ANKLE MUSCLE ACTIVATION WHEN USING THE BOTH
SIDES UTILIZED (BOSU) BALANCE TRAINER
KEVIN G. LAUDNER AND MATTHEW M. KOSCHNITZKY
Biomechanics Laboratory in the School of Kinesiology and Recreation, Illinois State University, Normal, Illinois
ABSTRACT
Laudner, KG and Koschnitzky, MM. Ankle muscle activation
when using the Both Sides Utilized (BOSU) balance trainer.
J Strength Cond Res 24(1): 218–222, 2010—The use of the
Both Sides Utilized (BOSU) balance trainer has become
increasingly popular among fitness and medical personnel.
Many fitness facilities, physical therapy clinics, and athletic
training rooms routinely use this piece of equipment for
strengthening, balance training, functional assessments, and
rehabilitating various injuries. However, there are currently little
data describing the effectiveness of this balance device.
Therefore, the purpose of this study was to determine which
side of the BOSU balance trainer would generate a greater
amount of tibialis anterior, peroneus longus, or medial gastro-
cnemius muscle activity using electromyography (EMG).
Twenty, healthy, collegiate male subjects participated (age =
21.4 6 1.4 years; height = 179.4 6 8.6 cm; mass = 80.0 6
12.1 kg). Each subject performed 3 single-leg stance trials
on each side of the BOSU balance trainer. The average EMG
data from these trials were compared with maximal voluntary
isometric contraction (MVIC) measures and represented an
average percentage of these MVICs. We found no significant
differences in EMG data for any muscle between conditions
(p . 0.54). With regard to ankle muscle activity, both sides
of the BOSU balance trainer produce similar difficulty during
a balance training task. Therefore, no particular side of this
device would provide any increase in muscle activity compared
with the other side when used for improvements in balance or
during the rehabilitation of lower extremity injuries.
KEY WORDS electromyography, neuromuscular control, sen-
sorimotor control, proprioception, rehabilitation
Address correspondence to Kevin G. Laudner, klaudner@ilstu.edu.
24(1)/218–222
Journal of Strength and Conditioning Research
Ó 2010 National Strength and Conditioning Association
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218 Journal of Strength and Conditioning Research
INTRODUCTION
R
ecently, the importance of balance training has
become a prevalent point of interest for fitness
professionals and consumers alike. Although the
average person may take it for granted, the
ability to balance is crucial for normal functional activity
and advanced movements common in athletics (19,23,24).
Although often used synonymously, balance and sensori-
motor control are not the same. Balance is the process by
which the individuals control their center of mass with
respect to their base of support (9,26). Sensorimotor control
is the precursor to good balance and provides postural
control by generating a musculoskeletal response to external
perturbations (12). Originally defined by Sherrington in
the early 1900s, proprioception, a component of sensorimotor
control, is used to describe sensory information originating
from the joints, muscles, tendons, and associated deep tissues.
Mechanical deformation of the aforementioned structures
will then result in a muscular response known as neuromus-
cular control (8,20). The speed at which the body responds
to these kinesthetic and joint position cues can be improved
with balance training or hindered as a result of injury or
inactivity (14).
Because of the high incidence of lateral ankle sprains
in athletics, such injuries have become the most prevalent
musculoskeletal injury in athletics (8,14). When an individual
sustains an ankle injury, it is not uncommon for the
surrounding musculature and associated neural structures
to be affected (8). If the functions of these neural structures
are not restored, the resultant deficits can lead to a chronic
instability of the ankle, predisposing the injured person to
possible future injuries (8,18). By incorporating a rehabilita-
tion protocol into the recovery period, and even following,
any deficits in neuromuscular function should be regained
and the individual can return to the functional level necessary
for his/her activity demands (8,18).
Although it may seem commonplace, the importance
of addressing proprioception and postural control in either
a fitness or rehabilitation protocol is still a relatively new
concept and current research is ongoing (8,25). Furthermore,
the increased interest in these areas has led to advances in
proprioception and balance training equipment, and more
of this equipment is being used (5,21,25). Various balance
platform systems have been created to increase the ankle

proprioception in injured patients (5,21,25). Subsequently,
more advanced computerized mechanical platforms have
been designed to challenge both the muscular and visual
systems in response to calculated perturbations (6,7,16,25).
