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Copyright © The McGraw-Hill Companies, Inc. Reprinted by permission. The Ankle and Foot Joint • • • • • Chapter 11 The Ankle and Foot Joints – Foot trouble - common ailment – Poor foot mechanics leads to foot discomfort – No substitute for adequate muscular development, strength, & proper foot mechanics Manual of Structural Kinesiology R.T. Floyd, Ed.D, ATC, CSCS Manual of Structural Kinesiology The Ankle and Foot Joints 26 bones 19 large muscles Many small (intrinsic) muscles More than 100 ligaments Support & propulsion 11-1 Manual of Structural Kinesiology The Ankle and Foot Joint • Walking & running – Stance phase – Swing phase • Heel-strike occurs when landing on heel, foot should be in supination • Midstance immediately follows with foot moving into pronation • Toe-off follows midstance, foots returns to supination prior to and during push off The Ankle and Foot Joints • occurs when foot leaves ground & leg moves forward to another point of contact 11-3 Manual of Structural Kinesiology The Ankle and Foot Joint 11-4 • 26 bones in each foot that form arch • Body weight is transferred from tibia to talus & calcaneus (tarsal bones) • 5 other rear & midfoot tarsal bones – foot is too rigid & does not pronate adequately – foot remains in pronation past midstance – Navicular - between talus & 3 cuneiform bones – Cuboid - between calcaneus and 4th & 5th metatarsals – 5 metatarsals - anterior to tarsals – 5 phalanges • 3 phalanxes in each except 1st toe (2 phalanxes) • 2 sesamoids beneath 1st metatarsophangeal joint • Walking – one foot is always in contact with ground • Running – point when neither foot is in contact with ground The Ankle and Foot Joints The Ankle and Foot Joints Bones • Problems arise Manual of Structural Kinesiology 11-2 The Ankle and Foot Joint • Walking & running Manual of Structural Kinesiology The Ankle and Foot Joints 11-5 Manual of Structural Kinesiology The Ankle and Foot Joints 11-6 1 Bones Bones – Pulley for posterior tendons • Peroneus brevis & peroneus longus - immediately behind lateral malleolus • Peroneus brevis & peroneus longus - immediately behind lateral malleolus • “Tom, Dick & Harry” muscles immediately posterior to medial malleolus – Tibialis posterior – Flexor digitorum longus – Flexor hallucis longus • Distal malleoli of tibia & fibula – Enlarged & protrude horizontally & inferiorly – Serve as pulley for posterior tendons to increase mechanical advantage of muscles in performing inversion & eversion actions Manual of Structural Kinesiology The Ankle and Foot Joints 11-7 Manual of Structural Kinesiology Bones • Tibialis anterior inserts on inner surface of medial cuneiform & base of 1st metatarsal • Peroneus longus inserts on undersurface of medial cuneiform & 1st metatarsal • Tibialis posterior - multiple insertions on lower inner surfaces of navicular, cuneiform, & 2nd - 5th metatarsal base – enlarged & prominent to serve as insertion for peroneus brevis & tertius The Ankle and Foot Joints 11-9 Manual of Structural Kinesiology Bones – very prominent & serves as insertion for Achilles tendon of gastrocnemius-soleus complex The Ankle and Foot Joints The Ankle and Foot Joints 11-10 Joints • Extensor digitorum longus inserts on tops of 2nd - 5th distal phalanxes bases • Flexor digitorum longus inserts on undersurfaces of 2nd - 5th distal phalanxes bases • Extensor hallucis longus inserts on top of 1st distal phalanx base • Flexor hallucis longus inserts on undersurface of 1st distal phalanx base • Posterior surface of calcaneus Manual of Structural Kinesiology 11-8 Bones • Base of 5th metatarsal Manual of Structural Kinesiology The Ankle and Foot Joints 11-11 • Tibiofibular joint – Syndesmotic amphiarthrodial joint – Joined at both proximal & distal tibiofibular joints – Ligaments and a strong, dense interosseus membrane between tibia & fibula shafts provide support – Minimal movement possible – Distal joint becomes sprained occasionally in heavy contact sport Manual of Structural Kinesiology The Ankle and Foot Joints 11-12 2 Joints Joints • Tibiofibular joint • Ankle joint (talocrural joint) – – – – – Hinge or ginglymus-type