Ankle ROM

Members do not see these Ads. Sign Up.

Hi Guys,

Very quick question regarding a reference:

I have heard much talk of 10 Degrees of ankle dorsiflexion in open chain to be an unsuitable measurement for gait ROM at the ankle, and one should perhaps look at quality and ease of movement of the TC joint during gait.

I have searched for a couple of days now on this forum, on the web and on JAPMA for articles relating to this and am having trouble finding anything on it..

Could someone please recommend some references for journals or perhaps, if they are super kind, to email a copy to me?

Kind regards,

Sam Randall

 

Sam

Not a lot published, but consider this;

- how hard do you push to dorsiflex the ankle when measuring dorsiflexion? The standard defnition is "until resistance", but I reckon I could get 10 degrees in everyone of I pushed hard enough!

- how hard should we push to dorsiflex? - intuitively shouldn't we apply as much force to dorsiflex the ankle as is applied during gait --- are we physically strong enough to apply that force?

- what happens if you walk faster - is 10 degrees still valid?; what happens if you walk slower? - is 10 degrees still valid?

- traditionally we are supposed to keep the STJ neutral when we measure the ankle ROM, so STJ pronation does not factor into it. But the Lunge test allows the foot to pronate, which a lot of people do not like, but who cares? ---- the lunge test is predictive of injury ...how many other clinical tests we use have been shown to be predictive of injury?

- we have data which we not published yet in which we looked at how far the tibia moved over the foot before the heel came off the ground at different velocities ... the conclusion of this study was there is no normal ankle joint ROM --- some people needed a greater range when they walked faster; some needed a less range; some people never came close to 10 degrees before the heel came of the ground (even if they had the ROM available); other used a greater range during gait than what they had during clinical exam!; etc, etc ...

Confused?

The answer probably rest with abandoning the concept of ROM and look at the force/degree curve for the ankle (ie how much force is needed to produce what degrees of dorsiflexion).

 

Hi Craig, thanks for the response.

Do you think that looking at ankle dorsi flexoin in open chain as part of a assessment is still valid? I feel that it is useful in a building a "clinical picture" of the patient, but maybe I am wrong. If there is gastroc-soleus tightness and the patient is exhibiting some pathology that can be related to this (i.e. Achillies tendinopathy, or plantar fasciitis 2ndary to escape pronation) this can be picked up in the assessment and thus treated (stretches, exercises etc..)?

How would it be possible to measure force/degree curves? I'm guessing some combination of forefoot plantar pressures (via an inshoe system) combined with some Vicon-like camera system?

Would a study that showed effects of stretching, exercises or manipulation (like the manips suggested by Howard Dananberg, 2000, Journal of the American Podiatric Medical Association 90:8) that increased the amount of dorsiflexion during gait by a few degrees, or decreased plantar pressure to reach the same amount of dorsi flexion be useful??

btw.. Happy birthday!!! :drinks

 

No.

All it does is give you another way (plan f) to possibly increase ankle dorsi-flexion.

This study only addresses (for memory) the tib fib component. In my clinical experience, this is somewhat relevant in 5-10% of cases.

First question is what is the restriction caused by? Tight capsule (posterior). Posterior tendons (peroneal, tib post, achilles?)? Anterior impingement etc...

If it is the mundane tight achilles and posterior capsule etc....there are (clinically significant) techniques out there that easily surpass the marginal statistical significance gains 'seen' in studies.



Craig is right. If you want to understand ankle ROM, start reading about the lunge test. It will take you the reading time to remember it; but more time clinically to actually understand its full usefulness.



Ron
Physiotherapist (Masters) & Podiatrist

 

Hi Ron, many thanks for the response.

I believe you are right re: the Tib/-fib component. I think I was trying to ask more if there have been many trials done looking at forefoot pressures and sagittal plane ankle progression together following an intervention, be it Dananbergs manipulations, massage, trigger point therapy, acupuncture, stretching programmes, voodoo, sham...

"there are (clinically significant) techniques out there that easily surpass the marginal statistical significance gains 'seen' in studies."

Which techniques would they be, and do you think (for example) that a 4 degree increase in dorsiflexion at the ankle would be of marginal significance? It is my impression that even a very small change in kinematics or kinetics, with regard to the ankle, could be very significant?

