Original Article J. Phys. Ther. Sci.

19: 251–256, 2007

Analysis of the Repeated One-Leg Heel-Rise
Test of Ankle Plantar Flexors in Manual
Muscle Testing

SATOSHI KASAHARA, RPT, PhD1), JUNJI EBATA, RPT2), MITSUHIKO TAKAHASHI, RPT, PhD1)
1)
Division of Physical Therapy, Department of Health Sciences, Hokkaido University School
of Medicine: West 5, North 12, Kita-ku, Sapporo, 060-0812, Japan. TEL +81 11-706-3391,
FAX +81 11-706-3391, E-mail: kasahara@cme.hokudai.ac.jp
2)
Department of Rehabilitation, KKR Sapporo Medical Center

Abstract. The purpose of this study was to evaluate the repeated one-leg heel-rise test method of ankle
plantar flexors in MMT with kinetic measuring devices and electromyograms (EMG). Seven healthy
young males (age, 23 ± 2 y) with no prior history of fractures or surgery involving the lower limbs
participated in this study. The ankle and knee motions from flexible electrogoniometers (EGM), ground
reaction forces (GRF) and center of pressure (COP) from one force plate and the root-mean-square (RMS)
and mean-power-frequency (MPF) from EMG in the medial head of the gastrocnemius and soleus muscles
during the repeated one-leg heel-rise test. Kinetic and kinematic data from EGM, GRF and COP were
unchanged during the tests. Although the RMS in both muscles and the MPF in the soleus muscles were
unchanged during this test, the MPF in the gastrocnemius muscles decreased with the number of iterations
(r=–0.79, p<0.001). The MPF of the gastrocnemius muscles in the late phase was significantly lower that
in the early and middle phases (respectively, p<0.05, p<0.05). Our results show that this repeated motion
method estimates muscle endurance rather than the muscle power.
Key words: Manual muscle testing (MMT), Ankle plantar flexors, Muscle fatigue

(This article was submitted May 8, 2007, and was accepted Jul. 4, 2007)

