A/P total COP excursion (cm) 63.61 T 20.03 54.16 T 11.00 0.58 , = 0.92, F(1,42) = 3.76, P = 0.060
M/L total COP excursion (cm) 64.63 T 15.89 54.88 T 9.03 0.75 , = 0.87, F(1,42) = 6.27, P = 0.016*
A/P mean COP velocity (cmIsj1) 3.17 T 1.00 2.59 T 0.39 0.76 , = 0.87, F(1,42) = 6.45, P = 0.015*
M/L mean COP velocity (cmIsj1) 3.23 T 0.80 2.74 T 0.45 0.75 , = 0.87, F(1,42) = 6.29, P = 0.016*
A/P maximum COP velocity (cmIsj1) 24.99 T 15.81 17.48 T 4.24 0.65 , = 0.90, F(1,42) = 4.62, P = 0.037*
M/L maximum COP velocity (cmIsj1) 21.53 T 7.93 18.07 T 3.47 0.54 , = 0.92, F(1,42) = 3.53, P = 0.067
COP area (cm2) 0.21 T 0.14 0.15 T 0.01 0.60 , = 0.92, F(1,42) = 3.82, P = 0.057
A/P time to stabilization (s) 1.86 T 0.67 1.44 T 0.33 0.80 , = 0.86, F(1,42) = 7.03, P = 0.011*
M/L time to stabilization (s) 2.09 T 0.80 1.70 T 0.38 0.62 , = 0.90, F(1,42) = 4.49, P = 0.040*
a
GRF SD for A/P and M/L measures were divided by body weight (N) and multiplied by 100.
* Statistical significance (P e 0.05).
A/P, anterior/posterior; M/L, medial/lateral; COP, center of pressure; GRF, ground reaction force; ES, effect size; ,, Wilks’ Lambda.

DISCRIMINATING UNSTABLE AND STABLE ANKLES Medicine & Science in Sports & Exercised 401

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 FIGURE 1—ROC curves for ground reaction force (GRF) SD.
Anterior/posterior (A/P) GRF SD and medial/lateral (M/L) GRF SD
discriminated between ankle groups. However, M/L GRF SD had
greater accuracy than A/P GRF SD in discriminating between ankle
groups. The diagonal dotted black line divides the area of the graphs
into the upper and lower 50%.
computer software package version 2.0 (MotionSoft Inc.,
Chapel Hill, NC) converted digital data to GRF vectors.
Data were filtered using a second-order recursive low-pass
Butterworth digital filter with an estimated optimum cutoff
frequency of 12.53 Hz (4,26–28).
Table 2 presents definitions of static and dynamic force
plate measures calculated to evaluate balance. Static force
plate measures analyzed in both anterior/posterior (A/P) and
medial/lateral (M/L) directions included the following: GRF
SD; COP SD; mean, maximum, and total COP excursion;
and mean and maximum COP velocity. COP area was also
analyzed for static balance. A/P and M/L time to stabilization
APPLIED SCIENCES
examined dynamic balance and were calculated using the
vibration magnitude curve fitting technique (27,28). Greater
magnitudes of force plate measures were indicative of im-
paired balance.
Statistical analysis. A stepwise discriminant function
analysis determined 1) the force plate measure differences
between groups with univariate F-tests; 2) the percentage
of subjects with FAI and subjects with stable ankles that
were correctly classified as having FAI or stable ankles,
respectively; and 3) the force plate measures that accurately
discriminated between ankle groups. Effect size (ES) values
were calculated using Cohen’s (5) ES d to indicate the de-
gree of differences between ankle groups on univariate
F-tests. Cohen (5) defines low, medium, and high ES as
0.30, 0.50, and 0.80, respectively. The stepwise discrimi-
nant analysis regressed force plate measures on group mem-
bership. In other words, this analysis determined force plate
measures that predicted group membership. Thus, force
plate measures that predicted group membership were ac-
curate at distinguishing between ankle groups. Additionally,
the percentage of individuals classified correctly as having
ankles with functional instability or stable ankles was iden-
tified with the discriminant analysis. Accuracy values for
discriminating between groups were determined by calcu-
lating the area under the curve (AUC) for receiver operating
402 Official Journal of the American College of Sports Medicine
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FIGURE 2—ROC curves for center-of-pressure (COP) SD. Neither
anterior/posterior (A/P) COP SD nor medial/lateral (M/L) COP SD
were accurate in discriminating between ankle groups. The diagonal
dotted black line divides the area of the graphs into the upper and
lower 50%.
