1

functional anatomy of the

foot and ankle

2
functional anatomy of the
foot and ankle
Edward P. Mulligan, MS, PT, SCS, ATC
VP, National Director of Clinical Education HealthSouth Corporation
Clinical Instructor UT Southwestern Physical Therapy Department
Grapevine, TX

The contents of this presentation are copyrighted 2002 by continuing ED.

They may not be utilized, reproduced, stored, or transmitted in any form or by
any means, electronic or mechanical, or by any information storage or retrieval
system, without permission in writing from Edward P. Mulligan.
3
Objectives
Following completion of this study, the participant will be able to:
identify the bony anatomy of the leg, foot, and ankle
identify the axis of motion and accessory motions of the
joints of the leg, foot, and ankle
identify the ligamentous, vascular, and nervous anatomy
of the leg, foot, and ankle
identify the muscular anatomy of the leg, foot, and
ankle
explain the muscular function of the leg, foot,
and ankle during gait
palpate the bony and soft tissue structures
of the leg, foot, and ankle

4
leg anatomy
Tibia
triangular shape with medial, lateral and
posterior surfaces
interosseus membrane connects the tibia
to the fibula
distally, articulates with the talus

anterior view
This is an anterior view
Distinct medial, lateral, and posterior surfaces with anterior tibial
crest representing the apex of the triangle
Strong, tough, interosseus membrane connects the tibia to the fibula
distally, the tibia articulates with the talus
5
leg anatomy
Fibula
long, thin bone located posterolateral to
the tibia
little weight bearing function; mainly for
muscle attachment
distally, the medial surface articulates with
the tibia and talus

posterior view
This is a posterior view:
Fibula is a long, thin bone positioned at about a 45 degree angle
posterolateral to the tibia
little weight bearing function; mainly for muscle attachment
distally, the medial surface articulates with the tibia and talus
6
foot anatomy

C
T
N
C1
Cu
C
C2 C3
Metatarsals
Phalanges
forefoot
midfoot
rearfoot
Superior
(dorsal)
Antetior
(distal)
Posterior
(proximal)
Inferior
(plantar)
Directional terminology
Superior = dorsal
Inferior = plantar
Posterior = proximal
Anterior = distal
The foot can be divided into three sections
Rearfoot = hindfoot
Midfoot
Forefoot
7
foot-ankle articulations
C = Calcaneus C1-2-3 = Cuneiforms
T = Talus Cu = Cuboid
N = Navicular Mt = Metatarsal

C
1
C3-2-1
Cu
N
T
5
4
3 2
Talocrural (ankle) joint
Talonavicular (midtarsal) joint
Tarsometatarsal joint
1
st
Metatarsophalangeal joint
Talocalcaneal (subtalar) joint
T
C
N
C1
1
st
Mt
1
st
PP
Talocrural (ankle) joint
Talocalcaneal (subtalar) joint
Talonavicular (midtarsal) joint calcaneocuboid joint not pictured
but is on the lateral side of the jont
Tarsometatarsal (LisFranc) joint - Cuneiforms articulate with mets 1-
3 and cuboid articulates with mets 4-5
1
st
metatarsophalangeal joint
Sustaniculum tali on medial calcaneus and is origin of
calcaneonavicular (spring ligament)
8

Lateral pillar Medial pillar

F F
C C
T T
Mt Mt
Cu Cu
TB TB
C C
N N
Mt Mt
MC MC
T T
Feiss Line
F Fibula
T Talus
Cu Cuboid
C Calcaneus
Mt Metatarsal
TB Tibia
N Navicular
MC Medial Cuneiform
Navicular Tuberosity should lie on the line that connects the medial
malleolus and medial 1
st
metatarsal head in both WBing and NWBing
postures. This line is called the Feiss line
Note that the lateral longitudinal arch is lower than the medial
longitudinal arch
9
tibiofibular joint
Superior
plane synovial joint
fibular head articulating with posterolateral
aspect of tibial condyle

Inferior
syndesmosis with fibroadipose tissue
connecting tibia and fibula
reinforced by anterior and posterior
tibiofibular ligaments
While geographically closer to the knee, the tibfib joint is functionally
associated with the foot and ankle
Interosseous membrane binds tibia an fibula together and is the
origin for many of the muscles that effect the foot and ankle
10
tibiofibular accessory motions
Plantarflexion
fibula slides caudally and lateral malleolus rotates
medially causing approximation of TCJ

Dorsiflexion
fibula slides cephalically and lateral malleolus rotates
laterally to spread the mortise and accommodate
the wider portion of the anterior talus
Accessory motions are defined as involuntary arthrokinematic spin,
glide, or roll at the joint surfaces that must accompany full, pain-free
osteokinematic motion.
Clinically, lack of dorsiflexion range may be partially associated with
tibiofibular hypomobility
11
tibiofibular accessory motions
Supination
fibula slides distally and posteriorly

Pronation
fibula slides proximally and anteriorly
Distal tibfib accessory motions
Supination fibula slides distally and posteriorly with external
rotation of the lower leg
Pronation fibula slides proximally and anteriorly with internal
rotation of the lower leg
12
Part 2 Talocrural Joint

