ANKLE AND FOOT
Dr. Michael P. Gillespie
ANKLE & FOOT
Walking and running require the foot to be both
pliable and rigid.
 It must be pliable to absorb stress and to conform
to various configurations of the ground.
 It must be rigid to withstand large propulsive
forces.

Dr. Michael P. Gillespie
2
MEDIAL ASPECT
MEDIAL TENDONS
POSTERIOR TIBIAL ARTERY, TIBIAL NERVE
LATERAL MALLEOLUS & ATTACHED LIGAMENTS
PERONEUS LONGUS AND PERONEUS BREVIS
TENDONS
ANTERIOR ASPECT
POSTERIOR ASPECT
OSTEOLOGY
Dr. Michael P. Gillespie
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BONES, JOINTS, & REGIONS OF THE
ANKLE
Dr. Michael P. Gillespie
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NAMING THE JOINTS AND REGIONS
The term ankle refers primarily to the talocrural
joint: the articulation among the tibia, fibula,
and talus.
 The term foot refers to all the tarsal bones, and
the joints distal to the ankle.
 Three regions of the foot:

Dr. Michael P. Gillespie
Rearfoot (hindfoot) – talus, calcaneus, and subtalar
joint
 Midfoot – remaining tarsal bones, transverse tarsal
joint, and smaller distal intertarsal joints
 Forefoot – metatarsals, phalanges, and all joints
distal to and including the tarsometatarsal joints.

12
FIBULA
Long and thin
 Lateral and parallel to the tibia
 The shaft transfers only 10% of body weight
through the leg
 Fibular head – lateral to the lateral condyle of
the tibia
 Lateral malleolus – pulley for tendons of the
fibularis (peroneus) longus and brevis.
 Articular facet for the talus

Dr. Michael P. Gillespie
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DISTAL TIBIA
The distal end of the tibia expands to
accommodate loads transferred across the ankle
 Medial malleolus
 Articular facet for the talus
 Fibular notch
 The distal end of the tibia is twisted externally
around the longitudinal axis by about 20 – 30
degrees – lateral tibial torsion

Dr. Michael P. Gillespie
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OSTEOLOGIC FEATURES OF THE
FIBULA AND DISTAL TIBIA

Fibula
Head
 Lateral malleolus
 Articular facet (for the talus)

Distal Tibia
Medial malleolus
 Articular facet (for the talus)
 Fibular notch

Dr. Michael P. Gillespie

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DISTAL END OF THE RIGHT TIBIA,
RIGHT FIBULA, AND TALUS
Dr. Michael P. Gillespie
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TARSAL BONES

Seven tarsal bones




Dr. Michael P. Gillespie

Talus
Calcaneus
Navicular
Medial, intermediate, and lateral cuneiform
Cuboid
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OSTEOLOGIC FEATURES OF THE
TARSAL BONES

Talus
Trochlear surface
 Head
 Neck
 Anterior, middle, and posterior facets
 Talar sulcus
 Lateral and medial tubercles

Dr. Michael P. Gillespie

Calcaneus





Tuberosity
Lateral and medial processes
Anterior, middle, and posterior facets
Calcaneal sulcus
Sustentaculum talus
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OSTEOLOGIC FEATURES OF THE
TARSAL BONES

Navicular
Proximal concave (articular) surface
 Tuberosity

Medial, Intermediate, & Lateral Cuneiforms


Transverse arch
Cuboid

Dr. Michael P. Gillespie

Groove (for the tendon of the fibularis longus)
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SUPERIOR (DORSAL) VIEW OF
RIGHT FOOT
Dr. Michael P. Gillespie
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INFERIOR (PLANTAR) VIEW OF
RIGHT FOOT
Dr. Michael P. Gillespie
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MEDIAL VIEW OF RIGHT FOOT
Dr. Michael P. Gillespie
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LATERAL VIEW OF RIGHT FOOT
Dr. Michael P. Gillespie
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TALUS
Most superiorly located bone of the foot
 Forms part of the talocrural joint
 70% of the talus is covered with articular
cartilage

Dr. Michael P. Gillespie
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SUPERIOR VIEW OF TALUS FLIPPED
LATERALLY
Dr. Michael P. Gillespie
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CALCANEUS
The largest of the tarsal bones
 Accepts the impact of heel striking the ground
during walking
 Calcaneal tuberosity – receives attachment of the
Achilles tendon
 Sustenaculum talus lies under and supports the
middle facet of the talus (shelf for the talus).