joint Talus, distal tibia, & distal fibula 50 degrees of plantar flexion 15 to 20 degrees of dorsiflexion Greater range of dorsiflexion with knee flexed (reduces gastrocnemius tension) – Fibula rotates 3 to 5 degrees externally with ankle dorsiflexion & 3 to 5 degrees internally during plantarflexion – Syndesmosis joint widens by 1 to 2 millimeters during full dorsiflexion – Syndesmosis joint sprain • “High ankle sprain” primarily involves anterior inferior tibiofibular ligament • More severe injuries can involve posterior tibiofibular ligament, interosseus ligament, & interosseus membrane Manual of Structural Kinesiology The Ankle and Foot Joints 11-13 Manual of Structural Kinesiology Joints • Metatarsophalangeal joints – Inversion & eversion occurs here – Classified as gliding or arthrodial – Combined movement of – Phalanges join metatarsals – Classified as condyloid-type joints – Great toe metatarsophalangeal (MP) joint flexes 45 degrees & extends 70 degrees – MP joints of the four lesser toes • 20 to 30 degrees of inversion • 5 to 15 degrees of eversion • Intertarsal & tarsometatarsal joints • 40 degrees of flexion • 40 degrees of extension • also abduct & adduct minimally – Arthrodial – Minimal movement The Ankle and Foot Joints 11-15 Manual of Structural Kinesiology Joints The Ankle and Foot Joints The Ankle and Foot Joints 11-16 Joints • Ankle sprains very common injury • Great toe interphalangeal (IP) joint flexes from 0 degrees of full extension to 90 degrees of flexion • Proximal interphalangeal (PIP) joints in lesser toes flexes from 0 degrees of extension to 35 degrees of flexion • Distal interphalangeal (DIP) joints flexes 60 degrees & extend 30 degrees • Much variation from joint to joint & from person to person Manual of Structural Kinesiology 11-14 Joints • Subtalar & transverse tarsal joints Manual of Structural Kinesiology The Ankle and Foot Joints – Sprains involve stretching or tearing of one or more ligaments – Most common ankle sprain results from excessive inversion that causes damage to lateral ligamentous structures, primarily anterior talofibular ligament & calcaneofibular ligament 11-17 Manual of Structural Kinesiology The Ankle and Foot Joints 11-18 3 Joints Joints • Ankle sprains very common injury • Ligaments in foot & ankle maintain arches • Two longitudinal arches – Excessive eversion forces injures deltoid ligament (medially) - less common Manual of Structural Kinesiology The Ankle and Foot Joints – Medial longitudinal arch - extends from calcaneus bone to talus, navicular, 3 cuneiforms, and proximal ends of 3 medial metatarsals – Lateral longitudinal arch - extends from calcaneus to cuboid and proximal ends of 4th & 5th metatarsals – Long arches may be high, medium, or low 11-19 Manual of Structural Kinesiology Joints The Ankle and Foot Joints 11-20 Movements • Transverse arch • Dorsiflexion (flexion) – extends across foot from 1st metatarsal to the 5th metatarsal – movement of top of ankle & foot toward anterior tibia • Plantar flexion (extension) – movement of ankle & foot away from tibia Manual of Structural Kinesiology The Ankle and Foot Joints 11-21 Manual of Structural Kinesiology Movements 11-22 Movements • Eversion • Toe flexion – turning ankle & foot outward; abduction, away from midline; weight is on medial edge of foot – movement of toes toward plantar surface of foot • Toe extension – movement of toes away from plantar surface of foot • Inversion – turning ankle & foot inward; adduction, toward midline; weight is on lateral edge of foot Manual of Structural Kinesiology The Ankle and Foot Joints The Ankle and Foot Joints 11-23 Manual of Structural Kinesiology The Ankle and Foot Joints 11-24 4 Movements Muscles • Group according to location & function • Pronation – Anterior ankle & foot - dorsal flexors – Posteriorly - plantar flexors – combination of ankle dorsiflexion, subtalar eversion, & forefoot abduction (toe-out) • triceps surae – gastrocnemius & soleus – Laterally - evertors – Medially - invertors • Supination – combination of ankle plantar flexion, subtalar inversion, & forefoot adduction (toe-in) Manual of Structural Kinesiology The Ankle and Foot Joints 11-25 Manual