According to Diamond (22), cognition is the study of cognitive processes or functioning in connection with the particular neural mechanisms that underlie them in the brain and any impairment of these mechanisms. In many sports situations that require focus, coordination, and control to override internal or external stimuli, higher-level cognitive functions, also known as “executive functions”, are crucial. As a collection of adaptive behaviors that enable athletes to successfully navigate the environment by shifting and adapting to changing environmental cues and needs, executive functions are defined as the capacity to coordinate cognitive, emotional, and motor processes (22). It is possible to distinguish between three primary executive functions: cognitive flexibility, working memory, and inhibition. The ability to regulate one's thoughts, behavior, attention, and/or emotions to overcome a strong internal inclination to act or an outside distraction is known as inhibition, or inhibitory control (22). Working memory, which describes a person's capacity to retain and hold information in an active, readily retrievable state while blocking out distractions and interference, is closely related to inhibitory control (22, 23). Cognitive flexibility is the ability to modify cognitive processing techniques in response to novel situations (22). For instance, processing speed (such as reaction time), visual attention, and dual tasking are examples of lower-level cognitive abilities. Information processing speed is the rate at which an athlete processes new information and the amount of time needed to retrieve previously stored information from memory. Information processing speed is a fundamental cognitive function required for more complex functions like working memory. It characterizes an athlete's capacity to perceive, process, and react to a sensory stimulus. A common metric for evaluating an athlete's ability to react quickly to a given stimulus is reaction time. The attempt to complete two or more tasks at the same time is known as dual tasking or multitasking (24). It is believed that training cognitive functions can be used to enhance one or more facets of sports performance by better understanding the distinct cognitive functions that underpin sports performance, both domain-general and domain-specific (25). This approach has been criticized, though, because it might not be sport-specific given the complexity of athletic settings (24). While domain-specific cognitive skill training is thought to have a higher transfer to sports performance because of its higher ecological validity, domain-general cognitive skill training is argued to not necessarily transfer to sports performance (25, 26).

Sensory reweighting refers to the central nervous system's (CNS) ability to dynamically adjust the relative importance (or “weight”) of different sensory inputs (i.e visual, vestibular, and somatosensory/proprioceptive) to maintain balance and posture (27–29). This process allows individuals to adapt to changing environmental conditions in order to maintain optimal postural control. The relative weight of each sensory system depends on factors such as task complexity, environmental conditions, and the accuracy of sensory input. For example, when standing on firm surfaces, the CNS primarily relies on proprioception and vision to maintain balance. However, when standing on an unstable surface, the CNS reduces reliance on somatosensory input and shifts to more reliable sources, such as visual cues if available. In eyes-closed (EC) conditions, an increased reliance on somatosensory cues is observed (21).

There are different ways to identify visual contribution during postural control. Recently, the development of strobe glasses allows patients to perform dynamic tasks under perturbed vision, whereas full EC conditions only permit static tasks (14, 30). By constraining visual input (i.e stroboscopic vision) during dynamic activities such as hopping or jumping, clinicians can assess sensory reweighting towards vision. A significant decrease in performance under SV conditions, particularly in comparison to the uninjured limb or healthy individuals, may indicate increased reliance on visual input.

To summarize, successful performance in dynamic tasks relies on the integrated function of both lower- and higher-order cognitive processes. Lower-order cognition involves the fundamental, often automatic, processing of sensory input, while higher-order cognition encompasses the complex mechanisms of attention, memory, decision-making, and executive control (31). Together, these processes shape how information is interpreted and acted upon by integrating incoming sensory data with prior knowledge and task goals to guide behavior. In parallel, sensory reweighting is an adaptive process where the central nervous system dynamically shifts its reliance among sensory modalities (e.g., vision, proprioception, vestibular) based on environmental conditions and task demands. A key distinction is that while cognition governs the interpretation of information and subsequent decision-making, sensory reweighting adjusts the input signals themselves to optimize sensorimotor control.

A decline in either cognitive function (affecting interpretation and decision-making) or sensory reweighting abilities (disrupting the quality of sensory input) can reduce motor performance. This creates a potential sensorimotor mismatch, where the brain's commands and the body's feedback are misaligned, increasing the risk of injury (Figure 1). These alterations are commonly described in patients with CAI and may explain the high rate of recurrence in this population.

