Chapter 19 - Ankle Joint and Foot (Clinical Kinesiology and Anatomy 7th ed. PDF)

Chapter 19 Ankle Joint and Foot Copyright ©2023 F.A. Davis Company  Chapter Objectives 1. Describe the leg, ankle, and foot 2. Identify the osteokinematic movements of the ankle joint and foot, including range of moti...

Chapter 19 Ankle Joint and Foot Copyright ©2023 F.A. Davis Company  Chapter Objectives 1. Describe the leg, ankle, and foot 2. Identify the osteokinematic movements of the ankle joint and foot, including range of motion (ROM) 3. Describe the arthrokinematic movements of the joints of the leg, ankle, and foot 4. Describe the normal end feels at the joints of ankle and foot 5. Describe the bones and landmarks of the leg, ankle, and foot 6. Identify the ligaments and unique structures of the leg, ankle. and foot 7. Describe the attachments, innervation, and actions of the muscles of the ankle and foot 8. Describe the effect of active and passive insufficiency on the ROM of the ankle joint 9. Describe common pathologies of the leg, ankle, and foot Copyright ©2023 F.A. Davis Company  Function of Leg, Ankle, and Foot ▪ Transmission of forces from body to supporting surface and from supporting surface to body ▪ Base of support (BOS) ▪ Ability to accommodate to a variety of support surfaces, including irregular surfaces ▪ Plantigrade – position where plantar surface of foot is perpendicular to leg when standing (normal) Copyright ©2023 F.A. Davis Company  Ankle Joint and Foot ▪ Ankle joint ▪ Foot Talocrural ▪ Hind foot, mid foot, forefoot ‒ Tibia, Talus, (including phalanges) Fibula Copyright ©2023 F.A. Davis Company  Regions of Foot ▪ Forefoot Metatarsals (5), phalanges ▪ Midfoot Cuboid, Navicular, cuneiform bones (3) ▪ Hind foot Talus, Calcaneus Copyright ©2023 F.A. Davis Company  Ankle and Foot Joints ▪ All joints of ankle and foot are synovial joints. ▪ Distal tibiofibular joint ▪ Ankle joint = talocrural joint (talus/tibia/fibula) ▪ Subtalar joint = Talocalcaneal joint (Hind Foot) ▪ Transverse Tarsal (Midtarsal) joint = Talonavicular and Calcaneocuboid joints ▪ Intertarsal joints - 10 (between talus, calcaneus, navicular, cuboid, and cuneiforms) ▪ Tarsometatarsals – 5 ▪ Intermetatarsals – 8 ▪ Metatarsophalangeal – 5 ▪ Interphalangeal – 9 Copyright ©2023 F.A. Davis Company  Osteokinematic Motions ▪ Difference of opinion Anatomists use cardinal planes to describe the motions of the ankle and foot. Clinicians use the oblique axis of motion to describe the motions of the ankle. Descriptions of ankle motions are those used by clinicians. Copyright ©2023 F.A. Davis Company  Movements Plantar flexion (0-50)/dorsiflexion(0-20) (sagittal plane, frontal axis) Inversion (0-35)/eversion (0-15) – (frontal plane in sagittal axis) Adduction/abduction - movement of forefoot towards/away from midline (transverse plane in vertical axis) Triplanar Motions Supination (PF, INV, and ADD) Pronation (DF, EV, and ABD) Copyright ©2023 F.A. Davis Company  Tri-Planar Axis of Motion of Ankle Because of oblique angle of joint, there are combination of directions with motion ▪ Dorsiflexion includes some abduction; Plantar flexion includes some adduction motion Copyright ©2023 F.A. Davis Company  Tri-Planar Axis of Motion of Ankle (cont) ▪ Angle of ankle joint axis causes: Open kinetic chain: ‒ Abduction during dorsiflexion ‒ Adduction during plantar flexion Closed kinetic chain: ‒ Leg to rotate