Name: diagnosis of musculus gastrocnemius tightness - key factors for the clinical examination
Uploaded: 2016-07-07T10:00:00.000+00:00
Duration: 8 min 43 s
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 flexed for each leg separately.
1. Participant Preparation
<ol>
	<li>Have the subject take off their pants and remove their footwear.</li>
	<li>Mark the axis of the fibula by drawing a line connecting the center of the distal fibula 5 cm and 15 cm above the tip of the fibula.</li>
</ol>
2. Non-weightbearing Measurement (Figure 2A)&#160;
<ol>
	<li>Have two investigators perform the measurement, one conducting the test, the other measuring the degree of ankle dorsiflexion.</li>
	<li>Place the subject in supine position on the examination couch. The examination couch must be freely accessible on both sides and the foot end.</li>
	<li>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 midfoot. Thereby one hand stabilizes the talonavicular joint, while the other hand applies force on the plantar aspect of the forefoot to achieve maximum ankle dorsiflexion.</li>
	<li>Have the first investigator ensure that the knee is fully extended.</li>
	<li>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. Align the other arm with the plantar aspect of the foot.</li>
	<li>Note the result on the documentation sheet.</li>
	<li>Have the first investigator ensure 90&#176; of knee flexion by placing one hand on the distal dorsal aspect of the thigh while the other hand applies force on the plantar aspect of the forefoot to achieve maximum ankle dorsiflexion.</li>
	<li>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 midfoot. Thereby one hand stabilizes the talonavicular joint and the other hand applies force on the plantar aspect of the forefoot to achieve maximum ankle dorsiflexion.</li>
	<li>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. Align the other arm with the plantar aspect of the foot.</li>
	<li>Note the result on the documentation sheet.</li>
	<li>Repeat steps 2.1 through 2.10 for the contralateral side.</li>
</ol>
3. Weightbearing Measurement (Figure 2B)
<ol>
	<li>Have one investigator perform the test.</li>
	<li>Place the subject standing opposite a wall.</li>
	<li>Have the subject get into the lunge position with the leg to be measured being the rear leg.</li>
	<li>Have the investigator help the subject to place his/her rear foot centered on the previously marked line. Ensure that the heel and the second toe of the rear leg are centered on the line.</li>
	<li>Have the subject hold onto the wall in order to stabilize their stance.</li>
	<li>Have the subject fully extend their rear leg. Have the investigator ensure that the knee is fully extended. Be aware that even slight knee flexion significantly influences ankle dorsiflexion.</li>
	<li>Have the subject move their hip towards the wall until just before heel lift off of the rear leg. The front leg can be flexed as needed / as comfortable.</li>
	<li>Have the investigator place one hand on the dorsal aspect of the subtalar joint to ensure a neutral pronation-supination position of the rear foot.</li>
	<li>Have the investigator perform the measurement of ankle dorsiflexion with the other hand. Align one arm of the goniometer connecting the start and end point of the previously marked axis of the fibula. Place the other arm on the floor.</li>
	<li>Note the result on the documentation sheet.</li>
	<li>Have the subject get into the lunge position with the leg to be measured being the rear leg. Therefore have the patient move towards the wall until a comfortable position has been reached.</li>
	<li>Have the investigator help the subject to place his/her rear foot centered on the previously marked line. Ensure that the heel and the second toe of the rear leg are centered on the line.</li>
	<li>Have the subject hold onto the wall in order to stabilize their stance.</li>
	<li>Have the subject flex the rear leg as comfortable and move their hip towards the wall until just before heel lift off of the rear leg. The front leg can be flexed as needed / as comfortable.</li>
