Original paper
A weightbearing technique for the measurement of ankle joint dorsiflexion with the knee extended is reliable

https://doi.org/10.1016/j.jsams.2007.06.009Get rights and content

Summary

Measurement of ankle joint dorsiflexion is routinely undertaken by clinicians who manage lower limb musculoskeletal pathology. This study aimed to determine the reliability of a technique to measure ankle joint dorsiflexion in a weightbearing position with the knee extended. Four raters with varying clinical experience measured ankle joint dorsiflexion in a weightbearing position with the knee extended on 30 asymptomatic participants. Measurements occurred on two occasions, 1 week apart using (i) a digital inclinometer and (ii) a clear acrylic plate apparatus. Intraclass correlation coefficients (ICCs) and 95% limits of agreement (LOAs) were calculated. Intra-rater reliability of the experienced raters was high for both the digital inclinometer (average ICC = 0.88, average 95% LOA = −6.6° to 4.8°) and the clear acrylic plate apparatus (average ICC = 0.89, average 95% LOA = −7.2° to 4.3°). Intra-rater reliability of the inexperienced rater was good to high for both the digital inclinometer (ICC = 0.77, 95% LOA = −9.1° to 8.3°) and the clear acrylic plate apparatus (ICC = 0.89, 95% LOA = −8.1° to 4.6°). Inter-rater reliability was high for both the digital inclinometer (ICC = 0.95, 95% LOA = −5.7° to 5.7°) and the clear acrylic plate apparatus (ICC = 0.97, 95% LOA = −4.7° to 4.7°). Measurements of ankle dorsiflexion in a weightbearing position with the knee extended can be performed reliably by experienced and inexperienced raters. However, the reliability of this measurement technique needs to be interpreted in the context of the purpose for which the measurement is intended.

Introduction

Ankle joint dorsiflexion is important to allow the body to progress forward over the weightbearing foot during gait and absorb impact force during ballistic activities such as jumping.1, 2 Limited ankle joint dorsiflexion is commonly caused by tightness of soleus and gastrocnemius muscles,3, 4 and has been shown to be a risk factor for and/or associated with several musculoskeletal pathologies of the foot including forefoot pain,3 plantar fasciitis5 and navicular stress fractures.6 Patella7 and Achilles tendinopathy,8 ankle sprains9 and lower limb overuse injuries in football players10 have also been shown to be caused by, or associated with limited ankle joint dorsiflexion. It is therefore important that clinicians who manage musculoskeletal pathology of the foot and lower limb are able to reliably assess ankle joint dorsiflexion range of motion. This would allow the practitioner to identify those at risk of developing foot and lower limb injuries, accurately measure the level of dysfunction post-injury and determine the effectiveness of an intervention aimed at improving ankle joint dorsiflexion range of motion.

The measurement of ankle joint dorsiflexion has traditionally occurred with the patient in a non-weightbearing position.4 However, the reliability of this measurement technique is questionable (intra-rater reliability ICCs ranging from 0.64 to 0.99 and inter-rater ICCs ranging from 0.29 to 0.81).11 In light of the questionable reliability of non-weightbearing measurements of ankle joint dorsiflexion, an alternative weightbearing ‘lunge’ technique has been described.12 This measurement technique has been shown to be reliable (high intra- and inter-rater reliability).12, 13 However, a major limitation of this measurement technique is that it primarily assesses the role of the soleus muscle and joint capsule structures of the ankle joint as it is performed with a flexed knee.4 This measurement technique is unable to determine if tightness of the gastrocnemius muscle is a contributing factor to limited ankle joint dorsiflexion.4 One way to overcome this limitation would be to perform the measurement of ankle joint dorsiflexion range of motion in a weightbearing position with the knee extended.

Only one study has investigated the reliability of the measurement of ankle joint dorsiflexion in a weightbearing position with the knee extended.14 Although the results showed high intra-rater reliability (coefficient of variation of 2.5%), the inter-rater reliability was not reported. Furthermore, only experienced clinicians were used, so it is unknown if this measurement technique is reliable when inexperienced raters perform this measurement.

Therefore, the aim of this study was to determine both the intra- and inter-rater reliability of the measurement of ankle dorsiflexion in a weightbearing position with the knee extended, using both experienced and inexperienced raters.

Section snippets

Participants

Participants were recruited from a student population at a University. Thirty individuals (10 male, 20 female), aged 19–42 years (mean ± S.D., 22.1 ± 5.6), height (mean ± S.D.) 171.8 ± 8.9 cm, BMI (mean ± S.D.) 22.8 ± 3.3 were recruited. Participants were excluded if they had any acute or chronic lower limb pathology in the previous 12 months, previous history of surgery to the lower limbs or any neurological or balance deficits. Institutional ethics approval was granted prior to the study and all

Ankle joint dorsiflexion measured with a digital inclinometer

The mean (range) values for each rater at the test and retest sessions are shown in Supplementary File 3. The main effect of session was not significant (F1 = 2.992, p = 0.09). Similarly, the main effect of rater was not significant (F3 = 2.470, p = 0.07). Clinically, these results suggest error associated with measurement between raters and between sessions was random and not a result of systematic differences.

Intra- and inter-rater reliability of the measurement of ankle joint dorsiflexion in a

Discussion

This study has demonstrated that measurement of ankle joint dorsiflexion in a weightbearing position with the knee extended can be performed reliably by experienced and inexperienced raters using both the digital inclinometer and the clear acrylic plate apparatus. These results are comparable to the findings from the study by Ekstrand et al.14 However, our study adds to the work of Ekstrand et al.14 as they assessed intra-rater reliability only and used experienced raters only.

An issue to

Practical implications

  • Measurements of ankle joint dorsiflexion with participants in a weightbearing position with the knee extended are reliable when performed by the same rater or by different raters.

  • The reliability of measurements of ankle joint dorsiflexion are not strongly affected by the experience of the rater or the equipment used.

References (25)

  • J. Agosta et al.

    Biomechanical analysis of athletes with stress fractures of the tarsal navicular bone: a pilot study

    Aust J Podiatr Med

    (1999)
  • K.R. Kaufman et al.

    The effect of foot structure and range of motion on musculoskeletal overuse injuries

    Am J Sports Med

    (1999)
  • Cited by (0)

    View full text