Dr. Michael P. Gillespie
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NAVICULAR
Named for its resemblance to a ship
 Proximal surface articulates with the talus
 Distal surface articulates with the three
cuneiform bones

Dr. Michael P. Gillespie
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MEDIAL, INTERMEDIATE, AND
LATERAL CUNEIFORMS
Cuneiform (Latin root meaning “wedge”)
 Spacer between the navicular and bases of the
three medial metatarsal bones
 Contribute to the transverse arch of the foot

Dr. Michael P. Gillespie
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CUBOID
Six surfaces, three of which articulate with
adjacent tarsal bones
 Articulates with 4th and 5th metatarsal bones

Dr. Michael P. Gillespie
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RAYS OF THE FOOT

A ray of the foot is functionally defined as one
metatarsal and its associated set of phalanges
Dr. Michael P. Gillespie
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METATARSALS
Five metatarsal bones link the distal tarsal bones
with the phalanges
 Numbered 1 – 5 starting with the medial side
 Plantar surface of the 1st metatarsal has two
facets for sesamoid bones
 Fifth metatarsal bone has a styloid process for
attachment of the fibularis brevis muscle

Dr. Michael P. Gillespie
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OSTEOLOGIC FEATURES OF A
METATARSAL
Base (with articular facets for articulation with
the bases of adjacent metatarsals)
 Shaft
 Head
 Styloid process (on the fifth metatarsal only)

Dr. Michael P. Gillespie
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PHALANGES
The foot has 14 phalanges
 The first toe, great toe or hallux has two
phalanges

Dr. Michael P. Gillespie
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OSTEOLOGIC FEATURES OF A
PHALANX
Base
 Shaft
 Head

Dr. Michael P. Gillespie
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ARTHROLOGY

Major joints of the ankle
Talocrural
 Subtalar
 Transverse tarsal joints

Dr. Michael P. Gillespie
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JOINTS OF THE ANKLE AND FOOT
Dr. Michael P. Gillespie
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TERMS THAT DESCRIBE MOVEMENTS
AND DEFORMITIES OF THE ANKLE &
FOOT
Axis of
Rotation
Plane of
Motion
Example of
Fixed
Deformity or
Abnormal
Posture
Plantar flexion
Dorsiflexion
Medial-lateral
Sagittal
Pes equinus
Pes calcaneus
Inversion
Eversion
Anterior-posterior
Frontal
Varus
Valgus
Abduction
Adduction
Vertical
Horizontal
Abductus
Adductus
Supination
Pronation
Oblique (varies by
joint)
Varying elements of
inversion, adduction,
and plantar flexion
Varying elements of
eversion, abduction,
and dorsiflexion
Inconsistent
terminology – usually
implies one or more
components of
supination
Inconsistent
terminology – usually
involves one or more
components of
pronation
Dr. Michael P. Gillespie
Motion
37
FUNDAMENTAL MOVEMENT
DEFINITIONS
APPLIED MOVEMENT DEFINITIONS
Dr. Michael P. Gillespie
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STRUCTURE AND FUNCTION OF THE
JOINTS ASSOCIATED WITH THE ANKLE
From an anatomic perspective, the ankle includes
one articulation: the talocrural joint.
 An important structural component of this joint
is the articulation formed between the tibia and
fibula. This articulation is reinforced by the
proximal and distal tibiofibular joints and the
interosseous membrane of the leg.

Dr. Michael P. Gillespie
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PROXIMAL TIBIOFIBULAR JOINT
Located lateral to and immediately inferior to the
knee.
 Synovial joint (diarthrosis)

Dr. Michael P. Gillespie
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DISTAL TIBIOFIBULAR JOINT
The articulation between the medial surface of
the distal fibula and the fibular notch of the tibia.
 Syndesmosis
 Interosseus ligament is an extension of the
interosseus membrane and forms the strongest
bond between these bones.

Dr. Michael P. Gillespie
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ANTERIOR-LATERAL VIEW RIGHT
DISTAL TIBIOFIBULAR JOINT
Dr. Michael P. Gillespie
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POSTERIOR VIEW RIGHT ANKLE
Dr. Michael P. Gillespie
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TALOCRURAL JOINT
The articulation of the trochlea (dome) and the
sides of the talus with the cavity formed from the
distal end of the tibia and both malleoli.
 Called the mortise joint due to its resemblance to
the wood joint used by carpenters.
 90 – 95% of the forces pass through the talus and
tibia. 5 – 10% pass through the talus and fibula.

