LE: Ankle and Foot | Transes

Leg, Ankle and Foot

Bones of the leg Fibula 10% non-weight-bearing

Aka “splint bone”

Tibia 90% weight-bearing

1) Head of the bula
Aka “shin bone”

Common Peroneal N: MC entrapped n and it

MC site of stress (incomplete) fx in runners — d/t
encircles the head of the bular

repetitive stress causing microtrauma

Cross-Leg Palsy: Paresthesia caused by the

MC site of Nonunion fx in the body: Distal 1/3 of the impingement of the common peroneal n

tibia
Fx of the head of Fibula: may also impinge
the common peroneal n.

1) Tibial Plateau Patella Tendon Bearing Cast

2) Tibial Tuberosity Bedridden px w/ leg always in ER: may also
Osgood Schlatter Disease/Jumper’s Knee: impinge the common peroneal

In ammation of tibial tuberosity/patellar Contraindicated: Prolonged icing since the

tendon — d/t repetitive trauma from jumping
common peroneal nerve is therre and may
M > F; 10 - 14 y.o. cause neurapraxia
Self-limiting
Foot Drop Deformity: DF weakness

Bilateral
Foot Slap/Steppage Gait: Gait caused by DF
Contraindicated Tx: Ultrasound — will weakness

stunt the growth of the child

Gait Compensation: ⬆ Hip & knee Flexion
3) Tibial Crest during swing
4) Tibial Plafond: Receives the 90% of WB
2) Neck
5) Medial Malleolus 3) Shaft
4) Lateral Malleolus

Projects more lower and posterior than the medial

malleolus

Proximal aspect of the convex lateral malleolus is

wedged w/in the bular notch of the lat. distal tibia

Distal aspect of the medial side of the lateral

malleolus articulates c talus

Medial Malleolus Most distal aspect of the tibia et forms a prominent

landmark on medial side of the ankle

Lateral Aspect: articulates c talus

Is non weight-bearing

Plafond Is the “ceiling” or distal end of the tibia w/c forms the
proximal surface of the talocrural jt

Convex medially to laterally; concave anteriorly to

posteriorly

Bears 90% of the weight

MEDIAL MALLEOLUS VS LATERAL MALLEOLUS

MEDIAL MALLEOLUS LATERAL MALLEOLUS

Shorter
Longer

More anterior in position More posterior in position

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 LE: Ankle and Foot | Transes

Note: Type Hinge/Ginglimus Joint

Fick Angle: The normal out-toeing angle of foot

DF/PF
Normal Fick Angle in Children: 5-10° (Average: 7°)
OPP 10° PF

CPP Full DF
Joints of the leg
Capsular Pattern PF more limited > DF
Superior Aka “Forgotten Joint” — because this jt is not
tibiofibular joint usually assessed

“Superior Tibio bular Jt”

Medial collateral ligament Lateral collateral ligament

Plane Synovial Jt (Deltoid)
Movements:
Superior & Inferior sliding of Fibula & 1) Antati — Anterior Tibial Lig.
1) Anta —Anterior Fibular Lig.

Rotation

2) Potati — Posterior Tibial Lig.

2) Pota — Post. Fibular Lig.

Articulations:
3) Cati — Calcaneo Tibial Lig.
3) Ca — Calcaneo bular Lig.

Head of Fibular + Proximal Aspect of Tibia

4) Tina — Tibionavicular Lig.

DF: Distal Fibula: ABD - IR; Superior
Fibula: Superiorly
More commonly sprained
PF: Distal Fibula: ADD-ER; Superior Fibula: group of ligaments, d/t:

Inferiorly Fewer ligaments

Inferior Syndesmotic Jt — pertains to brous tissue

Ligaments are
tibiofibular joint High Ankle Sprain
separate

Articulates: Tibial facet + Fibular facet

Inversion >
Ligaments: Eversion
Anterior TF Lig — prevents posterior
translation

Posterior TF Lig — prevents anterior Posterior Tibial N (Posterior Tibial N): Supplies all posterior
translation compartment compartment of the leg

Interosseous Lig. — syndesmotic sprain/ (+) Calcaneal gait: Foot is DF and the heel is always
high ankle sprain
in contact w/ the ground; a ected is tibial n.
- MOI: Talus ER ➡ Fibular fx ➡ AITF
Superficial Post. Gastrocnemius

