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Lunge Test: A Good Test for Only Running Sports??

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kevin Kirby, Mar 24, 2007.


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    Craig Payne mentioned today at the conference in Belgium the research that seems to correlate a lack of ankle joint dorsiflexion (from the lunge test) to increased prevalence of injury in rugby players. However, the lunge test is performed with the knee flexed, not the knee extended, so it makes sense that the lunge test may be more specific to running sport mechanics rather than walking mechanics.

    In other words, I would imagine that the lunge test may be a much better predictor of injury for running sports (the knee is never fully extended during running) than it is a good predictor of injury in walking activities since the lunge test is performed with the knee flexed. The lunge test is specific for restricted ankle joint dorsiflexion due to soleus or ankle equinus, but is not designed to test for gastrocnemius equinus.

    I predict that the measurement of the ankle joint dorsiflexion with the knee extended would be a better predictor of injury for walking activities, rather than the lunge test. Maybe a knee-extended type of weightbearing ankle joint dorsiflexion test similar to the lunge test could be devised for predicting walking injuries due to gastrocnemius equinus than our current model of using a non-weightbearing examination method with the subtalar joint place in neutral position. Anyone have any thoughts in regard to these ideas?

    Craig....Dave....are you still there??
     
  2. LCBL

    LCBL Active Member

    Interesting.

    Craig did mention that the Lunge test excluded any need to look at the STJ motion during the test for the results to be an accurate indicator of future injury (according to the quoted studies) Would this still be the case in a similar straight knee test?
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. Kenva

    Kenva Active Member

    Kevin,

    If i remembered correctly, the distance of the foot to the wall is been discarted (because short people alsways have less then 9 cm distance) and the angle of the tibia is measured and found to be a better predictor (38-39°)
    If that is the case, perhaps a test for walking could be by measuring the tibia angle (sagital plane) when the patiënt is trying to take an 'as big as possible 'step forward (calf stretching position / don't know the correct terminology for this one...)

    Ken
     
  5. Atlas

    Atlas Well-Known Member


    Kevin, we have been through this lunge debate before.

    Your theory is sound, but life is more than running and walking. Even your sedentary 80 year old descends steps, which involves extreme weight-bearing dorsiflexion with a bent knee.

    The lunge is ultra relevant in ADL; in running sports; and invariably most weightbearing activities.
     
  6. Ron:

    I suppose if the 80 year old descended steps all day long the lunge test would be a good predictor of injury in this age group. Do you have any references to back up your claim that the lunge test is a good predictor of injury (is that what you mean by your new term, "ultra relevant"??) in non-running weightbearing activities?
     
  7. People can invariably get more ankle joint dorsiflexion with their knee flexed than with their knee extended given the same magnitude of forefoot loading force. In running, the knee is at near maximal flexion when maximum ankle dorsiflexion is required so the lunge test makes good biomechanical sense for predicting injury in running sports. However, since, in walking, the knee is extended at the same time that maximum ankle dorsiflexion is required, then it would make better to not use the standard lunge test for patients who mostly walk. For these less athletic patients a type of "modified lunge test" may be more appropriate where the knee is fully extended and the ankle is maximally dorsiflexed. Theoretically this distinction between a knee flexed and a knee extended ankle dorsiflexion measurement makes good biomechanical sense for injury prediction.
     
  8. Atlas

    Atlas Well-Known Member


    Kevin, find me anyone with a negative lunge recording that can walk without a limp. I think Craig will find his forefoot varus before you do.

    As for relevance. The lunge test is ultra relevant in predicting the function and prognosis of mechanical ankle conditions; be it for the elite sportswoman or the sedentary 80 year old.

    As for references. I'll start reading the research when the researchers start addressing where the restriction lies. Many have been talking about the lunge for decades; but unfortunately not many have concerned themselves with as equally an important aspect as range/angle.

    No other clinical test can tell us whether an anterior ankle joint impingement exists.

    Give me a 75% range with a physiological stretch over 90% range with a pathological impingement...any day of the week.


    To say that the lunge test is not relevant or less relevant for the less athletic is something that I cannot agree with at all.

    Ron
     
  9. Ron:

    So you are now saying that anyone without a normal lunge test cannot walk without a limp? So everyone needs to have a normal lunge test to walk normally??

    By the way, I see forefoot varus weekly if you accept Root's definition that forefoot varus as being an inverted forefoot to rearfoot deformity. Of course, some people say there is only forefoot supinatus and no forefoot varus when an inverted forefoot deformity is seen. However, this is not the way Root originally defined the terminology. By the way, if you draw your heel bisection inverted enough, and find STJ neutral more pronated than other podiatrists do, you will never see an inverted forefoot to rearfoot relationship.
     
  10. Atlas

    Atlas Well-Known Member

    Yes you need an adequate lunge to walk normally. A negative lunge, from my viewpoint is where one cannot reach the wall with their knee whilst the heel is in contact with the ground, foot pointed to 12 o'clock, and the longest toe touching the wall. Anyone with this significant deficit cannot walk normally.


