Document Type : Research Paper
Authors
1
Department of Exercise Rehabilitation, Faculty of Sports Science, Bu-Ali Sina University, Hamedan, Iran
2
Department of Exercise Rehabilitation, Faculty of Sport Sciences, Bu-Ali Sina University, Hamedan, Iran
Abstract
Ankle sprains, especially lateral ankle sprains, are among the most prevalent musculoskeletal injuries in physically active populations, particularly athletes engaged in running, jumping, and pivoting sports. These injuries occur when the ankle is forced to twist excessively, leading to the disruption or stretching of stabilizing ligaments. The consequences can be severe and long-lasting, including chronic pain, swelling, instability, and functional limitations. Studies have demonstrated that approximately 20–30% of athletes sustain at least one ankle sprain during their competitive career, and nearly 75% of these individuals go on to develop chronic ankle instability (CAI). This chronic condition often results in recurrent sprains, impaired postural control, and decreased performance capacity in dynamic tasks.
Mounting evidence identifies poor postural control and impaired dynamic balance as key risk factors for sprains. For instance, athletes demonstrating suboptimal dynamic balance are up to seven times more likely to sustain an ankle sprain. Similarly, athletes scoring poorly on the dynamic Y-Balance Test have a 48% higher likelihood of suffering an ankle injury compared with their balanced counterparts. Effective postural control depends on adequate ankle muscle strength and a well-coordinated neuromuscular system capable of stabilizing the body during dynamic movements.
Scientific consensus indicates that therapeutic and preventive interventions aimed at strengthening ankle musculature, improving proprioceptive awareness, and minimizing postural sway can substantially improve balance and reduce the risk of injury recurrence. Neuromuscular and sensorimotor exercises, which combine balance, coordination, proprioception, and resistance have proven effective in enhancing the stability of the ankle joint and preventing further injury. These training regimens encourage the nervous system to develop optimal motor strategies and improve the coordination of joint stabilizers, making them integral to both prevention and rehabilitation programs.
Alongside neuromuscular training, cognitive interventions and dual-task exercises are gaining attention in contemporary sports rehabilitation research. The dual-task paradigm integrates cognitive and physical challenges simultaneously, aiming to replicate real-life athletic scenarios where athletes must execute complex motor tasks while processing cognitive information such as decision-making, reaction, and anticipation. Evidence suggests that coupling cognitive demands with motor activity promotes greater activation of cortical and sensorimotor regions in the brain, thereby improving both balance performance and neuromuscular control.
Given this background, the purpose of the current study was to investigate the combined effects of neuromuscular and cognitive interventions on ankle muscle strength and postural control in female athletes derived from sports disciplines associated with frequent ankle sprains. The working hypothesis was that neuromuscular training combined with dual-task cognitive exercises would generate greater improvements in ankle strength and more pronounced reductions in postural sway compared to neuromuscular training alone in female athletes exhibiting dynamic balance deficits.
Methods
This study adopted a randomized controlled trial design incorporating pre-test and post-test measurements to evaluate intervention outcomes. Ethical approval was granted by the Ethics Committee of Bu-Ali Sina University(code: IR.BASU.REC.1402.022), and the project was registered nationally in the Iranian Registry of Clinical Trials
(ID: IRCT20230619058535N1). Participants were informed about the study procedures and objectives and provided signed consent.The study population consisted of female athletes aged 15–30 years who had been continuously involved in structured sporting activities for at least three years. Using objective assessments, 36 athletes exhibiting measurable dynamic balance deficits were identified via performance on two widely recognized balance tests:
(1) a score below 94% on the Y-Balance Test (Plisky, 2006), and
(2) a score below 80% on the Noronha Test (2013) in the posterior–external direction of the dominant limb.
Qualified participants were randomly allocated to one of two groups:
Group A: Neuromuscular exercises with cognitive interventions (n = 18)
Group B: Neuromuscular exercises without cognitive interventions (n = 18)
At baseline, participants completed demographic and training history questionnaires, including previous injury status. Ankle muscle strength was objectively measured using a calibrated hand-held dynamometer, evaluating plantarflexor, dorsiflexor, inverter, and evertor muscle groups. Postural control was quantified via a computerized force platform (foot scan system), evaluating both eyes-open and eyes-closed conditions.
The training intervention spanned eight weeks, with three sessions per week lasting 45–60 minutes per session. Both cohorts performed structured neuromuscular exercise protocols targeting lower-extremity alignment, proprioception, strength, and plyometric capacity. Exercises included balance board training, single-leg hops, resistance band drills, and controlled landing mechanics. The experimental group incorporated additional cognitive tasks, such as backward counting in sequences of seven from random starting values, performed synchronously with each exercise. The cognitive challenge was designed to simulate the multitasking and divided attention environments athletes experience in real competition.
