











































MANUSCRIPT TYPE


VALIDATION CASE REPORT 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018 
 

Ankle Proprioception Training Program for Preventing Lateral Ankle 
Sprains in Adolescent Basketball Players: A Case Validation Study 
Matthew J. Rivera, DAT, LAT, ATC; Cameron J. Powden, PhD, LAT, ATC; Kenneth E. Games, PhD, LAT, ATC 
Indiana State University, Terre Haute, IN 
 

 
ABSTRACT 

The purpose of this case validation study was to examine the 
effects of a previously established proprioception training 
program on the number of lateral ankle sprains in secondary 
school basketball players. The patient population consisted 
of 22 patients (5 females, 17 males, age = 16±1 years old, 
height = 181.8±8.9 cm, weight = 74.8±12.8 kg) from a 
small rural high school in Illinois. The team completed the 
proprioceptive training program as part of a warm-up 
supervised by the athletic trainer and took approximately 
five minutes to complete. The program was completed every 
day for five weeks with one additional week of maintenance 
exercises. The main outcomes assessed were the number of 
lateral ankle sprains, anterior reach distance from the Y-
Balance Test, and Foot and Ankle Ability Measure (FAAM) 
Sport Scale scores. Data collection occurred at baseline (prior 
to starting the program), week 6, week 12, and follow-up. 
There were a total of 9 lateral ankle sprains and 3 re-injury 
throughout the course of the previous season without using the 
proprioceptive training program. There were 6 lateral ankle 
sprains and only 1 re-injury during this competition season. 
Anterior reach distances on the Y- Balance test improved from 
follow-up to week 6; but decreased from week 6 to week 12 
and follow-up. FAAM Sport scale scores remained consistent 
throughout the duration of the season. The proprioceptive 
training program was effective in reducing the number of 
lateral ankle sprains in the adolescent population and helped 
improve anterior reach distance while patients were 
completing the exercise program. Athletic trainers should 
incorporate more proprioceptive training programs with their 
patient population as primary prevention measures. 
 
Key Phrases 
Injury risk reduction, clinician-rated outcomes, secondary 
school patient population 
 
Correspondence 
Dr. Matthew Rivera, Indiana State University, 567 N. 5th 
Street, Terre Haute, IN 47809. 
E-mail: mrivera11@sycamores.indstate.edu  
Twitter: @Matt_RiveraAT 
 
Full Citation 
Rivera MJ, Powden CJ, Games KE. Ankle proprioception 
training program for preventing lateral ankle sprains in 
adolescent basketball players: A case validation study. Clin 
Pract Athl Train. 2018;1(1):3-10. 
https://doi.org/10.31622/2018/0001.2 
 
Submitted: May 14, 2018 Accepted: May 23, 2018 

ARTICLE CITATION AND SUMMARY 

Schiftan GS, Ross LA, Hahne AJ. The effectiveness 
of proprioceptive training in preventing ankle 
sprains in sporting populations: A systematic 
review and meta- analysis. J Sci Med Sport. 
2015;18:238-244 

We selected a guiding systematic review1 

that examined the evidence regarding the use of 
ankle proprioceptive training programs and its 
influence on ankle sprain rates. The authors 
completed a comprehensive literature search of 
MEDLINE, CINAHL, SPORTDiscus, and PEDro 
through October 2013. Studies were evaluated 
using the following criteria: (1) study design was 
a moderate-to-high level randomized controlled 
trial (4/10 on the PEDro scale), (2) participants 
were physically active (regardless of previous 
ankle injury), (3) intervention group received 
proprioceptive training only compared to a 
control group (no proprioceptive training), and (4) 
the rate of ankle sprains was reported as a main 
outcome. The authors examined the number of 
participants, interventions, and injury rates. Seven 
of the initial 345 studies were included in the 
review totaling 3,726 patients. A comprehensive 
meta-analysis of all patients from the 7 included 
studies, regardless of history of injury, revealed a 
significant reduction in ankle sprain rates for the 
proprioceptive training group compared to the 
control group (relative risk = 0.65, 95% CI = 
0.51-0.81). Proprioceptive training was 
statistically significant exclusively as a primary 
preventative measure (relative risk = 0.57, 95% 
CI = 0.34-0.97). The review concluded that 
proprioceptive training programs are effective at 
reducing the incidence rates of lateral ankle 
sprains, including those with a history of ankle 
sprains. 
 

https://doi.org/10.31622/2018/0001.2


Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

4 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

OBJECTIVE 

The purpose of our validation case study was to 
examine whether the use of a previously 
established ankle proprioceptive training 
program would effectively reduce the number of 
lateral ankle sprains in secondary school (grades 
9-12) patients, which student-athletes were 
competing in basketball. 

