Flexibility-enhancing Interventions for Ankle Range of Motion: A Network Meta-analysis

Abstract

This systematic review and network meta-analysis compared the effectiveness of five flexibility-enhancing interventions-static stretching, dynamic stretching, ballistic stretching, proprioceptive neuromuscular facilitation, and foam rolling-on ankle dorsiflexion range of motion in physically active healthy adults. A comprehensive search of multiple databases was conducted up to August 4, 2025. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and was registered in prospectively registered in the International Prospective Register of Systematic Reviews. Effect sizes were synthesized using a random-effects network meta-analysis, and intervention rankings were based on the surface under the cumulative ranking curve. Forty-one randomized controlled trials (n =1,670) were included. For the passive range of motion, proprioceptive neuromuscular facilitation (surface under the cumulative ranking curve: 76.8%) and foam rolling (67.8%) were the most effective overall. In long-term protocols (>1 mo), both proprioceptive neuromuscular facilitation (standardized mean difference 1.04 [0.64-1.44]) and foam rolling (standardized mean difference 1.03 [0.53-1.53]) remained superior to controls. For active range of motion, foam rolling ranked the highest (surface under the cumulative ranking curve: 87.2%) and demonstrated the largest short-term improvement, while static stretching showed the most favorable long-term maintenance (surface under the cumulative ranking curve: 72.4%). No intervention-related adverse events were reported. Proprioceptive neuromuscular facilitation and foam rolling are optimal for long-term flexibility enhancement, whereas foam rolling is recommended for short-term, pre-exercise movement preparation. Static stretching may support sustained active range of motion across extended training periods. Intervention selection should align with specific performance goals and training timelines.