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Ankle Joint Dorsiflexion A comparative study

Suvanne Harding Third Year Dissertation for BSc (Hons) Podiatry Department of Health Sciences University College Northampton

Abstract

Limited ankle joint dorsiflexion is destructive because of the abnormal compensation that it causes. The goniometer/tractograph is used to measure the amount of dorsiflexion available at the ankle joint. It has been criticised for lack of consistency between measurements and clinicians. The aim of this dissertation was two fold, firstly it attempted to control these variables to assess the extent of their impact on ankle joint dorsiflexion measurements. This was achieved by the development of the Dorsiflexion Measuring Device (DMD). Secondly, applying a controlled plantar force to see if this increased reliability between clinicians. There were three methods in use: A. B. C. Study 1, active/passive dorsiflexion measured with the goniometer. Study 2, active dorsiflexion with a further 45 Newton's on force applied to the plantar surface, measured with the goniometer. Study 3, Active and controlled passive with a further 45 Newton's, measured by an arc drawn by the DMD as the foot dorsiflexes, which when measured corresponds to the angle of dorsiflexion achieved.

Three methods were used to measure ankle dorsiflexion which allowed analysis of the method and the amount of reliability between clinicians. Statistical analysis of the results showed a significant difference between methods, indicating that study 3, using the DMD consistently measured a high angle. The coefficient of variation and correlation however, was significantly improved in study 3. This study raises questions about the accepted clinical method of measuring ankle joint dorsiflexion and highlights the need for further research in terms of clinical method and equipment used.

Acknowledgements

I would like to thank Paul Beeson, as my dissertation and personal tutor for all his help, advice, guidance and inexhaustible encouragement and patience. To my family and friends who have read and re-read this document to many times to count. A special thanks to William, without whom this would not be possible.

Contents Page

2 3 4 6 11 13 16 35 57 65 74 80 83

Content

Abstract Acknowledgements Contents of Introduction section List of Figures and Tables Experimental and Null Hypotheses Definition of Terms Contents of Literature Review section Contents of Methodology section Contents of Results section Contents of Discussion section References Bibliography Contents of Appendices

1.0 Contents

1.1 1.2 1.3 1.4 1.5 1.6 1.7

Introduction

Criticisms of the goniometer Aims and Objectives The Dorsiflexion Measuring Device (DMD) The methods in use Experimental Hypotheses Null Hypotheses Definition of Terms

List of Figures

Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: The Dorsiflexion Measuring Device (DMD) The DMD with foot in place The goniometer The study area layout The Tension and Compression Gauge The polypropylene in position Measurement of the arc

List of Tables

Table 4.1: Bar graph showing mean amounts of dorsiflexion for the left foot. Table 4.2: Bar graph showing mean amounts of dorsiflexion for the right foot. Table 4.3: Strength of significant relationship between left and right feet. Table 4.4: Strength of significant relationship of left foot between methods. Table 4.5: Strength of significant relationship of right foot between methods. Table 4.6: Table to show the mean coefficient of variation for left and right feet, for each method. Table 4.7: A table to indicate the strength of the coefficient of correlation in the left foot between clinicians. Table 4.8 A table to indicate the strength of the coefficient of relation in the right foot between clinicians.

1.

Introduction

Ankle joint dorsiflexion is one of the most common measurements taken in the podiatric clinic during an orthopaedic assessment. It is of great importance to clinically measure the loss of potential movement in a joint in scientific terms. The measurement of joint motion or position is termed goniometry (Nicol 1989). The need for a systematic method of measuring joint range of motion (ROM) was first recognised immediately after the First World War. Disability and pension boards required specific criteria to determine the state and level of impairment or injury (Clapper and Wolf 1986), resulting in the production of the goniometer (Tractograph) in 1918. By 1920, the accuracy of the goniometer was being criticised as the measurements were considered not to be repeatable (Moore 1949).

1.1

Criticisms of the goniometer

Previous research has cited the key to accurate use of the goniometer to being a precise methodology that is rigidly adhered to (Rome 1996). The problem with the clinical assessment of ankle joint dorsiflexion is that "no standard procedure has been defined" (Rome 1996). When research has been published that states that a rigid methodology has been applied, it has still been criticised for the variables that cannot be controlled. For example, if the force applied over the plantar surface of the fourth and fifth metatarsophangeal joint (MTPJ) is not sufficient to hold the subtalar joint (STJ) in a neutral position, as the foot dorsiflexes, it slips easily into a pronated position. In doing this, it opens up the

midtarsal joint (MTJ), increasing the amount of ankle joint dorsiflexion available. The same problem exists if excessive force is applied. This forces the foot into a pronated position, thereby forcibly opening the MTJ with the same consequences as detailed above (Payne 1998). Secondly, the existing clinical method using the goniometer does not control the internal/external rotation of the tibia as the foot dorsiflexes. If the tibia is allowed to internally or externally rotate while the foot is being dorsiflexed, the amount of dorsiflexion available as the foot pronates/supinates will also be affected, increasing or decreasing respectively the amount of dorsiflexion available (Tiberio 1987). Thirdly, as the foot is dorsiflexed, soft tissue moves over the underlying bone. This can affect the alignment of anatomical pen markings to which the goniometer is aligned (Fish and Wingate 1985). Finally, whether the foot is actually in a neutral subtalar joint position or not, both from the start and during the measurement. (Woodburn 1991). Or indeed, if subtalar joint neutral position actually exists and if it does, can it be found consistently enough to be used as a clinical standard? (Hamil, 1989). The literature available suggests that although the goniometer is cost effective, easy to use and non-invasive, the need for a standardised protocol is paramount for its successful use (Goodwin et al. 1992).

1.2

Aims and Objectives

The aim of this dissertation was firstly to attempt to isolate the variables outlined above and control them. The objective was to compare the results obtained using the traditional method of goniometry with a method where the variables were controlled to establish the extent of the relationship.

The second aim stemmed from a study by Gajdosik and Bohannon (1987) who suggested further research into the use of a Tension and Compression Gauge to control the amount of plantar force applied during measurements. The objective being to compare the controlled and uncontrolled methods and see if there was an improvement in reliability.

1.3

The Dorsiflexion Measuring Device (DMD)

In an effort to isolate the variables mentioned, the Dorsiflexion Measuring Device (DMD) was designed and made. The intention was not to replace the goniometer, rather to control the variables associated with its use. The Dorsiflexion Measuring Device Fig 1

The Dorsiflexion Measuring Device with the foot in position Fig 2

The photograph clearly shows the foot in position. As the foot dorsiflexed an arc was drawn on the graph paper. At the end of each session the graph paper is checked to ensure a start and finishing point is clearly visible. The arc corresponds to an angle once a 360 is aligned with it.

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1.4

The methods in use

For the purposes of this research, three methods were assessed: Study 1 dorsiflexion Study 2 Uncontrolled combined passive/active ankle joint measured with the goniometer. Controlled combined passive/active ankle joint dorsiflexion using the goniometer.

Study 3 -

Controlled passive/active ankle joint dorsiflexion using the DMD.

1.5

1.

Experimental Hypotheses

There is a significant difference between the amount of dorsiflexion measured with the goniometer, applying uncontrolled passive/active dorsiflexion (study 1) compared with controlled passive/active (study 2) dorsiflexion.

2.

There is a significant difference between the amount of dorsiflexion measured with the goniometer applying controlled (study 2) passive/active dorsiflexion and the DMD (study 3).

3.

There is a significant difference between the amount of dorsiflexion measured with the goniometer applying uncontrolled (study 1) passive/active dorsiflexion and the DMD (study 3).

1.6

1.

Null Hypotheses

There is no significant difference between the amount of dorsiflexion measured with the goniometer, applying uncontrolled (study 1) passive/active dorsiflexion compared with controlled (study 2) passive/active dorsiflexion.

2.

There is no significant difference between the amount of dorsiflexion measured with the goniometer, applying controlled (study 2) passive/active dorsiflexion and the DMD (study 3).

3.

There is no significant difference between the amount of dorsiflexion measured with the goniometer, applying uncontrolled (study 1) passive/active and the DMD (study 3).

1.7

Definition of Terms

Subtalar Joint (talocalcaneal joint): A triplane joint of substantial frontal and transverse plane movement and limited sagittal plane motion combining to form the movements of supination and pronation of the foot. (Lorimer D et al. 1996). Subtalar Joint Neutral Position: The position whereby the foot is neither pronated, nor supinated. (Root et al. 1977). Force: A force is a push or pull exerted by one object on another. The SI unit (Systeme International d'Unites) of force is a Newton. 1Kg = 10 N (Newton) Otoform: Otoform is a smooth, kneadable silicone impression material used with a hardening paste. Polypropylene: Polypropylene is a olefin polymer derived from the polymerisation of the monomer butadiene. Its chemical structure allows it to resist breakage. Poron: Poron 4000, manufactured in the USA since 1978. Distributed from Somerset, it absorbs a proportion of the impact created by (Valmassy 1996) (Werth Ltd, London) (Popple 1996)

walking or running. Tomography (CT Scans):

(Lecture notes, 1998)

Tomograms are similar to X-Rays, but have three dimensional characteristics, controlled by computer called Computerised Axial Tomography. Valgus filler pad: An insert incorporated into a functional shoe device which supports the arch and offers medial stability, enabling smooth function of the foot. Pronation: Pronation is a triplanar movement involving abduction (transverse plane), eversion (frontal plane) and dorsiflexion (sagittal plane). (Lorimer et al. 1997) Supination: Supination is triplanar movement involving adduction (transverse plane), inversion (frontal plane) and plantarflexion (sagittal plane). (Lorimer et al. 1997) Tractograph/Goniometer: Made of perspex, with two arms secured through the centre of two disks held by a friction bolt. The disk is calibrated to 1 increments. (Zimmer Ltd, Blackpool).

