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15 The Foot andAnkle
Forefood
Midfoot
Hindfoot
O
Fig. 15.3 Anatomic regions of the foot. (Reprinted from
Orthopedic Radiology, Weissman BNW & Sledge CB,
The Foot, p.628, Copyright Saunders (1985), with permission from Elsevier)
367
sesamoid bone within the peroneus longus at this
location referred to as an os peroneum. Three
cuneiform bones have distal articulations with
the rst, second, and third metatarsals and contribute to the formation of part of the tarsometatarsal or Lisfranc’s joint (Fig.15.5). The middle
cuneiform bone is shorter axially, adding to
greater stability in the second tarsometatarsal
joint. This is also known as the keystone.
The forefoot consists of the metatarsal and
phalangeal bones. Five metatarsals terminate distally with articulations to the proximal phalanges
creating metatarsal phalangeal (MTP) joints. The
fth metatarsal has a prominent styloid process
proximally to which the peroneus brevis attaches
dorsally, and the lateral band of the plantar fascia
attaches on the plantar aspect. Each of the lesser
toes, two through ve, has three phalanges—a
proximal, middle, and distal phalanx—and the
hallux has only two phalanges, proximal and distal. Each distal phalanx terminates in a tuft of
bone and serves as an anchor for the toe pad.
Underlying the rst MTP joint are the two sesamoid bones. Tibial (medial) and bular (lateral)
sesamoid bones are encased by the exor hallucis
a b
Talocalcaneo
navicular joint
Fig. 15.4 Photographic (a) and diagrammatic (b) anat-
omy of the normal ankle in tangential calcaneal (Harris)
projection. (Reprinted from Orthopedic Radiology,
Site of
talocalcaneal
ligament
Fifth
metatarsal
Sustentaculum tali
Weissman BNW & Sledge CB, The Foot, p. 628,
Copyright Saunders (1985), with permission from
Elsevier)
Subtalar joint
368
P. S. Cooper et al.
Fig. 15.5 Photographic,
diagrammatic, and
radiologic anatomy of
the normal foot in
posteroanterior (a, b)
and internal oblique
(c, d) projections.
(Reprinted from
Orthopedic Radiology,
Weissman BNW &
Sledge CB, The Foot,
p.626, Copyright
Saunders (1985), with
permission from
Elsevier)
a b
Phalanges
Metatarsals
Talus
C1
C2
Lisfranc's joint
Cuboid
Calcaneus
Cuneiform bones
Navicular
c d
Phalanges
Metatarsals
Cuneiform
bones
Navicular
C1
C2C3C3
Talus
brevis tendon (FHB) which inserts at the base of
the proximal phalanx and comprise the plantar
plate of the great toe.
Ligaments
The ligamentous structures of the ankle joint
(Fig. 15.6) include the medial deltoid ligament
complex and the lateral ankle ligament complex.
Cuboid
Calcaneus
The deltoid ligament medially has both supercial
and deep components and is the primary contributor to medial stability of the ankle joint. The supercial component is responsible for the majority of
the strength of the deltoid ligament. The lateral
ligament complex consists of three major ligaments including the anterior talobular ligament
(ATFL), the calcaneobular ligament (CFL), and
the posterior talobular ligament (PTFL). These
contribute to lateral stability of the ankle joint.
