Evaluation of Kinesthetic Deficits Indicative of
Balance Control in Gymnasts With Unilateral
Chronic Ankle Sprains
Donna Mulloy Forkin, MPT'
chris KOCZU~,M PT
Robert Battle, MS, MPT
Roberta A. Newton, PhD, PT4
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he central nervous sys
tem uses a dynamic com-
bination of sensory in-
puts from the vestibular,
somatosensory, and vi-
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
sual svstem to control balance. Infor-
mation from all three sensory sys-
tems, although somewhat redundant,
enables the central nervous system's
recognition and control of the body's
orientation in space, relative orienta-
tion of body segments, and relative
interaction of body center of gravity
and center of pressure (16). The cen-
Journal of Orthopaedic & Sports Physical Therapy®
tral nervous system varies the weight
assigned to each sensory input ac-
cording to initial conditions of the
individual and the environment. The
goal is central nervous system balance
control to maintain upright stance
(1,121.
When acuity of one sensory sys-
tem decreases due to disease or trau-
ma, the other sensory systems adjust
so the central nervous system receives
sufficient information to make appro-
priate motor responses to maintain
balance (16). The degree of compen-
sation by the other sensory systems is
dependent upon many factors, in-
cluding the individual's capability for
learning.
The present study evaluates one
of the sensory system's contributions
to balance abilities, proprioception.
Ankle injuries are common in sports
JOSPT Volome 23 Number 4 April 1996
If ankle proprioception can be determined to be impaired, then treatment can be more
specifically directed toward correcting the proprioceptive deficit, thereby improving functional
ability. The purpose of this study was to determine if collegiate level gymnasts with unilateral,
multiple ankle sprains (ie., chronic ankle sprains) had decreased ability to detect passive plantar
flexion of the ankle (ie., decreased ankle proprioception) and to determine if balance deficits existed
during one-legged stance. Eleven gymnasts participated in 30 passive movement trials (15 movement
and 15 nonmovement) presented randomly on both the injured and noninjured sides. The nonmove-
ment trials consisted of either no movement of the ankle or passive movement of the ankle into of
plantar flexion. Luce's choice theory determined that subjects were not biased in responding to a
"yes" in perceiving movement or no movement during the movement/nonmovement trials of passive
plantar flexion. Subjects were better able to detect movement during movement trials with their
uninjured ankles than their injured ankles. Subjects also performed single 30-second trials of one-
legged standing on each leg, with eyes open and with eyes closed. Subjects reported better balance
when standing on the uninjured ankle during the one-legged stance conditions. Although our results
cannot be extrapolated to balance abilities during complex gymnastic routines, they do suggest that
physical therapy assessment includes passive detection of joint position as well as single-legged
stance tests, and that perhaps rehabilitation programs incorporate sports-specific balance activities for
such injuries.
Key Words: proprioception, balance, ankle sprains, gymnasts
' Senior Physical Therapist, Frankford Hospital, Philadelphia, PA
Senior Physical Therapist, Thomas jefferson University Hospitals, Philadelphia, PA
' Director, Maryview Health Care Center at Chesapeake, Chesapeake, VA
Associate Professor, Department of Physical Therapy, College of Allied Health Professions, Temple University,
3307 North Broad, Philadelphia, PA 19140
and account for approximately 85% sprains was the result of partial deaf-
of all ankle injuries. In sports-specific ferentation occurring at the time of
studies, injuries occurring at the an- injury (5). Several investigators have
kle account for 17% of all injuries for examined the effects of ankle insta-
college-level gymnasts (19). These bility on balance abilities (2,6,7,1l ,l3,
athletes frequently develop a pattern 14,17,18).
of recurring ankle sprains, which may Tropp et al used stabiliometry to
result in an unstable ankle and po- measure postural control of male soc-
tentially decreased balance ability. cer players with recently sprained an-
Freeman et al postulated that insta- kles (18). Subjects stood one-legged
bility of the ankle joint following on force plates for 60 seconds, while
 RESEARCH STUDY
focusing on a light source. Subjects
performed one-legged standing on
the injured leg and uninjured leg.