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(Lorimer et al. 1996)

(Valmassy 1996)

The goniometer Fig 3

2.0

Literature Review Contents

2.1 2.2 Axes of the ankle joint Biomechanics of the foot and ankle 2.2.1 The ankle joint in Stance Phase 2.3 2.4 The stability of the ankle joint An ankle equinus deformity 2.4.1 An ankle equinus 2.4.2 Abnormal compensations associated with an ankle equinus 2.4.3 Aetiology of an ankle equinus 2.5 Measurement of ankle joint dorsiflexion 2.5.1 Podiatric relevance of ankle joint dorsiflexion 2.5.2 How ankle joint dorsiflexion is measured 2.5.3 Interpretation of ankle joint measurement 2.5.4 The starting point of the measurement 2.6 Subtalar joint neutral 2.6.1 Subtalar joint neutral 2.6.2 Subtalar joint neutral is important in measuring ankle joint dorsiflexion 2.6.3 Methods of determining subtalar joint neutral 2.6.4 Consistency of finding subtalar joint neutral

2.7 2.8

The effect of subtalar joint neutral on ankle joint dorsiflexion Is there a relationship between the midtarsal joint and subtalar joint? 2.8.1 The midtarsal joint 2.8.2 Isolation of the midtarsal joint movement from the subtalar joint movement 2.8.3 Do the movements need to be isolated?

2.9

Anatomical reference points

2.10 Circadian rhythm 2.11 Patient position 2.12 Active or passive ankle joint dorsiflexion? 2.12.1 Active dorsiflexion 2.12.2 Passive dorsiflexion 2.12.3 A combination of active and passive dorsiflexion 2.12.4 Does it matter which is applied? 2.13 The Universal Goniometer/Tractograph 2.13.1 The goniometer 2.13.2 Use of the goniometer 2.13.3 Previous research citing the reliability of the goniometer 2.13.4 How are the problems being addressed? 2.14 Summary

2. 2.1

Literature Review Axes of the ankle joint

Historically, there has been discussion whether the ankle joint was a simple hinge joint or a multi-axial joint. Goodsir in 1868 noted that a cone shape was produced by the head of talus, implying that the ankle joint had a single axis passing directly through the centre of the body of the talus (Goodsir 1868). Hamilton however, maintains that to call the ankle joint a hinge joint is an over simplification (Hamilton 1984). Bevans (1993) argue that because the main ligaments are on the lateral and medial sides of the ankle joint, it is essentially a hinge joint. This theory supported original research by Steindler (1961). The idea of two ankle joint axis was first postulated by Barnett and Napier in 1952. Their research was compounded by the findings of Hicks who also concluded that there were two axes, one each for dorsiflexion and plantarflexion (Hicks 1953). Inman observed that although motion may not be around a single axis for practical purposes, it can be considered uniaxial (Inman, 1976). Bevans maintains that the ankle should be considered a simple hinge joint in a clinical setting with a frontal plane axis which passes from the higher medial malleolus to the lower lateral malleolus (Bevans 1993; Foulston 1987; Cedell 1975). The axis of the ankle joint lies 8 from the transverse plane, 82 from the sagittal plane and 20-30 from the frontal plane (Valmassy 1996). Viewing from above, it passes distal to the tips of each malleolus, the

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examiner can gain a fair estimation of its position by placing the index fingers on the most distal bony prominence of the malleoli (Mann 1986); the axis said to be directed laterally, posteriorly and planterly (Lorimer et al. 1997). Ankle joint motion combines plantarflexion and dorsiflexion with slight internal and external rotation, together with some gliding of the talus on the tibia (Hicks 1953; Barnett and Napier 1952). Bevans and Inman appreciate that although this is thought to be the case, in clinical situations, the ankle joint should nevertheless be considered a hinge joint (Bevans 1993; Inman 1976).

2.2

2.2.1

Biomechanics of the foot and ankle

The ankle joint in stance phase:

The ankle joint plantarflexes, adducting on the leg throughout heel strike to forefoot loading ( Root et al. 1977). As the ankle accepts the load, the articulator cartilage deforms due to its 'visco-elastic' nature, enlarging the joint surface, increasing joint congruency and stability (Driscoll et al. 1994). As the leg moves forward, it forces the ankle to dorsiflex, abducting on the leg allowing the tibia to move anteriorly over the ankle joint. This continues throughout the remainder of contact and midstance (Root et al. 1977). "It has been established that at 40% and 60% of the midstance phase of gait, dorsiflexion of the foot on the leg beyond a right angle is necessary for bipedal locomotion" (D'Amico 1977). Just before heel lift the STJ is normally in a STJN position, therefore the normal ankle joint requires 10 of dorsiflexion when the foot is in its normal STJN position with the knee extended (Root et al. 1977). If the

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dorsiflexion is not available when called upon due to an osseous limitation or tight musculature, compensation will occur elsewhere ultimately leading to biomechanical problems (Bevans 1992). The functional range of motion for the ankle joint for normal gait is said to be 10 of dorsiflexion and 20 of plantarflexion (Kotwick 1982; Root et al. 1977). Abnormal biomechanics can be caused by any deviation from the ideal structure of the foot (Bevans 1992).

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2.3

The stability of the ankle joint

Dynamic stability of the ankle joint is maintained by forces of gravity, muscle action and the reaction of the foot to the ground (McCullough, 1980). The ligaments ensure the talus can not rock from side to side within the mortise, or backwards and forewords relative to the tibia and fibula (Bevan 1993). Many of the ligaments appear as thickenings of the synovial membrane which lines the fibrous capsule. The capsule appears loose on the anterior and posterior surfaces, allowing for maximum plantarflexion and dorsiflexion (Bevan 1993). Additionally, the ankle joint has adjacent stress relieving structures, including the fibula and structures of the subtalar complex, which serve as energy absorbing reservoirs, protecting the ankle by dissipating the applied ankle force. (Wynarsky and Greenwald 1983).

2.4

2.4.1

An ankle equinus deformity

An ankle equinus

An ankle equinus deformity is said to exist when the ankle joint shows a limited amount of dorsiflexion (Lorimer et al. 1996; Root et al. 1977). Nicoll (1995) however, states an ankle equinus exists when there is a limitation of passive ankle dorsiflexion to less than a 90 angle of the foot to the leg. Alternatively, Foulston (1987) states that an ankle equinus deformity exists when there is less than 20 of dorsiflexion and 50 of plantarflexion. While Root et al. (1977) argues it exists when the ankle joint exhibits less then 10 of dorsiflexion. If accepting that less than 10 is an ankle equinus deformity, as opposed to the 20 postulated by Foulston (1987), it is still extremely prevalent and is a primary causal agent in a significant proportion of foot pathologies (Russell 1995). Clinically, the difficulty arises in the fact that ankle dorsiflexion is a component of STJ pronation, therefore false measurements can be taken if the subtalar joint is allowed to pronate. "If during clinical measurements, the STJ pronates, it increases MTJ mobility thereby increasing ankle dorsiflexion around the oblique axis of the MTJ" (Tiberio 1987). 2.4.2 Abnormal compensations associated with an ankle equinus The biomechanical problems from an ankle equinus result from compensations which occur in an attempt to make up for the reduced ankle joint dorsiflexion. The term compensation implies an effort to make up in one place for something that is lacking in another (Russell 1995). This compensation often results in the STJ using its component of sagittal

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plane motion to compensate for the lack of dorsiflexion of the foot at the ankle. In doing this, the STJ is forced into a pronated, or subluxed position throughout the gait cycle. The STJ never has the opportunity to resupinate, therefore the foot is left in a pronated position throughout midstance and propulsion. This makes the foot unstable and prone to injury (Elveru et al. 1987). 2.4.3 Aetiology of an ankle equinus

An equinus deformity due to a short gastrocnemius muscle can be congenital or acquired. An acquired reduction may be for example caused by the habitual wearing of high heel shoes (Nigg 1992). The gastrocnemius muscle by Davies Law of soft tissue contracture will then reduce in length over time (Lorimer et al. 1996). Treatment to overcome this includes a small heel raise and muscle stretching exercises to increase muscle length. Abnormal compensation may appear as an early heel lift, increased arm swing, genu recurvatum, an abducted gait with excessive STJ pronation or a combination of the above (Russell 1995). Russell (1995) maintains that our environment induces most acquired muscular ankle equinus. His study revealed causal factors such as equinus sleeping positions, sitting, walking, all types of sports and high heels.

2.5

2.5.1 reasons: 1. 2. 3.

Measurement of ankle joint dorsiflexion

Podiatric relevance of ankle joint dorsiflexion

Clinically, the amount of ankle joint dorsiflexion is measured for several

to help diagnose the aetiology of any joint dysfunction measurements are used to determine treatment plans to document the effectiveness of treatment over time (Thomas and Rome 1997)

2.5.2

How ankle joint dorsiflexion is measured

Tight musculature is one of the most common reasons for limitation of ankle joint dorsiflexion (Bohannon and Larkin 1985). "The gastrocnemius muscle can restrict movement if it is spastic, in contracture, or is congenitally short". (Root et al. 1977) Once the foot has been placed in a STJN position, the amount of ankle joint dorsiflexion is measured with the knee extended and with knee flexed.

2.5.3

Interpretation of the measurement

If the amount of dorsiflexion is limited with the knee extended but increased with the knee flexed, the cause is related to a contracted gastrocnemius muscle (Root et al. 1977). If it is limited with the knee extended and flexed, it is nearly always due to an osseous or soleus abnormality within the ankle (Root et al. 1977). It is the result of these clinical procedures that is used to distinguish between the cause of the limitation.

2.5.4

Where the measurement is started from

The American Academy of Orthopaedic Surgeons (1966) recommended using the 'Neutral Zero position' as a clinical base line when measuring ankle dorsiflexion. The foot is dorsiflexed to a position 90 from the leg, the amount of ankle dorsiflexion from that point is measured. The main problem with the clinical assessment of ankle joint dorsiflexion is that "no standard procedure has been defined" (Rome 1996). Root et al. (1977) suggested using STJN but did not define a standard procedure to determine its position.