	<li>Have the investigator ensure that the rear knee is flexed at least 20 degrees. In case of doubt use the goniometer to ensure knee flexion greater than 19 degrees.</li>
	<li>Have the investigator place one hand on the dorsal aspect of the subtalar joint to ensure a neutral pronation-supination position of the rear foot.</li>
	<li>Perform the measurement of ankle dorsiflexion with the other hand. Align one arm of the goniometer connecting the start and end point of the previously marked axis of the fibula. Place the other arm on the floor.</li>
	<li>Note the result on the documentation sheet.</li>
	<li>Repeat steps 3.1 through 3.18 for the contralateral side.</li>
</ol>
4. Data Analysis and Interpretation
<ol>
	<li>Ask the subject to identify the symptomatic side.</li>
	<li>Review the ADF data on the documentation sheet.
	<ol>
		<li>First identify whether ADF with the knee extended is less than 10&#176; on the symptomatic side. If so, consider MGT to be a possible cause. Then, compare ADF with the knee extended and flexed. If knee flexion results in a significant increase of ADF, MGT is present.</li>
		<li>In case ADF is greater than 10&#176;, compare ADF with the knee extended between both legs. If ADF is reduced on the symptomatic compared to the non-symptomatic side consider MGT to be a possible cause. If knee flexion on the symptomatic side results in a significant increase of ADF, MGT is present.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Wilder, R. P., Sethi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Overuse+injuries:+tendinopathies,+stress+fractures,+compartment+syndrome,+and+shin+splints.">Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints.</a> Clin Sorts Med. 23, 55-81 (2004).</li><li>Irving, D. B., Cook, J. L., Menz, H. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+associated+with+chronic+plantar+heel+pain:+a+systematic+review.">Factors associated with chronic plantar heel pain: a systematic review.</a> J Sci Med Sport. 9, 11-22 (2006).</li><li>Patel, A., DiGiovanni, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+between+plantar+fasciitis+and+isolated+contracture+of+the+gastrocnemius.">Association between plantar fasciitis and isolated contracture of the gastrocnemius.</a> Foot Ankle Int. 32, 5-8 (2011).</li><li>DiGiovanni, C. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+gastrocnemius+tightness.">Isolated gastrocnemius tightness.</a> JBJS Am. 84-A, 962-970 (2002).</li><li>Bol&#236;var, Y. A., Munuera, P. V., Padillo, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+between+tightness+of+the+posterior+muscles+of+the+lower+limb+and+plantar+fasciitis.">Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis.</a> Foot Ankle Int. 34, 42-48 (2013).</li><li>Hill, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ankle+equinus.+Prevalence+and+linkage+to+common+foot+pathology.">Ankle equinus. Prevalence and linkage to common foot pathology.</a> J Am Podiatr Med Assoc. 85, 295-300 (1995).</li><li>Silfverskiold, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduction+of+the+uncrossed+two-joints+muscles+of+the+leg+to+one-joint+muscles+in+spastic+conditions.">Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions.</a> Acta Chir Scand. 56, 315-330 (1923).</li><li>Krause, D. A., Cloud, B. A., Forster, L. A., Schrank, J. A., Hollman, J. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Measurement+of+ankle+dorsiflexion:+a+comparison+of+active+and+passive+techniques+in+multiple+positions.">Measurement of ankle dorsiflexion: a comparison of active and passive techniques in multiple positions.</a> J Sport Rehabil. 20, 333-344 (2011).</li><li>Bennell, K. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intra-rater+and+inter-rater+reliability+of+a+weight-bearing+lunge+measure+of+ankle+dorsiflexion.">Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion.</a> Aust J Physiother. 44, 175-180 (1998).</li><li>Munteanu, S. E., Strawhorn, A. B., Landorf, K. B., Bird, A. R., Murley, G. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+weightbearing+technique+for+the+measurement+of+ankle+joint+dorsiflexion+with+the+knee+extended+is+reliable.">A weightbearing technique for the measurement of ankle joint dorsiflexion with the knee extended is reliable.