The Leg, Foot and Ankle

1
Chapter 19

• The Leg, Foot and Ankle

2
Overview

• The ankle and foot is a complex structure
  comprised of 28 bones (including 2 sesamoid
  bones) and 55 articulations (including 30
  synovial joints), interconnected by ligaments and
  muscles
• In addition to sustaining substantial forces, the
  foot and ankle serve to convert the rotational
  movements that occur with weight bearing
  activities into sagittal, frontal, and transverse
  movements

3
Anatomy

• Anatomically and biomechanically, the foot is
  often subdivided into
• The rearfoot or hindfoot (the talus and
  calcaneus)
• The midfoot (the navicular, cuboid and the 3
  cuneiforms)
• The forefoot (the 14 bones of the toes, the 5
  metatarsals, and the medial and lateral
  sesamoids)

4
Anatomy

• Distal Tibiofibular Joint
• Classified as a syndesmosis
• Consists of a concave tibial surface and a convex
  or plane surface on the medial distal end of the
  fibula

5
Anatomy

• The talocrural (ankle) joint
• Formed between the saddle-shaped talus and the
  distal tibia
• Classified as a synovial hinge or a modified
  sellar joint

6
Anatomy

• Subtalar (talocalcaneal) joint
• The subtalar joint is a synovial, bicondylar
  compound joint consisting of two separate,
  modified ovoid surfaces with their own joint
  cavities (one male and one female)
• This relationship ensures that the anterior and
  posterior aspects can move in opposite directions
  to each other during functional movements (while
  the anterior aspect is moving medially, the
  posterior aspect is moving laterally)

7
Anatomy

• Talocalcaneal joint ligaments
• A number of ligaments provide support to this
  joint, although some confusion exist in the
  descriptions and nomenclature of these ligaments
• The two superficial ligaments are the lateral and
  posterior talocalcaneal ligaments
• The deep ligaments include the interosseous,
  cervical, and axial ligaments, often referred
  together as the interosseous ligaments

8
Anatomy

• The midtarsal joint complex
• Consists of the talonavicular and calcaneocuboid
  articulations
• The talonavicular joint is classified as a
  synovial, compound, modified ovoid joint
• Formed by components of the talus, navicular,
  calcaneus and plantar calcaneonavicular (spring)
  ligament
• The calcaneocuboid joint is classified as a
  simple, synovial modified sellar joint

9
Anatomy

• Ligaments of the mid-tarsal joints
• A number of ligaments help provide support to
  this region
• The spring ligament (plantar calcaneonavicular)
  connects the navicular bone to the sustentaculum
  tali on the calcaneus
• The ligaments of the calcaneocuboid joint include
  the long plantar ligament and a portion of the
  bifurcate ligament dorsally

10
Anatomy

• The cuneonavicular joint
• Classified as a compound, synovial, modified
  ovoid joint

11
Anatomy

• Intercuneiform and Cuneocuboid Joints
• These joints are classified as compound,
  synovial, modified ovoid joints

12
Anatomy

• Cubometatarsal joint
• When considered alone, this joint is classified
  as a compound modified ovoid, synovial joint

13
Anatomy

• The cubonavicular joint
• Classified as a syndesmosis, or a plane surfaced
  joint

14
Anatomy

• Intermetatarsal joints
• The first intermetatarsal joint is classified as
  a simple, synovial, modified ovoid joint, while
  the 2nd, 3rd and 4th are classified as compound
  joints

15
Anatomy

• The metatarsophalangeal (MTP) joints
• Classified as simple, synovial, modified ovoid
  joints

16
Anatomy

• The interphalangeal (IP) joints
• Classified as simple, synovial modified sellar
  joints

17
Anatomy

• Plantar fascia/aponeurosis
• The plantar fascia is the investing fascial layer
  of the plantar aspect of the foot that originates
  from the os calcis and inserts through a complex
  network to the plantar forefoot
• A tough, fibrous layer, composed histologically
  of both collagen and elastic fibers
• Three portions

18
Anatomy

• Plantar fascia/aponeurosis
• With standing and weightbearing, the plantar
  fascia plays a major role in the support of the
  weight of the body by virtue of its attachments
  across the longitudinal arch.

