Lateral ankle sprains account for 80% of all athletic injuries1 and 40% to 70% of those individuals will go on to develop residual signs and symptoms.1,2 The most common residual symptoms reported are pain, swelling, laxity, and restrictions in dorsiflexion range of motion (DFROM).3,4 Decreases in DFROM may increase an individual's susceptibility to re-sprain and are recognized as a risk factor for many other orthopedic conditions, such as Achilles tendinopathies, plantar fasciitis, and knee pathologies.5–10 Given the increased risk of injury that has been associated with deficits in DFROM, it becomes important that clinicians are able to consistently measure DFROM.11
In general, DFROM measurements assess the available degrees of motion at the ankle joint.12 Traditionally, measurements of DFROM are taken in a non–weight-bearing position with the knee extended or flexed.3 Although this traditional method has been reported in the literature, a more recent approach to assessing DFROM is in a weight-bearing position. During the past 5 years, weight-bearing DFROM measurements have gained clinical popularity because it is believed that a weight-bearing position provides the clinician with an assessment of the patient's functional DFROM during weight-bearing functional activities, such as walking, running, and jumping.13–15 Although there are several systematic reviews that have reported reliabilities of weight-bearing DFROM measurements, there are many inconsistencies in the methods reported, making it difficult for clinicians to choose the most reliable measurement.16–18
The most common differences in weight-bearing measurement techniques reported are participant stances, measurement instructions, the instrument being used, and instrument placement during the measurement. During a weight-bearing measurement, the participant is instructed to stand with the test knee extended or flexed while maintaining complete contact with the plantar surface of the test foot on the floor. Weight-bearing DFROM with the knee in terminal extension stance is influenced by the flexibility of the triceps surae and heel cord.13,19 Therefore, greater DFROM measurements have been reported if the knee is flexed because it eliminates the influence of the triceps surae and heel cord.3,12,20 In each stance, DFROM is measured once maximal weight-bearing dorsiflexion is achieved, which is determined as when the plantar surface of the test foot no longer makes contact with the floor.
Although participant stance is important, so is the instrument being used to assess range of motion. Clinicians can use a tape measure to indirectly assess DFROM by measuring the distance between the testing foot (toe or heel) and a wall.4,13,14,20–22 Potential drawbacks to using a tape measure are the difficulty of interpreting the results clinically because the measurement has to be converted to degrees and only knee flexed DFROM can be assessed.13,20 More commonly, a goniometer or bubble inclinometer is used to measure the angle between the lower leg and the floor.12,13,19,21,23–27 Benefits of using bubble inclinometers include the ease of use and the relative small size. A thorough review of the literature has revealed inconsistencies in the placement of the inclinometer for the measurement of weight-bearing DFROM. Some of the placements that have been reported are over the tibial tuberosity,21,27–29 on the anterior crest of the tibia,13,18,19,30–32 and aligned along the distal fibula.3,12,25
Given the amount of variability in patient stances and bubble inclinometer positions used, it becomes clinically important to determine where the measurement device should be placed to produce the most reliable measurements of weight-bearing DFROM in each weight-bearing stance. Therefore, the purpose of this study was to measure the intra-rater and inter-rater reliability of three different bubble inclinometer placements on two different weight-bearing DFROM stances in healthy participants.
This repeated measures study design was conducted over 2 consecutive days. Participants performed all weight-bearing DFROM measurements for both examiner 1 and examiner 2 each day. Examiner 1, a novice clinician, was a senior athletic training student in an athletic training program accredited by the Commission on Accreditation of Athletic Training Education. Examiner 2, an experienced clinician, was a certified athletic trainer with more than 10 years of experience. A week prior to the start of data collection, examiner 1 underwent approximately 30 minutes of training with examiner 2 to standardize testing procedures and participant instructions and gain measurement experience.
Eighteen healthy participants (6 men, 12 women; age = 22.1 ± 3.4 years; height = 168.1 ± 8.2 cm; mass = 82.7 ± 23.3 kg) volunteered for this study. All participants were able to bear weight and were free from injury to the lower extremity at least 6 months prior to the start of data collection. Before participation, all participants read and signed an informed consent approved by the university's institutional review board. Data were collected on the dominant limb of barefoot participants, which was defined as the preferred limb to kick a ball.
The order of examiners (novice, experienced), testing stance (knee straight, knee bent), and inclinometer placement (tibial tuberosity, distal tibia, fibula) were counter-balanced using a Latin Square. Participants completed all trials for one testing stance prior to moving on to the other testing stance. Three trials from each inclinometer placement were collected prior to moving to the next inclinometer position. Thus, participants performed nine trials (three in each inclinometer placement) in one testing stance (either knee straight or knee bent) followed by nine trials in the other testing stance with one examiner prior to being assessed by the other examiner. The testing sequence for each participant was the same for each examiner.
