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 ...

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