Although there are many different balance training products
available, this study will focus on the Both Sides Utilized
(BOSU) balance trainer (Bosu Fitness, LLC, SanDiego, CA,
USA), which has become increasingly popular over the past
several years.
The BOSU balance trainer is a device that combines a solid
plastic base with an inflatable bladder, resembling a halved
Swiss ball. Designed for the athletic and recreationally active
population, the BOSU balance trainer is unique in that it
can be used with either the flat or bladder side on the ground,
making it a versatile piece of balance training equipment
and hypothetically resulting in varied difficulty depending
on which side of the device is being used. Consequently,
it has become quite popular in fitness gyms, strength and
conditioning rooms, athletic training rooms, and physical
therapy clinics. However, although there has been a recent
surge in research on balance training for performance
enhancement, injury prevention, and rehabilitation,
limited exploration of specific balance training devices and
the effects they have on the human body have been reported
(1,3,13–15,17).
The popularity and the relatively widespread general
acceptance of the BOSU balance trainer’s ability to generate
results has not been quantitatively reported in recent
literature. Furthermore, few studies even list this piece of
equipment as being used in reported postural control,
proprioception, or ankle rehabilitation protocols (25). Given
the scarce mention of this device in the professional
literature, the BOSU balance trainer needs to be further
examined. Therefore, the purpose of this study was to
quantitatively determine if one side of the BOSU balance
trainer produces greater ankle muscle activation than the
subsequent side. Such information may be beneficial for
athletes and coaches attempting to improve balance and
for clinicians interested in decreasing the risk of injury
and during the rehabilitation of various lower extremity
injuries.
METHODS
Experimental Approach to the Problem
This study used a repeated measures control group design.
Each subject randomly completed a balance task on one side
of the BOSU balance trainer and then repeated the balance
task on the opposite side to determine if there are differences
in ankle muscle activation between the 2 sides of the
device. The independent variables were the 2 conditions
being observed (condition 1: bladder side up; condition 2:
bladder side down). The dependent variable was average
electromyographic (EMG) activity for the tibialis anterior,
peroneus longus, and medial gastrocnemius during each
condition.
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Subjects
Twenty, recreationally, physically active, college-aged men
(age: 21.4 6 1.4 years; height: 179.4 6 8.6 cm; mass: 80.0 6
12.1 kg) volunteered to participate in this study. Recreational
physical activity was defined as any type of physical activity
participated in at least 3 times per week for a minimum of 30
minutes. The activities performed by the subjects all included
some form of aerobic exercise, such as running, bicycling, or
swimming at noncompetitive level. Individuals with any
history of lower extremity injury within the past 2 years of this
study, history of balance training, or who had any disorder
affecting balance or sensorimotor control were excluded.
Each subject was informed of the experimental risks and
signed an informed consent document before the investiga-
tion as approved by the university Institutional Review Board.
Procedures
Before data collection, all subjects were encouraged to ask
any questions regarding the study and their participation.
After all questions were answered to the subjects’ satisfaction,
they were prepared for electrode placement. Disposable pre-
gelled Ag-AgCl electrodes with a circular contact area of 1 cm
diameter on a 41-mm-diameter moisture resistant backing
(BIOPAC Systems, Inc., Goleta, CA, USA) were applied to
the skin after the areas were shaved, abraded, and cleansed
with 70% isopropyl alcohol. Two electrodes were placed on
tibialis anterior, peroneus longus, and medial gastrocnemius,
2 cm apart (center to center) and parallel to the muscle fibers.
To measure peroneus longus activity, the electrodes were
placed 3 cm distal to the fibular head and the lateral malleolus.
To measure tibialis anterior and medial gastrocnemius
activity, the muscles were palpated and the electrodes were
placed over the area of greatest bulk. One electrode was
placed over the tibial tuberosity of the same leg and used as
a ground. The leg used in this study was determined by asking
each subject which leg they preferred to kick a ball.
Once prepared, each subject was connected to the
MP-100 System (BIOPAC Systems, Inc.) to record his ankle
muscle activity at a frequency of 1,000 Hz per channel and
signals were amplified (DA100B; BIOPAC Systems, Inc.,
Santa Barbara, CA, USA) from the disposable surface
electrodes. Before collecting surface EMG data from each
condition, all subjects were required to perform a 5-second
maximal voluntary isometric contraction (MVIC) for each of
the 3 muscles. These initial measures were used as the norm
for each subject.
