Kinesiology of ankle

joint

2016

Presented by :

DR. ASER Mohamed kamal

Physical therapist / cairo university

DOCTOR OF EGYPTIAN TEAM OF HANDBALL

ANKLE JOINT

Ankle-FOOT COMPLEX

The ankle-foot complex is structurally analogues to the wrist-hand complex of

the upper extremity.

The ankle-foot complex must meet the stability and mobility demands.

Stability demands-

1. Providing a stable base of support for the body in a variety of weight bearing

postures without undue muscular activity and energy expenditure.

2. Acting as a lever for effective push-off during gait.

Mobility demands-

1. Dampening of rotations imposed by more proximal joints of LL.

2. Being flexible enough as a shock absorber

3. Permitting the foot to conform to the changing and varied terrain on which foot

is placed.

The ankle and foot meet its requirements

through

28 bones

25 joints.

These include:

1. proximal and distal tibiofibular joints

2. Talo-crural or ankle joint

3. Talocalcaneal or subtalar joint

4. Talonavicular joint

5. Calcaneocuboid joint

6. 5 tarso-metatarsal joints

7. 5 metatarso-phalangeal joints

8. 9 inter-phalangeal joints

The bones of the foot are traditionally

divided into 3 functional segments :

• HIND OR REAR FOOT-posterior

segment composed of talus and

calcaneus

• MID FOOT-middle segment composed

of navicular ,cuboid, 3 cuneiforms

• FOREFOOT-anterior segment composed of metatarsals and phalanges.

ANKLE JOINT

The term ankle specifically refers to :

• Talocrural joint-The formation of the mortise (a hole)

by the medial malleoli (Tibia) and lateral malleoli

(fibula) with the talus lying in between them makes

up the talocrural joint.

• The ankle is a synovial Hinge joint with joint capsule

and associated ligaments.

• It is generally considered to have a single oblique axis

with 1°of freedom.

PROXIMAL ARTICULAR STRUCTURE

• The proximal segment of ankle is composed of concave surface of distal tibia

and of tibial and fibular malleoli.

• The structure of distal tibia and the two malleoli is referred to as a MORITSE.

• The mortise of the ankle is adjustable, relying on the proximal and distal

tibio-fibular joints.

PROXIMAL TIBIO-FIBULAR JOINT

• It is a plane synovial joint formed by articulation of

head of fibula with the postero-lateral aspect of

tibia.

• Although facets are flat, a slight convexity of tibial

facet and slight concavity of fibula is predominant.

• Each proximal tibiofibular joint is surrounded by a

joint capsule that is reinforced by anterior and

posterior tibiofibular ligaments.

DISTAL TIBIOFIBULAR JOINT

• It is a syndesmosis or fibrous union.

• It is in between the concave facet of tibia and convex facet of

fibula.

• Tibia and fibula do not come into contact with each other at

this point but are separated by fibro-adipose tissue.

• The ligaments of distal tibio-fibular joint are primarily

responsible for maintaining a stable mortise.

Tibia Fibula

<<<Talocrural joint Talus

Bony landmark:

Tibia: 1. Medial condyle – on proximal end of tibia, medial aspect. 2. Tibial tuberosity – on proximal end, anterior aspect just below patella. (insertion for quadriceps tendon) 3. Tibial spine – “Shin bone” - anterior ridge along tibia. 4. Medial malleolus – large protuberance on medial aspect of ankle. 5. Tibial plateau 6. Lateral condyle 7. Shaft Fibula: 1. Head – Move distally and posteriorly from lateral femoral condyle. 2. Lateral malleolus – Large protuberance on lateral aspect of ankle. 3. Shaft 4. Styloid process Tarsals: 1. Calcaneus – heel bone. 2. Naviculr tubercle – On medial border of foot, large bony prominence. 3. Head of the Talus– Just proximal to navicular tubercle, especially palpable in eversion. 4. Sustentaculum tali – Located between the head of the Talus and the medial malleolus.Feels like a small ridge. 5. Peroneal tubercle of the calcaneus – On lateral aspect of foot just distal to lateral malleolus. 6. Medial tubercle of calcaneus – lies on the medial plantar surface of the calcaneus (not usually sharp or distinct unless itis associated with a heel spur.

