ANKLE AND FOOT

MUSCLE COMPARTMENT
1. ANTERIOR COMPARTMENT ( DORSAL FLEXORS ) ? 2. LATERAL COMPARTMENT ( EVERTORS ) ?

 3. DEEP POSTERIOR COMPARTMENT ( PLANTAR FLEXOR )

4. SUPERFICIAL PLANTAR COMPARTMENT ( PLANTAR FLEXOR )

 the same tendon, nearing its digital attachment on the distal phalanx, passes through an osteofibrous groove on the plantar surface of the big toe.

 Talocrural joint
Type of joint The talocrural joint, between the talus and the crus is a hinge joint with one degree freedom of motion. The talocrural joint is usually referred to as the ankle joint. The trochlea of the talus possesses a superior weight bearing surface that articulates with the distal end of the tibia nd has medial and lateral surfaces that articulate with the medial malleolus of the tibia and the lateal malleolus of the fibula.

TERMINOLOGY FOR MOTIONS OF THE TARSAL JOINTS

 Abduction and adduction of the foot and ankle from rotations that occurs in the knee and the hip for example, when a person is sitting in a chair with his or her feet on the floor, the foot can be moved medially or laterally around a vertical axis through the tibia. Motion however, is not occurring in the joints of the foot but rather between the tibia and femur by alternate activation of the medial and then lateral hamstring.

 Average motion in the frontal plane with 20 degrees of medial tilt (supination) and 20 degrees of lateral tilt (pronation) was greater for the talonavicular joint (13 and 8 degrees) than for the subtalar joint (6 and 3 degreees). Total motion, a composite including flexion extension, rotation, translation, and abduction-adduction, was measured in midfoot joints. Average motion in the talonavicular jont with dorsiflexionplantarflexion was 7 degrees and with supination-pronation, 17 degrees. The calcaneocuboid joint had an average of 2 and 7 degrees.

TARSOMETATARSAL JOINTS

MUSCLES OF THE ANKLE AND FOOT

FUNCTION OF THE TRICEPS SURAE

 The tendon of the flexor digitorum longus lies only slightly farther back. The flexor hallucis longus has somewhat better leverage, but its action as a plantarflexor of the ankle still is insignificant compared with that of the triceps surae.

 The importance of the soleus as a postural muscle has been confimed by EMG. Joseph (1960), in studying the activity of various muscles in the standing-at-ease position, found continuous electrical activity in the soleus in all of the 12 subjects investigated; activity in the gastrocnemius could be detected in only 7 of the 12 subjects. A force of one half the body weight was calculated for the soleus to maintain a unilateral stance.

 The tendons of the flexor digitorum longus and flexor hallucis longus have a shortening effect on the foot in a front-to-back direction, and the calcaneus, having lost the counterbalancing effect of the triceps surae, assumes a dorsiflexed position. Bilateral paralysis of the triceps surae causes loss of standing balance because there is insufficient muscle force to prevent the tibia from dorsiflexing and collapsing on the foot. they have no muscles to control closed-chain positions of the feet and ankles.

 INSPECTION AND PALPATION:

of walking.

 Note that when eversion of the foot is resisted in the sitting position, external rotation of the leg with respect to the thigh occurs simultaneously; the prominent tendon of the biceps femoris is seen at the knee.
In open-chain motion, the peroneus longus, brevis, and tertius are the main evertors of the subtalar joint and do so whether the ankle is in dorsiflexion or plantarflextion.

EXTENSOR DIGITORUM LONGUS

The extensor digitorum longus (EDL) and peroneus tertius muscles are described together because they usually are not well differentiated in their upper portions. The peroneus tertius is the most lateral part of the EDL but is sometimes described as a separate muscle.

 It is superficial, bordering laterally to the peronei muscles and medially to the EHL and the anterior tibialis. PA: The EDL attaches to the upper portion of the tibia and fibula, interosseous membrane, and intermuscular septa and fascia; the peroneus tertius attaches to the distal portion of the fibula and to the interosseous membrane.

 The common tendon passes on the dorsum of the ankle, and, like the other tendon in this region it is held down by the transverse and cruciate ligaments.

