REIDER PART 2
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286 Charter 7__Lower Leg, Foot, and Ankle

1 7-3 • When the Patient Complains of Painful Shoe Wear
Characterize the Offending (or Most Commonly	•	Cavus foot
Worn) Shoes:	Gait evaluation
• High heels	Palpation
• Narrow toe box	•	Localize area of tenderness
• Fiat sole	•	Rangę of motion—adjacent joints
• Type/amount of shock absorption	•	Neurovascular examination
Localize the Area of Pain:	•	Bunion deformity
		- Decreased mobility of first MTP joint
• Great toe MTP joint area—bunion	•	Bunionette deformity
• Lesser toes		- Notę callosities or other skin changes over
• Midfoot		5^th metatarsal head
• Medial longitudinal arch		- Splaying of forefoot
• Lateral foot—bunionette	•	Pes planus/planovalgus
Relevant Physical Examination:		-    Flexible or rigid -    Evaluate posterior tibial tendon function
General	•	Toe deformities
Inspect		- Claw toes
• Swelling		- Hammer toes
• Skin changes		- Mallet toes
- Look for callosities	•	Morton's neuroma
- May help localize the area of concern		- Painful click with medial/lateral forefoot com-
• Deformity		pression
• Hallux valgus		- Localized tenderness between metatarsal
•    Hammer, mallet, or claw deformity •    Pes planus or planovalgus		heads

and helps support the medial longitudinal arch. Passivcly hyperextending the toes tenses the fascia, making it morę visible and facilitating palpation. In painful conditions of the plantar fascia, this maneuver may itself aggravate the pain. Palpable nodules of the fascia are usually evidence of betiign fibromatosis. These nodules may or may not be tender. As prcviously noted, the medial plantar branch of the posterior tibial nerve may become entrapped within the medial longitudinal arch of the foot. This syndrome is usually associated with tenderness in the arch and some-times dysesthesias in the medial plantar foot.

The proximal portion of the plantar fascia is the usual site of plantar fasciitis, a condition sometimes called heel spur syndrome. In its most common presenta-tion, plantar fasciitis is an overuse injury to the proximal plantar fascia near its attachmcnt to the plantar surface of the calcaneus. This condition is usually marked by tenderness, which may be extreme, at the anterior margin of the medial plantar surface of the calcaneal tuberosity.

Palpation of the rest of the plantar surface of the heel allows the examiner to assess the integrity of the plantar fat pad of the heel. Because this fal pad is normally thick and dense, the examiner is able to only vaguely delineate the outlines of the calcaneal tuberosity when palpating the normal heel. With atrophy of the plantar fat pad of the heel, which may be associated with aging or inflam-matory arthritis, the contours of the plantar surface of the calcanel tuberosity are better delineated, and diffusc tenderness is usually elicited.

■ MANIPULATION

Muscle Testing

Functional Tests

The generał function of several major muscle groups may be rapidly assessed by asking the patient to perform vari-ous functional tests. The ability to walk on the toes is a good generał indicator of the strength of the ankle plantar flexors, primarily the gastroesoleus complex (Fig. 7-5SA). Normally, the patient should be able to walk around the examination room with the heels several cen-timeters off the floor. Heel walking is a generał test of the strength of the ankle dorsiflexors, particularly the tibialis anterior (Fig. 7-58B). Normally, the patient should be able to walk with the metatarsal heads several centimeters off the floor. Strength of inversion of the foot, primarily supplied by the tibialis posterior, may be grossly assessed by asking the patient to walk on the latcral borders of the feet (Fig. 7-58C). Eversion strength, supplied primarily by the peronei, may be grossly assessed by asking the patient to walk on the medial borders of the feet (Fig. 7-58D). These last two tests are somewhat awkward and may be difficult for the patient who is overweight or stiff. Individual manuał resistancc testing helps the examiner confirm suspicions raised by these functional tests. Ali these manuał resistance tests are usually performed with the patient seated and the leg dangling off the side or the end of the examination table.