medially at tibiofibular joint during dorsiflexion ‒ Leg to rotate laterally at tibiofibular joint during plantar flexion ▪ Combo of non-cardinal joint plane and accessory motion at tibiofibular joint Copyright ©2023 F.A. Davis Company  Arthrokinematic Motions ▪ Open kinetic Chain Dorsiflexion: Convex surface of talus rolls anteriorly and glides posteriorly on concave surface of tibia Plantar flexion: Convex surface of talus rolls posteriorly and glides anterior on concave surface of tibia ▪ Closed kinetic chain = concave moving on convex = same direction Copyright ©2023 F.A. Davis Company  Arthrokinematic Motions ▪ Ankle End feel = firm all directions. ▪ Talocrural Close-packed = full DF. Open-packed = 10 deg of PF Capsular pattern = PF > DF. Copyright ©2023 F.A. Davis Company  Arthrokinematic Motions ▪ Movement between bones of foot is minimal and planar Talus, calcaneus, navicular, cuboid, three cuneiforms, tarsometatarsal and intermetatarsal joints. ▪ End feel = firm all directions. Copyright ©2023 F.A. Davis Company  Movements ▪ Foot motion Metatarsophalangeal joint (MTP) ‒ Flexion/Extension ‒ Adduction/Abduction Interphalangeal joints = PIP and DIP; IP ‒ Flexion/Extension Copyright ©2023 F.A. Davis Company  Metatarsophalangeal Joint (MTP) ▪ Condyloid joint ▪ Two degrees of freedom ▪ Flexion / extension Sagittal plane about frontal axis ▪ Abduction/adduction Transverse plane about vertical axis Reference point is second metatarsal Copyright ©2023 F.A. Davis Company  Metatarsophalangeal Joint (MTP) ▪ MPT joint flexion / extension Open chain = concave on convex ‒ Flexion = roll / glide inferiorly ‒ Extension = roll/glide superiors Closed chain – convex on concave ‒ Extension = roll superior, glide inferior ▪ MPT joint abduction / adduction Open chain = concave on convex ‒ Roll/glide same direction – motion relative to second metatarsal Copyright ©2023 F.A. Davis Company  Interphalangeal (IP) joints ▪ Interphalangeal (IP) joints Hinge joint One degree of freedom Flexion/extension in a sagittal plane about a frontal axis Concave on convex ‒ Same direction roll/glide Copyright ©2023 F.A. Davis Company  Bones and Landmarks ▪ Tibia Medial condyle Lateral condyle Crest Medial and lateral plateau Tibial Tuberosity Interosseous membrane Medial malleolus ▪ Fibula Head Lateral malleolus Copyright ©2023 F.A. Davis Company Bones and Landmarks ▪ Tarsals (7) Calcaneus Calcaneal tuberosity Sustentaculum tali Tendons wrap around to change direction (TDH) Talus Navicular Attach – Tib Post Navicular tuberosity Cuboid Cuneiforms (3) Copyright ©2023 F.A. Davis Company Bones and Landmarks ▪ ▪ Metatarsals (5) Base Head ▪ Phalanges (14) Base Head Copyright ©2023 F.A. Davis Company Joints - Tibiofibular ▪ Superior Tibiofibular joint Synovial Plane joint - Little motion ▪ Inferior Tibiofibular joint Synovial Makes up talocrural joint Convex distal fibula and concave distal tibia Held together by fibrous ligaments Slight motion ▪ Tibia is weight-bearing bone Copyright ©2023 F.A. Davis Company  Joints - talocrural ▪ Ankle joint (talocrural joint) Uniaxial weight-bearing hinge joint “Horseshoe” “Mortise and tenon” ‒ Talotibial joint ‒ Talofibular joint ‒ Tibiofibular joint Copyright ©2023 F.A. Davis Company Copyright ©2023 F.A. Davis Company  Joints – Hind foot / subtalar ▪ Ankle /Foot joints Hind Foot ‒ Subtalar joint = Talocalcaneal ‒ Plane synovial joint ‒ Inversion / eversion and part