Standardized instructions were provided on how to perform each testing stance. Participants returned 24 to 26 hours following day 1 for day 2 data collection. The examiner, testing stance, and inclinometer placement order was the same for day 1 and day 2.
Knee Straight Stance
Participants performed the knee straight stance facing a wall. They started standing with weight evenly distributed between both feet and toes pointing forward. Participants were instructed to: (1) take a large step backward with their dominant limb so that their foot was completely on the floor, (2) lean as far forward as possible while keeping that back foot completely on the floor, (3) keep the knee of their dominant limb straight, and (4) keep all toes pointing forward. Participants were able to contact the wall with their hands to maintain balance if needed. The non-dominant limb was allowed to adjust to the testing stance as needed to maintain balance while keeping toes pointed forward. Examiners would encourage the participant to continue to lean forward until the test limb foot could not maintain full plantar surface contact with the floor. At this point, the examiner would place the inclinometer appropriately and record the dorsiflexion measurement. Participants returned to standing upright between each trial.
Knee Bent Stance
Participants performed the knee bent stance facing a wall. They started standing with weight evenly distributed between both feet and toes pointing forward. Participants were instructed to: (1) take a small step backward with their dominant limb so that their foot was completely on the floor, (2) bend their dominant knee, (3) try to bring their dominant knee as far in front of their toes as possible, and (4) keep all toes pointing forward. Participants were able to contact the wall with their hands to maintain balance if needed. The non-dominant limb was allowed to adjust to the testing stance to maintain balance while keeping toes pointed forward. Examiners would encourage the participants to continue to bend their knee until the foot could not maintain full plantar surface contact with the floor. At this point, the examiner would place the inclinometer appropriately and record the dorsiflexion measurement. Participants returned to standing upright between each trial.
Bubble inclinometers with 1° increments (Baseline Bubble Inclinometer; Fabrication Enterprises Inc., White Plains, NY) were used. Three inclinometer placements were used: tibial tuberosity, distal tibia, and fibula. For the tibial tuberosity placement, examiners palpated the tibial tuberosity, placed the most superior aspect of the base of the inclinometer on the tuberosity, and aligned the inclinometer along the anterior tibia (Figure 1A). For the distal tibia placement, examiners palpated the talar dome, placed the distal aspect of the base of the inclinometer just proximal to the talar dome (between the anterior tibialis and extensor digitorum tendons), and aligned the inclinometer along the distal anterior tibia (Figure 1B). For the fibula placement, examiners placed the middle of the base of the inclinometer just proximal to the lateral malleolus and aligned the top of the inclinometer with the head of the fibula (Figure 1C). To reduce measurement bias, no markings were made on participants. Examiners palpated necessary bony landmarks for inclinometer placement for each trial. Following each trial, the inclinometer was removed and zeroed prior to the start of the subsequent trial.
(A) Tibial tuberosity placement: examiners palpated the tibial tuberosity, placed the most superior aspect of the base of the inclinometer on the tuberosity, and aligned the inclinometer along the anterior tibia. (B). Distal tibia placement: examiners palpated the talar dome, placed the distal aspect of the base of the inclinometer just proximal to the talar dome (between the anterior tibialis and extensor digitorum tendons), and aligned the inclinometer along the distal anterior tibia. (C) Fibula placement: examiners placed the middle of the base of the inclinometer just proximal to the lateral malleolus and aligned the top of the inclinometer with the head of the fibula.
Knee straight and knee bent testing stances data were analyzed separately. Means and standard deviations were calculated for each measurement. Data were examined and determined to be normally distributed and did not violate homogeneity of variance. Intra-rater and inter-rater reliabilities were calculated for each testing stance and inclinometer placement.
Intra-rater reliability compared measurements from day 1 and day 2 for each examiner. Intraclass correlation coefficients (ICC2,2), standard error of the mean (SEM), and the minimal detectable change (MDC) at the 95% level were calculated for each examiner for day 1 compared to day 2. Inter-rater reliability compared measurements between the novice examiner compared to the experienced examiner. Day 1 and day 2 means for the novice examiner were combined and compared to combined means for the experienced examiner, then used to calculate ICCs, SEM, and MDC. ICCs were defined as poor (ICC < 0.50), moderate (0.50 < ICC < 0.75), and good (ICC > .75).33 All statistical analyses were performed with SPSS software (version 21.0; IBM Corporation, Armonk, NY).