13
talocrural joint
synovial mortise joint
concave tibial plafond and
convex talar dome

supported by:
Anterior talofibular ligaments
Posterior talofibular ligaments
Calcaneofibular ligament
Deltoid ligament
Referred to as a mortise joint because of its resemblance to a wood
joint used by carpenters
14
talocrural joint ligaments
lateral view

anterior tibiofibular
anterior talofibular
calcaneofibular
1
2
3
1 - Ant TibFib ligament injured in high ankle sprain. The
mechanism of injury is typically a rotational injury when tibia IR and
foot abducts. Evaluated by Kleiger test
2 - ATFL lies in the hollow depression just superior to EHB (called the
sinus tarsi) and resists anterior anterior talar translation when
plantarflexed; resists calcaneal inversion when ankle is plantarflexed
2 - ATF is most commonly injured ankle ligament and evaluated by
the anterior drawer test
3 - CFL is typically about 100 degrees inferior and resists calcaneal
inversion with the ankle dorsiflexed
15
talocrural joint ligaments
posterior view

posterior talofibular
posterior tibiofibular
Posterolateral lignaments are rarely injured
16
talocrural joint ligaments
medial view

Fan shaped medial

deltoid ligament
Anterior tibiotalar
Tibionavicular
Tibiocalcaneal
Posterior tibiotalar
Delotid resists ankle eversion and is typically injured with a
hyperpronation mechanism (calcaneal eversion)
Medial sprains are unusual because the lateral malleolous provides a
bony block to extreme eversion and the strength of the deltoid
ligament
17
talocrural joint axis
posterolateral inferior to anteromedial superior

approximately 10-15
off the frontal and
transverse plane
TRIPLANAR MOTION
PF Add Inv
DF Abd - Ever
Posterior View: axis is lateral and inferior to medial superior
Dorsal view: axis is posteior to anterior
Motion always occurs perfectly perpendicular to the axis
Sagittal plane plantar-dorsiflexion are primary motions because the
axis is nearly parallel to both the frontal and transverse planes
18

Inversion-eversion
Abduction - Adduction
PLANTAR-DORSIFLEXION
Texas
NJ
talocrural joint motion analogy
Arkansas
Sagittal plane plantar-dorsiflexion are primary motions because the
axis is nearly parallel to both the frontal and transverse planes
A lot (Texas size) of PF-DF motion
Some (Arkansas size) Ab-Add motion
A little (New Jersey size) Inv-Eversion motion
19
fluoroscopic talocrural
sagittal plane motion

Fluoroscopic motion movie clip of the talocrural joint

available for download
Sagittal plane plantar-dorsiflexion on talocrural joint
axis
PLANTAR-DORSIFLEXION
Abduction-Adduction
Inversion-Eversion
20
talocrural joint range of motion
20-0-50 sagittal plane plantar-dorsiflexion

AAOS standard 20-0-50 degrees

20 degrees dorsiflexion is with knee flexed to put gastroc on slack
21
talocrural joint
Resting Position
slight plantarflexion
10-15
Closed Pack Position
maximal dorsiflexion

Resting position ligaments on slack; maximal joint space; treatment

position
Closed Pack Position ligaments taught; talus engaged in mortise;
dynamically stable; testing position
Talus wider anteriorly than posteriorly and fully engages the mortise
in extreme dorsiflexion
22
talocrural accessory motion
anterior talar glide with plantarflexion
dorsiflexion

plantarflexion
posterior talar glide with dorsiflexion
Talus moves in NWB convex talus glides and rolls in opposite
directions
ConcaveTibia moves in WB - anterior with dorsiflexion
- posterior with dorsiflexion
23
Part 3 Subtalar Joint

24
subtalar joint
talocalcaneal synovial
articulation with uniaxial
oblique hinge
couples function of foot with
rest of kinetic chain
talus has no muscular
attachments

ER-
supination
IR-
pronation
Talus articulates with three facets on the calcaneus
Smaller, relatively flat anterior and middle facets and the larger,
concave talar posterior facet
Stand up and rotate feel the subtalar motion that accompanies
lower extremity rotation
25
subtalar joint ligaments
Interosseus
talocalcaneal ligament
Posterior
talocalcaneal ligament
Lateral
talocalcaneal ligament

Exploded View
26
subtalar joint axis orientation
16 off the sagittal plane
42off the frontal plane

42
16
To understand subtalar joint motion you must define the axis about
which motion will take place
Average of 16 degrees medial to sagittal plane and up 42 degrees
from the frontal plane
Frontal plane orientation varies from 20-60 degrees
27
subtalar joint axis of motion
Axis runs from
dorsal-medial-distal
to
plantar-lateral-proximal

PLP
DMD
Same orientation as TCJ anteromedial superior to posterolateral
inferior; only in different proportions
Dorsal (superior) Medial Distal (anterior)
Plantar (inferior Lateral Proximal (posterior)
Primary motion is frontal plane inversion-eversion
28

