Ankle and Foot DONALD A. NEUMANN, PT, PhD, FAPTA Pyvae swt POT ‘OsTEOLOGY, 573 Proximal Tifbular Joint, 579 Basic Terms and Concepts, 573 Distal Tibiofibular Joint, 578 "Naming the Joins and Regions, 573 Talorurl soit, 580 Osteclogie Similarities between the Distal Log and Distal Arm, 74, Individual Bones, 574 Subtalr Joint, 585 Structure and Function ofthe Joints Associated with the Foot, $85, [MUSCLE AND JOINT INTERACTION, 605 Innervation of Muscles and Joints, 605 Innervation of Muscles, 605, Sensory Imeration ofthe Joints, 608 ‘Anatomy and Function of the Muscles, 608, Extrinsic Muscles, 607 Fula, $74 “Transverse Tarsal Join (Talonaviclar Muscular Paralysis aftr Injury tothe Fibula Distal Tibia, 575 ‘and Calcaneocuboid Joints), 587 or Tibial Nerve, 614 Tarsal Bones, 875, Combined Action ofthe Subtalar Intrinsic Muscles, 615, Rays ofthe Foot, 578 ‘and Transverse Tarsal Joints, 64 Distal Inetarsal Joints, 599, sywoPsis, 617 “Tarsomatatarsal Jon's, 600 [ADDITIONAL CLINICAL CONNECTIONS, 619 ARTHROLOGY, 578 Intermetatarsal Joints, 601 ‘REFERENCES, 624 Terminology Used to Describe Movements, Metstarsophalangeal Joint, 601 ‘STUDY QUESTIONS, 628 378 Interphalangeal Joints, 603. ‘Structure and Function of the Joints Assoctated with the ‘Ankle, 578, 604 ‘eton of the Joints within the Forefoot uring the Late Stance Phase of Gat alking and running require the foot to be suffi W/ ciently pliable to absorb stress and to conform to the countless spatial configurations between it and the ground, In addition, walking and running require the foot to be relatively rigid in order to withstand potentially large propulsive forces. The healthy foot satisfies the seem- ingly paradoxical requirements of shock absorption, pliabil- ity, and strength through a complex functional and structural interaction among its joints, connective tissues, and muscles Although not emphasized enough in this chapter, the normal sensation of the healthy foot also provides important measures of protection and feedback to the muscles of the lower extremity. ‘This chapter sets forth a firm basis for an understanding ofthe evaluation and treatment of several disorders that allect the ankle and foot, many of which are kinesiologically related to the movement of the entire lower extremity. Several of the kinesiologic issues addressed in this chapter are related specifi aally to the process of walking, or gait, a topic covered in detail in Chapter 15. Figure 15-12 should be consulted as a reference to the terminology used throughout Chapter 14 to describe the different phases of the gait cycle OSTEOLOGY Basic Terms and Concepts NAMING THE JOINTS AND REGIONS Figure 14-1 depicts an_ overview of the terminology that describes the regions of the ankle and foot. 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. Within the foot are three regions, each consisting of a set of bones and one or more joints. The rearfoot (hindfoot) consists of the talus, caleaneus, and subtalar joint; the midfoot consists of the 573574 Section IV Lower Extromity Lateral view Superer ‘corsa (acta ria proaal sore lara tarsal joint Rearfoot Mistoot FIGURE 141. Overall organization of the bones, major joints, and regions of the foot and ankle Forefoot remaining tarsal bones, including the transverse tarsal joi and the smaller distal intertarsal joints; and the forgfoot con- sists of the metatarsals and phalanges, including all joints distal to and including the tarsometatarsl joints. Table 14-1 provides a summary of the organization of the bones and joints of the ankle and foot, ‘The terms anterior and posterior have their conventional meanings with reference to the tibia and fibula (ie, the leg) ‘When describing the ankle and foot, however, these terms are often used interchangeably with distal and proximal, respec- tively. The terms dorsal and plantar describe the superior (top) and inferior aspects of the foot, respectively OSTEOLOGIC SIMILARITIES BETWEEN THE DISTAL LEG ‘AND THE DISTAL ARM ‘The ankle and foot have several features that are structurally similar to the wrist and hand. The radius in the forearm and os) 1, Structural Organization of the Bones and Rearfoot: Caleancus and talus” Bones Tibia Bibula ‘Midfoot. Navicula, cuboid, and “Talus ‘cuseiforms Forefoot: Metatarsals and phalanges Joints Talocrural joint Rearfoot: Subtalar joint Proximal Midjoot: Transverse tsa joi Libiofbular talonavicular and joint caleaneocubotd; distal Distal sbiofbular —interarel joint: joint cuneonavicuar, cuboideonavicular, and interouneiform and cuncocuboid complex Forefoot: Tnsometattsl, intermetatareal, mtatatsophalange, interphalangeal joints a no the fea FIGURE 14-2, Topographic similarities between a pronated forearm and the ankle and foot. Note that the thuml and great toe are both located on the medial side of their respective extremity the tibia in the leg each articulates with a set of small bones-the carpus and tarsus, respectively. When the pisiform of the wrist is considered as a sesamoid (in contrast to a sepa- rate carpal bone), the carpus and tarsus have seven bones cach, The general plan of the metatarsus and metacarpus, as well as the more distal phalanges, is very similar. A notable exception is that the first (great) toe in the foot is not as functionally developed as the thumb in the hand As described in Chapter 12, the entite lower extremity progressively internally or medially rotates during embryo- logic development. As a result, the great toe is positioned on the medial side of the foot, and the top of the foot is actually its dorsal surface, This orientation is similar to that of the hand when the forearm is fully pronated (Figure 14-2), ‘This plantigrade position of the foot is necessary for walking and standing. With the forearm pronated, flexion and exten- sion of the wrist are similar to plantar flexion and dorsiflexion of the ankle, respectively Individual Bones FIBULA ‘The long and thin fibula is located lateral and parallel to the tibia (Figure 13-3). The fibular bead can be palpated just lateral to the lateral condyle of the tibia. The slender shaft of the fibula transfers only about 10% of body weight through theChaper 14 Anil and Foot 515 Anterior viow Anterior tbotibular Tigamer Lateral malleolus: Det Haman dQ) FIGURE 14-8, 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 leg; most of the weight is transferred through the thicker tibia. The shaft of the fibula continues distally to form the sharp and easily palpable lated malleolus (ftom the Latin root mallews, hammer). The lateral malleolus functions as a pulley for the tendons of the fbulars (peroneus) longus and brevis. On the medial surface of the lateral malleolus is the articular facet forthe talus (see ahead Figure 14-11). In the articulated ankle, this facet forms part of the talocrural joint Figure 143). DISTAL TIBIA The distal end of the tibia expands to accommodate loads transferred across the ankle, On its medial side is the promi- nent medial malleolus. On the lateral surface of the medial malleolus is the articular facet for the talus (sce ahead Figure 1411). In the articulated ankle, this facet forms a small part of the talocrusal joint. On the lateral side of the distal bia is the fibular notch, a triangular concavity that accepts the distal end of the fibula at the distal tibioftbular joint (see ahead Figure 14-11) I the adult the distal end of the tibia is twisted externally around its long axis approximately 20 or 30 degrees relative to its proximal end.“ This natural torsion is evidenced by the slight externally rotated position of the foot during stand- ing. This twist of the lower leg is referred to as lateral tibial torsion, based on the orientation of the bone’s distal end relative to its proximal end. ‘Osteologic Features of the Fibula and Distal Tibia Fibula “Head + Lateral malleolus + Articular facet (forthe talus) Distal Tibia * Medial malleolus + Amicular facet (forthe tals) + Fibelar notch TARSAL BONES The seven tarsal bones ate shown in four diflerent perspec- tives in Figures 14-4 through 14-7. ‘Osteologic Features of the Tarsal Bones Talus *Trochlear surface + Head + Neck + Anterior, middle, and posterior facets + Talarsuleus + Lateral and medial tubercles Cateanens Tuberosity Lateral nd meal processes ‘Anterior, middle, and posterior facets Caleanealsuleus Sustentaelum talus Nevialer * Proximal concave (artiular)surfice + Tuberosity Medial Intermediate, and Lateral Cuneforms * Transverse arch Cuboid * Groove (for the tendon ofthe fibulais longus) Talus ‘The talus is the most superiorly located bone of the foot. Its dorsal or trochlear surface is a rounded dome: convex ante- iorposteriorly and slightly concave mediallateraly (see Figures 14-4 and 14-6). Cartilage covers the trochlear surface and its adjacent sides, providing smooth articular surfaces for the talocrural joint.” The prominent head of the talus pro- jects forward and slightly medially toward the navicular. In the adult the long axis of the neck of the talus positions the head of this bone about 30 degrees medial to the sagital plane. In small children the head is projected medially about 40 to 50 degrees, partially accounting for the often inverted appearance of their feet. Figure 14-8 shows three articular facets on the plantar (inferior) surface of the talus. The anterior and middle facets are slightly curved and offen continuous with each other The articular cartilage that covers these facets also covers part of the adjacent head of the talus. The oval, concave posterior face's the largest facet. As a functional set, the three facets articulate with the three facets on the dorsal (superior) surface of the calcaneus, forming the subtalar joint. The talar sulcus is an obliquely running groove between the anteriormiddle and posterior facets, Lateral and medial tubercles ate located on the posterion- medial surface of the talus (see Figure 14-4) A groove formed between these tubercles serves as a pulley for the tendon of the flexor hallucis longus (see ahead Figure 14-12). Calcaneus The calcaneus, the largest of the tarsal bones, is well suited to accept the impact of the heel striking the ground during walking. The large and rough calcaneal tuberosity receives the attachment of the Achilles tendon. The plantar surface of the516 Section IV Lower Extremity Superior view Extensor digtoru longus and brevis Distal and proxial Exensor interphalangeal jonts halle longus Extensor clighorum brevis Metatarsal Medial cuneiform Fibula tertus Fibula brevis Intermediate cunetorm. Naveular- Tuberosiy — Heed Lateral cuneiform aus Nece uboid Crrochiea. Medal and lateral tubercle of al ‘Aches tendon atacning tuberosity FIGURE 14-4, A superior (dorsal) view of the bones ofthe right foot. Proximal atachments of muscles ate indicated in red, distal attach rents in gray FIGURE 14-6. A medial view ofthe bones ‘of the right foot. Invrior vow Flexor cigtorum longus Flexor hallucis longus [Adductorhalueis and ‘lexorhallucs brevis [Abductor and exor allucs brevis Plantar interossel [Abductor and. flexor aig mii Lateral and mesial 'sesamod bones ‘Adductor halve (ctlique mead} Plantar interoseei Floulais longus Albductor and Siexor dit minim’ Tisais anterior ‘Groove for Tislalisposteior fbularis angus Floxorhallue's brevis: ‘Quadratus plantae, Talus Sustentaculum talus Groove fr flexor hallacis longue Flexor cigitorum brevis ‘and abductor halluls Lateral process: FIGURE 14-5. An inferior (planta) view of the bones of the right foot. Proximal attachments of muscler are indicated in red, distal attachments in gray Medial view Facet for Distal phalanx Naviedlar 5 Miaale Proximal ‘uberosiy phalanx phatase tuberosity has lateral and medial proceses that serve as attache ‘ments for many of the intrinsic muscles and the deep plantar fascia of the foot (ve Figure 14-5), ‘The calcaneus articulates with other tarsal bones on its anterior and dorsal surfaces. The relatively small, curved ante- rior surface of the calcaneus joins the cuboid at the calcaneo- cuboid joint (see Figure 147). The more extensive dorsal surface contains three facets that join the matching facets on the talus (see Figure 148). The anterior and middle facets are relatively small and neatly flat. The posterior face is large and convex, conforming to the concave shape of the equally large posterior facet on the talus. Between the posterior and medial facets is a wide oblique groove called the calcancal sulcus, Located within this sulcus are the attachments of several strong ligaments that bind the subtalar joint. With the sub- talar joint articulated, the sulci of the calcaneus and talus form a canal within the subtalar joint, known as the tarsal sins (see Figure 14-7)Chaper 14 Anil and Foot S77 Lateral view Facet for aniculation swith lterat maliatue Subtalar joint (posterior atulation) Tarsal sinus Stylid process Proximal phalanx Miaate phalanx Superior view ‘Tlolais anterior Yenden Anterior Iacet Migate facet Socket for head of talus Interosseous ligament within falar sulcus FIGURE 14-7, A lateral view of the bones of the right foot. Distal phalanges FIGURE 14-8, A superior view of the talus Dipped laterally to reveal its plantar surface as well a the loreal surtace of the calcaneus, With the talus ‘moved, itis possible to observe the thice articular facets located on the talus and on the calcaneus Note also the deep, continuous concavity formed by the proximal sde ofthe navicelar and the spring ‘Spring ligament ‘Tiiais posterior Flexor digtrum longus Anterior facet Mica facet Invorossoous ligament vwilhin aleanea! euloue Posterior facets Cervical garment Flexor hallucs longue! tendon The sustentaculim talus projects medially as a horizontal shelf from the dorsal surface of the calcaneus (See Figure 146). The sustentaculum talus lies under and supports the middle facet of the talus. (Sustentaculum talus literally means a “shelf for the talus.) Navicuar ‘The navicular is named for its resemblance to a ship (Le. referring to “navy”). Its proximal (concace) surface accepts the head of the talus at the talonavicular joint (see Figure 144). The distal surface of the navicular bone contains three relatively flat facets that articulate with the three cuneiform bones. ‘The medial surface of the navicular has a prominent tuber- osify, palpable in the adult at about 2.5 em inferior and distal ligament. This concavity accepts the head of the talus, forming the talonaviculat joint. (The interos- seous and cervical ligaments and multiple tendons have been ent) CCalcaneal (Achiles) {anterioy) to the tip of the medial malleolus (see Figure 14-6) This tuberosity serves as one of several distal attachments of the tibialis posterior muscle ‘Medial, Intermediate, and Lateral Cuneitorms The cuneiform bones (from the Latin root meaning “wedge”) act as a spacer between the navicular and bases of the three medial metatarsal bones (see Figure 14-4). The cuneiforms contribute to the transverse arch of the foot, accounting, in part, for the transverse convexity of the dorsal aspect of the midfoot Cuboia As its name indicates, the cuboid has six surfaces, three of which articulate with adjacent tarsal bones (see Figures 144,578 Section IV Lower Extremity 1455, and 147). The distal surface articulates with