Weight bearing versus non-weight bearing ankle dorsiflexion measurement in people with diabetes: a cross sectional study

Weight bearing versus non-weight bearing ankle dorsiflexion measurement in people with diabetes:... Background: Accurate measurement of ankle dorsiflexion is important in both research and clinical practice as restricted motion has been associated with many foot pathologies and increased risk of ulcer in people with diabetes. This study aimed to determine the level of association between non-weight bearing versus weight bearing ankle dorsiflexion in adults with and without diabetes, and to evaluate the reliability of the measurement tools. Methods: One hundred and thirty-six adults with diabetes and 30 adults without diabetes underwent ankle dorsiflexion measurement non-weight bearing, using a modified Lidcombe template, and weight bearing, using a Lunge test. Pearson product-moment correlation coefficients, intraclass correlation coefficients (ICCs) with 95% confidence intervals, standard error of measurement and minimal detectable change were determined. Results: There was a moderate correlation (r = 0.62–0.67) between weight and non-weight bearing tests in the non-diabetes group, and a negligible correlation in the diabetes group(r = 0.004–0.007). Intratester reliability was excellent in both groups for the modified Lidcombe template (ICC = 0.89–0.94) and a Lunge test (ICC = 0.83–0.89). Intertester reliability was also excellent in both groups for the Lidcombe template (ICC = 0.91) and a Lunge test (ICC = 0.88–0.93). Conclusions: We found the modified Lidcombe template and a Lunge test to be reliable tests to measure non- weight bearing and weight bearing ankle dorsiflexion in adults with and without diabetes. While both methods are reliable, further definition of weight bearing ankle dorsiflexion normative ranges may be more relevant for clinical practice. Keywords: Dorsiflexion, Ankle, Diabetes, Lunge, Reliability, Lidcombe Background 10° [6, 7], less than 5° [3, 8, 9] or less than zero° of dorsi- Ankle dorsiflexion is essential for normal gait, as the flexion [3, 10, 11]. An equinus can result from a number ankle first plantarflexes after heel strike to bring the of causes including bony block, neurological abnormal- forefoot into contact with the ground, and then dorsi- ities, soft tissue contracture resulting from prolonged in- flexes as the centre of gravity of the body moves over activity or prolonged ankle plantarflexion, and metabolic the joint during forward movement [1]. It is generally changes common in aging and diabetes [12]. In the gen- agreed that a minimum of 5–10° of ankle dorsiflexion is eral population equinus has been associated with condi- required for normal gait [2–4]. Equinus refers to re- tions such as chronic heel pain [13], Achilles tendonitis stricted ankle dorsiflexion, and in the absence of a stan- [14] and plantar fasciitis [15, 16]. In people with dia- dardised definition [5], has been described as less than betes, equinus has been linked to increased ulcer risk [17] and delayed ulcer healing [11]. Therefore, accurate measurement of ankle dorsiflexion is important in both * Correspondence: Angela.Searle@newcastle.edu.au research and clinical practice to allow correct School of Health Sciences, Faculty of Health, University of Newcastle, PO Box 127, Ourimbah, NSW 2258, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 2 of 7 identification of restriction, and measurement of the effi- been used previously, and is considered to be sufficient cacy of interventions to improve motion. to reduce recall bias of testers to previous results [22]. The most common measurement method reported is The order of testers was randomised to minimise bias passive non-weight bearing ankle dorsiflexion using a from repeated testing. One podiatrist and one osteopath, goniometer, however major concerns have been raised both with 10 years of clinical experience performed all about the reliability of this method [18, 19]. A modified the measurements. Testing was conducted on the partic- Lidcombe template was developed to measure ipants’ dominant leg only to maintain independence of non-weight bearing ankle dorsiflexion and has been re- data [23]. Dominance was determined by asking the par- ported to have good reliability, but has not been tested ticipant which foot they would kick a football with. Par- in adult or diabetes populations [20]. Weight bearing ticipants in the diabetes group, who were part of an ankle dorsiflexion, measured with an extended knee ankle equinus trial, were asked at the completion of their Lunge test has also been shown to be reliable in popula- first appointment if they were available to attend another tions without diabetes, is practical for clinical use and measurement session in one weeks’ time. Those who may more accurately reflect restriction experienced dur- volunteered to attend two measurement sessions formed ing gait and activities of daily living [21]. If there is an the diabetes reliability group. association between the two measures, a Lunge test may Non-weight bearing ankle joint range of motion was be able to be recommended for use in clinical practice measured using a modified Lidcombe template which and research situations, while allowing comparison with was designed to address the deficiencies in goniometric previous results. testing [20]. This consisted of a 300 mm solid foot plate Therefore, the aims of this study were to test in adult hinged to a solid base plate (Fig. 1). A digital protractor populations with and without diabetes; 1) the reliability (Bear Digital Protractor 82201B-00, China) was fixed to of a modified Lidcombe template to measure passive the back of the foot plate to allow the degree of dorsi- non-weight bearing ankle dorsiflexion, and, a Lunge test flexion to be measured. To allow application of a con- to measure weight bearing ankle dorsiflexion, and 2) the sistent dorsiflexion force, a digital force gauge level of association between ankle dorsiflexion measured (FGD-200, Starr Instruments, Melbourne, Australia) was using the above methods. attached to the front of the foot plate at a distance of 200 mm from the hinge attachment. Participants were Methods required to lay reclined with their knees extended on an Ethics approval was granted by the University of New- examination table with the base plate of the device castle Human Research Ethics Committee and written placed under the dominant leg. Participants were ad- informed consent was obtained from all participants. A vised against actively dorsiflexing their ankle, flexing group of 136 adults with diabetes were recruited from their knee or resisting the applied force during the the University of Newcastle Podiatry Clinic at Wyong examination. A standardised force of 80.4 N was applied Hospital, NSW, Australia, and from newspaper adver- to the base plate, by