Order Form Total Contact Insoles Patient Order No: Fill & Download for Free

The foot and ankle form a complex system which consists of 28 bones, 33 joints, 112 ligaments, controlled by 13 extrinsic and 21 intrinsic muscles.The foot is subdivided into the rearfoot, midfoot, and forefoot.It functions as a rigid structure for weight bearing and it can also function as a flexible structure to conform to uneven terrain. The foot and ankle provide various important functions which includes:supporting body weight,providing balance,shock absorption,transferring ground reaction forces,compensating for proximal malalignment,and substituting hand function in individuals with upper extremity amputation/paralysis.[1][2][3]StructureAnatomy ankle and foot 3.jpgThe ankle or tibiotalar joint constitutes the junction of the lower leg and foot. The osseous components of the ankle joint include the distal tibia, distal fibula, and talus.The anatomic structures below the ankle joint comprise the foot, which includes:Hindfoot: The hindfoot, the most posterior aspect of the foot, is composed of the talus and calcaneus, two of the seven tarsal bones. The talus and calcaneus articulation is referred to as the subtalar joint, which has three facets on each of the talus and calcaneus.Midfoot: The midfoot is made up of five of the seven tarsal bones: navicular, cuboid, and medial, middle, and lateral cuneiforms. The junction between the hind and midfoot is termed the Chopart joint, which includes the talonavicular and calcaneocuboid joints.Forefoot: The forefoot is the most anterior aspect of the foot and includes the metatarsals, phalanges (toes), and sesamoid bones. There are a metatarsal and three phalanges for each digit apart from the great toe, which only has two phalanges. The articulation of the midfoot and forefoot forms the Lisfranc joint.[4]Talocrural (TC) JointThe talocrural joint is formed between the distal tibia-fibula and the talus, and is commonly known as the ankle joint. The distal and inferior aspect of the tibia – known as the plafond – is connected to the fibula via tibiofibular ligaments forming a strong mortise which articulates with the talar dome distally. It is a hinge joint and allows for dorsiflexion and plantarflexion movements in the sagittal plane.Subtalar (ST) JointSubtalar JointIt is also known as the talocalcaneal joint and is formed between the talus and calcaneus.There are three facets on each of the talus and calcaneus.The posterior subtalar joint constitutes the largest component of the subtalar joint.The subtalar joint allows for ankle and hindfoot inversion and eversion.[4]Midtarsal (MT) JointChopart's JointAlso known as transverse tarsal joints or Chopart’s joint. It is an S-shaped joint when viewed from above and consists of two joints – the talonavicular joint and calcaneocuboid joint.Talonavicular (TN) Joint - Formed between the anterior talar head and the concavity on the navicular. It does not have its own capsule, but rather shares one with the two anterior talocalcaneal articulations.Calcaneocuboid (CC) Joint - Formed between the anterior facet of the calcaneus and the posterior cuboid. Both articulating surfaces present a convex and concave surface, with the joint being convex vertically and concave transversely. Very little movement occurs at this joint.Tarsometatarsal (TMT) Joint ComplexAlso known as Lisfranc’s joint, this complex divides the midfoot from forefootThe distal tarsal rows including the three cuneiform bones and cuboid articulate with the base of each metatarsal to form the TMT complex. It is an S-shaped joint and is divided into 3 distinct columns[1]:Medial – composed of 1st metatarsal and medial cuneiformMiddle – composed of 2nd and 3rd metatarsals and intermediate and lateral cuneiforms, respectivelyLateral – composed of 4th and 5th metatarsals and the cuboidMetatarsophalangeal (MTP) Joints and Interphalangeal (IP) JointsThe MTP joints are formed between the metatarsal heads and the corresponding bases of the proximal phalanx. The interphalangeal joints of the toes are formed between the phalanges of the toes. Each toe has proximal and distal IP joints except for the great toe which only has one IP joint.Joint Type of Joint Plane of Movement MotionTC joint Hinge Sagittal Dorsiflexion & PlantarflexionST joint CondyloidMainly transverseSome sagittalInversion & EversionDorsiflexion & PlantarflexionMT jointTN joint - Ball and socketCC joint - modified saddleLargely in transverseSome sagittalInversion & EversionFlexion & ExtensionTMT joint PlanarMTP joint CondyloidSagittalSome TransverseFlexion & ExtensionAbduction & AdductionIP joint Hinge Sagittal Flexion & Extension[1]Kinematics[5]Talocrural JointAnkleAxisPost.jpgThe tip of the medial malleoli is anterior and superior to the lateral malleoli, which makes its axis oblique to both the sagittal and frontal planes. The axis of rotation is approximately 13°-18° laterally from the frontal plane and at angle of 8°-10° from the transverse plane.[1][6] Motion in other planes is required (like horizontal and frontal plane) to achieve a complete motion for plantarflexion and dorsiflexion.[7] The reported normal available range for dorsiflexion varies in the literature between 0°-16.5°[8] and 0°-25°[9], and this changes when in weightbearing. The normal range of plantarflexion has been reported to be around 0°- 50°.AnkleAxisSup.jpgSubtalar JointSTJaxis.jpgThe axis of the subtalar joint lies about 42° superiorly to the sagittal plane and about 16° to 23° medial to the transverse plane.[10][11] The literature presents vast ranges of subtalar motion ranging from 5° to 65°.[11] The average ROM for pronation is 5° and 20° for supination. Inversion and eversion ROM has been identified as 30° and 18°, respectively.[12] Total inversion-eversion motion is about 2:1 and a 3:2 ratio of inversion-to-eversion movement.[7]Midtarsal JointThe midtarsal joint rotates at two axes due to its anatomy, making its motion complex. The longitudinal axis (image 'A' below) lies about 15° superior to the horizontal plane and about 10° medial to the longitudinal plane. The oblique axis (image 'B' below) lies about 52° superior to the horizontal plane and 57° from the midline. The longitudinal axis is close to the subtalar joint axis and the oblique axis is similar to the talocrural joint axis.Midtarsal Longitudinal axis.pngMT Joint LockingAn important function of the foot is propulsion of weight during stance phase[13]. This function is made possible by the MT joint locking and unlocking. During heel strike, the foot needs to be flexible in order to adjust to the surface and the MT joint unlocks to provide this flexibility. Later in the gait cycle, the foot then needs to act as a rigid lever to propel the weight of the body forward which is made possible by MT joint locking. During pronation/eversion of the foot, the axis of the TN and CC joints are parallel to each other, making it easier for them to independently move and unlock the MT joint. The axes cross each other during supination/inversion which locks the MT joint making it difficult to move. Blackwood et al[14] concluded that there is increased forefoot movement when the calcaneus is everted. This is consistent with the MT joint locking mechanism.[15]Lisfranc Joint ComplexThe degree of sagittal motion for each TMT joint is presented below:[7]TMT Joint Degree of Motion1st 1.6o2nd 0.6o3rd 3.5o4th 9.6o5th 10.2oMTP and IP jointsThe MTP joints are bi-axial and move in sagittal and transverse planes. MTP joints have a greater sagittal plane movement and very little transverse plane movement. At the MTP joints, hyperextension is about 90° and flexion is about 30° to 50°. IP joints are hinge joints which limit motion in one direction.ArthrokinematicsArthrokinematics refers to the movement of joint surfaces.Talocrural Joint – The talus rolls within the mortise during dorsiflexion and plantarflexion. During dorsiflexion, the talus rolls anteriorly and it glides posteriorly. While with plantarflexion, the talus rolls posteriorly and glides anteriorly.Subtalar Joint – Secondary to the anatomy of the subtalar joint, the coupled motion of dorsiflexion, abduction and eversion produces pronation, whereas the coupled motion of plantarflexion, adduction and inversion produces supination. It presents two point of articulations – anterior talocalcaneal articulation and posterior talocalcaneal articulation.[16] During open kinetic chain inversion, the calcaneus rolls into inversion and it glides/slides laterally. And during eversion, the calcaneus rolls into eversion and it glides/slides medially.Midtarsal Joint – For the Talonavicular joint, the concave navicular moves on the convex talus and hence the roll and glide is in the same direction of movement. The calcaneocuboid joint is a saddle joint so the direction changes depending on the movement. During flexion-extension, the cuboid is concave and the calcaneus is convex; hence, the roll and glide occurs in the same direction as the talonavicular joint. During abduction-adduction, however, the cuboid is convex and the calcaneus is concave, and therefore the roll and glide occurs in the opposite direction.Lisfranc Joint – Secondary to the bony and ligamentous anatomy of the complex, its primary role is stability of the midfoot and has very little movement. It has three distinct arches and the main stabilizing structure of TMT joint is a Y-shaped ligament known as Lisfranc’s ligament.MTP and IP Joints – Glide and roll is in the same direction as the movement for the MTP joints as the concave base of the phalanx moves on the convex head of the metatarsal. The same is true for the IP joints, where glide and roll is in the same direction as the concave distal phalanx moves on the convex proximal phalanx.Joint Closed-Packed Position Open-Packed Position Capsular Pattern Concave Surface Convex SurfaceConcave-convex ruleRoll & glideTalocrural joint Full dorsiflexion 10o of plantarflexion and midway between pronation and supination Limitation of plantarflexion, although clinically dorsiflexion limitation is more common Proximal - Mortise formed by Tibia, tibiofibular ligament and fibula Distal - Trochlear surface of Talar dome Opposite directionSubtalar joint Full inversion Inversion/plantarflexion