The mean and standard deviation of each measurement are presented in Table 1. Inclinometer placements for the knee straight stance ICCs, SEMs, and MDCs for intra-rater and inter-rater reliabilities are presented in Table 2. The intra-rater reliability for all three inclinometer placements for the knee straight stance was good (ICC range: .776 to .917; SEM range: 1.89° to 2.91°; MDC range: 5.23° to 7.97°). The novice examiner had the best reliability with the fibular inclinometer position. The experienced examiner had the best reliability with the distal tibia position. The inter-rater reliability for all three inclinometer placements between day 1 and day 2 was good (ICC range: .877 to .927; SEM range: 1.83° to 2.20°; MDC range: 5.06° to 6.09°). The distal tibia position had the strongest inter-rater reliability.
Means ± Standard Deviation of All Trials
Intra-rater and Inter-rater Measurements and SEMs
Inclinometer placements for the knee bent stance ICCs, SEMs, and MDCs for intra-rater and inter-rater reliabilities are presented in Table 2. The intra-rater reliability for all three inclinometer placements for the knee straight stance were good (ICC range: .842 to .975; SEM range: 1.29° to 2.40°; MDC range: 3.59° to 6.60°). Both examiners had the strongest intra-rater reliability with the distal tibia inclinometer position. The inter-rater reliability for all three inclinometer placements between day 1 and day 2 were good (ICC range: .924 to .964; SEM range: 1.48° to 1.83°; MDC range: 4.12° to 5.09°). The distal tibia position had the stronger inter-rater reliability.
Both the novice and the experienced researcher established good intra-rater reliabilities for all three inclinometer placements for both stances. However, the highest intra-rater reliability occurred with inclinometer placement over the distal tibia. Similarly, the inter-rater reliability between the novice and experienced researchers was good for all three inclinometer placements with placement over the distal tibia, resulting in the highest inter-rater reliability. To our knowledge, this was the first study specifically evaluating the reliability of different inclinometer placements on weight-bearing DFROM.
All of our reliability measures are similar to reliabilities reported in the recent systematic review by Powden et al.17 The systematic review combined knee straight and knee bent stances, included multiple measurement tools (eg, inclinometers, goniometers, and tape measures), included any inclinometer placements, and included a wide range of researcher experience. Pooling data from 12 articles (45 ICCs), Powden et al.17 reported a good intra-rater reliability (ICC mean = 0.90). Our overall intra-rater reliability was 0.887, but the combined intra-rater reliability of the distal tibia inclinometer placement increased to 0.921. Pooling the data for nine articles, Powden et al.17 reported a good inter-rater reliability (ICC mean = 0.93). Our overall inter-rater reliability was 0.924 and the inter-rater reliability of only the distal tibia placement was 0.946.
Although the Powden et al.17 systematic review concludes that weight-bearing DFROM is reliable regardless of the measurement tool used, inclinometer placement, or experience of the clinician/researcher, we believe that it was important to conduct our study to determine the most reliable protocol. For our study, we opted to evaluate knee straight and knee bent stances separately. This was done for two reasons. First, from a clinical perspective, evaluating both knee straight and knee bent DFROM is critical. When performing injury assessments and rehabilitation, causes of deficits in DFROM should be determined. Tightness of the triceps surae muscle group, specifically the gastrocnemius, contributes to DFROM with the knee straight, whereas it is eliminated with the knee bent. Therefore, clinicians, especially novice clinicians, need to learn and be reliable at assessing both knee straight and knee bent DFROM. Second, because the knee bent stance typically increases DFROM, we believed it was important to evaluate this stance with the distal tibia inclinometer position specifically. With increased DFROM, the space between the lower leg and the foot decreases. We wanted to ensure that the decreased space would not interfere with inclinometer placement. In our study, the decreased space did not interfere with the distal tibia inclinometer placement. The overall DFROM mean ± standard deviation for knee bent was 36.79° ± 7.17° and our DFROM for the distal tibia placement was 36.17° ± 7.74°. Our numbers are on the lower end of the previously reported normative values (30° to 50°) for healthy individuals.13,21,23,24,31 More research should be conducted to determine whether distal tibia inclinometer placement is compromised with individuals with greater knee bent DFROM than our sample.
We believe that our findings of the distal tibia being the most reliable inclinometer placement occurred for many reasons. Inclinometer placement was easy to find just proximal to the dome of the talus between the anterior tibialis and extensor digitorum tendons. Also, the superficial aspect of the tibia allows for easy alignment along the distal tibia. Although many previous studies used a measured distance distal to the tibial tuberosity,13,18,19,31,32 we believe our placement is more clinically relevant. Tibial tuberosities are not always prominent to palpate and could be a cause of our slightly less reliable measures. Plus, using a set distance from the tibial tuberosity requires accurately finding the bony landmark and accurately measuring the desired distance. Inclinometer over the lateral fibula resulted in the least reliable measures, although they are still considered good. We believe the lateral fibula position findings occurred because this position allows the most subjective alignment by using the proximal bony landmark of the head of the fibula.