DA: Four tendons go to the bases of the middle and distal phalanges of the four lesser toes; the tendon of the peroneus tertius goes to the dorsum of the fith metatarsal bone.

 Innervation: Deep peroneal nerve (L4-S1). Anatomic actions: Extension of MTP and IP joints of the four lesser toes and dorsiflexion and eversion of the ankle. INSPECION AND PALPATION: Have the subject sit on a chair and lift the toes off the floor while maintaining the sole on the floor.

 If resistance is given to the four lesser toes, the individual tendons stand out better. The tendon of the peroneus tertius, when present and observable, is seen lateral to the tendon going to the fifth toes. The distal attachment of this tendon is variable, and the muscle may be missing altogether.

FUNCTION OF THE PRETIBIAL GROUP

The anterior tibialis is the primary dorsiflexor of the ankle. It has good leverage, a straight line of pull, acts on the upper ankle joint only, and has twice the cross-sectional area of the toe extensors combined. The EHL and the EDL extend the toes frist, and this lose effectiveness in dorsifleion of the ankle.

 When the anterior tibialis is paralyzed and the toe extensors are intact, a limited range of dorsiflexion of the ankle can be produced. If the EDL acts in isolation, a strong eversion of the ankle occurs. Paralysis of the muscles results in a drop-foot during the swing phase of walking and requires excess hip and knee flexion to keep from tripping or dragging the toes on the floor.

 The pretibial group moves the foot and toes in many important open-chain motions such as preventing the foot and toes from dragging in the swing phase of walking, placing the foot for driving, keeping time to the beat of music, or wiggling toes into shoes. Open-chain motions of the foot require little muscle force because the foot weighs only about 2 lb and the muscles have good leverage.

 Stronger contractions can be seen and palpated when a subject is standing on one foot in close-chain motion.

INTRINSIC MUSCLES OF THE FOOT

There are four layers of intrinsic muscles that occur on the plantar surface of the foot. These tissues form strong coupling of the status and dynamic structures.

 Although the muscles can perform motions such as abduction, adduction, and flexion of the toes, their major functions are supporting the arches in walking and running, supplementing the force of the long toe flexors, and maintaining the toes in extension for the forceful pull of the flexors at pull-off.

 If the toes are not maintained in extension, they curl and the force for push-off is not effective.
The extensor digitorum brevis is the only intrinsic muscle on the dorsum of the foot.
Its proximal attachments and muscle bely are on the dorsolateral side of the foot just below the sinus tarsi.

 Innervations: Branch of the deep peroneal nerve (L5-S1). Anatomical action: Extension of the MTP joints of the medial four toes. Contraction balances the medial pull of the extrinsic toe extensors.

USE OF TOES FOR SKILLED ACTIVITIES

With one exception, movements performed by the human hand can potentially be performed by the foot. Opposition of the thumb is not represented in the foot. The possibilities of developing the feet for grasping objects and performing skilled sensorimotor tasks have been amply demonstrated by children with congenital amputations of the upper extremities, particularly if the entire limbs are missing.

FUNCTION OF LOWER EXTREMITY MUSCLES

The lower extremities have major functional requirements in high-energy closed-chain motion. For example, when a person is standing, it is impossible to move one leg in open-chain motion to take a step or to kick a ball unless the person can stand and support body weight on the opposite leg in closed-chain motion.

 Palpation of muscles along with observation of these activites demonstrates that raising and lowering the body weight uses the same muscle groups with concentric and eccentric muscle contractions. These contractions are not related to anatomic actions of muscles that are defined for openchain motion.

 In addition to analysis of these activities, it is helpful to analyze in slow motion stair climbing for muscle activation in the moving extremity in open-chain motion, and in the fixed extremity in closed-chain motion.

ARCHES OF THE FOOT

The ability of the foot to change from rigid structure within a single step upon the bony structure of the three foot, static ligament-fascial support, muscle contraction. a flexible to a is dependent arches of the and dynamic

In closed-chain motion, superincumbent body weight is distributed through the talus posteriorly to the tuberosity of the calcaneus and anteriorly to the heads of the metatarsal bones and the toes.

 Body weight is distributed to these points through the three arches. The medial longitudinal arch is the longest and the highest. It is composed of the calcaneus, the talus, the navicular, the medial cuneiform, and the first metatarsal bones.

