Ankle and Foot

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					Ankle and Foot
The ankle joint is formed where the foot and the leg meet. The ankle, or talocrural
joint, is a hinge joint where 3 bones are connected to each other. They are the tibia
and fibula of the leg and talus bone of the foot. The articulation between the tibia and
talus bears more weight than between the smaller fibula and the talus.




          Navicular                                             Talus


       Cuneiforms                                                    Metatarsals


The ankle joint is responsible for moving the toes up as when standing only on the
heels (dorsiflexion) and moving the toes down, as when standing on the toes
(plantarflexion), and allows for the greatest movement of all the joints in the foot. The
ankle does not allow rotation.

In plantarflexion, the anterior ligaments of the joint become longer while the posterior
ligaments become shorter. The reverse is true for dorsiflexion. The anterior talus is
wider than the posterior talus. When the foot is dorsiflexed, the wider part of the
superior talus moves into the articulating surfaces of the tibia and fibula, creating a
more stable joint than when the foot is plantar flexed.

The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: the
anterior talofibular ligament, the posterior talofibular ligament, and the
calcaneofibular ligament. The deltoid ligament supports the medial side (inner) of the
joint, and the anterior and posterior talofibular ligaments and calcaneofibular
ligament support the lateral side (outer) of the joint.

The joint is most stable in dorsiflexion and a sprained ankle is more likely to occur
when the foot is plantar flexed. This type of injury more frequently occurs at the
anterior talofibular ligament.
The anatomy of the foot can be seemed quite complex. If the foot is considered in it's
three distinct regions, the forefoot, midfoot and the rear foot, the bony anatomy is
greatly simplified.

The forefoot includes the five metatarsal bones, and the phalanges (the toes). The first
metatarsal bone bears the most weight and plays the most important role in
propulsion. It is the shortest and thickest. It also provides attachment for several
tendons. The second, third, and fourth metatarsal bones are the most stable of the
metatarsals. They are well protected and have only minor tendon attachments and are
not subjected to strong pulling forces.

Near the head of the first metatarsal, on the plantar surface of the foot, are two
sesamoid bones (a small, oval-shaped bone which develops inside a tendon, where the
tendon passes over a bony prominence). They are held in place by their tendons, and
are also supported by ligaments.

The midfoot includes five of the seven tarsal bones (the navicular, cuboid, and three
cuneiform). The distal row contains the three cuneiforms and the cuboid. The midfoot
meets the forefoot at the five tarsalmetatarsal (TMT) joints. There are multiple joints
within the midfoot itself. Proximally, the three cuneiforms articulate with the
navicular bone.

The talus and the calcaneus make up the rear foot. The calcaneus is the largest tarsal
bone, and forms the heel. The talus rests on top of it, and forms the pivot of the ankle.

The toes are responsible for 4 movements, flexion, extension, abduction and
adduction. The foot as a whole (excluding the toes) has two movements: inversion
and eversion. All the joints of the rear foot and midfoot from the subtalar contribute to
these movements, which are complex and consist of several components. In addition,
foot movements ordinarily are combined with ankle movements.

The foot has two important functions: weight bearing and propulsion. These functions
require a high degree of stability. In addition, the foot must be flexible, so it can adapt
to uneven surfaces. The multiple bones and joints of the foot give it flexibility, but
these multiple bones must form an arch to support any weight.

The foot has three arches. The medial longitudinal arch is the highest and most
important of the three arches. It is composed of the calcaneus, talus, navicular,
cuneiforms, and the first three metatarsals. The lateral longitudinal arch is lower and
flatter than the medial arch. It is composed of the calcaneus, cuboid, and the fourth
and fifth metatarsals. The transverse arch is composed of the cuneiforms, the cuboid,
and the five metatarsal bases.

The arches of the foot are maintained not only by the shapes of the bones as well as
by ligaments. In addition, muscles and tendons play an important role in supporting
the arches.
Common sources of ankle pain

   •   Lateral ankle sprain
   •   Fractures
   •   Peroneal tendons sprain
   •   Medial ankle sprain
   •   Osteochondral lesion of the talus
   •   Tibialis posterior tendinopathy
   •   Flexor hallucis longus tendinopathy

Common sources of foot pain

   •   Plantar fasciitis
   •   Fat pad contusion
   •   Navicular stress fracture
   •   Midtarsal joint sprain
   •   Extensor tendinopathy
   •   Fracture of 5th metatarsal
   •   Stress fracture of metatarsal

What is lateral ankle sprain?

Lateral ankle sprain is the most common injury to the ankle and the long term
consequences of an ankle sprain is a common cause of chronic ankle pain. The most
common type is the inversion ankle sprain, in which the ankle rolls over on the

An ankle sprain is the stretching and tearing of ligaments - in the sprained ankle the
most common damage is done to the talo-fibula ligament (if the ankle sprain is worse,
the calcaneo-fibula ligament can also be damaged) - sometimes the tendons also get

Sprained ankle causes
Anything that makes the ankle 'tip over' increases the chance of an ankle sprain - this
can occur in sport (eg jumping and landing on someone else's foot), walking on
uneven surface, twisting motions etc.

