Ankle and foot

anatomy
 Introduction
• Understanding anatomy is crucial for diagnosing and treating
foot and ankle problems.

• Anatomy acts as a road map for clinicians.

• Most foot structures are superficial and easily palpated.

• Injured or inflamed anatomical structures hurt exactly where they

are affected.

• Basic surface anatomy knowledge helps quickly establish or

narrow down diagnoses.

• Detailed anatomical knowledge is vital for performing surgeries

efficiently and safely.

• A good grasp of foot anatomy reveals suitable surgical

approaches for different foot and ankle areas.
Regions of the Foot
 Hindfoot:

Starts at the ankle

joint, ends at the
transverse tarsal joint.

Bones: Talus,
Calcaneus.
 Midfoot:

• Starts at the transverse tarsal joint,

ends at the tarsometatarsal (TMT)
joint.

• Limited mobility in joints.

• Bones: Navicular, Cuboid, Three
Cuneiforms (Medial, Middle,
Lateral).
 Forefoot:
• Composed of metatarsals, phalanges,
sesamoids.
• Last to leave the ground during walking.
• Bones: 5 Metatarsals, 14 Phalanges, 2
Sesamoids.
• Great toe: Proximal and distal phalanx.
• Lesser toes: Proximal, middle, and distal
phalanges.
• Sesamoid bones embedded in flexor hallucis
brevis tendons under the first metatarsal at
the great toe joint.
Columns of the
Foot
 Two Columns of the Foot

Medial Column: Lateral Column:

• More mobile. • Stiffer.

• Includes: Talus, Navicular, • Includes: Calcaneus, Cuboid,
Medial Cuneiform, 1st 4th and 5th Metatarsals.
Metatarsal, Great Toe.
Bones and Joints

• The foot is comprised of 28 bones .

• Where two bones meet a joint is formed –
often supported by strong ligaments.

• It is helpful to think of the joints of the foot

based on their mobility .
• A few of the joints are quite mobile and are
required for the foot to function normally
from a biomechanical point of view.
Bones and Joints

• These are often referred to as essential joints.

There are some joints that move a moderate
amount, and there are other joints that are
held tightly together with strong ligaments.

• These non-mobile joints are sometimes

referred to as non-essential joints.

• (This may be a poor term in that it incorrectly

implies that the joints are not important; they
are important.

• Rather the correct sense is only that

movement from these joints is less critical.)
Joint Function in
the Foot
Mobile Joints of the Foot and Ankle (Essential
Joints):
• Ankle joint (tibiotalar joint)
• Subtalar joint
• Talonavicular joint (TN joint)
• Metatarsophalangeal (MTP) joints
Joints that Move a Moderate Amount:

• Calcaneal-cuboid joint
• Cuboid-metatarsal joint for the fourth and fifth metatarsal.
• Proximal interphalangeal joint (PIP)
• Distal interphalageal joint (DIP)
Joints with Minimal Movement (Non-Essential Joints):

• Navicular-cuneiform joints • Bones of the lower leg and hindfoot: Tibia,

Fibula, Talus, Calcaneus.
• Intercuneiform joints
• Joints of the hindfoot: Ankle (Tibiotalar),
• Tarsometatarsal (TMT) joint Subtalar.
“Lisfranc” Joint (a.k.a. midfoot
joint)
Tibia and Fibula (long bones)
• The foot is connected to the body
where the talus articulates with the
tibia and fibula.
• In a typical foot the tibia is
responsible for supporting about
85% of body weight.
• The fibula accepts the remaining
15%; its main role is to serve as the
lateral wall of the ankle mortise
Tibia and Fibula (long bones)

• . The tibia and fibula are held

together by the tibiofibular
syndesmosis, a collection of 5
ligaments.
• The prominence on the medial
side of the distal tibia is known
as the medial malleolus; the
distal aspect of the fibula is
known as the lateral malleolus.
 Talus
• Top (most proximal) bone of the foot.
• 70% covered with hyaline (joint) cartilage due
to multiple articulations.
• Connects to calcaneus via subtalar joint.
• Connects to navicular via talonavicular joint.
• Allows smooth foot rotation around it.
• No tendons attach to it.
• Poor blood supply due to cartilage coverage.
• Injuries take longer to heal; some may not
heal at all.
 Talus Parts:

Body:
• Roughly square in shape.
• Topped by the dome.
• Connects to the lower leg
at the ankle joint.
 Talus part :
Head:
• Adjacent to the navicular
bone.
• Forms the talonavicular
joint.
 Talus part :
Neck:
• Located between the body and
head.
• One of the few areas not covered
with cartilage.
• Entry point for blood vessels
supplying the talus.
 Calcaneus
• The calcaneus is commonly known as the heel
bone.
• The calcaneus is the largest bone in the foot, and
along with the talus, it makes up the area of the
foot known as the hind-foot.
• There are three protrusions (anterior, middle, and
posterior facet) on the superior surface of the
calcaneus that allow the talus to sit on top of the
calcaneus, forming the subtalar joint
• The calcaneus also connects to the cuboid bone to
form the calcaneal-cuboid joint.
 Subtalar Joint

• The talus rests above the calcaneus to form

the subtalar joint slightly offset laterally,
towards the 5th metatarsal/small toe.

