ORIGINAL RESEARCH

IJSPT ANKLE DORSIFLEXION RANGE OF MOTION

INFLUENCES DYNAMIC BALANCE IN INDIVIDUALS
WITH CHRONIC ANKLE INSTABILITY
Curtis R. Basnett, PT, DPT, ATC1
Michael J. Hanish, PT, DPT2
Todd J. Wheeler, PT, DPT3
Daniel J. Miriovsky, PT, DPT, ATC3
Erin L. Danielson, PT, DPT4
J.B. Barr, PT, DPT, OCS1
Terry L. Grindstaff, PT, PhD, ATC, SCS, CSCS1

ABSTRACT
Purpose/Background: Individuals with chronic ankle instability (CAI) often have impairments in ankle range of
motion (ROM) and balance. There is limited evidence that these impairments are related in individuals with CAI. The
purpose of this study was to determine the relationship between ankle dorsiflexion ROM and dynamic balance in
individuals with CAI.
Methods: Forty-five participants (age=23.2±2.8 y, height=172.1±10.8 cm, mass=70.6±13.3 kg, Foot and Ankle
Ability Measure Sport= 71.2±11.7, Modified Ankle Instability Instrument= 6.4±1.3) volunteered for this study.
Ankle dorsiflexion ROM was measured in a weight-bearing position while dynamic balance was measured using the
Star Excursion Balance Test (SEBT) in the anterior, posteromedial, and posterolateral directions. Linear regression
was used to determine the relationship between ankle dorsiflexion ROM and measures of dynamic balance.
Results: There were fair positive correlations between dorsiflexion ROM and the anterior reach direction (r = .55,
r2= .31, P < .001), posterolateral reach direction (r = .29, r2 = .09, P = .03), and the composite SEBT scores (r = .30,
r2 = .09, P= .02). There was little or no relationship between ankle dorsiflexion and the posteromedial reach direction
(r = .01, r2 = .001, P = .47).
Conclusions: Ankle dorsiflexion ROM can influence dynamic balance, specifically the anterior reach portion of the
SEBT.
Clinical Relevance: Individuals with CAI who demonstrate impairments in dorsiflexion ROM may also demonstrate
difficulty with portions of the SEBT. Clinicians may use this information to better optimize rehabilitation programs that
address ankle dorsiflexion ROM and dynamic balance.
Keywords: Ankle sprain, functional ankle instability, postural control
Level of Evidence: 5

1
Creighton University, Omaha, NE, USA
2
Capitol Orthopaedics & Rehabilitation, Rockville, MD, USA CORRESPONDING AUTHOR
3
Spooner Physical Therapy, Scottsdale, AZ, USA
4
Advanced Physical Therapy, Anchorage, AK, USA Terry L. Grindstaff, PT, PhD, ATC, SCS, CSCS
Study approval was granted by the Institutional Review Board Creighton University, School of Pharmacy &
at Creighton University. This study was supported by a grant Health Professions, Physical Therapy
from the Sports Section of the American Physical Therapy
Association. This trial was registered on ClinicalTrials.gov Department, 500 California Plaza, Omaha,
(NCT01423513). NE 68178.
Note: Basnett, Hanish, Wheeler were all DPT students at the
time of the study. Miriovsky and Danielson were Orthopedic E-mail: [email protected]
Physical Therapy Residents. Phone: 402-280-5674

