MSK 12b: bones, joints and muscles of the foot

Question 1

Name all the tarsal bones from proximal to distal

Answer 1

Tarsus (7 bones, proximal foot)
CALCANEUS-heel bone, when standing transmits majority of weight from the talus to the ground. Lateral surface has fibular trochlea which lies between the tendons of fibularis longus and braves, anchoring the evertors. Calcaneal tuberosity on posterior surface for weight-bearing; only medial tubercle contacts ground in standing. Allows levering at ankle to increase efficacy of plantar and dorsi flexion
TALUS-gripped superiorly by the malleoli (trochlea of talus). Only tarsal bone with no muscular or tendinous attachments
NAVICULAR-medial side, just distal to talus. Flattened, boat-shaped bone between head of tales and the 3 cuneiforms. Medial surface projects inferiorly as navicular tuberosity (tendon attachment)
CUBOID-most lateral in the distal row of the tarsus. Anterior to its tuberosity is a groove for tendon of fibularis longus
CUNEIFORMS-medial, intermediate and lateral. Wedge-shaped, each articulates with the navicular posteriorly and the base of the metatarsal anteriorly. Lateral cuneiform also with cuboid. Form the transverse arch

Question 2

Describe metatarsals and phalanges of the foot

Answer 2

Metatarsus: 5 metatarsals numbered from the medial side. 1st metatarsal is shorter than the others, 2nd is the longest. Each has a base proximally, a shaft, and a head distally. Bases articulate with cuneiform and cuboid, heads with proximal phalanges. Bases of 1st and 5th have tuberosity for tendon attachment, and tuberosity of 5th projects laterally over the cuboid. On plantar surface of 1st are prominent medial and lateral sesamoid bones

Phalanges: 14. Great toe has proximal and distal and the rest have proximal, middle and distal. Each has a base, shaft and head. 1st digit phalanges are short, broad and strong

Question 3

Calcaneal fracture

Answer 3

Hard fall onto heal may fracture it into several pieces (comminuted). Disrupts subtalar joint so usually disabling

Question 4

Fracture of talar neck

Answer 4

During severe dorsiflexion e.g. pressing extremely hard on break pedal. May dislocate posteriorly

Question 5

Fracture of metatarsals

Answer 5

Heavy object falls on foot and common in ballet dancers. Can also be transverse fatigue fractures from repeated stress e.g. excessive walking
If foot suddenly and violent inverted, tuberosity of 5th metatarsal may be avulsed by tendon of fibularis brevis

Question 6

What type of joint is the ankle (talocrural articulation)?

Answer 6

Hinge-type synovial joint

Question 7

Articulations of the ankle

Answer 7

Ankle: TIBIA, FIBULA and TALUS

Malleolar mortise: distal ends of tibia and fibula bound by tibiofibular ligaments and bound by hyaline cartilage
Body of talus fits into mortise (wedge-shaped articulating part)

Question 8

When is the grip of the malleoli tightest on the talus?

Answer 8

Dorsiflexion-as when descending a steep slope

So this is when the ankle is most stable

Question 9

Joint capsule of ankle

Answer 9

Thin anteriorly and posteriorly, but supported by strong medial and lateral collateral ligaments
This fits with movements, as plantar and dorsiflexion big movements but inversion and eversion more limited

Question 10

Describe the ligaments of the ankle

Answer 10

Lateral ligament: consists of 3 separate ligaments

• anterior talofibular: flat, weak, from lateral malleolus to neck of talus
• posterior talofibular: thick, quite strong, runs from malleolar fossa to lateral tubercle of talus
• calcaneofibular: round cord from tip of lateral malleolus to lateral surface of calcaneus

Medial ligament: large and strong, also called deltoid ligament, attaches proximally to medial malleolus then fans out into 4 adjacent and continuous parts:

• tibionavicular
• tibiocalcaneal
• anterior tibiotalar
• posterior tibiotalar

Question 11

Role of the medial ligament of the ankle?

Answer 11

Stabilise the ankle during EVERSION and prevents subluxation of the joint

Question 12

What are the main movements of the ankle, and how are they performed?

Answer 12

Dorsiflexion: by anterior compartment muscles

Plantarflexion: by posterior compartment muscles. Because the narrow end of the trochlea of talus lies loosely between malleoli during plantar flexion some “wobble” (small amounts of abduction, adduction, inversion and eversion) can occur in this unstable position

Question 13

Neuromuscular supply of the ankle

Answer 13

Blood: arteries derived from malleolar branches of the fibular and the anterior and posterior tibial arteries

Nerves: from tibial nerve and deep fibular nerve

Question 14

Role of the lateral ankle ligaments?

Answer 14

Resist inversion

Question 15

What could an inversion injury cause?

Answer 15

The relatively weak lateral ligament is likely to partially or fully tear, causing “sprained ankle”. Most likely is the anterior talofibular
In severe cases the lateral malleolus may fracture

Question 16

Pott’s fracture-dislocation

Answer 16

Foot forcibly everted, so pull of the medial ligament often causes an avulsion fracture of the medial malleolus and lateral displacement of talus, causing fracture of the lateral malleolus and/or fracture of the fibula above the inferior tibiofibular joint

Question 17

Which muscle groups produce the movements of the ankle and foot?

