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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??
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
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?
__________________
''The bottom line is too many people prescribe devices who haven't got the faintest idea of what they are doing. There are certain unscrupulous labs supporting this. There are too many people in it for the money.'' paraphrasing Simon Spooner
Re: Lunge Test: A Good Test for Only Running Sports??
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
__________________
Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Kevin Kirby
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??
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.
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Atlas
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.
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?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Kenva
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
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Kevin Kirby
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?
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.
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Atlas
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
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Kevin Kirby
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??
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.
Quote:
Originally Posted by Kevin Kirby
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
Varus versus supinatus if neither here nor there with me. Osseous is black; soft-tissue is white; but the world is often grey.
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Atlas
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.
They couldn't even walk normally in a shoe with a heel??
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Atlas
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.
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?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Kevin Kirby
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?
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.
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Atlas
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.
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........
Quote:
Originally Posted by Ron
Kevin, find me anyone with a negative lunge recording that can walk without a limp.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
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.
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Josh Burns
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
Josh:
Good to see your fingers have thawed out since Chicago's PFOLA meeting.
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
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?
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Josh Burns
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
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! :)
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Lunge Test: A Good Test for Only Running Sports??
Quote:
Originally Posted by Josh Burns
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?
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.
Quote:
Riemann BL, DeMont RG, Ryu K, Lephart SM. The Effects of Sex, Joint Angle, and the Gastrocnemius Muscle on Passive Ankle Joint Complex Stiffness. J Athl Train. 2001 Dec;36(4):369-375.
OBJECTIVE: To assess the effects of sex, joint angle, and the gastrocnemius muscle on passive ankle joint complex stiffness (JCS). DESIGN AND SETTING: A repeated-measures design was employed using sex as a between-subjects factor and joint angle and inclusion of the gastrocnemius muscle as within-subject factors. All testing was conducted in a neuromuscular research laboratory. SUBJECTS: Twelve female and 12 male healthy, physically active subjects between the ages of 18 and 30 years volunteered for participation in this study. The dominant leg was used for testing. No subjects had a history of lower extremity musculoskeletal injury or circulatory or neurologic disorders. MEASUREMENTS: We determined passive ankle JCS by measuring resistance to passive dorsiflexion (5 degrees.s(-1)) from 23 degrees plantar flexion (PF) to 13 degrees dorsiflexion (DF). Angular position and torque data were collected from a dynamometer under 2 conditions designed to include or reduce the contribution of the gastrocnemius muscle. Separate fourth-order polynomial equations relating angular position and torque were constructed for each trial. Stiffness values (Nm.degree(-1)) were calculated at 10 degrees PF, neutral (NE), and 10 degrees DF using the slope of the line at each respective position. RESULTS: Significant condition-by-position and sex-by-position interactions and significant main effects for sex, position, and condition were revealed by a 3-way (sex-by-position, condition-by-position) analysis of variance. Post hoc analyses of the condition-by-position interaction revealed significantly higher stiffness values under the knee-straight condition compared with the knee-bent condition at both ankle NE and 10 degrees DF. Within each condition, stiffness values at each position were significantly higher as the ankle moved into DF. Post hoc analysis of the sex-by-position interaction revealed significantly higher stiffness values at 10 degrees DF in the male subjects. Post hoc analysis of the position main effect revealed that as the ankle moved into dorsiflexion, the stiffness at each position became significantly higher than at the previous position. CONCLUSIONS: The gastrocnemius contributes significantly to passive ankle JCS, thereby providing a scientific basis for clinicians incorporating stretching regimens into rehabilitation programs. Further research is warranted considering the cause and application of the sex-by-position interaction.
Quote:
DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen ST Jr, Cziernecki J, Sangeorzan BJ. Isolated gastrocnemius tightness. J. Bone Joint Surg Am. 2002 Jun;84-A(6):962-70.
BACKGROUND: Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed. METHODS: This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed). RESULTS: With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group. CONCLUSIONS: On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present. Clinical Relevance: These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.
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Sammarco GJ, Bagwe MR, Sammarco VJ, Magur EG. The effects of unilateral gastrocsoleus recession. Foot Ankle Int. 2006 Jul;27(7):508-11.
