:Introduction

The ankle is a modified hinge joint. It plays a key role in

transferring the forces from the foot to the leg. The ankle joint
is made up of three bones, which are connected by ligaments,
muscles and tendons. A strong ligament joins the ends of the
tibia and fibula to form the ankle "mortis". The "dome" of the
talus (the highest bone of the foot) fits inside the ankle mortis
to form the ankle joint. The ankle allows movement in only one
plane. It allows the foot to move upwards (dorsiflexion) and
) .downwards (plantar flexion

The foot is made up of 26 bones. There are numerous joints

between these bones that allow the foot to be both a rigid lever
and a shock absorber. The largest joint in the foot is the
subtalar joint. Inward movement of the foot (inversion), and
outward movement of the foot (eversion) occur primarily at the
.subtalar joint
:Talus

Talus is an intercalated segment .

60%articular surface.
No muscle or tendon Insertions.
:Calcaneus

© 3facets .
©Various angles .
©Articulations with talus fibular and
cuboid.
©Tarsal sinus / canal .
:Subtalar joint

$ Allows eversion / inversion .

$Hindfoot position locks and unlocks the
midfoot.
$3facets .
:ROM
The normal end ranges of motion for the
foot and ankle vary between
individuals and between children and adults.
The following are approximate end ranges
:of motion for adults
Dorsiflexion - 20 degrees
Plantar flexion - 60 degrees
Eversion - 15 degrees
Inversion - 35 degrees
 :The Gait
The gait cycle (walk cycle) describes what happens to the
foot and ankle from the point of initial contact of one foot
with the ground to the point at which the same foot
contacts the ground again. The gait cycle is divided into the
swing phase and the stance phase. During the swing phase
the foot is not in contact with the ground. As the name
implies it is the phase of the gait cycle in which the foot
swings forward to take another step. During the stance
phase the foot is in contact with the ground. The stance
phase of the gait cycle can also be divided into three
stages. The first stage is called heel strike, the second
stage is called mid-stance, and heel lift is the final stage.
The biomechanics of the foot are best explained by
describing what happens to the foot during the stance
. phase of the gait cycle
During heel strike of the stance phase the foot begins to pronate.
Pronation of the foot is the term that describes the rolling motion
of the foot inwards and flattening of the inner (medial) arch of the
foot. Pronation allows the foot to adapt to uneven terrain and
absorb the impact of the foot striking the ground. It is during this
.phase that the foot begins to act like a shock absorber
During midstance the entire foot is in contact with the ground and
the weight of the body is directly over the foot. It is during this
phase that the foot is maximally pronated. The foot acts as a
shock absorber during the early part of this phase. As the body
weight shifts forward the foot begins to return to a neutral
.position in preparation for heel lift
:Heel strike

Tib ant contracts eccentrically

STJ everts and aligns (unlocks) the
midtarsal joints
Allows foot to pronate and accommodate
to absorb energy of heelstrike
Tibia internally rotates
Toe-off:

oTib post inverts hindfoot and locks

midfoot
oFoot more rigid for toe-off
oAs toes dorsiflex, plantar aponeurosis
tightens
Heel lift occurs at the end of the stance phase. Supination of the
foot is the term used to describe the rolling motion of the foot
outwards and the rising of the inner (medial) arch of the foot.
During heel lift, the foot supinates to act as a rigid lever. The
plantar fascia is a strong connective tissue that runs along the
bottom of the foot connecting the heel to the base of the toes.
The bones, muscles and the plantar fascia act together to form
.this rigid lever
:Ankle biomechanics
1. Axis of the ankle is oblique.
2. Movements therefore triplanar.
3. Everts (valgus) and abduction during dorsiflexion.
4. Inverts (varus) and adduction during plantarflexionAnkle.
5. Joint reaction force in stance is 4 times body weight.
6. At least 10 degrees of dorsiflexion is needed for normal gait .
7. 1 mm of lateral talar shift decreases tibio/talar surface contact
up to 40% .
Problem of
the foot
:Pes planus

•Valgus heel (STJ everted) .

