ANKLE and FOOT

BONES OF THE ANKLE AND FOOT

LIGAMENTS OF THE ANKLE AND FOOT

MEDIAL or DELTOID LIGAMENT

• A very strong ligament attached by its apex to the tip of the medial malleolus
• Resists valgus forces applied to the ankle joint
• Components:
a. Tibiotalar ligament
b. Tibiocalcaneal ligament
c. Tibionavicular ligament

LATERAL LIGAMENT

• Weaker than the medial ligament

• Resists varus forces applied to the ankle joint
• Components:
a. Anterior talofibular ligament
b. Calcaneofibular ligament
c. Posterior talofibular ligament

ARCHES OF THE FOOT

MEDIAL LONGITUDINAL ARCH

• Calcaneus
• Talus
• Navicular
• Three Cuneiforms
• 1st, 2nd, and 3rd metatarsal bone

LATERAL LONGITUDINAL ARCH

• Calcaneus
• Cuboid
• 4th, and 5th metatarsal bone

TRANSVERSE ARCH

• Bases of the metatarsal bones

• Cuboid
• Three Cuneiforms

EXTENSOR RETINACULUM OF THE ANKLE

SUPERIOR EXTENSOR RETINACULUM

• Thickened band of deep fascia that is attached to the distal ends of the anterior
borders of the fibula and tibia

INFERIOR EXTENSOR RETINACULUM

• Y-shaped band of deep fascia that is attached by its stem to the upper surface of
the anterior part of the calcaneus
• Upper limb of the Y is attached to the medial malleolus
• Lower limb is continuous with the plantar fascia on the medial border of the foot
STRUCTURES THAT PASS SUPERFICIAL TO THE EXTENSOR ETINACULA

• From medial to lateral

1. Saphenous nerve and Great saphenous vein (in front of the medial malleolus)
2. Superficial peroneal nerve

STRUCTURES THAT PASS UNDERNEATH THE EXTENSOR RETINACULA

• From medial to lateral

1. Tibialis anterior tendon

2. Extensor hallucis longus tendon
3. Anterior tibial artery with venae comitantes
4. Deep peroneal nerve
5. Extensor digitorum longus tendons
6. Peroneus tertius

FLEXOR RETINACULUM OF THE ANKLE (TARSAL

TUNNEL)
FLEXOR RETINACULUM (TARSAL TUNNEL)

• Thickened band of deep fascia that extends from the medial malleolus downward
and backward to be attached to the medial surface of the calcaneus
• Binds the tendons of the deep muscles to the medial side of the ankle as they pass
behind the medial malleolus

STRUCTURES THAT PASS BEHIND THE MEDIAL MALLEOLUS AND

UNDERNEATH THE FLEXOR RETINACULUM (TARSAL TUNNEL)

• From medial to lateral

1. Tibialis posterior tendon

2. Flexor digitorum longus
3. Posterior tibial artery with venae comitantes
4. Tibial nerve
5. Flexor hallucis tendon

PERONEAL RETINACULUM OF THE ANKLE

SUPERIOR PERONEAL RETINACULUM

• Thickened band of deep fascia that extends from the lateral malleolus downward
and backward to be attached to the lateral surface of the calcaneus
• Binds the tendons of the Peroneus longus and brevis to the lateral side of the
ankle

INFERIOR PERONEAL RETINACULUM

• Thickened band of deep fascia that is attached to the peroneal tubercle and to the
calcaneus above and below the peroneal tendons
• Binds the tendons of the Peroneus longus and brevis

STRUCTURES THAT PASS BEHIND THE LATERAL MALLEOLUS AND

SUPERFICIAL TO THE SUPERIOR PERONEAL RETINACULUM

1. Sural nerve
2. Small saphenous vein
STRUCTURES THAT PASS BEHIND THE LATERAL MALLEOLUS AND
UNDERNEATH THE SUPERIOR PERONEAL RETINACULUM

1. Peroneus longus tendon

2. Peroneus brevis tendon

THE SOLE OF THE FOOT

DEEP FASCIA

• The deep fascia of the sole of the foot is thickened to form the flexor retinaculum
and the plantar aponeurosis