No significant difference in stabilom-
etry recordings occurred between the
injured and uninjured ankle. They
concluded that trauma to the ankle
joint did not produce functional in-
stability of the ankle as measured by
stabiliometry.
Garn and Newton tested athletes
with multiple unilateral ankle sprains
(6). Injured and uninjured ankles
were tested by the subject's ability to
perform a one-legged balance test
with eyes closed and the ability to
detect passive plantar flexion. A kin-
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esthesiometer was used to move the
ankles to 5" of plantar flexion in a
15second period. Subjects showed
significantly less ability to detect pas-
sive plantar flexion in their injured
ankles than in their uninjured ankles.
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Thirteen of the 30 subjects stated
that they were more unstable when
standing on the injured ankle during
the one-legged balance test. Gross
also tested individuals with multiple
unilateral ankle sprains (11). The
subjects' ankles were secured in an
isokinetic dynamometer, allowing
only inversion and eversion to occur.
Journal of Orthopaedic & Sports Physical Therapy®
The ankle was placed in the test posi-
tion, then passively moved to both
ends of the range of motion. Subjects
actively tried to duplicate the original
start position. Gross found no signifi-
cant difference (two-way analysis of
variance, p < .01) in replication of
ankle joint position between injured
and uninjured ankles. He concluded
that ankle sprains have no significant
effect on an individual's ability to
judge ankle position. In both studies
(6,18), subjects had no edema or
joint pain at the time of testing.
Lentell et al studied individuals
with chronically unstable ankles (14).
They found no significant differences
in muscle strength between subjects'
injured and uninjured ankles. They
concluded that muscular weakness, as
measured by isokinetic peak torque
values, is not a primary factor in
chronically unstable ankles. These
researchers speculated that ankle in-
stability is due to chronic laxity of the
ankle ligaments and joint capsules
and from proprioceptive deficit$.
Soderberg et al also suggest that mus-
cle weakness is not a cause of ankle
instability (17). They found no differ-
ence in electromyographic activity
levels and rate of board rotation be-
tween normal and chronically
sprained ankles when subjects per-
formed on an ankle disk. Muscle
weakness may not be a contributory
factor to ankle instability, but muscle
control may be an important factor.
Konradsen and Ravn observed a de-
lay in onset of the peroneal muscle
activation to sudden ankle inversion
(IS), and Bnmt et al observed similar
delay in the tibialis anterior muscle
following linear perturbation (2).
Their results could be used to s u p
port Freedman's theory that ankle
instability results from alteration of
sensory input about the ankle,
thereby affecting proprioceptive re-
flexes and other motor control mech-
anisms about the ankle.
In summary, balance instability
following recurrent ankle injuries
may not be due to a single factor but
to the disruption between the neuro-
logic and biomechanical factors at
the ankle joint. Loss of balance may
result from inaccurate or altered sen-
sory information from the ankle
joint, control about the ankle, or al-
terations of the biomechanical align-
ment of the body resulting from re-
current ankle in-juries.
One purpose of our study was to
determine if active collegiate level
gymnasts with a history of unilateral,
multiple ankle sprains had decreased
kinesthetic ability to detect passive
plantar flexion motion in injured an-
kle joints compared with the unin-
jured side. The second purpose of
our study was to determine if these
individuals show balance deficits dur-
ing one-legged standing on the in-
jured ankle.
Two directional hypothesis
guided the study: I) multiple injuries
to the lateral ankle structures of ac-
tive collegiate level gymnasts result in
a significantly reduced kinesthetic
ability as indicated by responses to
detection of passive plantar flexion
motion; and 2) collegiate level gym-
nasts with unilateral, multiple ankle
sprains demonstrate significant reduc-
tion of balance as indicated by per-
formance of a one-legged standing
balance task on the in.jured ankle.
METHOD
Subjects
Two male and nine female gym-
nasts from high schools and colleges
in the greater Philadelphia, PA area
participated in this study. Gymnasts
ranged -in age between 16 and 22
years (X = 19.1 2 1.8) years. Inclu-
sion criteria included: 1) a history of
sustaining more than one sprain to
the lateral ligaments of one ankle,
1-12 months prior to testing, 2) no
signs of pain or effusion in either
lower extremity at the time of testing,
3) no neurologic or otologic in-jury or
disease, and 4) no current or history
of musculoskeletal injuries to the
back or contralateral lower extremity.