</a> J Sci Med Sport. 12, 54-59 (2009).</li><li>Wilken, J., Rao, S., Estin, M., Saltzman, C. L., Yack, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+device+for+assessing+ankle+dorsiflexion+motion:+reliability+and+validity.">A new device for assessing ankle dorsiflexion motion: reliability and validity.</a> J Orthop Sports Phys Ther. 41, 274-280 (2011).</li><li>Gatt, A., Chockalingam, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validity+and+reliability+of+a+new+ankle+dorsiflexion+measurement+device.">Validity and reliability of a new ankle dorsiflexion measurement device.</a> Prosthet Orthot Int. 37, 289-297 (2013).</li><li>Baggett, B. D., Young, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ankle+joint+dorsiflexion.+Establishment+of+a+normal+range.">Ankle joint dorsiflexion. Establishment of a normal range.</a> J Am Podiatr Med Assoc. 83, 251-254 (1993).</li><li>Menz, H. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+clinical+tests+of+foot+and+ankle+characteristics+in+older+people.">Reliability of clinical tests of foot and ankle characteristics in older people.</a> J Am Podiatr Med Assoc. 93, 380-387 (2003).</li><li>Rabin, A., Kozol, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Weightbearing+and+Nonweightbearing+Ankle+Dorsiflexion+Range+of+Motion:+Are+We+Measuring+the+Same+Thing?.">Weightbearing and Nonweightbearing Ankle Dorsiflexion Range of Motion: Are We Measuring the Same Thing?.</a> J Am Podiatr Med Assoc. 12, 406-411 (2012).</li><li>You, J. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastrocnemius+tightness+on+joint+angle+and+work+of+lower+extremity+during+gait.">Gastrocnemius tightness on joint angle and work of lower extremity during gait.</a> Clin Biomech (Bristol, Avon). 24, 744-750 (2009).</li><li>Baumbach, S. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+influence+of+knee+position+on+ankle+dorsiflexion+-+a+biometric+study.">The influence of knee position on ankle dorsiflexion - a biometric study.</a> BMC Musculoskelet Disord. 15, 246 (2014).</li><li>Martin, R. L., McPoil, T. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+ankle+goniometric+measurements:+a+literature+review.">Reliability of ankle goniometric measurements: a literature review.</a> J Am Podiatr Med Assoc. 95, 564-572 (2005).</li><li>Tiberio, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+functional+ankle+dorsiflexion+using+subtalar+neutral+position.+A+clinical+report.">Evaluation of functional ankle dorsiflexion using subtalar neutral position. A clinical report.</a> Phys Ther. 67, 955-957 (1987).</li><li>Tiberio, D., Bohannon, R. W., Zito, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+subtalar+joint+position+on+the+measurement+of+maximum+ankle+dorsiflexic.">Effect of subtalar joint position on the measurement of maximum ankle dorsiflexic.</a> Clin Biomech (Bristol, Avon). 4, 189-191 (1989).</li><li>Bohannon, R. W., Tiberio, D., Waters, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Motion+measured+from+forefoot+and+hindfoot+landmarks+during+passive+ankle+dorsiflexion+range+of+motion.">Motion measured from forefoot and hindfoot landmarks during passive ankle dorsiflexion range of motion.</a> J Orthop Sports Phys Ther. 13, 20-22 (1991).</li><li>Johanson, M., Baer, J., Hovermale, H., Phouthavong, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Subtalar+joint+position+during+gastrocnemius+stretching+and+ankle+dorsiflexion+range+of+motion.">Subtalar joint position during gastrocnemius stretching and ankle dorsiflexion range of motion.</a> J Athl Train. 43, 172-178 (2008).</li><li>Kim, P. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interrater+and+intrarater+reliability+in+the+measurement+of+ankle+joint+dorsiflexion+is+independent+of+examiner+experience+and+technique+used.">Interrater and intrarater reliability in the measurement of ankle joint dorsiflexion is independent of examiner experience and technique used.</a> J Am Podiatr Med Assoc. 101, 407-414 (2011).</li><li>Youdas, J. W., Krause, D. A., Egan, K. S., Therneau, T. M., Laskowski, E. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+static+stretching+of+the+calf+muscle-tendon+unit+on+active+ankle+dorsiflexion+range+of+motion.">The effect of static stretching of the calf muscle-tendon unit on active ankle dorsiflexion range of motion.</a> J Orthop Sports Phys Ther. 33, 408-417 (2003).</li><li>Worrell, T. W., McCullough, M., Pfeiffer, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+foot+position+on+gastrocnemius/soleus+stretching+in+subjects+with+normal+flexibility.">Effect of foot position on gastrocnemius/soleus stretching in subjects with normal flexibility.</a> TJ Orthop Sports Phys Ther. 19, 352-356 (1994).</li><li>Norkin, C. C., White, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Measurement of Joint Motion: A Guide to Goniometry. , (2003).</li><li>Williams, C. M., Caserta, A. J., Haines, T. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+TiltMeter+app+is+a+novel+and+accurate+measurement+tool+for+the+weight+bearing+lunge+test.">The TiltMeter app is a novel and accurate measurement tool for the weight bearing lunge test.</a> J Sci Med Sport. 16, 392-395 (2013).</li><li>Burns, J., Crosbie, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Weight+bearing+ankle+dorsiflexion+range+of+motion+in+idiopathic+pes+cavus+compared+to+normal+and+pes+planus+feet.">Weight bearing ankle dorsiflexion range of motion in idiopathic pes cavus compared to normal and pes planus feet.</a> Foot (Edinb). 15, 91-94 (2005).</li><li>Konor, M. M., Morton, S., Eckerson, J. M., Grindstaff, T. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+three+measures+of+ankle+dorsiflexion+range+of+motion.">Reliability of three measures of ankle dorsiflexion range of motion.</a> Int J Sports Phys Ther. 7, 279-287 (2012).</li><li>Basnett, C. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ankle+dorsiflexion+range+of+motion+influences+dynamic+balance+in+individuals+with+chronic+ankle+instability.">Ankle dorsiflexion range of motion influences dynamic balance in individuals with chronic ankle instability.</a> Int J Sports Phys Ther. 8, 121-128 (2013).</li><li>Kang, M. H., Lee, D. K., Park, K. H., Oh, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+ankle+kinematics+and+performance+on+the+y-balance+test+with+inclinometer+measurements+on+the+weight-bearing-lunge+test.">Association of ankle kinematics and performance on the y-balance test with inclinometer measurements on the weight-bearing-lunge test.</a> J Sport Rehabil. 24, 62-67 (2015).</li><li>Purcell, S. B., Schuckman, B. E., Docherty, C. L., Schrader, J., Poppy, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Differences+in+ankle+range+of+motion+before+and+after+exercise+in+2+tape+conditions.">Differences in ankle range of motion before and after exercise in 2 tape conditions.</a> Am J Sports Med. 37, 383-389 (2009).</li><li>Simondson, D., Brock, K., Cotton, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+and+smallest+real+difference+of+the+ankle+lunge+test+post+ankle+fracture.">Reliability and smallest real difference of the ankle lunge test post ankle fracture.</a> Man Ther. 17, 34-38 (2012).</li><li>Hoch, M. C., Staton, G. S., Medina McKeon, J. M., Mattacola, C. G., Mckeon, P. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dorsiflexion+and+dynamic+postural+control+deficits+are+present+in+those+with+chronic+ankle+instability.">Dorsiflexion and dynamic postural control deficits are present in those with chronic ankle instability.</a> J Sci Med Sport. 15, 574-579 (2012).</li><li>Hoch, M. C., Staton, G. S., Mckeon, P. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dorsiflexion+range+of+motion+significantly+influences+dynamic+balance.">Dorsiflexion range of motion significantly influences dynamic balance.</a> J Sci Med Sport. 14, 90-92 (2011).</li><li>Charles, J., Scutter, S. D., Buckley, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Static+ankle+joint+equinus:+toward+a+standard+definition+and+diagnosis.">Static ankle joint equinus: toward a standard definition and diagnosis.</a> J Am Podiatr Med Assoc. 100, 195-203 (2010).</li></ol>