characteristic (ROC) curves. ROC curves plot sensitivity
(true-positive rate) versus 1-speficity (false-positive rate),
describing how sensitivity and false-positive rate vary
together. The full area under the ROC curve was used as
an index to classify the accuracy of force plate measures.
Perfect accuracy is indicated by an AUC of 1.0, whereas a
no apparent accuracy is indicated by an AUC of less than or
equal to 0.50 (17,22). Thus, force plate measures were more
accurate at discriminating between ankle groups as AUC
values approached 1.0. A traditional academic point scale
was used to classify the accuracy of the AUC for discrim-
inating between ankle groups with force plate measures
(0.90–1.00 = ‘‘excellent’’; 0.80–0.89 = ‘‘good’’; 0.70–0.79 =
‘‘fair’’; 0.60–0.69 = ‘‘poor’’; and 0.50–0.59 = ‘‘fail’’) (17,22).
SPSS version 13.0 (SPSS, Inc., Chicago, IL) was used
for statistical analyses. The alpha and the asymptotic
FIGURE 3—ROC curves for mean center-of-pressure (COP) excur-
sion. Medial/lateral (M/L) mean COP excursion accurately discrimi-
nated between ankle groups, whereas anterior/posterior (A/P) mean
COP excursion did not. M/L mean COP excursion had greater
accuracy than A/P mean COP excursion in discriminating between
ankle groups. The diagonal dotted black line divides the area of the
graphs into the upper and lower 50%.
http://www.acsm-msse.org
FIGURE 4—ROC curves for maximum center-of-pressure (COP)
excursion. Neither anterior/posterior (A/P) maximum COP excursion
nor medial/lateral (M/L) maximum COP excursion were accurate in
discriminating between ankle groups. The diagonal dotted black line
divides the area of the graphs into the upper and lower 50%.
levels were set a priori at P e 0.05 to indicate statistical
significance.
RESULTS
Table 3 reports means T SD and ES for static and dynamic
force plate measures. The FAI group had greater force plate
values than the stable ankle group for A/P GRF SD, M/L
GRF SD, M/L COP SD, M/L mean COP excursion, M/L
total COP excursion, A/P mean COP velocity, M/L mean
COP velocity, A/P maximum COP velocity, A/P time to
stabilization, and M/L time to stabilization. No group dif-
ferences were found for A/P COP SD, A/P mean COP
excursion, A/P maximum COP excursion, M/L maximum
COP excursion, A/P total COP excursion, M/L maximum
COP velocity, or COP area.
FIGURE 5—ROC curves for total center-of-pressure (COP) excursion.
Medial/lateral (M/L) total COP excursion accurately discriminated
between ankle groups, whereas anterior/posterior (A/P) total COP
excursion did not. M/L total COP excursion had greater accuracy than
A/P total COP excursion in discriminating between ankle groups. The
diagonal dotted black line divides the area of the graphs into the upper
and lower 50%.
DISCRIMINATING UNSTABLE AND STABLE ANKLES
Copyright @ 2009 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
FIGURE 6—ROC curves for mean center-of-pressure (COP) velocity.
Anterior/posterior (A/P) mean COP velocity and medial/lateral (M/L)
mean COP velocity discriminated between ankle groups. However,
M/L mean COP velocity had greater accuracy than A/P mean COP
velocity in discriminating between ankle groups. The diagonal dotted
black line divides the area of the graphs into the upper and lower 50%.
The ROC curves for static and dynamic force plate mea-
sures are presented in Figure 1 (GRF SD), Figure 2 (COP
SD), Figure 3 (mean COP excursion), Figure 4 (maximum
COP excursion), Figure 5 (total COP excursion), Figure 6
(mean COP velocity), Figure 7 (maximum COP velocity),
Figure 8 (COP area), and Figure 9 (time to stabilization).