INTRODUCTION repeated one-leg heel-rise test, using the subject’s

Muscle evaluation and training are important for
the rehabilitation of patients with movement
disorders. Since its introduction by Lovett in the
early 1990s, manual muscle testing (MMT) has
been widely used by clinicians to assess muscle
strength when making training programs and
judging rehabilitation effects on patients.
Most of the grading criteria used in MMT are
based on the ability to move voluntarily against
gravity or the manual resistance added by an
examiner, using a 5-point grading scale 1 – 3 ) .
However, only the grading scales for the ankle
plantar flexors are decided by repetition during the
body weight as resistance1–3). Many studies have
examined the methodologies and judgments while
assessing the strength of the ankle plantar flexors
with MMT. Svantesson et al. 4) suggested that
muscle fatigue occurs in the calf muscles during this
test. Therefore, a diagnosis of muscle weakness
may actually be muscle fatigue caused by repetitive
movements.
There is disagreement about the judgment of the
grading criteria for “normal” ankle plantar flexors
with MMT2–7). A report by Beasley5) proposed five
or less heel-rises. On the other hand, Svantesson et
al. 4) and Lunsford & Perry 6) suggested that the
grading criteria for “normal” requires 20 or more
252 J. Phys. Ther. Sci. Vol. 19, No. 4, 2007
heel-rise repetitions in the one-leg standing
position. The differences in judgment between
these studies may have resulted from the different
“successful” tasks as defined by using either
electromyography or electrogoniometers. Also, if
muscle weakness occurs in ankle plantar flexors,
then the kinetic parameters (e.g., center of pressure,
ground reaction forces, etc.) of the motor
performance will change during the repeated one-
leg heel-rise movement. Previous studies4–6) have
n o t e x a m i n e d th is m ot o r ta s k u s i n g t h e s e
measurements simultaneously however. The
purpose of this study was to clarify changes in
motor performance by carrying out kinematic and
kinetic analyses, and to simultaneously investigate
the activities of the gastrocnemius and soleus
muscles during repeated one-leg heel-rise tests
using electromyogram analysis.
METHODS
Subjects
This study recruited 7 healthy males (mean age,
22.6 ± 1.8 years; mean height, 170.3 ± 2.6 cm; mean
weight, 60.9 ± 7.9 kg). Informed consent was
obtained from each subject according to protocols
approved by the Ethical Committee of the College
of Medical Technology of Hokkaido University.
All subjects were free of any lower limb pain for
at least one year prior to the study. Exclusion
criteria for all subjects included any previous
history of fractures or surgery involving the lower
limbs; diseases that could affect motion (e.g.,
rheumatoid arthritis, spondylolisthesis, etc); or
current symptoms of lower limb pain.
Measurements
Two flexible electrogoniometers (EGM)
(Biometrics, Cwmfelinfach, Gwent, UK) were used
to monitor both ankle and knee joint movements
during the one-leg heel-rise test (Fig. 1). One
sensor was attached to the outside of the upper and
lower thigh for knee motion, while another sensor
was attached over the lateral aspects of the lower
thigh and the fifth metatarsal bone for ankle motion,
as recommended by Biometrics8). Each sensor was
firmly fixed to the skin with double-sided medical
tape and covered by single-sided tape to minimize
movements between the sensors and the underlying
skin. Both Dolan et al. 9) and Thoumie et al. 10)
reported this method as having high validity and
Fig. 1. Illustration of the one-leg heel-rise test.
reliability. The EGM calibration was made in the
upright standing position so as to give a zero
reading.
Surface electromyogram (EMG) activities were
recorded from the medial head of the gastrocnemius
and soleus muscles (Fig. 1). After shaving and
scrubbing the skin with alcohol, bipolar surface disk
electrodes (Ag/AgCl, Blue sensor P-00-S, diameter
=3.3 mm, Ambu, Denmark) were fixed with
adhesive tape to each muscle at an inter-electrode
distance of approximately 30 mm. The EMG
electrodes were placed above the medial heads of
the gastrocnemius and soleus muscles according to
Basmajian and Blumenstein 1 1 ) . The ground
(reference) electrode was attached to the head of the
fibula on the left side. EMG signals were
preamplified (× 500) and band-pass filtered between
10 and 500 Hz. The EGM and EMG data were
sampled at a frequency of 1 kHz. The EGM and
EMG equipment consisted of a Multi-Telemeter
system WEB5000 (Nihon Kohden, Tokyo, Japan).
Kinetic data were collected from one force plate
(Kistler Instruments AG, Winterthur, Switzerland,
600 × 400 × 35 mm) that assessed anterior-posterior
(Fx), medial-lateral (Fy) and vertical (Fz) ground
reaction forces (GRF) and the center of pressure
(COP). All signals were sent to a PowerLab system
(PowerLab /16sp, ADInstruments, Castle Hill,
Australia) connected to a Windows PC. PowerLab
was equipped with an analog-digital converter
(ACD, 16-bit) used to digitize all signals.
PowerLab collected data at a frequency of 1 kHz
and high-cut filtered raw data at 30 Hz. All digital
signals were then transferred to a PC and stored on
disc for further analyses. All data were analyzed
using Chart software v5.4.2 for PowerLab systems.
 253