Additionally, we investigated the use of the 
proprioceptive training program on dynamic 
balance (Y-Balance Test) and perceived function 
of the ankle (Foot and Ankle Ability Measure 
Sport). 

PATIENT POPULATION 

The clinical practice setting was a secondary 
school in rural Illinois. Both female and male 
basketball programs from one secondary school 
were utilized for the project. Twenty-two patients 
(5 females, 17 males, age = 16±1 years old, 
height = 181.8±8.9 cm, weight = 74.8±12.8 kg) 
completed the proprioceptive training program 
throughout the basketball season. Patients were 
included regardless of ankle sprain history and 
were free of injury at the onset of the 
proprioceptive training program. There were 8 
males and 3 females with a history of previous 
ankle sprains.  

INTERVENTION 

The proprioceptive training program (Table 1) 
was developed based on recommendations 
provided by a study in the guiding review.2 Each 
participant completed the proprioceptive training 
program as a part of a structured, active, group 
warm-up supervised by the athletic trainer. The 
program was initiated at the beginning of the 
competitive season and consisted of 5-week long 
phases of increasing difficulty based on individual 
participant performance and concluded at the 
end of week four with a maintenance week (week 
5). The first 4 phases (weeks 1 through 4 ) 
required patients to complete 5 training sessions 
per week for approximately 15 to 20 minutes 

total per week. The final phase (week 5) consisted 
of maintenance exercises 3 times for 
approximately 10 minutes total per week. During 
each session, 3 to 4 tasks were completed. The 
patients did not complete the program on game 
days. 

The program (Table 1) consisted of single leg 
stance on flat surface, dribbling a basketball on 
a single leg, double leg stance on a balance 
board, single leg stance on a balance board, and 
dribbling a basketball in a single leg stance on 
the balance board (Figure 1).2 Each task was part 
of a progression and not every task was 
completed each day. Each exercise was 
performed for 30 seconds on each leg with a 30-
second rest period between each exercise. Each 
task was completed with eyes open initially and 
progressed to eyes closed in the subsequent 
phases. The balance boards were constructed 
using a round, precut 16-inch board. A piece of 
round plastic tubing approximately 5 inches wide 
was adhered to the middle of the board. 

 

Figure 1. Balance boards created for the 
proprioceptive training program. 

If a participant missed 5 consecutive days or was 
unable to perform the outcome assessments, the 
patient’s data were not used in the analysis. 
Patients were excluded from the outcome 
assessment if they had an injury that prevented 



Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

5 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

them from bearing weight on a single leg to 
perform the anterior reach distance at the time of 
data collection.  

Outcomes were assessed before starting the 
proprioceptive training program (baseline), at the 
conclusion of the training program (week 6), 6 
weeks after conclusion (week 12), and at the end 
of the season (follow-up). Outcomes data were 

collected before patients participated in practice. 
The 3 main outcomes that were assessed 
throughout the data collection period were 
number of lateral ankle sprains, anterior reach 
distances on the star excursion balance test, and 
the Foot and Ankle Ability Measure (FAAM) Sport 
Scale.  