the bases of both the fourth and fifth metatarsals. The cuboid is there- fore homologous to the hamate bone in the wrist. ‘The entire, curved proximal surface of the cuboid articu- lates with the calcaneus (see Figure 14-4). The medial surface has an oval facet for articulation with the lateral cuneiform and a small facet for articulation with the navicular. A distinct groove runs across the plantar surface of the cuboid, which in, life is occupied by the tendon of the fibulasis longus muscle (ee Figure 14-5) RAYS OF THE FOOT A ray of the forefoot is functionally defined as one metatarsal and its associated set of phalanges. Metatarsals ‘The five metatarsal bones link the distal row of tarsal bones with the proximal phalanges (sce Figure 144). Metatarsals axe numbered 1 through 5, starting on the medial side. The fisst metatarsal is the shortest and thickest, and the second is ‘usually the longest. The second and usually the third meta- tarsals are the most rigidly attached to the distal row of tarsal bones. These morphologic characteristics generally reflect the larger forces that pass through this region of the forefoot during the push off phase of gait. Each metatarsal has a base atts proximal end, a sha, and a convex head at its distal end (Gee Figure 144, fist metatarsal). The bases of the metatarsals have small articular facets that matk the site of articulation with the bases of the adjacent metatarsals Longitudinally, the shafis of the metatarsals are slightly coneave on their plantar side (see Figure 14-4). This arched shape enhances the load-supporting ability of the metatarsals, and provides space for muscles and tendons. The plantar surface of the first metatarsal head has two small facets for articulation with two sesamord bones that are imbedded within the tendon of the flexor hallucis brevis (see Figure 14-5). The fifth metatarsal has a prominent stloid process just lateral to its base, marking the attachment of the Abularis brevis muscle (ee Figure 14-7), Osteologic Features of a Metatarsal + Base (with articular facets For articulation with the bases of adjacent metatarsals) + Shast + Head + Styloid process (on the fith metatarsal only) Phatanges ‘As in the hand, the foot has 14 phalanges. Each of the four lateral toes contains a proximal, middle, and distal phalanx. ee Figure 14-4). The first tor-more commonly called the grat foe oF ballux—has two phalanges, designated as proximal, and distal. In general, each phalanx has a concave base at its proximal end, a shaft, and a convex head at its distal end Osteologic Features of a Phalanx + Bue + Shatt + Head Talocrural een Caleaneocubcid joint FIGURE 14-9. A radiograph from 2 healthy person showing the ‘major joints of the ankle and foot: talocrura, and caleancocuboid, The talonavicular and c de patt ofthe lager traneverse tarral joint. Note t of the talus ala, talonavieular, ocuboid joints central location, ARTHROLOGY ‘The major joints of the ankle and foot are the talocyal, subtalar, and transverse tarsal joints (Figure 14-9). As will be described, the talus is mechanically involved with all three of these joints. The multiple articulations made by the talus help to explain the bone’s complex shape, with nearly 70% of its surface covered with articular castlage. An understanding afte shape ofthe talus is crucial to an understanding ofthe Rinesiok ogy ofthe ankle and foot. Terminology Used to Describe Movements ‘The terminology used to describe movements of the ankle and foot incorporates two sets of definitions: a fundamental set and an applied set. The fimdamental terminology defines movement of the foot or ankle as occurring at right angles to the three standard axes of rotation (Figure 14-10, 4). Dars- flexion (extension) and plantar flexion describe motion that is parallel to the sagital plane, around a medial-lateral axis of rotation. Everson and inversion describe motion that is parallel to the fiontal plane, around an anterior-posterior axis of vota- tion, Abduction and adduction describe motion that is parallel to the horizontal (transverse) plane, around a vertical (supe- ior-inferior) axis of rotation. For at least the three major joints of the ankle and foot, these fundamental definitions are inadequate because most movements at these joints occur about an oblique axis rather than about the three standard, orthogonal axes of rotation depicted in Figure 14-10, 4. ‘Asecond and more applied terminology has therefore evolved im the attempt to define the movements that occur perpen- dicular to the prevailing oblique axes of rotation at the ankle and foot (fee Figure 1410, B). Pronation is defined as a motion that has elements of eversion, abduction, and dorsiflexion, Supination, in conteast, is defined as a motion that has ele- ments of inversion, adduction, and plantar flexion. The orien- tation of the oblique axis of rotation depicted in Figure 14-10, Byaries across the major joints but, in genta, hasa pitch thatChapter 14 Anil and Foot 379 Fundamental movement definitions EVERSION’ INVERSION (AP asi DORSIFLEXION’ omnaue as PLANTAR B FLEXION (ML axis) ‘Applod movernant definitions FIGURE 14-10. A, Fundamental move mont definitions ‘se based on the | JpRonanion: — suPINATION: ton edo EVERSION. INVERSION Imovement of any pan ofthe ankle AODUCTION ABDUCTION ADDUCTION _ et Loot m « plane perpendicular to DORSIFLEXION PLANTAR FLEXION the thee standard axes of rotation vertical, anteriorposterior (AP). and smedial-lateral (41). B, Applied move- mont definitions ate based on the movements that occur at right angles to one of several oblique axes of 0% tion within the foot and ankle. The two main movements are defined as either pronation ot supination, Plantar flexion Pes equinus Derslesion | Medabinteal Sait rae Inversion Varos Inversion Anterionposterior Frontal ve Abduction Abductus Adduction, Real aa Adductus Supination Varying lementsof inversion, Inconsistent rerminology-usully implies one ot } Oblique (v ‘dddction, and plantar flexion more of the components of supination Pronation_ joint) ‘Varying elements of eversion, Inconsistent terminology-usually implies one or abduction, and dorsiflexion more of the components of pronation is similar to that illustrated, The exact pitch of each major joint’s axis of rotation is described in subsequent sections Pronation and supination motions have been called “triplanar” motions. Unfortunately, this description is mis- leading, The term triplanar implies only that the movements “eut through” each of the three cardinal planes, not that the joint exhibiting this movement possesses three degrees of freedom. Pronation and supination occur in one plane ‘Table 14-2 summarizes the terminology used to describe the movements of the ankle and foot, including the terminology that describes abnormal posture or deformity. ‘Structure and Function of the Joints Associated with the Ankle From an anatomic perspective, the ankle includes one articu- Iation: the talocraral joint, An important structural component of this joint is the articulation formed between the tibia and fibula—an articulation reinforced by the proximal and distal tibiofbular joints and the interosscous membrane of the leg (see Figure 13-3), Because of this functional association, the proxi- mal and distal tibiofibular joints are included under the topic of the “ankle.” PROXIMAL TIBIOFIBULAR JOINT ‘The proximal tibiofibular joint is a synovial joint located lateral to and immediately inferior to the knes. The joint is formed between the head of the fibula and the posterior Jateral aspect of the lateral condyle of the tibia (see Figure 134). The joint surfaces are generally flat or slightly oval, covered by articular cartilage.” ‘A capsule strengthened by anterior and posterior ligaments encloses the proximal tibiofibular joint (see Figures 13-7 and 13.9) The tendon of the popliteus muscle provides adi tional. stabilization as it crosses the joint posteriorly Very litle gliding motion occurs at this joint; a firm articuls- tion is needed to ensure that forces within the biceps femoris and lateral collateral ligament of the knee ate transferred effectively ftom the fibula to the tibia DISTAL TIBIOFIBULAR JOINT The distal tibiofibular joint is formed by the asticulation between the medial surface of the distal fibula and the fibular notch of the tibia (Figure 14-11)" Anatomists frequently refer to the distal tbiofbular joint 26 a sgndesmosis, which isa type of fibrous synarthrodial joint that is closely bound by an interosseous membrane." Relatively litte movement is per mitted between the distal tibia and distal fibula, ‘The interosscous ligament provides the strongest bond between the distal end of the tibia and fibula (see Figure 14-3). This ligament is an extension of the interosseous ment- brane between the tibia and fibula. The anterior and posterior (distal) tibioibular ligaments also stabilize the joint (Figures 14-11 and 14-12). A stable union between the distal bia and580, Section IV Lower Extremity Antrirateral view Posterior tbo ligament Anterior tibofbule ligament (out Aricular facet for lus Lateral malleolus eto ligament {eut) FIGURE 14-11. An antesior‘atcral view of the right distal tbiofibular joint with the fibula reflected to show the anicular surfaces. Posterior view ligament Groove for tendons. Groove for tendons of hula longus cof sbialis posterior and fan brovie joxor digorum longus fexer digitorum long Posterior tiofbular ligament Inferior raneverse ligament ong [Ta on Posterior taltoular Igament Calcaneotbular Iigament Groove for tendon of lexor halves tongue Posterior alocaleanea ligament Achilles tendon (eu) FIGURE 14-12, Posterior view ofthe right ankle region shows several ligaments of the distal ubiofibulat, talocrural, and subtalar joints ‘The dashed line indicates the proximal attachments of the capsule ofthe talocrural (ankle) joint. fibula is essential to the stability and function of the talocrural joint Ligaments of the Distal Tibiofibular Joint * Tnterosseous ligament + Anterior ubiofbuls ligament + Posterior tibiofbular ligament TALOCRURAL JOINT Articular Structure ‘The talocrural joint is the articulation of the trochlea (dome) and sides of the talus with the rectangular cavity formed by The shape ofthe talocrual join carpenters Tia mortise joint Floula FIGURE 14-13. The similarity in shape of the talocraral joint (A) and 2 carpenter's mortise joint (B) is demonstrated. Note the extensive ares of the talus that i lined with articular cartilage (bl) the distal end of the tibia and both malleoli (see Figures 14-3 and 149). The talocrural joint is often referred to as the “mortise,” owing to its resemblance to the wood joint used by carpenters (Figure 14-13). The concave shape of the prox ‘mal side of the mortise is maintained by connective tissues that bind the tibia with the fibula, The confining shape of the talocrural joint provides a major source of natural stability to the ankle." ‘The structure of the mortise must be sufficiently stable to accept the forces that pass between the leg and foot. Although variable, approximately 90% to 959 of the compressive forces pass through the talus and tibia; the remaining SM to 10% pass through the lateral region of the talus and the fibula.” The talocrural joint is lined with about 3-mm of articular cartilage, which can be compressed by 30% to 40% in sesponse to peak physiologic loads.” This load-absoxption ‘mechanism protects the subchondral bone from damaging stress Ligaments A thin capsule surrounds the talocrural joint. Extemally, the capsule is reinforced by collateral ligaments that help main- tain. the stability between the talus and the rectangular “socket” of the mortise ‘The medial collateral ligament of the talocrural joint is called the deltoid ligament, Based on its triangular shape. This ligament is broad and expansive (Figure 14-14). Its apex is attached to the medial malleolus, with its base fanning into three sets of superficial fibers (see box). Deeper tibiotalar fibers blend with and strengthen the medial capsule of the talocrural joint. Distal Attachments of the Three Superficial Sets of Fibers within the Deltoid Ligament * Tibionaeuar ‘fibers attach to the naviculr, ear ite tuberosity. + Tibicalcanal fiber attach to the suetentaculum talus + Tibioralar fibers atach to the medial tubercle and adjacent pat of the talus.Chapter 14 Anil and Foot 581 ‘The primary function of the deltoid ligament is to limit eversion across the talocrural, subtalar, and talonavicular joints. Sprains of the deltoid ligament are relatively uncom- ‘mon, in part because of the ligament’s strength and because the lateral malleolus serves as a bony block against excessive eversion, ‘The lateral collateral ligaments of the ankle include the anterior and posterior talofibular and the calcaneofibularliga- ments, Because of the relative inability of the medial malleo- lus to block the medial side of the mortise, the overwhelming Medial vw Medial males “TWinavieda there bate | terneanea! hee ‘outlets Dorsal talonavicular Tigament Dorsal cuneonavicular ligament Dorsal arsometatarsat Tigamerts, plantar Media! tials igament_Plantar__talocaleaneal posteror ‘calcaneonavicular Egament tendon feu) {spring} Iigament FIGURE 14-14, Medial view of the sight ankle region highlights the ‘medial collateral (deltoid) ligament. Lateral view Posterior tibotbula ligament Posterior taloibular Achilles tendon ‘eat Calcaneofioular ligament Lateral taocalcanes! werent Fibularis Fibularis Tongs tendon rove endon Fula retain vet a Conical igament Bitureated igament majority of ankle sprains involve excessive inversion, often involving injury to the lateral collateral ligaments The anterior talofibular ligament attaches to the anterior aspect of the lateral malleolus, then courses anteriorly and medially to the neck ofthe talus (Figure 14-15). This ligament is the most frequently injured of the lateral ligaments. Injury is often caused by excessive inversion or (horizontal plane) adduction of the ankle, especially when combined with plantar flexion-for example, when inadvertently stepping into 2 hole or onto someone's foot while landing from 2 jump. The calcancofbular ligament courses inferiorly and posteriorly from the apex of the lateral malleolus to the lateral surface of the calcaneus (see Figure 14-15). This ligament resists inversion across the talocrural joint (especially when fully dorsiflexed) and the subtalar joint. As a pair, the calea- neofibular and anterior talofibular ligaments limit inversion throughout most of the range of ankle dorsiflexion and plantar flexion.” About two thirds of all ateral ankle ligament {injuries involve both of these ligaments." ‘Three Major Components of the Lateral Collateral Ligaments of the Ankle * Anterior talofibular ligament + Caleancofibula ligament * Posterior talofbula ligament ‘The posterior talofibula ligament originates on the posterior- medial side of the lateral malleolus and attaches to the lateral tubercle of the talus (see Figures 14-12 and 14-15). Its fibers run horizontally across the posterior side of the talocrural joint, in an oblique anterior lateral to posterior-medial dizec- tion (Figure 14-16), The primary function of the posterior talofibular ligament