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Lunge Test - normal range

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mart, Nov 16, 2005.

  1. Mart

    Mart Well-Known Member


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    Hi

    Thanks Craig Payne for your wonderful presentations in Ottawa last weekend and for encouraging Canadian involvement in this forum.

    The "lunge test" for ankle ROM stiffness was mentioned as predictive for musculoskeletal foot/leg injury in Australian footballers. I have tried unsuccesfully to get any further information online regarding accepted normal value ranges for this test or precise measurement method. Could anyone point me in the right direction in applying and interpreting this test.

    Thanks


    Martin.
    Winnipeg
     
    Last edited by a moderator: Nov 16, 2005
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Hi Martin - welcome to Podiatry Arena and thanks for the kind words re the conference.

    I first learnt of the lunge test when Kim Bennell published their reliability study:
    I promptly ignored it becasue of my (and the professions) mindset of the time .... ie the test was not done with the STJ in neutral, allegedly increasing the range.

    After that a number of things influenced my thinking:
    1. We started to wake up re the "mindset"
    2. Numerous podiatrists and, especially, physiotherapists anecdotally started to comment on how useful the lunge test was (even though it was not done STJ neutral)
    3. I started to understand more about the concepts of "range of motion" vs "stiffness"
    4. We did our research on the 10 degrees of ankle dorsiflexion being considered normal (...it not)
    5. A number of clinicians were beginning to make throw away lines like - "if your orthoses does not work, then add a heel raise' - this was based on their good clinical experience, but where I come from, we have to do better.
    6. Pope et al (1998) showed the lunge test was prospectively predictive of injury in army recruits and Gabbe et al (2004) showed an association with lunge and football injuries.

    At the end of the day, a clinical decision had to be made when adding a heel raise to a foot orthoses if the calf muscles are tight. We can not use the standard measurement and 10 degrees. Taking the work of Pape et al (1998) and Gabbe et al (2004) we now testing a protocol that involves doing the lunge test while standing on foot orthoses - if the tibia can not get to 35-38 degrees, a heel raise (usually only 3mm) is added. Some of the work suggests that 9-10cm distance between the wall and foot as a cut off point - the problematic nature is that all shorter people will have less than that, so I prefer the tibial angle part of the measurement.

    It may well be that 35-38 degrees as the cut of point is not correct, but we had to make a 'judgement call' and start somewhere - I suspect that its in the "ballpark"

    IMHO, the lunge test is one of the more important tests to do when issuing foot orthoses to a patient ..... we just need more data and a better understanding.
     
    Last edited: Nov 16, 2005
  3. musmed

    musmed Active Member

    Craig et al

    I cannot beleive that there is any such a method of testing that could possibly have any validity for measuring anything let alone dorsiflexion.

    I see many foot that is plantar flexed in passive dorsiflexion (5Kg pressure) and they do not have any problems other than tight hamstrings, calves, back pain, neck pain etc. etc.

    Being able to push ones foot to 35 degrees due to the fact that you are built like a brick shed means anything. All it means is that you have the ability to force ones foot to the magic 35 degrees and thus they do not need a 3mm heel raise.

    What about the 5 stone weakling?

    I can easliy block a talar motion in someone who has a passive dorsiflexion of 20 degrees into a passive dorsiflexion of -20 degree. Do these souls need a heel lift?

    The answer is simply no. What they need is to have ALL the joints of the foot and ankle mobilised/manipulated and their so called tight calves will be gone instantly.

    The talus controls all muscle length. This statement will be put to the test many times in 2006 and I bet I will win them all.

    No one needs a heel lift. It is simply bad mechanics. Look at it this way, a heel left suddenly gives the patient a short leg and we don't want that do we?

    Regards,

    Paul Conneely
    www.musmed.com.au
    PS come to Perth in March 2006.
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    I never said that - the heel lift is added on both sides!!!
    So why do so many who's foot orthoses that are not working suddenly start working when the heel raises are added?
     
  5. davidh

    davidh Podiatry Arena Veteran

    Paul,

    It maybe you misunderstood Craig, and I don't want to correct that.
    But if you are saying that bi-lateral heellifts are not necessary, you are plain wrong.
    They are very necessary for many orthoses patients.

    I can demonstrate (frequently do, on our Workshops) that 10 degrees of dorsiflexion with the STJ in neutral simply does not exist for most people.

    Craig,
    Like the idea of the lunge test. I'm afraid I still advocate the "try it without/try it with" approach :eek:

    Paul, if I misunderstood I apologise.

