Anatomy of Ankle & Foot. Chang-Hyung Lee, M.D., Ph.D. Physical Medicine & Rehabilitation Samsung Medical Center
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1 Anatomy of Ankle & Foot Chang-Hyung Lee, M.D., Ph.D. Physical Medicine & Rehabilitation Samsung Medical Center
2 Ankle
3 Introduction Most frequently injured major joint 3 main articulation: distal tibiofibular j (syndesmotic) ankle j (talocrural) subtalar j (talocalcaneal)
4 Coronal View of ankle js.
5 1. Distal Tibiofibular joint Tibiofibular syndesmosis Upward 3~5 mm prolongation of the synovium of the ankle j Distal focal thickening of the inteross. Memb Interosseous lig. Ant.& pot. Tibiofibular lig., transverse lig.
6 2. Ankle Joint Articular surface of the talar dome, distal ends of the tibia & fibula, covered with cartilage Hinge type: dorsiflexion : ~ 30 DF, ~50 PF In extreme PF: some lateral motion is allowed (Ankle mortis - post. Half talar dome is narrower than ant. Half ) Supporting structures: fibrous capsule, MCL, LCL Capsule: medial & lateral malleoli, acetabular margin of the tibia, talus
7 2. Ankle joint: LCL complex
8 Lateral Ligament Complex Ant. Tibio-fibular l. Pos. tibiofibul. L Transverse Tibiofibular PTF: strongest,deepest prevents post. Talar shift ATFL Pos. Talofib.L CFL ATFL : least strong, m/c injured prevents ant.talar motion CF : longest prevents excessive inversion
9 2. Ankle Joint : MCL complex
10 2. Ankle Joint : MCL complex Deltoid: stronger, extensive Superf. & deep l. Tibionavicular Ant : to navicular Tibiotalar Post to talus Tibiocalcaneal Interm : to sustentaculum tali
11 2. Ankle joint Ankle stabilizer Coronal view: CFL, deltoid In ankle PF: A T F L (vertical), resist varus deformity In ankle DF: TFL is stressed
12 3. Subtalar joint 1. Post. Talocalcaneal j.: post. Subtalar j. : supported by a fibrous capsule, ant,lat, post. Talocalcaneal lig. 10~20% : communicate with the ankle j. Inversion & eversion movement 2. Talocalcaneonavicular j.: ant. Subtalar j. : reinforced by dorsal talonavicular lig. Spring (plantar calcaneonavicular) lig. : ant. Of sustentaculum tali~undersurface of the navicular Major supporter of longitudinal arch
13 4. Anterior Tendons Dorsiflexed Dorsiflexed + Inversed
14 4. Anterior tendons 1. TA : most medial side ~ medial surface of medial cuneiform, plantar aspect of the base of the 1 st metatarsal DF, inversion of ankle 2. EHL 3. E D L : divides into 2~5th toes 4. P Tertius : aids in DF, eversion Superior & inferior extensor retinacula : prevent tendon bowstring action
15 5. Lateral tendons 1. Peroneus longus 2. Peroneus brevis : smaller, lies anterior (3) peroneus quartus: accessory m. from PB Retinacular : superior & inferior Peroneal tendons turn forward below the lateral malleolus and rest on the lateral aspect of the calcaneus
16 6. Medial tendons Ant~ post. Flexor tendons : TP, FDL, FHL 1. T. P. : inverter, major stabilizer of the hindfoot oval shape, twice larger than FDL.. below med. Malleolus, superficial to the spring lig. to 3 cuneiform & base of the 1~4 metatarsals if, ruptured acquired flat foot 2. FDL 3. FHL : most lateral, runs inferomedially of the tibia inferior aspect of the sustentaculum tali.
17 6. Medial tendons Flexor Retinaculum Tibial n.
18 6. Medial tendons Achilles Tibialis Anterior Flexor H. L Medial Malleolus Tibialis Posterior
19 7. Posterior tendons 1. Achilles tendons (tendo calcaneus) : longest, thickest, strongest tendon in the body (12~15 cm) Descends vertically in the midline to post. Of calcaneus Cross section: flattened crescent shape ( flat or concave in anterior margin & convex posterior margin) - at distal insertion: entirely convex Fibers of tendon twist laterally (90 ) Karger triangle : separated from FHL by fat pad, just proximal to its insertion
20 7. Posterior tendons Not invested by a tendon sheath Enveloped by a paratendon : dorsal, lateral, medially 2~6 cm cranial to its insertion : hypovascular area : tendon rupture occurs Insertion : enthesis made of a intervening layer of fibrocartilage, intermeshing into the bone marrow of the calcaneus (strong, less tendon rupture) 2. Plantaris : medial border of the Achilles small, long tendon
21 7. Posterior tendons Plantaris Achilles Kager fat pad
22 8. Neurovascular structures Ant. : Deep peroneal n., ant. Tibial a. 1. Deep peroneal. N - Crosses interosseous memb. With a. & v. 2. Ant. Tibial a. - ends at the ankle j. becomes dorsalis pedis a. Lateral : superficial peroneal n. Medial : tibial n. Passes deep to the flexor retinaculum Tibial n. divides into medial & lateral plantar n., + calcaneal n. (sensitive supply of the heel) Plantar n. : supply intrinsic foot m.(except for EDB : deep peroneal n.)