• This lateral positioning allows greater

flexibility in inversion/eversion (tilting).

• The subtalar joint moves in concert with

the talonavicular joint and the
calcaneocuboid joint, two joints located
near the front of the talus.

Bones of the midfoot: Cuboid, Navicular, Cuneiform (3).

Joints of the midfoot: talonavicular, calcaneocuboid, intercunneiform,
tarsometatarsal (TMT).
 Cuboid

• The cuboid bone is a square-

shaped bone on the lateral aspect
of the foot.
• The main joint formed with the
cuboid is the calcaneocuboid joint,
where the distal aspect of the
calcaneus articulates with the
cuboid.
 Navicular
• The navicular is distal to the talus and connects
with it through the talonavicular joint.
• The distal aspect connects to each of the three
cuneiform bones.
• Like the talus, the navicular has a poor blood
supply.
• On its medial side (closest to the middle of the
foot) the navicular tuberosity is the main
attachment of the posterior tibial tendon.
 Transverse Tarsal
Joint
• The transverse tarsal joint is not a true
joint, but the combination of the
calcaneocuboid and talonavicular joints.
• When these two joints are aligned in
parallel, the foot is flexible yet when their
axes are divergent, the foot becomes
stiff.
• The shift from a flexible state to a stiff one
allows the foot to serve as a shock
absorber and as a rigid level in different
phases of gait.
 Cuneiforms

• There are three cuneiform bones in

the foot: the medial, medial
(intermediate), and lateral
cuneiforms .
• These bones, along with the strong
plantar and dorsal ligaments that
connect to them, provide a good
deal of stability for the foot.

Bones of the forefoot: Metatarsals (5), Phalanges

(14), Sesamoid Bones (2)
 Metatarsals
• Each foot contains five metatarsals, numbered 1-
5 medial (great toe) to lateral. The first three
metatarsals medially are more rigidly held in
place than the lateral two.
• The metatarsals articulate with the mid-foot at
their base, a joint called the tarsal-metatarsal
(TMT) joint, or Lisfranc joint. The TMT joint is
made stable not only by strong ligaments
connecting these bones, but also because the
second metatarsal is recessed into the middle
cuneiform in comparison to the others
• . The metatarsal heads are the main weight
bearing surface and the site where the phalanges
attached at the metatarsal-phalangeal (MTP)
joint.
Phalanges

• The first toe, also known as the great toe or

hallux, is the only one to have two
phalanges; the other lesser toes have
three.
• These are known as the proximal phalanx
(closest to the ankle) and the distal phalanx
(farthest from the ankle).
• The phalanges form interphalangeal joints
between themselves: a proximal
interphalangeal joint (PIP) and the distal
interphalangeal joint (DIP)
Sesamoid Bones

• In the foot, there are two sesamoid bones located

directly underneath the first metatarsal head,
embedded in the medial (tibial) side and lateral
(fibular) aspect of the flexor hallucis brevis tendon
Common Ossicles of the Foot
Os Trigonum
• Located at the back of
the talar body, this bone
is connected to the talus
by a fibrous union that
didn't ossify properly. It
appears in about 10% of
people.
Os Naviculare (Os Tibiale Externum or Accessory
Navicular):
• This bone results from the
failure of the ossification
center at the navicular
tuberosity to unite with the
main bone. It is found in
about 15% of the
population.
Os Peroneum:
• Found within the peroneus
longus tendon sheath near
the cuboid, this bone is
present in about 20% of
individuals.
Bipartite Sesamoid:
• Occurs when one of the sesamoids associated with the
great toe doesn't ossify, resulting in two segments
connected by fibrous tissue. This condition is seen in about
20% of people, with over 90% occurring in the tibial
sesamoid.
Ligaments
Anterior Talofibular
Ligament (ATFL):
• This is the most frequently injured
ligament in ankle sprains. It extends
from the front of the distal fibula
(lateral malleolus) to the neck of the
talus, stabilizing the ankle against
inversion, especially when the ankle
is plantar-flexed.
Calcaneofibular
Ligament (CFL):

• Located on the lateral side of the

ankle, this ligament runs from the
tip of the fibula along the lateral
aspect of the ankle to the
calcaneus. It resists inversion,
particularly when the ankle is
dorsiflexed.
Posterior Talofibular
Ligament:
• This ligament extends from the
lower back part of the fibula to the
outer back portion of the calcaneus.
It helps stabilize both the ankle joint
and the subtalar joint.
Deltoid Ligament:
• This fan-shaped ligament is located
on the medial side of the ankle.
• It extends from the medial
malleolus to the talus and
calcaneus.
• The deeper part is firmly attached
to the talus, while the broader,
superficial part connects to the
calcaneus. Its main function is to
resist eversion.
Spring Ligament:
• Spring Ligament: Originating from
the sustentaculum tali, a bony
prominence on the calcaneus, this
strong ligament inserts into the
plantar medial aspect of the
navicular.
• It supports and cradles the talar
head.
Lisfranc Ligaments:
• These ligaments stabilize the
tarsometatarsal joints, providing
significant stability to the arch of the
foot.
• The plantar ligaments are stronger
than the dorsal ones.

