Clinical Biomechanics 54 (2018) 28–33

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Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

Predictors of chronic ankle instability: Analysis of peroneal reaction time, T

dynamic balance and isokinetic strength☆
⁎
Rafael Sierra-Guzmán, Fernando Jiménez, Javier Abián-Vicén
Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, Toledo, Spain

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Previous studies have reported the factors contributing to chronic ankle instability, which could
Electromyography lead to more effective treatments. However, factors such as the reflex response and ankle muscle strength have
Ankle instability not been taken into account in previous investigations.
Isokinetic Methods: Fifty recreational athletes with chronic ankle instability and 55 healthy controls were recruited.
Dynamic balance
Peroneal reaction time in response to sudden inversion, isokinetic evertor muscle strength and dynamic balance
with the Star Excursion Balance Test and the Biodex Stability System were measured. The relationship between
the Cumberland Ankle Instability Tool score and performance on each test was assessed and a backward multiple
linear regression analysis was conducted.
Findings: Participants with chronic ankle instability showed prolonged peroneal reaction time, poor performance
in the Biodex Stability System and decreased reach distance in the Star Excursion Balance Test. No significant
differences were found in eversion and inversion peak torque. Moderate correlations were found between the
Cumberland Ankle Instability Tool score and the peroneal reaction time and performance on the Star Excursion
Balance Test. Peroneus brevis reaction time and the posteromedial and lateral directions of the Star Excursion
Balance Test accounted for 36% of the variance in the Cumberland Ankle Instability Tool.
Interpretation: Dynamic balance deficits and delayed peroneal reaction time are present in participants with
chronic ankle instability. Peroneus brevis reaction time and the posteromedial and lateral directions of the Star
Excursion Balance Test were the main contributing factors to the Cumberland Ankle Instability Tool score. No
clear strength impairments were reported in unstable ankles.

1. Introduction
After their first ankle sprain, patients can suffer residual symptoms
such as pain, swelling, recurrent sprains, episodes of the ankle joint
“giving away” or decreased function (Arnold et al., 2009b; Delahunt
et al., 2010), which is referred to as Chronic Ankle Instability (CAI)
(Delahunt et al., 2010). Among self-reported outcome instruments that
are commonly used to determine the presence of CAI, one of the most
employed is the Cumberland Ankle Instability Tool (CAIT) (Arnold
et al., 2009b; Hiller et al., 2006), a questionnaire that also assesses the
severity of the instability, with a lower score meaning decreased ankle
function.
Several authors have associated CAI with certain deficits, but results
are equivocal. While some studies have reported a delayed reaction
time (RT) in ankles with CAI (Donahue et al., 2014; Hoch and McKeon,
2014; Mendez-Rebolledo et al., 2015), no differences have been found
in other studies (Eechaute et al., 2009; Munn et al., 2010). Similarly,
some authors have associated CAI with ankle weakness (Arnold et al.,
2009b; Willems et al., 2002), whereas no deficits have been reported by
others (Kaminski and Hartsell, 2002). Furthermore, dynamic balance
impairments have also been found in participants with CAI (Arnold
et al., 2009a; Munn et al., 2010).
These deficits have been connected to CAI individually and with
conflicting findings (Thompson et al., 2016). A few studies have taken a
multifactorial approach (Houston et al., 2015; Rosen et al., 2016).
Houston et al. (2015) analysed the prevalence of clinician and labora-
tory-oriented measures of function capable of explaining health-related
quality of life in individuals with CAI. It was found that postural con-
trol, dorsiflexion range of motion, plantar cutaneous sensation, and
ankle arthrometry contributed to a significant proportion of the var-
iance associated with health-related quality of life. Rosen et al. (2016)
examined how the active range of motion, dynamic postural stability
and lateral ankle laxity and stiffness contribute the most to self-reported
dysfunction as measured by the CAIT (Hiller et al., 2006). Previous

☆
All the authors declare that they have no conflict of interest derived from the outcomes of this study. This study did not receive any funding.
⁎
Corresponding author at: University of Castilla-La Mancha, Avda. Carlos III s/n, Toledo 45071, Spain.
E-mail address: javier.abian@uclm.es (J. Abián-Vicén).