is to stabilize the talus within the mortise, Anterior tiblefbulr igament Anterior talotibular ligament FIGURE 14-18. Lateral view of the night ankle region highlights Dercaltarsomatatarear ‘© aed collateral ligaments ligaments Dorsal caleaneocubold ligament582 Section IV Lower Extremity Extensor hallucis longus Thlals anterior FIGURE 14-16, A superior view displays a cross-section through the right talocrural joint. The talus remains, ‘but the lateral nd medial malleolus and all the tendons Medial malleolus of ‘ials posterior Flexor digtorum longus Flexor hallucis longus In particular, it limits excessive abduction of the talus, espe- cially when the ankle is fully dorsiffexed." ‘The inferior transverse ligament is a small thick strand of fibers considered part of the posterior talofibular ligament (ee Figure 14-12). The fibers continue medially to the poste- rior aspect of the medial malleolus, forming part of the posterior wall of the talocrural joint. In summary, the medial and lateral collateral ligaments of the ankle limit excessive eversion and inversion, respectively, at every joint that the fibers cross. Because most of the liga- ‘ments course, to varying degrees, from anterior to posterior, they also limit antesiorto-posterior translation of the talus within the mortise, As described in the section on arthrokine- ‘matics, the movements of plantar flexion and dorsiflexion are kinematically linked to anterior and posterior translation of the talus, respectively. For these reasons, several of the collateral ligaments are stretched at the extremes of dorsiflex- ion or plantar flexion of the talocrural joint. Several of the major ligaments that cross the talocrural joint also cross other joints of the foot, such as the subtalar and talonavicular joints. These ligaments therefore provide stability across multiple joints. Table 14-3 provides a summary. of the movements that stretch the major ligaments of the ankle. This information helps explain the mechanisms that frequently injure these ligaments, as well as the rationale behind the manual stress tests performed to evaluate the structural integrity of the ligaments after injury. Osteokinematics ‘The talocrural joint possesses one degree of freedom. Motion ‘occurs around an axis of rotation that passes through the body of the talus and through the tips of both malleoli Superior view Fibulars terius Extensor digitorum longus Extensor digtorum brevis muscle (out) Lateral malleolus ofthe fbula ‘iba Fibulars brevis Fibuars longus Posterior talofiouarigament Achilles tendon Because the lateral malleolus is inferior and posterior to the ‘medial malleolus (which should be verified by palpation), the axis of rotation departs slightly from a pure medial lateral axis. As depicted in Figure 14-17, 4 and B, the axis of rotation {in red) is inclined slightly superiorly and anteriorly as it passes laterally to medially through the talus and both mal- leoli.” The axis deviates fom a pure medialateral axis about 10 degrees in the frontal plane (see Figure 14-17, ) and 6 degrees in the horizontal plane (see Figure 14-17, 8), Because of the pitch of the axis of rotation, dorsiflexion is associated with slight abduction and eversion, and plantar flexion with slight adduction and inversion." By definition, therefore, the ‘alocrural joint produces a movement of pronation and supi- nation, Because the axis of rotation deviates only minimally. from the pure medialdateral axis, the main components of pronation and supination at the talocrural joint are over whelmingly doriflesom and planar flexion (ee Figure 14-17, D and B)."" The horizontal and frontal plane components of pronation and supination are indeed small,” and usually ignored in most clinica situations ‘The O-degree (neutral) position at the talocrural joint is defined by the foot held at 90 degrees to the leg. From this position, the talocrural joint permits about 15 to 25 degrees of dorsiflexion and 40 to 55 degrees of plantar flexion, although reported values differ considerably based on type and method of measurement.“ Accessory movements at the nearby subtalar joint may contribute to about 20% of the total reported range of motion.” Dorsiflexion and plantar flexion at the talocrural joint need to be visualized when the foot is off the ground and fee to rotate, and when the foot is fixed to the ground as the leg rotates forward, such as during the stance phase of gat.Chapter 14 Ankle and Foot 583 Deltoid ligament (ibiotala fibers) Talocrural joint alent eine Det me hina se) { Anterior talofbular ligament Talocrural joint ocrural joint Caleancofibular ligament Subtala joint Posterior talofibular ligament Talocrura joint Talonavicular joint Deltoid ligament (biocaleaneal fibers) Talocrural joint and subtalar joint version, dorsiflexion with associated posteior slide of talus within the mortise version, plantar flexion with associated anterior slide of talus within the mortise version, abduction version Plantar flexion with associated anterior slide of talus ‘within the mortise, inversion, adduction Dorsiflexion with associated posterior slide of talus ‘within the mortise, inversion Inversion, Doniflexion with associated posterior slide of talus ‘within the mortise abduction, inversion “The norton baeeé on movers ‘AgoucTION’ ADDUCTION (erica! axis) Posterior view re ule forebears le DORSIFLEXION/ PLANTAR EVERSION/ INVERSION (AP axis) DORSIFLEXION! jy PLANTAR. FLEXION (iL axe) | FIGURE 14-17. The axie of rotation and osteokinematice at the talocraral joint. The slightly oblique axis of| rotation (ed) ix shown from behind (A) and from above (B); this ais is shown again in C. The component ter and astocisted orteokinematics ae alo depicted in A and B, Note that, although subtle, dorsiflexion D) is combined with sight abduction and eversion, which are components of pronation; plantar flexion (B) is ‘combined with slight adduction and inversion, which ate components of supination584 Section IV Lower Extremity DORSIFLEXION Antaiot Casula ie FIGURE 14-18, A lateral view depicts the arthrokinematics at the talocrural joint during passive dor- siflexion (A) and plantar flexion (B). Steetched (tau) structures are shown as thin elongated arrows; slackened “structures ae shown as wavy atrow. Posterior Capsule Caleaneofibalar A ON ament Arthrokinematics ‘The following discussion assumes that the foot is unloaded and ffee to rotate. During dorlesion, the talus rolls forward tclative to the leg a it simultaneously slides posteriorly Figure 14-18, 4), The simultaneous posterior slide allows the talus to rotate forward with only limited anterior translation."*" Figure 14-18, A shows the calcaneofibular ligament becoming taut in response to the posterior sliding tendency of the talus: calcaneal segment. Generally, ay calateral ligament that becomes increasingly tant on posterior translation ofthe talus also becomes increasingly taut during dorsiflexion. Maximal dorsiflexion clon- gates the posterior capsule and all tissues capable of transmit ting plantar flexion torque, such as the Achilles tendon. Full dorsiflexion of the ankle is often limited after a sprain of the lateral ankle, One therapeutic approach aimed at increasing dorsiflexion involves passive joint mobilization of the talocrural joint. Specifically, the clinician applies a poste- rior-directed translation of the talus and foot relative to the Ieg."**" An appropriately applied posterior slide is designed to mimic the natural arthrokinematics of dorsiflexion at the talocrural joint. During plantar flexion, the talus rolls posteriosly as the bone simultaneously slides anterionly (see Figure 14-18, 8). Generally, any collateral ligament that becomes increasingly taut ‘on anterior translation of the talus alo Becomes increasingly tant during plantar flexion. As depicted in Figure 1418, B, the anterior talofibular ligament i stretched in fll plantar flexion, (Although not depicted, the tibionavicular fibers of the deltoid ligament would ‘also become taut at full plantar flexion [review Table 14-3). Plantar flexion also stretches the dorsiflexor muscles and the anterior capsule of the joint Progressive Stabilization ofthe Talocrural Joint throughout the Stance Phase of Gait ‘At initial heel contact during walking, the ankle rapidly plantar flexes in order to lower the foot to the ground (Figure 14-19; from 0% to 59% of the gait cycle). As soon as the foot flat phase of gait is reached, the leg starts to rotate forward (dossflex) over the grounded foot." Dorsiflexion continues until after just after heel off phase. At this point in the gait, cycle, the ankle becomes increasing stable owing to the inereased tension in many stretched collateral ligaments and “alocrual joint PLANTAR FLEXION ‘alotbular ligament Anterior Anterior \<2Peule_siofolar Posterior wnat capsule (degrees) ‘Ankle joint motion 30 a 70 #0 80 100 Swing phase contacto: Porcent of gat eycle FIGURE 14-19. The range of motion of the right ankle (talocrural) joint i depicted during the major phe ofthe gat cycle, The push ‘oft (propulsion) phase (about 40% to 60% of the gait eyce) is indi cated in the darker shade of green, plantar flexor muscles (Figure 1420, 4). The dorsiflexed ankle is further stabilized as the wider anterior part of the talus wedges into the tbiofibular component of the mortise (see Figure 14-20, 8). The wedging effect causes the distal tibia and fibula to spread apart slightly. This action is resisted by tension in the distal tbiofibular ligaments and interosseous membrane.‘ At the initiation of the push off phase of walking Gust after about 40% of the gait cycle; see Figure 14-19), the fully dorsflexed talocrural joint is well stabilized to accept compression forces that may reach over four times body weight." This inherent stability may partially account for the relatively low frequency of idiopathic osteoarthritis at the talocrural joint." Posttraumatic arthitis at the talocruralChapter 14 Anil and Foot 585 Achilles tendon Calcaneofbular, gament joint is, however, relatively common. Residual incongruity within the mortise after trauma can increase intraarticular stress to damaging levels, The slight natural spreading of the mortise at maximal dorsiflexion causes slight translation of the fibula.” The line of force of the stretched anterior and posterior (distal tibio- fibular ligaments and interosseous membrane produces a slight superior translation of the fibula that is transferred proximally to the proximal tibiofibulas joint. For this reason, the proximal tibiofibular joint is related more functionally to the ankle (alocrural joint) than to the knee Structure and Function of the Joints Associated with the Foot SUBTALAR JOINT ‘The subtalar joint, as its name indicates, resides under the talus (see Figure 14-9). To appreciate the extent of subtalar joint motion, one need only firmly grasp the unloaded cal- caneus and twist it in a side-to-side and rotary fashion. During this motion, the talus remains essentially stationary within the tight-fitting talocrutal joint, Pronation and supination during non-weight-beating activities occur as the calcaneus moves relative to the fixed talus. In weight bearing such as luring the stance phase of walking, for example, pronation and supination occur as the calcaneus remains relatively sta- tionary. This situation requires complex kinematics involving the leg and talus (as a common unit) rotating over the stable calcaneus. This mobility at the subtalar joint allows the foot to assume positions that are independent of the orientation of the superimposed ankle and leg. This function is essential to activities such as walking across a steep hill, standing with feet held wide apart, quickly changing directions while walking or running, and keeping one’s balance on a rocking boat. Articular Structure ‘The large, complex subtalar joint consists of three articula- tions formed between the posterior, middle, and anterior facets of the calcaneus and the talus. These articulations are depicted in yellow in Figure 1421 FIGURE 14-20. Factors that increase the mechanical stability of the fully dossiflexed talocrural joint are shown. A, The increated passive tension in several connective tissues and muscles is demonstrated. B, The twochlear surface of the talus is wider anteriorly than posteriorly (see red Tine), The path of dorsiflexion places the concave tbiofbular segment of the mortise in contact with the wider anterior dimension of the talus, thereby causing a wedging effect ‘within the tlocraral joint, Ee) Ankle Injury Resulting from the Extremes. of Dorsiflexion or Plantar Flexion ‘Suverior view FULL DORSIFLEXION he proximal and distal tiofbulr joints and interosseous ‘membrane are functionally and structural related to the talocrural joint This relationship is apparent after an injury related to extreme dorsfexion—tor example, landing trom a jump. An extreme and violent dorsfexion ofthe anke eg over the foot) can cause the mortise to “explode” outward, injuring ‘many ofthe collateral ligaments. The traumatic widening ofthe ‘mortise can also injure the ligaments that support the distal tiiofbular joint and interosseous, membrane—the so-called high ankle or syndesmatc sprain’ Ths type of injury occurs less frequenty than the common inversion ankle sprain but usualy requires a more prolonged recovery time.” Full plantar flexion—the loose-packed poston ofthe tlo- cual joint—slackens most collateral ligaments.of the ankle and al plantr flexor muscles. naddtion, plantar flexion places the narrower width of te talus between the malleol, thereby releasing tension within the mortise. AS a consequence, ful Plantar flexion causes the distal tia and fibula to “loosen ther tip” on the talus. Bearing body weight over a fuly plantar flexed ankle, therefore, places thetalocrural joint ina relatively unstable pasion. Wearing igh eels or landing fom a jump in a plantar flexed (and usualy inverted) poston increases the tikelhood of destabilizing the mors and potential injuring the lateral ligaments ofthe ankle.” ‘The prominent posterior articalation of the subtalar joint occupies about 70% of the total articular surface area. (Some anatomy texts limit the description of the subtalar joint to the prominent posterior facets only, referring to it as the talocalcancal joint) The concave posterior facet of the talus rests on the convex posterior facet of the calcaneus, The auticulation is held tightly opposed by its interlocking shape, ligaments, body weight, and activated muscle. The closely aligned anterior and middle articulations consist of smaller,586 Section IV Lower Extremity Superior view subtalar joint El Tatonavicutar joint Hi Head of aie ND Naveuar facet SL Spring ligament FIGURE 14-21. A superior view of the right foot is shown with the talus flipped medially, exposing most of its plantar surface. The articular surfaces of the subtalar joint are shown in yellow; the nearby aicular surfaces of tadonaoicelar junt are shown in light purple Replacing the talus to its natural position joins the tree set: of anticular facets within the subtalar joint—anterior facet (A), middle ‘facet (MB), and posterior facet (PF. Replacing the talus also rearticw lates the talonavicular joint by joining