Ligaments (lateral)

Lateral ligament It consists of 3

bands

Anterior talofibular ligament

Posterior talofibular

ligament

Calcaneofibular ligament

Distal articular surface

TALUS

3 Articular Surfaces

• Larger lateral facet-triangular shaped

• Smaller medial facet-comma shaped

• Superior facet- TROCHLEAR

Ligaments (medial)

• Fibrous capsule

• Deltoid or medial ligament- strong triangular

Superficial part

Deep part

Superficial part-

Deep Part

It is also called as Anterior tibio-talar ligament.

Attached to the anterior part of medial surface of talus.

ANTERIOR TIBIONAVICULAR

MIDDLE TIBIOCALCANEAN

POSTERIOR TIBIOTALAR

Ankle joint function:

• The primary ankle motion of dorsi-flexion and plantar-flexion occurs around

an oblique axis that causes the foot to move across all 3 planes. AXIS

• In neutral position of the ankle, the joint axis passes approximately through

the fibular malleolus and the body of the talus and through or just below the

tibial malleolus and posteriorly.

• Supination = PF + Adduction + Inversion

• Pronation = DF + Abduction + Eversion

• The distal tibia is twisted laterally compared with its proximal

portion accounting for toe-out position of the foot in normal

standing.

• The axis of angle is considered to be rotated laterally 20°-30°

in the transverse plane and inclined 10° down on the lateral

side.

Talar

rotation(7°

med and 10°

lat rotation)

Abduction-

adduction

Transverse

plane

Vertical axis

Talar

tilt(5°)

Inversion-

eversion

Frontal

plane

Anteroposterior

axis

Dorsiflexion-

plantar flexion

Antero-

posterior plane

Frontal axis

ARTHROKINEMATICS

• The shape of the body of talus is complex.

• The trochlea is wider anteriorly than posteriorly.

• The lateral (fibular) facet is substantially larger than the medial (tibial) facet

and its surface is oriented slightly obliquely to that of medial facet.

• This resembles a truncated cone.

• This causes greater displacement of fibular malleolus on lateral facet of talus

than the tibial on medial facet.

• The greater excursion of the lateral malleollus results in the imposition of

motion on the fibula in several directions through the ankle ROM.

• This motion is found to be small in magnitude and variable in direction

among individuals and with different loading conditions.

• This is related to the orientation of the proximal tibiofibular facet,with more

mobility available in those facets that are more vertical.

• It may depend on the tibiofibular ligamentous elasticity.

Dorsiflexion

1. Tibialis anterior

2. Extensor digitorum longus

3. Peroneus longus

4. Peroneus brevis

5. peroneus tertius (usually very close to extensor digitorum longus and often

considered as part of this muscle)

6. extensor halluces Longus (deep to ext. Digitorum longus)

Tibialis Anterior

Origin: Lateral condyle and proximal half to two-thirds of the lateral

surface of the tibial shaft, the adjoining anterior surface of the

interosseous membrane and the intermuscular septum between it and the

extensor digitorum longus.

Insertion: Inferomedial aspect of the medial cuneiform and base of the

first metatarsal.

Action: Inverts and adducts the free foot, assists in plantar flexion.

Prevents excessive pronation of the foot during walking.

Innervation: Deep Peroneal nerve (L4 – 5 )

Extensor Digitorum Longus

Origin: Lateral condyle of the tibia, the proximal two-

thirds of the medial surface of the fibula, the adjacent

anterior surface of the interosseous membrane, the

anterior intermuscular septum, and the septum

between it and tibialis anterior.

Insertion: Divides into four slips and inserts at the base

of each of the lateral four proximal phalanges. Each

tendon then divides into three slips: an intermediate

slip which attaches to the base of the middle phalanx,

and two collateral slips which attach to the base of the

distal phalanx.

Action: Extension of the four lateral toes, assists with dorsiflexion of the foot

at the ankle.