Table 4 reports the percentage of subjects correctly classi-
fied into their respective groups as well as the AUC and the
asymptotic significance for force plates measures. The AUC
values had accuracy ratings of ‘‘fair’’ for A/P GRF SD, M/L
GRF SD, M/L total COP excursion, M/L mean COP ve-
APPLIED SCIENCES
locity, and A/P time to stabilization. The AUC values had ac-
curacy ratings of ‘‘poor’’ for A/P COP SD, M/L COP SD, A/P
mean COP excursion, M/L mean COP excursion, A/P max-
imum COP excursion, A/P total COP excursion, A/P mean
FIGURE 7—ROC curves for maximum center-of-pressure (COP)
velocity. Anterior/posterior (A/P) maximum COP velocity accurately
discriminated between ankle groups, whereas medial/lateral (M/L)
maximum COP velocity did not. A/P maximum COP velocity had
greater accuracy than M/L maximum COP velocity in discriminating
between ankle groups. The diagonal dotted black line divides the area
of the graphs into the upper and lower 50%.
Medicine & Science in Sports & Exercised 403
 TABLE 4. Discriminant accuracy for force plate measures.
% Correctly Asymptotic
Force Plate Classified AUC Significance
A/P GRF SD 65.9 0.70 0.021*
M/L GRF SD 68.2 0.73 0.011*
A/P COP SD 59.1 0.62 0.185
M/L COP SD 59.1 0.64 0.110
A/P mean COP excursion 56.8 0.65 0.080
M/L mean COP excursion 56.8 0.69 0.034*
A/P maximum COP excursion 54.5 0.60 0.755
M/L maximum COP excursion 47.7 0.57 0.439
A/P total COP excursion 63.6 0.63 0.133
M/L total COP excursion 65.9 0.70 0.024*
A/P mean COP velocity 61.4 0.68 0.038*
M/L mean COP velocity 65.9 0.70 0.024*
A/P maximum COP velocity 61.4 0.67 0.050*
M/L maximum COP velocity 56.8 0.63 0.156
COP area 56.8 0.60 0.296
FIGURE 8—ROC curve for center-of-pressure (COP) area. COP area A/P time to stabilization 61.4 0.72 0.012*
was not accurate in discriminating between ankle groups. The diagonal M/L time to stabilization 54.5 0.64 0.121
dotted black line divides the area of the graphs into the upper and
lower 50%. * Statistical significance (P e 0.05).
A/P, anterior/posterior; M/L, medial/lateral; COP, center of pressure; GRF, ground
reaction force.
COP velocity, A/P maximum COP velocity, M/L maximum
COP velocity, COP area, and M/L time to stabilization. The
M/L maximum COP excursion failed to discriminate between the most accurate force plate measures for discriminating
ankle groups. between ankle groups. However, accuracy scores indicated
Accuracy scores indicated that five force plate measures that M/L GRF SD performed slightly better than A/P time to
had ratings of ‘‘fair.’’ The stepwise discriminant analysis stabilization at discriminating between ankle groups. These
indicated, however, that the M/L GRF SD and the A/P time results provide evidence for choosing M/L GRF SD and A/P
to stabilization were the most accurate force plate measures time to stabilization as primary force plate measures for
for discriminating between ankle groups (Wilks’ lambda evaluating static and dynamic balance deficits associated with
(,) = 0.76, F(2,41) = 6.45, P = 0.004). Furthermore, the step- FAI, respectively. These static and dynamic force plate mea-
wise discriminant analysis indicated that the M/L GRF SD sures might assist researchers in detecting balance impair-
slightly out performed A/P time to stabilization for dis- ments that might otherwise go undetected during static or
criminating between ankle groups (Wilks’ lambda (,) = dynamic single-leg balance tests with less accurate measures.
Additionally, M/L GRF SD and A/P time to stabilization
APPLIED SCIENCES

0.84, F(1,42) = 8.23, P = 0.006).

