The ankle and foot

The ankle and foot

Foot and ankle combine flexibility ( propulsion) with stability(support)

structure because consist of a complex of joints, bony structure,

ligamentous attachments, and muscle contraction. The flexible/rigid

characteristics of the ankle/foot complex provide multiple functions,

including:

1. Ankle joint forces up to 4.5 times body weight to occur while walking.

2. It provides a base of support.

3. It acts as a lever during push-off period of stance.

4. It provides adequate flexibility for absorption of the shock of the body

weight and for accommodation to uneven terrain.

5. Prehensile.

Structure of the ankle and foot (see figure 1).

Bony Parts: It contains a total of 26 bones

1. Leg

Tibia and fibula

2. Hindfoot

Talus and calcaneus

3. Midfoot

Navicular, cuboid, and three cuneiforms

4. Forefoot

Five metatarsals and 14 phalanges, which make up the 5 toes (3

phalanges for each toe except the large toe, which has 2 phalanges)

Figure 1: Structure of the ankle and foot

Arches of the Foot (see figure 2).

They are formed by the structure and arrangement of the bones (tarsus

and metatarsus) and maintained by ligaments and tendons the arches are

not rigid; they “give” when weight is placed on the foot, and they spring

back as the weight is lifted.

There are 2 types of arches:

Longitudinal arch: divided into medial and lateral parts

The medial part originates at the calcaneus, rises at the talus, and

descends to the first three metatarsal bones and receives weight of

the body. The medial arch is supported by the spring ligament.

Lateral part consists of the calcaneus, cuboid, and fourth and fifth

metatarsal bones and acting essentially as a space through which

tendons canpass. It is supported by the long and short

plantarligaments.

Transverse Arch – side to side concavity from anterior tarsal bones

(calcaneus, navicular, and cuboid) to all fivemetatarsal bones.

Figure 2: Arches of the Foot

The factors maintaining the arches of the foot (see figur3).

Figur3: The factors maintaining the arches of the foot.

Functions of the arches:

1. Support the weight of the body in standing.

2. Act as a lever to propel the body in walking and running.

3. During weight bearing, mechanical energy is stored released to assist

with push-off of the foot from the surface.

Transmission of body weight:

The structures of the foot are anatomically linked such that the load is

evenly distributed over the foot during weight bearing.

Approximately 50% of body weight is distributed through the subtalar

joint to the calcaneus, with the remaining 50% transmitted across the

metatarsal heads. The head of the first metatarsal sustains twice the load

borne by each of the other metatarsal heads. Tibia is the only true weight-

bearing bone in the body.

Muscle Function in the Ankle and Foot (see figuer4):

Both the extrinsic muscles (11) and the intrinsic (22) muscles of the foot

play a vital role in the mechanics of the foot. (See appendix 1).

Figure 4: Muscles

Muscle control of the ankle during gait

1. The muscles of the anterior compartment (dorsiflexors)

actprimarily during swing and early stance phase. This action

enables the foot to clear the ground during swing phase and then

allows it to be placed gently on the ground after heel strike.

2. The posterior, or calf, group acts from midstance to toe-off.

3. In normal standing, the gravitational line falls anteriorly to the

axis of the ankle joint, creating a dorsiflexion moment. The soleus

muscle contracts to counter the gravitational moment through its

pull on the tibia.

4. The intrinsic muscles of the foot activity in the last half of the

stance phase.

Joints

The joints of the foot are divided into three sections—hindfoot

(rearfoot), midfoot, and forefoot (see figure 5-6).

Figure 5: ankle and foot joints Figure 6: Joints

Hindfoot (Rearfoot)

1. Talocrural (Ankle) Joint.

2. Subtalar (Talocakanean).

Midfoot (Midtarsal Joints, Transverse Tarsal Joint, Chopart’s

amputation) .

1. Talocalcaneonavicula r joint.

2. Cuneocuboid Joint.

3. Cuneonavicular Joints

4. Cuboideonavicular joint

5. Calcaneocuboid Joint.

Fore foot

1. Tarsormetatarsal Joints.

2. Metathrsophafangeat Joints.

3. Interphalangeal joints.

Important joints of the foot:

Ankle Joint (Talocrural): The talocrural joint is a uniaxia (,modified

hinge, synovial joint) located between the talus, themedial malleolus of

the tibia, and the lateral malleolus of thefibula and the movements

possible at this joint are dorsiflexionand plantar flexion.

Subtalar (Talocakanean) Joint: A gliding multiaxialsynovial joint

which consists of the talus on top and calcaneuson the bottom. The

subtalar joint allows movements about an oblique axis, allowing the foot

to side to side motion (inversion and eversion).

Transverse tarsal joint: It is formed of 2 joints that lie sideby-side.

