Name: diagnosis of musculus gastrocnemius tightness - key factors for the clinical examination
Uploaded: 2016-07-07T10:00:00
Description: Watch this Scientific Journal Video about Diagnosis of Musculus Gastrocnemius Tightness - Key Factors for the Clinical Examination at JoVE.com

We would like to thank Jakob Binder for his help in subject acquisition and organization of the examinations, Mrs. Hella Thun for designing Figure 1 and 2 and finally Mr. Dipl.-Ing. (FH), M.Sc. M. Saller for his statistical support.

Ethics statement: The study was approval by the local ethics committee of the University of Munich (# 007-14).
Note: An examination couch freely accessible on both sides and the foot end is required for non-weightbearing testing. A line (tape, approximately 2 meters) on the ground perpendicular the wall is needed for weightbearing testing. A standard goniometer with 2&#176; increments and 20 cm length is used. We recommend documenting the results using a standardized fourfold table containing ADF measurement for the knee extended and ...

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Examinations on 20 healthy individuals revealed, that 20 degrees of knee flexion already eliminates the influence of the M. gastrocnemius on ADF. Further knee flexion resulted in no significant ADF increase. The herein presented video description of a standardized non-weightbearing and weightbearing examination for MGT builds the prerequisite for future studies establishing physiological norm values.
The study has limitations. First, no custom-made measurement device was used to asses...

Limited ankle dorsiflexion (ADF) alters the gait kinematics and is held responsible for common foot pathologies including Achilles tendinopathy, stress fractures, metatarsalgia and plantar heel pain 1-5. The most common cause for limited ADF is isolated Musculus gastrocnemius tightness (MGT) 3,6.
The joint kinematics of the ankle are influenced by knee flexion as the M. gastrocnemius bridges both joints. The muscle is under tension when the knee is fully extended, as the origin of the muscle is then furthest proximal. The M. gastrocnemius then restrains ADF. Knee flexion approximates the muscle&#39;s origin, thereby reducing the tension of the M. gastrocnemius, and consequently increases ADF. Ankle dorsiflexion is then limited by other anatomical structures of the ankle joint. Figure 1 illustrates this principle. In the case of MGT, ADF is limited with the knee fully extended but substantially increases by flexion of the knee 4.
Clinical examination for MGT takes advantage of the above outlined principled and was first published in 1923 by Silfverski&#246;ld, a Swedish orthopedic surgeon 7. Since then, numerous examination techniques have been described, all of which compare the ADF with the knee extended and flexed. Published clinical tests can be categorized into non-weightbearing 5,8, weightbearing 9,10, and instrumented 11,12. Today, non-weightbearing examination is most commonly conducted 13. The patient is placed supine on the examination couch and ADF is assessed with the knee fully extended and typically 90&#176; flexed (Figure 2A). On the contrary, weightbearing ADF measurements are conducted with the subject upright in lunge stance. The rear knee is extended or bent and the subject is asked to lean forward just before heel liftoff (Figure 2B). For both tests MGT is diagnosed, if the ADF with the knee extended is impaired and knee flexion results in a significant increase of ADF.
Although non-weightbearing tests are frequently performed, weightbearing testing has several advantages. First, only one investigator is needed for weightbearing examination, whereas two examiners are required to achieve reliable non-weightbearing measurements. Second, the weightbearing examination more closely reflects the load during gait. Third, the force applied to the ankle is independent of the examiner. Fourth, weightbearing examination features a higher intra- and inter- rater reliability 9,10,13-15.
The major limitation of all tests for MGT is that&#160;the minimal degree of knee flexion needed to eliminate the restraining effect of the M. gastrocnemius on ADF is unknown 8,15. Whereas 90&#176; of knee flexion are typically applied in non-weightbearing testing 5,8,16, this is not feasible for the weightbearing examination. The broad population is unable to perform a Lunge with 90&#176; of knee flexion without lifting the heel off the ground. Consequently, most studies conducting weightbearing examinations did not control for knee flexion 8,15. In order to perform reliable weightbearing examinations it is essential to identify the minimal degree of knee flexion needed to eliminate the restraining effect of the M. gastrocnemius on ADF.
Overall, literature argues for weightbearing testing for the diagnosis of MGT. In order to provide a valid weightbearing examination procedure, the minimal degree of knee flexion required to eliminate the ADF restraining effect of the M. gastrocnemius must be known. The aim of this study was to investigate the influence of knee flexion on ADF in non-weightbearing and weightbearing testing and to provide a step-by-step guide to conduct non-weightbearing and weightbearing examination for MGT.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Examination couch</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Standard goniometer&#160;</td>
			<td colspan="2">MDF Instruments USA, Inc. Malibu, CA, USA</td>
			<td>2&#176; increments</td>
		</tr>
	</tbody>
</table>

diagnosis of musculus gastrocnemius tightness - key factors for the clinical examination

