The Ankle/Foot

Anatomy:
-Blood supply: Anterior tibial artery (>dorsalis peds>tarsal artery>arcuate artery)+posterior tibial artery
(>medial/lateral plantar artery>plantar arch>digital arteries)+peroneal artery
-Venous drainage:
Superficial: Great saphenous vein(>dorsal venous arch>digital veins)+small saphenous vein
Deep: Ant tibial, post tibial, peroneal, popliteal and femoral
-Lymphatic drainage: (consider lymphadenopathy)
Medial superficial lymphatic vessels<superficial inguinal lymph nodes=vertical
(great saphenous) <deep inguinal=horizontal (femoral veinc <external iliac lymph nodes<lumbar
lymphatic trunks
Lateral superficial lymphatic vessels <popliteal lymph nodes<deep
inguinal=horizontal (femoral vein)<external iliac lymph nodes<lumbar lymphatic trunks
-Nerve supply:
Foot: Tibial nerve(>medial/lateral plantar nerves)+sup/deep fibular+sural nerve (<tibial nerve+
common fibular nerve) +saphenous+ medial (<tibial) and lateral (<sural) calcaneal branches.
Ankle: Tibial and deep fibular
-Dermatomes:
-Bones:
- 5 distal phalanges, 4 middle phalanges, 5 proximal phalanges
- 5 metatarsals
- navicula, cuboid and 3 cuneiforms
- calcaneus and talus
- Joints:
- 4 distal interphalangeal joints (DIP) of toes 2-5
- Interphalangeal (1
st
IP) of great toe and proximal interphalangeal joints (PIP) of toes 2-5
- metatarsophalangeal (MTP), 5
-intermetatarsal
-tarso-metatarsal (TMT), 5
-transverse tarsal joints: calcaneocuboid, talonavicular
-subtalar
-ankle joint


Structure Type: Hinge-type sinovial joint
Articular surfaces: distal end of tibia and fibula and sup aspect of
talus
Ligaments Lateral collateral: anterir talo-fibular, post talo-fibular and calcneo-
fibular
Medial collateral (deltoid lig): sup: Tibio-navicular, calcneo-tibial,
post. Talo-tibial //deep: ant talo-tibial
Subtalar joint:
Structure Type: post: plane//ant: ball and socked
Articular surfaces: post: talocalcaneal //ant: talocalcaneonavicular

Ligaments Post: Interosseous talocalcaneal ligament//ant: spring ligament
Medial, lateral and post talocalcaneal ligament
Transeverse tarsal joints: Calcaneocuboid and Talonavicular
Structure Type:
calcaneocuboid: plane joint
talonavicula: ball and socked
Ligaments Spring ligament (calcaneonavicular lig)
Long plantar ligament
Short plantar ligament
Bifurcated ligament (calcaneo-cuboid +calcaneo-navicular)
Tarsometatarsal (TMT)
1
st
TMT Synovial saddle
1
st
Met + 1
st
cuneiform
dorsal, plantar, and interosseous ligaments
2
nd
-5
th
TMT Synovial plane
2
nd
Met + 1
st
and 2
nd
cuneiform
3
rd
Met + 3
rd
cuneiform
4
th
Met + 3
rd
cuneiform and cuboid
5
th
Met + cuboid
dorsal, plantar, and interosseous ligaments
Intermetatarsal joints (IMT)
Synovial plane
Metatarsophalangeal (MTP)
MTP Metatarsal + proximal phalanx
Synovial condylar/ellipsoid
Flex/ext/abd/add/circumduction
3 lig: plantar, collateral and deep transverse(links heads of Mets
together)
1
st
MTP has 2 sesamoid bones
Interphalangeal joints (IP)
Distal & Proximal Synovial Hinge joint
Flex/Ext
2 lig: plantar + collateral
Retinaculum
Flexor Medial
Extensor Superior and inferior. Inferior being Y shaped band
Peroneal Superior and inferior
Arches:
2 longitudinal Medial:
Bones: clacaneous, talus, navicula, 3 cuniforma, 3 Met
Lig: Plantar aponeurosis, spring lig, ant fibres of deltoid lig
Musc: FHL, TP, TA, PL, EDL
Lateral:
Bones: Calcaneous, cuboid, 4
th
and 5
th
Met
Lig: Long plantar ligament
3 transverse arches Tarsal arch: cuboid, navicula, cuneiform. PL
Posterior metatarsal arch: ADD hallucis
Anterior metatarsal arch: intrinsic muscles and ligaments
Muscles:
superficial group EDB, ADB H, FDB, ABD b
2nd layer Quadratus plantae, Lumbricals
deep group FH b, Add H, F minimus b, dorsal interossei, plantar interossei
Function:
ANKLE JOINT
-Provide mobility in plantar flexion and stability in dorsi-flexion, allowing the ankle to fulfil its
role of weight transmission and locomotion; [stability and mobility].
- dorsi-flexion the fibula is directed laterally, superiorly and into slight medial rotation by
the shape of the mortise, so guiding the talus medially. So on dorsi flexion in the weight bearing
stance phase of walking, as the talus moves medially under influence of the rotating fibula
these ligaments (spring ligament) become tense to maintain the position of the talus.