19
Anatomy

• Retinacula
• There are four important ankle retinacula, which
  function to tether the leg tendons as they cross
  the ankle to enter the foot

20
Anatomy

• The extrinsic muscles of the foot
• Can be divided into anterior, posterior
  superficial, posterior deep, and lateral
  compartments

21
Anatomy

• The extrinsic muscles of the foot
• Anterior compartment
• This compartment contains the dorsiflexors
  (extensors) of the foot. These include the
  tibialis anterior, extensor digitorum longus,
  extensor hallucis longus, and peroneus tertius
• Posterior superficial compartment
• This compartment, located posterior to the
  interosseous membrane, contains the calf muscles
  which plantarflex (flex) the foot. These include
  the gastrocnemius, soleus, and the plantaris
  muscle

22
Anatomy

• The extrinsic muscles of the foot
• Posterior deep compartment
• This compartment contains the flexors of the
  foot. These muscles include the posterior
  tibialis, flexor digitorum longus, and flexor
  hallucis longus
• Lateral compartment
• This compartment contains the peroneus longus and
  brevis

23
Anatomy

• The intrinsic muscles of the foot
• Subdivided into 4 layers
• 1st layer
• Abductor hallucis
• Abductor digiti minimis
• Flexor digitorum brevis
• 2nd layer
• Flexor digitorum accessorius (quadratus plantae)
• Lumbricales

24
Anatomy

• The intrinsic muscles of the foot
• 3rd layer
• Flexor hallucis brevis
• Flexor digiti minimis
• Adductor hallucis
• 4th layer
• Dorsal interossei
• Plantar interossei

25
Anatomy

• The dorsal intrinsic muscles of the foot
• Consist of the extensor hallucis brevis (EHB) and
  extensor digitorum brevis (EDB) muscles

26
Anatomy

• Arches of the foot
• There are 3 main arches
• The medial longitudinal
• The lateral longitudinal
• The transverse

27
Anatomy

• Neurology
• The saphenous nerve, the largest cutaneous branch
  of the femoral nerve, provides cutaneous
  distribution to the medial aspect of the foot
• The sciatic nerve provides the sensory and motor
  innervation for the foot and leg
• It divides into the common peroneal and tibial
  nerves. The common peroneal nerve in turn
  divides into the superficial peroneal, deep
  peroneal nerves. The tibial nerve divides into
  the sural, medial calcaneal, medial plantar, and
  lateral plantar nerves

28
Anatomy

• Vascular supply
• Two branches of the popliteal artery, the
  anterior tibial artery and the posterior tibial
  artery, form the main blood supply to the foot

29
Biomechanics

• Terminology
• Motions of the leg foot and ankle consist of
  single plane and multi-plane movements. The
  single plane motions include
• The frontal plane motions of inversion and
  eversion
• The sagittal plane motions of dorsiflexion and
  plantarflexion
• The horizontal plane motions of adduction and
  abduction

30
Biomechanics

• A triplane motion describes a movement about an
  obliquely oriented axis through all three body
  planes.
• Triplanar motions occur at the talocrural,
  subtalar, and midtarsal, joints, and at the first
  and fifth rays.
• Pronation and supination are considered triplanar
  motions

31
Biomechanics

• Pronation
• The three body plane motions in pronation are
  abduction in the transverse plane, dorsiflexion
  in the sagittal plane, and eversion in the
  frontal plane

32
Biomechanics

• Supination
• The three body plane motions in supination are a
  combined movement of adduction, plantarflexion,
  and inversion

33
Biomechanics

• Proximal tibiofibular joint
• Because of the interaction between the proximal
  and distal tibiofibular joints with the knee and
  the ankle function, the clinician should always
  evaluate the functional mobility of both these
  complexes when treating one or the other

34
Biomechanics

• Talocrural Joint
• The primary motions at this joint are
  dorsiflexion and plantar flexion, with a total
  range of 70-80
• Theoretically, the capsular pattern of the ankle
  joint is more restriction of plantarflexion than
  dorsiflexion, although clinically this appears to
  be reversed
• The close-packed position is weight-bearing
  dorsiflexion, while the open-packed position is
  midway between supination and pronation.