    Cheers,
    davidh
     
  6. footdoctor

    footdoctor Active Member

    Craig,

    Following on from martin's initial question,do you know of any papers detailing the method involved in the lunge test?

    thanks
     
  7. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Bennell K et al: Intra-rater and Inter-tester reliability of a weightbearing lunge measure of ankle dorsiflexion. Australian Physiotherapy 24(2)211-217 1998
     
  8. musmed

    musmed Active Member


    Craig

    Simply put, the cause has not been addressed. There seems to be a mind set that what one sees is what they have got and thus treat the image.

    I have taught several hundred podiatrists biomechanics of the foot and ankle and how to mobilise them. Almost to a tee every podiatrist has orthotics!. There just cannot be so many souls needing such a device.

    I doubt every cardiologist has had an angiogram.

    The cause lies in the lack of motion in one or more joints in the ankle/foot complex.

    I was thinking about muscle tone. Eg test someone first thing in the morning when muscle tone is the least. Fill them with strong coffee- makes muscle tone increase and finally at the end of the day fill them with grog and retest. I bet you will get three different results.

    Tone changes from second to second from muscle to muscle and from person to person. I cannot see how such a variable event can be used as a standard.

    Regards,

    Paul Conneely.
    www.musmed.com.au
     
  9. Josh Burns

    Josh Burns Active Member

    Quote "Following on from martin's initial question,do you know of any papers detailing the method involved in the lunge test?"

    I have done some work using the lunge test as part of my PhD. For the lunge method and normal/cavus/planus values see:

    Burns J, Crosbie J. Weight bearing ankle dorsiflexion range of motion in idiopathic pes cavus compared to normal and pes planus feet. The Foot 2005; 15: 91-94.

    Background:Various factors are considered influential in the development of pes cavus. Short tendo-Achilles is one factor that has been hypothesised as a deforming mechanism of 'idiopathic' pes cavus.Objective:To measure tendo-Achilles length in subjects with idiopathic pes cavus, compared to normal and pes planus feet, and to examine the relationship between tendo-Achilles length and foot type.Method:Fifty-three healthy volunteers (34 female, 19 male) were recruited to encompass a wide range of foot types, varying in degree of cavoid, normal and planus features. Foot type was measured weight bearing using the Foot Posture Index (FPI). The length of the tendo-Achilles was also measured weight bearing using the lunge test.Results:Twenty-four subjects with pes cavus, 24 subjects with a normal foot type and five subjects with pes planus completed the study. Lunge angle in the pes cavus group was significantly less than the normal and pes planus groups (P r = 0.757, P r2 = 57.3%).Conclusion:Distinct differences exist in tendo-Achilles length in individuals with a pes cavus foot type, compared to normal and pes planus feet. A strong positive relationship between tendo-Achilles shortness and pes cavus severity has been identified.

    Available at:
    http://www.sciencedirect.com/science/article/B6WFR-4G7JSBG-8/2/642436ae866338980fb44e08adc2f0eb


    Kind regards
    Joshua Burns
     
  10. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Josh --- thanks (I missed that one!) --- what do you think of our initial assumptions for a value of 35-38 degrees as a "cut off" point?
     
  11. Josh Burns

    Josh Burns Active Member

    Hi Craig,
    With the technique that I used the 'normal' foot type had an average lunge angle of 32 degrees (SD, 6.0). I tend to use a magic cut-off value of 30 degrees. Any less and you are becoming 'limited' in ankle flexibility.
    Kind regards
    Josh
     
  12. Josh:

    Thanks for the interesting abstract and congratulations on your publication of the study. In reading the abstract, however, I would like to make some observations regarding your terminology which I find to be confusing and potentially misleading.

    I don't believe that a short Achilles tendon would, by itself, tend to cause a pes cavus deformity. I don't understand how a restriction of ankle joint dorsiflexion would cause a pes cavus deformity. In fact, I have never read in the medical literature that a short Achilles tendon by itself has been suspected as being a causative factor in the development of pes cavus deformity. Do you have any references for that statement?

    The structurally plantarflexed position of the forefoot (pseudoequinus deformity) relative to the rearfoot is the more likely cause of an association of an apparently "short Achilles tendon" with pes cavus deformity (Whitney AK, Green DR: Pseudoequinus. JAPMA, 72:365-371, 1982.) In other words, the apparent lack of ankle joint dorsiflexion with a pes cavus deformity is probably more caused by the plantarflexed forefoot position relative to the tibia and not so much caused by a shortness in the Achilles tendon or by a restriction in dorsiflexion at the talo-tibial joint.