15 The Foot andAnkle
369
Posterior talofibular
ligament
Calcaneofibular
ligament
a
Lateral talocalcaneal ligament
Superficial deltoid ligament
Tibiocalcaneal ligament
Superficial tibiotalar ligament
Tibionavicular ligament
b
Anterior-inferior tibiofibular
ligament
Anterior talofibular ligament
Cervical ligament
Bifurcate ligament
Interosseous talocalcaneal ligament
Deep portion
deltoid ligament
Posterior tibionavicular
ligament
Spring ligament
Deltoid ligament
Inferior extensor
retinaculum
Deltoid ligament
Anterior-inferior talofibular ligament
Anterior talofibular ligament
Calcaneofibular ligament
Cervical ligament
Posterior inferior tibiofibular
ligament
Posterior talofibular ligament
Calcaneofibular ligament
d
c
Fig. 15.6 Ligaments of the foot and ankle seen from the
(a) lateral view of the foot and ankle, (b) medial view of
the foot and ankle, (c) anterior view of the ankle and hindfoot, and (d) posterior view of the ankle and hindfoot. Not
pictured are two components of the syndesmosis: the
interosseous membrane which runs between the bula and
tibia, and the inferior transverse ligament which is a pos-
Ligaments of the ankle syndesmosis include
the anterior tibiobular, posterior tibiobular,
and interosseous ligaments. Injuries to these ligaments may occur with hyperdorsiexion and
external rotation, creating a “high-ankle sprain”
which is seen especially in athletes. Ligamentous
support of the subtalar joint is contributed by the
CFL, the ligaments of the anterior capsule, the
posterior subtalar joint capsule, the interosseous
talocalcaneal ligaments, and the ligaments of the
tarsal canal. The midfoot joints are stabilized by
multiple ligaments as well as the intrinsic bony
architecture of the wedge-shaped cuneiform
bones. Little motion occurs through the midfoot.
Stabilizing ligaments include the bifurcate ligament and a V-shaped structure composed of the
terior structure running from the lateral malleolus across
the posterior border of the tibial plafond. (Reprinted from
DeLee, Drez & Miller’s Orthopaedic Sports Medicine,
Miller MD & Thompson SR, Ligamentous Injuries of the
Foot and Ankle, Rothenberg P, Swanton E, Molloy A,
Aiyer AA, Kaplan JR, p.1445, Copyright Elsevier (2020),
with permission from Elsevier)
lateral calcaneonavicular and medial calcaneocuboid ligaments. They insert on the anterior process of the calcaneus, navicular, and cuboid
bones, respectively. Supercial and deep plantar
ligaments span from the calcaneus to the cuboid
bone and metatarsals. These serve as static stabilizers of the longitudinal arch. Another important
structure is the plantar aponeurosis (or plantar
fascia). This thick brous structure runs from the
plantar surface of the calcaneus to distally insert
into the metatarsals. It stabilizes the arch during
gait (Fig. 15.7). There is no true transverse
interosseous ligament between the rst and second metatarsal bases. Instead, there is an oblique
plantar ligament that connects the rst cuneiform
bone to the second metatarsal. It is known as
370
P. S. Cooper et al.
Fig. 15.7 Plantar aponeurosis and windlass mechanism
provide stability to the longitudinal arch of the foot when
the rst metatarsophalangeal joint is forced into dorsiexion and it secondarily plantar exes the rst metatarsal.
Lisfranc’s ligament. Stabilizing the MTP joints is
a deep transverse metatarsal ligament as well as
medial and lateral collateral ligaments.
Muscles
The muscles of the leg are encased in four leg
compartments: the supercial and deep posterior
compartments, the lateral compartment, and the
anterior compartment. The supercial posterior
compartment includes the gastrocnemius, the
plantaris, and the soleus muscles. This compartment houses the main plantar exors of the ankle
(Fig.15.8) that are innervated by the tibial nerve.
The tendon bers of the soleus merge with the
gastrocnemius tendon bers to form the tendo
calcaneus or Achilles tendon. The Achilles tendon rotates 90° to insert on the posterior-superior
tuberosity of the calcaneus. The deep posterior
compartment contains three muscles which invert
the foot and serve as secondary plantar exors.
