Grosss Anatomy LE foot

Ankle is more stable in dorsiflexion because the talus will wedge into the tibia and fibula and hold it in place causing it to be fixed.

Plantar flexed is more mobile and hence most ankle sprains (you jump up and then you plantar flex to prepare to land and you can roll the ankle causing an inversion sprain.) occurs because it can be bent more so when you jump and land on an uneven surface you can more easily roll the ankle.

plantar calcaneonavicular ligament (also known as the spring ligament) is a ligament on the underside of the foot that connects the calcaneus with the navicular bone. The plantar calcaneonavicular ligament is a broad and thick band of fibers, which connects the anterior margin of the sustentaculum tali of the calcaneus to the plantar surface of the navicular. This ligament not only serves to connect the calcaneus and navicular, but supports the head of the talus, forming part of the articular cavity in which it is received. The dorsal surface of the ligament presents a fibrocartilaginous facet, lined by the synovial membrane, and upon this a portion of the head of the talus rests Its plantar surface is supported by the tendon of the tibialis posterior; its medial border is blended with the forepart of the deltoid ligament of the ankle-joint. The plantar calcaneonavicular ligament helps to maintain the medial longitudinal arch of the foot and by providing support to the head of the talus bears the major portion of the body weight. It is the main part of the spring ligament complex.

talocalcaneal joint

Stieda process – name for the lateral tubericle of the talus.

Back of the talus there is a groove between the lateral and medial tubercles, were flexor hallicus longus passes through .

Os Trigonum – is an extra bone in the foot , right behind the lateral process – 10% of people have this bone - it a secondary ossification that never fuses with the talus which leaves a little round bone hanging off the back of the lateral tubicle. This can cause problems in people you spend a lot of time plantar flexing, such as soccer player or balla dancers, because the bone can impinge during this motion.

Posterior impingement syndrome – this is a catch all phrase for problems with the back of the ankle - the lateral process in plantar flexion bumps up against the tibia – can be caused by many things such as a very big lateral process or a weird shaped tibial termination (bottom of tibia), or when you have Os trigonum Call this the nut cracker phenomenon because this can crack the Os trigonum or lateral process between the clacaneous and tibial. Which can cause pain and inflammation. This is common in people who do a lot of jumping up and down like balla dancers because they move these bones up and down across each other a lot.


Treatment – in minor cases treat it with modalities in extreme cause they remove the OS trigonum or part of a bone through surgery to cut it out.

Calcaneous – first to ossify in development – common site of bone spurs is the back of this bone. Large tubercle on the back and there is a medial and lateral process which are a common site of bone spurs.

Plantar fasciaitis can mimic bone spurs but is more common. - in this condition the fascia on the underside (medial) of the foot hurts towards the heel , it very painful. Treatment is to stretch the hell out of it by pulling on the big toe when you get up in the morning, but it hard to get rid of , mostly modalities and stretching. Some sock which have a sting or band which goes to tibia and hence dorsi flex the foot can help treat this. As can a L shaped two by for on the foot. In exterme cases they may cut the plantar apernurosis. Special shoes or running in the woods can help runner deal with this

sustentaculum tali – At the upper and forepart of the medial surface of the calcaneus is a horizontal eminence, the sustentaculum tali (alternatively, the talar shelf), which gives attachment to the plantar calcaneo-navicular (spring) ligament, tibiocalcaneal ligament, and medial talocalcaneal ligament. This eminence is concave above, and articulates with the middle calcaneal articular surface of the talus; below, it is grooved for the tendon of the Flexor hallucis longus; its anterior margin gives attachment to the plantar calcaneonavicular ligament, and its medial margin to a part of the deltoid ligament of the ankle-joint.

Eye of the foot – or sinus tarsi - space that often gets inflamed in the foot , sinus tarsi syndrome – usual this is a result of inversion sprains or lax ligaments (ligaments inside it can get stretched out by inversion sprains, so they don't hold it together as well) which can lead to over pronation and if this happens a lot then it can lead to chronic inflammation and swelling and soft areas that hurts.

Cervical ligament – is in the sinus tarsi and connects the talus with the calcaneus and prevent to much inversion. Connect the talus neck to the calcaneous. It very important because if it get stretched out then it can lead to more inversion sprains because this ligament prevents inversion. Damaged in severe inversion sprains.

Morton's toe ( or Morton's syndrome, long toe) is the common term for the condition of a shortened first metatarsal in relation to the second metatarsal. It is a type of brachymetatarsia. This promotes an anterior position of the second metatarsal-phalangeal (MTP) joint in relation to the hallux (big toe). The condition may or may not result in the second toe (second from innermost) extending farther than the hallux if the second toe is of equal length to the big toe. This is a more specific form of greek foot.