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2.6

2.6.1

Subtalar joint neutral (STJN)

Subtalar joint neutral

STJN is said to be the position where the foot is neither pronated nor supinated (Root et al. 1977). However, the validity of its existence has never been established (Payne 1998). 2.6.2 STJN is important when measuring ankle joint dorsiflexion The first study to find the location of the STJ axis was performed by Manter in 1941 (Phillips et al. 1985 ). The importance of finding the STJN position and using it as the base line for the measurement of ankle joint dorsiflexion was postulated by Root et al. (1977). They state that because maximal ankle dorsiflexion occurs when the STJ is in its neutral position, practitioners must measure ankle dorsiflexion in the STJN position (Root et al. 1977). This statement of maximal dorsiflexion however, is not strictly true as further dorsiflexion can be achieved if the

STJ pronates, opening up the MTJ. This may mislead the clinician and conceal limited ankle dorsiflexion (Tiberio 1987). Bevans (1993) maintains that the STJN position provides the maximum congruity of the articulating surfaces, providing the most foot stability, which is why it is used as the clinical starting position. Historically, as no specific guidelines or criteria were stated to standardise the methods used, clinicians achieve a wide variety of results. Many sources of error exist when measuring the ROM of the ankle joint (Rome 1996). Questions arise about the use of measurement during assessments of patients for the prescription of orthoses (Payne 1998). 2.6.3 Methods of determining STJN position:

Clinically, the functional locking of the STJ into its neutral position is usually achieved by the `palpation method,' palpating the head of talus with the thumb and forefinger while the ankle is rolled through inverted and everted positions. In a weight bearing assessment, the patient rolls their foot through an inverted to everted position. In non-weight bearing, the clinician uses the force applied over the fourth and fifth MTPJ to move the foot themselves from an inverted to an everted position. In either case, when the head of talus is equally palpable on both lateral and medial sides, movement of the foot is stopped; the foot is then said to be in a neutral position (Lorimer et al. 1996). This is the most common method in use and used by clinicians such as Brunker 1997, Thomas and Rome 1997, Lorimer et al. 1996. Kirby (1996) states that the correct loading of the lateral column of the foot with this method, will eliminate most of the confusing accessory movements of the MTJ. Another method of finding the STJN position is that of `observation'.

Looking at the curvature formed beneath the lateral and medial malleoli, ensuring equality of curvature on both sides indicating a STJN position (Lorimer et al. 1996). A third method is by observing the skin creases. Skin creases on the lateral side of the malleoli and not the medial, indicate a pronated foot position. Skin creases on the medial side of the malleoli and not the lateral side, indicate a supinated foot position. The skin should appear smooth with no creases in a neutral position (Lorimer et al. 1996). However, these accepted methods in clinical use, do not establish validity of the existence of STJN (Payne 1998). In 1988, Cook et al. carried out a study hypothesising that the three techniques for determining STJN, that is palpation, observation of skin folds and observation of skin creases could be used inter-changeably. They concluded that they could be used inter-changeably. It should be considered however, that the technique of using skin creases is not possible in cases of oedema or soft tissue swellings. 2.6.4 Consistency of finding STJN

There is controversy about the professional ability of clinicians to consistently place the foot into STJN (Payne 1998). If doubt exists, should STJN be used as a clinical standard? The STJ axis has also been shown to exhibit great variability from individual to individual (Kirby 1996). In 1996, Mrynorczyk & Pierrynowski assessed the ability of experienced podiatrists and untrained physiotherapists in placing the foot into STJN. They found that to place the foot within 2 of the mean STJN position,

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produced the results 72.3% and 47.62% respectively. It could not be ascertained from their research however, why they had not used one profession or the other; nor why one group was trained and other not. This would have made the data more comparable.

2.7

The effect of the subtalar joint on ankle joint dorsiflexion.

Because maximal ankle joint dorsiflexion occurs in the gait cycle when the STJ is said to be in its neutral position, there can be no alternative in the measurement of ankle joint dorsiflexion (Root et al. 1977, Thomas and Rome 1997). Payne (1998) however, argues that Root et al. (1977) never considered their work to be the final word, just a starting point from which to build and challenge. Evidence suggests little doubt that if the foot is allowed to pronate during ankle dorsiflexion, the measurement will be increased with its contribution from the MTJ (Kirby 1996, Tiberio et al. 1989, Root et al. 1977). Tiberio et al. (1989) attempted to find the exact extent of the increase and therefore the importance of maintaining STJN. The study measured passive ankle joint dorsiflexion using a 35mm camera, the pictures being projected onto walls. One group was in STJN, the other in a pronated position. They found that the maximal ankle joint dorsiflexion was increased by an average of 10 with the foot in a pronated position compared to the STJN position. Tiberio et al. (1989) conclude "it would follow that the measurement with

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the STJ in neutral will give a more accurate measure of ankle dorsiflexion." The problem with this study was that they only looked at 18 female subjects. Arguably the results may have been the same had the sample been larger, but they stated this was the case, when clearly it is not. Secondly, if the clinician measures limb alignment from a radiograph, or projected film etc., both the clinician and the procedure are sources of variability. If the clinician measures the subject directly, the procedure and its variability do not apply (Wright 1992).

2.8

Is there a relationship between the midtarsal joint and subtalar joint ?

2.8.1

The MTJ

The MTJ lays distally to the STJ and is made up of the talonavicular and the calcaneocuboid articulations (Romanes 1996). The joint allows the forefoot to move relative to the rearfoot. It has two axis of motion, one oblique axis allowing mainly sagittal and transverse movement; one longitudinal allowing mainly frontal plane motion (Lorimer et al. 1996). 2.8.2 Isolation of MTJ movement from STJ movement

Bevans (1993) states that movement around each axis of the MTJ can be independent of each other, but not from the STJ to which it shares two articulations. Foulston (1987) also states that the STJ and MTJ are inextricably linked biomechanically. The movement of one without the movement of the other being all but impossible. The orientation of the articular facets also changes so that as the STJ pronates, the calcaneocubiod axis (midtarsal oblique axis) becomes parallel to the talonavicular axis allowing the foot to become more

flexible (Bevans 1993). It is the relationship between the STJ and the MTJ which is the cornerstone to accurate measurement of the ankle joint dorsiflexion. For an accurate reading to be taken, this relationship must be effectively understood and controlled. 2.8.3 Isolation of movements

Clinically, the control of the STJ and MTJ is thought to be achieved by applying an undetermined force over the fourth and fifth MTPJ to maintain the STJ in a supinated position, thereby locking the forefoot on the rearfoot. If too much pressure is applied, although the STJ is effectively supinated, it will force the MTJ into a pronated position, thereby increasing its mobility and adding to the dorsiflexion component of the measurement (Payne 1998).

2.9

Anatomical reference points

Previous research indicates that using different anatomical reference points on the lower limb to align the goniometer produces different results in the measurement of ankle joint dorsiflexion (Tiberio et al. 1989). "Although ankle joint ROM occurs primarily at the talocrural joint, it is measured typically in the clinic using surface landmarks quite proximal and distal to it" (Tiberio et al. 1989). Most clinicians use the head of fibula proximally (Rome 1996). Distally, it is less standard including: heel & underlying calcaneum midline, lateral side of the 5th MTPJ plantar surface of the foot (Bohannon et al. 1989) Bohannon et al. (1989) researched whether a difference existed between

results and anatomical sites used. They used a 'standard STJN procedure' taking slide films of the feet. On the slides different landmarks including the lateral mid-line of the 5th MTPJ, the heel and plantar surfaces, were marked and the measurements calculated. The head of fibula was marked as the anatomical reference for the rigid arm of the goniometer. Bohannon concluded significantly greater ankle joint dorsiflexion was available using the 5th MTPJ, than the plantar surface and least amounts with the heel. The problems with this research was that a protractor was used, not the goniometer. There was no mention of patient position, nor if this was controlled. Neither do they state whether the leg was extended, flexed or effects of soft tissue movement on anatomical reference points. Bohannon states they use a 'standardised STJN position', but do not define the procedure. As films, slides, radiographs etc. cannot be repeated ethically on the same subject on the same visit, the only variable considered is the clinician taking the measurement (Wright 1992). As a result, the measurement variability is underestimated because the subject and procedural variability have been excluded.

2.10

Circadian Rhythm

Mitchell et al. (1975) researched whether the normal circadian rhythm of the body was one of the reasons the goniometers were cited as inaccurate. They concluded that the results were not influenced by circadian rhythm, nor morning stiffness associated to diseases such as rheumatoid arthritis. This research was reinforced by that of Rome (1996).

2.11

Patient Position

Thomas and Rome (1997) researched the reliability of the most common positions to measure ankle dorsiflexion was prone, supine or seated (a position whereby the hip, knee and ankle are all flexed at 90 ). Subjects found the prone position the least comfortable, which could affect the measurement if subjects wanted the session to end quickly. The seated position was the least reliable, this maybe because the knee would not have been immobilised and may have been affected movements distal to it. Thomas and Rome (1997) concluded a significantly higher difference between sitting/prone and sitting/supine. "This suggests that the sitting position has a major effect in the other two positions" (Thomas and Rome 1997). They found the results more reliable using the head of the 5th MTPJ as a reference site rather than the base of it. This supported Bohannon's research on anatomical reference points (Bohannon 1989).

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2.12

2.12.1

Active or passive ankle dorsiflexion?

Active Dorsiflexion:

Requires the subject to actively dorsiflex their foot as far as possible with no external forces applied. 2.12.2 Passive Dorsiflexion:

An external force is applied to the plantar surface of the foot, increasing the amount of dorsiflexion.

2.12.3

A combination of active and passive dorsiflexion:

The subject actively dorsiflexes their foot, at the point when no more dorsiflexion can be achieved, a further external force is applied to the plantar surface (Rome 1996). 2.12.4 Considerations of which to apply

The differences between active or passive force applied pose inconsistencies (Rome 1996). The main problem with assessing and comparing two studies that have used passive dorsiflexion, is that the amount of force applied cannot be measured or repeated either between subjects or between clinicians. "Passive movements are extremely difficult to reproduce, because the stretching of soft tissues depend on the force applied to the limb" (Amis and Miller 1982). Gajdosik and Bohannon (1987) maintain the importance of both measurements in a clinical situation. They caution that the use of passive measurements allow for greater variation and decreased reliability. To overcome this, they suggest a standardised procedure where a hand held Tension and Compression Gauge is used to standardise the amount of force applied, decreasing the potential for error (Gajdosik and Bohannon 1987). No further research information on this subject has come to light.

