Ankle and Foot joints

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					                                                                              Ankle and Foot joints

Talocrural joint

Joint type- synovial hinge joint

Articulating surfaces

Tibia- distal end of tibia provides a continuous articular surface and medial edge of talus. Trochlear surface is concave anteroposteriorly and slightly convex transversely with
a blunt sagittal ridge which fits into corresponding groove on the talus. On either side of the medial and lateral ridge is a gutter, which receives the corresponding lips of the
talar trochlear. Medial malleolus.

Fibula- distal end of the fibula is triangular in shape with inferior apex being slightly convex. Base of the triangle extends up as far as the tibial articulating surface. Forms the
lateral malleolus.

Talus- body of talus forms the whole of the distal surface of the talocrural joint. The trochlear surface is convex anteroposteriorly with a central longitudinal groove bound by
lateral medial lips, slightly broader in front than behind. The medial surface is nearly plain except anteriorly where it is inclined medially articulates with medial malleolus,
lateral surface runs obliquely, anteriorly and laterally being concave superoinferiorly as well as anteroposteriorly articulates with lateral mallelous.

Joint capsule and Synovial membrane

Fibrous capsule completely surrounds the joint attaching above to the articular margins of the tibia and fibula, and below to the corresponding articular areas of the talus.
Except anteriorly where it attaches to the neck of the talus. The capsule is weakened anteriorly posteriorly to allow dorsi and plantar flexion, but strengthened medially and
laterally by the medial and lateral collateral ligaments. A synovial fold posteriorly pads interval between the tibia, fibula and the transverse tibiofibular ligament. The synovial
membrane lines the joint capsule and is reflected anteriorly on to the articular margins. Synovial membrane extends up towards the tibia and fibula up towards the interosseus
membrane.

Ligaments

Ligaments                             Origin                                                        Insertion
Deltoid ligaments (4 parts)
Anterior tibiotalar                   Apex of medial malleolus                                      Runs obliquely forwards and downwards inserts onto neck of talus.

Posterior tibiotalar                  Tip of medial malleolus                                       Runs lat and backwards to the comma shaped facet of talus
Tibionavicular                        Tip of medial malleolus                                       Tuberosity of navicular bone.
Tibiocalcaneal                        Tip of medial malleolus                                       Sustemticulum tali of talus
Lateral ligaments (3 parts)
Anterior talofibular                    Anterior border of the tip of lateral malleolus               Neck of talus
Posterior talofibular                   Bottom of lateral malleoli fossa                              Lateral tubercle of posterior process of talus
Calcaneofibular                         Tip of lateral malleoli                                       Peroneal tubercle on calcaneus
Role of collateral ligaments
Laxity of the ankle joint depends on the position of the ankle. Dorsi flexion being classed as a closed packed position so there is very little ankle laxity available. Plantar
flexion is an open packed position; there is a lot of laxity available in the joint whilst in this position.
Prime role of the collateral ligaments is to offer stability and controlling the movements of which it is capable. Damage to some or all of the ligaments compromise the
integrity of the joint.
The tibiocalcaneal/ tibionavicular bands control abduction of the talus. While adduction is controlled by the calcaneofibular ligament. The anterior tibiotalar/ talofibular
ligaments control plantar flexion. While dorsi flexion is controlled by the posterior tibiotalar/ talofibular ligament. External rotation of talus is controlled by both the
anterior tibionavicular/ tibiotalar and together with the anterior talofibular ligament they prevent internal rotation. The anterior talofibular ligament plays an extremely
important role in ankle stability possibly the prime stabilizer. It provides significant resistance to a varus tilt to the talus in all positions of flexion


Blood and nerve supply

Blood supply- Blood supply is from malleolus branches of the anterior tibial, peroneal and posterior tibial arteries. Venous drainage is from corresponding arterial branches.
Nerve supply- Fed by roots L4- S2 by articular branches from the tibial nerve and lateral branches of the deep peroneal nerve.

Palpation

Both medial and lateral malleoli can be palpated on their anterior and posterior borders.
Peroneal tendons can be palpated behind the lateral malleolus.
Tibialis posterior and flexor digitorum longus can be palpated behind the medial malleolus.

