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The 10 min Biomechanical assessment - what are the most important things to assess?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Berms, Oct 2, 2011.

  1. Berms

    Berms Active Member

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    I'd love more time but in reality, I generally have about 10 - 15 minutes of my consult time to perform a concise but thorough biomechanical assessment.

    Given the time constraints, exactly what tests/assessments are the most important?

    Thanks for your thoughts.
  2. Berms

    Berms Active Member

    I suppose a good place to start is by asking "why do we perform a biomechanical assessment?"

    My answer would probably be that in most cases we are looking for information to (a) help us diagnose any pathology or deformity and (b) gain useful information to assist with orthotic design.

    Am I on the right track here?? If so, what tests should be at the top of my list?

  3. The ones that identify the pathologic tissue.
  4. efuller

    efuller MVP

    That's sort of two different questions. What do you do get a diagnosis/ identify structure that needs less stress. What measures do you do that change your prescription. I don't do the biomechanical assessment until I have a diagnosis. Even when I'm referred a patient with a diagnosis I make sure that I agree.

    What measures do I feel that are most important for writing my prescription
    STJ axis position
    Maximum eversion height
    Medial arch height in stance
    Relative length 1st and 2nd met
    Promenent plantar fascia
    Ankle max dorsiflexion
    Tibial varum in stance

    The results of each of those measures will potentially alter my prescription.

  5. Lawrence Bevan

    Lawrence Bevan Active Member

    Hi Eric

    Sorry to the OP for diverting the thread but how does tibial angle and 1st met length vary your prescription?

  6. Berms

    Berms Active Member

    Thanks Simon, I agree that focusing on the pathologic structures/tissues is the key.... but does that mean your assessment is different for every different patient??
  7. Craig Payne

    Craig Payne Moderator

    What about the 10 second biomechanical assessment:

    1. What is the structure/tissue under load that is damaged?
    2. How can that load be reduced
    3. What (if any) foot orthotic prescription variables can reduce that load?
    4. What design features can deliver those prescription variables?
  8. Berms

    Berms Active Member

    Hi Eric, thanks for the reply and the list you provided.

    Sorry for my ignorance but what is "max eversion height?" and how do you measure it? and also do you measure arch height in "relaxed" stance or "STJ neutral" stance?

  9. Berms

    Berms Active Member

    Thanks Craig.... so given your approach above, what actual "measurements" (if any) do you typically find yourself doing when you are going through this process? Do you have a "set" of standard things you assess each time?

    Or does the assessment you do depend entirely on the structure/tissue under load?

  10. efuller

    efuller MVP

    With windlass pathology, I will often add a reverse Morton's extension. If there is a long 2nd I will often do a forefoot valgus extension. The concern is overloading the send metatarsal. Another thing to add to the list is examine the sock liner fore the location of the high pressure points or the callus pattern. Relative met length is similar to looking at where the calluses are.

    Tibial angle
    In a patient with high tibial varum and pronation related problems there is a concern when adding a varus wedge effect to increase supination moment that you will also increase external knee adduction moment. This will increase compression forces in the medial compartment of the knee. If I want to add supination moment, I will usually add less in the presence of tibial varum. I will also add another return visit to check on them.

  11. efuller

    efuller MVP

    Max eversion height see

    I measure arch height in relaxed stance position. There are some feet that will feel disomfort in the arch if you make the arch of the orthotic the height of neutral stance position. When I measure arch height I press gently into the arch and measure the height of my finger off of the ground. I've found I get very few complaints of too much pressure in the arch from the orthotic with this technique. There's a nice little project for someone. Do this measurement and make 3 orthotics, one lower arch, one at standing arch height, one higher. You could look at comfort and symptom relief and patient preference. STJ axis deviation or supination resistance might be a variable to add as well.

  12. efuller

    efuller MVP

    And possibly, 5 if you use those design features, what other possible problems are likely to occur.

  13. Berms is this 10 minutes just for the hands on assessment ?

    or history taking and discussing of treatment options etc etc.

    in 10 minutes of assessment time you could do a full Root assessment if you wanted to, palpate the STJ axis weight bearing and none weightbearing, dorsiflexion stiffness at the MTJ´s , supination resistance Eric tests, none weightbearing ankle dorsiflexion testing, lunge test.

    if it is for history taking etc as well then re-organise you appointment times imo
  14. Berms

    Berms Active Member

    Hi Mike. Yes it is "hands on" time I am talking about - not history and note taking etc.