the head of the talus (HT) ‘within the concavity formed by the concave surfaces ofthe navicular (N) and the spring ligament (SL). nearly flat joint surfaces. Although all three articulations con- tribute to movement at the subtalar joint, clinicians typically, focus on the more prominent posterior articulation when performing mobilization techniques to increase the flexibility of the rearfoot Ligaments The posterior and anterior-middle articulations within the subtalar joint are each enclosed by a separate capsule. The larger, posterior capsule is reinforced by three slender thicken- ings: medial, posterior, and lateral talocalcancal ligaments (sce Figures 14-12, 14-14, and 14-15). These ligaments are often indistinguishable from the capsule and serve as secondary stabilizers of the joint. Other moxe prominent ligaments provide the primary source of stabilization to the joint as a whole (Table 144) The calcancoibular ligament limits excessive inversion, and the delioid ligament (tibrocalcancal fibers) limit ‘excessive eversion. (The anatomy of these ligaments was described previously with the talocrural joint) The interosseous (talocaleaneal) and cervical ligaments attach directly between the talus and calcaneus” and therefore provide the greatest nonmuscular stability tothe subtalar joint. Calcancofibular Tibiocalcaneal fibers of the deltoid ligament Limits excessive inversion Limits excesive everson Interoscous ‘Both ligaments bind the talus with (talocaleanesl) the caleaneus; limit the extremes Cervical of all motions, especially ‘These broad and flat ligaments cross obliquely within the tarsal sinus and therefore ate difficult to view unless the joint is disartivulated, as depicted previously in Figure 14-8. The inter osseous (alocacanca) ligament has two distinct, flattened, ante- rior and posterior bands, These bands arise from the calcaneal siuleus and course superiorly to attach within the talar sulcus and adjacent regions. The larger cervical ligament has an oblique fiber arrangement similar to the interosscous ligament but attaches more laterally within the calcaneal sulcus. From this attachment the cervical ligament courses superiorly and medi- ally to attach primarily tothe inferior lateral surface of the neck of the talus (hence the name “cervical”) (ee Figure 14-15). The imterosseous and cervical ligaments limit the extremes of all motions-most notably inversion." Although the ligaments within the tarsal sinus are recog- nized as primary stabilizers at the subtalar joint, a precise anatomic description and 2 fall understanding of their func- tion are unclear” This lack of knowledge has limited the development of standard clinical “stress tests” to aid in the diagnosis of ligamentous injury. Cadaveric study suggest that a lateral-to-medial translational force applied to the calcaneus specifically stresses the interosseous ligament.” This finding is consistent with the ligament’s proposed function of resist- g inversion at the subtalar joint Kinematics ‘The arthrokinematics at the subtalar joint involve a sliding. motion among the three sets of facets, yielding a curvilinear arc of movement between the calcaneus and the talus Although considerable variation exists from one person to another,” the axis of rotation is typically described as a line that pierces the lateral-posterior heel and courses through the subtalar joint in anterior, medial, and superior directions (Figure 14-22, 4 to C sed)" The axis of rotation is positioned 42 degrees from the horizontal plane (see Figure 14-22, A) and 16 degrees from the sagittal plane (see Figure 14-22, B). Pronation and supination of the subtalar joint occur as the calcaneus moves relative to the talus (or vice versa when the foot is planted) in an arc that is perpendicular to the axis of rotation (see the red circular arrows in Figure 14-22, 4 to ©) Given the general pitch to the axis, only two of the three ‘main components of pronation and supination are strongly. evident: inversion and eversion, and abduction and adduc- tion (see Figure 14.22, A and 2B). Pronation, therefore, has ‘main components of everson and abdaction (se Figure 14-22,Chapter 14 Ankle and Foot 587 Subtaar joint ABDUCTIONIADDUCTION (Verical axis) |_eversiony } INVERSION GP axe) DORSIFLEXION! PLANTAR Fi (ML axe) EVERSION! INVERSION (WP axe) FIGURE 14-22. The axis of rotation and osteokinematic at the subtalar jo The axis of rotation Ged)is shown froma the side (A) and above (B; this axis ie shown again in C. The component axes and ascociated osteokine- iatics are also depicted im 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, i demonstrated in E. In D and E, blue arrows indica indicate eversion and inversion, D); supination has main. components of inversion and adduc- tion (see Figure 14-22, £). The caleaneus does dorsiflex and plantar flex slightly relative to the talus; however, this motion 4s small and usually ignored clinically. Overall, the kinematic pattern expressed at the subtalar joint is much greater than at the talocrural joint." For simplicity, the osteokinematics of the subtalar joint have been pictorially demonstrated by the calcaneus moving relative to a fixed and essentially immobile talus. During walking, however, when the calcaneus is relatively immobile because of the load of body weight, a significant portion of pronation and supination occur by horizontal plane rotation of. the talus and leg. Because of the inherent stability and fit pro- vided by the mortise, the majority of the horizontal plane rotation of the talus is mechanically coupled to the rotation of the leg. Small horizontal plane accessory motions within the talocrural joint absorb a small component of this rotation.” Range of Motion Grimston and colleagues reported active range of inversion and eversion motions at the subtalar joint across 120 healthy subjects (aged 9 through 79 years.” Results showed that inver- sion exceeds eversion by nearly double: inversion, 22.6 degrees; eversion, 12.5 degrees. Although these data include accessory rotations atthe talocrural joint, the much greater ratio of inver- duction and addiction, andl purple strows sion to eversion is typical of that reported forthe subtalar joint alone." Studies that measure passive ange of motion usually report greater magnitudes of motion, with inversion-to-ev sion ratios approaching 3:1." Regardless of active or passive motion, the distally projecting lateral malleotus and the rela- tively thick deltoid ligament naturally limit eversion TRANSVERSE TARSAL JOINT (TALONAVICULAR AND CALCANEOCUBOID JOINTS) nt, also known as the midtarsal joint, consists of two anatomically distinct articulations: the falona vicular joint and the calcancocubotd joint These joints connect the rearfoot with the midfoot (See organization of joints illustrated in Figure 14-23) At this particular point in this chapter, it may be instruc- tive to consider the functional characteristics of the transverse tarsal joint within the context of the other major joints of the ankle and foot. As described earlier, the talocrural (ankle) joint permits motion primarily in the sagittal plane: dorsiflex- ion and plantar flexion. The subtalar joint, however, permits a more oblique path of motion consisting of two. primary components: inversion-eversion. and abduction-adduction, This section now describes how the transverse tarsal joint, the ‘most versatile joint ofthe foot, moves through a more oblique588 Section IV Lower Extremity pie Focus ‘Standard Clinical Measurements of Subtalar Joint Range of Motion ccurately measuring the extent of pronation and supination a the subtalar joint through standard goniometry is very dificult. Measurement error reflects the inability of a standard, Tigid goniometer to follow the oblique arc of pronation and supina~ tion, compounded by simultaneous movements in surrounding joints. As 2 method of improving the usefulness of this measure- ‘ment, clinicians often report subtalar joint motion as a more simple ‘rontal plane motion of inversion and eversion of the rearfoot (calcaneus) The rather strict terminology described for subtalar motion is rot always adhered to in clinical and research settings. “Short- cuts" in terminology have evolved that, unfortunately, limit the ability to effectvely communicate the precise details of foot and ankle kinesiology. Pronation and supination at the subtalar joint are often referred to simply as eversion and inversion of the cal- ‘caneus, respectively. Eversion, for example, is only a component of, rather than a synonym of, pronation. Comparisons of range-ot- motion data among studies are often difficult, unless the motions ‘are expliily defined Clinically, the expression “subtalar joint neutral” is often used to establish a baseline or reference for evaluating a foot before fabrication of an orthotic device.” The neutral position of the ‘subtalar joint is attained by placing the subject's calcaneus in a Position that allows both lateral and medial sides ofthe talus to be equally exposed for palpation within the mortise. In this neural” position, the jointis typically one third the distance from {ull eversion and two thirds the distance from full inversion, 5 | setatarsophaiangea! 5 | tetaarophatanceal nt $ © | isematataral jon “arsometatrel jit Itsrcunsitr and Distal | mest] "Sorta 5 | meacal complex 2 ‘Cuneonavetr ont 5 Fodor = Cube deonavoubr joint trove tareverse Tanavrjon "S21 9°91) Calcaneocuboid joint 3 8 gf san A Achilles tendon Subtalar joint Caleaneocubd joint Talonavieularjlnt Cuboideonaviular joint CCuneonavieuar joint Intercunetiorm and ‘Cuneceubord joint complex “Tarzomelatarsal joints FIGURE 14-23. A, The bones and disarticulated joints of the sight foot are shown from two perspectives: superior posterior (A) and superioranterior(B). The overall organization ofthe joints is highlighted in A.Chapter 14 Anil and Foot 589 mneverse tartal joints allow for pronation and spination of the midfoot while one stands on uneven surfaces, path of motion, cutting neatly equally through all three cardinal ‘Planes. Among other important functions, the path of prona- tion and supination at the transverse tarsal joint allows the weight-bearing foot to adapt to a variety of surface contours (Figure 14-24), ‘The transverse tarsal joint has a strong functional relation- ship with the subtalar joint. As will be described, these two joints function cooperatively to control most of the prona- tion and supination posturing of the entire foot Articular Structure and Ligamentous Support Tealonavicular Joint The talonavicular joint (the medial compartment of the trans- verse tarsal joint) resembles a ball-and-socket joint, providing substantial mobility to the medial (longitudinal) column of the foot. Much of this mobility is expressed as a twisting (nverting and everting) of the midfoot relative to the rear foot The talonavicular joint consists of the atticulation between the convex head of the talus and the continuous, deep concavity formed by the proximal side of the navicular bone and “spring” ligament (see Figure 14-8). The conver: concave relationship of the talonavicular joint is evident in Figure 14-21. The spring ligament (labeled as SL in Figure 14-21) is a thick and wide band of collagenous connective tissue, spanning the gap between the sustentaculum talus of the caleaneus and the medial-plantar surface of the navicular bone.” By directly supporting the medial and plantar convex- ity of the head of the talus, the spring ligament forms the structural “floor and medial wall” of the talonavicular joint. Considerable support is required in this region during stand- ing because body weight tends to depress the head of the talus in plantar and medial directionstoward the earth. The surface of the spring ligament that directly contacts the head of the talus is lined with smooth fibrocartlage."” (The more formal and precise name of the spring ligament isthe plantar calcanconavicular ligament. The term “spring” is actually a mis- nomer because it has littl, if any, elasticity; its highly col- Jagenous nature offers considerable strength and resistance to clongation. Nevertheless, the term spring remains well estab- lished in the clinical and sesearch literature.") ‘An irregularly shaped capsule surrounds the talonavicular joint, The ligaments reinforcing this capsule are summarized in the box ‘Summary of Ligaments That Reinforce the Talonavieular Joint * Interosseous ligament (ofthe subtalar joint reinforces the caprule posteriorly (see Figure 11-8), + Dorsal talonavicular garment reinforces the capsule dorsally (sce igure 114). + Bifurcated ligament (clean the capsule lateral (ee Fagre 14-45). + Amtenr (ubionavicuay) fibers ofthe deltoid ligament sein- force the capsule medal (ee Tigute 14-14) avicular fibers) reinforces Calcaneacuboid Joint The caleaneocuboid joint is the lateral component of the transverse tarsal joint, formed by the junction of the anterior (distal) surface of the calcaneus with the proximal surface of the cuboid (see Figure 1423). Each articular surface has a concave and convex curvature. The joint surfaces form an interlocking wedge that resists sliding. The calcaneocuboid joint allows less motion than the talonavicular joint, espe- cially in the frontal and horizontal planes.” The relative inflexibility of the caleaneocuboid joint provides stability to the lateral (longitudinal) column of the foot The dorsal and lateral parts of the capsule of the calcanco- cuboid joint are thickened by the dorsal calcaneocuboid ligament (Gee Figure 14-15). Three additional ligaments further sta- bilize the joint. The bifurcated ligament is 2 Y-shaped band of tissue with its stem attached to the calcaneus, just proximal to the dorsal surface of the calcaneocuboid joint. The stem of the ligament flares into lateral and medial fiber bundles, The aforementioned medial (caleaneonaviculat) fibers rein- fosce the lateral side of the talonavicular joint, The lateral (calcaneocuboid) fibers cross the dorsal side of the calcaneo- cuboid joint, forming the primary bond between the two bones.” ‘The long and short plantar ligaments reinforce the plantar side of the calcaneocuboid joint (Figure 14-25). The dong Plantar view Firat tarsometatarsal joint Tioalis anterior (ext), Tioals posterior Navioular tuberosity Plantar caleaneonavieular ligament (spring ligament) Fibula longue: Plantar caleaneacuboid igame (short plantar igamert) Long plantar ligament Flexor digitorum longus (cut) Flexor halucls longus (eat FIGURE 14-25. Ligaments and tendons deep within the plantar aspect ofthe right foot. Note the course of the tendons of the fibur lari longus and tibialis posterior590 Section IV Lower Extremity ‘plantar ligament, the longest ligament in the foot, arises from, the plantar surface of the calcaneus, just anterior to the eal caneal tuberosity. The ligament inserts on the plantar surface of the bases of the lateral three or four metatarsal bones. The shor plantar ligament, also called the plantar calcancocuboid liga- ‘ment, arses just anterior and deep to the long plantar ligament and inserts on the plantar surface of the cuboid bone. By passing perpendicularly to the calcaneocuboid joint, the plantar ligaments provide excellent structural stability to the lateral column of the foot.” ‘Summary of Ligaments That Reinforce the Caleaneocuboid Joint * Dorsal caleancocuboid ligament reinforces the capsule dors lateral (see Figure 14-15). + Bisarcated ligament (calcaneocuboid flber) reinforces the calcaneocubotd joint doraly (see Figure 1415). + Long and short plantar ligaments (see Figure 14.25) rein force the plantar nde ofthe caleancocuboid joint Kinematics ‘The transverse tarsal joint rately moves without associated ‘movements at nearby joints, especially the subtalar joint. To appreciate the mobility that occurs primarily at the transverse tarsal joint, hold the calcaneus firmly while maximally px. nating and supinating the midfoot (Figure 14-26, 4 and C, respectively). During these motions the navicular spins within the talonavicalar joint." Combining motions across both the subtalar and transverse tarsal joints accounts for most of the pronation and supination throughout the foot (see Figure 14-26, B and D, respectively). As evident throughout Figure 14.26, mobility of the forefoot contributes to the pronation and supination of the entire foot. ‘Three noteworthy points should be made before the detailed kinematis of the transverse tarsal joint are addressed, First, two separate axes of rotation have been identified Second, the amplitude and direction of movement is typically different during weight-bearing as compared with non- weight-bearing activities. Third, the ability of the transverse tarsal joint to stabilize the midfoot depends strongly on the position of the subtalar joint. The upcoming sections discuss cach of these factors. ‘Axes of Rotation and Corresponding Movements Manter originally described two axes of rotation for move- ment at the transverse tarsal joint: longitudinal and obligue.