Anatomical and biomechanical information on the foot and ankle complex and

gait.

Anatomy of the foot and ankle

The foot and ankle complex is composed of twenty-eight irregular shaped bones making

up twenty-five component synovial joints. Together with other elements to be discussed

later, the bones and joints are able to meet the demands of transmitting the load of the

whole body mass under varying conditions e.g. changing terrain, standing, walking, and

running (Brukner & Khan, 2006; Levangie & Norkin, 2005; Hamill & Knutzen, 2003;

Watkins, 1999;).

The foot and ankle complex also provides stability and mobility, as well as a strong base

to assist with the repetitive impact and muscular activity that is required of it during

walking and running. It assists with efficient energy transfer from ground reaction forces

into the musculoskeletal system through the long bones and dissipation of force via the

musculature and in doing so this also facilitates efficient use of available energy stores.

Anatomically the foot and ankle complex is divided into three constituent parts; the

hindfoot, midfoot and the forefoot.

The Hindfoot

The hindfoot is composed of the talus and the calcaneus. The human talus is of

particular interest as its functions are varied. It has been described as the ‘unusual

bone’, ‘caged bone’ and the ‘relay station’ (Kapandji, 1987). This is due to its various
roles within the foot complex. It is ‘unusual’ in that it transmits force, derived from the

body mass, in three directions. The proportional force transmitted posterior towards the

heel can be up to 75% (Wang et al, 1995), and anterior and medially toward the medial

arch and laterally toward the lateral arch, dispersing the force during standing, walking

and running.

It has been described as the ‘caged’ bone due to the proximity of muscles and tendons

that pass from the leg to the foot, but do not insert into it. And finally it is also described

in Kapandji as the ‘relay station’ in that it’s whole surface constitutes articular facets

together with ligamentous insertions. The superior articular facet of the talus forms part

of the talocrural joint articulating with the surfaces of the distal tibia and fibula making a

tenon-mortise joint with two degrees of freedom allowing dorsiflexion and plantar

flexion, inferiorly the talus forms the complex subtalar joint with the calcaneus and

anteriomedially, the talonavicular joint, with the navicular bone (Levangie & Norkin,

2005). The talus articulates with the calcaneus at three different sites; posteriorly,

anteriorly and medially and allows in weight-bearing; subtalar neutral, subtalar pronation

(a combination of calcaneal inversion, abduction and dorsiflexion) and subtalar

supination (a combination of calcaneal eversion, talar adduction and plantarflexion).

The subtalar joint has been found to be highly variable (Bilodi, 2006: Levangie & Norkin,

2005).

Bilodi (2006) studied dry human tali (N = 240) of unknown sex and found up to 5

different types of articular facet on the plantar aspect of the talus. Their cohort was
drawn from the Nepalese population, and so their results may be biased towards that

population alone and the results may not be appropriate to apply to other western

populations, however this research does show the need for clinicians to take into

consideration ethnicity and cultural diversity when assessing foot and ankle injury.

The Midfoot

The midfoot is composed of the navicular, cuboid and three cuneiform bones. The joints

of note in the midfoot are the talonavicular joint and the calcaneocuboid together known

as the midtarsal joint. Subtalar joint pronation causes an increase in the range of motion

at the midtarsal joint making the foot more flexible. Subtalar joint supination decreases

the range of motion at the midtarsal joint and creates a more rigid foot (Graves et al.,

1994)

The forefoot

The forefoot is composed of the metatarsals and phanlanges. Of note are the first and

second metatarsals. The first metatarsal known as the Hallux has muscular insertions

of tibialis anterior and peroneus longus, bears the most weight of the toes during gait

and plays an important role in propulsion together with the second metatarsal,

discrepancies in weightbearing between these two toes may lead to imbalances in soft

tissues locally and further along the kinetic chain resulting in overload and injury

(Brukner & Khan, 2006)

The structure of the arches

In concert, the hindfoot, midfoot and forefoot form three architectural arches; the lateral

longitudinal arch, transverse arch and the largest of all three, the medial longitudinal

arch. All the constituent joints of the ankle and foot are stabilised by over one hundred

ligaments and mobility and stability is also produced by over thirty intrinsic foot and

extrinsic leg muscles.

