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Foot and Ankle


Clinical Summary and Recommendations

Patient History
Complaints

  • No studies of acceptable quality have assessed either the reliability or diagnostic utility of items from the subjective history in patients with foot and ankle problems.

Physical Examination
Screening

  • The Ottawa Ankle Rule for Radiography is highly sensitive for ankle and midfoot fractures in both adults and children. When patients can bear weight and have no tenderness on the malleoli, navicular bone, or base of the fifth metatarsal, providers can confidently rule out foot and ankle fractures (−LR [likelihood ratio] = .09–.14).

Range-of-Motion and Strength Assessment

  • Measuring ankle range of motion has consistently been shown to be highly reliable when one person does the measuring, but it is much less reliable when different people do the measuring.

  • Calf strength can be reliably assessed using repeated calf raises. The paper grip test is a simple yet accurate method to measure toe plantarflexion strength.

Other Assessments

  • Assessments of static foot alignment, sensation, swelling, proprioception, and dynamic performance have all been shown to be adequately reliable but are of unknown diagnostic utility. Dynamic assessments of hindfoot motion during gait are likely too unreliable to be clinically useful.

Special Tests

  • The Thompson test seems to show very good diagnostic utility in both identifying and ruling out subcutaneous tears of the Achilles tendon (+LR = 13.47, −LR = .04).

  • The impingement sign seems to show very good diagnostic utility in both identifying and ruling out anterolateral ankle impingement (+LR = 7.9, −LR = .06).

  • The triple compression test seems to show good diagnostic utility in ruling out tarsal tunnel syndrome (−LR = .14).

  • Clinical examination seems to show poor diagnostic utility for detecting syndesmotic injuries in acute ankle sprains.

Anatomy

Osteology

Figure 8-1, Bones of the foot.

Figure 8-2, Bones of the foot.

Arthrology

Figure 8-3, Talocrural (hinge) joint.

Joint Type and Classification Closed Packed Position Capsular Pattern
Talocrural Synovial: hinge Dorsiflexion Plantarflexion slightly more limited than dorsiflexion
Distal tibiofibular Syndesmosis Not available Not available
Subtalar Synovial: plane Supination Inversion greatly restricted; eversion not restricted
Talocalcaneonavicular Synovial: plane Supination Supination more limited than pronation
Calcaneocuboid Synovial: plane Supination
Transverse tarsal Synovial: plane Supination
Tarsometatarsal Synovial: plane Supination Not available
Metatarsophalangeal (MTP) Synovial: condyloid Extension Great toe: extension more limited than flexion
MTP joints 2 to 5: variable
Interphalangeal (IP) Synovial: hinge Extension Extension more limited than flexion

Ligaments

Posterior Ankle Ligaments

Figure 8-4, Calcaneus: posterior view with ligaments.

Ligaments Attachments Function
Posterior talocalcaneal Superior body of calcaneus to posterior process of talus Limits posterior separation of talus from calcaneus
Posterior tibiofibular Distal posterior tibia to distal posterior fibula Maintains distal tibiofibular joint
Posterior talofibular Posterior talus to posterior lateral malleolus Limits separation of fibula from talus
Interosseous membrane Continuous connection between tibia and fibula Reinforces approximation between tibia and fibula

Lateral Ankle Ligaments

Figure 8-5, Ligaments of ankle: lateral view of right foot.

Ligaments Attachments Function
Anterior tibiofibular Anterior aspect of lateral malleolus to inferior border of medial tibia Reinforces anterior tibiofibular joint
Lateral collateral
Posterior talofibular
Calcaneofibular
Anterior talofibular 		Lateral malleolus to lateral talus
Lateral malleolus to lateral calcaneus
Lateral malleolus to talus		 Limits ankle inversion
Interosseous talocalcaneal Inferior aspect of talus to superior aspect of calcaneus Limits separation of talus from calcaneus
Dorsal talonavicular Dorsal aspect of talus to dorsal aspect of navicular Limits separation of navicular from talus
Bifurcate
Calcaneonavicular
Calcaneocuboid 		Distal calcaneus to proximal navicular
Distal calcaneus to proximal cuboid		 Limits separation of navicular and cuboid from calcaneus
Dorsal cubonavicular Lateral aspect of cuboid to dorsal aspect of navicular Limits separation of navicular from cuboid
Dorsal cuneonavicular Navicular to three cuneiforms Limits separation of cuneiforms from navicular
Dorsal intercuneiform Joining of three cuneiforms Limits separation of cuneiforms
Dorsal tarsometatarsal Dorsal tarsal bones to corresponding metatarsal bones Reinforces tarsometatarsal joints

Medial Ankle Ligaments

Figure 8-6, Ligaments of ankle: medial view of right foot.