The International Journal of Sports Physical Therapy | Volume 8, Number 2 | April 2013 | Page 121
INTRODUCTION influence the anterior reach distance in healthy
Lateral ankle sprains are one of the most common individuals.21 Some individuals with CAI have been
lower extremity joint injuries and have a high recur- shown to have a deficit in ankle dorsiflexion ROM2,17
rence rate.1 The clinical manifestation is pain and which has been shown to translate to dynamic tasks
decreased function relating to deficits in strength, such as jogging22 and dynamic balance.17 Recently
range of motion (ROM), and dynamic balance that the relationship between ankle dorsiflexion ROM
can last for weeks after injury.1 Rehabilitation pro- and SEBT reach distances has been explored in
grams often address these impairments, but some individuals with CAI.17 Hoch et al17 reported a mod-
individuals may continue to demonstrate deficits in erate correlation (r = 0.47) between ankle dorsiflex-
ankle dorsiflexion ROM2,3 and balance4-6 which may ion ROM and the anterior reach component of the
contribute to the high risk of injury recurrence.1 The SEBT, while there was not a significant correlation
repetitive frequency of ankle sprains and associated between ankle dorsiflexion ROM and the posterome-
functional limitations has been described as chronic dial (r = 0.28) or posterolateral (r = 0.36) directions.
ankle instability (CAI).2 Mechanical (ligamentous) Although the Hoch et al17 study begins to provide
and functional (neuromuscular control) ankle insta- insight into the relationship between a static mea-
bility can contribute to CAI independently or in com- sure of ankle dorsiflexion ROM and a dynamic bal-
bination.7,8 Rehabilitation is more likely to address ance measure, the methods used to quantify ankle
functional ankle instability while surgery can address motion (distance to wall), measured in centimeters
mechanical laxity. may not be easily interpreted by healthcare profes-
sionals. The use of an inclinometer that provides a
Impairments in both static and dynamic balance measure of motion in degrees is likely more useful
have been shown to be present in individuals with for clinicians to quantify ankle dorsiflexion ROM.
CAI.9-15 These deficits are likely due to altered pro- The purpose of this study was to determine the
prioception and neuromuscular control.7 Most nota- relationship between a weight bearing measure of
bly balance deficits are greatest during dynamic ankle dorsiflexion ROM and SEBT reach distance in
activities.14 A clinical measure of dynamic balance is the anterior, posterolateral, and posteromedial reach
the Star Excursion Balance Test (SEBT) that requires directions as well as the composite SEBT scores in
the individual to maintain balance on a single limb individuals with CAI.
while reaching as far as possible in a predetermined
direction with the opposite limb.16 Greater reach dis- METHODS
tances are indicative of better dynamic balance and
Participants
individuals with CAI have been shown to demon-
Forty-five participants (12 males; 33 females) with
strate reductions in reach distances when compared
unilateral or bilateral CAI volunteered for this study
to their healthy control counterparts.4-6,17 Asymme-
(Table 1). Participants were recruited from the sur-
try between right and left anterior reach distances
rounding university community and metropolitan
(>4 cm)18 and limitations in posterolateral reach
area, but were not necessarily seeking medical care
distances (<80% normalized reach distance)19 have
for ankle pathology. CAI was defined as a history
been shown to be risk factors for lateral ankle sprains
of at least one ankle sprain, repetitive episodes of
and may contribute to CAI.
“giving way”, and diminished self-reported function.
The SEBT requires concurrent mobility and neuro- Mechanical instability or pathological laxity of the
muscular control of the lower extremity in order to ankle joint (ligamentous testing) was not measured
achieve maximal reach distances. The ability to uti-
lize available ROM at the hip, knee, and ankle has
Table 1. Participant demographics. Values are mean ± SD.
been shown to have a strong relationship positive
relationship with reach distance.20,21 Specifically,
sagittal hip and knee motion influence the anterior,
posteromedial, and posterolateral reach distances,20
while ankle dorsiflexion ROM has been shown to

The International Journal of Sports Physical Therapy | Volume 8, Number 2 | April 2013 | Page 122
or quantified. Diminished self-reported function
was defined as scoring 85% or less on the Foot and
Ankle Ability Measure (FAAM) Sport23 or at least 3
on the Modified Ankle Instability Instrument (AII).24
In the event participants reported bilateral CAI (31
participants), the limb with the greatest impair-
ment in ankle dorsiflexion ROM was used for data
analysis. Exclusion criteria were assessed by using a
healthy history form and included any lower extrem-
ity injury/surgery (including lateral ankle sprain)
within the last 6 months (to avoid influence of acute
symptoms), diagnosed ankle osteoarthritis, history
of ankle surgery involving intra-articular fixation,
or current pregnancy. The study was approved by
the Institutional Review Board of Creighton Univer-
sity and all participants signed an informed consent
form prior to participation.