•Flattened medial arch.
•Prominent navicular head.
•Forefoot abducted and supinated (too many
toes) .
) :Pes planus ( clinical assessment
:Diff dx)1
•Soft tissue (Tib post or RA ) .
•STJ pathology .
•Tib post function .
. STJ movement - Fixed or flexible)2
.Midtarsal movements and medial arch)3
Tib Post dysfunction :

:Stage 1
.Tenosynovitis, normal length - Non operative

:Stage 2
.No fixed deformity - Orthotic +/- tendon transfer

:Stage 3
.Fixed STJ deformity - Arthrodesis +/- triple

:Stage 4
.Ankle joint involved - Calcaneal osteotomy +/- fusion
Pes cavus
 :Pes cavus
An abnormally high arched foot

⁂Aetiology :

1-CMT /HSMN
Paralysis of tib ant and P. brevis with relative overactive
Peroneus longus
Leads to a plantar-flexed 1st ray

Poliomyelitis- 2
Overactive tib ant pulls the midfoot up
Lead to a calcaneus deformity
:Polio- 3

Relatively overactive tib ant

Calcaneus deformity
Varus or valgus
Sensation spared

:CMT-4

Adducted forefoot
Plantarflexed 1st ray
Equinus of the midfoot
Varus of the heel
:Club foot

is a congenital deformity involving one foot or

both. The affected foot appears rotated internally
at the ankle. TEV is classified into 2 groups:
Postural TEV or Structural TEV. Without
treatment, persons afflicted often appear to walk
on their ankles, or on the sides of their feet. It is
a common birth defect, occurring in about one in
every 1,000 live births. Approximately 50% of
cases of clubfoot are bilateral. In most cases it is
an isolated dysmelia . This occurs in males more
.often than in females by a ratio of 2:1
:Deformities

The deformities affect

joints of the foot occur at three joints of foot
:to varying degrees. They are
.Inversion at subtalar joint
adduction at talonavicular joint and
Equinus at ankle joint
Club foot
 :Ankle sprain
)An ankle sprain is a soft-tissue (non-bone
injury to the ligaments surrounding the joint.
Ligaments are tough bands of tissue that
connect bone to bone and support the joints
while allowing movement. The ankle is the most
commonly sprained due to its many movements
that are under constant stress. A sprain occurs
when a sharp twisting or wrenching movement
such as turning your ankle forces the joint
beyond its natural limits. As a result, the
ligament may be stretched to such an extent that
. it tears
Ankle sprain
:Problem of foot
Movement
: of ankle
:Dorsiflextion

Movement that brings the top of the foot towards

the lower leg. Dorsiflexion involves the combined
action of the tibialis anterior, peroneus tertius,
extensor hallucis longus, and extensor digitorum
longus muscles. It is not a powerful movement, but
it helps prevent the toes from dragging during
.walking
Dorsiflextion
: Plantar flextion

the movement which increases the

approximate 90 degree angle between the
front part of the foot and the shin, as when
depressing an automobile pedal. The word
"plantar" is commonly understood in medical
terminology as the bottom of the foot - it
".translates as "toward the sole
Muscles :
Gastrocnemius
soleus
plantaris
flexor hallucis longus
flexor digitorum longus
tibialis posterior
Lateral compartment of leg
peronaeus longus
peronaeus brevis
Plantar flextion
:Eversion

the movement of the sole of foot away from

the median plane. It occurs at the sutalar
.joint
.and peroneus brevis evert Peroneus longus
Inversion:

the movement of the sole towards the

median plane (as when an ankle is
).twisted
and tibialis posterior Tibialis anterior
invert. Some sources also state that the
triceps surae and extensor hallucis longus
.invert
.It occurs at the subtalar joint
INVERSION
:Fixed vs flexible

•Clawtoes correct with standing / passive

elevation of MT heads
•Cavus improved by elevation of 1st ray
•Hindfoot corrected by Coleman’s block
test