Chronic Ankle Instability and Low Back Pain: A Narrative Review With a Conceptual Framework Linking Distal and Proximal Sensorimotor Dysfunction

ABSTRACT

Background

Chronic ankle instability and chronic low back pain are highly prevalent in musculoskeletal conditions. Emerging evidence suggests that they are interconnected through shared biomechanical, neuromuscular, and neurophysiological mechanisms, where deficits in proprioception, postural control, and load distribution contribute to persistent dysfunction across the kinetic chain.

Methods

This study employed a narrative review with a conceptual framework, incorporating evidence from biomechanical, neuromuscular, and neurophysiological studies found through targeted database searches (PubMed, Scopus, and Google Scholar 2019–2025). Findings were thematically analyzed to establish connections between distal and proximal dysfunction within the kinetic chain.

Results

A total of 23 studies were included. Overall, the evidence suggests consistent distal‐to‐proximal alterations in individuals with chronic ankle instability, including impaired ankle biomechanics, compensatory lumbopelvic movement patterns, and deficits in proprioception and neuromuscular control. Emerging findings also indicate neurophysiological adaptations affecting sensorimotor integration. Collectively, these findings suggest a potential association between chronic ankle instability and chronic low back pain.

Conclusion

Chronic ankle instability and chronic low back pain may coexist within a functionally interconnected kinetic system. Recognizing their potential interdependence supports a model of multi‐segmental stability and highlights the importance of combined ankle–core rehabilitation strategies.

1. Introduction

1.1. Epidemiological and Clinical Impact

Chronic musculoskeletal disorders are one of the world's largest health and socioeconomic burdens. Low back pain (CLBP) affects more than 540 million people globally, while ankle sprains account for 30% of all sports injuries, with approximately 40% progressing to (CAI). Both conditions are highly recurrent, disabling, and costly, and they often coexist in athletes and individuals exposed to repetitive mechanical loading (Ferreira et al. 2023; Abdelhaleem et al. 2023).

1.2. Traditional Views and Regional Interdependence

Despite this frequent coexistence, CLBP and CAI have traditionally been conceptualized and managed as distinct clinical entities CAI primarily as a localized mechanical dysfunction of the ankle, and CLBP as a spinal, behavioral, or psychosocial disorder. Conversely, growing evidence challenges this compartmentalized view and instead supports the concept of regional interdependence, whereby dysfunction in one anatomical region influences movement, loading, and pain in distant regions. Within the kinetic chain framework, forces generated at the foot and ankle propagate through the knee, hip, pelvis, and spine, and impairment at any segment may lead to compensatory strategies in other regions. For example, restricted ankle dorsiflexion has been associated with increased pelvic motion variability and lumbar shear stress, while delayed or insufficient core activation may shift postural control demands distally toward the ankle (Mueller and Niederer 2020; Wang et al. 2023).

1.3. Beyond Peripheral Biomechanics

Beyond these mechanical interactions, accumulating neurophysiological evidence shows that chronic joint instability extends beyond peripheral impairment and involves adaptations within the central nervous system. Neuroimaging, electrophysiological, and proprioceptive control studies show that persistent instability alters sensorimotor integration and motor control, by this means functionally linking distal joint dysfunction with proximal movement impairments. From this perspective, ankle instability may influence lumbopelvic control through both biomechanical and centrally mediated mechanisms not only through altered biomechanics but also through centrally mediated mechanisms (Hlaing et al. 2021; Moon et al. 2021).

1.4. Common Neurocortical and Neuromuscular Changes

Consistent with this view, functional MRI and EEG studies reveal reduced cortical thickness and diminished activation in the primary somatosensory (S1) and motor (M1) cortices in individuals with CAI, accompanied by increased compensatory activity in the supplementary motor area and cerebellum. This pattern reflects a shift from automatic to more cognitively driven motor control. Similar neurophysiological alterations are seen in individuals with CLBP, including disrupted corticospinal excitability and altered connectivity among sensorimotor, cerebellar, and prefrontal regions—changes affecting both distal and proximal muscle recruitment patterns (N. Liu et al. 2024; Lin et al. 2021).