23 8. Neurovascular structures Posterior ankle : sural n. : posterolateral aspect of the inferior third of the leg, lateral margin of the foot & lateral side of the small toe : between lateral malleolus & achilles tendon with small saphenous vein On the dorsum of the foot: sural n. anastomosis with br. Of the superficial peroneal n.
24 Foot
25 Introduction Supports body weight, absorbs shock Congenital, inflammatory, infectious, degenerative causes
26 Clinical Anatomy 28 bones, 30 joints,100 muscles, tendos, ligaments Midline : 2nd toe long axis (Adduction: movement toward 2 nd toe, abduction: away from 2 nd toe)
27 Osseous and Articular Anatomy 1. Hindfoot: talus & calcaneus 2. midfoot: navicular, cuboid, 3 cuneiforms 3. forefoot: metatarsals & phalanges Subtalar joint: talus (large concave facet on the inferior) & calcaneus (convex posterior articular surface of the superior) Transverse tarsal joint: talonavicular j~ calcaneocuboid j. inversion & eversion Navicular j. : j. with 3 cuneiforms Tarsometatarsal j. : 3 cuneiforms & cuboid Forfoot j.
28 Foot Anatomy Calcaneus Medial longitudinal Arch Plantar cal-na. L cuboid Talus navicular cuneiforms Plantar aponeurosis Lateral longitudinal Arch Metatarsals & phalanges Plantar aponeurosis
29 3 Main arches 1. Medial longitudinal arch : calcaneus, talus, navicular, 3 cuneiforms, 1~3 metatarsals concave inferioly ligaments & muscles - plantar aponeurosis (calcaneus~ 3 medial prox. Phalanges) - plantar calcaneonavicular lig. (spring lig.) (navicular ~calcaneus) - Flexor hallucis longus m. : bowstring of the arch - Tibialis posterior & Tibialis anterior : inverting, adducting
30 3 Main arches 2. Lateral longitudinal arch : calcaneus, cuboid, 4~5 th metatarsal (calcaneus~lateral 2 metatarsal heads) Inferior concavity Ligaments, muscles & lateral extension of the plantar aponeurosis - Peroneus longus: bowstring action
31 3 Main arches 3. Transverse arch : base of 5 metatarsals, cuboid, cuneiforms Ligaments & peroneus longus tendon At the level of the metatarsal head - less concave, deep transverse ligament
32 Soft tissues - dorsal foot Thin skin: 0.064mm epidermis + subcut. Fat Dermatomes : Saphenous n. medial side Superficial peroneal n. central & lateral side Sural n. lateral border of the foot 1 st web space deep peroneal n.
33 Soft tissues dorsal foot Extrinsic tendons: TA, EHL, E.D.L Intrinsic muscles : EDB, EHB EDB- anterolateral part of the calcaneus ~ EDL tendon EHB into prox. Phalanx of the 1 st toe Dorsalis pedis a. : from ant. Tibial a.
