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Research Paper 2009
Title: Is There A Correlation Between Extension Of The First Metatarsophalangeal (FMTP) Joint And Extension Of The Hip?
Author: James Pickard
Supervisor: Adam Boucher D.O.
The British School of Osteopathy
275, Borough High Street, London SE1 1JE
I would firstly like to thank Adam Boucher for his feedback and support. Secondly I would like to thank Matt Harris for his inspiration into the function and mechanics of the lower extremity within an osteopathic context. A special thanks however goes to Melanie Wright for her encouragement and support throughout.
To determine if a correlation between extension of the first metatarsophalangeal joint and extension of the hip exists.
39 patients from the British School of Osteopathy were examined. Hallux and hip measurements from both legs, with the use of a two armed goniometer (hip) and fluid filled goniometer (hallux) were taken from all subjects. Hallux measurements were compared to both contralateral and ipsilateral hip and analyzed using a Spearman’s Rho test.
There was no statistical correlation between hallux movement and either the contralateral or ipsilateral hip joint. The greatest correlation existed between right hallux and right hip (r=0.46) which was not statistically significant (<0.05) as p=0.125.
This study does not provide statistical evidence to support a relationship between hallux and hip movement. It does however question the application of static measurements into a functional model, suggesting alternate investigation of a functional modality are more applicable to the assessment of the movement of both joints within the context of gait.
Osteopathic philosophy argues that the body functions as a unit. Each tissue has its own specific function – a ‘cog’ in the anatomical mechanism. It is therefore apparent that structure and function of each component is reciprocally related, signifying that dysfunction of one element will have a direct effect upon optimum functioning of the body as a whole.
One of the most autonomous yet complex series of movements the body has is that of walking. The process of gait, although subtly variable between individuals, has been recognised as a cyclical sequential series of events that uses all joints within the lower extremity. Two joints of particular importance in effective gait are the first Metatarsophalangeal joint (FMTP) and the hip.
Both joints move predominantly through the sagittal plane, however at the hip, smaller accessory movements occur within the frontal and transverse planes. These accessory movements, including adduction/abduction and internal/external rotation are mirrored and transferred to the Ankle joint as inversion/eversion and into the Foot as pronation/supination. The hallux plays a direct role in the resupination of the rear-foot during stance phase of gait creating a functional link between the great toe and hip (Hicks 1954) via the ankle.
During the process of gait, effective motion depends on the mobility of the weight bearing limb. Full ranges of passive hip, hallux and ankle extension, are essential elements in creating co-ordinated movement patterns (Perry 1992). This is important when looking at lower extremity function. For this study, however, it is important to look at a functional relationship between the FMTP and the hip in greater detail.
A FUNCTIONAL RELATIONSHIP
Extension of the FMTP Joint and the Windlass Mechanism
The Windlass mechanism is the process by which during extension of the hallux, the medial longitudinal arch (MLA) is increased. Hicks (1954) concluded that when the toe was extended, a pull upon the plantar aponeurosis occurred, increasing the medial arch of the foot allowing greater shock absorption (Larsen et al 2002).
The Hallux is not solely for propulsion but is also used for re-supination of the foot during the stance phase of gait (Hicks 1954). This is accomplished by an increase in tension of the plantar aponeurosis, caused via dorsiflexion of the ankle or extension of the toes (Sarrafian 1954). Kappel-Bargas’s (1998) small scale research project explored this idea concluding that those with a slower activation of the windlass mechanism exhibited a greater magnitude of rear-foot eversion. This paper proves that a specific joint directly affects another further up its kinetic chain providing a foundation on which Michaud (1997), Dananberg and Guiliano (1999) and Larsen et al (2002) have researched that the absence of a MLA will lead to a loss of shock absorption causing lower back pain.
Whittle (2007) suggests that the peak of ankle dorsiflexion is reached just after heel rise. During this phase extension occurs at the FMTP joint, accompanied with a supination of the foot (windlass mechanism). It is therefore appropriate to suggest that any inability to extend the hallux within its full range would limit the amount of dorsiflexion and reduce the ankles ability to re-supinate, during this phase of gait.
