Ankle and foot complex

TRANSVERSE TARSAL JOINT

BONES:

❍ The transverse tarsal joint, as its name implies,

runs transversely across the tarsal bones.

❍ The transverse tarsal joint is actually a

compound joint, meaning that it is composed of
two joints that are collectively called the
transverse tarsal joint.

❍ The two joints of the transverse tarsal joint are FIGURE 1 Dorsal view of the foot illustrating the
(1) the talonavicular joint, which is located transverse tarsal joint. The transverse tarsal joint is
between the talus and navicular bone, and (2) the actually a joint complex composed of the
calcaneocuboid joint, which is located between the talonavicular joint and the calcaneocuboid joint.
calcaneus and cuboid (Figure 1).

❍ Of the two joints of the transverse tarsal joint,

MAJOR MOTIONS ALLOWED:
the talonavicular joint is much more mobile than
the calcaneocuboid joint. ❍ Once the subtalar tarsal joint is understood, it is
possible to simplify the discussion of the
❍ Both of these joints are synovial joints.
transverse tarsal joint.
❍ The talonavicular joint shares its joint capsule
❍ The motions possible at the transverse tarsal
with one of the joint capsules of the subtalar joint.
joint are pronation and supination.
❍ The calcaneocuboid joint has its own distinct
❍ Any motion at the subtalar joint requires
joint capsule.
motion to occur at the transverse tarsal joint as
❍ The transverse tarsal joint is also known as the well.
midtarsal or Chopart’s joint.
❍ In fact, the named motions that occur at the
subtalar joint are the same named motions that
occur at the transverse tarsal joint.
❍ The interrelationship between the subtalar and A number of ligaments help to stabilize the
transverse tarsal joints can be understood by transverse tarsal joint. By virtue of stabilizing the
looking at the bones involved in each of these transverse tarsal joint, these ligaments also help
joints. The talus of the subtalar joint is also part of to indirectly limit motion and thereby stabilize the
the talonavicular joint of the transverse tarsal joint; subtalar joint. Ligaments of the transverse tarsal
the calcaneus of the subtalar joint is also part of joint include the following:
the calcaneocuboid joint of the transverse tarsal
❍ The spring ligament: The spring ligament
joint.
literally forms the floor of the talonavicular joint
Therefore movement of either the talus or the (of the transverse tarsal joint).
calcaneus requires movement at the transverse
❍ The spring ligament is also known as the plantar
tarsal joint when these more distal navicular and
calcaneonavicular ligament.
cuboid bones are fixed in a weight-bearing foot.
❍ The long plantar ligament: This ligament runs
❍ In addition, recall that the subtalar joint has
the length of the foot on the plantar side.
two joint capsules; of these, the anterior one is
shared with the talonavicular joint of the ❍ The short plantar ligament: This ligament runs
transverse tarsal joint. deep to the long plantar ligament on the plantar
side of the foot between the calcaneus and the
❍ Note: Because the talus shares a joint capsule
cuboid .
with both the calcaneus and the navicular bone,
and because motions of the subtalar and ❍ The short plantar ligament is also known as the
transverse tarsal joints are so intimately linked, plantar calcaneocuboid ligament.
some sources like to describe foot motion as
occurring at the talocalcaneonavicular (TCN) joint ❍ The dorsal calcaneocuboid ligament: This
complex. ligament is located between the calcaneus and
cuboid on the dorsal side.
Indeed, given the interrelationship of the cuboid of
the transverse tarsal joint as well, one could ❍ The bifurcate ligament: This Y-shaped ligament
describe foot motion as occurring at the is located on the dorsal side of the foot.
talocalcaneonaviculocuboid (TCNC) joint complex!
❍ Its medial band attaches from the calcaneus to
LIGAMENTS OF THE TRANSVERSE TARSAL JOINT the navicular bone. Its lateral band attaches from
the calcaneus to the cuboid.

❍ The medial band is also known as the lateral

calcaneonavicular ligament.

❍ The lateral band is also known as the

calcaneocuboid ligament.

CLOSED-PACKED POSITION OF THE TRANSVERSE

TARSAL JOINT:

❍ Supination
 TARSOMETATARSAL (TMT) JOINTS
BONES:

❍ The tarsometatarsal (TMT) joints are located

between the distal row of tarsal bones and the
metatarsal bones.

❍ Five TMT joints exist (Figure 2):

1. The first TMT joint is located between the first

cuneiform and the base of the first metatarsal.