https://doi.org/10.1016/j.clinbiomech.2018.03.001
Received 3 August 2017; Accepted 5 March 2018
0268-0033/ © 2018 Elsevier Ltd. All rights reserved.
R. Sierra-Guzmán et al.
Fig. 1. (a) Participant waiting on the custom-designed ankle inversion platform, (b) Participant after the opening of the platform causing an ankle inversion of 30°.
studies have identified balance measures as one of the contributing
factors to CAI from a multifactorial approach (Hartsell and Spaulding,
1999). Other functional measures such as the reflex response or ankle
muscle strength have been broadly studied individually, and have been
found to be impaired in individuals with CAI (Hertel et al., 2006).
However, research is lacking about the contribution of these functional
measures to CAI using comparative factor analysis. Identifying the
strongest contributors to CAI may help clinicians to develop more ef-
fective rehabilitation strategies to address this clinical condition.
Therefore, the aim of this study was to analyse peroneal RT, dynamic
balance and strength in participants with CAI compared to healthy
participants, and to determine what factors contribute the most to CAI.
Based on previous literature, it was hypothesised that peroneal RT,
dynamic balance and isokinetic strength would be impaired in unstable
ankles and be the main contributing factors to CAI.
2. Methods
2.1. Participants
One hundred and five recreational athletes volunteered to partici-
pate in the study. They were divided into a CAI group (n = 50, age:
22.6 (2.8) years, height: 172.0 (9.2) cm, body mass: 69.1 (10.1) kg,
CAIT: 19.5 (3.4) points), and a healthy group (n = 55, age: 20.9 (1.9)
years, height: 172.0 (7.9) cm, body mass: 66.5 (10.8) kg, CAIT: 28.7
(1.4 points). Sample size was previously calculated based on Linens
et al. (2014), who measured posteromedial reach direction comparing
participants with and without CAI. The minimal number of subjects
required for obtaining a power of 0.9 and a bilateral alpha level of 0.05
was calculated to be 50.
Participants in the CAI group were included if they reported a his-
tory of at least 1 significant ankle sprain (the most recent injury must
have occurred > 3 months prior to study enrolment), 2 or more
29
Clinical Biomechanics 54 (2018) 28–33
episodes of the ankle giving way in the last 6 months and a score of
≤24 on the CAIT (Hiller et al., 2006) in their dominant ankle. All
subjects had right dominant legs (the one they would use to kick a ball)
(Hertel et al., 2006). Exclusion criteria for both groups included a
history of previous surgeries to the musculoskeletal structures in either
lower extremity, a history of a fracture in either lower extremity re-
quiring realignment, or an acute injury to musculoskeletal structures of
other joints in the lower extremity in the previous 3 months that im-
pacted joint integrity and function, resulting in at least 1 interrupted
day of desired physical activity (Gribble et al., 2014). Each participant
was informed of the risks and discomforts associated with this in-
vestigation and signed an informed consent document before the onset
of the experiments. The experimental protocol was approved by the
Ethics Committee of Clinical Research at the Hospital Complex in To-
ledo (Spain).
2.2. Procedures
A cross-sectional design was used for the study. The first day par-
ticipants completed the CAIT, were familiarised with the testing pro-
cedure and each participant's position on the dynamometer was re-
corded to ensure that the test was always carried out under the same
conditions. Forty-eight hours later measurements were taken in the
following order: 1. Peroneal RT, 2. Balance test on the Biodex Stability
System (BSS), 3. Star Excursion Balance Test (SEBT), 4. Isokinetic
strength test. All tests were performed at the same time of day (between
9 am and noon). Individual testing procedures are described below.
2.2.1. Peroneal reaction time test
RT of the peroneus longus (PL) and peroneus brevis (PB) were
measured. Surface electrodes (Ag/AgC1 sensor, Ambu Blue Sensor N-
00-S/25, Ambu A/S, Ballerup, Denmark) were placed following the
guidelines for surface electromyography in non-invasive muscle
