Original Research

Lower Extremity Muscle Activation During Functional

Exercises in Patients With and Without Chronic
Ankle Instability
Mark A. Feger, MEd, Luke Donovan, MEd, Joseph M. Hart, PhD, Jay Hertel, PhD
Objective: To determine whether individuals with chronic ankle instability (CAI) exhibit
altered neuromuscular control as demonstrated by surface electromyography (EMG)
amplitudes compared with healthy controls during single-limb eyes-closed balance, Star
Excursion Balance Test, forward lunge, and lateral hop exercises.
Design: A cross-sectional laboratory study.
Setting: A research laboratory.
Participants: Fifteen young adults with CAI and 15 healthy controls.
Interventions: The subjects performed functional exercises while surface EMG signals
were recorded from the tibialis anterior, peroneus longus, lateral gastrocnemius, rectus
femoris, biceps femoris, and gluteus medius.
Main Outcome Measurements: Surface EMG amplitudes (root mean square area)
for each muscle, muscles of the shank (distal 3 muscles), muscles of the thigh (proximal
3 muscles), and total muscle activity (all 6 muscles) of the lower extremity were analyzed
and compared between the groups.
Results: Individuals with CAI demonstrated signicantly less EMG activity in the muscles
of the lower extremity during all 4 functional exercises. Effect sizes for signicant differ-
ences between groups ranged from 0.75 to 1.08, none of which had 95% condence
intervals that crossed zero, which indicates moderate to large decreases in muscle activity in
patients with CAI compared with healthy controls.
Conclusions: Patients with CAI demonstrated decreased muscle activity of ankle, knee,
and hip musculature during common functional rehabilitative tasks. Clinicians may benet
from implementing functional exercises for patients with CAI that target both distal and
proximal muscles of the lower extremity.
PM R 2014;6:602-611
INTRODUCTION
Ankle sprains account for 15%-23% of athletic injuries in the high school and collegiate
settings [1,2]. Furthermore, ankle sprains are the most common site for recurrent injury and
account for 25% of all recurrent injuries [3], and recurrent ankle sprains account for 15% of
all ankle sprains [4]. Recurrent ankle sprains are often associated with residual symptoms
such as pain, subjective instability, and decreased self-reported function [5,6]. A recent
position statement indicates that a history of at least 1 signicant ankle sprain, a subsequent
history of the ankle giving way, and self-reported functional limitations are dening
characteristics of a heterogeneous condition known as chronic ankle instability (CAI) [7].
Sensory, reexive, and motor control decits may contribute to CAI [8]. Visual in-
spection of motor control patterns in patients with CAI is difcult in practice; however,
adaptations have been reported with laboratory measures. Patients with CAI have
demonstrated altered motor control indicated by surface EMG (sEMG) during walking and
drop landing [9-11]. During walking, patients with CAI activate their peroneus longus (PL)
before initial contact (IC), whereas healthy controls do so after IC [9,10]. An opposite
relationship exists during drop landing, in which patients with CAI have less anticipatory
muscle activity compared with healthy individuals [12]. Altered motor control patterns also
M.A.F. Department of Kinesiology, University
of Virginia, 210 Emmet Street South Charlot-
tesville, VA 22904. Address correspondence
to M.A.F.; e-mail: mf3de@virginia.edu
Disclosure: nothing to disclose
L.D. Department of Kinesiology, University of
Virginia, Charlottesville, VA
Disclosure: nothing to disclose
J.M.H. Department of Kinesiology, University of
Virginia, Charlottesville, VA
Disclosure: nothing to disclose
J.H. Department of Kinesiology, University of
Virginia, Charlottesville, VA
Disclosure: nothing to disclose
Peer reviewers and all others who control
content have no relevant nancial relation-
ships to disclose.
602
PM&R
1934-1482/13/$36.00
Printed in U.S.A.
2014 by the American Academy of Physical Medicine and Rehabilitation
Vol. 6, 602-611, July 2014
http://dx.doi.org/10.1016/j.pmrj.2013.12.013
have been identied in proximal joint muscles, including
decreased gluteus maximus muscle activity during a rota-
tional squat exercise in patients with CAI [13]. During the
transition from a bipedal to a unipedal stance, a slower onset
of muscle activity and less anticipatory muscle activation in
the ankle, knee, and hip muscles were seen in patients with
CAI, which indicates a reliance on feedback, rather than
feedforward, motor control to complete the postural transi-
tion [14].