Lig
Compartment - Higher number of FAST-twitch bers

Resting Position: 10o PF

- For jumping, hopping, running
Close Packed Position: Full DF - Action: Knee Flex + PF

Soleus

- high number of SLOW-twitch bers

- Fatigue-resistance

Compartments of the leg - Action: PF

Plantaris: Is not always present in some
Anterior Commonly a ected compartment in the leg
individuals; Aka “Freshman’s Nerve”

compartment Anterior Compartment Syndrome:

- Action: Knee Flex + PF

6 P’s of Anterior Compartment Syndrome:

Note: Gastrocs and Soles are Plantar exors
Pain
Paresthesia Deep Postt. Tibialis Posterior:

Compartment
Pallor • Deepest mm of the calf

Pulselessness @ dorsalis pedis pulse • Main invertor

Paralysis of the DF • “Invertor Par Excellance”

Poikilothermia: Unable to regulate Flexor Digitorum Longus

temperature - Action: PF + inv

Flexor Hallucis Longus

Code for the Contents of the Compartment : Tom, - Master Knot of Henry

Dick, and Harry Potter - Action: Big toe EXT + PF + Inv

Pretibial Muscles/Contents of the An.

Popliteus:

Compartment (All capable of DF):

• Deepest mm in the leg

T = Tibialis Ant.

D = Extensor Digitorum longus

H = Extensor Hallucis Longus

P = Peroneus Tertius

Deep Peroneal N. (Ant. Tibial N.): Nerve supply of

the pretibial mm

Lateral Contents:

compartment Peroneus Longus

Peroneus Brevis

Evertors
Super cial Peroneal N (Musculocutaneous Nerve
of the Hip).: Nerve supply of the lateral compartment

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Medial Collateral Lig. “Deltoid Lig”

Major ligament of the ankle jt

Strongest ligament of ankle

Consists of:
Tibionavicular
Tibiocalcaneal
Post. Tibiotalar
Ant. Tibiotalar
Attaches to:
Navicular Tuberosity

Medial Malleolus

Sustentaculum Tali

Tibionavicular Resists talar abduction

Tibiocalcanean Resists talar abduction

Post. Tibiotalar Resists talar abduction

Ant. Tibiotalar Resists lateral translation and lateral rotation of

Ankle joint the talus

MC injured jt in sports Ant. Talo bular Provides stability against excessive inversion of
the talus
Aka “Talocrural jt”, “Ankle Mortise jt”

Type of Joint: Uniaxial, modi ed hinge, synovial jt

Post. Talo bular Resists ankle DF, adduction, medial rotation, and
medial translation of the talus
Loc: B/n talus, medial malleolus of tibia, and lateral malleolus of
bula
Calcaneo bular Provides stability against maximum inversion at
the ankle and subtalar ljts
Resting position: 10° of plantar exion, midway between maximum
inversion and maximum eversion

3 Bones:

Medial Malleolus of Tibia

Lat. malleolus of Fibula
Talus
Ankle Mortise: Socket intended for the talus b/n the med et lat
malleoli

Ligaments
Ankle Sprain: Commonly Sprained Ligaments:

Lateral Collateral Ligaments:

1) ATFL

MOI: PF + INV — Ant. Drawer Test

Prevents excessive PF + Inversion

Special Test: Anterior Drawer Test

2) CFL
MOI: DF + INV — Talar Tilt Test

Prevents excessive DF + Inversion

Special Test: Talar Tilt

3) PTFL
Prevents excessive DF + Inversion
1)
Medial Collateral Ligaments: MOI: Prevents excessive valgus


1) Anterior Talotibial Lig force

Special test: Foot

2) Calcaneotibial Lig
Kleiger’s Test
3) Post. Talotibial Lig
Talar Tilt (Abduction) 26 bones:

4) Tibionavicular Lig
7 Tarsals

Rear/Hind Foot
Talus

Calcaneus

Midfoot
Navicular

Cuboid

3 cuneiforms

Forefoot
5 Metatarsals

14 Phalanges

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Talus “Astralgus”

Bears all of the weight in single limb weight-

bearing

NO mm attachment

Is angled medially 30 degrees to face the

navicular

Dome of the Talus: is dome-shaped to

coincide c the saddle-shape of the inferior
tibia

Convex anteriorly-to-posteriorly

Concave medially-to-laterally

Articulates c:
Calcaneaus

Ant, Med, and Post Facets

Sinus Tarsi: Channel that runs b/n the

articulations of the talus and calcaneus

Diaz — avascular necrosis of the talus bone

Calcaneus “OS Calcis”