2. The second TMT joint is located between the FIGURE 2 Dorsal view that illustrates the
second cuneiform and the base of the second tarsometatarsal (TMT) joints of the foot. As the
metatarsal. name indicates, TMT joints are located between
the tarsal bones and the metatarsal bones. The
3. The third TMT joint is located between the third TMT joints are numbered from the medial to the
cuneiform and the base of the third metatarsal. lateral side of the foot as MTP joints #1 through
#5.
4. The fourth TMT joint is located between the
cuboid and the base of the fourth metatarsal. ❍ Because the second ray of the foot is the most
stable of the five rays, an imaginary line through it
5. The fifth TMT joint is located between the (when it is in anatomic position) is the reference
cuboid and the base of the fifth metatarsal. line for abduction and adduction of the toes. In
the hand, the third ray is the most stable and is the
❍ Each metatarsal and its associated phalanges
reference line for abduction and adduction of the
make up a ray of the foot.
fingers.
❍ The TMT joints are plane synovial joints.
❍ The more peripheral rays are the most mobile.
❍ Only the first TMT joint has a well-developed
❍ The first ray is the most mobile, followed by the
joint capsule.
fifth, fourth, third, and second rays (in that order).
❍ The second and third TMT joints share a joint
MAJOR MOTIONS ALLOWED:
capsule.
❍ The TMT joints allow dorsiflexion/plantarflexion
❍ The fourth and fifth TMT joints share a joint
and inversion/eversion.
capsule.
❍ Dorsiflexion occurs when the distal end of the
❍ The base of the second metatarsal is set back
metatarsal moves dorsally; plantarflexion is the
farther posteriorly than the other metatarsal
opposite motion.
bones, causingit to be wedged between the first
and third cuneiforms.This position of the second ❍ Inversion occurs when the plantar side of the
metatarsal decreases mobility of the second TMT ray turns inward (i.e., medially) toward the midline
joint. Therefore the second TMT joint is the most of the body; eversion is the opposite action.
stable of the five TMT joints. As a result, the
second ray of the foot is the central stable pillar of
the foot.
❍ These motions of the metatarsal bones at the
TMT joints are important for allowing the foot to
conform to the uneven surfaces of the ground on
which we stand and walk.

❍ When the metatarsals dorsiflex at the

metatarsal joints, the first ray inverts and the third
to fifth rays evert, and the foot flattens to meet
the ground. When the metatarsals plantarflex, the
first ray everts and the third to fifth rays invert, and
the arch contour of the foot raises, allowing the
foot to mold around a raised surface.

❍ In addition to the fibrous joint capsules, the

TMT joints are stabilized by tarsometatarsal
ligaments.

❍ Dorsal, plantar, and interosseus TMT ligaments

exist.
 INTERMETATARSAL (IMT) JOINTS
BONES AND LIGAMENTS:

❍ Intermetatarsal (IMT) joints are located

between the metatarsal bones of the foot.

❍ Proximal intermetatarsal joints and distal

intermetatarsal joints exist.

❍ All five metatarsal bones articulate with one

another, both proximally at their bases and distally
at their heads.

❍ The proximal intermetatarsal joint between the

big toe and the second toe is usually not well
formed.

Although ligaments are present, the joint cavity is

usually not fully formed.

❍ The proximal intermetatarsal joints are

stabilized by their fibrous joint capsules and
intermetatarsal ligaments.

❍ Dorsal, plantar, and interosseus intermetatarsal

ligaments connect the base of each metatarsal to FIGURE 3. Intermetatarsal joints of the foot (i.e.,
the base of the adjacent metatarsal(s). proximal and distal intermetatarsal joints). As the
name indicates, intermetatarsal joints are located
❍ The distal intermetatarsal joints are stabilized by between metatarsal bones. A, Dorsal view. B,
their joint capsules and deep transverse metatarsal Plantar view illustrates the ligaments of the plantar
surface of the forefoot.
ligaments (see Figure 3, B).