Balance and coordination training are effective interven-
tion strategies for reducing the risk of ankle sprains, espe-
cially in patients who have a history of ankle sprain but who
have not developed CAI [15], but the efcacy of such
exercises at reducing the risk of recurrent sprains in patients
with CAI is uncertain [15]. Altered motor control patterns
have been identied in muscles that act on the ankle, knee,
and hip during gait [9-11] and isolated functional exercises
[12-14,16] in patients with CAI; however, there has not
previously been a comprehensive analysis of the EMG
activity of both distal and proximal lower extremity muscles
during common functional exercises used for rehabilitation
in patients with CAI. An understanding of how patients with
CAI activate muscles to complete functional rehabilitative
exercises can give insight into how rehabilitation can be
tailored to specically target and improve patient outcomes.
Our purpose was to compare the sEMG root mean square
(RMS) area during common functional exercises, including
lunges, single limb balance, the Star Excursion Balance Test
(SEBT), and lateral hopping exercises to test the hypothesis
that patients with CAI would have decreased sEMG ampli-
tudes of ankle, knee, and hip musculature during all tasks
compared with healthy counterparts.
METHODS
Design
We performed a cross-sectional laboratory study in which
the independent variable was the group (CAI, healthy con-
trol) and the dependent variables were sEMG RMS area for
the tibialis anterior (TA), PL, lateral gastrocnemius, rectus
femoris (RF), biceps femoris, and gluteus medius during
single-limb eyes-closed balance, SEBT reach directions
(anterior, posterior medial, and posterior lateral), forward
lunges, and lateral hops. We also summed the normalized
sEMG amplitudes for individual muscles to analyze
segmental muscle activity for the distal musculature (TA, PL,
lateral gastrocnemius), proximal musculature (RF, biceps
femoris, gluteus medius), and total lower extremity muscu-
lature (all 6 muscles) between groups.
Subjects
Fifteen young adults with CAI and 15 healthy controls
volunteered (Table 1). This study was part of a larger study,
and the same cohorts have previously been reported in
another article that investigated EMG differences during gait
[9]. Briey, the control group was self-reported to be healthy
and to have no history of ankle sprain to either ankle. The
CAI group had a history of more than 1 ankle sprain with
the initial sprain occurring more than 1 year before the study
onset and current self-reported functional decits due to
ankle symptoms. The subjects were allocated to groups
based on their ankle health status (CAI or healthy), and
healthy test limbs were side matched (right or left) to the
involved CAI test limbs [9]. Subjects were excluded if they
had an ankle sprain within the 6 weeks before the study
onset, a history of lower extremity injury or surgery, balance
disorders, neuropathies, diabetes, or other conditions
known to affect balance. The subjects provided informed
consent, and the study was approved by the universitys
institutional review board.
Instruments
The sEMG signals were collected from disposable, pre-
gelled, 10-mm, round Silver-Silver Chloride (Ag-AgCl)
electrodes and amplied with a high-gain, differential-input
biopotential amplier with a gain of 1000 and digitized
with a 16-bit data acquisition system (MP 150, Biopac
Systems Inc, Goleta, CA) at 2000 Hz with a common-mode
rejection ratio of 110 dB, an input impedance of 1.0 MU,
and a noise voltage of 0.2 mV. Acqknowledge software
(v.4.0, Cambridge, England) was used for data collection
and processing of EMG signals. The EMG data were
collected by using real-time processing with a 10- to 500-
Hz band pass lter and a 10-sample moving average RMS
algorithm. A foot switch (BIOPAC Systems, Santa Barbara,
CA) was used to identify ground contact during the SEBT,
forward lunge, and lateral hopping exercises. All the sub-
jects wore standard athletic shoes for all exercises
(X755WB; New Balance, Brighton, MA).