Kind regards,

Sam Randall

 

See the attached - we use a force gauge to dorsiflex the foot with 10, 20, 30 .... etc newtons, then measure the angle --> force/degree curve (ie stiffness curve). eg 2 people may have the same end ROM, but the force to get them there may be very different.

...just had some ice cream cake with the Arena'ettes! (so much for the training routine for the run4thekids!)

 

I really do not know.

Life used to be simple when 10 degrees was normal. When they had more than 10 degrees, we left it (ignoring the measurement reliability issues) and when they had less then 10 degrees we intervened (heel raises; stretching; mobs; etc) ... wasn't it great!; wasn't the decision making simple?

Now its become obvious that the normal ROM is subject specific, its just determining that subject specific range! We think we getting closer using the lunge test in the shoes on top of the orthotic and aiming to get 35-38 degrees (see the lunge test threads for discussion on that)

 

If I have to measure an intra-sessional improvement with a goniometer and be content with 3 degree increase, I am kidding myself and should give the game away. A lay person with average vision should be able to clearly see a difference to be a clinically significant gain. For example, the touch-toes test in physiotherapy. If pre-treatment, they are reaching their knees; successful treatment in my book would be a 3-4 inch (not mm) improvement (with all other variables standardised (extended knee; stance width identical etc.) When I ask subjectively if the patient is better, if they think and pause for 5 seconds considering it, they are not better.

My big problem with EBP is that many researchers will, after the event go back and cherry-pick (from many variables) a statistically significant improvement after the event...rather than set out on an apriori (pre-set) variable which will be the focus of the research. Nowhere near enough allied health research looks at "clinical significance". You will find this explained in a recent systematic review done on 'successful' core stability papers. For memory most of the 41 were statistically significant. But when reviewed externally, only 4 were clinically significant. I have posted the link somewhere on Pod Arena...it is definitely worth a read.


Intra-sessional improvements are attainable. Your best research/study sample is the patient in front of you. Assess the lunge. Intervene with plan "a"; and then re-assess. No change? Go to plan b and so on. If re-assessment is worse, you may have tried to mobilise (into dorsiflexion) an anterior impingement.


More time involved unfortunately. More hands-on contact needed unfortunately. But you get results quicker and you get to understand the ankle better in the long-run.



Ron
Physiotherapist (Masters) & Podiatrist

 

A) thanks for all the info on lunge testing..

2).. Ron, I feel i need to explain my queries a little firther with regard to this point.. I would never expect anyone to measure a 4 degree change with any measuring aparatus that is at our disposal, especially a goniometer. Not all (hardly any!?) of the interventions we do a truely measurable, especially in a clinical environment.

D) My question was as much geared towards a theoreticaal point, as much towards kinetics as it was kinematics, with 4 degrees being a nominal figure I picked out of the air because it seemed "insignificant", quite small and ultimately immeasurable. Hence the question about using inshoe pressure analysis as well as a Vicon (equivalent) system for measuring gait.. a 4 degree increase in ankle dorsiflexoin: could it be relevant, to injury or rehab? I think it can.. can it be clinically measured, probably not... but if one was to record ankle dorsiflexoin and forefoot plantar pressures during gait pre and post intervention, it could be quite enlightening, one way or t'other..

xii) I am very keen to learn some of the techniques you mentioned, Ron. Can you point me towards any literature that details them??

Kind Regards

Sam Randall

 

Sam

As you know I am quite keen on mobilisation (mobs/ manips) to increase magnitude and decrease stiffness of ankle dorsiflexion RoM. I like to use the extended knee non weight bearing goniometer measurement of RoM.

These are my thoughts for open chain measurement and intervention.

As to the question 'is the improvement measurable, reliable or significant'

From my own experience I regularly see 8 - 15dgs increase in Range after mobilisation, If I were only to see 3dgs then I do not record that as an improvement and run thru the mobs again until I see greater improvement or conclude that none is possible at this time.

I feel that I do take great care in the application of my measuring technique to ensure that these changes are real and not imagined. Most patients say they can feel the extra and improved quality of the ankle RoM usually without prompting. I also see a change in gait E.G. most often there is an increase in step length and / or heel lift is later or less springy and / or there is less abductory twist at heel off. Patient very often can feel this change and often note a reduction in painful symptoms or feel more balanced when walking. Quite often, after the only intervention was mobilisation, they will phone up a week or so later and say " I don't know what you did to my foot Mr Smith but it's just so much better to walk on now I just had to phone and let you know" these words are repeated almost verbatim by every customer that phones for that reason.

