Tibiofibular and ankle joint complex

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2. MOB TCD
Tibifibular and Ankle Joint Complex
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin

3. Superior and Inferior
Tibio-Fibular Joints
•Superior is synovial plane joint
•Inferior is a syndesmosis
•Interosseous tibiofibular
ligament
•Anterior and posterior tibiofibular
ligament
MOB TCD

4. Ankle Joint
•The ankle joint is one of the most
common joints to be injured
•The foot is usually in the plantar
flexed and inverted position when the
ankle is most commonly injured
Bröstrom, 1966
MOB TCD

5. Tennis
MOB TCD

6. •Dorsiflexion and plantar
flexion take place at the
ankle joint
•In plantar flexion there is
some side-to-side
movement
Last, 1963
Ankle Joint
MOB TCD

7. •Uniaxial, modified synovial
hinge joint
•Close pack
•Dorsiflexion
•Least pack
•Plantarflexion
Williams & Warwick, 1980
Ankle Joint
MOB TCD

8. Proximal Articular Surface
•Distal surface of the tibia
•Medial malleolus has comma
shaped facet
•Lateral malleolus triangular
facet
Williams & Warwick, 1980
MOB TCD

9. Proximal Articulation
•Inferior transverse tibiofibular ligament
•Deepens it posteriorly
•Passes from the lower margin of the
tibia
•To the malleolar fossa of the fibula
Williams & Warwick, 1980
MOB TCD

10. •Proximally the articulation
depends on the integrity of the
inferior tibiofibular joint
•Syndesmosis
Proximal Articular Surface
MOB TCD

11. Distal Articular Surface
•The superior surface of the body of
the talus is wider anteriorly
•Convex from before backwards
•Concave from side to side
•Medial comma shaped facet
•Lateral triangular facet
Frazer, 1965
MOB TCD

12. Capsule
•Is attached just beyond the articular
margin
•Except anterior-inferiorly
•Attached to the neck of the talus
Williams & Warwick, 1980
MOB TCD

13. •The capsule is thin and weak in front
and behind
•It is strengthened on either side by the
collateral ligaments
Williams & Warwick, 1980
Ankle Joint
MOB TCD

14. Medial (Deltoid) Ligament
•A strong triangular ligament
•Superiorly attached
•The medial malleolus of the
tibia
Williams & Warwick, 1980
MOB TCD

15. •The tuberosity of the
navicular
•The edge of the spring
ligament
•The sustentaculum tali
•The body of the talus
Last, 1963
Medial Ligament
MOB TCD

16. Medial or Deltoid Ligament
(Superficial)
•Cross two joints
•Anterior tibionavicular pass
to the tuberosity of the
navicular
•The free edge of the spring
ligament
•The middle fibres
•The tibiocalcaneal are attached to
the sustentaculum tali
Williams & Warwick, 1980
MOB TCD

17. Medial or Deltoid Ligament
(Deep)
•The anterior tibiotalar to the
nonarticular part of the
medial surface of the talus
•The posterior tibiotalar to the
medial side of the talus
•The medial tubercle of the
talus
Williams & Warwick, 1980
MOB TCD

18. Lateral Ligaments of Ankle
•The anterior talofibular
ligament (ATFL)
•The calcaneofibular
ligament (CFL)
•The posterior talofibular
ligament (PTF)
•They radiate like the spokes
of a wheel
Liu & Jason, 1994
MOB TCD

19. Anterior Talofibular Ligament (ATFL)
•Is part of the capsule
•An upper and lower bands
•It is cylindrical
•6-10 mm long
•2 mm thick
Liu & Jason, 1994
MOB TCD

20. ATFL
•The anterior inferior border of
the fibula runs parallel to the
long axis of the talus when
the ankle is neutral or
dorsiflexion
•More perpendicular to the
talus when the foot is
equinus
MOB TCD

21. •It is the weakest ligament
•Strain increases with
increasing plantar flexion
and inversion
•The AFTL is a primary
stabiliser against inversion
and internal rotation for all
angles of plantar flexion
Liu & Jason, 1994
ATFL
MOB TCD

22. Calcaneofibular Ligament (CFL)
•A long rounded 20-25 mm
long, 6-8 mm in diameter
•It contains the most elastic
tissue
•It is attached in front of the
apex of the fibular malleolus
•To a tubercle on the lateral
aspect of the calcaneus
Williams & Warwick, 1980
MOB TCD

23. CFL
•It is separated from the
capsule by fibro-fatty tissue
•Part of the medial wall of the
peroneal tendon sheath
•Crosses both the ankle and
subtalar joints
MOB TCD

24. •The CFL is perpendicular to
the long axis of the talus
•Dorsiflexion and inversion
result in an increased strain
•Talar tilt tests the CFL
CFL
MOB TCD