Innervation: Deep Peroneal nerve (L5 – S1 )

Peroneus Longus Muscle

Origin: Head and proximal two-thirds of the lateral surface of the

fibula, and the anterior and posterior intermuscular septa of the

leg. Insertion: Passing behind the lateral malleolus, running obliquely

across the sole of the foot from lateral to medial, and ending on

the base of the first metatarsal and the medial cuneiform bones

Action: Eversion of the foot at the subtalar joint Innervation: Superficial Peroneal Nerve (L5, S1)

Peroneus Brevis Muscle

Origin: Distal two-thirds of the lateral surface of the

fibula, and the anterior and posterior intermuscular

septa

Insertion: Tubercle on the base of the lateral aspect of

the fifth metatarsal.

Action: Eversion of the foot at the subtalar joint

Innervation: Superficial Peroneal Nerve (L5, S1)

Peroneus Tertius

Origin: Distal third or more of the anterior surface of the fibula, the

adjoining anterior surface of the interosseous membrane and the

anterior intermuscular septum

Insertion: Inserts into the medial part of the dorsal surface of the base

of the fifth metatarsal and usually sends an expansion along the medial

border of the shaft the metatarsal

Action: Assists with dorsiflexion of the foot at the ankle

Innervation: Deep Peroneal (L5, S1)

Extensor Hallucis Longus Muscle

• Origin: Middle half of the medial surface of the fibula, medial to extensor digitorum longus, and adjacent anterior surface of the interosseous membrane

• Insertion: Dorsal aspect of the base of the distal phalanx of the great toe

• Action: Extension of the great toe, assists with dorsiflexion of the foot at the ankle.

• Innervation: Deep Peroneal nerve (L5 – S1-2 )

Plantar Flexors

1. Calf muscle (gastrocnemius and soleus)

2. Flexor hallucis longus

3. Flexor digitorum longus

4. Tibialis posterior

5. Plantaris

Gastrocnemius Muscle

Origin: Medial head: the depression at the upper and posterior part of the medial condyle of the femur and continuing behind the adductor tubercle to a slightly raised area on the popliteal surface of the femur, just above the medial condyle. Lateral head: area on the lateral surface of the lateral condyle of the femur and to the lower part of the corresponding supracondylar line.

Insertion: Receives the tendon of soleus on its deep surface to form the Achilles tendon to attach to the middle of three facets on the posterior surface of the calcaneus

Action: Plantarflexion of the foot at the ankle, assists with flexion of the leg at the knee.

Innervation: Tibial nerve S1-2

Soleus

Origin: Posterior surface of the head and proximal quarter of

the shaft of the fibula, spanning over to the soleal line and the

middle third of the medial border of the tibia, and a fibrous

band, which arches over the popliteal vessels and tibial nerve,

between the tibia and fibula

Insertion: Joins with the tendon of the gastrocnemius to form

the tendo calcaneus to attach to the middle of three facets on

the posterior surface of the calcaneus. The muscle is covered

proximally by gastrocnemius and is accessible on both sides.

Actions: Plantarflexion of the foot at the ankle

Innervation: Tibial nerve (S1 – 2 )

Flexor Hallucis Longus

Origin: Distal two-thirds of the posterior surfaces of

the fibula, the adjacent interosseus membrane, the

posterior intermuscular septum, and the lateral part of

the fascia covering tibialis posterior

Insertion: Plantar aspect of the base of the distal

phalanx of the great toe after traveling between the

two sesamoids associated with the first metatarsal

head.

Action: Flexion of the great toe, assists with

plantarflexion of the foot at the ankle.

Innervation: Tibial nerve (L5 – S1-2 )

Flexor Digitorum Longus

Origin: Posterior surface of the tibia, just below the soleal line to within

7 or 8 cm of the distal end of the bone, and to the medial part of the

fascia covering the tibialis posterior

Insertion: Plantar surfaces of the bases of the distal phalanges of the

four lateral toes

Action: Flexion of the four lateral toes, assists with plantarflexion of the

foot at the ankle.

Innervation: Tibial nerve (L5 – S1-2 )

Tibialis Posterior Origin: Proximal two-thirds of the posterior surfaces of the tibia and the

fibula and the interosseus membrane.