Stability

The anteroposterior stability of the ankle joint and its articulating surfaces depend on the effect of gravity to keep the tibia pressed against the superior surface of the talus.
Due to the congruency of the joints articulating surfaces tibia concave and tibia/fibular complex form a concave shape. The collateral ligaments improve the integrity of the
joint, as well as the muscles crossing the talocrural joint. The ankle can only dorsi flex and plantar flex. Transverse stability is provided by the interlocking structures of the
articulating surfaces. The malleoli grip the talus each side. Collateral ligament prevent any rolling movements of the talus around a longitudinal axis.
Movement

Movement (from neutral)             Range                               End feel/ ltd factors
Dorsi flexion                       AROM 0-20 degrees                   Firm/ hard end feel/ tension in posterior joint capsule, deltoid and posterior ligaments, contact
                                                                        between talus and tibia and fibular.
Plantar flexion                     AROM 0-50 degrees                   Firm/ hard end feel/ tension in anterior joint capsule and anterior ligaments. Contact between
                                                                        talus and tibia.

Accessory movements

    1.   Longitudinal distraction in which the talus is pulled away from the tibia and malleoli. Performed with the subject lying in prone position.
    2.   Anteroposterior direction lying in a supine position knee flexed at 90 dg keeping the sole of the foot on the plinth. Gripping tibia and fibular it can then be moved
         applying appropriate direction and force.
Subtalar joint

Joint type- synovial gliding joint (saddle).

Articulating surface

Talus- the articulating surface of concave facet of the underside of the body of the talus.

Calcaneus- the convex surface of the calcaneus, it is roughly oval with the long axis running anterolaterally. Consequently the joint surface can be seen as being cylindrical,
axis of the cylinder running obliquely from anterior, lateral and superior to posterior, medial and inferior.

Joint capsule- thin loose fibrous capsule surrounds the joint and attaches close to the margins of the articular surfaces. It is thickened medially, posteriorly and laterally
forming a medial, posterior and lateral talocalcaneal ligament. Capsule is lined with synovial membrane the joint cavity does not communicate with that of any joint. Anterior
part of capsule is thin and attaches to the floor and roof of the sinus tarsi. Also attaching within the sinus tarsi is the posterior part of the talocalcaneonavicular joint capsule.
Where the two capsules are adjacent to each other they are thickened and form the interosseus (talocalcanean) ligament.

Ligaments

Ligaments                            Origin                               Insertion
Medial talocalcanean                 Medial tubercle posterior            Posterior border of sustemticulum tali
                                     process of talus
Posterior talocalcanean              Lateral tubercle of talus            Medial surface of calcaneus
Lateral talocalcanean                Lateral tubercle of talus            Lateral surface of calcaneus
Ligamentum cervicis                  Neck of talus                        Calcaneal directly below
Interousseous talocalcanenean        Floor of sinus tarsi                 Neck of talus


Blood and nerve supply- n/a

Relations- n/a

Palpation- n/a
Stability- the interosseous talocalcanean ligament plays an essential part in maintaining stability of the subtalar joint. It occupies a central position and lies directly below the
long axis of the leg acting as a fulcrum around which movements of the leg and foot occur. For this reason it is under constant twisting and stretching pressure. Collateral
ligaments reinforce the stability as well as flexor halluci longus and peronei muscles.

Movement-

Movement                             Range                                End feel/ ltd factors
Inversion                            0-5 degrees                          Firm/ tension in lateral collateral ligaments, lateral ankle joint capsule, lateral ankle ligaments.
                                     0-30 degrees (forefoot)
Eversion                             0-5 degrees                          Hard firm feel/ contact between talus and calcaneus. Tension in medial capsule and medial
                                     0-15 degrees (forefoot)              structures.

Accessory movements- in prone with the talus fixed the calcaneaus can glide under it.
Talocalcaneonavicular joint

Joint type- synovial ball and socket joint.

Articulating surface

Talus- ball is formed by large continuous facet on head and neck of talus.

Calcaneus- part of the socket is the sustenticulum tali on the calcaneus. Concave in shape

Navicular- on the second part of the socket are faint ridges upon the navicular anteriorly. Concave in shape.

Joint capsule- thin and encloses the common articular cavity. Due to the nature of the joint the capsule is only present on the posterior and dorsal aspect of the joint. Fuses
into the deltoid, plantar calcaneonavicular, bifurcate and interosseous (talocalcanean) ligaments.

Synovial membrane- lines all non-articular surfaces, including the fat pad that lies between the ligaments within the joint.

