Chronic ankle instability: the end of standard protocols?

By Ana Espino | Published on March 18, 2026 | 3 min read


Chronic ankle instability (CAI) is a common complication of lateral ankle sprains, with nearly 40% of patients developing persistent symptoms after an initial injury. This condition is characterized by a heterogeneous clinical course, combining proprioceptive deficits, impaired postural control, muscle weakness, and delayed neuromuscular responses, all of which contribute to recurrent sprains and reduced functional performance.  

Despite the well-established benefits of exercise-based rehabilitation, protocols are often standardized and not precisely tailored to the individual deficit profile. Previous research has largely focused on single training modalities, without providing a comprehensive comparison of their effects across the entire sensorimotor system. This lack of prioritization limits the personalization of rehabilitation programs.  

In this context, a systematic review published in 2026 in the Journal of Foot and Ankle Research evaluated the comparative effectiveness of major exercise modalities in patients with CAI. The objectives were twofold: to quantify the impact of each intervention on specific sensorimotor deficits and to propose an evidence-based clinical framework to guide individualized prescription.  

Which exercise targets which deficit?  

The authors included 58 randomized controlled trials involving 2,097 participants. Interventions analyzed included balance training, muscle strengthening, vibration therapy, neuromuscular exercises, 3D approaches such as Tai Chi or dance, and stroboscopic visual training.  

 The results show that exercise significantly improves several key clinical dimensions. Balance training emerges as the most comprehensive modality, with significant improvements in patient-reported function (SMD 0.75), dynamic balance (SMD 0.59), and joint proprioception (SMD −0.68). It also improves concentric inversion and eversion strength, confirming its central role in management.  

Muscle strengthening demonstrates significant benefits on concentric strength and perceived function but does not convincingly improve eccentric strength. This highlights a critical gap in current strategies, as eccentric strength is essential for resisting inversion mechanisms responsible for recurrent sprains.  

Innovative modalities show differentiated efficacy profiles. Stroboscopic training improves dynamic balance and proprioception. Three-dimensional programs enhance function and dynamic stability, while vibration therapy primarily affects balance, with limited impact on muscle strength.  

A particularly notable finding is the significant reduction in muscle reaction time (SMD −8.19), reflecting a marked improvement in reflex neuromuscular control—an essential factor in preventing recurrent sprains.  

These findings enabled the authors to propose a clinical decision-making framework aimed at matching therapeutic modalities to the predominant deficit.

Toward personalized rehabilitation  

Chronic ankle instability remains a complex condition characterized by multiple, patient-specific deficits. The current challenge is no longer simply prescribing exercise, but selecting the most appropriate modality based on the individual functional profile.  

This study confirms that balance training is the cornerstone of rehabilitation while highlighting the value of targeted complementary approaches. Although some modalities are still supported by a limited number of trials and eccentric strength remains insufficiently explored, these results pave the way for a more personalized and stratified rehabilitation approach.  
Ultimately, this strategy could improve therapeutic effectiveness, reduce recurrence risk, and sustainably enhance functional performance in patients with chronic ankle instability.   

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