Insertion: Passing behind the medial malleolus to attach to the bones

that form the arch of the foot: the navicular, each cuneiform and cuboid

the calcaneus and metatarsals 2,3,4

Action: Inverts and adducts the free foot, assists in plantar flexion.

Prevents excessive pronation of the foot during walking.

Innervation: Tibial nerve (L4 – 5 )

Plantaris Origin: Lateral supracondylar ridge of the femur above the lateral head of

the gastrocnemius.

Insertion: Medial aspect of the posterior surface of the calcaneus, medial to

the Achilles tendon.

Action: Assists with flexion of the knee. Assist with plantarflexion of the foot

at the ankle

Innervation: Tibial Nerve (S1,2)

Invertors

A- Primary:

1- tibialis anterior

2- tibialis posterior

B- secondary :

1- extensor halluces Longus

2- Flexor digitorum longus

3- Flexor hallucis longus

Evertors

A- Primary:

1- Peroneus longus

2- Peroneus brevis

B- secondary :

1- peroneus tertius

2- Extensor digitorum long

Subtalar joint

• The talocalcaneal or subtalar joint is a composite

joint formed by three separate plane articulations

between the talus superiorly and calcaneus

inferiorly.

• Provides a triplanar movement around a single

joint axis.

• Articulations:

posterior talocalcaneal articulations-Largest

concave facet-undersurface of body of talus

convex facet- calcaneus

• Anterior and medial talocalcaneal articulations

Convex facet- Inferior body and neck of talus respectively

Concave facet-calcaneus

• Between the posterior articulation and anterior,middle articulation a bony

tunnel is present formed by a sulcus(concave groove) in the inferior talus and

superior calcaneus.

• This funnel shaped tunnel is called TARSAL CANAL

TARSAL CANAL

Larger end- SINUS TARSI-lies anterior to fibular malleolussmaller end- lies posterior

to the tibial malleolus. And above a bony out cropping on calcaneus is called

SUSTENTACULUM TALI

Posterior articulation has its own capsule

Anterior and middle articulations share a capsule with the talonavicular joint.

Ligaments

• Cervical ligament- strongest

• Interosseus talocalcaneal ligament

1- anterior band

2- posterior band

• Others-

1- Calcaneofibular lig

2- lateral talocalcaneal lig

3- Inferior extensor retinaculum –provides

subtalar support

4- Cervical,interosseus,collaterals-talocalcaneal stability

• Allow pronation/supination and rotation.

• The talus articulates with the calcaneus anteriorly, posteriorly and

medially.

• The axis of rotation runs diagonally from the posterior, lateral, plantar

surface to the anterior, medial, dorsal surface.

• The orientation of this axis makes pronation/supination triplanar with

reference to the cardinal planes.

COMPONENT MOVEMENTS

Tibial Rotation

• The subtalar joint can be likened to the action of a mitered hinge

(Inman and Mann, 1973).

• The orientation of the subtalar joint axis causes the tibia to

internally rotate during pronation and externally rotate during

supination.

• Thus, the tibia internally rotates with pronation or knee flexion and

externally rotates with supination or knee extension.

• It is important that knee flexion and pronation occur in

synchronization (as well as knee-extension and supination).

NON- WT BEARING WT-BEARING

SUPINATION CALCANEAL

INVERSION(VALGUS)

CALCANEAL

INVERSION(VARUS)

CALCANEAL

ADDUCTION

TALAR ABDUCTION

(LATERAL

ROTATION)

CALCANEAL

PLANTAR FLEXION

TALAR

DORSI-FLEXION

TIBIOFIBULAR LAT

ROT

NON-WT BEARING WT-BEARING

PRONATION CALCANEAL

EVERSION(VALGUS)

CALCANEAL

EVERSION(VALGUS)

CALCANEAL

ABDUCTION

TALAR ADDUCTION

(MEDIAL ROT)

CALCANEAL DORSI-

FLEXION

TALAR PLANTAR-

FLEXION

TIBIO-FIBULAR

MEDIAL ROTATION

• CLOSED PACKED POSITION:- FULL SUPINATION

• POSITION OF RELATIVE MOBILITY: – PRONATION

Transverse tarsal joint

• The transverse tarsal joint, also called the midtarsal or Chopart joint

It is a compound joint formed by the talonavicular and calcaneocuboid

joints .

