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Abstract

Purpose:

To propose a novel, accurate, and easy to perform test replacing the manual muscle testing. Our target is to develop a valuable tool for identification of patients with neurological motor impairment precisely, rapidly, and easily.

Methods:

We have randomly selected patients presenting to the clinic complaining of back pain with or without lower limb symptoms. These patients were asked to walk on their heels and on their toes. Being unable to walk on heels and/or toes, the patient is considered to have positive test result (abnormal finding). After that, a full and thorough neurological examination was performed on every patient by an orthopedic resident doctor. We looked specifically to the correlation between the ability to do toe–heel walking with the results of the detailed neurological examination.

Results:

Toe–heel walking test was able to detect all patients with weakness in their lower limb musculature. The results from the current investigation indicate a very high Pearson correlation of 0.95 (p = 0.001) between the toe–heel test and manual muscle testing.

Conclusion:

Toe–heel walking test is superior to detailed neurological examination in identification of patients with weakness, sphincter problem, and/or positive straight leg raising test. This test is both simple and rapidly performed test, which can be easily done by any health-care provider. Owing to its ease, this test is not restricted to medical doctors, but it could be accurately performed by any health-care provider such as nurses and physiotherapists. This will enable us to decrease the referral to the specialty clinic and to decrease the overall cost.

Keywords

low back pain manual muscle testing motor function sciatica spine toe–heel walking

Introduction

Low back pain (LBP) is an immense and costly health problem that any person may encounter at one point of his/her life with a prevalence of up to 58.1% and 1 year recurrent prevalence of up to 82.5%.^1
–3 In addition, it was reported as one of the top five complaints disclosed by patients in the emergency departments and as one of the common clinical presentation at orthopedic clinics.^{4, 5}

Despite its disabling nature, LBP is a self-limiting pain in most patients⁶ and could be the result of many conditions including, but not limited to, disc herniation, spinal stenosis, and psychological causes.

LBP could manifest itself by local dull pain, muscle spasm, difficulty standing, and sciatica neuralgia. The latter, which is a radicular pain along the distribution of the sciatic nerve, is a common feature with a prevalence of 40% in adult population (among which only 4–6% are considered of clinical significance.^7
–9

In patients who report LBP with sciatica neuralgia, clinicians should investigate the likelihood of radiculopathy due to lumbar disc herniation by means of history taking and explicit physical examination. Recent recommendation suggests the use of six outcome-measure domains, and the associated test instruments, to be used when assessing different patients complaining of LBP.¹⁰

Among these domains, physical functioning and pain intensity should be examined in patients complaining of sciatica neuralgia¹⁰ via straight leg raising test (SLR), tendon reflexes tests, sensory deficits, and signs of paresis or atrophy (by means of using manual muscles testing (MMT)).¹¹

MMT, which was first introduced in 1915,¹² was reported in the literature to be strongly correlated and a valid investigation tool for patients complaining of LBP.¹³ However, such test is considered a time-consuming test (executed in a long period of time) and highly correlated to the examiners strength (resisting force).¹⁴ In addition, it was shown that MMT can only challenge approximately 30% of the plantar flexor strength occurring during a single-heel rise; thus, it does not reflect the actual power needed during walking.¹⁵

Therefore, and due to the busy nature of the emergency department and orthopedic clinics as well as the fact that most LBP (or sciatica neuralgia) cases are self-limiting (and thus does not require treatment), this article presents a new testing method that is executed in a remarkably short time and relies on patient him/herself rather than examiners strength to replace the MMT.

The new test is based on investigating the patient ability to walk on the toes and then to walk on the heel (toe–heel walking), hence, testing the power of the muscles responsible for lower limb movements. In this context, being able to perform the new test without difficulties indicates a good muscles power and thus no need to perform the lengthy MMT. On the other hand, being unable to perform the test (or performing with limitations) indicates a problem in the muscles and thus a detailed MMT is required.

In particular, in addition to the required contraction of gastrocnemius and iliopsoas muscles during toe walking,¹⁶ the quadriceps, solus, and tibialis anterior muscles phasic contraction during the preswing (resembling toe walking) and initial contact (resembling heel walking) phases of normal gait cycle^17,18 was documented in the literature. Moreover, Correa et al.¹⁹ reported that gluteus medias, gluteus maximus, iliopsoas, hamstrings, vasti, and solues contraction throughout the normal gait cycle (including preswing and initial contact phases) is a main contributor to hip joint contact force. Finally, EMG (electromyography) activity of the gastrocnemius, quadriceps, iliopsoas, soleus, and tibialis anterior muscles was reported during walking on inclined and reclined surfaces (resembling heel and toe walking).²⁰

In this toe–heel walking test, time, capacity, cost, and human resources are preserved for patients who need supervision and care. Due to its simplicity, this test can be carried out by any health-care provider like a nurse, a physiotherapist, or a general physician, which means reliable assessment of the patient and decreasing overall unnecessary referrals to the specialty clinical service. Accordingly, implementing this test will vastly decrease the cost, save the time in the emergency departments, and decrease the overall number of patients referred to the specialty clinic.

