2Interesting Little Clowns Tarsal BonesTalusCalcaneousNavicularCuneiforms:1st-medial2nd-intermediate3rd- lateralCuboidTarsalsMnemonics:(Clean)The Circus Needs MoreInteresting Little Clowns(Or not)Tall Californian NavyMedical Interns Lay CutiesTarsals
3Metatarsals Calcaneus Talus Navicular Cuboid 1 3 2 Metatarsals 4 5 CuneiformsMetatarsalsNumbered 1-5Starting on big toe side
4Phalangeal bones 14 total Also numbered 1-5 with big toe being #1Proximal- (5) closest to metatarsalsMiddle-(4) between proximal and distal phalanxOnly 4--like the thumb on the hand the big toe doesn’t have a middle phalanxDistal-(5)tip of the toeDistal phalangeal bonesMiddlephalangealbonesProximal phalangeal bonesMetatarsals
5Similar to the Radius and Ulna there is an interosseous membrane between the Fibula and Tibia To remember which bone is which:FibuLA is LAteralThe Medial Malleolus is inferior and medial on the TibiaFIBULAThe Fibular notch is inferior and lateral on the TibiaMedial MalleolusFibular notchLateral MalleolusThe LAteral Malleolus is inferiorand lateral on the FibuLA
6The ankle joint is a synovial joint The ankle joint is a synovial joint. Articular cartilage is found at articulation points between the bones of the ankle and the foot
7There is also articular cartilage at each of the joints of the toes A little med term side note…The big toe is also called the HalluxA bunion is referred to as “Hallux Valgus”Hallux: Big toeValgus: abnormal angulation
8MTP, PIP, and DIP joints of the foot Proximal interphalangeal Distal interphalangealDIPEach MTP and IP joint is held together by several ligamentsOne medial, one lateral and one inferiorThank you Mr. Blevins for not putting them all on our list!!MetatarsophalangealMTP
9Plantar fasciitis What it is: Inflammation of the plantar fascia Causes:Over use or overstretching of the plantar fasciaRisk factors:Foot arch problems—too much or not enoughObesityLong distance runningTight Achilles tendonShoes with poor arch supportSymptoms:Pain and stiffness in the bottom of the heel-may be dull or sharpBottom of foot may ache or burn
10Treatment methods for Plantar Fasciitis Typical methods:Acetaminophen or ibuprofen to reduce pain and inflammationHeel stretching exercisesRest for at least a weekShoes with good supportApply ice to painful areaMore extreme cases may require:Boot castCustom orthoticsSteroid shots into the heelAnd other methods such as…….
12LIGAMENT LOCATIONSpring Ligament : runs from the sustentaculum tali to the tuberosity of the navicular forming a support for the head of the talus. Long Plantar Ligament: runs from the undersurface of the calcaneous to the cuboid and bases of the lateral metatarsals. The ligament runs over the tendon of the peroneous longus. Short Plantar Ligament: runs from the undersurface of the calcaneous to the cuboid. Posterior Tibiofibular Ligament: connects the tibia and fibula posteriorly. It is located on the lateral aspect of the ankle.
13LIGAMENT LOCATION (cont.) Anterior Tibiofibular : connects the tibia and fibula anteriorly. It is found on the lateral aspect of the ankle. Interosseous Tibiofibular: small ligament located at the base of the interosseous membrane between the tibia and fibula. Superior extensor retinaculum: broad band that crosses the anterior aspect of the foot just proximal to the malleoli. Inferior extensor retinaculum: a Y-shaped broad band that begins distal to the lateral malleolus on the calcaneous. It crosses the ankle , then divides, with one end attaching at the medial malleolus. The other fork connects to the navicular.
14LIGAMENT LOCATION (cont.) Plantar aponeurosisThe plantar aponeurosis lies deep to the superficial fascia of the sole and covers the 1st layer of muscles. It attaches to calcaneus and extends with slips to each toe.Interosseous membraneBetween the tibia and the fibula is the interosseous membrane. It runs between the interosseous crests on the tibia and fibula. It binds the two bones together as well as separating the muscles of the front of the leg from the back.