of supination/pronation Copyright ©2023 F.A. Davis Company Joints - Hindfoot - positions ▪ Neutral ▪ Valgus WB load into arch / medial foot ▪ Varus WB load onto lateral foot Copyright ©2023 F.A. Davis Company  Joints – Transverse tarsal ▪ Ankle /Foot joints Transverse tarsal joint “midtarsal” joint Synovial Talus and calcaneus to navicular and cuboid Separation of hindfoot and midfoot Accommodate to surfaces Gliding motions Copyright ©2023 F.A. Davis Company  Midfoot ▪ Midfoot includes remaining intertarsal joint: talocalcaneonavicular, calcaneocuboid, cuneonavicular, cuboideonavicular, intercuneiform, and cuneocuboid Synovial plane joints Minimal motion: roll and glide Numerous ligaments support joints and limit motion Copyright ©2023 F.A. Davis Company  Joints – Foot – MTP, IPs ▪ Foot joints Metatarsophalangeal joints (MTP = 5) Proximal interphalangeal joints (PIP = 4) Distal interphalangeal joints (DIP = 4) Interphalangeal joint (1) Copyright ©2023 F.A. Davis Company  Functional Aspects of the Foot ▪ Forefoot (metatarsals , phalanges Adapts to ground Assists with propulsion ▪ Midfoot (navicular, cuboid, cuneiform Provides mobility and stability Adapts to ground ▪ Hindfoot (talus, calcaneus) Contacts ground first Influences gait Copyright ©2023 F.A. Davis Company  Unique Structures of Foot ▪ Arches (3) Medial longitudinal arch ‒ Talus = keystone Lateral longitudinal arch ‒ Cuboid = keystone ‒ Shallow - on ground in WB Transverse arch ‒ Middle cuneiform = keystone Arches supported by ligaments, fascia, and muscles when activated. Copyright ©2023 F.A. Davis Company  Unique Structures of the Foot ▪ Medial longitudinal arch Calcaneus is base of posterior leg, and heads of first three metatarsals are base of anterior leg Talus (keystone), navicular, and three cuneiforms are curved portion of legs High, does not flatten with weight-bearing ▪ Lateral longitudinal arch Calcaneus base of posterior leg, and heads of fourth and fifth metatarsals are base of anterior leg Cuboid is curve portion of arch and keystone Shallow, flattens with weight-bearing Copyright ©2023 F.A. Davis Company  Unique Structures of the Foot ▪ Transverse arch Cuboid and lateral cuneiform is base of the lateral leg, and medial cuneiform is base of medial leg Middle cuboid is the curved portion of the arch and the keystone Shallow, flattens with weigh-bearing Copyright ©2023 F.A. Davis Company  Support Structures of the Foot and Arches Copyright ©2023 F.A. Davis Company  Ligaments – Tibiofibular ▪ Anterior Tibiofibular ligament ▪ Posterior Tibiofibular ligament ▪ Calcaneofibular ligament Copyright ©2023 F.A. Davis Company  Ligaments – Medial Ankle Deltoid ligament (4 parts) ‒ Tibionavicular lig ‒ Tibiocalcaneal lig ‒ Anterior Tibiotalar lig ‒ Posterior Tibiotalar lig Stabilize medially including medial arch Very stable Copyright ©2023 F.A. Davis Company  Ligaments - Medial Foot Spring Ligament (plantar calcaneonavicular lig) ‒ Maintains medial longitudinal arch Long Plantar Ligament ‒ Maintains lateral arch Short Plantar Ligament ‒ Helps support Long Plantar ligament Copyright ©2023 F.A. Davis Company  Ligaments – lateral ankle Lateral ”collateral” ligament (3 parts) ‒ Anterior talofibular ‒ Calcaneofibular ‒ Posterior talofibular Commonly injured ‒ Inversion sprain – Ant. Talofibular > calcaneofibular > Posterior talofibular Copyright ©2023 F.A. Davis Company  Ligaments – plantar surface ▪ Plantar