BONES OF THE FOOT & ANKLE

Interesting Little Clowns Tarsal Bones Talus Calcaneous Navicular Cuneiforms: 1st-medial 2nd-intermediate 3rd- lateral Cuboid Tarsals Mnemonics: (Clean) The Circus Needs More Interesting Little Clowns (Or not) Tall Californian Navy Medical Interns Lay Cuties Tarsals

Metatarsals Calcaneus Talus Navicular Cuboid 1 3 2 Metatarsals 4 5 Cuneiforms Metatarsals Numbered 1-5 Starting on big toe side

Phalangeal bones 14 total Also numbered 1-5 with big toe being #1 Proximal- (5) closest to metatarsals Middle-(4) between proximal and distal phalanx Only 4--like the thumb on the hand the big toe doesn’t have a middle phalanx Distal-(5) tip of the toe Distal phalangeal bones Middle phalangeal bones Proximal phalangeal bones Metatarsals

Similar to the Radius and Ulna there is an interosseous membrane between the Fibula and Tibia To remember which bone is which: FibuLA is LAteral The Medial Malleolus is inferior and medial on the Tibia FIBULA The Fibular notch is inferior and lateral on the Tibia Medial Malleolus Fibular notch Lateral Malleolus The LAteral Malleolus is inferior and lateral on the FibuLA

The ankle joint is a synovial joint The ankle joint is a synovial joint. Articular cartilage is found at articulation points between the bones of the ankle and the foot

There is also articular cartilage at each of the joints of the toes A little med term side note… The big toe is also called the Hallux A bunion is referred to as “Hallux Valgus” Hallux: Big toe Valgus: abnormal angulation

MTP, PIP, and DIP joints of the foot Proximal interphalangeal Distal interphalangeal DIP Each MTP and IP joint is held together by several ligaments One medial, one lateral and one inferior Thank you Mr. Blevins for not putting them all on our list!! Metatarsophalangeal MTP

Plantar fasciitis What it is: Inflammation of the plantar fascia Causes: Over use or overstretching of the plantar fascia Risk factors: Foot arch problems—too much or not enough Obesity Long distance running Tight Achilles tendon Shoes with poor arch support Symptoms: Pain and stiffness in the bottom of the heel-may be dull or sharp Bottom of foot may ache or burn

Treatment methods for Plantar Fasciitis Typical methods: Acetaminophen or ibuprofen to reduce pain and inflammation Heel stretching exercises Rest for at least a week Shoes with good support Apply ice to painful area More extreme cases may require: Boot cast Custom orthotics Steroid shots into the heel And other methods such as…….

The redneck treatment method To each his own…..

LIGAMENT LOCATION Spring Ligament : runs from the sustentaculum tali to the tuberosity of the navicular forming a support for the head of the talus. Long Plantar Ligament: runs from the undersurface of the calcaneous to the cuboid and bases of the lateral metatarsals. The ligament runs over the tendon of the peroneous longus. Short Plantar Ligament: runs from the undersurface of the calcaneous to the cuboid. Posterior Tibiofibular Ligament: connects the tibia and fibula posteriorly. It is located on the lateral aspect of the ankle.

LIGAMENT LOCATION (cont.) Anterior Tibiofibular : connects the tibia and fibula anteriorly. It is found on the lateral aspect of the ankle. Interosseous Tibiofibular: small ligament located at the base of the interosseous membrane between the tibia and fibula. Superior extensor retinaculum: broad band that crosses the anterior aspect of the foot just proximal to the malleoli. Inferior extensor retinaculum: a Y-shaped broad band that begins distal to the lateral malleolus on the calcaneous. It crosses the ankle , then divides, with one end attaching at the medial malleolus. The other fork connects to the navicular.

LIGAMENT LOCATION (cont.) Plantar aponeurosis The plantar aponeurosis lies deep to the superficial fascia of the sole and covers the 1st layer of muscles. It attaches to calcaneus and extends with slips to each toe. Interosseous membrane Between the tibia and the fibula is the interosseous membrane. It runs between the interosseous crests on the tibia and fibula. It binds the two bones together as well as separating the muscles of the front of the leg from the back.

Interosseous Tibiofibular Ligament Between the tibia and fibula there is an interosseous membrane. At the distal end the membrane thickens and becomes a ligament. This ligament is instrumental in holding these two bones together.

Anterior and Posterior Tibiofibular Ligaments (anterior view) ( posterior view)

Ligaments PLANTAR CALCANEONAVICULAR LIGAMENT (SPRING) SHORT PLANTAR

Plantar Aponeurosis The plantar aponeurosis lies deep to the superficial fascia of the plantar aspect of the foot and covers the 1st layer of muscles. It attaches to the calcaneus and sends a deep slip to each toe.