The left foot was measured because it was the

dominant foot in all subjects. MMT for ankle
plantar flexors was performed according to the
procedure of Hislop1). Briefly, each subject stood
barefoot in the center of the force plate with an
extended knee. Then, the subject put his fingers on
the examination table to maintain his balance. The
subject was then instructed “to raise his heel as
completely as possible 20 times, without losing his
balance.” The subject was directed to gaze at the
wall directly in front of him and to use a
comfortable and constant heel raising velocity.
Ankle and knee joint movements were recorded
over all trials. The subject’s body weight provided
the applied resistance during the one-leg heel-rise
test. To examine the effects of subjects’ body
weight on the range of ankle motion during a heel
rise in the one-leg position, the maximum ankle
plantar flexion (PF θmax) during the first trial was
compared with the passive range of motion for the
ankle plantar flexion (pROM) measured in the
supine position. PF θmax and the maximum knee
flexion angle (KF θmax) from an initial position
were measured for each trial.
All EMG signals were full-wave rectified and the
average amplitude of the rectified signal was Fig. 2. The raw data of the one-leg heel-rise test by one
calculated using the root-mean-square (RMS) subject. The knee (a) and ankle (b) joint angles from
method in each trial. Each trial was modified by a EGM. The muscle activities of the gastrocenemius
Cosine-Bell window and the fast Fourier transform muscle (c) and the soleus muscle (d) from EMG.
method was used to obtain the mean-power- The Fz of GRF (e) from the force plate.
frequency (MPF). The peak GRF value in all
directions was measured for each trial. All GRF
data were normalized for the resting standing separated into three phases (Early: 2–7, Middle: 8–
position. The maximum movement distance of 13, Late: 14–19) except in the first and last trials,
COP was computed in the anterior–posterior and one-way repeated measures analysis of variance
(COPx) and medial-lateral (COPy) directions. (one-factor ANOVA) was used for each phase.
COPx and COPy were calculated as a percentage of Furthermore, for those values showing a significant
the foot length and foot width, respectively. difference in ANOVA, Fisher’s PLSD was used to
Mean values and standard deviations (SD) are test the significance level. Statview 5.0 software
given in the description of the subjects. The mean (SAS institutes Inc, Berkley, CA) was used for
values and standard errors of the mean (SEM) are statistical analysis. The level of significance was
given and calculated using conventional methods. set at 0.05.
Student’s t-test was used to test for differences
between pROM and PF θmax during the first trial. RESULTS
One-way repeated measures analysis of variance
(one-factor ANOVA) was used for PF θmax, KF All subjects satisfactorily performed the twenty
θmax, GRF and COP between each trial to examine heel-rise test with a constant rhythm. Figure 2
performance changes. shows the raw data of ROM of the ankle and knee
Spearman’s Rank correlation coefficient was joints, EMG of the medial head of the
calculated for EMG data between each trial to gastrocnemius and soleus muscles and Fz GRF.
examine muscle fatigue4). Also, EMG data were PF θmax during first trial was lower than pROM,
254 J. Phys. Ther. Sci. Vol. 19, No. 4, 2007

Fig. 3. The root-mean-square (RMS) and mean power frequency (MPF) during the repeated one-leg heel-rise test. The
left panel (a) shows RMS and number of iterations and the right panel (b) shows MPF and number of iterations.
The filled circles ( ) indicate the gastrocenemius muscle and the filled triangles ( ) indicated the soleus muscle.
Linear regressions have been calculated for each data set.

Table 1. Mean ± SEM of the mean power frequency (MPF) of the

gastrocnemius muscle among 3 phases
Phase Early Middle Late
MPF (Hz) 123.4 ± 0.4* 122.7 ± 0.2* 120.0 ± 0.6
Asterisk denotes significant difference from the late phase (p<0.01).

37.9 ± 1.9, 47.9 ± 1.0 degree, respectively (p<0.01).
All subjects were unable to raise their heels to the
full range of motion, and thus failed to satisfy the
condition for movement range “from 0 degrees up
to 45 degrees” indicated by the 7th edition of
MMT1).
There were no significant differences between PF
θmax (F(17,108)=0.508) or PF velocity
(F(17,108)=0.355) and the number of iterations, and
KF θmax was always constant (F(17,108)=0.119).
There was no significant difference between trials
in both maximum COPx (F(17,108)=0.312) and COPy
(F(17,108)=0.569) displacement. The peak Fz GRF
was unchanged during the heel-rise movement
(F(17,108)=0.104). From these kinematic and kinetic
variances, similar motor performances were
accomplished over 20 one-leg heel-rise tests.
RMS of the medial head of the gastrocnemius and
soleus muscles showed no change during heel-rise
movement (Fig. 3a). There was a trend towards
decreased MPF of the medial head of the
gastrocnemius muscle with increasing number of
heel-rises (R=–0.79, P<0.001, Fig. 3b). The late
phase differed from the early (P<0.01) and middle
phases (P<0.01, Table 1). On the other hand, there
was no change in the MPF of the soleus muscle
during heel-rise movement.
DISCUSSION
The present study showed no changes in motor
performance during the repeated one-leg heel-rise
test in healthy young males. There was no change
in RMS and MPF of the EMG in the gastrocnemius
muscle of ankle plantar flexors decreased with
increasing number of repetitions. There were no
changes in either the RMS or MPF of the EMG of
the soleus muscle during this test.
Our study shows that the changes in muscle
activities are different between the gastrocnemius
and the soleus muscle in the ankle plantar flexors.
The change in the MPF of the EMG has been used
to evaluate the muscle fatigue12, 13). The decrease in
MPF is mainly a result of the decrease in action
potential conduction velocity14, 15). This decrease in
action potential conduction velocity has been found
to be related to the lactate concentration in the
muscle 16) . Gerdel et al. 17) found correlations
between MPF and the single amplitude of the EMG,
and suggest that a decrease in MPF along with an

