Ankle and Foot

Glea Vanessa D. Pavillar

I. Anatomy
Ankle Joint or Talocrural Joint
- ginglymus joint or hinge joint
- 1 degree of freedom PF and DF

Resting position: 10 PF midway between inversion and eversion

Closed Pack Position: DF
Capsular Patter:PF,DF

Subtalar Joint or Talocalcaneal Joint

-plane joint
- evert and invert

The 26 bones of the foot include:

7 tarsal bones (talus, calcaneus, cuboid, navicular and three cuneiforms)
5 metatarsals
14 phalanges
The foot is divided into the:
Hindfoot (talus and calcaneus)
Midfoot (navicular, cuboid and three cuneiforms)
Forefoot (metatarsals and phalanges)

Three Arches of the Foot

1. Medial Longitudinal Arch
Talus aka Astralagus keystone
- articulates with the tibia and fibula in the ankle mortise and with the calcaneus and navicular
distally
-the primary blood supply to the talar body is from the artery of tarsal canal(posterior tibial artery)
- only tarsal bone bone with no muscle attachment
Sinus Tarsi
- found between Talus and Calcaneus
- plantar view / inferior aspect
-location where proprioceptors are very rich
Calcaneus aka Os Calci
- first to ossify
-heel bone
-largest and strongest bone in the foot
-most common fracture bone in tarsals
Sustentaculum Tali
- is an overhanging horizontal eminence on the anteromedial surface of the calcaneus
-supports and sustains the talus in place
Navicular
-most medial tarsal bone that lies between the talus and cuneiforms
- distally, the navicular has three articular surfaces, one for each of the cuneiforms
Three cuneiforms
-medial, intermediate and lateral
1,2,3 metatarsals
1st metatarsal - connects with medial cuneiform; contains plantar cristae; sesamoid bones
2nd metatarsal - connects with intermediate cuneiform; longest metatarsal
3rd metatarsal connects with lateral cuneiform

Spring Ligament
- strongest ligament on foot
- plantar calcaneonavicular ligament
 Tibialis Posterior mm support; Invertor Par Excellans
Tibial nerve passes

Dorsalis Pedis artery

-between the 1st and 2nd metatarsals
Lateral boundary : Extensor Halllucis Longus
Tibialis Anterior
Medial Boundary: Extensor Digitorum Longus
2. Lateral Longitudinal Arch
Calcaneus
Cuboid key stone
- lying at the lateral aspect of foot
4th and 5th Metatarsals
-connects with cuboid
Tubercle of 5th metatarsal

Choparts Joint
-Talonavicular Joint + Calcaneocuboid Joint

Long Plantar Ligament

Peroneus Tertius mm support; DF and evert
Common Peroneal nerve

3. Tranverse or Metatarsal Arch

Cuboid
1st to 5th Metatarsals
Three cuneiforms
2nd cuneiform keystone

Intrinsic muscles lumbricals and interossei

Lisfrancs joint aka Metatarsophalangeal joint

Phalanges
Normal 2>3>1>4>5
Morton/Grecian 2>1>3>4>5
Egyptian most common 1>2>3>4>5
Squared 1=2>3>4>5

Ligaments
Medial Collateral Ligament / Deltoid Ligament Lateral Collateral Ligament
AnTaTi AnTaFi weakest ligament
PoTaTi PoTaFi
CaTi CaFi
TiNa
*stronger medial ligament; lateral malleolus longer

Muscles DF

Tibialis Peroneus
Anterior Tertius

INV EV
Peroneus
Tibialis
Longus, Brevis
Posterior

PF
Compartments

Dorsal Plantar

Extensor Digitrorum Brevis Abductor Hallucis

Flexor Digitorum Brevis
Abductor Digiti Minimi
Lumbricals
Quadratus Plantae
Flexor Hallucis Brevis
Adductor Hallucis
Flexor Digiti Minimi
Interrossei