Common foot and ankle pathologies have been linked to isolated Musculus gastrocnemius tightness (MGT). Various examination techniques have been described to assess MGT. Still, a standardized examination procedure is missing. Literature argues for weightbearing examination but the degree of knee flexion needed to eliminate the restraining effect of the M. gastrocnemius on ankle dorsiflexion (ADF) is unknown. This manuscript investigates the effect of knee flexion on ankle dorsiflexion and provides a detailed description of a standardized examination protocol. Examination on 20 healthy individuals revealed, that 20&#176; of knee flexion is sufficient to fully eliminate the influence of the M. gastrocnemius on ADF. This builds the prerequisite for a standardized examination for MGT. Non-weightbearing and weightbearing examination of ADF has to be conducted with the knee fully extended and at least 20&#176; flexed. Two investigators should conduct non-weightbearing testing with the subject in supine position. In order to obtain reliable results, the axis of the fibula should be marked. One examiner can conduct weightbearing examination with the subject in lunge stance. Isolated MGT is present if ADF is impaired with the knee fully extended and knee flexion results in a significant ADF increase. The herein presented standardized examination is the prerequisite for future studies aiming at establishing norm values.

Both ankles of 20 healthy individuals (mean age of 27.1 &#177; 3.9 years), 50% female, were examined. Non-weightbearing and weightbearing tests at six different degrees of knee flexion (full extension, 20&#176;, 30&#176;, 45&#176;, 60&#176;, 75&#176;) and the Lunge Test (uncontrolled knee flexion) were conducted. A functional brace was used to control knee flexion. Measurements were performed by two investigators blinded to each other&#39;s results. Between each individual, the order of t...

Watch this Scientific Journal Video about Diagnosis of Musculus Gastrocnemius Tightness - Key Factors for the Clinical Examination at JoVE.com

Diagnosis of Musculus Gastrocnemius Tightness - Key Factors for the Clinical Examination

Isolated Musculus gastrocnemius tightness is a common cause for foot and ankle pathologies. Currently no standardized examination procedure exists. This manuscript demonstrates that 20 degree of knee flexion eliminates the restraining effect of the M. gastrocnemius on ankle dorsiflexion and presents a video description of a standardized examination protocol.

Diagnosis of Musculus Gastrocnemius Tightness - Key Factors for the Clinical Examination

Common foot and ankle pathologies have been linked to isolated Musculus gastrocnemius tightness (MGT). Various examination techniques have been described ...