 

Table 1. Proprioceptive Training Program. 
Week Surface Eyes Exercises 
Week 1 Floor Open 

Open 
Open 
Open 

Single leg stance 
Single leg stance with leg swing 

Single leg squat (30°- 45°) 
Single leg stance while dribbling ball 

Week 2 Floor Closed 
Closed 
Closed 

Single leg stance 
Single leg stance with leg swing raised 

Single leg squat (30°- 45°) 
Week 3 Board Open 

Open 
Open 
Open 

Single leg stance 
Single leg stance with leg swing raised  

Single leg squat (30°- 45°) 
Double leg stance while rotating the board 

Week 4 Board Closed 
Open 
Open 
Open 

Single leg stance 
Single leg stance with leg swing raised  

Single leg squat (30°- 45°) 
Single leg stance while rotating the board 

Week 5-6 Board Closed 
Open 
Open 
Open 

Single leg stance  
Single leg squat (30°- 45°) 

Single leg stance while rotating the board 
Single leg stance while dribbling the ball 

 
 Table 2. Means (± Standard Deviations) for all Main Outcome Measures. 
 Baseline Week 6 Week 12 Follow-Up 

Y-Balance Test (%)     

Anterior Dominant Limb  84.23 ± 7.48 86.82 ± 6.60a 83.79 ± 6.44b 83.23 ± 6.63b 

Non-Dominant Limb 84.58 ± 7.82 87.89 ± 8.43a 84.09 ± 7.64b 83.05 ± 6.19b 

FAAM Sport scale     

Score 31.32 ± 1.76 30.55 ± 3.99 31.09 ± 3.07 31.36 ± 2.26 

Perceived Function (%) 96.91 ± 5.38 99.14 ± 3.23a 99.32 ± 2.34 99.09 ± 2.94b 

  a=Significantly different from pre-intervention at p<0.05, b=Significantly different from week 6   
  (termination of intervention) at P>0.05. 



Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

6 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

 
Ankle sprains were evaluated by the athletic 
trainer and defined as an injury localized to the 
lateral ankle (indicated by positive anterior 
drawer test and inversion stress test), required at 
least 48 hours of activity modification, and 
documented in the electronic medical record 
system (EMR). The number of ankle sprains were 
compared to the number of ankle sprains in the 
same population in the previous season that also 
fit the definition of injury and treatment outlined 
above.  
The anterior reach distance on the Y-Balance Test 
was utilized to assess any changes in dynamic 
postural control throughout the duration of the 
proprioceptive training program.3,4 The Y-
Balance Test has been shown to have good 
reliability and validity in assessing dynamic 
postural control as an indicator of LE injury in the 
adolescent population.4 The same evaluator 
collected anterior reach distances using a 
standard tape measure secured to the floor. 
Patients were instructed to place their big toe at 
the 0 indicator on the tape measure and to reach 
the opposite foot as far as they could straight 
ahead while maintaining single leg balance.4 The 
distance was recorded at the most distal aspect of 
the reach foot. Each patient completed three 
practice trials followed by three testing trials. 
Reach distances were normalized to patient height 
and classified as dominant limb or non-dominant 
limb. A trial was void if they could not maintain 
the single leg stance, stance foot was lifted off the 
ground, or of the non-stance limb touched the 
ground.4 

Perceived ankle function was measured using the 
FAAM Sport scale. The FAAM has been 
demonstrated to detect self-reported functional 
deficits in those with chronic ankle instability and 
a range of other musculoskeletal conditions in the 
foot and ankle.5,6 Patients were given an 
electronic version of the FAAM Sport scale and 
instructed to complete the form based on their 
current symptom score. Each item on the FAAM 
Sport scale is an 8-item measure scored on a 5-
point Likert scale of 0-4.5,7 Zero indicating the 

patient could not complete the task and “4” 
indicating the patient had no difficulty completing 
the task.5,7  

A 4x2 repeated measures ANOVA was used to 
assess differences in anterior reach scores over 
time (baseline, week 6, week 12, follow-up) and 
between limbs (dominant, non-dominant). A one-
way ANOVA was used to examine FAAM Sport 
scale differences over time. Post hoc analysis was 
completed using Fishers LSD test. Significance was 
set a-priori at P<0.05. All statistical analyses 
were completed using SPSS Version 24 (IBM Corp. 
Released 2016. IBM SPSS Statistics for Windows, 
Version 24.0. Armonk, NY: IBM Corp.). The number 
of ankle sprains was extracted from an EMR and 
compared to data from the year prior to the 
implementation of the proprioceptive training 
program.  
 
