REIDER PART 232
292 _Chapter 7_Lower Leg, Foot, and Ankle
Figurę 7-68. lnversion stress test. The turów indicates the direction of thc force applied to thc heel.
to visualizc and is usually assesscd only by feel. If thc examiner does not maximally dorsiflex thc ankle when performing this examination, substantial invcrsion movement occurs at the subtalar joint, making it difficult to detect whether abnormal inversion is taking place at the ankle joint.
Peroneal Tendon Instability Test The peroneal tendon instability test is an active test that seeks to rcproduce subluxation or dislocation of the per-oneal tendons anterior to thc lateral malleolus. To perform the instability test, the patient is seated on thc table with the leg dangling. The patient is instructed to rotate thc ankle and foot through maximal excursion, first in a eloekwise manner, then in a counterclockwise manner. The motion begins with the ankle dorsiflexed and the foot in a neutral position. The ankle is actively rotated front a position of maximum dorsiflexion, to maximal eversion, to maximum plantar flexion, to maximum iiwcrsion, and back to dorsiflexion again. After several cycles, the direction of rotation is reversed. As the patient performs this maneuver, the examiner lightly palpatcs the posterior bor-der of the lateral malleolus with two fingers (Fig. 7-69).
In the normal patient, the peroneal tendons are felt to move slightly anteriorly as they tense, but they remain behind the malleolus. When peroneal tendon instability is present, thc tendons are felt to begin to sublux over the malleolus, or they may even dislocate. If the patient expe-riences pain when this occurs and identifies the sensation as duplicating his or her symptoms, the diagnosis is strengthened. In cases of longstanding instability, damage to the tendons may have occurred, resulting in signs of peroneal tendinitis.
Thompson*$ Test
The Thompson test is a manipulative test for confirming the diagnosis of Achilles tendon rupture. Achilles’ tendon rupture is sometimes overlooked because thc patient is still able to plantar flex the ankle with the intact toe flex-ors. To perform the Thompson test, the patient is placed prone on the examination table with both feet dangling from the end. In this position, the examiner can see the swelling and eechymosis usually associated with Achilles’ tendon rupture and can palpate a gap in the tendon. The examiner should also observe thc resting position of the foot when the patient is relaxed.
In the normal case, resting tension in the gastroesoleus complex holds the foot in slight plantar flexion when the patient is lying prone (Fig. 7-70A). In the presence of Achilles’ rupture, this resting tension is lost and the foot comes to rest in a morę dorsiflexed position. The Thompson test itself is performed by grasping the patient’s calf with one or both hands and gently sąueezing the mus-cle. When the Achilles tendon is intact, the foot passively plantar flexes when the calf is squeezed (Fig. 7-70B). In the presence of Achilles’ tendon rupture, virtually no motion of the foot is observed. In the presence of a partial tear of the Achilles or injuries to the gastroesoleus aponeurosis, such as tennis leg, the normal plantar flexion response occurs.
First Metatarsal Rise Test
The first metatarsal rise test is a supplementary test for posterior tibial tendon dysfunction. The test is performed with the patient standing and facing away from thc examiner. The cxaminer grasps the patient’s lower leg and externally rotates it. This maneuver causes the heel to assume a varus position. In the presence of posterior tibial dysfunction, the patient’s first metatarsal rises off the ground in response to the manipulation; in a normal patient, the first metatarsal remains in contact with thc ground (Fig. 7-71). The test may also be donc by grasping the heel directly and turning it into varus.
Morton’s Test
Mortonłs test is an adjunctive test for the dctection of interdigital neuromas. The purpose of Mortoifs test is to reproduce the patientssymptoms bycompressingthe
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