
Muscular weakness, proprioceptive
deficits, and range of motion deficits
may challenge a persons ability to
maintain their center of gravity (COG)
› May lead to loss of balance
 Balance is the single most important
element dictating movement strategies
 Dynamic process involving multiple
neurological pathways

Joint position sense , proprioception, and
kinesthesia are vital to all athletic
performance requiring balance

Ability to balance and maintain postural
stability is essential to an athlete who is
acquiring or reacquiring complex motor
skills

Complex process involving sensory and
motor components

Most daily activities such as, walking,
climbing stairs, throwing a ball, require
static foot placement with controlled
balance shifts

Balance should be considered both a
static and dynamic process

Impaired balance is a result of one or a
combination of two reasons
› Position of COG relative to base of support is
not accurately sensed
› Automatic movements required to bring
COG to a balanced position are not timely
or effectively coordinated
Position of the body in relation to gravity
and its surroundings is sensed by combining
visual, vestibular and somatosensory
(proprioceptive)inputs
 Balanced movements also involve motions
of the ankle, knee, and hip joints

› Primary mechanisms for controlling balance
occur in joints of the lower extremity

Postural control system operates as a
feedback control circuit between brain
and the musculoskeletal system

Mechanoreceptors transmit messages to
brain through sensory nerves in spinal
cord
› Helps to control proprioception or body/joint
position

Provides information concerning the
orientation of body parts to one another
and to the support surface
Balance is the process of maintaining the
COG within the body's base of support
 Within kinetic chain each moving
segment transmits forces to every other
segment along chain

› Maintaining equilibrium or balance is
associated with injuries along the closed
kinetic chain
 Injuries to any one of the joints or corresponding
muscles along kinetic chain can result in loss of
appropriate feedback for maintaining balance

Human body is a tall structure on a
relatively small base
› COG is quite high, just above pelvis

Somatosensory input is preferred sense
for balance
› i.e. : feet in contact with support surface
and detection of joint movement

Visual input
› Measures orientation of the eyes and head in
relation to surrounding objects
› If eyes are closed balance becomes more
difficult

Vestibular input
› Sensory system that is leading contributor to
response to movement and sense of balance
› Sends signals, primarily to neural structures that
control our eye movement, and to muscles that
keep us upright

Proprioception: ability to determine the
position of a joint in space

Kinesthesia: ability to detect movement
› Mediated by mechanoreceptors found in
muscle and joints and by cutaneous, visual
and vestibular input

Joint mechanoreceptors
› Found in ligaments, capsules, menisci,
labra and fat pads
 Sensitive to change in shape of joint
structures and rate and direction of
movement of joint
 Most active at end ranges of motion

Muscle mechanoreceptors
› Found in muscles and tendons
 Muscle spindles and Golgi Tendon
Organs
 Muscle spindles sensitive to
changes in length of muscle
 Golgi tendon organs sensitive to
changes in tension

Subjective Assessments: Romberg's &
Balance Error Scoring System (BESS)

Romberg's test
› Feet together, arms out to side, and eyes
closed
› Positive test: sway or fall to one side
› indicates loss of proprioception

Balance Error Scoring System (BESS)
› 3 stances: double , single, and tandem
 Completed 2 x each: Once on firm
surface and once on unstable surface
(Foam pad)
 Total of 6 trials
 Hands on iliac crest and eyes closed
 In SL ex. Non stance leg held at 20-30
degrees hip flexion and 40 to 50
degrees of knee flexion
BESS Assessment Continued
 20 second test begins when eyes close
 Single leg stance on non-dominant leg
(NDL) and NDL is in the rear for tandem
stance
 Upon losing balance athlete returns to
testing position as quickly as possible

Balance Error Scoring System (BESS)
› Scoring
 1 point added for each error that occurs






Hands lifted off iliac crest
Opening eyes
Step, stumble or fall
Moving hip into > 30 degrees of flexion or Abduction
Lifting forefoot or heel
Remaining out of testing position >5 seconds
 Higher scores represent poor balance

Dynamic balance test include functional
reach test, timed agility, figure 8’s,
carioca, or hop test
› Ability to maintain upright posture while
moving

Advancements in technology have
provided equipment to quantitatively
assess and train dynamic balance
› Mostly computer -interfaced force- plate
technology
› Potential to assess possible abnormalities
that might be associated with injury and
help create appropriate training
programs

Stretched or damaged ligaments may
fail to provide adequate neural
feedback
› May contribute to decreased proprioceptive
mechanisms, and thus decreased balance
› Increased postural sway and balance
instability contributed to neurological factors
and biomechanical factors after injury

Rehab program, especially for lower
extremities must include exercises to
improve balance and postural
equilibrium
› Any injury can cause disruption at some
point between COG and base of support
› If neglected can lead to reinjury, decreased
performance, or other injuries

5 general rules
› Safe, yet challenging
› Stress multiple planes of motion
› Incorporate multisensory approach
› Begin with static, bilateral stable surface and
progress to dynamic, unilateral, and
unstable surface
› Progress toward sport specific activity

Balance Exercises
› Static: COG maintained over fixed base of
support while on stable surface
› Semi-dynamic:
 Maintain COG over fixed base on moving
support or unstable surface
 Person transfers their COG over a fixed base of
support on stable surface through range
and/or directions

Balance Exercises
› Dynamic: maintenance of COG over
moving base of support
 Usually stable surface, but could be unstable
 Base of support always changing position so
COG is forced adjust with each movement
› Functional
 Same as dynamic, but add sport specific tasks

Phase I
› Can be initiated once athlete can bear weight
›
›
›
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on the extremity
Static, non ballistic exercise
Hard firm surface
Bilateral to unilateral (double leg to single leg)
Eyes opened to eyes closed
Progress to unstable surface, perturbations (taps
or movement)
 Overload or stress somatosensory system

Phase II
› Transition of static to semi-dynamic & dynamic ex.
 Important for running, jumping, and cutting
athletes
 Progress only if sufficient healing has occurred
and ROM, muscle strength and endurance is
adequate
 Balance through movement
 Controlled hip and knee flexion and smooth
return to stabilization position
 Progress to added resistance and more
difficult movement patterns

Phase III
› Dynamic & Functional exercises
 Slow speed to fast speed
 Low force to high force
 Controlled to uncontrolled activities
› Jumping or hopping activities
 Bilateral to unilateral
 Single plane to multi-plane
 Exercises may differ between athletes
 Be sport specific
Balance and postural stability critical to
athletic performance and injury prevention
 A rehabilitation program must include
functional exercises that incorporate
balance and proprioceptive training

› Prepare athlete for return to activity
› Failure address balance problems may
predispose athlete to reinjury and injury
› Use imagination, be creative
› Use sport specific tasks