Table 1. Subject demographics
CAI
Group
Control
Group
Mean SD age, y 23 4.2 22.9 3.4
Mean SD height, cm 173 10.8 173 9.4
Mean SD mass, kg 72.4 14 70.8 18
Men:women 5:10 5:10
No. previous sprains, mean SD 4.5 3.2 N/A
Mean SD time since
last sprain, mo
15.2 9.3 N/A
Godin score, mean SD 94 47 84 40
FAAM ADL, mean SD 87.2 7.1 100 0
FAAM Sport, mean SD 68.5 5.7 100 0
CAI chronic ankle instability; SD standard deviation; N/A not
applicable; Godin score Godin Leisure-Time Exercise Questionnaire score;
FAAM ADL Foot and Ankle Ability Measure Activities of Daily Living scale
score; FAAM Sport Foot and Ankle Ability Measure Sport subscale score.
PM&R Vol. 6, Iss. 7, 2014 603
Testing Procedures
By using methods previously described in detail [9], surface
electrodes were placed 2 cm apart and oriented parallel to
the muscle-ber orientation over the midline of the muscle
belly determined via manual palpation during a voluntary
contraction. Before testing, the subjects performed a 5-
minute warm-up that consisted of walking at a self-selected
pace, and then standardized maximal voluntary isometric
contractions (MVIC) were recorded for each muscle against
manual resistance for normalization of sEMG amplitudes.
Exercises
The subjects completed at least 3 practice trials for each
exercise before testing and additional practice trials until
they self-reported to be comfortable with each task; how-
ever, no subject required more than 5 practice trials per task.
For all tasks, failed trials were repeated until the desired
number of repetitions was completed. Due to the submaxi-
mal nature of the tasks and the low volume of each exercise
performed, we did not expect fatigue to affect our outcome
measures. Thus, all the subjects completed the tasks in the
order described below.
Five consecutive lunges were performed and the lead leg
was tested. A target line was placed to signal the appropriate
heel strike position at a distance determined during practice
trials. The target distance was selected to ensure that the test
limb reached 90

of hip and knee exion when the knee of

the contralateral stance limb lightly contacted the ground
[17]. The subjects were visually monitored and required to
keep their hands on their hips, and failed trials included
removing hands from the hips or missing the target line
during heel strike. A single-limb eyes-closed balance trial
was performed for 15 seconds with the stance limb tested.
The subjects were required to place their hands on their hips
with the contralateral limb comfortably elevated and not in
contact with stance limb [18].
The SEBT was performed in the anterior, posteromedial,
and posterolateral reach directions by using previously
described methods (Figure 1A-C) [19]. Traditionally, the
SEBT has been used as a functional assessment for dynamic
balance decits; however, Donovan and Hertel [20] high-
lighted the benet of implementing the SEBT as a functional
rehabilitation exercise in patients with CAI. Lateral hops
were performed with the hopping limb tested. A modied
side hop test was performed [21]. The subjects hopped
laterally over a 1.5-inch line at a pace of 110 hops per
minute for 20 seconds. A metronome was used to set the
cadence. A foot switch was used to signal ground contact.
Data Processing
Forward Lunge. The middle 3 lunges of the 5 consecutive
lunge trials were analyzed. To gain an understanding of
preparatory muscle activation and reexive activation of all
muscles [22], a 50-millisecond epoch immediately before IC
was used to calculate the pre-IC area under the RMS curve
[22]. A 100-millisecond epoch immediately after IC was
used to calculate the post-IC area under the RMS curve [22].
Lunge amplitudes were normalized to respective MVIC
epochs.
Single-limb Eyes-closed Balance. A 3-second epoch
during the middle of the single-limb eyes-closed balance trial
was analyzed. The area under the RMS curve was calculated
and normalized to a 3-second MVIC epoch for each muscle.
SEBT. A 500-millisecond epoch just before maximum excur-
sion was averaged over 3 trials for each of the 3 directions.
Maximum excursion was dened as the time at which the
contralateral limb touched down. The average area under
the RMS curve over the 3 trials was normalized to a 500-
millisecond MVIC epoch for each muscle.