means of the tester pulling on the tisements in local newspapers, between June 2016 and strain gauge, as this is believed to best replicate the October 2017. An additional 30 adults without diabetes forces experienced during gait [5]. The degree of dorsi- were recruited from the student population of the flexion was read from the digital inclinometer by an- University of Newcastle, Ourimbah, Australia. Inclusion other investigator. The digital inclinometer was not criteria were adults, 18 years of age and over, able to visible to the tester which ensured blinding. The test was provide informed consent and a diagnosis of either type 1 or type 2 diabetes for the diabetes group. Exclusion criteria were existing foot ulcer, wound or infection in the lower leg, any previous lower limb amputation, any surgery to the foot or lower limb involving fixation of a joint, any recent injury to the foot or ankle that may be exacerbated or result in pain due to movement of the ankle, and any problems that would prevent the partici- pant from lying reclined for approximately 5 min. Procedures To assess the reliability of the measurement techniques, 30 participants from each group were assessed by two testers at the same testing session on two separate occa- Fig. 1 Lidcombe template sions, five to ten days apart. This period of time has Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 3 of 7 completed three times, with 10 s rest between tests, and > 25 V was regarded as abnormal [28]. Participants were the average score was documented as the test result. assessed as neuropathic if they recorded one or more ab- A Lunge test with the knee extended was used to de- normal test results. termine ankle joint dorsiflexion range of motion in a weight bearing position (Fig. 2). This method was chosen Sample size as it has been reported to have excellent interrater (ICC For the measurement tool reliability calculations a sam- = 0.82) and interrater (ICC = 0.88) reliability, and it mea- ple size of 30 participants per group was determined sures the effects of gastrocnemius tightness, which is re- based on α = 0.05, β = 0.20 for two observations per par- ported to be a main contributor to ankle dorsiflexion ticipant, with a target intraclass correlation coefficient restriction [3, 24]. A tape line was placed on the floor (ICC) of 0.8 and a lowest acceptable ICC of 0.50 [29]. perpendicular to the wall. The participant placed both hands on the wall in front of them and then positioned Statistical analysis their dominant leg behind them as far as possible. The All statistical tests were conducted using SPSS Release second toe and the centre of the heel of the participant’s 24 for Windows (SPSS Inc., Chicago, Ill., USA). Intra- dominant foot were situated over the tape line to min- and intertester reliability was assessed using interclass imise subtalar joint pronation during measurement. The coefficients (ICC) and standard error of measurement participant was asked to lean forward until a maximum (SEM) with 95% confidence intervals (CIs) and minimal stretch was felt in the dominant leg, while keeping the detectable change (MDC). An ICC [1, 3] was calculated heel of the dominant foot in contact with the ground, for intertester reliability between testers 1 and 2 in ses- and the knee of the dominant leg fully extended. The sion one and intratester reliability between sessions one digital protractor described above was placed on the and two. Interpretation of ICCs was in accordance with midpoint of the anterior border of the tibia and the Portney and Watkins [30]:> 0.75 = good, 0.5 to 0.75 = reading in degrees was recorded by the tester [21]. No moderate, and < 0.5 = poor reliability. Measurement pre-conditioning stretching was performed [25]. The test error was expressed in the original units using the stand- was completed three times, with 10 s rest between tests, ard error of measurement, SEM = SD*√(1-ICC) and the and the average score was documented as the test result. 95% CI = mean score ± 1.96(SEM) [30]. To determine Each tester read and recorded their own Lunge scores as the smallest amount of change in ankle dorsiflexion that would occur in clinical practice. must be achieved to reflect a true change, outside the Neuropathy status was assessed using a monofilament error of the tests, the MDC was calculated as MDC = and a neurothesiometer which are reliable tests for 1.96*SEM*√2[30]. Paired t tests were performed for measuring foot sensation [26, 27]. Four points on the mean ankle dorsiflexion measures to determine whether plantar surface of the dominant foot (1st, 3rd and 5th a statistically significant difference existed for intratester metatarsal heads and the distal hallux) were tested with scores between sessions 1 and 2 and for intertester a 10 g Semmes-Weinstein monofilament. An abnormal scores in session 2 [30]. Differences in participant char- test was noted if the participant failed to identify the acteristics between the diabetes and diabetes reliability monofilament at one or more test sites [28]. A neurothe- groups were evaluated by independent samples t-test for siometer (Horwell, Bailey Instruments, Manchester,UK) continuous variables and Chi-square test for categorical was used to detect the vibration perception threshold variables [30]. (VPT) at the pulp of the hallux. Three readings were Pearson product-moment correlation coefficients were taken and the average used in analysis. A VPT value of calculated to assess any correlation between a Lunge test and the modified Lidcombe template scores using the full diabetes group (n = 136) and the control group [30]. The Pearson r values were interpreted as follows: 0 to ±0.30 indicates a negligible relationship, ±0.30 to ±0.50 a low, ±0.50 to ±0.70 a moderate, ±0.70 to 0.90 a high and ± 0.91 to ±1.00 a very high relationship [31]. Results One hundred and thirty-six people with diabetes and 30 people without diabetes were recruited for the study (Table 1). The diabetes group were older, heavier, had a higher body mass index (BMI) and less weight bearing Fig. 2 Measurement of ankle joint dorsiflexion using a Lunge test and non-weight bearing range of ankle dorsiflexion than with knee extended the non-diabetes group (p < 0.01). There were no Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 4 of 7 Table 1 Participant Characteristics. Values are mean (SD) unless stated otherwise Diabetes group (n = 136) Diabetes reliability group (n = 30) Non-diabetes group (n = 30) Age (years) 68.8 (10.7) 65.8 (16.0) 28.0 (6.8) Age range (years) 25.6–91.8 25.6–86.5 21.7–55.9 Female (n) 65(47.8%) 17(56.7%) 14(46.7%) Weight (kg) 92.9 (19.0) 97.2 (24.5) 78.0 (19.6) BMI 32.7 (6.2) 34.5 (7.5) 25.6 (6.6) Ankle dorsiflexion Lidcombe (degrees) 3.2 (5.8) 3.6 (6.7) 9.2 (5.8) Ankle dorsiflexion Lunge (degrees) 33.0 (7.4) 34.5 (6.3) 39.8 (7.9) Neuropathy (n(%)) 65 (47.8%) 10 (33.3%) 0 (0%) significant