Limitation of inversion in chronic arthritis. Limitation of eversion in traumatic Proximal - Anterior, middle and posterior facet of talus Distal – Calcaneal Anterior, middle and posterior talar articular surface Opposite directionTalonavicular joint Full supination Midway between extreme ROM Limitation of dorsiflexion, plantarflexion, adduction and internal rotation. Proximal - Head of Talus Distal - Concavity on Navicular bone for talus Same directionCalcaneocuboid joint Full supination Midway between extreme ROM Limitation of dorsiflexion, plantarflexion, adduction and internal rotation. Distal - Cuboid is concave during flexion-extension.Calcaneus is concave during adduction-abductionProximal - Calcaneus is convex during flexion-extension.Cuboid is convex during adduction-abductionFlexion-extension = Same directionAdduction-abduction = Opposite directionLisfranc joint Full supination Midway between supination and pronation1st MTP joint Hyperextension Slight (10o) extension Loss of motion more in extension than flexion Distal - Base of phalanx Proxmial - Head of Metatarsal Same direction2nd to 5th MTP joint Maximum flexion Slight (10o) extension Loss of flexion Distal - Base of phalanges Proximal - Head of metatarsals Same directionInterphalangeal Joint Full extension Slight flexion Restriction in all direction with more in extension Distal Phalanx Proximal Phalanx Same directionGait and the Foot8 phases of gait cycle.pngGait is made up of repetitive cycles of the stance phase when the foot is on the ground (foot strike, mid stance, and terminal stance) and the swing phase when the foot is in the air. When running, there is an additional phase: the float phase when both feet are off the ground.During walking foot strike, the foot is supinated, and Chopart joint is locked, making the foot rigid when the heel first lands.The foot pronates and flattens during mid-stance coming in full contact with the surface.Terminal stance is then characterized by propulsion via heel off and toe-off.The Lisfranc joint allows slight dorsiflexion and plantarflexion.Force then transfers to the middle column of the forefoot during the toe-off phase of stepping, and the forefoot supinates.The lateral column acts during the final phase of push-off while stepping, providing primarily sensory input.The base of the fifth metatarsal alone absorbs significant force and weight.The combination of fixed midfoot, slightly flexible Lisfranc joint, and flexible metatarsophalangeal joints create a lever for propulsion during gait[4].Influence on Kinetic Chain/GaitAs discussed above with MT joint locking, the transition in the foot from pronation to supination is an important function that assists in adapting to uneven terrain and acting as a rigid lever during push off.During pronation, the MT joint unlocks, providing flexibility of the foot and assisting in maintaining balance.During supination, the MT joint locks, providing rigidity of the foot and maximizing stability.If the foot remains pronated, this would lead to hypermobility of the midfoot and place greater demand on the neuromuscular structures that stabilize the foot and maintain upright stance. Whereas if the foot remains supinated, the midfoot would be hypomobile, which would compromise the ability of the foot to adjust to the terrain and increase demand on surrounding structures to maintain postural stability and balance. Cote et al.[17] concluded that postural stability is affected by foot position in both static and dynamic conditions. Chain reactions occur secondary to the positioning of the foot.In closed chain movements, the following kinetic chain reaction takes place in an over-pronated foot:Kinetic chain.pngCalcaneal eversionAdduction and plantarflexion of talusMedial rotation of talusMedial rotation of tibia and fibulaValgus at kneeMedial rotation of femurAnterior tilting of pelvisIn closed chain movement the following kinetic chain reaction takes place in an over-supinated foot:Calcaneal inversionAbduction and dorsiflexion of talusLateral rotation of talusLateral rotation of tibia and fibulaVarus at kneeLateral rotation of femurPosterior tilting of pelvisArches of FootArches of foot.jpgThe arches of the foot provide functions of force absorption, base of support and acts as a rigid lever during gait propulsion.The medial longitudinal arch, lateral longitudinal arch and transverse arch are the 3 arches that compromises arches of foot.Medial Longitudinal Arch (MLA)It is the longest and highest of all the arches. Bony components of MLA include the calcaneus, talus, navicular, the three cuneiform bones and the first 3 metatarsals. The arch consists of two pillars: the anterior and posterior pillars. The anterior pillar consists of the head of first 3 metatarsal heads whereas the posterior pillar consists of the tuberosity of the calcaneus. The plantar aponeurosis forms the supporting beam connecting the two pillars[1]. The apex of the MLA is the superior articular surface of talus. In addition to the plantar aponeurosis the MLA is also supported by the spring ligament and the deltoid ligament. The Tibialis anterior and posterior muscles play an important role in raising the medial border of the arch, whereas Flexor hallucis longus acts as bowstring.Lateral Longitudinal Arch (LLA)It is the lowest arch and compromises of the calcaneus, cuboid and fourth & fifth metatarsal as its bony component. Like the Medial Longitudinal Arch (MLA) the posterior pillar consists of the tuberosity of the calcaneus whereas the anterior pillar is formed by the metatarsal heads of 4th and 5th metatarsals.The plantar aponeurosis, and long & short plantar ligaments provide support for the LLA. The Peroneus longus tendon plays an important role in maintaining the lateral border of the arch.Transverse ArchIt is concave in non-weight bearing and runs medial to lateral in the midtarsal and tarsometatarsal area. The bony component of the arch consists of the metatarsal heads, cuboids and 3 cuneiform bones. The medial and lateral pillars of the arch is formed by the medial and lateral longitudinal arch respectively. The arch is maintained by the Posterior tibialis tendon and the Peroneus longus tendon which cross the plantar surface from medial to lateral and lateral to medial respectively.Windlass Mechanism of the FootWindlass.jpgThe plantar aponeurosis acts similarly to a windlass mechanism. A windlass is typically a horizontal cylinder that rotates with a crank or belt on a chain or rope to pull heavy objects. The common use of a windlass is seen in pulling the anchor of the ship known as an anchor windlass. This mechanism can be seen in the foot. When the MTP joints are hyperextended, the plantar aponeurosis becomes taut as it is wrapped around the MTP joints. This actions brings the metatarsal and tarsal bones together converting it into a rigid structure and eventually causing the longitudinal arches to rise. This function is important in providing a rigid lever for gait propulsion during push off.Function of the FootThe foot requires sufficient mobility and stability for all of its functions. Mobility is necessary for absorbing the ground reaction force of the body.[13] Subtalar pronation has a shock absorbing effect during initial heel contact.[13][1][18][17] Pronation is also necessary to enable rotation of the leg and to absorb the impact of this rotation. Subtalar pronation plays a role in shock absorption through eccentric control of the supinators.[13] On the other side, the joint of Chopart becomes unlocked so that the forefoot can stay loose and flexible.[1] In midstance, the foot needs mobility to adapt to variation in surfaces.[13][1][18][17]Foot stability is necessary to provide a stable base for the body. The foot needs the capacity to bear body weight and act as a stable lever to propel the body forward.[13][1][18][17] This function requires pronation control of the subtalar joint.[1][18][17]Normal foot function provides the foot with the capacity to transform at the right time from a mobile adapter to a rigid lever. The foot needs sufficient mobility to move into all the positions of the gait cycle while maintaining mobility and stability.[10][13] Physiological mobility is essential; if mobility was too large, the foot would not have the capacity to be stable. When this condition is fulfilled, the joint can support standing in the stable maximally close packed position.[13][1] When the normal transition of the two functions isn’t normal many overload injuries can be observed, like in the foot, under leg, upper leg but also in the lower back.[1][18][17] Therefore the three phases of ground contact have to fall in the normal time interval, otherwise some compensation mechanisms (example: genu recurvatum in cases of reduced dorsiflexion) will be used, which cause overuse syndromes.[1][19](Example: chondromalacia, shinsplints...)In the transition from midstance to propulsion phase, the mechanisms often fail. The transition from eversion to inversion is facilitated by the tibialis posterior muscle.[13] The muscle is stretched like a spring and potential energy is stored.[13] At the end of the midstance, the muscle passes from eccentric to concentric work and the energy is released. The tibialis posterior muscle then causes abduction and dorsiflexion of the caput tali in which the hindquarter is everted.[13] At the same time, the peroneus longus muscle, at the end of the midstance, will draw the forefoot with a plantar flexion of the first toe.[13] This is how the forefoot becomes stable.[13]When the forefoot moves in the propulsion phase, the windlass phenomena starts. When the dorsiflexion of the metatarsophalangal joints begins the plantar fascia undergoes stress, so the os calcaneus becomes vertical and teared in inversion. Like this, the hindquarter rests in inversion in the unwinding of the forefoot.[13]When there are some abnormalities in the normal gait cycle of functions of the body, some functional ortheses can be used.[1][18][17] This ortheses have the capacity to correct the biomechanical function of the foot.[1][18][17] In contrast, insoles only support the arch of the foot. Reduced or limited mobility in the lower limbs can be caused by a articular limitation.