Dr.

Agostini Francesco

ANKLE
TALOCRURAL JOINT Dr. Agostini Francesco
 TALOCRURAL JOINT Dr. Agostini Francesco

The talocrural joint is the articulation of the trochlea and

sides of the talus with the rectangular cavity formed by
the distal end of the tibia and both malleoli.
The talocrural joint is often referred to as the “mortise,”
owing to its resemblance to the wood joint used by
carpenters. The concave shape of the proximal 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 95% of the
compressive forces pass through the talus and tibia; the
remaining 5% to 10% pass through the lateral region of
the talus and the fibula.
 TALOCRURAL JOINT: MEDIAL COLLATERAL LIGAMENTS Dr. Agostini Francesco

The medial collateral ligament of the talocrural joint is

called the deltoid ligament, based on its triangular shape.
This ligament is broad and expansive. Its apex is
attached to the medial malleolus, with its base fanning
into three sets of superficial fibers. Deeper tibiotalar
fibers blend with and strengthen the medial capsule of
the talocrural joint.
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
uncommon, in part because of the ligament’s strength
and because the lateral malleolus serves as a bony block
against excessive eversion.
 TALOCRURAL JOINT: LATERAL COLLATERAL LIGAMENTS Dr. Agostini Francesco

Because of the relative inability of the medial malleolus

to block the medial side of the mortise, the overwhelming
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 of the talus. 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 a hole or
onto someone’s foot while landing from a jump.
 TALOCRURAL JOINT: LATERAL COLLATERAL LIGAMENTS Dr. Agostini Francesco

The calcaneofibular ligament courses inferiorly and

posteriorly from the apex of the lateral malleolus to the lateral
surface of the calcaneus. This ligament resists inversion
across the talocrural joint (especially when fully dorsiflexed)
and the subtalar joint. As a pair, the calcaneofibular and
anterior talofibular ligaments limit inversion throughout most
of the range of ankle dorsiflexion and plantar flexion. About
two thirds of all lateral ankle ligament injuries involve both of
these ligaments.
The posterior talofibular ligament originates on the
posterior- medial side of the lateral malleolus and attaches to
the lateral tubercle of the talus. Its fibers run horizontally
across the posterior side of the talocrural joint, in an oblique
anterior-lateral to posterior-medial direction. The primary
function of the posterior talofibular ligament is to stabilize the
talus within the mortise. fibers considered part of the posterior
talofibular ligament. The fibers continue medially to the
posterior aspect of the medial malleolus, forming part of the
posterior wall of the talocrural joint.
 TIBIO FIBULAR JOINT Dr. Agostini Francesco

The proximal tibiofibular joint is a synovial joint

located lateral to and immediately inferior to the knee.
The joint is formed between the head of the fibula and
the posterior lateral aspect of the lateral condyle of the
tibia. 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. The
tendon of the popliteus muscle provides additional
stabilization as it crosses the joint posteriorly. Very little
gliding motion occurs at this joint; a firm articulation is
needed to ensure that forces within the biceps femoris
and lateral collateral ligament of the knee are transferred
effectively from the fibula to the tibia.
The distal tibiofibular joint is formed by the
articulation between the medial surface of the distal
fibula and the fibular notch of the tibia Anatomists
frequently refer to the distal tibiofibular joint as a
syndesmosis, which is a type of fibrous synarthrodial
joint that is closely bound by an interosseous membrane.
OSTEOKINEMATICS Dr. Agostini Francesco
 OSTEOKINEMATICS Dr. Agostini Francesco

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. Because the lateral malleolus is inferior
and posterior to the medial malleolus, the axis of rotation departs slightly from a pure medial-lateral axis.
The axis of rotation (in red) is inclined slightly superiorly and anteriorly as it passes laterally to medially
through the talus and both malleoli. The axis deviates from a pure medial-lateral axis about 10 degrees in the
frontal plane and 6 degrees in the horizontal plane.
 OSTEOKINEMATICS Dr. Agostini Francesco

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 talocrural joint produces a movement of pronation and supination.
The 0-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.
ARTHROKINEMATICS Dr. Agostini Francesco
 ARTHROKINEMATICS Dr. Agostini Francesco

During dorsiflexion, the talus rolls forward

relative to the leg as it simultaneously slides
posteriorly. The simultaneous posterior slide
allows the talus to rotate forward with only
limited anterior translation. The calcaneofibular
ligament becoming taut in response to the
posterior sliding tendency of the talus-
calcaneal segment. Generally, any collateral
ligament that becomes increasingly taut on
posterior translation of the talus also becomes
increasingly taut during dorsiflexion. Maximal
dorsiflexion elongates 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 posterior-directed translation of the
talus and foot relative to the leg.
 ARTHROKINEMATICS Dr. Agostini Francesco

During plantar flexion, the talus rolls

posteriorly as the bone simultaneously
slides anteriorly. Generally, any collateral
ligament that becomes increasingly taut
on anterior translation of the talus also
becomes increasingly taut during plantar
flexion. The anterior talofibular ligament
is stretched in full plantar flexion.
(Although not depicted, the tibionavicular
fibers of the deltoid ligament would also
become taut at full plantar flexion. Plantar
flexion also stretches the dorsiflexor
muscles and the anterior capsule of the
joint.
ARTHROKINEMATICS Dr. Agostini Francesco
MUSCLES: DORSIFLEXORS Dr. Agostini Francesco
 MUSCLES: DORSIFLEXORS Dr. Agostini Francesco

