Journal of Science and Medicine in Sport 20 (2017) 992–996

Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Original research

Hip strength and star excursion balance test deficits of patients with
chronic ankle instability
Ryan S. McCann a,∗ , Ian D. Crossett b , Masafumi Terada c , Kyle B. Kosik a , Brenn A. Bolding a ,
Phillip A. Gribble a
a
Department of Rehabilitation Sciences, University of Kentucky, United States
b
Orthopaedic Center, University of Utah, United States
c
College of Sport and Health Sciences, Ritsumeikan University, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To examine isometric hip strength in those with and without CAI, and determine the degree
Received 23 July 2016 of Star Excursion Balance Test (SEBT) variance explained by isometric hip strength.
Received in revised form 21 April 2017 Design: Single-blinded, cross-sectional, case-control study.
Accepted 15 May 2017
Methods: Thirty individuals with CAI, 29 lateral ankle sprain (LAS) copers, and 26 healthy controls par-
Available online 25 May 2017
ticipated. We assessed dynamic postural control with the SEBT anterior (SEBT-ANT), posteromedial
(SEBT-PM), and posterolateral (SEBT-PL) reaches, and isometric hip extension (EXT), abduction (ABD) and
Keywords:
external rotation (ER) strength with hand-held dynamometry. The CAI and LAS coper groups’ involved
Chronic ankle instability
Lateral ankle sprain coper
limbs and randomly selected limbs in controls were tested. Separate Kruskal–Wallis tests compared SEBT
Hip muscular strength scores and isometric hip strength between groups. Backwards linear regression models determined the
Star excursion balance test degree of SEBT variance explained by isometric hip strength. Statistical significance was set a priori at
Dynamic postural control P < 0.05.
Results: The CAI group had lower SEBT-ANT scores compared to LAS copers (P = 0.03) and controls
(P = 0.03). The CAI group had lower ABD compared to LAS copers (P = 0.03) and controls (P = 0.02). The CAI
group had lower ER compared to LAS copers (P = 0.01) and controls (P = 0.01). ER (R2 = 0.25, P = 0.01) and
ABD (R2 = 0.25, P = 0.01) explained 25% of the CAI group’s SEBT-PM and SEBT-PL variances, respectively.
Conclusions: The CAI group had deficient dynamic postural control and isometric hip strength compared
to LAS copers and controls. Additionally, the CAI group’s isometric hip strength significantly influenced
dynamic postural control performance. Future CAI rehabilitation strategies should consider hip muscular
strengthening to facilitate improvements in dynamic postural control.
© 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

1. Introduction motion,4,5 ankle muscular strength,4 mechanical joint stability,5

Lateral ankle sprains (LASs) contribute significantly to the
U.S. healthcare burden, with societal costs estimated as high
as $6.2 billion annually.1 Additionally, LASs are associated with
long-term consequences including decreased health-related qual-
ity of life, decreased physical activity, and post-traumatic ankle
osteoarthritis.1 Persistent symptoms and functional impairments
further amplify concern for LASs. Chronic ankle instability (CAI)
commonly succeeds LAS, and is marked by repetitive injury, senso-
rimotor and mechanical insufficiencies, and perceived instability of
the ankle.2 Conversely, LAS copers are marked by a history of LAS,
but an absence of CAI-related characteristics.3 Laboratory stud-
ies have reported that LAS copers have favorable ankle range of
∗ Corresponding author.
E-mail addresses: mccannatc59@yahoo.com, rsmc223@uky.edu (R.S. McCann).
and postural control4,6 compared to those with CAI. Thus, some
patients may have alternative recovery mechanisms or rehabilita-
tion experiences that preclude the development of CAI. Although
patients with a LAS clearly demonstrate diverse levels of recov-
ery, broadening the examination of differences between LAS copers
and those with CAI will contribute to our understanding of why
outcomes vary among patients, as well as to the development of
comprehensive rehabilitation protocols.
Dynamic postural control performance is among the most
widely reported activity limitation in those with CAI.4,7,8 The
Star-Excursion Balance Test (SEBT) is a simple clinical measure
of dynamic postural control that consistently demonstrates such
deficits.7 Although capable of distinguishing those with and with-
out ankle pathology, SEBT performance relies on mobility and
neuromuscular control of the entire lower extremity.7 Robinson
and Gribble9 conducted a kinematic analysis of the SEBT and found
a need for greater functional hip mobility to achieve greater reach

http://dx.doi.org/10.1016/j.jsams.2017.05.005
1440-2440/© 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
 R.S. McCann et al. / Journal of Science and Medicine in Sport 20 (2017) 992–996
distances in a healthy population. As a potential adaptive strat-
egy, individuals with CAI may have an even greater influence of hip
flexion motion on the SEBT.10 Therefore, concurrent proximal neu-
romuscular impairments may exacerbate dynamic postural control
deficiencies of ankle-injured populations.