Lateral Hops. Six total consecutive hops (3 in each direc-
tion) were selected from the middle of the lateral hopping
trial. To gain an understanding of preparatory and reexive
activation of all muscles, a 50-millisecond epoch immedi-
ately before IC was used to calculate the pre-IC area under
the RMS curve [22]. A 100-millisecond epoch immediately
Figure 1. (A) Star Excursion Balance Test, anterior reach. (B) Star
Excursion Balance Test, posteromedial reach. (C) Star Excursion
Balance Test, posterolateral reach.
604 Feger et al EXTREMITY MUSCLE ACTIVATION IN FUNCTIONAL EXERCISES
after IC was used to calculate the post-IC area under the
RMS curve [22]. Lateral hopping amplitudes were normal-
ized to respective MVIC epochs.
Distal, Proximal, and Total Muscle Activity. To gain a
more comprehensive understanding of the EMG activity of
the entire lower extremity during rehabilitative tasks, we
summed the normalized muscle activity of the distal (TA, PL,
and lateral gastrocnemius), proximal (RF, biceps femoris,
and gluteus medius), and entire lower extremity (all 6
muscles). The summed values were analyzed as separate
dependent variables for each task as described below.
Statistical Analysis
The independent variable was group (CAI and healthy
control), and the main outcome measures were sEMG
RMS areas for a predetermined epoch respective of each
task for each individual muscle, the sum of the 3 distal
muscles, the sum of the 3 proximal muscles, and the sum
of all 6 muscles. We performed an independent t test for
each dependent variable to compare the groups. The level
of signicance was set a priori at P .05 for all analyses.
Per contemporary statistical recommendations [23], we
did not control for multiple comparisons; instead, in
addition to inferential statistical comparison, we calculated
Cohen d effect sizes and associated 95% condence in-
tervals to estimate the magnitude and precision of group
differences for each measure. Effect sizes were interpreted
as 0.80, large; 0.50, moderate; and 0.20, small.
Negative effect sizes indicated that CAI muscle activation
was less than that of the control group. Positive effect sizes
indicated that CAI muscle activation was greater than that
of the control group. Data were analyzed by using the
Statistical Package for the Social Sciences version 20.0
(SPSS Inc, Chicago, IL).
RESULTS
Forward Lunges
There was signicantly less proximal muscle activation
before IC in the CAI group compared with healthy controls
(Table 2). There was signicantly less muscle activation
for the TA in the CAI group compared with the healthy
controls for post-IC amplitude. In addition, there were
signicantly less distal and total lower extremity post-IC
amplitudes in the CAI group compared with the healthy
control group. Effect sizes for signicant ndings during
forward lunges ranged from 0.79 (moderate) to 1.08
(large), with 95% condence intervals that ranged
from 0.05 (small) to 1.85 (large), which indicated
moderate-to-large decreases in muscle activity in the CAI
group (Table 2).
Single-limb Eyes-closed Balance
There was signicantly less muscle activity in the CAI group
when compared with healthy controls for the TA and RF
sEMG amplitudes during single-limb eyes-closed balance.
For total lower extremity muscle activation, the CAI group
had a signicantly lower sEMG amplitude compared with
the healthy control group. Effect-size point estimates for
the signicant ndings during single-limb eyes-closed
balance ranged from 0.76 (moderate) to 0.95 (large),
with 95% condence intervals that ranged from 0.02
(small) to 1.71 (large), which indicated moderate-to-large
decreases in muscle activity in the CAI group (Table 3).
SEBT
Results for the SEBT in the anterior, posteromedial, and
posterolateral direction are summarized in Table 4. There
was signicantly less muscle activity in the CAI group during
the SEBT in the TA during the anterior and posteromedial
reach directions. No other signicant differences were
identied between the groups during SEBT trials in any
direction. Effect sizes for signicant ndings during SEBT
trials ranged from 0.75 (moderate) to 0.88 (large), with
95% condence intervals that ranged from 0.01 (small)
to 1.62 (large), which indicated a moderate to large
decrease in muscle activity in the CAI group compared with
the control group.
Lateral Hops
There was signicantly less pre-IC amplitude for distal and
total lower extremity amplitudes in the CAI group during
lateral hopping. Effect sizes for signicant ndings in pre-IC
amplitude during lateral hops ranged from 0.90 (large)
to 0.93 (large), with 95% condence intervals that ranged
from 0.15 (small) to 1.68 (large), which indicated large
decreases in preparatory muscle activity with the CAI group
relative to the control group (Table 5). There were no
signicant differences between the groups during lateral
hopping for post-IC amplitude measures (Table 5).
