Ankle joint and joints of foot

Ankle joint and joints of foot

1. Ankle Joint and the Joints of Foot Dr. Komal Parmar 9 th of March, 2021

2. Part 1- Tibiofibular Articulation

3. Tibiofibular Joints Before we begin, let’s revise…. Superior/ Proximal Interosseus Inferior/ Distal

4. Superior Tibiofibular Joint P lane type synovial joint The primary function of the PTFJ is dissipation of torsional stresses applied at the ankle and the lateral tibial bending moments. Joint capsule attached along the margins of articular surfaces. A nterior and Posterior proximal tibiofibular ligaments T he synovial membrane lines the articular capsule which may communicate with the knee joint via the subpopliteal recess in about 10% of the population. The fibular facet is usually elliptical or circular and nearly flat or slightly grooved. The surfaces are covered with hyaline cartilage underlining the synovial nature of this joint.

5. The tunnel entrance is a musculo -aponeurotic arch derived from the peroneus longus muscle. Unyielding musculo -aponeurotic fibular arch . Fibular Tunnel

6. Interosseous joint Syndesmosis R un downward and lateralward . The membrane is continuous distally with the interosseous ligament of the distal tibiofibular joint. T he interosseous membrane acts as a conduit for stress transmission to the fibula. An intact membrane keeps the fibula active during the loads and motions of normal gait.

7. Remember that there are Tibiofibular and Talofibular ligaments near the formation of ankle joint. Don’t get them confused.

8. The PITFL is made up a superficial ligament and deep ligament (often called the inferior transverse tibiofibular ligament)

9. Part 2- Ankle Joint

10. ANKLE (TALOCRURAL) JOINT Hinge, uniaxial Mortise for Talus- The lower end of the tibia, malleolus of the fibula and inferior transverse tibiofibular ligament

11. Range of Motion Hinge joint with a dynamic axis of rotation N ormal range of dorsiflexion is 10º when the knee is straight, and 30º with the knee flexed (when the calcaneal tendon will be relaxed). The range of normal plantar flexion is 30º. Dorsiflexion results in the joint adopting the ‘ closepacked ’ position, with maximal congruence and ligamentous tension F rom this position, all major thrusting movements are exerted, in walking, running and jumping. The superior talar surface is broader in front, and in dorsiflexion the malleolar gap is increased by slight lateral rotation of the fibula , by ‘give’ at the inferior tibiofibular syndesmosis and gliding at the superior tibiofibular joint

12. Articulating Surfaces covered by hyaline cartilage

13. Joint Capsule attachment It is attached proximally to the borders of the tibial and malleolar articular surfaces, and distally to the talus near the margins of its trochlear surface, except in front where it reaches the dorsum of the talar neck.

14. Amaha , K., Nimura , A., Yamaguchi, R.  et al.  Anatomic study of the medial side of the ankle base on the joint capsule: an alternative description of the deltoid and spring ligament.  J EXP ORTOP   6,  2 (2019). https://doi.org/10.1186/s40634-019-0171-y

15. Ligaments

16. Medial (Deltoid) Ligament TIBIA: Attached to the apex and the anterior and posterior borders of the medial malleolus. Superficial fibres : Anterior ( tibionavicular ) : navicular tuberosity, medial margin of the plantar calcaneonavicular ligament Intermediate ( tibiocalcaneal ): entire length of the sustentaculum tali ; Posterior fibres (posterior tibiotalar): medial side of the talus and its medial tubercle.

17. Deep fibres (anterior tibiotalar): tip of the medial malleolus to the non-articular part of the medial talar surface. Relations: The ligament is crossed by the tendons of tibialis posterior Flexor digitorum longus. Medial (Deltoid) Ligament

18. Lateral Ligament Complex

19. The lateral ligament has three discrete parts. Anterior talofibular ligament: the anterior margin of the fibula to front of the lateral articular facet of Talus and to the lateral aspect of its neck The posterior talofibular ligament: The distal part of the lateral malleolar fossa to the lateral tubercle of the posterior talar process; a ‘tibial slip’ of fibres connects it to the medial malleolus. The calcaneofibular ligament: From a depression anterior to the apex of the fibular malleolus to a tubercle on the lateral calcaneal surface crossed by the tendons of fibularis longus and brevis The lateral ligament complex is injured most commonly with inversion sprains, often during sport; the posterior talofibular ligament is almost always spared.