BACKGROUND: Gastrocsoleus recession is commonly performed to correct equinus contracture of the ankle that may accompany foot and ankle disease in adults. There is concern that mechanical lengthening of the myotendinous unit causes permanent weakness and disability. This retrospective study reviewed the short-term and long-term objective and subjective results of patients who have had this procedure to determine if it is an appropriate adjunct to corrective foot surgery. METHODS: Forty patients who had unilateral gastrocsoleus recession either as an isolated procedure or in conjunction with other surgeries were available for evaluation at an average 25.3 (range 6 to 50) months. Followup evaluation included the AOFAS ankle hindfoot score, subjective questionnaire, and physical examination. Preoperative and postoperative ranges of motion were compared. Mechanical strength testing was done using the contralateral extremity as a control. Maximal strength was measured by peak torque using a Cybex device (CYBEX International, Inc., Ronkonkoma, New York). Fatigue resistance was measured by comparing the maximal number of toe raises between the operative and nonoperative sides. RESULTS: Range of motion improved from -3.5 to 15.3 degrees average dorsiflexion. Subjectively, two patients reported pain at the operative site, and one patient reported moderate weakness. The AOFAS score improved from 62.3 to 79.5. Strength testing of plantarflexion peak torque found the operative extremity to be 74% of the contralateral leg at followup. Peak torque improved from an average of 62.6% at 6 to 18 months to 82.2% after 18 months compared to the contralateral extremity. Fatigue resistance improved from 37.6% to 50.3% at 18 months. Two patients reported paresthesias in the sural nerve distribution. CONCLUSION: Gastrocsoleus recession is an effective procedure to correct equinus contracture either as an isolated procedure or as an adjunct to other foot surgery. While both fatigue resistance and strength decreased initially, both demonstrated improvement over time. Four patients had subjective complaints after the procedure.
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Pinney SJ, Hansen ST Jr, Sangeorzan BJ. The effect on ankle dorsiflexion of gastrocnemius recession. Foot Ankle Int. 2002 Jan;23(1):26-9.
Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical diseases of the foot and ankle and in ulcer formation in the foot. The purpose of this study is to assess the correction in ankle dorsiflexion that can be achieved with a gastrocnemius recession. An isolated gastrocnemius release (Strayer procedure) was performed on 26 legs, in 20 consecutive patients, for clinically significant gastrocnemius equinus contracture. Ankle dorsiflexion was assessed using a validated electrogoniometer. Ankle dorsiflexion was recorded with the knee straight and with the knee bent. Measurements were recorded preoperatively, and immediately postoperatively. Measurements at an average of 55.0 days postsurgery (range, 37 to 128 days) were performed on 20 legs (15 patients). RESULTS: Average preoperative ankle dorsiflexion with the knee straight was 5.1 degrees. Average preoperative ankle dorsiflexion with the knee bent was 22.8 degrees. Immediately following surgery the average ankle dorsiflexion with the knee straight was 23.2 degrees. The average correction was 18.1 degrees and this increase was significant (p < 0.0001.) In the 15 patients (20 legs) available for follow-up, the increase in ankle dorsiflexion with the knee straight was maintained (average: 24.9 degrees). Patients with gastrocnemius contracture who underwent an isolated gastrocnemius release increased their ankle dorsiflexion (knee straight) by an average of 18.1 degrees with postoperative ankle dorsiflexion (knee straight) being equivalent (23.2 and 22.8 degrees) to preoperative ankle dorsiflexion (knee bent). This correction appears to be maintained (23.2 vs. 24.9 degrees) at short-term follow-up.
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Matjacic Z, Olensek A, Bajd T. Biomechanical characterization and clinical implications of artificially induced toe-walking: differences between pure soleus, pure gastrocnemius and combination of soleus and gastrocnemius contractures. J Biomech. 2006;39(2):255-66.
The purpose of this study was to characterize biomechanically three different toe-walking gait patterns, artificially induced in six neurologically intact subjects and to compare them to selected cases of pathological toe-walking. The subjects, equipped with lightweight mechanical exoskeleton with elastic ropes attached to the left leg's heel on one end and on shank and thigh on the other end in a similar anatomical locations where soleus and gastrocnemius muscles attach to skeleton, walked at speed of approximately 1m/s along the walkway under four experimental conditions: normal walking (NW), soleus contracture emulation (SOL), gastrocnemius contracture emulation (GAS) and emulation of both soleus and gastrocnemius contractures (SOLGAS). Reflective markers and force platform data were collected and ankle, knee and hip joint angles, moments and powers were calculated using inverse dynamic model for both legs. Characteristic peaks of averaged kinematic and kinetic patterns were compared among all four experimental conditions in one-way ANOVA. In the left leg SOL contracture mainly influenced the ankle angle trajectory, while GAS and SOLGAS contractures influenced the ankle and knee angle trajectories. GAS and SOLGAS contractures significantly increased ankle moment during midstance as compared to SOL contracture and NW. All three toe-walking experimental conditions exhibited significant power absorption in the ankle during loading response, which was absent in the NW condition, while during preswing significant decrease in power absorption as compared to NW was seen. In the knee joint SOL contracture diminished, GAS contracture increased while SOLGAS contracture approximately halved knee extensor moment during midstance as compared to NW. All three toe-walking experimental conditions decreased hip range of motion, hip flexor moment and power requirements during stance phase. Main difference in the right leg kinematic and kinetic patterns was seen in the knee moment trajectory, where significant increase in the knee extensor moment took place in terminal stance for GAS and SOLGAS experimental conditions as compared to SOL and NW. The kinetic trajectories under SOL and GAS experimental conditions were qualitatively compared to two selected clinical cases showing considerable similarity. This implies that distinct differences in kinetics between SOL, GAS and SOLGAS experimental conditions, as described in this paper, may be clinically relevant in determining the relative contribution of soleus and gastrocnemius muscles contractures to toe-walking in particular pathological gait.
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Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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