INVERSION-EVERSION
Abduction-Adduction
plantar-dorsiflexion
Texas
Arkansas
NJ
subtalar joint motion analogy
A lot of (Texas size) Inverison-Eversion
Some (Arkansas size) Ab-Adduction
Little (New Jersey size) pf-df because axis is so close to sagittal plane
29
subtalar joint motion
approximate one to one relationship with calcaneal
inversion/eversion and tibial internal-external rotation
With low level of inclination
increased calcaneal mobility

With high level of inclination

decreased calcaneal mobility
Clinical Consideration:
If the STJ axis is at the typical 40-45 pitch then there is appoximatley
a one-to-one relationship between calcaneal inversion-eversion and
tibial internal-external rotation
Meaning that for every degree of IR there is one degree of calcaneal
eversion as a component of STJ pronation
As the axis moves toward the transverse plane Lower Level
greater risk for hypermobility, overuse injures tendinitis, fasciitis; pf
syndrom
As the axis moves more parallel to the long axis of the tibia - High
level greater risk for hypombobility injuries poor shock absorption
and prxomail injuries stress fractures; LBP
30
STJ range of motion
20 0 10
at least 8-12 of supination and 4-6
of pronation required for normal gait

20
inv
10
ever
Inversion Eversion
20-0-10 degree is normal STJ motion
at least 8-12 of supination and 4-6 of pronation required for
normal gait
Rule of 1/3rds
Podiatrists use this mathematical model to determine STJN position.
1. Determine the total STJ ROM and divide by 3
2. Move this amount from end range eversion to locate the STJ
neutral position
3. Example: 6 eversion + 30 = 36 of total motion/3 = 12
4. 6 eversion - 12 = 6 inverted as STJ neutral
Works well as an average of the entire population but lacks
individual validity. Subsequently, recommend palpaltion method
for determining individual STJ neutral position.
31
subtalar joint
Closed Pack Position
full supination
Open Pack Position
subtalar joint neutral

Full supination offers maximaly stability as during propulsion

STJ neutral provides maximal mobility as at heel strike into forefootl
loading where terrain adaptation must occur
STJ neutral - 1/3 of the distance from full eversion of total STJ range
32
subtalar joint accessory motions
convex portion of calcaneus
slides laterally with
inversion

INV
EVER
convex portion of calcaneus
slides medially with
eversion
Convex posterior facet on calcaneus is up to 70% of the surface area
of the STJ) articulation
33
Part 4 Midtarsal Joints

34
midtarsal joint
(transverse tarsal joint)
two joints functioning together
(talonavicular and calcaneocuboid
articulations) about two common axes
of motion (longitudinal and oblique)

ligamentous support from calcaneo-

navicular (spring), deltoid, dorsal
talonavicular, and calcaneocuboid
ligaments (long and short plantar)
ligaments
Also called Choparts (sho-par) Joint after the French surgeon who
first described an amputation at this level of the foot
35
calcaneonavicular ligament
Spring Ligament

Spring ligament runs from the sustanaculum tali to the navicular

tuberosity and supports medial longitudinal arch by cradling or
supporting the talus and navicular
36
dorsal-plantar ligamentous support
Long and short
plantar ligaments
Dorsal talonavicular
ligament

Superior View Inferior View

Long calcanenus to base of lateral metatarsals
Short - calcaneocuobid
37
plantar fascia
Dense multilayered fibrous
connective tissue
Originates at the medial
calcaneal tuberosity
Inserts into the plantar plates of
the MTP joints and bases of the
proximal phalanges

Dense multilayered fibrous connective tissue

Originates at the medial calcaneal tuberosity
Inserts into the plantar plates of the MTP joints and bases of the
proximal phalanges
Provides truss support and assists with propulsion through windlass
mechanism in the late stance phase of gait.
38
midtarsal joint oblique axis of motion
Equally angulated from
transverse and sagittal planes
allowing coupled motions of
plantarflexion-adduction and
dorsiflexion-abduction
52 off transverse plane and
57 off sagittal plane

52
57
Ab-Adduction of foot occurs on the 52 degree axis
Plantar-dorsiflexion of mid-foot occurs on the 57 degree axis
39
midtarsal joint longitudinal axis of motion
15 off transverse plane
and 9 off sagittal plane
Parallel to the
transverse and sagittal
planes allowing only
frontal plane motion of
inversion and eversion

15
9
Inversion-Eversion motion of mid-foot occurs on the longitudinal axis
40
midtarsal joint motion vs. position
No clinically reliable method of quantifying the amount of
midtarsal ROM. Midtarsal joint motion is dictated by the
position of the subtalar joint.