An early investigation11 identified associations of isometric
hip adductor and abductor weakness with chronic ankle and
foot pathologies, including repetitive ankle sprain. More recently,
decreased isometric hip abduction strength in the involved limb
compared to the contralateral limb was revealed in individuals with
CAI.12 However, to date, no study has investigated hip strength
differences between those with CAI and LAS copers. Furthermore,
no study has investigated how potential hip strength deficits may
affect dynamic postural control in those with and without CAI. If
isometric hip strength is impaired, yet consequential to functional
tasks in those with CAI, common LAS and CAI rehabilitation pro-
tocols may need to include strategies for correcting hip muscular
strength deficiencies.
Therefore, the purpose of this study was to examine differences
in SEBT performance and isometric hip strength in those with and
without CAI. Additionally, we aimed to determine the extent to
which isometric hip strength explains SEBT performance variance.
We hypothesized that those with CAI would have decreased SEBT
scores and isometric hip strength compared to LAS copers and
healthy controls. Furthermore, we hypothesized that isometric hip
strength would explain a significant degree of SEBT score variance
in individuals with CAI, as well as LAS copers and controls.
2. Methods
We utilized a single-blinded, cross-sectional, case-control study
design. A single member of the research team screened and
assigned participants to either a CAI, LAS coper, or control group.
We recruited eighty-four participants (F: 61, M: 23;
23.75 ± 4.49 years, 167.38 ± 7.66 cm, 70.09 ± 14.69 kg) from
the surrounding university community. We estimated the needed
sample size using hip abduction strength and dynamic postural
control data from previous studies.4,12 Utilizing a predetermined
alpha level of 0.05 and power of 0.80, we estimated 25 partici-
pants in each group (75 total) were needed to detect statistically
significant differences. Exclusionary criteria consisted of a history
of any lower extremity injuries other than LAS in the previous 2
years, and any history of lower extremity fracture or surgery.2
A CONSORT-style flow chart illustrating group allocation is
present in Supplementary material. Potential participants initially
qualified for one of two groups: those that did or did not have his-
tory of LAS. Those without a LAS were placed in the healthy control
group. Participants with a previous LAS were designated to either a
CAI or a LAS coper group, based on the inclusion criteria endorsed
by the International Ankle Consortium2 as well as work by Wik-
strom and Brown.3 To confirm appropriate group placement, we
utilized ankle-specific self-reported outcomes including the Ankle
Instability Instrument (AII), Identification of Functional Ankle Insta-
bility (IdFAI), Cumberland Ankle Instability Tool (CAIT), number
of previous LASs, months since the most recent LAS, number of
“giving way” episodes in the past six months, and months since
the most recent “giving way” for each participant.2 If a participant
reported a history of bilateral ankle injury, we tested the limb with
the higher number of giving-way episodes and the greatest amount
of self-reported functional limitations on the Foot and Ankle Abil-
ity Measure activity of daily living (FAAM-ADL) and sport (FAAM-S)
subscales.
We conducted laboratory assessments of each participant
within two weeks of enrollment and screening. Upon arrival for lab-
oratory testing, participants read and signed an informed consent
993
document approved by the university institutional review board.
Participants partook in five minutes of self-selected warm-up and
stretching prior to testing. Participants in the CAI and LAS coper
groups underwent testing on the involved limb, and members of
the control group underwent testing on a randomly selected limb.
We utilized a randomly selected limb of the controls (as opposed
to a matched dominant/non-dominant limb) since the CAI and
LAS coper groups differed in which limb was injured. Previous
studies13,14 reported a lack of SEBT differences between domi-
nant and non-dominant limbs of healthy individuals, suggesting
the use of a randomly selected limb would not affect the results. The
investigators measuring and analyzing all outcome measures were
blinded to group membership of the participants. We conducted
all tests in the same order for each participant: (1) leg length, (2)
SEBT, (3) isometric hip strength.
