Journal of Foot and Ankle Research BioMed Central Research Open Access Ultrasound evaluation of the abductor hallucis muscle: Reliability study Alyse FM Cameron, Keith Rome and Wayne A Hing* Address: AUT University, School of Rehabilitation & Occupation Studies, Health & Rehabilitation Research Centre, Private Bag 92006, Auckland, 1142, New Zealand Email: Alyse FM Cameron - [email protected]; Keith Rome - [email protected]; Wayne A Hing* - [email protected] * Corresponding author Published: 25 September 2008 Received: 29 May 2008 Accepted: 25 September 2008 Journal of Foot and Ankle Research 2008, 1:12 doi:10.1186/1757-1146-1-12 This article is available from: http://www.jfootankleres.com/content/1/1/12 © 2008 Cameron et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The Abductor hallucis muscle (AbdH) plays an integral role during gait and is often affected in pathological foot conditions. The aim of this study was to evaluate the within and between-session intra-tester reliability using diagnostic ultrasound of the dorso-plantar thickness, medio-lateral width and cross-sectional area, of the AbdH in asymptomatic adults. Methods: The AbdH muscles of thirty asymptomatic subjects were imaged and then measured using a Philips HD11 Ultrasound machine. Interclass correlation coefficients (ICC) with 95% confidence intervals (CI) were used to calculate both within and between session intra-tester reliability. Results: The within-session reliability results demonstrated for dorso-plantar thickness an ICC of 0.97 (95% CI: 0.99–0.99); medio-lateral width an ICC: of 0.97 (95% CI: 0.92–0.97) and cross- sectional area an ICC of 0.98 (95% CI: 0.98–0.99). Between-session reliability results demonstrated for dorso-plantar thickness an ICC of 0.97 (95% CI: 0.95 to 0.98); medio-lateral width an ICC of 0.94 (95% CI 0.90 to 0.96) and for cross-sectional area an ICC of 0.79 (95% CI 0.65 to 0.88). Conclusion: Diagnostic ultrasound has the potential to be a reliable tool for evaluating the AbdH muscle in asymptomatic subjects. Subsequent studies may be conducted to provide a better understanding of the AbdH function in foot and ankle pathologies. Background sesamoid bone [4]. As the tendon lies beneath the trans- The intrinsic muscles of the foot work as a functional unit verse axis of the first metatarsal, AbdH performs abduc- in order to dynamically stabilise and assist in the support tion and plantar flexion of the first metatarsal phangeal of the medial longitudinal arch [1-3]. The abductor hallu- joint [5], being active in the late stance and toe-off phases cis muscle (AbdH) is the most medial muscle in the first of gait [6], and is a dynamic stabiliser of the longitudinal layer of intrinsic muscles of the plantar surface of the foot. arch [7]. Musculoskeletal conditions such as hallux valgus The proximal attachment is from the medial process of the (commonly known as a bunion) and pes planus can result calcaneus tuberosity, and its distal attachment is the prox- in the structure and function of AbdH being adversely imal phalanx with or without attachment onto the medial affected [5,8]. sesamoid bone, or with insertion exclusively at the medial Page 1 of 9 (page number not for citation purposes) Journal of Foot and Ankle Research 2008, 1:12 http://www.jfootankleres.com/content/1/1/12 An observation commonly seen in patients with diabetes landmarks as reference points for the perpendicular posi- is atrophy of the intrinsic foot muscles, including AbdH, tion of the transducer in relation to the long axis of the secondary to peripheral motor neuropathy [9]. Atrophy of limb, in a set repeatable patient position for carrying out the intrinsic foot muscle, which is a close representative of the imaging of the identified muscle [11,19-21]. Quanti- the level of motor dysfunction, is understood to result in tative analyses of the intrinsic foot muscles, including an imbalance and altered arrangement, thereby causing AbdH, have predominantly been performed on cadaveric prominent metatarsal heads, clawing of the toes, and the feet through dissection [2,22]; however, to date there development of pressure areas predisposing to possible appears to be no studies that have measured AbdH in the foot ulceration [9,10]. Alternatively, previous studies have asymptomatic population using ultrasonography. This also suggested that the muscle's anatomical line is altered may be beneficial for the diagnosis of pathology, moni- and the strength of the muscle is compromised, conse- toring adaptations, and providing evidence for the effec- quently affecting the biomechanics of gait, the medial tiveness of non-surgical interventions in relation to the longitudinal arch configuration, and degenerative pes pla- AbdH muscle. nus [5,8-11]. The aim of this study was to evaluate intra-tester within In hallux valgus the AbdH muscle is at a