Twenty-one volunteers were
screened and 10 were excluded from
the study. Due to the difficulty in
finding subject5 with unilateral ankle
sprains, the criteria were modified to
include subject5 with prior contralat-
era1 ankle sprains of at least 2 years
prior to the date of testing. Eight
subjects had unilateral ankle sprains
and three had bilateral ankle sprains.
All subjects signed informed consent
forms. The study was approved by the
Institutional Review Board of Temple
University, Philadelphia, PA.
Apparatus
A kinesthesiometer used by Garn
and Newton was used to measure
perception of passive movement at
the ankle joint (Figure) (6). The kin-
esthesiometer consists of a support
base, a hinged foot plate, and a han-
dle. One end of the foot plate is at-
Volume 23 Number 4 April 1W6 JOSFT

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FIGURE. Kinesthesiometer. The subject laces the ankle on the foot plate that is attached to the handle. The foot
plate in the photo is in 5" of plantar fleiion.
tached to the support base by a
hinge. The foot plate can be lowered
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
by turning the handle, thereby pro-
ducing plantar flexion. A scale with
15 demarcations, each representing
1 second, is attached to the surface
of the foot plate around the handle.
The scale provides visual feedback to
the operator to ensure that the foot
plate is moved at a steady velocity.
For this study, the plate was moved
Journal of Orthopaedic & Sports Physical Therapy®
5" during each l h e c o n d trial. The
tester also used a metronome beat,
heard through earphones, to pace
the foot plate movement. Prior to the
study, the tester (DM) practiced,
then tested four subjects to ensure
that movement of the foot plate was
consistent. Each subject was tested,
then retested following a short rest
period. Intratester reliability was 0.99
(Pearson product moment correla-
tion coefficient, p < .001).
Procedure
Passive plantar flPmon test Each
subject was tested barefoot. The s u b
ject sat on a chair with a back rest,
and the height of the chair was ad-
justed so that the subject's hips and
knees were flexed to 90". Test order
was randomly determined between
the injured and uninjured ankles.
JOSPT Volume 23 Number 4 April 1996
The tested ankle was placed lightly
on the foot plate of the kinesthesiom-
eter in a neutral position. The poste-
rior aspect of the heel was aligned
directly over the hinge of the kines-
thesiometer. To decrease extraneous
cues that could help the subject iden-
tify passive movement, the foot/ankle
was not stabilized on the platform
nor did the tester touch the foot dur-
ing the entire testing procedure. A
curtain was placed in front of the
subject to block the view of the foot
plate and the tester.
Thirty test trials, each 15 seconds
in length with 10-second intervals
between trials, were given. Half of
the trials produced movement of the
ankle; the other half did not produce
movement. Movement and nonmove-
ment trials were sequenced ran-
domly. When the 30 trials were con-
cluded, the other ankle was tested in
the same manner.
During each 15second move-
ment trial, the foot plate of the kines-
thesiometer passively moved the an-
kle into 5" of plantar flexion. During
the 15-second nonmovement trials,
the foot plate was not moved. After
each 15-second trial, subjects were
requested to state "yes" if ankle move-
ment was perceived and "no" if
ankle movement was not perceived.
RESEARCH
.-.- - .. - - -S T U
.-
DY
Responses were recorded and the
foot plate was returned to the start
position.
Olu~legqrdbalance task The one-
legged balance task was used instead
of stabiliometry because of the cost
of the equipment and such equip
ment may not be available in the
clinical setting. The leg tested first
was randomly selected. The contralat-
era1 hip was oriented in neutral posi-
tion with the knee flexed to 90". The
subject then stood on one leg with
eyes open for 30 seconds. The s u b
ject then repeated this condition on
the opposite leg. The same task was
then repeated on each leg, but with
eyes closed. After each ta..k, subjects
were asked, "On which side did you
perceive better balance?" and their
responses were recorded. In addition,
two observers recorded indepen-
dently which side, if any, demon-
strated better balance. The indepen-
dent observers were "blind" to the
side of injury. The criteria used by
the two observers to compare balance
abilities between the injured and un-
injured leg were: 1) number of times
the elevated foot contacted the floor,
and 2) relative degree of trunk and
upper limb motion needed to main-
tain balance. Relative degree of trunk
and upper limb motion was deter-
mined by frequency counts of how
often trunk flexion/extension was
used and the position of the arms
(low or high guard). Intertester reli-
ability was assessed using Pearson
product correlation coefficients to
ensure the consistency of replies be-
tween observers. The Pearson r value
was .99 (p < .001).