20. Synovial membrane The joint is lined by synovial membrane which projects into the inferior (distal) tibiofibular joint. Vascular supply and lymphatic drainage The talocrural joint is supplied by malleolar branches of the anterior and posterior tibial and fibular arteries. Lymphatic drainage is via vessels accompanying the arteries and via the long and short saphenous veins superficially. Innervation The talocrural joint is innervated by branches from the deep fibular, saphenous, sural and tibial nerves (or medial and lateral plantar nerves, depending on the level of division of the tibial nerve).

21. Relations

22. The long saphenous vein and saphenous nerve cross the ankle joint medial to the tendon of tibialis anterior and anterior to the medial malleolus, the nerve lying posterior to the vein.

23. Factors maintaining stability Passive stability is conferred upon the ankle mainly by the medial and lateral ligament complexes, the distal tibiofibular ligaments, the tendons crossing the joint, the bony contours and the capsular attachments. Dynamic stability is conferred by gravity, muscle action and ground reaction forces. Stability requires the continuous action of soleus assisted by gastrocnemius: it increases when leaning forward, and decreases when leaning backwards. If backward sway takes the projection of the centre of gravity (‘weight line’) posterior to the transverse axes of the ankle joints, the plantar flexors relax and the dorsiflexors contract.

24. Part 3- Small Joints of Foot Inferior Tibiofibular Talocalcaneal (Subtalar Joint) Talocalcaneonavicular joint (Subtalar Joint) Calcaneocuboid joint Naviculocuneiform joints Cuboideonavicular joint Intercuneiform and cuneocuboid joints Tarsometatarsal articulations Intermetatarsal joints Metatarsophalangeal articulations Interphalangeal articulations

25. Talocalcaneal Joint Anterior and posterior articulations between the calcaneus and talus form a functional unit often termed the ‘subtalar joint’. The posterior articulation is referred to as the talocalcaneal joint and the anterior articulation is regarded as part of the talocalcaneonavicular joint . The bones are connected by a fibrous capsule, and by lateral, medial, interosseous talocalcaneal and cervical ligaments.

26. Talocalcaneal Joint

27. Talocalcaneal Joint

28. Joint Capsule Attached to the margins of articular surfaces Talocalcaneal Joint Ligaments Lateral talocalcanal eligaments medial talocalcaneal ligaments interosseous talocalcaneal ligaments Cervical ligament .

29. Lateral talocalcaneal ligament- lateral talar process to the lateral calcaneal surface. Medial talocalcaneal ligament- medial talar tubercle to the back of the sustentaculum tali and adjacent medial surface of the calcaneus. Its fibres blend with the medial (deltoid) ligament of the ankle joint. Interosseous talocalcaneal ligament: flat, bilaminar transverse band in the sinus tarsi Sulcus tali to the calcaneal sulcus. The posterior lamina of the ligament is associated with the talocalcaneal joint, and the anterior lamina with the talocalcaneonavicular joint. Cervical ligament : On talar Neck lateral to the tarsal sinus and attached to the superior calcaneal surface. Talocalcaneal Joint

30. Talocalcaneal Joint

31. Talocalcaneal Joint

32. Talocalcaneal Joint

33. Talocalcaneal Joint

34. Synovial membrane The synovial cavity of the talocalcaneal joint is usually quite separate and does not communicate with those of other tarsal joints. However, direct communication with the ankle joint has been observed in rare instances. Innervation The talocalcaneal joint is innervated by branches of the posterior tibial, medial plantar and sural nerves. Relations Posteromedially , posterior tibial artery and vein, the tibial nerve and the tendon of flexor hallucis longus. These neurovascular structures are at risk in posteromedial approaches to the ankle and talocalcaneal joints. On the lateral side, the tendon of fibularis brevis lies anterior to the tendon of fibularis longus, both passing behind the fibular malleolus. The sural nerve lies just posterior to the fibular tendons and is at risk during lateral exposure of the joint. Muscles producing movement Heel inversion is controlled by tibialis anterior, tibialis posterior and the gastrocnemius–soleus complex via the calcaneal tendon; the long flexors of the toes also contribute. Heel eversion results from the pull of fibularis longus, brevis and tertius in addition to the long extensors of the toes. Talocalcaneal Joint