Recent studies have identified subtle cognitive impairments in CAI mostly assessed using computerised cognitive tasks (CNT) and dual-task paradigms (10). The most commonly used paradigms to assess cognitive deficits were the number generation or digit span task and the serial subtraction performed during single-leg stance or gait (10).

Seated CNT have revealed deficits in visual memory (32), while evidence for impairments in attention (32–34) and processing speed is mixed (32, 34–38). Dual-task assessments have provided additional evidence for compromised cognitive-motor integration in CAI (39–44). Specifically, dual-task paradigms that tested inhibitory control and attentional resource allocation have demonstrated reduced performance in CAI populations compared to healthy controls (45, 46). This is particularly relevant given the functional overlap between perception–action coupling and executive control: many sport-specific or daily tasks require cognitive regulation of movement, especially when there is time pressure, adaptability is required. Understanding this interplay offers important insight into the central mechanisms that may underpin persistent functional deficits in CAI.

Indeed, CAI patients often exhibit longer reaction times, reduced spatial perception, and impaired memory (32, 38, 42, 47, 48). These deficits result in a reduced ability to respond to a dynamic and unpredictable environment, which is particularly common in sport, thereby increasing the likelihood of sensorimotor mismatch.

It should be noted that all mentioned studies relied relatively small patient samples (n < 30) and presented heterogeneity in the inclusion criteria for CAI, which may account for result variability (10, 39). Differences in dual-task outcomes could also reflect task difficulty and heterogeneity within CAI groups. Despite the accumulation of scientific data, the level of evidence remains limited and additional high-quality studies are needed to better understand, identify, and target cognitive deficits in patients with LAS/CAI.

An increased reliance on visual information has been identified in CAI patients compared to healthy individuals during single-leg stance (13–15). While inconsistent results have been observed in eyes-open conditions, CAI patients almost consistently exhibit postural control impairments during eyes-closed conditions. Inadequate sensory reweighting may contribute to the functional deficits observed in CAI, caused by over- or under-reliance (beyond or under utilising what's optimal) on specific types of sensory input. For instance, while increased reliance on visual input may help maintain balance during traditional rehabilitation exercises, this strategy often breaks down in more complex, sport-specific environments. In such setting visual resources are already heavily engaged in managing gameplay demands such as tracking opponents, anticipating ball trajectories, and responding to unpredictable events.

The exact cause of this mechanism among CAI patients remains unclear. Since somatosensory receptors, such as articular receptors or muscle spindles, are frequently disrupted following LAS, loss of proprioception is frequently observed (6, 49). It could be argued that the CNS is enabled to overcome this loss of proprioceptive signals and shift to compensate for its reliance on visual information. Recent results (13) revealed that CAI patients show stronger but less stable functional connectivity between the superior parietal cortex and visual cortices, as well as greater variability in connectivity with the spinocerebellum, which correlates with increased visual reliance. Overall results align with Freeman's articular deafferentation theory (50).

Increased visual reliance is therefore considered as a compensatory mechanism that could partially explain postural control impairments and functional deficits observed following LAS and the high rate of recurrences. Therefore, it is crucial to identify individuals who rely excessively on vision for balance and implement rehabilitation strategies to restore appropriate sensory reweighting following injury.

Overall results confirm that central deficits occurred following LAS and could exist among CAI patients. However, it should be noted that there are significant discrepancies regarding inclusion criteria and the definition of CAI patients across studies. We recommend that authors follow the IAC guidelines when including CAI patients (3). More specifically, patient should (i) have suffered a history of at least one significant ankle sprain at least 12 months prior to the study enrolment, (ii) reported ankle joint “giving way”, and/or recurrent sprain and/or “feelings of instability” on the same ankle and (iii) reported diminished self-reported function.

Poor management of RTS is a key contributor to high recurrence rates and the development of CAI. Given recent data, it therefore seems essential to target central alterations throughout the RTS phase, particularly in sports patients performing dual-task situations. The following section reviews the current management of RTS, existing validated objective criteria and identifies their potential limitations in this regard.

Return-to-Sport decisions are critical at the end of rehabilitation, particularly in populations such as individuals with CAI, where the risk of re-injury remains high. While physical recovery (e.g., restoration of range of motion, strength, and balance) is necessary, it is not sufficient to ensure safe and sustained RTS (51). A systematic review highlighted the lack of objective criteria to safely guide return-to-sport decisions (52). To date, there is no consensus on the specific criteria to be used, and decisions are still largely based on time-based guidelines (16).