Data Reduction and Analysis
Passive plantarj&?xiontest Data
from the passive plantar flexion test
were composed of "yes" and "no" re-
sponses given by the subjects during
the 30 movement or nonmovement
trials (Table). Frequency of responses
was determined for: I ) the number of
correct "yes" statements and the
 Uninjured Ankle
Movement No Movement
Y N Y N
Total 158 7 165
Uninjured ankle = 12nklc spr'1ins hme not hccn sust'lincd on this anklc.
lnjured ankle = Ankle sustaining multiple ankle sprains.
Movement = Trials where the kinesthesiometer was moved into passive plantar flexion.
No movement = Trials where the kinesthesiometer was not moved.
Y = Subjects' response that movement occurred iollowing the trial.
N = Subjects' response that movement did not occur following the trial.
Total = Total number of subjects' responses.
TABLE. Subjects' responses to passive plantar flexion trials.
number of incorrect "no" statements
made when movement occurred; and
2) the number of incorrect "yes"
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statements and the number of cor-
rect "no" statements made when no
movement occurred.
To determine if a subject was
biased in his/her answer, Luce's
choice theory measurements of hit
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
rate, false alarm rate, sensitivity, and
response bias were calculated (15).
Luce's definitions and calculations
for each of these factors are de-
scribed below. Hit rate is the number
of trials the subject correctly re-
sponds "yes" to in perceiving passive
movement of the foot divided by the
total number of movement trials (15
Journal of Orthopaedic & Sports Physical Therapy®
trials). False alarm rate is the number
of trials the subject incorrectly re-
sponds "yes" to no movement of the
foot divided by the total number of
nonmovement trials (15 trials). A
sign test was performed to determine
if the hit rate was significantly differ-
ent between injured and uninjured
ankles and whether false alarm rate
values for injured and uninjured an-
kles were significantly different (4).
Sensitivity and response bias of
the subject's responses were deter-
mined. Sensitivity, as defined by
Luce, measures the subject's accuracy
in making correct responses and
avoiding incorrect responses, ie., cor-
rectly responding "yes" to movement
trials and correctly responding "no"
to nonmovement trials. Sensitivity was
determined by the following formula:
S= [FAR(l - HR)]""(HR)(I - FAR),
Injured Ankle
Movement No Movement
Y N Y N
0 143 22 163 2 and the eyes closed asks and were
where S = sensitivity, FAR= false
alarm rate, and HR = hit rate.
Sensitivity will equal zero if either
the FAR or HR is perfect. The sensi-
tivity product equals zero when a s u h
ject is able to correctly identify all
passive movement and/or nonmove-
ment trials.
Response bias is a measure of the
subject's preference for one response,
regardless of the correct response.
The calculation for response bias is:
where b = response bias, HR = hit
rate, and FAR= false alarm rate.
We used the limits of 1 and 0 for
FAR and HR, respectively, and we
assumed that 1 - FAR = HR and 1
- HR = FAR. The response bias
equation is unsolvable when the HR
or FAR and HR are at their limits. In
this case, we assume that b = 1, ie.,
then b = (1 - 0)(1 - 1)"~/(0)(1)
If the subject preferred the "yes"
or the "no" response, then b < 1 or
b > 1, respectively. If the subject had
no preference for either response,
then b = 1. Sensitivity and response
bias data were analyzed by a two-
tailed t test.
Onp-bgpd stnnrp t a t The second
portion of the data consisted of re-
sponses made by the subject and two
independent observers for which side
demonstrated better balance during
the one-legged balance task. Both the
observers and subjects' responses of
"injured," "uninjured," or "neither"
were obtained after the eyes open
analyzed using frequency counts.