Ligaments Attachments Function
Medial (deltoid)
Posterior tibiotalar Medial malleolus to medial talus Limits ankle eversion
Tibiocalcaneal Anterior distal medial malleolus to sustentaculum tali
Tibionavicular Medial malleolus to proximal aspect of navicular
Anterior tibiotalar Medial malleolus to talus
Medial talocalcaneal Sustentaculum tali to talus Limits posterior separation of talus on calcaneus
Plantar calcaneonavicular (spring) Sustentaculum tali to posteroinferior navicular Maintains longitudinal arch of foot

Plantar Foot Ligaments

Figure 8-7, Capsules and ligaments of metatarsophalangeal and interphalangeal joints: lateral view.

Ligaments Attachments Function
Long plantar Plantar of calcaneus to cuboid Maintains arches of foot
Plantar calcaneocuboid (short plantar) Anteroinferior aspect of calcaneus to inferior aspect of cuboid Maintains arches of foot
Plantar calcaneonavicular (spring) Sustentaculum tali to posteroinferior aspect of talus Maintains longitudinal arch of foot
Plantar cubonavicular Inferior navicular to inferomedial cuboid Limits separation of cuboid from navicular and supports arch
Plantar tarsometatarsal Connects metatarsals 1 to 5 to corresponding tarsal on plantar aspect Limits separation of metatarsals from corresponding tarsal bones
Collateral Distal aspect of proximal phalanx to proximal aspect of distal phalanx Reinforces capsule of IP joints
Plantar plate Thickening of plantar aspect of joint capsule Reinforces plantar aspect of IP joint
Deep transverse metatarsal MTP joints on plantar aspect Limits separation of MTP joints

Figure 8-8, Ligaments and tendons of foot: plantar view.

Muscles

Lateral Muscles of Leg

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Gastrocnemius Lateral head: lateral femoral condyle
Medial head: popliteal surface of femur		 Posterior aspect of calcaneus Tibial nerve (S1, S2) Plantarflexes ankle and flexes knee
Soleus Posterior aspect of head of fibula, fibular soleal line, and medial aspect of tibia Posterior aspect of calcaneus Tibial nerve (S1, S2) Plantarflexes ankle
Fibularis longus Superolateral surface of fibula Base of first metatarsal and medial cuneiform Superficial fibular nerve (L5, S1, S2) Everts foot and assists in plantarflexion
Fibularis brevis Distal aspect of fibula Tuberosity of base of fifth metatarsal Superficial fibular nerve (L5, S1, S2) Everts foot and assists in plantarflexion
Fibularis tertius Anteroinferior aspect of fibula and interosseus membrane Base of fifth metatarsal Deep fibular nerve (L5, S1) Dorsiflexes ankle and everts foot
Extensor digitorum longus Lateral condyle of tibia, medial surface of fibula Middle and distal phalanges of digits 2 to 5 Deep fibular nerve (L5, S1) Extends digits 2 to 5 and assists with ankle dorsiflexion
Extensor hallucis longus Anterior fibula and interosseous membrane Dorsal base of distal phalanx of great toe Deep fibular nerve (L5, S1) Extends great toe and assists with ankle dorsiflexion
Extensor digitorum brevis Superolateral aspect of calcaneus, extensor retinaculum Dorsal base of middle phalanx of digits 2 to 5 Deep fibular nerve (L5, S1) Extends digits 2 to 4 at MTP joints
Tibialis anterior Lateral condyle and anterior surface of tibia Inferomedial aspect of medial cuneiform and base of first metatarsal Deep fibular nerve (L4, L5) Ankle dorsiflexion and foot inversion

Figure 8-9, Muscles of foot and ankle: lateral view.