These muscles are the tibialis posterior muscle,
the exor digitorum longus (FDL) muscle, and
the exor hallucis longus muscle. The lateral
compartment, innervated by the supercial peroneal nerve, contains the peroneus longus and
(Reprinted from Orthopedic Clinics of North America,
20(4), Mann RA, The Great Toe, p.524, Copyright (1989),
with permission from Elsevier)
peroneus brevis muscles, the main evertors of the
foot. The deep peroneus longus muscle courses
distally underneath the cuboid to insert on the
base of the rst metatarsal and medial cuneiform
bone. The peroneus brevis inserts on the base of
the fth metatarsal. The anterior leg compartment contains the tibialis anterior, the extensor
hallucis longus (EHL), and the extensor digitorum longus (EDL) muscles. These muscles serve
as the primary dorsiexors of the ankle and foot.
These muscles are innervated by the deep peroneal nerve.
The intrinsic muscles of the foot are arranged
in four plantar layers and there is a single dorsal
muscle, the extensor digitorum brevis (EDB).
The EDB is innervated by the deep peroneal
nerve. The rst supercial layer of the intrinsic
plantar muscles includes the exor digitorum
brevis (FDB), the abductor hallucis, and the
abductor digiti minimi (ADM) muscles. The second layer contains the muscles for toe motion and
includes the quadratus plantae and lumbrical
muscles as well as the tendons of the FHL and
FDL.The third layer includes the exor hallucis
brevis, abductor hallucis, and the adductor hallu-
ab
15 The Foot andAnkle
Dorsiflexion
371
Tibial axis
Plantarflexion
Internal
cd
Eversion Inversion Adduction Abduction
Fig. 15.8 Motions of the foot and ankle. (a) Plantar ex-
ion and dorsiexion refer to movement of the foot down-
ward or upward. Supination and pronation refer to rotation
of the foot internally or externally around the longitudinal
axis of the foot. (b) Internal rotation and external rotation
of the foot refer to motion around the vertical axis of the
tibia. (c) Eversion directs the sole laterally, whereas inver-
cis (ADH) tendon. These muscles assist in rst
and fth toe function. The fourth and deepest
layer of intrinsic muscles contains the seven
interosseous muscles and the insertions of the
peroneus longus and anterior and posterior tibial
tendons. The interossei are divided into two
groups with four dorsal interossei and three plantar interossei. The dorsal interossei are involved
in toe adduction, and the plantar interossei are
involved in toe abduction.
sion refers to rotation of the foot until the sole is directed
medially. (d) Adduction and abduction describe motion of
the forefoot toward or away from the midline. (Reprinted
from Orthopedic Radiology, Weissman BNW & Sledge
CB, The Ankle, p.606, Copyright Saunders (1985), with
permission from Elsevier)
terminal branches of the sciatic nerve which arises
from the lumbosacral plexus. The common peroneal nerve from L5 branches into the supercial
peroneal nerve and deep peroneal nerve. The
supercial peroneal nerve courses through the lateral compartment and exits the lateral compartment approximately 10–15 cm above the lateral
malleolus through a fascial defect and continues
subcutaneously to provide sensory innervation of
the dorsal aspect of the foot and toes. The deep
peroneal nerve courses through the anterior com-
Nerves andVessels
The neurovascular structures of the foot and ankle
include ve major nerve branches and three arteries. The tibial and common peroneal nerves are
partment with the anterior tibial artery, continues
into the foot with the dorsalis pedis artery to provide innervation to the intrinsic foot muscles
including the EDB and EHB muscles, and termi-
External
Rotation
372
P. S. Cooper et al.
nates as a cutaneous nerve in the rst web space.
The tibial nerve, a branch of S1, travels through
the popliteal fossa into the deep posterior compartment. It courses medial to the Achilles tendon,
enters the tarsal tunnel just posterior to the medial
malleolus, and divides into the median and lateral
plantar nerves. The medial and lateral plantar
nerves supply motor and sensory function to the
plantar aspect of the foot. The sural nerve is a sensory branch of the tibial nerve and provides sensation to the posterolateral hindfoot and lateral
border of the foot. The saphenous nerve courses
along the anteromedial aspect of the lower limb
posterior to the greater saphenous vein and provides sensation to the medial side of the ankle.
