Ankle and Foot Flashcards
Distal Tibiofibular Joint
-Fibrous/syndesmosis type of joint
-Movement:
Small amount of spread with (1-2mm) at the ankle to allow full DF [talus wedging]
DF causes fibula to move superiorly which can also stress the proximal tibiofibular joint
Lose stability of joint -> lose stability of entire ankle
Distal Tibiofibular Joint Ligamentous Support
- Anterior tibiofibular
- Posterior tibiofibular
- Inferior transverse
- Interosseous ligament / syndesmosis
Talocrural (Ankle) Joint
-Modified hinge, synovial joint:
Talus - Wider anteriorly (more mobile in PF, less in DF)
Lateral malleolus of fibula - Extends down to almost subtalar level
Medial malleolus of tibia - Extends down to mid talus
Responsible for DF & PF
Subtalar Joint
- Synovial joint w/ 3 DOF
- Inversion & eversion are responsible for the alignment of the transverse tarsal joint axes
- -Locking & unlocking the mid-foot
- Pronated hind foot = parallel axes = increased movement
- Supinated hind foot = axes not parallel = decreased movement
Subtalar Joint Articular Facets
- Posterior: Talus concave, calcaneus convex
- Two Anterior: Talus is convex, calcaneus is concave
Subtalar Joint Positions
- Resting: Midway between extremes of ROM
- Closed: Supination
- Capsular Pattern: Varus, valgus
Talocrural (Ankle) Joint Positions
- Resting: 10 deg plantar flexion, midway between inversion/eversion
- Closed: Maximum DF
- Capsular Pattern: PF, DF
Distal Tibiofibular Joint Positions
- Resting Position: PF
- Closed: Maximum DF
- Capsular Pattern: Pain when joint is stressed
Midfoot (Mid Tarsal Joints)
- Talonavicular and Calcaneocuboid
- In isolation, minimal movement
- Together, significant movement allowing the foot to adapt to many positions
- Chopart Joint = mid tarsal joints between talus-calcaneous and navicular-cuboid [separates medial from lateral side]
- Don’t measure range of midfoot
Midfoot (Mid Tarsal Joints) Positions
- Resting Position: Midway between extremes of ROM
- Closed: Supination-most rigid/close together
- Capsular Pattern: DF, PF, adduction, medial rotation
Forefoot Joints
- Tarsometatarsal Joint
- Metatarsophalangeal Joints
- Interphalangeal Joints
Tarsometatarsal Joint Postions
- Resting Position: Midway between extremes of ROM
- Closed Packed Position: Supination
- Capsular Pattern: None
Metatarsophalangeal Joints Positions
- Resting: 10 deg extension
- Closed: Full extension
- Capsular Pattern
- -Big Toe = extension, flexion (make sure to check the big toe for gait, make sure there’s about 70dg of extension)
- -Second to fifth toe = variable
Interphalangeal Joints Positions
- Resting: Slight flexion
- Closed: Full extension
- Capsular Pattern: Flexion, extension
Movements at Each Region of the Ankle/Foot
- Talocrural joint: PF and DF
- Subtalar joint: Inversion and eversion
- Midtarsal joints: Adduction and abduction
Lateral Malleolus
- Distal aspect of the fibula
- Three main ligaments attach here:
- -Anterior talofibular ligament
- -Calcaneofibular ligmaent
- -Posterior talofibular ligment
Medial Malleolus
- Distal aspect of tibia
- Higher than lateral
- Main ligament: Deltoid
- -Tibionavicular
- -Tibocalcaneal
- -Tibiotalar
Talus (Talar Dome)
- Moves out in PF
- Wider anteriorly
- Palpate in the depressions anterior to the lateral and medial malleolus
- -Invert to feel lateral dome “pop out”
- -Evert to feel medial dome “pop out”
Sinus Tarsi
- Small canal under the talus on the outer lateral aspect
- Soft tissue depression just anterior to lateral malleolus
- Swelling and pain can occur here
- Filled by extensor digitorum brevis
Calcaneus / Peroneal Tubercle
- Bump on the lateral aspect of the calcaneus distal to the lateral malleolus
- Separates peroneus brevis and longus. (fibularis brevis and longus)
- Can be sensitive area
Cuboid
- Between the 5th metatarsal and calcaneus
- Can be felt as an indentation between these structures
- Articulates with 4th & 5th metatarsals
5th Metatarsal
- Large palpable styloid process at the flared base.
- Peroneus brevis inserts here
Medial Tubercle of Talus
- Posterior to the distal end of the medial malleolus
- Posterior portion of the deltoid ligament attaches here
Sustentaculum Tali
- Bony shelf approximately 1 finger width distal to the medial malleolus
- Attachment site for the spring ligament
Navicular Tubercle
- Most medial prominence distal the the sustentaculum tali
- See how close it is to the floor
1st Cuneiform
Between navicular and the base of 1st metatarsal.