❍ The deep transverse metatarsal ligaments that

connect the distal ends of the metatarsals to each
other hold the big toe in the same plane as the
other toes; therefore the big toe cannot be
opposed. In the hand, the deep transverse
metacarpal ligaments connect only the index
MAJOR MOTIONS ALLOWED:
through little fingers, leaving the thumb free to be
❍ These intermetatarsal joints are plane synovial
opposable. Therefore the foot is designed primarily articulations that allow nonaxial gliding motion of
for weight bearing and propulsion, whereas the one metatarsal relative to the adjacent
hand is designed primarily for manipulation (i.e., metatarsal(s).
fine motion). In theory, the only difference ❍ Because motion at a TMT joint requires the
between the potential coordination of the hand metatarsal bone to move relative to the adjacent
metatarsal bone(s), intermetatarsal joints are
and the foot is the ability to oppose digits.
functionally related to TMT joints.
 METATARSOPHALANGEAL (MTP) JOINTS
BONES:

❍ The MTP joints are located between the

metatarsals and the phalanges of the toes.

❍ More specifically, they are located between the

heads of the metatarsals and the bases of the
proximal phalanges of the toes.

❍ Five MTP joints exist (Figure 4):

1. The first MTP joint is located between the first FIGURE 4 Dorsal view illustrating the
metatarsal and the proximal phalanx of the big metatarsophalangeal (MTP) joints of the foot. Five
MTP joints are located between the metatarsals
(first) toe.
and the proximal phalanges of each ray of the foot.
2. The second MTP joint is located between the They are numbered from the medial (i.e., big toe)
side to the lateral (i.e., little toe) side as MTP joints
second metatarsal and the proximal phalanx of the
#1 through #5.
second toe.
MAJOR MOTIONS ALLOWED:
3. The third MTP joint is located between the third
metatarsal and the proximal phalanx of the third The average ranges of sagittal plane motion of the
toe. toes at the MTP joints are given in Table (Figure 5).
4. The fourth MTP joint is located between the ❍ The MTP joint allows flexion and extension
fourth metatarsal and the proximal phalanx of the (axial movements) within the sagittal plane around
fourth toe. a mediolateral axis.

5. The fifth MTP joint is located between the fifth ❍ The MTP joint allows abduction and adduction
metatarsal and the proximal phalanx of the little (axial movements).
(fifth) toe.
❍ The sagittal plane motions of flexion and
❍ Joint structure classification: Synovial joint extension of the toes at the metatarsophalangeal
(MTP) joints is much more important than the
❍ Subtype: Condyloid actions of abduction and adduction of the toes at
the MTP joints. Most people have very poor motor
❍ Joint function classification: Diarthrotic
control of abduction and adduction of their toes.
❍ Subtype: Biaxial
❍ Normally, abduction and adduction movements
occur within the frontal plane around an
anteroposterior axis. However, because the foot is
oriented perpendicular to the leg, abduction and
adduction of the toes occur within the transverse
plane around a vertical axis.
 ❍ The reference for abduction/adduction of the
toes at the MTP joints is an imaginary line drawn
through the second toe when it is in anatomic
position. Movement toward this imaginary line is
adduction; movement away from it is abduction.

❍ Because transverse plane movement of the

second toe in either direction is away from this
imaginary line, both directions of movement are
termed abduction.

Lateral movement of the second toe is termed

fibular abduction; medial movement of the second
toe is termed tibial abduction.

LIGAMENTS OF THE
METATARSOPHALANGEAL JOINTS :
Fibrous Joint Capsule:
❍ The capsule of the MTP joint is stabilized by
collateral ligaments and the plantar plate(Figure 6)

FIGURE 5 Motion of the toes at the

metatarsophalangeal (MTP) joints. A and B, flexion and
extension of the toes respectively (at both the MTP and Collateral Ligaments:
interphalangeal [IP] joints). C and D, abduction and ❍ The medial collateral ligament and the lateral
adduction of the toes at the MTP joints. The reference collateral ligament are thickenings of the joint
line for abduction and adduction of the toes is an capsule and are located on their respective side of
imaginary line through the center of the second toe the MTP joint.
when it is in anatomic position. Toes #1, #3, #4, and #5
abduct away from the second toe and adduct toward it.
The second toe abducts in either direction it moves. E,
Fibular abduction of the second toe at the MTP joint. F,
Tibial abduction of the second toe at the MTP joint.
Plantar Plate: ❍ Major extensors include the extensors
❍ The plantar plate is a thick, dense, fibrous tissue digitorum and hallucis longus and the extensors
structure located on the plantar side of the MTP digitorum and hallucis brevis.
joint. ❍ Major adductors are the plantar interossei and
❍ The plantar plate’s main function is to protect the adductor hallucis.
the head of the metatarsal during walking. ❍ Major abductors are the dorsal interossei pedis,
❍ This is necessary because when the foot pushes as well as the abductor hallucis and abductor digiti
off the ground, the metatarsal moves relative to minimi pedis.
the toe, exposing the articular surface of the head
of the metatarsal to the ground. The plantar plate
is placed between the head of the metatarsal and
the ground.

