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The Standing Heel-Rise Test for Ankle Plantar Flexion Criterion

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					                                 The Standing Heel-Rise Test for Ankle Plantar
                                 Flexion: Criterion for Normal
                                 Brenda Rae Lunsford and Jacquelin Perry
                                 PHYS THER. 1995; 75:694-698.




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Research Report

The Standing Heel-Rise Test for Ankle Plantar
Flexion: Criterion for Normal



Background and Purpose. Manual muscle testing with the examinerprovid-                                         Brenda Rae Lunsford
 ing the resistance has long been a standard test of muscle strength. mrough the                               Jacquelin Pey
 use of extremities acting as levers, clinicians have been able to effectively apply
 resistance to all muscle groups except the the ankle plantar flexors. As a result,
a standing heel-rise test that uses body weight as the resistance has been substi-
tuted. The number of heel-rises that represent normal plantar-flexor "strength"
and the ability of subjects to repeatedly use that "strength" remain unresolved.
Because walking is an endurance task, the hypothesis tested by this study was
 that individuals without known weakness would be able to pe@orm more than
the standard recommended one to five standing heel-rises. The purpose of this
study was to measure the number of standing heel-rises that individuals with-
out known weakness could accomplish.Subjects. Two hundred three subjects
were studied for their ability to do standing heel-rises, as is done when testing
plantar-flexion strength using the upright test. mere were 122 male subjects
and 81 female subjects, ranging in age from 20 to 5 9 years. Methods. Each
subject was asked to do as many standing heel-rises as he or she could, with
careful monitoring of body and limb alignment and of ankle motion, with
specijic criteria for stopping. Results. m e average number of heel-rises was
27.9 (SD=11.1, minimum= 6, maximum= 70)for all groups and both genders,
with no differences between male and female subjects. The lower 99% conj-
dence interval was 25. Conclusion and DCscusskrr A recommendation is
made to change the standard of testing plantar-flexion function, when using
the standing heel-rise test, to require 25 repetitionsfor a grade of Normal.
fLunsford BR, Perry J. m e standing heel-rise test for ankle plantar flexion: crite-
rion for normal. Phys 7ber. 1995 75:694- 698.1

Key Words: Function, Muscle test, Plantarflexion, Strength, Terminal stance.




Manual muscle testing (MMT) has                    to assess muscle forces since its intro-         All grading is based o n the ability of a
been a standard clinical measure used              duction by Lovettl in the early 190s.            subject to move voluntarily against
                                                                                                    gravity and to resist a force applied by
                                                                                                    an e~aminer.~-5 muscle is judged to
                                                                                                                     A
B Lunsford, PT, was Assistant Director, Clinical Services, Physical Therapy Department, Rancho
 R                                                                                                  have Normal strength when the pa-
Los Amigos Medical Center, Downey, C 90242, when this study was conducted. She is currently
                                         A                                                          tient can hold rigidly against the ex-
Visiting Assistant Professor, School of Physical Therapy, Texas Woman's University, and Contract                                   ~ . con-
                                                                                                    aminer's maximum e f f ~ r t .We ~
Physical Therapist, The Institute for Rehabilitation and Research, Houston, TX.Address all corre-
spondence to Mrs Lunsford c/o School of Physical Therapy, Texas Wom'an's University, 1130 M    D    tend the purpose of the MMT is to
Anderson Blvd, Houston, TX 77030 (USA).                                                             ident~fy areas of weakness that may
                                                                                                    prevent individuals from meeting the
J Perry, MD, IS Chief, Pathokinesiology Service, Rancho Los Amigos Medical Center, and Professor
of Orthopedics, University of Southern California, Los Angeles, CA 90007.                           normal demands of daily life. This
                                                                                                    measure is different from quantdying
This study was approved by the Los Amigos Research and Educational Institute Research Review
Committee.
                                                                                                    the force generated by the muscles of
                                                                                                    athletes.
'Ihis article u>assubmitted January 4, 1994, and was accepted March 31, 1995.