Ligaments

Ligaments                                           Origin                                           Insertion
Plantar calcaneonavicular                           Anterior end of the medial border of the         Attaches to the entire width of the inferior surface of the navicular.
(Also known as the spring ligament)                 sustemticulum tali posteriorly
Bifurcate                                           Upper surface of the anterior end of             Lateral surface of the navicular bone.
                                                    calcaneus
Dorsal talonavicular                                Neck of talus                                    Dorsal surface of navicular.

Blood and nerve supply- n/a
Relations- n/a
Palpation- n/a

Stability- the ligaments along with the tendon of tibilias posterior are major elements in providing stability to this joint. They resist the tendency of the body weight to push
the head of talus down between the navicular and calcaneus.

Movement- further explanation in gait cycle.
Calcaneocuboid joint

Articulating surface

Calcaneus- upper part of facet on the calcaneus, which is concave transversely and vertically, whilst the lower part is convex both transversely and vertically.

Cuboid- the articulating surface is concavoconvex in relation to the calcaneus surface.

Joint capsule and synovial membrane- thin and simple fibrous capsule lines the joint. Thickened above and below by the dorsal/ plantar calcaneocuboid ligaments, synovial
membrane lines the entire joint and articulating surfaces

Ligaments

Ligaments                            Origin                                                                Insertion
Dorsal calcaneocuboid                N/a                                                                   N/a
Bifurcate                            Deep hollow on the upper surface of calcaneus.                        Adjacent dorsomedial angle of the cuboid.
Plantar calcaneocuboid               Rounded eminence at anterior end of inferior surface of               Plantar surface of cuboid behind ridge that bounds peroneal
                                     calcaneus                                                             groove.
Long plantar                         Posterior and anterior tubercle of calcaneus                          Attaches to ridge and groove on the cuboid


Blood and nerve supply- n/a

Relations- n/a

Palpation- line can be felt proximal to the 5th metatarsal tubercle.

Stability- receives the weight of the body as it is transmitted to the lateral part of the longitudinal arch of the foot. Stability for the joint is provided by the plantar
calcaneocuboid and long plantar ligament. Tendon of peroneus longus also reinforces the ligaments and integrity of the longitudinal arch.

Movement- full explanation in gait cycle.
Cuneonavicular joint

Articulating surface

Cuneiforms 1st /2nd /3rd - posterior end of the cuneiform bones.

Navicular- convex in shape with 3 distinct facets separated by vertical facets.

Joint capsule- fibrous capsule covers the entire joint except laterally where it may communicate with the cuboideonavicular joint when present.

Synovial membrane- present

Ligaments

Ligaments                                                                             Origin                                     Insertion
Dorsal cuneonavicular                                                                 navicular                                  Each cuneiform
Plantar cuneonavicular (blend with tibilias posterior tendon)                         Navicular                                  Each cuneiform

Blood and nerve supply- n/a

Relations- n/a

Palpation- n/a

Stability- n/a

Movement- n/a
Cuneocuboid joint

Articulating surface

Cuboid- round facet on the posterosuperior surface of the cuboid.

3rd cuneiform- large round articular surface of posterolateral aspect of lateral cuneiform.

Joint capsule-n/a

Synovial membrane- n/a

Ligaments

Ligaments                           Origin                                                    Insertion
Dorsal cuneocuboid                  Dorsal surface of cuneiform                               Dorsal surface of cuboid
Plantar cuneocuboid                 Plantar surface of cuneiforms                             Plantar surface of cuboid.
Interosseous cuneocuboid            Anterior surface of cuneiform                             Anterior surface of the cuboid

Blood and nerve supply- n/a

Relations- n/a

Palpation- the tuberosity of the navicular can be palpated.

Stability- stability and integrity of the joint is maintained by the strong interosseous and plantar intercuneiform and cuneocuboid ligaments. Peroneus longus tendon provides
additional support.

Movement- permit slightly gliding movements between the adjacent bones.
Tarsometatarsal joint

Articulating surface

1st/2nd/3rd Cuneiforms, 1st/2nd/3rd/4th Metatarsals and Cuboid- 1st metatarsal articulates with 2nd cuneiform, 2nd metatarsal held in mortise of the 3 cuneiforms it is the least
mobile. 3rd metatarsal articulates with the lateral cuneiform. 4th metatarsal articulates with lateral cuneiform and cuboid. The 5 th metatarsal articulates with the cuboid only.

