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

Abstract

OBJECTIVE: To evaluate the relative efficacy of various physical therapy interventions for chronic ankle instability (CAI). DESIGN: A network meta-analysis of randomized controlled trials. LITERATURE SEARCH: PubMed, Cochrane Library, Embase, Scopus, and CINAHL bibliographic databases were searched up to December 2023. STUDY SELECTION CRITERIA: Randomized controlled trials examining nonsurgical treatments for CAI. DATA SYNTHESIS: We used frequentist network meta-analysis to assess 8 outcomes across 44 trials, including the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) scale or Sport scale, Cumberland Ankle Instability Tool (CAIT), Star Excursion Balance Test (SEBT) in 3 directions (anterior [A], posteromedial [PM], and posterolateral [PL]), dorsiflexion range of motion, and pain. Surface under the cumulative ranking curve (SUCRA) values identified the most effective interventions. RESULTS: Based on SUCRA rankings, a regimen combining balance and strengthening exercises, augmented with either manual therapy or dry needling, was identified as the most effective in enhancing function (SUCRA: FAAM ADL = 95.2% [manual]/83.9% [dry needling]; FAAM Sport = 87.9% [manual]/80.1% [dry needling]), improving dynamic balance (SUCRA [manual]: SEBT-A = 92.1%; SEBT-PM = 98.0%; SEBT-PL = 90.8%), and significantly relieving pain (SUCRA: 99.9%). A multimodal exercise approach combined with manual therapy showed superior efficacy in increasing dorsiflexion (SUCRA: 61.6%). Tai chi emerged as the most promising intervention for improving stability (SUCRA: 99.9%). CONCLUSION: Interventions that emphasized strengthening and balance exercises were the most effective strategy for achieving best function and pain relief for patients with CAI. Multimodal exercises and tai chi might improve ankle range of motion and instability, respectively. J Orthop Sports Phys Ther 2025;55(1):26-44. Epub 20 December 2024. doi:10.2519/jospt.2024.12601.

Keywords: ankle sprain; chronic ankle instability; network meta-analysis; physical therapy; rehabilitation.