Dr. Michael P. Gillespie
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LIGAMENTS OF THE DISTAL
TIBIOFIBULAR JOINT
Interosseous ligament
 Anterior tibiofibular ligament
 Posterior tibiofibular ligament

Dr. Michael P. Gillespie
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LIGAMENTS
A thin capsule surrounds the talocrural joint.
 Reinforced by collateral ligaments.
 Medial collateral (deltoid) ligament – broad and
expansive
 Lateral collateral ligament

Dr. Michael P. Gillespie
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DISTAL ATTACHMENTS OF THE THREE
SUPERFICIAL SETS OF FIBERS WITHIN THE
DELTOID LIGAMENT
Tibionavicular fibers attach to the navicular,
near its tuberosity.
 Tibiocalcaneal fibers attach to the sustentaculum
talus.
 Tibiotalar fibers attach to the medial tubercle
and adjacent part of the talus.

Dr. Michael P. Gillespie
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MEDIAL COLLATERAL (DELTOID)
LIGAMENT
Dr. Michael P. Gillespie
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THREE MAJOR LIGAMENTS OF THE LATERAL
COLLATERAL LIGAMENTS OF THE ANKLE
Anterior talofibular ligament
 Calcaneofibular ligament
 Posterior talofibular ligament

Dr. Michael P. Gillespie
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LATERAL COLLATERAL LIGAMENTS
Dr. Michael P. Gillespie
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MOVEMENTS THAT STRETCH AND
ELONGATE THE MAJOR LIGAMENTS OF THE
ANKLE
Crossed Joints
Movements That
Stretch or Elongate
Ligaments
Deltoid Ligament
(Tibiotalar fibers)
Talocrural Joint
Eversion, dorsiflexion
with associated
posterior slide of
talus
Deltoid ligament
Talocrural joint
(tibionavicular fibers) Talonavicular joint
Eversion, plantar
flexion with
associated anterior
slide of talus
Deltoid ligament
Talocrural joint and
(tibiocalcaneal fibers) subtalar joint
Eversion
Dr. Michael P. Gillespie
Ligaments
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MOVEMENTS THAT STRETCH AND
ELONGATE THE MAJOR LIGAMENTS OF THE
ANKLE
Crossed Joints
Movements That
Stretch or Elongate
Ligaments
Anterior talofibular
ligament
Talocrural joint
Plantar flexion with
associated anterior
slide of the talus
Calcaneofibular
ligament
Talocrural joint
Subtalar joint
Dorsiflexion with
associated posterior
slide of the talus
Posterior talofibular
ligament
Talocrural joint
Dorsiflexion with
associated posterior
slide of the talus
Dr. Michael P. Gillespie
Ligaments
52
LIGAMENTOUS INSTABILITY

Ligaments

Anterior and posterior talofibular, anterior tibiofibular, and
deltoid ligaments.
If any of these ligaments are torn, the tibia can separate
from the fibula and the talus may become unstable.
 Common mechanism of injury is a supination or
inversion force.

LIGAMENTOUS INSTABILITY
The foot turns under the ankle after walking or running
on uneven surfaces or when landing on an inverted foot
after a jump.
 The most common injured ligament is the anterior
talofibular ligament.
 Ligament laxity can lead to chronic ankle sprains.

LIGAMENTOUS INSTABILITY

Clinical Signs and Symptoms
Ankle swelling
 Static ankle pain
 Pain on passive motion
 Tenderness over affected ligament

LIGAMENTS
Drawer’s Foot Sign
Procedure: Patient supine. Stabilize ankle with one
hand. Press posterior on tibia with the other hand. Next,
grasp anterior aspect of the foot with one hand and the
posterior aspect of the tibia with the other. Pull anterior.
 Rationale:

Gapping with posterior push – tear anterior talofibular
 Gapping with anterior pull – tear posterior talofibular

Drawer’s Foot Sign
Drawer’s Foot Sign
LATERAL STABILITY
Procedure: Patient supine. Passively invert foot.
 Rationale: Gapping secondary to trauma. Suspect tear of
anterior talofibular ligament or calcaneofibular ligament.

LATERAL STABILITY
LATERAL STABILITY
MEDIAL STABILITY
Procedure: Patient supine. Passively evert foot.
 Rationale: Gapping secondary to trauma. Suspect tear of
deltoid ligament.