    How can the lunge test measure the length of the Achilles tendon??? The only way to measure the length of the Achilles tendon would be by MRI or ultrasound, to my knowledge. What the lunge test is measuring is the relative ability of the plantar foot to dorsiflex relative to the tibia, for a given force applied to the plantar forefoot. This is dependent on the following factors:

    1. Tensile stiffness in the posterior extrinsic muscles of the foot especially the soleus, gastrocnemius and Achilles tendon but also in the PT, FDL, FHL, and peroneals.
    2. Tensile stiffness in posterior ankle joint capsule.
    3. Morphology of osseous structures in anterior aspect of talo-tibial joint.
    4. Dorsiflexion stiffness of forefoot relative to the rearfoot (which is dependent on internal morphology of the osseous structures of the longitudinal arches of the foot and the tensile stiffness of plantar arch ligaments).

    Therefore, I believe it is potentially misleading to say that the "length of the Achilles tendon can be measured by the lunge test" since the length of the Achilles tendon in only one small factor that determines the results of the lunge test.

    In other words, unless we have actually measured the length of the Achilles tendon, then we can't say that it is short, now can we?!
     
  13. Josh Burns

    Josh Burns Active Member

    Dear Kevin,
    I agree with your comments and these are discussed in the paper. The references you request are also in the paper.
    Kind regards
    Josh
     
  14. I would love to read it, Josh. Can you send a pdf my way?? (kevinakirby@comcast.net)

    Thanks for the quick response.
     
  15. davidh

    davidh Podiatry Arena Veteran

    Paul,
    You wrote
    "I have taught several hundred podiatrists biomechanics of the foot and ankle and how to mobilise them. Almost to a tee every podiatrist has orthotics!. There just cannot be so many souls needing such a device."

    OK, I see where you are coming from with this.
    How about adopting this as a simple working hypothesis.
    The human foot has not adapted for life on a hard, flat surface, and orthoses act as an interface between the foot and that surface, making standing/ambulation that little bit easier.

    Actually, as a single case study, I've worn orthoses for over 25 years. My feet roll excessively without them, yet at 55 I display none of the foot problems my father did (hallucial nail symptomology due to repeated trauma, and HR). In fact they look good, and work well :)
    Actally the nail symptomology was present before I wore orthoses - I remember Arthur Brown remarking on it and packing them, when I was a student at Glasgow 68-71.

    My contention is this.
    No matter how good the stretches, mobilisations or whatever, if our feet have to conform to one uniform surface, then some structures are going to stretch/others compress, and over time that can lead to microtrauma, and symptomology. Soft tissue work, which includes manipulatione etc, on its own may well relieve the symptoms, but unless you remove the underlying cause (the flat, hard surfaces) or deal with that in some way, then symptoms will eventually return.

    Regards,
    davidh
     
  16. I have taught several thousand podiatrists biomechanics of the foot and ankle over the past 21 years, Paul. I have taught them how to better understand biomechanics and make foot orthoses work better for their patients. Some podiatrists wear orthoses, others do not. However, most of them would not walk around without them since they not only understand, but more importantly, feel the benefit that foot orthoses provide for their own bodies. I think that foot orthoses are under-utilized by the medical profession, not over-utilized since they have had tremendous medical benefit for hundreds of thousands if not millions of patients over the years.

    If you would like references from peer-reviewed journals showing statistically signficant research evidence that explain the mechanical function of foot orthoses and their therapeutic effectiveness, then I will gladly provide them to you. Since you brought up the subject, I would appreciate it if you would provide us with research published in peer-reviewed journal that supports your statement: "The cause lies in the lack of motion in one or more joints in the ankle/foot complex."

    One more thing, Paul, how can you compare foot orthoses to an angiogram? One is a medical therapy and one is a diagnostic study. One is noninvasive and has little medical risk while the other is invasive and carries very signficant medical risk. Your suggestion that because you see that a lot of podiatrists wearing foot orthoses is somehow analagous to the lack of cardiologists having angiograms is simply ludicrous. Why didn't you just make the equally ludicrous statement: "I doubt every general surgeon has had exploratory abdominal surgery." There is no comparison between foot orthosis therapy and an angiogram!