The position of the midtarsal joint is

dictated by ground reaction forces and
muscular forces, motion of the joint is
determined by the position of the
subtalar joint.
Rhetorical question How do you measure midtarsal joint motion?
obviously we cant
We tend to subjectively qualify mobility instead of trying to quantify
the amount of angular motion at the midtarsal joints
41
midtarsal joint axes relationship
When the STJ is pronated
the two axes of the MTJ
diverge (become more
parallel and allow motion)
When the axes converge
during supination, the MTJ
locks, allowing little motion

Roots and Weeds classic explanation of how midtarsal joint axes

relationship can be both a flexible adaptor to terrain and a rigid lever
for propulsion
42
midtarsal joint locking
Root and Weeds contention of converging axis
may be challenged by the fact that:
talonavicular joint is a ball and socket joint
with an infinite number of axes
consequently, at any one time an axis is
both parallel and askew to the
calcaneocuboid joint

If both parallel and askwed simultaneously, the axes can never

converge or diverge
43
midtarsal joint locking
Anterior facet of the talus articulates
with the cuboid in supination
talus acts as a bony block to cuboid
motion
Glasser, 1999

Anterior facet of the talus articulates with the cuboid in supination as

evidenced by presence of hyaline cartilage at the talocuboid interface
talus acts as a bony block to cuboid motion when the STJ is supinated
Clinically, it is simply important to assess if midtarsal mobility is
increased with pronation and decreased (stiffened) with supination
44
midtarsal joint
Closed Pack Position
Subtalar joint supination
Resting Position
Subtalar joint neutral

Rember that motion availability is dependent upon the position of the

STJ
45
midtarsal joint accessory motion
SUPINATION
dorsal glide of the navicular on the talus

PRONATION
plantar glide of the navicular on the talus
supination
pronation
Functionally, supination is assisted by posterior tib pulling the
navicular up and by the peroneals pulling the navicular down with
the eversion component of STJ pronation
46
Part 5 First Ray - 1
st
MTP Joint

47
first ray
functional articulation consisting of the
1
st
metatarsal, medial cuneiform, and
navicular

axis angulated 45 from the frontal

and sagittal planes and parallel to
transverse plane
distal-lateral to proximal-medial
DL
PM
Scapulohumeral analogy like the scapula gliding across the thorax,
the first ray is not a typical diarthrodial joint but has important
functional contribution
Distal lateral (instead of distal-medial) to Proximal medial
(instead of proximal-lateral)
48
first ray motion
coupled motion of

dorsiflexion and inversion

plantarflexion and eversion
49
PRONATION
medial longitudinal arch lowers
increased 1
st
ray mobility
peroneus longus important stabilizer
Subtalar Joint Effect on 1st Ray

SUPINATION
medial longitudinal arch elevation
increased 1st ray stability
50
1
st
ray accessory motion
1st ray motion of plantar-dorsiflexion is
influenced by the subtalar joints position
1st ray motion is increased with
pronation and decreased with
supination

Normal mobility is .5 to 1 cm
(thumb's width) in plantar and
dorsal directions
Method by which to determine mobility of first ray (hypo or hyper)
51
1
st
metatarsophalangeal joint
articulation between 1st metatarsal
and the
1
st
proximal phalanx
sesamoids articulate with plantar
metatarsal head

52
1
st
MTP joint axis of motion
horizontal axis allowing sagittal
plane motion of plantar-dorsiflexion
vertical axis allowing abduction-
adduction

20-30 with 1st ray stabilized

60-70 when 1st ray allowed
to plantarflex
horizontal (medial to lateral) axis allowing the sagittal plane motion
of plantar-dorsiflexion
vertical (superior to inferior) axis allowing abduction-adduction
20-30 with 1st ray stabilized
60-70 when 1st ray allowed to plantarflex
Common to have less 1
st
MTP dorsiflexion range implications to
many pathologies.
53
1
st
MTP joint
Closed Pack Position
full dorsiflexion

Resting Position
slight plantarflexion
54
1
st
MTP joint accessory motion
PLANTARFLEXION
Plantar glide of proximal phalanx

DORSIFLEXION (extension)
Dorsal glide of proximal phalanx
PF plantar glide of proximal phalanx or dorsal glide of metatarsal
DF dorsal glide of proximal phalanx or plantar glide of metatarsal
55
Bony palpation landmarks
1st Met Head
1
st
Metatarsal
1st Cunieform
2nd Cuneiform
3rd Cuneiform
Navicular Tuberosity
Talar Head
Medial Malleolus
Sustentaculum Tali
Calcaneus
5th Metatarsal
Styloid Process
Cuboid
Sinus Tarsi
Talar Dome
Calcaneus
Lat. Malleolus
Medial Calcaneal Tuberosity

1st Met Head bunions, gout, sesamoids

First Metatarsal
Medial Cunieform articulates with 1st met
2nd Cuneiform articulates with 2nd met
3rd Cuneiform articulates with 3rd met
Navicular Tuberosity landmark of feiss line
Talar Head palpated for STJ neutral (no muscle attachments) more prominent
with pronation
Sustentaculum Tali large medial extension of calcaneus; fingers width below
medial malleolus; origin of spring ligament
Medial Malleolus -
Calcaenus
5th Metatarsal
Styloid Process at Base of 5th insertion of peroneus brevis
Cuboid notch for peroneus longus
Sinus Tarsi EHB origin; area of ATF ligament
Calcaneus
Lateral Malleolus
Tibiofibular Synostosis
Talar Dome can palpate anterior talus in the sinus tarsi with
plantarflexion/inversion
Medial Calcaneal Tuberosity origin of plantar fascia
Met Heads
56
Lower Leg Muscles