I use 10dgs dorsiflexion as a guide not a target, If they have say -5dgs max dorsiflexion and I mob it to +5dgs then that change is what is important and not the absolute degree of dorsiflexion RoM. (Where 0dgs position of reference is a 90dg angle between lateral shank bisection of the TC,Joint and and lateral plantar aspect of the foot.)

I also assess the unilateral quality of RoM and the difference between left and right. So even tho a customer may achieve 10dgs dorsiflexion RoM I may still mobilise to improve the quality of the RoM I.E. make it less stiff to dorsiflexion. I consider that these changes in quality of RoM and magnitude of RoM be more reliable and significant achieving a predetermined 'Normal' Range or stiffness.

Often a subject will have 10dgs on both ankle but the right require much more force to achieve that same RoM. I may also note that he has a hip level difference, often on the more stiff side but not always. After mobs it is not unusual to find that the hip are then level and there is no need to think about differential heel lifts.

I consider that these changes, which include quality of RoM and magnitude of RoM, be more reliable and significant than achieving a predetermined 'Normal' Range or stiffness.

Cheers Dave

 

I can vouch for that, after Dave manipulated my right ankle I felt more `balanced`in my gait and also noted a reduction in right hip pain, shame it didn`t last longer than a couple of months though.

Cheers,
Bel

 

I disagree.

I can see where you are coming from, in relation to dynamic assessment and joints such as STJ...midfoot joints etc.


But the ankle joint? Learn about the lunge test. Change your techniques (In vogue physiotherapy evertor strengthing is overrated; as is podiatric theory on ankle ROM. In fact, the some masseurs who have done a weekend course in massage probably have more influence as they are hands-on) and you will one day revisit your quote and look at it a lot differently.



Ron
Physiotherapy (Masters) & Podiatrist

 

Dave and Ron,

Thanks for the info.. the brain is still whirring (or wheezing.. not sure which) I have been looking into lunge testing alot over the last couple of days.. (although some of the journals published in the australian physio journals I have been, frustratingly, unable to access). I will incorporate it into my assessment today, I'll also try looking at it pre- and post- those mobilisations Mr. Smith showed us back at T2.

Dave, would you agree with Ron's statement that the ankle RoM mobilisation is only relevant in 5-10% of patients??

Ron, I still am very keen to learn more about some of the techniques you previously mentioned. Can you please point me towards any literature that details them??

Kind regards,

Sam Randall

 

Sam:

The future of understanding ankle-foot joint dorsiflexion requirements will most likely be in determining the load-deformation curve for the ankle-foot complex. The slope of the load-deformation curve at any point along the curve would be considered "ankle-foot joint stiffness".

The standard lunge test (done with the knee flexed) will only be good at estimating ankle joint dorsiflexion for running activities (i.e. with the knee flexed) since during walking, maximal ankle dorsiflexion occurs with the knee nearly completely extended. In running, maximal ankle joint dorsiflexion and maximal knee flexion occur nearly simultaneously, which would be more equivalent to the information that a standard lunge test provides.

Clinically, I have found that the passive ankle joint dorsiflexion measurements (i.e. no patient assistance) I perform on patients both with the knee flexed and extended are pretty good indicators of foot and lower extremity function. However, from a quantitative scientific research standpoint, ankle-foot stiffness will likely be much more predictive of the kinetics and kinematics of gait function, since it will allow more rigorous mathematical analysis and actually includes more data points along the load-deformation curve to aid in better understanding how the foot and lower extremity function during weightbearing activities.

 

Sam,

I have some research papers on the Lunge test. If you give me your email I will happily send you what I've got.

Regards,


Tim

 

Disagree. The future of understanding will rest with a better understanding of what structures are involved in the dorsi-flexion deficit.

Actually a fellow named Maitland (for memory) combined your thinking with 'structure' and spoke about end-feel. An anterior impingement was 'springy' I recollect, whereas a tight capsule was firm and leathery.

We have argued this before, and I still maintain that this is not true. I understand where you are coming from here, and it is theoretically sound; but in clinical practice the lunge is the ultimate barometer for walking, stairs, running, jumping,....you name it.

A negative lunge being foot pointing at 12 o'clock; distal hallux touching wall; heel in contact with ground; not being able to dorsi-flex so the knee can't touch the wall.