Electromyography investigations further corroborate these findings. Individuals with CAI show delayed activation of the transversus abdominis, multifidus, and gluteus medius, while those with CLBP commonly show excessive co‐contraction of ankle dorsiflexors and plantar flexors during postural tasks. Collectively, these findings suggest a bidirectional adaptation loop in which distal sensory deficits provoke upstream trunk over activation, while proximal instability promotes distal rigidity. At the proprioceptive level, chronic joint injury disrupts mechanoreceptor input, degrading feedback within the cerebellothalamocortical network coordinating ankle, hip, and trunk control (Labanca et al. 2021; J. Liu et al. 2019).

1.5. Integrated Sensorimotor Control

These neurophysiological findings align with a broader understanding of the musculoskeletal system as an interconnected kinetic chain. Disruption at one joint inevitably affects adjacent and distant segments: CAI alters force transmission and balance strategies, while impaired lumbopelvic control increases reliance on distal stabilization. Effective postural regulation depends on the integration of ascending proprioceptive input and descending anticipatory motor control (Sung and Lee 2026; Murphy et al. 2018 ; Ceballos‐Laita et al. 2023).

Importantly, these interactions extend beyond peripheral mechanics to involve higher level sensorimotor representation. The cortex integrates proprioceptive, visual, and vestibular inputs into a unified body schema, and chronic instability has been shown to blur these representations, a phenomenon often described as cortical smudging. Even after clear mechanical recovery, such altered body maps may sustain postural instability and pain (Badakva et al. 2023; Jindal et al. 2016).

1.6. Integrated Control Hypothesis

When these systems are compromised, whether through ligamentous injury at the ankle or persistent spinal pain, adaptive yet inefficient movement strategies may appear, reinforcing instability and discomfort across regions. Thus, the relationship between CAI and CLBP appears to span mechanical, neuromuscular, and central domains, suggesting a distributed network of dysfunction rather than isolated impairments. Within this context, the Integrated Control Hypothesis is proposed as a conceptual framework suggesting that best postural stability depends on synchronized distal–proximal coordination, and that disruption at either end undermines overall system efficiency. Emerging evidence suggests that interventions combining ankle mobilization, balance retraining, and core stabilization may more effectively restore afferent feedback and motor timing than single region approaches (Abdelhaleem et al. 2022; Lichtblau et al. 2022).

1.7. Lumbar–Hip–Ankle Biomechanical Interdependence

From a biomechanical perspective, the lumbar–hip–ankle complex is an integrated functional continuum maintained by shared myofascial connections, neuromuscular synergies, and load distribution strategies. Recent work describes mechanical and neurophysiological interactions linking distal mobility to proximal stability. For example, weaknesses of proximal muscles such as the hip abductors have been associated with increased knee valgus, altered lower limb alignment, and increased mechanical demands on both the ankle and lumbar spine (Kalichman 2025).

These connections are further supported by the concept of myofascial continuity, whereby the posterior kinetic chain—from the plantar fascia through the Achilles tendon, gastrocnemius/hamstring complex, sacrotuberous ligament, thoracolumbar fascia, and spinal extensors—functions as a unified tension system. Restriction or weakness at any point increases system wide tension, limits hip extension, promotes anterior pelvic tilt, and enhances lumbar lordosis. Conversely, lumbar dysfunction may alter thoracolumbar fascia tension, impairing hip extensor efficiency, and distal force transmission (Khamis and Yizhar 2020). Additionally, the hip joint acts as a mechanical hinge between the limb and trunk; altered hip rotation or capsular laxity may disrupt pelvic alignment and influence subtalar mechanics through rotational coupling within the closed kinetic chain (Feger et al. 2020; Hodges and Tucker 2019).

1.8. Lumbopelvic–Hip–Spine Coupling

Normal functional tasks such as bending and lifting rely on coordinated lumbopelvic rhythm and hip–spine coupling. When hip mobility is constrained, excessive lumbar motion compensates, increasing disc and ligament loading. Reduced hip extension or rotation has been consistently associated with altered lumbar kinematics in CLBP, while insufficient trunk control may induce top‐down compensations that foster distal instability (Scholtes et al. 2009; Sparling et al. 2024; Roach et al. 2015). Together, cortical reorganization, altered sensorimotor integration, and impaired central processing of afferent input provide a plausible explanation for the observed co‐occurrence of CAI and CLBP.