57
muscular anatomy

58
anterior compartment
Muscles
TA, EHL, ED, PT
General Function
Ankle df; toe extension
Innervation
Deep peroneal nerve
L4,5 S1
Blood Supply
Anterior Tibial Artery

59
PT
AT
EHL
EDL
anterior compartment muscle function
Ever Lat Dorsiflex PT
Lat
Med
STJ
Axis
Ever Extend ED
Extend EHL
Inv Dorsiflex
Anterior
AT
TCJ
Axis
Mm
STJ Axis
TCJ Axis

x-section of left lower leg

medial
lateral
anterior
posterior
60
Anterior Tibialis
Origin
lateral tibial condyle; proximal 2/3 of anterolateral
surface of tibia; interosseous membrane
Insertion
medial & plantar surface of base of 1st metatarsal
medial & plantar surface of the cuneiform
Action
strongest dorsiflexor; inverts & adducts the foot

Origin is on the laterallateral tibial condyle; upper 2/3 of anterolateral

surface of tibia; interosseous membrane
Anterior tib wraps around the foot to insert on the medial & plantar
surface of base of 1st metatarsal and medial cuneiform
Anterior tibi is the strongest dorsiflexor; inverts & adducts the foot
61
Extensor Hallicus Longus
Origin
middle half of anterior shaft of fibula;
interosseous membrane
Insertion
dorsal surface of base of proximal and
distal phalanx of hallux
Action
extends distal phalanx of big toe; weak
dorsiflexor; weak inversion & adduction

Lateral to the Anterior tib

Questionable inversion/eversion effect as tendon is on the STJ axis
62
Extensor Digitorum
Origin
lateral condyle of the tibia; upper ant.
surface of fibula; interosseous membrane
Insertion
dorsal surface of the bases of the middle
& distal phalanxes of the 2nd-5th rays
via 4 tendons creating a fibrous expansion
Action
extends the lateral 4 toes; weak
dorsiflexor & evertor of foot

63
Peroneus Tertius
Origin
distal 1/3 of anterior fibula; distal &
lateral aspect of extensor digitorum
Insertion
dorsal surface of base of 5th metatarsal
Action
extends the 5th toe; weak dorsiflexor &
evertor of foot

Origin is on lower 1/3 of anterior fibula; distal & lateral aspect of

extensor digitorum and inserts on top of the dorsal surface of base
of 5th metatarsal
Action - extends the 5th toe; weak dorsiflexor & evertor of foot
64
lateral compartment

Muscles
Peroneus Longus and Brevis
General Function
Ankle pf; STJ eversion; plantarflexion
of 1
st
ray
Innervation
Superficial peroneal nerve
L4,5 S1
Blood Supply
Peroneal branch from posterior tib
artery
no arteries in lateral compartment apart from a muscular branch to
the peroneal muscles from the peroneal artery, a branch of the
posterior tibial artery
65
lateral compartment muscular function

Ever Lat Plantarflex Posterior

PB
PL
STJ
Axis
TCJ
Axis
Mm
TCJ Axis
STJ Axis
Posterolateral quadrant
66
Peroneus Longus
Origin
head of the fibula; proximal 2/3 of lateral
fibula
Insertion
plantar surface of cuboid; base of 1st &
2nd metatarsal; plantar surface of medial
cuneiform
Action
eversion & abduction of the foot;
plantarflexion of the 1
st
ray

Originates from the head head and the upper 2/3 of lateral fibula
Passes through the cuboid notch or pulley on its way to its insertion
at the base of 1st & 2nd metatarsal; plantar surface of medial
cuneiform
Action - eversion & abduction of the foot; plantarflexion of the 1
st
ray
67
Peroneus Brevis
Origin
distal 2/3 of lateral fibula
Insertion
styloid process at base of 5th
metatarsal
Action
eversion & abduction of the foot;
weak plantarflexion of foot

68
superficial posterior compartment

Muscles
Gastroc, soleus, and plantaris
General Function
Ankle pf; STJ supination
Innervation
Tibial nerve which is derived from
L5-S1 nerve roots
Blood Supply
Posterior Tibial Artery
69
superficial posterior compartment
muscular function

Soleus
Inv Med Plantarflex Posterior
Gastroc
STJ
Axis
TCJ
Axis
Mm
TCJ Axis
STJ Axis
Posteromedial
quadrant
70
Gastrocnemius
Origin
medial head: just above medial condyle
of femur
lateral head: just above lateral condyle of
femur
Insertion
calcaneus via achilles tendon
Action
plantarflex the ankle
knee flexion (when not weight bearing)

Gastroc is a phasic (fast twitch) muscle that is better recruited with

high intensity activity
71
Soleus
Origin
upper fibula
soleal line of tibia (upper 1/3 of
posterior tibia
Insertion
calcaneus via achilles tendon
Action
plantarflex the ankle

Soleus is a tonic or slow twitch predominant muscle

Soleal line located on upper 1/3 of posterior tibia
72
deep posterior compartment