There are many tools used to measure weight-bearing DFROM, most commonly inclinometers, goniometers, and tape measures.4,12–14,19–27 We chose to evaluate reliability using an inclinometer for many reasons. First, unlike a tape measure, an inclinometer can be used for both knee straight and knee bent stances. Measurements with a tape measure can also be difficult to interpret in a clinical setting.13,18 Second, unlike the goniometer, there are many placement positions of the inclinometer. Although goniometer placement is standardized to the lateral aspect of the lower leg, it can be time-consuming and difficult to align the proximal arm up accurately with the fibula, the fulcrum over the lateral malleolus, and the distal arm parallel with the floor.21,32 An inclinometer is generally easy to use and does not require alignment of multiple parts. Our novice examiner was able to learn and practice use the bubble inclinometer in a 30-minute training session.
Many methods have been described for weight-bearing DFROM by other authors,16–18 but the consistent instructions include attainment of the greatest DFROM by bringing the lower leg as anterior as possible while maintaining full plantar surface contact of the foot being evaluated.16–18 Some researchers have suggested that increased DFROM can be achieved with subtalar neutral positioning.34,35 Although subtalar neutral positioning may increase DFROM, we do not believe it would alter our results, unless there was such an increase in DFROM to interfere with the inclinometer placement over the distal tibia.
A potential limitation of this study is the number of weight-bearing dorsiflexion repetitions performed by each participant. During each day of data collection, each participant performed a total of 36 weight-bearing dorsiflexion measurements. With the high number of repetitions, there is a risk that stretching and tissue elongation of the triceps surae muscles may have influenced weight-bearing dorsiflexion range of motion. Although this is a potential issue, we do not believe it influenced our reliability results. Using a counterbalanced order of stances reduced the chance of bias if tissue stretching and elongation occurred. Also, each weight-bearing dorsiflexion repetition took less than 15 seconds to measure, which is not long enough to result in tissue elongation.
Implications for Clinical Practice
Our study has shown that the most reliable inclinometer placement for measuring weight-bearing DFROM in healthy individuals is over the distal tibia. These findings are consistent regardless of knee straight or knee bent stance for intra-rater reliability within a novice examiner and experienced examiner and inter-rater reliability between the novice and experienced examiners. It is recommended that clinicians incorporate weight-bearing DFROM using the distal tibia inclinometer placement for their patients.
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Means ± Standard Deviation of All Trials
|Test||Novice Day 1||Novice Day 2||Experienced Day 1||Experienced Day 2||Novice and Experienced Overall|
|Knee straight stance|
| Distal tibia (°)||35.78 ± 6.33||36.37 ± 8.38||28.44 ± 7.46||30.88 ± 5.65||32.87 ± 6.96|
| Fibula (°)||33.83 ± 7.13||34.33 ± 6.36||30.22 ± 6.96||30.50 ± 4.59||32.22 ± 6.26|
| Tibial tuberosity (°)||37.98 ± 5.38||35.43 ± 6.93||33.00 ± 7.11||34.43 ± 5.64||35.21 ± 6.27|
| Average (°)||35.86 ± 6.28||35.38 ± 7.22||30.55 ± 7.18||31.94 ± 5.29||33.43 ± 6.50|
|Knee bent stance|
| Distal tibia (°)||32.98 ± 7.62||33.72 ± 7.32||38.44 ± 8.52||39.54 ± 7.84||36.17 ± 7.74|
| Fibula (°)||34.13 ± 6.53||33.65 ± 5.03||38.22 ± 7.06||36.65 ± 8.00||35.66 ± 6.66|
| Tibial tuberosity (°)||39.76 ± 7.91||38.94 ± 7.52||36.80 ± 7.38||38.63 ± 5.62||38.53 ± 7.11|
| Average (°)||35.62 ± 7.35||35.44 ± 6.62||37.83 ± 7.65||38.27 ± 7.15||36.79 ± 7.17|
Intra-rater and Inter-rater Measurements and SEMs
|Inclinometer Placement||Novice||Experienced||Novice and Experienced|
|ICC||SEM (°)||MDC (°)||ICC||SEM (°)||MDC (°)||ICC||SEM (°)||MDC (°)|
|Knee straight stance|
| Distal tibia||.847||2.88||7.97||.917||1.89||5.23||.927||1.89||5.21|
| Tibial tuberosity||.776||2.91||8.07||.884||2.17||6.02||.877||2.20||6.09|
|Knee bent stance|
| Distal tibia||.944||1.77||4.90||.975||1.29||3.59||.964||1.48||4.12|
| Tibial tuberosity||.903||2.40||6.60||.911||1.94||5.38||.935||1.81||5.02|