Objectives: After completion of this presentation, it is expected that the students will be able to Musculoskeletal Anatomy Describe the distal end of the tibia and be able to identify: • the shaft • the sharp anterior border • the subcutaneous anteromedial surface or “shin” • the interosseous border • the medial malleolus • articular surfaces Describe the distal end of the fibula and be able to identify: • the shaft • the interosseous border • the lateral malleolus with grooves for peroneal tendons • articular surface Identify the key features of the seven tarsal bones: • the calcaneus  calcaneal tuberosity  medial, lateral and anterior tubercles  the sustentaculum tali  peroneal trochlea • the talus:  head  neck  body  dome  posterior tubercle with groove for flexor hallucis longus • the cuboid with groove for peroneus longus on the plantar surface • the navicular with tuberosity for the insertion of tibialis posterior • the five metatarsals with fifth tuberosity for peroneus brevis • the phalanges with 2 on big toe, 3 on others • sesamoid bones at base of 1st metatarsals Describe the structure, function and maintenance (bones, muscles, tendons, ligaments) of the arches of the foot:  medial longitudinal  lateral longitudinal  transverse Identify the attachments and understand the functions of the deep fascia: • plantar aponeurosis • fibrous septa of the sole • extensor, flexor and peroneal retinaculae Describe the components & function of the foot & ankle joints: • ankle joint:  articular surfaces  fibrous capsule  synovial membrane  Ligaments (medial/deltoid, lateral/tri-fascicular)  Movements (plantar/dorsi flexion) • subtalar joints: • distal tibiofibular joint • talo-calcaneo-navicular (mid-tarsal) joint • tarso-metatarsal joints • metatarsophalangeal • interphalangeal Recognise the shape, size and attachments of: • the long plantar ligament • the short plantar (plantar calcaneocuboid) ligament Clinical Anatomy Explain the relevant anatomy of: • the differences between the superior and inferior tibiofibular joints • fracture of the second & fifth metatarsals • ankle sprain with fractured shaft of fibula • the three degrees of ankle sprain • the ratio of lateral to medial ankle ligament sprains • plantar fasciitis and calcaneal spur • pes planus • hallux valgus and its predominance in females • the ankle jerk and plantar reflex Radiological Anatomy Identify: • the antero-posterior and lateral views of the distal tibia, fibula and foot bones • the ankle joint space

1. The Ankle & Joints of the Foot
Dr. Akram Jaffar
Ph.D.
Dr. Akram Jaffar
Dr. Akram Jaffar

2. References and suggested reading
• Moore KL & Dalley AF (2006): Clinically oriented anatomy. 5th ed. Lippincott Williams
& Wilkins. Baltimore
• Snell RS (2006): Clinical anatomy by systems. Lippincott Williams & Wilkins.
Baltimore
Dr. Akram Jaffar
Dr. Akram Jaffar

3. Superior tibio-fibular joint
• Plain type of synovial joint Lat condyle
• Between the head of the fibula and the
lateral condyle of the tibia.
• Some passive rotation of the fibula around head
tibia
its own axis takes place at the proximal
tibio-fibular joint during dorsi and plantar Sup. T.F.
flexion at the ankle joint because of the fibula joint
antero-posterior, convexity of the lateral
articular surface of the talus.
• Its cavity may communicate with popliteus
bursa, which always communicate with the
knee joint cavity. talus
Lat articular
surface
Dr. Akram Jaffar
Popliteus bursa
Dr. Akram Jaffar

4. Inferior tibio- fibular joint tibia
fibula
• Fibrous joint of syndesmosis type
inf. T.F.
• Between the inferior ends of the tibia and joint
fibula.
• Its integrity is important for the stability of
the ankle joint
• It holds the 2 malleoli together forming a
socket for the talus. inf. T.F.
joint
Dr. Akram Jaffar
Dr. Akram Jaffar

5. tibia
The talus
fibula
Groove for
Flex hal long
Lat tubercle
• The trochlea of the talus has three articular med tubercle
calcaneus
surfaces
– Inferior surface of the tibia: trochlea is
wider anteriorly than posteriorly. talus
trochlea neck
– Medial malleolus head
– Lateral malleolus
navicular
neck
trochlea
head
talus
calcaneus
Dr. Akram Jaffar
No muscle is attached to the talus
Dr. Akram Jaffar

6. tibia
Ankle joint
fibula
• Type and articulation
– Hinge type of synovial joint
– Between the inferior ends of the
talus
tibia and fibula which form a deep
socket (mortise) and the trochlea of
the talus.
Dr. Akram Jaffar
Dr. Akram Jaffar

7. tibia
Ankle joint Dorsiflexion
(extension)
fibula
• Movements
– Mainly dorsi flexion and
plantar flexion
talus
– Some degree of rotation
(inversion and eversion) is
possible when the foot is Plantar flexion
(flexion)
plantar flexed.
• The joint is relatively unstable
during plantar flexion. WHY?
inversion eversion
Dr. Akram Jaffar
Dr. Akram Jaffar