These are the talo-navicular joint (between the headof talus and

navicular), and calcaneo-cuboid joint (between the caleaneus. and

cuboid). It is little to no motion and assists in eversion and inversion.

Locking and unlocking of the ankle joint: During

dorsiflexion, the wide anterior part of the trochlear surface of the talus is

lodged into the narrow posterior part of the superior articular surface

(socket). In this position, the ankle joint is locked as the foot cannot be

moved from side to side. During plantar flexion, the narrow posterior part

of the trochlear surface is lodged in the wide anterior part of the socket.

In this position, the ankle joint is unlocked as the foot can be

movedslightly from side to side.

Accordingly, the ankle joint is locked during dorsiflexion and unlocked

during plantar flexion.

Ligaments:

Figure 7: Ankle Ligaments Figure 8:

Ligaments

Ankle Ligaments (see figure 7-8) :

Lateral Ankle Ligaments:

Talofibular ligaments: from the lateral malleolus of the fibula to

connects the talus and support the lateral side of the joint .

Divided in:

Anterior Talofibular Ligament: It is prevents anterior

subluxation of talus when ankle is in plantar flexion.

Posterior Talofibular Ligament: it is prevents posterior and

rotatory subluxation of the talus.

Calcaneofibular: connecting lateral malleolus to calcaneus.

It acts primarily to stabilize sub-talar joint & limit inversion. it is lax in

normal, standing position due to relative valgus orientation of calcaneus

Medial Ankle Ligaments

Deltoid ligaments: supports the medial side, triangular shaped, apex

at tip of medial malleolus,, base at talus, navicular, calcaneus which has

two major components;

- Superficial deltoid which resist talar abduction and primarily

resists eversion of hindfoot. Tibionavicular portion prevents inward

displacement of head of talus, while tibiocalcaneal portion prevents

valgus displacement.

- Deep deltoid ligament is prevents lateral displacement of talus &

prevents external rotation of the talus and latter effect is

pronounced in plantar flexion, when deep deltoid tends to pull talus

into internal rotation.

Ligaments of the Foot:

Spring ligament: attaches from calcaneus to navicular. It is supports

longitudinal arch and the head of talus especially in standing.

Plantar aponeurosis: runs from calcaneus to proximal phalanges, ties

posterior an anterior sections together and windlass action in ankle, where

full dorsflexion is limited by plantar aponeurosis.

Movements of the Foot and Ankle

1. Primary plane motions defined

a. Sagittal plane motion is dorsflexion and plantarfiexion.

b. Frontal plane motion is inversion and eversion .

c. Transverse plane motion is abduction and adduction.

2. Triplanar motions occurring about oblique axes defined

a. Pronation is a combination of dorsiflexion, eversion, and

abduction.

b. Supination is a combination of plantarfiexion, inversion, and

adduction.

ROM:

Plantar flexion(55°), Dorsiflexion(15°), Inversion(35°),

Eversion(20°), Pronation (20°)and Supination(35°).

The ankle and foot during gait:

The biomechanics of the foot are best explained by describing

what happens to the foot during the stance phase of the gait

cycle.

Stance phase:

Heel strike

The impact of the heel as it contacts the floor, with subsequent rapid

loading of the foot, results in a floor reaction that exceeds the body

weight by 20 per cent. The sudden impact is partially absorbed by

lowering the body through plantar flexion of the ankle. It is during this

phase that the foot begins to act like a shock absorber. The ankle

dorsiflexors function during the initial foot contact to counter the

plantarflexion torque and to control the lowering of the foot to the

ground.

Midstance

During midstance the entire foot is in contact with the ground (ankle is

neutral again) and the weight of the body is directly over the foot. The

vertical floor reaction is less than the body weight because of the falling

CM. The longitudinal arch of the foot is elevated and the foot everts, with

concomitant motion in the subtalar joint due to the eversion , pronation

and external rotation of the lower limb.

As the body weight shifts forward the foot begins to return to a neutral

position in preparation for heel lift.

Push-off

The ankle plantarflexors , supinates and the metatarsal phalangeal joints

go into extension begin functioning near the end of mid-stance and during

terminal stance and preswing (heel-off to toe-off) to control the rate of

forward movement of the tibia and also to plantarfiex the ankle for push-

off.

During this period the heel rises rapidly with increased ground reaction,

up to 40 per cent above body weight.

Swing Phase of Gait:

Much of kinetic energy for swinging limb is provided by inertia, which is

augmented by the plantarflexors (85%) and hip flexors (15%). During

swing, the ankle dorsiflexes by the concentric contraction of anterior

tibialis muscle and all other muscles are silent. Sub-talar joint assumes

near neutral position, and toes dorsiflex slightly as foot prepares for next

episode.

Common injuries of the ankle and foot

Foot injuries may develop from various causes, such as congenital

malformations of bones, muscular paralysis or spasticity, stresses and

strains in weight-bearing.