The Lateral Longitudinal Arch

The lateral longitudinal arch is derived from the calcaneus, cuboid and the fourth and

fifth metatarsals, it contacts the ground via the soft tissues. It is relatively rigid

compared to the medial longitudinal arch. This more fixed structure provides a lever

arm for the triceps surae to create a propulsive force during gait. The peroneus longus,

brevis and the abductor digit minimi exert force on the lateral longitudinal arch to

enhance rigidity to give this propulsive force a greater mechanical advantage (Kapandji,

1987).

The Transverse Arch

As the longitudinal arches run the whole length of the foot, so does the transverse arch.

From the first to the fifth metatarsal (‘anterior heel’ of the transverse arch) where it

approximates the ground via the soft tissues, to the cuneiforms and cuboid bone

laterally, more medially the navicular is above the ground and is supported by fibres of

the tibialis posterior. The peroneus longus also supports the transverse curvature of the

foot at this point.

The Longitudinal Medial Arch

The longitudinal medial arch constituent bones are from posterior to anterior; the

calcaneus, talus, navicular, medial cuneiform and first metatarsal. The calcaneus and

the head of the first metatarsal are in contact with the ground, the navicular is the

keystone of the longitudinal medial arch and lies approximately 15 – 18 mm above the

ground and is pulled inferior and posterior toward the talus by the tibialis posterior, and

the keystone is further supported by the plantar ligament. The curvature is further

enhanced by the peroneus longus flexing the first metatarsal against the medial

cuneiform, this together with flexor hallucis longus ‘tightens’ the curvature through the

full forefoot and midfoot. Abductor hallucis longus running from the calcaneus to the

great toe approximates these two points to further tighten the medial longitudinal arch.

This musculoskeletal architectecturally structural arrangement within the foot serves

several purposes. It is strong enough to support the entire weight of the body as well as

flexible enough to begin to absorb the shock of impact of the foot during gait (Reilly et

al., 2006). To understand the importance of the structure of the human foot, within the

kinetic chain, it is necessary to review the gait cycle in both walking and running.

The Gait Cycle in Walking

One full gait cycle is defined as the time from when one foot heel strikes the ground to

the next time that heel strikes the ground once more. The gait cycle can be divided into
stance and swing phases. The stance phase can be further broken down into an initial

‘double support’ phase, one ‘single support’ phase followed by a further ‘double support’

phase. Double support and single support refer to both feet being in contact with the

ground and single foot contact respectively. The swing phase as it suggests is whilst the

limb is not in contact with the ground. Although the gait cycle is descriptively divided into

these phases and stages for ease of understanding it must be understood that these

divisions are in reality one continuous movement so that one or more stages tend to

blend together during walking, so although we have tried to demonstrate what happens

in the gait cycle in the following paragraphs it is somewhat difficult to be completely

accurate.

Stance Phases

The entire stance phase comprises 3/5ths of the complete cycle. The limb is supporting

the whole body whose mass is transferred from the calcaneus to the head of the

metatarsals as the center of gravity passes anterior through the foot. Stance is broken

down into double support, single support and then double support once more. These

phases are described as follows:

First Double Support Phase

For ease of description this first phase is broken down into a further 2 stages, initial

contact and loading response.

The Initial Contact Stage

 This begins with the lateral heel striking the ground in a momentary supinated

position and then a rapid change to subtalar joint pronation as the heel rolls

forward and inward, this subtalar joint pronation also increases the range of

motion at the midtarsal joint allowing a degree of flexibility within the foot and

shock absorption (James et al., 1978; Hetsroni et al., 2006). There is internal

rotation at the pelvis, femur and tibia, which carries on through loading response

until the initiation of midstance.

Loading Response Stage

Also known as foot pronation; the foot reacts to the mass of the body by rolling

forward and medially on to the heel to sustain body momentum and the foot is

brought into full contact with the ground.

The Single Support Phase

Single support phase is further broken down into two stages; midstance, terminal stance

stages.

Midstance Stage

This stage initiates the single stance phase. An ankle rolling action occurs to

bring the body weight over the planted foot, this helps sustain the body’s forward

momentum. There is subtalar joint supination which decreases the midtarsal joint

range of motion and in so doing creates a more rigid foot to assist with

propulsion. There is external rotation of the pelvis, femur and tibia. Additonally

the plantar fascia tightens during this stage to further assist with a ‘springy’
 tightening of the foot, this mechanism is known as the Windlass Effect (Aquino &

Payne, 2001).

Terminal Stance Stage

This begins with raising the heel off the ground and the lower limb rolls forward

on to its forefoot. The body mass advances ahead of the sole-supporting foot.