25. Lateral Ligament
•The angle between the
ATFL and CFL varies
between 100
o
and 135
o

•Increasing the potential
instability of the lateral
ligament
Hamilton, 1994; Peters, 1991
MOB TCD

26. Ankle Stability
•The ATFL is the main talar
stabiliser and the CFL acts
as a secondary restraint
MOB TCD

27. ATFL and CFL
•A difference of 10
o
between
the two ankles is significant
•A talar tilt of more than 10
o
is
a lateral ligament injury in
99% of cases
•The AFTL is injured in 65%
and combined injuries of the
AFTL and CFL occur in 20%
•The CFL is a major stabiliser
of the subtalar joint
Liu & Jason, 1994
MOB TCD

28. Posterior Talofibular (PTL)
•The PTL is the strongest part of the
lateral ligament
•It runs almost horizontally from
malleolar fossa to lateral tubercle of
talus
MOB TCD

29. PTL
•During plantar flexion the posterior
talofibular and the posterior tibio
fibular ligament are edge to edge
•They separate during dorsiflexion
MOB TCD

30. Ankle Joint
•The flexor hallucis longus lies in
a grove between the smaller
medial and larger lateral
tubercles
•In 7% the lateral tubercle has a
separate ossification and is
called an os trigonum
MOB TCD

31. Synovial Membrane
•Lines the capsule and the non articular area
•Covers the neck of talus
•The fatty pads inside the capsule
•It extends upwards to the interosseous
ligament of the inferior tibiofibular joint
Plastanga et al., 1980
MOB TCD

32. Blood Supply of Ankle
•Malleolar branches of the anterior
tibial
•Perforating peroneal and posterior
tibial arteries
MOB TCD

33. Nerve Supply of Ankle
•Nerve supply is via articular
branches of the deep peroneal
•Tibial nerve from L4 - S2
MOB TCD

34. Anterior Aspect
•Dorsiflexors
•Tibialis anterior
•Flexor hallucis longus
•Anterior tibial > dorsalis pedis artery
•Deep peroneal nerve
•Extensor digitorum longus
•Peroneus tertius
MOB TCD

35. Postero-Medial Aspect of Ankle
•Tibialis posterior
•Flexor digitorum longus
•Posterior tibial vessels
•Posterior tibial nerve and
branches
•Flexor hallucis longus
MOB TCD

36. Posterior Aspect
•Posterolateral portal
•Lateral to achilles tendon, sural
nerve, short saphenous vein at
risk
•Posteromedial not used; flexor
retinaculum structures at risk
Jaivin & Ferkel, 1994
MOB TCD

37. Lateral Aspect of Ankle
•The inferior extensor
retinaculum
•Extensor digitorum brevis
•Peroneus longus and brevis
•Peroneal retinaculum
•Ligament of the neck of talus
•Bifurcate ligament
MOB TCD

38. •Plantar flexor and evertor
–Peroneus longus
–Peroneus brevis
•Dorsiflexor and evertor
–Peroneus tertius
Lateral Aspect of Ankle
MOB TCD

39. Nerves Related to Ankle Joint
MOB TCD

40. •In the anatomical position the axis of the
ankle joint is horizontal
•But is set at 20-25
o
obliquely to the
frontal plane
•Running posteriorly as it passes laterally
Plastanga et al., 1990
Ankle Joint
MOB TCD

41. •The ankle is most stable in
dorsiflexion, with increasing
plantar flexion there is more
anterior talar translation
(drawer) and talar inversion
(tilt)
Ankle Joint
MOB TCD

42. Ankle Examination
•Anterior drawer
•Suction sign
•Inversion stress
•Squeeze test
•External rotation
•Test
MOB TCD

43. •Achilles tendon
•Peroneal tendons
•Posterior tibial tendon
•Anterior process of calcaneus
•Talar dome
•Sinus tarsi
•Bifurcate ligament
Ankle Examination
MOB TCD

44. Tests for Ankle Ligament Injury
MOB TCD

45. Ottawa Ankle Rules
•Anteroposterior
•Oblique
•Lateral views
•Bone tenderness
•Medial or lateral
•Malleolus
•Unable to weight bear
•Four steps post injury
MOB TCD

46. Tibialis Posterior / Superficial
Peroneal Nerve
MOB TCD

47. •ATFL
•CFL
•Distal tibiofibular
•Syndesmosis
•Deltoid ligament
•Lateral malleolus
•Medial malleolus
•Base 5
th
metatarsal
Ankle Examination
MOB TCD

48. •Inversion or supination
•Raising the medial
border
•Sole faces medially
Inversion and Eversion
•Eversion or pronation
•Raising the lateral
border
•Sole faces laterally

MOB TCD

49. •Initiated at the transverse
tarsal joint
•Calcaneocuboid
•Anterior portion of the
talocalcaneonavicular
Last, 1963