Is the largest and strongest tarsal

Loc: Under the talus

First bone contact the ground and transmits the

forces from the talus to the ground

Protected by a fat pad

1st to ossify

Sustentaculum Tali: medial extension of the

calcaneus and is a horizontal shelf on w/c the
talus is supported
Supports inferior medial aspect of talus

Articulations:
Ant: cuboid

Navicular Is boat-shaped

Hallux Valgus Deformity/Bunion: MC foot deformity in RA

Loc: B/n head of talus and 3 cuneiforms

Common in those who wear pointed shoes

Articulations:
Normal Hallux Valgus Angle: 15°

Post: Talus

Ant: 3 Cuneiforms

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3 Cuneiforms Loc: Anterior to navicular bone

Medial Cuneiform

- Largest of the cuneiforms

- Loc: b/n navicular tuberosity and base

of 1st metatarsal
Intermediate Cuneiform

- Smallest cuneiform

Lateral Cuneiform

- articulates c medial cuboid

Forms the transverse arch of the foot

Cuboid Is six-sided

Articulations:
Post: calcaneus

Medial: Lateral cuneiform

Ant: 4th and 5th metatarsals

Lateral and Plantar surfaces: Groove for the

peroneus longus tendon

Metatarsals Head of Metatarsals — ball of the foot

1st Metatarsal:

Shortest

Thickest

2nd metatarsal:

Longest

Thinnest

Most securely anchored

3rd Metatarsal

4th Metatarsal

5th Metatarsal

Contains a tuberosity for peroneus brevis

insertion

Contains:
Base

Shaft

Convex head

Phalanges 14 phalanges

2 in the great toe and 3 on the others

Middle Phalanges

Broader than the proximal phalanges

Shorter

Distal Phalanges

Flatter and smaller

Talus Calcaneus

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Aka “Astragalus”
Longest Tarsal bone
Medial Component Bones: Supporters:

longitudinal Talus
1) Plantar
Has no mm attachment
1st to ossify in the tarsal Calcaneonavicular/
TB of the foot is common in bones
arch • Head of the Spring Ligament

Talus: Keystone
the talus bone
MC to fx
responsible for the 2) Tibialis Posterior
Can invert more than it can Os Calcis
stability of the Tendon: Main tendon
evert
medial longitudinal support of the med.
(+) Sustentaculum Tali: arch
longitudinal lig

Diaz Disease: Avascular Supports the head of the Navicular

necrosis of the talus talus; found in the medial part Calcaneus

of the calcaneus 1, 2, 3 Cuneiforms

Pes Planus Deformity/
Flat Foot: Collapsed med
1, 2, 3 Metatarsals
longitudinal arch

- Pronated foot

- Pes Valgus

Metatarsals - Everted

METATARSALS Normal WB Ration of MT: 2 : 1 : 1 : 1 : 1

Pes Cavus/High Arched
Foot:

N Forward Projection of MT bones: 2 > - Supinated

3> 1> 4> 5 (2nd MT is longer, followed by - Pes Varus

the 3rd MT, then the 1st, 4th, and 5th) - Inverted

- MC foot deformity in
Charcot Marie Tooth
1st Metatarsal Strongest
Disease/Peroneal
Shortest
Muscular Atrophy. —
d/t the 1st mm to
Has 2x the WB atrophy in CMTD is
the peroneals w/c are
2nd Metatarsal Longest
evertors and if they
Thinnest
atrophy, there is
strong inversion
2nd Metatarsal Shaft: March Fx

Freiberg’s Disease: Avascular necrosis of Lateral 1) Calcaneus

1) Long Plantar Lig.

