Glenn Wellmann DPT

If your ankle has rolled once and never felt trustworthy since, you have probably been handed a wobble board and told to stand on one leg. Fair enough, balance work belongs in the plan. The question this study asks is sharper: out of everything a physical therapist can do for a chronically unstable ankle, which combination actually delivers the most?

The study, briefly

A research team ran a network meta-analysis of randomized controlled trials of non-surgical treatments for chronic ankle instability, searching PubMed, Cochrane, Embase, Scopus, and CINAHL through December 2023. They pooled 44 trials and compared treatments across 8 outcomes, including self-reported daily function and sport function on the Foot and Ankle Ability Measure, the Cumberland Ankle Instability Tool, three directions of the Star Excursion Balance Test, ankle dorsiflexion motion, and pain (Yang et al., Journal of Orthopaedic and Sports Physical Therapy, 2025;55(1):26-44).

Chronic ankle instability is the label for what happens after a sprain that never fully resolved: repeated giving way, a sense that the ankle cannot be trusted on uneven ground, and lingering symptoms months or years later. A network meta-analysis matters here because it lets you compare treatments that were never tested head to head in the same trial, then rank them. The ranking statistic is called SUCRA, expressed as a percentage, where a higher number means a treatment more often landed near the top across the network.

What they found

One pairing showed up at or near the top of almost every outcome, and it was not balance training by itself.

• Balance plus strengthening exercise, augmented with hands-on manual therapy, ranked first for function. SUCRA was 95.2 percent for daily living function and 87.9 percent for sport function.
• The same combination dominated dynamic balance. On the Star Excursion Balance Test it ranked first in all three directions: 92.1 percent anterior, 98.0 percent posteromedial, and 90.8 percent posterolateral.
• For pain, balance plus strengthening augmented with either manual therapy or dry needling topped the list at a SUCRA of 99.9 percent.
• Two niche winners. Multimodal exercise plus manual therapy ranked highest for dorsiflexion range of motion at 61.6 percent, and tai chi ranked highest for perceived stability at 99.9 percent.

Read the pattern rather than the individual numbers. Balance and strengthening together formed the base of every top-ranked option. What changed the ranking was what got added on top of that base, most often a hands-on component from a clinician.

The catch

SUCRA is a probability ranking, not an effect size. A treatment can rank first while the real difference between it and the runner up is small, uncertain, or clinically meaningless. The published record reports no mean differences and no confidence intervals for these rankings, and follow-up lengths are not stated, so we cannot tell whether these advantages hold at six months or a year.

The network is also built from 44 heterogeneous trials, most of them small, using different exercise doses and different definitions of instability. Add the fact that manual therapy and dry needling are difficult to blind, and some of the advantage for the hands-on add-ons could reflect attention and expectation rather than the technique itself. I read this study as a direction to lean, not proof of superiority. That is the same caution I applied to the evidence on dry needling after rotator cuff repair, where the honest answer was more modest than the marketing.

What this means for you

If your ankle keeps giving way, here is how I would translate this into a plan.

1. Keep the balance work, but stop treating it as the whole program. Single-leg stance progressions, eyes closed variations, and unstable surfaces still belong there. They were the base of every winning combination, never the winner alone.
2. Add real strength, especially at the outside of the ankle. Banded eversion and inversion, 3 sets of 15 each, plus heel raises loaded to the 8 to 12 rep range, 3 to 4 sets, two or three times a week. Do not skip the hip. Single-leg deadlifts and lateral band walks give the ankle a more stable platform to work from.
3. Layer in hopping and cutting before you call it done. Function and sport scores improved most in programs that were doing real work, not just standing still. Line hops, then lateral hops, then decelerations and change of direction at controlled speed.
4. Consider a hands-on component if you are stalling. Joint mobilization to restore dorsiflexion, or functional dry needling if the calf and peroneal muscles are guarded and painful, are reasonable additions on top of the exercise base. Neither replaces the exercise.
5. If confidence is the main problem, treat confidence. Tai chi topping the perceived stability outcome is a useful hint that slow, controlled, weight-shifting practice moves how safe an ankle feels, which is often what stops people from getting back to the trail or the ice.

Give it eight to twelve weeks of consistent work before you decide it is not working. Progress in chronic ankle instability shows up as fewer giving-way episodes and more confidence on uneven ground, not as a single pain-free day. This is the same load-and-progress logic behind what the evidence supports for lateral hip pain: build capacity first, add the adjuncts second.

Where to go from here

The trap with an unstable ankle is going back to sport on the basis of feeling ready rather than testing ready. Return-to-sport testing puts numbers on it: hop tests, side-to-side comparisons, and change of direction under fatigue, so you know whether the ankle can handle the season instead of guessing. If you are earlier than that and just want the right combination built for your ankle, a comprehensive evaluation gives you a full hour, one on one, and a written progression you leave with.

References

• Yang YS, Lai PC, Liu ZW, Fang CJ, Tu YK, Chang CH, Huang MT, Wu PT, Su WR, Hong CK, Kuan FC, Hsu KL, Chang CW, Lin CJ, Shih CA. What Will Deliver the Best Bang-For-Your-Treatment-Buck? Treatment Effects of Physical Therapy Approaches to Managing Chronic Ankle Instability: A Network Meta-Analysis of Randomized Controlled Trials. Journal of Orthopaedic and Sports Physical Therapy. 2025;55(1):26-44. doi:10.2519/jospt.2024.12601. https://pubmed.ncbi.nlm.nih.gov/39741454/