The authors have nothing to disclose. 
A biometric version of this study has been published 17. The herein presented paper focuses on the actual conduct of the clinical examinations for isolated MGT. The findings of the biometric paper 17 on the influence of the degree of knee flexion are implanted in this paper.

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><tbody><tr><td>Examination couch</td><td></td><td></td><td></td></tr><tr><td>Standard goniometer&amp;nbsp;</td><td>MDF Instruments USA, Inc. Malibu, CA, USA</td><td></td><td>2&amp;deg; 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 ± 3.9 years), 50% female, were examined. Non-weightbearing and weightbearing tests at six different degrees of knee flexion (full extension, 20°, 30°, 45°, 60°, 75°) 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's results. Between each individual, the order of the investigators and the ord...

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 ...

diagnosis-musculus-gastrocnemius-tightness-key-factors-for-clinical

Research

JoVE Journal

Medicine

14.1K Views.  Munich University Hospital. 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.

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

In Vivo Canine Muscle Function Assay

We describe a minimally-invasive and reproducible method to measure canine pelvic limb muscle strength and muscle response to repeated eccentric 
contractions. The pelvic limb of an anesthetized dog is immobilized in a stereotactic frame to align the tibia at a right angle to the femur. Adhesive wrap affixes the 
paw to a pedal mounted on the shaft of a servomotor to measure torque. Percutaneous nerve stimulation activates pelvic limb muscles of the paw to either push (extend) or 
pull (flex) against the pedal to generate isometric torque. Percutaneous tibial nerve stimulation activates tibiotarsal extensor muscles. Repeated eccentric (lengthening) 
contractions are induced in the tibiotarsal flexor muscles by percutaneous peroneal nerve stimulation. The eccentric protocol consists of an initial isometric contraction 
followed by a forced stretch imposed by the servomotor. The rotation effectively lengthens the muscle while it contracts, e.g., an eccentric contraction. During 
stimulation flexor muscles are subjected to an 800 msec isometric and 200 msec eccentric contraction. This procedure is repeated every 5 sec. To avoid fatigue, 4 min rest 
follows every 10 contractions with a total of 30 contractions performed.

In Vivo Canine Muscle Function Assay

We describe a minimally-invasive and painless method to measure canine hindlimb muscle strength and muscle response to repeated eccentric contractions.

We describe a minimally-invasive and reproducible method to measure canine pelvic limb muscle strength and muscle response to repeated eccentric 
...

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients 

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, and persistent nerve and muscle impairments after hospital discharge.1-6 Using an explicit protocol with a structured approach to training and quality assurance of research staff, manual muscle testing (MMT) is a highly reliable method for assessing strength, using a standardized clinical examination, for patients following ARDS, and can be completed with mechanically ventilated patients who can tolerate sitting upright in bed and are able to follow two-step commands. 7, 8 
This video demonstrates a protocol for MMT, which has been taught to &ge;43 research staff who have performed &gt;800 assessments on &gt;280 ARDS survivors. Modifications for the bedridden patient are included. Each muscle is tested with specific techniques for positioning, stabilization, resistance, and palpation for each score of the 6-point ordinal Medical Research Council scale.7,9-11 Three upper and three lower extremity muscles are graded in this protocol: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion. These muscles were chosen based on the standard approach for evaluating patients for ICU-acquired weakness used in prior publications. 1,2.

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups. This video demonstrates MMT using the 6-point Medical Research Council scale.

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, ...

Tibial Nerve Transection - A Standardized Model for Denervation-induced Skeletal Muscle Atrophy in Mice

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of denervation-induced skeletal muscle atrophy in rodents. Although originally developed and used extensively in the rat due to its larger size, the tibial nerve in mice is big enough that it can be easily manipulated with either crush or transection, leaving the peroneal and sural nerve branches of the sciatic nerve intact and thereby preserving their target muscles. Thus, this model offers the advantages of inducing less morbidity and impediment of ambulation than the sciatic nerve transection model and also allows investigators to study the physiologic, cellular and molecular biologic mechanisms regulating the process of muscle atrophy in genetically engineered mice. The tibial nerve supplies the gastrocnemius, soleus and plantaris muscles, so its transection permits the study of denervated skeletal muscle composed of fast twitch type II fibers and/or slow twitch type I fibers. Here we demonstrate the tibial nerve transection model in the C57Black6 mouse. We assess the atrophy of the gastrocnemius muscle, as a representative muscle, at 1, 2, and 4 weeks post-denervation by measuring muscle weights and fiber type specific cross-sectional area on paraffin-embedded histologic sections immunostained for fast twitch myosin.