8. capsule
Capsule of the ankle joint
• Extends anteriorly onto Med malleolus
the neck of the talus.
• Strengthened by
collateral ligaments.
– Medial collateral
ligament (deltoid)
• Delta-shaped
• Very strong.
talus
navicular
calcaneus
– Lateral collateral
ligament Lat malleolus
Ant..
• Consists of 3 Post.
Talofibular lig
slips connecting Talofibular lig
the lateral
Calcaneo-fibular lig
malleolus to the
talus and
calcaneus.
Dr. Akram Jaffar
Dr. Akram Jaffar

9. Ankle sprain
Dr. Akram Jaffar
Dr. Akram Jaffar

10. Injury of lateral collateral ligament
• When the foot is forcibly inverted as when the
weight-bearing foot trips on an uneven
surface.
• The anterior talofibular ligament is the
most vulnerable and most commonly torn.
• In severe cases, the calcaneofibular ligament
is torn and the lateral malleolus is fractured.
Inf tibiofibular joint
Lat malleolus
fracture
Dr. Akram Jaffar
Dr. Akram Jaffar

11. Injury of deltoid ligament
• So strong that when the foot is forcibly everted the
ligament is not torn but it causes
– avulsion of the medial malleolus
– talus moves laterally causing a break in the fibula
superior to the inferior tibio-fibular joint (Pott
fracture dislocation). eversion
Dr. Akram Jaffar
Dr. Akram Jaffar

12. Posterior tibio-fibular ligament
• Between malleolar fossa of the fibula to the
posterior edge of the tibia.
Post. Tibio-fibular lig.
• Prevents the leg to slide foreword on the
talus under the influence of gravity when the
foot is plantar flexed at the take off stage in
Post. Talo-fibular lig.
walking.
inf. T.F.
joint
Post. Tibio-fibular lig.
Malleolar
facet
Dr. Akram Jaffar
Malleolar
fossa
Dr. Akram Jaffar

13. tibia
Stability of the ankle joint
• Bone: mortise fibula
• Ligaments: collateral & tibiofibular
• Muscle: surrounding tendons.
• Forward sliding of the leg on the talus is prevented by:
– The mortise is deepened at the back talus
• Posterior lip of the tibia
• Posterior tibio-fibular ligament
– The superior articular surface of the talus is wider in
front than behind.
• The joint is unstable with the foot plantar flexed
(walking downhill)  ankles are more commonly
sprained whilst walking downstairs rather than when
going upstairs.
Dr. Akram Jaffar
Dr. Akram Jaffar

14. Parts of the foot
• Hindfoot
• Midfoot
• Forefoot
Hindfoot Midfoot Forefoot
cuneiforms
navicular
talus
cuboid
calcaneus metatarsals
phalanges
Dr. Akram Jaffar
Dr. Akram Jaffar

15. Joints of inversion and eversion: anatomical classification
• Subtalar joint Subtalar j.
– Synovial joint between the inferior talus
surface of the body of the talus
and the superior surface of the cuboid
calcaneus. calcaneus
• talocalcaneonavicular joint
– Synovial joint between the head of Calcaneo-cuboid j.
the talus on one side and the
posterior surface of the
navicular, superior surface of the
spring ligament, and the
talus
navicular
sustentaculum tali of the
calcaneus on the other side.
• calcaneocuboid joint calcaneus
– Synovial joint between the anterior
surface of the calcaneus and the
posterior surface of the cuboid.
Talo-calcaneo-cavicular j.
Dr. Akram Jaffar
Dr. Akram Jaffar

16. Spring ligament
• Officially, plantar calcaneonavicular
ligament
• Between the sustentaculum tali and
the navicular bone.
• Forms part of the socket for the head
of the talus.
• Important in maintaining the medial
longitudinal arch of the foot.
Spring lig.
Sustentaculum tali
talus
navicular
calcaneus
Sustentaculum tali
Dr. Akram Jaffar
Sustentaculum tali
Dr. Akram Jaffar

17. Joints of inversion and eversion: functional classification
talus
Subtalar j.
calcaneus
calcaneus
Midtarsal j. talus
talus cuboid navicular
Subtalar j.
calcaneus
• Mid-tarsal joint (transverse tarsal joint): Articulation of the head of
the talus with the navicular lies in line with the calcaneocuboid
joint.
• Subtalar joint: Articulation of the head of the talus with the spring
ligament and the sustentaculum tali + anatomical subtalar joint
Dr. Akram Jaffar
Dr. Akram Jaffar

18. Foot amputation
• Transection across the transverse
tarsal joint is a standard method for
surgical amputation of the foot.
Dr. Akram Jaffar
Diabetic foot
Dr. Akram Jaffar

