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MOB TCD Feet Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin MOB TCD Foot • • • • • • • • Tarsal bones Calcaneus Talus Navicular Cuboid Cuneiforms Five metatarsals Phalanges 3 MOB TCD Tarsal Canal and Tarsal Sinus 4 MOB TCD Inversion and Eversion • Inversion is raising the medial border of the foot • Sole of the foot looks medially • Close pack • Eversion is raising the lateral border of the foot • Sole of the foot looks laterally • Least pack 5 MOB TCD Inversion and Eversion • Initiated at the transverse tarsal joint • Calcaneocuboid • Anterior portion of the talocalcaneonavicular Last, 1963 6 MOB TCD Inversion and Eversion • Main movement takes place at the clinical sub-talar joint i.e. • Talocalcaneal • Inferior portion of the talocalcaneonavicular • The pivot is the ligament of the neck of the talus 7 MOB TCD Axis • Upwards forwards and medially • Middle of most convex posterior facet on superior surface of calcaneus • Middle of most convex of the anterior head of talus 8 Talocalcaneal Anatomical SubTalar Joint MOB TCD • Synovial plane joint • Concave inferior aspect of body of talus • Convex posterior facet on superior surface of the calcaneus • Articular surface is covered with hyaline cartilage • Part of the clinical subtalar joint 9 Talocalcaneal Anatomical SubTalar Joint MOB TCD • Capsule attached just beyond the articular margins • Synovial membrane lines capsule and non articular structures • Interosseous ligament 10 MOB TCD Subtalar Interosseosus • Capsule of both talocalcaneal • Posterior portion of the talocalcaneonavicular joint 11 MOB TCD Talocalcaneonavicular Joint • Synovial ball and socket joint • Ball is anterior and inferior aspect of the head of the talus 12 MOB TCD Talocalcaneonavicular Joint • Socket • Two anterior facets on the superior surface of the calcaneus • Posterior aspect of the navicular • Spring ligament • Medial limb of birfurcate i.e. lateral calcaneonavicular (LCN) 13 MOB TCD Talocalcaneonavicular Joint • Capsule attached just beyond the articular margin • Interosseous ligament post • Medial are the • Spring ligament and superficial portion deltoid ligament • Lateral are the lateral calcaneo navicular ligament of bifurcate • Ligament neck of talus 14 MOB TCD Plantar Calcaneonavicular Ligament • Plantar calcaneonavicular or spring ligament is attached to • Sustentaculum tali • Tuberosity of navicular • Covered by articular cartilage 15 MOB TCD Ligaments of Sub-Talar Joint • • • • Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament 16 MOB TCD Ligament of Neck of Talus • Sinus tarsi to • Lateral aspect of neck of talus • Pivot of inversion and eversion * Last,1963 17 MOB TCD Inferior Extensor Retinaculum • Medial root inside the tarsal sinus • Intermediate to talus with the interosseous ligament, inside sinus • Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 18 MOB TCD Tarsal Canal and Tarsal Sinus • Fat • Nerve endings • Branches of posterior tibial and peroneal arteries • Capsules and ligaments of talocalcaneal and talocalcaneonavicular joints 19 MOB TCD Ligament Attachments 20 MOB TCD Bifurcate Ligament • Lateral calcaneonavicular ligament (CNL) is medial limb • Medial calcaneocuboid ligament (CCL) is lateral limb 21 MOB TCD Bifurcate Ligament • • • • Two individual ligaments Separate attachments Different fiber orientation Different histology Smith, 2001 22 MOB TCD Lateral Calcaneonavicular Ligament • Folded and twisted appearance • Prominent medial and lateral edges/folds • Three groups of fibres • Medial • Lateral (deep) • Intra-articular N C A Smith 2001 23 MOB TCD Medial Calcaneo Cuboid Ligament • Intra-capsular CC joint • Smaller than CNL, always present • Hourglass shaped fibres, twisted medially Smith 2001 24 MOB TCD Talocalcaneonavicular Joint • Synovial membrane lines the capsule and non-articular structures nerve supply • Tibial nerve • Deep and superficial peroneal nerves 25 MOB TCD Talocalcaneonavicular Joint • • • • • Invertors In dorsi-flexion Tibialis anterior In plantar-flexion Tibialis posterior 26 MOB TCD Talocalcaneonavicular Joint • • • • • • Evertors In dorsi-flexion Peroneus tertius In plantar-flexion Peroneus longus Peroneus brevis 27 MOB TCD Calcaneo Cuboid Joint • • • • Plane synovial Ligaments Capsular Ligament of neck of talus • Long and short plantar ligament • Bifurcate ligament 28 MOB TCD Calcaneo Cuboid Joint • The long plantar ligament • Short plantar ligament • Support the calcaneo cuboid portion of the transverse tarsal joint 29 MOB TCD Long Plantar Ligament • Long plantar is attached to • Medial, lateral and anterior