RESULTS
There was a significant difference
in the hit rate between injured and
uninjured ankles using the sign test.
This means that subjects were better
at detecting movement during move-
ment trials of their uninjured ankles
(158/165) than their injured ankles
(143/165). The subjects' ability to
detect no movement during non-
movement trials did not differ signifi-
cantly between the in-jured (l63/ 165)
and uninjured ankles (165/165). The
standard deviation of the false alarm
rate among the injured and unin-
jured ankles was .012 and 0, respec-
tively. The twetailed t test analysis of
sensitivity and response bias indicated
no significant difference between the
injured and uninjured ankles.
During single-legged stance with
eyes opened, nine of 11 subjects per-
ceived balance to be better on the
uninjured ankle, while the remaining
two subjects perceived balance to be
better on the in-jured ankle. The o h
servers rated balance on the unin-
jured leg and judged balance as fol-
lows.
Balance was judged to be better
on the uninjured ankle in four of the
11 subjects by the first observer and
in five of the 11 subjects by the sec-
ond observer. Balance was judged to
be better on the in-jured leg in one
of the 11 subjects by both observers.
Balance was judged to be equal bilat-
erally in six subjects by the first o h
server and in five subjects by the sec-
ond observer.
During single-legged stance with
eyes closed, nine of 11 subjects per-
ceived balance to be better on the
uninjured ankle and one subject per-
ceived his balance was equal bilater-
ally. The remaining subject perceived
Volume 23 Number 4 April 1996 JOSFT

balance to be better when standing
on the injured ankle.
The two independent observers
judged balance ability to be better on
the uninjured ankle in seven of the
11 subjects. The other four subjects
were judged to have better balance
when standing on the injured ankle.
The two observers did not judge any
subjects to have equal balance abili-
ties bilaterally during the eyes closed
condition of the task.
DISCUSSION
The gymnasts' ability to sense
movement during passive ankle mo-
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tion (hit rate) was significantly dimin-
ished on the injured side (142/165)
compared with the uninjured side
(158/ 165). These results support our
first hypothesis that multiple injuries
to the lateral ankle structures of ac-
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tive collegiate level gymnasts result in
significantly reduced kinesthetic abil-
ity. These results also support Garn
and Newton who demonstrated a sig-
nificant decrease in ability of athletes
to detect passive motion in injured
ankles (428/450) compared with the
uninjured ankles (445/450) (6). In
addition, our results of the one-
Journal of Orthopaedic & Sports Physical Therapy®
legged standing balance task are simi-
lar to those of Garn and Newton. In
our study, the independent observers
judged that 63% (7/11) of subjects
displayed a balance deficit during
standing on the injured ankle and
with eyes closed. In the Garn and
Newton study, an independent o b
server judged that 53% of SO subjects
displayed a balance deficit when
standing on the injured ankle. In
Freeman et al's study, 34% of 84 s u b
jects were observed to display a bal-
ance deficit when standing on the
injured ankle (5). The results need
to be interpreted in light of the type
of athlete and mechanism of injury.
We limited our sample to one group
of athletes, gymnasts, and did not
explore the influence of mechanism
of injury on detection of passive plan-
tar flexion or single-legged standing
abilities.
JOSF'T Volume 23 Number 4 April 1996
The degree of
compensation by the
were able to actively compete in gym-
other sensory systems
is dependent upon
many factors,
including the
individual's capabiMy
with decreased somatosensory input
for learning.
Our study does not refute Free-
man et al's postulate that partial
deafferentation may occur at the
time of an ankle injury and may
cause a proprioceptive deficit and
subsequent balance instability at the
ankle joint. The lower percentage of
proprioceptive deficits noted in Free-
man et al's study may be due to the
following: 1) Freeman et al's sample
had a history of only one ankle
Ankle instability may also be due to
sprain rather than multiple ankle
sprains, and 2) subjects were tested
weakness, bony malalignment, and
shortly after incurring the injury.
joint adhesions. The present study
Therefore, Freeman et al's sample
was not representative of chronic an-
kle sprains. Garn and Newton's study
and our study tested people with
multiple unilateral ankle sprains;
however, they tested subjects 1-60
months postinjury. This may have
allowed more recovery time, thus a
lower incidence of balance deficits
presented. The gymnasts in our study
were tested 1-1 2 months postinjury.
