ANKLE COMPLEX-

ESSENTIAL BIO AND

PATHOMECHANICS IN
MANUAL THERAPY
PERSPECTIVE
MANGALA PREMA M
MPT ORTHO II SEM
CONTENTS
• ANKLE JOINT COMPLEX-ANATOMY
• TALOCRURAL JOINT
• SUBTALAR JOINT
• INFERIOR TIBIOFIBULAR JOINT
• BIOMECHANICS
• PATHOMECHANICS
• FOOT COMPLEX-ANATOMY,BIOMECHANICS AND
PATHOMECHANICS
ANKLE COMPLEX

• The ankle complex comprises 3 articulations:

The talocrural joint

The subtalar joint

 The distal tibiofibular syndesmosis

• These 3 joints work in concert to allow coordinated movement of the
rearfoot.
• Rearfoot motion is often defined as occurring in the cardinal planes as
follows:
sagittal-plane motion (plantar flexion-dorsiflexion)
frontal-plane motion (inversion-eversion)
transverse-plane motion (internal rotation-external rotation)
ANKLE JOINT
• The ankle or talocrural joint is the distal joint of the lower limb.
• It is a hinge ioint and has therefore only one degree of freedom.
• It controls the movements of the leg in the sagittal plane relative to
the foot.
• These movements are essential for walking on flat or rough ground.
• It is a tightly intelocked joint exposed to extreme mechanical stresses
during single limb support, when it is subjected to the fuIl weight of the
body and to the force generated by the dissipation of kinetic energy
when the foot rapidly makes contact with the ground during walking,
running or jumping.
3 main axes of ankle joint complex
• The three main axes of this joint complex
intersect roughly in the hindfoot. Often
the foot is in the reference position,
these three axes are orthogonal. In the
diagram, ankle extension changes the
direction of the Z axis, while the other
two axes remain stationary.
• The transverse axis passes through the
two malleoli and corresponds to the axis
of the ankle ioint. It lies almost entirely in
the coronal plane and controls the
movements of flexion and extension of
the foot that occur in the sagittalplane.
• The long axis of the leg Y is vertical and controls
the movements of adduction and abduction of the
foot occurring in a transverse plane.
• These movements are possible only
because of the axial rotation of the flexed knee. To a
lesser degree they depend on the joints of the posterior
tarsus, but they are always combined with movements
around the third axis.
•The long axis of the foot Z is horizontal and lies in
a sagittal plane. lt conlrols the orientation of the foot
and allows it to face directly inferiorly, whether
laterally
or medially. By analogy with the upper limb, these
movements are called pronation and supination,
respectively
TALOCRURAL JOINT ANATOMY
• The talocrural, or tibiotalar, joint
is formed by the articulation of :
• the dome of the talus
• the medial malleolus
• the tibial plafond
• the lateral malleolus.
ANKLE STABILITY
• The 3 major contributors to stability of the ankle joints are

(1) the congruity of the articular surfaces when the joints are loaded

(2) the static ligamentous restraints

(3) the musculotendinous units, which allow for dynamic stabilization

of the joints.
The axis of rotation of the talocrural joint
passes through the medial and lateral malleoli.
It is slightly anterior to the frontal plane as it
passes through the tibia but slightly posterior
to the frontal plane as it passes through the
fibula. Isolated movement of the talocrural
joint is primarily in the sagittal plane, but small
amounts of transverse- and frontal-plane
motion also occur about the oblique axis of
rotation
• The talocrural joint receives ligamentous support from a joint capsule
and several ligaments:
• Anterior talofibular ligament (ATFL)
• Posterior talofibular ligament (PTFL)
• Calcaneofibular ligament (CFL)
• Deltoid ligament