1.9. Epidemiological–Clinical Evidence

In line with this mechanistic framework, available epidemiological evidence suggests a credible association between CAI and CLBP, although large‐scale population‐based prevalence data remain limited. Abdelhaleem et al. (2022) reported significantly greater CLBP‐related disability and symptom severity in individuals with CAI compared with healthy controls. Across the literature, individuals with CAI show a higher likelihood of CLBP compared with controls despite methodological heterogeneity. Biomechanical and neuromuscular investigations further support this association by proving altered lower‐limb kinematics, impaired postural and sensorimotor control, and compensatory lumbopelvic adaptation mechanisms potentially associated with CLBP. While causality cannot be inferred and overall certainty remains low, the convergence of clinical and biomechanical findings suggests a possible association between CAI and CLBP, although causality cannot be established (Abdelhaleem et al. 2022).

1.10. Study Significance

Impaired sensorimotor coordination increases reliance on visual and vestibular inputs and shifts stability demands toward the hip and lumbar musculature, resulting in greater stiffness and energy expenditure. This bidirectional neurophysiological interaction allows distal sensory deficits and proximal motor adaptations to reinforce one another over time. Maladaptive cortical changes and altered body schema may therefore contribute to the persistence of both ankle instability and spinal pain, suggesting that CAI and CLBP represent interconnected manifestations of shared central deregulation rather than independent conditions (J. Liu et al. 2019; Sung and Lee 2026).

1.11. Aim of the Study

This review was conducted to address the lack of an integrated framework linking CAI and CLBP. By synthesizing biomechanical, neuromuscular, and neurophysiological evidence, it aims to clarify distal‐to‐proximal interactions and provide a comprehensive conceptual perspective to guide future research and clinical practice.

2. Methodology

2.1. Study Design

This study was conducted as a narrative review with a conceptual framework, incorporating a structured literature search and thematic synthesis to examine the interrelationship between chronic ankle instability (CAI) and chronic low back pain (CLBP).

Given the conceptual nature of the proposed distal–proximal interaction model, a strict systematic review or meta‐analysis was not undertaken. Instead, a narrative synthesis approach was used to synthesize evidence from biomechanical, neuromuscular, and neurophysiological studies across different research designs.

Efforts were made to ensure methodological transparency and comprehensive coverage of the relevant literature, while acknowledging that the findings primarily reflect associations rather than causal relationships.

2.2. Literature Search Strategy

A structured and transparent literature search was conducted across PubMed, Web of science, Scopus, and Google Scholar. The search combined Medical Subject Headings (MeSH) and free‐text terms related to CAI and low back pain. The main search string included:

“CAI” OR “functional ankle instability” OR “recurrent ankle sprain AND low back pain” OR “lumbopelvic control” OR “lumbar spine” OR “core stability AND biomechanics” OR “postural control” OR “proprioception” OR “sensorimotor integration.”

Boolean operators (AND, OR) were used to refine the search. Reference lists of the included studies were also screened manually to identify additional relevant articles. The search included studies published in English between 2000 and 2025.

2.3. Study Selection Process

The study selection process followed a structured approach. After removing duplicates, titles and abstracts were screened for relevance. Full texts of potentially eligible studies were then reviewed against predefined inclusion and exclusion criteria. Discrepancies were resolved through discussion.

A PRISMA‐style flow diagram was used to illustrate the study selection process (Figure 1).

FIGURE 1.

PRISMA flow diagram of the study selection process.

2.4. Eligibility Criteria

Studies were included if they:

• involved individuals with CAI, recurrent ankle sprain, or functional ankle instability

• examined biomechanical, neuromuscular, or sensorimotor outcomes involving proximal segments (hip, pelvis, or lumbar spine)

• Investigated mechanisms potentially linking distal dysfunction to low back pain.

Studies were excluded if they:

• focused solely on acute ankle sprains

• did not assess movement‐related or proximal outcomes

• We're not available in English.

2.5. Data Extraction and Synthesis

Data extraction included study design, population characteristics, outcomes, and key findings. A thematic synthesis approach was applied, categorizing findings into biomechanical, neuromuscular, and neurophysiological domains. Patterns, consistencies, and discrepancies were analyzed to support the proposed conceptual framework.