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of skeletal muscle atrophy. The model surgical protocol is described and demonstrated in C57Black6 mice. &#160;

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of denervation-induced skeletal muscle atrophy in rodents. ...

Assessment of Neuromuscular Function Using Percutaneous Electrical Nerve Stimulation

Percutaneous electrical nerve stimulation is a non-invasive method commonly used to evaluate neuromuscular function from brain to muscle (supra-spinal, spinal and peripheral levels). The present protocol describes how this method can be used to stimulate the posterior tibial nerve that activates plantar flexor muscles. Percutaneous electrical nerve stimulation consists of inducing an electrical stimulus to a motor nerve to evoke a muscular response. Direct (M-wave) and/or indirect (H-reflex) electrophysiological responses can be recorded at rest using surface electromyography. Mechanical (twitch torque) responses can be quantified with a force/torque ergometer. M-wave and twitch torque reflect neuromuscular transmission and excitation-contraction coupling, whereas H-reflex provides an index of spinal excitability. EMG activity and mechanical (superimposed twitch) responses can also be recorded during maximal voluntary contractions to evaluate voluntary activation level. Percutaneous nerve stimulation provides an assessment of neuromuscular function in humans, and is highly beneficial especially for studies evaluating neuromuscular plasticity following acute (fatigue) or chronic (training/detraining) exercise.

We present a protocol to assess changes in neuromuscular function. Percutaneous electrical nerve stimulation is a non-invasive method that evokes muscular responses. Electrophysiological and mechanical properties of these responses permit the evaluation of neuromuscular function from brain to muscle (supra-spinal, spinal and peripheral levels).

Percutaneous electrical nerve stimulation is a non-invasive method commonly used to evaluate neuromuscular function from brain to muscle (supra-spinal, ...

Neuroscience

Procedures for Rat in situ Skeletal Muscle Contractile Properties

There are many circumstances where it is desirable to obtain the contractile response of skeletal muscle under physiological circumstances: normal circulation, intact whole muscle, at body temperature. This includes the study of contractile responses like posttetanic potentiation, staircase and fatigue. Furthermore, the consequences of disease, disuse, injury, training and drug treatment can be of interest. This video demonstrates appropriate procedures to set up and use this valuable muscle preparation.
To set up this preparation, the animal must be anesthetized, and the medial gastrocnemius muscle is surgically isolated, with the origin intact. Care must be taken to maintain the blood and nerve supplies. A long section of the sciatic nerve is cleared of connective tissue, and severed proximally. All branches of the distal stump that do not innervate the medial gastrocnemius muscle are severed. The distal nerve stump is inserted into a cuff lined with stainless steel stimulating wires. The calcaneus is severed, leaving a small piece of bone still attached to the Achilles tendon. Sonometric crystals and/or electrodes for electromyography can be inserted. Immobilization by metal probes in the femur and tibia prevents movement of the muscle origin. The Achilles tendon is attached to the force transducer and the loosened skin is pulled up at the sides to form a container that is filled with warmed paraffin oil. The oil distributes heat evenly and minimizes evaporative heat loss. A heat lamp is directed on the muscle, and the muscle and rat are allowed to warm up to 37&deg;C. While it is warming, maximal voltage and optimal length can be determined. These are important initial conditions for any experiment on intact whole muscle. The experiment may include determination of standard contractile properties, like the force-frequency relationship, force-length relationship, and force-velocity relationship.
With care in surgical isolation, immobilization of the origin of the muscle and alignment of the muscle-tendon unit with the force transducer, and proper data analysis, high quality measurements can be obtained with this muscle preparation.

Procedures for Rat in situ Skeletal Muscle Contractile Properties

This video demonstrates the surgical preparation and procedures needed to study the contractile responses of the rat medial gastrocnemius muscle preparation in situ. This preparation allows measurement of skeletal muscle contractile properties under physiological conditions. The animal is anesthetized and the muscle is separated from surrounding tissue at its distal end. The Achilles tendon is attached to a force transducer, allowing measurement of the muscle&#x2019;s contractile response at 37 degrees C with an intact circulation.