DISCUSSION
We identied group differences in sEMG activity during all
4 functional exercises. The CAI group exhibited less muscle
activity in muscles that act on the ankle, knee, and hip when
completing the rehabilitative exercises compared with
healthy controls. Decreased preparatory muscle activity was
demonstrated in the pre-IC analyses during lunges and
lateral hopping exercises. Decreased reexive muscle activity
was seen after IC during lunges as well as during static and
dynamic balance tasks.
Previous studies have identied altered motor control
patterns in patients with CAI compared with healthy
PM&R Vol. 6, Iss. 7, 2014 605
counterparts during gait [9-11,24], drop landing [12], and
various isolated functional tasks [13,14,16,25]. To our
knowledge, however, this is the rst study to identify altered
motor control patterns in muscles that act on the ankle,
knee, and hip during common rehabilitative tasks in patients
with CAI. This same CAI cohort demonstrated earlier acti-
vation of ankle, knee, and hip musculature but not differ-
ences in measures of sEMG amplitude before or after IC
during walking [9]. Specically, there was a shift to a
preactivation of the PL in those with CAI, which is hy-
pothesized to be a mechanism to control the excessive
inversion positioning of the rear foot observed during ter-
minal swing [9]. The differences in the type of compensatory
motor control pattern within the same cohort leads us to
believe that alterations in motor control in patients with CAI
are task dependent.
Similar to our current study, patients with CAI demon-
strate decreased soleus muscle activity during a time to sta-
bilizationtask after a jumplanding [25], anddecreasedgluteus
maximus muscle activity during a rotational squat exercise
[13]. Delahunt et al [16], however, found increased muscle
activity before and after IC in a lateral hopping task in patients
with CAI. This unidirectional lateral hop landing phase has
been suggested to directly stress the stability of the lateral
ankle [26] and to signicantly increase the demand on the PL
muscle as a dynamic stabilizer [27]. The increased demand on
the lateral dynamic stabilizers in the presence of ankle insta-
bility may have selectively provided a stimulus for an increase
in preparatory and responsive muscle activity in patients with
CAI [16]. However, in the absence of a direct stimulus, such as
instability induced during the unidirectional landing phase
of the side hop test or an inverted foot position before ground
Table 2. Muscle activation patterns with forward lunge
Muscles
Isolated Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
Anterior tibialis
Pre-IC 0.46 0.16 0.57 0.26 0.51 (1.24 to 0.22) .21
Post-IC 0.44 0.13 0.61 0.18 1.08 (1.85 to 0.32) .01
Peroneus longus
Pre-IC 0.22 0.12 0.30 0.27 0.38 (1.11 to 0.34) .33
Post-IC 0.33 0.15 0.48 0.35 0.56 (1.29 to 0.17) .16
Lateral gastrocnemius
Pre-IC 0.40 0.36 0.45 0.33 0.14 (0.86 to 0.57) .67
Post-IC 0.34 0.23 0.55 0.37 0.68 (1.42 to 0.05) .08
Rectus femoris
Pre-IC 0.13 0.09 0.21 0.20 0.52 (1.24 to 0.21) .21
Post-IC 0.23 0.17 0.17 0.09 0.44 (0.28 to 1.17) .38
Biceps femoris
Pre-IC 0.13 0.07 0.19 0.11 0.65 (1.39 to 0.08) .14
Post-IC 0.12 0.05 0.17 0.09 0.69 (1.42 to 0.05) .12
Gluteus medius
Pre-IC 0.10 0.07 0.17 0.19 0.49 (1.22 to 0.24) .18
Post-IC 0.17 0.10 0.20 0.10 0.30 (1.02 to 0.42) .40
CAI chronic ankle instability; SD standard deviation; ES Cohen d effect size; CI confidence interval; Pre-IC 50ms pre-initial
contact root mean square area; Post-IC 100ms post-initial contact root mean square area.
*A negative ES indicates decreased muscle activity in the subjects with CAI; a positive ES indicates increased muscle activity in
the subjects with CAI.
y
Independent t test statistical results; level of significance was set a priori at P .05.