 The lateral longitudinal arch is lower and composed of the calcaneus, the cuboid, and the fifth metatarsal. The transverse arch is concave from medial to lateral in the midtarsal and tarsometatarsal areas.

 Structurally, the arches of the foot have some of the properties of the mechanical arch, such as wedge-shaped bones, but lack the peripheral buttresses needed to prevent collapse of the arch.
Ligaments, however, connect the tarsal and metatarsal bones on the dorsal and plantar surfaces to bind the bones of the curved beam bends, and compression forces occur on the top (convex side) and tension forces occur on the plantar surface (concave side).

 As the amount of load increases, the beam eventually collapses. Larger forces can be supported by the beam if a ties-rod is placed across the base of the beam to prevent the two ends from moving apart. Mechanically, this is the truss, which is a variant of the arch.

 In the foot, the tie-rod is represented by the plantar aponeurosis as well as by contraction of intrinsic and extrinsic muscles of the foot. The plantar aponeurosis is a strong series of fascial bands that invest the sole and sides of the foot from a 2- to 3-cm proximal attachment on the tuberosity of the calcaneus to the toes.

 The aponeurosis is an attachment for instrinsic muscles of the foot and is the fascial covering for others. Complex vertical septa (walls) and lateral mooring structures connect the longitudinal bands to deep structures, the skin, and each other.

When the joint is hyperextended, tension is placed on the plantar aponeurosis.

 This tension prevents the displacement of the calcaneus from the metatarsal heads and collapse of the arches in addition to compressing the tarsal and metatarsal bones into a rigid structure. Such rigidity is needed when standing on the toes and in the terminal stance phase of walking.

 Mechanically, the MTP anoneurotic mechanism is similar to the windlass, which is a drum with rope wound around it and with a crank to turn it. The quarter turn produced by the MTP joints in hypertension converts the tarsal joints into a rigid structure and a flexible structure when the MTP joint is in a neutral or flexed position.
This can be experienced when a person stands on a step or a large telephone book with the edge of the book at the MTP joint.

 Weight bearing on the foot is seen to be flexible in pronation to conform to the surface and the MTP joint goes into flexion. When the MTP joint is manually placed in about 45 degrees hyperextension, however, the arches of the foot become rigid, and the plantar aponeurosis can be felt to be firm.

DYNAMIC MUSCLE FORCES

All the extrinsic and most of the intrinsic muscles on the plantar surface of the foot cross under the arches. When the muscles contract in closed-chain motion, the forces that are produced tighten the arches.

 The posterior tibialis and the peroneus longus with their extensive plantar attachments have major effects on the transverse arch but also tighten the longitudinal arches. The flexor hallucis longus and the abductor hallusis span the medial arch, and the abductor digiti minimi runs the length of the lateral arch.

 The flexor digitorum brevis, quadrates plantae, and flexor digitorum longus run the midplantar length and tighten the longitudinal arches. The adductor hallucis affects the transverse arch.

LOADING OF THE FOOT

Conventionally, weight distribution in standing is stated to be in a 50-50 percent manner on the calcaneus and the metatarsal heads with the first metatarsal head absorbing twice the weight that each of the four lateral metatarsal heads supports in a proportion of 2:1:1:1:1.

 Vertical loading of the medial longitudinal arch of the foot in bilateral standing can be measured clinically by the distance of the tubersotiy of the navicular from the floor when the person is sitting (non-weight bearing) and standing (weight bearing).

 The foot is supported by osseous and ligamentous structures using the curved beam and truss mechanics. As the load increases and arches are stressed., the muscles become the second line of stability.

 With walking, running and standing on the toes, muscle contraction and windlass mechanism are added to support the arches. EMG activity of the extrinsic and intrinsic muscles that support the arches begins shortly after the foot contacts the ground in the stance phase and continues as the heel rises and the MTP joint hyperexterds to tighten the plantar aponeurosis.

 The muscle activity and the tension on the aponeurosis continue until the toe leaves the ground. These mechanisms can be observed and palpated on another person during standing and rising up on the toes.
Note the marked supination of the longitudinal arch and inversion of the calcaneus when standing on the toes.

 THE END YEAHHHH.