1. ANKLE AND FOOT
Dr. Michael P. Gillespie

2. 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

3. Medial Aspect

4. Medial Tendons

5. Posterior Tibial Artery, Tibial Nerve

6. Lateral Malleolus & Attached Ligaments

7. Peroneus Longus and Peroneus Brevis Tendons

8. Anterior Aspect

9. Posterior Aspect

10. OSTEOLOGY
Dr. Michael P. Gillespie

11. BONES, JOINTS, & REGIONS OF THE ANKLE
Dr. Michael P. Gillespie
FIGURE 14-1.   Overall organization of the bones, major joints, and regions of the foot and ankle.

12. 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:
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.
Dr. Michael P. Gillespie

13. 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

14. 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

15. OSTEOLOGIC FEATURES OF THE FIBULA AND DISTAL TIBIA
Head
Lateral malleolus
Articular facet (for the talus)
Distal Tibia
Medial malleolus
Fibular notch
Dr. Michael P. Gillespie

16. DISTAL END OF THE RIGHT TIBIA, RIGHT FIBULA, AND TALUS
Dr. Michael P. Gillespie
FIGURE 14-3.   An anterior view of the distal end of the right tibia and fibula, and the talus. The articulation of the three bones forms the talocrural (ankle) joint. The dashed line shows the proximal attachment of the capsule of the ankle joint.

17. TARSAL BONES Seven tarsal bones Talus Calcaneus Navicular
Medial, intermediate, and lateral cuneiform
Cuboid
Dr. Michael P. Gillespie

18. OSTEOLOGIC FEATURES OF THE TARSAL BONES
Talus
Trochlear surface
Head
Neck
Anterior, middle, and posterior facets
Talar sulcus
Lateral and medial tubercles
Calcaneus
Tuberosity
Lateral and medial processes
Calcaneal sulcus
Sustentaculum talus
Dr. Michael P. Gillespie

19. OSTEOLOGIC FEATURES OF THE TARSAL BONES
Navicular
Proximal concave (articular) surface
Tuberosity
Medial, Intermediate, & Lateral Cuneiforms
Transverse arch
Cuboid
Groove (for the tendon of the fibularis longus)
Dr. Michael P. Gillespie

20. SUPERIOR (DORSAL) VIEW OF RIGHT FOOT
Dr. Michael P. Gillespie

21. INFERIOR (PLANTAR) VIEW OF RIGHT FOOT
Dr. Michael P. Gillespie
FIGURE 14-5.   An inferior (plantar) view of the bones of the right foot. Proximal attachments of muscles are indicated in red, distal attachments in gray.

22. MEDIAL VIEW OF RIGHT FOOT
Dr. Michael P. Gillespie
FIGURE 14-6.   A medial view of the bones of the right foot.

23. LATERAL VIEW OF RIGHT FOOT
Dr. Michael P. Gillespie
FIGURE 14-7.   A lateral view of the bones of the right foot.

24. 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

25. SUPERIOR VIEW OF TALUS FLIPPED LATERALLY
Dr. Michael P. Gillespie
FIGURE 14-8.   A superior view of the talus flipped laterally to reveal its plantar surface as well as the dorsal surface of the calcaneus. With the talus moved, it is possible to observe the three articular facets located on the talus and on the calcaneus. Note also the deep, continuous concavity formed by the proximal side of the navicular and the spring ligament. This concavity accepts the head of the talus, forming the talonavicular joint. (The interosseous and cervical ligaments and multiple tendons have been cut.)

26. 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

27. 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

28. 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

29. CUBOID
Six surfaces, three of which articulate with adjacent tarsal bones
Articulates with 4th and 5th metatarsal bones
Dr. Michael P. Gillespie

30. 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

31. 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

32. 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

33. PHALANGES The foot has 14 phalanges
The first toe, great toe or hallux has two phalanges
Dr. Michael P. Gillespie

34. OSTEOLOGIC FEATURES OF A PHALANX
Base
Shaft
Head
Dr. Michael P. Gillespie

35. ARTHROLOGY Major joints of the ankle Talocrural Subtalar
Transverse tarsal joints
Dr. Michael P. Gillespie

36. JOINTS OF THE ANKLE AND FOOT
Dr. Michael P. Gillespie
FIGURE 14-9.   A radiograph from a healthy person showing the major joints of the ankle and foot: talocrural, subtalar, talonavicular, and calcaneocuboid. The talonavicular and calcaneocuboid joints are part of the larger transverse tarsal joint. Note the central location of the talus.