MEDIAL STABILITY
MEDIAL STABILITY
SUPERIOR VIEW RIGHT
TALOCRURAL JOINT
Dr. Michael P. Gillespie
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THE AXIS OF ROTATION AND
OSTEOKINEMATICS TALOCRURAL
JOINT
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NEUTRAL
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DORSIFLEXION
Dr. Michael P. Gillespie
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PLANTAR FLEXION
Dr. Michael P. Gillespie
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ARTHROKINEMATICS TALOCRURAL
JOINT
Dr. Michael P. Gillespie
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ROM TALOCRURAL JOINT DURING
GAIT
Dr. Michael P. Gillespie
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FACTORS THAT INCREASE THE MECHANICAL
STABILITY OF DORSIFLEXED TALOCRURAL
JOINT
Dr. Michael P. Gillespie
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SUBTALAR JOINT
Resides under the talus
 Grasp the unloaded calcaneus and twist it from
side to side and rotary fashion
 Pronation and supination occur at this joint
 During walking the talus moves over a relatively
fixed calcaneus

Dr. Michael P. Gillespie
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AXIS OF ROTATION AND OSTEOKINEMATICS
AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
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AXIS OF ROTATION AND OSTEOKINEMATICS
AT THE SUBTALAR JOINT
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AXIS OF ROTATION AND OSTEOKINEMATICS
AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
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AXIS OF ROTATION AND OSTEOKINEMATICS
AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
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BONES & JOINTS OF THE RIGHT
FOOT
Dr. Michael P. Gillespie
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TRANSVERSE TARSAL JOINT
(TALONAVICULAR AND CALCANEOCUBOID
JOINTS)
The transverse tarsal joint, also known as the
midtarsal joint, consists of two anatomically
distinct articulations: the talonavicular joint and
the calcaneocuboid joint.
 These joints connect the rearfoot and midfoot.
 Pronation and supination occurs at this joint to a
great extent.

Dr. Michael P. Gillespie
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TRANSVERSE TARSAL JOINT
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PLANTAR ASPECT RIGHT FOOT
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AXES OF ROTATION &
OSTEOKINEMATICS TRANSVERSE
TARSAL JOINT
Dr. Michael P. Gillespie
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AXES OF ROTATION &
OSTEOKINEMATICS TRANSVERSE
TARSAL JOINT
Dr. Michael P. Gillespie
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MEDIAL LONGITUDINAL ARCH OF
THE FOOT
This arch is evident as the “instep” of the medial
side of the foot.
 This arch is the primary load bearing and shock
absorbing structure of the foot.
 The bones that form the arch are the calcaneus,
talus, navicular, cuneiforms, and associated three
medial metatarsals.
 Additional supports include plantar fat pads,
plantar fascia, and sesamoid bones.

Dr. Michael P. Gillespie
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MEDIAL LONGITUDINAL ARCH
Dr. Michael P. Gillespie
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ACCEPTING BODY WEIGHT DURING
STANDING
Dr. Michael P. Gillespie
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PES PLANUS – “ABNORMALLY
DROPPED” MEDIAL LONGITUDINAL
ARCH
Pes planus or “flatfoot” describes a chronically
dropped or abnormally low medial longitudinal
arch.
 Often results from joint laxity and an
overstretched or weak plantar fascia.
 Flexible ples planus appears normal when
unloaded, but drops when loaded.

Dr. Michael P. Gillespie
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PES CAVUS – ABNORMALLY RAISED
MEDIAL LONGITUDINAL ARCH
Dr. Michael P. Gillespie
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CHANGE IN HEIGHT IN THE
MEDIAL LONGITUDINAL ARCH
Dr. Michael P. Gillespie
90
ACTIONS ASSOCIATED WITH EXAGERRATED
PRONATION OF THE SUBTALAR JOINT
DURING WEIGHT BEARING
Action
Hip
Internal rotation, flexion, and
adduction
Knee
Increased valgus stress
Rearfoot
Pronation (eversion) with a
lowering of medial longitudinal
arch
Midfoot and Forefoot
Supination (inversion)
Dr. Michael P. Gillespie
Joint of Region
91
OSTEOKINEMATICS OF FIRST
TARSOMETATARSAL JOINT
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METATARSOPHALANGEAL JOINT
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HALLUX VALGUS
Dr. Michael P. Gillespie
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COMMON FIBULAR (PERONEAL)
NERVE
Dr. Michael P. Gillespie
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TIBIAL NERVE
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TARSAL TUNNEL SYNDROME
Tarsal tunnel syndrome occurs when the posterior tibial
nerve becomes entrapped in its tunnel as it passes behind
the medial malleolus to enter the foot.
 The tunnel can be compressed either intrinsically or
extrinsically.
 Space-occupying lesions account for 50% of the cases.

TARSAL TUNNEL SYNDROME
Direct trauma and repetitive dorsiflexion account for a
significant portion of the remaining cases.
 A severe flat foot can unduly stretch the posterior tibial
nerve.
 Other possible causes include: fracture callus, ganglion of
the tendon sheath, lipoma, engorged venus plexus, and
excessive pronation of the hind foot.