• The ATFL, PTFL, and CFL support the lateral aspect of the ankle, while
the deltoid ligament provides medial support.
ATFL
• The ATFL lies on the dorsolateral aspect
of the foot and courses from the lateral
malleolus anteriorly and medially
toward the talus at an angle of
approximately 45° from the frontal
plane
• The ATFL prevents anterior
displacement of the talus from the
mortise and excessive inversion and
internal rotation of the talus on the
tibia. The strain in the ATFL increases as
the ankle moves from dorsiflexion into
plantar flexion.
• The ATFL demonstrates lower maximal load and energy to failure
values under tensile stress as compared with the PTFL, CFL,
anterior inferior tibiofibular ligament, and deltoid ligament.This
may explain why the ATFL is the most frequently injured of the
lateral ligaments.
CFL
• The CFL courses from the lateral malleolus posteriorly and inferiorly
to the lateral aspect of the calcaneus at a mean angle of 133° from
the long axis of the fibula.
• The CFL restricts excessive supination of both the talocrural and
subtalar joints.
• the CFL restricts excessive inversion and internal rotation of the
rearfoot and is most taut when the ankle is dorsiflexed.
• The CFL is the second most-often injured of the lateral talocrural
ligaments.
PTFL
• The PTFL runs from the lateral malleolus posteriorly to the
posterolateral aspect of the talus.
• The PTFL has broad insertions on both the talus and fibula and
provides restraint to both inversion and internal rotation of the
loaded talocrural joint.
• It is the least commonly sprained of the lateral ankle ligaments
MEDIAL LIGAMENT OF ANKLE
• The deltoid ligament, consists of four ligaments that form a triangle
connecting the tibia to the navicular, the calcaneus, and the talus. It
stabilises the ankle joint during eversion of the foot and prevents
subluxation of the ankle joint. [3]
• The anterior and posterior tibiotalar ligaments connect the tibia to
the talus.
• The tibionavicular ligament which attaches to the navicular anteriorly
and the tibiocalcaneal ligament which attaches to the calcaneus
inferiorly
OSTEOKINEMATICS OF
TALOCRURAL JOINT
• Talocrural joint possess one degree of freedom
• Motion occurs at axis passing through
• Body of Talus
• Tips of both malleoli
• The medial lateral axis is slightly deviated due to the inferior and
posterior positioning of lateral malleolus in comparison with the
medial malleolus
• Frontal plane- 10degrees
• Horizontal plane- 6 degrees
ARTHROKINEMATICS OF
TALOCRURAL JOINT
• DURING DORSIFLEXION
• Superior surface of talus rolls forwards
• Simultaneously slides posteriorly
• This allows talus to rotate forward without much anterior
translation
• Elongates posterior capsule and achilles tendon which is capable
of transmitting the plantarflexion torque
• Stretches the calcaneofibular ligament
DURING PLANTAR FLEXION
• The superior surface of the talus rolls backwards
• Slides anteriorly simultaneously
• Stretches anterior talofibular ligament
• Tibionavicular fibres of the deltoid ligament becomes taut at full
plantar flexion
• Stretches anterior capsule and dorsiflexors
Subtalar Joint Anatomy
• The subtalar joint is formed by
the articulations between the
talus and the calcaneus and, like
the talocrural joint, it converts
torque between the lower leg
(internal and external rotation)
and the foot (pronation and
supination).
• The subtalar joint allows the
motions of pronation and
supination and consists of an
intricate structure with 2 separate
joint cavities.
• The posterior subtalar joint is formed between the inferior posterior
facet of the talus and the superior posterior facet of the calcaneus.

• The anterior subtalar, or talocalcaneonavicular, joint is formed from

the head of the talus, the anterior-superior facets, the sustentaculum
tali of the calcaneus, and the concave proximal surface of the tarsal
navicular. This articulation is similar to a ball-and-socket joint, with
the talar head being the ball and the anterior calcaneal and proximal
navicular surfaces forming the socket in conjunction with the spring
ligament.
• The anterior and posterior subtalar joints have separate ligamentous
joint capsules and are separated from each other by the sinus tarsi
and canalis tarsi.
• The anterior joint lies farther medial and has a higher center of
rotation than the posterior joint, but the 2 joints share a common axis
of rotation.
• This discrepancy results in an oblique axis of rotation of the subtalar
joint, which averages a 42° upward tilt and a 23° medial angulation
from the perpendicular axes of the foot
LIGAMENTS OF SUBTALAR JOINT
• The ligamentous support of the subtalar joint is extensive and not
well understood. Marked discrepancies exist in the literature
regarding the terminology for the individual ligaments and the
functions these ligaments serve.
• Essentially, the lateral ligaments may be divided into 3 groups:

(1) deep ligaments

(2) peripheral ligaments
(3) retinacula
• The deep ligaments consist of the cervical and interosseous
ligaments. Together these ligaments stabilize the subtalar joint and
form a barrier between the anterior and posterior joint capsules.