Extension of the Hip and Ankle
During the pre-swing phase of gait, Whittle (2007) suggests that the hip is at its most extended position, along with the ankle and foot ensuring all joints are in a position whereby they are able to generate maximum power (Winter 1983). The dorsiflexed position of the ankle places the gastro-soleus complex under maximum tension with adductor longus also placed under maximal load for efficient hip flexion (whittle 2007).
As the movement of both the Hip and ankle work within this highly co-ordinated manner, both joints become integral to the successful motion of the mechanism as a whole, they are functionally linked. This suggests that if one joint were damaged it would have a direct effect upon the other. (Clark 2001) shows how reduced dorsiflexion of the ankle following injury can lead to hip immobility.
Movement of the Hip and Hallux (a Functional Relationship) and Compensatory Mechanisms
With a restriction of joint movement in the foot, there are two main ways in which the body may compensate in order to preserve functional gait:
Whilst the complex knee mechanism provides a degree of compensatory adjustment where a lack of range is exhibited it is not entirely able to absorb fully the effect resulting in a compensatory loss of range to the hip.
Perry (1992) suggests that both immobility of the fore-foot and valgus (excessive eversion), created through an ineffective windlass mechanism, during stance phase leads to increased heel contact. This prolonged contact requires flexion of both the knee and hip joints through the weight bearing limb, leading to a possible shortening of hip flexors, and therefore a limitation of hip extension. With this in mind it may be suggested that ankle movement may actually increase.
It is also presented by Perry (1992) that with an inability to dorsiflex the FMTP during stance phase, weight is shifted through the lateral aspect of the foot, creating an ankle varus (excessive inversion). This, accompanied by a rigid ankle and/or pain over the FMTP, further accentuates the existing varus causing a premature heel rise in the gait cycle in order to compensate (Whittle 2007). This early heel rise causes a forward lean of the trunk in order to preserve effective locomotion with an associated anterior pelvic tilt in order to maintain balance over the grounded foot. This anterior posture leads to a shortening of the hip flexors, and therefore a reduction of hip extension. (Kendall et al 2005)
Secondary to shortening of the hip flexors, (Kendel 2005) suggests that an anterior pelvic tilt will lead to an increase in lumbar spine lordosis, causing undue posterior compression of the articular facets, anterior longitudinal ligaments and vertebrae resulting in lower back pain.
There will be a positive correlation between the ranges of first Metatarsophalangeal joint dorsiflexion and hip extension.
There will be no correlation between the ranges of first Metatarsophalangeal joint dorsiflexion and hip extension.
This research study used an opportunistic sample from the British School of Osteopathy (BSO) clinic. The subjects were chosen through their attendance of the BSO clinic between the 6th and 9th January 2009.
60 subjects were given patient information sheets and a total of 39 were eligible to partake in the study following their completion of the consent form (appendix 3) and screening questionnaire (appendix 2) containing information regarding exclusion criteria. This criteria is outlined below:
Injury: Injury/damage to the lower extremity within the last six months. This included participants with any pain and/or degeneration from the hip to the big toe.
Prosthesis/Surgery: Fusion to any joint of the lower extremity, or surgery within the last six months.
Lying Prone: Those unable to lie in a prone position were excluded due to the nature of the Hip examination. This included pregnancy and abdominal surgery within the last six months.
Age: Any persons under the age of 18 were excluded due to the complications of using chaperones and necessity for parental consent.
To address the issue of confidentiality all data was marked with an identification number. This information is stored safely so that the researcher and supervisor are the only persons who have access ensuring total anonymity. The data will be held for 6 years and then destroyed.
Equipment and Procedure
The procedure gathered data from two separate joints of the ipsilateral and contralateral limbs. When examining the joints care was taken to avoid any contact to the second joint prior to examination.
To obtain a true representation of movement that occurs within the lower extremity during gait, ideally analysis of the joints during locomotion would be most useful. However due to the unavailability of video analysis equipment, static measurements were obtained with a goniometer.
Hip and Hallux movement was examined on both lower extremities. Examinations were performed 3 times with a mean average taken in order to improve quality and accuracy of the results. Hallux movement was measured in a weight bearing possition providing a more functional representation of its potential movement during gait. Due to the complexity in measuring the hip in such a possition the hip was measured in a non-weight bearing possition.
