Diagnosis Physical Examination

Patients report local pain in rest, worsening on weight bearing. Hindfoot ailments can derive from intra- and extra-articular problems. In arthritis of the tibiotalar or subtalar joint, motion will usually be painful. Anterior ankle impingement is painful at palpation. The posterolateral aspect of the ankle and the subtalar joint can be palpated with the ankle at 15-20° of plantar flexion between the Achilles tendon and the peroneal tendons. The posteromedial aspect of the ankle joint cannot be palpated because of the overlaying neurovascular bundle and tendons (Fig. 14.1).

Posterior ankle impingement syndrome is diagnosed by forced plantar hyperflexion of the ankle. Recognizable pain on forced plantar hyperflexion is pathognomic.

All insertional and noninsertional Achilles tendon problems can be palpated. There may be subtle swelling and local tenderness. The patient recognizes the pain on palpation. It is important to differentiate between tendinopathy and para-tendinopathy. In insertional tendinopathy, the pain on palpation is typically located in the mid-portion of the insertion at the calcaneus. In retro-calcaneal bursitis, the thickened bursa can be palpated just medial and lateral from the Achilles tendon and directly proximal of the dorsal aspect of the calcaneus.

In tendinopathy of the main body of the Achilles tendon, there is a nodular tender swelling 46 cm proximal to the insertion onto the calcaneus. The nodular swelling moves up and down on passive plantar- and dorsiflexion of the ankle (Fig. 14.2). In paratendinopathy, the swelling does not move on passive plantar- and dorsiflexion of the ankle.

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