Physical Therapy / Volume 75, Number 8 / August 1995                                                                                694 / 49


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Measurements of muscle force are              the contralateral foot so that the plan-         Beasley5 reported a systematic over-
thought to be needed to enable clini-         tar flexors being tested simulate single-        grading when MMT was used and
cians to judge a patient's potential for      limb support, the ipsilateral knee is            implied that patients who had been
function. In the case of walking, tests       fully extended, and the heel is llfted           defined as having "good to normal"
for hip, knee, and ankle muscles are          off the floor through maximum                    muscle function actually had as much
required. In designing a manual test-         plantar-flexion range. During this test,         as a 6 M strength deficit and therefore
ing system for the lower extremity, the       the subject is allowed light finger              that the reliability of such assessments
basic challenge was to find techniques                                             .~
                                              touch only for balance ~ u p p o r tUnre-        is generally in doubt. Studies of pa-
that enable examiners to exert a force        solved, however, was the number of               tients with post-polio syndrome have
(using mainly their triceps and pecto-        heel-rises that represented normal               shown a loss of muscle function sec-
ral muscles) to counter the force of          capacity. Kendall and McCreary3 and              ondary to chronic fatigue believed to
muscles capable of supporting body            Beasley5 required only a single heel-            be related to ovemse.lR-2l
weight. Leverage was the answer.              rise to evaluate "normal" capacity.
When testing the hip muscles, resis-          Because persons without weakness                 Although the standing heel-rise test
tance is applied proximal to the knee         are capable of performing more than a            continues to be used by clinicians,
to give the examiner the leverage             single heel-rise, this test represents a         some published research has de-
advantage of the full length of the           vigorous test not influenced by a sub-           scribed only instrumented,
femur. Similarly, muscles crossing the        ject's ability to repeatedly generate            non-weight-bearing methods, utilizing
knee joint are challenged by applying         force. The standing heel-rise test was           both isometric and isokinetic tech-
the resisted force proximal to the            modified by Daniels and Worthing-                                 9.~~
                                                                                               n i q ~ e s . ~ -The purpose of this study,
ankle. The foot, however, lacks the           ham,2 who suggested that patients                therefore, was to further refine the
length necessary for challenging the          performing four to five repetitions be           standing heel-rise test by assessing the
ankle plantar-flexor muscles. Static          assigned a Normal grade, regardless of           number of heel-rises that can be ac-
calculations indicate that normal plan-       age or gender, with instruction to go            complished by both male and female
tar flexors are capable of producing a        through "a full range-of-motion." The            subjects without known weakness. A
force that appmximates 2.7 times the          actual number o heel-rise repetitions
                                                                  f                            documented standard that reflects the
subject's body weight to counter the          required for "normal" muscle function            normal number of heel-rises could
torque demand caused by the floor             has never been documented. There is              provide an improved clinical guideline
reaction acting on the forefoot at ter-       no evidence that defines the maxi-               for testing plantar-flexion function.
minal stance? Although most examin-                              f
                                              mum number o heel-rises that can be
ers, by taking advantage of a long            expected of subjects with normal                 Method
lever, can produce torques that exceed        plantar-flexor muscle function.
those produced by muscle groups                                                                Subjects
such as the hip abductors and exten-          Clinical experience with patients with
sors, this is not possible when testing       post-polio syndrome has shown that               We tested 203 subjects (122 men and
the triceps surae muscles. During a           such limited heel-rise capability (1-5           81 women) (Tab. 1). The mean age of
manual test of the plantar flexors, for       repetitions) does not allow the patient          the male subjects was 34.7 years
example, the examiner's force would           a normal gait." For example, in our              (SD=8.5), and the mean age of the
have to equal the subject's body              opinion, a patient who can maximally             female subjects was 29.3 years
weight, a force that far exceeds the          complete 5 repetitions will demon-               (SD= 5.0). The mean height and
                         f
average arm strength o many examin-           strate weakness in the calf muscula-             weight of the male subjects were 178.9
          ~ - ~ ~
e r ~ . During normal wallung, the            ture by excessive dorsiflexion in mid-           cm (SD=7.9) and 79.7 kg (SD= 11.51,
demand on the triceps surae muscles           stance to terminal stance and will lack          and the mean height and weight of
increases as the body mass advances           heel-off at terminal stance. Our recent          the female subjects were 164.8 cm
from loading response through termi-          clinical experience with patients who            (SD=6.0) and 60.0 kg (SD=8.6). The
nal stance, with active contraction           have spinal cord injuries has shown              right lower extremity was the domi-
during approximately 9 % of this
                          0                   that patients who can achieve 10                 nant limb tested for both gender
period and with a peak torque de-             standing heel-rise repetitions and               groups (94% and 95% for the male
mand during 52% of each stance                therefore were relieved of their ankle-          and female subjects, respectively)
period.I1-'6                                  foot orthoses have returned to the               (Tab. 1). Each subject was screened
                                              clinic demonstrating a loss of force             for, and excluded if he or she had,
During the peak poliomyelitis era             production with repeated efforts that            any history of musculoskeletal or joint
(1940-19551, practitioners recognized         led to impairment in their gait. Their           pathology involving the hip, knee, or
the inadequacy of a non-weight-               loss of force-generating capacity was            ankle. All subjects gave informed
bearing test of plantar-flexor force.5        identhed by gait deviations (excessive           consent before participating in the
They substituted a standing heel-rise         dorsiflexion during stance) and retest-          study.
test, which relied on weight bearing          ing using the standing heel-rise test.
challenge the plantar flex0rs.~.3.5 The
standing heel-rise test consists o lifting
                                  f

