Biomechanics of the heel-raise test performed on an incline in two knee flexion positions

Devices to measure calf raise test outcomes: A narrative review

BACKGROUND

The calf raise test (CRT) is commonly administered without a device in clinics to measure triceps surae muscle function. To standardise and objectively quantify outcomes, researchers use research-grade or customised CRT devices. To incorporate evidence-based practice and apply testing devices effectively in clinics, it is essential to understand their design, applicability, psychometric properties, strengths, and limitations. Therefore, this review identifies, summarises, and critically appraises the CRT devices used in science.

METHODS

Four electronic databases were searched in April 2022. Studies that used devices to measure unilateral CRT outcomes (i.e., number of repetitions, work, height) were included.

RESULTS

Thirty-five studies met inclusion, from which seven CRT devices were identified. Linear encoder (n = 18) was the most commonly used device, followed by laboratory equipment (n = 6) (three-dimensional motion capture and force plate). These measured the three CRT outcomes. Other devices used were electrogoniometer, Häggmark and Liedberg light beam device, Ankle Measure for Endurance and Strength (AMES), Haberometer, and custom-made. Devices were mostly used in healthy populations or Achilles tendon pathologies. AMES, Haberometer, and custom-made devices were the most clinician-friendly, but only quantified repetitions were completed. In late 2022, a computer vision mobile application appeared in the literature and offered clinicians a low-cost, research-grade alternative.

CONCLUSION

This review details seven devices used to measure CRT outcomes. The linear encoder is the most common in research and quantifies all three CRT outcomes. Recent advances in computer-vision provide a low-cost research-grade alternative to clinicians and researchers via a n iOS mobile application.

Midfoot and Ankle Mechanics in Block and Incline Heel Raise Exercises

ABSTRACT

Chiu, LZF and Dæhlin, TE. Midfoot and ankle mechanics in block and incline heel raise exercises. J Strength Cond Res 35(12): 3308-3314, 2021-Although the heel raise exercise is performed to strengthen the calf muscles, the combination of calf muscle and ground reaction forces elicits moments that may deform the foot's longitudinal arch. The primary purpose of this investigation was to examine whether the foot muscles contribute to supporting the longitudinal arch during heel raises. The secondary purpose was to compare foot and ankle mechanical efforts between traditional block vs. 22° incline heel raises. Six women and 6 men performed heel raises with body mass plus a barbell loaded with 40% (BM + 40%) and 60% (BM + 60%) of their body mass. Three-dimensional motion analysis and force platform data were collected. The midfoot joint was evaluated from the angle between the forefoot and rearfoot (i.e., arch angle) and net joint moment, which may elevate or reduce the arch height. Midfoot joint arch elevator moment seemed to be greater for BM + 60% than BM + 40% (p < 0.05; Cohen's d = 1.24-1.61), with minimal change in arch angle (p < 0.05; Cohen's d = 0.15-0.19). Midfoot joint arch elevator and ankle plantar flexor moments seemed to be greater in incline vs. block heel raises for both loads (p < 0.05; Cohen's d = 0.58-0.67). The increase in midfoot joint arch elevator moment with trivial change in arch angle supports the hypothesis that the foot muscles contribute to longitudinal arch support during heel raises. Performing incline heel raises may be hypothesized to be more effective to stimulate foot and calf muscle adaptations than block heel raises.

Plantarflexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus

OBJECTIVES

Determine how the strength and endurance of the plantar flexors are affected by Achilles tendinopathy and whether one muscle is more affected than another.

DESIGN

Case control study.

SETTING

University Laboratory.

PARTICIPANTS

39 Runners with mid-portion Achilles tendinopathy and 38 healthy runners participated in this study.

MAIN OUTCOME MEASURES

Isokinetic dynamometry was completed bilaterally in two knee positions on all subjects to assess the torque and endurance capacity of the plantar flexors.

