REIDER PART 2
06

266 Chapter 7 Lowcr Leg, Foot, and Ankle

Figurę 7-28. A, Halłux valgus. B, Hałłiuc varus.

notę how many of the patients toes can be seen from behind. Normally, only one or at most two toes are visi-ble from this perspective. Johnson noted that, in the pres-ence of acquired pes planus secondary to posterior tibial tendon injury, the abducted position of the forefoot allows the examiner to see too many toes from behind. The ability to sec morę toes than usual from the posterior perspective in a patient with unilateral flatfoot has thus come to be called the too-many-toes sign. Although orig-inally described for accjuired flatfoot secondary to posterior tibial tendon dysfunction, the too-many-toes sign may be present in any case of unilateral pes planus, no matter what the cause (Fig. 7-33).

While still vievving from the posterior perspective, the examiner should ask the patient to rise up on tiptoe. This maneuver is also called a heel raise. The forced dor-siflexion of the metatarsophalangeal joints that is pro-duced by this maneuver passively tightcns the plantar fascia. This sequence of events has been called the wind-lass effect; it normally produces an involuntary invcrsion of the heel and an accentuation of the medial longitudi-nal arch (Fig. 7-34). Absence of the normal windlass effect may be secondary to stiffness owing to arthritis, a tarsal coalition, or injury to the posterior tibial tendon or

Figurę 7-29. A, Hammer toe.