REIDER PART 222

282 Chaptek 7_Lower Leg, Foot, and Ankle

7-2 • When the Patient Complains of Heel Pain

If there was a History of Trauma or a Specific Injury: Major diagnostic possibilities include:

• Calcaneus fracture

• Contusion

• Achilles avulsion

• Plantar fascia injury

• Foreign body

Describe Initial Injury Mechanism

• A fali from a height or direct focal impact to the heel

- Calcaneus fracture

• Sensation of popping or tearing during activities

- Achilles tear/avulsion

- Plantar fascia injury

If There was No Specific Injury Event:

Major diagnostic possibiuties include:

• Calcaneal stress fracture

• Achilles tendinopathy

- Calcaneal apophysitis

• Retrocalcaneus bursitis

• Plantar fasciitis

• Bonę spur(s)

• Nerve impingement (must rule out proximal nerve involvement)

- Posterior tibial (tarsal tunnel syndrome)

- Medial calcaneal (heel neuroma)

- Medial plantar

- Lateral plantar,

- including branch to abductor digiti minimi -Sural, including lateral calcaneal

• Atrophy of plantar fat pad

• Intrinsic processes (infection, tumor)

LOCATION OF THE PAIN

- Plantar heel

- Contusion, plantar fascia injury, nerve impingement

- Posterior heel

-Achilles injury, retrocalcaneal bursitis, tendinopathy

Exacerbating actmties

• Is the pain worsened after a period of rest, fol-lowed by ambulation, such as with plantar fasciitis?

Aggravating shoe wear

• Do the symptoms worsen with the use of shoes that have poor shock absorption, such as with Achilles tendinopathy?

Associated weakness

• Weakened heel rise may suggest Achilles rupture/tendinopathy

Associated numbness or tingung

• Nerve impingement Timing of onset with actmties

• Immediate vs. delayed

-Tendinitis may cause symptoms to occur in a delayed fashion with activity, as compared with plantar fasciitis, fractures, or other acute/chronic conditions

• Morning vs. evening

- Morning pain with weightbearing common for plantar fasciitis

Relevant Physical Examination:

General

Inspection

• Congenital or developmental anomaly, swelling, Haglund's deformity, skin changes

• Gait evaluation

Pal pat i on

• Identify location of maximal tenderness

• Identify masses if present

Rangę of motion

• Dorsiflexion—tight Achilles?

Strength

• Single foot heel-rise Maneuvers

• Thompson test (calf squeeze)—Achilles rupture Calcaneus fracture

• Hindfoot swelling

• Inspection for fracture blisters

Achilles avulsion

• Palpable bony prominence posterior to ankle

• Loss of gastrocnemius/soleus complex strength

Achilles tendinopathy

• Compare size, tenderness of contralateral Achilles tendon

• Heel rises

Plantar fasciitis

• Forced dorsiflexion of ankle and metatarsopha-langeal joints, simultaneously

• Tenderness along medial longitudinal arch/plantar fascia

Nerve impingement (must rule out proximal nerve involvement)

• Tinel's sign

• tenderness

of a Maisonneuve injury is usually missed by routine ankle radiographs.

Posterior Aspect

Calf. The posterior leg, ankle, and foot are best palpated with the patient lying prone with the feet dangling over the end of the examination table. The gastrocsoleus mus-cle complex and the associated Achilles tendon are common sites of injury. Muscle tears most commonly occur at the junction of the medial gastrocnemius muscle belly with the ensuing aponeurosis (see Fig. 7-17). This site is visible in many individuals as a distinct demarcation where the bulge of the medial calf terminates and the leg bccomes thinner. Tenderness at this site suggests an acute