37. TERMS THAT DESCRIBE MOVEMENTS AND DEFORMITIES OF THE ANKLE & FOOT
Motion
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

38. FUNDAMENTAL MOVEMENT DEFINITIONS APPLIED MOVEMENT DEFINITIONS
Dr. Michael P. Gillespie
FIGURE    A, Fundamental movement definitions are based on the movement of any part of the ankle or foot in a plane perpendicular to the three standard axes of rotation: vertical, anterior-posterior (AP), and medial-lateral (ML). B, Applied movement definitions are based on the movements that occur at right angles to one of several oblique axes of rotation within the foot and ankle. The two main movements are defined as either pronation or supination.

39. 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

40. PROXIMAL TIBIOFIBULAR JOINT
Located lateral to and immediately inferior to the knee.
Synovial joint (diarthrosis)
Dr. Michael P. Gillespie

41. 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

42. ANTERIOR-LATERAL VIEW RIGHT DISTAL TIBIOFIBULAR JOINT
Dr. Michael P. Gillespie
FIGURE    An anterior-lateral view of the right distal tibiofibular joint with the fibula reflected to show the articular surfaces.

43. POSTERIOR VIEW RIGHT ANKLE
Dr. Michael P. Gillespie
FIGURE    Posterior view of the right ankle region shows several ligaments of the distal tibiofibular, talocrural, and subtalar joints. The dashed line indicates the proximal attachments of the capsule of the talocrural (ankle) joint.

44. 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

45. LIGAMENTS OF THE DISTAL TIBIOFIBULAR JOINT
Interosseous ligament
Anterior tibiofibular ligament
Posterior tibiofibular ligament
Dr. Michael P. Gillespie

46. 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

47. Tibionavicular fibers attach to the navicular, near its tuberosity.
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

48. MEDIAL COLLATERAL (DELTOID) LIGAMENT
Dr. Michael P. Gillespie
FIGURE    Medial view of the right ankle region highlights the medial collateral (deltoid) ligament.

49. THREE MAJOR LIGAMENTS OF THE LATERAL COLLATERAL LIGAMENTS OF THE ANKLE
Anterior talofibular ligament
Calcaneofibular ligament
Posterior talofibular ligament
Dr. Michael P. Gillespie

50. LATERAL COLLATERAL LIGAMENTS
Dr. Michael P. Gillespie
FIGURE    Lateral view of the right ankle region highlights the lateral collateral ligaments.

51. 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 (tibionavicular fibers)
Talocrural joint
Talonavicular joint
Eversion, plantar flexion with associated anterior slide of talus
Deltoid ligament (tibiocalcaneal fibers)
Talocrural joint and subtalar joint
Eversion
Dr. Michael P. Gillespie

52. 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
Subtalar joint
Dorsiflexion with associated posterior slide of the talus
Posterior talofibular ligament
Dr. Michael P. Gillespie

53. 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.

54. 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.

55. Ligamentous Instability
Clinical Signs and Symptoms
Ankle swelling
Static ankle pain
Pain on passive motion
Tenderness over affected ligament

56. Ligaments

57. 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

58. Drawer’s Foot Sign

59. Drawer’s Foot Sign

60. Lateral Stability Procedure: Patient supine. Passively invert foot.
Rationale: Gapping secondary to trauma. Suspect tear of anterior talofibular ligament or calcaneofibular ligament.

61. Lateral Stability

62. Lateral Stability

63. Medial Stability Procedure: Patient supine. Passively evert foot.
Rationale: Gapping secondary to trauma. Suspect tear of deltoid ligament.

64. Medial Stability

65. Medial Stability

66. SUPERIOR VIEW RIGHT TALOCRURAL JOINT
Dr. Michael P. Gillespie
FIGURE    A superior view displays a cross-section through the right talocrural joint. The talus remains, but the lateral and medial malleolus and all the tendons are cut.

67. THE AXIS OF ROTATION AND OSTEOKINEMATICS TALOCRURAL JOINT
Dr. Michael P. Gillespie
FIGURE 14-17A&B.   The axis of rotation and osteokinematics at the talocrural joint. The slightly oblique axis of rotation (red) is shown from behind (A) and from above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. Note that, although subtle, dorsiflexion (D) is combined with slight abduction and eversion, which are components of pronation; plantar flexion (E) is combined with slight adduction and inversion, which are components of supination.

68. NEUTRAL Dr. Michael P. Gillespie
FIGURE 14-17C.   The axis of rotation and osteokinematics at the talocrural joint. The slightly oblique axis of rotation (red) is shown from behind (A) and from above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. Note that, although subtle, dorsiflexion (D) is combined with slight abduction and eversion, which are components of pronation; plantar flexion (E) is combined with slight adduction and inversion, which are components of supination.