Alignment Anomalies of the Foot and Abnormal foot contact (see

figure 9):

1. Pes varus (Club foot).

2. Pes valgus (Pes planus or flat foot).

3. Pes equines.

4. Pes cavus.

5. Pes Calcaneus.

Figure 9: Alignment Anomalies of the Foot.

Injuries Related to High and Low Arch Structures:

Arches that are higher or lower than the normal range have been found to

influence lower extremity kinematics and kinetics, with implications for

injury. High- arched exhibit increased vertical loading rate, with related

higher incidences of ankle sprains, plantar fascitis, and 5° metatarsal

stress fractures. Low-arched exhibit increased range of motion and

velocity in rearfoot eversion, as well as an increased eversion to tibial

internal rotation ratio.

Injuries of the Ligaments

Ankle sprains (see figure 10).

Figure 10: Ankle sprains.

Injuries of the lateral ligament

Ankle sprains usually occur on the lateral side because the joint capsule

and ligaments are stronger on the medial side of the ankle. Mechanism

injury of ankle sprain is inversion of the supinated , plantarflexed foot . It

usually occurs when the foot rolls over on the outside of the ankle. When

the ligament is completely torn or detached from the fibula, the talus is

free to tilt in the mortice of the tibia and fibula.

If the lateral ligament fails to heal, chronic instability of the ankle results.

Fractures with Deloid Injury ligament (Maisonneuve fracture):

The medial ligament is immensely strong and if stressed in ankle joint

injuries generally avulses the medial malleolus rather than itself tearing.

Nevertheless tears do occur, and are seen particularly in conjunction with

lateral malleolar fractures. A mechanism is combination of external

rotation at ankle, abduction of hindfoot,& eversion of forefoot while the

upper body externally rotates over the fixed foot.

Paralysis or Spasticity:

Tibialis Posterior:

Paralysis of tibialis posterior alone causes a planovalgus deformity.

Spasticity of Tibialis Posterior cause dynamic varus deformities of foot.

Tibialis Anterior:

Paralysis (polio) results in development of equinovalgus deformity this is

seen initially during swing phase of gait. Failure to raise the foot

sufficiently during the early swing phase causes Toe drag.

gastrocnemius-soleus paralyzed:

The patient cannot rise on tiptoes, and the gait is severely affected

because inability to increase walking speeds beyond the normal pacing.

However, despite uneven step lengths, she had uniform forward

progression. She had excessive dorsiflexion of the ankle and diminished

plantar flexion on the involved side .

The act of climbing stairs is awkward and slow, and activities such as

running and jumping are all but impossible.

Other soft tissues injuries:

Footballer’s ankle:

Repeated incidents of forced plantar flexion of the foot which result in

tearing of the anterior capsule of the ankle joint. These may lead to

mechanical restriction of dorsiflexion.

Peroneal tendon disruption (peroneus brevis tear):

Mechanism of this injury is forced dorsiflexion with slight inversion and

concomitant eccentric contraction of the peroneal muscles may produce a

subluxation or dislocation of the peroneal tendons.

Anterior (Talotibial) Impingement Syndrome:

The mechanism of injury is repetitive forced dorsiflexion as demiplie

position in ballet can lead to impingement of anterior lip of tibia on talar

neck.

Posterior (Talotililal,) Impillgement Syndrome:

The mechanism of injury is repetitive, forced plantarflexion such as may

occur with practicing karate kicks or dancing en pointe.

Shortening of the Achilles tendon

Mechanisms for tendinitis have been proposed by repeated tension or

repeated loading .Shortening results in plantar flexion of the foot and

clumsiness of gait as the heel fails to reach the ground (Insufficient push

off).

Plantar Fasciltis:

Mechanism of Injury are overuse or repetitive stretching of the plantar

fascia associated with training errors or associated with incomplete

rehabilitation (strengthening) following a previous ankle injure because

weak peroneal muscles may inadequately support the arch. Thus placing

additional stress on the plantar fascia. All of which reduce the foot’s

shockabsorbing capability.

Fracture:

Both the end of the fibula (1) and the tibia (2) are broken .If

both malleoli are broken, this is called a bimallolar fracture or Pott's

fracture.

Stress Fractures

The shafts of the second through the fifth metatarsals are the most

common sites of injury. These injuries are perhaps most commonly seen

in athletes involved in endurance running activities.

Pediatric Ankle Fractures

The age distribution of was typical: malleolar fractures predominated

among the younger children, epiphyseal fractures among the older.

Most common epiphyseal injury to ankle is distal tibia caused by

supination and external rotation. Complications of this fracture is :

1. Growth Plate Arrest.

2. Angular Deformities - varus or valgus deformity.

3. Leg Length Discrepancy.

Appendix 1:

Muscles of ankle and foot

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