PT Tip of the Month Archive

Balance Training


People who have experienced or undergone an anterior cruciate ligament (ACL) injury or reconstruction, low back pain, or chronic ankle instability/sprains often are at increased risk for recurrent injury unless balance or proprioceptive training is incorporated into their care. Athletes who return to sport participation after ACL reconstruction have a higher risk of a second ACL injury compared with non-ACL-injured athletes, with a study reporting a rate of 1 of 17 (6%) second ACL injuries within 2 years after initial injury, whereas rate of initial ACL injury is reported to occur in 1 of 60-100 or higher (Paterno et al., 2010). Back pain is also a common injury experienced by active individuals, with an incidence reported as high as 50% (Carlson et al., 2009). Gymnasts and football players are at most risk for back injuries. As with ACL injury, recurrent back problems are common once an individual has experienced back pain. Lastly, ankle sprains are the most common musculoskeletal injury that occurs in athletes, with basketball and soccer causing the highest percentage of these injuries due to the sudden stops and cutting movements these sports entail (McGuine et al., 2006).

What is balance training and why is important?

Balance training is a way of training the neuromuscular system to operate with proper activation, timing, and sequencing. In other words, nerves that innervate muscles need to send electrical signals at the correct time and for the right duration, as well as stop at the proper time. Engaging in balance training also leads to strength and proprioceptive gains (ability to know your joint position in space). Balance training can vary depending on what the physical therapy goals are. In patients with ACL-related injuries and ankle instability, balance programs may include activities such as: maintaining single-leg stance on different surfaces or with eyes opened/closed, performing functional sports activities such as throwing, catching, or dribbling on one leg, maintaining single or double-leg stance on a balance board, dynamic balance activities involving perturbations and/or lateral movements, and other closed-chain exercises. These activities can be adjusted in terms of surfaces, visual feedback, speed, and intensity. Balance exercises for patients with back pain focus on neuromuscular training of the core muscles.

For patients with ACL-related injuries, return to pre-injury status must include agility and balance training in order to increase stability of the ligaments and other soft tissue that support the knee. Only then will the patient will be able to respond to those quick lateral movements they will face with return to sport. Patients who have back problems often demonstrate decreased neuromuscular control of the spinal stabilizers, including the transverse abdominis, lumbar multifidus, obliques, and quadratus lumborum muscles. (See past archive on Core Stability.) Exercises that challenge postural control and engage the core muscles are key to preventing recurrent back pain. Patients with ankle sprains due to underlying instability have resulting damage to surrounding soft tissue and ligamentous structures. Chronic ankle instability is thought to be the result of a combination of neural, muscular, and mechanical issues (laxity). Thus it is imperative to strengthen not only the damaged structures, but also to address any strength deficits in the other foot/ankle muscles or ligaments as well as any proprioceptive deficits in the ankle joint itself. It is important that balance training is incorporated into the rehabilitative process in order to prevent future recurrence of injury. Current literature indicates that sport-specific balance training (although the specifics vary by individual) is paramount to returning to pre-injury status and function.


Many of the key structures that serve to stabilize the knee are located outside of the joint, such as the quadriceps and the semimembranosus muscles, extracapsular ligaments, and the medial collateral ligament (MCL), which has portions outside of the joint and within the joint capsule. The joint capsule itself and the ACL and posterior cruciate ligament (PCL) are inside the knee joint, and these along with the menisci aid in stabilization of the knee joint.

There are a variety of spinal stabilizers, with the aforementioned being the main structures where weakness and improper neuromuscular control of these structures have been implicated in recurrent back pain. Other structures which aid in postural control and spinal stability can be found in the Core Stability archived article.

There are two locations of stabilization for the ankle. The first is the high ankle joint, made of the distal tibia and fibula, which are the two lower leg bones. The corresponding stabilizing structures at this joint include the interosseous membrane and the anterior and posterior tibiofibular ligaments. The low ankle joint consists of the tibia, fibula, and the tarsal bones of the foot. The stabilizing structures at this joint include the lateral ligaments (anterior and posterior talofibular ligaments and the calcaneofibular ligament) and the deltoid ligament on the medial side. The tendons of the peroneus longus muscle on the lateral side of the ankle and of the posterior tibialis muscle on the medial side of the ankle form a stirrup of the foot, also aiding in stability of the ankle.

Role of PT

If you have been through an ACL injury/reconstruction, have acute or chronic low back pain, or experience chronic ankle sprains/instability, a physical therapy exam will be necessary to determine the underlying factors contributing to your pain or injury. Although the above images are examples of balance exercises, please do not attempt these exercises on your own without first consulting your physical therapist. They will be able to assess what specific exercises regarding balance training will best restore your functional ability and return you to higher level activities or sports. During your physical therapy visits, your physical therapist will prescribe various exercises to promote correct neuromuscular control, address strength and proprioceptive deficits, and prevent future injury. If you would like to schedule an evaluation, call 617-232-PAIN for our Brookline office, and 617-325-PAIN for our West Roxbury office to see one of our skilled physical therapists.


  1. Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals. Phys Ther. 2000;80(2):128-40.

  2. Fitzgerald GK, Axe MJ, Snyder-Mackler L. Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals. J Orthop Sports Phys Ther. 2000;30(4):194-203.

  3. Laskowski ER, Newcomer-Aney K, Smith J. Refining rehabilitation with proprioception training: expediting return to play. Phys Sportsmed. 2010;25(10).

  4. Mattacola CG, Dwyer MK. Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. 2002;37(4):413-29.

  5. McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34(7):1103-11.

  6. Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. 2010;38:1965-67.

  7. Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007;87(6):737-50.

  8. van Rijn RM, van Ochten J, Luijsterburg PA, et al. Effectiveness of additional supervised exercises compared with conventional treatment alone in patients with acute lateral ankle sprains: systematic review. BMJ. 2010;341:c5688.

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