Muscles
PT, FDL, FHL
General Function
Ankle pf; STJ inversion; toe flexion
Innervation
Tibial nerve
L5-S1
Blood Supply
Posterior Tibial Artery
FHL
FDL
PT
73
deep posterior compartment
muscular function

Inv
Med
Plantarflex
Posterior
PT
Inv Plantarflex FHL
Inv Plantarflex FDL
STJ
Axis
TCJ
Axis
Mm
TCJ Axis
STJ Axis
FHL
FDL
PT
74
Posterior Tibialis
Origin
Postermedial portion of the proximal tibia;
interosseous membrane; medial surface of
fibula
Insertion (broad expansive insertional area)
navicular tuberosity (principle); all three
cuneiforms (plantar surface); bases of 2nd-4th
metatarsals; cuboid; sustentaculum tali of
calcaneus
Action
stabilizes ankle; inverts and adducts the foot;
weak ankle plantarflexor; control and reverse
pronation

Posterior tib origin palpable a hands width superior to medial

malleolus; tendon palpable just posterior to medial malleolus with
resistance plantarflexion and inversion
75
Flexor Digitorum Longus
Origin:
posterior surface of tibia and crural fascia
Insertion
plantar surface of bases of the 2-5th
distal phalanges
Action:
primarily flexes 2nd - 5th toes
weak ankle plantarflexor and inversion &
adduction of foot

Crural fascia also known as interosseous membrane

76
Flexor Hallicus Longus
Origin:
posterior, inferior 2/3 of fibula; interosseous
membrane;
crural fascia & posterior intermuscular septum
Insertion
plantar surface of distal phalanx of hallux
Action:
flexes big toe (hallux); weak plantarflexion of the
foot; weak inversion & adduction of foot

Origin is from posterior, lower 2/3 of fibula; interosseous membrane;

crural fascia & posterior intermuscular septum
Inserts onto the plantar surface of the big toe
Action: flexes big toe (hallux); weak plantarflexion of the foot; weak
inversion & adduction of foot
Trivia Question: What kind of athlete is susceptible to FHL tendinitis?
Commonly injured in ballet dancers
77
Foot Intrinsic Muscles

78
Intrinsic Muscles of the Foot

Superficial First Layer

ADM ADM
FDB FDB
AH AH
Muscles that originate and insert within the foot
foot muscles have gross rather than precise functions compared to the
hand
many muscles in the foot have names that imply a function they rarely
perform, or, for some individuals, are unable to perform
however, and somewhat ironically, loss of function or surgical
alteration of these muscles can result in the development of a foot
deformity
79
Abductor Hallicus
Origin
medial process of calcaneal tuberosity;
Insertion
medial aspect of base of proximal
phalanx of hallux
Action
flexes the big toe (primary action);
may assist in abduction of big toe
Blood Supply
medial plantar artery
Innervation
medial plantar nerve, L5,S1

Muscles which produce transverse plane motion (ab/adduction) in

the foot are named relative to the midline of THE FOOT, not the
midline of the body
The midline of the foot is a line passing through the heel and the
2
nd
toe
Abduction of the big toe is a medial motion while abduction of the
little toe is a lateral motion
Weakness of AH may contribute to hallux valgus
80
Flexor Digitorum Brevis
Origin
medial and lateral process of calcaneal
tuberosity; plantar aponeurosis
Insertion
both sides of the bases of the middle
phalanx of rays 2-5 with each of the 4
tendons splitting to form tunnel for FDL
Action
flexes toes 2-5
Blood Supply
medial plantar artery
Innervation
medial plantar nerve, L5,S1

Originates from the medial and lateral process of calcaneal tuberosity

and plantar fascia
Insertion is from both sides of the bases of the middle phalanx of
rays 2-5 with each of the 4 tendons splitting to form tunnel for FDL
Action flexes the less four toes
Blood Supply is from medial plantar artery
Innervated by the medial plantar nerve, L5,S1
Origin is the site of calcaneal spurs typically associated with plantar
fascitis
81
Abductor Digiti Minimi
Origin
lateral & medial processes of the
calcaneal tuberosity and plantar
aponeurosis
Insertion
lateral aspect of base of proximal
phalanx of 5th ray
Action
abducts and assist in flexing the 5th toe
Blood Supply
lateral plantar artery
Innervation
lateral plantar nerve, S1,2

Most lateral of the three muscles in the superficial layer

82
Intrinsics Muscles of the Foot

Second Layer
FHL
FDL
Quadratus Plantae
Lumbricales
Both intrinisc muscles (quadratus plantae and the lumbricales) are
functionally related to the FDL
83
FHL - FDL
Flexor Hallicus Longus

Flexor Digitorum Longus

From posterior deep compartment
84
Quadratus Plantae
Origin
medial head: medial calcaneus
lateral head: lateral calcaneus & long plantar
ligament
Insertion
lateral margin of tendon of FDL and may send
slips into the distal tendons
Action
assists FDL in flexing the distal phalanges of toes
2-5; corrects FDL from pulling toes medially
Blood Supply
lateral plantar artery
Innervation
lateral plantar nerve, S1,2