Leg length data were necessary for normalization of postural
control and strength data. Full leg length, used for SEBT normaliza-
tion, was measured from the participants’ anterior superior iliac
spine to the most distal aspect of the medial malleolus.7 Grib-
ble et al.15 reported excellent inter-rater reliability of the full
leg length measurement (ICC = 0.92). Lower extremity segment
lengths were included for normalization of isometric hip strength
outcomes.16,17 Femur length was measured from the center of the
greater trochanter to the most distal aspect of the lateral femoral
epicondyle. Tibia length was measured from the medial knee joint
line to the most distal aspect of the medial malleolus.
The SEBT consisted of three lower extremity reaching tasks pre-
viously described extensively.7 The SEBT required each participant
to maintain a single-leg stance on the involved limb while reach-
ing for maximum distance in anterior (SEBT-ANT), posterolateral
(SEBT-PL), and posteromedial (SEBT-PM) directions. The partici-
pant’s hands were required to remain on their hips and the stance
heel remained in contact with the ground. Four practice trials were
performed in each direction,18 followed by three test trials in each
direction, in a randomized order. During test trials, if any of the cri-
teria were violated, the trial was discarded and repeated. Previous
authors have reported excellent intra-rater (ICC = 0.85–0.92)19 and
inter-rater reliability (ICC = 0.88–0.92)15 for the SEBT.
Isometric strength was measured in random order for hip
extension (EXT), abduction (ABD), and external rotation (ER),
using a portable load cell and attachments designed for hand-
held dynamometry (BTETM Evaluator; BTE, Hanover, MD). We
employed testing procedures previously described.20 For EXT, par-
ticipants were in a prone, knee-flexed position with stabilization
straps secured across the posterior superior iliac spines and the
dynamometer. For ABD, participants were in side-lying position
with stabilization straps secured across the iliac crest and the
dynamometer. For ER, participants were in a seated position with
a single stabilization strap secured across the participants’ thighs.
We placed the dynamometer 5.08 cm proximal to the knee joint
line during EXT and ABD assessments and 5.08 cm proximal to the
most distal aspect of the medial malleolus during ER assessment.21
Each isometric strength test consisted of one practice trial, followed
by three test trials. For each trial, participants ramped up the inten-
sity of the contraction for the first three seconds, and then provided
maximal effort for the fourth and fifth seconds. A 30-s rest inter-
val followed each trial. Excellent test-retest reliability has been
reported for EXT (ICC = 0.81), ABD (ICC = 0.76), and ER (ICC = 0.95)
used in the current study.20 Previous authors have reported fair
to excellent intra-rater and inter-rater reliability of similar mea-
sures of EXT (intra-rater ICC = 0.79–0.93, inter-rater ICC = 0.65), ABD
(intra-rater ICC = 0.92–0.97, inter-rater ICC = 0.87), and ER (intra-
rater ICC = 0.90–0.96, inter-rater ICC = 0.85).22
We calculated mean SEBT scores from three trials in each direc-
tion, and then normalized the scores as a percentage of total stance
leg length (%LL).7 We calculated mean peak torque (lbs) from three
994 R.S. McCann et al. / Journal of Science and Medicine in Sport 20 (2017) 992–996

Table 1
Between-groups comparison of primary outcomes and demographics.

CAI (n = 30) median, IQR LAS Coper (n = 29) median, IQR Control (n = 25) median, IQR Kruskal–Wallis Significance

SEBT-ANT (% LL) 61.0, 8.0a,b 66.7, 9.4 66.1, 9.3 2 (2) = 6.50 P = 0.04
SEBT-PM (%LL) 82.5, 11.3 85.5, 8.9 84.5, 15.1 2 (2) = 4.13 P = 0.13
SEBT-PL (%LL) 73.1, 10.0 78.9, 12.1 72.9, 16.8 2 (2) = 2.75 P = 0.12
EXT (Nm/Kg) 1.3, 0.3 1.6, 0.7 1.6, 0.6 2 (2) = 1.95 P = 0.07
ABD (Nm/Kg) 1.4, 0.5a,b 1.7, 0.6 1.8, 0.9 2 (2) = 1.71 P = 0.03
ER (Nm/Kg) 0.5, 0.1a,b 0.6, 0.2 0.7, 0.3 2 (2) = 3.53 P < 0.01
Age (years) 23.5, 5.3 23.0, 8.0 22.0, 4.3 2 (2) = 3.22 P = 0.44
Height (cm) 168.2, 8.3 167.0, 12.5 168.9, 11.4 2 (2) = 0.43 P = 0.81
Mass (kg) 68.6, 16.8 66.4, 16.1 68.8, 17.9 2 (2) = 0.52 P = 0.39
FAAM-ADL 89.3, 10.1a,b 100.0, 1.2b 100.0, 0.0 2 (2) = 46.8 P < 0.01
FAAM-S 71.9, 25.9a,b 100.0, 14.3b 100.0, 0.0 2 (2) = 49.36 P < 0.01
AII 6.0, 2.0a,b 3.0, 2.0b 0.0, 0.0 2 (2) = 68.45 P < 0.01
IdFAI 17.0, 6.0a,b 8.0, 10.0b 0.0, 0.0 2 (2) = 70.07 P < 0.01
CAIT 15.0, 8.5a,b 26.0, 6.0b 30.0, 0.0 2 (2) = 58.48 P < 0.01
Previous LAS (#) 4.0, 4.0a,b 2.0, 1.0b 0.0, 0.0 2 (2) = 58.21 P < 0.01
Previous LAS (mo) 24.0, 77.5a 36.0, 95.0 – 2 (1) = 5.86 P = 0.02
“Giving way” last 6 mo (#) 5.0, 8.0a,b 0.0, 1.0 0.0, 0.0 2 (2) = 60.85 P < 0.01
Previous “giving way” (mo) 0.8, 2.8a 8.0, 10.0 – 2 (1) = 7.89 P = 0.01
a
Statistically different from the LAS coper group.