[1][18][17] In these cases some classic mobilizations or mobilizations according to manual therapy can be applied.[1][18][17] When the cause is a muscle shortening some stretching can be prescribed. Also, good (running) shoes are indicated.[20]Related articlesBiomechanical Assessment of Foot and Ankle - PhysiopediaIntroduction Foot assessment is a common approach in clinical practice for classifying foot type with a view to identifying possible aetiological factors relating to injury and prescribing therapeutic interventions. This approach is underpinned by a contextual model of the foot whereby structural alignment, or position of the foot, is used to infer characteristics of dynamic foot function, and theoretically establish injury mechanisms leading to pathology. This model of foot function is primarily derived from the work of Root et al who proposed static assessment measures to enable clinicians to identify deviations from an ideological ‘normal’ foot[1]. A large variety of methods have been developed to classify the foot based on structure and alignment. These methods include radiographic measurements, qualitative and semi-quantitative visual appraisal, anthropometric measurements, footprint analysis and analysis of captured images[2] Barnes and colleagues[3] suggested that quantitative measures of foot alignment were superior to a qualitative classification, based on better reliability. However, some researchers identify that observer subjectivity and bias may undermine the accuracy of these qualitative appraisal tools[2][1]. The lack of strong consensus between measures for foot classification underpins the need for a consensus on appropriate clinical measures of foot structure. Radiographic evaluation is the widely accepted gold standard for assessing foot and medial longitudinal arch alignment but there is currently no study that has validated visual/physical assessment approaches with radiographic measurements[2]. Terminology Tong et al[2] identified three foot type classifications: High Arch - High arch, pes cavus, cavus feet, varus foot, supinated, underpronating, nonpronating Neutral Foot - Neutral, normal, middle, average arch, rectus, normal foot Flat Foot - Flatfoot, pes planus, flat arch, planus feet, low arch, valgus foot Other classifications may include: Neutral Foot - Time Sequences of shock absorption, adaptation, stance, and propulsion take place at the correct time. Can do lots of mileage. Forefoot Varus - This foot spends too much time in the shock absorbing phase and converts to propulsion late. Symptoms include superficial knee pain, shin pains, Achilles tendonitis, I-T band pain, plantar fascitis, low back pain, etc. Orthotic treatment include orthotics that trick the foot into thinking it's down to the ground by bringing the ground up to the forefoot. Rearfoot Varus - This foot functions the same as Forefoot Varus when found with a Forefoot Varus. However, it functions like a Valgus foot when found with a Valgus Foot. Orthotic treatment is with an orthotic with rear foot control. Rigid Forefoot Valgus - This foot prematurely converts to propulsion at a time when it should still be absorbing shock. Symptoms include a tendency to ankle sprains, an unsure gait, every foot pain imaginable, leg muscle problems, stress fractures, etc. Orthotic treatment includes an orthotic that tricks the fore foot into thinking all the bones are level with each other by bringing the ground up to the foot. Very rare foot type. Flexible or Plantar Flexed First Metatarsal - This is the hardest foot type to classify. It is capable of functioning like a Forefoot Varus, Rearfoot Varus, and in some cases, like a Rigid Valgus, but not as severe. Symptoms include everything including sciatica. Orthotic treatment is with orthotics to put the forefoot in neutral. Equinus - This foot type has the inability to place the foot 10 degrees closer to the shin as the center of gravity passes over the ankle. Symptoms are a foot that spends too much time in the shock absorbing phase and little or no conversion to propulsion. Uncompensated, it is the worst running imbalance to treat. Stretching and heel lifts help most people but not all. Other biomechanical factors include: angles of the shin bones, knee, hip, and leg length diffentials, structural, and functional. Foot Posture Index (FPI-6) The foot posture index (FPI-6) is a clinical tool used to quantify the degree to which a foot is pronated, neutral or supinated. It is a robust measure and reliable means of static foot assessment and offers a more valid approach to assessing static foot structure[1]. A series of six observations and palpation are made by clinician and each measure is scored from -2 to 2. A total score of 0 is considered a neutral foot, a positive score is for pronated foot whereas supinated foot is given negative score. For scoring patient stands in double stance position and is asked to stand still. Following table describes the scoring criteria of FPI taken from Lee et al[4]. -2 -1 0 +1 +2 Talar head palpation Talar head palpable on lateral side/but not on medial side Talar head palpable on lateral/slightly palpable on medial side Talar head equally palpable on lateral and medial side Talar head slightly palpable on lateral side/palpable on medial side Talar head not palpable on lateral side/but palpable on medial side Supra and infra lateral malleoli curvature (viewed from behind) Curve below the malleolus either straight or convex Curve below the malleolus concave, but flatter/more than the curve above the malleolus Both infra and supra malleolar curves roughly equal Curve below the malleolus more concave than curve above malleolus Curve below the malleolus markedly more concave than curve above malleolus Calcaneal frontal plane position (viewed from behind) More than an estimated 5o inverted (varus) Between vertical and an estimated 5o inverted (varus) Vertical Between vertical and an estimated 5o everted (valgus) More than an estimated 5o everted (valgus) Prominence in region of TNJ (viewed at an angle from inside Area of TNJ markedly concave Area of TNJ slightly, but definitely concave Area of TNJ flat Area of TNJ bulging slightly Area of TNJ bulging markedly Congruence of medial longitudinal arch (viewed from inside) Arch high and acutely angled towards the posterior end of the medial arch Arch moderately high and slightly acute posteriorly Arch height normal and concentrically curved Arch lowered with some flattening in the central position Arch very low with severe flattening in the central portion - arch making ground contact Abduction/adduction of forefoot on rearfoot (view from behind) No lateral toes visible. Medial toes clearly visible Medial toes clearly more visible than lateral Medial and lateral toes equally visible Lateral toes clearly more visible than medial No medial toes visible. Lateral toes clearly visible. [4] Static Biomechanical Measures Medial Longitudinal Arch Angle (MLAA) The MLAA is robust uni-planar measure with a higher level of reliability, good agreement within measure for foot classification and broader foot classification boundaries[1]. A line is drawn from center of medial malleoli to navicular tuberosity and another line is drawn from navicular tuberosity to head of first metatarsal. The obtuse angle between these lines is known as LAA. The normal maximum LAA is between 1310 and 1520. Foot with lower LAA is considered to have low-arch and angle greater than 1520 is considered to be high-arched[5][6]. Feiss line is drawn from center of medial malleoli to head of 1st metatarsal. If it is high arch the navicular tuberosity is above the arch and in low-arched foot the navicular tuberosity is below the line[1]. Navicular Drop Test (ND) The navicular drop test is a measure to evaluate the function of the medial longitudinal arch, which is important for examination of patients with overuse injuries. Conflicting results have been found with regard to differences in navicular drop between healthy and injured participants. Normal values have not yet been established as foot length, age, gender, and Body Mass Index (BMI) may influence the navicular drop[7]. Langley et al[1] report that it is not an acceptable measure for characterising the foot. Rearfoot Angle (RFA) Four locations are palpated and marked using a skin marker pen. These are: (1) the base of the calcaneus; (2) the Achilles tendon attachment; (3) the centre of the Achilles tendon at the height of the medial malleoli; (4.) the centre of the posterior aspect of the calf 15 cm above marker three. The RFA was measured using a goniometer. The arms of the goniometer were aligned with the line connecting marker one and two (line 1) and the other arm with the lines connecting marker three and four (line 2). The RFA is measured as the acute angle between the projection of line one and line two. RFA ≥ 5° valgus represents a pronated foot type, 4° valgus to 4° varus a neutral foot and ≥ 5° varus a supinated foot. Tibial Torsion Measurement/Thigh-foot angle (TFA) To measure internal or external tibial torsion, patient is positioned in prone lying with knees flexed to 90o. A thigh-foot ankle (TFA) is measured between the line bisecting the posterior thigh and another line bisecting the foot. Normally the angle is between 0o to 30o, TFA more than 30o is excessive external tibial torsion and TFA less than 0o is considered internal tibial torsion[8]. [9] Subtalar Joint Neutral (STJN) It is the position in which the foot is neither pronated nor supinated. STJN acts as a reference point for STJ PROM and for lower extremity measurements. It is also the position which is used for orthosis fabrication and casting. To find STJN in OKC patient is in prone lying with the foot to be measured off the plinth and other lower extremity in the position to make a “4”. The talus is palpated between the thumb and index finger, and the forefoot is moved gently into supination-pronation to the point where medial and lateral aspect of talus are palpated equally on both sides. The foot is then moved into slight dorsiflexion until a soft end-feel, this is STJN position. For OKC measurement, once the STJN is established the angle between the line bisecting calf and another line bisecting calcaneus is taken. Normally the calcaneal angle is in 2o to 8o of