-The stabilising collateral ligaments extend from the malleoli inferiorly on each side, with the
fibular malleolus extending lower than the medial malleolus and the axis of movement
running roughly through its centre. So ligaments running from this malleolus coincide with
the axis of movement and are therefore tense throughout all movements except eversion.
Medially the ligaments vary in tension throughout movement.
- inversion strain, due to the shortness of the medial malleolus, it may act as a pivot against
the talus causing avulsion of the ligaments laterally or even fracture of the lateral malleolus
(spiral)
- Toe-off: As the medial arch of the foot is flattened by the weight force, not only is the arch
restored by the contraction of the muscles in the plantar fascia but also the active contraction of
tibialis anterior and posterior, peroneus longus, extensor digitorum longus and extensor
hallucis longus as the toe-off is approached. This also helps maintain the position of the talus,
particularly as tibialis posterior runs under the sustentaculum tali. FHL supports the talus
posteriorly.
- The joint capsule is thin A-P but thick Med-Lat

FOOT:
1. Provides a stable platform for weight bearing; normally the weight-bearing areas are the
metatarsal heads (2/3 1
st
MTT, 1/3 rest 4 MTT) and posterior portion of the calcaneum. The
centre of gravity on standing falls between the heel and the forefoot through a line joining the
navicular tubercle medially and the base of the fifth metatarsal.

2. Provides mobility to support locomotion and also to allow for variation in ground surface
below and abnormality of gait from above. Medial adaptability and lateral stability.
Medial: Raised nature of the medial arch, talonavicular joint
Rotations: occurs mainly at the sub-talar joints and the navicular cuboid articulation. The inter-
tarsal joints give suppleness

3. Force dissipation from above and below: trabeculae and their bony shape up into the soft
tissues of the calf, and also by arch capacity to flatten temporarily.

4. Proprioception to inform static and dynamic posture.





Common Problems:
Pes planus
Collapse of the plantar vault due to weakening or fatigue of the muscular
and ligamentous support.
In children mobile pes planus is normal due to ligamentous laxity and
usually disappears as the child grows. Supportive orthotics or physical
exercises may be indicated in some cases, when excessive wear is shown
on one aspect of the childs shoe. Rigid pes planus in children is less
common and involves a persistent arch deformity on- and off-
weightbearing. The rigidity is due to muscle spasm / tarsal joint
abnormalities. This type should be investigated and the precise cause
should be treated
In adults, pes planus commonly occurs later in life and usually is
associated with ligamentous laxity or O/A changes. Other causes include
poliomyelitis, R/A or tendon ruptures. There may be pain on walking or
prolonged standing. Navicular tuberosity will be prominent on standing and
there will be a valgus deformity at the ankle. Treatment is normally
symptomatic.
Meyers line, Feiss line, Helbings line