Answer 17

Plantar flexion: inserting posterior to malleoli
Dorsiflexion: inserting anterior to malleoli
Inversion: inserting on medial aspect of foot
Eversion: inserting on lateral aspect of foot

Question 18

Why is dorsiflexion more limited than plantarflexion?

Answer 18

Talus is wider anteriorly, so when dorsiflex the talus is wedged and thus more stable

Question 19

What is the tarsal tunnel?

Answer 19

Medial aspect of ankle.
Roof: flexor retinaculum
Floor: medial surfaces of talus and calcaneus
Contents (from anterior to posterior):
-tibialis posterior tendon
-flexor digitorum longus tendon
-neurovascular bundle (posterior tibial artery and vein + tibial nerve)
-flexor hallucis longus tendon

Tom, Dick And Very Nervous Harry

Question 20

Describe the innervation of the sole of the foot

Answer 20

Similar distribution to median and ulnar nerve: serial homologue
LOOK AT DIAGRAM
Medial plantar nerve: medial 3.5 digits
Saphenous nerve: small area on medial side towards heel
Tibial nerve: heel area
Sural nerve: small area on lateral side towards heel
Lateral plantar nerve: lateral 1.5 digits

Question 21

Describe the 3 major joints of the foot

Answer 21

SUBTALAR JOINT: inferior surface of body of talus articulates with superior surface of calcaneus. Plane synovial joint which performs inversion and eversion

CALCANEOCUBOID JOINT: anterior end of calcaneus with posterior surface of cuboid. Plane synovial joint, helps with inversion and eversion

TALOCALCANEONAVICULAR: clinically is included within the subtalar joint because it only works when with the anatomical subtalar joint. The head of talus articulates with calcaneus navicular

Question 22

Describe the arches of the foot

Answer 22

Lateral longitudinal arch: act as a unit with the transverse arch, spreading weight in all directions. Flat, rests on ground during standing. Made up of calcaneus, cuboid and lateral 2 metatarsals

Medial longitudinal arch: higher and more important than the LLA. Made up of calcaneus, navicular, 3 cuneiforms and 3 metatarsals. Keystone is the talar head. Fibularis longus tendon supports

Transverse longitudinal arch: cuboid, cuneiforms and bases of metatarsals. Many now doubt its existence and believe MLA is the only one of importance.

Question 23

Function of the arches of the foot

Answer 23

Distribute weight over the foot acting as shock absorbers and “spring board” (elasticity) for propelling it during walking, running and jumping. Become slightly flattened by body weight during standing and normally resume their curvature when body weight is removed

Question 24

What is “flat feet” (pes planus)?

Answer 24

Excessive stretching of the spring ligaments and plantar aponeurosis: talar head is displaced inferomedially and MLA is flattened so some lateral deviation is produced

Flat appearance of sole of foot. Can be flat only when weight-bearing (flexible) or all the time (rigid)

Acquired flatfeet “fallen arches” likely to be secondary to dysfunction of tibialis posterior due to trauma, degeneration with age or denervation

Question 25

Describe the importance of the foot in standing and walking

Answer 25

Main weight-bearing bones: heel and the head of the metatarsals
Arches maintained by shape of interlocking bones, ligaments of foot, intrinsic muscles of foot and pull of long tendons of extrinsic muscles
When standing the arches sink and individual bones lock together as ligaments at maximum tension
As soon as walk the weight is released from the arches which unlock and become a mobile level system in the spring-like action of locomotion

Question 26

What is the general arrangement of the muscles of the foot?

Answer 26

Many extrinsic muscles attach to dorsum, but dorsum only has 2 intrinsic muscles
Plantar intrinsic muscles arranged in 4 layers within four compartments. However they function primarily as a group during the support phase of stance, maintaining the arches of the foot. Most active in push off

Question 27

Name the 18 muscles in the plantar aspect of the foot

Answer 27

1st layer (closest to ground):

• abductor hallucis
• flexor digitorum brevis
• abductor digiti minimi

2nd layer:

• quadratus plantae
• lumbricals x 4

3rd layer:

• flexor hallucis brevis
• adductor hallucis
• flexor digiti minimi brevis

4th layer:

• plantar interossei x 3
• dorsal interossei x 4

Question 28

What is the innervation of the intrinsic plantar muscles?

Answer 28

Branches of the plantar nerve (S2-S3)

Question 29

Interossei of feet?

Answer 29

PAD DAB:
Plantar interossei ADduct and arise from a single metatarsal as unipennate muscles
Dorsal interossei ABduct and arise from two metatarsals as bipennate muscles

Question 30

Intrinsic muscles in the dorsum of the foot

Answer 30

Extensor digitorum brevis

Extensor hallucis brevis

Question 31

Innervation of the dorsal intrinsic muscles of the foot?

Answer 31

Deep peroneal nerve (L5-S1)

Question 32

Describe the cutaneous innervation of the foot

Answer 32

Medially: saphenous nerve (extends distally to head of 1st metatarsal)
Superiorly (dorsum): superficial and some of deep peroneal nerves
Inferiorly (sole): medial and lateral plantar nerves
Laterally: sural nerve (inc part of heel)
Posteriorly (heel): medial and lateral calcaneal branches of the tibial and sural nerves respectively

Question 33

Common peroneal and tibial nerve injuries

Answer 33

PED TIP:

common Peroneal Everts and Dorsiflexes (so injury=foot drop)

Tibial Inverts and Plantarflexes (so injury=can’t walk on tip toes)