The ankle and foot

The ankle and foot Foot and ankle combine flexibility ( propulsion) with stability(support) structure because consist of a complex of joints, bony structure, ligamentous attachments, and muscle contraction. The flexible rigid characteristics of the ankle foot complex pro!ide multiple functions, including" #. $nkle joint forces up to %.& times body weight to occur while walking. '. (t pro!ides a base of support. ). (t acts as a le!er during push*off period of stance. %. (t pro!ides ade+uate flexibility for absorption of the shock of the body weight and for accommodation to une!en terrain. &. ,rehensile. Structure of the ankle and foot (see figure 1). Bony Parts: (t contains a total of '- bones 1. Leg Tibia and fibula 2. Hindfoot Talus and calcaneus ). Midfoot .a!icular, cuboid, and three cuneiforms . !orefoot Fi!e metatarsals and #% phalanges, which make up the 5 toes () phalanges for each toe except the large toe, which has ' phalanges)

Figure #" /tructure of the ankle and foot "rches of the !oot (see figure 2). They are formed by the structure and arrangement of the bones (tarsus and metatarsus) and maintained by ligaments and tendons the arches are not rigid0 they 1gi!e2 when weight is placed on the foot, and they spring back as the weight is lifted. There are ' types of arches" 3ongitudinal arch" di!ided into medial and lateral parts The medial part originates at the calcaneus, rises at the talus, and descends to the first three metatarsal bones and recei!es weight of the body. The medial arch is supported by the spring ligament. 3ateral part consists of the calcaneus, cuboid, and fourth and fifth metatarsal bones and acting essentially as a space through which tendons canpass. (t is supported by the long and short plantarligaments. Trans!erse $rch 4 side to side conca!ity from anterior tarsal bones (calcaneus, na!icular, and cuboid) to all fi!emetatarsal bones.

Figure '" $rches of the Foot The factors #aintaining the arches of the foot (see figur$).

Figur)" The factors maintaining the arches of the foot. !unctions of the arches: #. /upport the weight of the body in standing. '. $ct as a le!er to propel the body in walking and running. ). 5uring weight bearing, mechanical energy is stored released to assist with push*off of the foot from the surface. Trans#ission of %ody &eight: The structures of the foot are anatomically linked such that the load is e!enly distributed o!er the foot during weight bearing. $pproximately &67 of body weight is distributed through the subtalar joint to the calcaneus, with the remaining &67 transmitted across the

metatarsal heads. The head of the first metatarsal sustains twice the load borne by each of the other metatarsal heads. Tibia is the only true weight* bearing bone in the body. Muscle !unction in the "nkle and !oot (see figuer%)" 8oth the extrinsic muscles (##) and the intrinsic ('') muscles of the foot play a !ital role in the mechanics of the foot. (/ee appendix #).

Figure %" 9uscles Muscle control of the ankle during gait #. The muscles of the anterior compartment (dorsiflexors) actprimarily during swing and early stance phase. This action enables the foot to clear the ground during swing phase and then allows it to be placed gently on the ground after heel strike. '. The posterior, or calf, group acts from midstance to toe*off. ). (n normal standing, the gra!itational line falls anteriorly to the axis of the ankle joint, creating a dorsiflexion moment. The soleus muscle contracts to counter the gra!itational moment through its pull on the tibia. %. The intrinsic muscles of the foot acti!ity in the last half of the stance phase. 'oints The joints of the foot are di!ided into three sections:hindfoot (rearfoot), midfoot, and forefoot (see figure &*-).

Figure &" ankle and foot joints Figure -" ;oints Hindfoot ((earfoot) #. Talocrural ($nkle) ;oint. '. /ubtalar (Talocakanean). Midfoot (9idtarsal ;oints, Trans!erse Tarsal ;oint, <hopart=s amputation) . #. Talocalcaneona!icula r joint. '. <uneocuboid ;oint. ). <uneona!icular ;oints %. <uboideona!icular joint ). <alcaneocuboid ;oint. !ore foot #. Tarsormetatarsal ;oints. '. 9etathrsophafangeat ;oints. ). (nterphalangeal joints. *#+ortant ,oints of the foot: "nkle 'oint (Talocrural): The talocrural joint is a uniaxia (,modified hinge, syno!ial joint) located between the talus, themedial malleolus of

the tibia, and the lateral malleolus of thefibula and the mo!ements possible at this joint are dorsiflexionand plantar flexion. Su%talar (Talocakanean) 'oint: $ gliding multiaxialsyno!ial joint which consists of the talus on top and calcaneuson the bottom. The subtalar joint allows mo!ements about an obli+ue axis, allowing the foot to side to side motion (in!ersion and e!ersion). Trans-erse tarsal ,oint: (t is formed of ' joints that lie sideby*side. These are the talo*na!icular joint (between the headof talus and na!icular), and calcaneo*cuboid joint (between the caleaneus. and cuboid). (t is little to no motion and assists in e!ersion and in!ersion. Locking and unlocking of the ankle ,oint: 5uring dorsiflexion, the wide anterior part of the trochlear surface of the talus is lodged into the narrow posterior part of the superior articular surface (socket). (n this position, the ankle joint is locked as the foot cannot be mo!ed from side to side. 5uring plantar flexion, the narrow posterior part of the trochlear surface is lodged in the wide anterior part of the socket. (n this position, the ankle joint is unlocked as the foot can be mo!edslightly from side to side. $ccordingly, the ankle joint is locked during dorsiflexion and unlocked during plantar flexion. Liga#ents:

Figure >" $nkle 3igaments Figure ?" 3igaments "nkle Liga#ents (see figure ./0) :

3ateral $nkle 3igaments" Talofibular ligaments" from the lateral malleolus of the fibula to connects the talus and support the lateral side of the joint . 5i!ided in" $nterior Talofibular 3igament" (t is pre!ents anterior subluxation of talus when ankle is in plantar flexion. ,osterior Talofibular 3igament" it is pre!ents posterior and rotatory subluxation of the talus. <alcaneofibular" connecting lateral malleolus to calcaneus. (t acts primarily to stabili@e sub*talar joint A limit in!ersion. it is lax in normal, standing position due to relati!e !algus orientation of calcaneus 9edial $nkle 3igaments 5eltoid ligaments" supports the medial side, triangular shaped, apex at tip of medial malleolus,, base at talus, na!icular, calcaneus which has two major components0 * Su+erficial deltoid which resist talar abduction and primarily resists e!ersion of hindfoot. Tibiona!icular portion pre!ents inward displacement of head of talus, while tibiocalcaneal portion pre!ents !algus displacement. * 1ee+ deltoid liga#ent is pre!ents lateral displacement of talus A pre!ents external rotation of the talus and latter effect is pronounced in plantar flexion, when deep deltoid tends to pull talus into internal rotation. Liga#ents of the !oot: /pring ligament" attaches from calcaneus to na!icular. (t is supports longitudinal arch and the head of talus especially in standing. ,lantar aponeurosis" runs from calcaneus to proximal phalanges, ties posterior an anterior sections together and windlass action in ankle, where full dorsflexion is limited by plantar aponeurosis.

Mo-e#ents of the !oot and "nkle #. ,rimary plane motions defined a. /agittal plane motion is dorsflexion and plantarfiexion. b. Frontal plane motion is inversion and eversion . c. Trans!erse plane motion is abduction and adduction. '. Triplanar motions occurring about obli+ue axes defined a. Pronation is a combination of dorsiflexion, e!ersion, and abduction. b. Supination is a combination of plantarfiexion, in!ersion, and adduction. (2M: ,lantar flexion(&&B), 5orsiflexion(#&B), (n!ersion()&B), C!ersion('6B), ,ronation ('6B)and /upination()&B). The ankle and foot during gait: The biomechanics of the foot are best explained by describing what happens to the foot during the stance phase of the gait cycle. Stance +hase: Deel strike The impact of the heel as it contacts the floor, with subse+uent rapid loading of the foot, results in a floor reaction that exceeds the body weight by '6 per cent. The sudden impact is partially absorbed by lowering the body through plantar flexion of the ankle. (t is during this phase that the foot begins to act like a shock absorber. The ankle dorsiflexors function during the initial foot contact to counter the plantarflexion tor+ue and to control the lowering of the foot to the ground. 9idstance

5uring midstance the entire foot is in contact with the ground (ankle is neutral again) and the weight of the body is directly o!er the foot. The !ertical floor reaction is less than the body weight because of the falling <9. The longitudinal arch of the foot is ele!ated and the foot e!erts, with concomitant motion in the subtalar joint due to the e!ersion , pronation and external rotation of the lower limb. $s the body weight shifts forward the foot begins to return to a neutral position in preparation for heel lift. ,ush*off The ankle plantarflexors , supinates and the metatarsal phalangeal joints go into extension begin functioning near the end of mid*stance and during terminal stance and preswing (heel*off to toe*off) to control the rate of forward mo!ement of the tibia and also to plantarfiex the ankle for push* off. 5uring this period the heel rises rapidly with increased ground reaction, up to 3 per cent abo!e body weight. S&ing Phase of 4ait: 9uch of kinetic energy for swinging limb is pro!ided by inertia, which is augmented by the plantarflexors (?&7) and hip flexors (#&7). 5uring swing, the ankle dorsiflexes by the concentric contraction of anterior tibialis muscle and all other muscles are silent. /ub*talar joint assumes near neutral position, and toes dorsiflex slightly as foot prepares for next episode. 5o##on in,uries of the ankle and foot Foot injuries may de!elop from !arious causes, such as congenital malformations of bones, muscular paralysis or spasticity, stresses and strains in weight*bearing. "lign#ent "no#alies of the !oot and "%nor#al foot contact (see figure E)"

#. ,es !arus (<lub foot). '. ,es !algus (,es planus or flat foot). ). ,es e+uines. %. ,es ca!us. &. ,es <alcaneus.