TARSAL TUNNEL SYNDROME

Clinical Signs and Symptoms
Intermittent paresthesia of plantar aspect of foot
 Pain on foot inversion and / or eversion of the foot
 Pain radiating to posterior / medial aspect of the leg
 Pain made worse by activity and improved by rest

TARSAL TUNNEL
Tinel’s Foot Sign
Procedure: Tap over the posterior tibial nerve with a
neurological reflex hammer.
 Rationale: Paresthesias radiating to the foot indicate
irritation of the posterior tibial nerve that may be caused
by constriction at the tarsal tunnel.

Tinel’s Foot Sign
ACHILLES TENDON RUPTURE
Achilles tendon rupture generally occurs in adults aged 30
to 50.
 It is usually spontaneous in athletes who account for most
of these injuries.
 Decreased vascularity of the Achilles tendon as the patient
ages may contribute.

ACHILLES TENDON RUPTURE
Mechanism of injury - forced dorsiflexion of the foot as
the soleus and gastrocnemius contract.
 Rupture occurs 2 to 6 cm from the insertion of the
Achilles tendon into the calcaneus.
 As the proximal aspect of the tendon retracts, there is
usually a palpable defect of the tendon.

ACHILLES TENDON RUPTURE

Clinical Signs and Symptoms
Severe posterior ankle pain
 Inability to stand on toes
 Posterior leg and heel swelling
 Posterior leg and heel ecchymosis

Thompson’s Test
Procedure: Patient prone. Flex knee. Squeeze the calf
muscles against the tibia and fibula.
 Rationale: The the gastrocnemius and soleus are
squeezed, they mechanically contract. They are attached
to the Achilles tendon, which plantar-flexes the foot. If
the tendon is ruptured, contraction of the gastrocnemius
and soleus muscles will NOT plantar-flex the foot.

Thompson’s Test
ACTIONS ACROSS TALOCRURAL
AND SUBTALAR JOINTS
Dr. Michael P. Gillespie
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MUSCLES OF THE ANTERIOR COMPARTMENT
OF THE LEG (PRETIBIAL “DORSIFLEXORS”)

Muscles
Tibialis anterior
 Externsor digitorum longus
 Extensor hallucis longus
 Fibularis tertius

Innervation

Deep branch of the fibular nerve
Dr. Michael P. Gillespie

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PRETIBIAL MUSCLES
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LATERAL COMPARTMENT MUSCLES
Dr. Michael P. Gillespie
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LATERAL COMPARTMENT OF THE
LEG (“EVERTORS”)

Muscles
Fibularis longus
 Fibularis brevis

Innervation

Superficial branch of the fibular nerve
Dr. Michael P. Gillespie

112
MUSCLES OF THE POSTERIOR
COMPARTMENT OF THE LEG

Superficial Group (“Plantar Flexors”)
Gastrocnemius
 Soleus
 Plantaris

Deep Group (“Invertors”)
Tibialis posterior
 Flexor digitorum longus
 Flexor hallucis longus


Dr. Michael P. Gillespie

Innervation

Tibial nerve
113
POSTERIOR COMPARTMENT
MUSCLES: SUPERFICIAL
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POSTERIOR COMPARTMENT
MUSCLES: DEEP
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NERVE INJURY AND RESULTING
DEFORMITIES OR ABNORMAL
POSTURES
Deformity or
Abnormal
Posture
Common Clinical
Name
Deep branch of fibular
nerve / paralysis
pretibial muscles
Plantar flexion of
talocrural joint
Drop-foot or pes equinus
Superficial branch
fibular nerve / paralysis
of fibularis longus and
brevis
Inversion of the foot
Pes varus
Common fibular nerve /
paralysis of all
dorsiflexor and evertor
muscles
Plantar flexion of the
talocrural joint and
inversion of the foot
Pes equinovarus
Dr. Michael P. Gillespie
Nerve Injury /
Associated
Paralysis
116
NERVE INJURY AND RESULTING
DEFORMITIES OR ABNORMAL
POSTURES
Deformity or
Abnormal
Posture
Common Clinical
Name
Proximal portion of tibial
nerve / paralysis of all
plantar flexor and
supinator muscles
Dorsiflexion of the
talocrural joint and
eversion of the foot
Pes calcaneovalgus
Middle portion of the
tibial nerve / paralysis of
supinator muscles
Eversion of the foot
Pes valgus
Medial and lateral
plantar nerves
Hyperextension of the
metatarsalphalangeal
joints and flexion of
the interphalnageal
joints
Clawing of the toes
Dr. Michael P. Gillespie
Nerve Injury /
Associated
Paralysis
117
PROPRIOCEPTIVE TRAINING