2.13

2.13.1

The Universal Goniometer/Tractograph

The goniometer

The goniometer can be defined as a "calibrated device designed to

measure the arcs or ROM of a joint" (Thomas and Rome 1997). It is simple to use, non-invasive and inexpensive. However, despite its practical advantages, reliability is low (Rome, 1996). It is made of perspex with two arms secured through the centre of two disks held by a friction bolt. The disk is calibrated to 1 increments. (Zimmer Ltd, Blackpool). 2.13.2 Use of the goniometer

o

Often the pivot of the goniometer is lined up to an anatomical landmark, however, Moore (1949) suggests this method is falsifying the movement actually available at the joint. Moore maintains that if the moving arm is placed as near as possible to parallel of the moving limb, and the stationary arm parallel to the apparent fixed limb, the axis of motion will fall where the two intersect and will automatically localise in an approximately correct position. This she maintains is particularly important for joints such as the ankle, where the axis of motion is not immediately apparent. 2.13.3 Previous research reference the reliability of the goniometer: Since the introduction of the goniometer, research has questioned its reliability. Hewitt (1928) questioned the reproducibility of measurements taken with the goniometer. Low (1976) and Boone et al. (1978) confirmed that intra-tester variation was less than inter-tester variation. Boven et al. (1978) concluded that the intra-tester variation strongly depended on the size of the angle measured . It has never been clear whether the results obtained using this equipment are reliable or valid (Bovan et al. 1990).

2.13.4

How are the problems being addressed?

In recognising the problems associated with the goniometer, several new types of instrument have been introduced. The desire to address the afore mentioned issues, and the prospect of making measurements more accurate, avoiding erroneous joint recordings caused by the misinterpretation of results has been the driving force. These have included the Biplane Goniometer, the Orthoranger, the Fluid Goniometer and the Electrogoniometer. Each have not been without their critics due to problems of repeatability between clinicians and the control of variables. (Goodwin 1992, Bevans 1993, Donnery 1988, Clapper and Wolf 1987, Muwanga and Dove 1985).

2.14

Summary

In summary, the problems associated with the accurate use of the goniometer are recognised within the Podiatric profession (Rome 1996). However, the development of equipment to overcome its downfalls need to address some of the other questions raised in this chapter. For example, the movement of the ankle and its axis are not fully understood. Nor is the relationship between the axis of the ankle and the STJ/MTJ. Questions continue to be raised, looking for evidence to justify the profession's approach to assessments and treatments. Payne (1998) maintains that many anomalies have, and will, continue to come to light in Podiatry as attempts are made to improve the match between theory and reality. He argues that critical evaluation of theories should not be regarded as a destructive process, it should be considered a

sign of the profession's maturity (Payne 1998).

3.0 Contents

3.1 3.2 3.3 3.4 3.5

Method

Introduction Ethical Committee Approval Pilot Study Sample Size Statistical Analysis of Data 3.5.1 Related t-Test 3.5.2 A comparison between means 3.5.3 Coefficient of variation between methods 3.5.4 Coefficient of correlation between methods 3.6 3.7 3.8 Inclusion Criteria Exclusion Criteria Equipment 3.8.1 Tractograph 3.8.2 Model 16 Tension and Compression Gauge

3.8.3 Polypropylene forefoot shield 3.8.4 Water based ink pen 3.9 Calibration of equipment 3.9.1 Tension and Compression Gauge 3.9.2 DMD 3.10 Research Guide 3.11 Responsibilities of the observer 3.12 Study 1 - Uncontrolled combined passive/active ankle joint dorsiflexion measured with the goniometer 3.13 Study 2 - Controlled combined passive/active ankle joint dorsiflexion measuring with the goniometer 3.14 Study 3 - Controlled passive/active ankle joint dorsiflexion measured with the Dorsiflexion Measuring Device (DMD) 3.15 Rationale for method 3.15.1 Why the study only measured ankle dorsiflexion with knee extended? 3.15.2 Exclusion Criteria 3.15.3 Selection of clinicians 3.15.4 Selection of anatomical reference sites 3.15.5 `Blinding' the goniometer

3.15.6 STJN and the starting position 3.15.7 The clinical standard (study 1) 3.15.8 Controlled passive force (study 2) 3.15.9 Study 3

3.0 3.1

Method Introduction

The aim of the methodology was to measure the amount of ankle dorsiflexion in both left and right feet. The measurements were taken by three third year podiatry students referred to as clinicians throughout this study. Three methods of obtaining the measurement were used. Three measurements were taken using each method so that an average could be calculated. The subjects remained in the same cubicle, the three clinicians moved between them. Each clinician measured each subject three times with each method of measurement. The three methods in use were: Study 1 dorsiflexion Study 2 Uncontrolled combined passive/active ankle joint measured with the goniometer. Controlled combined passive/active ankle joint dorsiflexion

measured with the goniometer. Study 3 Controlled passive/active ankle joint dorsiflexion measured with the DMD.

Diagram of study layout Fig 4

3.2

Ethical Committee Approval

An application for Ethical Committee was submitted as applying a passive plantar force to the foot was considered to increase the risk of dislodging a deep vein thrombosis. Even though this condition was within the exclusion criteria, it was felt prudent as some subjects may be unaware of their vascular status. Approval was received on 18 October, 1999. A copy of the approval letter, Ref 99/67 can be seen at Appendix A.

3.3

Pilot Study

The pilot study found that the results sheets proved too confusing, making it difficult for the observer to switch between sheets. The results sheet can be seen at Appendix C : 1. The procedure took longer then estimated, waiting for the Tension & Compression Gauge caused delay. This problem could not be resolved as only one Tension & Compression Gauge was purchased due to financial constraints. The pilot took over two hours to gather the raw data required therefore the sample size

was reduced from twenty subjects to eight subjects. This still allowed meaningful comparison. The pilot study revealed that clinicians could not sit down and use the equipment. This was because as passive force was applied, the clinical chair (which was on wheels) was forced backwards. To overcome this, all clinicians stood throughout the study, clinician height varied, so to accommodate everyone the flat bed couches were lifted to 120 cm. The anatomical reference points were firstly marked with the foot in a relaxed position. However, it was found when the foot was brought to a 90 starting position, soft tissue movement meant the lines were no longer in the correct position. Therefore, the lines where drawn with the foot in a 90 starting position in the first instance.

o o

3.4

Sample Size

The sample was taken from Podiatry Students within the Northampton School of Podiatry. Eight mean measurements of each method for left and right leg were required for the study. This represented eight subjects, each having left and right ankle dorsiflexion measured three times with each of the three methods.

3.5

Statistical Analysis of Data

The data was parametric and interval. 3.5.1 A comparison between left and right feet

The Related t-Test was used to test for the significance of a relationship between left and right feet. Previous research by A'Roas and Anderson (1992) stated that there was no relationship between feet. If a significant relationship was found, only one set of data for the left foot (selected by toss of a coin) would be analysed and represented. If no relationship was found, then both sets of data would be assessed. 3.5.2 A comparison between methods

The Related t-Test was used to measure the strength of relationship between methods. 3.5.3 Coefficient of Variation (COV) between methods

For research purposes it is important to look at the extent to which the data for a variable are spread about the mean. The COV was used instead of the standard deviation, although if the sample is greater than 30 then there is little difference between the two (Wisniewski 1997). The COV is used when comparing data that used different methods of collection. It measures relative variation rather than absolute variation. COV = Standard Error of the Mean x 100

Mean

(Saunders et al. 1997)

The COV measures the consistency and variability of a method. Measuring the variability by the standard deviation would not help if the mean value itself was altering, the COV overcomes this (Wisniewski 1997). The distribution with the largest COV has the largest spread of data about the mean. For scientific research, any percentage less than 15% is considered a workable method. If the percentage falls below 10% the methodology is considered more sensitive and therefore more reliable. A percentage less than 5% is considered very sensitive to change and therefore very reliable (Langley-Evans 2000) 3.5.4 Coefficient of Correlation (COC) between methods

The COC was used to statistically calculate the correlation between variables. In this case, it was used to identify any trends between methods. Zero implies literally no correlation, while +1 implies a perfect correlation.

3.6

1. 2.

Inclusion Criteria

Male and female subjects Age 18 - 40 years (Boone and Azen, 1979)

3.7

1. 2.

Exclusion Criteria

No gross ankle oedema (Youndas 1993) No forefoot equinus deformities (Freeman 1989)

3. 4. 5.

No history of deep vein thrombosis or severe venous disease Not on any medication with a known secondary neurological effect (Bagget and Young 1993) No history of surgery to the ankles, calves or tendons which may impinge range of motion (Bagget and Young 1993)

6. 7. 8. 9. 10. 11.

No history of compartment syndrome or surgery for its treatment (Youndas 1993) No lower motor neurone lesions (Bagget and Young 1993) No upper motor neurone lesions (Bagget and Young 1993) No history of severe ankle trauma, such as a severe sprain (Nigg 1992) No artificial limbs (Nigg 1992) No inflammatory arthritis (Bagget and Young 1993)

3.8

3.8.1

Equipment

Tractograph (used in Study 1 and Study 2):

o

Two goniometers, calibrated to 1 increments were used throughout the study. From Nova Instruments (£9.95 each).

3.8.2

Model 16 Tension and Compression Gauge (used in Study 3):

Supplied by Salters (Gearge St, West Bromwich, West Midlands) for £135.00. The device was 300 mm long and 190 mm wide. The body of the gauge was made from brass with the weight in pounds (lbs) and kilograms (kg) inscribed on the side of the shaft. Tension and Compression Gauge Fig 5

3.8.3

Polypropylene Forefoot Shield (used in Study 2):

A polypropylene shield was manufactured to the width of a medium adult forefoot. It was held in place on the plantar surface of the forefoot with 4 cm wide velcro. The shield had an Otoform `plug' in the centre of its base, which when the shield was fixed to the plantar surface of the foot was centrally located in the area of the forefoot.