mechanical dis- and between-session reliability using diagnostic ultra- advantage as the distance between the proximal and distal sound imaging of the AbdH dorso-plantar thickness, attachments is increased, resulting in the muscle losing its medio-lateral width and cross-sectional area. abduction force [8,12]. An imbalance between the mus- cles of AbdH and Adductor hallucis muscle, which are Methods responsible for coordinating the first metatarsophalan- Subjects geal joint movements, is also evident, possibly leading to A convenience sample of thirty subjects were recruited joint deformity [13]. These effects have been demon- from the University population. Subjects were included if strated to increase the load on the posterior tibial muscle, they reported no history of inflammatory arthritis, previ- further increasing the likelihood of dysfunction [13]. ous foot or ankle surgery, diabetes, lower limb amputa- tion, or severe hallux valgus as defined by the Manchester There are a number of non-invasive techniques to image Scale [23]. All subjects provided written informed con- soft tissue structures. These include magnetic resonance sent. The procedures used in this study were approved by imaging (MRI), computerized tomography (CT), and the Universities Ethics Committee. ultrasound (US), although not all are feasible or practical to operate in the clinical environment. Electromyography Equipment (EMG) has also been utilised to measure skeletal muscle A Philips HD11 Ultrasound machine linear probe (L12-5 activity [14]. Current evidence suggests a good correlation MHz, 50 mm broadband linear array) was used to scan between ultrasound imaging and the "gold standard" of images of the AbdH muscle. An Aquaflex® Ultrasound Gel MRI and CT [15]. Furthermore, muscle imaging tech- Pad (Fairfield, USA) was applied directly on the skin niques such as MRI and US have been shown to be of superficial to the AbdH muscle for optimal transducer value in inflammatory myopathies [15]. Ultrasound contact and signal penetration. A stable platform held the imaging is safe, non-invasive, easily performed and is a foot in neutral position at zero degrees. Philips Q-lab Soft- considerably less expensive process to undertake, all mak- ware (Release 5.0) was employed for data quantification. ing it an advantageous piece of clinical equipment [16]. Ultrasonography has also already been shown to be a Experimental procedure valid and reliable tool diagnostically in the imaging of Subjects were laid in a supine position. The heel and skeletal muscle, producing quantitative and qualitative plantar aspect, excluding the first metatarsal, of the information about muscle architecture [17]. involved foot rested against a stable platform designed to fix the ankle in a zero degree neutral position. The poste- Ultrasound imaging has previously been used for measur- rior aspect of the knee was supported in approximately 15 ing and analysing muscle cross-sectional area of vastus lat- degrees flexion. The uninvolved leg was also supported. eralis [18], lumber multifidus [19], and a range of intrinsic foot muscles that includes extensor digitorum The researcher (AC) palpated the bony anatomical land- brevis, the first interosseus dorsalis muscle, adductor hal- mark of the anterior aspect of the medial malleolus and a lucis and the first lumbrical muscle [11]. Ultrasound perpendicular scanning line was drawn directly inferiorly. imaging has previously been used on the foot to measure The ultrasound gel pad was applied onto the AbdH mus- plantar fascia band thickness in symptomatic and asymp- cle belly, inferior to the medial malleolus. Scanning tomatic feet and to establish a plantar fasica index [20]. occurred with the transducer applied at a perpendicular Methodologically, previous studies have used anatomical angle to the aforementioned scanning line and long axis Page 2 of 9 (page number not for citation purposes) Journal of Foot and Ankle Research 2008, 1:12 http://www.jfootankleres.com/content/1/1/12 of the foot on the proximal aspect of the reference line to for each subject. The paired data was collapsed into a sin- encompass the muscle fibres of AbdH. Minimal pressure gle measure by taking the mean of the left and right feet. was applied with the transducer to reduce any possible The probe was reset in its holding port between each scan. alterations to the muscle architecture (Figure 1). This entire process was then repeated three to seven days later to gain between day test results. All ultrasonic imag- Using digital callipers, the dorso-plantar thickness and ing measurements were undertaken by AC who was a nov- medial-lateral width of the AbdH was measured from the ice researcher but with training using US imaging over 3- echogenic tissue interface between the muscle belly and months in a musculoskeletal paper run at the university.