Table 3. Muscle activation patterns with single-leg eyes-closed balance
Muscles
Isolated Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
Anterior tibialis 0.35 0.18 0.49 0.19 0.76 (1.5 to 0.02) .05
Peroneus longus 0.45 0.22 0.48 0.26 0.12 (0.84 to 0.59) .74
Lateral gastrocnemius 0.25 0.11 0.33 0.19 0.52 (1.24 to 0.21) .16
Rectus femoris 0.09 0.10 0.19 0.11 0.95 (1.71 to 0.20) .02
Biceps femoris 0.07 0.07 0.12 0.11 0.54 (1.27 to 0.19) .13
Gluteus medius 0.16 0.11 0.13 0.09 0.30 (0.42 to 1.02) .55
CAI chronic ankle instability; SD standard deviation; ES Cohen d effect size; CI confidence interval.
*A negative ES indicates decreased muscle activity in the subjects with CAI; a positive ES indicates increased muscle activity in the
subjects with CAI.
y
Independent t test statistical results; level of significance was set a priori at P .05.
606 Feger et al EXTREMITY MUSCLE ACTIVATION IN FUNCTIONAL EXERCISES
contact during walking, patients with CAI demonstrated
decreased muscle activation of the entire lower extremity.
Clinically, there has traditionally been a rehabilitative
focus on distal ankle musculature, specically, the peroneals,
for their ability to provide dynamic lateral ankle stability.
Interestingly, we did not identify a decit in the extent of
peroneal activation during any of the rehabilitative tasks in
our study. Gribble et al [28] analyzed dynamic postural
control following open chain ankle and lunge fatiguing
protocols, and found that decits caused by motor control
alterations in proximal joints could be exposed by functional
fatiguing protocols. We were able to identify alterations in
distal and proximal joint muscle activity without completing
a fatiguing protocol. In addition, we identied segmental
differences in distal, proximal, and total muscle activation
between the groups When using total muscle activation
per epoch used for analysis as an indication of task intensity,
the magnitude of the group differences in our study was
not exacerbated as the intensity of the rehabilitative tasks
increased. Hubbard et al [29] found strong correlations be-
tween measures of strength and power of multiple lower
extremity muscles, and they speculated that central mecha-
nisms were involved in the global decreases in functional
decits associated with CAI [29]. Patients with CAI also have
exhibited gait initiation strategies different from those of
healthy counterparts, which have been attributed to altered
supraspinal mechanisms of motor control [30]. These nd-
ings, along with ours, support that central nervous system
mechanisms are likely playing a role in the functional decits
associated with CAI, and that a comprehensive approach to
rehabilitation is required, which includes centrally mediated
muscle function of distal and proximal muscles.
Distal-Proximal Muscle Activation Total Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
1.08 0.57 1.32 0.58 0.42 (1.14 to 0.31) .28
1.11 0.32 1.64 0.71 0.96 (1.72 to 0.21) .02
1.45 0.59 1.88 0.82 0.60 (1.33 to 0.13) .12
1.63 0.48 2.30 0.99 0.86 (1.61 to 0.11) .03
0.36 0.16 0.56 0.32 0.79 (1.53 to 0.05) .05
0.52 0.25 0.67 0.37 0.48 (1.20 to 0.25) .22
Table 2. Continued