• These ligaments, which cross obliquely through the canalis tarsi, have
been described as the “cruciate ligaments of the subtalar joint.”

• The cervical ligament lies anterior and lateral to the interosseous

ligament and runs from the cervical tubercle of the calcaneus anteriorly
and medially to the talar neck.
• The cervical ligament lies within the sinus tarsi and provides support
to both the anterior and posterior joints.
• It is the strongest of the subtalar ligaments and has been shown to
resist supination.
LIG OF SUBTALAR JT (CONTD..)
• The interosseous ligament lies just posterior to, and courses more
medially than, the cervical ligament. The interosseous ligament
originates on the calcaneus just anterior to the posterior subtalar
joint capsule and runs superiorly and medially to its insertion on the
talar neck. Because of its diagonal orientation and oblique fiber
arrangement across the joint, portions of the interosseous ligament
are taut throughout pronation and supination. This ligament is
sometimes called the ligament of the canalis tarsi.
LIG OF SUBTALAR JT (CONTD..)
• Fibers of the inferior extensor retinacula (IER) have also been proposed
to provide support to the lateral aspect of the subtalar joint. Three roots
of the IER have been identified within the sinus tarsi: lateral,
intermediate, and medial. Only the lateral root of the IER has been
shown to significantly affect subtalar joint stability; however, injury to
any of the roots has been suggested in the cause of sinus tarsi syndrome.
• The sinus tarsi is a tube or tunnel between the talus and the calcaneus
bones. Sinus tarsi syndrome is pain or injury to this area. Traumatic injury
to the ankle/foot (such as an ankle sprain) or overuse (such as repetitive
standing or walking) are the main causes of this syndrome. It may also
occur if the person has a pes planus or an over-pronated foot, which can
cause compression in the sinus tarsi.
• Some characteristics are pain at the anterior lateral side of the ankle
(anterior to the lateral mallelous) and a feeling of instability or
difficulty walking on unstable surfaces.