34 Soft tissues - plantar foot Significant thicker skin 8 times thicker epidermis Innervation 1. medial plantar n. 2. lateral plantar n. 3. calcaneal branches of tibial & sural n. : sensory br. To heel Heel pad : ave. 18mm, multiple fat-containing cells vertical fibrous & elastic septa shock absorber
35 Soft tissues - plantar foot Midfoot level (skin becomes thinner) at the metatarsophalangeal j.(thicker again for toe off) Plantar fascia : fibrous thickening of the superficial fascia: dynamic support for longitudinal arch network of compacted collagen fibers arranged mostly longitudinally
36 Soft tissues - plantar foot Plantar Fascia 3 cords of plantar fascia 1. Central: thickest, strongest, triangular thick posterior and thin anterior, fans out calcaneus~ flexor tendons of the toes (into fibrous digital sheath, proximal phalanx) 2. Medial : thin, covers abductor hallucis 3. Lateral : thin, overlies abductor digiti minimi - maintains medial and lateral longitudinal arch - firm attachement to skin Protects underlying skin, n. tendon
37 Intrinsic muscles & plantar tendons 1 layer - most superficial : AH, FDB, ADM AH : medial calcaneus~ medial base of prox. Phalax of the 1 st toe : large abductor, partially flexor of the 1 st toe (in severe HV, if tendon moves to plantarward, no flexion) FDB : from plantar fascia & medial calcaneus~ 4 tendons flexor of the PIP j. ADM :abductor, calcaneus & lateral plantar fascia~5 th Prox. phalax
38 Foot Anatomy Extrinsic T. Intrinsic T. EHB EDB Central-FDB lateral medial
39 Foot Anatomy EHB FHB lumb D-I FDB AH FDL FHL FDM addh P-I PL ADM Q-plant TP 1 st 2 nd 3 rd 4 th
40 Anatomy of the Foot- intrinsic Lateral S Intermed S Medial S
41 1 st Layer
42 Intrinsic muscles & plantar tendons 2 nd layer 1. Quadratus plantae : medial calcaneus (medial head), lateral calcaneus (lateral head) ~ FDLtendon (4 tendons) Assists the action of FDLongus (pulling tendons) 2. 4 Lumbricalis : from respective tendinous slips of the FDLongus ~ medial dorsal extensor hood of the 2~5 toes
43 2 nd Layer of Foot
44 Intrinsic muscles & plantar tendons 3 rd layer 1. FHB : cuboid plantar surface,peroneal groove, lateral cuneiform(lateral head), plantar surface of the medial & intermediate cuneiforms, tibialis post. tendon (medial head), ~ proximal phalanx of the 1 st toe (medial & lateral) Flexor of the 1 st metatarsophalangeal j. 2. Adductor hallucis : larger transverse head + smaller oblique head Adductor of the 1 st toe, flexor and maintain transverse arch
45 3 rd Layer of Foot
46 Intrinsic muscles & plantar tendons 3. FDMb : plantar surface of the base of 5 th metatarsal~ base of 5 th proximal phalanx Flexor of the 5 th toe (MP j)
47 Intrinsic muscles & plantar tendons 4 th layer Interosseous muscles (4 dorsal & 3 plantar) 1. Dorsal interossei m. : metatarsal shat~lateral surface of the base of the proximal phalanx of the toes (except 1 st ) Action: Abduct 2nd, 3rd and 4th Assist lumbricals in extending I-P joints while flexing metatarso-phalangeal joints 2. plantar interosseous m. : plantar and medial surface of the base of the 3,4,5 metatarsals~ medial surface of the base of the prox. Phalanx Action: Adduct 3rd 4th and 5th toes, Assist lumbricals in extending interphalangeal joints while flexing metatarso-phalangeal joints
48 Dorsal Interossei muscles
49 Plantar Interossei muscle
50 Intrinsic muscles & plantar tendons Several tendons : T.P, FHL, F.D.L, PL, PB T.P cross medial malleolus to cuneiform inverter, plantar flexor FHL passes under sustentaculum tali, F.D.L~ medial & lateral sesamoid at the base of the 1 st metatarsal, distal 1 st toe flexor of the 1 st toe, assists in plantar flexion of the foot maintenance of medial longitudinal arch F.D. L superficial to susten. Tali~ 2 to 5 th toe flexes the phalanges, ankle PF
51 Intrinsic muscles & plantar tendons PL, PB - ~ cuboid/ styloid process of the base of the 5 th metatarsal enters an osteofibrous tunnel, sole of the foot ~ 1 st metatarsal & medial cuneiform evertors, plantar flexors
52 Plantar Vessels and Nerves Main arteries Posterior tibial a. lateral plantar (large), medial plantar (small) artieries. pass deep to AbHallucis (with tibial n. br.) Lateral plantar a: ~ base of the 1 st metatarsal bone, joins the deep plantar br. Of the dorsalis pedis a. plantar a. arch
53 Joints & para-articular structures of the toes Metatarsophalangeal, proximal & interphalangeal j. Synovial- lined j. : flexion, extension Thick fibrocartilaginous plantar plate : insert into base of the proximal phalanx - weight bearing platform, main stabilizer of the metatarsophalangeal j. resisting dorsiflexion connected with collateral ligaments Deep transverse intermetatarsal ligament: connected with plantar plate
54 Plantar Plate PP FDP PP Deep tran intermet. L
55 Joints & para-articular structures of the toes 1 st toe : two phalanges Two sesamoid bones : medial (tibial) and lateral (fibular) in plantar aspect of the 1 st toe : embeded in the tendon of the FHB, AH Capsuloligamentous sling : mechanical benefit during j. flexion absorbing weight bearing stress
56 Hallux sesamoids Thin superfial L Inter-ses L prominence
57 Bipartite hallux sesamoid medial lateral Usus larger than normal one Cf) same size in fracture
58 Thank you for your attention!
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