The foot and ankle

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The foot and ankle

• Stephen Milner DM, FRCS (Tr Orth)
• Consultant Trauma Orthopaedic Surgeon
• Derbyshire Royal Infirmary

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Mans foot is all his own

• It is unlike any other foot. It is the most
  distinctly human part of the whole of his
  anatomical make-up. It is a human specialisation
  and, whether he be proud of it or not, it is his
  hallmark and so long as Man has been Man and so
  long as he remains Man, it is by his feet that he
  will be known from all other members of the
  animal kingdom.
• Frederick Wood Jones (1879-1954).
• Professor of Human and Comparative Anatomy
• Royal College of Surgeons of England

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Apes have four hands
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Evolution of the foot
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Bones joints of the foot
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Ligaments Muscles
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Functional parts of the foot
Forefoot
Midfoot
Hindfoot
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Functions of the foot ankle

• Weight bearing
• Posture
• Locomotion
• Shock absorption

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Terminology of movement

• Relative to the 3 orthogonal planes
• Sagittal plane
• Flexion - extension
• Coronal plane
• Abduction - adduction
• Transverse plane
• Internal external rotation

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Foot and ankle movements

• No foot/ankle joint moves in one orthogonal plane
• Movements are biplanar or triplanar
• Such movements have their own names
• Dorsiflexion - plantarflexion
• Inversion eversion

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The ankle

• Is formed by the tibia, fibula talus
• Is a hinge
• Takes over 5x body weight through a contact area
  of only approx 4.5cm2
• Very rarely develops primary osteoarthritis

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Find the axis of the ankle!
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The talus is part of a cone
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The ankle axis
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Biplanar movements of ankle

• Dorsiflexion
• Extension, external rotation
• Plantarflexion
• Flexion, internal rotation

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Why have an ankle joint?

• Lengthen stride
• Reduce up and down movement of the bodys centre
  of gravity
• Reduce force transmission through other joints
• Reduces energy expenditure

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The subtalar joint

• Is formed by the talus and the calcaneum
• Consists of 3 separate articular facets
• Is important when walking on uneven ground
• Is a triplanar joint
• Is a mitred hinge

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Mitred hinge concept
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Subtalar movements

• Inversion
• Flexion Adduction Internal Rotation
• Eversion
• Extension Abduction External Rotation

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The foot - arches

• Transverse
• Medial longitudinal
• Lateral longitudinal

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Transverse arch
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Longitudinal arches

• Medial is relatively immobile
• Lateral is lower but more mobile

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The foot

• Is a tripod
• Is sometimes flexible
• Shock absorber
• Is sometimes rigid
• Lever

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The foot as a tripod
Zone of stability
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The foot as a shock absorber

• Heel strike
• Hindfoot moves into eversion
• Transverse tarsal joint unlocks
• Midfoot becomes flexible

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The foot as a lever

• Toe off
• Hindfoot in inversion
• Transverse tarsal joint locked
• Midfoot rigid

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Human gait
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The action of muscles

• Force couples with opposing actions
• Tibialis posterior Peroneus brevis
• Tibialis anterior Peroneus longus
• Alter the rigidity of the foot through the gait
  cycle
• Position the foot in stance
• Maintaining a stable base

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Examination of foot ankle

• Look
• Feel
• Move

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Look

• Shape of foot
• Alignment of leg and foot in stance
• Gait
• Active movements
• Tiptoes, heels, inversion, eversion
• Skin
• Pressure points, callosities
• Shoes

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Feel

• This is where you need to know your surface
  anatomy!
• Palpate individual structures for tenderness
• Assess swellings/synovitis
• Sensation/circulation

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Move

• Each joint in turn
• Work from proximal to distal
• Compare with the other side
• Watch the patients face!

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Special tests

• Ankle stability
• Ankle Impingement
• Gastrocnemius tightness
• Peroneal tendon subluxation
• Tibialis posterior function
• Coleman block test for hindfoot stiffness
• Mulder click test
• Lesser MTP joint stability

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Common problems

• Injuries
• Fractures
• Ligament injuries
• Wear and tear
• Arthritis
• Tendonopathies
• Muscle imbalance
• Cavus feet
• Hallux valgus
• Lesser toe problems

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Further information

• Interactive foot and ankle CDROM
• MacRaes Clinical Orthopaedic Examination
• Lots on the internet, one of the best is Jim
  Barries Foot Ankle Hyperbook
• http//www.blackburnfeet.org.uk/hyperbook/hist_exa
  m.htm

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The end!