differences between the total diabetes group ankledorsiflexioninbothdiabetes and non-diabetes (n = 136) and the subset of participants in the diabetes groups was excellent, with ICCs of 0.91 and 95% CIs reliability group (n = 30) for ankle dorsiflexion Lidcombe from 0.81 to 0.96 (Table 3). Intertester reliability was (p = 0.69), ankle dorsiflexion Lunge (p = 0.30), age (p = also excellent for the use of a Lunge test to measure 0.33), BMI (p = 0.17), weight (p = 0.29), gender (p = 0.38) weight bearing ankle dorsiflexion in both groups or neuropathy status (p = 0.15). Mean ankle dorsiflexion with ICCs of 0.93 (non-diabetes group) and 0.88 measurements did not differ significantly between ses- (diabetes group) and 95% CIs from 0.77 to 0.96 sion 1 and session 2 for either tester (Table 2). (Table 3). SEM values for the modified Lidcombe template were 1.7° (non-diabetes group) and 1.9° Intratester reliability (diabetes group), with MDCs of 4.8° and 5.1°. The Intratester reliability for the use of the modified Lid- Lunge test SEM values were also low at 2.1°, with combe template to measure non-weight bearing ankle MDC values of 5.5° and 5.6°. dorsiflexion in both diabetes and non-diabetes groups was excellent for both testers (Table 3). The ICCs ranged from 0.89 to 0.94 with 95% CIs from 0.78 to 0.97. Simi- Correlations between weight bearing and non-weight larly, intratester reliability for the use of the Lunge test bearing measures to measure weight bearing ankle dorsiflexion in both There was a negligible correlation between the weight groups was excellent for both testers, with ICCs from bearing and non-weight bearing measures of ankle 0.83 to 0.89 and 95% CIs from 0.67 to 0.94 (Table 3). dorsiflexion (r < 0.01, p =0.99 and r = 0.01, p =0.97 for The modified Lidcombe template SEM values were low, testers 1 and 2 respectively) in the diabetes group. ranging from 1.6° to 2.0°, for both testers across the two There was a moderate, significant correlation between groups, and the MDC were between 4.6° and 5.2°. The the measures of ankle dorsiflexion in the non-diabetes Lunge test SEM values were also low, ranging from 2.4° group (r =0.62 and r = 0.67 for testers 1 and 2 re- to 3.2°with MDC values between 6.2° and 7.6°. spectively, p < 0.01) in session 1. The weight bearing range of motion was approximately four times larger Intertester reliability than the non-weight bearing motion in the Intertester reliability for the use of the modified non-diabetes group and approximately 10 times larger Lidcombe template to measure non-weight bearing in the diabetes group (Table 1). Table 2 Mean tester ankle dorsiflexion measurements and intratester p values in groups with and without diabetes. Values are degrees (SD) Diabetes reliability group (n = 30) Non-diabetes group (n = 30) Session 1 Session 2 p value Session 1 Session 2 p value Lidcombe template Tester 1 3.6 (6.7) 3.5 (6.8) 0.80 9.2 (5.9) 9.6 (5.0) 0.51 Tester 2 3.3 (5.9) 3.3 (6.5) 0.98 9.2 (5.8) 9.5 (5.3) 0.45 Lunge test Tester 1 34.5 (6.3) 34.2 (6.5) 0.66 39.1 (8.2) 39.1 (7.2) 0.97 Tester 2 34.4 (6.3) 35.1 (6.8) 0.30 40.6 (7.7) 41.5 (7.1) 0.17 Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 5 of 7 Table 3 Intratester and Intertester reliability of ankle dorsiflexion measurements in groups with and without diabetes Diabetes reliability group Non-diabetes group Measure ICC (95% CI) SEM (95% CI) degrees MDC ICC (95% CI) SEM (95% CI) degrees MDC Intratester Reliability Lidcombe template Tester 1 0.94 (0.88–0.97) 1.6 (0.4–6.8) 4.6 0.89(0.78–0.95) 2.0 (5.4–13.0) 5.2 Tester 2 0.90 (0.80–0.95) 1.9 (−0.4–7.0) 5.1 0.89(0.78–0.95) 1.9 (5.5–13.0) 5.2 Lunge test Tester 1 0.83 (0.67–0.92) 2.6 (29.4–39.6) 6.5 0.85 (0.72–0.93) 3.2 (32.9–45.3) 7.6 Tester 2 0.85 (0.71–0.93) 2.4 (29.6–39.6) 6.2 0.89(0.78–0.94) 2.6 (35.6–45.6) 6.4 Intertester Reliability Lidcombe template 0.91 (0.83–0.96) 1.9 (− 0.2–7.2) 5.1 0.91 (0.81–0.95) 1.7 (5.8–12.6) 4.8 Lunge test 0.88 (0.77–0.94) 2.1 (30.3–38.7) 5.6 0.93 (0.85–0.96) 2.1 (35.7–43.9) 5.5 Abbreviations: ICC intraclass correlation coefficient, CI confidence interval, SEM standard error measurement, MDC minimal detectable change Discussion problems with non-weight bearing measurement, and We found the modified Lidcombe template and a Lunge we have shown it to be reliable in diabetes cohort and a test to be reliable tests to measure non-weight bearing healthy adult population, there are still limitations to its and weight bearing ankle dorsiflexion in adults with and use in clinical practice. The device is not commercially without diabetes. The modified Lidcombe template available, there is a cost of acquiring the equipment and showed excellent levels of intratester and intertester reli- it requires two people for assessment. In contrast, a ability. While this is the first study to assess the reliabil- Lunge test requires only one individual with an inclin- ity of a modified Lidcombe template in people with ometer or smartphone [36], is fast, and may more accur- diabetes, our findings are consistent with previously re- ately reflect restriction experienced during activities of ported reliability in healthy participants and participants daily living [37, 38]. Consequently an aim of this study with pathology using both the original and modified was to determine any correlation between weight and Lidcombe templates. Moseley and Adams [32] and non-weight bearing measures of ankle dorsiflexion, with Keating et al. [33] both reported excellent intertester re- an objective of being able to use a Lunge test in future liability of a Lidcombe template (ICC = 0.97 and > 0.92 practice while allowing comparison to past evidence. to 0.97 respectively) in unimpaired adults, stroke im- Our results showed a moderate correlation (r = 0.62 paired adults [32, 33] and those with head injuries [32]. and r = 0.67, p < 0.01) between weight and non-weight Similarly Scharfbillig et al. [20] found excellent intrates- bearing measures of ankle dorsiflexion in the ter and intertester reliability (ICC > 0.99) when using a non-diabetes group, which is in line with the findings of modified Lidcombe template to measure ankle dorsiflex- other authors. Rabin and Kozol [39] also found a moder- ion in fourteen children aged 7 to 14 years. ate correlation (r = 0.6 and r = 0.64, p < 0.01) between Our Lunge test results also showed excellent intertes- ankle dorsiflexion measured weight bearing and ter and intratester reliability for both the diabetes and non-weight bearing in a group of 43 healthy young men non-diabetes groups. These results are consistent with a and women (mean (SD) age and body mass: 25.5(4.9) recent systematic review of reliability of the weight bear- years,63.3(12.2) kg). However, their non-weight bearing ing lunge test in healthy populations [34]. The review assessment was performed with a goniometer which has found intertester reliability was excellent, ranging from been