PLANTAR APONEUROSIS

• Triangular in shape and occupies the central area of the sole

• Apex of the aponeurosis is attached to the medial and lateral tubercles of the
calcaneus
• Base of the aponeurosis divides at the bases of the toes into five slips
• Function of the plantar aponeurosis:
a. To give firm attachment to the overlying skin
b. To protect the underlying vessels, nerves, and tendons and their synovial
sheaths
c. To assist in maintaining the arches of the foot

MUSCLES OF THE FOOT (4 Layers)

FIRST LAYER

1. Abductor hallucis
2. Flexor digitorum brevis
3. Abductor digiti minimi

SECOND LAYER

1. Quadratus plantae (Flexor digitorum accessorius)

2. Lumbricals
3. Flexor digitorum longus tendon
4. Flexor hallucis longus tendon

THIRD LAYER

1. Flexor hallucis brevis

2. Adductor hallucis
3. Flexor digiti minimi brevis

FOURTH LAYER

1. Interossei
2. Peroneus longus tendon
3. Tibialis posterior tendon

MUSCLES OF THE FIRST LAYER

Abductor hallucis

1. Origin
• Medial tuberosity of calcaneus and flexor retinaculum

2. Insertion
• Base of proximal phalanx of big toe
3. Innervation
• Medial plantar nerve

4. Action
• Flexes and abducts the big toe
• Braces the medial longitudinal arch

Flexor digitorum brevis

1. Origin
• Medial tuberosity of calcaneus

2. Insertion
• Four tendons inserted into borders of the middle phalanx of 2nd, 3rd, 4th, and 5th
toe

3. Innervation
• Medial plantar nerve

4. Action
• Flexes the 2nd, 3rd, 4th, and 5th toe
• Braces the medial and lateral longitudinal arches

Abductor digiti minimi

1. Origin
• Medial and lateral tuberosities of the calcaneus

2. Insertion
• Base of proximal phalanx of 5th toe

3. Innervation
• Lateral plantar nerve

4. Action
• Flexes and abducts the 5th toe
• Braces the lateral longitudinal arch

MUSCLES OF THE SECOND LAYER

Quadratus plantae (Flexor digitorum accessorius)

1. Origin
• Medial and lateral sides of the calcaneus

2. Insertion
• Tendons of Flexor digitorum longus

3. Innervation
• Lateral plantar nerve

4. Action
• Assists the Flexor digitorum longus in flexing the 2nd, 3rd, 4th, and 5th toe

Lumbricals (4)

1. Origin
• Tendons of Flexor digitorum longus

2. Insertion
• Dorsal extensor expansion
• Bases of proximal phalanges of lateral four toes
3. Innervation
• Lumbrical # 1 –Medial plantar nerve
• Lumbrical # 2, # 3, & # 4 –Lateral plantar nerve

4. Action
• Extends the toes at the interphalangeal joints

Flexor digitorum longus (TENDON)

1. Origin
• Posterior surface of shaft of tibia

2. Insertion
• Bases of distal phalanges of lateral four toes

3. Innervation
• Tibial nerve

4. Action
• Flexes the DIP of the lateral four toes
• Plantarflexes the ankle joint
• Supports the medial and lateral longitudinal arches of the foot

Flexor hallucis longus (TENDON)

1. Origin
• Posterior surface of shaft of fibula

2. Insertion
• Base of distal phalanx of big toe

3. Innervation
• Tibial nerve

4. Action
• Flexes the DIP of the big toe
• Plantarflexes the ankle joint
• Supports the medial longitudinal arch of the foot

MUSCLES OF THE THIRD LAYER

Flexor hallucis brevis

1. Origin
• Cuboid, lateral cuneiform, and Tibialis posterior insertion

2. Insertion
• Medial tendon into medial side of base of proximal phalanx of big toe
• Lateral tendon into lateral side of base of proximal phalanx of big toe