    Thanks for the list of assessments you suggested, very helpful. Although I am curious as to why you included a "full Root assessment"?? What exactly do you mean by a full Root assessment and I thought that biomechanics of today had evolved beyond Roots theories and the measurements he advocated?

    Thanks. Berms.
  15. Berms

    Berms Active Member

    Thanks Eric. Correct me if I'm wrong, but if you measure your arch height in relaxed stance, you will get a device that supports and holds the arch and the STJ as it is in relaxed stance and therefore what "correction" has been achieved??

    Up 'til now I have been placing the weightbearing foot in close to STJ neutral and then measuring arch height. I do this because that's the joint position and arch height of the foot I (think) I want to achieve when the foot is on the orthotic device. Have I got it wrong?
  16. Thats why I wrote if you wanted to-

    ie 10 mins is a lot of time to take measurements - Also a lot of the Root stuff will give you important info as long as you don´t take measure . Forefoot to rearfoot - Supinatus-flat or Valgus, Position of the 1st MTPJ plantarflexed -flat and Dorsiflexed.

    Great for ROM and QOM of the joints of the foot - again without taking measurment - eye ball and feel.

    So a Root exam without degrees if you will.

    People will argue that measurements are only needed if it will change your prescription, but some times a good look and feel will give you information.
  17. Berms

    Berms Active Member

    Mike, what exactly do you do with the info you get from assessing the dorsiflexion stiffness of the 1st ray (and other rays)? ie how does it affect your orthotic design and prescription variables?

    Thanks, Berms
  18. Dorsiflexion stiffness @ the 1st -5th MTPJ - Windlass mechanism and how wide to make the FF valgus / reverse mortons extension. 95 % 2-5 but have used 3-5 and even 4-5

    Dorsiflexion stiffness of the 1st ray ( I never mentioned but) Would/could be used to look at MLA stiffness - ie a ray with greater resistance to dorsiflexion would indicate a arch which would have greater resistance to elongation without increased pressure on the plantar fascia. Would also help to determine where the GRF moments are coming from as COP move distally.

    Got me thinking re ray dorsiflexion stiffness :drinks
  19. James Welch

    James Welch Active Member

    It's all in your history taking, the key thing ;)
  20. efuller

    efuller MVP

    Why do you want to achieve that arch height? I want the patient to be comfortable and have their symptoms relieved. Trying to push on the medial arch can be quite uncomfortable in some people. I'm one of them. I have a quite medially deviated STJ axis and pushing in the arch is not far enough medial to the axis to make the STJ supinate. Also, there is a lot of soft tissue between the plantar skin of the medial arch and the bones. My functional hallux limitus feels much better with an orthotic as compared to barefoot and the arch of my orthotic is lower than STJ neutral arch height.

  21. Yes (ish) because each patient is unique(ish). Why would I perform say an Apley's compression test on someone complaining of pain in their 2nd MTPJ? Why wouldn't I perform that test on someone with medial knee pain, along with a raft of others? Experience dictates that when a patient presents with knee pain and you focus your attention on the foot first off, more often than not you'll fail to diagnose the problem and alienate the patient in the process. Similarly, I'm not likely going to be performing an anterior draw test at the knee in someone with a pain in their big toe- right?
  22. Berms, this is a wonderful opportunity for a learning experience.... Why do you think that? YOU ready? If we really going to learn, we really got to think and be honest before we flick at the keyboard.
  23. Berms

    Berms Active Member

    Dear Simon, what exactly are you saying here? thinking and learning is why I posted these questions in the first place and why wouldn't I be honest???? :confused:
  24. Berms

    Berms Active Member

    Thanks Eric.... for some reason I still have it in my head that I should be "correcting" the foot position with the orthotic device into the STJ neutral zone. The only reason I still do this is because that is all I know.

    So with your foot as an example, if your device arch height is lower than your STJ neutral arch height.... then how does your orthotic address your medially deviated STJ axis and your FnHL?

  25. Berms

    Berms Active Member

    Thanks Mike, thats a good point you make there. I have always routinely checked 1st ray dorsiflexion stifffness but haven't really understood what to do with that information....

    Cheers, Berms.
  26. Berms

    Berms Active Member

    OK I see that was a rather stupid question, of course your assessment is not going to "exactly" the same for every patient as they all havve different pathology affecting different anatomical structures. What I mean't was more along the lines of - do you have a standard "set" of assessments you always do in preparation for prescribing an orthotic?

  27. Because I knew what was coming...

    This misunderstanding is a classic misrepresentation of the Rootian paradigm.
  28. Berms

    Berms Active Member

    I accept that may well be true. I am fully aware that I could significantly improve the way I do things and change the current paradigms/concepts I have - starting with the original post I made trying to make the biomechanical assessment I do more efficient, more effective and above all more useful.