Vascular supply to the foot and ankle is derived
from the anterior and posterior tibial arteries and
peroneal arteries. The anterior tibial artery becomes
the dorsalis pedis in the foot. The posterior tibial
artery divides into the medial plantar artery and lateral plantar artery to supply the plantar structures in
the foot. The peroneal artery branches from the
posterior tibial artery and travels posterior to the
interosseous membrane, deep to the FHL muscle,
terminating at the distal tibiobular joint.
The major structures of the venous system of
the leg include the greater saphenous vein and the
lesser saphenous vein. The greater saphenous
vein courses anteromedial to end in the femoral
vein. It drains the dorsum of the foot. The lesser
saphenous vein runs posterior to the bula and
drains the lateral foot and arch.
Gait Cycle
The gait cycle consists of one heel strike to the next
heel strike of the same foot. It is traditionally
divided into a stance phase that makes 62% of the
cycle and the swing phase that makes the remaining 38% of the cycle. At initial heel strike, the lower
extremity is in internal rotation. The ankle joint is
plantar exed, and the subtalar joint is everted. The
transverse tarsal joint is unlocked to allow shock
absorption. Anterior compartment muscles are
active in helping decelerate the limb. At foot at,
the lower extremity externally rotates, the ankle
joint dorsiexes, and the subtalar joint begins to
invert. This increases stability throughout the midfoot in anticipation of push- off. Anterior compartment muscles become inactive. Intrinsic muscles
of the foot become active, and the posterior compartment calf muscles are contracting. At preswing, the ankle joint is in plantar exion.
Clinical Evaluation oftheFoot
andtheAnkle
History andPhysical Examination
A complete medical and surgical history, the
mechanism of injury, and the duration of the
symptoms should be elicited. The location and
quality of pain should be documented. Existing
systemic disorders should be ruled out with an
emphasis on diabetes and gout. Musculoskeletal
history involving the spine and lower extremities
is helpful. A physical examination should be
done with both stockings and shoes removed.
Gait patterns should be determined, with the
patient walking both toward and away from the
examiner. The stance phase or station should be
examined with emphasis placed on the relationship of the hindfoot with the forefoot and longitudinal arch. Once inspection has been completed,
examination of the bony and soft tissue structures
follows. The area should be examined for the
presence of edema, effusion, skin temperature
changes, and previous sites of surgery or trauma.
Systemic examination can be divided into the
ankle, hindfoot, midfoot, and forefoot subgroups.
When examining the ankle, note any effusion.
Range of motion of the ankle is normally 20° of
dorsiexion and 40–50° of plantar exion. Loss
of ankle dorsiexion may be associated with a
tight Achilles tendon, posterior capsular contracture, or bony impingement. Limitation of dorsiexion with the knee in full extension that
improves passively with the knee exed to 90°
indicates a contracture of the gastrocnemius muscle. This is diagnosed clinically with the
Silfverskiöld test, where the examiner compares
ankle dorsiexion in knee full extension and 90°
exion. Ligamentous laxity should be evaluated
in comparison with the contralateral ankle joint
15 The Foot andAnkle
and palpation of the tendons should be performed
to note evidence of subluxation or dislocation.
Midfoot examination involves selective palpation
of the bony anatomy to isolate specic joint or
joint involvement. Forefoot examination should
include MTP joint motion with any documentation of subluxation and pain.
Pulses and sensation are vital to the evaluation. Both the dorsalis pedis and posterior tibial
artery should be documented for strength and
quality. Sensation evaluation should document
intact levels in all nerve distributions around the
foot, for pin, light touch, and vibratory. In addition, the Semmes–Weinstein monolament test is
applied in the diabetic patient to quantitate protective sensation. A failed test at the 5.07 level
indicates a loss of sensation and signies a risk
for skin ulceration.