A number of factors predispose to ankle sprains:
   1. poor rehabilitation of a previous sprained ankle
   2. poor proprioception (proprioception is the ability to sense where a joint is. If
      you don't know where your ankle is, the muscles will not be able to prevent
      the ankle sprain)
   3. some feet are very easy to 'tip over' - this is common in those who frequently
      'roll the ankle', without actually doing any damage and spraining the ankle
   4. weak muscles (they are just not strong enough to prevent the sprain occurring)

Ankle sprain types

The sprained ankle is often classified as to how severe it is:

Grade 1 ankle sprain:
   • Some stretching or mild tearing of the ligament.
   • Little or no functional loss - the joint can still function and bear some weight
   • Mild pain
   • Some swelling
   • Some joint stiffness.

Grade 2 ankle sprain:
   • Some more severe tearing of the ligaments
   • Moderate instability of the joint
   • Moderate to severe pain - weightbearing is very painful
   • Swelling and stiffness

Grade 3 ankle sprain:
   • Total rupture of a ligament - there is a loss of motion
   • Gross instability of the joint - joint function is lost
   • Severe pain initially followed by no pain
   • Severe swelling

Treatment and Management

The sooner treatment starts for a sprained ankle, the greater chance to prevent chronic
pain and long term instability.
For all grades of ankle sprain follow the R.I.C.E. principles as soon as possible:

   •   Rest your ankle - do not walk on it.
   •   Ice - this helps to keep the swelling down. Use ice on the injury several times
       a day for 15-20 minutes (more than 20 minutes is not advised)
   •   Compressive bandages are needed to immobilize the ankle sprain and to
       support the injury.
   •   Elevate the ankle above your heart level for as much as you can for 48 hours.
Your physiotherapist will provide a wide range of treatment options include manual
therapy like friction massage, electrical modalities like ultrasound and exercises for
rehabilitation of the sprained ankle when the acute phase is over.

Rehabilitation for the sprained ankle include:
   • Exercises to increase proprioception
   • Ankle braces and strapping to facilitate activity
   • Muscle strengthening and flexibility exercises
   • Gradual return to any sporting activities
   • Maintain fitness by doing alternative activities.

Exercises after the first 48 hours play a major role in the in the rehabilitation of the
sprained ankle and to prevent of ankle sprains.

ROM exercises:
Start by using a towel to gently pull the foot towards you. Repeat this
several times a day. Later use calf muscle stretches against the wall.

Balance exercises:
Start by balancing on one foot - hold for as long as possible - repeat
several times a day. Later, a wobble board can be used to make it harder
for balancing on one foot.

Start by pushing the foot outward against a wall, hold for 3 seconds -
repeat 20 times, several times a day. Later, use an elastic band that is tied
to a heavy object and move the foot outward against this.

What causes long term pain after ankle sprains:
The most common cause for long term pain after an ankle sprain is poor rehabilitation
of a previous ankle sprain. All causes of chronic pain after an ankle sprain should be
evaluation by a health professional.

The common causes are of chronic ankle pain are:
   • Poor rehabilitation
   • A fracture that was not initially diagnosed
   • Congenital abnormality
   • Post traumatic arthritis
   •    Osteochondritis dissecans (loose bit of bone in the joint)
   •    Sinus tarsi syndrome
   •    Syndesmotic ligament injury
   •    Functional instability (feeling of giving way)
   •    Ankle impingement

Prevention of the sprained ankle:
A number of things can be done to prevent an ankle sprain, especially if there is a
history of recurrent sprained ankles:
    • Continue to stretch the calf muscles, strengthen the muscles and the balance
    • Use strapping or an ankle brace.
    • Insoles or wedge to be inserted in the shoe can sometimes help prevent the
        ankle from tipping over.
    • Surgical procedure to tighten the ligaments or move a tendon to help stabilise
        the ankle for those who chronically sprain the ankle on a regular basis.

What is Plantar Fasciitis

Plantar fasciitis is an overuse condition of the plantar fascia at it's attachment to the
calcaneus. It commonly results from activities that require maximal plantarflexion of
the ankle and dorsiflexion of the metatarsophalangeal joints e.g. running. It is usually
painful in the heel and the arch of the foot. Stretching the plantar fascia may
reproduce pain. There may be some underlying leg or foot abnormal biomechanic

Treatment and Management

   1.   Avoid doing activity that aggravates the pain.
   2.   Ice the foot after activity.
   3.   Stretching of the plantar fascia.
   4.   Stretching of the gastrocnemius and soleus.
   5.   Heel cup or wedge can be inserted into shoes to relieve the pressure.
   6.   NSAIDs (anti-inflammatory)
   7.   Transverse friction massage therapy
   8.   Electrotherapy, taping.

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