® Movement at this joint therefore occurs naturally in two unique planes, each oriented perpendicular to a specific axis of rotation. The longitudinal axis is neatly coincident with the straight anteriorposterior axis (Figure 14-27, to ©), with the primary component motions of eversion and inversion (see Figure 14-27, D and 2). The oblique axis, im conteast, has a strong vertical and medial-lateral pitch (see Figure 14-27, F to H), Motion around this axis, therefore, occurs freely as a combination of abduction and doriflevion (Figure 14-27, 1), and adduction and plantar flesion (see Figure 14-27, J. ‘The transverse tarsal joint possesses two separate axes of rotation, with each axis producing a unique kinematic patter. Although this may be technically correct, the functional kine- matics associated with most weight-bearing activities oceur as a blending of movements across both axesa blend that yields the purest form of pronation and supination (ie., movement that maximally expresses components of all three cardinal planes). Pronation and supination at the transverse tarsal joint allow the midfoot (and ultimately the forefoot) to adapt to many varied shapes and contours Range of motion at the transverse tarsal joint is difficult to measure and isolate from adjacent joints. By visual and ‘manual inspection, however, itis evident that the midfoot allows about twice as much supination as pronation. The amount of pute inversion and eversion of the midfoot occurs im a patter similar to that observed at the subtalar joint: about 20 to 25 degrees of inversion and 10 to 15 degrees of eversion. ‘Anthrokinematics ‘The arthrokinematics at the transverse tarsal joint are best described in context with motion across both the rearfoot and midfoot. Consider the movement of active supination of the unloaded foot in Figure 14-26, D. The tibialis posterior muscle, with its multiple attachments, isthe prime supinator of the foot." Because of the relatively rigid calcancocuboid joint, an inverting and adducting calcaneus draws the lateral column of the foot “under” the medial column of the foot, ‘The important pivot point for this motion is the talonavicular joint. The pull ofthe tibialis posterior contributes to the spin of the navicular, and to the raising of the medial longitudinal Position of the Subtalar Joint Affecting Stability of the Transverse Tarsal Joint 1 addition to controling the position of the rearfoot, the subtalar jint also indirectly controls the stability ofthe more distal joints, especially the transverse tarsal joint. Athough the relevance of this concept is discussed later in this chapter, full supination at the subtalar joint restricts the overall flewbilty of the midfoot A loosely articulated skeletal model helps to dem- onstrate ths principle. With one hand stabilizing the talus, maxi- mally “swing” the calcaneus into full inversion and note that the lateral aspect of the midfoot “drops” relative to the medial aspect. As a result, the talonavicular and calcaneocubold joints (components ofthe transverse tarsal joint) become twisted lon- gitudinally, thereby increasing the rigidity of the midfoot. Full pronation of the subtalar joint, in contrast, increases the overall ‘exibilty ofthe midfoot, Again, returning toa loosely articulated skeleton madel, maximal eversion ofthe calcaneus untwists the medial and lateral aspects of the midfoot, placing them in @ nearly parallel position. As a result, the talonavicular and cal- Caneocuboid joints untwist longitudinally, thereby increasing the flexibility of the midfoot. Make the effort to “feel” on a partner the increased multi-planar flexibility ofthe midfoot (and {orefoot) as the calcaneus is gradually taken from a maximal inversion to a maximal eversion position. As described in sub- sequent sections, the ability ofthe midfoot to change its flexbil- ity has important mechanical implications during the stance Phase of gat.Chapter 14 Ankle and Foot 591 PRONATION ofthe foot (dorsalmedal view) “Transverse tarsal joint tarsal joint Subtalar joint Transverse. = \Cearaljont FIGURE 14-26. Pronation and supination of the unloaded right foot demonstrates the interplay of the subtalar and transverse tarsal joints, With us beld fixed, pronation and supination occur primanly 2t the foot (A and €). When the calcaneus is free, pronation and supination occur as a summation across both 1d midfoot (B and D). Rearioot movement is indicated by pink arrows; midfoot movement ie y blue arrows, The pull ofthe tibialis posterior muscle is shown in D as it directs active supination592 Section IV Lower Extremity ‘Transverse tarsal jin: longitudinal axis ABDUCTIONADDUCTION DORSIFLEXION/PLANTAR FLEXION eral axis) (axis) ry evension” menaeN Rvension Lives Vikas A Medial view Superior view es van ‘Transverse tarsal joint oblique axis ABDUCTION/ADDUCTION DORSIFLEXIONPLANTAR FLEXION (Werical ass) (ML xis) (INVERSION W INVERSION > F Medial view 6 J Superior view oy Sie rer Syniy ty FLEXION FIGURE 14-27, ‘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 ©) and fiom 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 (B) sapination (with the main component of inveision). The oblique axis of rotation is shown in red from the side (F and H) and from above (G). (The component axes and asocated esteokinematics ate also depicted in Fand G) Movements that occur ound the blige ‘are Q) pronation three components of abduction and domlesion) snd Q) apna oth main ESmponents of adduction and plantar exon). Ind ana, blue arowsindeate Abduction and adction, and fect tows indicate dorfedon and planar exionChapter 14 Anil and Foot 593 arch (instep) of the foot. During this motion, the concave proximal surface of the navicular and the spring ligament both spin around the convex head of the talus Pronation of the unloaded foot occurs by similar but reverse kinematics as those described, The pull of the fibularis longus helps lower the medial side and raise the lateral side of the foot. The previously described arthrokinematics of supination and pronation assume that the foot is unloaded, or off the ground. The challenge is to understand these arthrokinemat- ics when the foot is on the ground, typically during the walking process. This topic is addressed later in this chaptex. Medial Longitudinal Arch of the Foot Figure 14-28 shows the locations of the medial longitudinal and transverse arches of the foot. Both arches lend very important elements of stability and resiliency to the loaded foot. The talonavicular joint serves as the Keystone to the medial longitudinal arch, For this reason, the structure and function of the medial longitudinal arch is addressed in this section. The transverse arch is described later during the study of the distal intertarsal joints, ‘The medial longitudinal arch is evident as the characteristic concave “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 medial arch are the calca- nus, talus, navicular, cuneiforms, and associated three medial metatarsals. Without this arched configuration, the large and rapidly produced forces applied against the foot during running, for example, would likely exceed the physiologic weight-bearing capacity of the bones. Additional structures that assist the arch in absorbing loads are the plantar fat pads, sesamoid bones located at the plantar base of the great toe, and superficial plantar fascia (which attaches primarily to the overlying thick dermis, functioning primarily to reduce shear forces.) As will be described, the medial longitudinal arch and associated connective tissues ate usually adequate to support the foot during relatively low-stress or nearstaticconditions— for example, standing at ease. Active muscular forces, however, assist the arch when the stresses and loads on the foot are larger and more dynamic, such as during standing on tiptoes, walking, jumping, or running. The following section describes the passive support mechanism provided by the medial lon- situdinal arch, The role of muscles in providing active support 4s described later, in the study of muscles of the ankle and foot Passive Support Mechanism of the Medal Longitudinal Arch ‘The talonavicular joint and associated connective tissues form the keystone of the medial longitudinal arch. Additional non- muscular structures responsible for maintaining the height and general shape of this arch are the plantar fascia, spring ligament, and first tarsometatarsal joint. The plantar Javcia of the foot provides the primary passive support to the medial longitudinal arch." This extremely strong {ascia consists of a series of thick, longitudinal and transverse bands of colla- gen-tich tissue.” The plantar fascia covers the sole and sides of the foot and is organized into superficial and deep fibers, The superficial fibers, introduced above, attach primarily to the overlying thick dermis. The more extensive deep plantar fascia attaches posteriorly to the medial process of the calea- neal tuberosity. From this origin, lateral, medial, and central FIGURE 14-28. The medial side ofa nottaal foot shows the medial longitudinal ach (bie) and the wansverse arch (ed). sets of fibers course anteriorly, blending with and covering the fist layer of the intrinsic muscles of the foot. The main, larger, central set of fibers extends toward the metatarsal heads, where the fibers attach to the plantar plates (ligaments) of the metatarsophalangeal joints and fibrous sheaths of the adjacent flexor tendons of the digits. Active toe extension therefore stretches the central band of deep fascia, adding tension to the medial longitudinal arch. This mechanism is useful because it increases tension in the arch when one stands on tiptoes, or during the push off phase of gat. ‘When one stands normally, the weight of the body falls through the foot near the region of talonavicular joint. This load is distributed anteriorly and posteriorly throughout the ‘medial longitudinal arch, ultimately passing to the fat pads and the thick dermis over the heel and ball (metatarsal head region) of the foot (Figure 14-29, 4). Normally the rearfoot receives about twice the compressive load as the forefoot.” ‘The mean pressure under the forefoot is usually greatest in the region of the heads of the second and third metatarsal bones. During standing, body weight tends to depress the talus inferiorly and flatten the medial longitudinal arch, This action increases the distance between the caleaneus and metatarsal heads. Tension in stretched connective tissues, especially the deep plantar fascia, acts as a semielastic tiexod that “gives* slightly under load, allowing only a marginal drop in the arch (Gee stretched spring in Figure 14-29, A). Acting like 2 truss, the tierod supports and absorbs body weight. Experiments con cadaveric specimens indicate that the deep plantar fascia is the major structure that maintains the height of the medial longitudinal arch; cutting the fascia decreased arch stiffness by 2506. As the arch is depressed, the rearfoot normally pronates a few degrees. This is most evident from a posterior view as the calcaneus evers slightly relative to the tibia, As the foot is unloaded, such as through the shifting of body weight to the other leg during walking, the naturally elastic and flexible arch setums to its preloaded raised height. The calcaneus invests slightly back to its neutral position, allowing the mechanism to repeat its shock absorption function once again,594 Section IV Lower Extremity Normal aren Dropped aren FIGURE 14-29. 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 primanly through elongation ofthe plantar fascia, depicted as a red spring. The foot print illustrates the concavity of the normal ach. B, With an abnor mally dropped medial longitudinal arch, the overstretched and weakened plantar facia, depicted as an oversuctched red «pring, cannot adequately accept or dissipate body weight. As a conse (quence, various extrinsic and intrinsic muceles are active a a second ty source of support to the arch. The footprint illustrates the dropped arch and loss of a characteristic instep Standing at ease on healthy feet typically produces very little activity ftom the intrinsic oF extrinsic muscles of the foot The height and shape of the medial longitudinal arch is controlled primarily by passive restraints from the connec- tive tissues depicted by the spring in Figure 14-29, A. Active muscle support during standing is usually required only as a “seconday line of support”—for example, when 2 heavy load is held, or when the arch lacks inherent support because of overstretched connective tissues." Pes Planus—‘Abnormally Dropped” Medial Longitudinal Arch Pes planus or “flatfoot” describes a chronically dropped or abnormally low medial longitudinal arch." This condition is often the result of joint laxity within the midfoot or prox- ‘mal forefoot regions, typically combined with an over stretched or weakened plantar fascia, spring ligament, and tibialis posterior tendon.” During the stance phase of walking, the subtalar joint subsequently pronates excessively as the rearfoot assumes an exaggerated valgus posture (calca- neus excessively everted away from the midline)."” The depressed talus and navicular bones often cause a callus on the adjacent skin. Figure 14-29, B shows the foot ofa person with pes planus. ‘The abnormally wide midfoot region evident in the footprint is indicative of excessive laxity within the joints that normally support the arch.’ A person with moderate or severe pes planus typically has a compromised ability to dissipate loads optimally throughout the foot. Active forces from intrinsic and extrinsic muscles are often required to compensate for the lack of tension produced in overstretched of weakened connective tissues. Increased muscular activity may be needed even during quiet standing, which may contribute to fatigue and various overuse symptoms, including pain, “shin splints.” bone spurs, and a thickened and inflamed plantar fascia" Pes planus is often described as being either a rigid or a flexible deformity. The foot with rigid pes planus (as shown in Figure 14-29, B) demonstrates a dropped arch even in non ‘weight-bearing positions. This deformity is often congenital, secondary to bony or joint malformation, such as tarsal coali- tion (ie., partial fusion of the calcaneus with the talus fixed im eversion). Pes planus may also occur from spastic paralysis and the resultant overpull from certain muscles. Because of the fixed nature and potential for producing painful symp- toms, rigid pes planus may requite surgical comtection duing childhood. Flexible pes planus is the more common form of a dropped arch, The medial longitudinal arch appears essentially normal when unloaded but drops excessively on weight beating Acquired flexible pes planus is often associated with tend nopathy or generalized dysfunction of the tibialis posterior muscle, increased laxity of local connective tissues, or struc tural anomalies and/or compensatory mechanisms that cause excessive pronation of the foot. Surgical intervention is raely indicated for flexible pes planus, Treatment is usually in the form of orthosis, specialized footwear, and exercise." COMBINED ACTION OF THE SUBTALAR AND TRANSVERSE TARSAL JOINTS When the foot is unloaded (.c., not bearing weight), pronation twists the sole of the foot outward, whereas supination twists the sole of the foot inward. While the foot is under load during the stance phase of walking, however, pronation and supination permit the leg and talus to rotate in al three planes relative to a relatively fixed caleaneus. This important mecha nism is orchestrated primarily through an interaction among the subtalar joint, transverse tarsal joint, and medial longite- inal arch. Much remains to be learned about this complex topicChapter 14 Ankle and Foot 595 PECIAL FOCUS 14-4 Pes Cavus—Abnormally Raised Medial Longitudinal Arch 1 its least complicated form, pes cavus describes an abnor- mally raised medial longitudinal arch, typically associated with excessive rearfoot varus (inversion) (Figure 14-30). Excessive forefoot valgus (eversion) may also be present, often as a com- pensation mechanism used to keep the medial forefoot firmly in contact with the ground, Pes cavus may be fixed or progressive and may manifest in carly childhood or fter in life, An abnormally raised medial longi- tudinal arch receives far less clinical attention than an abnormally dropped or low arch (pes planus).’* Several factors can cause or are associated with pes cavus, Many relatively mild forms of pes Ccavus are considered idiopathic with a strong genetic predisposi- tion, such as the subject depicted in Figure 14-30. Functional limitations assoclated with mild or subtle pes cavus vary from nonexistent to marked; often the disorder goes undiagnosed Regardless of severity, a chronically high arch alters the biome chanics of walking and running. AS clearly depicted in Figure Pes cavus cred Sea J, malo Ee FIGURE 14-30, A photograph of a right foot of a man with idiopathic pes cavas. Several key joints and bony landmatks are indicated, 14-30, the abnormally high arch places the metatarsal bones at 2 greater angle with the ground. As a result, contact pressures ‘can increase in the region of the metatarsal heads, often causing callus formation and metatarsalgia. Furthermore, a foot with a chronically raised (and relatively rigid) arch cannot optimally absorb the repeated impacts of running.” A person with pes ceavus Is therefore more vulnerable to stress-related injury, not only in the foot but also throughout the lower limb. This clinically held premise has received mixed support by several studies of military recruits during their basic training."*""*#*** More severe cases of pes cavus also exist—many of which are associated with a known cause, Pes cavus may be posttraumatic, caused by, for example, severe fracture, crush injury, or bur. An Unresolved “clubfoot”in childhood may persis ater in life as pes ccavus. Perhaps the most involved cases of pes cavus havo a neurologic origin, such as Charcat-Marie-Tooth disease, poliomy- ellis, cerebral palsy, peripheral nerve injury, and various. motor and sensory neuropathies. Although usually for different reasons, these disorders often cause marked force imbalances within the ‘muscles that act on the foot, Overtime, a persistent force imbal- ance utimately causes the pes cavus deformity. For example, spastic or otherwise overpowering tibialis posterior and fibularis longus muscles combined with a weakened or paralyzed tialis anterior muscle eventually favor development of a rearfoot varus and forefoot valgus deformity, The weakened tibialis anterior ‘muscle may also alow the fibularis longus to overpull the first metatarsal into excessive plantar flexion. A combined rearfoot varus, forefoot valgus, and excessively plantar flexed first meta- tarsal are often the more prominent features of pes cavus Treatment of pes cavus varies depending on severity or pro- gressive nature of the underlying cause. Conservative manage- ‘ment may include stretching of tight muscles (including the ‘ypically tight gastrocnemius and soleus) and the use of special- ized footware or orthotic devices.” Braces may be helpful for joint alignment or support in cases of muscle paralysis, In more severe or involved cases, surgery may be indicated, including osteotomy, tendon transfer, or Achilles tendon and other soft-tissue lengthen ing procedures." In the healthy foot the medial longitudinal arch rises and lowers cyclically throughout the gait cycle. During most of the stance phase, the arch lowers slightly in response to the progressive loading of body weight (Figure 14-31, 4). Structures that resist the lowering of the arch help to absorb local stress as the foot is progressively compressed by body weight. Although not always verifiable through controlled research, this load attenuation mechanism likely protects the foot and lower limb against stesselated injury." °*"* Dring the frst 309% to 35% of the gait cycle, the subtalar joint pronates (everts), adding an clement of flexibility to the ‘midfoot (see Figure 14-31, B).* By late stance, the arch rises as the supinated subtalar joint adds rigidity to the midfoot. The rigidity prepares the foot to support the large loads produced at the push off phase of gait. The ability of the foot to repeatedly transform from a flexible and shock absorbent structure to 2 more rigid lever during each gait cycle is one of the most important and clinically relevant actions of the foot. As subsequently described, the subtalar joint is the principal joint that directs the pronation and supination kinematics of the foot. Early to Mid-Stance Phase of Gait Kinematics of Pronation at the Subtalar Joint Immediately after the heel contact phase of gait, the dorsi- flexed talocrural joint and slightly supinated subtalar joint rapidly plantar flex and pronate, respectively (compare Figures 14-19 and 1431, 8). Although the data plotted in Figure 1431, B show only 2 degrees of average maximum eversion (beyond the resting posture). other researchers596 Section IV Lower Extremity 1007 20 30 Foot tat Heel ot § Too ot & Percent of gait cycle using asymptomatic subjects report higher values, in the range of 5 to 9 degrees.” Differences in defining the O-degree position of the subtalar joint, dissimilar sample sizes, and the varying measurement techniques account for much of this inconsistency within the literature." For this reason, it is often difficult to define what constitutes “abnormal” eversion (pronation) during walking. ‘The pronation (eversion) atthe subtalar joint during stance occurs primarily by two mechanisms, Fist, the calcaneus tips into slight eversion in response to the ground reaction force passing upward and just lateral to the midpoint of the posterior calcaneus. The simultancous impact of heel contact also pushes the head of the talus medially in the horizontal plane and inferiorly in the sagittal plane. Relative to the cal caneus, this motion of the talus abducts and (slightly) dorsi flexes the subtalar joint. These motions are consistent with the formal definition of pronation, A loosely articulated skel- stal model aids in the visualization of this motion. Second, during the early stance phase, the tibia and fibula, and to a lesser extent the femur, intemally rotate after initial heel contact." Because of the embracing configuration of the talocrural joint, th internally rotating lower leg ster the subtalar Joint into further pronation. The argument is often raised that 7 8 90 Swing phase FIGURE 14-31. 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 ais, the 100% value isthe height of the arch when the foot ir unloaded during the swing phase B, Plot of frontal plane range of motion at the subtalar joint (G6, inversion and eversion of the calcaneus) throughout the stance phase: The O-degree reference for frontal plane motions fined as the postion of the calcaneus (observed posters ‘while a subject stands at rest. The push off phase of svaking i indicated by the darker shade of purple * INVERSION EVERSION, + Pus OFF I 100 with the calcaneus in contact with the ground, pronation at the subtalar joint causes, rather than follows, internal rotation of the leg; either perspective is valid ‘The amplitude of pronation at the subtalar joint during carly to mid-stance phase of walking is indeed relatively small-about 5 degrees on average—occurring for only one quarter ofa second during average-speed walking. The amount and the speed of the pronation nevertheless influence the Kinematics of the more proximal joints ofthe lower extremity ‘These effects can be readily appreciated by exaggerating and dramatically slowing the pronation action of the rearfoot during the initial loading phase of gait. Consider the demon- stration depicted in Figure 14-32, While standing over a loaded and fixed foot, forcefully but slowly internally rotate the lower limb and observe the associated pronation at the rearfoot (subtalar joint) and simultaneous lowering of the ‘medial longitudinal arch,” If sufficiently forceful, this action also tends to internally rotate, slightly flex, and adduct the hip and create a valgus stress on the knee (Table 14-5). These ‘mechanical events are indeed exaggerated and do not all occur to this degree and pattern during walking at normal speed, Nevertheless, because of the linkages throughout the lower limb, excessive of uncontrolled pronation of theChapter 14 Ankle and Foot 597 Hip Internal rotation, flexion, and seduction Knee Increased valgus stress Rearfoot Pronation (eversion) with a lowering cof medial longitudinal arch rearfoot could exaggerate one or more of these mechani related joint actions.” Clinically, a person who excessively pronates during eatly stance may complain of medial knee pain, possibly from excessive valgus stress placed on the knee and subsequent overstretching of the medial collateral liga- ment, Whether the overpronation causes excessive strain on the medial collateral ligament or vice versa is not always obvious Although widely accepted, a predictable kinematic rela- tionship between the magnitude and timing of excessive pro- nation and excessive internal rotation throughout the lower FIGURE 14-32, With the foot fixed, fll internal rote tion of the lower limb is mechanically ascciated with seatfoot pronation (eversion), lowering ofthe medial longitudinal arch, and valgus steve atthe knee, Ni that as the rearfoot pronates, the floor “pushes” the forefoot and midfoot into’ a relatively supinat postion limb has not been established conclusively. Precise mea- surements of these kinematic relationships while a subject is walking are technically difficult. The kinematics themselves ate highly variable and poorly defined. Some studies report the kinematics as a rotation of a single bone, and others report relative rotations between bones. Additional studies are needed in this area before definite cause-and-effect relation- ships are known. These relationships are important, as th serve as the basis for many exercises and for the use of orthot- ics to reduce painful conditions related to excessive or poorly controlled pronation, Biomechanical Benefits of Limiting Pronation during the Stance Phase Controlled pronation of the subtalar joint through the mid- stance phase of walking has several useful biomechanical effects, Pronation at the subtalar joint permits the talus and entize lower extremity to rotate internally slightly afer the calcaneus has contacted the ground. The strong horizontal orientation of the facets at the subtalar joint certainly facili- tates this ation. Without such a joint mechanism, the plantar surface of the calcaneus would otherwise “spin” like a child's top against the walking surface, along with the intemally rotating leg, Eccentric activation of supinator muscles, such as the tibialis posterior, can help to decelerate the pronation598 Section IV Lower Extremity eT aee ee Example of the Kinematic Versatility of the Foot aC ZN The Use of a Foot Orthosis ari in this section, the point was made that pronation of, the unloaded foot occurs primarily as a summation of the pronation at both the subtalar and tvansverse tarsal joints (review Figure 14-26, 8). This summation of motion does not necessarily occur, however, when the foot is under the load of body weight. With the foot loaded or otherwise fixed to the ground, pronating the rearfoot may cause the midfoot and fore- {oot regions, which are receiving frm upward counterforce from ‘the floor, to twist into relative supination (see Figure 14-32)."" ‘This reciprocal kinematic relationship between the rearfoot and ‘more anterior regions ofthe foot demonstrates the versatility of ‘the foot, either amplifying the other region's action when the {oot is unloaded (see Figure 14-26, 6), or counteracting the other region's action when the foot i loaded (see Figure 14-32). and resist the lowering of the medial longitudinal arch. Con- trolled pronation of the subtalar joint favors relative flexibil ity of the midfoot, allowing the foot to accommodate to the varied shapes and contours of walking surfaces. Biomechanical Consequences of Abnormal Pronation during the Stance Phase Innumerable examples exist on how malalignment within the foot affects the kinematics of walking, One common scenario results from excessive, prolonged, or poorly controlled prona- tion at the subtalar joint during the stance phase. This disor der can have multiple causes, including weakness of muscles throughout the lower extremity, laxity or weakness in the mechanisms that normally support and control the medial longitudinal arch, of abnormal shape or mobility of the tarsal bones. Regardless of cause, the rearfoot falls into excessive valgus (eversion) after heel contact.” Excessive subtalar joint pronation may be a compensation for excessive or restricted ‘motion throughout the lower extremity, particulasly in the frontal and horizontal planes. Paradoxically, one of the most common structural defor- ities within an overpronated foot isa relatively fixed rearfoot ‘varus. (Varus describes a segment of the foot that is inverted toward the midline) As a response to rearfoot varus, the subtalar joint often overcompensates by excessively pronat- ing, in speed and/or magnitude, to ensure that the medial aspect of the forefoot contacts the ground during stance phase." Similar compensations may occur with a forefoot ‘uarus deformity. Whether the forefoot varus deformity causes or results from excessive pronation of the rearfoot is not always clear, ‘As described previously, excessive rearfoot pronation is typically associated with excessive (horizontal plane) internal rotation of the talus and leg during walking, Such a move- ment may create a “chain reaction” of kinematic disturbances and compensations throughout the entire limb, such as those depicted in Figure 1432, As described in Chapter 13, the abnormal kinematic sequence between the tibia and femur may alter the contact area at the patellofemoral joint, poten- tially increasing stress at this joint. Furthermore, excessive linicians generally agree that some form of foot orthosis. or specialized footwear can provide therapeutic benefits in persons with pes planus or ther conditions that cause exces- sive pronation during walking or running.