Procedures
Each participant completed an informed consent
form and was screened to match the above inclusion
and exclusion criteria using a standardized health
history form and self-reported outcomes forms
(FAAM and AII). Once inclusion criteria were met,
measures of ankle dorsiflexion ROM and dynamic Figure 1. Ankle dorsiflexion range of motion was measured
balance during the SEBT were obtained bilaterally using a weight bearing lunge. The digital inclinometer was
aligned with the tibial tuberosity and the anterior tibial crest.
with the participants barefoot, with data from the
The participant was instructed to lunge forward, to dorsiflex
involved limb used for statistical analysis. the ankle as far as possible, keeping the heel on the floor. The
angle of the tibia relative to the floor was used to quantify
Ankle Dorsiflexion Range of Motion ankle dorsiflexion ROM.
Ankle dorsiflexion ROM was measured using a digi-
tal inclinometer (Acumar Single Digital Inclinom- Star Excursion Balance Test (SEBT)
eter; Lafayette Instrument Company, Lafayette, The SEBT was used as a functional test to quantify
IN) during a weight-bearing lunge (Figure 1).25-27 dynamic balance. For the current study, participants
The digital inclinometer was aligned with the tibial performed the anterior, posterolateral, and postero-
tuberosity and the anterior tibial crest. The partic- medial reach directions (Figure 2). Participants placed
ipant was instructed to lunge forward by bending their great toe at the zero point of a tape measure,
both knees, to dorsiflex the ankle as far as possi- while the posterolateral and posteromedial directions
ble, keeping the heel on the floor. The angle of the required the participant to place their heel on the
tibia relative to the floor was used to quantify ankle zero point. This foot position was slightly modified
dorsiflexion ROM. Participants were allowed three from the standard SEBT where the geometric cen-
practice trials and then performed three trials, with ter of the foot is aligned with the intersection of the
the average used for data analysis. A previous study crosshairs6 and was altered in order to better standard-
has shown good reliability (ICC3,1 ⱖ 0.99)26 and a ize the starting position of the foot. Participants were
low minimal detectable change (1.5°) in individuals instructed to reach as far as possible with their contra-
with ankle pathology and the authors have demon- lateral limb in the respective reach direction. Reach
strated good reliability (ICC2,3= 0.96) and a minimal distance was quantified as the furthest point the con-
detectable change of 4° in healthy individuals in tralateral foot was able to touch on the tape measure
their laboratory.28 while maintaining balance on the test limb and hands

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 Data Analysis
Linear regression was used to determine the rela-
tionship (r) and explained variance (r2) between
ankle dorsiflexion ROM and SEBT anterior, postero-
medial, and posterolateral normalized reach dis-
tances and composite SEBT scores. Relationships
were interpreted as follows little or no relationship
(r = 0.0-0.25), fair relationship (r = 0.25-0.50), mod-
erate to good relationship (0.50-0.75), good to excel-
lent relationship (r > 0.75).33 The alpha level was
set a priori at P < 0.05 and all statistical analyses
were performed with SPSS Version 19.0 (SPSS Inc.,
Chicago, IL).