b
Statistically different from the control group.

trials of each hip strength test, and then converted the values to Table 2
Pairwise comparisons and effect sizes.
Newtons (N), multiplied by the length of the moment arm (m), and
divided by body mass (kg) to obtain normalized torque (Nm/kg). Mann–Whitney U Significance Effect size
The moment arm for EXT and ABD was femur length, and the SEBT-ANT
moment arm for ER was tibia length. CAI vs. LAS coper Z = −2.21 P = 0.03 r = 0.31
Kolmogorov–Smirinov tests identified normal distributions for CAI vs. control Z = −2.15 P = 0.03 r = 0.30
just three variables: height, SEBT-ANT, and SEBT-PM. All other LAS coper vs. control Z = −0.08 P = 0.94 –

demographic, primary outcome, patient-reported outcome, and ABD

injury history variables were non-normally distributed. Due to CAI vs. LAS coper Z = −2.15 P = 0.03 r = 0.30
CAI vs. control Z = −2.27 P = 0.02 r = 0.32
the presence of non-normal distributions in the majority of vari-
LAS coper vs. control Z = −0.48 P = 0.63 –
ables, we conducted all between-group comparisons with separate
non-parametric Kruskal–Wallis tests. In the event of a signif- ER
CAI vs. LAS coper Z = −2.81 P = 0.01 r = 0.40
icant Kruskal–Wallis test, we utilized separate Mann–Whitney
CAI vs. control Z = −2.84 P = 0.01 r = 0.40
U tests for pairwise comparisons. Additionally, we employed Z = −0.62
√ LAS coper vs. control P = 0.54 –
r effect sizes (Z/ n) to determine the magnitude of signifi-
cant group differences.23 Effect sizes were interpreted as small
months since the most recent LAS, number of “giving way” episodes
(r = 0.10–0.29), moderate (r = 0.30–0.49), large (r = 0.50–0.69), and
in the past six months, and months since the most recent “giving
very large (r > 0.70).24
way.”
Separate backwards multiple linear regression analyses
Kruskal–Wallis tests identified significant differences for SEBT-
assessed the degree of SEBT score variance explained by isometric
ANT, ABD, and ER, whereas no significant group differences existed
hip strength for each group. In each linear regression analysis, all
for SEBT-PM, SEBT-PL or EXT. Separate Mann-Whitney U tests
three isometric hip strength variables were initially included as
revealed the CAI group had lower SEBT-ANT, ABD, and ER compared
predictor variables. The non-significant predictor variable with the
to LAS copers and controls (Table 2). No significant differences in
highest p-value was removed from the model first. We repeated
SEBT-ANT, ABD, or ER were identified between LAS coper and con-
this step until we found a model containing only significant
trol groups. All effect sizes for significant pairwise comparisons
predictors or all predictor variables had been eliminated from the
reached a moderate level (Table 2).
model. Cohen’s f2 effect sizes assessed the magnitude of each pre-
Backward multiple linear regression analyses resulted in a single
dictor variable’s effect on the regression model. Effect sizes were
final predictor variable explaining SEBT score variance. Specifically,
interpreted as small (f2 = 0.02–0.14), moderate (f2 = 0.15–0.34),
and large (f2 ≥ 0.35).25 Significance was set a priori at p < 0.05.