Medial Calcaneal Tubercle
- Medial plantar aspect of the calcaneus
- Broad and large, may be sharp if patient has “heel spurs”
- 3 main things attach here
- -Medially: Abductor Hallucis
- -Anteriorly: Flexor digitorum brevis & Plantar aponeurosis / fascia
1st MTP
- Restriction here can lead to hallucis rigidis/limitis
- Site of gout
Sesmoids
- Small bone located at the distal end of the 1st metatarsal
- Embedded within flexor hallucis brevis
Deltoid Ligament
- Anterior to navicular
- Inferior to calcaneus
- Posterior to talus
- “Fan-like”
Tibialis Posterior Tendon
- Most anterior of the Tom, Dick, an Harry group
- Invert and plantar flex
Flexor Digitorum Longus Tendon
- Just behind tibialis posterior
- Flex toes
Posterior Tibial Artery
- Posterior to FDL
- Easier to palpate in non-weight-bearing
Tibial Nerve
- Posterior and lateral to posterior tibial artery
- Difficult to palpate in isolation
Flexor Hallucis Longus Tendon
- Posterior aspect of the TC joint
- Flex great toe though difficult to palpate due to Achilles
ATFL
- Anterior lateral malleolus to anterolateral talar neck
- Resists excessive inversion
- 1st one “to go”
- Plantar flex and invert to tension
- Usually the weakest with more mobility
CFL
- Inferior lateral malleolus to calcaneus
- Resists maximum inversion
- Posterior to peroneal tubercle
- Invert with foot in neutral to tension
PTFL
- Posterior lateral malleolus to posterior talus
- Resists ankle DF, adduction (tilt), medial rotation, and medial translation of talus
Peroneus Longus
- Tendon is the inferior division at peroneal tubercle
- Inserts onto the 1st cuneiform and base of the 1st metatarsal
- Evert to contract
Peroneus Brevis
- Superior tendon
- Inserts onto the styloid process of the 5th metatarsal
- Evert to contract
Extensor Digitorum Brevis
Palpate within the sinus tarsi while patient extends toes
Tibialis Anterior
- Most medial and prominent tendon on dorsum of ankle joint
- Dorsiflex and invert to feel
Extensor Hallucis Longus
- Lateral to tibialis anterior
- Extend the great toe to feel
Extensor Digitorum Longus
- Lateral to extensor halluces longus
- Extend the toes to feel
Dorsal Pedal Artery
Between EHL and EDL on dorsum of the foot.
Plantar Fascia
- Medial tubercle of the calcaneus to MTP
- Will feel rough
- Look at in DF and PF
- Helps with Windlass Effect
Abductor Hallucis
- Most medial aspect of the plantar aspect of the foot
- If unable to abduct great toe, shorten foot in standing
Dorsiflexion ROM
- Normal: 20 dg
- End Feel: Firm
- F=lat. aspect of lateral malleolus
- S=lat. midline of the fibula
- M= // to lat. aspect of 5th metatarsal
Plantarflexion ROM
- Normal: 50 dg
- End Feel: Firm
- F=lat. aspect of lateral malleolus
- S=lat. midline of the fibula
- M= // to lat. aspect of 5th metatarsal
Inversion ROM
- Normal: 35 dg
- End Feel: Firm
- F= anterior aspect of the ankle mid-way between the malleoli
- S=anterior midline of the lower leg [tibial tuberosity]
- M= anterior midline of the second metatarsal
Eversion ROM
- Normal: 15 dg
- End Feel: Hard
- F= anterior aspect of the ankle mid-way between the malleoli
- S=anterior midline of the lower leg [tibial tuberosity]
- M= anterior midline of the second metatarsal
1st MTP Flexion
- Normal: 45 dg
- End Feel: Firm
- F=dorsal aspect of 1st MTP
- S=dorsal midline of the metatarsal
- M=dorsal midline of the proximal phalanx
1st MTP Extension
- Normal: 70 dg
- End Feel: Firm
- F=dorsal aspect of 1st MTP
- S=dorsal midline of the metatarsal
- M=dorsal midline of the proximal phalanx
Non-Weight-Bearing ML Testing-Gastrocnemius
- Patient supine with knee fully extended and foot in neutral inversion/eversion
- Passively DF the ankle
- Look for compensation at knee joint [Knee flexion]
Weight-Bearing ML Testing-Gastrocnemius
- Pt standing with knee fully extended and foot/heel in contact with floor
- Pt leans body forward keeping heel down
-To quantify the muscle length measure the amount of ankle dorsiflexion
Ankle Figure 8 Measurement
- Pt in long sitting with ankle off edge of table foot in neutral
- Can put something under the patient’s knee if needed for comfort
Landmarks: Midway between tibialis anterior and the lateral malleolus. Navicular tuberosity Base of the 5th metatarsal Distal medial and lateral malleolus
Circumferential Malleoli Measurement
Standard circumferential measurements at the inferior aspect of the ankle.