RESULTS

Subjects with Achilles tendinopathy were statistically weaker (by 26.1Nm Concentric 90°/sec, 14,8Nm Concentric 225°/sec and 55.5Nm Eccentric 90°/sec for knee extended testing and 17.3Nm, 10.1Nm and 52.3Nm for the flexed knee respectively) than healthy controls at all isokinetic test speeds and contraction modes irrespective of knee position (p value = <0.001). The endurance capacity of the plantar flexors was significantly reduced (Total work done 613.5Nm less) in subjects with Achilles tendinopathy when compared to the healthy controls (p value = <0.001).

CONCLUSIONS

Achilles tendinopathy is associated with large deficits in plantar flexor torque and endurance. The deficits are bilateral in nature and appear to be explained by a greater loss of the soleus force generating capacity rather than the gastrocnemius.

Using Bilateral Functional and Anthropometric Tests to Define Symmetry in Cross-Country Skiers

The aim of this study was to evaluate the symmetry of anthropometry and muscle function in cross-country skiers and their association to vertical jumping power. Twenty cross-country skiers were recruited (21.7 ± 3.8 yrs, 180.6 ± 7.6 cm, 73.2 ± 7.6 kg). Anthropometric data was obtained using an iDXA scan. VO_2max was determined using the diagonal stride technique on a ski treadmill. Bilateral functional tests for the upper and lower body were the handgrip and standing heel-rise tests. Vertical jump height and power were assessed with a counter movement jump. Percent asymmetry was calculated using a symmetry index and four absolute symmetry index levels. At a group level the upper body was more asymmetrical with regard to lean muscle mass (p = 0.022, d = 0.17) and functional strength (p = 0.019, d = 0.51) than the lower body. At an individual level the expected frequencies for absolute symmetry level indexes showed the largest deviation from zero for the heel-rise test (χ2 = 16.97, p = 0.001), while the leg lean mass deviated the least (χ2 = 0.42, p = 0.517). No relationships were observed between absolute symmetry level indexes of the lower body and counter movement jump performance (p > 0.05). As a group the skiers display a more asymmetrical upper body than lower body regarding muscle mass and strength. Interestingly at the individual level, despite symmetrical lean leg muscle mass the heel-rise test showed the largest asymmetry. This finding indicates a mismatch in muscle function for the lower body.

Posterior tibial tendon dysfunction: Clinical and magnetic resonance imaging findings having histology as reference standard

OBJECTIVE

To investigate the correlation between MRI, clinical tests, histopathologic features of posterior tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot deformity surgically treated with medializing calcaneal osteotomy and flexor digitorum longus tendon transposition.

MATERIALS AND METHODS

Nineteen patients (11 females; age: 46 ± 15 year, range 18-75) were pre-operatively evaluated using the single heel rise (HR) and the first metatarsal rise (FMR) sign tests. Two reviewers graded the PTT tears on a I-III scale and measured the hindfoot valgus angle on the pre-operative MRI of the ankle. The specimens of the removed portion of PTT were histologically analysed by two pathologists using the Bonar and Movin score. Linear regression, Spearman's rank-order, and intraclass correlation coefficient (ICC) statistics were used.

RESULTS

ICC for MRI was excellent (0.952). Correlation between FMR and HR tests was at limit of significance (r = 0.454; P = 0.051). The HR and FMR tests were significantly correlated to the Movin score (r = 0.581; P = 0.009 and r = 0.538; P = 0.018, respectively) and were not significantly correlated to the Bonar score (both with a r = 0.424; P = 0.070). PTT tendinopathy grading at MRI was significantly correlated to the FMR test (p = 0.041) but not to the hindfoot valgus angle (p = 0.496), the HR test (p = 0.943), the Bonar score (p = 0.937), and the Movin score (p = 0.436). The hindfoot angle was not correlated to any of the other variables (p > 0.264).

