Windlass Test: Difference between revisions

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== Definition  ==
== Description ==


A “windlass” is the tightening of a rope or cable.&nbsp;<ref name="Viel">Viel, E ; Esnault M., The effect of increased tension in the plantar fascia : a biomechanical analysis, Physiother Practica 1989 ;5 :69-73.</ref>
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.  


During the swing phase in the [[Gait Cycle|gait cycle]], there is about 30 to 40 degrees of extension at MTP joints to prevent the toes stubbing the ground.<ref name="Reid" /> At the terminal part of the stance phase, as the heel lifts extension is achieved at the MTP joints depending on the individuals flexibility.<ref name="Reid">Reid C.D. et al., Sports Injury Assessment and Rehabilitation, 1st edition, Churchill Linvingstone, 1992, 130-131.</ref> The plantar fascia simulates a cable attached to the calcaneus and the metatarsophalangeal joints.<ref name="maf" /><ref name="Lori">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.</ref> 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.<ref name="maf" /><ref name="Lori">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.</ref>This mechanism creates a dynamic stable arch and hence a more rigid level for push off. <ref name="maf">Maffuli N. et al.Tndon injuries: basic science and clinical medicine, London, Springer Verlag, 2005.</ref>
<span style="font-size: 13.28px;">The test can be important in the decision-making process involved in the evaluation and treatment of </span>[[Plantarfasciitis|plantar fasciitis]]<span style="font-size: 13.28px;">.</span>
 
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.<ref name="Fuller">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.</ref> The test can be important in the decision-making process involved in the evaluation and treatment of [[Plantarfasciitis|plantar fasciitis]] which is often seen in joggers and tennis players.&nbsp;<ref name="Reid" />  
 
A positive windlass test: heel pain reproduced with passive dorsiflexion of the toes.<ref name="maf" />  


== Purpose of the test  ==
== Purpose of the test  ==


When we divided this test in some subclass of the [http://www.who.int/classifications/icf/en ICF], we can say that we measure the impairments of body structures: fascia and ligaments of the foot. <ref name="DG">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.</ref>
<span style="font-size: 13.28px;">The test achieves a direct stretch on the plantar aponeurosis which can be effective in examining plantar heel pain.</span>
 
It is a test to determine plantar fascia abnormalities is terms of over- and underpronation.<ref name="Lori" />(C) Such information is important clinically because it may provide healthcare professionals with a clear understanding bout the relationship between abnormalities and biomechanical influences..&nbsp;<ref name="Lori">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.</ref>
 
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. <ref name="Hsin">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.</ref>
 
== Clinically Relevant Anatomy  ==
 
To understand this test a good [[Anatomy|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.<ref name="maf" /><ref name="Reid" />  


The windlass mechanism occurs during terminal stance when the heel is off the ground.<ref name="maf" /><ref name="Sarra">Sarrafian L.R, Functional characteristics of the foot and plantar aponeurosis under tibio-talar loading., Foot Ankle, 1987;8(1): 4-18</ref><ref name="hicks">Hicks J.H., The mechanics of the foot. The plantar aponeurosis and the Arch, J Anat 1954;88: 25-30</ref>The windlass effecting acting trough the MTP joints with particular contribution from the first MTP joint.
== Clinically relevant anatomy  ==


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.<ref name="maf" /> The plantar fascial bands envelops &nbsp; the convex surface of the metatarsal heads producing the windlass effect. &nbsp;<ref name="maf" />  
The plantar aponeurosis acts similarly as windlass mechanism. Windlass is typically a horizontal cylinder that rotates with a crank or belt on a chain or rope to pull a heavy objects. The common use of windlass is seen in pulling the anchor of the ship known as anchor windlass. This mechanism can be seen in foot. When the MTP joints are hyperextended, the plantar aponeurosis becomes taut as it is wrapped around the MTP joints. This actions brings the metatarsal and tarsal bones together converting it into a rigid structure and eventually causing the longitudinal arches to rise.&nbsp;<span style="font-size: 13.28px;">This winding of the plantar fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch.</span><span style="font-size: 13.28px;">This function is important in providing a rigid lever for gait propulsion during push off.</span>


It accumulates the tension in the plantar fascia, raises the longitudinal arc and tends to resist the posterior and superior rotation of the calcaneus.<ref name="Hunt">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.</ref><br>  
<span style="font-size: 13.28px;">Also with an increased hallux valgus or in cases of hallux limitus this mechanism didn’t function anymore.</span><ref name="Fuller">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.</ref><span style="font-size: 13.28px;">&nbsp;</span><br>


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== Performance of the test ==
== Performong the test ==
 
<span style="font-size: 13.28px;">A positive windlass test: heel pain reproduced with passive dorsiflexion of the toes.</span><ref name="maf" />


The difference between bearing weight and non-weight is that the sensibility is higher when the patient carries his weight.<ref name="Cole">Cole C. et al. ,Plantar fasciitis: evidence-based review of diagnosis and therapy, Am Fam Physican, 2005;73(11);2237-2242,2247-2248.</ref>  
The difference between bearing weight and non-weight is that the sensitivity is higher in weightbearing<ref name="Cole">Cole C. et al. ,Plantar fasciitis: evidence-based review of diagnosis and therapy, Am Fam Physican, 2005;73(11);2237-2242,2247-2248.</ref>&nbsp;&nbsp;<span style="font-size: 13.28px;">De Garceau et al. showed 100% specificity for weightbearing and sensitivity of 32&nbsp;% for non-weight bearing tests.&nbsp;</span><ref name="mcp" /><ref name="dg" /><span style="font-size: 13.28px;">&nbsp;</span>  