The overall goal of this diagnostic study is to define a standardized evidence-based examination procedure to assess ankle dorsiflexion with the knee extended and flexed. As there's no standardized test to assess ankle dorsiflexion, this examination method can help to define physiological and pathological values of ankle dorsiflexion. Clinicians will then be able to identify patients with impaired ankle dorsiflexion, which is the root of various pathologies to the foot and ankle.The main advantage of this technique is that it is a standardized evidence-based diagnostic approach. We first had the idea of this study when review literature on impaired ankle dorsiflexion. Many of the existing examination protocols vary significantly, therefore we aim to define a more standardized test to assess impaired ankle dorsiflexion.The visual demonstration of this examination technique is very beneficial, as it shows all of the key elements of this procedure in great detail.Mrs. Alena Sint is a member of our foot and ankle research group, and will help us to present the examination procedure. Begin by asking the subject to remove footwear and any clothing covering the legs.Have two investigators perform the measurement. One conducting the test, and the other measuring the degree of ankle dorsiflexion. Place the subject in a supine position on the examination couch.Mark the axis of the fibula by drawing a line connecting the center of the distal fibula at five centimeters and 15 centimeters above the tip of the distal fibula. Then have the first investigator place one hand at the level of the subtalar joint to ensure a neutral pronation supination position of the rear foot. And place the other hand around the mid-foot.Note that one hand stabilizes the subtalar joint and the other hand stabilizes the talonavicular joint, and applies force on the plantar aspect of the forefoot. To achieve maximum ankle dorsiflexion, ensure that the knee is fully extended. Next have the second investigator perform the measurement of the ankle dorsiflexion using a goniometer.Place one arm of the goniometer connecting the start and end point of the previously-marked axis of the fibula and align the other arm with the plantar aspect of the foot. Note this result on the documentation sheet. Then have the subject flex their knee 90 degrees and repeat this measurement procedure.Finally, repeat this entire procedure for the contralateral side. Note these results on the documentation sheet. Begin by asking the subject to stand opposite a wall.Ask the subject to get into a lunge position with the leg to be measured being the rear leg. Help the subject place their rear foot centered on the previously-marked line. Ensure that the heel and second toe of the rear leg are centered on the line.Have the subject hold on to the wall to stabilize the stance. Then ask the subject to fully extend their rear leg. Ensure that the knee is fully extended.Next have the subject move the hips toward the wall just before the heel of the rear leg lifts off the ground. The investigator has to ensure that the heel has not lifted off the ground. Place one hand on the dorsal aspect of the subtalar joint to ensure a neutral pronation supination position of the rear foot.With the other hand, perform the measurement of the ankle dorsiflexion by placing one arm of the goniometer on the floor, and align the other arm along the previously marked axis of the fibula. Note the result on the documentation sheet. Next have the subject move closer to the wall.Again, have the subject get into the lunge position, where their rear foot is centered on the previously-marked line. Have the subject hold on to the wall to stabilize their stance. Now ask the subject to flex their rear leg and move their hip toward the wall, just before the heel of the rear leg lifts off the ground.Use the goniometer to ensure that the rear knee is flexed at least 20 degrees. Then place one hand on the dorsal aspect of the subtalar joint to ensure a neutral pronation supination position of the rear foot. With the other hand, perform the measurement of the ankle dorsiflexion in the same manner as previously measured.Note the result. Repeat all steps for the contralateral side. Review the ankle dorsiflexion data on the documentation sheet, based on the subject's symptomatic side.Identify whether ankle dorsiflexion with the knee extended is less than 10 degrees on the symptomatic side. Then compare ADF with the knee extended and flexed. If ADF is greater than 10 degrees, compare ankle dorsiflexion with the knee extended between both legs.Consider musculus gastrocnemius tightness to be a possible cause, if ankle dorsiflexion is reduced on the symptomatic compared to the non-symptomatic side. This protocol demonstrates a standardized examination protocol for musculus gastrocnemius tightness, using a Non-weightbearing and a Weightbearing technique. The mean Ankle dorsiflexion of each step of Knee flexion indicated significantly higher values for Weightbearing measurements, compared to Non weightbearing measurements.Here, the difference of ADF between each step of knee flexion is shown. Significant differences were only observed between full knee extension and 20 degrees of knee flexion. After watching this video, you should have a good understanding of how to conduct this standardized examination to assess ankle dorsiflexion with the knee extended and flexed.Based on this, one can diagnose impaired ankle dorsiflexion as well as musculus gastrocnemius tightness. Once internalized, this technique can be done in a couple of minutes. While performing this procedure, it's important to keep the hind foot in neutral position, to stabilize the talonavicular joint and to ensure the appropriate knee position.This technique will pave the way for researchers in the field of foot and ankle disorders to finally agree on a consistent definition for physiological and pathological values of ankle dorsiflexion.

Research

JoVE Journal

Medicine

Clinical Examination Protocol to Detect Atypical and Classical Scrapie in Sheep

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Echocardiographic and Histological Examination of Cardiac Morphology in the Mouse

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Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

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Transthoracic Echocardiographic Examination in the Rabbit Model

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OP-IVM: Combining In vitro Maturation after Oocyte Retrieval with Gynecological Surgery

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Development of an Effective Mice Model for Studying Oronasal Fistulas

Establishment of an Oronasal Fistula Mice Model

Author Spotlight: Investigating Wound Healing in Mice Models of Oronasal Fistulas 

This study presents a method utilizing heated ophthalmologic cautery to develop a viable model for investigating oronasal fistulas. C57BL/6 mice were used ...

Subclavian Vein Puncture Method for Repeated Blood Collection in Conscious Rats

Subclavian Vein Blood Sampling in Conscious Rats

Author Spotlight: Developing an Efficient Blood Collection Method in Non-Anesthetized Rats 

There are several established methods for obtaining repeated blood samples from rats, with the most commonly employed methods being lateral tail vein ...

Extraction of 3D Region of the Liver for Hepatic Fibrosis Diagnosis

Advancing Cryostorage of Human Stem Cell-Derived Retinal Pigment Epithelial Cells

Cryopreservation of Human Embryonic Stem Cell-Derived Retinal Pigment Epithelial Cells at the Optimal Stage

Author Spotlight: Development of an Efficient and Feasible Method of Retinal Pigment Epithelial Cell Freezing

Retinal pigment epithelial&#160;(RPE) cells derived from human embryonic stem cells (hESCs) are superior cell sources for cell replacement therapy in ...

Exploring Obliterative Airway Disease in Lung Transplants

Murine Intrapulmonary Tracheal Transplantation: A Model for Investigating Obliterative Airway Disease After Lung Transplantation

Author Spotlight: Investigating the Key Factors of Obliterative Bronchiolitis After Lung Transplantation

Murine intrapulmonary tracheal transplantation (IPTT) is used as a model of obliterative airway disease (OAD) following lung transplantation. Initially ...