tubercles of calcaneus • Either side of the groove on the cuboid • Base of middle three • Metatarsals 30 MOB TCD Short Plantar Ligament • Short plantar • Broader and wider and deep to long plantar • Anterior to anterior tubercle of calcaneus • Posterior to posterior ridge on cuboid 31 MOB TCD Inferior Surface 32 MOB TCD Cutaneous Supply of Sole 33 MOB TCD Sole of Foot • • • • • • • • Skin Plantar aponeurosis Attached to Medial and lateral tubercles of calcaneus Five slips Divide into two Fuse deep transverse ligament of sole Abduction and adduction from a line drawn through the middle of second toe 34 MOB TCD First Layer of Sole • • • • • • Abductor hallucis Medial plantar nerve Flexor digitorum brevis Medial plantar nerve Abductor digiti minimi Lateral plantar nerve 35 MOB TCD Second Layer of Sole • • • • • • • • • • • Long flexor tendons Tibial nerve Flexor hallucis longus Tibial nerve Flexor digitorum longus Tibial nerve Four lumbricals Unipennate medial plantar nerve Bipennate lateral plantar nerve Flexor accessorius Lateral plantar nerve 36 MOB TCD Third Layer of Sole • • • • • • Flexor hallucis brevis Medial plantar nerve Adductor hallucis Flexor digiti minimi Lateral plantar nerve Vessels run between 1st and 2nd layer 3rd and 4th layers 37 MOB TCD Fourth Layer of Sole • • • • • • • Tendons Tibialis posterior Tibial nerve Peroneus longus Superficial peroneal nerve Dorsal interossei Lateral plantar nerve 38 MOB TCD Seasmoid Bones • Larger medial in • Abductor hallucis and medial half of flexor hallucis brevis • Smaller lateral in • Adductor hallucis and • Lateral half of flexor hallucis brevis 39 MOB TCD Foot • If sesamoid bones are bipartite • It is always bilateral • If fracture single • Take off point of walking is hallux • Flexor hallucis longus • Tibial nerve 40 MOB TCD Joints of Foot • • • • • • Mid-tarsal compound synovial Metatarso-phalangeal joint Synovial condylar joint Deep transverse ligament of sole Interphangeal joints Synovial hinge 41 MOB TCD Second Metatarsal • Second metatarsal is the most fixed • Thinnest • Longest • Stress fractures 42 MOB TCD Longitudinal Arches 43 MOB TCD Arches Longitudinal • Medial • Lateral Transverse • Tarsal • Metatarsal heads 44 MOB TCD Medial Longitudinal Arches Posterior pillar • Calcaneus Keystone • Talus • Navicular, medial, intermediate and lateral cuneiforms Anterior pillars • Heads of medial three metatarsals 45 MOB TCD Medial Longitudinal Arches • Tie beam • Plantar aponeurosis 46 MOB TCD Medial Longitudinal Arches • • • • • • • Spring ligament Deltoid ligament Tibialis anterior Deep peroneal nerve Tibialis posterior Flexor hallucis longus Tibial nerve 47 MOB TCD Medial Longitudinal Arches • • • • Tibialis anterior Tibialis posterior Flexor hallucis longus Flexor medial longus (medial 3) • Short flexor muscles 48 MOB TCD Supports of Arches 49 MOB TCD Lateral Longitudinal Arches Posterior pillar • Calcaneus Anterior pillars • Heads of lateral two metatarsals Keystone • Cuboid 50 MOB TCD Lateral Longitudinal Arches Tie beam • Plantar aponeurosis 51 MOB TCD Supports of Lateral Arches • • • • Peroneus longus Peroneus brevis Short flexor muscles on lateral aspect Long and short plantar ligaments 52 MOB TCD Supports of Lateral Arches 53 MOB TCD Transverse Arch 54 MOB TCD Transverse Arch • • • • Medial pillar Head of first metatarsal Lateral pillar Deep transverse ligament of sole • Transverse head of adductor hallucis 55 MOB TCD Transverse Arch • Depressed arch • Head of the third metatarsal compresses the lateral branch of medial digital nerve • Morton’s metatarsalgia • Pain increased by tight shoes, relieved by taking shoes off 56 MOB TCD Morton’s Metatarsalgia 57 MOB TCD Second Metatarsal • Second metatarsal is the most fixed • Thinnest • Longest • Stress fractures • Can effect any other bone 58 MOB TCD Foot Problems 59 MOB TCD Nerve Supply of the Foot • • • • • Medial calcaneal nerve Medial plantar nerve Three and half toes Lateral plantar nerves One and half toes 60 MOB TCD Nerve Supply of Dorsum • Superficial peroneal nerve • Deep peroneal nerve, first cleft • Saphenous nerve, medial border to base of big toe • Sural nerve, lateral border 61 MOB TCD Nerve Supply 62 MOB TCD Feet • • • • • • Pronated or flat foot Increase knee and back pain Medial tibial syndrome Cuboid syndrome Pes cavus rigid foot Achilles tendonosis 63 MOB TCD Pronated Foot 64 MOB TCD Foot Prints 65 MOB TCD Pes Cavus 66 MOB TCD Foot Problems 67 MOB TCD Foot Problems 68 MOB TCD Foot Problems 69 MOB TCD Foot Problems Server’s 70 MOB TCD Heel Pain Netter 71 MOB TCD Heel Pain Netter 72 “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