As a group, these “pretibial” muscles have their proximal

attachments on the anterior and lateral aspects of the
proximal half of the tibia, the adjacent fibula, and the
interosseous membrane. The tendons of these muscles cross
the dorsal side of the ankle, restrained by a synovial-lined
superior and inferior extensor retinaculum.
Located most medially is the prominent tendon of the
tibialis anterior, coursing distally to attach to the medial-
plantar surface of the first tarsometatarsal joint.
The tendon of the extensor hallucis longus passes just
lateral to the tendon of the tibialis anterior as it courses
toward the dorsal surface of the great toe.
The four tendons of the extensor digitorum longus attach to
the dorsal surface of the middle and distal phalanges via the
dorsal digital expansion.
The fibularis tertius is part of the extensor digitorum longus
muscle and may be considered as this muscle’s fifth
tendon.The fibularis tertius attaches to the base of the fifth
metatarsal bone.
 MUSCLES: DORSIFLEXORS Dr. Agostini Francesco

The pretibial muscles are most active during the early

stance phase and again throughout the entire swing
phase of gait. During early stance, the muscles are
eccentrically active to control the rate of plantar
flexion. Controlled plantar flexion is necessary for a
soft landing of the foot. Through similar eccentric acti-
vation, the tibialis anterior helps to decelerate the
lowering of the medial longitudinal arch and therefore
indirectly helps to control pronation (eversion) of the
rearfoot During the swing phase, the pretibial muscles
actively dorsiflex the ankle and extend the toes to
ensure that the foot clears the ground.
MUSCLES: EVERTORS Dr. Agostini Francesco
 MUSCLES: EVERTORS Dr. Agostini Francesco

Both muscles attach proximally along the lateral fibula.

The tendon of the fibularis longus, the more superficial of
the two, courses distally a remarkable distance. After
wrapping around the posterior side of the lateral malleolus,
the tendon enters the plantar side of the foot through a
groove in the cuboid bone. The tendon then travels
between the long and short plantar ligaments to its final
distal attachment on the plantar-lateral aspect of the first
tarsometatarsal joint. It is noteworthy that the fibularis
longus and tibialis anterior attach on either side of the
plantar surface first tarsometatarsal joint. This pair of
muscles therefore provides kinetic stability to the base of
the first ray.
The tendon of the fibularis brevis travels posterior to the
lateral malleolus alongside the fibularis longus. Both
fibular tendons occupy the same synovial sheath as they
pass under the fibular retinaculum . Just distal to the
retinaculum, the tendon of the fibularis brevis separates
from the fibularis longus tendon and courses toward its
distal attachment on the styloid process of the fifth
metatarsal.
 MUSCLES: EVERTORS Dr. Agostini Francesco

The fibularis longus and brevis are most active throughout the
middle and late stance phases of walking.During most of this
time, the subtalar joint is supinating (inverting) as the
dorsiflexing talocrural joint rapidly changes its direction to
plantar flexion. An important function of the fibularis muscles
during this phase of walking is to decelerate, and thus control,
the rate and extent of the supinating subtalar joint. Furthermore,
the active force within the fibularis longus helps to fixate the
first ray securely to the ground, During most of this time, the
subtalar joint is supinating (inverting) as the dorsiflexing
talocrural joint rapidly changes its direction to plantar
flexion.An important function of the fibularis muscles during
this phase of walking is to decelerate, and thus control, the rate
and extent of the supinating subtalar joint. Furthermore, the
active force within the fibularis longus helps to fixate the first
ray securely to the ground,
MUSCLES: PLANTARFLEXORS and INVERTORS Dr. Agostini Francesco
 MUSCLES: PLANTARFLEXORS and INVERTORS Dr. Agostini Francesco

The gastrocnemius muscle forms the

prominent belly of the calf. This two-headed
muscle attaches by separate heads from the
posterior side of the medial and lateral
femoral condyles. The larger, medial head
joins the lateral head midway down the leg to
form a tendinous expansion that, after
insertion of the tendon from the soleus
muscle, forms the Achilles tendon.
The broad flat soleus muscle lies deep to the
gastrocnemius, arising primarily from the
posterior side of the proximal fibula and
middle tibia. Like the gastrocnemius, the
soleus blends with the Achilles tendon for its
distal attachment to the calcaneal tuberosity.
The soleus is a very thick muscle,
approximately twice the cross-sectional area
as the overlying gastrocnemius. The
gastrocnemius crosses the knee but the soleus
does not.
 MUSCLES: PLANTARFLEXORS and INVERTORS Dr. Agostini Francesco

The tendon of the flexor hallucis longus courses distally

through the ankle in a groove formed between the
tubercles of the talus and the inferior edge of the
sustentaculum talus. Once in the plantar aspect of the
foot, the tendon of the FHL courses between the two
sesamoid bones of the first metatarsophalangeal joint,
finally attaching to the plantar side of the base of the
distal phalanx of the great toe.
The tendon of the flexor digitorum longus courses
distally across the ankle posterior to the medial
malleolus. At the level of the base of the metatarsals, the
main tendon of the FDL divides into four smaller
tendons, each attaching to the base of the distal phalanx
of the lesser toes.
The tendon of the tibialis posterior lies anterior to the
tendon of the flexor digitorum longus in a shared groove
on the posterior side of the medial malleolus. The tendon
divides into superficial and deep parts, establishing
attachments to every tarsal bone, except the talus, and to
the bases of several of the more central metatarsals.
 MUSCLES: PLANTARFLEXORS and INVERTORS Dr. Agostini Francesco

The plantar flexor and supinator muscles are

active throughout most of the stance phase of
gait, particularly between foot flat and toe off
phases
The tibialis posterior, flexor hallucis longus, and
flexor digitorum longus muscles are all capable of
resisting pronation and assisting with supination
during the stance phase of walking. Of the three
muscles, however, the tibialis posterior is most
designed for this function.
Of all the plantar flexor muscles, the
gastrocnemius and soleus are by far the most
powerful, theoretically capable of producing
about 80% of the total plantar flexion torque at
the ankle.