ligaments and aponeurosis Spring ligament ‒ Medial support Long plantar ligament ‒ Lateral support Short plantar ligament ‒ Support long plantar lig. Plantar aponeurosis (fascia) Copyright ©2023 F.A. Davis Company  Plantar Fascia ▪ Anterior plantar surface of calcaneus to proximal phalanges ▪ Supports longitudinal arches ▪ Increase foot stability in WB Copyright ©2023 F.A. Davis Company  Role of Plantar Fascia – “Windlass Effect” ▪ PF and MTP Ext ▪ Increase fascial tension ▪ Locks bones of arch in place ▪ Creates rigid foot Push-off Copyright ©2023 F.A. Davis Company  Muscles ▪ Extrinsic muscles of the leg, ankle, and foot (12) Superficial posterior group ‒ Gastrocnemius: planter flexion, knee flexion ‒ Soleus: plantar flexion ‒ Plantaris: plantar flexion, knee flexion Deep posterior group (Tom, Dick and Harry) ‒ Tibialis posterior: planter flexion, inversion ‒ Flexor digitorum longus: MTP and IP flexion, plantar flexion, inversion ‒ Flexor hallucis longus: MTP and IP great toe flexion, plantar flexion, inversion Copyright ©2023 F.A. Davis Company  Muscles (cont) ▪ Anterior group Tibialis anterior: dorsiflexion, inversion Extensor hallucis longus: MTP and IP great toe extension, dorsiflexion, inversion Extensor digitorum longus: MTP and IP of four lesser toes extension, dorsiflexion ▪ Lateral group Fibularis longus: eversion, plantar flexion Fibularis brevis: eversion, plantar flexion Fibularis tertius: eversion, dorsiflexion Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Superficial posterior Gastrocnemius ‒ Two joint; femur to calcaneus ‒ PF, flex knee ‒ Tibial N (S1-2) Soleus ‒ Post fibular head to calcaneus ‒ PF ‒ Tibial N (S1-2) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Superficial posterior Plantaris ‒ Two joint: Above lat femoral condyle to calcaneus ‒ Assist knee flexion and PF ‒ Tibial N (S1-2) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Deep posterior Tibialis posterior ‒ Interosseous membrane and posterior surfaces of fibula and tibia to tuberosity of navicular and medial cuneiform, metatarsals 2-4 ‒ Inv foot, PF ankle ‒ Tibial nerve (L5, S1) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Deep posterior Flexor digitorum longus ‒ Middle half of posterior surface of tibia to base of distal phalanges of 2-5 ‒ Flex MTP, PIP and DIPs of digits 2-5; PF ankle, inversion (some) ‒ Tibial n (L5, S1-2) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Deep posterior Flexor hallucis longus ‒ Lower 2/3 posterior fibula to base of distal phalanx of great toe ‒ Flex MTP and IP of 1st digit, PF ankle, inversion (some) ‒ Tibial n (L5, S1-2) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Anterior Tibialis anterior ‒ Lateral Tibial condyle and upper tibia to medial cuneiform and 1st metatarsal ‒ DF ankle; INV foot ‒ Deep peroneal n (L4-5) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Anterior Extensor hallucis longus ‒ Middle half of anterior fibula and interosseus membrane to base of distal phalanx ‒ Extend MTP, IP of 1 st digit, DF ankle, inversion (some) ‒ Deep peroneal n (L4-S1) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Anterior Extensor digitorum longus ‒ Lat condyle tibia, anterior fibula, lateral interosseus membrane to dorsum of lateral 4 toes via extensor expansion ‒ Ext MTP, PIP and DIPs - digits 2-5; DF ankle ‒ Deep peroneal n (L5, S1) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Lateral Peroneus (fibularis) longus ‒ Upper 2/3 of lateral fibula to medial cuneiform and base of 1st metatarsal ‒ EV foot and PF ankle ‒ Superficial Peroneal n (L5, S1) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Lateral Peroneus (fibularis) brevis ‒ Lower 1/3 fibula - base 5th metatarsal ‒ EV foot, PF ankle ‒ Superficial Peroneal n (L5, S1) Peroneus (fibularis) tertius ‒ Distal anterior fibula to 5th metatarsal ‒ EV foot, Dorsiflexion (some) ‒ Deep Peroneal n (L5, S1) Copyright ©2023 F.A. Davis Company  Muscles of the Ankle and Foot ▪ Intrinsic muscles on plantar surface of foot – 4 layers First layer ‒ Abductor hallucis: abduction, flexion MTP great toe ‒ Flexor digitorum brevis: flexion PIPs lesser four toes ‒ Abductor digiti minimi: abduction, flexion of MTP of 5th toe Second layer ‒ Quadratus plantae: changes line of pull of flexor digitorum longus muscle ‒ Lumbricals: flexion of MTPs with extension of the IPs Third layer ‒ Flexor hallucis brevis: flexion of MTP of great toe ‒ Adductor hallucis: adduction, flexion of MTP of great toe Fourth layer ‒ Dorsal interossei: abduction of 2nd through 4th toes ‒ Plantar interossei: adduction of 3rd through 5th toes Copyright ©2023 F.A. Davis Company Muscles of the Ankle and Foot ▪ Layer 1 ▪← ▪ Layer 2 ▪→ Copyright ©2023 F.A. Davis Company Muscles of the Ankle and Foot ▪ Layer 3 ▪← ▪ Layer 4 ▪→ Copyright ©2023 F.A. Davis Company  Muscles (cont) ▪ Intrinsic muscles of dorsal surface of the foot Extensor digitorum brevis: extension of the PIPs of 2nd through 5th toes Extensor hallucis brevis: extension of the MTP of the great toe Copyright ©2023 F.A. Davis Company  Anatomical Relationship Copyright ©2023 F.A. Davis Company  Anatomical Relationship Copyright ©2023 F.A. Davis Company  Superficial and Deep Tibial Peroneal Copyright ©2023 F.A. Davis Company  Dermatomes Root levels Peripheral nerve (skin) Copyright ©2023 F.A. Davis Company  Common Ankle Pathologies ▪ Shin splints – anterior leg Inflammation of periosteum of tibia, overuse injury ▪ Ankle sprain Lateral (INV) > medial (EV) Avulsion fracture – fracture of bony attachment of ligament ‒ Ant. Talofibular ligament ▪ Calcaneal (Achilles) tendonitis: Inflammation of calcaneal tendon at its insertion Ruptured calcaneal tendon Copyright ©2023 F.A. Davis Company  Common Pathologies (cont) ▪ Ankle fracture Lateral malleolus commonly involved Bi-malleolar involves both malleoli Tri-malleolar fracture – both malleoli and posterior lip of distal tibia ▪ Calcaneal valgus ▪ Calcaneal varus ▪ Equinus foot: Hindfoot is fixed in plantar flexion ▪ Calcaneal foot: Hindfoot fixed in dorsiflexion Copyright ©2023 F.A. Davis Company  Common Pathologies (cont) ▪ Pes cavus: High medial longitudinal arch ▪ Pes planus: Flat medial longitudinal arch ▪ Hallux valgus: Lateral deviation great toe ▪ Hallux rigidus: Degenerative condition of first MTP pain; loss of ROM ▪ Hammer toe: PIPs flexed and DIPs extended ▪ Mallet toe: PIPs extended and DIPs flexed ▪ Claw toe: PIP and DIP both flexed Copyright ©2023 F.A. Davis Company  Common Pathologies (cont) ▪ Metatarsalgia: pain at metatarsal heads ▪ Morton’s neuroma: usually between 3rd and 4th metatarsal heads. Plantar digital nerves. Pain with weight-bearing ▪ Turf toe: force hyperextension of the MTP of the great toe ▪ Plantar fasciitis: overuse injury. Pain often in heel during weight-bearing ▪ Fractures: toes and metatarsals Copyright ©2023 F.A. Davis Company