35
Biomechanics

• The subtalar joint
• Subtalar joint supination and pronation are
  measured clinically by the amount of calcaneal or
  hindfoot inversion and eversion
• In normal individuals, there is an inversion to
  eversion ratio of 23 to 13, which amounts to
  approximately 20 of inversion and 10 of
  eversion

36
Biomechanics

• Subtalar joint
• The capsular pattern of this joint varies. In
  chronic arthritic conditions, there is an
  increasing limitation of inversion, but with
  traumatic arthritis, eversion appears most
  limited clinically
• The close-packed position for this joint is full
  inversion, while the open-packed position is
  inversion/plantarflexion

37
Biomechanics

• The midtarsal joint complex
• Provides the foot with an additional mechanism
  for raising and lowering the arch, and to absorb
  some of the horizontal plane tibial motion that
  is transmitted to the foot during stance
• The talonavicular joint two degrees of freedom
  plantar flexion/dorsiflexion and
  inversion/eversion, with motion occurring around
  a longitudinal and oblique axis, both of which
  are independent of each other
• The capsular pattern is a limitation of
  dorsiflexion, plantar flexion, adduction and
  internal rotation
• The close packed position is pronation
• The open packed position is midway between
  extremes of range of motion

38
Biomechanics

• The midtarsal joint complex
• The capsular pattern for the calcaneocuboid joint
  is a limitation of dorsiflexion, plantar flexion,
  adduction and internal rotation

39
Biomechanics

• The cuneonavicular joint
• Has one to two degrees of freedom
  plantar/dorsiflexion, inversion/eversion
• The capsular pattern is a limitation of
  dorsiflexion, plantar flexion, adduction and
  internal rotation
• The close-packed position is supination
• The open-packed position is considered to be
  midway between the extremes of range of motion

40
Biomechanics

• Intercuneiform and Cuneocuboid Joints
• Due to their very plane curvature, these joints
  have only one degree of freedom
  inversion/eversion
• The close packed position for these joints is
  supination
• The open packed position is considered to be
  midway between extremes of range of motion

41
Biomechanics

• Cubometatarsal Joint
• The capsular pattern of this joint is a
  limitation of dorsiflexion, plantar flexion,
  adduction and internal rotation
• The close-packed position is pronation.
• The open-packed position is considered to be
  midway between extremes of range of motion

42
Biomechanics

• Cubonavicular Joint
• The close-packed position for this joint is
  supination
• The open-packed position is midway between
  extremes of range of motion

43
Biomechanics

• Intermetatarsal Joints
• The close-packed position for these joints is
  supination
• The open-packed position is midway between
  extremes of range of motion

44
Biomechanics

• Metatarsophalangeal Joints
• The MTP joints have two degrees of freedom
  flexion/extension and abduction/adduction.
• Range of motion of these joint is variable,
  ranging from 40 to 100 dorsiflexion (with a
  mean of 84), 3 to 43 (mean, 23) plantar
  flexion, and 5 to 20 varus and valgus
• The closed-packed position for the MTP joints is
  full extension
• The capsular pattern for these joints is
  variable, with more limitation of extension than
  flexion
• The open-packed position is 10º of extension.

45
Biomechanics

• 1st Metatarsophalangeal Joint
• The function of the great toe is to provide
  stability to the medial aspect of the foot, and
  to provide for normal propulsion during gait.
  Normal alignment of the 1st MTP joint varies
  between 5 varus and 15 valgus
• The great toe is characterized by having a
  remarkable discrepancy between active and passive
  motion. Approximately 30 of active plantar
  flexion is present, and at least 50 of active
  extension, which can be frequently increased
  passively to between 70-90.

46
Biomechanics

• Interphalangeal (IP) Joints
• Each of the IP joints has one degree of freedom
  flexion/extension
• The capsular pattern is more limitation of
  flexion than of extension
• The close-packed position is full extension
• The open-packed position is slight flexion

47
Examination

• The examination is used to identify static and
  dynamic, structural or mechanical foot
  abnormalities
• The clinical diagnosis is based on an assessment
  of the changes in joint mobility and tissue
  changes at the foot and ankle, and the effect
  these have on the function of the remainder of
  the lower kinetic chain

48
Examination

• History
• The primary purposes of the history are to
• Determine the severity of the condition
• Determine the area, nature and behavior of the
  symptoms
• Help determine the specific structure at fault
• Detect systemic conditions (collagen disease,
  neuropathy, radiculopathy, and vascular
  problems), or the presence of serious pathology

49
Examination

• Systems Review
• As symptoms can be referred distally to the leg,
  foot and ankle from a host of other joints and
  conditions, the clinician must be able to
  differentially diagnose from the presenting signs
  and symptoms
• The cause of the referred symptoms may be
  neurological or systemic in origin. If a
  disorder involving a specific nerve root (L 4, L
  5, S1, or S 2) is suspected, the necessary
  sensory, motor and reflex testing should be
  performed
• Peripheral nerve entrapments, although not
  common, may also occur in this region and often
  go unrecognized

