Foot and

Ankle

Jovet Lo PTRP, MAAG(c),CMTP

EAC-C, School of Physical Therapy

Consist of

3 bones (ankle)

26 bones (foot)

34 joints

Can change in a single step from a flexible

structure to a rigid structure

Functions

Support in super incumbent position

Control and stabilization of the leg on the

planted foot

Adjustment in irregular surfaces

Elevation of the body

Shock absorption

Operation on machine tools

Substitute for hand function

Bones

Calcaneus

Largest tarsal bone

1st to ossify

MC Fx

(+)sustentaculum tali

Talus

TB of the foot

No (M) attachment

Metatarsals

2nd MT (shaft)

2nd MT (head)

5th MT (base)

(N) projection of metatarsal head

2>3>1>4>5

Mortons / atavistic/ greek foot

Egyptian foot

Squared foot

Palpable structures

Medial side of the foot

Sustentaculum tali

Deltoid Lig

Tuberosity of the
navicular

First cuneiform

First TMT jt

First MT

First MTP jt

Talus

Medial tubercle of the

talus

Lateral Side of the foot

Calcaneus

Lateral Collateral Lig

Tuberosity at the base of 5th MT bone

Cuboid

Segments of the Foot

Arches

2 longitudinal

1 transverse

MLA

Contents

Calcaneus

Talus (keystone)

Navicular

Cuneiform

1,2 ,3 MT

LLA

Contents

Calcaneus

Cuboid (keystone)

4th & 5th MT

TA

Cuboid

3 cuneiform(2nd keystone)

Base of all MT

Supporting structures of
the arches
MLA

LLA

Ligament

Spring/Plantar
Calcaneonavicular
Ligament

Long plantar Ligament

Tendon

Tibialis Posterior
Tendon

Peroneus Longus

Talocrural joint

Connection between the talus and the crus

Hinge joint with one degree of freedom

Considered as the upper ankle joint

Superior articulating surface with tibia

Lateral articulating surface with medial

malleolus of tibia and lateral malleolus of fibula

Ligaments

Medial collateral or Deltoid Lig

Anterior Talotibial Lig

Posterior Talotibial Lig

CalcaneoTibial Lig

TibioNavicular Lig

Lateral Collateral Lig

Anterior Talofibular Lig

Posterior Talofibular Lig

Calcaneo Fibular Lig

OPP: 10 PF

CPP: Max DF

CP:PF>DF

TibialTorsion

Angle formed between the horizontal axes of the

knee and the ankle

(N) 20 to 23

Triplanar Motion

Supination

Inversion

Plantarflexion

Adduction

Pronation

Eversion

Dorsiflexion

Abduction

Subtalar joint

Talocalcaneal joint

Inversion & eversion

(+) SINUS TARSI

Midtarsal joint

Transverse/Choparts/ Surgeons Joint

Talonavicular joint

Calcaneocuboid joint

Primarily: ABD & ADD

Inv & Eve

Tarsometatarsal Joint

Cuboid & 3 cuneiform articulate with base of 5

metatarsal

Slight degree of flexion and extension

Metatarsophalangeal
Joints
condyloid synovial joints with 2 of freedom:
flex/ext, add/ abd
metatarsal heads are convex and the prox.
phalangeals are concave.
second metatarsal is longer than the rest making the
2nd MTP more ant.

1st metatarsal head has 2 grooves for articulation

with 2 sesamoid bones. inc. lever arm for muscular
forces and help make the foot a rigid lever.

Range of Motion of the

MTP joints
Flexion
Extension
Abduction

30
90
10 from 2nd metatarsal
long axis throught the metatarsal
Position of reference and phalangeal bones in a straight
line

Resting position

slight extension

closed packed position

full extension

Interphalangeal joints
synovial hinge (modified sellar) with one degree
of freedom
5 prox interphalangeal joint and 4 distal
interphalangeal joints.
Flex ROM

90 PIP, 40 DIP

long axis through the metatarsal and

position of reference
phalangeal bones is a straight line

resting position
closed packed
position

slight flexion
Full flexion

Important Landmarks

Popliteal Fossa

Tarsal Tunnel

Tibialis Posterior

FDL

Post Tibial A,V,N

FHL

Extensor Retinaculum

Tibialis anterior

EHL

Tibial A, V

Deep peroneal nerve

EDL

PT

Blood Supply

Femoral Artery

Popliteal Artery

Below Inguinal Lig

Below Popliteal Fossa

Post Tibial Artery

Behind Medial Malleolus

Dorsalis Pedis Artery

Lat to TA

Lat to EHL

Between 1st and 2nd MT

Between EDH and EHL

Muscles of the lower leg

Anterior

TA

EDL

EHL

PT

Posterior

Superficial

Gastronemius

Soleus

Plantaris

Deep

Tbialis Posterior

FDL

FHL

Popliteus

Lateral

PL

PB

Foot Muscles

Dorsal

EDB

Plantar

Abd Hallucis

Flexor Digitorum Brevis

Abd Digiti Minimi

Lumbricals

Quatratus Plantaris/ Flexor accesorius

Flexor Hallucis Brevis

Adductor Hallucis

Flexor Digiti Minimi

Interossei(4) dorsal (3) plantar

Muscle originated at the

Calcaneus

EDB

Abd Hallucis

Flexor Digitorum Brevis

Abd Digiti Minimi

Quatratus Plantaris/ Flexor accesorius

Muscles that are

innervated by the MPN

FHB

Abd Hallucis

1st Lumbrical

FDB

Foot Conditions

Equinus

Calcaneus

Valgus

Varus

Classes of Conditions
> Traumatic surgical intervention
non surgical intervention