Muscles of the Soles of the Foot

Abductor Hallucis
st
1 Layer FDB
ADM
Quadratus Plantae
Lumbricals
2nd Layer
FDL
FHL
FHB
3rd Layer Adductor Hallucis
FDM
Interossei
4th Layer Peroneus Longus
Tibialis Anterior

Muscles originate at the Calcaneus

EDB
Abductor Hallucis
FDB
ADM
Quadratus Plantae

Innervations of Tibial Nerve

Medial Lateral
FHB the rest
Abductor Hallucis
FDB
1st Lumbricals

Tarsal Tunnel located medially Flexor Retinaculum/ Lancinate Ligament

Tom Tibialis Posterior
Dick Flexor Digitorum Longus
And Tibial Artery
Very Tibial Vein
Nervous Tibial Nerve
Halley Flexor Hallucis Longus
 INV EV

OKC SINADP PEVABD

SINABD PEVADP
CKC

II. Conditions of Ankle and Foot

A. Ankle Sprain
- tearing of the ligaments
i. Inversion or Medial Sprain more common
ii. Eversion or Lateral Sprain
Causes:
Weal lateral ligament
Shorter medial malleolus
Medial talar torsion

Treatment:
PRICE
Immobilization
Joint manipulation
Towel stretch
Wobble board balance
Prevention:
Proper stretching prior to exercise
Choose level surface; avoid rocks and holes
Do not wear more than 2 inches heels

B. Flatfoot or Pes Planus

-collapse of medial arch
-it is either rigid or flexible
- Talus is the primary culprit.
-Tibialis Posterior muscle tendon and Plantar Calcaneonavicular ligament is stretched 2 to the depression of
talar head.
-Talar head is displaced anteriorly, inferiorly and medially. Navicular bone is also displaced.
-other factors that cause Flatfoot deformity: lax ligament, overweight and in born.

Feiss Line Measurement measure the degree of flat footedness

Inferior pole of medial malleolus

navicular
1st metatarsal head

MLA Rigid or Congenital Flexible or Acquired

WB
- -
 NWB
- +
Toe Standing
- +
Treatment:
Raising the medial border of the heels of their shoes 3 mm
Soft arch supports
Thomas heel

C. Clawfoot or Pes Cavus

- has an abnormally high longitudinal arch and associated with clawing of the toes characterized by dorsiflexion
of the MTP joints and plantarflexion of the IP joints
-Navicular moves above the Feiss Line
-associated with disorders such as peroneal muscular atrophy,myelomeningocele, spinal dysraphism and
poliomyelitis

Treatment:
Mild: stretching of plantar fascia and achiles tendon; wearing of proper shoes which fitted with
metatarsal pads or bars to relieve stress of the anterior portion of the foot
Moderate:carry out plantar fasciotomy anf to stretch the foot under anesthesia
Severe: strip the plantar fascia from its attachment to the calcaneus, section or transfer the flexor or
extensor tendon of the toes and lengthen the Achilles tendon
Advanced: dorsal wedge osteotomy combined with triple arthrodesis
Idiopathic:corrective foot exercises should be started early

D. Kohlers Disease
- osteonecrosis of the navicular bone
-begins insidiously in childhood about the 4th and 6th year of age

Treatment:
Support of longitudinal arch
Immobilize foot in slight inversion by means of a plaster cast for a period of 6 to 8 weeks

E. Mortons Toe
-interdigital neuroma
-a type of metatarsalgia characterized by sudden attacks of sharp pain that is localized
-web space between 3rd and 4th toes
-more common to women
-sharp and lancinating pain
-localized thickening of the common digital nerve at its bifurcation in the web space