R. Sierra-Guzmán et al.
assessment (Hermens et al., 2000). The skin was shaved and cleaned
with a 70% alcohol solution to ensure correct conductivity of the
myoelectrical pulse. Two electrodes for each muscle were placed with a
10 mm inter-electrode distance and in the direction of the muscle fibres.
A third reference electrode was placed on the tibial tuberosity. The test
was performed on a custom-designed ankle inversion platform capable
of producing a 30° inversion (Fig. 1) (Sierra-Guzman et al., 2017). The
start and the end of the inversion were marked by a double axis goni-
ometer (SG110/A, Biometrics Ltd., Gwent, UK) attached to the platform
doors. To eliminate an anticipatory response of the ankle, participants
wore occlusion glasses and earphones with music. Three trials were
performed with a minimum of 60 and a maximum of 90 s between
trials. The average from three trials was used for the analysis. Muscular
activity was recorded using a portable eight-channel telemetry and data
logger (ME6000-T8, Mega Electronics, Kuopio, Finland) and was ana-
lysed using MegaWin 3.1-b10 software (Mega Electronics, Kuopio,
Finland). Electromyographic signals were amplified with a bandwidth
of 15 to 500 Hz, 14-bit analog-to-digital converter and a common-mode
rejection ratio of 110 dB. The raw signals were sampled at 1000 Hz and
expressed in microvolts (μV). RT was defined as the time from the
platform opening to electromyographic onset determined by an in-
crease greater than twice the noise level (Keles et al., 2014).
2.2.2. Balance test on the biodex stability system
Ankle balance was assessed with the BSS (Biodex Medical Systems,
Shirley, New York, USA). The platform, which is interfaced with com-
puter software (Biodex, Version 1.32, Biodex Medical System), gen-
erates the Overall Stability Index (OSI), the Anterior/Posterior Stability
Index (APSI) and the Medial/Lateral Stability Index (MLSI) from the
degree of tilt. APSI and MLSI represent platform displacements from the
horizontal in the sagittal (Y) and frontal (X) planes respectively, and the
OSI is a composite of the APSI and MLSI. The following formulas were
used: OSI = [(Σ(0-Y)2 + Σ(0−X)2 / samples)]0.5, APSI = [(Σ(0-Y)2 /
samples)]0.5, MLSI = [(Σ(0-X)2 / samples)]0.5 (Cug and Wikstrom,
2014). Higher values represent poorer stability. The platform allows 12
dynamic stability levels with level 12 being the most stable and level 1
the most unstable. The test was performed at level 8 with participants
barefoot in single-leg stance. Participants were asked to step onto the
BSS platform with their eyes open and assume a comfortable position
while keeping their knees slightly flexed (15°), to look straight ahead at
the monitor and to place their hands on their hips. They also had to
keep a cursor, which represents the centre of the platform, in the centre
of the bull's-eye on a visual feedback screen. Three practice trials, to
reduce any learning effects (Cug and Wikstrom, 2014), and three test
evaluations were performed. Each trial lasted 20 s with 10 s rest. The
average of the three test evaluations was used for data analysis.
2.2.3. Star excursion balance test
The SEBT, as previously described (Hertel et al., 2006; Robinson
and Gribble, 2008), was performed with the participants standing
barefoot in the middle of a grid formed by eight tape measures ex-
tending out at 45° from each other, each of which was labelled ac-
cording to the direction of excursion in relation to the standing leg. The
stance foot was centred on the grid aligned with the anterior and pos-
terior directions. A verbal and video instruction was given to each
participant before the test. Participants were asked to maintain a single-
stance on the unstable ankle while reaching with the contralateral leg to
touch lightly as far as possible along the chosen direction with the most
distal part of their foot and then return to a bilateral stance. A stan-
dardised protocol of 4 practice trials followed by 3 test trials was per-
formed in each of the eight directions to minimise the learning effect
(Robinson and Gribble, 2008). Reach distances were measured by the