Bursae RETRO-CALCANEAL BURSA This bursa is located between the Achilles tendon and the superior region of the posterior surface of the calcaneous. SUBCUTANEOUS CALCANEAL BURSA It is found posterior (superficial) to the Achilles tendon, lying between the skin and the posterior aspect of the distal Achilles tendon. This is also known as the Achilles Bursa. Both contain synovial fluid to help lubricate these high friction areas.

Nerves of The Foot/Ankle Anterior: Saphenous nerve Superficial fibular (peroneal) nerve Deep fibular (peroneal) nerve Sural Palmar: Medial plantar Lateral plantar

Nerve/muscle Innervations of the Ankle and Foot DEEP PERONEAL nerve innervates THESE muscles: Extensor digitorum longus muscle Extensor hallucis longus muscle Tibialis anterior muscle Peroneous tertius muscle SUPERFICIAL PERONEAL nerve innervates THESE muscles: Peroneous longus muscle Peroneous brevis muscle TIBIAL nerve innervates THESE muscles: Gastrocnemius muscle Soleus muscle Plantaris Tibialis posterior Flexor hallucis longus Flexor digitorum longus

Arteries of the foot and ankle

Arteries of the Ankle and Foot Anterior Tibial Artery This artery originates as the popliteal artery and becomes the anterior tibial artery. It descends the tibia on the anteriomedial aspect of the tibia and becomes the dorsalis pedis at the ankle. Dorsalis Pedis This is a continuation of the anterior tibial artery. It begins at the ankle and runs anteriomedially. The dorsalis pedis is a main blood supply to the foot. Posterior Tibial Artery This artery is a continuation of the popliteal artery. It begins at the inferior border of the popliteus and descends medially through the calf of the leg. It enters the foot at the medial side of the calcaneus .

Arteries of the Ankle and Foot (cont.) Arcuate Artery One of the branches of the dorsalis pedis is this artery. It runs anteriorly and transversely at the base of the metatarsal bones towards the lateral aspect of the foot. Deep Plantar Arch Artery (NOTE: Vein of same name accompanies) Both the arcuate and deep planter arteries branch at the base of the metatarsal of the big toe. The deep plantar artery runs into the plantar aspect of the foot . It travels transversly across the remaining metatarsals towards the lateral side of the foot. Lateral Tarsal Artery A branch of the dorsalis pedis, this artery begins at the midline of the talus anteriorly and runs at an angle towards the lateral aspect of the foot.

DORSAL VENOUS ARCH VEIN: Carries blood from the toes to both the great and lesser saphenous veins. GREATER SAPHENOUS VEIN: This vein is formed by the dorsal digital vein of the big toe and the dorsal venous arch. It runs from the dorsal venous arch along the medial anterior aspect of the foot and anterior to the medial malleolus . LESSER SAPHENOUS VEIN: The lesser saphenous vein is formed by the dorsal venous arch and the dorsal digital vein of the 5th digit of the foot. It runs along the lateral aspect of the foot and posterior to the lateral maleolus . PLANTAR ARCH VEIN: This vein is not pictured here, however, with each artery there is a co-ordinating vein. SEE NEXT SLIDE. It is located on the plantar side of the foot, running next to the plantar arch artery.

SURFACE ANATOMY

SURFACE ANATOMY

Arches of the Foot Medial Longitudinal Arch Lateral Longitudinal Arch Includes the calcaneous, talus, navicular, the 3 cunieforms, and the 3 medial metatarsals. The arch is supported by the spring ligament, muscles and the tibialis anterior and posterior from above. Lateral Longitudinal Arch Includes the calcaneous, cuboid, and the two lateral metatarsals. The arch is bound by the short and long plantar ligaments. The peroneous longus and brevis muscles support it superiorly. Transverse Arch Includes the cunieforms and bases of all the metatarsals. This arch gains its support from the deep transverse ligament, plantar ligaments, and the interossei which binds it together. The peroneous longus and brevis support it superiorly. Fundamental Longitudinal Arch This arch is comprised of the calcaneus, cuboid, 3rd cunieform, and 3rd metatarsal. These bones run through the center of the foot and form the basic longitudinal arch of the foot. Arches of the Foot

A Little “Footnote” The human foot and ankle is a strong and complex mechanical structure containing more than 26 bones, 33 joints (20 of which are actively articulated), and more than a hundred muscles, tendons, and ligaments. Let’s all be grateful they are NOT all on the test!