varus/inversion. For CKC measurement, patient is standing on a box in unilateral stance position with support for balance. The talar dome congruency is palpated and the joint is place in STJN. The angle between the line bisecting the calf and the line bisecting the calcaneal is taken in this position. [10] Forefoot Angle The relationship of forefoot to rearfoot is measured to quantify forefoot varus or forefoot valgus. To measure the relationship, patient is prone lying with figure ‘4’ position for non-examined lower extremity. Once the STJN is achieved the relationship of forefoot to rearfoot is observed. The stationary arm of the goniometer is place perpendicular to line bisecting calcaneus with fulcrum on the point bisecting calcaneus. The movable arm of the goniometer is placed parallel to imaginary line passing through metatarsal heads. Forefoot angle of 0o is considered neutral, whereas positive degree is forefoot varus and negative degree is forefoot valgus[11]. [12] Arch Height Index (AHI) AHI is used to measure medial longitudinal arch and based on which foot can be categorized into high-arched, normal and low-arched. Williams & McClay[13] compared various foot measurements and ratios, and came up to the conclusion that height of dorsum of foot at 50% of foot length divided by truncated foot length was reliable and valid measure to determine AHI. A caliper and a graph-sheet can be used for the measurement. Patient is in standing position and caliper is used to measure foot length, height of the dorsum of the foot at 50% of foot length and truncated foot length as shown in the image. AHI = Height of the dorsum of foot at 50% of foot length ÷ Truncated foot length If the ratio is 0.356 or greater the foot is considered high arched, and ratio of less than or equal to 0.275 is considered a low-arched foot. Description of arch mobility can be assessed by having AHI taken at 10% and 90% of body weight. Arch Rigidity Index (ARI) is also been suggested which is calculated as standing AHI/sitting ARI and it can offer a valid and reliable alternative to navicular drop test[14]. Range of Motion Measurement (ROM) Subtalar Joint ROM For measurement of 1st MTP fulcrum of goniometer is placed on the medial aspect of 1st MTP joint axis. Stationary arm is parallel to the floor and movable arm is parallel to the proximal phalanx of great toe[15]. Normal ROM for flexion is 0-45o, and for extension is 0-70o. Normal ROM for lateral four MTP flexion is 0-40o, and lateral four MTP extension is 0-40o. Normal ROM for great toe IP flexion is 0-90o, and great toe IP extension is 0o. Normal ROM for lateral four PIP flexion is 0-35o and PIP extension is 0o. And normal ROM for lateral four DIP flexion is 0-60o and extension is 0-30o[11]. Talocural Joint ROM TC joint ROM of dorsiflexion and plantarflexion is taken with knee flexed, if the knee is extended the tightness of gastrocnemius can overshadow the TC joint ROM. Fulcrum of the goniometer is placed approximately 1.5 cm inferior to lateral malleoli. Stationary arm is parallel to longitudinal axis of fibula with taking head of fibula as the reference point. And the moveable arm is parallel to the longitudinal axis of 5th metatarsal with head of 5th metatarsal as reference[11][16],[17] Practical Considerations Barefoot vs Shoes Barefoot running has gained popularity within the running community. Many runners have been inspired by the 2010 book by Christopher McDougall, 'Born to Run'[18]. There is limited supporting evidence for barefoot running to prevent injuries[19] but the practice remains popular. During assessment, a clinician may ask their client to remove footwear so they are able to gain better appreciation of the biomechanics or gait. With some runners choosing to run barefoot and clinical scenarios where a client may be barefoot, it is important to consider any biomechanical differences between the two styles of running. In 2014, Hall et al. published a systematic review to evaluate biomechanical differences between running barefoot and shod, in Sports Medicine.[20] Evidence quality was moderate at best and they report reduced peak ground reaction force is reduced, increased foot and ankle plantarflexion and increased knee flexion at ground contact compared with shoe running. Geriatric Population The medial longitudinal arch acts as a 'shock-absorber' and is important in generating force for the propulsion phase of gait. From the middle age there is a gradual reduction in the height of the arch which manifests as greater medial contact of the midfoot.[21] as well as higher FP1-6 scores.[22] It is unclear why these changes occur to the adult foot but the prevailing thought is that degenerative changes and deconditioning to the tibialis posterior muscle and tendon is the most common reason for older adults with flat-feet.[23]Ankle and Foot Mobilisations - PhysiopediaIntroduction Joint mobilization refers to manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint. The altered joint mechanics may be due to pain and muscle guarding, joint effusion,contractures or adhesions in the joint capsules or supporting ligaments, or malalignment or subluxation of the bonysurfaces.[1] Tibiofibular Joint Distal tibiofibular distraction .The convex talus articulates with the concave mortise made up of the tibia and fibula. 10 degree plantarflexion is the resting position.Patient lies supine,with the lower extremity extended. The mobilization begins with the ankle in resting position and progress to the end of the avail- able range of dorsiflexion or plantarflexion. Therapist stands at the end of the table, wrap the fingers of both hands over the dorsum of the patient’s foot and pull the foot away from the long axis of the leg in a distal direction by leaning backward. https://www.youtube.com/watch?v=mw-B9E7Hxcw Talocrural Joint Anterior(Ventral) Glide The ventral glide is indicated to increase plantarflexion Patient lies prone, with the foot over the edge of the table. Working from the end of the table, Therapist stand and place his lateral hand across the dorsum of the foot to apply a grade I distraction.Place the web space of the other hand just distal to the mortise on the posterior aspect of the talus and calcaneus. He pushes against the calcaneus in an anterior direction (with respect to the tibia); this glides the talus anteriorly. Posterior (Dorsal) Glide This mainly to increase dorsiflexion. Patient lies supine with the leg supported on the table and the heel over the edge. Therapist stands to the side of the patient, stabilize the leg with his cranial hand or use a belt to secure the leg to the table.he then places the palmar aspect of the web space of his other hand over the talus just distal to the mortise.Wrap his fingers and thumb around the foot to main- tain the ankle in resting position. Grade I distraction force is applied in a caudal direction and the talus is glided posteriorly with respect to the tibia by pushing against the talus. Subtalar (Talocalcaneal) Joint Subtalar Distraction This mobilization is indicated in pain control, general mobility for inversion/eversion. The patient is placed in a supine position, with the leg supported on the table and heel over the edge.The hip is externally rotated so the talocrural joint can be stabilized in dorsiflexion with pressure from the therapist thigh against the plantar surface of the patient’s forefoot. The distal hand grasps around the calcaneus from the pos terior aspect of the foot. The other hand fixes the talus and malleoli against the table and the calcaneus is pulled distally with respect to the long axis of the leg. Subtalar Medial Glide or Lateral Glide Medial glide to increase eversion; lateral glide to increase inversion. The patient is side-lying or prone, with the leg supported on the table or with a towel roll. The Therapists aligns shoulder and arm parallel to the bottom of the foot, stabilizes the talus with the proximal hand and places the base of the distal hand on the side of the calcaneus medially to cause a lateral glide and laterally to cause a medial glide. Wraps the fingers around the plantar surface and apply a grade I distraction force in a caudal direction, then pushes with the base of the hand against the side of the calcaneus parallel to the planter surface of the heel. Intertarsal and TarsometatarsalPlantar Glide Indication: To increase plantarflexion accessory motions (necessary for supination) The patient is supine with hip and knee flexed, or sitting, with knee flexed over the edge of the table and heel resting on the Therapist lap. Therapist stabilizes the joint by fixating the more proximal bone with the index finger on the plantar surface of the bone. To mobilize the tarsal joints along the medial aspect of the foot, Therapist positions himself on the lateral side of the foot and places the proximal hand on the dorsum of the foot with the fingers pointing medially so the index finger can be wrapped around and placed under the bone to be stabilized. He then places his thenar eminence of the distal hand over the dorsal surface of the bone to be moved and wrap the fingers around the plantar surface. To mobilize the lateral tarsal joints,he positions himself on the medial side of the foot, point his fingers laterally and position his hands around the bones as just described. b Heading 3 Resources bulleted list x or numbered list xModels of Foot Function - PhysiopediaIntroduction The evidence has provided many theories regarding how the ankle foot complex are functioning in weight bearing and non weight bearing tasks. Some of these theories are outdated and others are in need for further investigations. This proposes challenges on the clinical practice and complicates the assessment and management process. It is important not just to understand the models of foot function but also to be critical and develop questions in regards with their applicability and functionality. 