Radiographic Investigation of Angular and Linear Measurements Including First Metatarsophalangeal Joint Dorsiflexion and Rearfoot to Forefoot Axis Angle

doi:10.1053/j.jfas.2005.02.011

The Journal of Foot and Ankle Surgery

Volume 44, Issue 3, May–June 2005, Pages 190-199

https://doi.org/10.1053/j.jfas.2005.02.011 Get rights and content

This study investigated intra- and inter-rater reliability of several radiographic angular and linear parameters using 6 subjects. Using standard weight-bearing radiographs, the following measurements were performed: first metatarsal protrusion distance, hallux abductus, first intermetatarsal, calcaneal inclination and lateral intermetatarsal angles. Measurement of lateral stressed dorsiflexion of the first metatarsophalangeal joint and the rearfoot-to-forefoot-axis angle taken using a composite view were also obtained. All parameters were measured independently by 2 raters, and measurements were repeated on 3 separate occasions at weekly intervals. Intrarater reliability of radiographic measurements ranged between R= 0.65–1.00 for lateral stressed dorsiflexion, and between R = 0.91 and 0.99 for the rearfoot to forefoot axis angle. Inter-rater reliability of radiographic measurements ranged from R= 0.82–0.99. Specifically, lateral stressed dorsiflexion showed R = 0.87 with a mean difference of −1.47 (confidence interval [CI]: −3.42, 0.47), indicating no significant difference (t = 1.54, P = 0.13). The rearfoot-to-forefoot-axis angle showed R = 0.92 with a mean difference of −0.15 (CI: −1.05, 0.74), indicating no significant difference (t = 0.35, P = 0.73). The 7 angular and linear measurements chosen demonstrated high inter- and intrarater reliability. These results indicate that weight-bearing radiographic first metatarsophalangeal joint dorsiflexion using the lateral stressed dorsiflexion view, and measurement of the rearfoot-to-forefoot-axis angle using a composite view could be measured reliably within and between raters.

Section snippets

Methods

A convenience sample of 6 adults presenting with hallux limitus or hallux valgus was recruited from a metropolitan private podiatry practice. Patients were excluded if they had a history of lower limb surgery, trauma, gait abnormalities, neurological disorders, or any systemic disease. The Human Research Ethics Committee at the University of Western Australia approved the study, and subjects provided informed consent before participation.

Bilateral weight-bearing radiographs were performed on

Results

The sample consisted of 2 men and 4 women with a mean age of 58±14 years, a mean body weight of 62.2±11.8 kg, and a mean height of 1.57±0.11 m. Descriptive statistics obtained from the seven dependent variables are presented in Table 1.

Intrarater reliability for the dependent variables for each rater is presented in Table 2. Intrarater reliability of the group of radiographic measurements as assessed by Pearson’s product moment correlation ranged between 0.83–0.99 for rater 1, and 0.65–1 for

Discussion

Subjects in this study presented with a deformity of the first MTPJ, so values obtained from the dependent variables were expected to vary from normal reference ranges observed in the literature. The following discussion presents the mean values of each dependent variable with scores presented in parentheses for raters 1 and 2, respectively.

Both raters reported mean values of CIA (26.0°, 25.1°) consistent with the classification of a high CIA (30). Most authors agree a HAA value of less than

Conclusion

Selected measurement parameters from weight-bearing foot radiographs were assessed and found to exhibit high intra- and inter-rater reliability. Specifically, the method of obtaining the lateral stressed dorsiflexion of the first MTPJ was shown to be reliable. Similar reliability was observed for the rearfoot to forefoot axis angle obtained from the composite view of the foot, providing a unique method of assessing the radiographic forefoot to rearfoot relationship in the transverse plane.

Acknowledgments

The authors express their appreciation to Dr Garry T. Allison, PhD, Center for Musculoskeletal Studies, University of Western Australia, for his help with statistical analyses.

