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Chapter 15 Additional Tests and Adjustments for the Foot and Ankle 395

Major muscles of the plantar aspect of the foot, originating on the calcaneus and inserting distally at the phalanges, are mainly flexors, adductors,
and abductors of the toes.9 The abductor of the great toe helps form the fleshy portion of the medial border of the sole of the foot. The short
flexor muscles of the toes and the quadrate muscle of the sole make up most of the soft tissue mass of the plantar aspect of the foot. (The bellies
of the long flexor muscles of the toes are located in the calf, but their tendons run through the plantar aspect of the foot.) Overlying the plantar
musculature is the plantar aponeurosis, a sheet of strong fibrous tissue that runs from the calcaneal tuberosity to the phalanges. The plantar
aponeurosis and the plantar muscle group also provide support for the medial longitudinal arch of the foot. The integrity of the plantar fascia
plays a significant role in maintenance and stability of the medial longitudinal arch.19
The plantar soft tissue is subject to chronic or repetitive strain/sprain injury from long periods of standing, walking, or running, especially in
shoes or boots without adequate arch support. 18 Patients who work in environments that require them to be on their feet for most of the day also
may be particularly vulnerable to development of plantar fasciitis if they are not careful about their footwear. Occupations that require operation
of a foot pedal, such as machinists, assemblers, tailors and seamstresses, and long distance drivers, can also produce stress in the plantar soft
tissues by stretching the ligaments and muscles. Usually, the onset of plantar fasciitis is gradual and insidious. Signs and symptoms include
plantar pain and swelling of the feet by the end of the workday. Pain may be diffused and may be distributed throughout the plantar soft tissue, or
it may be focal, especially at the bottom of the heel near the calcaneal tuberosity, where even ordinary heel-strike during walking can exacerbate
it.
The plantar soft tissues are subject to acute strain/sprain injury. Jumping from a high platform, such as a loading dock, the back of a truck, or
scaffolding, can deliver enormous stresses to the plantar arches and the tissues that support them. Sudden, forceful plantar flexion of the foot in
athletic activities such as sprinting, basketball, tennis, and even baseball can strain the plantar muscles and produce foot pain. Dancers, especially
ballet performers dancing en pointe, are at risk of developing plantar fasciitis because of the extreme, forceful plantar flexion required by the
position.20 Signs and symptoms may include swelling and pain,
especially at the metatarsophalangeal joints. Point tenderness and edema may occur along the instep of the foot as well. Clinically, classic
symptoms of plantar fasciitis are described as a sharp pain at the inferior calcaneal attachment of the plantar fascia. Patient symptoms include a
distinct, "glasslike" pain that occurs after prolonged sitting, upon arising from sleep, or after a period of rest without support under the arch. As
the condition develops, the patient will draw up the arch and walk on the outside of the foot to avoid pain on weight bearing.
Whether plantar fasciitis is of sudden or gradual onset, be sure to assess the patient for the following neuroarticular dysfunctions:
• Medial calcaneus
• Lateral calcaneus
• Superior calcaneus
• Posterior calcaneus
• Medial navicular
• Cuboid
• Anterior lateral talus
• Inferior first metatarsal and inferior medial
first cuneiform
• Inferior metatarsal heads
Detailed instructions for performing Stress Tests and adjustments where indicated for these neuroarticular dysfunctions are provided later in this
chapter. See the research related to plantar fasciitis in Box 15-2.
Metatarsalgia
When the patient reports pain at the ball of the foot, palpation of the metatarsophalangeal joints may reveal tenderness and inflammation, most
often in the second and third joints. Metatarsalgia is aggravated by squatting down with toes extended (heels off the floor). An example would be
in an elementary school teacher who repetitively squats to speak to children at eye level. Metatarsalgia also can be associated with foot
pronation.Z1 When a patient presents with metatarsalgia, assess the foot for the following neuroarticular dysfunctions:
• Inferior metatarsal heads
• Distal first metatarsal and superior proximal
first phalanx
Detailed instructions for performing
Stress Tests and adjustments where indicated for these involvements are given later in this chapter.
Retrocalcaneal Bursitis
Several bursae and synovial sheaths near the heel, when inflamed, can produce retrocalcaneal bursitis. A subcutaneous bursa on the posterior

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