Patient-centred assessment with objective clinical tests
Learn more about these commonly used evidence-based tests and how they impact orthotic prescription. This video series covers each test in detail. *Note: for medical professionals only.
Test 1: Foot morphology and motion test
Test 2: Alignment Test
Test 3: Windlass (Jack’s) test
Test 4: Supination resistance test
Test 5: Proximal control knee bend test
Test 6: Neuromotor balance test
OPEN KINETIC CHAIN (NON-WEIGHT-BEARING TESTS)
Test 1: Foot morphology and motion test (including finding the Subtalar Joint Axis)
The first test relates to the general principles of open kinetic chain foot biomechanics, joint position and passive range of motion. Non-weight bearing alignment of the rearfoot, forefoot and first ray is assessed while supported in subtalar joint neutral.
This method gives you the ability to assess and record the individual’s foot morphology as a ‘baseline’, which then assists in the understanding of the foot’s compensations under weight-bearing conditions.
Assess the range of available joint motion and identify both restrictions and hypermobility. This will give you information to understand how and why the foot compensates once it is weight-bearing and during gait.
What does it tell you?
Subtalar joint neutral and range of motion assessment: Subtalar joint neutral is the position when the foot is neither pronated or supinated and acts as a reference point to determine range of motion at the joint. The range of motion test is used to assess subtalar joint range of motion and the position of the patient’s foot when non-weight bearing.
It is important there is adequate range and direction of motion at this joint for normal effective pronation and supination of the joint. There is usually about 2/3 inversion to 1/3 eversion, or twice as much inversion as eversion, at the joint.
Forefoot to rearfoot assessment: Assessment is important as it can provide clues to foot pathology and help determine management options.
This test is used to assess whether a forefoot varus or valgus is present. The forefoot can present as one of the following:
Neutral: Where the metatarsals lie in a plane perpendicular to the axis
Varus: Where the forefoot appears supinated with the lateral border relatively planter flexed compared to the medial border
Valgus: Where the forefoot appears pronated with the medial border relatively plantar flexed compared to the lateral border
Test 2: Alignment Test
This is a test of clinical observation and is the analysis of the subject’s gait. With the patient in a relaxed stance, it involves watching a patient walk up and down a space and observing what happens. Any deviations from what is considered normal are written down and it is usual to start at the head and work down to lower limbs and feet.
In biomechanical assessment alignment and gait analysis examine structure, alignment and movement of lower limbs and feet.
The alignment test is a test of clinical observation where the clinician notes how their patient stands when in relaxed stance.
What does it tell you?
In this test you are considering how the patient’s anatomical structure may be contributing to any lower limb pathology. For example if one shoulder is lower than another and arm swing is not the same it may indicate a possible leg length discrepancy.
Gait analysis is the observation of walking or running patterns during the gait cycle.
Test 3: Windlass (Jack’s) test
The ‘windlass’ is the primary mechanism that lifts the medial longitudinal arch during toe off and is essential for effective forward propulsion during gait. The mechanism should begin to engage when the heel lifts, the STJ should supinate, the hallux dorsiflexes creating the rigid lever needed to move forward when walking or running. When the windlass mechanism does not occur, it contributes to many foot and lower limb pathologies.
The ‘windlass’ is the primary mechanism that lifts the medial longitudinal arch during toe-off and is essential for effective forward propulsion during gait. The mechanism should begin to engage when the heel lifts to move forward when walking or running. When the windlass mechanism does not occur, it contributes to many foot and lower limb pathologies.
Assesses the function of the windlass mechanism using the ‘Jack’s test’.
The windlass (aka Jack’s) test helps to assess the function of this mechanism.
What does it tell you?
If the hallux moves freely in open chain, but is restricted during Jack’s Test, it may signify a functional hallux limitus. If it doesn’t move freely in open chain, it signifies a structural hallux limitus. If it doesn’t move at all, it signifies a hallux rigidus.
A medially deviated subtalar joint axis will increase ground reaction force beneath the 1st MTPJ and prevent the first ray plantarflexing, the hallux dorsiflexing and will show up as a restricted windlass (Jack’s) Test.
Test 4: Supination resistance test
The supination resistance test is used to quantify the external load that is applied to the subtalar joint. It aims to determine how easy or hard it is to supinate the foot and the type of orthotics that may be required, for example the greater the supination resistance, the greater the force will be required in the orthotic to supinate the foot.
What does it tell you?
As the test is an estimation of the amount of resistance the foot has to supination it helps to determine the amount of force needed in an orthotic to supinate the foot.
Test 5: Proximal control knee bend test
This test assesses the patient’s balance and strength of muscles in the lower limb. The test allows the clinician to assess the position of the knee and foot while weight bearing.
What does it tell you?
The test allows you to assess postural control and how it may be compensating for muscle imbalance, dysfunction or weakness.
Test 6: Neuromotor balance test
Assessing neuromotor skills provides insight to how well the motor skills of your patient are working. These skills are important for balance, agility and co-ordination and all have an impact on gait.
There are 3 test options depending on the patient’s strength and balance ability as follows:
i. Open/Closed eye single limb test
This test assesses proprioception, balance and the effort required to maintain stability.
ii. Star Excursion Test
This is a test of balance that requires strength, flexibility and proprioception skills. The test can indicate where deficits are for example patients with ankle problems may find it difficult to move around different points.
iii. Forefoot stability test
There are three areas of interest when doing this test, as follows:
the effort or perceived effort that is made to be able to rise onto tip toes
the ability to maintain balance
if there is instability in the forefoot when balancing for example does the patient sway more medially or laterally
inability to rise up could indicate Posterior Tibial Tendon Dysfunction
What does it tell you?
The neuromotor tests allow you to assess how well the body’s systems maintain a stable upright position. Where the body is unable to do this, compensatory change to function and gait may be noted. The 3 tests for motor function help assess the following:
Open/Closed eye single limb test This indicates the patient’s balance and proprioception.
Star Excursion Test The test can indicate where deficits exist for patients, for example a patient with ankle instability will find it challenging to balance whilst moving the other foot in different directions to different points.
Forefoot stability test This test assesses the type of forefoot modification that maybe required, for example does the patient’s forefoot appear more supinated or pronated when weight bearing and therefore require additional medial or lateral postings?
What's next?
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