4 Models will be discussed: Root theory, Sagittal Plane Facilitation Theory, Subtalar Joint Axis Location and Rotational Equilibrium Theory, and the Tissue Stress Model. Root Theory The root theory was originally developed by Dr.Merton L. Root during the late 1950s through early 1960s. It is also known as “the foot morphology theory,” “the subtalar joint neutral theory,” or simply “Rootian theory”[1]. Simply the root theory is based on a series of static measurements that is believed by the author to predict kinematic function. In order for the foot to be normal, the subtalar joint (STJ) should be in neutral position with the midtarsal joint fully locked[2], this occurs between mid-stance and heel-off during walking[3]. Any deviations from the stated STJ alignment is considered to be abnormal and should, therefore, exhibit mechanical dysfunction. Despite receiving clinical popularity and being utilized in most podiatry and orthopedic literature, the root theory is questioned with regards to its reliability, validity and practicality[1][3]. In the 1950s and 60s advanced measuring equipment wasn't available. In addition, most of the research done using this method has been conducted with techniques different from those proposed by Dr. Root. It is also worth to note that Dr. Root has prescribed orthotics in his practice, but the exact methods weren't published or documented, therefore, interpretations of such methods cannot be reliable[1]. A 2017 study by Jarvis et al[4] was conducted to investigate foot kinematics between normal and abnormal feet classified according to Root et al, determine if the degree of structural deformity is associated with the degree of compensations and finally to measure subtalar joint position during gait in pain free feet. The results of the kinematic analysis of this study reported no association between the deformities proposed by Root et al. and the differences in foot kinematics during gait. STJ inversion in neutral calcaneal standing position (NCSP ) has no relation to rearfoot kinematics, this means that the clinical use of “subtalar joint neutral” might not provide clinicians with realistic information. Jarvis et al also found the first MPJ dorsiflexion during gait propulsion much less than 65°as proposed by Root. It is evident that not all feet with structural deformities should exhibit symptoms and their function will be affected, therefore the root's classification seems to be invalid and believed to be no longer suitable for professional practice. A simple explanation of why static assessment doesn't necessary reflect kinematic characteristics is that it is taken in non-weight bearing position which may not mimic the applied external and muscular force in weight bearing. Watch this video if you want to learn more: [5] Sagittal Plane Facilitation Theory The center of the body mass translates anteroposteriorly during each step. For this to occur, approximately 75° of the step motion is required during the single limb support and about 15° of simultaneous internal and external rotation of the weight bearing side. Therefore, the amount of sagittal plane motion required with every step is 500% that of transverse or frontal plane motion. For the motion to be transmitted smoothly and efficiently through the sagittal plane, the movement passes through three pivotal sites: The rocker bottom side of the calcaneum, to allow motion from heel strike to forefoot contact. 10° dorsiflexion of tibia on talus prior to heel-off. Metatarsophalangeal joints rocker are the final pivotal site with heel-off, providing foot stability through the windlass mechanism. Based on this, the sagittal plane movement could be affected by three types of blockages: Ankle equinus, or limited weight bearing ankle dorsiflexion to 10° or less. Forefoot equinus, or a lower forefoot on the ground plane relative to the heel. Loss of metatarsophalangeal joints motion that could be structural or functional as in hallux limitus or hallux rigidus. In functional hallux limitus, there is a relationship between hallux dorsiflexion and first metatarsal plantarflexion. The dorsiflexion restriction is limited to weight bearing positions. Because other structures may get involved to compensate the insufficient movement, it makes it hard to be detected by clinical gait observation (occurs for a very short time 100 msec)[6]. The loss of MTP movement can possibly explain late-midstance excessive foot pronation, the timing and direction of knee and hip motion, and improper flexion motions of the torso[7]. In order to understand compensations of the lower limb, Howard Dananberg explained the lower limb joints functioning as a scissor-jack. The hip, knee, ankle, and MTP joints all extend and flex in an opposite direction from their adjacent joints. Restriction in the movement specific to propulsion during gait at any level will consequently affect the other joints and compensations will be required to occur either proximally and/or distally. For example, limited hip extension was found to be associated with functional hallux limitus[8]. Dysfunction of foot mechanisms can be compensated by: apropulsive gait with delayed heel lift-off after contralateral foot contact, vertical lift of the foot off the supporting surface, the avoidance of first ray loading by adopting inversion and loading of the lateral column of the foot, propulsion with foot adduction or abduction and flexed body posture[6]. The sagittal plane facilitation theory role is highlighted in the conservative treatment of functional hallux limitus by facilitating plantarflexion and eversion movement at the first metarsal level with hallux dorsiflexion[6]. The Dananberg theory was further confirmed by Nester et al[9]. The study measured the 3D kinematics using a 6 segment model; leg, calcaneus, midfoot (navicular and cuboid), lateral forefoot (fourth and fifth metatarsals), medial forefoot (first metatarsal) and hallux (Salford foot model) in a population of 100 pain free aged 18-45. They reported high variations in kinematic data and multi articular mechanism that result from interaction of all three body planes, however, the greatest contribution was notes at the sagittal plane from the ankle and sub talar joints (calcaneus-tibia in our data) and the hallux-medial forefoot joint. Swing phase kinematics were also highlighted in this study. It comprised primarily of dorsiflexion (except for the hallux), eversion and abduction, especially at the lateral and medial forefoot-midfoot joints. These movements resulted from both active muscle forces (e.g. concentric action of anterior tibialis and long toe extensor muscles) and passive elastic forces, e.g. plantar flexion of the hallux after toe off due to elastic energy stored in the plantar facia and long toe flexor muscle/tendons during propulsion. Passive forces are necessary to control the active forces, prepare a safe next step and avoid injuries. Subtalar Joint Axis Location and Rotational Equilibrium Theory The oblique triplanar orientation of the subtalar joint (STJ) allows pronation and supination of the foot. Pronation is important during weight bearing activities to allow foot adaptation to irregular surfaces, while supination increases stability in the sagittal plane in the propulsive phase of the gait. The STJ is a complex joint that is believed to have multiple axes of rotation that depends on the joint's rotational position. Determining the spatial location of the STJ axis was investigated by several authors[10][11][12][13], their work suggests that the anatomical structure of the articulating surfaces; talus and calcaneus, integrate with each other in a three-dimentional relationship within the STJ range of motion to determine the spatial location of the STJ[14]. In a study by Manter[10], the average STJ axis was placed in a 16° angulation from the sagittal plane and 42° from the transverse plane. However, other researchers found great variations between individuals in the STJ axis angulation in the sagittal and in the medial and/or lateral position directions in relation to the plantar foot. [15] The weight bearing structures of the foot are: the medial calcaneal tubercle, the first through the fifth metatarsals and the base of the fifth metatarsal. Ground reaction force (GRF) and muscles (the posterior tibial, gastrocnemius, soleus, anterior tibial, flexor hallucis longus, and flexor digitorum longus) acting on the medial tubercle causes supination of the STJ. The opposite is true for GRF and muscles (the peroneus brevis, peroneus tertius, and extensor digitorum longus) exerting forces over the second through fifth metatarsals and the fifth metatarsal base cause pronation of the subtalar joint. On the other hand, Intrinsic muscles cannot produce either pronation or supination moments directly, since none of them cross the STJ. Their effect becomes prominent in resisting deformities and stabilizing the subtalar joint[14]. Regardless of the force location, rearfoot or forefoot, acting medial or lateral to the subtalar joint it produces supination or pronation. Watch this video if you want to learn more: [16] The palpation method is used to determine the axis of the STJ. [17] [18] Normally, in relaxed bipedal stance, the STJ is slightly pronated from neutral with it's axis passing through the postero-lateral calcaneus. A medial deviation in the STJ axis is likely to increases the pronation moment, resulting in pronated foot in standing. On the other hand, when the axis deviates laterally the supination moment increases and the foot is displaced neutrally or in supination[14]. Based on this, any translation or deviation (as little as 1-2 mm) from the spatial location of the subtalar joint axis from the normal position will result in changes in moment arm lengths of the attached muscles and eventually disturb the STJ balance and the loading forces and patterns acting on foot and lower extremity during weight bearing activities[14]. Medially deviated subtalar joint can be identified clinically by three characteristics: A convex shaped midfoot at the transverse plan, seen from above. A more medially positioned and internally rotated soft-tissue contour of the talar head and neck in relation to the calcaneus, also seen from above. A concavity in the medial midfoot and anterior t the medial malleolus, viewd from behind. The medial longitudinal arch height might be normal or lower than normal. These feet will tend to have increased compression of interosseous forces between lateral process of the talus and the floor of the sinus tarsi. Medially deviated STJ is associated with conditions as: plantar