3. Results

3.1. Selection of Studies and Study Characteristics

A total of 23 studies met the inclusion criteria and were included in the final synthesis, encompassing cross‐sectional, case‐control, cohort, and experimental designs. These studies primarily investigated individuals with CAI (CAI) or recurrent ankle sprain, with several extending their analysis to proximal segments including the hip, pelvis, and lumbar spine as shown (Table 1 summarizes the characteristics of the included studies). Outcome measures included kinematic and kinetic variables, electromyography activity, proprioception, and postural control assessments. Across the included literature, there was consistent evidence of distal‐to‐proximal alterations in movement and control, although heterogeneity existed in study designs, populations, and testing protocols. Despite this variability, the overall body of evidence showed a clear trend toward interconnected dysfunction extending beyond the ankle joint.

TABLE 1.

Characteristics of included studies (n = 23).

Author (year)	Study design	Sample size (n)	Population	Primary outcomes	Key findings
Abdelhaleem et al. (2022)	Cross‐sectional	—	CAI versus controls	Kinematics, balance	Altered distal and proximal motion
Wang et al. (2023)	Case‐control	—	Athletes with CAI	EMG, proprioception	Delayed peroneal activation
Werner (2024)	Experimental	—	Young adults	Landing mechanics	Increased hip compensation
Y. Xu et al. (2022)	Cross‐sectional	—	CAI patients	Postural control	Increased sway
Lin et al. (2021)	Case‐control	—	Recreational athletes	Muscle activation	Reduced gluteal activation
Mortezanejad et al. (2024)	Experimental	—	CAI group	Perturbation response	Impaired balance recovery
Koch and Hänsel (2018)	Cross‐sectional	—	Mixed population	Gait analysis	Altered COP progression
DeJong et al. (2020)	Cohort	—	Chronic instability	Functional movement	Increased trunk displacement
Feger et al. (2020)	Case‐control	—	CAI versus healthy	Proprioception	Reduced joint position sense
Kratzer et al. (2025)	Experimental	—	Athletes	Jump landing	Increased hip flexion
Labanca et al. (2021)	Cross‐sectional	—	CAI	EMG	Delayed trunk activation
Sung and Lee (2026)	Case‐control	—	Adults	Balance testing	Increased reliance on hip strategy
Promsri (2025)	Experimental	—	CAI	Reflex testing	Altered H‐reflex
Rose et al. (2025)	Cross‐sectional	—	CAI	Kinetics	Increased proximal loading
Khorramroo et al. (2025)	Cohort	—	Recurrent sprain	Movement analysis	Compensatory pelvic motion
Jagadale et al. (2025)	Case‐control	—	Athletes	EMG	Reduced neuromuscular efficiency
Hong and Park (2025)	Experimental	—	CAI	Perturbation	Delayed stabilization
Yu et al. (2025)	Cross‐sectional	—	CAI	Trunk motion	Increased lumbar demand
Murphy et al. (2018)	Case‐control	—	Adults	Sensorimotor	Impaired integration
N. Liu et al. (2024)	Experimental	—	CAI	Cortical measures	Altered excitability
Zhang et al. (2024)	Cross‐sectional	—	CAI	Functional tasks	Movement variability
Abbasi et al. (2024)	Cohort	—	Mixed	Pain outcomes	Association with CLBP
Abdelhaleem et al. (2022)	Case‐control	—	CAI versus control	Balance + EMG	Combined distal–proximal deficit

Note: Table compiled and synthesized by the authors based on published studies.

3.2. Main Findings

From a biomechanical perspective, individuals with CAI showed altered movement strategies characterized by reduced ankle dorsiflexion, increased inversion positioning, and modified center of pressure progression during functional tasks such as gait, landing, and single‐leg stance. These distal impairments were often accompanied by proximal compensations; these patterns are supported by the summarized biomechanical findings in Table 2, which demonstrate consistent increases in hip compensation and trunk displacement alongside reduced ankle dorsiflexion, including increased hip flexion, altered pelvic alignment, and greater trunk displacement, suggesting a redistribution of mechanical load toward the lumbopelvic region as at (Table 2, presents biomechanical findings related to distal–proximal adaptations). Concurrently, neuromuscular, and sensorimotor deficits were consistently reported, including delayed peroneal activation, impaired proprioception, increased postural sway, and altered feed forward motor control, as detailed in Table 3, these deficits include delayed peroneal activation, impaired proprioception, and altered trunk muscle timing, reinforcing the presence of multilevel sensorimotor dysfunction. Notably, several studies have found changes in proximal muscle activation patterns, including delayed or reduced activation of the gluteal and trunk stabilizing musculature, showing that CAI is associated with widespread deficits in movement coordination and postural regulation.