In order to correctly examine range of movements within the lower extremity in a repeatable and efficient manner, a pilot study was performed. Ten particpants were selected and examined (in the same manor as the main study). This study helped to identify the most accurate form of measuring devices to be a long armed goniometer to measure hip extension and a fluid filled goniometer to measure hallux dorsiflexion.
Procedure 1: Hip
Extension of the hip is measured with a two-armed goniometer in a prone position to ensure good pelvis stabilisation. The stationary arm of the goniometer is aligned along the lateral midline of the pelvis/trunk and remained in this horizontal position with the aid of a spirit level. The greater trochanter was the bony landmark used for the positioning of the measuring dial. The moving arm is positioned in line with the lateral femoral epicondyle.
The hip is passively extended to its end range with the practitioners hand placed firmly on the ipsilateral Ilium in order to stabilise the pelvis preventing extension and rotation of the lumbar spine. The arm of the goniometer is held in place by a second examiner throughout the procedure as the patient’s leg is extended and range of motion recorded. In order to further reduce any confounding variables the same second examiner was used throughout the entire experiment.
Procedure 2: 1st Metatarsophalangeal Joint
During piloting, it became apparent that when measuring the FMTP, the two-armed goniometer was impractical as it was unable to lay flat on the floor when the foot is in a weight bearing position. It became therefore necessary to use a fluid filled goniometer.
The participant is firstly asked to stand with their weight evenly distributed through both feet. The goniometer is then placed on the dorsum of the hallux with one corner placed directly over the bony landmark of the head of the first metatarsal. The joint is then passively extended whilst care is taken to ensure the goniometer remains flat against the first metatarsal. To avoid any feeling of instability during the procedure, the subject is stood with their back gently pressed up against a wall.
All data obtained from the experiment was continuous interval data. Descriptive analysis identified gender percentiles, Medians and Interquartile Ranges (IR) of Hip and Hallux range of movement. Exploratory statistical analysis aimed to identify spread of the data for normality.
In order to explore a statistically positive correlation between Hallux and Hip movement, a spearman’s Rho Correlation Coefficient test was used. This hypothesis was successfully supported when the probability (‘p” value) was less than 0.05 (p<0.05).
With three measurements taken from each joint, firstly a mean value was calculated. To ensure the data was accurate and evenly spread, a coefficient of variation equation was used. Any mean data scoring higher than a 10% in variation was considered unreliable and therefore the value causing the largest variation was removed. This process led to the exclusion of one subject, who scored above 10% in three joints.
With the exclusion of one participant there were 39 participants that took part, of which, 24 (61.5%) were male and 15 (38.5%) were female. This information is displayed in Table 1.
Table 1. Gender Ratios of Participants.
A Kolmogorov-smirnov test was used to asses the data for skewness (normal distribution).
Normal distribution was identified when the statistic < (if positive) or > (if negative) 2 x S.E. (Standard Error) of skewness (-0.796). This data is shown in Table 2.
Table 2. Distribution of Data in Relation to the Spread of Normality.
Table 2. shows that only Left Hip movement is > -2 x S.E with a value of 0.667 and therefore normally distributed. This information is further displayed in fig.1. The other three measurements all fell outside the boundaries for normality, creating non-parametric data.
Fig 1. Histogram Displaying the Spread of Data Collected from Left Hip
Opposed to using means and standard deviations, the 25th 50th (median value) and 75th percentiles (Interquartile-Ranges (IR)) were used for further describing the non-parametric data as shown in Table 3.
Table 3. Data Values for the Median and Interquartile-Ranges of Hallux and Hip movement.
Thirty nine measurements were taken for each joint with both hallux medians at 34 degrees. However the ranges between the right hallux (28.5 to 38.7) is far greater than the left (23.8 to 36.1). Left and right hip measurements compare similar Interquartile Ranges, left hip measuring 27.2 to 45.2 degrees with the right hip measuring 28.7 to 46.3, whilst the medians differ from 36.3 (left hip) to 38.8 (right hip).
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