    If you wanted to use an analogy regarding the frequency of foot orthoses being worn by podiatrists you would have more accurately portrayed the analogy as follows: "Podiatrists wear foot orthoses with probably the same frequency that dentists floss and brush their teeth on a daily basis." Foot orthoses are preventative treatments that most podiatrists acknowledge are useful not only for their own bodies but also for their patients.

    I'll wait patiently on you providing us those references.
     
  17. Josh:

    In reading your and Jack's paper, I really like the direction that you are going with this research. I am currently writing a series of Precision Intricast newsletters on forefoot dorsiflexion stiffness and ankle joint dorsiflexion stiffness that would fit in nicely with your research topic. This has arisen from my Precision Intricast newsletters and Tom Roukis and my published paper on first ray hypermobility and dorsiflexion stiffness (Kirby KA, Roukis TS: Precise naming aids dorsiflexion stiffness diagnosis. Biomechanics, 12 (7): 55-62, 2005), and also from my discussions with Craig Payne regarding his ideas on ankle joint dorsiflexion stiffness.

    However, I still find that, in reading your paper, that you may be missing a very important point that fits into Whitney and Green's pseudoequinus theory. For the pes cavus group you determined a lunge test of 26.2 degrees, for normal it was 31.8 degrees and for the pes planus group it was 42.8 degrees. In other words, there was a 16.6 degree difference in lunge test from pes planus and pes cavus and a 11.0 degree difference in lunge test from pes planus and pes cavus.

    I think that if you performed lateral weightbearing radiographs that you would find that the pes planus feet had calcaneal inclination angle (CIA) of about 10 degrees, normal feet would have a CIA of about 20 degrees and the CIA in cavus feet would be about 30 degrees. Isn't it now interesting that the difference in calcaneal inclination angle from pes planus to normal to pes cavus is very similar to the difference in lunge test values you found for each of these three foot types?

    My point is that there is probably very little difference in "Achilles tendon length" between these three foot types but is more a difference in the position of the tibia relative to the sagittal plane angulation of the forefoot within the sagittal plane. I would suspect that the rotational position of the talo-tibial joint during the lunge test is very similar regardless of whether the subject has a normal, pes planus or pes cavus foot type. In other words, they are all very close to maximum talo-tibial dorsiflexion during the lunge test which, in turn, is determined more by the plantarflexed position of the forefoot to the rearfoot during the lunge test for each foot type rather than by "Achilles tendon length".

    Therefore, I believe that your research is good, but I think that I would look at internal osseous alignment of the ankle and foot to allow us to gain a better understanding of the differences that you are seeing with the lunge test between pes planus, pes cavus and normal, than worrying so much about "Achilles tendon length".

    I would be interested in your and anyone else's comments on this interesting topic.
     
  18. Josh Burns

    Josh Burns Active Member

    Thank you for your thoughtful response Kevin,
    I too thought the tibio-talar osseous block due to an increased calcaneal inclination angle was to blame for the reduced ankle range of dorsiflexion seen in our pes cavus patients. However, when performing the lunge test on people with pes cavus many feel the tension or "tightness" at their Achilles tendon and only a few felt the restriction at the anterior ankle. This clinical observation formed the basis for my study.

    However, to truly understand which structure is limiting range of ankle dorsiflexion imaging such as radiographs/fluoroscopy, ultrasound or ideally MRI is required. The study published by Jack and I in "The Foot" provides a rationale for more invasive and expensive examination of the ankle joint complex in the future.

    Kind regards
    Joshua
     
  19. musmed

    musmed Active Member

    Dear Kevin

    Thanks for the god laugh regarding coronary angiography.

    There are more modern techniques available. They are performed using intravenous contrast and a modern CT scanner designed by General electrics. It takes 10 minutes, non invasive and unbelievably accurate. They leave arterial angiography for dead.

    I think if you are over 50 and have BP or a family history, you wold be mad not to find out your coronary position, would you not?

    People floss for a reason, others wear orthotics because they are told too!

    As for the data, I have been collecting it for 15 years and hopefully by the end of next year it will be collated and presented.

    Regards,
    Paul Conneely
    musmed
     
  20. Paul, people won't wear foot orthoses for long if they are uncomfortable, no matter what the podiatrist says. The dentist tells all his patients to floss, but how many patients of the dentist do you think actually do this on a daily basis....probably less than 50%!!

    Don't fool yourself into thinking that people are wearing orthoses for the wrong reasons. I think, on the contrary, the vast majority of individuals who wear foot orthoses are wearing them for the right reasons...they are more comfortable wearing orthoses and the orthoses allow them to walk and run without pain.
     
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