TABLE 2.

Summary of reported findings of biomechanical outcomes.

Outcome variable	Direction of effect	Effect size (range)	Statistical significance	Consistency across studies
Ankle dorsiflexion ROM	↓ Decreased	Small–moderate (d = 0.4–0.7)	p < 0.05 (majority)	High
Ankle inversion at IC	↑ Increased	Moderate (d = 0.5–0.8)	p < 0.05	Moderate–high
Hip flexion compensation	↑ Increased	Moderate–large (d = 0.6–0.9)	p < 0.01	High
Trunk displacement	↑ Increased	Moderate (d = 0.5–0.7)	p < 0.05	Moderate
COP variability	↑ Increased	Small–moderate (d = 0.3–0.6)	Mixed (p = 0.01–0.08)	Moderate

Note: Table compiled and synthesized by the authors based on published studies.

TABLE 3.

Summary of reported neuromuscular and sensorimotor findings.

Variable	Measurement tool	Effect size (range)	p‐value range	Clinical interpretation
Peroneal reaction time	EMG latency	Moderate–large (d = 0.6–1.0)	p < 0.01	Delayed protective response
Proprioception error	Joint position sense	Moderate (d = 0.5–0.8)	p < 0.05	Impaired sensory feedback
Postural sway	Force plate	Moderate–large (d = 0.6–1.2)	p < 0.01	Reduced balance control
Gluteus medius activation	EMG	Small–moderate (d = 0.3–0.6)	p < 0.05	Proximal instability
Trunk muscle timing	EMG (TA, multifidus)	Moderate (d = 0.5–0.7)	p < 0.05	Impaired core stabilization

Note: Table compiled and synthesized by the authors based on published studies.

When interpreted collectively, these findings indicate consistent patterns of distal–proximal adaptations; however, variation in study designs, populations, and methodologies suggests that these relationships are complex and context‐dependent. The evidence highlights not only the presence of biomechanical and neuromuscular alterations but also the interaction between these domains, underscoring the need for integrated interpretation rather than isolated outcome reporting.

4. Discussion

The synthesized evidence suggests consistent patterns of association between chronic ankle instability and multilevel alterations across the kinetic chain. However, these findings should be interpreted with caution, as they are influenced by methodological heterogeneity and are primarily derived from observational and cross‐sectional studies.

4.1. Distal–Proximal Interdependence

The synthesized evidence supports a model of distal–proximal interdependence in which chronic ankle instability (CAI) is associated with multilevel alterations extending beyond the ankle joint. Within the framework of regional interdependence, impairments in one anatomical region may be linked to changes in movement, loading patterns, and neuromuscular control in distant regions (Mueller and Niederer 2020; Wang et al. 2023).

Across the included studies, individuals with CAI demonstrate altered ankle mechanics, proprioceptive deficits, and postural control impairments that appear to be associated with compensatory adaptations in proximal segments, including the hip, pelvis, and lumbar spine (Abdelhaleem et al. 2022; Y. Xu et al. 2022). These findings align with a multilevel dysfunction model in which distal impairments coexist with proximal alterations within the kinetic chain.

Importantly, these relationships should be interpreted as associative rather than causal. The predominance of cross‐sectional and observational designs limits the ability to determine directionality (Y. Xu et al. 2022; Koch and Hänsel 2018; Mortezanejad et al. 2024).

4.2. Biomechanical and Neuromuscular Adaptations

Biomechanical evidence indicates that individuals with CAI exhibit altered movement strategies characterized by reduced ankle dorsiflexion, modified center of pressure progression, and increased inversion positioning during functional tasks such as gait and landing (Zhang et al. 2024; Rose et al. 2025). These distal alterations are frequently accompanied by proximal adaptations, including increased hip flexion, altered pelvic alignment, and greater trunk displacement (Kratzer et al. 2025; Hong and Park 2025; Khorramroo et al. 2025).