***°*"* in general, a foot orthosis is a device inserted into the shoe in order to ‘modify the foot's mechanics. Often a wedge Is placed on the ‘medial aspect of the orthosis, effectively “bringing the floor up ‘o the foot.” This modification theoretically helps to control the rate, amount, and temporal sequencing of pronation at the subtalar joint! The precise mechanisms of how orthotics affect ‘the kinematics and kinetics of the foot and lower limb are not completely understood.” Asan adjunct to orthosis, some clinicians also stress the need to improve the “eccentric control” of the muscles that deceler- ate pronation and other associated motions mechanically inked ‘o pronation (such as those listed in Table 14-6). These muscle groups include the supinators of the foot (notably the tibialis posterior) and the more proximal external rotators and abduc- tors ofthe hip. This therapeutic approach strives to reduce the rate of pronation as well as the rate of loading on the foot. rearfoot eversion may create an increased valgus stress on the medial side of the knee." These situations may predispose a person to patellofemoral joint pain syndrome or instability. For these reasons, clinicians often note the position of the subtalar joint while the patient stands and walks as part of an evaluation for a mechanical cause of patellofemoral joint pain or other related dysfunction.” ‘The underlying pathomechanics of an excessively pro- nated foot are complex and not fully understood. The pathomechanics can involve many kinematic relationships, both within the joints of the foot and between the foot and the rest of the lower limb. The origin of the pathomechanies may be related to interactions between the hip and knee (described in Chapter 13) and expressed distally as impair- ‘ments at the subtalar joint. Even if the pathomechanics are obviously located within the foot, abnormal motion in the forefoot may be compensated for by abnormal motion im the rearfoot and vice versa. Furthermore, extrinsic factors, such as footwear, orthotics, terrain, and speed of walking or running, alter the kinematic relationships within the foot and lower extremity. An understanding of the complex kinesiok ogy of the entive lower extremity is a definite prerequisite for the effective treatment of the painful or misaligned foot. Mid-to-Late Stance Phase of Gait: Kinematics of Supination atthe Subtalar Joint ‘At about 15% to 20% into the gait cycle, the entire stance limb reverses its horizontal plane motion from intemal to extemal rotation." External rotation of the leg while the foot remains planted coincides roughly with the beginning of the swing phase of the contealateral lower extremity. With the stance foot securely planted, extemal rotation of the femur, followed by the tibia, gradually reverses the horizontal plane direction of the talus from internal to external rotation. As aChapter 14 Anil and Foot 599 Coase ano oer} bris result, at about 30% to 35% into the gait cycle, the pronated (everted) subtalar joint starts to move sharply toward supina- tion (inversion) (see Figure 1431, B). As demonstrated in Figure 14-33, with the rearfoot supinating, the midfoot and forefoot must simultaneously twist into relative pronation in order for the foot to remain in full contact with the ground.” By Iate stance, the supinated subtalar joint and the elevated and tensed medial longitudinal arch convert the midfoot (and ultimately the forefoot) into a more rigid lever." Muscles such as the gastrocnemius and soleus use this stability to transfer forces from the Achilles tendon, through the midioot, to the metatarsal heads during the push off phase of walking or running. Apperson who, for whatever reason, remains relatively pro- nated late into stance phase often has difficulty stabilizing the midfoot at a time when it is naturally required. Conse- quently, excessive activity may be required ftom extrinsic and intrinsic muscles of the foot to reinforce the medial longitu- dinal arch, Over time, hyperactivity may lead to generalized muscle fatigue and painful “overuse” syndromes throughout the lower limb and foot. DISTAL INTERTARSAL JOINTS The distal intestasal joints are a colle joint complexes, each occupying a patt of the midfoot organization of joints of the foot; see Figure 1423). The articular surfaces of the distal intertarsal joints are exposed and color-coded in Figure 14-34. Collection of Articulations within the Distal Intertarsal Joints + Canconavicular joint + Cuboideonavicular joint + Intercuneiform and cuncocuboid joint complex FIGURE 14-33. With the foot fixed to. the ‘ground, full external rofation of the lower limb is mechanically associated with: rearfoot supi- nation (inversion) and vaising of the medial longitudinal arch, Note that as the reatfoot supinate, the forefoot and midfoot pronate to ‘maintain contact with the ground, Posterior superior view louneonaviesar int Ne esa feet Ur Ciera tee calcaneocuboid Ton i cuboideonaint int i tercuretorm and neoeboi in omplex FIGURE 14-34. A posteriorauperior view of the right foot is shown vwith the talar and calcaneus removed. The navicular bone has been flipped medially, exposing its anterior surface andthe ray aaticuls- sions within the distal iertarsal joints. Artcular surlaces have been colored-caded as follows cumeonaoscular joint ight parple the saall. cuboideomaciculr jot in green: and the intecunciform and cuncocuboid Joint complex in blue. Replacing the navicular to its natural position ‘woul join the thre sets of articular facets within the cuneonavicular joint-medial facet (MB), intermediate facet (ZB), and lateral facet (ZB), Replacing the navicular would also reartcalate the cuboideo- navicular joint fen)600 Section IV Lower Extremity Basic Structure and Function ‘Asa group, the distal intertarsal joints (1) assist the transverse tarsal joint in pronating and supinating the midfoot, and (2) provide stability across the midfoot by forming the trans- verse arch of the foot. Motions in these joints are small and typically not formally described. Guneonavicular Joint ‘Three articulations are formed between the anterior side of the navicular and the posterior surfaces of the three cunei- form bones (see Figure 14-34, purple). Surrounding these articulations are plantar and dorsal ligaments. The slightly concave facets (lateral, intermediate, and medial) on each of the three cuneiforms fit into one of three slightly convex facets on the anterior side of the navicular. The major function of the cunconavicular joint is to. help transfer components of pronation and supination distally toward the forefoot.” Cuboideonavicular Joint ‘The small synarthrodial (Rbrous) or sometimes synovial cuboideonavicular joint is located between the lateral side of the navicular and a proximal region of the medial side of the cuboid (see Figure 14-34, green). This joint provides a ela- tively smooth contact point between the lateral and medial longitudinal columns of the foot. Observations on cadaver specimens show that the articular surfaces slide slightly against each other during most movements of the midioot, most notably during inversion and eversion. Intercuneiform and Cuneocuboid Joint Complex The intercuneiform and cuneocuboid joint complex consists of three articulations: two between the set of three cunei- forms, and one between the lateral cuneiform and medial surface of the cuboid (see Figure 14-34, blue). Articular sur- faces are essentially flat and aligned neatly parallel with the long axis of the metatarsals. Plantar, dorsal, and interosseous ligaments strengthen this set of articulations. ‘The intercuneiform and cuneocuboid joint complex forms the transverse arch of the foot (Figure 14-35, 4). This arch provides transverse stability to the midfoot. Under the load of body weight, the transverse arch depresses slighty, allowing body weight to be shared across all five metatarsal heads. The transverse arch receives support from intrinsic ‘muscles; extrinsic muscles, such as the tibialis posterior and fibularis longus; connective tissues; and the Keystone of the transverse arch: the intermediate (IF) cuneiform (see Figure 14-34), TARSOMETATARSAL JOINTS Anatomic Considerations ‘The tarsometatarsal joints ate frequently called Lisranc’s Joints after Jacques Listranc, a French field surgeon in Napo- Teon’s amy who described an amputation in this region of the foot, As a group, the five tarsometatarsal joints separate the midfoot from the forefoot (review organization of joints in Figure 14-23). The joints consist ofthe articulation between the bases of the metatarsals and the distal surfaces of the three cuneiforms and cuboid. Specifically, the first (most medial) metatarsal articulates with the medial cuneiform, the second adie 2 N FIGURE 14-35, Structural and functional features ofthe midfoot and forefoot. A, The transverse arch is formed by the intecuneiform and cuneoeuboid joint complex. B, The stable second ray is reinforced by the recessed second tatsometatarsal joint. C, Combined plantar flexion and eversion of the lelttarsometataral joint of the fist ray allow the forefoot to better conform to the surface of the rock. with the intermediate cuneiform, and the third with the lateral cuneiform. The bases of the fourth and fifth metatar sals both articulate with the distal surface of the cuboid. ‘The articular surfaces of the tarsometatarsal joints are gen- erally flat, although the medial two show slight, irregular curvatures. Dorsal, plantar, and interosseous ligaments add stability to these articulations. Only the first tarsometatarsal joint has a well-developed capsule.“ Kinematic Considerations ‘The tarsometatarsal joints serve as the base joints of the fore- foot. Mobility is least at the second and third tarsometatarsal joints, in part because of strong ligaments and the wedged position of the base of the second ray between the medial and lateral cunciforms (see Figure 14-35, B). Consequently, the second and third rays produce an element of longitudinal stability throughout the foot, similar to the second and thisd rays in the hand.” This stability is useful in late stance as the forefoot prepares for the dynamics of push off Mobility is greatest in the first, fourth, and fith tarsometa- tarsal joints, most notably in the first (most medial) joint." During walking, the first tatsometatarsal joint normally expresses about 10 degrees of sagittal plane movement; mobil ity in other planes is usually slight.” During the early to mid-stance phase of walking, the first tarsometatarsal joint gradually dorflxes about 5 degrees. This ‘motion occurs as body weight depresses the cuneiform region downward as the ground simultaneously pushes the distal end of the first ray upward. This movement is associated with 2 ‘gradual lowering of the medial longitudinal arch’”—a mecha nism that helps absorb the stress of body weight acting on the foot. At late stance (push off) phase of gait, however, the first tarsometatarsal joint rapidly planter flexes about 5 degrees.” The plantar flexion of the first ray, controlled in part by pull of the fibularis ongus, effectively “shortens” the ‘medial column of the foot slightly, thereby helping to raise the medial longitudinal arch. This mechanism increases theChapter 14 Ankle and Foot 601 stability ofthe arch (and medial column of the foot) at atime in the gait cycle when the midfoot and forefoot are under higher loads. ‘Although the descriptions are dated and still partially unre- solved, most literature describes a natural mechanical cou- pling of the kinematics at the first tarsometatarsal joint specifically, plantar flexion occurs with slight eversion, and dorsiflexion with slight inversion."