The action or line of pull corrects the natural medial vector that the
FDL would create if acting alone
85
Lumbricales
Origin
from tendons of FDL:
1st: medial aspect of tendon to 2nd ray
2nd-4th: two heads between the tendons in which
they lie
Insertion
extensor tendons of EDL on dorsal foot
Action
flex proximal phalanges at 2-5 MTP; extend middle &
distal 2-5 phalanges at IP
Blood Supply
1st: medial plantar artery; 2nd-4th: lateral plantar artery
Innervation
1st: medial plantar nerve, L5,S1; 2nd-4th: lateral plantar
nerve, S1,2

Lumbricale flex the MTPs and extend the PIP and DIPs
86
Intrinsics Muscles of the Foot

Third Layer
Flexor Hallicus Brevis
Adductor Hallicus
Flexor Digiti Minimi Brevis
87
Flexor Hallicus Brevis
Origin
plantar aspect of the cuboid and lateral
cuneiform
Insertion
medial and lateral aspect of base of
proximal phalanx of hallux
Action
flexes hallux at MTP
Blood Supply
medial plantar artery
Innervation
medial plantar nerve, L5,S1

Insertion is on both sides of the base of the 1

st
proximal phalanx
88
Adductor Hallicus
Origin
oblique head: base of 2nd-4th metatarsals &
long plantar ligament
transverse head: deep transverse metatarsal
ligament & plantar ligaments at MTP joints
Insertion
lateral aspect of base of proximal phalanx of
hallux
Action
adduction and flexion of hallux at MTP
Blood Supply
lateral plantar artery
Innervation
lateral plantar nerve, S1,2

Often become contracted with hallux valugus and is released as a

part of soft tissue realingment procedures with bunions
89
Flexor Digiti Minimi Brevis
Origin
base of 5th metatarsal
digital sheath of peroneus longus
Insertion
lateral aspect of base of 5
th
proximal
phalanx
Action
flexes the 5th toe at MTP
Blood Supply
lateral plantar artery
Innervation
lateral plantar nerve, S1,2

90
Intrinsics Muscles of the Foot

Deepest Fourth Layer

Plantar Interossei
Dorsal Interossei
Deepest fourth layer contains the plantar and dorsal interossei
Similar function as in hand except the reference digit is the 2
nd
digit
instead of the 3
rd
in the hand
91
Plantar Interossei 3 muscles
Origin
medial aspect of 3rd-5th metatarsals (each
muscle has a single head)
Insertion
medial aspect of base of proximal phalanx of the
same ray (3rd-5th rays)
Action
adduct toes 3-5 and flex toes 3-5 at MTP
Blood Supply
lateral plantar artery
Innervation
lateral plantar nerve (deep branch), S1,2

92
Dorsal Interossei 4 muscles
Origin
from both metatarsals between which they lie
Insertion
base of proximal phalanx closest to the axis of
the foot (2nd ray)
Action
abduct toes 2-4
flexes toes 2-4 at MTP
Blood Supply
lateral plantar artery
Innervation
lateral plantar nerve (deep branch), S1,2

93
Interossei Function Pneumonic
PAD
Plantar Interossei ADduct

DAB
Dorsal Interossei ABduct
94
Extensor Hallicus Brevis
Origin
upper anterolateral calcaneus and inferior extensor
retinaculum
Insertion
base of proximal phalanx of hallux
Action
extends hallux
Blood Supply
dorsalis pedis artery
Innervation
deep peroneal nerve, L4,5

Some consider this muscle to anatomically be a part of the Extensor

Digitorum brevis
95
Extensor Digitorum Brevis
Origin
upper anterolateral calcaneus and inferior extensor
retinaculum
Insertion
middle & distal phalanges of 2nd-4th rays (via EDL)
Action
extends 2nd-4th rays
Blood Supply
dorsalis pedis artery
Innervation
deep peroneal nerve, L4,5

Same origin as extensor hallicus brevis

96
Muscle Action in Gait

97
muscular function in gait

Contrast the open kinetic chain muscular function as dictated by the

tendons location relative to axes with their functional responsibilities
in gait
98
Muscular Function in Gait
Anterior Group
Tibialis Anterior:
concentric function in swing phase and
eccentric function in stance
assist in ground clearance, controls forefoot
loading and midstance pronation
Long Extensors:
hold the oblique axis of the MTJ in a pronated
position at heel strike and assist controlled
deceleration of forefoot loading and midstance
pronation

Long Extensors = EHL and EDL

99
Muscular Function in Gait
Posterior Deep Group
Posterior Tibialis:
controls STJ pronation at heel strike and reverses it
through midstance
maintains stability of the MTJ in the direction of
supination around the oblique axis during stance phase
Flexor Digitorum Longus:
stabilizes the foot as a weight bearing platform for
propulsion.
Works antagonistically with the intrinsics.
supports the medial arch
Flexor Hallicus Longus:
functions in concert with the other posterior deep
muscles, specifically stabilizing the 1st ray during
propulsion and supporting the medial arch.