DISCUSSION
Although 10 force plate measures identified group differ-
ences, the M/L GRF SD and the A/P time to stabilization were
FIGURE 9—ROC curves for time to stabilization. Anterior/posterior
(A/P) time to stabilization accurately discriminated between ankle
groups, whereas medial/lateral (M/L) time to stabilization did not. A/P
time to stabilization had greater accuracy than M/L time to
stabilization in discriminating between ankle groups. The diagonal
dotted black line divides the area of the graphs into the upper and
lower 50%.
measures might help researchers in detecting individuals at
risk for sprains or help researchers determine the efficacy of
an injury prevention program.
Although less accurate than M/L GRF SD, A/P GRF SD
and several COP measures detected static balance impair-
ments associated with FAI. Our significant COP force plate
measures for detecting ankle group differences indicate that
subjects with FAI swayed excessively and quickly com-
pared with subjects with stable ankles. Swaying quickly is
associated with greater accelerations of the center of mass,
which was quantified in the GRF SD force plate measures.
Thus, greater A/P GRF SD and M/L GRF SD resulting from
greater GRF indicates that subjects with FAI had greater
center of mass accelerations than subjects with stable ankles.
We speculate that sensorimotor deficits associated with FAI
might have impaired subjects’ ability to control or to detect
changes in center of mass positions. Damaged articular, mus-
culotendinous, and cutaneous receptors associated with FAI
have been purported to disrupt sensorimotor function by di-
minishing messages related to ankle joint movement and po-
sition to afferent pathways (10,11,19). These deficits could
lead to reduced postural reflex responses and consequently
diminish stabilizing moments that are important in maintain-
ing balance. Additionally, sensorimotor deficits have been
implicated in causing subjects with FAI to balance closer to

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Copyright @ 2009 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
their limits of stability (18). Given this significant information,
we speculate that sensorimotor deficits associated with FAI
might have caused subjects’ center of mass to accelerate to
their limits of stability without adequate stabilizing moments.
Furthermore, sensorimotor impairments and strength de-
ficits associated with FAI might have also contributed to
increased time to stabilization values in subjects with FAI.
Evidence indicates that subjects with recurrent ankle sprains
have impaired sensorimotor reflexes during dynamic bal-
ance (25). Sufficient sensorimotor reflexes are essential for
controlling balance. Additionally, eccentric plantarflexion
strength deficits of the foot have been associated with FAI
(9). Eccentric strength of the plantarflexors is important in
energy absorption after landing; however, plantarflexors of
the foot have been underused in producing deceleration
moments after landing (32). On the basis of this informa-
tion, we hypothesize that subjects with FAI might have
underused potentially weak plantarflexors of the foot after
landing, impacting their ability to develop adequate decel-
eration moments to control their center of mass after land-
ing. Additionally, a delay in sensorimotor reflexes might
have decreased the time subjects with FAI had to develop
deceleration moments to stabilize the center of mass.
Consequently, muscle force requirements might have
increased to produce deceleration moments in very short
periods of time for subjects with FAI. Subjects with stable
ankles likely had adequate muscle force to develop ap-
propriate deceleration moments to stabilize their center of
mass and lower extremity very quickly. Subjects with FAI,
however, might have gone longer without adequate decel-
eration moments, consequently increasing stabilization
times. We did not directly measure moment generation
capabilities of ankle muscles in this study, and future re-
search should explore relationships between ankle moment
production, muscle activation, and time to stabilization to
confirm our contention.
We recommend that researchers use M/L GRF SD for
static single-leg balance and A/P time to stabilization for
dynamic single-leg balance to discriminate ankles with
functional instability and stable ankles. This recommenda-
tion is based on our results that indicate the M/L GRF
SD and the A/P time to stabilization had the greatest ac-
curacy scores of 0.73 and 0.72, respectively. Interestingly,
ES were greatest for the univariate F-tests of M/L GRF SD
(0.92) and A/P time to stabilization (0.80). Thus, these high
ES indicate that these measures distinguish between
ankle groups. These findings are not surprising, as Goldie
et al. (15) reported that the M/L GRF SD was a good
predictor of single-leg balance deficits, and M/L GRF SD
was greater in individuals with a history of inversion ankle
sprains than individuals with stable ankles (16). Addition-
ally, A/P time to stabilization has consistently detected
differences between ankles with functional instability and
stable ankles (4,26–28,39). Using these two force plate
measures might help researchers detect balance impairments
associated with FAI.