Table 3
All statistical analyses were conducted using IBM SPSS Statistics,
Backwards linear regression models.
version 21 (IBM Corporation, Armonk, NY).
Outcome variable Predictor variable ˇ R2 f2 Significance

SEBT-ANT
3. Results
CAI ABD 4.11 0.10 0.11 P = 0.09
LAS coper ER −1.94 0.00 0.00 P = 0.78
A Pearson Chi-Square test determined that CAI (F: 26, M: 4), LAS Control EXT 5.08 0.14 0.16 P = 0.07
coper (F: 20, M: 9), and control groups (F: 15, M: 11) did not dif-
SEBT-PM
fer significantly in distributions of males and females (2 (2) = 5.941, CAI ER 30.73 0.25 0.33 P = 0.01
P = 0.051), and thus, the primary statistical analyses remained unaf- LAS coper ABD 3.61 0.07 0.08 P = 0.16
fected. Between-groups comparisons of primary outcomes and Control ABD 8.30 0.15 0.18 P = 0.06
demographics are presented in Table 1. Separate Kruskal–Wallis SEBT-PL
tests revealed no significant differences between groups for age, CAI ABD 12.65 0.25 0.34 P = 0.01
height, and mass. Significant groups differences were found for LAS coper ABD 4.88 0.09 0.09 P = 0.13
Control ABD 6.94 0.09 0.10 P = 0.15
FAAM-ADL, FAAM-S, AII, IdFAI, CAIT, number of previous LASs,
 R.S. McCann et al. / Journal of Science and Medicine in Sport 20 (2017) 992–996
ER and ABD explained approximately 25% of the CAI group’s SEBT-
PM and SEBT-PL score variance, respectively (Table 3). Both linear
regression models were associated with moderate effect sizes. The
CAI group’s isometric hip strength did not explain a significant
degree of SEBT-ANT score variance. Neither the LAS coper nor con-
trol groups’ isometric hip strength explained a significant degree
of SEBT variance. Linear regression models for the control group’s
SEBT-ANT and SEBT-PM were associated with moderate effect sizes.
4. Discussion
Our primary finding was that individuals with CAI had lower
SEBT-ANT scores, ABD, and ER compared to LAS coper and con-
trol groups. The SEBT-ANT performance deficits are consistent with
previous findings,7,26 indicating that dynamic postural control in
individuals with CAI is compromised. Additionally, while previ-
ous studies have investigated hip strength deficits in those with a
previous LAS,11,12 ours is the first to detect deficient isometric hip
strength in individuals with CAI compared to LAS coper and control
groups. Aside from strength deficits, others have noted altered hip
muscular activation27,28 and functional movement patterns29,30 in
populations with ankle instability. Our findings and those of previ-
ous investigations support the hypothesis that some patients with
a peripheral joint injury may experience central nervous system
alterations that manifest as neuromuscular impairments in unin-
jured lower extremity joints.31
While the SEBT can discriminate between those with and with-
out ankle pathology, test performance relies on mobility and
neuromuscular control of the entire lower extremity.9,32 Linear
regression models of the current study found that approximately
25% of the CAI group’s SEBT-PM and SEBT-PL score variance was
explained by ER and ABD, respectively. Moderate effect sizes sig-
nify these associations had clinical significance. The CAI group’s
increased influence of hip musculature during a dynamic postu-
ral control test compared to LAS coper and control groups agrees
with other recent reports.6,8 Doherty et al.6 described increased
ankle-hip linked coordination during a static postural control
task in individuals with CAI compared to LAS copers. Rios et al.8
reported increased proximal lower extremity muscular activa-
tion and decreased ankle muscular activation during a single-leg
dynamic postural control task in those with CAI. Both studies6,8
postulated that individuals with CAI adapt a greater hip strategy for
postural control in order to compensate for neuromuscular deficits
at the ankle joint. We may have observed a similar compensatory
strategy in our CAI group, but we included no quantification of ankle
muscular function specifically, which limits our interpretation. Our
study is unique in that we found that a notable influence of hip
muscular strength on the SEBT in the CAI group occurred in con-
junction with decreased hip muscular strength in this cohort. Thus,
while individuals with CAI may partially depend on hip muscu-
lature for dynamic postural control, those recruited muscles may
themselves be impaired, possibly inhibiting balance performance
and perpetuating recurrent instability.