MUSCLES of the Ankle and Foot

Gastrocnemius: #24 A/B Origin: Media and lateral condyles of femur. Insertion: Posterior Calcaneous Action: Knee flexion, ankle plantar flexion Innervation: Tibial nerve Vascular supply: Popliteal artery

Extensor Digitorum Longus: #21 Origin: Fubula, interosseous membrane, tibia Insertion: Distal phalanx of four lesser toes Action: Extends four lesser toes, assists in ankle dorsiflexion Innervation: Deep peroneal nerve Vascular supply: Anterior tibial artery

Soleus: # 24C Origin: Posterior tibia and fibula Insertion: Posterior calcaneous Action: Ankle plantar flexion Innervation: Tibial nerve Vascular supply: Posterior tibial artery

Extensor Hallucis Longus: #20 (removed) Origin: Fubula, interosseous membrane Insertion: Distal phalanx of great toe Action: Extend first toes, assist ankle inversion and dorsiflexion Innervation: Deep peroneal nerve Vascular supply: Anterior tibial artery

Plantaris: #25 Origin: Posterior lateral condyle of femur. Insertion: Posterior calcaneous Action: Knee flexion (weak), ankle plantar flexion Innervation: Tibial nerve Vascular supply: Popliteal artery

Tibialis Anterior: #19, Big Bob #142 Origin: Lateral tibia and interosseous membrane Insertion: 1st cuneiform and metatarsal Action: Ankle inversion, dorsiflexion Innervation: Deep peroneal nerve Vascular supply: Anterior tibial artery

Tibialis Posterior: # 28, 146 Big Bob Origin: Interosseous membrane, adjacent tibia and fibula Insertion: Navicular and most tarsals and metatarsals Action: Ankle inversion, assist plantar flex Innervation: Tibial nerve Vascular supply: Fibular artery

Peroneus Longus: #22, Big Bob #138 Origin: Lateral proximal fibula and interosseous membrane Insertion: Plantar surface of 1st cuneiform and metatarsal Action: Ankle eversion, assist plantar flex Innervation: Superficial peroneal nerve Vascular supply: Fibular artery

Flexor Hallucis Longus: #29 Origin: Posterior fibula and interosseous membrane Insertion: Distal phalanx of great toe Action: Flex great toe, assist inversion and plantar flexion Innervation: Tibial nerve Vascular supply: Fibular artery

Peroneus Brevis: #23, Big Bob #139 Origin: Lateral distal fibula Insertion: base of 5th metatarsal Action: Ankle eversion, assist plantar flex Innervation: Superficial peroneal nerve Vascular supply: Fibular artery

Flexor Digitorum Longus: #27 Origin: Posterior tibia Insertion: Distal phalanx of 4 lesser toes Action: Flex 4 little toes, assist inversion and plantar flexion Innervation: Tibial nerve Vascular supply: Posterior tibial artery

Peroneus Tertius: not seen on models Origin: Distal medial fibula Insertion: Base of 5th metatarsal Action: Assist ankle eversion, dorsiflexion Innervation: Deep peroneal nerve Vascular supply: Anterior tibial artery

Movements of the Ankle and Foot Plantar flexion Dorsiflexion Ankle Inversion Ankle Eversion Flexion of Big Toe Flexion of little toes

Plantar Flexion Gastrocnemius, Soleus, Plantaris, Tibialis Posterior, Peroneus Longus, Peroneus Brevis, Flexor digitorum longus, Flexor Hallucis longus,

Dorsiflexion Extensor digitorum longus, extensor hallucis longus, tibialis anterior, peroneus teritius

Gait Cycle Defined as human locomotion, or the way that we walk. Every individual has a unique gait pattern, which can be affected by injury or disease process. Therapist can determine weakness or shortening of muscles by observing a persons gait. The gait cycle is divided into two phases: 1)Stance -- interval in which the foot is on the ground (60% of the gait cycle) 2) Swing -- interval in which the foot is not in contact with the ground (40% of the gait cycle) Stance is divided into four phases: 1) Heel strike to foot flat 2) Foot flat through midstance 3) Midstance through Heel off 4) Heel off to Push off Swing phase deals with acceleration and deceleration around the midstance.

Gait Cycle

References The Gait Cycle From Laura Inverarity, D.O., former About.com Guide,Updated August 03, 2007 www.dreamstime.com tibia: human tibia and fibula. [Art]. In Encyclopædia Britannica. Retrieved from http://www.britannica.com/EBchecked/media/101354/Anterior-view-of-the-bones-of-the-lower-right-leg http://mikescottdpt.com/2011/02/03/revisiting-plantar-fasciitis Google images