MAIN FINDINGS 
 
Nine first time lateral ankle sprains were sustained 
in the competition year prior to the proprioceptive 
training program. During the proprioceptive 
training program year, 6 first time lateral ankle 
sprains were sustained. In the previous year, 3 
patients sustained a second lateral ankle sprain to 
the same ankle in the same competition year. 
While using the proprioceptive training program, 
only 1 patient sustained a re-injury in the same 
competition year. There were no major changes in 
competition level, number of patients, training 
schedules, competition schedules, etc. 
A significant time main effects was found for 
anterior reach distance (P<0.001). Post hoc 
analysis indicated that anterior reach distances 
were significantly greater at six 6 weeks 
compared to baseline (P<0.001), week 12 (P 
=0.003), and follow-up (P<0.001). No other 
significant differences were found between each 
time point (P>0.17). There was no limb main 
effect for the anterior reach distances (P=0.58). 
There was no time by limb interaction detected (P 



Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

=0.51). After patients, ceased participation in the 
proprioception training program anterior reach 
distances decreased in both dominant and non-
dominant limbs.  

There was no time main effect for FAAM Sport 
scale scores throughout data collection (P =0.56). 
There was no time main effect in the perceived 
level of function (0-100% scale) on the FAAM 
Sport scale (P=0.56) (Table 2).   

DISCUSSION 

No statistical tests were used to compare the rates 
of ankle sprains due to the small patient 
population; rather, the number of ankle sprain 
were reported. Our findings are consistent with 
other literature investigating the use of 
proprioceptive training programs to prevent 
lateral ankle sprains.1,2,8-10 Specifically, from 
investigations within the guiding review, both the 
number of initial injury and re-injury rates 
decreased for patient populations utilizing the 
proprioceptive training programs.1 However, 
perhaps a greater achievement in the reduction of 
ankle sprains is time saved treating these injuries. 
Athletic trainers spend an increased amount of 
time treating patients with time-loss injuries 
compared to non-time-loss injuries.11 Athletic 
trainers primarily use therapeutic exercise and 
neuromuscular reeducation as treatments for 
patients with ankle sprains.11 This current study 
suggests that athletic trainers can reduce the 
amount of ankle sprains they are treating and 
further reduce the amount of time spent treating 
ankle sprains by using a primary prevention 
program targeting proprioception.  

The results from the current study suggest that 
proprioceptive training programs can improve 
dynamic balance as we identified increases in 
anterior reach distances from baseline to week 6. 
Further evidence of the improvements are 
indicated by the decreases in anterior reach 
distances at week 12 and follow-up once 
compliance rates dropped. This reduction in scores 

highlights the need to assure compliance with 
proprioceptive training programs to ensure 
optimal outcomes. A similar investigation looking 
at balance improvements with the use of 
neuromuscular training also found comparable 
improvements in the SEBT.12 Similar to the current 
investigation the authors found improvements in 
the reach distances after a 6 week program 
targeted at neuromuscular control.12 However, the 
previous study utilized a program that also 
incorporated strength and plyometric exercise 
with longer training sessions.12 Furthermore, other 
investigations examining dynamic balance found 
an 8-week balance and strength program to 
increase the anterior reach distances in collegiate 
female soccer players.13 The program focused 
primarily on strength and conditioning for more 
elite athletes compared to the current 
investigation. However, the findings of improved 
dynamic balance with a targeted program are 
similar. Overall, the use of the proprioceptive 
training program can help patients improve 
dynamic balance and thus could reduce the risk of 
suffering an ankle sprain.  

There was no time main effect for FAAM Sport 
scale scores suggesting that the proprioceptive 
training program did not change perceived foot 
and ankle function. There was also no time main 
effect for perceived level of function ranked from 
0-100% function. Other investigations 
implementing rehabilitative protocols or 
proprioceptive training programs have found 
improvements in FAAM scores.14,15 However, these 
previous investigations used participants that had 
chronic ankle instability whereas the current 
investigation used healthy subjects from baseline. 
The patients in this study were athletes functioning 
at a high level with no disability to start. Previous 
research has shown that participants that are 
healthy have higher FAAM scores and therefore 
could have had a ceiling effect on FAAM scores in 
the current project.5 Future investigations should 
focus on the use of a proprioceptive training 
program and severity of ankle sprains that 



Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

patients sustain. Additionally, future studies should 
investigate the influences of a prophylactic 
proprioception training program and the amount 
of time patients take to return to baseline outcome 
scores.  