fasciitis, hallux limitus, second metatarsophalangeal joint capsulitis, abductor hallucis muscle strain, sinus tarsi syndrome, posterior tibial tendinopathy, posterior tibial tendon dysfunction, medial tibial stress syndrome, chondromalacia patellae, and pes anserinus bursitis. Lateral deviation of STJ is less common. It is more evident at the rearfoot than the forefoot in STJ palpation technique. GRF and muscular force will increased magnitude of STJ supination moment and decrease that of pronation. Clinical characteristics: From above: concave medial border of the midfoot The shape of the talar head and neck at the anterior ankle area will be more laterally positioned than normal From posterior: increased concavity in the medial mallelous Higher than normal longitudinal arch and pes cavus deformity During standing, one or both of the peroneal tendons may be under tension (Bowstring) when observed from the side The peroneal muscle tension is neccessary to counteract the excessive STJ supination moment to prevent the invidual from walking on the lateral aspect of the feet and also to prevent inversion ankle sprains. Inversion ankle sprains and peroneal tendinopathy are both associated with laterally deviated STJ[14]. Tissue Stress Model This theory was considered by researchers and clinicians in the management of foot conditions as an alternative to the root theory. It could be explained using the load deformation curve. Consisting of two regions; an elastic region and a plastic region. The area separating the elastic and plastic regions is considered the microfailure zone. the first region represent the area of normal tissue elasticity or the "give-and-take" of soft tissues, where regular loading and unloading occurs without inflammation or at tolerable level. Increasing levels of activity, deformation could occur beyond the zone of microfailure in the plastic region resulting in overuse injuries. Levels of tolerance are different among individuals according to their level of function and daily activities[3]. [19] Assessment and Management Based on the tissue stress model, the aims of examination are: Identify over stressed tissue through history, symptoms and subjective examination methods. Apply controlled stress to further test injured tissue by: weight bearing and non-weight bearing tests, as well as palpation, range of motion, and muscle function/strength assessment. Based on the evaluative findings, determine if the cause of the symptoms is secondary to excessive mechanical loading. Build your management protocol with the aim of: Reducing tissue stress to a tolerable level through rest, footwear, and foot orthoses; Promote tissue healing using soft tissue mobility techniques; Restore flexibility and muscle strength to facilitate recovery Clinically relevant tests Navicular drop test: a positive test along with tibial bending varus stress are associated with medial tibial stress syndrome, particularly in runners. Single leg squat test: is able to detect patellofemoral pain syndrome. Supination resistance test: used by orthotists and podiatrists for orthotics and foot cast modeling to determine the appropriate amount of force needed for correction[20]. Jacks test: to measure hallux dorsiflexion. relevant to sagittal plane facilitation theory. Knee to wall (Lunge test) [21] [22] [23] [24] [25] Outcome measures Foot Posture Index Case Study A 29-year-old female college student presents with left heel pain for the past 2 months. Radiographic examination was negative. Her symptoms started one week after she began working as a waitress (standing 10-12 hours daily, 5 days a week). Before this job, the patient stated that she had a sedentary office job. Her current pain has become worse over the past 4 weeks particularly in the morning and resolves after 20-30 minutes of activity. It then starts again after 3-4 hours of constant walking and standing. the pain is relieved whenever she sat down for rest but revisits again as she stands up and resume working. The area of most pain was anterior and medial to the bottom of the heel. It is the first time for her to experience similar pain. her physician prescribed anti-inflammatory. When her footwear was examined, they were found to be extremely worn as well as poor fitting. The patient is also slightly overweight. From the history examination: it seems that this patient has over stressed her plantar fascia, resulting in tissue inflammation.The increased activity level (from sedentary job to a relatively demanding weight bearing job) appears to be related to the onset of symptoms. A moderate genuvalgum was noted bilaterally and excessive pronation. The patient was then asked to walk approximately 15 feet independently. She demonstrated a slight antalgic gait with minimal decrease in weight bearing on the left foot. Her ROM of the STJ, midtarsal articulations, MTPJ extension were normal and painless. Palpation over the anterio-medial aspect of the left calcaneus triggered marked discomfort. The windlass effect over the plantar fascia was tested by passively extending the first MTPJ from standing and was associated with a slight discomfort after 45" of extension These clinical tests aims to stress the involved tissue in both weight-bearing and nonweight-bearing positions. Based on the evaluative findings, plantar fasciitis is caused by excessive mechanical loading resulting in over stressed tissue of the plantar aponeurosis. At this stage, the use of foot orthoses to reduce tissue stress might help with symptom-modulation. However, a more effective strategey should be integrated to correct pronation on the long term. Management Approach: A- For short-term/immediate stress reduction: The patient was asked to amend her working schedule to decrease the consecutive working hours. Invest in a proper footwear with cushioned midsoles, leather uppers with at least 5 to 6 eyelets, and a firm heel counter to assist in controlling excessive foot pronation Immediate use of over-the-counter foot orthoses or have her foot strapped with adhesive tape to control the amount of foot pronation B- Symptomatic relief treatment is introduced once tissue stress is reduced. This include; modalities, soft tissue mobilization, and massage. C- Prevent recurrence of plantar fascia e.g; soft tissue mobility exercises to facilitate restricted the 1st MTPJ extension and strengthening exercises of the intrinsic and extrinsic muscles of the leg and foot to provide dynamic stabilization. The patient was also given recommendations to see a dietitian regarding a weight control program. Conclusion The models of foot function face uncertainty and there is still a gap between research and practice that needs to be addressed. Although the root theory has been doubted and questioned, it is still hasn't faded in the clinical use and in the research. Can we assume that this theory has become an accepted 'clinical function'despite being considered as a clinical fiction[1]? Until research comes with answers, it is important to keep an open mind and consider various philosophies in the realm of evidence. Recources Interview with Kevin Bruce about the role of the podiatrist in the multidisciplinary MSK team in managing conditions of the foot and ankle and he provides his perspective on the latest developments in orthotic use and treatmentsArches of the Foot - PhysiopediaIntroduction The foot has three arches: two longitudinal (medial and lateral) arches and one anterior transverse arch. These arches are formed by the tarsal and metatarsal bones and are supported by the ligaments and tendons in the foot. [1] The arches shape is designed in a similar manner to spring; bears the weight of the body and absorbs the shock that is produced with locomotion. The foot's flexibility conferred by the arches is what facilitates everyday loco-motor functions such as walking and sprinting. The energy-sparing spring theory of the foot’s arch has become central to interpretations of the foot’s mechanical function and evolution. The metabolic energy saved by the arch is largely explained by the passive-elastic work it supplies that would otherwise be done by active muscle. Anatomy Medial, Lateral and Longitudinal arch Medial Arch The medial arch is the higher of the two longitudinal arches. It is made up of the calcaneus, the talus, the navicular, the three cuneiforms, and the first, second, and third metatarsals. Its summit is at the superior articular surface of the talus, and its two extremities or piers, on which it rests in standing, are the tuberosity on the plantar surface of the calcaneus posteriorly and the heads of the first, second, and third metatarsal bones anteriorly. The chief characteristic of this arch is its elasticity, due to its height and to the number of small joints between its component parts. Its weakest part, i. e., the part most liable to yield from overpressure, is the joint between the talus and navicular, but this portion is braced by the plantar calcaneonavicular ligament, which is elastic and is thus able to quickly restore the arch to its pristine condition when the disturbing force is removed. The ligament is strengthened medially by blending with the deltoid ligament of the ankle joint and is supported inferiorly by the tendon of the Tibialis posterior, which is spread out in a fan-shaped insertion and prevents undue tension of the ligament or such an amount of stretching as would permanently elongate it. The arch is further supported by the plantar aponeurosis, by the small muscles in the sole of the foot, by the tendons of the Tibialis anterior and posterior and Peronæus longus, and by the ligaments of all the articulations involved. [2] Lateral Arch The lateral arch is the flatter of the two longitudinal arches and lies on the ground in the standing position. It is composed of the calcaneus, the cuboid, and the fourth and fifth metatarsals. Its summit is at the talocalcaneal articulation, and its chief joint is the calcaneocuboid, which possesses a special mechanism for locking, and allows only a limited movement. The most marked features of this arch are its solidity and its slight elevation; two strong ligaments, the long plantar and the plantar calcaneocuboid, together with the Extensor tendons and the short muscles of the little toe, preserve its integrity.