Morton's neuroma (also known as Morton's metatarsalgia, Morton's neuralgia, plantar neuroma and intermetatarsal neuroma) is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the third and fourth intermetatarsal spaces. This problem is characterised by pain and/or numbness, sometimes relieved by removing footwear.

Greek foot – shorter big toe then second toe

Egyptian foot – square type of foot with most of the toes other then the little being level

5 metatarsal has a large styloid process were the peroneus brevis inserts and in sever inversion sprains you palpate this to see if there is a break because it can break off in inversion sprains.

Methheads – two sesomoid bones – make a tunnel for the tendon of flexor hallicus longus

2 major extensor retinaculum on the dorsal side – they can become inflamed do to impingement in them by tendons.

• Superior extensor retinaculm -
• inferior extensor retinaculum – y shaped

Flexor retinaculum – holds tom dick and harry to the medial maleolus and calcaneous and this is were we get tarsal tunnel. - it between the heel and the medial maleolus – a nerve (usually the medial plantar nerve) passing through this tunnel with the flexors can get squashed if they become inflamed. Causes burning pain along the bottom of the big toe.

Lateral side of the foot - peroneol retinaculum – it has a superior and inferior retinaculum that hold the peroneus longus and brevis tendons and if this become lacks or breaks then the tendons can move.

If the peroneol retinaculum become slack then there can be snapping of the foot.

Plantar aperoneurosis – massive ligamentous sheath that maintains the longitudinal arch of the foot.

• Outside ligaments – all ligaments are the ankle bone and the fibula Lateral collateral ligament – attaches the fibual to the ankle – made up of Posterior talofibular ligament
• – talus to fibula Calcaneofibular ligament – stabilizes the outside of ankle anterior talofibular ligaments

These ligaments resist inversion sprains and hence can often get ripped because ether not very big. These plus the cervical ligament help resist inversion sprains. Cervivle ligament = talocalcaneal ligament.

• Bifurcate ligament - maintain stability on the outside of the ankle on the lateral side
• calcaneonavicular ligament
• calcaneocuboid ligament

These two ligaments form a y shaped band which maintains stability of the outside of the ankle.


Deltoid means triangle

Medial collateral ligament – triangle shaped ligament also called the deltoid ligament- on this side every ligament is tibia something - 4 parts

posterior tibiotalar – forms the back side of the ligament

anterior tibiotalar – sometimes gets ossified in soccer players do to the large amounts of force going through a plantar flexed foot this ligament – it is called Footballer ankle – get streched and resits flexion from kicking a soccer ball and so will start to ossify. Forms the front of the deltoid

tibiocaneal

tibionavicular

Medial collateral ligament is much stronger then the lateral collateral so wont break the ligament, the bone breaks first such as in a pot fracture.

• Outside ligaments – all ligaments are the ankle bone and the fibula
• Lateral collateral ligament – attaches the fibual to the ankle – made up of
• Posterior talofibular ligament – talus to fibula
• Calcaneofibular ligament – stabilizes the outside of ankle
• anterior talofibular ligaments

These ligaments resist inversion sprains and hence can often get ripped because ether not very big. These plus the cervical ligament help resist inversion sprains. Cervivle ligament = talocalcaneal ligament.

You get more inversion sprains rather then eversion because the lateral maleolus comes way down and so is in the way, though the fibula head can be broken in a pot fracture by to much force. So it easier to go the medal

Pain in outside of the ankle could be from an injury to the LCL. This can happen when a person jumps and is Plantar flexed, with a lose ankle whent hey they land this can invert the foot and rip the hell out of the lateral collateral , can be confused with chronic inflammation of sinus tarsi, or sinus tarsi syndrome which is not a sprained ankle, it can also be confused with a big swelling on the ankle this large black and blue can also be bruise in the extensor Hallucis and digitorum brevis can be confused with a lateral ankle sprain.

• strong ligaments on the bottom of the
• foot – 2 major ligaments – that maintain the longitudinal arch of the foot and in pes planis these get stretched out and so you get pain in the lower back.

long plantar ligament – goes from calcaneous to the base of the metatarsals – longest ligament other then the plantar aprenuerosis short plantar ligament – starts on calcaneous and ends on the cuboid – maintains the arch of the foot if stretched they can cause pes planus.

Spring ligament goes from the sustinum tali to the edge of the navicular.(Plantarcalcanioligament) - hold the talus up if damaged the foot drops on the medial side of the foot. Help maintain arch of foot.

Longitudinal arch is maintained by the listed ligaments and the muscles tendons and the shape of the bones which fit together to make a bridge. Without this arch you loss the springiness of the foot and this may channel more shock up through the legs to the spine.