Pes cavus The arch is abnormally high and is often associated with a varus strain
through the heel and clawing of the toes (due to the pull of the long
extensors). The foot is shorter than normal (due to shortening of the foot
flexors).This can occur as a result of a congenital problem but can also be
acquired due to neurological problems affecting the intrinsic foot muscles.
Commonly a patient presents with pain over the plantar aspect of the
metatarsal heads because of their prominence (dropped metatarsal
heads). It can be associated with other conditions such as spina bifida
occulta, peroneal muscular atrophy, Friedreichs ataxia and poliomyelitis.
Treatment is often unnecessary however repositioning of tendons and joint
fusion may be considered.

Hallux rigidus
This causes extreme stiffness of 1
st
MTPJ. It is secondary to conditions
such as O/A, local trauma, osteochondritis dissecans of 1
st
met head and
gout. It affects men more often than women and the pain is aggravated by
walking up slopes or high heels. There is gross reduction in dorsiflexion
usually by osteophytic growth. A patient will roll their weight around lateral
edge of foot to avoid stressing the hallux.
Treatment initially conservative, rocker-soled shoes or very firm soled
shoes, thus reducing the need to dorsiflex when walking. Surgical
treatment will remove osteophytes and undertake an osteotomy of
proximal part of 1st phalanx. Arthrodesis of 1st MTPJ or replacement of
1st MTPJ are other possibilities

Hallux valgus
A very common condition with an unknown cause. Most common in 50+
women often with a strong family history. Varus of 1
st
metatarsal
predisposes to an increased hallux valgus. It is often asymptomatic, but if
there is pain it may be due to:
bursitis over the 1
st
MTPJ (bunions)
hammer toe deformity
metatarsalgia
O/A of the 1
st
MTPJ
Treatment can be symptomatic using sponge pads, splints while corrective
treatment is surgery either:
osteotomy of 1
st
metatarsal (adolescents)
release of AddH tendon on lateral side of Hallux and possibly
trimming head of 1
st
metatarsal
rarely fusion of 1st

MTPJ
not completely successful as all surgical options remove/ modify the
normal function of the joint and hence reduce the natural push off while
walking
P.F: Metartasus varus, footwear, pes planus
Mortons
syndrome
This is metatarsalgia of the 1
st
and 2
nd
Met normally due to abnormal mechanics
of the area:
-Short 1
st
Met
-Excessive mobility of the 1
st
Met at its base
-Post displacement of the sesamoids
-Thickening of the shaft of the 2
nd
Met due to excessive wb leading to callus
formation and depression of the transverse arch
Mortons
neuralgia
An entrapment neuropathy of the interdigital nerve may be due to formation of
a neurofibroma of the digital nerve. It is a swelling that normally forms where
the interdigital nerve branches into the digits normally at the 3
rd
and 4
th
toes
Pt wants to keep the shoes off and tends to complain of P&N and numbness
Hammer toes
The PIP is fixed in flexion with hyperextension of DIP, it is not painful of
itself, but causes corns and calluses which are. May require corrective
surgery if severe

Osteochondritis

Characterized by interruption of blood supply in particular to the epiphysis,
followed by localised bony necrosis and later regrowth of the bone in the shape
adopted after the necrosis phase.
Usually self limiting, lasting less than 3 years and spontaneously re-hardenening
Unknown aetiology, however onset often relates to trauma or stress on the area
affected
Kohlers O/C

(navicular)

This is an avascular necrosis of the navicular. There is pain in the hindfoot
and the navicular is tender to touch. It causes mid tarsal pain and
limp.child tends to weight bear on lateral foot.
The bone reforms over subsequent 2-3years original shape is changed,
but there is a good functional result
X-ray: Shows squarer and denser navicula
Ttt: rest and occasionally plaster cast