increase or no change in the single amplitude of the
EMG is considered to be a practical measurement of
muscle fatigue. According to the definition by
Lindström et al. 13) , no change in RMS and a
decrease in MPF indicates the development of
muscle fatigue. Therefore, our study suggests
fatigue in the medial head of the gastrocnemius, but
not in the soleus muscle during repeated one-leg
heel-rise test in healthy young males.
The EMG data of the soleus muscle did not
change during this motor task. The soleus is located
in a deeper position than the gastrocnemius, and it is
generally accepted that the gastrocnemius is
composed of a mix of fast- and slow-twitch muscle
fibers while the soleus is primarily composed
mostly of slow-twitch muscle fibers 18–20) . The
difference in muscle fatigue between the two
muscles may be related to the characteristics of the
muscle fiber–the soleus being dominated by type I
fibers21). Svantesson et al.4, 22, 23) and Österberg et
al.13) reported that muscle fatigue appeared in both
the gastrocnemius and the soleus during a standing
heel-rise test. We instructed subjects to accomplish
the one-leg heel-rise 20 times, whereas Svantesson
et al. 4, 22, 23) and Österberg et al. 13) instructed
subjects to perform the task until no further heel-
rises could be performed due to exhaustion.
Therefore, muscle fatigue will occur in the medial
head of gastrocnemius first and occur in the soleus
muscle later.
There is disagreement about the “normal”
criterion between studies. Kendal et al.7), Beasley5)
and Daniels et al.3) proposed five or less heel-rises.
On the other hand, Hislop et al.1, 2), Lunsford &
Perry6) and Svantesson et al.4) suggested 20 or more
heel-rises. The procedure and definition of the
repeated one-leg heel-rise movement differ
between these experiments. For keeping balance
during this test, subjects were allowed to touch the
examiner6, 24), the wall4, 13) or the table1, 2) with the
finger of one hand1–3, 6, 24) or both hands4, 13, 22, 23).
Also, subjects were instructed to perform the
plantar flexion ROM at complete or more than 50%
of the starting ROM6, 24). Subjects in our study were
permitted to touch the table with two fingers of one
hand and instructed to perform the ankle plantar
flexion ROM at complete starting ROM. Our study
showed that subject’s weight influenced PF θmax
during the first trial. All kinetic data, however, was
unchanged during this study and healthy young
males could accomplish 20 heel-rises. Thus,
255
although we support the essential qualification of
“normal” is 20 times or more in healthy young
males, the criteria repetition of “normal” should
consider the subject’s weight, sex and age24).
Muscle strength generally includes the functions
of power and endurance25). Most MMT evaluate
muscle power, but the ankle plantar flexion in MMT
does not. Finally, our EMG results show muscle
fatigue in the ankle plantar flexors during the
repeated one-leg heel-rise test, and suggest that this
test estimates muscle endurance rather than muscle
power. Therefore, to estimate muscle power, the
development of new method is required. Finally,
although the motor performance of the 20 repeated
one-leg heel-rise movement does not change if
MMT is used to assess the muscle power of the
ankle plantar flexors in healthy young males,
muscle fatigue may potentially occur in the ankle
plantar flexors. Since repetitive movements
examine muscle endurance rather than power, an
improvement in MMT will be required to strictly
estimate the muscle power of the ankle plantar
flexors in the future.
REFERENCES
1) Hislop HJ, Montgomery J: Daniels and Worthingham’s
Muscle Testing:Techniques of Manual Examination.
7th ed. Philadelphia, Pa: WB Saunders Co, 2002.