After the collection of MVIC EMG, each subject was ready
to begin their trials for each condition. Condition 1 was
defined as having the BOSU balance trainer with the base
(hard flat side) down and performing the single-leg stance on
the bladder side. This is the manufacturer’s recommended
use for the BOSU balance trainer with regard to the lower
extremity (4). The second condition consisted of using the
BOSU balance trainer with the base up and the inflatable
bladder on the ground. Each subject was required to perform
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Ankle Muscle Activation Using BOSU Trainer
TABLE 1. Descriptive statistics for average percentage of maximal voluntary isometric contraction (mean 6 SD).*
n = 20 C1
Tibialis anterior 40.5 6 19.2 42.6 6 20.4
Peroneus longus 48.1 6 14.5 46.7 6 17.5
Medial gastrocnemius 49.2 6 17.6 47.5 6 20.8
*C1 = bladder side up; C2 = bladder side down; CI = confidence interval.
3 trials for each condition. All 6 trials were randomized, and
each lasted 10 seconds.
The same BOSU balance trainer was used for the entirety of
the study. Before each subject’s participation, the investigators
placed the device on the bladder side and measured for the
manufacture’s recommended height of 25.4 cm to ensure
proper inflation (4). Before beginning the trials, subjects were
allowed to practice each condition to the point of being
able to complete the task for at least 10 seconds. Once they
displayed the ability to complete each condition, they were
not allowed any further practice. Subjects were instructed to
perform a barefoot single-leg stance with their eyes open,
hands on their hips, and the opposite leg flexed under the
body, but not touching the balancing leg, which was allowed
to be slightly flexed. They were advised to focus on a specific
point in front of them. If at any point the subject broke form,
the data were discarded and the trial was repeated. A break
in form included removing the hands from the waist, touch
down of the non-balancing leg, touching the balancing leg,
leaving the surface of the BOSU balance trainer, or extending
the non-balancing leg or trunk and upper extremity outside
the borders of the BOSU balance trainer. Subjects were
allowed to rest for at least 30 seconds between each trial
and were allowed additional time if necessary. However, no
subjects requested any additional time.
Statistical Analyses
A statistical package for the social sciences 14.0 for Windows
(SPSS, Inc., Chicago, IL, USA) was used for statistical
analysis. Electromyographic data from each subject’s 3
muscles were analyzed using a repeated measures analysis
of variance (ANOVA; p # 0.05) to determine significant
differences between conditions 1 and 2 for each muscle.
RESULTS
Mean and SDs for the average EMG for each ankle muscle
can be viewed in the Table 1. The repeated measures
ANOVA yielded no significant differences between the
2 sides of the BOSU balance trainer for the values of the
tibialis anterior (p = 0.54), peroneus longus (p = 0.74), and
medial gastrocnemius (p = 0.65).
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C2 95% CI Effect size p Value
31.5–52.1 0.02 0.54
38.5–54.9 0.01 0.74
37.7–57.2 0.01 0.65
DISCUSSION
The results of this study imply that there are no significant
differences in ankle muscle activity when using alternate sides
of the BOSU balance trainer. This study is unique in that it
attempts to provide quantitative data to confirm the anecdotal
evidence, suggesting that the BOSU balance trainer is
a versatile and effective piece of equipment. The present
literature focuses on the outcomes of implementing balance
training, but there is sparse research documenting the actual
physiological effects that specific balance training devices
generate.
Only one readily available article documents the use of
the BOSU balance trainer, which is somewhat surprising
given that this device has been around since 1999, when it
was invented by David Weck, and has seen so much recent
popularity. Yaggie and Campbell (25) incorporated the
BOSU balance trainer into their balance training regimen,
using exercises that were both commercially available with
the product and consistent with those described in the
literature (2,10,11,22,25). Their subjects underwent a 4-week
training program to determine if there were any benefits on
selected functional skills. After the training period, single-leg
stance duration on the BOSU balance trainer was used as one
of these functional skills to determine if any benefits were
observed. They found significance with their ‘‘time on ball’’
measures and were able to determine that there were
improvements in postural control and sport-related activities
(25). Based on this previous investigation and the results
of our study, it appears that the BOSU balance trainer does
provide some balance training benefits; however, the side of
the device used does not appear to matter.