same researcher by making a mark on the tape measure. The average of
the three test trials normalised for length of the stance leg was used for
analysis. Participants' legs were measured with the subjects lying supine
from the anterior superior iliac spine to the distal tip of the medial
30
Clinical Biomechanics 54 (2018) 28–33
malleolus using a standard tape measure. A trial was discarded and
repeated if (1) balance was lost, (2) any part of the foot was lifted or
moved from the centre grid, (3) hands did not remain on hips, or (4) the
reach leg provided support upon touching down (Mendez-Rebolledo
et al., 2015).
2.2.4. Isokinetic strength test
Ankle evertor muscles were tested on a Biodex Multi-Joint System 3
dynamometer (Biodex Medical System, New York, USA) at three dif-
ferent velocities: 60, 180 and 300° per second for eccentric and con-
centric contractions. The test protocol was similar to that described in
the study by Keles et al. (2014). Participants warmed up for 10 min,
first using general range of motion and stretching exercises for joint
movements of inversion/eversion on the floor, and then performing 3
submaximal repetitions on the dynamometer. Participants sat on the
Biodex chair with the backrest at an angle of 70°. The limb was fixed by
a strap and the foot was attached to the footplate with two straps.
Participants were positioned with a 90° knee flexion, the lower leg
parallel to the floor, the subtalar joint in a neutral position and the
rotational axis of the dynamometer at the subtalar joint level. All par-
ticipants took the test in sports shoes to minimise the loss of force
transmission to the dynamometer and range of motion was reduced by
10° (Keles et al., 2014). Participants performed 5 repetitions for each
test velocity, and eccentric and concentric contractions were executed
in a continuous alternating manner. Encouragement and visual feed-
back from the computer screen was given to ensure maximal effort.
Evertor muscle strength was measured as the peak torque normalised
for body mass during isokinetic concentric and eccentric contractions.
Eccentric to concentric isokinetic strength ratios (E/C ratios) were also
calculated.
2.3. Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics v.22.0.h
The level of significance was set at P < 0.05. The normality of each
variable was initially tested with the Kolmogorov-Smirnov test. All the
variables presented a normal distribution. Independent sample t-tests
were used to compare performance in each test between the CAI and
healthy group. The effect size was calculated in all pairwise compar-
isons according to the formula proposed by Glass et al. (1981). The
magnitude of the effect size was interpreted as low (0.20), medium
(0.50) and high (0.80) (Cohen, 1988). Pearson product moment cor-
relation coefficients (r) were calculated to analyse the relationship be-
tween the CAIT score and performance on each test. A backward
multiple linear regression analysis was conducted with the Cumberland
Ankle Instability Tool serving as the criterion variable and the variables
from each measure serving as explanatory variables. Only variables
with a significant Pearson correlation (P < 0.05) were entered into the
regression model.
3. Results
Results of the comparison between groups are presented in Table 1.
Participants in the CAI group showed prolonged RT in the PB and PL
(P = 0.001), poor performance in the OSI (P = 0.003), APSI
(P = 0.036) and MLSI (P = 0.005) of the BSS and decreased reach
distance (P < 0.001) for the eight directions of the SEBT. No sig-
nificant differences were found in eversion and inversion peak torque. A
significant difference (P = 0.020) between groups was only evident in
the E/C ratio at 180°·s−1, where participants in the CAI group showed a
higher ratio.
Results of correlation analyses between the CAIT score and perfor-
mance on each test are shown in Table 2. Significant moderate corre-
lations (r > 0.30) were found between the CAIT score and the RT of
the PL and PB and all the directions of the SEBT except for the AL.
Significant small correlations (r < 0.30) were found between the CAIT
R. Sierra-Guzmán et al. Clinical Biomechanics 54 (2018) 28–33