2) Hislop HJ, Montgomery J: Daniels and Worthingham’s
Muscle Testing:Techniques of Manual Examination.
6th ed. Philadelphia, Pa: WB Saunders Co, 1995.
3) Daniels L, Worthingham C: Muscle Testing:
T e c h n i qu e s of M a n u a l E x a mi n a t io n . 5 t h e d.
Philadelphia, Pa: WB Saunders Co, 1986.
4) Svantesson U, Österberg U, Thomee R, et al.: Muscle
fatigue in a standing heel-rise test. Scand J Rehab Med,
1998, 30: 67–72.
5) Beasley WC: Quantitative muscle testing: principles
and applications to research and clinical servise. Arch
Phys Med Rehabil, 1961, 42: 398–425.
6) Lansford BR, Perry J: The standing heel-rise test for
ankle plantar flexion: Criterion for normal. Phys Ther,
1995, 75: 49–53.
7) Kendall HO, Kendall FP, Wadsworth GE: Muscle:
testing and function. 2nd ed. Baltimore, Williams &
Wilkins, 1971.
8) Biometrics Ltd.: Goniometer and torsiometer
operating manual. Gwent, UK: Biometrics Ltd., 2002.
9) Dolan KJ, Green A: Lumbar spine reposition sense: the
effect of a ‘slouched’ posture. Man Ther, 2006, 11:
202–207.
10) Thoumie P, Drape JL, Aymard C, et al.: Effects of a
lumbar support on spine posture and motion assessed
256 J. Phys. Ther. Sci. Vol. 19, No. 4, 2007
by electrogoniometer and continuous recording. Clin
Biomech, 1998, 13: 18–26.
11) Basmajian JV, Blumenstein R: Electrode placement in
electromyographic biofeedback. In: Biofeedback
Principles and Practice for Clinicians. Basmajian JV
(ed.), Baltimore: Williams & Wilkins, 1983, pp 369–
382.
12) Komi PV, Tesch P: EMG frequency spectrum, muscle
structure and fatigue during dynamic contractions in
man. Eur J Appl Physiol, 1979, 42: 41–50.
13) Österberg U, Svantesson U, Takahashi H, et al.:
Torque, work and EMG development in a heel-rise
test. Clin Biomech, 1998, 13: 344–350.
14) Lindström L, Magnusson R, Petersen I: Muscular
fatigue and action potential conduction velocity
changes studied with frequency analysis of EMG
signals. Electromyography, 1970, 4: 341–353
15) Lindström L, Kadefors R, Petersen I: An
electromyographic index for localized muscle fatigue.
J Appl Physiol, 1977, 43: 750–754.
16) Tesch P, Komi PV, Jacobs I, et al.: Influence of lactate
accumulation of EMG frequency spectrum during
repeated concentric contractions. Acta Physiol Scan,
1983, 119: 61–67.
17) Gerdle B, Eriksson N, Brundin L: The behavior of the
mean power frequency of the surface electromyogram
in biceos brachii with increasing force and during
fatigue. With special regard to the electrode distance.
Electromyogr Clin Neurophysiol, 1990, 30: 483–489.
18) Costill DL, Daniels WJ, Evans WJ, et al.: Skeletal
muscle enzymes and fiber composition in male and
female track athletes. J Appl Physiol, 1976, 40: 149–
154.
19) Gollnick PD, Sjodin B, Karlsson J, et al.: Human
soleus muscle: a comparison of fibre composition and
enzyme activities with other leg muscles. Pflugers
Arch, 1974, 348: 247–255.
20) Trappe SW, Trappe TA, Lee GA, et al.: Calf muscle
strength in humans. Int J Sports Med, 2001, 22: 186–
191.
21) Edgerton VR, Smith JL, Simpson DR: Muscle fiber
type populations in human leg muscles. Histochem J,
1975, 7: 259–266.
22) Svantesson U, Osterberg U, Grimby G, et al.: The
standing heel-rise test in patients with upper motor
neuron lesion due to stroke. Scand J Rehabil Med,
1998, 30: 73–80.
23) Svantesson U, Osterberg U, Thomee R, et al.: Fatigue
during repeated eccentric-concentric and pure
concentric muscle actions of the plantar flexors. Clin
Biomech, 1998, 13: 336–343.
24) Jan MH, Chai HM, Lin YF, et al.: Effects of age and
sex on the results of an ankle plantar-flexor manual
muscle test. Phys Ther, 2005, 85: 1078–1084.
25) Zachazewski JE, Magee DJ, Quillen WS: Athletic
injuries and rehabilitation. UK: WB Saunders Co,
1996, p 207.