RESULTS
Point estimates and standard deviations for the
measures are as follows: dorsiflexion ROM (41.3° ±
7.9°), anterior reach (64.4 ± 6.0%), posteromedial
reach (78.7 ± 8.9%), posterolateral reach (69.1 ±
9.7%), and the composite SEBT score (70.8 ± 6.7%).
There were fair positive correlations between dorsi-
flexion ROM and the anterior reach direction (r =
.55, r2 = .31, P < .001) (Figure 3a), posterolateral
reach direction (r = .29, r2 = .09, P = .03) (Figure
Figure 2. Star Excursion Balance Test was performed in the 3c) and the composite SEBT scores (r = .30, r2 = .09,
anterior, posteromedial, and posterolateral reach directions.
P = .02) (Figure 3d). There was little or no relation-
ship between ankle dorsiflexion and the postero-
on their hips. To record a measurement, the partici-
medial reach direction (r = .01, r2 = .001, P = .47)
pant needed to reach with one lower extremity as far
(Figure 3b).
as possible in the appropriate direction and return to
center without any loss of balance. Each participant
DISCUSSION
was allowed four practice attempts in each direction
The purpose of this study was to determine the rela-
before any measurements were recorded.21,29 Three
tionship between a weight-bearing measure of ankle
trials were performed in a randomized order and the
dorsiflexion ROM and dynamic balance measured
average of three trials in each direction was used for
using the SEBT in participants with CAI. The results
data analysis. A SEBT composite score was also deter-
indicate that there was a significant positive relation-
mined by averaging the three reach directions. Reach
ship between ankle dorsiflexion ROM and dynamic
distances were normalized to limb length (anterior
balance measures in participants with CAI. Ankle
superior iliac spine to the ipsilateral distal medial mal-
dorsiflexion ROM had the strongest relationship (r=
leolus).30 Intersession reliability for the three reach
.55) with the anterior reach direction of the SEBT
directions of the SEBT has been described as good
and explained 31% of the variance in reach distance
(ICC2,1=.74 to .92) for individuals with CAI.31 The ante-
which indicates that mechanical impairments in
rior reach direction demonstrates the best reliability
ankle motion can impact dynamic function during
(ICC2,1=.92), while the posteromedial (ICC2,1=.86)
a balance task.
and posterolateral (ICC2,1=.74) directions have lower
reliability estimates. The minimal detectable change Visual examination during performance of the SEBT
for SEBT normalized reach distances has been pre- reach directions indicates the anterior reach compo-
viously established: anterior (1.8%), posteromedial nent requires the most ankle dorsiflexion in comparison
(3.2%), and posterolateral (5.3%).32 to the other reach directions. In this study ankle dorsi-

The International Journal of Sports Physical Therapy | Volume 8, Number 2 | April 2013 | Page 124
Figure 3. Scatter plots for ankle dorsiflexion range of motion and a) anterior reach, b) posteromedial reach, c), posterolateral
reach, and d) composite SEBT scores. Ankle dorsiflexion range of motion is expressed in degrees and reach distances are expressed
as a percentage of leg length.

flexion ROM was able to explain 31% of the variance particularly in the posteromedial and posterolateral
in the anterior reach distance, which is slightly greater directions. A limitation of this study was that measures
than previously reported explained variance estimates of ROM or strength at other joints were not obtained
of 22% in individuals with CAI.17 Clinically this high- and to date no study has concurrently investigated the
lights the importance of adequate ROM for dynamic kinematic contributions of the entire lower extremity
tasks in individuals with ankle pathology. Furthermore, to reach distances during the SEBT.15,16,28
the current results indicate there is also a relationship,
although small (9% of variance explained), with the pos- The amount of ankle dorsiflexion ROM has been shown
terolateral reach direction and composite SEBT scores. to affect a number of dynamic activities. Ankle dorsi-
The clinical relevance of these measure relationships is flexion ROM has been shown to affect jogging mechan-
likely minimal and may also be due to the calculation ics22 and landing mechanics35 in individuals with CAI,
method of the composite score as it incorporates reach balance in older individuals,36 and squat37,38 and step39
distances in all three test directions. biomechanics in healthy individuals. Limitations in
ankle dorsiflexion have also been shown to be a risk
Although weight-bearing ankle dorsiflexion ROM has factor for lower extremity40 and knee joint pathology41-43
been shown to contribute to dynamic balance in this Additionally an asymmetry between right and left ante-
study and others,17,21 it is not the only contributing fac- rior reach distances (>4 cm)18 and limitations in pos-
tor. There was still a large portion of the variance in terolateral reach distances (<80% normalized reach
reach distances that could not be explained by ankle distance)19 have been shown to be a risk factors for lat-
dorsiflexion ROM. Motion and neuromuscular control eral ankle sprains. This may be a contributing factor
of the lower extremity also likely contribute to SEBT for recurrent ankle sprains experienced by individuals
reach distances. Strength of the hip musculature34 and with CAI. It is possible that impairments in ankle dorsi-
hip and knee flexion motion20 have been shown to flexion ROM may concurrently contribute to decreased
have strong relationships with SEBT reach distances, anterior reach distance and elevated injury risk.

The International Journal of Sports Physical Therapy | Volume 8, Number 2 | April 2013 | Page 125
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