Freiburgs O/C

(2nd metatarsal
head)

Affects the 2
nd
met head, normally in adolescents and tends to be asymptomatic
until the deformity predisposes to early O/A of the 1
st
MTP joint. X-Ray shows
dorsal displacement of the head. Causes stiffness, O/A and altered foot
mechanics
Paratendonitis The Achilles tendon is protected by paratendon, a cross between a bursa and a
fascial sheath. It reduces friction but also protects the tendon. However, if the
paratendon becomes tight or suffers trauma it tends to stenose preventing the
tendon from running freely, causing pain on excess use, and may become
inflamed.
Posterior tendo-
achilles bursitis
Here a bursa exists to protect the tendon and its paratendon from friction with
skin and any footwear. It tends to be prone to trauma from badly fitting shoes
and becomes red and swollen. This may cause a reduction in comfortable heel
movement and so problems elsewhere. It commonly occurs in runners and ballet
dancers, where, if chronic, excision may be attempted.
Severs disease Osteochondritis of tha calcaneous causing necrosis.
calcaneal apophysitis repeated microtrauma at attachment of Achilles
tendon > 10-13 yrs (cf Osgood-Schlatters)
if severe a short cast for 2-12 weeks It usually resolves in about a year without
treatment, however occasionally a small heel raise (put into both shoes) is
sometimes used to reduce tension on the insertion.

Inferior Calcaneal
bursitis-
Tender Heel Pad
Inflammation of the pad of fatty tissue under the promince of wb part of the
calcaneum. Normally due to changes in wb mechanics: shortening of grastrocs
complex, altering the part of the calcaneum that is in contact with the ground;
development of pes planus putting different stress on the heel. Simply due
trauma with hard surfaces. Tenderness under the heel and pain on standing and
walking.
Plantar fascitis
Inflammation of the plantar aponeurosis at its attachment to the heel,
normally due to overuse. The fascia may fatigue and give ischaemic pain.
There may be an associated bony spur at insertion point that may be the
site of pain. There is tenderness on palpation esp. over insertion points.
Pain on standing and walking.
Agg: exx . PF: ant wb, weight increase and pes planus.
Ttt may just involve soft heel pads (with a hole over the calcaneal spur)
and arch support for a while to ease pressure or NSAIDs and ice.
Persistent/severe cases may require cortisone injections but these are
painful and success is limited. Excision of the calcaneal spur may be
necessary again with limited success

Calcaneal spur Proliferation of bone on the plantar surface of the calcaneum and into the
plantar fascia. Due to pressure or traction on the calcaneum causing osteoblastic
activity, often associated with plantar fasciitis.
There tends to be point tenderness on the heel and X-Rays confirm diagnosis.
Plantar Formation of a nodule in the fibrous tissue of the fascia. Uncommon but may be
fibromatosis associated with Dupuytrens contracture of the hand or be trauma related. Can
be pre-cancerous and excision may be performed if its nature is in doubt, but
may recur
Calcaneal # Result of a vertical compression force, such a fall. There will be difficulties wb
and heel will appear broad as inflammation fills the hollows. If minor, prognosis
is good, but if it involves the sub-talar joint then can be serious. Check for spinal
# and future possibility of O/A
O/A subtalar joint Wear and tear process which affects foot mechanics
Causes: bone eburnation, osteophytes, cysts, narrowing of the interart space
PF: previous calcaneal # or severe pes planus
avulsion fracture treatment generally the same for sprained or fracture; but if avulsion is
severe may require a cast for 6-8 weeks.
commonly at the ankle usually lateral malleoli following a severe force via
the ligament(s). These either resist, tear (sprain) or avulse the bone at its
attachment. + Base of the 5
th
Met due to spasmodic contraction of fibularis
brevis after of ankle sprain.
need to X-ray to confirm diagnosis
Pott's fracture,
(Dupuytren
fracture)
a bimalleolar ankle fracture. Injury is caused by a combined abduction and
external rotation of the foot from an eversion force.
An avulsion fracture of medial malleoli (at attachment of deltoid ligament), the
talus forced laterally and fractures fibular malleoli or superior to syndesmosis.
Avascular necrosis
of the talus
(# Neck)