Figure E" $lignment $nomalies of the Foot. *n,uries (elated to High and Lo& "rch Structures: $rches that are higher or lower than the normal range ha!e been found to influence lower extremity kinematics and kinetics, with implications for injury. Digh* arched exhibit increased !ertical loading rate, with related higher incidences of ankle sprains, plantar fascitis, and &B metatarsal stress fractures. 3ow*arched exhibit increased range of motion and

!elocity in rearfoot e!ersion, as well as an increased e!ersion to tibial internal rotation ratio. *n,uries of the Liga#ents "nkle s+rains (see figure #6).

Figure #6" $nkle sprains. *n,uries of the lateral liga#ent $nkle sprains usually occur on the lateral side because the joint capsule and ligaments are stronger on the medial side of the ankle. 9echanism injury of ankle sprain is in!ersion of the supinated , plantarflexed foot . (t usually occurs when the foot rolls o!er on the outside of the ankle. Fhen the ligament is completely torn or detached from the fibula, the talus is free to tilt in the mortice of the tibia and fibula. (f the lateral ligament fails to heal, chronic instability of the ankle results. !ractures &ith 1eloid *n,ury liga#ent (9aisonneu!e fracture)" The medial ligament is immensely strong and if stressed in ankle joint injuries generally a!ulses the medial malleolus rather than itself tearing. .e!ertheless tears do occur, and are seen particularly in conjunction with lateral malleolar fractures. $ mechanism is combination of external rotation at ankle, abduction of hindfoot,A e!ersion of forefoot while the upper body externally rotates o!er the fixed foot.

Paralysis or S+asticity: Ti%ialis Posterior" ,aralysis of tibialis posterior alone causes a plano!algus deformity. /pasticity of Tibialis ,osterior cause dynamic !arus deformities of foot. Ti%ialis "nterior" ,aralysis (polio) results in de!elopment of e+uino!algus deformity this is seen initially during swing phase of gait. Failure to raise the foot sufficiently during the early swing phase causes Toe drag. gastrocne#ius/soleus +araly6ed: The patient cannot rise on tiptoes, and the gait is se!erely affected because inability to increase walking speeds beyond the normal pacing. Dowe!er, despite une!en step lengths, she had uniform forward progression. /he had excessi!e dorsiflexion of the ankle and diminished plantar flexion on the in!ol!ed side . The act of climbing stairs is awkward and slow, and acti!ities such as running and jumping are all but impossible. 2ther soft tissues in,uries: !oot%aller7s ankle: Gepeated incidents of forced plantar flexion of the foot which result in tearing of the anterior capsule of the ankle joint. These may lead to mechanical restriction of dorsiflexion. Peroneal tendon disru+tion (peroneus bre!is tear)" 9echanism of this injury is forced dorsiflexion with slight in!ersion and concomitant eccentric contraction of the peroneal muscles may produce a subluxation or dislocation of the peroneal tendons. "nterior (Taloti%ial) *#+inge#ent Syndro#e: The mechanism of injury is repetiti!e forced dorsiflexion as demiplie position in ballet can lead to impingement of anterior lip of tibia on talar neck.

Posterior (Talotililal8) *#+illge#ent Syndro#e: The mechanism of injury is repetiti!e, forced plantarflexion such as may occur with practicing karate kicks or dancing en pointe. Shortening of the "chilles tendon 9echanisms for tendinitis ha!e been proposed by repeated tension or repeated loading ./hortening results in plantar flexion of the foot and clumsiness of gait as the heel fails to reach the ground ((nsufficient push off). Plantar !asciltis" 9echanism of (njury are o!eruse or repetiti!e stretching of the plantar fascia associated with training errors or associated with incomplete rehabilitation (strengthening) following a pre!ious ankle injure because weak peroneal muscles may inade+uately support the arch. Thus placing additional stress on the plantar fascia. $ll of which reduce the foot=s shockabsorbing capability. !racture: 8oth the end of the fibula (#) and the tibia (') are broken .(f both malleoli are broken, this is called a bimallolar fracture or ,ottHs fracture. Stress !ractures The shafts of the second through the fifth metatarsals are the most common sites of injury. These injuries are perhaps most commonly seen in athletes in!ol!ed in endurance running acti!ities. Pediatric "nkle !ractures The age distribution of was typical" malleolar fractures predominated among the younger children, epiphyseal fractures among the older. 9ost common epiphyseal injury to ankle is distal tibia caused by supination and external rotation. <omplications of this fracture is " #. Irowth ,late $rrest.

'. $ngular 5eformities / !arus or !algus deformity. ). 3eg 3ength 5iscrepancy. $ppendix #"

9uscles of ankle and foot Geferences: #. $dams,;. and Damblen,5.(#EE&).Outline of Orthopaedics. (#' th

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