Inversion and Eversion
MOB TCD

50. •Main movement take
place at the clinical
subtalar joint i.e.
–talocalcaneal
–inferior portion of the
talocalcaneonavicular
•The pivot is the ligament
of the neck of the talus
Last, 1963
Inversion and Eversion
MOB TCD

51. •Axis passes through the
middle of the convex
posterior facet on
calcaneus
•Upwards forwards and
medially
•Through middle of convex
articular facet of head of
talus
Last, 1963
Inversion and Eversion
MOB TCD

52. Talocalcaneal
•Synovial plane joint
•Articular surface
•Concave facet inferior body
of talus
•Convex posterior facet,
superior aspect of calcaneus
MOB TCD

53. Talocalcaneal Joint
•Capsule attached just beyond
articular margin ligaments
•Interosseous
•Ligament of neck of talus
MOB TCD

54. Tarsal Canal and Tarsal Sinus
MOB TCD

55. Inversion or Supination
•Invertor and dorsiflexion
•Tibialis anterior
•Invertor and plantarflexion
•Tibialis posterior
MOB TCD

56. Eversion and Pronation
•Evertor and dorsiflexion
•Peroneus tertius
•Evertor and plantarflexion
•Peroneus brevis
•Peroneus longus
MOB TCD

57. Talocalcaneonavicular Joint
•Synovial ball and socket
•Ball head of talus
•Socket
•Posterior aspect of the
navicular, two anterior facets
on superior surface of
calcaneus
•Spring ligament and CNL
MOB TCD

58. •Synovial ball and socket
joint
•Ball is anterior and inferior
aspect of the head of the
talus
Talocalcaneonavicular Joint
MOB TCD

59. •Socket
•Two anterior facets on the
superior surface of the
calcaneus
•Posterior aspect of the
navicular
•Spring ligament
•LCN ligament
Talocalcaneonavicular Joint
MOB TCD

60. •Capsule attached just beyond
the articular margin
•Interosseous ligament
•Spring ligament
•Superficial portion deltoid
ligament
•LCL of bifurcate
•Ligament neck of talus
Talocalcaneonavicular Joint
MOB TCD

61. •Synovial membrane lines the
capsule and non-articular
structures
•Nerve supply
•Tibial nerve
•Deep and superficial
peroneal nerves

Talocalcaneonavicular Joint
MOB TCD

62. Subtalar Interosseosus
•Capsule of both
talocalcaneal
•Posterior portion of the
talocalcanoeonavicular
joint
MOB TCD

63. Ligaments of Subtalar Joint
•Inferior extensor retinaculum
•Ligament of the neck of talus
•Interosseous ligament
•Bifurcate ligament
MOB TCD

64. Ligament of Neck of Talus
•Sinus tarsi
•Lateral aspect of neck of talus
•Pivot of inversion and
eversion
Last, 1963
*
MOB TCD

65. Tarsal Canal and Tarsal Sinus
•Fat
•Nerve endings
•Branches of posterior tibial
and peroneal arteries
•Capsules and ligaments of
talocalcaneal and
talocalcaeonavicular joints
MOB TCD

66. Inferior Extensor Retinaculum
•Medial root inside the tarsal
sinus
•Intermediate to talus with the
interosseous ligament, inside
sinus
•Lateral root to calcaneus
outside sinus
Klein & Spreitzer, 1993
MOB TCD

67. Ligament Attachments
MOB TCD

68. Bifurcate Ligament
•Lateral calcaneo-
navicular ligament (CNL)
•Medial calcaneocuboid
ligament (CCL)
MOB TCD

69. •Two individual ligaments
•Separate attachments
•Different fibre orientation
•Different histology
Bifurcate Ligament
MOB TCD

70. Talocalcaneonavicular Joint
•Invertors
•In dorsiflexion
•Tibialis anterior
•In plantarflexion
•Tibialis posterior
MOB TCD

71. •Evertor
•In dorsiflexion
•Peroneus tertius
•In plantarflexion
•Peroneus longus
•Peroneus brevis
Talocalcaneonavicular Joint
MOB TCD

72. Calcaneo Navicular Ligament
•Folded and twisted appearance
•Prominent medial and lateral
edges / folds
•Three groups of fibres
–Medial
–Lateral (deep)
–Intra-articular
N
A
C
MOB TCD

73. Calcaneocuboid Ligament
•Intra-capsular CC joint
•Smaller than CNL, always
present
•Hourglass shaped fibres,
twisted medially
MOB TCD

74. Calcaneocuboid Joint
•Plane synovial
•Ligaments
•Capsular
•Ligament of neck of talus
•Long and short plantar
ligament
•Bifurcate ligament
MOB TCD

75. •The long and short plantar ligaments
support the calcaneocuboids portion of
the transverse tarsal joint
Calcaneocuboid Joint
MOB TCD

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