March 2026

When Balance is Not Enough, Rethinking Chronic Ankle Instability Rehabilitation

Rehabilitation strategies for lateral ankle sprains (LAS) and chronic ankle instability (CAI) have remained relatively consistent for decades. LAS intervention strategies for early-phase rehabilitation outcomes, such as range of motion, strength, and balance, are effective.^1,2 However, despite the efficacy of these strategies, athletes remain at an elevated risk for reinjury following return to sport, with a substantial proportion of LAS injuries progressing to CAI.^3,4 CAI is associated with long-term ankle joint degeneration and contributes meaningfully to the burden of post-traumatic osteoarthritis.⁵

For athletic trainers, the critical concern in managing LAS is not whether early rehabilitation “works”, but whether it adequately prevents progression to CAI and prepares the athlete for the sensory, neuromuscular, and mechanical demands of sport. The persistent gap between successful rehabilitation and elevated risk of reinjury likely reflects limitations in traditional training paradigms rather than a deficiency in care. Altered sensory organization strategies and the limited integration of hop-stabilization tasks are increasingly recognized as contributing factors.^6-8 Evidence demonstrates that augmenting balance training with visual input manipulation can restore more appropriate sensory organization and produce greater improvements in postural control than traditional balance training alone.^9-13 Similarly, repeated hopping tasks (e.g., hop stabilization, plyometric pogos) have been shown to improve a range of neuromuscular outcomes in individuals with CAI.^14-17

"Effects of balance training with stroboscopic glasses on postural control in chronic ankle instability patients." Hyunwook Lee, Seunguk Han, Garritt Page, Dustin A. Bruening, Matthew K. Seeley, J. Ty Hopkins

This randomized controlled trial demonstrated that adding stroboscopic glasses to a 4-week supervised balance program (3×/week, 12-20 min/sessions) produced greater improvements in postural control than balance training alone in patients with CAI. Refining your practice: Use stroboscopic glasses as a progression to reduce visual reliance and improve medial-lateral stability, adding them during mid- to late-rehabilitation phases, after athletes demonstrate good landing mechanics.

Visual Disruption

“The Effect of Balance Training with Stroboscopic Glasses on Postural Stability and Activity Level in Patients: A Meta-Analysis.” Oguzhan Bahadir Demir et al., 2025

Individuals with CAI demonstrate increased reliance on visual information during single-limb balance tasks. Sensory reweighting, the automatic process by which the central nervous system adjusts the relative contribution of visual, vestibular, and somatosensory inputs, occurs when sensory input is altered, prompting increased reliance on alternative inputs. For example, during single-limb stance or landing tasks performed with intermittent visual occlusion, reduced visual feedback forces the nervous system to upregulate proprioceptive and vestibular input to maintain stability. Over repeated exposure, this results in reduced visual dependence and improved integration of non-visual sensory information. Consequently, stroboscopic balance training improves both static postural control (single-limb stability) and dynamic postural control (e.g., landing mechanics). Refining your practice: stroboscopic glasses, used as a sensorimotor progression tool, are supported by Level I evidence as an effective method for improving postural stability in individuals with CAI and other neurologic conditions.

“The Effects of Augmenting Balance Training with Stroboscopic Goggles on Postural Control in Chronic Ankle Instability Patients: A Critically Appraised Topic.” Josh Mohess et al., 2024

Individuals with CAI often undergo balance training, but residual instability suggests traditional protocols may lack key components. Evidence from three studies indicates that adding stroboscopic goggles during balance exercises can yield greater improvements in certain static and dynamic postural control measures than balance training alone.

“Balance Training With Stroboscopic Glasses and Neuromechanics in Patients With Chronic Ankle Instability During a Single-Legged Drop Landing.” Hyunwook Le et al., 2024

Balance training with stroboscopic glasses in individuals with CAI led to significant improvement in landing neuromechanics, including increased ankle dorsiflexion and eversion angles and greater activation of the tibialis anterior and peroneus longus muscles. These adaptations occurred during critical phases of a single-legged drop landing, suggesting improved dynamic stability and safer landing mechanics. Refining your practice: If CAI rehabilitation improves balance but the athlete still lands stiff or risky, “Add stroboscopic glasses during hop-to-stabilization and single-leg balance progressions in mid-to-late rehab, aiming to improve pre-landing positioning (eversion) and early landing absorption (dorsiflexion) plus peroneal/tibialis anterior timing.”