References (60)

A. Bryant et al.
A comparison of radiographic measurements in normal, hallux valgus, and hallux limitus feet
J Foot Ankle Surg
(2000)
P. Cavanagh et al.
The relationship of static foot structure to dynamic foot function
J Biomech
(1997)
T. Roukis et al.
A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus
J Foot Surg
(2002)
H. Menz
Clinical hindfoot measurementa critical review of the literature
The Foot
(1995)
B. Umberger et al.
Reliability and validity of first metatarsophalangeal joint orientation measured with an electromagnetic tracking device
Clin Biomech
(1999)
S. Green et al.
The influence of radiographic projection on the appearance of deformities
Orthop Clin North Am
(1994)
A. Bryant et al.
Review of radiographic measurements following Austin bunionectomy
Am Podiatr Med Assoc
(1998)
W. Schneider et al.
Intra- and inter-observer repeatability of radiographic measurements in hallux surgeryImprovement and validation of a method
Acta Orthop Scand
(2002)
R. Kilmartin et al.
The x-ray measurement of hallux valgusAn inter- and intra- observer error study
The Foot
(1992)
M. Coughlin et al.
The reliability of angular measurements in hallux valgus deformities
Foot Ankle Int
(2001)

F. Bojsen-Moeller et al.

Significance of free-dorsiflexion of the toes in walking

Acta Orthop Scand

(1979)

H. Kelikian

Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia

(1965)

J. Joseph

Range of movement of the great toe in men

J Bone Joint Surg Br.

(1954)

T. Buell et al.

Measurement of the first metatarsophalangeal joint range of motion

J Am Podiatr Med Assoc

(1988)

K. Allen

Dorsiflexion at the first metatarsophalangeal jointa comparison of measurement by tractograph and digital biometer

R. Evans

Illustrated Essentials in Orthopedic Physical Assessment

(1994)

J. Gerhardt et al.

Measuring and Recording of Joint MotionInstrumentation and Techniques

(1990)

N. Giannestras

Foot DisordersMedical and Surgical Management

(1973)

S. Hoppenfield

Physical Examination of the Spine and Extremities

(1976)

M. Hopson et al.

Motion of the first metatarsophalangeal jointreliability and validity of four measurement techniques

J Am Podiatr Med Assoc

(1995)

R. Mann et al.

Hallux rigidusa review of the literature and a method of treatment

Clin Orthop

(1979)

R. McRae

Clinical Orthopedic Examination

(1990)

D. Tollafield et al.

Assessment of the locomotor system, ch. 8

C. Norkin et al.

Measurement of Joint MotionA Guide to Goniometry

(1985)

M. Palmer et al.

Clinical Assessment Procedures in Physical Therapy

(1990)

M. Root et al.

T. Sgarlato

A Compendium of Podiatric Biomechanics

(1971)

V. Hetherington et al.

Necessary dorsiflexion of the first metatarsophalangeal joint during gait

J Foot Surg

(1990)

D. Nawoczenski et al.

Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait

J Bone Joint Surg Am

(1999)

J. Montagne et al.

Atlas of Foot Radiology

(1981)

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Original articleRadiographic Investigation of Angular and Linear Measurements Including First Metatarsophalangeal Joint Dorsiflexion and Rearfoot to Forefoot Axis Angle

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgments

J Foot Ankle Surg

J Biomech

J Foot Surg

The Foot

Clin Biomech

Orthop Clin North Am

Review of radiographic measurements following Austin bunionectomy

Am Podiatr Med Assoc

Intra- and inter-observer repeatability of radiographic measurements in hallux surgeryImprovement and validation of a method

Acta Orthop Scand

The x-ray measurement of hallux valgusAn inter- and intra- observer error study

The Foot

The reliability of angular measurements in hallux valgus deformities

Foot Ankle Int

Significance of free-dorsiflexion of the toes in walking

Acta Orthop Scand

Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia

Range of movement of the great toe in men

J Bone Joint Surg Br.

Measurement of the first metatarsophalangeal joint range of motion

J Am Podiatr Med Assoc

Dorsiflexion at the first metatarsophalangeal jointa comparison of measurement by tractograph and digital biometer

Illustrated Essentials in Orthopedic Physical Assessment

Measuring and Recording of Joint MotionInstrumentation and Techniques

Foot DisordersMedical and Surgical Management

Physical Examination of the Spine and Extremities

Motion of the first metatarsophalangeal jointreliability and validity of four measurement techniques

J Am Podiatr Med Assoc

Hallux rigidusa review of the literature and a method of treatment

Clin Orthop

Clinical Orthopedic Examination

Assessment of the locomotor system, ch. 8

Measurement of Joint MotionA Guide to Goniometry

Clinical Assessment Procedures in Physical Therapy

A Compendium of Podiatric Biomechanics

Necessary dorsiflexion of the first metatarsophalangeal joint during gait

J Foot Surg

Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait

J Bone Joint Surg Am

Atlas of Foot Radiology

Original article
Radiographic Investigation of Angular and Linear Measurements Including First Metatarsophalangeal Joint Dorsiflexion and Rearfoot to Forefoot Axis Angle