trauma and nontraumatic. In the case of trauma, a fracture (breaking) of the
bone disrupts the blood supply to the bone leading to AVN. There are many
causes of nontraumatic AVN. These include idiopathic (no cause is ever found),
steroids (eg. anabolic and high dose corticosteroids (prednisone) given for such
diseases as rheumatoid arthritis, lupus, and cancer), excess alcohol consumption,
sickle cell anemia, radiation treatments, and chemotherapy.
march fracture

Stress fracture of the shaft of 2nd or 3rd metatarsal after heavy or unaccustomed
exercise
Charcotts foot neuropathic joints, often called Charcot joints, are caused by loss of sensation in
the joint so that it is severely damaged and disrupted

Ankle sprain A common medical condition where one or more of the ligaments of the ankle is
torn or partially torn.
The anterior talofibular ligament is one of the most commonly involved
ligaments in this type of sprain. Approximately 70-85% of ankle sprains are
inversion injuries.
Ankle sprains are classified as grade 1, 2, and 3A grade 1 sprain is defined as mild
damage to a ligament or ligaments without instability of the affected joint. A
grade 2 sprain is considered a partial tear to the ligament, in which it is stretched
to the point that it becomes loose. A grade 3 sprain is a complete tear of a
ligament, causing instability in the affected joint.

Bruising may occur around the
ankle.
In medicine, the Ottawa ankle rules are a set of guidelines for clinicians to help
decide if a patient with foot or ankle pain should be offered X-rays to diagnose a
possible bone fracture. Ankle X-ray is only required if there is any pain in the
malleolar zone and any one of the following:
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or
tip of the medial malleolus, OR
Bone tenderness along the distal 6 cm of the posterior edge of the fibula
or tip of the lateral malleolus, OR
An inability to bear weight both immediately and in the emergency
department for four steps.
Additionally, the Ottawa foot rules indicate whether a foot X-ray series is
required. It states that it is indicated if there is any pain in the midfoot zone and
any one of the following:
Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
Bone tenderness at the navicular bone (for foot injuries), OR
An inability to bear weight both immediately and in the emergency
department for four steps.


Anterior tibio-talar
impingement
spurs
Tibio talar spurs and osteochondral lesions of the talus are the most common
osseous lesions of the ankle joints. They give chronic inflammatory synovitis,
fibrosis and hyalinised connective tissue.
They are commonly found after and inversion sprain, there is a prevalence of
these spurs in athletes and as many as 50 of the dancers are found to have
them. Not all the spurs develop symptoms, but, if dysfunction occurs the
persisten pain and swelling over the ant ankle develops.
Lat X-Ray view, sometimes just seen in MRI
Ttt: Heel raise to surgery
Diabetic foot Microneurovascular dysfunction, loss of nocicepative reflex and inflammatory
response.
Foot problems are very common in diabetics due to the effects of the
peripheral vascular disease causing claudication, trophic skin changes,
ulceration and gangrene. This can often result in the amputation of the
lower extremity:

1. Peripheral vascular disease causing claudication, trophic skin
changes, ulceration, gangrene
2. Peripheral Neuropathy may cause foot/ankle defor
mities and even Charcots joints
3. Osteoporosis
4. Infection


Foot drop Foot drop can be caused by nerve damage alone (common peroneal
&piriformis). However, it is also caused by muscle or spinal nerve trauma,
abnormal anatomy, toxins or disease. Diseases that can cause foot drop include
stroke, Amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease), muscular
dystrophy, Charcot Marie Tooth disease, multiple sclerosis, Cerebral palsy and
Friedreich's ataxia. It may also occur as a result of hip replacement surgery.