CONCLUSION

For PTT dysfunction, there is high correlation between HR and FMR test and histology evaluated using the Movin score, while no correlation was seen for the Bonar score. Semiquantitative grading of PTT dysfunction at MRI only correlates to the FMR and not to histology. The hindfoot valgus angle is not correlated to any of the considered variables.

Updated reliability and normative values for the standing heel-rise test in healthy adults

OBJECTIVES

The heel-rise test is used to assess the strength and endurance of the plantar flexors in everyday clinical practice. However, several factors may affect outcomes, including sex, age, body mass index and activity level. The aims of this study were to revisit the reliability and normative values of this test, and establish normative equations accounting for several factors.

DESIGN

Cross-sectional observational study with test-retest.

SETTING

Community.

PARTICIPANTS

Volunteers (n=566, age 20 to 81 years).

INTERVENTIONS

Subjects performed single-legged heel rises to fatigue, standing on a 10° incline, once on each leg. A subset of subjects (n=32) repeated the test 1 week later. Reliability was quantified using intraclass (ICC) correlation coefficients and Bland-Altman plots {mean difference [95% limits of agreement (LOA)]}, whereas the impact of sex, age, body mass index and activity level on the number of heel rises was determined using non-parametric regression models.

RESULTS

The test showed excellent reliability (ICC=1.0 right leg, 1.0 left leg), with mean between-day differences in the total number of heel-rise repetitions of 0.2 (95% LOA -6.2 to 6.5) and 0.1 (95% LOA -6.1 to 6.2) for right and left legs, respectively. Overall, males completed more repetitions than females (median 24 vs 21). However, older females (age >60years) outperformed older males. According to the model, younger males with higher activity levels can complete the most heel rises.

CONCLUSIONS

The heel-rise test is highly reliable. The regression models herein can be employed by clinicians to evaluate the outcomes of heel-rise tests of individuals against a comparable normative population.

Prospective randomized clinical trial of aggressive rehabilitation after acute Achilles tendon ruptures repaired with Dresden technique

BACKGROUND

Rupture of the Achilles tendon is a common injury during working years. Aggressive rehabilitation may provide better outcomes, but also a greater chance of re-rupture.

OBJECTIVE

To determine if aggressive rehabilitation has better clinical outcomes for Achilles tendon function, Triceps surae function, one-leg heel rise capacity and lower complication rate during twelve weeks after percutaneous Achilles tendon repair compared to conventional rehabilitation.

DESIGN

Randomized controlled trial.

METHOD

Thirty-nine patients were prospectively randomized. The aggressive group (n=20, 41.4 ± 8.3 years) received rehabilitation from the first day after surgery. The conventional group (n=19, 41.7 ± 10.7 years) rested for 28 days, before rehabilitation started. The statistical parameters were the Achilles tendon rupture score (ATRS), verbal pain scale, time to return to work, pain medication consumption, Achilles tendon strength, dorsiflexion range of motion (RoM), injured-leg calf circumference, calf circumference difference, one-leg heel rise repetition and difference, re-rupture rate, strength deficit rate, and other complication rates. Mixed-ANOVA and Bonferroni's post hoc test were performed for multiple comparisons. Student's t-test was performed for parameters measured on the 12th week.

RESULTS

The aggressive group with respect to the conventional group had a higher ATRS; lower verbal pain score; lower pain medication consumption; early return to work; higher Achilles tendon strength; higher one-leg heel rise repetitions; and lower one-leg heel rise difference. The re-rupture rate was 5% and 5%, the strength deficit rate was 42% and 5%, and other complications rate was 11% and 15% in the conventional and aggressive group, respectively.

CONCLUSION

Patients with Dresden repair and aggressive rehabilitation have better clinical outcomes, Achilles tendon function and one-leg heel rise capacity without increasing the postoperative complications rate after 12 weeks compared to rehabilitation with immobilization and non-weight-bearing during the first 28 days after surgery.