[2] While these medial and lateral arches may be readily demonstrated as the component antero-posterior arches of the foot, yet the fundamental longitudinal arch is contributed to by both, and consists of the calcaneus, cuboid, third cuneiform, and third metatarsal: all the other bones of the foot may be removed without destroying this arch.[2] Transverse Arch In addition to the longitudinal arches the foot presents a series of transverse arches. The transverse arch is located in the coronal plane of the foot. At the posterior part of the metatarsus and the anterior part of the tarsus the arches are complete, but in the middle of the tarsus they present more the characters of half-domes the concavities of which are directed downward and medial, so that when the medial borders of the feet are placed in apposition a complete tarsal dome is formed. The transverse arches are strengthened by the interosseous, plantar, and dorsal ligaments, by the short muscles of the first and fifth toes (especially the transverse head of the Adductor hallucis), and by the Peroneous longus, whose tendon stretches across between the piers of the arches.[2] Clinical Relevance Patients commonly present with foot and ankle problems, and many find it challenging to assess these patients. This is probably related to the complexity and multiplicity of joints in this part of the body. There are 26 bones, 33 Joints, more than 100 ligaments, tendons and muscles in each foot. On average, we walk 10000 steps per day, 1000000 steps per year and 115000 miles in our lifetime. The foot stands 3-4 times body weight during running[3] As an example a person with a low longitudinal arch, or flat feet often stands and walks with their feet in a pronated position, where the foot everts. This makes the person susceptible to heel pain, arch pain, and plantar fasciitis. With high arches you have less surface area for absorbing impact and you place excessive pressure on your rearfoot and forefoot areas. This can make you susceptible to foot conditions such as heel pain, metatarsalgia, or plantar fasciitis. Assessment of Arches For a detailed assessment of the arches of the foot see below: Foot Posture Index (FP1-6) Foot Function Index (FFI) Biomechanical Assessment of Foot and Ankle Common Foot Postures and Associated Conditions Pes planus or pes valgus (flat foot) Pes planus is a common condition in which the longitudinal arches have been lost. Arches do not develop until about 2-3 years of age, meaning flat feet during infancy is normal. For most individuals, being flat-footed causes few, if any, symptoms. Treatment, if indicated, generally involves the use of arch-supporting inserts for shoes. Pes cavus (claw foot) Pes cavus is a foot condition characterised by an unusually high medial longitudinal arch. Due to the higher arch, the body's normal ability to absorb shock during walking is diminished and there is a greater degree of stress placed on the ball and heel of the foot. Treatment is usually provided by supporting the foot through the use of special shoes or sole cushioning inserts. Reducing the load the foot can bear is also advantageous. This is most effective through weight loss. Hallux Valgus Hammer Toe Club foot (talipes equinovarus) Metatarsalgia Morton's Toe and Morton's Neuroma Plantar FasciitisAnkle Joint - PhysiopediaDescription The ankle joint is a hinged synovial joint that is formed by the articulation of the talus, tibia, and fibula bones. Together, the three borders (listed below) form the ankle mortise. The articular facet of the lateral malleolus (bony prominence on the lower fibula) forms the lateral border of the ankle joint The articular facet of the medial malleolus (bony prominence on the lower tibia) forms the medial border of the joint The superior portion of the ankle joint forms from the inferior articular surface of the tibia and the superior margin of the talus. The talus articulates inferiorly with the calcaneus and anteriorly with the navicular. The upper surface, called the trochlear surface, is somewhat cylindrical and allows for dorsiflexion and plantarflexion of the ankle. The talus is wider anteriorly and more narrow posteriorly. It forms a wedge that fits between the medial and lateral malleoli making dorsiflexion the most stable position for the ankle.[1] Anatomy This 7 minute video is a good summary of the ankle. [2] Structure and Function The ankle joint is important during ambulation because it adapts to the surface on which one walks. The movements that occur at the ankle joint are plantarflexion, dorsiflexion, inversion, and eversion. The muscles of the leg divide into anterior, posterior, and lateral compartments. [1] Articulating Surfaces Trochlea of Talus Malleolar Mortis formed by Tibia & Fibula Lateral & Medial Malleolus Joint Capsule The articular capsule surrounds the joints, and is attached, above, to the borders of the articular surfaces of the tibia and malleoli; and below, to the talus around its upper articular surface. The joint capsule anteriorly is a broad, thin, fibrous layer, posteriorly the fibres are thin and run mainly transversely blending with the transverse ligament and laterally the capsule is thickened, and attaches to the hollow on the medial surface of the lateral malleolus. The synovial membrane extends superiorly between Tibia & Fibula as far as the Interosseous Tibiofibular Ligament.[3] Ligaments The main stabilizing ligaments Medially the deltoid ligament, consists of four ligaments that form a triangle connecting the tibia to the navicular, the calcaneus, and the talus. It stabilise’s the ankle joint during eversion of the foot and prevents subluxation of the ankle joint. [3] The anterior and posterior tibiotalar ligaments connect the tibia to the talus. The last two ligaments of the triangle are the tibionavicular ligament which attaches to the navicular anteriorly and the tibiocalcaneal ligament which attaches to the calcaneus inferiorly 2. Laterally the ankle has stabilization from three separate ligaments, the anterior and posterior talofibular ligaments, and the calcaneofibular ligament. [1] The anterior talofibular ligament connect the talus to the fibula, the weakest of the three lateral ligaments and thus the most frequently injured. The posterior talofibular ligament connect the talus to the fibula The calcaneofibular ligament connects the fibula to the calcaneus inferiorly. The lateral ligaments stabilize the ankle, and serve as a guide to direct ankle motion by attaching the lateral malleolus to the bones below the ankle joint. They are responsible for resistance against inversion and internal rotation stress. [3] See table below for full description of ligamants. LIGAMENT DESCRIPTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT ROLE Anterior Talofibular Ligament (ATFL) Flat Weak Band that extends Anteriomedially. Most commonly damaged ligament of the ankle. Lateral Malleolus Neck of Talus Restrain anterior displacement of the talus in respect to the fibula and tibia. Resists Inversion in planterflexion. Posterior Talofibular Ligament (PTFL) Thick, fairly strong band that runs horizontally medially. This ligament is under greater strain in full dorsiflexion of ankle. Rarely injured because bony stability protects ligaments when ankle in dorsiflexion. Malleolar Fossa of Fibula Lateral Tubercle of Talus Forms the back wall of the recipient socket for the talus' trochlea. Resists posterior displacement of the talus. Calcaneofibular Ligament (CFL) Round cord that passes posterioinferiorly Tip of Lateral Malleolus Lateral Surface of Calcaneus Aids Talofibular stability during Dorsiflexion. Restrain inversion of the calcaneus with respect to the fibula. Prevent Talar tilt into Inversion. LIGAMENTS DESCRIPTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT ROLE Anterior Tibiotalar Ligament Medial Malleolus Head of Talus Reinforces Ankle Joint. Control Plantarflexion & Eversion Posterior Tibiotalar Ligament Talus Posteriorly Control Dorsiflexion Tibionavicular Ligament Forms most anterior part of the Deltoid Ligament Dorsomedial Aspect of Navicular Reinforces Ankle Joint Tibiocalcaneal Ligament Very thin ligament Sustentaculum Tali Reinforces Ankle Joint Muscles The muscles of the leg divide into anterior, posterior, and lateral compartments. The leg's posterior compartment of the leg divides into the superficial posterior compartment and the deep posterior compartment. The superficial posterior compartment consists of the gastrocnemius and the soleus muscles, which are the primary muscles involved in ankle plantarflexion. The deep compartment plays a role in ankle joint inversion. The tibialis anterior muscle, found in the anterior compartment of the leg, is the primary muscle that facilitates dorsiflexion of the ankle joint. The peroneus longus and peroneus brevis muscles, found in the lateral compartment of the leg, function to facilitate eversion of the ankle joint.