69. DORSIFLEXION Dr. Michael P. Gillespie
FIGURE 14-17D.   The axis of rotation and osteokinematics at the talocrural joint. The slightly oblique axis of rotation (red) is shown from behind (A) and from above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. Note that, although subtle, dorsiflexion (D) is combined with slight abduction and eversion, which are components of pronation; plantar flexion (E) is combined with slight adduction and inversion, which are components of supination.

70. PLANTAR FLEXION Dr. Michael P. Gillespie
FIGURE 14-17E.   The axis of rotation and osteokinematics at the talocrural joint. The slightly oblique axis of rotation (red) is shown from behind (A) and from above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. Note that, although subtle, dorsiflexion (D) is combined with slight abduction and eversion, which are components of pronation; plantar flexion (E) is combined with slight adduction and inversion, which are components of supination.

71. ARTHROKINEMATICS TALOCRURAL JOINT
Dr. Michael P. Gillespie
FIGURE    A lateral view depicts the arthrokinematics at the talocrural joint during passive dorsiflexion (A) and plantar flexion (B). Stretched (taut) structures are shown as thin elongated arrows; slackened structures are shown as wavy arrows.

72. ROM TALOCRURAL JOINT DURING GAIT
Dr. Michael P. Gillespie
FIGURE    The range of motion of the right ankle (talocrural) joint is depicted during the major phases of the gait cycle. The push off (propulsion) phase (about 40% to 60% of the gait cycle) is indicated in the darker shade of green.

73. FACTORS THAT INCREASE THE MECHANICAL STABILITY OF DORSIFLEXED TALOCRURAL JOINT
Dr. Michael P. Gillespie
FIGURE 14-20A, B.   Factors that increase the mechanical stability of the fully dorsiflexed talocrural joint are shown. A, The increased passive tension in several connective tissues and muscles is demonstrated. B, The trochlear surface of the talus is wider anteriorly than posteriorly (see red line). The path of dorsiflexion places the concave tibiofibular segment of the mortise in contact with the wider anterior dimension of the talus, thereby causing a wedging effect within the talocrural joint.

74. 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

75. AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
FIGURE 14-22A&B.   The axis of rotation and osteokinematics at the subtalar joint. The axis of rotation (red) is shown from the side (A) and above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. The movement of pronation, with the main components of eversion and abduction, is demonstrated in D. The movement of supination, with the main components of inversion and adduction, is demonstrated in E. In D and E, blue arrows indicate abduction and adduction, and purple arrows indicate eversion and inversion.

76. AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
FIGURE 14-22C.   The axis of rotation and osteokinematics at the subtalar joint. The axis of rotation (red) is shown from the side (A) and above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. The movement of pronation, with the main components of eversion and abduction, is demonstrated in D. The movement of supination, with the main components of inversion and adduction, is demonstrated in E. In D and E, blue arrows indicate abduction and adduction, and purple arrows indicate eversion and inversion.

77. AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
FIGURE 14-22D.   The axis of rotation and osteokinematics at the subtalar joint. The axis of rotation (red) is shown from the side (A) and above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. The movement of pronation, with the main components of eversion and abduction, is demonstrated in D. The movement of supination, with the main components of inversion and adduction, is demonstrated in E. In D and E, blue arrows indicate abduction and adduction, and purple arrows indicate eversion and inversion.

78. AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
Dr. Michael P. Gillespie
FIGURE 14-22E.   The axis of rotation and osteokinematics at the subtalar joint. The axis of rotation (red) is shown from the side (A) and above (B); this axis is shown again in C. The component axes and associated osteokinematics are also depicted in A and B. The movement of pronation, with the main components of eversion and abduction, is demonstrated in D. The movement of supination, with the main components of inversion and adduction, is demonstrated in E. In D and E, blue arrows indicate abduction and adduction, and purple arrows indicate eversion and inversion.

79. BONES & JOINTS OF THE RIGHT FOOT
Dr. Michael P. Gillespie
FIGURE 14-23A, B.   A, The bones and disarticulated joints of the right foot are shown from two perspectives: superior-posterior (A) and superior-anterior (B). The overall organization of the joints is highlighted in A.

80. 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

81. TRANSVERSE TARSAL JOINT
Dr. Michael P. Gillespie
FIGURE    The transverse tarsal joints allow for pronation and supination of the midfoot while one stands on uneven surfaces.

82. PLANTAR ASPECT RIGHT FOOT
Dr. Michael P. Gillespie
FIGURE    Ligaments and tendons deep within the plantar aspect of the right foot. Note the course of the tendons of the fibularis longus and tibialis posterior.