Although isometric strength explained a significant degree of
the CAI group’s SEBT-PM and SEBT-PL performance, 75% of score
variance remained unexplained, and isometric hip strength did not
contribute significantly at all to SEBT-ANT performance. A possible
explanation for this finding is that isometric hip strength may be
a suboptimal representation of hip muscular function during the
SEBT. Instead, concentric or eccentric hip strength or hip muscu-
lar activation may illustrate the influence of hip musculature on
the CAI group’s dynamic postural control performance more effec-
tively. Additionally, dorsiflexion range of motion deficits commonly
found in individuals with CAI4,5 may also partially explain the lack
of association between the CAI group’s SEBT-ANT scores and iso-
995
metric hip strength. Ankle dorsiflexion ROM is a limiting factor
for SEBT-ANT performance,33,34 which was decreased in our CAI
group. Although not consistently reported,29,35 some evidence sug-
gests ankle dorsiflexion ROM deficits in those with CAI can restrict
mobility at the knee and hip joints during functional movement.36
If our CAI group had decreased ankle dorsiflexion ROM, it may
have reduced knee and hip mobility and the influence of hip mus-
culature on SEBT-ANT performance. Unfortunately, as we did not
measure ankle dorsiflexion ROM nor lower extremity kinematics
in this study, we can only speculate on these influences on our
findings.
The LAS coper and control groups’ isometric hip strength did not
significantly explain SEBT score variance in these cohorts. Again,
this may allude to the inability of static strength measures to rep-
resent dynamic movement accurately. However, we must note that
moderate effect sizes suggest that the control group’s EXT and ABD
had a clinically meaningful contribution to SEBT-ANT and SEBT-PM
scores, respectively, whereas the LAS coper group had smaller asso-
ciations. LAS copers appear to have an adaptive strategy that allows
them to avoid developing characteristics of CAI,3 but they are not
necessarily similar to healthy controls. Plante and Wikstrom4 found
that LAS copers had favorable ankle dorsiflexion ROM compared to
those with CAI. However, a moderate effect size (0.65) indicated
that their LAS coper group still had lower ankle dorsiflexion ROM
compared to controls.4 If our control and LAS groups had a sim-
ilar difference in ankle dorsiflexion range of motion, the controls
may have demonstrated greater functional hip mobility and use
of the hip extensors during the SEBT. Since the current study did
not measure lower extremity mobility or mechanical restrictions of
the ankle, the proposed explanations for varying dynamic postural
control strategies require further inquiry.
The current findings echo the importance of correcting dynamic
postural control deficits in patients with CAI. A number of stud-
ies utilizing postural control training protocols have successfully
corrected postural control impairments as well as self-reported
dysfunction related to CAI.37 Individuals with CAI appear to have
a need for hip abductor and external rotator strengthening as
well. We detected hip strength impairments with the use of hand-
held dynamometry, which is among the simplest, most affordable
means of accurately quantifying isolated muscular dysfunction in a
clinical setting. Manual muscle testing is a more common method
of assessing muscular strength, but may lack the sensitivity nec-
essary to detect subtle strength deficits that require consideration
during rehabilitation.38 Recent clinical recommendations for LAS
treatment have not included guidelines for correcting hip muscular
weakness,39 likely due to a lack of original research investigat-
ing the benefits of hip muscular strengthening in ankle-injured
populations. Kosik et al.40 reported that patients with lower self-
reported function benefitted from the inclusion of exercises that
target gluteal activation compared to a traditional ankle-specific
rehabilitation protocol. We are unware of any other study that
utilized hip strengthening exercises for patients with CAI. As a
result, the optimal strategy for increasing isometric hip strength
while concurrently improving self-reported dysfunction related to
CAI remains unknown. Therefore, clinicians and researchers should
integrate rehabilitation of hip musculature into LAS and CAI treat-
ment protocols and aim to identify best methods for correcting
impairments.
While we acknowledge limitations within this study above,
a few additional limitations are notable. First, although neu-
romuscular impairments may develop following an index LAS,
the retrospective study design limits our understanding of when
dynamic postural control and strength impairments actually arose
in the CAI group. To improve clinical applicability, we measured
hip strength isometrically, but that method may insufficiently
estimate the influence of hip musculature on dynamic postural con-
996 R.S. McCann et al. / Journal of Science and Medicine in Sport 20 (2017) 992–996
trol performance. Other investigators6,8 also reported an increased
involvement of hip musculature in CAI populations during postu-
ral control tasks, potentially indicating a “shift” in balance strategy.