Tropp et al's stabilometric find-
ings do not support Freeman et al's
deafferentation theory. Subjects did
not differ in unilateral stance abilities
on the injured vs. the uninjured an-
kles. Tropp et al's subjects were simi-
lar to Freeman et al's in that both
had acute ankle sprains when tested
(18). Because visual feedback was not
excluded during the unilateral stance
task, visual compensation may have
obscured any proprioceptive deficits.
Although the gymnasts in our
study showed a decreased ability to
- R E- S E A R C H S T U D Y
detect passive movement and main-
tain balance during one-legged stand-
ing on the injured ankle as com-
pared with the uninjured ankle, they
nastic routines. Gymnasts may be
able to compensate for some of the
somatosensory deficits of an injured
ankle by relying on somatosensory
inputs of other limb segments as well
as other sensory input from visual
and vestibular systems. Individuals
are often able to execute a balance
response despite this insufficient sen-
sory input. Gymnaqts, by the nature
of their sport, learn to balance under
different conditions and this learning
effect may enable them to resume
training shortly after an ankle injury.
Partial deafferentation is a plausi-
ble notion to explain the decreased
ability to detect passive plantar flex-
ion, but it may not be the only factor
contributing to instability at the an-
kle during standing balance activities.
ligamentous instability, muscular
cannot differentiate if a decreased
balance ability, associated with
chronic ankle sprains, is due to a de-
crease in proprioceptive input or due
to other musculoskeletal conditions
since the focus was static balance abil-
ities and passive joint motion detec-
tion. In addition, studies examining
postural control mechanisms about
the ankle (S,9,10) and compensatory
postural control effects following an-
kle injury are needed. Gauffin et al
noted that individuals with unilateral
anterior cruciate injuries had bilat-
eral postural alterations (8). An ex-
tension of this present study is to ex-
amine postural control about the
pelvis in individuals with unilateral
chronic ankle sprains. The underly-
ing premise is that sensory deficits at
a single joint influences interlimb
and trunk postural control.
Gymnasts use both static and dy-
namic balance abilities in their daily
 . - - -
Partial deaHerentation
is a plausible notion to
explain the decreased
ability to detect
passive plantar flexion,
but it may not be the
only factor
contributing to
instability at the ankle
during standing
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balance activities.
routines. Therefore, our results on
the static one-legged balance test may
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
not be reflective of dynamic balance
abilities performed routinely by gym-
nasts. Winstein has determined that
static balance tasks are not represen-
tative of dynamic balance tasks (20).
Assessments of balance abilities,
therefore, should be performed in
the context in which the subject will
be using those abilities. Winstein
Journal of Orthopaedic & Sports Physical Therapy®
found that balance abilities are task
specific; thus, female gymnasts should
be tested using balance beam activi-
ties or other activities specific to their
training. For example, videotaping
each gymnasts' performance may
help identify those movement pat-
terns affected by decreased balance
abilities. This information might be
~ l identifying gymnasts who
u s e f ~ for
are at risk for recurrent ankle
sprains. In addition, it is recom-
mended that rehabilitation programs
for athletes include balance training
(7) and, more specifically for gym-
nasts, balance rehabilitation pro-
grams that incorporate elements of
their gymnastic routines.
CONCLUSION
Balance and kinesthetic deficits
are common in gymnasts who have
sustained multiple ankle sprains. S u b
jects in this study demonstrated a
higher incidence of balance and kin-
esthetic deficits in their injured leg
than in the uninjured leg as mea-
sured by the one-legged standing bal-
ance task and passive plantar flexion
test, respectively. The results of this
study and those of Garn and Newton
(6) suggest the need for clinicians to
assess balance and kinesthetic deficits
in patients who sustain one or more
ankle sprains. Such information, in
conjunction with clinical data, can
provide clinicians with additional
clinical insight for classifying or cate-
gorizing impaired posture and/or
movement conditions with a focus on
causal elements. Then treatment can
be more specifically focused on allevi-
ating the cause of the condition
rather than being generally directed
toward treatment of signs and symp
toms. IOSPT
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