• The Lisfranc ligament specifically

connects the medial cuneiform to
the base of the second metatarsal.
Inter-Metatarsal
Ligaments:
• These ligaments connect the neck
region of each metatarsal bone to
the adjacent one at the base of the
toes, ensuring the metatarsals move
together. They can sometimes
irritate the digital nerve, leading to
a condition known as Morton's
neuroma.
1st MTP Joint
Capsule of the Great
Toe:
• This ligament forms a capsule from
the medial portion of the first
metatarsal head to the distal
phalanx, stabilizing the great toe on
the medial side. In cases of bunions,
this ligament stretches, causing the
great toe to angle outward.
Anterior Inferior
Tibiofibular
Ligament (AITFL):
• Located on the anterolateral aspect
of the ankle joint, this ligament
helps keep the tibia and fibula
together. High ankle sprains occur
when this ligament is injured,
typically when the foot is planted
and the leg rotates inward.
Interosseous
Membrane:
• This strong fibrous tissue runs along
the tibia and fibula, keeping the two
bones moving as a unit.
Syndesmosis:
• This group of ligaments, including
the AITFL, interosseous membrane,
posterior inferior tibiofibular
ligament, transverse ligament, and
interosseous ligament, holds the
tibia and fibula together, forming
the mortise for the talus.
 Muscles and Tendons
There are four muscle compartments in the lower leg each separated by strong fascia:
1. the superficial posterior compartment;

2. the deep posterior compartment;

3. the anterior compartment and;
4. the lateral compartment

Collectively the muscles in these four compartments are referred to as the EXTRINSIC
MUSCLES of the foot because they originate above the foot in the leg, but insert within
the foot.
 Superficial Posterior
Compartment:
• This compartment contains the gastrocnemius
and soleus muscles, which form the Achilles
tendon and are innervated by the tibial nerve.
• The gastrocnemius is the more superficial muscle,
originating above the knee and inserting into the
calcaneus.
• The soleus lies deeper and does not cross the
knee.
• The plantaris, a smaller muscle in this
compartment, is not functionally significant for
most people but can still be injured.
Deep Posterior
Compartment:
• Located deep to the soleus muscle, this
compartment includes the flexor hallucis
longus, flexor digitorum longus, and tibialis
posterior muscles.
• These muscles cross the ankle and insert on
the foot bones, and are innervated by the
tibial nerve.
Anterior
Compartment:
• This compartment consists of four
muscles that dorsiflex the foot and
ankle: the tibialis anterior, extensor
hallucis longus, extensor digitorum
longus, and peroneus tertius.
• All are innervated by the deep
peroneal nerve.
Lateral
Compartment:
• This compartment includes the
peroneus longus and peroneus
brevis muscles, which evert the foot.
• The peroneus longus also
plantarflexes the first metatarsal.

• Both muscles are controlled by the

superficial peroneal nerve.
Muscles within the Foot:
• The intrinsic muscles of the foot help move the toes and stabilize the foot.
• The extensor hallucis brevis and extensor digitorum brevis, located on the
dorsal aspect, extend the toes and are innervated by the deep peroneal
nerve.
• The flexor hallucis brevis and flexor digitorum brevis, located in the plantar
arch, flex the toes and are innervated by the medial plantar nerve.
Plantar Fascia:
• This strong fibrous tissue originates from the calcaneus and
extends to the base of the toes.
• It supports the arch of the foot by maintaining the distance
between the calcaneus and the metatarsal heads, a
mechanism known as the windlass effect. It also protects
the muscles of the sole of the foot.
NERVES
 NERVES OF THE FOOT
1. Tibial Nerve: A branch of the sciatic • All these nerves are derived from
nerve that runs past the ankle into the the lumbar spine, with the sciatic
foot. nerve branching into four of the
2. Sural Nerve: A branch of the tibial nerve. primary nerves of the foot, and the
3. Deep Peroneal Nerve: A branch of the femoral nerve giving rise to the
peroneal nerve, which itself is a segment saphenous nerve.
of the sciatic nerve.
4. Superficial Peroneal Nerve: Another
branch of the peroneal nerve.
5. Saphenous Nerve: Originates from the
femoral nerve and runs into the foot.
END.