                                                                          Physical Therapy / Volume 75, Number 8 /August 1995

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-
Table 1 .

Variable


Men (n= 122)
                Subject Description

                          -
                          X               SD
                                                   determined by having the subjects
                                                   kick a ball that was rolled to them.24
                                                   With the subject in a standing posi-
                                                   tion, the ankle goniometer, strapped
                                                   to the leg and midfoot, was calibrated
                                                   so that a tibia-foot angle of 90 degrees
                                                   was read as zero on the digital meter
                                                   (Figure). Subjects were instructed to
                                                                                                    data were analyzed using Crunch
                                                                                                    Software.



                                                                                                    Repetitions

                                                                                                    The mean number of standing heel-
  Age (Y)                                          stand straight and to rise and lower on          rise repetitions was 27.9 (SD= 11.1,
  Height (cm)                                      the balls of their feet in rhythm with           minirnum=6, maximum= 70). The
  Weight (kg)                                      the metronome, which was set at a                                    5
                                                                                                    upper and lower 9% confidence
  Dominant limb                                    rate of one heel-rise every 2 seconds.           intervals for the whole group were
    Right                                          Each subject was allowed to touch the            29.8 and 25.8, respectively. There
    Left                                           examiner with a single finger for bal-           were no differences in the mean num-
Women (n-81)                                       ance. The test was terminated if the             ber of standing heel-rise repetitions
                                                   subject leaned or pushed down on the             accomplished between male and fe-
  Age (Y)
  Height (cm)                                      examiner, the subject's knee flexed,             male subjects (Tab. 2). The mean
                                                   the plantar-flexion range of motion              number of heel-rise repetitions for the
  Weight (kg)
                                                    decreased by more than 50% of the               male subjects was 27.8 (SD= 11.51,
  Dominant limb
                                                    starting range of motion, or the subject        with upper and lower confidence
    Right
                                                   quit or asked to stop. There were                intervals of 30.5 and 24.9, respectively
    Left                                                                                            (Tab. 2). The mean number of heel-
                                                   three testers for each subject. One
                                                    tester provided the finger-touch sup-           rise repetitions for the female subjects
                                                    port, one tester observed the subject           was 28.4 (SD=9.8), with 33% confi-
                                                    laterally for any extraneous trunk lean         dence intervals of 30.8 and 25.2, re-
                                                    or knee flexion, and one tester man-            spectively (Tab. 2).
A parallelogram electrogoniometer                   aged the electrogoniometer output.
(Antonelli D, Rehabilitation Engineer-                                                              Angle (Degll~esof Plantar
ing Center, Rancho Los Amigos Hospi-                Data Analysis                                   Rexion)
tal, Downey, Calif; unpublished report;
1975) fitted with a digital readout was             The data were screened, and descrip-             The female subjects achieved a greater
used for measuring range of motion at               tive statistics were calculated and              plantar-flexion angle during the stand-
the ankle during the heel-rises. This               summarized. These data included the              ing heel-rise test than did the male
goniometer was designed to measure                  means of the subjects' age, height, and          subjects. The mean plantar-flexion
angular motion only in the sagittal                 weight and identification of the domi-           angle achieved at 28 repetitions was
plane and to adapt to a variable axis               nant limbs Gab. 1). Means and stan-              24.9 degrees (SD=9.5) for the male
of motion. A metronome was used to                  dard deviations for the standing heel-           subjects and 34.6 degrees (SD=lO.I)