    Varus versus supinatus if neither here nor there with me. Osseous is black; soft-tissue is white; but the world is often grey.
     
  11. They couldn't even walk normally in a shoe with a heel?? :rolleyes:
     
  12. Atlas

    Atlas Well-Known Member

    I'm sure they would cut it in a stiletto Kevin.
     
  13. Ron:

    I suppose we will have to agree to disagree. I don't believe that a "negative lunge" as you describe would necessarily produce a "limp". It may or may not produce an early heel off, but I wouldn't call the gait finding of an early heel-off a "limp". Do you have any research to back up your claims or is this anecdotal information only?
     
  14. Atlas

    Atlas Well-Known Member

    Research is all tip and no iceberg in relation to the lunge. In fact research is all tip about most things musculoskeletal IMO.

    I have used the lunge clinically on multiple occasions everyday for more than a decade; as a post-intervention re-assessment tool; as a barometer for progress; as an indicator of the likelihood of conservative therapy success;as an indicator of impingement; as a correlation with subjective and objective findings.

    Kevin, from what I remember from previous discussions you haven't used the lunge in a clinical setting for too long nor often enough.


    My advice is that if you want to understand the lunge, spend minutes using it clinically (and correlating it with your findings) rather than hours reading research on it. Or try to absorb a scintilla from someone who regularly uses it and understands it.




    BTW Kevin. A decade ago, when I was prescribing rearfoot valgus wedges for medial knee compression pathology (OA), I had no research to support it.
    Today, thanks to Payne and Hinman, now I do.

    Give me results-based-practice over evidence-based-practice any day of the week.
     
  15. Ron:

    No need to get defensive. I'm a big fan of many clinical tests that have little to no research behind them. Just wanted to understand whether you were speaking from clinical experience or from research evidence since you seem so confident that a negative lunge test will always produce a limp........
     
  16. Josh Burns

    Josh Burns Active Member

    Dear All,
    The lunge test measures ankle range of motion and considers all restraining structures e.g. muscles, osseous, joint capsule, ligaments, retinacula, etc. Given that the knee is never fully extended in walking or running (excluding race walking) the lunge test aims to simulate the weight bearing 'functional' nature of locomotion, albeit, statically. It is not the ideal measure, but is very reliable and seems more valid than our traditional non-weight bearing measures of ankle range.

    Incidentally, there is also a straight leg lunge test used by many research groups e.g. Bennell K, Khan KM, Matthews B, De Gruyer M, Cook E, Holzer K, et al. Hip and ankle range of motion and hip muscle strength in young novice female ballet dancers and controls. Br J Sports Med 1999;33:340-6.

    Kind regards
    Josh Burns
     
  17. Josh:

    Good to see your fingers have thawed out since Chicago's PFOLA meeting. :rolleyes:

    While I would agree with you that full knee extension does not occur in running, many references conclude that full knee extension (within 5 degrees of full extension) occurs twice during the walking gait cycle, at heel contact and at heel off. Here is a quote from Perry's textbook.

    "At initial contact the knee is flexed about 5 degrees. Subjects vary in their knee posture at initial contact between slight hyperextension (-2 degrees) and flexion (5 degrees).
    ......
    During the rest of midstance, the knee gradually extends. Minimum stance phase flexion (averaging 3 degrees) is reached about midway in terminal stance (40% GC) and persists for only a short time before the knee slowly begins to flex again. The rate of knee extension is approximately half that of flexion during limb loading." (Perry J: Gait Analysis: Normal and Pathological Function. SLACK Inc., Thorofare, NJ, 1992. pp. 91-92)

    Therefore, I can hardly consider the standard lunge test, where the knee is flexed at 10 degrees or more, to be a good reproduction of the near full knee extended position (averaging 3 degrees) that is present at the time of maximum ankle joint dorsiflexion during walking gait. However, I would agree that the straight leg lunge test would likely be a better test for the dynamics of walking while the standard lunge test seems more appropriate for running sports.

    It must be remembered that running and walking are two very different activites dynamically with the center of mass (CoM) reaching its minimum during the middle of stance phase in running while, during walking, the CoM reaches a maximum during the middle of stance phase.

    During walking, when the CoM rises over the stance phase foot to reach a maximum height above the ground at the middle of midstance, then potential energy (PE) is at a maximum and kinetic energy (KE) is at a minimum due to the CoM being decelerated as it rises higher. As the CoM falls toward the ground to reach a minimum height at the initiation of double support, then PE is at a minimum and KE is at a maximum due to the CoM being accelerated as it is lowered toward the ground. Therefore, KE and PE are out of phase in walking.

    During running, since the CoM falls as it moves over the support phase foot to reach a minimum height at the middle of midsupport, then PE is at a minimum at the middle of midsupport. KE is also at a minimum at the middle of midsupport in running due to the deceleration of the CoM by the lower extremity. As the CoM rises away from the ground and increases its velocity, the PE is increased to a maximum and KE is also increased to a maximum. Therefore, KE and PE are in phase in running.