Methodology

The test

The newly developed test was termed “toe–heel walking test” and was tested on patients in the orthopedic clinic, emergency department, and orthopedic ward. The test involved asking the patient to walk on his/her toes for approximately four successive steps and then to walk on his/her heels for approximately four successive steps.

This test procedure relied on the fact that walking on toes and heels examines the strength and innervation of lower limb musculature. Table 1 relates every motor function in the lower limb with its responsible nerve root as reported by American Spine Injury Association (ASIA).²¹ In particular, walking on toes and heels requires active contraction of the hip flexors, hip extensors, knee extensors, ankle dorsiflexors, ankle planterflexors, toe dorsiflexors, and toe planter flexors¹⁷ (see Table 1).

Table 1.

Lower limb musculature and their corresponding enervation.

Musculature	Nerve root
Hip flexors	L2
Knee extensors	L3
Ankle dorsiflexors	L4
Toes dorsiflexors and hip extensors	L5
Toes plantarflexors and ankle plantarflexors	S1

The test was built on the assumption that only patients who cannot fully perform the toe–heel walking test were considered to motor function problems and thus needed a detailed MMT of the lower limbs.

Subjects

The test was performed on 75 patients (17 males and 58 females) who complained of LBP with or without sciatica neuroglia. Test participants were 18 years old or older (mean age was 55). Of those patients, 58 were females.

Ethics

Ethical approval (reference number 6700-7-4289) for conduction of this study was granted from the University of Jordan Hospital Scientific Research Ethical Committee. Once granted, and for the purposes of this study, recruited patients were orally informed about the aim of the study and the procedure of the investigation. Those who agreed to take part in the study were asked to sign a written consent form.

Data collection

For each recruited patient, a detailed history was taken including LBP duration, presence of sciatica neuralgia and its site if present. In addition, explicit physical examination was performed including:

SLR test with positive findings upon reproduction of symptoms at <60° of raising.

Knee reflex (patellar deep tendon reflex examination) obtained at both knees with patient lying supine, findings were scored as hypoactive (+), normal (++), and hyperactive (+++).

Ankle reflex (Achilles deep tendon reflex examination) obtained at both ankles with patient lying supine, findings were scored as hypoactive (+), normal (++), and hyperactive (+++).

MMT for both lower limbs including hip flexion, hip extension, knee flexion, knee extension, ankle dorsiflexion, ankle plantarflexion, toes flexion, and toes extension. The MMT¹² results were graded according to the Medical Research Council grading scale (Table 2).

Moreover, the presence of sphincteric dysfunction (urinary or fecal) or neurogenic claudication was reported as part of the standard protocol when investigating LBP patients.

Table 2.

MMT grading system.

Grade	Function of the muscle
5	Normal power
4	Active movement against gravity and resistance
3	Active movement against gravity and resistance
2	Active movement gravity with gravity
1	Only slight movement
0	No movement

MMT: manual muscles testing.

Statistical analysis

Collected data were processed on Statistical Package for the Social Sciences (IBM SPSS statistics, 2015, IBM). Pearson correlation test for nonparametric data was used to investigate the correlation between the results of the toe–heel walking test (where if performed fully on both lower limbs, it was considered positive [+1] and if not in either or both lower limbs, it was considered negative [−1]) and the MMT results (where a full score (normal power) for all tested muscles was considered positive [+1] and a less than full score in any or all tested muscles was considered negative [−1]). A correlation of <0.35 is considered weak, 0.36–0.67 is considered moderate correlation, 0.68–0.90 is considered high, >0.9 is considered very high, and 1 is considered perfect correlation²²

Results

The toe–heel walking test was developed and named by the authors in Jordan. The test idea was derived from gait cycle characteristics as well as the ASIA. This test gives a rapid overall indication of a patient’s lower limbs muscles power. Practically, the toe–heel test is executed in no more than 10 s and its results clearly roll out the presence of motor impairment, thus significantly reducing (p < 0.05) the time required in performing detailed examination of LBP patients with sciatica neuralgia (an average of 8 min in our sitting in a university hospital with a well-trained residents).

In addition, unlike the currently available examination techniques, the newly developed test requires no prior knowledge or expertise to perform. In particular, any health-care provider (such as a nurse) could easily perform the test. Thus, orthopedic specialists or physicians time could be saved for patients who need actual care.

The results from the current investigation (Tables 3 and 4) indicate a very high correlation of 0.95 (p = 0.001) between the toe–heel test and MMT. In spite of the less than perfect correlation (r < 1.00), only 3 of the 75 participants showed opposite results (positive results of toe–heel test and negative results of MMT). This, however, indicates that the toe–heel test is perfectly sensitive in detecting motor function impairments where it was 100% at S1, L5, L4, and L3 nerve roots. In addition, the specificity was 68, 69, 71, and 51% at S1, L5, L4, and L3 nerve roots, respectively. Nonetheless, all recruited subjects had MMT score of 5 in hip flexion, and thus, both sensitivity and specificity could not be determined at L2 nerve root. In particular, only if the results were positive with toe–heel walking and negative with MMT, the new test could not be considered dependent on to be accurate.