aid in maintaining a consistent rhythm              rise repetitions and degrees of plantar          for the female subjects (Tab. 2).
of heel-rises for each subject. This                flexion achieved were calculated, as
goniometer has been shown to have                   were the upper and lower 93 confi-
                                                                                  !h                 Discussion
an error of 10% when used at the                    dence intervals of the mean. The for-
knee,23 and less than that when used                mula for calculating the confidence              The subjects of this study compared
at the ankle.ll We did not examine the              interval, as specified by the manufac-           closely with those of other s t u d i e ~ ~ , ~ . ~ ~
reliability of these measures in the                turer of the Crunch Software*used in             in age, height, and weight. Although
context of our study.                               this study, was                                                                   recom-
                                                                                                     the muscle testing literat~re~.3.~
                                                                                                     mends 1 to 5 repetitions as a test for
                                                                                                     normal muscle function, this study
                                                                                                     provides a new standard for repeti-
Each subject's height and weight were               A two-sample t test was used to com-             tions. The average number of standing
measured at the outset of the session.              pare the differences between the male            heel-rise repetitions completed in this
Testing was conducted on the dorni-                 and female groups for both repetitions           study was 28, almost six times the
nant limb. Previous studies8~9 have                 and plantar-flexion angle.                       maximum number currently
shown the nondominant limb to be                                                                     re~ommended.~
stronger than the dominant limb. Test-              Simcance testing was set at an alpha
ing was done on the dominant limb                   level of .05. Only data that reached             Walking demands that the plantar
because we believed that a standard                 this level of sigmficance will be dis-           flexors restrain forward momentum
based on the weaker of two normal                   cussed as being differentin the "Re-             when the body mass passes over the
limbs wcbuld have a broader applica-                sults" and "Discussion"sections. All                                     During each
                                                                                                     stance lirnb.ll-13,15~2~28
tion. This functional preference was                                                                 stride, the soleus muscle is active

Physical Therapy / Volume 75, Number 8 / August 1995


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                                                                                                 showed no ddferences between male
                                                                                                 and female subjects in number of
                                                                                                 standing heel-rise repetitions achieved.
                                                                                                 The differences in body mass would
                                                                                                 explain this result. We contend that a
                                                                                                 test that challenges the individual
                                                                                                 against his or her own body mass
                                                                                                 produces a more relevant, functional
                                                                                                 result. The male subjects were 32%
                                                                                                 heavier than the female subjects. This
                                                                                                 body mass difference could be the
                                                                                                 equalizer. If male subjects can gener-
                                                                                                 ate more force, but are heavier, this
                                                                                                 could explain their equality with fe-
                                                                                                 male subjects, in number of repeti-
                                                                                                 tions, when doing the standing heel-
                                                                                                 rise test.