• The peripheral ligaments of the subtalar joint include the CFL and
lateral talocalcaneal (LTCL) and fibulotalocalcaneal (FTCL) ligaments.
The CFL is integral in preventing excessive inversion and internal
rotation of the calcaneus in relation to the talus. While the CFL does
not normally connect the calcaneus to the talus, various attachments
of the anterior aspect of the CFL to the talus have been reported.
• The LTCL runs parallel and anterior to the CFL but only crosses the
posterior subtalar joint . While the LTCL is smaller and weaker than
the CFL, it helps prevent excessive supination of the subtalar joint.
Various shapes of the LTCL have been reported, and occasionally its
fibers are continuous with those of the CFL.
• The FTCL, or ligament of Rouviere, runs from the posterior surface of
the lateral malleolus to the posterolateral surface of the talus and
then to the posterolateral calcaneus. It lies distinctly posterior to the
CFL and assists in resisting excessive supination.
LATERAL ANKLE SPRAINS
• Lateral ankle sprains most commonly occur due to excessive
supination of the rearfoot about an externally rotated lower leg soon
after initial contact of the rearfoot during gait or landing from a jump.
• Excessive inversion and internal rotation of the rearfoot, coupled with
external rotation of the lower leg, results in strain to the lateral ankle
ligaments. If the strain in any of the ligaments exceeds the tensile
strength of the tissues, ligamentous damage occurs. Increased plantar
flexion at initial contact appears to increase the likelihood of suffering
a lateral ankle sprain.
• The ATFL is the first ligament to be damaged during a lateral ankle
sprain, followed most often by the CFL.
• Cadaveric-sectioning studies have demonstrated that after the ATFL is
ruptured, the amount of transverse-plane motion (internal rotation) of
the rearfoot increases substantially, thus further stressing the remaining
intact ligaments.
• This phenomenon has been described as “rotational instability” of the
ankle and is often overlooked when considering laxity patterns in the
sprained ankle.
• Concurrent damage to the talocrural joint capsule and the ligamentous
stabilizers of the subtalar joint is also common with lateral ankle sprains.
Martin et al demonstrated significantly greater strain in the cervical
ligament after complete disruption to the CFL.
PATHOMECHANICS OF CHRONIC
INSTABILITY
• The mechanism of recurrent ankle injury is not thought to be different than
that of initial acute ankle sprains; however, adverse changes that occur after
primary injury are believed to predispose individuals to recurrent sprains.
• Two theories of the cause of CAI have traditionally been postulated:
mechanical instability and functional instability. These 2 terms, however, do
not adequately describe the full spectrum of abnormal conditions related to
CAI. By further clarifying the potential insufficiencies leading to each type of
instability, we can better describe the full complement of potential causes of
CAI. Mechanical instability and functional instability are probably not
mutually exclusive entities but more likely form a continuum of pathologic
contributions to CAI
Arthrokinematic Impairments
• Another potential insufficiency contributing to mechanical instability of the ankle is
impaired arthrokinematics at any of the 3 joints of the ankle complex. One
arthrokinematic restriction related to repetitive ankle sprains involves a positional fault
at the inferior tibiofibular joint.
• Mulligan suggested that individuals with CAI may have an anteriorly and inferiorly
displaced distal fibula. If the lateral malleolus is indeed stuck in this displaced position,
the ATFL may be more slack in its resting position. Thus, when the rearfoot begins to
supinate, the talus can go through a greater range of motion before the ATFL becomes
taut. This positional fault of the fibula may result in episodes of recurrent instability,
leading to repetitive ankle sprains.
• The findings of 2 case studies and one pilot study present preliminary evidence for
restriction of posterior fibular glide after lateral ankle sprain, suggesting that the
lateral malleolus may be subluxated in an anteriorly displaced position.
• Hypomobility, or diminished range of motion, may also be thought of as a
mechanical insufficiency.
• Restricted dorsiflexion range of motion is thought to be a predisposition to
lateral ankle sprain. If the talocrural joint is not able to fully dorsiflex, the
joint will not reach its closed-pack position during stance and, therefore,
will be able to invert and internally rotate more easily. Limited dorsiflexion
in the closed kinetic chain is also typically compensated for by increased
subtalar pronation.
• Some evidence demonstrates dorsiflexion restrictions in athletes with
repetitive ankle sprains. Greene et al recently demonstrated that altered
arthrokinematics may limit dorsiflexion after acute ankle sprain. Patients
with acute ankle sprains who were treated with posterior mobilization of
the talus on the tibia recovered their dorsiflexion range of motion more
quickly than those not treated with joint mobilization.
• Denegar et al found restricted posterior talar glide in athletes 12 weeks
after acute ankle sprain. Interestingly, these athletes did not have
significantly decreased dorsiflexion range of motion as assessed through
standard clinical measures.
• This suggests that dorsiflexion may be returned to normal ranges in the
absence of normal arthrokinematics due to extensive stretching of the
triceps surae. Further research is needed to elucidate the clinical
implications of altered arthrokinematics after ankle sprain.
DISTAL TIBIOFIBULAR JOINT
• Articular surfaces
• Convex medial surface of distal
fibula
• Concave fibular notch of the
tibia
• Joint type:
• Synarthoses
• Synovial membrane continuous
with the talocrural joint
LIGAMENTS OF DISTAL
TIBIOFIBULAR JOINT
• Interosseus ligament provides the
strongest bond between the distal
ends of tibia and fibula
• It is a distal extension of the
interosseus membrane
• Anterior and posterior tibiofibular
ligament reinforce the joint
• It is essential for the stability and
function of the talocrural joint
Distal Tibiofibular Joint

