Surface Anatomy of Ankle and Foot Palpation Lab Outline 2023 PDF

**[Clinical Conference I]** **Lower Extremity: The Ankle/Foot Complex** **Medial Ankle/Foot** Partner begins in sidelying or long sitting with the medial aspect of the foot and ankle parallel to the plinth and the foot in neutral. - **medial malleolus** - at the distal end of tibia medi...

**[Clinical Conference I]** **Lower Extremity: The Ankle/Foot Complex** **Medial Ankle/Foot** Partner begins in sidelying or long sitting with the medial aspect of the foot and ankle parallel to the plinth and the foot in neutral. - **medial malleolus** - at the distal end of tibia medially, the broader structure of the medial malleolus can be located - it curves both posteriorly and anteriorly - careful not to palpate too distally (this is the talus) - as you palpate anteriorly you will come to a sharp edge which runs medially and laterally across the anterior aspect of the leg, this is the tibial aspect of the **mortis** - draw a dotted line from the posterior aspect of the medial malleolus, projecting perpendicular to the plantar aspect of the foot; this will be your "helper's line"; just proximal to this line and distal to the end of the medial malleolus is a bony structure of the **posterior medial talar tubercle** - the posterior medial talar tubercle can become more prominent with eversion and inversion https://images.app.goo.gl/YEU6sUpP3XBJxUtK7 - **sustentaculum tali** - start at the medial, plantar edge of the foot (bottom of foot) - begin palpation distal to the helper's line as you palpate proximally (upward) - the first hard bony structure is the **sustentaculum tali of the calcaneus**, about one inch distal (towards the toes) to medial malleolus  https://www.flickr.com/photos/70933541\@N03/6417729833/ - **navicular tuberosity** - from the sustentaculum tali, slide along the foot's medial side and continue distally (towards the toes) until you come upon the prominent surface of the **navicular tuberosity** - its dorsal and medial surfaces are superficial and palpable; this is the attachment site for the tibialis posterior muscle - **talar head** - place your finger between the navicular tuberosity and the medial malleolus, slide proximally off the navicular tubercle to the **head of the talus** - passively invert and evert the foot to distinguish between the two landmarks; the talar head is more prominent in foot eversion and less prominent in foot inversion **Deltoid Ligament (TCL, TTL, TNL, TTL)** - **tibiocalcaneal ligament (TCL)** - run from the distal medial malleolus to the sustentaculum tali - **anterior tibial talar ligament (TTL)** - anterior to the tibiocalcaneal ligament; running from the distal medial malleolus to the talar head **tibionavicular ligament (TNL)** - from the distal medial malleolus superficial to the anterior tibial talar ligament to attachment on the navicular tuberosity **posterior tibiotalar ligament (TTL)** - posterior aspect of helper's line; from the posterior distal medial malleolus to the posterior talar tubercle **"Spring Ligament"** - **plantar calcaneonavicular ligament (CNL)** - courses from the bottom part of the sustentaculum tali to the bottom part of the navicular tuberosity - it serves as a support of the talar head C:\\Users\\hjonely\\Downloads\\FullSizeRender (14).jpg **Dorsal & Medial Soft Tissue Structures** - anterior to the medial and lateral malleolus is the **neck of the talus** - place your thumb over the lateral neck and your index finger over the medial neck - if you passively invert the foot, you will note the lateral neck will become more prominent - if you passively evert the foot, you will note the medial neck will become more prominent  On the dorsal and medial aspect of the foot we can identify many soft tissue structures as various tendons of the muscles of the leg have attachments in this area including: - **extensor digitorum longus** - extend phalange's 2-5, dorsiflex and evert the foot/ankle - the four tendons of the EDL are clearly palpable on the dorsal surface of the foot - **extensor hallicus longus** - extension of the 1^st^ phalanx, the tendon of the EHL can be easily found on the dorsal aspect of the foot as it leads to the first toe - **anterior tibialis** - locate the shaft of the tibia and slide off of it onto the muscle belly of the **anterior tibialis** - invert and dorsiflex of the foot/ankle - follow the muscle into the tendon to the medial side of the foot as it inserts on the plantar aspect of 1^st^ cuneiform and 1^st^ metatarsal - the **dorsalis pedis artery** can be palpated between the first and second metatarsal bones; if the pulse is difficult to palpate make sure you are lateral to the tendon of the extensor hallucis longus C:\\Users\\hjonely\\Downloads\\FullSizeRender (12).jpg - **tibialis posterior** - plantarflexion and Inversion of the foot/ankle **Tarsal Tunnel** - ask the patient to resist plantar flexion and inversion to locate the **posterior tibialis tendon** on the medial aspect of the ankle - you will see the tendon as it courses to the tuberosity of the navicular bone; this is the most prominent part on medial aspect of foot - **flexor digitorum longus** - posterior to tibialis posterior - flexion of phalanges 2-5 - hold great toe up into extension while flex other toes - **tibial artery, vein and nerve** - posterior to FDL - posterior aspect of the medial malleolus you can find the following structures in order: tibialis posterior, flexor digitorum longus, the tibial artery, vein, nerve, and flexor hallicus longus; these structures comprise the contents of the tarsal tunnel - You can palpate the pulse of the artery in this area - **flexor hallicus longus** - posterior to vascular structures and FDL - passing on proximal and posterior aspect of sustenaculum tali - flexion of 1^st^ Phalanx  Image result for posterior tibial artery medial malleolus **Lateral Ankle/Foot** - follow and find the distal end of the fibula, this is the **lateral malleolus** which it curves posteriorly and anteriorly - the distal tip of the lateral malleolus is more plantar than the medial malleolus - as you palpate anteriorly you will come to a sharp edge which runs medially and laterally across the anterior aspect of the leg, this junction represents the fibular aspect of the **mortis** - locate the shaft of the fifth metatarsal - follow the shaft proximally until you locate a sharp projection, just past where the base of the metatarsal bulges laterally - draw a line between the lateral malleolus and fifth metatarsal, - following this line, the **cuboid** is around half an inch from the tuberosity **Lateral Ankle Ligaments** - **anterior talofibular ligament (ATFL)** - locate the anterior aspect of the lateral malleolus; slide your thumb towards the head of the talus - short ligament, an inch in length, courses to its attachment on the talar neck - **calcaneofibular ligament** - laterally from the distal aspect of the lateral malleolus - **posterior talofibular ligament** - on the posterior side of the lateral malleolus continue around the talus's lateral tubercle, just before the calcaneal tendon; difficulty to isolate and palpate  - **peroneal trochlea** - palpate from the distal end of the fibula until you come in contact with a small round projection on the calcaneus - you can now locate the tendons of the **peroneus longus and brevis** - ask patient to perform an isometric contraction of ankle plantar flexion and eversion - peroneus brevis will course superior to the peroneal trochlea as it runs toward its attachment at the base of the 5^th^ metatarsal - the peroneus longus course plantar to the peroneal trochlea and projects plantarly toward its attachment on the base of the first metatarsal and medial cuneiform **Posterior Ankle/Foot** - the common tendon of the gastrocnemius and soleus muscles of the leg, the **achilles tendon,** is found posterior to the ankle - it can be observed by asking the patient to perform an isometric contraction of the foot/ankle into plantar flexion C:\\Users\\hjonely\\Downloads\\FullSizeRender (11).jpg Reichert B. Palpation Techniques Surface Anatomy for Physical Therapists. Stuttgart, Germany: Thieme; 2011. Sizer P., et al. International Academy of Orthopedic Medicine-US Presents Diagnosis-Specific Orthopedic Management of the Shoulder Complex. OPTP.