Foot and Ankle Biomechanics

Talocrural Joint

• Uniaxial hinge joint

• The talus is wider anteriorly than

posteriorly

• Talus is convex AP

• Medial malleolus is shorter than the lateral

 Arthrokimenatics talocrural joint

In dorsiflexion the talus rolls anterior and glides posterior

The distal fibula moves superior, posterior and externally rotates

In plantarflexion the talus rolls posterior and glides anterior

The distal fibula moves inferior, anterior and internally rotates

ROM: DF 20 degrees PF 50 degrees

Close packed position dorsiflexion

Capsular pattern plantarflexion, dorsiflexion

Resting position 10 degrees plantarflexion

 Subtalar joint
• Allows the calcaneus to adapt its position to the terrain

• Three facets on the talus articulate with three facets on the

calcaneus

• The posterior articulation is convex on the calcaneus and

concave on the talus

• The anterior articulation consists of 2 calcaneal facets,

which are biconcave. It articulates with 2 biconvex facets on
the inferior surface on the head of the talus

• It shares its joint capsule with the talonavicular joint

Much confusion with wide variety of terminology describing the same motion

For all practical purposes we will use the following terminology:

Supination
Combined motion consisting of
• talocrural plantar flexion
• mid/forefoot adduction
• subtalar inversion
Pronation
Combined motion consisting of:
• talocrural dorsiflexion,
• mid/forefoot abduction
• subtalar eversion
 Arthrokinematics subtalar joint

Open chain
• In supination the calcaneus moves medially and inverts

• In pronation the calcaneus moves laterally and everts

Closed chain
• Pronation consists of tibial IR, talar plantar flexion/adduction and calcaneal eversion

• Supination consists of tibial ER, talar DF/abduction and calcaneal inversion

 Arthrokinematics subtalar joint

ROM approximately 20 degrees inversion, 10 degrees eversion

Closed pack position supination

Resting position midway between eversion/inversion, 10 degrees of PF

Capsular pattern inversion

 Midtarsal joints

•Talonavicular joint

•Calcaneal cuboid joint

•Cubonavicular joint

•Cuneonavicular joint

•Intercuneiform joints
 Tarsometatarsal joints

Joints between the distal row of tarsals and the proximal row of the proximal
metatarsals

• MT 1 articulates with medial cuneiform. Very lax joint capsule. First ray takes
care of 60% of the weightbearing. The subsequent rays are responsible for 10%
each

• MT 2 articulates with intermediate cuneiform

• MT 3 articulates with lateral cuneiform

• MT 4 and 5 articulate with the cuboid

 Metatarsalphalangeal joints
Convex distal MT articulating with concave proximal phalanx

The base of the proximal phalanx has 2 sesamoids

Sesamoid function:

•Anatomic pulley for flexor hallucis brevis

•Protect FHL tendon from weightbearing trauma as it passes through the tunnel formed by
sesamoids and intersesamoidal ligament
 Metatarsalphalangeal joints
ROM MTP I extension 70 degrees (60 required for normal gait)
flexion 45 degrees

Close pack position max extension

Resting position neutral

Capsular pattern extension, flexion

 Tibiofibular joints

Inferior tibiofibular joint

Concave fibular notch articulates with facet on distal fibula.
It contains no cartilage and is therefore classified as a syndesmosis

Arthrokinematics

Dorsiflexion
•Increased distance between medial and lateral malleolus, which tightens
interosseous membrane
•Fibula externally rotates (due to the wedge shape of the talus) and glides
superior

Plantar flexion
•Decreased distance between medial/lateral malleolus
•Fibula glides inferiorly and internally rotates
 Sources of stability

• Wedge shaped mid tarsal bones

• Medial longitudinal arch

• Lateral longitudinal arch

• Transverse arch

• Ligamentous support

• Intrinsic foot muscles

 Gait
In the landing phase, the foot has to be able to act as a a loose adapter, so it can
absorb the ground reactive forces
In order to do so, the calcaneus everts. This unlocks the mid tarsal joints, allowing
them to become torque converters

In toe off, the foot has to function as a solid lever

In order to do so, the calcaneus inverts. This locks the mid tarsal joints, as the
calcaneal inversion in effect places all the midtarsal bones in their close packed
position

Therefore, subtalar arthrokinematics are hugely important in the overall function of

the foot.
 Clinical Prediction Rules
•Overuse of radiologic imaging has been a significant economic
problem in the US.

•CPR’s that indicate when there is a need for radiographic

studies for specific type of injuries have been developed to
reduce unnecessary imaging

•They were developed primarily for use by ER physicians. They

are developed for maximum sensitivity to avoid missing relevant
findings.

•PT’s using CPR’s should also bear in mind that the rules also
apply to acute first time presentations of significant injuries
 Ottawa Ankle Rules
Ankle
•Pain in the malleolar area and tenderness over the posterior edge or tip of the
lateral or medial malleolus
•Unable to bear weight immediately and on examination.

Foot
•Pain in the midfoot region, tenderness of base 5th metatarsal or navicular bone
•Unable to bear weight immediately and on examination

Diagnostic accuracy for ankle fractures

Sensitivity = 100%
Specificity = 40%
Foot/ankle Lateral View

Point out the following:

Fibula

•Tibia

•Calcaneus

•Talus

•Cuboid

•First metatarsal

•Navicular
 Ankle Trauma

In adults the ankle is the most frequently injured major joint in the body

Ankle radiographs are among the most frequently ordered studies in the ER
department

However, only a small percentage of these patients will have a fracture that
requires definition by radiography

Radiographs are recommended for acute conditions meeting the Ottawa

criteria, and for all chronic pain conditions

Advanced imaging is used after the radiographic findings are either insufficient
or when they are negative and further injury is suspected
 DVT’s
• Homan’s sign is traditionally used: passive
ankle extension with knee extended. Pain in
the calf indicates a positive test for DVT’s
• Neither sensitive or specific for DVT’s
• It is recommended to use Well’s clinical
prediction rule for DVT’s
 Well’s CPR for DVT’s
Clinical Presentation Possible Score Client’s Score

Active cancer (within 6 months of 1

diagnosis or receiving palliative care)
Paralysis, paresis, or recent 1
immobilization of lower extremity
Bedridden for more than 3 days or 1
major surgery in the last 4 weeks
Localized tenderness in the center of 1
the posterior calf, the popliteal space, or
along the femoral vein in the anterior
thigh/groin
Entire lower extremity swelling 1

Unilateral calf swelling (more than 3 1

cm larger than uninvolved side)
Unilateral pitting edema 1

Collateral superficial veins 1

(nonvaricose)
An alternative diagnosis is as likely (or -2
more likely) than DVT (e.g., cellulitis,
postoperative swelling, calf strain)
Total Points
 Score Key
-2 to 0 Low probability of DVT
1 to 2 Moderate probability of DVT
3 or more High probability of DVT
 
• Medical consultation is advised in the
presence of low probability
• Medical referral is required with moderate or
high score.
Palpation medial side foot

1. Medial malleolus

2. Sustentaculum talus

3. Navicula tuberosity

4. First MT joint

5. Tibialis posterior

6. Tibialis anterior

7. Extensor hallucis longus

Palpation lateral side foot
1. Achilles tendon

2. Abductor digiti minimi

3. Bursa

4. Fifth MT

5. Insertion peroneus brevis

6. Peroneus longus

7. Peroneus tertius