                                                                                                 When the torque data from previous
                                                                                                 studies788 were converted to force
                                                                                                 values, the following was revealed. Up
                                                                                                 to the age of 60 years, the force capa-
                                                                                                 bility of the calf muscles exceeds that
                                                                                                 of body weight, by 1% to 7596.778
                                                                                                 Even though the body mass accounts
                                                                                                 for less than the force capability of the
                                                                                                 plantar flexors, it still provides a major
                                                                                                 challenge of 58% to W h of muscle
                                                                                                 capability in subjects less than 60 years
                                                                                                 of age. For subjects over 60 years of
                                                                                                 age, the body mass'is 10% to 15%
                                                                                                 greater than the plantar-flexion mus-
                                                                                                 cles' force-producing capability.7

                                                                                                 Ineffectiveness in the response of the
                                                                                                 plantar flexors causes instability during
                                                                                                 walking and therefore increases en-
                                                                                                 ergy cost and decreases ~afety.".~5.~9
                                                                                                 Whipple et a129measured the power
                                                                                                 and peak torque in a group of nursing
                                                                                                 home residents with a history of fall-
                                                                                                 ing (mean age =82 years) compared
                                                                                                 with a control group (mean age=85
                                                                                                 years).28 Compared with the control
Figure. Subject shown in standing position with goniometer attached and with                     group, the "fallers" showed a marked
ankle in neutral startingposition. Note zero reading on digital dkplay.
                                                                                                 loss of power and peak torque (77%
                                                                                                 and 7741, respectively) in the ankle
approximately 45% of the gait cycle,            sharply with the average level of                musculature. An accurate deterrnina-
and throughout the muscle's period of           quadriceps femoris muscle activity (ie,
                                                                                                 tion of force-generating capacity,
activity the intensity continually in-          peak effort of 35% and duration of               therefore, is especially important to
creases, reaching 80% of the maxi-              activity of 20% of the gait cycle)."
                                                                                                 avoid overestimating functional capa-
mum heel-rise demand." A similar                                                                 bility, especially in older subjects.
demand is placed on the gastrocne-              Although studies using instrumented
mius muscle. Consequently, both                 techniques consistently show that
                                                                                                 Conclusions and
endurance and high force are re-                male subjects produce greater torque
quired. This level of effort contrasts                                       our
                                                than do female subjects,7~8~22 study
                                                                                                We believe that a non-weight-bearing
                                                                                                manual test of ankle plantar-flexion
'Crunch Software Corp, 2366 Diamond St, #292, San Francisco, CA 94131                           strength is inadequate because of the

52 / 697                                                                    Physical Therapy / Volume 75, Number 8 /August 1995