[1] A complete listing of muscles are described below. Plantarflexion Muscles which contribute to Plantarflexion MUSCLE ACTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERVATION POSTERIOR COMPARTMENT SUPERFICIAL Gastrocnemius Plantarflexion when Knee Extended Flexion Knee Raises Heel during Walking Lateral Head: Lateral Aspect of Lateral Femoral Condyle Medial Head: Popliteal Surface of Femur Superior to Medial Femoral Condyle Posterior Surface Calcaneus via Calcaneal Tendon (Achilles Tendon) Tibial Nerve S1-S2 Soleus Plantarflexion Steadies Leg on Foot Posterior Aspect of Head Fibula Superior ¼ Posterior Surface Tibia Soleal Line & Medial Border Tibia Plantaris Weakly Assists Gastrocnemius in Plantarflexion Inferior end Lateral Supracondylar Line of Femur Oblique Popliteal Ligament DEEP Tibialis Posterior Plantarflexion Inversion Supports Medial Longitudinal Arch Interosseous Membrane Posterior Surface Tibia inferior to Soleal Line Posterior Surface Fibula Navicular Tuberosity Cuneiform Cuboid Bases of Metatarsals 2-4 Tibial Nerve L4-L5 Flexor Digitorum Longus Plantarflexion Flexion Lateral Four Digits Supports Longitudinal Arch Medial Part Posterior Surface Tibia inferior to Soleal Line Broad Tendon to Fibula Base Distal Phalanges Digits 2-4 Tibial Nerve S2-S3 Flexor Hallucis Longus Weak Plantarflexion Flexion Big Toe at all Joints Supports Medial Longitudinal Arch Inferior 2/3 Posterior Surface Fibula Inferior Part Interosseous Membrane Base Distal Phalanx of Big Toe LATERAL COMPARTMENT Peroneus Brevis Weak Plantarflexion Eversion Inferior 2/3 of Lateral Surface Fibula Dorsal Surface Tuberosity of Base 5th Metatarsal Superficial Peroneal Nerve (Superficial Fibular Nerve) L5 - S2 Peroneus Longus Weak Plantarflexion Eversion Supports Transverse Arch Head & Superior 2/3 of Lateral Surface Fibula Base 1st Metatarsal Medial Cuniform Dorsiflexion Muscles which contribute to Dorsiflexion MUSCLE ACTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERVATION ANTERIOR COMPARTMENT Tibialis Anterior Dorsiflexion Inversion Supports Medial Longitudinal Arch Lateral Condyle Tibia Superior ½ Lateral Surface Tibia Interosseous Membrane Medial & Inferior Surfaces Medial Cuniform Base of 1st Metatarsal Deep Peroneal Nerve (Deep Fibular Nerve) L4-L5 Extensor Digitorum Longus Dorsiflexion Extends Lateral Four Digits Lateral Condyle Tibia Superior ¾ Anterior Surface Interosseous Membrane Middle & Distal Phalanges of Lateral Four Digits Deep Peroneal Nerve (Deep Fibular Nerve) L5-S1 Extensor Hallucis Longus Dorsiflexion Extends Big Toe Middle Part Anterior Surface Fibula Interosseous Membrane Dorsal Aspect of Base Distal Phalanx of Big Toe Peroneus Tertius Dorsiflexion Aids Eversion Inferior 1/3 Anterior Surface Fibula Interosseous Membrane Dorsum Base 5th Metatarsal Blood Supply Derived from Malleolar Branches of: Peroneal Artery Anterior and posterior Tibial Artery Nerve Supply Common Peroneal Nerve Tibial Nerve see image at R Clinical Significance Ankle Fracture - Ankle fractures are common in all ages with the involvement of one or both malleoli. The fracture pattern determines the stability of the fracture. Patients typically present with pain, swelling, and inability to bear weight on the ankle joint. Management of stable fractures includes a short leg cast for 4 to 6 weeks. Unstable fractures require an open reduction and internal fixation (ORIF) to restore a congruent mortise and fibular length. Talus Fracture - This injury usually occurs from a high energy injury like a motor vehicle accident or a fall from a height. The talus has a tenuous blood supply and is at high risk of avascular necrosis (AVN) in displaced fractures.[1] Ligament Injury - Ankle sprain is one of the most common musculoskeletal injuries, Females were at a higher risk of sustaining an ankle sprain compared with males and children compared with adolescents and adults, with indoor and court sports the highest risk activity.[4] Motions Available Talocrural Joint is a uniaxial hinge joint which has just 1° of Motion The reported normal available range for dorsiflexion varies in the literature between 0-16.5o[5] and 0-25o[6]. This changes in weight bearing. The normal range of Plantarflexion has been reported to be around 0°- 50° Closed Packed Position Maximum Dorsiflexion Open Packed Position 10° Plantarflexion Structures Limiting Movement Movement Limiting Structures Plantarflexion Posterior & Lateral Compartment Anterior Talofibular Ligamanet Anterior Part of Medial Ligament Anterior Joint Capsule Tension Contact of Talus with Tibia Dorsiflexor Tension Dorsiflexion Anterior Compartment Medial Ligament Calcaneofibular Ligament Posterior Talofibular Ligament Posterior Joint Capsule Tension Contact of Talus with Tibia Plantarflexors Tension Clinical Examination Assessment Ankle & Foot Examination Ankle Joint Assessment Video Special Tests Kaltenborn Ankle & Foot Examination Anterior Drawer of the Ankle Ligament Tests Squeeze Test Talar Tilt Test Kleiger Test Clinical Predicition Rules Ottawa Ankle Rules to rule in/out radiography of the ankle after trauma. Ankle X-ray is necessary if any of the following are present. Inability to bear weight on the affected ankle Bone tenderness along the posterior aspect of the distal 6 cm of either the medial or lateral malleolus Point tenderness at the proximal base of the fifth metatarsal Point tenderness over the navicular bone[1] Outcome Measures Foot and Disability Index&is a 34-item self report questionnaire divided into two subscales: the Foot and Ankle Disability Index and the Foot and Ankle Disability Index Sport Pathology/Injury Ankle Arthrodesis Ankle Impingement Ankle Osteoarthritis Ankle Osteochondral Lesions Ankle Sprain Ankle and Foot Fractures Ankle and Foot Arthropathies Chronic Ankle Instability Physiotherapeutic Techniques Rehabilitation of ankle injuries should be structured and individualized. In the acute phase, the focus should be on controlling inflammation, reestablishing full range of motion, and gaining strength. Once pain-free range of motion and weight bearing have been established, balance-training exercises should be incorporated to normalize neuromuscular control. Advanced-phase rehabilitation activities should focus on regaining normal function eg exercises specific to those that will be performed during sport. While having a basic template to follow for the rehabilitation of ankle injuries is important, clinicians must remember that individuals respond differently to exercises. Therefore, each program needs to be modified to fit the individual's needs.[7] Below are examples of techniques that could be incorporated in rehabilitation. Manual Therapy Talocrural Joint Posterior Glide to Promote Dorsiflexion Talocrural Joint Anterior Glide to Promote Plantarflexion Talocrural Joint Distal Distraction [8][7][6][6][6][6][7][7][6][5][5][5] Balance Retraining Balance Balance Boards Proprioception Perturbation Techniques Return to activity specific training. For sports persons an example is given below. When painfree walking is acheived , progress to a regimen of 50% walking and 50% jogging. Using the same criteria, jogging eventually progresses to running, backward running, and pattern running. Circles and figures of 8 are commonly employed patterns. The final phase of the rehabilitation process is the athlete can perform sport-specific exercises pain free and at a level consistent with preinjury status. These routines represent the final phase of ankle-joint rehabilitation, and completion of this program is essential for the recovery of ankle stability. Physiotherapists need to create exercises and movement patterns that will increasingly challenge the neuromuscular coordination of the injured athlete.[7] Procedures Ankle Arthroplasty Resources Anatomy of the Ankle Ligaments: A Pictorial Essay - In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.References↑ Jump up to: 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 Houglum PA, Bertoti DB. Brunnstrom's clinical kinesiology. FA Davis; 2012Jump up ↑ Anatomy Zone. Ankle Joint - 3D Anatomy Tutorial. Available from: https://www.youtube.com/watch?v=lPLdoFQlZXQ [last accessed 19/03/2015]Jump up ↑ AnimatedBiomedical. Ankle Joint, Bones of the Foot - 3D Medical Animation. Available from: https://www.youtube.com/watch?v=X-eAXKS4pJM [last accessed 19/03/2015]↑ Jump up to: 4.0 4.1 4.2 Ficke J, Byerly DW. Anatomy, Bony Pelvis and Lower Limb, Foot. InStatPearls [Internet] 2019 Sep 3. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK546698/#_article-21883_s2_ ( last accessed 11.3.2020)Jump up ↑ Dr Glass DPM.Ankle & Subtalar Joint Motion Function Explained Biomechanic of the Foot - Pronation & Supination. Published on 21 January 2008. Available from https://www.youtube.com/watch?v=0R4zRSE_-40&t=29s (last accessed 10 June 2019)Jump up ↑ http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINlower/Ankle.htm#Kinematics↑ Jump up to: 7.0 7.1 7.2 Lundberg A, Goldie I, Kalin B, Selvik G. Kinematics of the ankle/foot complex: Plantarflexion and dorsiflexion. Foot and Ankle 9(4):194–200, 1989.Jump up ↑ Baggett BD, Young G. Ankle joint dorsiflexion. Establishment of a normal range. Journal of the American Podiatric Medical Association. 1993 May;83(5):251-4.Jump up ↑ CDCP. Normal joint range of motion study. Acceessed Normal Joint Range of Motion Study | CDC↑ Jump up to: 10.0 10.1 Wheeless' Textbook of Orthopaedics↑ Jump up to: 11.0 11.1 Stagni R, Leardini A, O'Connor JJ, Giannini S. Role of passive structures in the mobility and stability of the human subtalar joint: a literature review. Foot andankle international. 2003 May 1;24(5):402-9.Jump up ↑ Ball P, Johnson GR. Technique for the measurement of hindfoot inversion and eversion and its use to study a normal population. Clinical Biomechanics 11(3):165–169, 1996↑ Jump up to: 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 13.12 13.13 VA.gov | Veterans AffairsJump up ↑ Blackwood CB, Yuen TJ, Sangeorzan BJ, Ledoux WR. The midtarsal joint locking mechanism. Foot and ankle international. 2005 Dec 1;26(12):1074-80Jump up ↑ Midtarsal joint axis during pronation. Available from: midtarsal joint axis during pronationJump up ↑ Subtalar joint - Wikipedia↑ Jump up to: 17.0 17.1 17.2 17.3 17.4 17.5 17.6 17.7 17.8 17.9 Cote KP, Brunet II ME, Gansneder BM, Shultz SJ. Effects of pronated and supinated foot postures on static and dynamic postural stability. Journal of athletic training. 2005 Jan 1;40(1):41.↑ Jump up to: 18.0 18.1 18.2 18.3 18.4 18.5 18.6 18.7 18.8 Langer PS, et al. A practical manual of clinical electrodynography. 2nd ed. Deer Park: The Langer Foundation for Biomechanics and Sports Medicine Research, 1989.Jump up ↑ Den Dekker JB, et al. Jaarboek 1991 Fysiotherapie Kinesitherapie, 1st ed, Houten/Zwaventem, Bohn Stafleu Van Longhum,1993. (201-241)Jump up ↑ Shephard R.J. and Taunton J.E., Foot and Ankle in Sport and exercise, Basel, 1987. (p.30-38).Sign up to receive the latest Physiopedia newsEmail AddressSubscribeOur PartnersDOT.PHYSIOWorld PhysiotherapyICRCClinically RelevantHumanity and InclusionHealth Volunteers OverseasThe content on or accessible through Physiopedia is for informational purposes only. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Read morepPhysiopediaoPhysiospot+PhysioplusGet the Physiopedia App on Google Play Get the Physiopedia App on the AppstorePhysiopediaAboutNewsCoursesContributeContactContentArticlesCategoriesPresentationsResearchProjectsLegalDisclaimerTermsPrivacyCookies© Physiopedia 2020 | Physiopedia is a registered charity in the UK, no. 1173185