Posterior Muscles of Leg

Figure 8-10, Muscles of leg: posterior view.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Tibialis posterior Interosseous membrane, posteroinferior aspect of tibia, and posterior fibula Navicular tuberosity, cuneiform, cuboid, and bases of metatarsals 2 to 4 Tibial nerve (L4, L5) Plantarflexes ankle and inverts foot
Flexor hallucis longus Posteroinferior fibula and interosseous membrane Base of distal phalanx of great toe Tibial nerve (S2, S3) Flexes great toe and assists with ankle plantarflexion
Flexor digitorum longus Posteroinferior tibia Bases of distal phalanges 2 to 5 Tibial nerve (S2, S3) Flexes lateral four digits, plantarflexes ankle, supports longitudinal arch of foot

Muscles of Dorsum of Foot

Figure 8-11, Muscles, arteries, and nerves of front of ankle and dorsum of foot: deeper dissection.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Extensor digitorum brevis Superolateral aspect of calcaneus and extensor retinaculum Dorsal base of middle phalanx of digits 2 to 5 Deep fibular nerve (L5, S1) Extends digits 2 to 4 at MTP joints
Extensor hallucis brevis Superolateral aspect of calcaneus and extensor retinaculum Dorsal base of proximal phalanx of great toe Deep fibular nerve (L5, S1) Extends great toe at MTP joints
Dorsal interossei Sides of metatarsals 1 to 5 First: medial aspect of proximal phalanx of second digit
Second to fourth: lateral aspect of digits 2 to 4		 Lateral plantar nerve (S2, S3) Abducts digits 2 to 4 and flexes
MTP joints

First Layer of Muscles: Sole of Foot

Figure 8-12, Muscles of sole of foot: first layer.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Abductor hallucis longus Medial calcaneal tuberosity, flexor retinaculum, and plantar aponeurosis Base of proximal phalanx of first digit Medial plantar nerve (S2, S3) Abducts and flexes great toe
Flexor digitorum brevis Medial calcaneal tuberosity and plantar aponeurosis Sides of middle phalanges of digits 2 to 5 Medial plantar nerve (S2, S3) Flexes digits 2 to 5
Abductor digiti minimi Medial and lateral calcaneal tuberosities Lateral aspect of base of proximal phalanx of fifth metatarsal Lateral plantar nerve (S2, S3) Abducts and flexes fifth digit

Second Layer of Muscles: Sole of Foot

Figure 8-13, Muscles of sole of foot: second layer.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Lumbricals Tendons of flexor digitorum longus Medial aspect of expansion over lateral four digits Lateral three: lateral plantar nerve (S2, S3)
Medial one: medial plantar nerve (S2, S3)		 Flexes proximal phalanges and extends middle and distal phalanges of digits 2 to 5
Quadratus plantae Medial and plantar aspect of calcaneus Posterolateral aspect of tendon of flexor digitorum longus Lateral plantar nerve (S2, S3) Assists in flexing digits 2 to 5

Third Layer of Muscles: Sole of Foot

Figure 8-14, Muscles of sole of foot: third layer.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Flexor digiti minimi brevis Base of fifth metatarsal Base of proximal phalanx of fifth metatarsal Superficial branch of lateral plantar nerve Flexes proximal phalanx of fifth digit
Adductor hallucis (transverse head) Plantar ligaments of MTP joints Lateral base of proximal phalanx of great toe Deep branch of lateral plantar nerve (S2, S3) Adducts great toe
Adductor hallucis (oblique head) Bases of metatarsals 2 to 4
Flexor hallucis brevis Plantar cuboid and lateral cuneiforms Sides of proximal phalanx of great toe Medial plantar nerve (S2, S3) Flexes proximal phalanx of great toe

Deep Interosseous Muscles: Sole of Foot

Figure 8-15, Interosseous muscles and plantar arterial arch.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Plantar interosseous Bases of metatarsals 3 to 5 Medial bases of proximal phalanges 3 to 5 Lateral plantar nerve (S2, S3) Adducts digits 2 to 4 and flexes MTP joints
Dorsal interosseous Sides of metatarsals 1 to 5 First: medial aspect of proximal phalanx of second digit
Second to fourth: Lateral aspect of digits 2 to 4		 Lateral plantar nerve (S2, S3) Abducts digits 2 to 4 and flexes MTP joints

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