• The two joints together present an S-shaped joint line that transects

the foot horizontally, dividing the hindfoot from the midfoot and

forefoot.

• The navicular and the cuboid bones are considered, immobile in the

weight-bearing foot.

Talonavicular joint

• The proximal portion of the talonavicular articulation is formed by the

anterior portion of the head of the talus, and the distal portion of the

articulation, by the concave posterior aspect of the navicular bone.

• A single joint capsule encompasses the talonavicular joint facets and the

anterior and medial facets of the subtalar joint.

Ligaments

• Inferior aspect of the joint capsule-plantar

calcaneo-navicular lig/spring lig

• Medially- deltoid lig

• Laterally-bifurcate lig

Calcaneo-cuboid joint

• The calcaneo-cuboid joint is formed proximally by the anterior calcaneus and

distally by the posterior cuboid bone

• The calcaneocuboid articulation has its own capsule that is reinforced by

several important ligaments.

The capsule is reinforced

• Laterally - lateral band of the bifurcate ligament (also known as the

calcaneocuboid ligament)

• Dorsally –dorsal calcaneocuboid ligament,

• Inferiorly -plantar calcaneocuboid (short plantar) and the long plantar

ligaments

Midtarsal Joint

• During pronation, the axes of these two joints are

parallel, this unlocks the joint and creates a

hypermobile foot that can absorb shock.

• During supination the axes are not parallel and this

joint becomes locked allowing efficient transmission

of forces.

• Actually consists of two joints: the calcaneocuboid

on the lateral side and the talonavicular on the

medial side.

Tarsal transverse joint axis

• The transverse joint is considered to have two axis around which the talus

and calcaneus moves on the relatively fixed naviculo-cubiod unit.

1- LONGUTUDINAL AXIS

2- OBLIQUE AXIS

Longitudinal axis-

• Motion around this axis is triplanar producing supinaion /pronation with

coupled components similar to those seen in subtalar joint.

• It approaches a true A-P axis producing inversion and eversion component

predominate.

Oblique axis

• This triplanar axis also provides supination/pronation with coupled

component movements of the talus and calcaneus segments moving

together on the navicular and cuboid bones.

• The dorsiflexion/plantarflexion and abduction/adduction components

predominate over inversion/eversion motions.

• Motions about the longitudinal and oblique axes are difficult to separate and

quantify.

• The longitudinal axis of the transverse tarsal joint

• Inclined 15° superiorly from the transverse plane

• Inclined 9° medially from the sagittal plane.

Oblique axis

• This triplanar axis also provides supination/pronation with

coupled component movements of the talus and calcaneus

segments moving together on the navicular and cuboid bones.

• The dorsiflexion/plantarflexion and abduction/adduction

components predominate over inversion/eversion motions.

• Motions about the longitudinal and oblique axes are difficult to

separate and quantify.

• The oblique axis of the transverse tarsal joint .

• Inclined 57° from the sagittal plane

• Inclined 52°superiorly from the transverse plane.

15°

9°

57°

52°

TRANSVERSE TARSAL JOINT FUNCTION

• Any weight-bearing subtalar motion includes talar abduction/adduction-

dorsiflexion/plantarflexion that also causes motion at the talonavicular

joint

• calcaneal inversion/eversion that causes motion at the calcaneocuboid joint.

• As the subtalar joint supinates, its linkage to the transverse tarsal joint causes

both the talonavicular joint and the calcaneocuboid joint to begin to supinate

also.(CLOSE PACKED POSITION)

• When the subtalar joint is pronated and loose-packed, the transverse tarsal

joint is also mobile and LOOSE PACKED .

• The transverse tarsal joint is the transitional link between the hindfoot and

the forefoot, serving to

(1)add to the supination/pronation range of the subtalar joint and

(2) compensate the forefoot for hindfoot

position.