Joint capsule and synovial membrane- joint cavity is separated into 3 distinct parts, by 2 strong interosseous ligaments. The medial cavity is confined to the articulation
between 1st metatarsal and medial cuneiform. The intermediate cavity includes the articulations of 2nd and 3 rd metatarsals and intermediate and lateral cuneiform. The lateral
cavity encloses the articulation between the 4th and 5th metatarsals and the cuboid. Very few fibres actually form a joint capsule.

Ligaments

Ligaments                            Origin                                                                          Insertion
Dorsal tarsometatarsal               Adjacent dorsal surfaces of the tarsal bones                                    Adjacent dorsal surfaces of the metatarsal bones
Interosseous tarsotatarsal           Passes from anterolateral surface of medial cuneiform                           Medial side of the base of the 2nd metatarsal

                                     Anterolateral angle of lateral cuneiform to medial surface of 4th               Medial surface of the base of 4th metatarsal.
                                     metatarsal.
Plantar tarsotatarsal                N/a                                                                             N/a

Blood and nerve supply- n/a

Relations- n/a

Palpation- n/a

Stability- stability is enhanced medially due to the insertion of tibilias anterior/ posterior, peroneal longus also improve stability of the tarsometatarsal joint of great toe.

Movement-n/a
Intermetatarsal joint

Articulating surface

4 lateral metatarsal articulate by small synovial joints between the facets and their adjacent side. No joint between the 1 st and 2nd metatarsals as they are joined together by
interosseous fibres only. The joint spaces are closed on their dorsal and plantar ligament passing between the adjacent surfaces of the bases of the metatarsals.

Ligaments- See tarsometatarsal ligaments

Blood and nerve supply- branches from the dorsal pedis on their dorsal aspects and their medial and lateral plantar arteries of their plantar aspect. Nerve supply is from the
deep peroneal nerve dorsally and the medial and lateral plantar nerves on their plantar aspect.

Relations- n/a

Palpation- n/a

Stability- the strong dorsal, plantar and interosseous ligaments help maintain the transverse arch of the foot by holding the bases of the metatarsals together.

Movement- see gait cycle.
Metatarsophalangeal joint

Articulating surface- synovial condyloid joints between the rounded head of the metatarsal and base of the proximal phalanx.

Joint capsule & synovial membrane - the capsule is loose and attaches close to the articular margins of the bones. It is also lined by synovial membrane which also attaches to
the articular margins. The joint is reinforced by the below ligaments.

Ligaments

Ligaments                           Origin                                                                       Insertion
Collateral                          Tubercles each side of the metatarsal head. In a fanning arrangement.        Attaching on the proximal end of adjacent phalanx
                                                                                                                 restrict flexion.
Plantar                             Proximal plantar border of the proximal phalanx forming articular            Attaches to the sides of the collateral and deep
                                    surface for metatarsal head.                                                 transverse metatarsal ligaments.
Deep transverse metatarsal          N/a                                                                          N/a
(Connects all heads and joint
capsules)

Blood and nerve supply- dorsal and plantar digital vessels and nerves.

Relations- n/a

Palpation- plantar flexion the heads of the metatarsal can be seen.

Stability- long flexor and extensor tendons cross the joints on the plantar and dorsal sides respectively. This provides a reasonable amount of stability for the 4 lateral toes but
not the great toe, as there are no tendons crossing the joint only fascia.

Movement- permit plantar/ dorsi flexion, abduction, adduction and circumduction (accessory)
Interphalangeal joint

Articulating surface- head of more proximal phalanx articulates with the next distal phalanx.

Joint capsule- attaches closely to articulating margins reinforced/ replaced by collateral ligaments at the side.

Synovial membrane- lined by a synovial membrane.

Ligaments

Ligaments                            Origin                                                                         Insertion
Collateral                           Tubercles each side of the metatarsal head. In a fanning arrangement.          Attaching on the proximal end of adjacent phalanx
                                                                                                                    restrict flexion.
Plantar                              Proximal plantar border of the proximal phalanx forming articular              Attaches to the sides of the collateral and deep
                                     surface for metatarsal head.                                                   transverse metatarsal ligaments.

Blood and nerve supply- dorsal and plantar digital vessels and nerves.

Relations-n/a

Palpation- n/a

Stability- n/a

Movement – plantar/ dorsi flexion.

				
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posted:8/20/2011
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