The escalating incidence of ankle sprains in athletic populations has emerged as a significant public health concern, with recent epidemiological data indicating these injuries account for up to 60% of all sports-related musculoskeletal trauma [1]. While acute lateral ankle sprains are often perceived as minor injuries, approximately 40% of cases progress to chronic ankle instability (CAI), which represents a pathological condition characterized by mechanical joint laxity and impaired neuromuscular control, resulting in recurrent ankle sprains and persistent symptoms of giving way [2, 3]. In understanding CAI, it is essential to distinguish between mechanical instability, defined as the inability of a joint to withstand loads, and clinical instability, characterized by the clinical consequences of neurological deficit and/or pain [4, 5]. Modern biomechanical analysis has revealed that approximately 70% of affected individuals exhibit complex neuromuscular deficits extending beyond simple mechanical instability [3], highlighting the need for a comprehensive assessment approach that considers both aspects of instability.

Recent advances in biomechanical analysis have revolutionized our understanding of CAI pathomechanics, demonstrating that approximately 70% of affected individuals exhibit complex neuromuscular deficits extending beyond simple mechanical instability [3]. Modern imaging studies have revealed significant alterations in sensorimotor integration and cortical activation patterns, suggesting a more sophisticated pathophysiological model than previously recognized [6]. Furthermore, advanced motion analysis has identified specific biomechanical signatures, including altered center of pressure trajectories and compromised dynamic postural control strategies [7].

The contemporary therapeutic landscape for CAI has evolved significantly, with emerging evidence supporting various intervention strategies. Recent systematic reviews and meta-analyses have demonstrated the efficacy of targeted neuromuscular training [8], novel manual therapy techniques [9], and advanced rehabilitation protocols [10]. Particularly noteworthy is the growing evidence supporting active therapeutic approaches, which have shown promising results in enhancing both mechanical stability and neuromuscular control [11, 12].

While traditional passive joint mobilization (PJM) techniques have historically dominated clinical practice, recent research has highlighted the potential advantages of active, weight-bearing mobilization strategies [13–16]. These emerging approaches theoretically provide enhanced proprioceptive input and more functionally relevant neuromuscular activation patterns. However, robust comparative analyses of these contrasting therapeutic paradigms remain limited.

Therefore, this investigation aims to evaluate the differential effects of active joint mobilization (AJM) versus traditional PJM in individuals with CAI. We hypothesize that the integration of active components may yield superior outcomes through enhanced proprioceptive feedback and neuromuscular recruitment patterns.

Figure 1 shows a flowchart of this study based on the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Fifty-two potential participants were screened, and twenty-two participants were excluded, with twelve not meeting inclusion criteria. All 30 enrolled participants were analyzed without any dropouts.

This study investigated the comparative effects of active versus PJM in individuals with CAI. Our findings contribute to the growing body of evidence regarding therapeutic approaches for CAI management while highlighting several important insights.

Research on joint mobilization for CAI has traditionally focused on passive techniques, with recent systematic reviews indicating their effectiveness in improving ankle dorsiflexion and dynamic postural control [31]. Our study extends this understanding by directly comparing active and passive approaches, addressing a significant gap in the literature.

Both AJM and PJM groups demonstrated significant within-group improvements across multiple parameters. The PJM group showed substantial improvements in CAIT scores (p < 0.001), DFROM (p < 0.001), and JPS (p < 0.01), consistent with previous findings [2]. The AJM group exhibited comparable improvements, with slightly larger effect sizes in DFROM (d = 1.951) and proprioceptive function (d = 1.300), though between-group differences were not statistically significant. The relatively modest effect sizes observed in static balance measures (PJM d = 0.386; AJM d = 0.514) compared to other outcome parameters reflect the complexity of postural control mechanisms. While both interventions demonstrated improvements in balance, these moderate effects suggest that static balance may require additional targeted interventions beyond joint mobilization alone. The slightly larger effect size in the AJM group may indicate that active engagement facilitates better integration of proprioceptive input into postural control strategies, although this difference did not reach statistical significance.

The mechanisms underlying these improvements likely involve multiple pathways. First, joint mobilization techniques may enhance mechanoreceptor activation and sensorimotor integration, as suggested by recent neuroimaging studies showing altered cortical activation patterns in CAI patients [32, 33]. Second, the mechanical effects on joint arthrokinematics could improve talocrural joint mobility, addressing the restricted posterior talar glide commonly observed in CAI [11].

The slightly enhanced outcomes in the AJM group, particularly in proprioceptive measures, may be attributed to increased neuromuscular recruitment during active engagement. This aligns with contemporary motor learning principles emphasizing task-specific training [6]. Recent research has demonstrated that active, weight-bearing exercises can enhance both mechanical stability and neuromuscular control in CAI patients [14].

However, our findings contrast with some previous studies suggesting superior outcomes with active mobilization techniques [34]. This discrepancy might be explained by differences in intervention protocols, patient populations, or outcome measures. Furthermore, the similar effectiveness of both approaches suggests that the mechanical stimulus provided by joint mobilization, whether active or passive, may be the primary driver of therapeutic benefits.

These results have important clinical implications. While both techniques prove effective, the choice between AJM and PJM might be influenced by individual patient factors such as pain tolerance, activity level, and rehabilitation stage. The comparable outcomes suggest clinicians can confidently employ either approach, potentially selecting based on patient preference or specific clinical circumstances.

Clinical decision-making for intervention selection should consider individual patient characteristics. AJM may be more appropriate for patients demonstrating good pain tolerance and capability for active engagement, particularly those requiring enhanced proprioceptive training. Conversely, PJM might be better suited for patients in acute phases or those with pain limitations. Treatment selection should be guided by factors including activity level, rehabilitation stage, and specific functional deficits identified during initial assessment.

Study limitations include the relatively short intervention period and focus on immediate outcomes. Future research should investigate long-term effects and potential differences in return-to-sport outcomes, while also considering the development of patient-specific treatment algorithms based on individual functional deficits and recovery patterns. The protocol could be optimized by adjusting treatment parameters (e.g., mobilization intensity, duration) according to patient’s baseline characteristics and their response to intervention [31]. Furthermore, our methodology was limited to clinical and functional outcome measures without incorporating structural imaging or comprehensive biomechanical analyses. The inclusion of magnetic resonance imaging (MRI) or ultrasound evaluation could provide valuable insights into structural adaptations of ligamentous and soft tissue components following different mobilization techniques, while gait analysis could quantify functional movement pattern changes resulting from treatment. Studies incorporating such advanced imaging and neurophysiological measurements could better elucidate the underlying mechanisms of improvement, potentially helping identify patient subgroups who respond better to specific interventions. Such an evidence-based personalization approach could enhance treatment efficiency and lead to more robust outcomes in managing CAI.

In conclusion, both AJM and PJM demonstrated effectiveness in improving functional ankle stability, range of motion, and proprioceptive function in individuals with CAI. While the active approach showed slightly larger effect sizes in certain parameters, both techniques can serve as viable therapeutic options. For clinical practice, we recommend that therapists consider incorporating either approach based on individual patient characteristics and treatment phase, with AJM potentially offering additional benefits for patients requiring enhanced proprioceptive training. Future research investigating the long-term effects and combining these approaches with other rehabilitation strategies may further optimize treatment outcomes for CAI patients.