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As a new grad (1 year out), i learn something new everyday. Actually, i usually learn many new things everyday! In rather unpleasant ways. Anyway...
I'm interested in the lunge test.
I found this quote on a thread somewhere, (Craig Payne)
"we now know that ankle joint stiffness is more important than ankle joint ROM; the weightbearing lunge test for ankle ROM is showing huge promise in reliability; predicting dynamic function and adjusting orthoses prescribing based on it -"
I've been looking around for some furthur info but it seems a bit elusive. I've seen the thread on the lunge test, but i'm after some specific information regarding...
1. How do you perform a weightbearing lunge test?
2. How is it measured, or is it even measured at all?
3. What does it mean, what does it measure, what does it predict?
4. How can it be used to adjust orthoses prescription?
I was taught the old "10 degrees dorsiflexion is what you're looking for", and then i hear all this talk about lunge tests... It's all a bit distressing for a youngster like me!
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
1. Patient stands against wall with about 10cm between foot and wall.
2. Have them move one foot back a foot's distance behind the other
3. Bend knee of front limb until knee touchs wall - keep heel on ground.
4a. If knee can not touch wall without heel coming off ground, move foot closer to wall --> repeat
4b. If knee can touch wall without heel coming off ground, move foot further away from wall --> repeat
5. Keep repeating 4 until can just touch knee to wall and heel stays on gorund.
6. Measure either:
a) Distance between wall and great toe (<9-10cm is considered restricted)
b) The angle made by anterior tibia to vertical (<35-38 degrees is restricted)
(see discussion in other thread on reasoning behind actual values)
I do test when issuing/dispensing foot orthoses with them standing on foot orthoses and always add a heel raise (usually only ~3mm is enough) if they can not get to 35-38 degrees.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
1. Patient stands against wall with about 10cm between foot and wall.
2. Have them move one foot back a foot's distance behind the other
3. Bend knee of front limb until knee touchs wall - keep heel on ground.
4a. If knee can not touch wall without heel coming off ground, move foot closer to wall --> repeat
4b. If knee can touch wall without heel coming off ground, move foot further away from wall --> repeat
5. Keep repeating 4 until can just touch knee to wall and heel stays on gorund.
6. Measure either:
a) Distance between wall and great toe (<9-10cm is considered restricted)
b) The angle made by anterior tibia to vertical (<35-38 degrees is restricted)
(see discussion in other thread on reasoning behind actual values)
I do test when issuing/dispensing foot orthoses with them standing on foot orthoses and always add a heel raise (usually only ~3mm is enough) if they can not get to 35-38 degrees.
I can see the usefulness of the lunge test for patients involved in running sports where the demands for ankle joint dorsiflexion are the greatest when the knee is flexed. Therefore, the lunge test seems like a good test possibly for soleus and ankle joint equinus.
However, I can't see how the lunge test helps us, in any way, for those patients that have symptoms related to walking where the demand for ankle joint dorsiflexion is greatest when the knee is extended, and the ankle never comes close to 35 to 38 degrees of dorsiflexion during the stance phase of gait.
Craig, please explain the mechanical reasons behind always adding a 3 mm heel lift to these patients when they have, for example, 33 degrees on the lunge test but their ankle joint is never dorsiflexed more than about 10 degrees during walking gait and they are not involved in running activities.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kevin - we still testing and experimenting, looking at outcomes etc etc, but the rationale for what we did was (and this is a cut and paste from other thread):
Quote:
I first learnt of the lunge test when Kim Bennell published their reliability study:
Bennell K et al: Intra-rater and Inter-tester reliability of a weightbearing lunge measure of anbkle dorsiflexion. Australian Physiotherapy 24(2)211-217 1998
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"
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.
Rodney Pope, Rob Herbert and John Kirwan: Effect of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Australian Physiotherapy 44(3)165-172
We have found no correlation between the value obtained for traditional non-weightbearing ankle joint ROM and the weightbearing lunge test ROM.
A 3mm heel raise moves most people past the 35-38 degrees. Shannon Munteanu has done a whole lot of trig calculations on this - I will see if he can reply.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
So, back to the question of "what does it measure?"
what does it measure?