In order to be more proactive in injury reduction, 
athletic trainers should attempt to incorporate 
more preventative measures in their clinical 
practice. By becoming more proactive, athletic 
trainers can reduce the amount of time spent 
treating initial injury and re-injuries for ankle 
sprains.11 Neuromuscular reeducation is the 
second most common intervention used when 
treating ankle sprains in the secondary school 
setting.11 Treating from a reactionary standpoint 
after a patient is injured may costs athletic trainers 
more time and limits their focus on other aspects 
of their duties. By becoming more proactive in 
using neuromuscular training as a prevention 
method, athletic trainers can reverse this cycle. 
Furthermore, by decreasing the amount of injuries 
sustained athletic trainers can help combat 
inflating healthcare costs and long-term 
consequences of injury such as chronic ankle 
instability and osteoarthritis.  

The implementation of a prevention program can 
be a difficult task to accomplish, especially in 
settings where no previous effort in injury 
prevention has been made. There are a variety of 
variables that should be considered and 
accounted for to successfully implement a 
prevention program. First, the time required for 
patients, coaches, and practitioners to complete 
the prevention program is considered a limitation 
of injury prevention.16 In an investigation looking 
at a comprehensive prevention program in youth 
football, investigators found coaches were 87% 
less likely to not implement a prevention program 
if they felt the time required was too long.16 
However, through this case validation the 
investigators implemented a program with a 
realistic length to track changes in positive 
outcomes. The overall time required was less than 
5 minutes per player, per day, totaling only 25-

30 minutes for the entire week. Additionally, the 
proprioceptive training program was 
implemented as a component of a team warm up 
before practice each day to ensure daily 
compliance for each player. As previously 
established, compliance rates with injury 
prevention measures can greatly improve the 
outcomes seen for participants.17 Additionally, it 
has been shown that supervised programs (either 
by athletic trainer or coaches) are likely to have 
higher adherence rates than unsupervised 
programs.17,18 Athletic trainers need to evaluate 
their clinical practice, the common injuries they 
treat, and the time required to implement a 
prevention program for such injuries to leverage 
compliance from coaches, patients, and 
stakeholders.  

Data collection, management, and analysis was 
simple and effective for this clinical practice site. 
The EMR in the project, which was already in place 
at the clinical practice site, was utilized to store 
and protect data. The use of electronic fillable 
PDFs made data collection for the FAAM Sport 
score easy. Data collection periods were quick 
and efficient with 1 athletic training student 
facilitating the FAAM Sport scale administration 
and 1 athletic trainer measuring the anterior 
reach distances. Data were downloaded from the 
EMR and exported onto a Microsoft Excel 2016 
(Microsoft Corp, Richmond WA) sheet for analysis. 
Athletic trainers should explore the data 
management capabilities of their record systems 
in place; additionally, athletic trainers should 
investigate which clinician and patient reported 
outcomes would be most appropriate to track 
based on their patient population, needs, time, 
and prevention methods being implemented. 
Resources such as money, equipment, and training 
are required for the implementation of prevention 
practices. However, for this project, the only 
associated costs were those required for the 
building of the balance boards, which was 
minimal. The budget for a program used in this 
project was small and the time required to 



Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

complete the exercises was minimal. Athletic 
trainers should leverage resources and positive 
relationships with coaches to explore options for 
prevention program implementation.  
 
CLINICAL BOTTOM LINE 
 
The findings from this case validation study concur 
with the guiding systematic review and meta-
analysis that the use of proprioceptive training 
programs are effective in the reduction of lateral 
ankle sprains. Additionally, the use of the 
proprioceptive training program also improved 
dynamic stability and postural control of patients 
as the anterior reach distances of the Y-Balance 
Test increased. Athletic trainers should begin to 
examine their own clinical practice to determine 
the feasibility of implementing a proprioceptive 
training program with their patient population to 
reduce the incidence of ankle sprains.   
 
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Ankle Proprioception Training Program for Preventing Lateral Ankle Sprains in  
Adolescent Basketball Players: A Case Validation Study 

 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 1 – Issue 1 – June 2018  

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