Table 3.

A table showing the raw data as collected from the patients.

MMT	Gender		Toe walking		Heel walking		Sciatica		Site of symptoms			SLR test		Knee reflex			Ankle reflex
	M	F	Y	N	Y	N	P	NP	R	L	RL	Po	Ne	+	++	+++	+	++	+++
Normal	5	32	36	1	35	2	24	13	12	9	3	7	30	0	37	0	0	37	0
Abnormal	12	26	17	21	8	30	32	5	19	13	2	27	11	0	31	6	0	35	2

MMT: manual muscle testing results where only normal refers to a full score for all tested muscles, M: male, F: female, Y: yes can perform, N: no cannot perform, P: present, NP: not present, R: right, L: left, RL: both right and left sides, Po: positive results, Ne: negative results, +: hypo reflex, ++: normal reflex, +++: hyper reflex; SLR: straight leg raising test.

Table 4.

The number of patients who scored <5 in MMT for each movement and its corresponding nerve root.

Nerve root	S1		L5	L4	L3	L2
Nerve root	Ankle PF	Toe PF	Toe DF	Ankle DF	Knee extension	Hip flexion
MMT score 4	18	14	19	21	5	0
MMT score 3	2	5	6	6	2	0
MMT score 2	1	1	0	0	0	0
MMT score 1	2	2	1	0	0	0

PF: planer flexion, DF: dorsiflexion, MMT: manual muscles testing.

The results also indicate a moderate correlation between toe–heel walking and SLR test (r = 0.6). In addition, the results indicate a weak correlation between the toe-heel walking test and both knee jerk as well as ankle jerk (r = 0.3 and 0.2, respectively). This, however, was expected as these three tests focus on sensory and reflex tests that are not related to motor dysfunction.

Interestingly, all patients with a sphincteric dysfunction were found to have negative toe–heel walking test results. This may be due to the high sensitivity of this test toward subtle forms of muscle weakness.

Discussion

LBP is a symptom, not a diagnosis. Most often, it is not associated with an underlying structural abnormality.²³

LBP also is a common problem for competitive sports.²⁴ McCarroll et al. ²⁵ reported that 30% of college football players lost playing time due to LBP. Also, Hainline²⁶ found that 38% of professional tennis players reported LBP as the reason for missing at least one tournament. Moreover, 90% of all tour injuries in professional golfers involve the neck or back.²⁷

We aimed in this study to point at effective test to locate patients with significant positive findings regarding LBP and associated muscle weakness.

Heel walking and toe walking are very demanding on patients because it involves activation of hips, knees, ankles, and toes muscles. To perform either one we need to generate more power than the power generated by the clinician hands during MMT. So, we expect our tests can pick up even subtle forms of weakness.¹⁷

We took randomly all the patients presented to the clinic or the patients available in the hospital wards who are complaining from LBP ± sciatica. Toe–heel walking test was performed by different resident doctors and followed by a detailed neurological examination of the lower limb musculature.

Our findings suggest that this test (toe–heel walking) is superior to MMT as a screening test. Toe–heel walking test could identify all patients with abnormal MMT results. On the other hand, it even identified three patients whom were shown to be normal by MMT. If the patient was unable to do either one, he needs further evaluation in form of detailed physical examination and radiological investigation.

Most importantly, this simple test can be done easily by nurses, physical therapists, or any health-care provider, so as to stratify patients and to distinguish patients who are in need for referral for further clinical assessment by a clinician from the patients who are suffering from simple back pain and/or sciatica who needs only simple analgesia and reassurance. This will decrease the total cost of managing back pain and/or sciatica.

Although our findings showed high significance of our test, the sample size was a limitation in this study. Also, we do not know whether the test will be effective in picking up patients with more proximal weakness. We think this should be assessed in further studies.

Considering that all patients who scored <5 in MMT of knee extension (nerve root L3) have also scored <5 in MMT of ankle PF (S1 nerve root), toe DF (L5 nerve root), and/or ankle DF (L4 nerve root), it could be assumed that the current toe–heel test could not be specific to L3 and L2 nerve roots. This is so because patients may have been unable to perform the test due to problems in ankle PF/DF and/or toe flexion/extension rather than a problem in knee extension or hip flexion.

Therefore, the results from the current investigation suggest that the toe–heel walking test could be a successful investigation tool for S1, L5, and L4 nerve roots. Whereby further investigations on larger sample groups are needed to establish this tests feasibility in detecting problem in L3 and L2 innervation.

Conclusions

Toe–heel walking test is a novel, easily performed and a reliable test in assessing lower limb muscle weakness, which could decrease the total cost of managing LBP. However, it needs further evaluation due to the limitations of this study.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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