Table 1
Differences between groups.

CAI Healthy P value Effect size 95% CI

Reaction time
Peroneus brevis (ms) 59.71 (9.15) 50.84 (8.34) < 0.001⁎ 1.064 −12.27, −5.47
Peroneus longus (ms) 58.75 (11.37) 49.11 (8.78) < 0.001⁎ 1.097 −13.55, −5.72

BSS
OSI 1.30 (0.65) 0.98 (0.38) 0.003⁎ 0.840 −0.53, −0.11
APSI 0.80 (0.40) 0.65 (0.30) 0.036⁎ 0.482 −0.28, −0.01
MLSI 0.91 (0.54) 0.66 (0.27) 0.005⁎ 0.906 −0.41, −0.07

SEBT
Anterolateral (cm) 70.21 (7.53) 75.37 (7.27) 0.001⁎ 0.709 2.29, 8.02
Anterior (cm) 81.65 (6.70) 87.21 (5.71) < 0.001⁎ 0.975 3.16, 7.97
Anteromedial (cm) 84.41 (6.93) 91.53 (4.61) < 0.001⁎ 1.544 4.86, 9.38
Medial (cm) 88.77 (7.69) 96.54 (6.36) < 0.001⁎ 1.223 5.05, 10.50
Posteromedial (cm) 92.99 (9.43) 102.62 (5.56) < 0.001⁎ 1.729 6.58, 12.67
Posterior (cm) 95.09 (10.35) 103.83 (5.64) < 0.001⁎ 1.551 5.46, 12.03
Posterolateral (cm) 87.27 (9.70) 96.31 (5.67) < 0.001⁎ 1.594 5.92, 12.17
Lateral (cm) 75.31 (10.03) 84.53 (7.53) < 0.001⁎ 1.224 5.81, 12.63

ConPT (Nm·kg−1)
60° ·s−1 29.61 (7.41) 29.72 (7.84) 0.944 0.014 −2.87, 3.08
180° ·s−1 24.18 (7.07) 26.17 (7.01) 0.155 0.284 −0.77, 4.75
300° ·s−1 23.87 (8.00) 24.46 (6.67) 0.680 0.089 −2.25, 3.44

EccPT (Nm·kg−1)
60°·s−1 34.81 (8.57) 34.56 (8.63) 0.878 0.030 −3.59, 3.08
180°·s−1 35.02 (6.97) 34.57 (8.50) 0.767 0.053 −3.50, 2.59
300°·s−1 33.78 (8.51) 35.00 (7.79) 0.444 0.156 −1.94, 4.40

E/C Ratios
60°·s−1 1.19 (0.15) 1.17 (0.11) 0.562 0.182 −0.07, 0.04
180°·s−1 1.51 (0.38) 1.35 (0.27) 0.020⁎ 0.593 −0.29, −0.03
300°·s−1 1.48 (0.37) 1.52 (0.57) 0.683 0.070 −0.15, 0.23

Values are mean (SD). BSS = Biodex Stability System; OSI = Overall Stability Index; APSI = Anterior/Posterior Stability Index; MLSI = Medial/Lateral Stability Index; SEBT = Star
Excursion Balance Test; ConPT = Concentric Peak Torque; EccPT = Eccentric Peak Torque; E-C Ratios = eccentric to concentric isokinetic strength ratios.
⁎
P < 0.05.

score and the OSI and MLSI of the BSS, the AL direction of the SEBT and
the E/C ratio at 180°·s−1. The model that was able to explain the
greatest amount of variance was obtained using the predictor variables
of RT of the PB and the posteromedial and lateral directions of the
SEBT. The regression model (Table 3) explained 36% of the variance
(R = 0.60, R2 = 0.36, F = 18.10, P = 0.000) for the CAIT.
4. Discussion
The most important finding in this study was that deficits in per-
oneal RT and dynamic balance were associated with CAI, the RT of the
PB and the posteromedial and lateral directions of the SEBT being the
main contributing factors. However, the null hypothesis that isokinetic
strength would be impaired in unstable ankles could not be accepted
because no clear differences were found compared to healthy ankles.
In the present study, significant prolonged RT in the PB and PL
within the CAI group was found compared with the healthy group
showing a strong effect size. A moderate correlation was also evident
between the CAIT score and the peroneal RT. This could indicate ar-
ticular differentation in the unstable ankles, leading to alterations in