Distal-Proximal Muscle Activation Total Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
1.05 0.36 1.31 0.43 0.66 (1.39 to 0.08) .10
1.37 0.42 1.75 0.56 0.77 (1.51 to 0.03) .05
0.32 0.17 0.45 0.24 0.63 (1.36 to 0.11) .11
Table 3. Continued
PM&R Vol. 6, Iss. 7, 2014 607
Table 4. Muscle activation patterns with Star Excursion Balance Test
Muscles Reach Direction
Isolated Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
Anterior tibialis
Anterior 0.40 0.22 0.71 0.45 0.88 (1.62 to 0.13) .03
Posteromedial 0.50 0.19 0.68 0.28 0.75 (1.49 to 0.01) .05
Posterolateral 0.75 0.28 0.89 0.31 0.47 (1.20 to 0.25) .22
Peroneus longus
Anterior 0.48 0.20 0.44 0.29 0.16 (0.56 to 0.88) .66
Posteromedial 0.34 0.12 0.38 0.18 0.26 (0.98 to 0.46) .61
Posterolateral 0.35 0.12 0.40 0.24 0.26 (0.98 to 0.46) .48
Lateral gastrocnemius
Anterior 0.39 0.28 0.51 0.39 0.35 (1.07 to 0.37) .34
Posteromedial 0.18 0.11 0.25 0.18 0.47 (1.19 to 0.26) .23
Posterolateral 0.22 0.10 0.29 0.20 0.44 (1.17 to 0.28) .23
Rectus femoris
Anterior 0.42 0.23 0.44 0.30 0.07 (0.79 to 0.64) .83
Posteromedial 0.54 0.28 0.70 0.41 0.46 (1.18 to 0.27) .24
Posterolateral 0.54 0.31 0.73 0.47 0.48 (1.20 to 0.25) .22
Biceps femoris
Anterior 0.17 0.07 0.18 0.10 0.12 (0.83 to 0.60) .66
Posteromedial 0.11 0.06 0.13 0.06 0.33 (1.05 to 0.39) .62
Posterolateral 0.16 0.08 0.16 0.07 0 (0.72 to 0.72) .89
Gluteus medius
Anterior 0.17 0.12 0.13 0.09 0.38 (0.34 to 1.10) .31
Posteromedial 0.25 0.14 0.23 0.18 0.12 (0.59 to 0.84) .70
Posterolateral 0.24 0.15 0.20 0.14 0.50 (1.23 to 0.22) .52
CAI chronic ankle instability; SD standard deviation; ES Cohen d effect size; CI confidence interval.
*A negative ES indicates decreased muscle activity in the subjects with CAI; a positive ES indicates increased muscle activity in the
subjects with CAI.
y
Independent t test statistical results; level of significance was set a priori at P .05.
Table 5. Muscle activation patterns with lateral hop
Muscles
Isolated Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
Anterior tibialis
Pre-IC 0.24 0.16 0.34 0.17 0.61 (1.34-0.13) .13
Post-IC 0.35 0.26 0.54 0.31 0.66 (1.40 to 0.07) .10
Peroneus longus
Pre- IC 0.50 0.17 0.70 0.46 0.58 (1.31 to 0.15) .16
Post-IC 0.67 0.19 0.88 0.52 0.54 (1.26 to 0.19) .19
Lateral gastrocnemius
Pre-IC 0.83 0.55 1.39 0.86 0.78 (1.52 to 0.03) .06
Post-IC 1.21 1.23 1.61 1.06 0.35 (1.07 to 0.37) .38
Rectus femoris
Pre-IC 0.28 0.38 0.30 0.21 0.07 (0.78 to 0.65) .88
Post-IC 0.62 0.47 0.77 0.40 0.34 (1.06 to 0.38) .41
Biceps femoris
Pre-IC 0.38 0.20 0.49 0.30 0.43 (1.16 to 0.29) .28
Post-IC 0.31 0.26 0.32 0.15 0.05 (0.76 to 0.67) .96
Gluteus medius
Pre-IC 0.35 0.20 0.56 0.44 0.61 (1.35 to 0.12) .13
Post-IC 0.60 0.26 0.69 0.43 0.25 (0.97 to 0.47) .53
CAI chronic ankle instability; SD standard deviation; ES Cohen d effect size; CI confidence interval; Pre-IC 50 ms pre-initial
contact root mean square area; Post-IC 100 ms post-initial contact root mean square area.
*A negative ES indicates decreased muscle activity in the subjects with CAI; a positive ES indicates increased muscle activity in the
subjects with CAI.
y
Independent t test statistical results; level of significance was set a priori at P .05.