83. AXES OF ROTATION & OSTEOKINEMATICS TRANSVERSE TARSAL JOINT
Dr. Michael P. Gillespie
FIGURE 14-27A-E.   The axes of rotation and osteokinematics at the transverse tarsal joint. The longitudinal axis of rotation is shown in red from the side (A and C) and from above (B). (The component axes and associated osteokinematics are also depicted in A and B.) Movements that occur around the longitudinal axis are (D) pronation (with the main component of eversion) and (E) supination (with the main component of inversion). The oblique axis of rotation is shown in red from the side (F and H) and from above (G). (The component axes and associated osteokinematics are also depicted in F and G.) Movements that occur around the oblique axis are (I) pronation (with main components of abduction and dorsiflexion) and (J) supination (with main components of adduction and plantar flexion). In I and J, blue arrows indicate abduction and adduction, and green arrows indicate dorsiflexion and plantar flexion.

84. AXES OF ROTATION & OSTEOKINEMATICS TRANSVERSE TARSAL JOINT
Dr. Michael P. Gillespie
FIGURE 14-27F-J.   The axes of rotation and osteokinematics at the transverse tarsal joint. The longitudinal axis of rotation is shown in red from the side (A and C) and from above (B). (The component axes and associated osteokinematics are also depicted in A and B.) Movements that occur around the longitudinal axis are (D) pronation (with the main component of eversion) and (E) supination (with the main component of inversion). The oblique axis of rotation is shown in red from the side (F and H) and from above (G). (The component axes and associated osteokinematics are also depicted in F and G.) Movements that occur around the oblique axis are (I) pronation (with main components of abduction and dorsiflexion) and (J) supination (with main components of adduction and plantar flexion). In I and J, blue arrows indicate abduction and adduction, and green arrows indicate dorsiflexion and plantar flexion.

85. 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

86. MEDIAL LONGITUDINAL ARCH
Dr. Michael P. Gillespie
FIGURE    The medial side of a normal foot shows the medial longitudinal arch (white) and the transverse arch (red).

87. ACCEPTING BODY WEIGHT DURING STANDING
Dr. Michael P. Gillespie
FIGURE 14-29A, B.   Models of the foot show a mechanism of accepting body weight during standing. A, With a normal medial longitudinal arch, body weight is accepted and dissipated primarily through elongation of the plantar fascia, depicted as a red spring. The footprint illustrates the concavity of the normal arch. B, With an abnormally dropped medial longitudinal arch, the overstretched and weakened plantar fascia, depicted as an overstretched red spring, cannot adequately accept or dissipate body weight. As a consequence, various extrinsic and intrinsic muscles are active as a secondary source of support to the arch. The footprint illustrates the dropped arch and loss of a characteristic instep.

88. 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

89. PES CAVUS – ABNORMALLY RAISED MEDIAL LONGITUDINAL ARCH
Dr. Michael P. Gillespie
FIGURE    A photograph of a right foot of a man with idiopathic pes cavus. Several key joints and bony landmarks are indicated.

90. CHANGE IN HEIGHT IN THE MEDIAL LONGITUDINAL ARCH
Dr. Michael P. Gillespie
FIGURE    A, The percent change in height of the medial longitudinal arch throughout the stance phase (0% to 60%) of the gait cycle. On the vertical axis, the 100% value is the height of the arch when the foot is unloaded during the swing phase. B, Plot of frontal plane range of motion at the subtalar joint (i.e., inversion and eversion of the calcaneus) throughout the stance phase. The 0-degree reference for frontal plane motions is defined as the position of the calcaneus (observed posteriorly) while a subject stands at rest. The push off phase of walking is indicated by the darker shade of purple.

91. ACTIONS ASSOCIATED WITH EXAGERRATED PRONATION OF THE SUBTALAR JOINT DURING WEIGHT BEARING
Joint of Region
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

92. OSTEOKINEMATICS OF FIRST TARSOMETATARSAL JOINT
Dr. Michael P. Gillespie
FIGURE 14-36A, B.   The osteokinematics of the first tarsometatarsal joint. Plantar flexion occurs with slight eversion (A), and dorsiflexion occurs with slight inversion (B).

93. METATARSOPHALANGEAL JOINT
Dr. Michael P. Gillespie
FIGURE    A medial view of the first metatarsophalangeal joint showing the cord and accessory portions of the medial (collateral) capsular ligament. The accessory portion attaches to the plantar plate and sesamoid bones. (Redrawn from Haines R, McDougall A: Anatomy of hallux valgus, J Bone Joint Surg Br 36:272, 1954.)