neuromuscular control (Gutierrez et al., 2012). Previous studies have
also identified delayed RT in the peroneal muscles (Donahue et al.,
2014; Mendez-Rebolledo et al., 2015). As in the present study, Mendez-
Rebolledo et al. (2015) found significant differences using an inversion
platform capable of producing a 30° inversion. A longer response time
in peroneal muscles has also been identified during sudden 30° inver-
sion while walking (Donahue et al., 2014). These results do not agree
with the meta-analysis by Munn et al. (2010) where deficits in peroneal
muscle RT following perturbation were not evident. However, these
conflicting results may be due to methodological differences. In a more
recent systematic review (Hoch and McKeon, 2014), the lack of con-
sistency in the findings was attributed to patient recruitment. Some
studies include a broader spectrum of patients reporting diverse his-
tories of ankle sprains. Hoch and McKeon (2014) concluded that in-
dividuals with CAI exhibit delayed peroneal RT, whereas no deficits are
evident in those with a variety of different ankle sprain histories. In our
study, all the participants in the CAI group were recruited following the
selection criteria established by the International Ankle Consortium
(Gribble et al., 2014). Differences among studies could be also because
of the sprain simulation. For example, most of the studies that have
reported a delay in peroneal RT used an inversion test with around
20–37° inversion, whereas Eechaute et al. (2009) reported no differ-
ences in RT using a 50° inversion test.
It also was found that participants with CAI showed a poor perfor-
mance on the dynamic balance test compared to a healthy group,
confirming previous studies (Arnold et al., 2009a; Munn et al., 2010;
Rahnama et al., 2010). On the BSS, Rahnama et al. (2010) found that
participants with CAI had poor stability on the OSI and the MLSI. Si-
milarly, in the present study, participants in the CAI group showed a
poor performance in the OSI and the MLSI, but also in the APSI.
However, correlations between the CAIT and the performance on the
BSS were only found with the OSI and MLSI. On the SEBT, participants
with CAI reached a shorter distance in all the directions, which supports
findings from previous research (Doherty et al., 2016; Hertel et al.,
2006; Hoch et al., 2012). Hertel et al. (2006) found that the poster-
omedial, anteromedial, and medial directions were all able to dis-
criminate between healthy and unstable ankles, the posteromedial di-
rection being the most representative. Similarly, in our study the
highest effect size was found in the posteromedial direction. Also, the
highest correlations between the CAIT score and the reach distance in
the directions of the SEBT was found in the anteromedial, poster-
omedial, posterolateral and lateral directions. Doherty et al. (2016) also
found a shorter reach distance in unstable ankles in the anterior, pos-
teromedial and posterolateral direction, whereas other studies only