Mid and terminal stance make up the single stance interval (changing from

pronation to re-supination).

The Second Double Support Phase

This is the last stance phase and the last interval of double support, consists of

one stage, Preswing.

Pre-swing Stage

The lower limb is positioned to quickly swing forward beneath the advancing

body as the body weight is unloaded from one limb and transferred to the

opposite limb. It ends with the forefoot rolling off the ground leading to the

beginning of the next phase or toe off. The stance phase ends with no hip

flexion, ~40° knee flexion and ~15° ankle flexion.

Muscular activity during stance phases

 The gluteus maximus and hamstrings extend the hip early in the stance phase

and the hip flexors control this movement before toe-off.

  The gluteus medius and minimus abduct the hip and the hip medial rotators act

in the first half of the stance phase. Late in the stance phase the adductors and

lateral rotators control the momentum generated by the aforesaid muscle groups.

 The quadriceps femoris acts at the beginning of the stance phase extending the

knee. The hamstrings flex the knee just before toe-off.

 The dorsiflexors of the foot act eccentrically, immediately after heel strike to

control plantar flexion under the force of gravity and bring the foot into full contact

with the ground. This involves the anterior compartment of the leg; tibialis

anterior, extensor hallucis longus and extensor digitorum longus, as well as

quadriceps femoris.

 The plantar flexors act throughout the second half of the stance phase powering

the forward thrust of the body using the thigh and leg as a single unit. The body

is powered forward by the plantar flexors and hip extensors (triceps surae,

gluteus maximus and the hamstrings).

 6. As the body weight comes onto the foot the extrinsic and intrinsic foot muscles

contract to support the plantar ligaments (abductor hallucis longus, peroneus

longus, peroneus brevis and the abductor digit minimi).

The Swing Phase

This phase is broken down into three final stages, initial swing, midswing and terminal

swing stages.
 Initial Swing Stage

This begins with toe-off of the supporting limb. The foot is pushed off the ground

and the now un-supporting limb accelerates forward helping to provide the force

to sustain forward body momentum.

Midswing Stage

The limb passes beneath the body to where the tibia is vertical.

Terminal Swing Stage

The limb decelerates forward motion in preparation for the initial contact of the

stance to initiate a new gait cycle.

Muscular activity during swing stages

 The hip flexors already functioning at the end of the stance phase continue into

early swing phase along with the adductors and lateral rotators of the hip;

however they are essentially ‘silent’ in mid-swing as the mass of the thigh

‘swings’ the lower limb forward. Limb motion is controlled at the end of the swing

phase by the eccentric activity of the hip extensors.

 The hamstrings function late in the stance phase and continue into early swing

phase to flex the knee. The forward motion of the limb in the swing results in the

transition from flexion to extension at the knee with some assistance from the

quadriceps muscles. This movement is stopped by the hamstrings just before

heel strike.
The Gait Cycle in Running

The running gait is comparative to the walking gait in that it is divided once more into

stance and swing phases. The stance phase is further broken down into three stages;

contact, mid-stance and propulsion stages. The swing phase is broken down into

follow-through, foot-swing, and foot descent. Relative timings of stance to swing ratio

also change from that of walking, which is approximately 60:40 respectively (Mann,

1975). This ratio changes in running from a similar ratio to that of walking in slow

running, to approximation of each phase in faster running and then stance phase

becomes shorter than swing phase during sprinting. In walking there are periods of

double support and single support by the limb that may be occurring at any one time.

During running there is a ‘flight stage’ when neither foot is in contact with the ground.

This change in foot contact affects the forces borne by the ankle and foot in both

walking and running. Vertical compressive forces of between 0.8 and 1.1 times the

individuals’ body weight act at these joints during heel strike in walking. This increases

to 1.3 times the body weight, at toe-off. Shearing forces also contribute to the stress at

these joints of between 0.45 and 0.8 times the body weight. Burdett (1982) postulated

that peak ankle joint forces in running may reach between 9 and 13 times that of body

weight. Since the talus is the ‘keystone’ of the foot, this bone, along with it’s

articulations with the calcaneus and navicular are also subject to these forces. The

importance of investigating the mechanics of these joints then becomes apparent.

Forces are large at these articulations as the foot must transmit not only the force of the
body mass to the foot but also the ground forces from impact, to the body via the foot

and ankle (Hamill & Knutzen, 2003).