Treatment:
Metatarsal arch

F. Metatarsalgia
- is not a specific diagnosis but a descriptive term referring to pain in the region of the metatarsal heads and
usually associated with abnormal distribution of weight on the forefoot that subjects one or more metatarsal
heads to excessive loading
-most frequently in individuals over 30 years old
-more common in women
-first symptom is a burning, cramping painin the anterior part of the foot, usually under the middle metatarsal
heads
-tenderness is most often found beneath the fourth metatarsal head

Treatment:
 Wear a shoe that has a thick sole, adequate width at the toes, a supporting longitudinal arch and a
narrow counter
Small felt or rubber pad, placed immediately behind the metatarsal heads

G. March Fracture
-stress fracture of a metatarsal bone
-fracture of a metatarsal shaft usually the second or third
-common in army recruits during their basic training

Treatment:
Rest, adhesive strapping, and use of an anterior arch pad

H. Freibergs Disease
-osteonecrosis of a metatarsal head
-characterized by the gradual development of degenerative changes in the head of the second bone

Treatment:
Plaster boot or anterior arch pad

I. Hallux Valgus
-lateral angulation of the greaty toe at its MTP joint.
-associated with enlargement of the medial side of the head of the first metatarsal bone, together with
formation of bursa and callus over this area bunion
-familial
- more common in women
- narrow, pointed and short shoes

Treatment:
Proper shoe fitting
Stretching
Sleep with a pad or other device separating the first and second toes
Surgery

J. Hallux Varus
-medial angulation of the great toe at the MTP joint
-trauma, infection,muscle imbalance from paralysis of the adductor hallucis or a bunion operation

Treatment:
Surgery

K. Hallux Rigidus
-characterized by restriction of motion, especially extension in the first MTP joint occasioned usually by
degenerative arthritis, trauma or disuse associated with chronic foot strain
-burning or throbbing pain

Treatment:
Wearing thick inflexible sole on the shoe
Having a long steel strip inserted between inner and outer soles of the shoe
Use of metatarsal bar
Cheilectomy

L. Hammer Toe, Claw Toe and Mallet Toe

Hammer Toe
- characterized by extension of MTP joint and flexion of the PIP joint
-second toe is most frequent affected
 -contracture of the FDL

Claw Toe
-characterized by hyperextension of MTP joint and flexion of PIP and DIP joint

Mallet Toe
- flexion contracture of DIP joint

Treatment:
Surgery

M. In toeing
- aka pigeon toe
-habitual turning in of the feet on walking
-often found together with hallux varus, metatarsus varus, bowlegs, medial torsion of tibia, congenital
contracture of the internal rotatorsof the hip, increased anteversion of the femoral neck or relapsed clubfoot

Treatment:
Infants or young children should not be allowed too much time in sleeping and sitting position in which
the lower limbs are internally rotated
Raising the border of the soles of the shoes 3 to 6 mm
Denis Browne night splint

N. Out-toeing
-seen frequently in children and occasionally in adults
-ER contracture of the extended hip, external tibial torsion, forefoot abduction associated with flatfoot and
retroversion of the femoral neck

Treatment:
Denis Browne splint

O. Tarsal Tunnel Syndrome

TP Undergo Tenosynovitis and impinges Tibial nerve

FDL
FHL

P. Plantar Fascitis
- aka joggers heel
-pain in the heel and the botto of the foot
- most severe pain with the first steps of the day or the following a period of rest
-pain is also frequently brought on bending the foot and toes up towards the shin and may be worsened by
tight Achilles tendon
-(+) heel spur

Treatment:
Rest, heat, ice, calf stretching exercises
Reduce weight
NSAIDs
Shockwave therapy
Corticosteroid
Plantar iontophoresis
Supportive footwear
Arch taping
Q. Congenital Anomalies
a.) Talipes
Types:
1. Simple
i. Talipes quinus
ii. Talipes calcaneus
2. Combined
i. Equinovalgus
ii. Equinovarus (clubfoot)
iii. Calcaneovarus
iv. Calcaneovalgus

Equino PF
Calcaneo DF
Valgus eversion
Varus - inversion