FIGURE 6 Fibrous capsule, collateral ligament, and

plantar plate of the metatarsophalangeal (MTP)
joint. (Note: These structures are also illustrated
for the proximal interphalangeal [PIP] and distal
interphalangeal [DIP] joints.)

CLOSED-PACKED POSITION OF THE

METATARSOPHALANGEAL JOINT:
❍ Extension

MAJOR MUSCLES OF THE

METATARSOPHALANGEAL JOINT:
❍ The MTP joint is crossed by both extrinsic
muscles (that originate on the leg) and intrinsic
muscles (wholly located within the foot).
❍ Major flexors include the flexors digitorum and
hallucis longus, flexors digitorum and hallucis
brevis, quadratus plantae, and flexor digiti minimi
pedis, as well as the lumbricals pedis, plantar
interossei, and dorsal interossei pedis.
 INTERPHALANGEAL (IP) JOINTS OF THE FOOT
❍ Interphalangeal (IP) joints pedis (i.e., of the
foot) are located between phalanges of the toes
(Figure 7).
❍ More specifically, each IP joint is located
between the head of the more proximal phalanx
and the base of the more distal phalanx.
❍ When motion occurs at an interphalangeal (IP)
joint of the foot, we can say that a toe has moved
at the proximal interphalangeal (PIP) or distal
interphalangeal (DIP) joint. To be more specific, we
could say that the distal phalanx moved at the DIP
joint and/or that the middle phalanx moved at the
PIP joint.
❍ Note: IP joints are found in both the foot and FIGURE 7 Dorsal view that illustrates the
the hand. To distinguish these joints from each interphalangeal (IP) joints
other, the words pedis (denoting foot) and manus of the foot. Except for the big toe, which has only
(denoting hand) are used. one IP joint, each toe has two IP joints: (1) the
❍ The big toe has one IP joint. It is located proximal interphalangeal (PIP) joint and (2) the
between the proximal and distal phalanges of the distal interphalangeal (DIP) joint. Furthermore, the
big toe. IP joints are numbered #1 to #5 from the medial
❍ Because toes #2 to #5 each have three (i.e., big toe) side to the lateral (i.e., little toe) side.
phalanges, two IP joints are found in each of these (Note: In this photo, the fifth DIP joint [of the little
toes. toe] has fused.)
❍ The IP joint located between the proximal and
middle phalanges is called the PIP joint (pedis). MAJOR MOTIONS ALLOWED:
❍ The IP joint located between the middle and ❍ The IP joints allow flexion and extension (i.e.,
distal phalanges is called the DIP joint (pedis). axial movements) within the sagittal plane around
❍ In total, nine IP joints are found in the foot (one a mediolateral axis.
IP, four PIPs, and four DIPs).

❍ Joint structure classification: Synovial joint

❍ Subtype: Hinge
❍ Joint function classification: Diarthrotic
❍ Subtype: Uniaxial

LIGAMENTS OF THE INTERPHALANGEAL

JOINTS OF THE FOOT :
As in the MTP joints, each IP joint has a capsule
that is thickened and stabilized by medial and
lateral collateral ligaments; plantar plates are also
present. These structures are usually not as well
developed as they are in the MTP joints.
❍ Fibrous capsule
❍ Medial collateral ligament
❍ Lateral collateral ligament
❍ Plantar plate
CLOSED-PACKED POSITION OF THE
INTERPHALANGEAL JOINTS OF THE FOOT:
❍ Extension

MAJOR MUSCLES OF THE

INTERPHALANGEAL JOINTS:
❍ The IP joints are crossed by both extrinsic and
intrinsic muscles of the foot.
❍ Major flexors include the flexors digitorum and
hallucis longus and the flexor digitorum brevis, as
well as the quadratus plantae.
❍ Major extensors include the extensors
digitorum and hallucis longus, the extensor
digitorum brevis, and the lumbricals pedis, plantar
interossei, and the dorsal interossei pedis. (Some
of the aforementioned muscles do not cross the
DIP joint.)

All the very best ….

R.Vijayapradeep MPT.,