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Is chronic ankle instability associated with impaired muscle strength? Ankle, knee and hip muscle strength in individuals with chronic ankle instability: a systematic review with meta-analysis
  1. Nafiseh Khalaj1,
  2. Bill Vicenzino1,
  3. Luke James Heales2,3,
  4. Michelle D Smith1
  1. 1 School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
  2. 2 Health and Exercise Science, Central Queensland University, Rockhampton, Queensland, Australia
  3. 3 School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
  1. Correspondence to Dr Michelle D Smith, University of Queensland, Brisbane, QLD 4072, Australia; m.smith5{at}


Objective Determine whether impairments in lower limb muscle strength exist in individuals with chronic ankle instability (CAI) compared with uninjured controls.

Design Systematic review with meta-analysis.

Data source A comprehensive search of PubMed, Cochrane, CINAHL, Web of Science and EMBASE electronic databases from inception to 10 February 2019.

Eligibility criteria for selecting studies Cross-sectional and case–control studies were included if they objectively measured lower limb muscle strength in individuals with CAI compared with controls. Risk of bias and quality of included studies were assessed. Data of included studies were extracted, and meta-analysis was conducted where appropriate.

Results 12 397 unique studies were identified, of which 20 were included and 16 were eligible for meta-analysis. Reviewed studies clearly described the aim/hypothesis and main outcome measure, but most lacked sample size calculation and assessor blinding. Meta-analyses showed individuals with CAI had lower eccentric and concentric evertor strength (30 and 120°/s; Nm; standardised mean difference (SMD) between −0.73 and −0.95), eccentric invertor strength (60 and 120°/s; both Nm and Nm/kg; SMD between −0.61 and −1.37), concentric invertor strength (60 and 120°/s; Nm; SMD=−0.7) and concentric knee extensor strength (SMD=−0.64) compared with control participants. Ankle eccentric dorsiflexor strength was not different between groups. Although pooling was not possible, data from three separate studies indicated that hip flexor, abductor and external rotator strength, but not hip adductor and extensor strength, was lower in individuals with CAI than in control participants.

Conclusion Individuals with CAI have ankle inversion and eversion strength deficits. Our data also point to differences between individuals with CAI and controls in hip and knee strength. These elements of the kinetic chain should be evaluated by clinicians who rehabilitate individuals with CAI.

PROSPERO registration number CRD42016037759.

  • strength
  • ankle
  • sprain

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  • Twitter @Bill_Vicenzino, @luke_heales, @@MichelleD_Smith

  • Contributors NK: study design; data collection and data analysis; quality rating and statistical analysis; writing of the manuscript. BTV and MS: study design; supervision of data collection and analysis; writing of the manuscript. LJH: data collection; quality rating of the papers; reviewing the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.