Radiology oftheFoot andAnkle
373
Radiographic studies of the foot and ankle require
weight-bearing X-rays when possible. Important
views involve the anteroposterior (AP), lateral,
and oblique views of the foot and AP, lateral, and
mortise views of the ankle. The AP view of the
foot can be used to assess forefoot and midfoot
pathology. The lateral view of the foot shows the
relationship of the talus and calcaneus to that of
the midfoot, forefoot, and ankle joint. The medial
oblique view is used to evaluate the lateral tarsometatarsal joints. Other studies are available to
assess the sesamoids, the calcaneus, or the subtalar joint. The sesamoid view involves the X-ray
beam directed tangential to the plantar surface of
the sesamoid region, while the patient’s toes are
in hyperextension. Harris axial heel view is used
to assess the calcaneal tuberosity and is important in calcaneus fractures or tarsal coalitions.
Ancillary radiographic studies include computed
tomography (CT) (Fig. 15.9), magnetic resonance imaging (MRI), and radionuclide studies.
MRI can be used to assess soft tissue structures
such as soft tissue tumors, osteomyelitis, avascular necrosis, bone tumors, chondral lesions, ligamentous injuries, and tendon abnormalities. CT
is best to assess bone abnormalities including
Fig. 15.9 Normal hindfoot and ankle anatomy seen on
computed tomography (CT) scan
sequestrum and nonunions. Weight-bearing CT
scanners now allow evaluation of complex
pathology of the bones and joints of the foot and
ankle in three dimensions with the foot in a position of function.
Diseases oftheFoot andAnkle
This overview of the pathologic states that affect
the foot and the ankle is discussed by diagnostic
category. This is not meant to be an exhaustive
catalog of every afiction but rather a
representative sampling of the more common disease states that mandate medical care.
Trauma
Ankle
Injuries of the ankle mortise include pilon
fractures, ankle fractures, and syndesmotic
injuries.
374
ac
P. S. Cooper et al.
Pilon Fractures
Pilon fractures involve the intraarticular fractures
of the tibial metaphysis which extend to the
weight-bearing portion of the tibia (Fig.15.10).
There is often extensive comminution. Nondisplaced pilon fractures may be treated nonoperatively with immobilization in a cast; however,
since these are often displaced injuries, treatment
consists of some type of operative xation. Initially and temporarily, an ankle-spanning external xator may be applied to maintain length and
ankle joint reduction until soft tissue swelling
subsides within 1–2 weeks. At that point, open
reduction and internal xation using screws and a
plate can be done. In high-energy injuries with
soft tissue compromise, external xation may be
the denitive treatment.
Ankle Fractures
Ankle fractures are discussed in the trauma
chapter.
Syndesmosis Injuries
With disruption of the syndesmotic ligaments, a
diastasis, or separation, of the distal tibia and
bula can occur (Fig.15.11). This injury is often
associated with higher grades of ankle fractures
when medial stability is compromised by a
medial malleolar fracture or a deltoid tear. Denitive diagnosis of a syndesmotic injury can be
made with stress X-rays which show a diastasis
at the distal tibial and bular joint. If this exists,
reduction and stabilization of the syndesmosis
are achieved with screw placement, or exible
xation, across the tibial and bular joint or tibial
and bular syndesmosis. The transsyndesmotic
screw should remain in place for a minimum of
12–16weeks and is then removed, most exible
xation techniques no longer require subsequent
removal.
Fractures totheHindfoot
Fractures of the hindfoot involve the calcaneus,
talus, and navicular bones.
Talus Fractures
The talus articulates with the ankle, calcaneus,
and navicular bones and is covered by articular
cartilage on 60% of its surface (Fig.15.12). Since
the majority of the talus is covered by articular
b
Fig. 15.10 (a) AP, (b) mortise, and (c) lateral radiographs showing a pilon fracture with involvement of the distal third
tibial shaft. The fracture line extends into the tibial plafond (arrow) making it a pilon fracture
tubercle
ension
Superior
15 The Foot andAnkle
ab c
375
Fig. 15.11 (a) AP, (b) mortise, and (c) lateral radio-
graphs showing syndesmotic injury with a mid-shaft bula and medial malleolus avulsion fractures (red arrows).