In my understanding, it could only measure the angle at which the achilles/soleus prevents further weightbearing ankle joint dorsiflexion, with the knee flexed. It obviously dosen't account for ankle joint dorsiflexion resistance with the knee extended. I would have thought this would be a major limitation of the usefullness of this test.
If i do this test with one of my patients, should I add heel raises if they cannot get to 35/38 deg?
Does anyone use this test in their clinic?
Why is this test used, and what are its benefits against other measures of equinus?
Why is this test used, and what are its benefits against other measures of equinus?
1. It has been shown to prospectively predict injury (how many other clinical tests do that?)
2. It is related to dynamic function (how many other clinical tests do that?)
3. It may be predictive of orthotic outcomes (how many other clinical tests do that?)
How many of the clinical tests do you use that meet those 3 criteria ... or even just one of them? None?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I can see the usefulness of the lunge test for patients involved in running sports where the demands for ankle joint dorsiflexion are the greatest when the knee is flexed. Therefore, the lunge test seems like a good test possibly for soleus and ankle joint equinus.
However, I can't see how the lunge test helps us, in any way, for those patients that have symptoms related to walking where the demand for ankle joint dorsiflexion is greatest when the knee is extended, and the ankle never comes close to 35 to 38 degrees of dorsiflexion during the stance phase of gait.
Craig, please explain the mechanical reasons behind always adding a 3 mm heel lift to these patients when they have, for example, 33 degrees on the lunge test but their ankle joint is never dorsiflexed more than about 10 degrees during walking gait and they are not involved in running activities.
Kevin, these same people who don't run, can't avoid inclines (escalators/slopes) and can't avoid descending steps or gutters.
This undoubtedly quashes the magic '10 degree figure' that many believe and are side-tracked about. The other thing is that why do we assume that the sedentary don't hurry for a few steps during an intermittent but urgent activity (late for a pedestrian crossing; catching bus etc.)
The whole point of the lunge is not a magic minimum figure/angle. It provides information about (a) symmetry (My advice is not to be too concerned about 10, 12, 33 or 35 degrees. The most important benchmark (in unilateral conditions) is the contra-lateral lunge reading.) and (b) ankle joint health and whether stretching is appropriate or inappropriate.
I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test.
If the shoe has a higher heel say 20mm HHD do you still apply the raise?
With 20mm HHD, they won't need a heel raise as they will get the assumed minimum with the lunge test with shoes on.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test.
Atlas,
You will need to try and expand your imagination a little if you can't understand how a clinician can appreciate the pathology and bimechanics of the ankle joint especially regarding the diagnosis of its conditions, prognosis, etc, without utilizing the lunge test. The lunge test, even though I have no problems with practitioners using it to evaluate patients, does not test for gastrocnemius equinus, does not test for strength of the ankle joint plantarflexors, or for internal derangements of the ankle joint. Therefore, not only is the lunge test only one test in a wide range of available tests for the clinician, I think that it would be foolish to jump to the conclusion that simply because a clinician does not use the lunge test that he or she can not properly diagnose and treat mechanically-based conditions of the foot and lower extremity.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
You will need to try and expand your imagination a little if you can't understand how a clinician can appreciate the pathology and bimechanics of the ankle joint especially regarding the diagnosis of its conditions, prognosis, etc, without utilizing the lunge test. The lunge test, even though I have no problems with practitioners using it to evaluate patients, does not test for gastrocnemius equinus, does not test for strength of the ankle joint plantarflexors, or for internal derangements of the ankle joint. Therefore, not only is the lunge test only one test in a wide range of available tests for the clinician, I think that it would be foolish to jump to the conclusion that simply because a clinician does not use the lunge test that he or she can not properly diagnose and treat mechanically-based conditions of the foot and lower extremity.
Kevin, how do you test for anterior ankle impingement(AAI)? I guess the classic AAI involves bone on bone and can be viewed in a lateral xray film. But the more common, under-diagnosed, misunderstood variety of AAI involves non-osseous structures.
There is a huge difference in how one should treat an ankle equinus on the basis of end-feel. Physiologically, end-range dorsi-flexion is limited by posterior ankle joint structures. Pathologically, this is limited by anterior structures. Although most musculo-skeletal practitioners prescribe stretching for every equinus, to do so with an anteriorly impinging ankle does not make sense.