3. Innervation
• Medial plantar nerve

4. Action
• Flexes MTP joint of big toe
• Supports medial longitudinal arch

Adductor hallucis

1. Origin
• Oblique head –bases of 2nd, 3rd, and 4th metatarsal bones
• Transverse head –from plantar ligaments
2. Insertion
• Lateral side of base of proximal phalanx of big toe

3. Innervation
• Deep branch of Lateral plantar nerve

4. Action
• Flexes MTP joint of big toe
• Holds together the metatarsal bones

Flexor digiti minimi brevis

1. Origin
• Base of 5th metatarsal bone

2. Insertion
• Lateral side of base of proximal phalanx of little toe

3. Innervation
• Lateral plantar nerve

4. Action
• Flexes MTP joint of little toe

MUSCLES OF THE FOURTH LAYER

Dorsal interossei (4)

• Bipennate muscle

1. Origin
• Adjacent sides of metatarsal bones

2. Insertion
• Dorsal interossei #1 –Medial side of proximal phalanx of 2nd toe
• Dorsal interossei #2 –Lateral side of proximal phalanx of 2nd toe
• Dorsal interossei #3 –Lateral side of proximal phalanx of 3rd toe
• Dorsal interossei #4 –Lateral side of proximal phalanx of 4th toe

3. Innervation
• Lateral plantar nerve

4. Action
• Abduction of toes
• Flexes the MTP and extends the IP joints of the toes

Plantar interossei (3)

• Unipennate muscle

1. Origin
• Inferior surfaces of 3rd, 4th, and 5th metatarsal bones

2. Insertion
• Plantar interossei #1 –Medial side of proximal phalanx of 3rd toe
• Plantar interossei #2 –Medial side of proximal phalanx of 4th toe
• Plantar interossei #3 –Medial side of proximal phalanx of 5th toe

3. Innervation
• Lateral plantar nerve
4. Action
• Adduction of toes
• Flexes the MTP and extends the IP joints of the toes

Peroneus longus (TENDON)

1. Origin
• Upper 2/3 lateral surface of fibula

2. Insertion
• Base of 1st metatarsal and the medial cuneiform

3. Innervation
• Superficial peroneal nerve

4. Action
• Plantarflexes the ankle joint
• Everts the subtalar and transverse tarsal joints
• Supports the lateral longitudinal and transverse arches of the foot

Tibialis posterior (TENDON)

1. Origin
• Posterior surface of shafts of tibia and fibula, and interosseous membrane

2. Insertion
• Tuberosity of Navicular bone

3. Innervation
• Tibial nerve

4. Action
• Plantarflexes the ankle joint
• Inverts the subtalar and transverse tarsal joints
• Supports the medial longitudinal arch of the foot

INTRINSIC MUSCLE OF THE DORSUM OF FOOT

Extensor digitorum brevis

1. Origin
• Anterior part of the upper surface of the calcaneus
• Inferior extensor retinaculum

2. Insertion (with four tendons)

• Tendon #1 –base of proximal phalanx of big toe
• Tendon #2 –base of proximal phalanx of 2nd toe
• Tendon #3 –base of proximal phalanx of 3rd toe
• Tendon #4 –base of proximal phalanx of 4th toe

3. Innervation
• Terminal part of Deep peroneal nerve

4. Action
• Extends the 1st, 2nd, 3rd, and 4th toes at the interphalangeal and MTP joints

NERVE SUPPLY OF THE EXTRINSIC AND INTRINSIC MUSCLES OF THE

FOOT

ARTERIAL SUPPLY OF THE ANKLE AND FOOT

ANTERIOR TIBIAL ARTERY

• Smaller of the terminal branches of the Popliteal artery

• Accompanied by the Deep peroneal nerve
• Passes underneath the superior extensor retinaculum
• Becomes the Dorsalis pedis artery in front of the ankle joint