    I appreciate you and others taking the time to respond to my posts as I am trying to evolve my understanding and the way I practice.
  29. efuller

    efuller MVP

    Medial heel skive, forefoot valgus intrinsic post, reverse Morton's extension and contact in the medial arch that does not irritate my prominent plantar fascia.
  30. efuller

    efuller MVP

    You need to look at what structures are creating the stiffness. When the fascia has little tension the plantar ligaments will become tight when the ray is dorsiflexed. However, when the first toe is dorsiflexed, the windlass will make the ray plantarflex. When the ray is plantarflexed the plantar ligaments will no longer be tight and cannot contribute to ray stiffness.

  31. RobinP

    RobinP Well-Known Member


    Simon is right, you have a great learning opportunity here. You have started to question the validity of the measurements you take because that is all you know.

    We've all been there. You want to know what measures are important/worthwhile but more crucially, you need to know why they are important.

    I measure almost nothing. Occasionally, I quantify numerically an ankle lunge test. Why do I not measure anything? Because it is unlikely make any difference to what I prescribe.

    Craig does a great section in his bootcamps that state that there is only point in testing something if it is likely to affect your prescription. So if I measure forefoot to rearfoot angulation, what can I do with that information? Not much

    The biggest thing, in my opinion, is to understand the difference between performing kinetic tests and kinematic tests.

    Good luck
  32. Griff

    Griff Moderator

  33. Berms

    Berms Active Member

    Exactly.... this is exactly what I need to know. Hopefully by the end of this thread I will have a better understanding than I do now.

    So if you don't measure anything in your assessment, what exactly do you do?

    Thanks Robin. So am I on the right track by thinking that Kinetic tests would include things that measure forces like Supination resistance and Kinematic tests would be things that involve movement such as ankle jt dorsiflexion??
  34. Berms

    Berms Active Member

  35. RobinP

    RobinP Well-Known Member

    OK ...what do I do if I don't measure? Good Question;)

    Well, as most of the people posting on this thread have mentioned, the assessment that you perform needs to be appropriate to the presenting complaint. So you're history taking is critical to the process.

    You then need to identify the injured structure(s). Now, I am a fan of having a diagnosis prior to treatment. That doesn't mean to say that if I don't have a definitive diagnosis, I will not embark upon treatment. As long as I don't feel that treatment will be contraindicated based on the differential diagnosis, I will treat based on a "working diagnosis" whilst further investigations are being performed.

    So based on the injured structures and the diagnosis I have arrived at, I will look at potential biomechanical causes of the tissue stress

    Unfortunately for you, I cannot give you a list of tests to perform as it depends on the tissue under consideration. However, given that the majority of things that come through my clinic are probably going to be pronation related problems(eg PTTD, plantar fasciitis/MTSS) I am probably reliant on just a few tests to determine the caused of the tissue stress.

    Here's the bit that is important. If I perform a supination resistance test. What information does it give me and why is it important. Moreover, what difference does it make to what I prescribe?
  36. David Smith

    David Smith Well-Known Member

  37. OneFoot

    OneFoot Active Member

    Hmmm this is interesting I use more of the hallux RoM... but out of interest what do you do with these measurements please?

    PS - Im not trying to be a dick... :p
  38. Berms

    Berms Active Member

    Thanks Robin, that all makes good sense.

    So lets say I have a patient with typical plantar fasciosis.... Now that I have the diagnosis, what particular tests or assessments are most valid in determining the biomechanical causes of the tissue stress in this case? What tests will give me the information I need to prescribe an effective orthotic device, and why?

    I have a basic list of examinations that I would generally perform, such as:-
    > Leg Length discrepancy
    >Ankle joint dorsiflexion (not exactly sure what to do with this information)
    >Subtalar jt range and quality of motion
    >Midtarsal jt range and quality of motion
    >First Ray dorsiflexion stiffness (not exactly sure what to do with this information)
    >First MTP jt range and quality of motion (not exactly sure what to do with this information)
    >foot posture in resting stance
    >Medially deviated STJ axis?? (I don't measure, I just take an educated guess)
    >Arch height

    So as you can see I am a bit confused with the whole deal.... I would like to hear what assessments other wiser and more experienced practitioners like yourself would do in this case, and why....
    Cheers, Berms
  39. efuller

    efuller MVP

    No problem. Is there anything you want me to add to my answer in post #10 in this thread?


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