Polypropylene device in position on the foot Fig 6

3.8.4

Water Based Ink Pen:

This was used to mark the anatomical land sites for the accurate alignment of the Tractograph (Staples, Northampton, £2.99).

3.9

3.9.1

Calibration of Equipment

Tension and Compression Gauge

The Tension and Compression Gauge was calibrated in the sagittal plane in which it was used throughout the study. The Tension and Compression Gauge was calibrated using an end screw which was turned until the indicator rested at the `zero' position which was used as the starting position. This method of calibration was recommended by Salters (Salters, West Bromwich). Accuracy was stated to be within half a division (Salters, West Bromwich).

3.9.2

Dorsiflexion Measuring Device (DMD)

The DMD was calibrated by placing pre-mitred wedges on the base plate. The footplate was lowered and the arc drawn on graph paper. The first wedge was 45 , as the footplate was made to sit at 90 , a 45 wedge should have drawn a 45 arc, which it did. Another test was carried out using a 65 wedge. The arc drawn measured 25 . With these tests complete the DMD was considered calibrated, valid and reliable.

o o o o o o

3.10

·

Research Guide

All measurements were be taken in the School of Podiatry, in the clinical cubicles on flat bed couches lifted to 120 cms.

·

Each subject only took part in the study once they had signed to confirm that they meet the criteria and had given written consent seen at Appendix B.

·

Subjects were given an Information Sheet, seen at Appendix D and filled out an Inclusion/Exclusion Sheet prior to commencement of the study which can be seen at Appendix C.

·

To save time, three subjects were be measured simultaneously by three clinicians. The clinicians rotated round the three subjects.

·

The outer most 360 disc of the two goniometers were shielded with mefix prior to commencement of the study.

o

·

The sequence in which each subject was tested was randomised owing to time and equipment constraints.

3.11

· ·

Responsibilities of the Observer

Present throughout the study Ensured the subjects were in a cubicle, on a couch in the seated position with both lower legs extended and exposed.

·

Briefing the three clinicians, prior to the study to ensure each had the same knowledge of the methods being used to measure ankle joint dorsiflexion. This was one half hour open forum to ask questions and use the equipment (Wright 1992).

·

Ensured that the subjects had read the information sheet, signed the consent form and was available to answer any questions they had.

·

Marking the anatomical land marks on the legs with a water based pen.

·

Noting measurements as reported to them by the clinicians. The observer was also responsible for opening the goniometer back to a 90 starting position so that the clinician could not see the amount of dorsiflexion measured on the previous occasion.

o

·

The calibration of the Tension and Compression Gauge prior to the commencement of each study session.

·

Ensuring that each new subject being measured with the DMD had a new piece of graph paper inserted which was labelled appropriately.

3.12

Study 1 - Uncontrolled combined passive/active ankle joint dorsiflexion measured with the goniometer

1.

Using the non-weight bearing palpation method (Cook et al, 1988), the foot was placed into STJN, the other hand applied pressure to the plantar surface over the fourth/fifth MTPJ.

2.

The goniometer was lined up, the rigid arm with the leg and the mobile arm with the foot bisection (Moore 1949) while the hand on plantar surface applied force to bring the foot to a position of 90 . This position was used throughout as the `starting position.'

o

3.

The subject was asked to maximally dorsiflex their foot. At the point of no further dorsiflexion, the clinician applied plantar force to achieve further dorsiflexion.

4.

Once the goniometer had been aligned with the new leg and foot bisections, it was handed to the observer and the measurements noted. The goniometer was handed back to the clinician in a 90 position.

o

After each measurement the subjects foot was released and allowed to relax for an undetermined period until the next measurement was ready to be taken. The procedure was repeated three times. The clinician was not aware of the measurements they had taken at any stage.

3.13

Study 2 - Controlled combined passive/active ankle joint dorsiflexion measuring with the goniometer

1.

The polypropylene device was held on the plantar surface of the forefoot. The top edge of the polypropylene was aligned with the interphalangeal joint (IPJ) of the hallux.

2.

The velcro was tightened around the forefoot ensuring the Otoform plug was centrally located on the forefoot. The polypropylene was to be secure enough to prevent movement of the foot within the polypropylene.

3.

The base of the Tension and Compression Gauge was inserted into the Otoform plug with one hand while the foot was raised to a position of 90 . The Tension and Compression Gauge held the foot in this position while the other hand put the foot into STJN using the non-weight bearing palpation method. The subject was then asked to maximally dorsiflex their foot.

o

4.

Once maximal active dorsiflexion was achieved, a further force was applied with the Tension and Compression Gauge until the scale was level with 10lbs (45 Newton's).

5.

With the hand that was holding the foot in STJN, the clinician aligned the goniometer, the rigid arm level with the leg and the mobile arm with the foot bisections (Moore 1949).

6.

Once this was achieved, the goniometer was handed to the observer

who took note of the measurement and returned the Goniometer to a 90 starting point for the next measurement.

o

After each measurement the subjects foot was released and allowed to relax for an undetermined period until the next measurement was ready to be taken. The procedure was repeated three times. The clinician was not aware of the measurement at any stage.

3.14

Study 3 - Controlled passive/active ankle joint dorsiflexion measured with the Dorsiflexion Measuring Device (DMD)

1.

The lower leg was lifted and placed into the DMD with the knee extended. It was ensured that the whole plantar surface of the foot made contact with the footplate.

2.

An appropriate size D filler was selected from a sample for left and right feet and placed under the arch, held in position by velcro. The D filler could be moved medially/laterally, distally/proximally to ensure the best fit.

3.

The lower leg was secured in the frontal plane by 4 cm wide velcro.

4.

The Tension and Compression Gauge was seated into the Otoform

plug which was located on the posterior surface of the footplate with one hand while the other hand placed the foot into STJN using the weight bearing palpation method. 5. The subject maximally dorsiflexed their foot. As their foot dorsiflexed, the hand holding the Tension & Compression Gauge was moved forward in the sagittal plane to ensure the foot maintained contact with the footplate. At the point of maximal dorsiflexion, a further force was applied to the posterior surface of the footplate by the Tension and Compression Gauge until the scale read 10lbs (45 Newton's). The foot was released and allowed to relax after each measurement for an undetermined period of time until the next measurement was ready to be taken. The graph paper was checked to ensure an arc had been drawn and was moved up to a new position for the next reading. The graph paper was examined after each measurement to ensure that a start and finishing point could be identified. At the end of the data collection a 360 protractor was aligned with the arc, the 0 aligned with the starting point of the arc. The measurement in degrees was read from the finishing point of the arc and represented the total amount of ankle joint dorsiflexion for that subject.

o o

Measurement of the arc

Fig 7

3.15

3.15.1

Rationale for Methodology

Why the study only measured ankle dorsiflexion with knee extended?

The study was carried out in a clinical environment so that a fair comparison could be made to the standard measurement of ankle joint dorsiflexion that is currently in use. The flat bed couches were used so the knee in each case was extended (Rome 1997). The measurements did not need to be repeated again with the knees flexed as the study was not measuring the increase in ankle joint dorsiflexion available when the gastrocnemius muscle was taken off stretch but was measuring the accuracy of the measurement technique.

3.15.2

Exclusion Criteria

My exclusion criteria was based on previous research identifying areas causing a reduction in ankle dorsiflexion or caused pain to the subjects. These exclusions included examples such as trauma or surgery which caused fibrosis around the joint, to oedema which reduced the dorsiflexion available (Youndas 1993, Baggot and Young 1993, Nigg 1992, Freeman 1989). A previous history, or treatment of deep vein thrombosis was an exclusion criteria because the methodology required a passive plantar force to be applied which could dislodge a thrombosis causing an embolism. There was no previous research to accredit this exclusion, although most previous research appears to test active ankle joint dorsiflexion. Upper or lower neurone lesions were excluded as active movements require the integrity of both sensory and motor nerves, intact muscles, a moveable joint and willingness on the part of the subject (Rome 1996). 3.15.3 Selection of the clinicians

Three clinicians were chosen as this allowed tests of correlation. It also minimised variables of difference, as all the clinicians had a similar period of experience and practise of putting the foot into STJN (Wright, 1992). All measurements were carried out in the same clinical environment to control the variables they would have brought to the procedure, the subjects and the clinicians (Wright 1992, Goodwin and Clark 1991). 3.15.4 Selection of anatomical reference sites Head of Fibula Bisection of the lateral fifth MTPJ Highest point of the lateral malleoli These reference points were chosen as Bohannons (1989) research found

The anatomical landmarks used throughout the study were :

them to produce the most consistent results (Bohannon et al. 1989). The lines ensured that the goniometer was aligned to the same point which ever clinician was measuring (Wright 1992). 3.15.5 `Blinding' the goniometer

The face of the goniometer was masked so that the clinicians could not be influenced by last digit expectation and end digit preference (Rome 1996). The method of reporting the angle was also standardised. In each case the report was made to the observer who noted the angle on the goniometer and moved it back to a 90 starting position before handing it back to the clinician. This ensured that there was no knowledge of the previous angle (Elvero 1987). The method of using the goniometer was also standardised. This was achieved by ensuring that the arm of the goniometer aligned to the leg remained rigid, while the arm aligned to the foot was always the mobile arm. This method was first postulated by Moore (1949). 3.15.6 STJN and the starting position

o

Throughout the study, either the non-weight bearing, or the weight bearing palpation method was used to find STJN. While the foot was being dorsiflexed, the clinician maintained this position to ensure the foot did not pronate as it dorsiflexed ( Thoms and Rome 1997, Rome 1996, Freeman 1989). In each case, the foot was first brought to a 90 starting position as suggested by the American Academy of Surgeons (1966). This technique appears to have been adopted as standard in prominent research since that period (Thoms and Rome 1997; Rome 1996; Bohannon et al. 1989). This method ensured each clinician started measuring from the same point.

o

3.15.7

The Clinical Standard (Study 1)

The method of study 1 was used because that is the standard method in use in a clinical environment. Therefore if comparisons were to be made, they had to be compared to the current clinical method. 3.15.8 Controlled passive force (Study 2)

Study 2 introduced a controlled plantar force of 45 Newton's additional to of any active ankle dorsiflexion produced, identified by Gajdosik and Bohannon (1987) as an area for further research. The problem with the Tension & Compression Gauge was that the end applied to the plantar surface of the foot was just 5mm in diameter. Therefore any plantar force applied needed to be dispersed over the forefoot to avoid causing pain and injury to the subjects. EVA (ethylene vinyl acetate) was first considered, but rejected because it was thought it would absorb some of the 45 Newton's applied, making it impossible to calculate how much force had been transferred to the foot. The polypropylene material was more robust and transferred most of the force to the plantar surface of the foot and only absorbing a small amount. To stop the Tension & Compression Gauge from shearing off the polypropylene device when force was applied, an Otoform `Plug' was made. This `plug' measured 2 cm square having a hole in the centre to accommodate the end of the Tension & Compression Gauge, which prevented it from moving as the force was applied.