shown to be unreliable [19, 40]. The authors found ICC 0.80 to 0.99 across nine studies, while intertester re- a similar moderate correlation (r = 0.61 and r = 0.55, p liability was reported as good to excellent, ranging from < .01) when they repeated the trial with 64 healthy young ICC 0.65 to 0.99 across twelve studies [34]. As 33.3% of males (mean (SD) age and body mass: 19.6 (1.0) the reliability group had neuropathy, and neuropathy is years,71.4 (7.7) kg) [41]. The moderate correlation may reported to affect 16 to 66% of people with diabetes [35], be a result of the two tests measuring different joint mo- our results may be generalised to the wider diabetes tions as some subtalar, midtarsal or tarsometarsal joint population. motion could be expected to occur in weight bearing The high reliability of a weight bearing lunge test when the foot is fully loaded [22]. found in this study is particularly relevant to a clinical In contrast, we found a negligible correlation (r < 0.01, context. While ankle dorsiflexion measurement using p = 0.99 and r = 0.01, p = 0.97) between the two measures the Lidcombe template addresses many of the known in the diabetes group. The heavier body weight in our Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 6 of 7 diabetes group may have contributed to the differing re- results. Finally, the testers had practice sessions prior to sults. During the stance phase of walking the ankle joint the start of the trial to familiarise themselves with the experiences forces of up to five times body weight, Lidcombe template equipment therefore similar reliabil- which in heavier people may be much larger than the ity may not be achieved by inexperienced testers. standardised 80.4 N force applied in non-weight bearing [42]. In addition, non-enzymatic glycosylation occurring Conclusions in diabetes and older age may have contributed to the A modified Lidcombe template is a reliable tool for development of stiffer tendon structures and increased measuring non-weight bearing ankle dorsiflexion in both resistance to the standardised force [12]. This is sup- young adults and people with diabetes. A Lunge test is ported by the diabetes group having weight bearing mea- also a reliable test in these populations and, being weight surements up to 10 times larger than the non-weight bearing, is arguably a more functional measure of ankle bearing measurements, compared to only four times lar- dorsiflexion. A moderate correlation was found between ger in the non-diabetes group. the weight bearing and non-weight bearing measures in To achieve comparative results between the two tests people without diabetes and the correlation was negli- it may be necessary to normalise the standardised force gible in people with diabetes. Further investigation to to body weight [8]. Alternatively, given the ease, high re- define weight bearing ankle dorsiflexion normative liability and more functional position of weight bearing ranges may prove to be more clinically relevant than re- measurement [34], it may be more clinically relevant for finement of non-weight bearing dorsiflexion assessment. further research to investigate a Lunge test in varied Abbreviations populations. This could provide a range of normative BMI: Body mass index; CIs: 95% confidence intervals; ICC: Intraclass values for weight bearing ankle dorsiflexion and for correlation coefficient; MDC: Minimal detectable change; SEM: Standard error of measurement ankle dorsiflexion restriction, similar to the zero and five degrees values that are in common use for non-weight Funding bearing ankle equinus. A recent trial investigating stan- This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. dardised examination and normative values for weight bearing ankle dorsiflexion, proposed that in young Availability of data and materials healthy people values of < 30° with the knee extended The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. should be considered impaired [43]. Our results indicate that 30.9% of our diabetes group and 16.7% of our Authors’ contributions non-diabetes group displayed weight bearing ankle VHC and MJS planned the trial. AS and MJS conducted the trial. VHC conducted data analysis and interpretation. VHC, MJS and AS drafted the dorsiflexion of < 30°. final manuscript. All authors read and approved the final manuscript. MDC values were calculated for use in a clinical context such as before and after an intervention designed to in- Ethics approval and consent to participate Ethics approval was granted by the University of Newcastle Human Research Ethics crease ankle dorsiflexion range of motion. Average modi- Committee and written informed consent was obtained from all participants. fied Lidcombe template MDC scores of 4.9° (diabetes group) or 5.2° (non-diabetes group) represent a clinically Competing interests The authors declare that they have no competing interests. significant change in ankle joint motion and are well in excess of the SEM, indicating that such a change would be unlikely to be due to error and more likely to be due to an Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in actual change in range of dorsiflexion. Keating reports published maps and institutional affiliations. similar figures of 7° for stroke impaired subjects and 3° for unimpaired students [33]. The average MDC scores for Author details School of Health Sciences, Faculty of Health, University of Newcastle, PO the Lunge test of 6.4°(diabetes group) and 7° (non-diabetes Box 127, Ourimbah, NSW 2258, Australia. Priority Research Centre for group) are slightly higher than the 4.7° reported in a re- Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, view of healthy populations [34]. Australia. The results of this study need to be interpreted with Received: 12 February 2018 Accepted: 25 May 2018 the knowledge of its limitations. The tester was not blinded to the ankle dorsiflexion readings from the References Lunge test, however, this is the method used in clinical 1. Dawe EJ, Davis J. Anatomy and biomechanics of the foot and ankle. practice. All the range of motion testing was conducted Orthopaedics and Trauma. 2011;25(4):279–86. in one session which may have resulted in the muscle 2. Cornwall MW, McPoil TG. Effect of ankle dorsiflexion range of motion on rearfoot motion during walking. J Am Podiatr Med Assoc. 1999;89(6):272–7. unit stretching during the session. This was mitigated by 3. 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Clinical examination for the detection of protective sensation in the feet of diabetic patients. J Gen Intern Med. 1999;14(7):418–24. 27. van Deursen RW, Sanchez MM, Derr JA, Becker MB, Ulbrecht JS, Cavanagh PR. Vibration perception threshold testing in patients with diabetic neuropathy: ceiling effects and reliability. Diabet Med. 2001 Jun;18(6):469–75. 28. Boulton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest Group of the American Diabetes http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Musculoskeletal Disorders Springer Journals