15Interosseous Tibiofibular Ligament Between the tibia and fibula thereis an interosseous membrane. Atthe distal end the membranethickens and becomes a ligament.This ligament is instrumental inholding these two bones together.
16Anterior and Posterior Tibiofibular Ligaments (anterior view) ( posterior view)
17Ligaments PLANTAR CALCANEONAVICULAR LIGAMENT (SPRING) SHORT PLANTAR
19Plantar Aponeurosis The plantar aponeurosis lies deep to the superficial fascia of the plantar aspect of the foot and covers the 1st layer of muscles. It attaches to the calcaneus and sends a deep slip to each toe.
21Bursae RETRO-CALCANEAL BURSA This bursa is located between the Achilles tendon and the superior region of the posterior surface of the calcaneous.SUBCUTANEOUSCALCANEAL BURSAIt is found posterior (superficial) to the Achilles tendon, lying between the skin and the posterior aspect of the distal Achilles tendon. This is also known as the Achilles Bursa.Both contain synovial fluid to help lubricate these high friction areas.
22Nerves of The Foot/Ankle Anterior:Saphenous nerveSuperficial fibular (peroneal) nerveDeep fibular (peroneal) nerveSuralPalmar:Medial plantarLateral plantar
23Nerve/muscle Innervations of the Ankle and Foot DEEP PERONEAL nerve innervates THESE muscles:Extensor digitorum longus muscleExtensor hallucis longus muscleTibialis anterior musclePeroneous tertius muscleSUPERFICIAL PERONEAL nerve innervates THESE muscles:Peroneous longus musclePeroneous brevis muscleTIBIAL nerve innervates THESE muscles:Gastrocnemius muscleSoleus musclePlantarisTibialis posteriorFlexor hallucis longusFlexor digitorum longus
25Arteries of the Ankle and Foot Anterior Tibial ArteryThis artery originates as the popliteal artery and becomes the anterior tibial artery. It descends the tibia on the anteriomedial aspect of the tibia and becomes the dorsalis pedis at the ankle.Dorsalis PedisThis is a continuation of the anterior tibial artery. It begins at the ankle and runs anteriomedially. The dorsalis pedis is a main blood supply to the foot.Posterior Tibial ArteryThis artery is a continuation of the popliteal artery. It begins at the inferior border of the popliteus and descends medially through the calf of the leg. It enters the foot at the medial side of the calcaneus .
26Arteries of the Ankle and Foot (cont.) Arcuate Artery One of the branches of the dorsalis pedis is this artery. It runs anteriorly and transversely at the base of the metatarsal bones towards the lateral aspect of the foot. Deep Plantar Arch Artery (NOTE: Vein of same name accompanies) Both the arcuate and deep planter arteries branch at the base of the metatarsal of the big toe. The deep plantar artery runs into the plantar aspect of the foot . It travels transversly across the remaining metatarsals towards the lateral side of the foot. Lateral Tarsal Artery A branch of the dorsalis pedis, this artery begins at the midline of the talus anteriorly and runs at an angle towards the lateral aspect of the foot.
27DORSAL VENOUS ARCH VEIN: Carries blood from the toes to both the great and lesser saphenous veins.GREATER SAPHENOUS VEIN:This vein is formed by the dorsal digital vein of the big toe and the dorsal venous arch. It runs from the dorsal venous arch along the medial anterior aspect of the foot and anterior to the medial malleolus .LESSER SAPHENOUS VEIN:The lesser saphenous vein is formed by the dorsal venous arch and the dorsal digital vein of the 5th digit of the foot. It runs along the lateral aspect of the foot and posterior to the lateral maleolus .PLANTAR ARCH VEIN:This vein is not pictured here, however, with each artery there is a co-ordinating vein. SEE NEXT SLIDE. It is located on the plantar side of the foot, running next to the plantar arch artery.