“Short-Term Effects of Balance Training with Stroboscopic Vision for Patients with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial.” Kyung-Min Kim et al., 2021.

A single-blinded randomized controlled trial examined the short-term effects of balance training with stroboscopic vision in 73 individuals with chronic ankle instability (mean age 29.8 ± 10.0 years; 48% male, 52% female). Outcome measures included dynamic balance (Star Excursion Balance Test (SEBT)), ankle dorsiflexion (Weight-Bearing Lunge Test (WBLT)), and self-reported measures of ankle instability and function. Compared with traditional balance training alone, the addition of stroboscopic vision resulted in greater improvements in anterior SEBT reach distance and greater reductions in self-reported ankle instability. Refining your practice: When Phase I–II rehabilitation goals (range of motion, strength, basic balance) are met, but deficits persist in dynamic postural control or patient-reported stability, stroboscopic vision can be introduced during progressively challenging balance and neuromuscular training.

Hop Stabilization

“Hop Stabilization Training Improves Functional Movement Patterns and Quality of Life in Female Athletes With Chronic Ankle Instability.” Lale Pooryamanesh et al., 2025

A 6-week hop stabilization program significantly improved ankle dorsiflexion, functional movement patterns, and patient-reported outcomes in female athletes with CAI compared to controls. These improvements were consistent with prior findings in male cohorts, though females demonstrated larger effect sizes. Repeated hopping exercises are an effective intervention for enhancing mobility and functional performance in female athletes with CAI. Refining your practice: Repeated hop-stabilization training is a high-yield neuromuscular intervention that has been shown to improve mobility, movement quality, and perceived function in athletes with chronic ankle instability. Clinicians should incorporate hopping into early-to-mid rehabilitation to teach control rather than to express power. What hop-stabilization is: low-amplitude, high-intent land-and-stabilize tasks, with emphasis on preparatory and reactive muscle activation while coaching load acceptance and control, not maximal explosiveness.

“Effect of Hop-Stabilization Training on Ankle Instability and Function of Adolescent Female Basketball Players with Chronic Ankle Instability: A Double-Blind, Prospective, Cluster-Randomized Controlled Trial.” Han-Soo Park et al., 2025

A double-blind, prospective, cluster-randomized controlled trial examined the effects of a 6-week hop-stabilization program in adolescent female basketball players with chronic ankle instability. Objective outcome measures included dynamic performance testing and ankle strength, while self-reported ankle stability and balance were assessed using validated questionnaires. Both the hop-stabilization and traditional balance training groups demonstrated improvements in self-reported ankle stability and balance. However, the hop-stabilization group showed significantly greater gains in dynamic performance and in dorsiflexion and eversion strength compared with balance training alone. Refining your practice: In adolescent female basketball players with CAI, hop-stabilization training is more effective than balance training for improving objectively measured dynamic performance and ankle strength.

These Free Communications emphasize a crucial clinical distinction: while altering sensory input can change movement behavior, change itself does not necessarily imply improvement. For example, interventions such as visual perturbation and gait feedback can elicit short-term shifts in balance strategy, or blood flow restriction (BFR) training during balance tasks can impair performance. None of these methods establishes lasting functional gains. These findings highlight the importance of prioritizing higher-intent neuromuscular retraining, such as repeated hopping and visually constrained tasks, which require athletes to organize, time, and manage load in ways that are directly applicable to their sport.

“Effects of Blood Flow Restriction on Performance During Balance Exercises in Individuals With Chronic Ankle Instability” Clark et al., page S-36. Modified Star Excursion Balance Training reach distances were decreased while incorporating BFR compared to no BFR.

“Feasibility of a Short Real-World Gait Retraining Program on Biomechanics for Chronic Ankle Instability” Migel et al., page 601. A two-week vibration-based feedback gait retraining intervention can alter the center of pressure during walking.

“Continuous Visual Perturbations Alter Walking Balance in those with Chronic Ankle Instability” Uzlasir et al., page 616. CAI participants showed altered foot placement after a 10-minute intervention incorporating continuous mediolateral visual perturbations, suggesting a shift in balance strategy and possible sensory reweighting.