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                                                                                                       9 Fugl-Meyer AR, Sjostrom M, Wahlby L. Hu-
                                                                                                       man plantar flexion strength and structure.
Table 2.        Comparison o Heel-Rise Repetitions and Angle
                            f                                                                          Acta Physiol Scand. 1979;107:47-56.
                                                                                                       10 Oberg B, Bergman T, Tropp H. Testing of
                                                                                                       isokinetic muscle strength in the ankle. Med
                                Men*                  Womena               Total                       Sci Sports Exerc. 1987;19:318-322,
                                (n=122)               (n=81)               Group              P.       11 Perry J. Gait Analysis: Nonnal and Patho-
                                                                                                       logical Function. Thorofare, NJ: Slack Inc;
                                                                                                       1992.
Repetition                                                                                             12 Murray MP, Drought AB, Kory RC. Walk-
 -                                                                                                     ing patterns of normal men. J Bone Joint Sutg
 X
                                                                                                       [Am]. 1964;46:335-361.
  SD                                                                                                   13 Sutherland DH, Cooper LC, Daniel D. The
  Minimum                                                                                              role of the ankle olantar flexors in normal
                                                                                                      walking. J Bone joint Sutg Dm]. 1980;62:354-
  Maximum                                                                                              363.
  Mode                                                                                                 14 Skinner SR, Antonelli D, Perry J, Lester
  Median                        26                    28                   26                          DK. Functional demands on the stance limb in
                                                                                                      walking. Orthopedics. 1985;8:355-361.
Confidence intervalC                                                                                   15 Sutherland DH. An electromyographic
  99% upper                     30.5                  30.8                 29.8                        study of the plantar flexors of the ankle in
  99% lower                     24.9                  25.2                 25.8                        normal walking on the level. J Bone Joint Sutg
                                                                                                      [Am]. 1966;48:66-71.
Plantar-flexion angle                                                                                  16 Inman VT,Ralston HJ, Todd F. Human
  ("1
  -                                                                                                    Walking. Baltimore, Md: Williams & Wilkins;
  X                             24.9                  34.6                 NAd                <.01     1981.
  SD                              9.5                 10.1                                             17 Mulroy SJ, Perry J, Gronley JK. A compari-
                                                                                                      son of clinical tests for ankle plantar-flexion
                                                                                                      strength. Trans Orthop Res Soc. 191;16:667.
"One comparison between men and women.                                                                 18 Agre JC, Rodriquez AA. Neuromuscular
 not significant                                                                                      function: comparison of symptomatic and
                                                                                                      asymptomatic polio subjects to tontrol s u b
Tonfidence interval for repetitions.                                                                  jects. Arch Phys Med Rehabil. 1330;71:545-
                                                                                                       551.
            t
d N ~ = n o applicable.
                                                                                                       19 Perry J, Barnes G, Gronley JK. The post-
                                                                                                      polio syndrome: an overuse phenomenon.
inability of the examiner to counter                 References                                        Clin Orthop. 1988;233:145-162.
the torque produced by the plantar                                                                    20 Bennett RL, Knowlton GC. Overwork
                                                     1 Loven RW. The Treatment of Infantile Pa-       weakness in partially denervated skeletal mus-
flexors with normal arm strength.                    ralysis. 2nd ed. Philadelphia, Pa: Blakiston's   cle. Clin Orthop. 1958;12:22-29.
Given that the role of the plantar flex-            sonB, co: 1917.
                                                              2   -                                   21 Knowlton GC, Bennett RL. Overwork.
ors is to counter high degrees of                   2 Daniels L, Worthingham C. Muscle Testing        Anrh Phys Med Rehabil. 1957;38:18-20.
torque produced by the forward mo-                   Technique of Manual Examination. 4th ed.         22 Falkel J. Plantar-flexor strength testing us-
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mentum of the body mass, and that                                                                      Ther. 1978;58:847-850.
                                                    3 Kendall FP, McCreary EK. Muscles: Testing
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recommendations are set forth. We                   liams & Wilkins; 1983.                            ometer. In: Orthopedic Seminars, RLAMC.
                                 ,
                                 .
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                                                                                                      Center; 1974;7:275-286.
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                                                    1%1:398-425.                                      Downey, Calif: Professional Staff Association,
repetitionsas the standard for a                    6 Haxton HA. Absolute muscle force in the         Rancho Los Amigos Medical Center; 1989.
of Normal.                                          ankle flexors of man. JPhysiol. 1944;103:276-     26 Simon SR, Mann RA,Hagy JL, Larsen LJ.
                                                    273.                                              Role of the posterior calf muscles in normal
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                                                    put and iEMG of isokinetic plantar flexion in     27 Sutherland DH, Olshen R, Cooper LC. The
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tlons: Poor (2)=maximum manual                      8 Sepic SB, Murray MP, Mollinger LA, et al.       28 Murray MP, Geten GN, Sepic SB, et al.
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                                                    two age groups of men and women. Am J             J Bone Joint Sutg [Am] 1978;60:475475.
single heel-rise (F/BW=.312), and Fair                    Med, 1986;65:75-84,                         29 Whipple RH, Wolfson LI, Amerman Phl.
(3)=able to hold body weight once in                                                                  The relationship of knee and ankle weakness
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mise body weight from neutral                                                                         netic study. J A m Geriatr Soc. 1987;35:1520.
(F/BW= .823).




Physical 'Therapy / Volume 75, Number 8 /August 1995

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                                 The Standing Heel-Rise Test for Ankle Plantar
                                 Flexion: Criterion for Normal
                                 Brenda Rae Lunsford and Jacquelin Perry
                                 PHYS THER. 1995; 75:694-698.




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