McGuine and Keene (14) and Verhagen et al. (22) took
different approaches and described the benefits of incorpo-
rating an external balance device into a training program
for the prevention of ankle sprains. Both studies used a
protocol that began with simple single-leg tasks and, over
time, progressed to more advanced exercises using a wobble
board. Similar results were found, in that both investigations
document a significant decrease in ankle sprains in the
intervention groups when compared with the control groups

(14,22). Paillard et al. (17) used a balance device to determine
postural performance and strategy differences between
national and regional soccer players. A seesaw was placed
on a force platform and used to measure anterior/posterior
and medial/lateral control between groups. Using the
information gathered, the authors were able to determine
that national players were the more stable athletes. Based
on these past studies, it appears important for athletes to
incorporate balance training, such as the use of a BOSU
balance trainer or other balance exercises, into their exercise
regimen as a means of improving athletic performance and
decreasing the risk of injury.
One study that investigated the efficacy of a specific balance
training device was done by Blackburn et al. (3). These authors
reported on the effect of using exercise sandals during a
rehabilitation program as a means of increasing ankle muscle
activity. They ultimately concluded that using the exercise
sandals did increase the ankle muscle activity while perform-
ing functional activities (3). However, Michell et al. (15)
conducted a study that incorporated the exercise sandal
into a rehabilitation protocol and tested against a control
group. Their findings indicate that the balance device did
contribute to significant gains but not any more significant
than functional balance training alone without the exercise
sandals (15). Our study reported similar results showing good
activity while using the BOSU balance trainer but no difference
in activity based on which side of the device was used.
There are several limitations to this study. The first is
related to subject participation. The EMG data suggest that
some subjects’ trials were able to produce more ankle muscle
activity than the MVIC. Although not uncommon, this can
occur because of the lack of familiarity with the motion
needed to produce the MVIC or can be the unfortunate result
of poor motivation to produce a maximal contraction. Each
subject was coached and encouraged throughout each MVIC
measure to try to avoid this problem. There are also some
inherent problems with surface EMG that can produce these
findings. The lower extremity comprises many overlapping
muscles, and although the 3 muscles used are superficial,
there is still some cross talk from other muscles that can cause
altered EMG activity. Furthermore, it is necessary to realize
that this study only made observations of 3 ankle muscles in
the lower extremity. That does not rule out changes occurring
in other muscles, and hip and core musculature should also
be recorded in the future. Finally, there was a limited ability
to control the amount of pressure and displacement in the
BOSU balance trainer. Measuring the BOSU balance trainer
height before each subject participated was used in an attempt
to keep this constant. However, with the varying weights of
each subject, the displacement of the bladder would be higher
for heavier subjects, consequently lowering the BOSU
balance trainer to the ground in each condition. In condition
1, this would increase the instability of the device. Conversely,
this would generate more surface area in the second con-
dition, giving the subject a larger base of support.
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PRACTICAL APPLICATIONS
Using the BOSU balance trainer for exercise and rehabilita-
tion is one way to create a unique and diverse training
experience for a client or patient. With regard to ankle muscle
activity, our study demonstrates that there is no benefit to the
amount of ankle muscle activity that results from flipping the
BOSU balance trainer onto the bladder side. As such, athletes
using this device as a means for improving balance, for injury
prevention, or for rehabilitating a lower extremity injury may
use either side of the BOSU balance trainer with similar
results.
REFERENCES
1. Baltaci, G and Kohl, HW. Does proprioceptive training during knee
and ankle rehabilitation improve outcome? Phys Ther Rev 8: 5–16,
2003.
2. Bernier, JN and Perrin, DH. Effect of coordination training on
proprioception of the functionally unstable ankle. J Orthop Sports
Phys Ther 27: 264–275, 1998.
3. Blackburn, JT, Hirth, CJ, and Guskiewicz, KM. Exercise sandals
increase lower extremity electromyographic activity during func-
tional activities. J Athl Train 38: 198–203, 2003.
4. DW Fitness, LLC. BOSU Balance Trainer Instruction Manual.
Madison, NJ: DW Fitness, LLC, 2001.
5. Fiore, RD and Leard, JS. A functional approach to the rehabilitation
of the ankle and rear foot. J Athl Train 15: 231–235, 1980.
6. Hagemann, PA, Leibowitz, JM, and Blanke, D. Age and gender
effects on postural control measures. Arch Phys Med Rehabil 76:
961–965, 1995.