Podcasts:

Videos with hop stabilization exercise examples:

References in Introduction

1. Yang YS, Lai PC, Liu ZW, et al. What will deliver the best bang-for-your-treatment-buck? Treatment effects of physical therapy approaches to managing chronic ankle instability: A network meta-analysis of randomized controlled trials. J Orthop Sports Phys Ther. 2025;55(1):26-44.

2. Tsikopoulos K, Mavridis D, Georgiannos D, Cain MS. Efficacy of non-surgical interventions on dynamic balance in patients with ankle instability: A network meta-analysis. J Sci Med Sport. 2018;21(9):873-879.

3. Wikstrom EA, Cain MS, Chandran A, et al. Lateral ankle sprain and subsequent ankle sprain risk: A systematic review. J Athl Train. 2021;56(6):578-585.

4. Herzog MM, Mack CD, Dreyer NA, et al. Ankle sprains in the National Basketball Association, 2013-2014 through 2016-2017. Am J Sports Med. 2019;47(11):2651-2658.

5. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006;20(10):739-744.

6. Song K, Franz JR, Wikstrom EA. Optical flow balance perturbations alter gait kinematics and variability in chronic ankle instability patients. Gait Posture. 2022;92:271-276.

7. Sugimoto YA, McKeon PO, Rhea CK, et al. Sensory reweighting system differences on vestibular feedback with increased task constraints in individuals with and without chronic ankle instability. J Athl Train. 2024;59(7):713-723.

8. Song K, Burcal CJ, Hertel J, Wikstrom EA. Increased visual use in chronic ankle instability: A meta-analysis. Med Sci Sports Exerc. 2016;48(10):2046-2056.

9. Demir OB, Bilgin A. The effect of balance training with stroboscopic glasses on postural stability and activity level in patients: a meta-analysis. Afr Health Sci. 2025;25(3):184-195.

10. Mohess JS, Lee H, Uzlaşir S, Wikstrom EA. The effects of augmenting balance training with stroboscopic goggles on postural control in chronic ankle instability patients: A critically appraised topic. J Sport Rehabil. 2024;33(6):467-472.

11. Lee H, Han S, Hopkins JT. Balance training with stroboscopic glasses and neuromechanics in patients with chronic ankle instability during a single-legged drop landing. J Athl Train. 2024;59(6):633-640.

12. Lee H, Han S, Page G, Bruening DA, Seeley MK, Hopkins JT. Effects of balance training with stroboscopic glasses on postural control in chronic ankle instability patients. Scand J Med Sci Sports. 2022;32(3):576-587.

13. Kim KM, Estudillo-Martínez MD, Castellote-Caballero Y, Estepa-Gallego A, Cruz-Díaz D. Short-term effects of balance training with stroboscopic vision for patients with chronic ankle instability: A single-blinded randomized controlled trial. Int J Environ Res Public Health. 2021;18(10):5364.

14. Minoonejad H, Karimizadeh Ardakani M, Rajabi R, Wikstrom EA, Sharifnezhad A. Hop stabilization training improves neuromuscular control in college basketball players with chronic ankle instability: A randomized controlled trial. J Sport Rehabil. 2019;28(6):576-583.

15. Ardakani MK, Wikstrom EA, Minoonejad H, Rajabi R, Sharifnezhad A. Hop-stabilization training and landing biomechanics in athletes with chronic ankle instability: A randomized controlled trial. J Athl Train. 2019;54(12):1296-1303.

16. Pooryamanesh L, Hovanloo F, Wikstrom EA. Hop stabilization training improves functional movement patterns and quality of life in female athletes with chronic ankle instability. J Sport Rehabil. 2025;34(8):824-830.

17. Park HS, Oh JK, Hong YI, Kim JY, Yoon JH. Effect of hop-stabilization training on ankle instability and function of adolescent female basketball players with chronic ankle instability: A double-blind, prospective, cluster-randomized controlled trial. J Clin Med. 2025;14(10):3502.

This content was developed in part by Erik Wikstrom, PhD, ATC, LAT; Lisa Custer, PhD, ATC; Christina L. Fanning, DAT, LAT, ATC; and the NATA Foundation Educational Resources Committee.

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