3.15.9

Control of variables - Study 3

Foot pronation: In an effort to ensure the foot could not pronate during ankle joint dorsiflexion, poron valgus fillers (D-fillers) were manufactured to fit small, medium and large foot types for both left and right feet. These were secured to the footplate with velcro. Stopping the foot from pronating during dorsiflexion was considered an important issue. Since the distal arm of the goniometer is usually aligned with the fifth MTPJ, which lays distally to the MTJ, the dorsiflexion component of the MTJ is incorporated into the measurement. Therefore sagittal plane motion at the STJ and MTJ may lead the clinician to an inaccurate measurement (Tiberio et al. 1989). Tibial rotation: The internal/external rotation of the tibia was addressed by placing two velcro straps around the leg securing it in the frontal plane position. One strap was distal to the knee, the other proximal to the ankle joint. The straps had to be secure to ensure the tibio-fibular segment could not make any obvious internal or external movements during dorsiflexion. The poron D-filler was placed under the arch of the foot to stop it pronating, this was used in conjunction with the palpation method of maintaining the STJN position. The hand of the clinician remained on the head of talus while the foot was dorsiflexed. If the foot pronated during measurement, the clinician was able to palpate the medial head of talus, if the foot supinated the lateral head was palpated.

End digit expectation/last digit preference: To control the end digit expectation or last digit preference (Rome 1996) of the clinicians, graph paper was used. It was attached to the side plate which sat adjacent to the footplate. The footplate had a pencil inserted into its side, the end of which was in contact with the graph paper. As the foot dorsiflexed, an arc was drawn. When the start and end points of the arc were measure it corresponded to the angle of dorsiflexion.

4.0 Contents

4.1 4.2

Results

Descriptive Data Bar graphs to show the mean amounts of dorsiflexion by study and clinician 4.3 4.4 4.5 4.6 4.7 Related t-Test for comparison of left and right feet Related t-Test for comparison between methods Coefficient of variation between methods Coefficient of correlation between clinicians Experimental Hypotheses

4.

Results

Prior to the analysis of results, the mean amount of dorsiflexion for each method by each clinician was calculated for both left and right feet, using the results sheet which can be seen at Appendix D. It is these mean amounts that have formed the basis of these results. The research study comprised of measurement of ankle joint dorsiflexion of both left and right feet of 8 subjects. Measurements were taken by three clinicians A, B and C. There were three methods in use: Study 1: Uncontrolled passive/active measurement with the goniometer Study 2: Controlled force, passive/active measurement with the goniometer. Study 3: Controlled force measured with the DMD

4.1

Subjects

Descriptive Data

8 8 26.33 yrs

Females Mean Age

4.2

Table 4.1

Bar graphs to show mean amounts of dorsiflexion by study and clinician ( to nearest whole number).

Left Foot

Mean amounts of dorsiflexion 30 25 20 Degrees 15 10 5 0 study 1 study 2 Method Clinician A Clinician B Clinician C study 3

Table 4.2

Right Foot

Mean amounts of dorsiflexion 40

30 Degrees

20

10

0

study 1

study 2 Method

study 3

Clinician A

Clinician B

Clinician C

The graphs in Tables 4.1 and 4.2 show the mean amounts of dorsiflexion for left and right feet respectively, to their nearest whole number (the raw data for these tables can be seen in Appendix E). We can see that the clinicians measure greater amounts of dorsiflexion in study 3 than study 1 and 2, the difference between clinicians is significantly reduced however. The graphs are based on mean amounts of dorsiflexion, the calculations of which can be seen at Appendix F.

4.3

Related t-Test Samples for comparison of left and right feet

For each method, the Related t-Test was used to assess if the relationship between left and right feet was significant. The full test results can be seen at Appendix G : 1. Strength relationship between left and right feet. Table 4.3

Std. Deviation +/-6.7 +/-5.13 +/-3.6

Pair Study 1 - Left V Right Study 2 - Left V Right Study 3 - Left V Right

Mean -0.55 -1.25 -1.17

Significance 0.69 0.24 0.12

Result: There was no significant relationship between left and right feet. As a result of these findings, both sets of data for lrft and right were analysed and represented.

4.4

Related t-Test for comparison between methods

The results of the methods were compared with each other using the Related t-Test. It was used to see if there was a significant relationship methods. The full test results can be seen at Appendix G : 2 for left foot and Appendix G : 3 for right foot, a summarised version is in Table 4.4. Strength of relationship between methods Table 4.4 LEFT FOOT

Comparison Study 1 Study 2 Study 1 Study 3 Study 2 Study 3 Mean 1.3 Correlation 0.8 Std. Deviation +/-5.4 Sig 0.253

Pair 1

Pair2

-10.9

0.7

+/-6.6

0

Pair 3

-12.2

0.7

+/-6.6

0

Table 4.5 RIGHT FOOT

Comparision Study 1 Study 2 Study 2 Study 3 Study 1 Study 3 Mean 0.58 Correlation 0.85 Std. Deviation +/-3.7 Sig 0.448

Pair 1

Pair 2

-11.58

0.79

+/- 5.1

0

Pair 3

-12.17

0.7

+/- 5.8

0

Results: The results indicate that there is no relationship between methods, in fact there is a significant difference between studies 1, 2 and 3.

4.5

Coefficient of Variation (COV) between methods

The full test details can be seen at Appendix F The mean COV of left and right feet for each study Table 4.6

Study 1 LEFT 14.6% RIGHT 11.6% LEFT 11.4% Study 2 RIGHT 10% LEFT 5.6% Study 3 RIGHT 4.3%

Interpretation:

The COV in Study 1 has a larger distribution of data

around the mean, a opposed to study 2 which has less. Study 3 shows a smaller distribution about the mean.

4.6

Coefficient of Correlation's (COC) between clinicians

The full test results for the left foot can be seen at Appendix G :4 to G : 6. The strength of COC between clinicians Table 4.7 LEFT FOOT

Pair Pair 1 Pair 2 Pair 3 Clinician A&B A&C B&C Study 1 COC 0.344 0.481 0.861 Study 2 COC 0.755 0.866 0.829 Study 3 COC 0.895 0.94 0.9

Table 4.8 RIGHT FOOT

Pair Pair 1 Pair 2 Pair 3 Clincian A&B B&C A&C Study 1 COC 0.502 0.762 0.728 Study 2 COC 0.374 0.758 0.586 Study 3 COC 0.909 0.901 0.897

Interpretation:

The COC between clinicians improves from study 1 to

studies 2 and 3. It improves further between study 2 and 3, giving a strong positive correlation.

4.7

1.

Experimental Hypotheses

There is a significant difference between the amount of dorsiflexion measured with the goniometer applying uncontrolled passive/active dorsiflexion (Study 1) compared with controlled passive/active dorsiflexion (Study 2). There was a difference between the measurements in Study 1 and 2 (t = 1.172, DF = 23, p > 0.005) The experimental hypotheses is accepted.

2.

There is a significant difference between the amount of dorsiflexion measured with the goniometer, applying an controlled (study 2) passive/active compared with the measurements obtained with the DMD (study 3). There is a significant difference between the measurements in

Study

2 and 3 (t = -8.974, DF = 23, p <0.001) The experimental hypothesis accepted.

3.

There is a significant difference between the amount of dorsiflexion measured with the goniometer, applying an uncontrolled (study 1) passive/active force compared to the DMD (study 3). There is a significant difference between the measurements in

Study

1 and 3 (t = -8081, DF = 23, p <0.001). The experimental hypotheses is accepted.

5.0 Contents

5.1

Discussion

Significance of results 5.1.1 A comparison between methods 5.1.2 Coefficient of variation between methods 5.1.3 Coefficient of correlation between methods 5.1.4 Coefficient of correlation between clinicians

5.2

Critique of methodology 5.2.1 Limitations of subject numbers 5.2.2 Focus on study 2 5.2.3 Focus on study 3

5.3

Observations 5.3.1 The methodology 5.3.2 The Tension and Compression Gauge 5.3.3 The increased dorsiflexion measured in study 3

5.4

Recommendations for Further Research

5.5

Conclusion

5.0 5.1

Discussion Significance of Results

The results showed there was no significant relationship between left and right feet, therefore both sets of data are represented (study 1 - p > 0.005, study 2 - p>0.005, study 3 - p>0.005). These results supported previous research by A'Roas and Anderson (1992) indicating that there is no relationship between measurement of left and right feet and ankle joint dorsiflexion. 5.1.1 A comparison between methods.

The results can be seen in Table 4.4 for the left foot, and Table 4.5 for the right foot. Both sets of results indicate a significant difference between studies 1 and 3 (p<0.001) and studies 2 and 3 (p<0.001). However, the significance level between studies 1 and 2 (p>0.005) indicated a weak relationship. 5.1.2 Coefficient of Variation (COV) between methods

All three studies of both left and right feet fall below the 15% threshold. The results indicated in Table 4.6 suggest that study 1 and study 2 are more variable relative to their means than study 3, this is a strength of study 3. 5.1.3 Coefficient of Correlation (COC) between methods

The COC is used to statistically calculate the correlation between variables. In this case, it was used to identify any trends between methods and clinicians. Zero implies literally no correlation, while +1 implies a perfect correlation.

