Professional Baseball Strength & Conditioning


Balance Training- Ankles, ACL’s, and Rehabilitation

Daniel S. Cobian – Chicago White Sox

Balance training is designed to stimulate the sensorimotor system and may be implemented in various forms aimed at addressing multiple areas of injury prevention.  By challenging the sensorimotor system, balance training protocols may enhance the posture and joint stability needed to reduce the likelihood of injury (McGill & Montel, 2019).  Balance training promotes the visual, somatosensory, vestibular, and musculoskeletal systems that may help prevent the incidence of ankle sprains (Bellows & Wong, 2018).  Postural control deficits have been shown to increase the risk of anterior cruciate ligament (ACL) injuries resulting in a need to engage in the adaptational responses elicited from balance training (Kadlec, 2018).  Also, balance stability training on unstable surfaces may help promote neuromuscular control that may aid in producing increased muscle activation properties under lower forces during the rehabilitation process (Behm & Sanchez, 2012).  

Balance Training and Ankle Sprains. Instability symptoms after an ankle sprain may continue to be between 35 and 73%, while there is a 70% chance that an ankle sprain may reoccur (Bellows & Wong, 2018).  Balance training has been shown to reduce the incidence of ankle sprains in athletes compared to controls with a reduced rate of 35 to 38% (Bellows & Wong, 2018).  Recently in 2018, the review by Bellows and Wong noted that when 3,557 athletes across various sports were randomly selected into either a balance exercise treatment intervention (n=1867) or controls (n=1710), only 178 athletes exhibited an ankle sprain with a 46% reduced risk versus 274-athletes with no-treatment controls (p=0.0057).  Balance stability exercises may be progressed by decreasing the base of support from double-leg support to single-limb stance, opened eyes to closed, and altering a stable base to unstable while adding perturbations from simple arm actions.   

ACL Responses to Balance Training. The ACL holds an essential role in providing knee stabilization, sensorimotor control, and knee joint mechanics.  After an ACL injury, there may be a disruption to efficient movement patterns leading to the need of utilizing specific balance training interventions as there may be an inverse dose-response relationship between prevention strategies and injuries (Kadlec, 2018).  There is limited evidence of balance training and the prevention of ACL injuries in trained athletes.  However, between two to three balance and neuromuscular training sessions inter-spread throughout the week during the pre and in-season for a total of at least 30-min has been recommended to reduce the likelihood of non-contact ACL injuries (Kadlec, 2018).  This highlights the importance of implementing balance stability training as part of a multimodal approach to a performance protocol rather than balance training in isolation in athletic populations.

Unstable Surface Balance Training and Rehabilitation. One can argue that unstable surface training may mimic movements in sports but most movements in sports occur on a stable surface and may be considered as a non-specific training modality.  However, an unstable training environment does enhance proprioception and may have a place during the return to play process.  In circumstances where a recuperating weaker muscle is limited from exerting higher forces, unstable balance training methods allow lower external forces to be applied while being able to attain a higher degree of activation (Behm & Sanchez, 2012).  Also, co-contractile activity increases under unstable environments that are characterized by increased antagonist activity under low forces (Behm & Sanchez, 2012).  Activation of the antagonist is necessary for joint stiffness and stability that may serve as a protective mechanism from excessive forces (Behm & Sanchez, 2012).   

In conclusion, balance stability training may be an effective means of preventative care.  The incidence of ankle sprains may be reduced when balance stability protocols are practiced compared to controls.  While balance training may promote adaptational mechanisms with the sensorimotor system, including balance exercises with neuromuscular training may be more beneficial for ACL injury prevention.  Finally, balance stability training in unstable environments allows for higher muscle activation without the need for including excessive forces, which may be a practical program addition during the return to play process. 



Behm, D., & Sanchez, J. C. C. (2012).  The effectiveness of resistance training using unstable surfaces and devices for rehabilitation.  The International Journal of Sports Physical Therapy, 7(2), 226-243. 

Bellows, R., & Wong, C. K. (2018).  The effect of bracing and balance training on ankle sprain incidence among athletes: A systematic review with meta-analysis.  The International Journal of Sports Physical Therapy, 13(3), 379-390.

Kadlec, D. (2018).  Reducing the likelihood of anterior cruciate ligament injuries: A brief review.  Journal of Australian Strength & Conditioning, 26(1), 85-96.

McGill, E., & Montel, I. (2019).  NASM essentials of sports performance training.  Burlington, MA: Jones & Bartlett Learning.


Daniel S. Cobian MS, CSCS, RSCC*, CES, is a Strength and Conditioning Coach for the Chicago White Sox.


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