Rheumtological conditions:
Unilateral
O/A: Talo-crural O/A, subtalar
O/A, Hallux Rigidus
Def: a non inflammatory degeneration of synovial joints
marked by degeneration of the articular cartilage, hypertrophy
of bone at the margins with associated changes in the
synovial membrane

Age/Sex: 2F:1M, 55

Aetiology: Primary: Non underlying cause
Secondary: congenital/developmental, metabolic,
inflammatory, traumatic

Pathophysiology: Breakdown of articular surface, synovial
irritation,remodelling,eburnation & cyst formation,
disorganisation

Clinical signs & symptoms:
Onset: Insidious
Symptoms: Burning/Aching, stiffness, crepitus/clicking
Pain behavior: Agg:activity,PM + Rel: Rest
Signs: Swelling, crepitus, reduced ROM, wasting, deformity

Test:
X-Ray: Reduced joint space, subchondral sclerosis,
osteophytic grow, deformity, subchrondral cyst

Reiters/reactive Def: Inflammatory arthritis as a result of an infection elsewhere in
the body.

Age/Sex: 5M:1F, 20-40

Aetiology: Pt gets an infection as GI/STD. 2-6 weeks later abnormal
immunological response will occur. HLA-B27

Pathophysiology:Immune system tries to fight the infection, so
inflammation ensues. Scraps of the bacteria travel to the joints and
triggers arthritis.

Signs and symptoms: pain in the knees when sees and pees
Articular features:
Onset: Rapid
Symptoms: Unilat knee/foot/ankle, pain, LBP
Extraarticular:
Fever
Urethritis
Conjuntivitis
Keratoderma blenhorragieum
Pericarditis

Test: increased ESR, HLA-B27


Psoriatic arthritis Def: Inflammatory joint disease linked with psoriasis

Age/Sex: M:F , 36-46

Aetiology: Stress, trauma, hormonal, infection, genetics (HLA-B27)

Pathophysiology: Inflammation of the synovial membrane

Articular features:
Onset: Insiduous
Symptoms:Unilateral distal joint pain, pitting nails, sausage fingers
Extra-articular features:
Skin lesions esp. scalp
Iritis/Conjunctivitis

Test:
X-Ray: pencil in cup, sacroilitis
Increased ESR + HLA-B27

Enteropathic Def: Inflammatory bowel Disease associated with inflammatory
arthritis

Age/Sex: M:F , 25-55, 1 in 5 pts with chrons disease or UC may get
this

Pathophysiology: Theory 1: AI
Theory 2: Gi inflammation leads to increased
permeability so more bacterial antigens are absorbed which then
lodge in to the MSk causing inflammation

Clinical signs and symptoms:
Peripheral arthritis/enthesitis
Axial arthritis/enthesitis
IBS symptoms too

Test: increased ESR, HLA-B27, barium meal to identify bowel lesions
Gout Def: Inflammatory arthritis of peripheral joint/tendons due to
monosodium urate crystal deposition

Age/sex: M25:F1, 40-60

Aetiology: Hyperuricaemia (raised uric acid in blood)

Pathophysiology: Monosodium urate crystals are high in blood and
so they deposit in the synovium and other connective tissue

Clinical signs and symptoms:
Onset: Sudden onset (acute inflammatory monoarthritis of the 1
st

MTP)

Test: Joint aspiration, increased ESR and CRP
Pseudogout
Bilateral:
RA Def: Chronic systemic inflammatory disease

Age/Sex: 3F:1M, 30-40

Aetiology: genetics (HLA-DR4), environmental (viral, bacterial),AI,
hormonal

Pathophysiology:
Inflammatory reaction in the synovium
Pannus
Effusion distends the capsule and stretches ligaments
Laxity, joint deformity and rheumatoid nodes

Clinical signs and symptoms:


Other conditions c bilateral presentation:
Unilateral:
Neural claudication
Vascular claudication
Billateral:
Peripheral neuropathy
Diabetes