We observed a similar occurrence, but unlike the previous studies,
did not quantify contributions of ankle musculature. Therefore, we
cannot confirm that our CAI group exhibited a greater hip strategy
compared to an ankle strategy in the other groups.
5. Conclusion
Individuals with CAI demonstrated deficits in SEBT performance
as well as isometric hip strength compared to LAS coper and con-
trol groups. Isometric hip strength explained approximately 25%
of the CAI group’s SEBT posterior reach variance, whereas it did
not influence the LAS coper’s SEBT variance and explained a lesser
degree of the control groups’ SEBT variance. Rehabilitation exer-
cises that target hip strength are likely necessary for patients with
CAI, and may have an added positive effect on dynamic postural
control. Future studies should strive to determine if hip strength-
ening exercises can augment CAI rehabilitation, and if so, determine
the best method for incorporating hip muscular strengthening in
the treatment plan.
Practical implications
• Dynamic postural control and isometric hip strength deficiencies
are often present in patients with CAI.
• Clinicians treating patients with CAI should expand rehabilitation
protocols to target hip muscular strength deficiencies.
• Correcting hip strength deficits in patients with CAI may have
an addition positive effect on dynamic postural control perfor-
mance.
Acknowledgement
We thank the National Athletic Trainers’ Association Research &
Education Foundation for providing financial support for this study.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at 10.1016/j.jsams.2017.05.005.
References
1. Gribble PA, Bleakley CM, Caulfield BM et al. 2016 consensus statement of
the International Ankle Consortium: prevalence, impact and long-term conse-
quences of lateral ankle sprains. Br J Sports Med 2016; 50(24), 1493–1493.
2. Gribble PA, Delahunt E, Bleakley C et al. Selection criteria for patients with
chronic ankle instability in controlled research: a position statement of the
International Ankle Consortium. Br J Sports Med 2014; 48(13):1014–1018.
3. Wikstrom EA, Brown CN. Minimum reporting standards for copers in chronic
ankle instability research. Sports Med 2014; 44(2):251–268.
4. Plante JE, Wikstrom EA. Differences in clinician-oriented outcomes among
controls, copers, and chronic ankle instability groups. Phys Ther Sport 2013;
14(4):221–226.
5. Wright CJ, Arnold BL, Ross SE et al. Clinical examination results in individu-
als with functional ankle instability and ankle-sprain copers. J Athl Train 2013;
48(5):581–589.
6. Doherty C, Bleakley C, Hertel J et al. Lower limb interjoint postural coordina-
tion one year after first-time lateral ankle sprain. Med Sci Sports Exerc 2015;
47(11):2398–2405.
7. Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess
dynamic postural-control deficits and outcomes in lower extremity injury: a
literature and systematic review. J Athl Train 2012; 47(3):339–357.
8. Rios JL, Gorges AL, dos Santos MJ. Individuals with chronic ankle instability com-
pensate for their ankle deficits using proximal musculature to maintain reduced
postural sway while kicking a ball. Hum Mov Sci 2015; 43:33–44.
9. Robinson R, Gribble P. Kinematic predictors of performance on the star excursion
balance test. J Sport Rehabil 2008; 17(4):347–357.
10. de la Motte S, Arnold BL, Ross SE. Trunk-rotation differences at maximal reach
of the star excursion balance test in participants with chronic ankle instability.
J Athl Train 2015; 50(4):358–365.
11. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different
pathological states of the lower extremity. Am J Sports Med 1976; 4(6):241–248.
12. Friel K, McLean N, Myers C et al. Ipsilateral hip abductor weakness after inversion
ankle sprain. J Athl Train 2006; 41(1):74–78.
13. Munro AG, Herrington LC. Between-session reliability of the star excursion bal-
ance test. Phys Ther Sport 2010; 11(4):128–132.
14. Stiffler MR, Sanfilippo JL, Brooks MA et al. Star excursion balance test perfor-
mance varies by sport in healthy division I collegiate athletes. J Orthop Sports
Phys Ther 2015; 45(10):772–780.
15. Gribble PA, Kelly SE, Refshauge KM et al. Interrater reliability of the star excur-
sion balance test. J Athl Train 2013; 48(5):621–626.
16. Baggaley M, Noehren B, Clasey JL et al. Frontal plane kinematics of the hip dur-
ing running: are they related to hip anatomy and strength? Gait Posture 2015;
42(4):505–510.