2) Cuboid 2) Peroneus Longus

the 2nd MT head longitudinal
- Keystone of the Tendon
arch
lat longitudinal
3rd Metatarsal arch

3) 4th & 5th MT

4th Metatarsal
Transverse 1) Cuboid
1) Intrinsic mm of the foot

2) 3 cuneiforms

5th Metatarsal Jone’s Fx: Fx of the 5th metatarsal base

arch - 2nd Cuneiform is Splayfoot
Iselin Disease: Apophysis of the 5th MT the keystone
- results to mm weakness
bone 3) Bases of all MT of the intrinsic mm of the
foot

Foot configuration

1) Morton’s/Greek Foot: Shortened 1st toe ( 2 ➡ 1➡ 3➡ 4➡ 5)

2) Egyptian Foot: Long 1st toe (1➡ 2➡ 3➡ 4➡ 5)

- 69% of the general population

3) Squared Foot: 1 = 2➡ 3➡ 4➡ 5

Joints of the foot

Arches of the foot Subtalar Joint “Talocalcaneal joint”

Supination — Pronation

3 DOF

Type: Multiplanar/Uniaxial Synovial

Injury: becomes hypomobile

Composed of:
Talocalcaneonavicular Jt

Cuneonavicular Jt

Cuboideonavicular Jt

Intercuneiform Jts

Cuneocuboid Jt

Calcaneocuboid Jt

Ligaments:
Med & Lat Talocalcaneal Lig

Interosseous (Talocalcaneal) Lig: Restricts end-

range eversion motion

- has connections to the cerebellum

- Proprioceptive subtalar center

Cervical Lig: Restricts end-range inversion

motion

- largest talocalcaneal ligament

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Talocalcaneonavicular Type: Ball-and-socket synovial

Pronation PEVABD PEvAdP
Jt 3 DOF

Pronation

Supporting Lig: SPITT: Subtalar

Eversion

Dorsal talonavicular lig

Pronation = Internal
Bifurcated lig
Abduction
Tibial Torsion
Plantar calcaneonavicular (spring) lig Dorsi exion

Midtarsal joint “Transverse Tarsal Joint”. “Chopart’s Joint”,

“Surgeon’s Joint”

Supination — Pronation
Muscles of the foot
Articulation:
Talonavicular Jt + Calcaneocuboid Jt.

Ligaments
Muscles in the Extensor Digitorum Brevis

Talonavicular lig: restricts movement of talus on

dorsum of the Extensor Hallucis Brevis
navicular; allows rotation
foot
Plantar Calcaneonavicular Lig: maintains medial
longitudinal arch
Plantar part of 1st Layer: (AFA)

Bifurcated lig: Supports transverse tarsal jt

the foot Abductor hallucis

Long Plantar Lig: Limits depression of the lateral - Porta Pedis: Is a portal seen in abd.
longitudinal arch

Hallucis mm only

Short Plantar Lig: Maintains the lateral longitudinal

arch
- Baxter’s N.: nerve that passes thru the
Dorsal Ligs: Protects and support the porta pedis; 1st branch of the lateral
tarsometatarsal jts; permits gliding b/n tarsals and plantar n.
metatarsals
Flexor digitorum brevis

Talonavicular Jt Type: Synovial Jt

Abductor digiti minimi

Articulation:
B/n round head of talus, upper surface of
sustentaculum tali + posterior concave surface of 2nd Layer (LQ) + (FDL, FHL Tendons)

navicular
Lumbricals

Calcaneocuboid Jt Type: Plane Synovial

Quadratus Plantae

Articulation:
B/n anterior end of the calcaneum + posterior
surface of the cuboid Master Knot of Henry:
Flexor Digitorum Tendon

Tarsometatarsal Connection b/n the tarsal and metatarsals

Flexor Hallucis Longus Tendon

Joint “Lisfranc Joint”

Type: Plane Synovial

3rd Layer: (FAF)

Articulation: Cuboid + 3 Cuneiforms + 5 MTT

Most Mobile: 4th & 5th TMT Jt

Flexor Hallucis Brevis

Ligaments of tarsometatarsal Jt: Adductor Hallucis

Plantar Ligs.
Flexor Digiti Minimi Brevis
Interosseous Cuneometatarsal Ligs

Ligaments of Intermetatarsal Jt: 4th layer: (I)

Dorsal, Plantar, and Interosseous Ligs Dorsal & Plantar Interossei

Type: Synovial, Condyloid Jt

Tibial Posterior Tendon

Metatarsophalang
eal Joint 2 Mechanism: Peroneus Longus Tendon
Metatarsal Break: MTP jts serves to allow the
weight-bearing foot to rotate over the toes

Plantar Fascia
N Flexion of MCP jt: 0 - 90°

N Ext of MCP: 0 - 30°

Ligaments of MTP Jt:

Collateral ligs

Plantar ligs

Deep Transverse Metatarsal lig

Ligaments of Interphalangeal Jt:

Collateral ligs

Plantar ligs

Supination vs. pronation

OKC CKC

Supination SInAdPa SInAbD

Supination

SSETT: Subtalar
Inversion

Supination External
Adduction
Tibial Torsion
Plantar Flexion

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As the heel lifts, extension is achieved at the MTP joints

Ankle pf Triceps Surae

depending on the individuals exibility

Gastrocnemius

DF During Propulsive Phase:

- Greatest activity c ankle PF
Plantar fascia winds around head of MT = Plantar fascia shortens
against resistance and c knee
the distance b/n calcaneus & MT to elevate medial longitudinal
extension

arch
- (+) Fast twitch mm bers

Soleus

- Covered by gastrocs
Nerve supply
- Stabilizes the ankle and controls
postural sway
Tibial N.
- (+) SLOW twitch mm bers

Tibialis Posterior
Lateral Plantar N. Medial Plantar N.

“Invertor Pars Excellence”

(FAF1)

Deepest mm of the calf

1) Flexor Hallucis Brevis

Fxn: Supports med longitudinal arch

2) Abductor Hallucis

Flexor Hallucis Longus

3) Flexor Digitorum Brevis

Stabilize proximal phalanx and ex 4) 1st Lumbrical

distal phalanx

Flexor Digitorum Longus

Support longitudinal arches

Anatomical landmark
Apply force on ground for push-o
during running and walking
Tarsal tunnel
Peroneus Tertius
Peroneus Brevis
MC site of entrapment of tibial n

Strongest abductor of the foot

Loc: Medial side of medial malleolus

Plantaris
Roof: Flexor retinaculum

“Fishermans/Freshman’s Nerve” Floor: Medial malleolus & calcaneum

Contents: (Tom, Dick, And, Very, Nervous, Harry)

Ankle evertors Peroneus Longus

1) Tibialis Posterior Tendon

Most constant mm to support all 2) Flexor Digitorum Longus Tendon

plantar arches
3) Posterior Tibial Artery

Peroneus Brevis
4) Posterior Tibial vein

Peroneus Tertius
5) Posterior Tibial N.

Extensor Digitorum Longus 6) Flexor Hallucis Longus Tendon

Ankle df Tibialis Anterior

Strongest/Primary DF
Extensor retinaculum
2x the cross-section of EHL & EDL
Is a at lig

Extensor Digitorum Longus

Structures that pass under the extensor retinaculum: (Tom Hanks
Extensor Hallucis Longus
And Very Nervous Dick Tracy)

Peroneus Tertius 1) Tibialis Anterior Tendon: will then insert on the base of 1st
MT

Ankle invertors Tibialis Anterior

2) Extensor Hallucis Longus: Insert in distal phalanx of big toe

Tibialis Posterior

3) Anterior Tibial Artery: will become the Dorsalis Pedis A.

Flexor Digitorum Longus
After it passes the extensor retinaculum

Flexor Hallucis Longus 4) Anterior Tibial Vein

5) Anterior Tibial N./Deep Peroneal N

6) Extensor Digitorum Tendons: Extends into 4 slips

Note: 7) Peroneus Tertius Tendon: insert on the base of the 5th MT

Extensor Digitorum Brevis: Only mm in the dorsum in the foot w/out

a counterpart in the hand
Dorsalis pedis artery
Flexor Retinaculum: “Lanciniate Lig” To palpate the dorsalis pedis:

1) Lateral to Tibialis Anterior Tendon

2) Lateral to Extensor Hallucis Longus Tendon

PLANTAR APONEUROSIS
3) B/n 1st and 2nd MT

Attachment for intrinsic mm

4) Medial to Extensor Digitorum Longus

Windlass E ect: acts as a shock absorber during initial contact;

aids in propulsion

Windlass Mechanism: Mechanical model that describes the manner

w/c plantar fascia supports the foot during weight-bearing

Pt Apps
During Swing Phase:
30-40o MTP Extension (to prevent stubbing toe on ground)
Cause of Overuse Injuries:
During Terminal Part of Stance Phase: Prolonged training season

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Impact force of activity

Training or competing on hard surfaces

Change of training surface

Downhill running

Lack of exibility

Individual mm weakness or poor reciprocal mm strength

Overstriding

Poor posture

High mileage or sudden change in mileage

Too much, too soon

Overtraining

Anatomical factors (e.g., malalignment)

Wrong type of footwear

Road or sidewalk camber

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