31
R. Sierra-Guzmán et al. Clinical Biomechanics 54 (2018) 28–33

Table 2 functional test and found that evertor muscle weakness in unstable
Correlations. ankles was only revealed by the functional assessment. Neuromuscular
control, which plays a determinant role in participants with CAI
CAIT score
(Gutierrez et al., 2009), may not be sufficiently challenged by the iso-
r Value P value kinetic strength test. This could explain why in the present study defi-
cits were only reported in the reaction time test and in the balance tests.
Reaction time
These tests compared to the isokinetic strength test, demand greater
Peroneus brevis −0.409⁎ < 0.001
Peroneus longus −0.403⁎ < 0.001 neuromuscular control to respond to postural control perturbations
than a simple isokinetic contraction on a Biodex dynamometer.
BSS
OSI −0.280⁎ 0.004
When the variables with a significant correlation with the CAIT
APSI −0.159 0.108 score were entered into the regression analysis, a model representing
MLSI −0.287⁎ 0.003 36% of the variance was obtained. The largest effect on the CAIT score
SEBT was found on RT of the PB (β = 0.34), followed by the posteromedial
Anterolateral 0.221⁎ 0.024 (β = 0.26) and lateral (β = 0.21) directions of the SEBT. As in the
Anterior 0.315⁎ 0.001 present study, previous studies (Houston et al., 2015; Rosen et al.,
Anteromedial 0.437⁎ < 0.001
2016), have proposed dynamic balance as a predictor variable for CAI.
Medial 0.388⁎ < 0.001
Posteromedial 0.451⁎ < 0.001 However, to our knowledge, this is the first study to have included the
Posterior 0.370⁎ < 0.001 RT from a multifactorial approach. More research is necessary to con-
Posterolateral 0.460⁎ < 0.001 firm these results, but RT appears to be the most determinant factor to
Lateral 0.422⁎ < 0.001 assess ankle instability. From among the directions of the SEBT, the
ConPT posteromedial was the variable with the highest contribution to the
60°·s−1 0.081 0.416 CAIT, confirming previous studies where this direction was the most
180°·s−1 0.146 0.143
representative in participants with CAI (Hertel et al., 2006; Linens
300°·s−1 0.091 0.356
et al., 2014). The relevance of the lateral direction can be explained by
EccPT
the findings of Doherty et al. (2016), who reported the most deficits in
60°·s−1 0.032 0.749
180°·s−1 −0.025 0.803
the posterolateral direction in participants with CAI compared with
300°·s−1 0.113 0.255 both lateral ankle sprain copers and controls using a simplified version
E/C ratios
of the SEBT. In this direction participants with CAI displayed lesser
60°·s−1 −0.123 0.216 knee flexion and ankle dorsiflexion at the point of maximum reach,
180°·s−1 0.199⁎ 0.046 along with a reduced fractal dimension of the centre of pressure path.
300°·s−1 0.021 0.835 The lateral direction was not analysed by Doherty et al. (2016), how-
ever, as the movement pattern to reach the lateral direction is similar to
CAIT = Cumberland Ankle Instability Tool; BSS = Biodex Stability System; OSI = Overall
Stability Index; APSI = Anterior/Posterior Stability Index; MLSI = Medial/Lateral
the posterolateral direction, it could be hypothesised that an alteration
Stability Index; SEBT = Star Excursion Balance Test; ConPT = Concentric Peak Torque; in the movement pattern of the lateral direction is also present.
EccPT = Eccentric Peak Torque; E-C Ratios = eccentric to concentric isokinetic strength There are some limitations in this study. First, as mentioned pre-
ratios. viously, it is possible that even though strength deficits were present in
⁎
P < 0.05. unstable ankles, the testing protocol was unable to detect them.
Another limitation was that the sample only included recreational
Table 3 athletes, which means that results are not applicable to other popula-
Regression model for variables predicting the Cumberland Ankle Instability Tool
tions such as professional athletes, sedentary or elderly people with
(N = 105).
CAI. Although all participants were in a good state of health, balance
Variable B SE B β P value measures could be affected by factors such as concussions or inner ear
problems that were not taken into account. Furthermore, it was not
Peroneus brevis −0.180 0.044 −0.343 < 0.001
recorded if participants followed a rehabilitation program before the
Posteromedial direction 0.150 0.062 0.264 0.017
Lateral direction 0.111 0.056 0.212 0.049 recruitment, which could affect our measures. The order of testing was
not randomised among participants, and, therefore, fatigue and/or
learning could have impacted study results. Also, results from peroneal
reported deficits in the posteromedial (Linens et al., 2014) or the reaction time should be considered with caution because of the sprain
anterior direction (Hoch et al., 2012). simulation test. The highest incidence of ankle sprain occurs in athletes
In the isokinetic strength analysis, deficits were not evident in competing in indoor and court sports during dynamic conditions such
participants with CAI. However, participants with CAI showed a sig- as landings or contacts (Doherty et al., 2014), whereas the test used in
nificantly higher E/C ratio at 180°·s−1 because of weaker non-sig- the present study was developed in a static condition. Finally, for fur-
nificant concentric peak torque at this velocity. Contrary to our results, ther research, it would be necessary to make comparisons between not
in a previous study (Hartsell and Spaulding, 1999), differences were only patients with and without CAI, but also between groups with
found in the peak torque but not in the E/C ratios. Findings from the different severity of CAI.
literature are equivocal. For example, Kaminski and Hartsell (2002)
concluded that deficits in isokinetic ankle strength are not connected to
CAI, whereas evertor muscle weakness has been reported in other stu- 5. Conclusions
dies (Arnold et al., 2009b; Willems et al., 2002). Although a significant
difference was found in the E/C ratio at 180°·s−1, based on our results, The results obtained in this study suggest that dynamic balance
we cannot confirm that strength deficits are present in unstable ankles deficits and delayed peroneal RT are present in participants with CAI.
(Donahue et al., 2014). It is possible that the isokinetic test was not RT of the PB and the posteromedial and lateral directions of the SEBT
accurate enough to discriminate between healthy and CAI groups. Re- were the variables analysed which most contributed to the CAIT score.
cently, Terrier et al. (2016) assessed the ability of an isokinetic test to As a significant deficit was only found in the E/C ratio at 180°·s−1 but
discriminate between healthy and CAI participants compared with a not in the rest of velocities and the different peak torques, it was not
possible to affirm that strength impairments are associated with CAI.

32
R. Sierra-Guzmán et al.
Acknowledgments
This research received no specific grant from any funding agency in
the public, commercial or not-for-profit sectors.
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