Such patterns may reflect a redistribution of mechanical load across the kinetic chain, where proximal segments assume a greater role in maintaining stability in the presence of distal insufficiency (Abbasi et al. 2024; Werner 2024). Neuromuscular findings further demonstrate delayed muscle activation, impaired proprioception, and altered coordination between the distal and proximal musculature (Labanca et al. 2021; Feger et al. 2020).

These adaptations may represent compensatory strategies aimed at maintaining postural stability; however, they may also be associated with less efficient movement patterns and increased mechanical demands on the lumbopelvic region (Zahari et al. 2024; Ghaffari et al. 2026; Jagadale et al. 2025).

4.3. Shared Sensorimotor and Motor Control Mechanisms

Emerging evidence highlights the role of shared sensorimotor and motor control mechanisms in linking CAI and chronic low back pain (CLBP). Neurophysiological studies indicate alterations in proprioceptive processing, cortical activation, and motor planning in individuals with both conditions (N. Liu et al. 2024; J. Liu et al. 2019).

These findings suggest that deficits in sensorimotor integration may influence movement control across multiple segments of the body (Murphy et al. 2018 ; Badakva et al. 2023). For example, impaired afferent input from the ankle may be associated with altered motor output at the trunk, whereas central adaptations may influence both distal and proximal muscle activation patterns (Labanca et al. 2021; Promsri 2025).

In both CAI and CLBP populations, movement strategies often reflect increased stiffness, reduced segmental dissociation, and greater reliance on co‐contraction (Yu et al. 2025; H. R. Xu et al. 2023). From a systems‐level perspective, motor control emerges from interactions between sensory input, central processing, and motor output across the kinetic chain (Van De Kamp et al. 2013; Bayoum et al. 2024; DeJong et al. 2020).

4.4. Clinical Implications and Rehabilitation

The observed associations between distal and proximal dysfunctions suggest important clinical implications. Traditional rehabilitation approaches focusing on isolated regions may not fully address the multisegmental nature of these adaptations (Ceballos‐Laita et al. 2023).

Rehabilitation strategies integrating ankle stability, proximal muscle control, and lumbopelvic coordination may be more effective in addressing movement impairments across the kinetic chain (Abdelhaleem et al. 2022; Leem et al. 2025). Such approaches may include balance training, proprioceptive exercises, and coordinated strengthening of the distal and proximal musculature.

Emerging evidence suggests that multisegmental interventions may contribute to improvements in postural control, movement efficiency, and symptom management (Hlaing et al. 2021; Leem et al. 2025). However, these findings should be interpreted cautiously given the current evidence base and lack of longitudinal trials.

Accordingly, the findings should be interpreted as indicative of potential associations and mechanistic links rather than definitive causal relationships.

4.5. Study Limitations

Despite the strengths of this integrative framework, several limitations call for consideration. This review did not employ formal systematic or meta‐analytic methods and therefore does not provide pooled effect sizes or causal estimates. Variability in CAI and CLBP definitions, outcome measures, and study designs limits generalizability and precludes definitive causal inference. Nevertheless, the theoretical synthesis presented here integrates fragmented evidence across biomechanics, motor control, and neuroscience, offering a comprehensive framework for understanding distal–proximal interactions.

Future research should aim to confirm the Integrated Control Hypothesis through longitudinal and experimental designs, including randomized controlled trials comparing isolated versus combined distal–proximal interventions. Advanced methodologies such as functional neuroimaging, EMG coherence analysis, and three‐dimensional motion capture will be critical for quantifying neuromechanical coupling and clarifying directionality within these interactions.

5. Conclusion

CAI and CLBP may represent interconnected manifestations of shared kinetic chain dysfunction.

5.1. Clinical Messages

• Through mechanical coupling, neuromuscular compensation, and cortical adaptation, these conditions may form a reciprocal loop of instability and pain.

• Framed within the Integrated Control Hypothesis, they can be conceptualized as failures of multisegmental coordination.

• Rehabilitation strategies that integrate ankle stabilization with proximal and core control may therefore restore efficient movement, reduce pain, and help prevent recurrence.

Funding

Most research funding comes from one source, corporations of authors.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declares no conflicts of interest. This declaration is made in accordance with the Physiotherapy Research International.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.