DORSALIS PEDIS ARTERY

• Begins in front of the ankle joint as a continuation of the Anterior tibial artery
• Joins the lateral plantar artery and completes the plantar arch
• Pulsations can be felt between the tendon of EHL and EDL tendons
• Branches of the Dorsalis pedis artery:
a. Lateral tarsal artery –crosses the dorsum of the foot just below the ankle joint
b. Arcuate artery –gives off metatarsal branches to the toes
c. First dorsal metatarsal artery –supplies both sides of the big toe

MEDIAL PLANTAR ARTERY

• Smaller of the terminal branches of the Posterior tibial artery

• Arises beneath the flexor retinaculum
• It ends by supplying the medial side of the big toe

LATERAL PLANTAR ARTERY

• Larger of the terminal branches of the Posterior tibial artery

• On reaching the base of the fifth metatarsal bone, the artery curves medially to
form the Plantar arch
• Joins the Dorsalis pedis artery
• The Plantar arch gives off plantar digital arteries to the adjacent sides of the
lateral four toes and the lateral side of the little toe

VENOUS DRAINAGE OF THE ANKLE AND FOOT

MEDIAL AND LATERAL PLANTAR VEIN

• Accompany the corresponding arteries

• They unite behind the medial malleolus to form the Posterior tibial venae
comitantes

DORSAL VENOUS ARCH OF THE FOOT

• A superficial vein that connects the Small saphenous vein and the Great
saphenous vein
• Anatomically, it is defined by where the dorsal veins of the first and fifth digit,
respectively, meet the Great saphenous vein and Small saphenous vein
• Lies superior to the metatarsal bones midway between the ankle joint and the
MTP joints

GREAT SAPHENOUS VEIN

• Drains the medial end of the dorsal venous arch of the foot
• Passes upward directly in front of the medial malleolus
• Ascends in company with the Saphenous nerve in the superficial fascia over the
medial side of the leg
• The vein passes behind the knee and curves forward around the medial side of the
thigh
• Goes to the saphenous opening and joins the Femoral vein
• Possesses numerous valves
• Connected to the Small saphenous vein by one or two branches that pass behind
the knee
SMALL SAPHENOUS VEIN

• Drains the lateral end of the dorsal venous arch of the foot
• Ascends behind the lateral malleolus in company with the Sural nerve
• Passes between the two heads of the Gastrocnemius muscle to end in the Popliteal
vein
• Has numerous valves along its course

SENSORY INNERVATIONS OF THE ANKLE AND FOOT

PERIPHERAL NERVE INJURIES

COMMON PERONEAL NERVE INJURY

• Sciatic nerve branch most liable to injury

• Site of injury at the level of fibular head
• Causes a foot drop deformity and an equinovarus deformity
• Both sensory and motor deficits

DEEP PERONEAL NERVE INJURY

• Presents with a foot drop deformity

• “Steppage gait”
• Sensory deficit dorsally between big toe and 2nd toe

SUPERFICIAL PERONEAL NERVE INJURY

• No total loss of eversion and plantarflexion

• Patient can still evert but weak
• Patient can still plantarflex with enough force since the Gastrocsoleus is still
intact
• Both motor and sensory deficits

TIBIAL NERVE INJURY

• Plantarflexion present but weak

• Toe flexion absent
• Atrophy of Gastrocsoleus
• Calcaneal gait, pes cavus deformity
• Inversion impaired but not completely lost
• Sensory loss over sole of foot
• Nerve involved in Tarsal tunnel syndrome

FOOT DEFORMITIES

TALIPES EQUINOVARUS (CLUB FOOT)

• Forefoot adduction, subtalar joint inversion, and ankle joint plantarflexion

• Cause of congenital club foot is unknown
• Associated with Edward’s syndrome, Breech presentation, Spina bifida cystica,
use of MDMA and smoking during pregnancy

PES PLANUS (FLAT FOOT)

• A condition in which the medial longitudinal arch is depressed or collapsed

• Forefoot is displaced laterally and everted
• Head of the talus is no longer supported and the body weight forces it downward
between the calcaneus and the navicular

PES CAVUS (CAVE FOOT/HIGH ARCH FOOT/CLAW FOOT)

• A condition in which the medial longitudinal arch is unduly high

• Most cases are due to muscle imbalances