30Arches of the Foot Medial Longitudinal Arch Lateral Longitudinal Arch Includes the calcaneous, talus, navicular, the 3 cunieforms, and the 3 medial metatarsals. The arch is supported by the spring ligament, muscles and the tibialis anterior and posterior from above.Lateral Longitudinal ArchIncludes the calcaneous, cuboid, and the two lateral metatarsals. The arch is bound by the short and long plantar ligaments. The peroneous longus and brevis muscles support it superiorly.Transverse ArchIncludes the cunieforms and bases of all the metatarsals. This arch gains its support from the deep transverse ligament, plantar ligaments, and the interossei which binds it together. The peroneous longus and brevis support it superiorly.Fundamental Longitudinal ArchThis arch is comprised of the calcaneus, cuboid, 3rd cunieform, and 3rd metatarsal. These bones run through the center of the foot and form the basic longitudinal arch of the foot.Arches of the Foot
31A Little “Footnote”The human foot and ankle is a strong and complex mechanical structure containing more than 26 bones, 33 joints (20 of which are actively articulated), and more than a hundred muscles, tendons, and ligaments. Let’s all be grateful they are NOT all on the test!
38Tibialis Anterior: #19, Big Bob #142 Origin: Lateral tibia and interosseous membraneInsertion: 1st cuneiform and metatarsalAction: Ankle inversion, dorsiflexionInnervation: Deep peroneal nerveVascular supply: Anterior tibial artery
39Tibialis Posterior: # 28, 146 Big Bob Origin: Interosseous membrane, adjacent tibia and fibulaInsertion: Navicular and most tarsals and metatarsalsAction: Ankle inversion, assist plantar flexInnervation: Tibial nerveVascular supply: Fibular artery
40Peroneus Longus: #22, Big Bob #138 Origin: Lateral proximal fibula and interosseous membraneInsertion: Plantar surface of 1st cuneiform and metatarsalAction: Ankle eversion, assist plantar flexInnervation: Superficial peroneal nerveVascular supply: Fibular artery
41Flexor Hallucis Longus: #29 Origin: Posterior fibula and interosseous membraneInsertion: Distal phalanx of great toeAction: Flex great toe, assist inversion and plantar flexionInnervation: Tibial nerveVascular supply: Fibular artery
42Peroneus Brevis: #23, Big Bob #139 Origin: Lateral distal fibulaInsertion: base of 5th metatarsalAction: Ankle eversion, assist plantar flexInnervation: Superficial peroneal nerveVascular supply: Fibular artery
43Flexor Digitorum Longus: #27 Origin: Posterior tibiaInsertion: Distal phalanx of 4 lesser toesAction: Flex 4 little toes, assist inversion and plantar flexionInnervation: Tibial nerveVascular supply: Posterior tibial artery
44Peroneus Tertius: not seen on models Origin: Distal medial fibulaInsertion: Base of 5th metatarsalAction: Assist ankle eversion, dorsiflexionInnervation: Deep peroneal nerveVascular supply: Anterior tibial artery
45Movements of the Ankle and Foot Plantar flexionDorsiflexionAnkle InversionAnkle EversionFlexion of Big ToeFlexion of little toes
48Gait CycleDefined as human locomotion, or the way that we walk. Every individual has a unique gait pattern, which can be affected by injury or disease process. Therapist can determine weakness or shortening of muscles by observing a persons gait.The gait cycle is divided into two phases:1)Stance -- interval in which the foot is on the ground (60% of the gait cycle)2) Swing -- interval in which the foot is not in contact with the ground (40% of the gait cycle)Stance is divided into four phases: 1) Heel strike to foot flat 2) Foot flat through midstance 3) Midstance through Heel off 4) Heel off to Push offSwing phase deals with acceleration and deceleration around the midstance.