DISCRIMINATING UNSTABLE AND STABLE ANKLES
Copyright @ 2009 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Additional static force plate measures with slightly less
accuracy than M/L GRF SD might also be used to dis-
criminate between ankle groups. Fifteen percent (2/13)
and 23% (3/13) of our traditional COP sway measures had
AUC values classified as ‘‘fair’’ (AUC values Q0.70) and
‘‘poor’’ (AUC between 0.67 and 0.69) with statistically
significant asymptotic values, respectively. Although these
significant COP measures were not better than M/L GRF
SD at discriminating between ankle groups, the follow-
ing static force plates measures could be additional
measures included in single-leg balance assessments to
discriminate between ankles with functional instability and
stable ankles: 1) ‘‘fair’’ measures: A/P GRF SD, M/L total
COP excursion, and M/L mean COP velocity; and 2) ‘‘poor’’
measures: M/L mean COP excursion, A/P mean COP
velocity, and A/P maximum COP velocity. The remaining
62% of our static force plate measures with AUC values
less than or equal to 0.66 and asymptotic values greater than
0.05 should not be used to discriminate between ankle
groups.
Reasons for certain COP measures being inaccurate for
discriminating between ankle groups than other COP mea-
sures during static balance are not currently known. We
speculate that the dimensions of the foot may have negated
the effect of sensorimotor deficits associated with FAI on
static balance. The long A/P dimension of the base of sup-
port allowed subjects in both ankle groups to use long
excursion paths to maintain stability in the A/P direction.
Additionally, our data indicate that subjects in both groups
might have swayed excessively and very quickly in the
short M/L base of support at some point during single-leg
APPLIED SCIENCES
balance, causing maximum excursions and maximum
velocity measures to lack sensitivity in discriminating
between ankle groups.
A/P time to stabilization might have been more accurate
than M/L time to stabilization at discriminating between
ankle groups as a result of the anterior jump protocol
perturbing sagittal plane stability. Wikstrom et al. (40) re-
cently reported that a lateral jump protocol increased M/L
dynamic postural stability scores over an anterior jump
protocol in subjects with stable ankles. A lateral jump pro-
tocol might tax frontal plane postural control more than
an anterior jump protocol. We speculate, therefore, that a
lateral jump protocol might increase the accuracy of M/L
time to stabilization in discriminating between ankle
groups. Future research should explore the accuracy of
A/P and M/L time to stabilization measures in distinguish-
ing between ankle groups with lateral jump protocols.
We did not control for the type of athletic shoes worn in
our study. Subjects wore running and cross-trainer athletic
shoes. Differences in shoe support or soles could have
affected balance and introduced variability into our data.
Future research should explore the impact of different
athletic shoes on our static and dynamic balance tasks. An
additional limitation to our study was subject spectrum bias.
Balance deficits associated with FAI could be similar to
Medicine & Science in Sports & Exercised 405
 balance impairments associated with other ankle injuries. In
the first 3 wk after an ankle sprain injury, for example,
balance impairments have been present in subjects with
acute ankle sprains (8). Future research should examine the
accuracy of force plate measures in discriminating between
ankles with functional instability, stable ankles, and other
ankle pathologies.
CONCLUSION
The M/L GRF SD and the A/P time to stabilization
accurately discriminated between ankle groups. Our results
provide evidence for choosing M/L GRF SD and A/P time
to stabilization as primary force plate measures for
evaluating static and dynamic balance deficits associated
with FAI, respectively. Other noteworthy static force plate
measures that did not perform as well as M/L GRF SD and
A/P time to stabilization but still accurately discriminated
between ankle groups were as follows: A/P GRF SD, M/L
mean COP excursion, M/L total COP excursion, A/P mean
COP velocity, M/L mean COP velocity, and A/P maximum
COP velocity. Traditional COP and GRF force plate
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Medicine & Science in Sports & Exercised 407