    All in all, in walking, PE and KE are out of phase (i.e. when PE is high, KE is low) similar to the energy transfer that occurs in a swinging pendulum. In running, PE and KE are in phase (i.e. when PE is high, KE is also high) similar to the energy transfer that occurs with a pogo stick or bouncing ball. (Novacheck, Tom F.: The biomechanics of running. Gait and Posture, 7:77-95, 1998.)

    This diametrically opposed dynamic difference in PE and KE transfer between human walking and running actiivites are linked mechanically very closely to the very different sagittal plane flexion angles of the knee and ankle during the middle of stance phase of walking and running. This is the main reason why I strongly believe that the type of lunge test being performed should be determined by whether the patient's predominant injury producing activity is from walking or running.
     
  18. Josh Burns

    Josh Burns Active Member

    Kevin,
    Yes it was very cold in Chicago for us Aussies, but thawed out nicely thanks.

    Given that we agree the knee does not generally reach full extension during normal walking, but rather to within 5 degrees of full extension, do you think the gastrocnemius muscles have such an important role in limiting ankle range of dorsiflexion as perhaps the soleus or other soft tissues around the ankle joint?

    A recent small RCT showed that passive straight leg gastrocnemius stretches performed two times daily, for 3 weeks increased passive ankle dorsiflexion, but did not alter ankle dorsiflexion or time-to-heel-off during the stance phase of gait (Johanson et al. Effects of gastrocnemius stretching on ankle dorsiflexion and time-to heel-off during the stance phase of gait. Physical Therapy in Sport 2006;7:93-100).

    Perhaps the gastrocnemius is not as important in limiting ankle range of dorsiflexion during normal walking gait as we think?

    Regards
    Josh Burns
     
  19. Josh:

    From a clinical standpoint of measuring ankle joint dorsiflexion in 15,000+ individuals over the past 20+ years in the standard non-weightbearing fashion, gastrocnemius equinus is not only much more prevalent than soleus or ankle equinus but possibly more clinically important. For example, patients that have had a gastrocnemius recession type surgery show dramatic changes in gait function and symptoms post surgically. Children that have normal ankle joint dorsiflexion with knee flexed but have restriction of ankle joint dorsiflexion with knee extended will be more likely to have early heel off or toe walking type gait pattern.

    However, as you know, gait kinematics is not simply a function of passive ranges of motion of the major joints of the foot and lower extremity but also is very dependent on the magnitude and temporal pattern of contractile activity of the muscles of the foot and lower extremity, which can not be measured by simple experiments that assess range of motion only. Therefore, passive range of motion is only part of the important picture of what may produce abnormal gait patterns and mechanically-based pathologies in the foot and lower extremities of the individuals who seek our medical help on a daily basis.

    Josh, thanks for taking the time to respond. Your excellent clinical research shows that you are one of the bright young stars of the foot and lower extremity biomechanics research world. I am very excited about your cavus foot research and think it was a long time coming for our profession. Keep up the good work! :)
     
  20. Josh:

    Just wanted to follow up on our discussion of the importance of performing an extended knee evaluation of ankle joint dorsiflexion on our patients, and not only performing a knee flexed evaluation of ankle joint dorsiflexion, such as is done when one only uses the standard lunge test with a flexed knee.

    First of all, Perry's quoted 3 degrees of knee flexion, to most clinicians, would mean an extended knee. Given that for some patients, 3 degrees flexed is the end range of motion of extension at the knee, and that the measurement error for performing knee joint flexion-extension measurements is likely +/- 3 degrees, then I, and most clinicians that I respect, would consider 3 degrees flexed to mean an extended knee, not a flexed knee. Therefore, during walking, when the greatest ankle joint dorsiflexion is demanded by the human gait cycle, the knee is basically very close to being fully extended. Wouldn't you agree?? It wouldn't then make sense to only evaluate ankle joint dorsiflexion with the knee flexed, as in the standard lunge test, but an evaluation should also be done with the knee extended.

    Secondly, there is considerable research evidence that the gastrocnemius muscle does influence ankle joint dorsiflexion stiffness, contrary to the stretching experiment you cited by Johanson. Here are a few abstracts that should be of interest to you that certainly suggest that the gastrocnemius muscle greatly affects ankle joint range of motion and ankle joint dorsiflexion stiffness both during non-weightbearing and weightbearing examination and activities.

     
  21. Jo BB

    Jo BB Active Member

    I am curious regarding the effect of the Plantar fasciosis and heel lunge measurement. Is there any research regarding this? We tend to see most research stretching gastrocnemius and soleus. In the clinical setting massaging the plantar foot with a spiky ball for 1 minute also improves heel lunge measurement [and the windlass mechanism].
    Any thoughts?

    Kind regards,

    Joanne
     
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