• The structural integrity of the sydesmosis is necessary to form the

stable roof for the mortise of the talocrural joint.
• The anterior inferior tibiofibular ligament is often injured in
conjunction with eversion injuries, and damage results in the so-
called high ankle sprain rather than the more common lateral ankle
sprain.
Muscles and Tendons
• When contracted, musculotendinous units generate stiffness, which
leads to dynamic protection of joints. The muscles that cross the
ankle complex are often described based on their concentric actions;
however, when considering their role in providing dynamic stability to
joints, it may be helpful to think about eccentric functions. The
peroneal longus and brevis muscles are integral to the control of
supination of the rearfoot and protection against lateral ankle sprains.
• In addition to the peroneals, the muscles of the anterior compartment
of the lower leg (anterior tibialis, extensor digitorum longus, extensor
digitorum brevis, and peroneus tertius) may also contribute to the
dynamic stability of the lateral ankle complex by contracting
eccentrically during forced supination of the rearfoot. Specifically, these
muscles may be able to slow the plantar-flexion component of
supination and thus prevent injury to the lateral ligaments.
DISTAL TIBIOFIBULAR JOINT
MOBILIZATION
• The mobility of the tibiofibular joint can become restricted
during immobilization of the ankle, even with no direct ankle pathology.
• Gentle remobilization of the distal tibiofibular joint is a frequently applied
intervention to relieve pain and improve function.
• Individuals whose activities demand large ankle and foot mobility may
require increased tibiofibular joint mobility. But even in individuals who
are moderately sedentary, increased mobility of the distal tibiofibular joint
may increase functional ability by restoring the normal contact area
between the tibia and talus, thereby decreasing joint stress and increasing
comfort during weight-bearing activities.
FOOT
• HINDFOOT-TALUS AND CALCANEUS
• MIDFOOT- REMAINING TARSALS
• FOREFOOT-METATARSAL AND PHALANGES
• FIRST RAY- FIRST METATARSAL, MEDIAL CUNEIFORM
• SECOND AND THIRD RAY- RESPECTIVE METATARSALS AND THEIR
PROXIMAL CUNEIFORMS
• FOURTH AND FIFTH RAY-RESPECTIVE METATARSALS ALONE
TRANSVERSE TARSAL
TARSAL JOINT/CHOPART’S
JOINT/CHOPART’S
JOINT/MIDTARSAL JOINT
JOINT
• TALONAVICULAR

• CALCANEOCUBOID
TALONAVICULAR JOINT
• Articulating surfaces
• Well curved talar head

• Reciprocally concave posterior

surface of navicular

• Capsule
• The capsule that encloses the
anterior articulation between the
talus and calcaneus also supports the
talonavicular articulation
LIGAMENTS OF TALONAVICULAR
JOINT
• PLANTAR CALCANEONAVICULAR(SPRING )