7. Hamann, RG, Mekjavic, I, Mallinson, AI, and Longridge, NS. The
effects during repeated therapy sessions of balance training visual
feedback. Arch Phys Med Rehabil 73: 738–744, 1992.
8. Kawaguchi, J. Ankle: Proprioceptive exercises balance rehabilitation.
Biomechanics Rehabil Suppl 23: 133–140, 1999.
9. Kim, BJ and Robinson, CJ. Postural control and detection of slip/fall
initiation in the elderly population. Ergonomics 48: 1065–1085, 2005.
10. Laskowski, ER, Newcomer, AK, and Smith, J. Refining rehabilitation
with proprioception training: Expediting return to play. Phys
Sportsmed 25: 89–102, 1997.
11. Lephart, SM, Pincivero, DM, Giraldo, JL, and Fu, FH. The role of
proprioception in the management and rehabilitation of athletic
injuries. Am J Sports Med 25: 130–137, 1997.
12. Lephart, SM, Riemann, BL, and Fu, FH. Introduction to the
sensorimotor system. In: Proprioception and Neuromuscular Control in
Joint Stability. Lephart, SM and Fu, FH, eds. Champaign, IL: Human
Kinetics, 2000. pp. 37–51.
13. Malliou, P, Gioftsidou, A, Pafis, G, Beneka, A, and Godolias, G.
Proprioceptive training (balance exercises) reduces lower extremity
injuries in young soccer players. J Back Musculoskeletal Rehabil
17: 101–104, 2004.
14. McGuine, TA and Keene, JS. The effect of a balance training
program on the risk of ankle sprains in high school athletes. Am J
Sports Med 34: 1103–1111, 2006.
15. Michell, TB, Ross, SE, Blackburn, JT, Hirth, CJ, and Guskiewicz, KM.
Functional balance training, with or without exercise sandals,
for subjects with stable or unstable ankles. J Athl Train 41: 393–398,
2006.
16. Nichols, DS, Glenn, TM, and Hutchinson, KJ. Changes in mean
center of balance furring balance testing in young adults. Phys Ther
75: 699–706, 1995.
17. Paillard, T, Noe, F, Riviere, T, Marion, V, Montoya, R, and Dupui, P.
Postural performance and strategy in the unipedal stance of soccer
VOLUME 24 | NUMBER 1 | JANUARY 2010 | 221
Ankle Muscle Activation Using BOSU Trainer
players at different levels of competition. J Athl Train 41: 172–176,
2006.
18. Ross, SE and Guskiewicz, KM. Examination of static and dynamic
postural stability in individuals with functionally stable and unstable
ankles. Clin J Sport Med 14: 332–338, 2004.
19. Sato, K and Mokha, M. Does core strength training influence
running kinetics, lower-extremity stability, and 5000-m performance
in runners? J Strength Cond Res 2008.
20. Sherrington, CS. The Integrative Action of the Nervous System.
Cambridge, United Kingdom: Cambridge University Press, 1948.
21. Soderberg, GL, Cook, TM, Rider, SC, and Stephenich, BL.
Electromyographic activity of selected leg musculature in subjects
with normal and chronically sprained ankles performing on a BAPS
Board. Phys Ther 71: 514–522, 1991.
22. Verhagen, E, van der Beek, A, Twisk, J, Bouter, L, Bahr, R, and van
Mechelen, W. The effect of a proprioceptive balance board training
the TM
222 Journal of Strength and Conditioning Research
program for the prevention of ankle sprains: A prospective
controlled trial. Am J Sports Med 32: 1385–1393, 2004.
23. Wang, HK, Chen, CH, Shiang, TY, Jan, MH, and Lin, KH. Risk-
factor analysis of high school basketball-player ankle injuries: A
prospective controlled cohort study evaluating postural sway,
ankle strength, and flexibility. Arch Phys Med Rehabil 87: 821–825,
2006.
24. Wilk, KE, Meister, K, Fleisig, G, and Andrews, JR. Biomechanics of
the overhead throwing motion. Sports Med Arthrosc Rev 8: 124–134,
2000.
25. Yaggie, JA and Campbell, BM. Effects of balance training on selected
skills. J Strength Cond Res 20: 422–428, 2006.
26. Yocheved, L, Schwarzmann, R, Sivan, D, and Sprecher, E. Postural
control of patients with hemiparesis: Force plates measurements
based on the clinical sensory organization test. Physiother Theory
Pract 21: 163–171, 2005.