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Windlass test

From Physiopedia

Original Editor - Alesha Walker, Bilitis Crokaert

Lead Editors  


Contents

Definition

A “windlass” is the tightening of a rope or cable. [1]

During the swing phase in the gait cycle, there is about 30 to 40 degrees of extension at MTP joints to prevent the toes stubbing the ground.[2] At the terminal part of the stance phase, as the heel lifts extension is achieved at the MTP joints depending on the individuals flexibility.[2] The plantar fascia simulates a cable attached to the calcaneus and the metatarsophalangeal joints.[3][4] Dorsiflexion during the propulsive phase of gait winds the plantar fascia around the head of the metatarsal. This winding of the plantar fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch. The plantar shortening that results from dorsiflexion is the essence of the windlass mechanism principle.[3][4] This mechanism creates a dynamic stable arch and hence a more rigid level for push off. [3]

This windlass mechanism is a mechanical model that describes the manner which plantar fascia supports the foot during weight-bearing activities and provides information regarding the biomechanical stresses placed on plantar fascia. Also with an increased hallux valgus or in cases of hallux limitus this mechanism didn’t function anymore.[5] The test can be important in the decision-making process involved in the evaluation and treatment of plantar fasciitis which is often seen in joggers and tennis players. [2]

A positive windlass test: heel pain reproduced with passive dorsiflexion of the toes.[3]

Purpose of the test

When we divided this test in some subclass of the ICF, we can say that we measure the impairments of body structures: fascia and ligaments of the foot. [6]

It is a test to determine plantar fascia abnormalities is terms of over- and underpronation.[4](C) Such information is important clinically because it may provide healthcare professionals with a clear understanding bout the relationship between abnormalities and biomechanical influences.. [4]

The test achieves a direct stretch which can be effective in the treatment for plantar fasciitis.( diGiovanni et al., 2003,2006; Ross, 2002) For a tight plantar fascia stretch beyond the end range of motion is usually suggested to regain his proper flexibility. (Dogerty,1985) The direct stretch onto plantar fascia by dorsiflexing the toes were more desired than Achilles tendon stretch alone in treating plantar fasciitis. DiGiovanni et al. (2003,2006) discovered that fascia stretch group demonstrated less pain and achieved higher activity level.(A1) [7]


Clinically Relevant Anatomy

To understand this test a good anatomic knowledge of the foot is indispensable. Therefore it’s important to know what happens in some movements, to get some good information you can read “Kapanji of the lower extremity”.

One thing that’s important is that the ball of the foot is very important in shock absorbation.[3][2]

The windlass mechanism occurs during terminal stance when the heel is off the ground.[3][8] [9]The windlass effecting acting trough the MTP joints with particular contribution from the first MTP joint.

During the terminal stance, as the soleus and de gastrocnemius muscles contract actively to lift the heel of the ground, extension occurs at the metatarsophalangeal joints.[3] The plantar fascial bands envelops  the convex surface of the metatarsal heads producing the windlass effect. [3]

It accumulates the tension in the plantar fascia, raises the longitudinal arc and tends to resist the posterior and superior rotation of the calcaneus.[10]



figure 1: Komentar P., The dicriptives stages of the gait cycle, (http://orthoteers.blogspot.com/2007/10/gait.html), internet, 15-05-2011.
Gait1.jpg

Performance of the test

The difference between bearing weight and non-weight is that the sensibility is higher when the patient carries his weight.[11]

Non-weight bearing position: [12] [13][14] (B)

Passively raise the toes of the patient while he/she is sitting to see whether this causes pain.

  • Patient’s knee is flexed to 90° while in non-bearing position
  • Examiner stabilized the ankle (with one hand placed just behind the first metatarsal head)  and extends the MTP joint while allowing the IP to flex (preventing motion limitations due to short hallucis longus)
  • Positive test if pain was provocated at the end range of the MTP extension

figure2: James G., Functional Hallux limitus, (http://www.lowerextremityreview.com/issues/october09/functional-hallux-limitus-diagnosis-and-treatment), internet, 2011.


Weight-bearing position [13][14] (B)

With the patient in a weight bearing position, the examiner creates a great toe extension

  • The patient stands on a step stool and positions the metatarsal of heads of the foot to be tested just over the edge of the step.
  • The subject is instructed to place equal weight on both feet.
  • The examiner then passively extends the first metatarsophalangeal joint while allowing the interphalangeal joint to flex.
  • Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient’s pain is reproduced.