17. Malloy PJ, Morgan AM, Meinerz CM et al. Hip external rotator strength is asso-
ciated with better dynamic control of the lower extremity during landing tasks.
J Strength Cond Res 2015; 30(1):282–291.
18. Robinson RH, Gribble PA. Support for a reduction in the number of trials needed
for the star excursion balance test. Arch Phys Med Rehabil 2008; 89(2):364–370.
19. Hertel J, Miller SJ, Denegar CR. Intratester and intertester reliability during the
star excursion balance test. J Sport Rehabil 2000; 9:104–116.
20. Thorborg K, Petersen J, Magnusson SP et al. Clinical assessment of hip strength
using a hand-held dynamometer is reliable. Scand J Med Sci Sports 2010;
20(3):493–501.
21. Ireland ML, Willson JD, Ballantyne BT et al. Hip strength in females with and
without patellofemoral pain. J Orthop Sports Phys Ther 2003; 33(11):671–676.
22. Kelln BM, McKeon PO, Gontkof LM et al. Hand-held dynamometry: reliability
of lower extremity muscle testing in healthy, physically active,young adults. J
Sport Rehabil 2008; 17(2):160–170.
23. Rosenthal R. Meta-Analytic Procedures for Social Research, Newbury Park, CA, Sage
Publications, 1991.
24. Rosenthal JA. Qualitative descriptors of strength of association and effect size. J
Soc Serv Res 1996; 21(4):37–59.
25. Cohen J. A power primer. Psychol Bull 1992; 112(1):155–159.
26. Doherty C, Bleakley C, Hertel J et al. Dynamic balance deficits in individuals
with chronic ankle instability compared to ankle sprain copers 1 year after a
first-time lateral ankle sprain injury. Knee Surg Sports Traumatol Arthrosc 2016;
24(4):1086–1095.
27. Beckman SM, Buchanan TS. Ankle inversion injury and hypermobility: effect on
hip and ankle muscle electromyography onset latency. Arch Phys Med Rehabil
1995; 76(12):1138–1143.
28. Bullock-Saxton JE. Local sensation changes and altered hip muscle function fol-
lowing severe ankle sprain. Phys Ther 1994; 74(1):17–28.
29. Brown CN, Padua DA, Marshall SW et al. Hip kinematics during a stop-jump task
in patients with chronic ankle instability. J Athl Train 2011; 46(5):461–467.
30. Delahunt E, Monaghan K, Caulfield B. Changes in lower limb kinematics, kinet-
ics, and muscle activity in subjects with functional instability of the ankle joint
during a single leg drop jump. J Orthop Res 2006; 24(10):1991–2000.
31. Ward S, Pearce AJ, Pietrosimone B et al. Neuromuscular deficits following
peripheral joint injury: a neurophysiological hypothesis. Muscle Nerve 2015;
51(3):327–332.
32. Feger MA, Donovan L, Hart JM et al. Lower extremity muscle activation during
functional exercises in patients with and without chronic ankle instability. PMR
2014; 6(7):602–611, quiz 611.
33. Gabriner ML, Houston MN, Kirby JL et al. Contributing factors to star excur-
sion balance test performance in individuals with chronic ankle instability. Gait
Posture 2015; 41(4):912–916.
34. Terada M, Harkey MS, Wells AM et al. The influence of ankle dorsiflexion and
self-reported patient outcomes on dynamic postural control in participants with
chronic ankle instability. Gait Posture 2014; 40(1):193–197.
35. Caulfield BM, Garrett M. Functional instability of the ankle: differences in pat-
terns of ankle and knee movement prior to and post landing in a single leg jump.
Int J Sports Med 2002; 23(1):64–68.
36. Hoch MC, Farwell KE, Gaven SL et al. Weight-bearing dorsiflexion range of
motion and landing biomechanics in individuals with chronic ankle instability.
J Athl Train 2015; 50(8):833–839.
37. McKeon PO, Hertel J. Systematic review of postural control and lateral ankle
instability, part II: is balance training clinically effective? J Athl Train 2008;
43(3):305–315.
38. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate
screening test? Clin Rehabil 2005; 19(6):662–667.
39. Kaminski TW, Hertel J, Amendola N et al. National Athletic Trainers’ Association
position statement: conservative management and prevention of ankle sprains
in athletes. J Athl Train 2013; 48(4):528–545.
40. Kosik K, Terada M, McCann R et al. Comparison of two rehabilitation protocols on
patient and disease oriented outcomes in chronic ankle instability individuals.
Int J Athl Ther Train 2017; 22(3):57–65.