of Structural Kinesiology Muscles – Superficial posterior compartment – Dense fascia - tightly surrounds & binds each • Gastrocnemius, soleus, & plantaris - plantar flexors • Facilitates venous return & prevents excessive swelling of muscles during exercise – Deep posterior compartment – Anterior compartment • Dorsiflexor group - tibialis anterior, peroneus tertius, extensor digitorum longus, & extensor hallucis longus • Flexor digitorum longus, flexor hallucis longus, popliteus, & tibialis posterior • All are plantar flexors & invertors except popliteus – Lateral compartment • Peroneus longus & peroneus brevis (two most powerful evertors) The Ankle and Foot Joints 11-27 Manual of Structural Kinesiology Muscles 11-28 • Painful cramps - acute muscle spasm in gastrocnemius & soleus – “Shin splints” - common term describing painful leg condition often associated with running activities – Occur somewhat commonly – May be relieved through active & passive dorsiflexion • Not a specific diagnosis • Attributed to a number of different specific musculotendinous injuries • Most often involves tibialis posterior, medial soleus, or anterior tibialis, but may also involve extensor digitorum longus • May be partially prevented by stretching plantar flexors & strengthening dorsiflexors The Ankle and Foot Joints The Ankle and Foot Joints Muscles • Acute & chronic injuries are common Manual of Structural Kinesiology 11-26 Muscles • Lower leg - divided into 4 compartments Manual of Structural Kinesiology The Ankle and Foot Joints • Complete rupture of Achilles tendon – very disabling injury • Several ankle & foot muscles produce more than one movement 11-29 Manual of Structural Kinesiology The Ankle and Foot Joints 11-30 5 Muscles Muscles Ankle & foot joint muscles by function • Plantar flexors Ankle & foot joint muscles by function • Evertors – – – – – – – – Gastrocnemius Flexor digitorum longus Flexor hallucis longus Peroneus (fibularis) longus Peroneus (fibularis) brevis Plantaris Soleus Tibialis posterior Manual of Structural Kinesiology The Ankle and Foot Joints – Peroneus (fibularis) longus – Peroneus (fibularis) brevis – Peroneus (fibularis) tertius – Extensor digitorum longus 11-31 Manual of Structural Kinesiology The Ankle and Foot Joints Muscles Muscles Ankle & foot joint muscles by function • Dorsiflexors Ankle & foot joint muscles by function • Invertors – Tibialis anterior – Peroneus (fibularis) tertius – Extensor digitorum longus (extensor of lesser toes) – Extensor hallucis longus (extensor of great toe) Manual of Structural Kinesiology The Ankle and Foot Joints – Tibialis anterior – Tibialis posterior – Flexor digitorum longus (flexor of lesser toes) – Flexor hallucis longus (flexor of great toe) 11-33 Manual of Structural Kinesiology The Ankle and Foot Joints Muscles Muscles Ankle & foot joint muscles by compartment • Anterior compartment Ankle & foot joint muscles by compartment • Lateral compartment – – – – Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus (fibularis) tertius Manual of Structural Kinesiology The Ankle and Foot Joints 11-32 11-34 – Peroneus (fibularis) longus – Peroneus (fibularis) brevis 11-35 Manual of Structural Kinesiology The Ankle and Foot Joints 11-36 6 Muscles Nerves • Sciatic nerve Ankle & foot joint muscles by compartment – tibial division • gastrocnemius (medial head), soleus, tibialis posterior, flexor digitorum longus, & flexor hallucis longus • medial & lateral plantar nerves - intrinsic foot muscles – medial plantar nerve » abductor hallucis, flexor hallucis brevis, first lumbricale, & flexor digitorum brevis • Deep posterior compartment – Flexor digitorum longus – Flexor hallucis longus – Tibialis posterior • Superficial posterior compartment – Gastrocnemius (medial head) – Gastrocnemius (lateral head) – Soleus Manual of Structural Kinesiology The Ankle and Foot Joints 11-37 Manual of Structural Kinesiology The Ankle and Foot Joints Nerves Nerves • Sciatic nerve • Sciatic nerve – tibial division – common peroneal (fibular) division • medial & lateral plantar nerves - intrinsic foot muscles – lateral plantar nerve » adductor hallucis, quadratus plantae, lumbricales (2, 4, & 