If patient x has a negative lunge clinically, there is no way their gait will be physiological. They will either compensate by externally rotating at proximal joints (hip etc.) so they 'avoid' ankle dorsiflexion; or they will get into swing phase prematurely at midstance....and shorten the step length of the contra-lateral limb. Patient x will find it difficult to walk uphill as the dorsi-flexion demand increases. Patient x will find it difficult to descend stairs.


If through appropriate treatment intervention, one can improve the lunge of patient x by 2-3 cm, then you can bet London-to-a-Brick that walking will be less antalgic (more quality), and less symptomatic.

If the improvement in lunge cannot be attained....
The greater the lunge deficit, the greater the need and impact for heel-lifts (until lunge improves). Put a heel raise under the heel of patient x, and they get a psuedo increase into positive lunge territory. They walk better immediately.

 

Sam,

I know Tim has beat me to it and already kindly offered but I also have pdfs of the 2 key papers regarding the lunge test (Pope et al, Gabbe et al) and am more than happy to mail you the pdfs if you PM me your e-mail

Ian

 

Hi Ian,

The ones I have are Pope et al and Bennell et al. Haven't got Gabbe. Which one is that? And would you mind sending me a copy?!

Many thanks

Tim

 

Hi Tim,

My mistake - when referring to the 2 key papers regarding the Lunge Test I totally meant Pope et al and Bennell et al! The other paper I was referring to was:

Gabbe BJ, Finch CF, Wajswelner H, Bennell KL. Predictors of lower extremity injuries at the community level of Australian football.Clin J Sport Med. 2004 Mar;14(2):56-63.

I think I got mixed up as Bennell was an author on both. However pretty certain I have this archived somewhere as well so will hunt it down for you and ping it over

Ian

 

Ta!

I wonder why Bennell measured toe to wall as well as tibial angle. Was that to take account of foot size in the correlation of data?

 

Yes..

 

The main validity issue with the toe to wall measurement was with respect to the proportions/ratios between an individuals leg length and foot length. This was not directly addressed in Bennell's 1998 reliability paper (which they fully acknowledge in the discussion). As as been mentioned on the forum previously perhaps we should be more concerned with the tibial angle than the toe to wall distance, as anyone with a 'small' foot is unlikely to achieve >9cm

Ian

 

We only use tibial angle -- as you said, any tall person will have the minimum distance and any short person will not have the minimum distance --> use the tibial angle!

 

Harder in a clinical enviroment to use tibial angle.


Surpisingly, the different foot sizes don't end up changing assessment, diagnosis and improvement status.


Most of the time, we are dealing with one pathologically affected ankle, and one physiologically normal one.

So much easier to measure toe to wall; because "normal" is what the other foot is measuring. That is the aim, to restore symmetry etc.


Goniometers and landmark stickers work in lab....but are irrelevant in the clinical world where we are seeing 20 a day.


Ron
Physiotherapist (Masters) & Podiatrist

 

I have an angle measuring thingy.. It is like a gravity controlled device for architecture or carpentry or the like.. makes me look a little like a builder, but that fits in with the plaster i have coating my shoes and trousers (how I miss the foam boxes...)

I tried measuring tibial angle during the lunge test yesterday on a few patients and have been trying to use the same area of the anterior border of the tibia for measuring. It takes about 4 seconds and gives me an idea of the 35-38 degrees that Craig was talking about. Seems to be working ok.

Using amazing foresight, when the hospital I work in was constructed, the powers that be put a very useful line on the floor around my room that is approximately 9.5cm from the wall.. I find this a very useful starting position when measuring before and after mobilisations. It is also very useful to have the wall in front of the patient to help them balance.

Thanks to Ian for the papers..

Kind regards,

Sam Randall

 

I am currently using a fluid goiniometer to measure tibial angle in the lunge test. It's quite straightforward to use and a lot less fiddly than a universal goiniometer. A bit pricy though.
Agree with Ron re the clinical relevance but I'm doing a study so I have to measure!

Cheers

Tim

 

Tim,

I have found the Gabbe et al paper - PM me your email address and I'll get it to you

Ian

 

Validity and reliability of a new ankle dorsiflexion measurement device.
Gatt A, Chockalingam N.
Prosthet Orthot Int. 2012 Dec 4. [Epub ahead of print]

 

Hi people, Does someone have the full paper?