50
Examination

• Systems Review
• Systemic problems that may involve the leg, foot
  and ankle include diabetes mellitus (peripheral
  neuropathy), osteomyelitis, gout and pseudogout,
  sickle cell disease, complex regional pain
  syndrome, peripheral vascular disease, and
  rheumatoid arthritis

51
Examination

• Observation
• Observation of the lower extremity is extensive.
  It is extremely important to observe the entire
  kinetic chain when assessing the leg, foot, and
  ankle. Weight bearing and non-weight bearing
  postures of the foot are compared.
• Observing the patient while they move from sit to
  stand, and walk to the treatment area, gives the
  clinician a sense of the patients functional
  ability in weight bearing, and provides the first
  opportunity for gait analysis.

52
Examination

• Palpation
• Careful palpation should be performed around the
  leg, foot, and ankle to differentiate tenderness
  of specific ligaments and other structures
• Areas of localized swelling and ecchymosis over
  the ligaments on the medial or lateral aspects of
  the foot and ankle should be noted

53
Examination

• Active and Passive Range of Motion
• AROM tests are used to assess the patients
  willingness to move and the presence of movement
  restriction patterns such as a capsular on
  non-capsular pattern
• General active range of motion of the foot and
  ankle in the non-weight bearing position is
  assessed first, with painful movements being
  performed last
• In addition to the foot and ankle tests, the
  clinician should also assess hip and knee range
  of motion

54
Examination

• Strength testing
• Isometric tests are carried out in the extreme
  range, and if positive, in the neutral range
• The straight plane motions of ankle dorsiflexion,
  plantar flexion, inversion and eversion are
  tested initially. Pain with any of these tests
  requires a more thorough examination of the
  individual muscles

55
Examination

• Strength testing
• The individual isometric muscle tests can give
  the clinician information about patterns of
  weakness other than from spinal nerve root or
  peripheral nerve palsies and can also help to
  isolate the pain generators
• A painful weakness is invariably a sign of
  serious pathology, and depending on the pattern,
  could indicate a fracture or a tumor. However,
  if a single motion is painfully weak this could
  indicate muscle inhibition due to pain.

56
Examination

• Strength testing
• Weakness on isometric testing needs to be
  analyzed for the type
• Increasing weakness with repeated contractions of
  the same resistance indicating a palsy
• Consistent weakness with repeated contractions
  which could suggest a deconditioned muscle, or a
  significant muscle tear), and the pattern of
  weakness (spinal nerve root, nerve trunk or
  peripheral nerve)

57
Examination

• Passive articular mobility
• Passive articular mobility tests assess the
  accessory motions available between the joint
  surfaces. These include tests of the joint
  glides, joint compression and joint distraction
  tests. As with any other joint complex, the
  quality and quantity of joint motion must be
  assessed to determine the level of joint
  involvement

58
Examination

• Special tests
• Special tests are merely confirmatory tests
• Selection for their use is at the discretion of
  the clinician and is based on a complete patient
  history
• The results from these tests are used in
  conjunction with the other clinical findings and
  should not be used alone to form a diagnosis
• To assure accuracy with these tests, both sides
  should be tested for comparison

59
Examination

• Neurological tests
• Important neurological structures that pass
  through the ankle and terminate in the foot are
  the saphenous, superficial peroneal, deep
  peroneal, posterior and anterior tibial nerves,
  and the sural nerve
• Symptoms can be referred to the foot and ankle
  from the L 4-S 2 nerve roots (sciatic) and from a
  host of non-neurological conditions

60
Examination

• Neurological tests
• Common reflexes tested in this area are the
  Achilles reflex (S 1-2), and the posterior tibial
  reflex (L 4-5)
• The pathological reflexes (Babinski, and
  Oppenheim), tested when an upper motor neuron
  lesion is suspected

61
Intervention
62
Intervention

• Acute phase goals
• Decrease pain, inflammation and swelling
• Protect the healing area from re-injury
• Re-establish pain-free range of motion
• Prevent muscle atrophy
• Increase neuromuscular control
• Maintain fitness levels
• Patient to be independent with home exercise
  program

63
Intervention

• Functional phase goals
• Restore normal joint kinematics
• Attain full range of pain free motion
• Improve neuromuscular control of the lower
  extremity in a full weight bearing posture on
  both level and uneven surfaces
• Regain and improve lower extremity strength and
  endurance through integration of local and
  kinetic chain exercises

64
Intervention