The COC can be seen in Table 4.7 for the left, and in Table 4.8 for the right foot. The correlations suggest a strong positive relationship. This would indicate that as the amount of dorsiflexion increases or decreases in one study, there is a corresponding increase or decrease in the other studies. 5.1.4 Coefficient of Correlation (COC) between Clinicians

Using Table 4.7 for the left and Table 4.8 for the right foot also give an indication of the relationship between clinicians. These results indicate a stronger correlation in study 3 than studies 1 and 2. The COC in study 3 is an almost perfect correlation for both and right feet indicating a strong reproducibility between clinicians. The COC between clinicians has been illustrated in the graphs on Table 4.1 and 4.2.

5.2

5.2.1

Critique of Methodology

Limitations of subject numbers

The research only measured eight individuals, all of whom were female. However, the subjects in this research represented a sample to test three methods of measurement and not a sample population. Therefore no conclusions that related to whole populations could, or would be drawn from this data, as this was not the intention of this study. 5.2.2 Focus on Study 2

During this study a polypropylene prop was used to mount an Otoform `plug' in which the Tension and Compression was seated. Polypropylene was chosen in an attempt to transfer most of the force applied through the polypropylene onto the plantar surface of the foot. It is that the polypropylene did not transfer all of the force applied but absorbed a

proportion of it. To measure the amount absorbed is beyond the remit of this dissertation. The amount absorbed compared to the amount transferred to the foot however, was the same for each subject and for all clinicians. The Otoform `plug' was located centrally on the polypropylene so that an even force could be distributed over the whole of the plantar surface. As the polypropylene only covered the forefoot, it was observed that in a hypermobile foot it was difficult to stop the forefoot moving relative to the rearfoot when the force was applied. This was the case even though the palpation method was used throughout dorsiflexion to ensure that the foot remained in the STJN. This problem may have been addressed had the polypropylene been the entire length of the plantar surface of the foot. 5.2.3 Focus on Study 3

During study 3 a poron valgus filler was used in an attempt to stop the foot pronating during dorsiflexion. Although the COV and the correlation of measurements between studies indicate it went some way to achieve this, poron is an absorbent material. On hindsight material that is less absorbent would have been better, such as cleron or even a moulded polypropylene device. Having acknowledged this as a potential weakness however, it is also stressed that the same device was used for all subjects, thereby levelling the playing field. A different piece of graph paper was inserted in the DMD for each foot with each subject. Therefore each piece of graph paper had three arcs on it. The logic behind the drawing the arc was to remove any knowledge of the clinicians to the readings they were taking. This may be a major criticism of this methodology, as the clinician could see the length of the

arc after the first reading and not have gone beyond that point on the next occasion, or ulturnatively applied more force to ensure the orginal mark was met on successive measurements. To rectify this problem, the graph paper should have been changed after each measurement. The lower leg was secured into the DMD with velcro attempting to stop the internal/external rotation of the leg during dorsiflexion. This method appeared to be successful, but subjects were observed to compensate by flexing their knee slightly. This was an observation that had to be closely monitored by the Observer as flexing the knee would have increased the amount of dorsiflexion by releasing the stretch of the Gastronemus muscle. While this problem was observed visually by the Observer, it must be accepted that this problem may not have been totally alleviated. When the subjects foot was secured into the DMD, it had to be ensured that the heel was seated against the foot plate. If this was not the case, the foot was not at a 90 starting position which increased the measurement of dorsiflexion available.

o

5.3

5.3.1

Observations

The methodology

The clinicians used throughout the study, all found the methodology of study 2 (controlled force, passive/active measurement) the hardest to operate. Study 1 was second and study 3 was considered the easiest to operate by far.

5.3.2

The Tension and Compression Gauge

The Tension and Compression Gauge on hindsight was not ideal, as although small and effective, it was difficult to use with one hand and a force of 10lbs (45 Newton's) difficult to apply, especially for the smaller clinician. 5.3.3 The increased dorsiflexion measured in study 3 The amount of dorsiflexion measured with the DMD in study 3 was far greater than the amounts measured with study 1 or study 2. The figures obtained, compare favourably with Baggot and Young's (1993) study measuring ankle dorsiflexion in a weight bearing position compared with non-weight bearing. They found a substantial increase in weight bearing measurements. Although Baggot and Young's methods were entirely different and the results of their tTest stated significantly unrelated measurements (p<0.01), they assessed their methods on how they correlated with one another, arguing if they correlated well, then either method could be considered a valid reflection of dorsiflexion. Their study did not have a strong correlation, however, using the same argument here, the results indicate a strong correlation between methods. The reason why the DMD increases the amount of dorsiflexion available may to due to the distribution of the force being applied over the whole plantar surface of the foot as opposed to just the MTPJ area which was used in study 1 and 2. Bojsen-Moller and Lamoreux's (1979) research found that force applied to the toes, forces them into a dorsiflexed position. This tightens the framework of the foot, restricting passive movements of the skin, enabling shearing forces to be transferred directly to the skeleton (Bojsen-Moller and Lamoreux 1979). In the normal standing position, the plantar aponeurosis is slack and unable to support the arch. However, when the toes are dorsiflexed by a plantar force, a

pull is exerted on the plantar aponeurosis by the `windlass mechanism', supporting the arch of the foot (Hicks 1954). Enabling shearing and accelerating forces to be transferred to the skeleton and not accepted by the skin alone (Bojsen-Moller and Lamoreux 1979). To confirmation this, study 2 had the same controlled force applied, but applied only to the MTPJ area and no such increases were found. In study 3, the force was distributed to entire plantar surface of the foot which was in contact with the footplate at all stages of dorsiflexion. This would more realistically mimic the ground reaction forces at work in closed chain motion.

5.4

Recommendations for Further Research

It is recommended that future research use a wider base for random sampling and makes the minor modifications to the methodology discussed above. Previous literature in this area highlights the problems associated with the clinical use of the goniometer. They concentrate on reliability and validity as major issues to question its worth as a clinical tool. With this in mind, the following study proposals are recommended: · the · Further research into weight bearing and non-weight bearing measurements to attempt to see if there is a relationship between two. Research to establish a reliable range of motion for dorsiflexion which will either confirm existing theories or, by evidence based research, set new parameters of ankle joint dorsiflexion.

·

Further research to investigate the use of applying controlled plantar force in measuring passive ankle joint dorsiflexion and setting a standard clinical methodology for it use.

·

The method for using the goniometer was not discovered, only suggestions to improve its reliability. Methods should be researched the greatest to attempt to identify one methodology which offers reliability.

5.5

Conclusion

The aim of this dissertation was to isolate some of the variables identified as main reasons why the use of the goniometer in a clinical setting was criticised. The objective being to attempt to see if they were valid or controllable. The results of COV show that the data falls closely around the mean measurement in study 3. This indicated that despite the criticisms of the methodology highlighted earlier, the DMD appears to have gone some way to controlling the variables associated with the Goniometer. The fact that this was the case also indicates that the criticisms associated with the Goniometer are valid.

The second aim of this dissertation was to investigate the aspect of further research cited by Gajdosik and Bohannon (1987) in applying a controlled plantar force, the objective being to achieve a more reliable active/passive dorsiflexion measurement.

The results indicate at times a stronger correlation between clinicians when a controlled force is applied compared to an uncontrolled force. The stronger correlation however, is not consistent. Therefore questions of its reliability must be asked. It is appreciated however, that for a meaningful comparison between clinicians, the study should have been repeated on different days with the same subjects. An associated problem with study 2, was that the goniometer was being used to measure the amount of dorsiflexion, when it is acknowledged to have a low reproducibility. This makes it difficult to address the success or failure of the methodology and the effect of the goniometer on it. It is accepted that this makes final interpretation of these results difficult, but highlights an area for further research. Although there was no significant relationship between the studies in terms of the Related t-Test, it was interesting to see such a strong correlation and a reduced COV in study 3. The COV would indicate that the methodology of study 3 succeeded in the aim controlling some of the variables, indicating that these are valid criticisms of the goniometer in terms of research. It would also indicate that there are justifiable reasons to question whether the continued use of the goniometer in a clinical situation is appropriate.

The question of validity remains an issue. With the apparent success of study 3, it can clearly be seen that there is obviously no relationship between the amounts of dorsiflexion measured with study 3, compared to the accepted methods. Yet the COC and COV for study 3 imply that there

is an improvement. It would be naive on the basis on one piece of research to state that the methodology of study 3 was successful, it does however, pose questions mentioned in further research. The Podiatric profession is in constant change. We are encouraged to question methods as in this study and justify treatments, which is important in this era of evidence based healthcare. As the aetiologies of an ankle equinus deformity are better understood and our treatments for such a problem are appropriate and beneficial, we must ensure that our interpretation of diagnosis is correct and constant between clinicians.

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Appendices

Contents

Appendix A: B: C:

Ethical Committee Approval letter Consent Form Inclusion/Exclusion Criteria Form

C1: Results Sheet D: Subject Information Sheet Raw Data

E1 - E8:

F1 - F2: G1 - G9:

Calculated Means from Raw Data Related t-Tests

Appendix B

Consent Form

ANKLE JOINT DORSIFLEXION - A COMPARATIVE STUDY

I...................................agree to participate in the above research study. The tests that will be undertaken have been fully explained. I have had an information made available for me and have had the opportunity to ask any questions prior to commencement of the tests. I understand that may participation is voluntary and that I am free to

withdraw at any stage without giving reason. This withdrawal will not affect my right the future treatment.

Signature..................................

Date of Birth.............................

1 copy to subject 1 copy to researcher

Appendix C

Subject Inclusion/Exclusion Criteria Please circle Yes or No to which is appropriate for you.

1. 2. 3. 4.

Are you between 18 - 40 years old? Do you suffer from ankle oedema? Do you have a known forefoot equinus deformity? Are you on any medication? a. b. c.

Yes/No Yes/No Yes /No

If yes - do you know if they have a known neurological effect? Yes/No 5. Have you ever had surgery to: a. Your calf area? Yes/No b. Tendons of ankle? Yes/No If yes - please give details..................................................................... 6. Any history of compartment syndrome, of treatment for its effects? Yes/No 7. 8. 9. Any lower motor neurone problems? Any upper motor neurone problems? Any history of severe ankle trauma? Yes/No Yes/No Yes/No

Thank you for taking the time to fill out the questionnaire. These results are kept in confidence and only filed under a `subject number'.