Weight bearing versus non-weight bearing ankle dorsiflexion measurement in people with diabetes: a cross sectional study

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Medicine & Public Health; Orthopedics; Rehabilitation; Rheumatology; Sports Medicine; Internal Medicine; Epidemiology
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Abstract

Background: Accurate measurement of ankle dorsiflexion is important in both research and clinical practice as restricted motion has been associated with many foot pathologies and increased risk of ulcer in people with diabetes. This study aimed to determine the level of association between non-weight bearing versus weight bearing ankle dorsiflexion in adults with and without diabetes, and to evaluate the reliability of the measurement tools. Methods: One hundred and thirty-six adults with diabetes and 30 adults without diabetes underwent ankle dorsiflexion measurement non-weight bearing, using a modified Lidcombe template, and weight bearing, using a Lunge test. Pearson product-moment correlation coefficients, intraclass correlation coefficients (ICCs) with 95% confidence intervals, standard error of measurement and minimal detectable change were determined. Results: There was a moderate correlation (r = 0.62–0.67) between weight and non-weight bearing tests in the non-diabetes group, and a negligible correlation in the diabetes group(r = 0.004–0.007). Intratester reliability was excellent in both groups for the modified Lidcombe template (ICC = 0.89–0.94) and a Lunge test (ICC = 0.83–0.89). Intertester reliability was also excellent in both groups for the Lidcombe template (ICC = 0.91) and a Lunge test (ICC = 0.88–0.93). Conclusions: We found the modified Lidcombe template and a Lunge test to be reliable tests to measure non- weight bearing and weight bearing ankle dorsiflexion in adults with and without diabetes. While both methods are reliable, further definition of weight bearing ankle dorsiflexion normative ranges may be more relevant for clinical practice. Keywords: Dorsiflexion, Ankle, Diabetes, Lunge, Reliability, Lidcombe Background 10° [6, 7], less than 5° [3, 8, 9] or less than zero° of dorsi- Ankle dorsiflexion is essential for normal gait, as the flexion [3, 10, 11]. An equinus can result from a number ankle first plantarflexes after heel strike to bring the of causes including bony block, neurological abnormal- forefoot into contact with the ground, and then dorsi- ities, soft tissue contracture resulting from prolonged in- flexes as the centre of gravity of the body moves over activity or prolonged ankle plantarflexion, and metabolic the joint during forward movement [1]. It is generally changes common in aging and diabetes [12]. In the gen- agreed that a minimum of 5–10° of ankle dorsiflexion is eral population equinus has been associated with condi- required for normal gait [2–4]. Equinus refers to re- tions such as chronic heel pain [13], Achilles tendonitis stricted ankle dorsiflexion, and in the absence of a stan- [14] and plantar fasciitis [15, 16]. In people with dia- dardised definition [5], has been described as less than betes, equinus has been linked to increased ulcer risk [17] and delayed ulcer healing [11]. Therefore, accurate measurement of ankle dorsiflexion is important in both * Correspondence: Angela.Searle@newcastle.edu.au research and clinical practice to allow correct School of Health Sciences, Faculty of Health, University of Newcastle, PO Box 127, Ourimbah, NSW 2258, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 2 of 7 identification of restriction, and measurement of the effi- been used previously, and is considered to be sufficient cacy of interventions to improve motion. to reduce recall bias of testers to previous results [22]. The most common measurement method reported is The order of testers was randomised to minimise bias passive non-weight bearing ankle dorsiflexion using a from repeated testing. One podiatrist and one osteopath, goniometer, however major concerns have been raised both with 10 years of clinical experience performed all about the reliability of this method [18, 19]. A modified the measurements. Testing was conducted on the partic- Lidcombe template was developed to measure ipants’ dominant leg only to maintain independence of non-weight bearing ankle dorsiflexion and has been re- data [23]. Dominance was determined by asking the par- ported to have good reliability, but has not been tested ticipant which foot they would kick a football with. Par- in adult or diabetes populations [20]. Weight bearing ticipants in the diabetes group, who were part of an ankle dorsiflexion, measured with an extended knee ankle equinus trial, were asked at the completion of their Lunge test has also been shown to be reliable in popula- first appointment if they were available to attend another tions without diabetes, is practical for clinical use and measurement session in one weeks’ time. Those who may more accurately reflect restriction experienced dur- volunteered to attend two measurement sessions formed ing gait and activities of daily living [21]. If there is an the diabetes reliability group. association between the two measures, a Lunge test may Non-weight bearing ankle joint range of motion was be able to be recommended for use in clinical practice measured using a modified Lidcombe template which and research situations, while allowing comparison with was designed to address the deficiencies in goniometric previous results. testing [20]. This consisted of a 300 mm solid foot plate Therefore, the aims of this study were to test in adult hinged to a solid base plate (Fig. 1). A digital protractor populations with and without diabetes; 1) the reliability (Bear Digital Protractor 82201B-00, China) was fixed to of a modified Lidcombe template to measure passive the back of the foot plate to allow the degree of dorsi- non-weight bearing ankle dorsiflexion, and, a Lunge test flexion to be measured. To allow application of a con- to measure weight bearing ankle dorsiflexion, and 2) the sistent dorsiflexion force, a digital force gauge level of association between ankle dorsiflexion measured (FGD-200, Starr Instruments, Melbourne, Australia) was using the above methods. attached to the front of the foot plate at a distance of 200 mm from the hinge attachment. Participants were Methods required to lay reclined with their knees extended on an Ethics approval was granted by the University of New- examination table with the base plate of the device castle Human Research Ethics Committee and written placed under the dominant leg. Participants were ad- informed consent was obtained from all participants. A vised against actively dorsiflexing their ankle, flexing group of 136 