4), dorsal interossei, plantar interossei, abductor digiti minimi, & flexor digiti minimi Manual of Structural Kinesiology 11-38 The Ankle and Foot Joints • Superficial peroneal nerve – peroneus longus & peroneus brevis • Deep peroneal nerve – tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius, & extensor digitorum brevis 11-39 Manual of Structural Kinesiology Gastrocnemius Muscle The Ankle and Foot Joints 11-40 Soleus Muscle Plantar flexion of ankle Plantar flexion of ankle Flexion of knee Manual of Structural Kinesiology The Ankle and Foot Joints 11-41 Manual of Structural Kinesiology The Ankle and Foot Joints 11-42 7 Peroneus Longus (fibularis) Muscle Peroneus Brevis (fibularis) Muscle Eversion of foot Eversion of foot Plantar flexion of ankle Plantar flexion of ankle Manual of Structural Kinesiology The Ankle and Foot Joints 11-43 Peroneus Tertius (fibularis) Muscle Manual of Structural Kinesiology The Ankle and Foot Joints 11-44 Extensor Digitorum Longus Muscle Extension of four lesser toes Eversion of foot Dorsal flexion of ankle Dorsal flexion of ankle Eversion of foot Manual of Structural Kinesiology The Ankle and Foot Joints 11-45 Manual of Structural Kinesiology Extensor Hallucis Longus Muscle The Ankle and Foot Joints 11-46 Tibialis Anterior Muscle Dorsal flexion of ankle Dorsiflexion of ankle Extension of great toe Inversion of foot Weak inversion of foot Manual of Structural Kinesiology The Ankle and Foot Joints 11-47 Manual of Structural Kinesiology The Ankle and Foot Joints 11-48 8 Tibialis Posterior Muscle Flexor Digitorum Longus Muscle Plantar flexion of ankle Flexion of four lesser toes Inversion of foot Plantar flexion of ankle Inversion of foot Manual of Structural Kinesiology The Ankle and Foot Joints 11-49 Flexion of great toe 11-50 • All originate & insert within the foot • Extensor digitorum brevis is on dorsum of foot • Remainder are in a plantar compartment in 4 layers on plantar surface of foot Inversion of foot Plantar flexion of ankle The Ankle and Foot Joints 11-51 Intrinsic Muscles of the Foot Manual of Structural Kinesiology The Ankle and Foot Joints 11-52 Intrinsic Muscles of the Foot – First (superficial) layer: Abductor hallucis, flexor digitorum brevis, abductor digiti minimi (quinti) – Second layer: Quadratus plantae, lumbricales (4) Manual of Structural Kinesiology The Ankle and Foot Joints Intrinsic Muscles of the Foot Flexor Hallucis Longus Muscle Manual of Structural Kinesiology Manual of Structural Kinesiology – Third layer: Flexor hallucis brevis, adductor hallucis, flexor digiti minimi (quinti) brevis – Fourth (deep) layer: Dorsal interossei (4), plantar interossei (3) The Ankle and Foot Joints 11-53 Manual of Structural Kinesiology The Ankle and Foot Joints 11-54 9 Intrinsic Muscles of the Foot Intrinsic Muscles of the Foot – Central location • Grouped by location • Beneath the foot – Quadratus plantae, 4 lumbricales, 4 dorsal interossei, 3 plantar interossei, flexor digitorum brevis • Dorsal compartment – Extensor digitorum brevis – Medial - attach to great toe proximal phalanx • Abductor hallucis & flexor hallucis brevis medially • Adductor hallucis - centrally beneath metatarsals – Lateral – attach on lateral aspect of base of 5th phalange proximal phalanx • abductor digiti minimi, flexor digiti minimi brevis • quinti is sometimes used instead of minimi Manual of Structural Kinesiology The Ankle and Foot Joints 11-55 Intrinsic Muscles of the Foot 11-56 • Grouped by action – 4 muscles act on great toe – quadratus plantae • flexors of 2nd, 3rd, 4th, & 5th phalanges at DIP joints • abductor hallucis - abduction of great toe & assists flexor hallucis brevis in flexing great toe at MP joint • adductor hallucis - adduction of great toe • extensor digitorum brevis - extension of great toe at MP joint – 3 plantar interossei • adductors & flexors of proximal phalanxes of 3rd, 4th, & 5th phalanges – 4 dorsal interossei – 4 lumbricales • abductors & flexors of 2nd, 3rd, & 4th phalanges MP joints • flexors of the 2nd, 3rd, 4th, & 5th phalanges at MP joints The Ankle and Foot Joints The Ankle and Foot Joints Intrinsic Muscles of the Foot • Grouped by action Manual of Structural