Use of Balance Tests to Identify Chronic Ankle Instability


Many people are prone to ankle sprains, and that places them at risk for falls and injury. Identifying and treating chronic ankle instability (CAI) early on can spare patients the foot and ankle pain that comes with a sprain. Once CAI is identified, treatment for ankle pain can center around strengthening and correcting the muscles, connective tissue and nerves that stabilize and govern ankle movement.

There are many assessment tools available for identifying CAI, yet excessive testing can be uncomfortable for patients who suffer from chronic ankle pain. Most of the tests evaluate balance and landing, which requires the patient to hop. Testing for CAI is important before initiating treatment for ankle pain, but how much testing is needed?

Putting CAI Tests to the Test

Traditionally CAI has been identified by having patients complete self-reported questionnaires, yet those tools do not reveal objective information about functional limitations. Researchers wanted to test the efficacy of objective clinical assessments to see if they could differentiate between subjects who had CAI and those who did not. They used ankle injury questionnaires and the Cumberland Ankle Instability Tool (CAIT) to categorize study participants.

Twenty-five of 58 study participants were identified as having CAI, and a control group of 33 participants showed no evidence of CAI. All participants then performed clinical balance tests that included the Time in Balance Test (TIB), Foot Lift Test (FLT), Star Excursion BalanceTest (SEBT), and Single-Leg Hop Test (SLHT), in randomized order. Using test results as data, the study’s authors found that 71% of participants had been assigned to the correct group, when looking at combined results from two, three and four of the tests. The Star Excursion balance test yielded the highest single-test match rate with about 66% accuracy.

Implicatons for Cllinicians

The authors concluded that clinicians could effectively identify CAI using just the Star Excursion Balance test and the single-leg hop test, in conjunction with a self-reported questionnaire. The balance tests offer objective information about ankle functionality, giving clinicians quick clinical tools for assessing CAI. They propose future research to see whether the tests are also useful in evaluating the effectiveness of rehab treatment for chronic ankle pain and instability.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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