100
Muscular Function in Gait
Posterior Superficial Group
Gastroc-Soleus:
active throughout the stance phase of gait
at heel strike, eccentrically decelerate tibial IR &
forward progression of the tibia over the foot.
Gastroc decelerates femoral IR while the soleus
assists in tibial IR deceleration.
during midstance and heel off, concentrically
supinating the subtalar joint, externally rotating
the tibia, and plantarflexing for push off.
gastroc contributes to smooth knee extension by
maintaining tension on the knee while the knee
extends in midstance

101
Muscular Function in Gait
Lateral Group
Peroneus Longus
provides support to the transverse and lateral
longitudinal arches
actively stabilizes the 1st ray
transfers body weight from lateral to medial
during stance
Peroneus Brevis
functions in concert with the peroneus longus
stabilizes the calcaneocuboid joint allowing the
peroneus longus to work efficiently over the
cuboid pulley

102
Muscular Function in Gait
Intrinsics
EDH/EDL
Posterior Tib
Soleus
Gastroc
FHL
Concentric Eccentric
Peroneals
Loading Phase
FDL
Anterior Tib
Swing Propulsion Midstance

Anterior to
Deep to
Superficial to
Lateral
Compartment
firing
Left Leg
Anterior
Superficial
Deep
Lateral
Tibia
Fibula
103
Neurovascular Anatomy

104
Innervation and Vascular Anatomy
of the Leg -Ankle - Foot

Anatomical Review of Segmental Innervation

Motor control of spinal cord levels
Nerve root from L4 spinal cord level provide SJT inverter motor
control
Nerve root from L5 spinal cord level provides TCJ dorsiflexion motor
control
Nerve root from S1 spinal cord level provides TCJ plantarflexion or
STJ Inversion motor control
105
Nerve Anatomy
sciatic
common peroneal
tibial
common peroneal
superficial
deep
tibial
medial and lateral
calcaneal nerves
medial and lateral
plantar nerves

Superficial Peroneal
branch of common peroneal
passes down anterior compartment of leg, then branches off into:
medial dorsal cutaneous nerve
intermediate dorsal cutaneous nerve
Deep peroneal nerve
Deep in leg, then passes into foot and supplies 1
st
web space
Common peroneal most commonly injured resulting in paralysis of dorsiflexors and
evertors = drop foot
Posterior tibial nerve is affected in tarsal tunnel syndrome (just posteror to anterior
compartment
106
tibial nerve and its branches
Medial and Lateral Calcaneal
Medial and Lateral Plantar

Terminal branches of tibial nerve

medial plantar nerve
larger
passes deep to abductor hallucis and runs between AbdH and FDB, lateral to
medial plantar artery
supplies medial 3 digits, and slightly wraps over onto dorsum
lateral plantar nerve
smaller
deep to flexor retinaculum and AbdH and runs medial to lateral plantar
artery between 1
st
and 2
nd
muscle layers
supplies lateral 1 toes
Compression of this nerve is often mistaken for plantar fascitis
107
Cutaneous Nerve Anatomy

Saphenous
Superficial peroneal
Lateral cutaneous
Sural
saphenous nerve
Cutaneous branch of femoral nerve
serves posteromedial aspect of the leg
superficial peroneal
enters foot on dorsomediall aspect, anterior to medial malleolus
supplies skin along medial side of foot, sometimes as distal as the head of
the first metatarsal
lateral cutaneous nerve of calf
branch of common peroneal
supplies skin over upper part of posterolateral aspect of the leg
sural nerve
branch of tibial nerve
supplies posterolateral aspect of the leg and foot
enters foot posterior to lateral malleolus
supplies lateral border of foot and 5
th
digit
108
cutaneous sensory innervation
Medial plantar

Sural
Deep Peroneal
Superficial peroneal Superficial peroneal
Lateral Plantar
Calcaneal branch of
medial plantar
109
cutaneous sensory innervation
Medial plantar
Lateral Plantar
Calcaneal branch of
medial plantar
Superficial peroneal Superficial peroneal
Deep peroneal
Sural
Saphenous

Medial View Lateral View

110
Arterial Anatomy
Anterior Tibial Artery
Posterior Tibial Artery
Peroneal Artery

111
Arterial Anatomy
Anterior view
Posterior view
posterior
tibial artery
peroneal
artery
dorsalis
pedis artery

Femoral
Dorsalis
Pedis
Anterior
Tibial
Post.
Tibial
Lateral
Plantar
Medial
Plantar
Digital
Popliteal
Peroneal
Dorsalis pedis is palpated on the dorsum ot the foot between the
EHL and EDL
112
references

113
references

Grants Anatomy
Mulligan EP. Foot-Ankle Chapter in
Physical Rehabilitation of the Injured
Athlete. ed Andrews, Harrelson, Wilk.
Saunders, 2003.
Foot-Ankle Special Theme Issue. J Orthop
Sports Phys Ther 21:6, 1995.
Foot-Ankle Special Theme Issue. Phys
Ther 68:12, 1986
Seibel MO. Foot Function: A Programmed
Text. Lippincott Williams & Wilkins, 1988
114
Thank you

Reminder: TCJ and STJ flouroscopic and motin-axis video clips will be archived for
download along with the recording files from this broadcast.