Kinesiology Manual of Structural Kinesiology 11-57 Manual of Structural Kinesiology Intrinsic Muscles of the Foot The Ankle and Foot Joints 11-58 Ankle Dorsiflexion • Agonists • Grouped by action – Tibialis anterior – Extensor digitorum longus – Peroneus tertius – flexor digitorum brevis • flexes middle phalanxes of 2nd, 3rd, 4th, & 5th phalanges – extensor digitorum brevis • Extensor hallucis longus • extends great toe & 2nd, 3rd, 4th phalanges at MP joints – 5th toe muscles • abductor digiti minimi abducts proximal phalanx • flexor digiti minimi brevis flexes proximal phalanx Manual of Structural Kinesiology The Ankle and Foot Joints 11-59 Manual of Structural Kinesiology The Ankle and Foot Joints 11-60 10 Ankle Plantar Flexion Transverse Tarsal & Subtalar Inversion • Agonists • Agonists – Gastrocnemius – Soleus • • • • • • – Tibialis anterior – Tibialis posterior Flexor digitorum longus Flexor hallucis longus Peroneus (fibularis) longus Peroneus (fibularis) brevis Plantaris Tibialis posterior Manual of Structural Kinesiology The Ankle and Foot Joints • Flexor digitorum longus • Flexor hallucis longus 11-61 Manual of Structural Kinesiology Transverse Tarsal & Subtalar Eversion • Agonists – Peroneus (fibularis) longus – Peroneus (fibularis) brevis – Peroneus tertius – Extensor digitorum longus – Flexor hallucis longus – Flexor digitorum longus The Ankle and Foot Joints 11-63 Manual of Structural Kinesiology Toe Extension 11-64 Anatomy & Physiology Tutorials www.gwc.maricopa.edu/class/bio201/index.htm Radiologic Anatomy Browser http://radlinux1.usuf1.usuhs.mil/rad/iong/index.html – This site has numerous radiological views of the musculoskeletal system. University of Arkansas Medical School Gross Anatomy for Medical Students http://anatomy.uams.edu/htmlpages/anatomyhtml/gross.html – Dissections, anatomy tables, atlas images, links, etc. Loyola University Medical Center: Structure of the Human Body www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/GA.html – An excellent site with many slides, dissections, tutorials, etc. for study of human anatomy. – Extensor hallucis longus – Extensor digitorum longus The Ankle and Foot Joints The Ankle and Foot Joints Web Sites • Agonists Manual of Structural Kinesiology 11-62 Toe Flexion • Agonists Manual of Structural Kinesiology The Ankle and Foot Joints 11-65 Manual of Structural Kinesiology The Ankle and Foot Joints 11-66 11 Web Sites Web Sites Wheeless' Textbook of Orthopaedics www.ortho-u.net/ – This site has an extensive index of links to the fractures, joints, muscles, nerves, trauma, medications, medical topics, lab tests as well as links to orthopaedic journals, other orthopaedic, and medical news. Foot and Ankle Web Index www.footandankle.com The University of Texas MD Anderson Cancer Center Multimedia and Learning Resources www.mdacc.tmc.edu/mmlearn/anatomy.html – This site has numerous cadaveric cuts of the foot, knee, hand, and elbow; an interactive ankle; and a rotating foot and ankle American Orthopaedic Foot and Ankle Society www.aofas.org – Numerous patient education brochures regarding foot and ankle problems are found here Premiere Medical Search Engine www.medsite.com – This site allows the reader to enter any medical condition and it will search the net to find relevant articles. – The foot and ankle link library located at this site is very helpful. American College of Foot and Ankle Surgeons www.acfas.org – This site, sponsored by podiatric surgeons and doctors of podiatric medicine (DPM), has information on topics relating to foot healthfoot and ankle deformities and injuries; care of the diabetic foot; foot and ankle disorders caused by arthritis, aging, trauma and sports injuries; and congenital deformities and disease. Manual of Structural Kinesiology The Ankle and Foot Joints 11-67 Manual of Structural Kinesiology The Ankle and Foot Joints 11-68 Web Sites Virtual Hospital www.vh.org – Numerous slides, patient information, etc. The Dynamic Human version 2.0 CD-ROM: The Visual Guide to Anatomy & Physiology www.mhhe.com/biosci/ap/dynamichuman2/ – Web site that accompanies this CD-ROM Manual of Structural Kinesiology The Ankle and Foot Joints 11-69 12