adults with diabetes were recruited from their knee or resisting the applied force during the the University of Newcastle Podiatry Clinic at Wyong examination. A standardised force of 80.4 N was applied Hospital, NSW, Australia, and from newspaper adver- to the base plate, by means of the tester pulling on the tisements in local newspapers, between June 2016 and strain gauge, as this is believed to best replicate the October 2017. An additional 30 adults without diabetes forces experienced during gait [5]. The degree of dorsi- were recruited from the student population of the flexion was read from the digital inclinometer by an- University of Newcastle, Ourimbah, Australia. Inclusion other investigator. The digital inclinometer was not criteria were adults, 18 years of age and over, able to visible to the tester which ensured blinding. The test was provide informed consent and a diagnosis of either type 1 or type 2 diabetes for the diabetes group. Exclusion criteria were existing foot ulcer, wound or infection in the lower leg, any previous lower limb amputation, any surgery to the foot or lower limb involving fixation of a joint, any recent injury to the foot or ankle that may be exacerbated or result in pain due to movement of the ankle, and any problems that would prevent the partici- pant from lying reclined for approximately 5 min. Procedures To assess the reliability of the measurement techniques, 30 participants from each group were assessed by two testers at the same testing session on two separate occa- Fig. 1 Lidcombe template sions, five to ten days apart. This period of time has Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 3 of 7 completed three times, with 10 s rest between tests, and > 25 V was regarded as abnormal [28]. Participants were the average score was documented as the test result. assessed as neuropathic if they recorded one or more ab- A Lunge test with the knee extended was used to de- normal test results. termine ankle joint dorsiflexion range of motion in a weight bearing position (Fig. 2). This method was chosen Sample size as it has been reported to have excellent interrater (ICC For the measurement tool reliability calculations a sam- = 0.82) and interrater (ICC = 0.88) reliability, and it mea- ple size of 30 participants per group was determined sures the effects of gastrocnemius tightness, which is re- based on α = 0.05, β = 0.20 for two observations per par- ported to be a main contributor to ankle dorsiflexion ticipant, with a target intraclass correlation coefficient restriction [3, 24]. A tape line was placed on the floor (ICC) of 0.8 and a lowest acceptable ICC of 0.50 [29]. perpendicular to the wall. The participant placed both hands on the wall in front of them and then positioned Statistical analysis their dominant leg behind them as far as possible. The All statistical tests were conducted using SPSS Release second toe and the centre of the heel of the participant’s 24 for Windows (SPSS Inc., Chicago, Ill., USA). Intra- dominant foot were situated over the tape line to min- and intertester reliability was assessed using interclass imise subtalar joint pronation during measurement. The coefficients (ICC) and standard error of measurement participant was asked to lean forward until a maximum (SEM) with 95% confidence intervals (CIs) and minimal stretch was felt in the dominant leg, while keeping the detectable change (MDC). An ICC [1, 3] was calculated heel of the dominant foot in contact with the ground, for intertester reliability between testers 1 and 2 in ses- and the knee of the dominant leg fully extended. The sion one and intratester reliability between sessions one digital protractor described above was placed on the and two. Interpretation of ICCs was in accordance with midpoint of the anterior border of the tibia and the Portney and Watkins [30]:> 0.75 = good, 0.5 to 0.75 = reading in degrees was recorded by the tester [21]. No moderate, and < 0.5 = poor reliability. Measurement pre-conditioning stretching was performed [25]. The test error was expressed in the original units using the stand- was completed three times, with 10 s rest between tests, ard error of measurement, SEM = SD*√(1-ICC) and the and the average score was documented as the test result. 95% CI = mean score ± 1.96(SEM) [30]. To determine Each tester read and recorded their own Lunge scores as the smallest amount of change in ankle dorsiflexion that would occur in clinical practice. must be achieved to reflect a true change, outside the Neuropathy status was assessed using a monofilament error of the tests, the MDC was calculated as MDC = and a neurothesiometer which are reliable tests for 1.96*SEM*√2[30]. Paired t tests were performed for measuring foot sensation [26, 27]. Four points on the mean ankle dorsiflexion measures to determine whether plantar surface of the dominant foot (1st, 3rd and 5th a statistically significant difference existed for intratester metatarsal heads and the distal hallux) were tested with scores between sessions 1 and 2 and for intertester a 10 g Semmes-Weinstein monofilament. An abnormal scores in session 2 [30]. Differences in participant char- test was noted if the participant failed to identify the acteristics between the diabetes and diabetes reliability monofilament at one or more test sites [28]. A neurothe- groups were evaluated by independent samples t-test for siometer (Horwell, Bailey Instruments, Manchester,UK) continuous variables and Chi-square test for categorical was used to detect the vibration perception threshold variables [30]. (VPT) at the pulp of the hallux. Three readings were Pearson product-moment correlation coefficients were taken and the average used in analysis. A VPT value of calculated to assess any correlation between a Lunge test and the modified Lidcombe template scores using the full diabetes group (n = 136) and the control group [30]. The Pearson r values were interpreted as follows: 0 to ±0.30 indicates a negligible relationship, ±0.30 to ±0.50 a low, ±0.50 to ±0.70 a moderate, ±0.70 to 0.90 a high and ± 0.91 to ±1.00 a very high relationship [31]. Results One hundred and thirty-six people with diabetes and 30 people without diabetes were recruited for the study (Table 1). The diabetes group were older, heavier, had a higher body mass index (BMI) and less weight bearing Fig. 2 Measurement of ankle joint dorsiflexion using a Lunge test and non-weight bearing range of ankle dorsiflexion than with knee extended the non-diabetes group (p < 0.01). There were no Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 4 of 7 Table 1 Participant Characteristics. Values are mean (SD) unless stated otherwise Diabetes group (n = 136) Diabetes reliability group (n = 30) Non-diabetes group (n = 30) Age (years) 68.8 (10.7) 65.8 (16.0) 28.0 (6.8) Age range (years) 25.6–91.8 25.6–86.5 21.7–55.9 Female (n) 65(47.8%) 17(56.7%) 14(46.7%) Weight (kg) 92.9 (19.0) 97.2 (24.5) 78.0 (19.6) BMI 32.7 (6.2) 34.5 (7.5) 25.6 (6.6) Ankle dorsiflexion Lidcombe (degrees) 3.2 (5.8) 3.6 (6.7) 9.2 (5.8) Ankle dorsiflexion Lunge (degrees) 33.0 (7.4) 34.5 (6.3) 39.8 (7.9) Neuropathy (n(%)) 65 (47.8%) 10 (33.3%) 0 (0%) significant differences between the total diabetes group ankledorsiflexioninbothdiabetes and non-diabetes (n = 136) and the subset of participants in the diabetes groups was excellent, with ICCs of 0.91 and 95% CIs reliability group (n = 30) for ankle dorsiflexion Lidcombe from 0.81 to 0.96 (Table 3). Intertester reliability was (p = 0.69), ankle dorsiflexion Lunge (p = 0.30), age (p = also excellent for the use of a Lunge test to measure 0.33), BMI (p = 0.17), weight (p = 0.29), gender (p = 0.38) weight bearing ankle dorsiflexion in both groups or neuropathy status (p = 0.15). Mean ankle dorsiflexion with ICCs of 0.93 (non-diabetes group) and 0.88 measurements did not differ significantly between ses- (diabetes group) and 95% CIs from 0.77 to 0.96 sion 1 and session 2 for either tester (Table 2). (Table 3). SEM values for the modified Lidcombe template were 1.7° (non-diabetes group) and 1.9° Intratester reliability (diabetes group), with MDCs of 4.8° and 5.1°. The Intratester reliability for the use of the modified Lid- Lunge test SEM values were also low at 2.1°, with combe template to measure non-weight bearing ankle MDC values of 5.5° and 5.6°. dorsiflexion in both diabetes and non-diabetes groups was excellent for both testers (Table 3). The ICCs ranged from 0.89 to 0.94 with 95% CIs from 0.78 to 0.97. Simi- Correlations between weight bearing and non-weight larly, intratester reliability for the use of the Lunge test bearing measures to measure weight bearing ankle dorsiflexion in both There was a negligible correlation between the weight groups was excellent for both testers, with ICCs from bearing and non-weight bearing measures of ankle 0.83 to 0.89 and 95% CIs from 0.67 to 0.94 (Table 3). dorsiflexion (r < 0.01, p =0.99 and r = 0.01, p =0.97 for The modified Lidcombe template SEM values were low, testers 1 and 2 respectively) in the diabetes group. ranging from 1.6° to 2.0°, for both testers across the two There was a moderate, significant correlation between groups, and the MDC were between 4.6° and 5.2°. The the measures of ankle dorsiflexion in the non-diabetes Lunge test SEM values were also low, ranging from 2.4° group (r =0.62 and r = 0.67 for testers 1 and 2 re- to 3.2°with MDC values between 6.2° and 7.6°. spectively, p < 0.01) in session 1. The weight bearing range of motion was approximately four times larger Intertester reliability than the non-weight bearing motion in the Intertester reliability for the use of the modified non-diabetes group and approximately 10 times larger Lidcombe template to measure non-weight bearing in the diabetes group (Table 1). Table 2 Mean tester ankle dorsiflexion measurements and intratester p values in groups with and without diabetes. Values are degrees (SD) Diabetes reliability group (n = 30) Non-diabetes group (n = 30) Session 1 Session 2 p value Session 1 Session 2 p value Lidcombe template Tester 1 3.6 (6.7) 3.5 (6.8) 0.80 9.2 (5.9) 9.6 (5.0) 0.51 Tester 2 3.3 (5.9) 3.3 (6.5) 0.98 9.2 (5.8) 9.5 (5.3) 0.45 Lunge test Tester 1 34.5 (6.3) 34.2 (6.5) 0.66 39.1 (8.2) 39.1 (7.2) 0.97 Tester 2 34.4 (6.3) 35.1 (6.8) 0.30 40.6 (7.7) 41.5 (7.1) 0.17 Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 5 of 7 Table 3 Intratester and Intertester reliability of ankle dorsiflexion measurements in groups with and without diabetes Diabetes reliability group Non-diabetes group Measure ICC (95% CI) SEM (95% CI) degrees MDC ICC (95% CI) SEM (95% CI) degrees MDC Intratester Reliability Lidcombe template Tester 1 0.94 (0.88–0.97) 1.6 (0.4–6.8) 4.6 0.89(0.78–0.95) 2.0 (5.4–13.0) 5.2 Tester 2 0.90 (0.80–0.95) 1.9 (−0.4–7.0) 5.1 0.89(0.78–0.95) 1.9 (5.5–13.0) 5.2 Lunge test Tester 1 0.83 (0.67–0.92) 2.6 (29.4–39.6) 6.5 0.85 (0.72–0.93) 3.2 (32.9–45.3) 7.6 Tester 2 0.85 (0.71–0.93) 2.4 (29.6–39.6) 6.2 0.89(0.78–0.94) 2.6 (35.6–45.6) 6.4 Intertester Reliability Lidcombe template 0.91 (0.83–0.96) 1.9 (− 0.2–7.2) 5.1 0.91 (0.81–0.95) 1.7 (5.8–12.6) 4.8 Lunge test 0.88 (0.77–0.94) 2.1 (30.3–38.7) 5.6 0.93 (0.85–0.96) 2.1 (35.7–43.9) 5.5 Abbreviations: ICC intraclass correlation coefficient, CI confidence interval, SEM standard error measurement, MDC minimal detectable change Discussion problems with non-weight bearing measurement, and We found the modified Lidcombe template and a Lunge we have shown it to be reliable in diabetes cohort and a test to be reliable tests to measure non-weight bearing healthy adult population, there are still limitations to its and weight bearing ankle dorsiflexion in adults with and use in clinical practice. The device is not commercially without diabetes. The modified Lidcombe template available, there is a cost of acquiring the equipment and showed excellent levels of intratester and intertester reli- it requires two people for assessment. In contrast, a ability. While this is the first study to assess the reliabil- Lunge test requires only one individual with an inclin- ity of a modified Lidcombe template in people with ometer or smartphone [36], is fast, and may more accur- diabetes, our findings are consistent with previously re- ately reflect restriction experienced during activities of ported reliability in healthy participants and participants daily living [37, 38]. Consequently an aim of this study with pathology using both the original and modified was to determine any correlation between weight and Lidcombe templates. Moseley and Adams [32] and non-weight bearing measures of ankle dorsiflexion, with Keating et al. [33] both reported excellent intertester re- an objective of being able to use a Lunge test in future liability of a Lidcombe template (ICC = 0.97 and > 0.92 practice while allowing comparison to past evidence. to 0.97 respectively) in unimpaired adults, stroke im- Our results showed a moderate correlation (r = 0.62 paired adults [32, 33] and those with head injuries [32]. and r = 0.67, p < 0.01) between weight and non-weight Similarly Scharfbillig et al. [20] found excellent intrates- bearing measures of ankle dorsiflexion in the ter and intertester reliability (ICC > 0.99) when using a non-diabetes group, which is in line with the findings of modified Lidcombe template to measure ankle dorsiflex- other authors. Rabin and Kozol [39] also found a moder- ion in fourteen children aged 7 to 14 years. ate correlation (r = 0.6 and r = 0.64, p < 0.01) between Our Lunge test results also showed excellent intertes- ankle dorsiflexion measured weight bearing and ter and intratester reliability for both the diabetes and non-weight bearing in a group of 43 healthy young men non-diabetes groups. These results are consistent with a and women (mean (SD) age and body mass: 25.5(4.9) recent