• TALONAVICULAR LIGAMENT

• DORSAL CALCANEONAVICULAR LIGAMENT(MEDIAL BRANCH OF

BIFURCATE LIGAMENT)
TALONAVICULAR JOINT MOTION
• Motion at this joint is triplanar
• Consists of pronation and supination
• Mobility is similar to that of subtalar joint
• Lundberg et al. report that approximately 12%
of the first 30° degrees of plantarflexion is attributable to
talonavicular joint motion
CALCANEOCUBOID JOINT
• The calcaneocuboid joint is a saddle joint supported by a
synovial joint capsule and by several reinforcing ligaments
• Articulating surfaces:
• anterior (distal) surface of the calcaneus
• proximal surface of the cuboid
• Forms an interlocking wedge that resists sliding
• This joint is therefore relatively inflexible providing an element of
rigidity to the lateral column of the foot
LIGAMENTS OF THE
CALCANEOCUBOID JOINT
• Dorsal calcaneocuboid
• Bifurcate ligament(dorsal calcaneonavicular part)
• Short plantar ligament
• Long plantar ligament
OSTEOKINEMATICS OF
TRANSVERSE TARSAL JOINT
• Two separate axes of rotation exist
• Amplitude and direction of movement may be different during weight
bearing and non weight bearing activities
• The stabilizing function of it is influenced by the position of the
subtalar joint
AXIS AND MOTION OF THE
TRANSVERSE TARSAL JOINT
• LONGITUDINAL AND OBLIQUE AXIS
• LONGITUDINAL axis nearly coincident with the AP axis - Inversion and
Eversion
• OBLIQUE axis has a strong vertical medial lateral pitch
-abduction and dorsiflexion
-adduction and plantarflexion
• Movement at the tarsal joint makes the midfoot very adaptable in shape
• 20-25 degrees of inversion
• 10-15 degrees of eversion
ARTHROKINEMATICS OF
TRANSVERSE TARSAL JOINT
• Supination:
• Tibialis posterior is the prime supinator of foot
• Inverting and adducting calcaneus because of calcaneocuboid rigidity
brings the lateral column under the medial column
• Important pivot is the talonavicular joint
• Pull of TP contributes to the
• spin of navicular
• spring ligament spun around the convex head of talus
Pronation
• Reverse kinematics occur
• Pull of peroneus longus contributes to the
• lowering of medial side
• rising of the lateral side of the foot
TARSAL COALITION
• Tarsal coalition is an abnormal connection between tarsal bones,
leading to decreased mobility between the affected bones.
• The connections may be bony, cartilaginous, or fibrous and may be
partial or
complete.
• Because the joints among the tarsal bones provide important
amplification of the motion at the ankle and subtalar joints, any loss of
tarsal motion may lead to excessive motion elsewhere, including the
ankle and hind foot. A retrospective analysis of 223 acute ankle sprains
suggests that tarsal coalitions may be a risk factor for ankle sprains.
TRANSVERSE TARSAL JOINT
MOTION:
• Together the talonavicular and calcaneocuboid joints are quite mobile
and amplify the motion of the ankle and subtalar joints.
• Dorsiflexion is a component of pronation and consequently,pronation of
the transverse tarsal joint can provide additional “functional” dorsiflexion
ROM in an individual with a flexible midfoot. However, the use of large
midfoot motion during activities that require dorsiflexion ROM such as
squatting, jumping, walking, or running may lead to excessive stress
to structures on the medial side of the foot such as the posterior tibialis
tendon, or to abnormal loads to the knee.
SUBTALAR NEUTRAL
• the position of the subtalar joint that is neither pronated nor supinated
• Subtalar neutral position appears to maximize the area of contact
between the talus and calcaneus
• The angle made by a line bisecting the leg and another bisecting
the posterior aspect of the calcaneus quantifies the subtalar
neutral position
• Medial deviation of the calcaneus with respect to the leg constitutes a
varus deformity, while valgus indicates a lateral deviation of the
hindfoot on the leg
FOOT ORTHOSES FOR A VARUS
HINDFOOT DEFORMITY:
The use of foot orthoses to treat knee pain is
based on an under standing of the natural
coupling between foot pronation or supination
and tibial rotation and knee motion in closed-
chain movement. Medial wedge orthoses are
reported to decrease pain in individuals with
patellofemoral joint pain
. In contrast, gait studies demonstrate that
medial wedges exhibit a small but significant
ability to control medial rotation of the tibia
that occurs with excessive pronation
DISTAL INTERTARSAL JOINT
• The distal intertarsal joints include those between the navicular and
the cuneiform bones, between the cuboid and lateral cuneiform, and
among the cuneiform bones themselves.
• These articulations are supported by joint capsules that frequently
communicate with one another and by dorsal and plantar ligaments
that run between adjacent bones
CUBOIDEONAVICULAR JOINT
• Articular surfaces
• Lateral side of navicular
• Proximal 1/5 th of the medial side of the cuboid
• Links medial and lateral components of the transverse tarsal joint
• Assist in transferring pronation and supination movements across
more proximal regions of midfoot
• Strengthened by dorsal, plantar and interosseus ligaments
INTERCUNEIFORM AND
CUNEOCUBOID JOINT COMPLEX
• THREE ARTICULATIONS
• Two between cuneiforms and one between the lateral cuneiform and
medial surface of the cuboid
• Articular surfaces are essentially flat and aligned nearly parallel to the
long axis of the metatarsals
• The intercuneiform and
cuneocuboid joint complex forms
the transverse arch of the foot
• This arch provides transverse
stability to the midfoot
• Under load of body weight, the
transverse arch depresses slightly
allowing body weight to be shared
across all five metatarsal heads