As for an internally deranged ankle, I am confident the lunge test will be restricted on the ipsilateral side, and that the end-feel restriction will not be posterior to the joint; hence I disagree that the lunge has no place in testing for such pathology.
The other thing, is that if used properly, the lunge test can determine whether the inferior tib/fib joint and/or syndesmosis is relevant in ankle joint hypomobility. I have presented this in Craig's presence, and have yet to fill in the research blanks.
But I will stick to my foolish conclusion that "I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test". I did not suggest foot nor lower extremity; simply the ankle joint.
I would be interested to see how you test and treat AAI without the functional weightbearing dorsi-flexion lunge test.
Last edited by Atlas : 2nd February 2006 at 08:40 PM.
Kevin, how do you test for anterior ankle impingement(AAI)? I guess the classic AAI involves bone on bone and can be viewed in a lateral xray film. But the more common, under-diagnosed, misunderstood variety of AAI involves non-osseous structures.
There is a huge difference in how one should treat an ankle equinus on the basis of end-feel. Physiologically, end-range dorsi-flexion is limited by posterior ankle joint structures. Pathologically, this is limited by anterior structures. Although most musculo-skeletal practitioners prescribe stretching for every equinus, to do so with an anteriorly impinging ankle does not make sense.
As for an internally deranged ankle, I am confident the lunge test will be restricted on the ipsilateral side, and that the end-feel restriction will not be posterior to the joint; hence I disagree that the lunge has no place in testing for such pathology.
The other thing, is that if used properly, the lunge test can determine whether the inferior tib/fib joint and/or syndesmosis is relevant in ankle joint hypomobility. I have presented this in Craig's presence, and have yet to fill in the research blanks.
But I will stick to my foolish conclusion that "I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test". I did not suggest foot nor lower extremity; simply the ankle joint.
I would be interested to see how you test and treat AAI without the functional weightbearing dorsi-flexion lunge test.
Atlas:
You have now changed your statement from "I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test" to "I would be interested to see how you test and treat AAI without the functional weightbearing dorsi-flexion lunge test." To me, this is quite a change in statements going from understanding the ankle joint and all its potential pathologies and biomechanics to then changing your story and now wanting to isolate it down to one solitary pathology in the ankle.
To answer your question, I use a weightbearing stress dorsiflexion radiographic projections of the ankle to diagnose "anterior ankle impingement".
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
You have now changed your statement from "I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test" to "I would be interested to see how you test and treat AAI without the functional weightbearing dorsi-flexion lunge test." To me, this is quite a change in statements going from understanding the ankle joint and all its potential pathologies and biomechanics to then changing your story and now wanting to isolate it down to one solitary pathology in the ankle.
To answer your question, I use a weightbearing stress dorsiflexion radiographic projections of the ankle to diagnose "anterior ankle impingement".
That is the whole point Kevin. If you can only rely on radiology to detect/diagnose anterior ankle impingement, you are only picking up the classic osseous bone-to-bone variety; and I agree that this is one solitary pathology.
However, you are not picking up the more common variety that accompanies many ankle conditions from a sprain to post-ORIF-immobilisation. The soft-tissue underpinning of anterior-ankle-impingement is a detrimental adjunct that will slow recovery; invariably will not respond to dorsi-flexion stretching; and be aggravated by fast walking, and/or slow walking up-hill or down stairs.
I stand by my comment that "I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test." Because if the practitioner misses a soft-tissue anterior ankle impingement, the diagnosis is not complete; the prescribed exercise(s) (eg. dorsi-flexion stretching) can be counter-productive; the prognosis is overestimated and referring back to a specialist is often delayed.
In relation to "changed statements", how did you infer that I meant that if a "clinician does not use the lunge test that he or she can not properly diagnose and treat mechanically-based conditions of the foot and lower extremity." I never said foot and lower extremity. I am the one who has been consistent all along.
That is the whole point Kevin. If you can only rely on radiology to detect/diagnose anterior ankle impingement, you are only picking up the classic osseous bone-to-bone variety; and I agree that this is one solitary pathology.
