Biomechanical Examination Parameters EvenKeel| Advanced Custom Orthotics™ Biomechanical Examination Parameters

Essentials Parameters Contents Essentials Parameters 1. Calcaneal Stance Position 2. Tibia Lower Third 3. Torsion 4. Internal Hip Rotation / External Hip Rotation 5. Ankle Dorsiflexion - Knee Extended / Knee Flexed 6. Subtalar Joint - Supination / Pronation / Neutral 7. Metatarsal Joint Positions - Mets 1-5 / Mets 2-5

1. Calcaneal Stance Position Overview: Measure of the position of the heel bisection relative to the ground in mid-stance. Range of Measurement: 6° – 7° Ideal Measurement: 0° Examination Technique: Patient stands erect barefoot with weight equally placed on both feet in proper angle of gait with feet totally relaxed in this position. The posterior calcaneus is bisected and that line is measured off the perpendicular to the ground. The angle formed between these two lines is the calcaneal stance position angle in eversion or inversion.

2. Tibia Lower Third Overview: Measure of the angle of the lower third portion of the leg in midstance when the subtalar joint is in neutral position. Range of Measurement: 10° Varus – 5° Valgus Ideal Measurement: 3° - 6° Varus Examination Technique: : Patient stands barefooted with legs exposed, the subtalar/ talo-navicular joints palpated in neutral congruous position, and in the determined angle of gait. Line is drawn through the bisection of the lower third of the leg this line is compared to the perpendicular to the ground. The angle formed is either varus or valgus or zero. Angled towards the midline is varu, angled away from the midline is valgus.

3. Torsion Overview: Difference in degrees between the axis of the knee joint motion and the axis of the ankle joint motion. Range of Measurement: -20° Internal to +20° External Ideal Measurement: 0° (Neutral) Examination Technique: Patient sits on elevated bench with feet hanging in relaxed position, knee a few inches away from bench and leg set perpendicular to the length of the bench top, so that when the knee joint is moved forward and back the axis of the knee is parallel to the length of the bench. Examiner raises and lowers the lower portion of the leg moving the knee joint and checking that thigh is in fact perpendicular to the table. Then she checks for neutral subtalar joint position and holding the foot across the top, moves the ankle joint up and down (ensuring the foot stays in neutral position). Then she compares the angle of the ankle joint axis to the angle of the knee joint axis.

4a. Internal Hip Rotation Overview: Measure of the maximum degree the hip joint will move or rotate towards the midline of the body. Range of Measurement: 0° – 90° Ideal Measurement: 45° Examination Technique: The patient lies prone on the table with knees bent. With the patient completely relaxed, the practitioner holds the ankle and measures 0° with the patient’s lower leg in the vertical position. Then the practitioner slowly moves the foot and leg laterally (away from midline) in the patient’s transverse plane until the patient’s hip provides natural resistance to motion. The practitioner measures the angle from the vertical position (0°) to this position.

4b. External Hip Rotation Overview: Measure of the maximum degree the hip joint will move or rotate away from the midline of the body. Range of Measurement: 0° – 90° Ideal Measurement: 45° Examination Technique: : Patient lies prone on table with knees bent. With patient completely relaxed, practitioner holds ankles and measures 0° with patients lower leg in vertical position. Then slowly moves foot and leg medially (towards the midline) in patients transverse plane until the patient’s hip provides natural resistance to motion noted by the pelvis moving upward from the table. Practitioner measures the angle from the vertical position (0°) to this position.

5a. Ankle Dorsiflexion - Knee Extended Overview: Measure of the maximum degree the foot can be bent upwards towards the knee (dorsiflexed) at the ankle joint with the foot in the neutral (or slightly supinated) subtalar joint position and the knee fully flexed. Range of Measurement: -15° to +15° Ideal Measurement: 5° Examination Technique: Patient lies prone on the table with knees fully extended. With the patient completely relaxed, the practitioner holds the foot in a neutral subtalar position, or slightly supinated. Practitioner measures 0° when the foot is positioned 90 degrees to the leg. When measuring the right foot the practitioner holds the arch of the right foot with his left hand and while holding the foot in a neutral position bends the foot on the leg in dorsiflexion until resistance. At that point the angle of the outside line of the foot from heel to fifth metatarsal head is compared to the middle line of the leg and the angle is recorded. An angle less than 90° is positive (dorsiflexion). An angle greater than 90° is negative (plantarflexion). Note: opposite hands hold with opposite foot.