• The key stone of the transverse
arch is the intermediate cuneiform
• The tarsometatarsal joint serves as the base of each of the rays of the
foot
• Mobility is least in the second tarsometatarsal joint due to the
wedged position of its base between the lateral and medial
cuneiforms
• Second rays forms a stable central pillar through the foot similar to
third ray in hand
• This stability is useful in late stance as the forefoot prepares for the
dynamics of push off
TARSOMETATARSAL AND INTERMETATARSAL
JOINTS OF THE TOES
• The tarsometatarsal joints of the toes,
also known as the
Lisfranc’s joint, are gliding joints with
limited mobility
• First metatarsal- medial cuneiform
• Second metatarsal-intermediate
cuneiform
• Third metatarsal-lateral cuneiform
• Base of fourth and fifth metatarsal with
distal surface of cuboid
• The articulations are supported by joint capsules
that typically form three separate joint spaces, one enclosing
the articulation between the medial cuneiform and metatarsal
of the great toe, another enclosing the second and third
metatarsals with the middle and lateral cuneiform bones, and
the lateral joint space encircling the cuboid and the fourth
and fifth metatarsal bones.
• The synovial spaces also expand to include the intermetatarsal joints
of the metatarsals within each joint capsule.
• Dorsal and plantar ligaments, the latter of which are thick and strong
to support the arches of the foot,reinforce the joint capsules.
• The cuneometatarsal ligaments of the great and second toes are
particularly strong and appear to provide the primary support to
these joints
• The first tarsometatarsal joint provides an element of flexibility to the
medial longitudinal arch
• During loading phase of walking, first ray yields (dorsiflexes)slightly
under the force of the body weight
• Stiffness of the first ray limits the shock absorption ability of the
medial longitudinal arch
INTERMETATARSAL JOINTS
• The base of the four lateral metatarsals are interconnected by
plantar,dorsal and interosseus ligaments
• A true joint does not typically form between the bases of the first and
second metatarsals
• The lack of articulation increases the relative movement of the first ray
in a manner similar to the hand
• Unlike hand, distal end of all 5 metatarsals are connected by the deep
transverse metatarsal ligaments
• Slight motion at this joint augments the flexibility at the
tarsometatarsal joints
METATARSOPHALANGEAL JOINTS
• Articulating surfaces
• Convex head of each metatarsal
• Shallow concavity of the proximal
end of each proximal phalanx
• The joints are biaxial supported by
a joint capsule, collateral
ligaments and a fibrous plantar
plate covering the plantar surface
of the joints
• Like the joint capsules in the fingers, the capsules of the toes are
reinforced dorsally by the extensor tendons and by collateral
ligaments that extend from the dorsal aspects of the medial and
lateral surfaces of the metatarsal heads toward the plantar aspects of
the medial and lateral sides of the proximal phalanges
PLANTAR PLATE
• The plantar plate serves a similar purpose in the toes as in the fingers,
protecting the articular surface of the metatarsal heads.
• The weight-bearing function of the foot makes the plantar plate
particularly important in the toes.
• The plates are attached to the metatarsal heads and the bases of the
phalanges and are pulled distally with hyperextension of the toes to
protect the distal aspect of the articular surface. Their function is critical
to protecting the metatarsal heads during ambulation, when the body
rolls over the stance foot, pushing the toes into hyperextension while
the foot participates in propelling the body forward
MOTION AT MTP JOINT
• The metatarsophalangeal joints of the toes are biaxial joints
but exhibit motion primarily in the sagittal plane.
• Flexion and extension occur about a moving joint axis,
indicating that the motions include rotation and translation
• The great toe displays deviation in the transverse
plane with slight rotation motion in the frontal plane in the
familiar hallux valgus deformity in which the proximal phalanx deviates
laterally on the metatarsal head
• Toe hyperextension mobility bears considerable clinical significance,
since reports of the hyperextension used during locomotion as the
body rolls over the foot vary from 40 to 90°
HALLUX RIGIDUS:
• Limited hyperextension mobility of the metatarsophalangeal joint of the
great toe, known as hallux rigidus, can produce pain and significant
functional limitations and disability.
• Inability to hyperextend the great toe alters normal walking and running
patterns, since these activities require the ability to roll over the toes,
hyperextending the great toe to at least 40°.
• Hallux rigidus usually results from degenerative joint disease at the
metatarsophalangeal joint and progresses insidiously, leading to
progressive pain and disability. Conservative management includes shoe
modifications to protect the toe, but severe cases often require surgery
INTERPHALANGEAL JOINTS OF THE
TOES
• Articular surfaces:
• Convex head of more proximal phalanx
• Concave base of more distal phalanx
• Mobility at the joint is limited primarily to flexion and extension
• Amplitude of flexion generally exceeds extension and motion tends to
be greater at the proximal than the distal joints
• Extension is limited passively by the toe flexors and plantar ligaments
WINDLAS
S EFFECT
References
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164367/
• Kinesiology- The mechanics and Pathomechanics of Human
Movement- Carol A. Oatis
• Kinesiology of the musculoskeletal system- Donald A. Neumann
• Google photos