94. HALLUX VALGUS Dr. Michael P. Gillespie
FIGURE 14-39A.   Hallux valgus. A, Multiple features of hallux valgus (bunion) and associated deformities. B, Radiograph shows the following pathomechanics often associated with hallux valgus: (1) adduction of the first metatarsal (toward the midline of the body), evidenced by the increased angle between the first and second metatarsal bones; (2) lateral deviation of the proximal phalanx with dislocation or subluxation of the first metatarsophalangeal joint; (3) displacement of the lateral sesamoid; (4) rotation (eversion) of the phalanges of the great toe; and (5) exposed first metatarsal head, forming the so-called “bunion.” (From Richardson EG: Disorders of the hallux. In Canale ST, ed: Campbell’s operative orthopaedics, vol 4, ed 9, St Louis, 1998, Mosby.)

95. COMMON FIBULAR (PERONEAL) NERVE
Dr. Michael P. Gillespie
FIGURE    The path and general proximal-to-distal order of muscle innervation for the deep and superficial branches of the common fibular (peroneal) nerve. The primary spinal nerve roots are in parentheses. The general sensory distribution of this nerve (and its branches) is highlighted along the dorsal-lateral aspect of the leg and foot. The dorsal “web space” of the foot is innervated solely by sensory branches of the deep branch of the fibular nerve. The cross-section highlights the muscles and nerves located within the anterior and lateral compartments of the leg. (Modified with permission from deGroot J: Correlative neuroanatomy, ed 21, Norwalk, 1991, Appleton & Lange.)

96. TIBIAL NERVE Dr. Michael P. Gillespie
FIGURE    The path and general proximal-to-distal order of muscle innervation for the tibial nerve and its branches. The primary spinal nerve roots are in parentheses. The general sensory distribution of this nerve is highlighted along the lateral and plantar aspects of the leg and foot. The cross-section highlights the muscles and nerves located within the deep and superficial parts of the posterior compartment of the leg. (Modified with permission from deGroot J: Correlative neuroanatomy, ed 21, Norwalk, 1991, Appleton & Lange.)

97. 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.

98. 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.

99. 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

100. Tarsal Tunnel

101. 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.

102. Tinel’s Foot Sign

103. 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.

104. 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.

105. 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

106. 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.

107. Thompson’s Test

108. ACTIONS ACROSS TALOCRURAL AND SUBTALAR JOINTS
Dr. Michael P. Gillespie
FIGURE    The multiple actions of muscles that cross the talocrural and subtalar joints, as viewed from above. The actions of each muscle are based on its position relative to the axes of rotation at the joints. Note that the muscles have multiple actions.

109. MUSCLES OF THE ANTERIOR COMPARTMENT OF THE LEG (PRETIBIAL “DORSIFLEXORS”)
Tibialis anterior
Externsor digitorum longus
Extensor hallucis longus
Fibularis tertius
Innervation
Deep branch of the fibular nerve
Dr. Michael P. Gillespie

110. PRETIBIAL MUSCLES Dr. Michael P. Gillespie
FIGURE    The pretibial muscles of the leg: tibialis anterior, extensor digitorum longus, extensor hallucis longus, and fibularis tertius. All four muscles dorsiflex the ankle.

111. LATERAL COMPARTMENT MUSCLES
Dr. Michael P. Gillespie
FIGURE    A lateral view of the muscles of the leg is shown. Note how both the fibularis longus and fibularis brevis (primary evertors) use the lateral malleolus as a pulley to change direction of muscular pull across the ankle.

112. LATERAL COMPARTMENT OF THE LEG (“EVERTORS”)
Muscles
Fibularis longus
Fibularis brevis
Innervation
Superficial branch of the fibular nerve
Dr. Michael P. Gillespie

113. 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
Innervation
Tibial nerve
Dr. Michael P. Gillespie

114. POSTERIOR COMPARTMENT MUSCLES: SUPERFICIAL
Dr. Michael P. Gillespie
FIGURE 14-48A, B.   The superficial muscles of the posterior compartment of the right leg are shown: A, gastrocnemius; B, soleus and plantaris.

115. POSTERIOR COMPARTMENT MUSCLES: DEEP
Dr. Michael P. Gillespie
FIGURE    The deep muscles of the posterior compartment of the right leg: the tibialis posterior, flexor digitorum longus, and flexor hallucis longus.

116. NERVE INJURY AND RESULTING DEFORMITIES OR ABNORMAL POSTURES
Nerve Injury / Associated Paralysis
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

117. NERVE INJURY AND RESULTING DEFORMITIES OR ABNORMAL POSTURES
Nerve Injury / Associated Paralysis
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

118. Proprioceptive Training