35. Talocalcaneonavicular joint T wo articulations, i.e. the anterior ‘subtalar’ joint and the talonavicular joint. C ompound, multiaxial articulation. Talocalcaneonavicular Joint

36. Talocalcaneonavicular Joint

37. The ovoid talar head is continuous with the triple-faceted anterior area of its inferior surface. The whole head fits the concavity formed collectively by the posterior surface of the navicular, the middle and anterior talar facets of the calcaneus, and the superior fibrocartilaginous surface of the plantar calcaneonavicular ligament (spring ligament). Talocalcaneonavicular Joint

38. Fibrous Capsule- Thin and poorly developed anteriorly, posteriorly blends with the anterior part of the interosseous ligament filling the tarsal sinus. Ligaments: Talonavicular ligament: connects the dorsal surfaces of the neck of the talus and the navicular Plantar calcaneonavicular (spring) ligament: Spring Ligament t hick band connecting the anterior margin of the sustentaculum tali to the plantar surface of the navicular. Sustains the medial longitudinal arch of the foot The dorsal surface of the ligament has a triangular fibrocartilaginous facet on which part of the talar head rests. Its plantar surface is supported medially by the tendon of tibialis posterior and laterally by the tendons of flexors hallucis longus and digitorum longus; its medial border is blended with the anterior superficial fibres of the medial (deltoid) ligament. Talocalcaneonavicular Joint

39. Talocalcaneonavicular Joint

40. Sinus Tarsi

41. Calcaneocuboid Joint same level as the talonavicular joint and, together, they represent the transverse tarsal joint. Saddle ( sellar ) or biaxial joint with concavo-convex surfaces. 2 cm proximal to the tubercle on the fifth metatarsal base Calcaneocuboid Joint

42. Fibrous capsule: T hickened dorsally as the dorsal calcaneocuboid ligament. The synovial cavity of this joint is separate, and does not communicate with those of other tarsal articulations Ligaments The ligaments of the calcaneocuboid joint are the Bifurcate ligament long plantar ligament plantar calcaneocuboid ligaments Calcaneocuboid Joint

43. Bifurcate Ligament: strong Y -shaped band attached by its stem proximally to the anterior part of the upper calcaneal surface, and distally it divides into calcaneocuboid and calcaneonavicular parts. Calcaneocuboid part forms the main bond between the two rows of tarsal bones T he (medial) calcaneonavicular ligament is attached to the dorsolateral aspect of the navicular. Calcaneocuboid Joint

44. Long plantar ligament L ongest ligament associated with the tarsus Attachment : calcaneus: anterior to the processes of its tuberosity and from its anterior tubercle Cuboid: the ridge and tuberosity on the plantar surface of the and continue to the bases of the second to fourth, and sometimes fifth, metatarsals . This ligament, together with the groove on the plantar surface of the cuboid, makes a tunnel for the tendon of fibularis longus . It is a most powerful factor limiting depression of the lateral longitudinal arch. Calcaneocuboid Joint

45. Calcaneocuboid Joint

46. Plantar calcaneocuboid ligament Aka Short Planter Ligament Deeper than the long plantar ligament Attachment: Anterior calcaneal tubercle and the depression anterior to it, to the adjoining part of the plantar surface of the cuboid Calcaneocuboid Joint

47. Calcaneocuboid Joint

48. Calcaneocuboid Joint

49. Calcaneocuboid Joint

50. Naviculocuneiform joints Articulating surfaces the distal navicular surface : transversely convex and divided into three facets Fibrous capsule The fibrous capsule is continuous with those of the intercuneiform and cuneocuboid joints and it is also connected to the second and third cuneometatarsal joints and intermetatarsal joints between the second to fourth metatarsal bones.

51. Ligaments The ligaments of the naviculocuneiform joint are the dorsal and plantar ligaments. Dorsal and plantar ( Cuneionavicular ) ligaments connect the navicular to each cuneiform; of the three dorsal ligaments, one is attached to each cuneiform. The fasciculus from the navicular to the medial cuneiform is continued as the capsule of the joint around its medial aspect, and then blends medially with the plantar ligament. Plantar ligaments have similar attachments and receive slips from the tendon of tibialis posterior.