• Weight-Bearing Hindfoot Pronation and Transverse Tarsal Joint Motion

In the weight-bearing position, medial rotation of the tibia

for example-pivoting on a fixed foot

• Weight-Bearing Hindfoot Supination and

Transverse Tarsal Joint Motion

• A lateral rotatory force on the leg will create

• subtalar supination in the weight-bearing subtalar joint with a relative

pronation of the transverse tarsal joint (opposite motion of the forefoot

segment) to maintain appropriate

• weight-bearing on a level surface Supination of the subtalar joint, however,

can proceed to only a certain point before the transverse

• tarsal joint also begins to supinate.

PRONATION

With pronation occurring at the subtalar joint through medial rotation of the

leg, the transverse tarsal joint is free to

(A) supinate slightly to maintain the relatively fixed position of the forefoot

segment;

(B) pronate slightly as occurs in normal standing; or

(C) supinate substantially to maintain appropriate weight-bearing of the forefoot

segment on uneven terrain

SUPINATION

With supination occurring at the subtalar joint through lateral rotation of the

leg, the transverse tarsal joint has limited ability to pronate to maintain the

relatively fixed position of the forefoot segment

(A) will begin to supinate with a greater range of subtalarsupination and

lateral rotation of the leg

(B) or will fully supinate along with a fully supinated subtalar joint and

maximal lateral rotation of the superimposed leg .

TARSOMETATARSAL JOINTS

• The tarsometatarsal TMT joints are plane synovial joints formed by the distal

row of tarsal bones (posteriorly) and the bases of the metatarsals.

• LIGAMENT

Deep transverse metatarsal ligament

• This spans the heads of the metatarsals on the plantar surface and is similar

to that found in the hand.

• Contribute to stability of proximal located TMT joints by preventing excessive

motion and splaying of metatarsal heads.

Axis

• A ray is defined as a functional unit formed by a metatarsal and (for the first

through third rays) its associated cuneiform bone.

• The cuneiform bones are included as parts of the movement units of the

TMT rays because of the small and relatively insignificant amount of motion

occuring at the cuneonavicular joints.

• The axis of the first ray is inclined in such as way that dorsiflexion of the first

ray also includes inversion and adduction, whereas plantarflexion is

accompanied by eversion and abduction.

• The abduction/adduction components normally are minimal.

• Movements of the fifth ray around its axis are more restricted and occur

with the opposite arrangement of components.

• Dorsiflexion is accompanied by eversion and abduction, and

plantarflexion is accompanied

*by inversion and adduction.

• The axis for the third ray nearly coincides with a coronal axis; the

predominant motion, therefore, is dorsiflexion/plantarflexion.

• The axes for the second and fourth rays were not determined

FUNCTION

• In weightbearing,the TMT joints function primarily to augment the function

of the transverse tarsal joint; that is, the TMT joints attempt to regulate

position of the metatarsals and phalanges (the forefoot) in relation to the

weight-bearing surface.

SUPINATION TWIST

• When the hind foot pronates substantially in wt-bearing position.

• The TTJ Joint counter acts the forefoot to keep the plantar aspect of the foot

in contact with the ground.

• TMT –medial forefoor will press the ground

lateral foot will lift off the ground

1st and 2nd ray -dorsiflexion

4th and 5th ray-plantarflexion

• the entire forefoot undergoes an inversion rotation around a hypothetical

axis at the second ray.

• PRONATION TWIST

• When the hind foot and TTJ are locked in supination ,the adjustment of

forefoot position will be left entirely to TMT Joints.

• TMT-forefoot medial –lift off the ground

• lateral-press to the ground

1st and 2nd-plantarflex

4th and 5th –dorsiflexion

• Eversion accompanies

Arches

• Needed for traction between the floor & foot’s wt bearing structures.

• Tensed throughout stance phase.

• Compared to a tie rod.

• Plantar plates of mtp resist compressive & tensile forces transferred through

plantar aponeurosis.

• In toe extension- mt heads act as pulleys that pull this fascia– supination.