Exercise Therapy for Chronic Ankle Instability: Which Modality for Which Deficit? A Systematic Review and Meta-Analysis.

Fifty-eight randomised controlled trials involving 2097 participants were included in this systematic review and meta-analysis of exercise therapy for chronic ankle instability.

• Studies were identified from searches of 9 electronic databases from inception to 1 September 2025.
• Of the 58 included studies, 28 were rated as low risk of bias, 19 as unclear risk, and 11 as high risk using the Cochrane Risk of Bias tool 2.
• Methodological quality was also assessed using PEDro criteria.
• Two reviewers independently conducted screening and data extraction.

Balance training provided the most comprehensive benefits across sensorimotor outcomes in chronic ankle instability.

• Balance training improved patient-reported function, dynamic balance, joint position sense, concentric strength, and functional performance.
• Balance training was identified as 'foundational' among exercise modalities for CAI.
• Effects were summarised using standard mean difference for sensorimotor indicators.
• Sensitivity analysis and I2 statistics were used to evaluate heterogeneity across studies.

Strength training improved patient-reported function, dynamic balance, and concentric strength in individuals with chronic ankle instability.

• Strength training did not significantly improve eccentric strength based on the meta-analysis results.
• The effects of strength training were more limited in scope compared to balance training.
• Results were derived from the subset of included RCTs examining strength training modalities.

3D, stroboscopic, and neuromuscular training each improved patient-reported function and dynamic balance, with stroboscopic training additionally benefiting joint position sense.

• Stroboscopic training was unique among these modalities in also improving joint position sense.
• 3D and neuromuscular training effects were limited to patient-reported function and dynamic balance.
• These modalities represent targeted rather than comprehensive intervention approaches for CAI sensorimotor deficits.

Vibration training improved only dynamic balance among the sensorimotor outcomes assessed for chronic ankle instability.

• Vibration training did not significantly improve patient-reported function, joint position sense, force sense, concentric strength, eccentric strength, or functional performance.
• This represented the most limited efficacy profile among all exercise modalities examined.
• Results were based on RCTs included in the meta-analysis comparing vibration training against no intervention.

No exercise interventions significantly improved force sense or eccentric strength in individuals with chronic ankle instability.

• Force sense and eccentric strength deficits remained unaddressed by all exercise modalities examined, including balance, strength, vibration, 3D, stroboscopic, and neuromuscular training.
• This finding highlights gaps in current evidence-based exercise prescription for CAI.
• These outcomes were assessed as part of the broader sensorimotor deficit framework used in the review.

The authors proposed an evidence-based framework for deficit-specific exercise prescription in chronic ankle instability based on the distinct efficacy profiles of different exercise modalities.

• The framework positions balance training as foundational for CAI rehabilitation.
• Therapy can be personalised according to specific sensorimotor deficits identified in individual patients.
• The framework was designed to optimise management of the heterogeneous sensorimotor deficits characteristic of CAI.
• The systematic review was registered in the PROSPERO database (CRD42024606683).