Twenty-two patients with plantar fasciitis, 23 patients with other types of foot pain, and 30 patients in a control group were evaluated with the Windlass test performed in a weightbearing and non-weightbearing position.[13] In the non-weightbearing test, the first MP joint was maximally dorsiflexed with the ankle stabilized. The weightbearing test was performed with the toes hanging off the edge of a stool and dorsiflexion of the first MP was performed. Seven of the 22 patients in the plantar fasciitis group had a positive weight bearing Windlass test (31.8%), while only three had a positive test result in a non-weightbearing position (13.6%). None of the patients in the other foot pain group or control group had pain in the weightbearing and non-weightbearing position.[15]


A research of De Garceau et al. showed that the windlass test had a specificity of 100% and a sensitivity of 32 % fot the weight bearing and non-weight bearing tests. [14][13] (B)

Diagnostic 

The plantar fascia strain increases with the increment of toe dorsiflexion angle and also with the increment of the Achilles tendon forces. [2]

 Regression analysis of clinical data indicates that changing the toe angles caused more fascia strain change than the change in the Achilles tendon force (100N). The weighted influence of toe dorsiflexion angles and Achilles tendon force was 66,14% and 33,86% comparing to Carlon’s paper 84,5% and 15,5% respectively. These statistical results corresponded to the findings from DiGiovanni et al. (2003,2006) that a direct stretch by dorsiflexing the toes contributed more plantar tension than the Achilles tendon stretch alone. [7]

The valuate the effects of various combinations of toe dorsiflexion degree and Achilles tendon pulling force on plantar fascia response, the medial cuneiform and cuboids’ bones were fixed, and the at the top of the talus, only vertical movement was allowed. A total of 15 combinations were analyzed, with different toe dorsiflexion angles (15°, 30° and 45°) in combination with Achilles tension forces (100,200,300,400 and 500N). [7]

After tests and X-ray the results showed that the maximum stress was concentrated near the medial calcaneal tubercle.[16]

Backstorm and More[17] also suggested stretching using a contract-relax-contract PNF method.

Key Research


Brown C. A review of subcalcaneal heel pain and plantar fasciitis. Aust Fam Physician. 1996;25:875–885.

De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. 2003;24:251–255.

Clinical Bottom Line

A good knowledge of the anatomy and function of the foot are very important to understand this page.

Recent Related Research (from Pubmed)

Search Strategy

For search use: Pubmed, Archives of Physical Medicine and Rehabilitation, PEDro

Sugested keywords: Windlass-test, windlass-mechanism, toe dorsiflexion test, plantar fasciitis.

References

References will automatically be added here, see adding references tutorial.

  1. Viel, E ; Esnault M., The effect of increased tension in the plantar fascia : a biomechanical analysis, Physiother Practica 1989 ;5 :69-73.
  2. 2.0 2.1 2.2 2.3 2.4 Reid C.D. et al., Sports Injury Assessment and Rehabilitation, 1st edition, Churchill Linvingstone, 1992, 130-131.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Maffuli N. et al.Tndon injuries: basic science and clinical medicine, London, Springer Verlag, 2005.
  4. 4.0 4.1 4.2 4.3 Lori A. Bolga and Terry R. Malone: Plantar fasciitis and the Windlass Mechanism: A biomechanical link to Clinical Practice, J. Athl. Train., 2004,77-82.
  5. Fuller E.A., The Windlass Mechanism of the foot: A Mechanical model to explain pathology, Journal of the American Podiatric Medical Association, 2000, 35-46.
  6. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int.2003;24:251-255.
  7. 7.0 7.1 7.2 Hsin-YI Kathy Cheng, Chun-Li Lin, Hsein-Wen Wang, Shih-Wei Chou; Finite element analysis of plantar fascia under stretch- the relative contribution of windlass mechanism and achilles tendon force, Journal of Biomechanics, 2008, 1937-1944.
  8. Sarrafian L.R, Functional characteristics of the foot and plantar aponeurosis under tibio-talar loading., Foot Ankle, 1987;8(1): 4-18
  9. Hicks J.H., The mechanics of the foot. The plantar aponeurosis and the Arch, J Anat 1954;88: 25-30
  10. Hunt G.C. et al.: Biomechanical and histiological considerations for development of the plantar fasciitis and evaluation of arch taping as a treatment option the control associated plantar heel pain: a single-subject design, Foot AnkleElsevier Ltd., 2004, 147-53.
  11. Cole C. et al. ,Plantar fasciitis: evidence-based review of diagnosis and therapy, Am Fam Physican, 2005;73(11);2237-2242,2247-2248.
  12. Wong M., Pocket Orthopaedics: Evidence-Based Survival Guide(2010),Mississauga, Jones and Barlett Publishers, (p. 361).
  13. 13.0 13.1 13.2 13.3 De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int.2003;24:251-255.
  14. 14.0 14.1 14.2 MC Poil T.G., Clincal Guidelines, Heel- Pain, Plantar Fasciitis, journal of orthopaedic & sports physical therapy, 2008, A1-A19.
  15. De Garceau D, Dean D, Requejo SM, Thordarson DB: The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. 2004 Sep;25(9):687
  16. Hsin-YI Kathy Cheng, Chun-Li Lin, Hsein-Wen Wang, Shih-Wei Chou; Finite element analysis of plantar fascia under stretch- the relative contribution of windlass mechanism and achilles tendon force. Journal of Biomechanics 41 (2008) 1937-1944
  17. Backstorm K.M., More A. Plantar fasciitis ; Phys Ther Case REp, 2000, 3: 154-162.
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Achilles Tendinopathy

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