systematic review of reliability of the weight bear- years,63.3(12.2) kg). However, their non-weight bearing ing lunge test in healthy populations [34]. The review assessment was performed with a goniometer which has found intertester reliability was excellent, ranging from been shown to be unreliable [19, 40]. The authors found ICC 0.80 to 0.99 across nine studies, while intertester re- a similar moderate correlation (r = 0.61 and r = 0.55, p liability was reported as good to excellent, ranging from < .01) when they repeated the trial with 64 healthy young ICC 0.65 to 0.99 across twelve studies [34]. As 33.3% of males (mean (SD) age and body mass: 19.6 (1.0) the reliability group had neuropathy, and neuropathy is years,71.4 (7.7) kg) [41]. The moderate correlation may reported to affect 16 to 66% of people with diabetes [35], be a result of the two tests measuring different joint mo- our results may be generalised to the wider diabetes tions as some subtalar, midtarsal or tarsometarsal joint population. motion could be expected to occur in weight bearing The high reliability of a weight bearing lunge test when the foot is fully loaded [22]. found in this study is particularly relevant to a clinical In contrast, we found a negligible correlation (r < 0.01, context. While ankle dorsiflexion measurement using p = 0.99 and r = 0.01, p = 0.97) between the two measures the Lidcombe template addresses many of the known in the diabetes group. The heavier body weight in our Searle et al. BMC Musculoskeletal Disorders (2018) 19:183 Page 6 of 7 diabetes group may have contributed to the differing re- results. Finally, the testers had practice sessions prior to sults. During the stance phase of walking the ankle joint the start of the trial to familiarise themselves with the experiences forces of up to five times body weight, Lidcombe template equipment therefore similar reliabil- which in heavier people may be much larger than the ity may not be achieved by inexperienced testers. standardised 80.4 N force applied in non-weight bearing [42]. In addition, non-enzymatic glycosylation occurring Conclusions in diabetes and older age may have contributed to the A modified Lidcombe template is a reliable tool for development of stiffer tendon structures and increased measuring non-weight bearing ankle dorsiflexion in both resistance to the standardised force [12]. This is sup- young adults and people with diabetes. A Lunge test is ported by the diabetes group having weight bearing mea- also a reliable test in these populations and, being weight surements up to 10 times larger than the non-weight bearing, is arguably a more functional measure of ankle bearing measurements, compared to only four times lar- dorsiflexion. A moderate correlation was found between ger in the non-diabetes group. the weight bearing and non-weight bearing measures in To achieve comparative results between the two tests people without diabetes and the correlation was negli- it may be necessary to normalise the standardised force gible in people with diabetes. Further investigation to to body weight [8]. Alternatively, given the ease, high re- define weight bearing ankle dorsiflexion normative liability and more functional position of weight bearing ranges may prove to be more clinically relevant than re- measurement [34], it may be more clinically relevant for finement of non-weight bearing dorsiflexion assessment. further research to investigate a Lunge test in varied Abbreviations populations. This could provide a range of normative BMI: Body mass index; CIs: 95% confidence intervals; ICC: Intraclass values for weight bearing ankle dorsiflexion and for correlation coefficient; MDC: Minimal detectable change; SEM: Standard error of measurement ankle dorsiflexion restriction, similar to the zero and five degrees values that are in common use for non-weight Funding bearing ankle equinus. A recent trial investigating stan- This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. dardised examination and normative values for weight bearing ankle dorsiflexion, proposed that in young Availability of data and materials healthy people values of < 30° with the knee extended The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. should be considered impaired [43]. Our results indicate that 30.9% of our diabetes group and 16.7% of our Authors’ contributions non-diabetes group displayed weight bearing ankle VHC and MJS planned the trial. AS and MJS conducted the trial. VHC conducted data analysis and interpretation. VHC, MJS and AS drafted the dorsiflexion of < 30°. final manuscript. All authors read and approved the final manuscript. MDC values were calculated for use in a clinical context such as before and after an intervention designed to in- Ethics approval and consent to participate Ethics approval was granted by the University of Newcastle Human Research Ethics crease ankle dorsiflexion range of motion. Average modi- Committee and written informed consent was obtained from all participants. fied Lidcombe template MDC scores of 4.9° (diabetes group) or 5.2° (non-diabetes group) represent a clinically Competing interests The authors declare that they have no competing interests. significant change in ankle joint motion and are well in excess of the SEM, indicating that such a change would be unlikely to be due to error and more likely to be due to an Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in actual change in range of dorsiflexion. Keating reports published maps and institutional affiliations. similar figures of 7° for stroke impaired subjects and 3° for unimpaired students [33]. The average MDC scores for Author details School of Health Sciences, Faculty of Health, University of Newcastle, PO the Lunge test of 6.4°(diabetes group) and 7° (non-diabetes Box 127, Ourimbah, NSW 2258, Australia. Priority Research Centre for group) are slightly higher than the 4.7° reported in a re- Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, view of healthy populations [34]. Australia. The results of this study need to be interpreted with Received: 12 February 2018 Accepted: 25 May 2018 the knowledge of its limitations. The tester was not blinded to the ankle dorsiflexion readings from the References Lunge test, however, this is the method used in clinical 1. Dawe EJ, Davis J. Anatomy and biomechanics of the foot and ankle. practice. All the range of motion testing was conducted Orthopaedics and Trauma. 2011;25(4):279–86. in one session which may have resulted in the muscle 2. Cornwall MW, McPoil TG. Effect of ankle dorsiflexion range of motion on rearfoot motion during walking. J Am Podiatr Med Assoc. 1999;89(6):272–7. unit stretching during the session. This was mitigated by 3. 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BMC Musculoskeletal DisordersSpringer Journals

Published: Jun 2, 2018

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