5b. Ankle Dorsiflexion - Knee Flexed Overview: Measure of the maximum degree the foot can be bent upwards towards the knee (dorsiflexed) at the ankle joint with the foot in the neutral subtalar joint position and the knee fully flexed. Range of Measurement: -15° – 15° Ideal Measurement: 5° Examination Technique: Patient lies prone on the table with knees bent at 90 degree angle. With the patient completely relaxed, the practitioner holds the foot in a neutral subtalar position, or slightly supinated. Practitioner measures 0° when the foot is positioned 90 degrees to the leg. When measuring the right foot the practitioner holds the arch of the right foot with his left hand and while holding the foot in a neutral position bends the foot on the leg in dorsiflexion until resistance. At that point the angle of the outside line of the foot from heel to fifth metatarsal head is compared to the middle outside line of the leg and the angle is recorded. An angle less than 90° is positive dorsiflexion). An angle greater than 90° is negative (plantarflexion). Note: opposite hands hold with opposite foot.

6. Subtalar Joint - Supination / Pronation / Neutral Overview: The talocalcaneal joint situated below the ankle joint (talocrural joint ) has 3 facets (places where the ligament connects to the bone and allows movement). This joint moves in 3 planes (triplanar motion): Frontal (Coronal) Plane Eversion / Inversion Transverse Plane Abduction / Adduction Sagital Plane Dorsiflexion / Plantarflexion (Eversion, Abduction & Dorsiflexion) (Inversion, Adduction & Plantarflexion)

6a. Subtalar Joint - Supination Overview: The talocalcaneal joint situated below the ankle joint (talocrural joint ) has 3 facets (places where the ligament connects to the bone and allows movement). This joint moves in 3 planes. Range of Measurement: 0 – 40° Examination Technique: Patient lies prone on the table with feet hanging over edge. Right foot examined with RIGHT hand on dorsal lateral aspect of foot, supinating foot to max – recording bisection of posterior surface of heel and noting angle with lower portion of leg (in supination the foot is moved towards the midline in pronation the foot is moved away from the midline).

6b. Subtalar Joint - Pronation Overview: The talocalcaneal joint situated below the ankle joint (talocrural joint ) has 3 facets (places where the ligament connects to the bone and allows movement). This joint moves in 3 planes. Range of Measurement: 0 – 15° Ideal Measurement: 4 - 5° Examination Technique: Patient lies prone on the table with feet hanging over edge. The lower portion of Right hand pushes against the bottom of the 3rd 4th and 5th metatarsals to maximum range of motion. The angle of the bisection of the heel with the bisection of the lower leg is recorded. A straight line from the lower leg though the bisection of the heel is 0 degrees. Pronation is measured from that point.

6c. Subtalar Joint - Neutral Overview: there is a position within the range of motion of the STJ that is neutral – that is – neither pronated or supinated. There are various formulas to calculate the e.g. take the total ROM – 2/3rd is supination and 1/3rd is pronation. Generally the best way we have found is to palpate the subtalar and talonavicular joints to find a congruous area that denotes the neutral STJ and talonavicular joint positions. Range of Measurement: -6 to 6° Ideal Measurement: 0° Examination Technique: With Patient prone with feet over edge of table, right hand on right foot on dorsal lateral surface of forefoot taken through range of supination and pronation while Left hand thumb and index finger placed medial of lateral sides of talonavicular joint and STJ. Foot moved through ROM several times to allow the Left hand (thumb and index fingers) to experience (feel) the changes in the bulging of the bones in the joints when moved from pronation to supination. At the same time, the right hand specifically the thumb and index fingers (not at the tips but halfway along the inside of the thumb and at the base of the index finger) is placed at the patient’s Right foot in the sulcus of the 4th and 5th toes and the toes are grasped firmly to load the foot. The fourth and fifth toes are pulled in traction to simulate a weight bearing position (mid Stance). Care must be taken to not dorsiflex the toes when putting traction (loading) on the toes/foot, and to not grasp the metatarsal heads. The fingers should not interfere with the visualization of the metatarsal heads 1-5.

7. Midtarsal Joint – Forefoot to Rearfoot Relationship Overview: Forefoot to Rearfoot Relationship are two angled measurements of the forefoot: Mets 1 – 5 : the relationship between: the bottom plane of the heel (rearfoot plane) and the plantar surface plane created between the fifth metatarsal head and the first metatarsal head.

7. Midtarsal Joint – Forefoot to Rearfoot Relationship Overview: Forefoot to Rearfoot Relationship are two angled measurements of the forefoot: Mets 1 – 5 : the relationship between: the bottom plane of the heel (rearfoot plane) and the plantar surface plane created between the fifth metatarsal head and the first metatarsal head. Mets 2—5 : The relationship between: the plane of the bottom of the heel (rearfoot plane) and the plane created between the plantar surface of the fifth metatarsal head and the second metatarsal head. Both measurements require that the subtalar joint be in a neutral position and require the foot be positioned to simulate mid-stance weight bearing (loading). Range of Measurement: 6° – 7° Ideal Measurement: 0° Examination Technique: Patient stands erect barefoot with weight equally placed on both feet in proper angle of gait with feet totally relaxed in this position. The posterior calcaneus is bisected and that line is measured off the perpendicular to the ground. The angle formed between these two lines is the calcaneal stance position angle in eversion or inversion.