Appendix C : 1

Results Sheet A = Clinician A B = Clinician B Study 1 Left Foot C = Clinician C

A......../......../........ Subject 1 B......../......../........

A......../......../........ B......../......../........

C......../......../........ C......../......../........ Study 1 Right Foot A......../......../........ Subject 1 B......../......../........ A......../......../........ B......../......../........

C......../......../........ C......../......../........ Study 2 Left Foot A......../......../........ Subject 1 B......../......../........ A......../......../........ B......../......../........

C......../......../........ C......../......../........ Study 2 Right Foot A......../......../........ Subject 1 B......../......../........ C......../......../........ A......../......../........ B......../......../........ C......../......../........ Appendix D Subject Information Sheet Ankle Joint Dorsiflexion - a comparative study

The measurement of ankle joint dorsiflexion is used to diagnose an ankle equinus deformity. An equinus deformity is defined as a limitation of ankle joint dorsiflexion of less than 10 (Root et al. 1977). The goniometer is used to make this clinical measurement. First developed after the First World War, it is now criticised as being inaccurate between clinicians. The aim of this study is to measure ankle joint dorsiflexion using three different methods of collection on both left and right feet. There are three separate `clinicians' who will be taking the measurements. Each clinician will use all three methods collection. Each method will be repeated three times so that a mean figure can be calculated.

o

Only the lower legs needs to be exposed for this study. The duration of the study will be 1.5 hours. Please feel free to ask any questions prior to commencement of the study.

Appendix E:1 RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer) Study 3 = Controlled (with DMD)

Subject 1 Study 1 1A 1B 1C

L R L R L R 18 22 16 12 10 18 17 17 11 16 17 8 21 18 18 16 17 8 ----------------------------------------------------------------------------------mean 19 19 15 15 14 13 Study 2 1A 1B 1C

L R L R L R 8 22 7 16 12 14 18 18 12 13 12 19 17 18 9 18 12 18 ----------------------------------------------------------------------------------mean 14 19 9 16 12 17 Study 3 1A 1B 1C

L R L R L R 27 30 27 31 20 24 28 31 27 32 20 27 27 32 29 32 23 25 -----------------------------------------------------------------------------------mean 27 31 28 32 21 25

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:2

Study 3 = Controlled (with DMD)

Subject 2 Study 1 2A 2B 2C

L R L R L R 23 34 12 8 26 16 25 32 12 10 28 16 29 24 14 16 24 23 -----------------------------------------------------------------------------------mean 26 30 13 11 26 18 Study 2 L 2A R L 2B R L 2C R

24 26 8 13 14 16 22 29 13 14 18 10 25 29 12 12 16 16 ----------------------------------------------------------------------------------mean 24 28 11 13 16 14

Study 3

2A

2B

2C

L R L R L R 33 28 26 28 35 28 33 29 29 28 34 29 34 32 29 26 33 30 ----------------------------------------------------------------------------------mean 33 30 28 27 34

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:3

Study 3 = Controlled (with DMD)

Subject 3 Study 1 L 3A R L 3B R L 3C R

23 20 26 20 34 16 22 30 26 22 31 17 18 20 28 26 32 19 -----------------------------------------------------------------------------------mean 14 23 27 23 32 17 Study 2 L 30 28 3A R 25 22 L 24 28 3B R 24 18 L 27 22 3C R 26 24

33 26 26 22 22 20 ----------------------------------------------------------------------------------mean 30 24 26 21 24 23

Study 3 L

3A R L

3B R L

3C R

28 28 33 35 27 36 29 29 35 37 28 37 31 32 35 37 26 36 -----------------------------------------------------------------------------------mean 29 30 34 36 27 36

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:4

Study 3 = Controlled (with DMD)

Subject 4 Study 1 L 4A R L 4B R L 4C R

19 34 24 24 30 28 12 28 25 20 29 32 14 30 20 23 22 26 ----------------------------------------------------------------------------------mean 15 31 23 22 27 29 Study 2 L 20 22 4A R 26 28 L 18 18 4B R 22 20 L 26 20 4C R 30 30

20 25 22 22 27 34 -----------------------------------------------------------------------------------mean 21 26 19 21 24 31

Study 3

4A

4B

4C

L R L R L R 39 37 43 40 40 33 38 39 42 40 37 33 39 38 44 40 39 34 -----------------------------------------------------------------------------------mean 39 38 43 40 39 33

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:5

Study 3 = Controlled (with DMD)

Subject 5 Study 1 L 5A R L 5B R L 5C R

21 14 13 13 9 11 18 14 10 16 6 13 16 14 12 12 8 9 ----------------------------------------------------------------------------------mean 18 14 12 14 8 11

Study 2 L 10 8 12

5A R 10 12 18 L 12 10 10

5B R 10 12 12 L 2 5 3

5C R 11 8 10

-----------------------------------------------------------------------------------mean 10 13 11 11 3 10

Study 3 L

5A R L

5B R L

5C R

28 27 19 26 20 22 28 29 19 22 19 23 28 29 21 22 20 23 -----------------------------------------------------------------------------------mean 28 28 20 23 20 23

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:6

Study 3 = Controlled (with DMD)

Subject 6 Study 1 L 6A R L 6B R L 6C R

28 30 21 28 33 36 32 30 28 23 35 36 30 26 28 28 32 26 ----------------------------------------------------------------------------------mean 30 27 26 26 33 33 Study 2 L 6A R L 6B R L 6C R

26 20 28 32 34 21 26 22 30 28 28 24 30 25 27 26 29 24 -----------------------------------------------------------------------------------mean 27 22 28 29 30 23

Study 3 L

6A R

6B L R

6C L R

43 47 48 44 44 48 44 47 46 45 44 48 43 48 46 44 46 47 -----------------------------------------------------------------------------------mean 43 47 47 44 45 48

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:7

Study 3 = Controlled (with DMD)

Subject 7 Study 1 7A 7B 7C L R L R L R 10 22 6 18 10 14 5 20 8 17 9 16 8 22 8 10 11 21 -----------------------------------------------------------------------------------mean 8 21 7 15 10 17

Study 2

7B 7C L R L R L R 10 16 12 19 8 16 12 16 6 20 11 21 12 12 8 18 15 19 -----------------------------------------------------------------------------------mean 11 15 9 19 11 19

7A

Study 3

7A

7B

7C

L R L R L R 22 27 22 28 25 28 23 28 24 28 25 28 27 30 22 30 25 28 ------------------------------------------------------------------------------------mean 24 28 23 29 25 28

RAW DATA

Different 'clinicians' represented as A, B and C. Results in Degrees Study 1 = Uncontrolled (with Goniometer) Study 2 = Controlled (with Goniometer)

Appendix E:8

Study 3 = Controlled (with DMD)

Subject 8 Study 1 8A 8B 8C L R L R L R 15 12 16 8 20 13 14 11 13 12 18 14 20 10 12 12 18 14 -----------------------------------------------------------------------------------mean 16 11 14 11 19 14

Study 2

8A

8B

8C

L R L R L R 12 10 20 12 18 14 15 11 16 16 17 14 14 10 20 14 18 12 -----------------------------------------------------------------------------------mean 14 10 19 14 18 13

Study 3

8A

8B

8C

L R L R L R 17 19 19 19 17 18 21 19 22 22 18 20 20 19 21 20 19 20 -----------------------------------------------------------------------------------mean 19 19 21 20 18 19

Appendix F : 1 Calculated Means from Raw Data.

Cl = Clinician L = left foot R = right foot

COV = Coefficient of Variation (%)

Subject 1 Cl A B C COV Study 1 L R 19 19 15 15 14 13 9.55 11.26 Cl A B C Study 2 L R 14 19 9 16 12 17 12.45 5.09 Cl A B C Study 3 L R 27 31 28 32 21 25 8.64 7.46

Subject 2 Cl A B C COV Study 1 L R 26 30 13 11 26 18 20.0 28.21 Cl A B C Study 2 L R 24 28 11 13 16 14 22.27 26.46 Cl A B C Study 3 L R 33 30 28 27 34 29 5.86 3.1

Subject 3 Cl A B Study 1 L R 14 23 27 23 Cl A B Study 2 L R 30 24 26 21 Cl A B Study 3 L R 29 30 34 36

C COV

32 22.1

17 9.53

C

24 6.6

23 3.9

C

27 7.0

36 5.9

Subject 4 Cl A B C COV Study 1 L R 15 31 23 22 27 29 16.28 10.0 Cl A B C Study 2 L R 21 26 19 21 24 31 6.8 11.1 Cl A B C Study 3 L R 39 38 43 40 39 33 3.3 5.9

Appendix F : 2

Subject 5 Cl A B C COV Study 1 L R 18 14 12 14 8 11 23.0 7.7 Cl A B C Study 2 L R 10 13 11 11 3 10 31.5 7.8 Cl A B C Study 3 L R 28 28 20 23 20 23 11.8 6.7

Subject 6 Cl A B C COV Study 1 L R 30 27 26 26 33 33 6.8 7.6 Cl A B C Study 2 L R 27 22 28 29 30 23 3.1 8.8 Cl A B C Study 3 L R 43 47 47 44 45 48 2.6 2.6

Subject 7 CL A B C COV Study 1 L R 8 21 7 15 10 17 10.6 10.0 Cl A B C Study 2 L R 11 15 9 19 11 19 6.5 7.5 Cl A B C Study 3 L R 24 28 23 29 25 28 2.4 1.2

Subject 8 Cl A B C COV Study 1 L R 16 11 14 11 19 14 8.9 8.3 Cl A B C Study 2 L R 14 10 19 14 18 13 8.9 9.7 Cl A B C Study 3 L R 19 19 21 20 18 19 4.5 1.7

Total mean of COV Study 1 Study 2 Study 3 L R L R L R 14.6% 11.6% 11.4% 10% 5.7% 4.3%

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