608 Feger et al EXTREMITY MUSCLE ACTIVATION IN FUNCTIONAL EXERCISES
Distal-Proximal Muscle Activation Total Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
1.26 0.44 1.66 0.82 0.61 (1.34 to 1.10) .12
1.02 0.25 1.30 0.49 0.72 (1.46 to 0.02) .06
1.32 0.33 1.58 0.61 0.53 (1.26 to 0.20) .16
2.02 0.64 2.4 1.13 0.41 (1.14 to 0.31) .27
1.93 0.52 2.36 0.75 0.67 (1.40 to 0.07) .09
2.25 0.53 2.67 1.05 0.50 (1.23 to 0.22) .19
0.76 0.38 0.75 0.37 0.03 (0.69 to 0.74) .97
0.91 0.37 1.06 0.49 0.35 (1.07 to 0.38) .37
0.94 0.45 1.09 0.56 0.30 (1.01 to 0.42) .42
Table 4. Continued
Distal-Proximal Muscle Activation Total Muscle Activation
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
CAI, Mean SD Control, Mean SD ES (95% CI)* P
y
1.57 0.68 2.43 1.12 0.93 (1.68 to 0.17) .03
2.22 1.31 3.03 1.22 0.64 (1.37 to 0.09) .12
2.57 0.99 3.77 1.61 0.90 (1.65 to 0.15) .03
3.76 1.62 4.81 1.86 0.60 (1.33 to 0.13) .14
1.00 0.51 1.34 0.65 0.58 (1.31 to 0.15) .15
1.54 0.78 1.78 0.81 0.30 (1.02 to 0.42) .45
Table 5. Continued
PM&R Vol. 6, Iss. 7, 2014 609
Although centrally mediated decits are likely playing an
integral role in functional decits in patients with CAI, many
of the studies that identied decreases in muscle activity
associated with CAI have been performed with tasks that
allowed participants to self-select the intensity at which tasks
were completed. We attempted to standardize subject effort
on tasks when possible. For example, the subjects were
required to reach as far as possible during SEBT trials.
During lunging tasks, the distance was standardized to the
individual person, but the rate of lunging was self-selected
based on the associated comfort with the task. Similarly, in
the lateral hopping task, the subjects were required to hop
over a xed width at a standardized pace; however, the
height and maximal lateral excursion were not controlled
nor recorded. Although the EMG RMS area does not provide
great insight into the quality of the movement or the motor
recruitment patterns adopted by each subject, it does pro-
vide insight into the extent of motor unit recruitment
required to complete the designated exercise with respect to
the maximal voluntary capacity of the muscle. Donovan and
Hertel [20] developed a paradigm specically designed for
clinicians when targeting decits associated with CAI. A key
component of the paradigm includes an initial assessment of
functional limitations so that interventions can be chosen to
specically target those decits. In the rehabilitation setting,
allowing patients to self-select the intensity of various tasks
in the presence of ankle instability may result in an uncon-
scious decrease in the intensity at which tasks are performed
and may impair clinicians ability to improve decits in
muscle activation. However, setting a safe but specic
objective goal that includes not only the quantity but also the
quality of the movement pattern may require patients to
stress the sensorimotor system beyond what they may have
otherwise achieved.
Study Limitations
Limitations of this study include the lack of kinematic and
kinetic data to help support the aforementioned hypotheses
of centrally mediated inhibition or unconscious protection
via lower intensity or rate of task completion. In addition, the
relatively small sample size used in this study, when coupled
with the large standard deviations that are inherent with
sEMG, collectively increase the potential risk of a type II error
in comparisons when statistical signicance was not found.
CONCLUSION
We identied decreased muscle activation in patients with
CAI during common functional rehabilitation exercises.
Clinicians should be aware of distal and proximal alterations
in motor control in patients with CAI. Identifying novel
ways to increase muscle activity and motor recruitment
beyond what is currently used for functional rehabilitation
may improve patient outcomes.
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This journal-based CME activity is designated for 1.0 AMA PRA Category
1 Credit and can be completed online at www.me.aapmr.org. This
activity is FREE to AAPM&R members and available to non-members for
a nominal fee. For assistance with claiming CME for this activity, please
contact (847) 737-6000.
CME Question
In comparing the subjects with chronic ankle instability to the healthy controls while performing forward lunges, which of the following muscles
showed a statistically signicant decrease in muscle activation pre- or post-initial contact (IC)?
a. peroneus longus pre-IC.
b. gluteus medius post-IC.
c. anterior tibialis post-IC.
d. lateral gastrocnemius pre-IC.
Answer online at me.aapmr.org
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