Fig. 15.12 Important
anatomic structures of
Medial
the talus. (Reprinted
from Orthopedic Clinics
of North America, 20(4),
Adelaar RS, The
treatment of complex
fractures of the talus,
p.692, Copyright
Saunders (1989), with
permission from
Elsevier)
Lateral process
Tubercle for
insertion of
deltoid lig.
Lateral
Notice the increased medial clear space widening (white
line) and decreased tibia-bula overlap (white arrow) on
the (a) AP and (b) mortise radiographs
Articular surface
for medial malleolus
Posteromedial
tubercle
Articular surface
for lateral malleolus
Anteromedial ext
of trochlear surface
Trochlear surface
lateral process
Inferior
Anterior calcaneal
articular surface
Middle calcaneal
articular surface
Posterior calcaneal
articular facet
Posteromedial
Posterior
Posterolateral
tubercle
Canal for
flexor hallucis
longus tendon
Posterior calcaneal
articular surface
376
Dorsalis
Ta
sinus brs.
s.
Posterior
P. S. Cooper et al.
cartilage and there are no muscle or tendinous
attachments, there is limited space for blood vessels to enter this bone, making the blood supply
tenuous. The blood supply enters the talus at the
neck and travels retrograde into the body and the
dome (Fig.15.13). Fractures of the talus, depending upon the severity, can often disrupt this blood
supply. Fractures of the talus typically occur
through the neck and result from an acute dorsiexion injury. Standard radiographs with CT
scans are usually adequate to demonstrate the
nature of the fracture. Treatment is tailored to
restore normal talar anatomy. If nondisplaced,
conservative nonsurgical treatment with cast
immobilization can be used. If displaced, often
anatomic reduction and rigid xation is the best
pedis a.
rsal
Fig. 15.13 Extraosseous and intraosseous circulation of
the talus. (Reprinted from Orthopedic Clinics of North
America, 20(4), Adelaar RS, The treatment of complex
fractures of the talus, p.693, Copyright Saunders (1989),
with permission from Elsevier)
Deltoid br.
tibial a.
Posterior
tubercle br
approach. This is done in an effort to prevent
avascular necrosis which can result as a disruption of the tenuous blood supply. Hawkins’ classication of talar neck fractures categorizes these
fractures into three patterns (Fig.15.14): Type I is
a nondisplaced fracture of the neck, type II is a
displacement of the neck fracture with subluxation or dislocation of the talar body from the
subtalar joint, and type III is a neck displacement
fracture with subluxation or dislocation of the
body from both the ankle and the subtalar joints.
A fourth pattern, which has been described,
involves a displaced neck fracture which includes
dislocation of the talonavicular joint. The incidence of avascular necrosis increases signicantly with each increase in type. Radiographic
signs of intact vascularity of the talus are demonstrated by the crescent or “Hawkins” sign at
8–10weeks out from injury.
Calcaneus Fractures
The calcaneus is the most commonly fractured
tarsal bone. Fractures are classied as intraarticular or extraarticular (Figs. 15.15 and 15.16).
Calcaneus fractures are often seen when an axial
load is applied to the foot, resulting from falls or
motor vehicle accidents. Patients typically present with severe pain and swelling. Radiographs
including the axial heel view in addition to CT
scanning can fully dene the injury. Closed treat-
ab c
Fig. 15.14 Classication of talus neck fractures: (a)
Class I, (b) class II, (c) class III. (Modied from Journal
of Bone and Joint Surgery, 52A, Fractures of the neck of
the talus, Hawkins LG, p.991–1002, 1970; and reprinted
from Orthopedic Clinics of North America, 20(4), Adelaar
RS, The treatment of complex fractures of the talus,
p.696, Copyright Saunders (1989), with permission from
Elsevier)