However, you are not picking up the more common variety that accompanies many ankle conditions from a sprain to post-ORIF-immobilisation. The soft-tissue underpinning of anterior-ankle-impingement is a detrimental adjunct that will slow recovery; invariably will not respond to dorsi-flexion stretching; and be aggravated by fast walking, and/or slow walking up-hill or down stairs.
I stand by my comment that "I cannot fathom how one can fully understand the ankle joint in terms of complete diagnoses, prognosis and when to refer on, without first understanding and utilizing the lunge test." Because if the practitioner misses a soft-tissue anterior ankle impingement, the diagnosis is not complete; the prescribed exercise(s) (eg. dorsi-flexion stretching) can be counter-productive; the prognosis is overestimated and referring back to a specialist is often delayed.
In relation to "changed statements", how did you infer that I meant that if a "clinician does not use the lunge test that he or she can not properly diagnose and treat mechanically-based conditions of the foot and lower extremity." I never said foot and lower extremity. I am the one who has been consistent all along.
I can see that I will now need to perform the lunge test on all of my patients so that, one day, I too can become an expert in diagnosing and treating conditions of the ankle.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I can see that I will now need to perform the lunge test on all of my patients so that, one day, I too can become an expert in diagnosing and treating conditions of the ankle.
Sincerely?
I don't know about expert-status, but applying and understanding the lunge test will make the musculo-skeletal clinician more adept at assessing and treating ankle joint conditions; unquestionably.
Quote:
"we now know that ankle joint stiffness is more important than ankle joint ROM; the weightbearing lunge test for ankle ROM is showing huge promise in reliability; predicting dynamic function and adjusting orthoses prescribing based on it -"
I would add that determining the limiting structure (anterior v. posterior) is equally as important.
1. It has been shown to prospectively predict injury (how many other clinical tests do that?)
2. It is related to dynamic function (how many other clinical tests do that?)
3. It may be predictive of orthotic outcomes (how many other clinical tests do that?)
How many of the clinical tests do you use that meet those 3 criteria ... or even just one of them? None?
Hi Craig, excuse my ignorance, I am still an undergraduate student, and was a little timid to reply in the presence of such 'in-tuned' minds.
I have perused the work of Pape et al (1998) and Gabbe et al (2004) in regards to predicting lower extremity injuries and the correlations that arise between the lunge test.
You stated the lunge test may be predictive of orthotic outcomes?
Is this in relation to the protocol you were testing? Were you implying if the patient (whilst dynamically standing on the orthotic during the lunge test) had a tibial angle of greater than 35-38 degrees, they would be less prone to the recurrence of their pre-orthotic pathology? Using the studies of Pape et al (1998) and Gabbe et al (2004) as the basis for this?!? Or did I miss something?
You stated the lunge test may be predictive of orthotic outcomes?
Is this in relation to the protocol you were testing?
Maybe - its work in progress...
Quote:
Were you implying if the patient (whilst dynamically standing on the orthotic during the lunge test) had a tibial angle of greater than 35-38 degrees, they would be less prone to the recurrence of their pre-orthotic pathology? Using the studies of Pape et al (1998) and Gabbe et al (2004) as the basis for this?!? Or did I miss something?
Maybe ---- we had to start somewhere with an angle that we had a heel raise as part of the testing. 35-38 degrees was a good a place as anywhere to start as there was nothing else to base it on. We have a major project starting in the new year to try and more definitively define the "cut-off"
Think about it this way -
1. We know from a lot of peoples good clinical experience about the importance of heel raises for better outcomes in a number of circumstances.
2. We also know that 10 degrees for normal ankle joint ROM using the traditional technique is wrong - the "normal" angle is very subject specific and varies substantially from person to person
3. The traditional technique says something like "dorsiflex the foot to resistance" ... but what is resistance? I could probably get >10 degrees in most people if I push hard enough
4. How hard should you push when measuing ankle joint ROM? If you think about it intuitively, you should push as hard as the forces that are generated during gait .... enter the weightbearing lunge tests, which probably better represents those forces that are present during gait. .... which also brings in the concept of ankle joint stiffness (ie the force degree curve) rather than ROM.
....its not gospel, its work in progress.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Lunge test- Please explain...
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