There are many circumstances where it is desirable to obtain the contractile response of skeletal muscle under physiological circumstances: normal ...

Biology

Muscle Imbalances: Testing and Training Functional Eccentric Hamstring Strength in Athletic Populations

Many hamstring injuries that occur during physical activity occur while the muscles are lengthening, during eccentric hamstring muscle actions. Opposite of these eccentric hamstring actions are concentric quadriceps actions, where the larger and likely stronger quadriceps straighten the knee. Therefore, to stabilize the lower limbs during movement, the hamstrings must eccentrically combat against the strong knee-straightening torque of the quadriceps. As such, eccentric hamstring strength expressed relative to concentric quadricep strength is commonly referred to as the &#34;functional ratio&#34; as most movements in sports require simultaneous concentric knee extension and eccentric knee flexion. To increase the strength, resiliency, and functional performance of the hamstrings, it is necessary to test and train the hamstrings at different eccentric speeds. The main purpose of this work is to provide instructions for measuring and interpreting eccentric hamstring strength. Techniques for measuring the functional ratio using isokinetic dynamometry are provided and sample data will be compared. Additionally, we briefly describe how to address hamstring strength deficiencies or unilateral strength differences using exercises that specifically focus on increasing eccentric hamstring strength.

The hamstrings are a group of muscles that are sometimes problematic for athletes, resulting in soft tissue injury in the lower limbs. To prevent such injuries, functional training of the hamstrings requires intensive eccentric contractions. Additionally, hamstring function should be tested in relation to quadricep function at different contraction speeds.

Many hamstring injuries that occur during physical activity occur while the muscles are lengthening, during eccentric hamstring muscle actions. Opposite ...

Ultrasound Evaluation of Achilles Tendon Morphology

Measurement of Healthy and Injured Triceps Surae Morphology

Achilles tendon injuries occur throughout the lifespan and can negatively affect quality of life and overall health. Achilles tendinopathy is generally classified as an overuse injury associated with fusiform tendon thickening, neovascularization, and interstitial tendon degeneration. Current literature suggests these structural changes are associated with&#160;symptoms and lower physical activity levels, as well as&#160;symptoms and lower extremity function in the long term. Surgically and non-surgically managed Achilles tendon ruptures result in increased tendon cross-sectional area (CSA) and a lengthened Achilles tendon. Both structural outcomes have clinical implications, as larger CSA positively predicts function, whereas increased tendon lengthening predicts reduced function after Achilles tendon rupture. Given the relationship between structural changes associated with Achilles tendon injuries for both injury severity and injury recovery, it is critical to be able to quantify Achilles tendon structure reliably and accurately. Silbernagel&#39;s group has established a valid and reliable method for efficiently evaluating triceps surae muscle and tendon structure. In this protocol, B-mode musculoskeletal ultrasound imaging is used to measure triceps surae structure, including Achilles tendon thickness and CSA, soleus thickness, and the presence of additional findings (calcifications and bursitis). B-mode extended field-of-view is used to measure Achilles tendon length and gastrocnemius anatomical CSA. Finally, power Doppler is used to identify intratendinous neovascularization. Quantification of triceps surae structure allows for comparison between limbs as well as longitudinal changes in response to exercise and treatment for healthy individuals and those with Achilles tendon injuries. This protocol has been used in many research studies to date and proves valuable in understanding the relationship between tendon structure and injury development, severity, and recovery. As ultrasound devices are becoming more affordable and portable, this protocol proves promising as a clinical tool, given its quick and efficient methods.

Author Spotlight: Exploring the Complexities of Achilles Tendon Injuries &#8212; Research and Future Directions

Ultrasound imaging is becoming more accessible in clinical and research settings, and a consistent protocol will be beneficial for comparison between studies and for clinical interpretations. This protocol for ultrasound evaluation is a valid and reliable method to evaluate Achilles tendon morphology in healthy, tendinopathic, and ruptured tendons.

Achilles tendon injuries occur throughout the lifespan and can negatively affect quality of life and overall health. Achilles tendinopathy is generally ...