Non-weight bearing position:&nbsp;<ref>Wong M., Pocket Orthopaedics: Evidence-Based Survival Guide(2010),Mississauga, Jones and Barlett Publishers, (p. 361).</ref>&nbsp;<ref name="dg">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.</ref><ref name="mcp" />&nbsp;
'''Non-weight bearing position:'''&nbsp;<ref>Wong M., Pocket Orthopaedics: Evidence-Based Survival Guide(2010),Mississauga, Jones and Barlett Publishers, (p. 361).</ref>&nbsp;<ref name="dg">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.</ref><ref name="mcp" />&nbsp;  


Passively raise the toes of the patient while he/she is sitting to see whether this causes pain.  
Passively raise the toes of the patient while he/she is sitting to see whether this causes pain.  
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{{#ev:youtube|iQD5qtO5-zE}}  
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Weight-bearing position <ref name="dg" /><ref name="mcp">MC Poil T.G., Clincal Guidelines, Heel- Pain, Plantar Fasciitis, journal of orthopaedic and sports physical therapy, 2008, A1-A19.</ref>&nbsp;
'''Weight-bearing position '''<ref name="dg" /><ref name="mcp">MC Poil T.G., Clincal Guidelines, Heel- Pain, Plantar Fasciitis, journal of orthopaedic and sports physical therapy, 2008, A1-A19.</ref>&nbsp;  


With the patient in a weight bearing position, the examiner creates a great toe extension  
With the patient in a weight bearing position, the examiner creates a great toe extension  
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*Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient’s pain is reproduced.
*Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient’s pain is reproduced.


<br> {{#ev:youtube|fg0PtnoAzSs}} <ref> Physiotutors. The Windlass Test | Plantar Fasciitis. Available from: https://www.youtube.com/watch?v=fg0PtnoAzSs</ref>  
{{#ev:youtube|fg0PtnoAzSs}} <ref> Physiotutors. The Windlass Test | Plantar Fasciitis. Available from: https://www.youtube.com/watch?v=fg0PtnoAzSs</ref><br>
 
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.<ref name="dg" /> 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 <span style="line-height: 105%; mso-bidi-font-size: 12.0pt; mso-bidi-font-family: arial" lang="EN-US"> non-weightbearing position. <ref name="The association between diagnosis of plantar fasciitis and Windlass test results">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</ref>
</span>
 
A research of De Garceau et al. showed that the windlass test had a specificity of 100% and a sensitivity of 32&nbsp;% fot the weight bearing and non-weight bearing tests. <ref name="mcp" /><ref name="dg" />&nbsp;
 
== Diagnostic&nbsp;  ==
 
The plantar fascia strain increases with the increment of toe dorsiflexion angle and also with the increment of the Achilles tendon forces. <ref name="Reid" />
 
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. <ref name="Hsin">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.</ref>
 
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). <ref name="Hsin">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</ref>
 
After tests and X-ray the results showed that the maximum stress was concentrated near the medial calcaneal tubercle. <ref name="Finite element analysis of plantar fascia under stretch- the relative contribution of windlass mechanism and achilles tendon force.">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</ref>
 
Backstorm and More<ref name="Back">Backstorm K.M., More A. Plantar fasciitis ; Phys Ther Case REp, 2000, 3: 154-162.</ref> also suggested stretching using a contract-relax-contract [http://www.ipnfa.org PNF] method.<br>  


== References  ==
== References  ==

Revision as of 17:03, 29 March 2017

Original Editor - Brooke Kennedy

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Description[edit | edit source]

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.

The test can be important in the decision-making process involved in the evaluation and treatment of plantar fasciitis.

Purpose of the test[edit | edit source]

The test achieves a direct stretch on the plantar aponeurosis which can be effective in examining plantar heel pain.

Clinically relevant anatomy[edit | edit source]

The plantar aponeurosis acts similarly as windlass mechanism. Windlass is typically a horizontal cylinder that rotates with a crank or belt on a chain or rope to pull a heavy objects. The common use of windlass is seen in pulling the anchor of the ship known as anchor windlass. This mechanism can be seen in foot. When the MTP joints are hyperextended, the plantar aponeurosis becomes taut as it is wrapped around the MTP joints. This actions brings the metatarsal and tarsal bones together converting it into a rigid structure and eventually causing the longitudinal arches to rise. This winding of the plantar fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch.This function is important in providing a rigid lever for gait propulsion during push off.

Also with an increased hallux valgus or in cases of hallux limitus this mechanism didn’t function anymore.[1] 

Performong the test[edit | edit source]

A positive windlass test: heel pain reproduced with passive dorsiflexion of the toes.[2]

The difference between bearing weight and non-weight is that the sensitivity is higher in weightbearing[3]  De Garceau et al. showed 100% specificity for weightbearing and sensitivity of 32 % for non-weight bearing tests. [4][5] 

Non-weight bearing position: [6] [5][4] 

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

Weight-bearing position [5][4] 

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.

[7]

References[edit | edit source]

  1. ↑ 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.
  2. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named maf
  3. ↑ Cole C. et al. ,Plantar fasciitis: evidence-based review of diagnosis and therapy, Am Fam Physican, 2005;73(11);2237-2242,2247-2248.
  4. ↑ 4.0 4.1 4.2 MC Poil T.G., Clincal Guidelines, Heel- Pain, Plantar Fasciitis, journal of orthopaedic and sports physical therapy, 2008, A1-A19.
  5. ↑ 5.0 5.1 5.2 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.
  6. ↑ Wong M., Pocket Orthopaedics: Evidence-Based Survival Guide(2010),Mississauga, Jones and Barlett Publishers, (p. 361).
  7. ↑ Physiotutors. The Windlass Test | Plantar Fasciitis. Available from: https://www.youtube.com/watch?v=fg0PtnoAzSs
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