52. Cuboideonavicular joint The cuboideonavicular joint is usually a fibrous joint. Syndesmosis dorsal, plantar and interosseous ligaments articular capsule and synovial lining are continuous with naviculocuneiform joint. The interosseous ligament is made of strong transverse fibres and connects nonarticular parts of adjacent surfaces to the two bones

53. Intercuneiform and cuneocuboid joints all synovial and approximately plane or slightly curved. Their articular capsules and synovial linings are continuous with those of the naviculocuneiform joints.

54. Tarsometatarsal Joints Plane, Synovial Articulating surfaces F irst metatarsal: medial cuneiform S econd: between the medial and lateral cuneiforms and articulates with the intermediate cuneiform Third: lateral cuneiform Fourth: lateral cuneiform and the cuboid F ifth : cuboid.

55. Fibrous capsule The hallucal joint has its own capsule. The articular capsules and cavities of the second and third are continuous with those of the intercuneiform and naviculocuneiform joints, but are separated from the fourth and fifth joints by an interosseous ligament between the lateral cuneiform and fourth metatarsal base. Ligaments The bones are connected by dorsal and plantar tarsometatarsal and interosseous cuneometatarsal ligaments.

56. Interosseous cuneometatarsal ligaments three One (the strongest) passes from the lateral surface of the medial cuneiform to the adjacent angle of the second metatarsal Known as Lisfranc’s ligament . A second ligament connects the lateral cuneiform to the adjacent angle of the second metatarsal A third ligament connects the lateral angle of the lateral cuneiform to the adjacent fourth metatarsal base.

57. Dorsal, Plantar and Interosseus Ligaments The intermetatarsal interosseous ligaments are very strong and are present between all the lateral four metatarsals they are absent between the first and second metatarsals. The base of the second metatarsal is joined to the first tarsometatarsal joint by the medial interosseous ligament (Lisfranc’s ligament) which connects the plantar aspect of the second metatarsal to the medial cuneiform. Intermetatarsal joints

58. Metatarsophalangeal Joints Articulating surfaces Articular surfaces cover the distal and plantar, but not the dorsal, aspects of the metatarsal heads. The plantar aspect of the first metatarsal head has two longitudinal grooves separated by a ridge (the crista). Articular areas on the proximal phalangeal bases are concave.

59. Plantar ligaments . Deep transverse metatarsal ligaments The deep transverse metatarsal ligaments are four short, wide, flat bands that unite the plantar ligaments of adjoining metatarsophalangeal joints. Collateral ligaments They are attached to the dorsal tubercles on the metatarsal heads and the corresponding side of the phalangeal bases and they slope downwards and forwards. The first metatarsophalangeal joint also contains metatarso -sesamoid ligaments. Each collateral ligament consists of the phalangeal collateral ligament, which inserts into the base of the proximal phalanx, and the accessory collateral ligament, which inserts into the plantar plate.

60. movements the range of active extension (50–60º) flexion (30–40º When the foot is on the ground, metatarsophalangeal joints are already extended to at least 25º The range of passive movements in these joints is 90º (extension) and 45º (flexion)

61. Interphalangeal articulations pure hinge joints Each has an articular capsule two collateral ligaments. The plantar surface of the capsule is a thickened fibrous plate , like the plantar metatarsophalangeal ligaments, and is often termed the plantar ligament.

62. Part 4- Postures and Movements of Foot

63. Foot Posture Foot posture is generally characterized by the contour of the medial longitudinal arch, and is typically divided into normal (rectus) low-arched (planus) highly-arched ( cavus )

64. The term “pronated” is used t o indicate a foot that undergoes greater lowering of the medial longitudinal arch and more medial distribution of plantar loading during gait and “supinated” to indicate a foot that undergoes greater elevation of the medial longitudinal arch and more lateral distribution of plantar loading during gait. As the foot is loaded,  eversion  of the subtalar joint,  dorsiflexion  of the ankle, and  abduction  of the forefoot occur

65. Talipes Equinovarus

66. Midtarsal Joints

67. Talus Anatomy The junction of the head and body of the talus subtends an angle approximately measuring 120◦ when measured between the axis of the head and a transverse coronal plane passing across the superior articular surface of the talus. The transverse or long axis of the articular surface of the head appears to be medially rotated with respect to the transverse plane drawn across the superior articular surface of the talus, corresponding roughly with the mid-points of the tibial and fibular articulating surfaces on either side of the body of the talus

68. average inclination of 42° in the sagittal plane and 23° medial deviation in the axial plane when relating to the long axis of the foot.