Research shows that nearly half of athletes resume their sports activities the day after the injury, and within a week, up to 80% have returned to play (53, 54). However, most athletes do so without having fully recovered from the impairments caused by the sprain—such as deficits in postural control and joint range of motion (55, 56).

An expert consensus conducted by the International Ankle Consortium (IAC) emphasized the importance of evaluating five key domains before clearing an athlete to return to sport (57). The authors proposed a new “PAASS” framework to evaluate Pain, Ankle-specific impairments, Athlete perception (including kinesiophobia and psychological readiness), Sensorimotor control, and Sport-specific functional performance to guide clinicians in assessing readiness. Unfortunately, it does not specify how clinicians should assess these items.

This tool is a cluster of six items selected on their relevance for monitoring LAS patients (58, 59) and the recommendation of PAASS framework (57). All items and threshold values were selected based on their ability to distinguish between healthy individuals, copers, and patients with CAI. Finally, they were selected if they demonstrated sufficient reliability and validity and did not require specific or expensive equipment. The total duration of the Ankle-GO™ test does not exceed 30 min.

It has been recently developed and validated among patients suffering from CAI and could help to identify patients who will RTS at the same level of play (58), those who will suffer reinjury (60), and those who are more likely to become coper (61). The total score is 25 points (Table 1) spread over two self-reported questionnaires as well as four functional tests.

Athletes recovering from CAI often revert to novice-like motor patterns, necessitating the relearning of previously automatic skills. This regression stems from the adoption of maladaptive movement strategies that increase reliance on cognitive resources and visual input, thereby reducing motor efficiency. Due to compromised sensorimotor pathways, these individuals typically engage in more conscious control of movement, which places greater demands on attentional capacity and slows reaction time. Athletes with CAI may exhibit increased attention directed toward their injured ankle, as they consciously monitor movement patterns and joint stability (81–83). This self-attentional focus is further reinforced during rehabilitation, when rehabilitation specialists frequently provide internal focus instructions—directing the athlete's attention to specific body mechanics, such as knee alignment or muscle activation (84). These cues may inadvertently contribute to excessive cognitive load. This adaptation reduces cognitive resources available for other tasks (85, 86). To restore automaticity, an external focus of attention—such as concentrating on the outcome of movement rather than its mechanics—can help free up cognitive resources. This shift enables enhanced cerebellar involvement in sensorimotor control, fostering improved internal modeling for predictive adjustments and real-time motor corrections.

According to Gibson's ecological theory of perception, movement and sensory information are inherently linked in a continuous feedback loop (87). Movement generates sensory information by interacting with the environment, while sensory input, in turn, guides and refines movement. This bidirectional relationship allows individuals to adapt their actions based on real-time environmental cues. In the context of sports, athletes rely on this dynamic interplay to adjust their positioning, timing, and force production in response to rapidly changing game conditions. This interplay between movement and sensory information highlights the need for rehabilitation programs that incorporate enriched environments to facilitate optimal recovery. By exposing patients to practice variability and/or different situational conditions, they can actively explore and refine movement patterns in response to real-time sensory input.

This framework applies particularly to athletic populations of patients with LAS/CAI, especially those who participate in sports involving dual tasks or risky movements, such as jumping, landing, and cutting movement. It also applies to athletes whose vision is focused on managing their environment (movements and positioning of opponents and teammates) or tracking the trajectory of a ball, for example.

A recent meta-analysis reveals that dual-task training may be effective in improving static and dynamic postural stability among CAI patients but confirms the need for more high-quality studies to confirm the short and long-term effectiveness (43). This applies regardless of age, level of practice or severity of injury. It also seems important to introduce dual-task situations and neurocognitive exercises, as well as assessments targeting these elements, with the aim of primary injury prevention among these athletes.

In the second part of this topic (Targeting Visual-Sensory and Cognitive Impairments Following Lateral Ankle Sprains: A Practical Framework for Functional Assessment Across the Return-to-Sport Continuum. Part 2: From theory to practice: recommendations for optimizing Return To Sport after lateral ankle sprains using cognitive and visual-sensory assessments, Frontiers in Sports and Active Living, [under review]), we will propose a “β(rain)” extension of the Ankle-GO™ score that could help clinicians to target sensory-visual and cognitive deficits among patients following LAS in the RTS continuum.