*** Such passive mobility does indeed appear to occur naturally when assessed in a non-weight-beating condition (Figure 14-36). These move- ment combinations are atypical, however, because they do not fit the standard definitions of pronation or supination, Nevertheless, the unique mobility at the first tarsometatarsal joint may provide useful functions. Combining. plantar flexion and eversion, for example, allows the medial side of the foot to better conform around irregular surfaces on the ground (see Figure 1435, ©), (This motion of the first meta- tarsal is generally similar to the movement of the thumb metacarpal as the pronated hand attempts to grasp a large spherical object) Exactly how these atypical movement com- binations relate functionally to the overall kinematics of the foot during walking remains uncertain, See ca FLEXION FIGURE 14-36, The osteokinematice of the fist tareometatarel joint, Plantar flexion occurs with slight eversion (A), and dorsiflexion ‘occurs with slight inversion (B) INTERMETATARSAL JOINTS Structure and Function Plantar, dorsal, and interosscous ligaments interconnect the bases of the four lateral metatarsals. These points of contact form three small intermetatarsal synovial joints. Although interconnected by ligaments, a true joint does not typically form between the bases of the first and second metatarsals, This lack of articulation increases the relative movement of the first ray, in a manner similar to the hand. Unlike in the hand, however, the deep transverse metatarsal ligaments inter connect the distal end of all five metatarsals. Slight motion at the intermetatarsal joints augments the flexibility at the tarsometatarsal joints. METATARSOPHALANGEAL JOINTS Anatomic Considerations Five metatarsophalangeal joints are formed between the convex head of each metatarsal and the shallow concavity of the proximal end of each proximal phalanx (see Figure 14-23), ‘These joints are located about 2.5 cm proximal to the “web spaces” of the toes. With the joints flexed, the prominent heads of the metatarsals are easily palpable on the dorsum of the distal foot ‘Articular cartilage covers the distal end of each metatarsal head (Figure 14-37). A pair of collateral ligaments spans each ‘metatarsophalangeal joint, blending with and reinforcing the capsule. As in the hand, each collateral ligament courses obliquely from a dossal-proximal to a plantar-istal direction, forming a thick cord portion and a fanlike accessory portion. ‘The accessory portion attaches to the thick, dense plantar ‘plat, located on the plantar side of the joint. The plate, or ligament, is grooved for the passage of flexor tendons. Fibers from the deep plantar fascia attach to the plantar plates and sheaths of the flexor tendons. Two sesamoid bones located within the tendon of the flexor hallucis brevis rest against the plantar plate of the frst metatarsophalangea! joint (Figure 1438), Although not depicted in Figure 14-38, four deep transverse metatarsal ligaments blend with and join the adjacent plantar plates of al five metatarsophalangeal joints. By inte connecting al five plates, the transverse metatarsal ligaments help maintain the first ray ina similar plane as the lesser rays, thereby adapting the foot for propulsion and weight beating 7 Medial capsular ligament (cord portion) Planta plate and seeamoise FIGURE 14-37. A medial view of the first metatatsophalangeal joint showing the cord and accessory portions of the medial (collateral) capsular ligament, The accessory portion attaches tothe planta plate and sesamoid bones. (Redrawn ftom Haines R, McDougal Anatomy of hallux valgus, J Bone Jomt Surg Br 36:372, 1954)602 Section IV Lower Extremity Interphalanges! Extensor halucie Tongus (et) Extensor cigtorur, FIGURE 14-38. Muscles and joints of the dossal surface ‘of the sight forefoot, The distal half ofthe fist metatar- ‘lie removed to expose the concave surface of the tt imetatarsophalangeal joint. A pair of sesamoid bones is located deep within the fret metatarsophalangeal join. ‘The proximal phalanx of the second toe is removed to ‘expose the concave side ofthe proximal interphalangeal joint Aue tather than manipulation. In the hand, the deep transverse ‘metacarpal ligament connects only the fingers, freeing the thumb for opposition, ‘A fibrous capsule encloses each metatarsophalangeal joint and blends with the collateral ligaments and plantar plates, A poorly defined dorsal digital expansion covers the dorsal side of each metatarsophalangeal joint. This structure (analogous to the extensor mechanism in the digits of the hand) consists of a thin layer of connective tissue that is essentially insepa- rable from the dorsal capsule and extensor tendons. Kinematic Considerations Movement at the metatarsophalangeal joints occurs in two degrees of freedom. Extension (dossiflexion) and flexion (plantar flexion) occur approximately in the sagittal plane about a medialdateral axis; abduction and adduction occur in the horizontal plane about a vertical axis. The second digit serves as the reference digit for naming the movements of abduction and adduction of the toes. (The reference digit for naming abduction and adduction in the hand is the third or middle digit) The axes of rotation for all volitional move- ments of the metatarsophalangeal joints are through the center of each metatarsal head. ‘Most people demonstrate limited dexterity in active move ments at the metatarsophalangeal joints, especially in abduc- tion and adduction. From a neutral position, the toes ean be passively extended about 65 degrees and flexed about 30 to 40 degrees. The great toe typically allows greater extension, to near 85 degrees." This magnitude of extension is readily apparent as one stands up on “tptoes.” Planta plate ‘Sesamoid bones: Flexor hallucis brevis Superior view Distal attachment of extensor ‘dgitorum longus and brevis (cul) joint Distal interphalangeal joint Proximal interphalangeal jent revs (ou) Dorsal digital expansion Dorsal interossel Extensor digitorum brevis or allie E Extensor an Detormities or Trauma involving the Metatarsophalangeal soint of the Great Toe Hallux Limits Hall lmitus, ox “vigids” in its less severe form, is primarily 2 posttraumatic condition characterized by gradual marked limitation of motion, articular degeneration, and pain at the ‘metatarsophalangeal joint of the great tos. Although any trauma or sprain of the great toe can progress to hallux limitus, the mechanism of injury frequently involves forceful yperextesion of the metatarsophalangeal joint. More severe injuries may involve complete or incomplete tears of the plantar ligaments, capsule, and associated tendons, as well as fracture of the sesamoid bones." Injury caused by forced hyperextension of the great toe is often called “turf toe” and occurs relatively frequently in American football players. Historically, the term tf toe ‘originated from the increase in this injury after the replace- ‘ment of natutal grass with artifical turf and the use of ighter- weight shoes. Regardless of the initiating trauma, a diagnosis of hallux limitus is often made if pain persists along with reduced range of extension, usually to less than 55 degrees.”* In some cases the condition will evolve to osteoarthritis; ‘excessive osteophyte formation may then limit motion in all directions ‘The impairments associated with hallux limitus can have significant impact on walking.” Normally, walking requires about 65 degrees of extension atthe fist metatarsophalangeal joint as the heel rises at late stance phase. A person with hallux limites may attempt to avoid extending the painful great toe during the late stance phase of walking. Often thisChapter 14 Ankle and Foot 603 is accomplished by walking on the outer surface of the affected foot, or by walking with the foot pointed outward and “rolling over” the medial arch of the foot. Those affected may be advised to wear stiftsoled shoes (or stiff inserts placed within the shoes) and to avoid inclines or declines. Physical therapy has been shown to be effective in restoring range of motion and reducing pain.” Surgery is often recommended in more severe cass. Halux Valgus The central feature of hallex vafgas (or bunion) isa progressive lateral deviation of the great toe relative to the midline of the body. Although the deformity appeats to involve primarily the metatarsophalangeal joint, the pathomechanies of hallux valgus typically involve the entire frst ray (Figure 14-39, 4 and B), As depicted in the radiograph, hallux valgus is typi- cally associated with excessive adduction ofthe first metatarsal (defined in this case relative to the body and not the second digit) about its tarsometatarsal joint." The adducted position of the fist metatarsal can eventually lead to lateral dislocation of the metatarsophalangeal joint, thereby completely expos- ing the metatarsal head asa lump or “bunion.” The deformed metatarsophalangeal joint often becomes inflamed and painful. Ifthe proximal phalanx laterally deviates in excess of about 30 degrees, the proximal phalanx often begins to evert about its long axis. The bunion deformity is also referred to as “hallux abducto-valgus” in order to account for the devia- tions in both horizontal and fiontal planes, The progressive axial rotation of the laterally deviated proximal phalanx of the hallux creates a muscular imbalance 4m the forces that normally align the metatarsophalangeal joint. The abductor hallucis muscle (normally located medial to the first metatarsophalangeal joint) may gradually shift toward the plantar side of the joint, The subsequent nop- posed pull of the adductor hallucis and lateral head of FIGURE 14-9, Hallux valgus. A, Multiple featur of ballux valgus (bunion) and associated deformi- ties. B, Radiograph shows the following pathome- chanics often associated with hallox valgus: (1) adduction of the first metatarral (toward the midline of the body), evidenced by the increased angle between the first and second metataral bbones: (2) lateral deviation ofthe proximal phalanx swith dslecation or eubluxation ofthe firrt metatar- sophalangeal joint; (3) displacement of the lateral sesamoid; (4) rotation (evession) of the phalanges of the great toe; and (5) exposed first metatarsal head, forming the so-called "bunion,” (Brom Rich- ardson EG: Disorders of the hallux. In Canale ST, ed: Campbell’ opeatze onopaclcs, vol 4, ed 9, St Louis, 1998, Mosby.) the flexor hallucis brevis progressively increases the lateral deviation posture of the proximal phalanx. In time, the overstretched medial collateral ligament and capsule’ may weaken or rupture, removing an important source of rein- forcement to the medial side ofthe joint. Persons with marked haallux valgus may avoid bearing weight over the first meta- tarsophalangeal joint, causing the lateral metatarsal bones to accept a greater proportion of the load, The pathomechar ics of marked hallux valgus involve a zigzagelike collapse of the fist ray, similar to the “ulnar drift” of the metacarpo- phalangeal joint in the hand with sheumatoid arthritis (see Chapter 8) Although the cause of hallux valgus is not totally clear, genetics, incorrect footwear, pronated feet that cause valgus strain at the hallux, and asymmetry of the bones and joints can all contribute to the condition, ‘The full spectrum of severe hallux valgus often includes dislocation and osteoar thritis of the metatarsophalangeal joint, metatarsus varus, valgus (lateral deviation) of the great toe, bunion formation (and bursitis) over the medial metatarsopophalangeal joint, hammer toe of the second digit, calluses, and metatarsalgia Surgical intervention is often indicated in cases of marked deformity and dysfunction. INTERPHALANGEAL JOINTS As in the fingers, each toe has & proximal interphalangeal and a distal interphalangeal joint. The great toe, ox hallux, being analogous to the thumb, has only one interphalangeal joint All interphalangeal joints of the foot possess similar ana- tomie features. The joint consists of the convex head of the ‘more proximal phalanx articulating with the concave base of the more distal phalanx. The proximal phalanx of the second toc is removed in Figure 14-38 to expose the concave side of the proximal interphalangeal joint. The structure and604 Section IV Lower Extremity function of the connective tissues at the interphalangeal joints are_gencrally similar to. those described for the ‘metatarsophalangeal joints. Collateral, ligaments, plantar plates, and capsules are present but smaller and less defined. Mobility atthe interphalangeal joints is limited primarily to flexion and extension. The amplitude of flexion generally exceeds extension, and motion tends to be greater at the proximal than the distal joints. Extension is limited primarily, by passive tension in the toe flexor muscles and plantar ligaments ACTION OF THE JOINTS WITHIN THE FOREFOOT DURING THE LATE STANCE PHASE OF GAIT ‘The joints of the forefoot include the articulations associated with each ray, from the tarsometatarsal joint to the distal interphalangeal joints of the toe. Depending on the phase of anit, these joints provide an element of flexibility or stability to the forefoot During the end of the stance phase, the midfoot and fore- foot must become relatively stable to accept the stress associ- ated with push off. In addition to activation of local intrinsic and extrinsic muscles, arising of the medial longitudinal arch further stabilizes the foot. Although the rise of the arch is highly variable, it averages 6 mm during the push off phase ‘The primary mechanism used to lift the arch has been histor cally described asthe "windlass effect,” which is demonstrated by standing on tiptoes (Figure 14-40, 4). Because of the attachments of the deep plantar fascia to the proximal pha- langes, full extension of the metatarsophalangeal joints increases the tension throughout the medial longitudinal arch, In theory, the increased tension raises and stabilizes the arch. As the heel and most of the foot are lifted, body weight shifis anteriorly toward the more medial metatarsal heads, Local fat pads reduce potentially damaging stress to the bone, and the sesamoid bones protect the long flexor tendon of the great toe. Once stabilized by the stretched plantar fascia and a reinforced arch, the second and third rays act as rigid levers capable of withstanding the potentially large bending moments created by the contracting gastrocnemius and soleus muscles. The tensile force within the stretched plantar fascia during very late stance phase has been estimated to be near 100% of body weight.” Failure of the plantar fascia to trans- mit this force from the calcaneus to the base of the toes would limit the effectiveness of the windlass mechanism in raising the arch, This, indeed, is often observed by noting the guarded or ineffective manner of “push off” in a person who has had a plantar fasciotomy or is experiencing painful plantar fasciitis Tn contrast to the healthy foot, consider the pathomechan- ics involved as a person with an unstable “flat foot” (pes planus) attempts to rise up on tiptocs (sec Figure 14-40, 8). Although the individual has no neuromuscular pathology, there is significant loss in the lift ofthe heel, even on maximal ‘muscular effort. Without an effective medial longitudinal arch, the unstable, unlocked midfoot and forefoot sag under body weight. This typically causes a movement toward dort Alexion of the tarsometatarsal joints (in contrast to normal slight plantar flexion). This kinematic response may stretch the extrinsic toe flexor muscles and, if significant, limit toe extension. Regardless ofthe specific cause-and-effect relation- ship, the reduced extension of the metatarsophalangeal joints Normal foot Foot with pes planus FIGURE 14-40, The “windlass effect” of the plantar facia is demon. strated while a subject stands on tiptoes. (A windlass isa hauling or lifing device consisting of a rope wound around a eylinder that is tumed by a crank. The rope is analogous to the plantar fascia, and the cylinder is analogous to the metatarsophalangeal joint) A, In the normal foot, contraction of the extinsie plantar flexor muscles lifs the calcaneus, thereby transferring body weight forward over the rmetatatsl heads, The resulting extension ofthe metatarsophalangeal joints (shown collectively as the white disk) stretches (or winds up) the plantar Fascia within the medial longitudinal arch (ted spring). ‘The increased tension from the stretch raises the arch and strength ens the midfoot and forefoot. Contraction of the intrinsic museles he arch. B, The foot with pes planus (at foot) typically bas a poorly supported medial longitud hal ach. During an attempt to stand up on tiptoes, the forefoot sage under the load of body weight, The reduced extension of the mets tarsophalangeal joints limits the usefulness of the windlats effec. Even with song activation ofthe intrinsic muscles, the arch remains flattened and the midfoot and forefoot unstable provides additional reinforcer: