hapter 15 Additional Tests and Adjustments for the Foot and Ankle 397
Stress Tests and adjustments as indicated for the following neuroarticular dysfunctions:
• Anterior lateral talus
• Anterior-superior navicular
• Anterior distal tibia
• Medial calcaneus
• Superior calcaneus
• Posterior distal fibula
Detailed instructions for performing Stress Tests and adjustments where indicated for these neuroarticular dysfunctions are given later in this
chapter.
Achilles Tendonitis
Strain injury with inflammation of the Achilles tendon is a common problem among dancers, runners, and other athletes.2o Symptoms may occur
at the insertion of the tendon on the posterior aspect of the calcaneus, or, more proximally, at the musculotendinous junction of the
gastrocnemius-soleus complex. Most often, this is described as diffuse pain in or about the Achilles tendon that is aggravated by activity.
In more severe cases of a chronic inflammatory
process, swelling, crepitus, and a ��Ipable tender
nodule are noted in the tendon. Calf muscle hypertonicity, contracture, or sharply painful spasm may accompany Achilles tendonitis.25
Resisted dorsiflexion of the foot and ankle reproduces localized pain in the Achilles tendon. Pressure applied to the tendon while the foot is held
firmly in a neutral or slightly dorsiflexed position also confirms Achilles tendonitis. The Achilles (S1) reflex is typically present, but It may be
slightly exaggerated if calf muscles are hypertonic. On the other hand, the reflex may be apparently diminished if the peritendineum and
surrounding tissues are boggy and edematous.
The pain of Achilles tendonitis is exacerbated when the patient climbs stairs or walks uphill because the forced dorsiflexion of the foot and ankle
stretches the tendon. The patient may develop a limp or other antalgic gait to avoid pain, especially during the "toe-off" portion of the gait cycle.
A patient who frequently wears high heels or Western boots and changes abruptly to flat shoes, running shoes, or slippers can experience calf
muscle pain similar to Achilles tendonitis after walking or running even a short distance. Runners, dancers, skaters, and skiers can experience
moderate to severe calf muscle strain injury and Achilles tendonitis if they fail to warm up
by passively stretching the calf muscles before beginning strenuous activity. .. 26-28
When a patient experiences Achilles tendonitis or calf muscle pain, assess the patient for the following neuroarticular dysfunctions:
• Superior calcaneus
• Medial calcaneus
Detailed instructions for performing Stress Tests and adjustments where indicated for these neuroarticular dysfunctions are given later in this
chapter.
CONCURRENT CONDITIONS
Several disorders can contribute to foot problems and altered biomechanics of the ankle. The source of foot pain may actually be referred from
the knee, hip, or lumbosacral level of the spine. Syndromes, especially sciatic neuralgia, should be ruled out with appropriate orthopedic and
neurological assessment. Nerve entrapment can produce sensory deficit (hypoesthesia), altered or painful sensation (dysesthesia), and atrophy of
lower extremity muscles.29 The most common motor deficit affects the evertors and dorsiflexors of the ankle, leading to foot drop.
Patients with diabetes mellitus are especially at risk of developing foot and lower extremity problems.30 Good patient education for the diabetic
patient emphasizes meticulous care of the feet, including daily visual inspection for blisters, sores, and signs of poor circulation. In advanced
diabetes mellitus, significant loss of vascular supply and sensory and proprioceptive innervation to the lower extremity can occur. Diabetic
arthropathy, a painless degeneration of articular soft tissue and bone, can lead to changes in the structural and functional integrity of the foot,
knee, and hip.
Atherosclerotic plaquing in the arterial circulation, with occlusion of the blood supply to tissues, underlies two of the top three causes of death in
the North American population: heart disease and stroke.31 In addition to the coronary and cerebral blood vessels, other branch points in the
circulatory system are vulnerable to atherosclerosis. Intermittent claudication results when the common iliac arteries are occluded. Ischemic
injury to active muscles, whose physiological demand for oxygen becomes greater than the supply, causes pain that can mimic sciatica, arthritis,
or sprain/strain injuries. Diminished pulse pressures at the popliteal artery and dorsum of the foot can indicate vascular occlusion from
intermittent claudication.1 6
TESTING AND ADJUSTING THE FOOT, ANKLE, AND RELATED STRUCTURES
When patient complaints or examination findings indicate involvement of the foot, ankle,
