Effects of exercise therapy on dynamic posture control and self-report function in individuals with chronic ankle instability: a systematic review with pairwise and network meta-analysis.

TL;DR

A network meta-analysis of 48 trials found that visual occlusion balance training and blood flow restriction training produced the largest improvements in dynamic posture control and self-reported function in people with chronic ankle instability, though evidence certainty remains very low across all interventions.

What the Study Found

Chronic ankle instability (CAI) affects roughly 40% of people who experience an ankle sprain, characterized by recurrent giving way, persistent instability, and impaired postural control. Treatment typically relies on exercise therapy, but clinicians and patients have lacked clear guidance on which approach works best. This systematic review and network meta-analysis synthesized 48 randomized controlled trials involving 1,630 individuals to directly compare seven different exercise therapies.

The headline finding: all seven exercise approaches significantly improved dynamic posture control, a key marker of ankle stability. However, some stood out. Visual occlusion balance training, where participants performed balance exercises with eyes closed or obscured vision, produced notably stronger improvements in dynamic postural control compared to plyometric training (the effect size difference was 0.72 points on a standardized scale, suggesting a clinically meaningful advantage). The research team found that visual occlusion training and blood flow restriction training delivered the largest gains in self-reported function, a measure of real-world ankle stability and confidence during daily activities. Blood flow restriction training, which applies controlled pressure to reduce blood flow during exercise, showed an effect size of 1.49 compared to standard strength training. Visual occlusion training showed an effect size of 0.90 over strength training.

Notably, whole-body vibration training was the only approach that failed to show clear benefits for self-reported function, though the authors noted this was partly due to limited available evidence rather than evidence of harm. Comprehensive training programs that combined multiple modalities improved both measures, reinforcing that exercise remains the foundation of CAI management. The authors evaluated the quality of evidence as very low across all comparisons, meaning confidence in these rankings should be tempered by the reality that many included trials were small, used different outcome measures, and varied substantially in intervention duration and intensity.

This work matters because chronic ankle instability reduces quality of life, increases injury risk in athletic populations, and can accelerate joint degeneration. Exercise is more effective than no treatment, but determining which exercise type offers the best return on effort has remained unclear. The network meta-analysis approach allowed researchers to rank interventions even when direct head-to-head comparisons didn't exist, creating a practical hierarchy for clinical decision-making. However, the "very low" certainty designation means these rankings may shift as higher-quality evidence accumulates.

What This Means for You

If you have chronic ankle instability, this analysis suggests your rehabilitation should prioritize structured exercise over inactivity, but the choice of which type matters less than consistency. The evidence points toward potential advantages for visual occlusion balance training (essentially balance work with eyes closed) and blood flow restriction training (which requires equipment and usually professional supervision), but both approaches remain understudied compared to conventional strength and balance training.

Practical implementation: start with standard balance training and resistance training if those are accessible, as the evidence supporting them is stronger in absolute terms even if effect sizes are slightly smaller. If progress plateaus, consider consulting a physical therapist about visual occlusion progressions or blood flow restriction methods. The very low certainty of evidence means individual response varies considerably; what works best for your ankle depends on factors the trials didn't capture: your baseline strength, proprioceptive awareness, sport or activity demands, and training adherence.

Rehabilitation timelines matter too. Most included studies ran 4 to 12 weeks of intervention. Expecting improvement in postural control and self-reported function within that window is reasonable, but building durable ankle stability often requires several months of consistent work. The fact that all seven approaches improved postural control suggests that the quality of execution and consistency matter more than selecting the theoretically optimal modality.

Study Details

Sources

Deng Z, et al. Effects of exercise therapy on dynamic posture control and self-report function in individuals with chronic ankle instability: a systematic review with pairwise and network meta-analysis. EFORT Open Rev. 2025. PubMed ID: 42227253