All pre- and post-training measurements were conducted under identical conditions. Data analysis employed SPSS version 26, verifying distribution normality using the Shapiro–Wilk test. Descriptive statistics (means, SDs) characterized baseline and outcome variables, and a repeated-measures ANOVA evaluated within- and between-group changes across time and condition. Statistical significance was maintained at p ≤ 0.05 throughout all analyses.
Results
Baseline demographic and anthropometric variables showed no significant differences between groups (p > 0.05), confirming comparable conditions before intervention.
The repeated-measures ANOVA showed significant improvements across time for most variables but differential gains between the two interventions. Specifically, participants in the dual-task group exhibited statistically significant enhancements in plantarflexor strength (p = 0.008) and evertor strength (p = 0.004) relative to the neuromuscular-only group, reflecting superior capacity for ankle stabilization. Conversely, no significant between-group differences were observed for dorsiflexor (p = 0.323) or invertor strength (p = 0.932). Overall, both groups demonstrated meaningful pre-to-post improvements in ankle muscle force production (p < 0.05).
With respect to postural control indices, the time × group interaction effects were non-significant (p > 0.05), suggesting both programs improved balance but to similar extents. Nonetheless, within-group comparisons revealed substantial improvements in internal–external sway, anterior–posterior sway, center of pressure (COP) path distance, and elliptical area, particularly under eyes-open conditions (p < 0.05). Under eyes-closed conditions, however, adjustments in internal–external sway and COP distance failed to reach significance (p > 0.05) for either group, possibly due to reliance on visual cues or limited training adaptation.
These findings collectively indicate that neuromuscular training effectively increased proprioceptive efficiency and ankle stability, while combining cognitive tasks further amplified specific muscle strength outcomes. The lack of group difference in postural control may suggest that longer durations or higher cognitive loads are needed to induce measurable sensorimotor adaptations.
Conclusion
This randomized controlled trial explored how pairing neuromuscular and cognitive interventions influences ankle strength and balance performance in female athletes prone to lateral ankle sprains. The results reveal that while both interventions lead to significant gains in muscle strength and postural stability, introducing concurrent cognitive challenges yields greater improvements in plantarflexor and evertor strength, muscles vital for mediolateral ankle control and injury mitigation.
However, the combined approach did not produce statistically superior results in postural sway reduction, implying that dynamic balance improvements are influenced more by physical than cognitive exercise components within the eight-week timeframe. It is plausible that cognitive dual-tasking primarily enhances motor unit recruitment and attentional allocation during complex functional movements, which might require prolonged training exposure to translate into measurable balance performance indices.
From a mechanistic viewpoint, neuromuscular programs improve the sensorimotor loop by enhancing proprioceptive input and muscle responsiveness. Cognitive load integration, meanwhile, may improve central processing efficiency and attentional focus, fostering multi-domain adaptations essential for sports performance. Collectively, these functions are pivotal to mitigating injury risk, particularly among athletes with preexisting balance deficits.
In practical terms, incorporating cognitive challenges—such as reaction, decision-making, or problem-solving tasks—into neuromuscular programs could make rehabilitation and prevention strategies more sport-specific. Coaches and clinicians should consider adding progressive cognitive loads to conditioning sessions, adjusting task complexity to ensure cognitive stimulation without compromising motor accuracy.
While neuromuscular and dual-task interventions demonstrated meaningful benefits, limitations of the present study include reliance on a specific age and gender demographic, relatively short intervention duration, and a homogeneous selection of sports. Future research should investigate mixed-gender cohorts, varied cognitive protocols (such as visual-spatial or decision-time tasks), and longitudinal effects to evaluate retention and re-injury prevention.
Overall, these findings underscore that neuromuscular training substantially enhances ankle strength and postural stability; however, when paired with cognitive tasks, the intervention achieves superior strength gains and potentially more durable neurological adaptations. Such integrated programs promise to advance preventive and rehabilitative care for athletes susceptible to ankle sprains.
Article Message
Integrated cognitive and physical training outperforms physical training alone for improving ankle strength and balance in female athletes. The combined method yields greater gains in key leg muscles. This mind-body approach builds a more injury-resilient system.
Ethical Considerations
This research was approved by the Bu-Ali Sina University Ethics Committee
(IR.BASU.REC.1402.022) and is registered in the Iranian Clinical Trial Registration Center
(IRCT20230619058535N1). All participants gave written informed consent and were assured confidentiality under ethical research standards.
Authors’ Contributions
Conceptualization: Farzaneh Saki
Data Collection: Mina Mansouri
Data Analysis: Farzaneh Saki, Farzaneh Ramezani
Manuscript Writing: Mina Mansouri, Farzaneh Ramezani
Review and Editing: Farzaneh Saki
Literature Review: Mina Mansouri, Farzaneh Ramezani
Project Management: Farzaneh Saki
Conflict of Interest
The authors declare no conflicts of interest related to this study.
Acknowledgments
The authors express heartfelt appreciation to the athletes for their enthusiastic participation and to the research assistants who contributed to data acquisition and program supervision. The project did not receive any form of financial support or external funding.
Keywords
Subjects