Insidious onset

Congenital

Traumatic

Fractures Ankle
Mid foot

Forefoot

Tendon tears Achilles (plantaris)

Posterior Tibialis
Peroneal

Repair, ORIF +/- Immobilization, WB, PT

ORIF

ORIF

ORIF

OREF (Hoffman)

Immobilization

Repair

MRI

Immobilization

Amputation

Pirigoff- arthrodesis of Tibia & Calcaneus

Lysfranc- tarsometatarsal

Symes- Transmalleolar; above ankle

disarticulation

Boyds- removal of talus; such as calcaneus will

weight bear

Choparts- midtarsal joint

Non traumatic Injuries

Insidious Onset

Tendinosis

Stress fractures

Bunions , Hallux Limitus

Hammer toes

Metatarsalgia

Neuromas

Plantar Fascitis

Compartment Syndrome

Peroneal Tendons

Medial Tendons

Tendinitis
(post. tib., achilles, peroneal)

Usually insidious in onset

Pain with WB stretch or contraction

Improves with light activity

Latent inflammatory response

warm

Labs and Radiography not helpful

Treatment

Relative rest

Ice 15

Anti inflamatories dosage and duration

PT - Find the biomechanical cause

modalities, stretching, strengthening (hip

partner), transverse friction massage,
biomechanical control (shoes, inserts, lifts
or orthotics)

Ankle Sprains

Account for 25% of all sports injuries

Lateral (ATF+CF)(85%)

Medial (Deltoid)>

High (Syndesmosis)>

Mid tarsal

Possible causes:

Cavus, poor proprioception, poor rehab,

over weight and poorly conditioned

Ankle Ligaments

High Ankle sprain

Midtarsal Sprain

Treatment

Surgery?

RICE

Progressive WB

Immobilization and Early mobilization

Closed Chain Exercise

Looking for a cause

Closed chain Exercise

Plantar Fascitis

Causes

Unlocked midtarsal joint at push off phase of gait

causing stretch to fascia

Variety of foot types

Tight heelcords for level of function

Tight great toe flexors or fascia

Weakness in control of pronation

Training errors, shoes

Windlass Mechanism

Windlass Mechanism
toe extension during propulsion, puts tension
on the plantar fascia and passively raises the
arch.

Body weight

Plantar fascia

GRF

GRF

Truss Support Function

When a superior load is applied on the arch, the

plantar fascia (truss) prevents the migration of th

two ends away from one another, thus supportin

Treatment

No correlation to heel spurs

Differentiate from tarsal tunnel

Treat the cause:

Stretch tight heel cords and FHL

Support unstable biomechanics orthotics,

taping or arch strapping

Night splints, morning/first step routine

Analgesic modalities, injections? Surgery?

Treatment for Plantar

Fascitis

Treatment for plantar

fascitis

Bunions
(Hallux Valgus)

Bunions

Both medial (1st MTP) and lateral (5th)

In medial bunion:

Over pronated foot with abductus (toe out)

Tight heel cords

Forefoot varus

Treatment

Treat the cause

Symptomatic relief with modalities

Heel cord stretching

Fore foot support via orthotic

Strengthening

When is surgery the best option?

Treatment
stretching
orthotics

Stress Fractures Micro

Fractures
Most common sites:
metatarsals

Tibia

Calcaneal

Calcaneal

Femur

Stress Fractures
Probable Causes

Increasing the amount or intensity of an activity

too quickly (most common)

Hard or uneven running surface

Improper or old shoes

Untreated biomechanical imbalances

Biomechanical limitations of motion

(subtalar and midtarsal joints)

Other Risk Factors for

Stress Fractures
Risk Factors

Female, short, thin and caucasian

Certain sports, especially involving plyometric loading:

Distance running

Gymnastics

Dance

Basketball and Tennis

Amenorrhea>decrease hormone support

Metatarsalgia

Treatment

Rest, ice and NSAIAs

Shoe, cushioned insoles

Callous reduction (egg)

Biomechanical exam to determine extent of

forefoot imbalance and prescription of custom
orthotic with FF balancing and relief cut outs

Treatment

Inter Metatarsal (Mortons)

Neuroma

Enlarged, fibrotic and benign interdigital

nerves

Most commonly between the third and forth

metatarsals

Brought on by shearing between metatarsals

Aggravated by narrow shoes and forefoot

imbalance

Treatments include special shoes or inserts,

NSAIAs and/or cortisone injections, but

Neuromas

Treatment

Calcaneal Apophypisis

Male Adolescence

Severs Dse

Hoglands Dse

Self limiting

Osteo arthritis

condition characterized by the breakdown and

eventual loss of cartilage in one or more joints
(ankle>MTJ>1st MTP>ST)

degenerative arthritis, reflecting its nature to

develop as part of the aging process

Pain and stiffness in the joint, swelling in or near

the joint, difficulty walking or bending the joint

Radiography