19. Avulsion fracture of the 5th metatarsal
• Forcible inversion of the foot  Avulsion of the
tuberosity of the 5th metatarsal bone by the
attached tendon on peroneus brevis
Dr. Akram Jaffar
Dr. Akram Jaffar

20. “March” fracture of the 2nd metatarsal bone
• The base of the 2nd metatarsal is firmly
fixed between the anterior ends of the
medial and lateral cuneiforms.
• The 2nd metatarsal and toe form the axis
of the foot.
• The immobility of the 2nd metatarsal and
the slenderness of its shaft contribute to
its „spontaneous‟ fracture following mild
repetitive trauma (stress fracture).
Dr. Akram Jaffar
Dr. Akram Jaffar

21. Hallux valgus
• Lateral deviation of the great toe to an abnormal
extent  prominent head of the 1st metatarsal.
• Predisposed by pressure from ill-fitting shoes.
• The first metatarsal shifts medially and the
sesamoids shift laterally.
• The distortion is increased by the action of the
long flexor and extensor tendons and the
adductor hallucis.
• A bursa develops over the projecting head of the
1st metatarsal (bunion).
Dr. Akram Jaffar
>
Dr. Akram Jaffar

22. Long and short plantar ligaments
• Long plantar ligament
– Passes from the plantar
surface of the
calcaneus to the cuboid
bone
– Bridges the groove on
the cuboid and converts
it into a tunnel for the
passage of the tendon
of peroneus longus
muscle. cuboid
Groove for
• Short plantar ligament peroneus long. Peroneus
longus
– Deep to the long plantar
ligament
– From the plantar long plantar lig.
surface of the
calcaneus to the cuboid Short plantar lig.
bone.
Dr. Akram Jaffar
Dr. Akram Jaffar

23. Formation of the arches of the foot
lateral long. arch
cuboid
calcaneus 2 metatarsals cuneiforms
cuboid
Transverse arch
Medial long. arch cuneiforms
talus
navicular
3 metatarsals
calcaneus
• Medial longitudinal arch
– formed by the calcaneus, talus, navicular, 3 cuneiform bones, and the medial
three metatarsals
• Lateral longitudinal arch
– formed by the calcaneus, cuboid, and the lateral two metatarsals
Dr. Akram Jaffar
• Transverse arch
– formed by the cuneiforms, cuboid, and the bases of the metatarsals.
Dr. Akram Jaffar

24. Function of the arches of the foot
• Support and divide the body weight about equally
between the calcaneus and the heads of the metatarsal 80 Kg
bones.
• Propel the body in walking or running:
– Allow the long flexors and the muscles of the foot to
act on the bones of the fore part of the foot and toes
(take-off part) and greatly assist the propulsive force
of gastricnemius and soleus muscles.
• Shock absorption.
• Adapt to changes when walking on uneven surfaces.
Dr. Akram Jaffar
Dr. Akram Jaffar

25. Mechanism of arch (bridge) support
Tie beam
Key stone
staples
• Shape of the stones: Wedge-shaped stones with
the thin edge of the wedge lying inferiorly. This is
especially true for the stone at the center of the
arch “key stone”. suspension
• Staples: Tie the inferior edges of the stones.
• Tie beams: Connect the pillars and prevent their
separation.
• Suspension by slings
Dr. Akram Jaffar
Dr. Akram Jaffar

26. Mechanism of foot arch support
• Shape of bones: e.g. head of the talus “key stone”.
• Staples: e.g. the long and short plantar ligaments.
• Tie beam: e.g. tendon of flexor hallucis longus.
• Suspension: e.g. tendons of tibialis anterior, tibialis
posterior, and the peroneii
Short plantar lig.
staples
Long plantar lig.
Tibialis ant.
suspension
Tibialis post.
cuneiform
talus
Dr. Akram Jaffar
Key stones
Tie beam
Flex hal long
Dr. Akram Jaffar

27. Factors maintaining the arches of the foot
• Bones, ligaments, and muscles.
• Passive support: Ligaments are sufficient to
support the arches when standing still
• Active support: muscles are brought into action to
support the arches during running or walking
**
ligaments
Dr. Akram Jaffar
muscles bones
Dr. Akram Jaffar

28. Flat feet (pes planus)
• The arch of the foot collapses, with the entire sole of the
foot coming into contact with the ground.
• Normal before age of 3 years.
• Affects the medial longitudinal arch.
• Causes: failure of factors maintining the arches
– Bone: deformity  rigid flat foot
– Ligaments: loose or degenerated  flexible flat foot
(only when weight bearing)
– Muscle: trauma, degeneration, or denervation 
acquired flat foot.
Dr. Akram Jaffar
Dr. Akram Jaffar

29. head
sesamoid
head
base
Metatarsal 1 neck
navicular
tibia
talus fibula
phalanx
Metatarsal 5
cuboid
trochlea
tuberosity condyle
calcaneus
Calcaneocuboid joint
tuberosity
Dr. Akram Jaffar
Dr. Akram Jaffar