Joints


ankle joint – between the tibila, fibula and superior talus – talocrural joint – big hing shaped joint which open in plantar flexion and wedges back in dorsi flexion restricting motion. used for dorsi and plantar flexion -

Subtalar joint – joint beneath the talus, the head of the talus has hyline cartilage on it which articulates with spring ligament– gives you inversion and eversion but it not a straight axis it has a oblique axis

transverse tarsal joint – between the calcaneous and the cuboid and the talus and the navicular


tarsalmetatarsal joint – separates tarsal and metatarsals

MTP joint

IP – PIP , DIP

Hallus valgus - rigid big toe - Sometimes the first (big toe) ray bends outward and phalanx bends inward , because the sesomoid migrate outward and the tendon flexor hallisuc will pull the toe back creating the bowstring effect, which makes the whole toe bow outwards– can cause a bunion if you have this for a long time. This can be caused by bad shoes or wearing high heels a lot.


Treatment – break the toe and reset it , cut tendon of FHL and reset it or they can use a screw and a wire to pull the bone back into place. Wire method may simple reoccur later. Adductor hallucis may also be cut of the bone to stop it from pulling in the big toe so it stop holding the toe at a weird angle so the bunion goes away.

Hammer toe – long second ray – inappropriate shoes , cramming foot into small space – same as the mallet finger in the hand – loss of intrinsic and hyperextension and flexion tip in flexion. Lumbricals wont be working well.

A hammer toe or contracted toe is a deformity of the proximal interphalangeal joint of the second, third, or fourth toe causing it to be permanently bent, resembling a hammer. Mallet toe is a similar condition affecting the distal interphalangeal joint.

10 muscles make up the bottom of the foot – one less then the hand because there is no oppones muscles and no palmaris brevis.

• 3 big toe movers – abducto, adducto, flexor hallucis brevis
• 2 little toe movers – abductor and flexor digiti minimi (sometimes called brevis but no longus)
• 2 toe flexors (generic) - quadratus planta, flexor digitorum brevis
• 3 tiny muscles -4 lumbricals, 3 plantar interossei, 4 dorsal interossei

sole is in 4 layers

• 1 level
• abductor hallucis – on other side
• flexor digit brevis - in the middle
• abductor digit mini – on one side

• 2 level
• quadratus plantea
• lumbricals Also see tendons of the flexor digitorum , hallucis longus run through this layer.

• 3 level
• flexor muscles of digit minimi
• flexor hallucis brevis
• adductor hallucis

• 4 level
• Palmar and dorsal interossei

All instrinsic muscles of the foot are innervated by the lateral plantar nerve except for LAFF, which is the medial plantar nerve.

• L – one medial lumberical – most
• medial lumbrical on toe side
• A – abductor hallucis
• F – flexor hallucis brevis
• F – flexor digitorum brevis

Most nerve roots in the foot are S2-3

Quadratus plantae – help to straighten the angle of pull of the obliquely running tendons of the peroneus longus.

Arteries of top of the foot

Anterior tibula artery comes down anterior side of leg and cross ankle joint and becomes the dorsal pedius artery – a branch of this dives into the web space and becomes the deep plantar artery (like radial artery in hand goes through web space to get to palm, this artery goes through to bottom of the foot).

Also can see arcuate artery which comes across top of the foot and gives rise to dorsal metarsal and digital arteries.

• Another branch Comes off of dorsal pedial artery to become the medial and lateral tarsal arteries and
• further down the foot it a branch gives rise to the

Allens test – can't really be done in the foot, you simply palpate posterior tibial artery (not on lateral maleolus) and dorsal pedal artery ,

• Nerves of the foot
• Top of foot

• Saphrinous nerve – comes down medial side of the past medial malleouls to inside of the big toe– branch of the femoral
• Sural nerve – lateral side down to little toe
• Superfical peroneol – most of the top of foot - can be damaged by inversion sprains , leading to numbness of the toes.
• Deep peroneol nerve – web space of top of foot (area of L5 dermotome)

• Bottom of the foot – four strips of nerves across the bottom – in order from medial to lateral
• Saphernous nerve
• medial plantar – bottom of the foot big toe to 1/2 of 4 toe – supplies mostly skin
• lateral plantar – little toe and 1/2 of 4 toe – supplies more muscles sureal nerve

Inversion sprains can damage the intermediate dorsal nerves and other nerves that come around the medial maleolus and hence the foot can go dead.

• Joggers foot – is when the medial plantar nerve gets impinged underneath the abductor hallucis brevis.
• Symptoms: burning pain down the course of the medial plantar nerve so hence under big toe.

• Tarsal tunnel syndrome – impingement of the tibial nerve going through the tarsal tunnel can impinge in different places but usually underneath the flexor retinaculum.
• Symptoms: first effects is tingling in the toes , followed by pain and palsy of foot muscles. No real signs like in the hand Benediction sign, claw hand.

High tarsal tunnel syndrome – were the nerve comes out from under the triceps sureal and become impinged by the muscle often due to hypertrophy of the muscle. Same symptoms but entrapped in different place.