Motor Exam I

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women&#39;s/Massachusetts General Hospital, Boston, Massachusetts, USA
Abnormalities in the motor function are associated with a wide range of diseases, from movement disorders and myopathies to strokes. The motor assessment starts with observation of the patient. When the patient enters the examination area, the clinician observes the patient&#39;s ability to walk unassisted and the speed and coordination while moving. Taking the patient&#39;s history provides an additional opportunity to observe for evidence of tremors or other abnormal movements, such as chorea or tardive dyskinesia. Such simple but important observations can yield valuable clues to the diagnosis and help to focus the rest of the examination. The motor assessment continues in a systematic fashion, including inspection for muscle atrophy and abnormal movements, assessment of muscle tone, muscle strength testing, and finally the examination of the muscle reflexes and coordination. The careful systematic testing of the motor system and the integration of all the findings provide insight to the level at which the motor pathway is affected, and also help the clinician to formulate the differential diagnosis and determine the course of the subsequent evaluation and treatment.

Motor Exam I: Evaluation of Muscle Tone and Strength

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women&#39;s/Massachusetts General Hospital, Boston, Massachusetts, USA
...

Education

JoVE Science Education

Clinical Skills

Physical Examinations III

Hip Exam

Source: <a href="https://www.jove.com/author/Robert+E._Sallis">Robert E. Sallis</a>, MD. Kaiser Permanente, Fontana, California, USA
The hip is a ball-and-socket joint that consists of the femoral head articulating with the acetabulum. When combined with the hip ligaments, the hip makes for a very strong and stable joint. But, despite this stability, the hip has considerable motion and is prone to degeneration with wear and tear over time and after injury. Hip pain can affect patients of all ages and can be associated with various intra- and extra-articular pathologies. Anatomic location of pain in the hip region can often provide initial diagnostic clues. Essential aspects of the hip exam include an inspection for asymmetry, swelling, and gait abnormalities; palpation for areas of tenderness; range of motion and strength testing; a neurological (sensory) exam; and additional special diagnostic maneuvers to narrow down the differential diagnosis.

Hip Exam: Trendelenburg, Hop, Leg Roll, Ober and FABER Tests

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA
The hip is a ball-and-socket joint that consists of the femoral head ...

Knee Exam

Source: <a href="https://www.jove.com/author/Robert+E._Sallis">Robert E. Sallis</a>, MD. Kaiser Permanente, Fontana, California, USA
The knee is a hinged joint that connects the femur with the tibia. It is the largest joint in the body, and due to its location in the middle of the lower leg, it is subjected to a variety of traumatic and degenerative forces. Examination of the knee can be quite complex, owing to the fact it is an inherently unstable joint held together by various ligaments and supported by menisci, which act as shock absorbers and increase the contact area of the joint. In addition, the patella lies in front of the knee, acting as a fulcrum to allow the forceful extension of the knee needed for running and kicking. As the largest sesamoid bone in the body, the knee is a common source of pain related to trauma or overuse.
When examining the knee, it is important to remove enough clothing so that the entire thigh, knee, and lower leg are exposed. The exam begins with inspection and palpation of key anatomic landmarks, followed by an assessment of the patient's range of motion (ROM). The knee exam continues with tests for ligament or meniscus injury and special testing for patellofemoral dysfunction and dislocation of the patella. The opposite knee should be used as the standard to evaluate the injured knee, provided it has not been previously injured.

Knee Exam: Ligament, Meniscal and Patella Tests

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA
The knee is a hinged joint that connects the femur with the tibia. It is the ...

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

Summary

Explore More Videos

Chapters in this video

In Vivo Canine Muscle Function Assay

Manual Muscle Testing: A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

Tibial Nerve Transection - A Standardized Model for Denervation-induced Skeletal Muscle Atrophy in Mice

Assessment of Neuromuscular Function Using Percutaneous Electrical Nerve Stimulation

Procedures for Rat in situ Skeletal Muscle Contractile Properties

Muscle Imbalances: Testing and Training Functional Eccentric Hamstring Strength in Athletic Populations

Measurement of Healthy and Injured Triceps Surae Morphology

Motor Exam I

Hip Exam

Knee Exam