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Foot & Ankle

Normal Anatomy of Foot and Ankle

The foot and ankle in the human body work together to provide balance, stability, movement, and propulsion.

This complex anatomy consists of:

  • 26 bones
  • 33 joints
  • Muscles
  • Tendons
  • Ligaments
  • Blood vessels, nerves, and soft tissue

In order to understand conditions that affect the foot and ankle, it is important to understand the normal anatomy of the foot and ankle.

Ankle

The ankle consists of three bones attached by muscles, tendons, and ligaments that connect the foot to the leg.

In the lower leg are two bones called the tibia (shin bone) and the fibula. These bones articulate (connect) to the Talus or ankle bone at the tibiotalar joint (ankle joint) allowing the foot to move up and down.

  • Tibia (shin bone)
  • Fibula
  • Talus
  • Lateral Malleolus
  • Medial Malleolus

The bony protrusions that we can see and feel on the ankle are:

  • Lateral Malleolus: this is the outer ankle bone formed by the distal end of the fibula.
  • Medial Malleolus: this is the inner ankle bone formed by the distal end of the tibia.

Hindfoot

The foot can be divided into three anatomical sections called the hindfoot, midfoot, and forefoot. The hindfoot consists of the Talus bone or ankle bone and the calcaneous bone or heel bone. The calcaneus bone is the largest bone in your foot while the talus bone is the highest bone in your foot. The calcaneus joins the Talus bone at the subtalar joint enabling the foot to rotate at the ankle.

The hindfoot connects the midfoot to the ankle at the transverse tarsal joint.

  • Talus
  • Calcaneus

Midfoot

The midfoot contains five tarsal bones: the navicular bone, the cuboid bone, and 3 cuneiform bones. It connects the forefoot to the hindfoot with muscles and ligaments. The main ligament is the plantar fascia ligament. The midfoot is responsible for forming the arches of your feet and acts as a shock absorber when walking or running.

The midfoot connects to the forefoot at the five tars metatarsal joints.

  • Navicular
  • Cuboid
  • Cuneiform Bones

Forefoot

The forefoot consists of your toe bones, called phalanges, and metatarsal bones, the long bones in your feet. Phalanges connect to metatarsals at the ball of the foot by joints called phalange metatarsal joints. Each toe has 3 phalange bones and 2 joints, while the big toe contains two phalange bones, two joints, and two tiny, round sesamoid bones that enable the toe to move up and down. Sesamoid bones are bones that develop inside of a tendon over a bony prominence.

The first metatarsal bone connected to the big toe is the shortest and thickest of the metatarsals and is the location for the attachment of several tendons. This bone is important for its role in propulsion and weight bearing.

  • Phalanges
  • Metatarsal

Soft Tissue Anatomy

Our feet and ankle bones are held in place and supported by various soft tissues.

  • Cartilage: Shiny and smooth, cartilage allows smooth movement where two bones come in contact with each other.
  • Tendons: Tendons are soft tissue that connects muscles to bones to provide support. The Achilles tendon, also called the heel cord, is the largest and strongest tendon in the body. Located on the back of the lower leg it wraps around the calcaneus, or heel bone. When inflamed it causes a very painful condition called Achilles tendonitis and can make walking almost impossible due to the pain.
  • Ligaments: Ligaments are strong rope like tissue that connects bones to other bones and help hold tendons in place providing stability to the joints. The plantar fascia is the longest ligament in the foot, originating at the calcaneus, heel bone, and continuing along the bottom surface of the foot to the forefoot. It is responsible for the arches of the foot and provides shock absorption. A common cause of heel pain in adults, plantar fasciitis can occur when repetitive micro tears occur in the plantar fascia from overuse. Ankle sprains, the most commonly reported injury to the foot and ankle area, involve ligament strain, and usually occur to the talo-fibular ligament and the calcaneo-fibular ligament.
  • Muscles: Muscles are fibrous tissue capable of contracting to cause body movement. There are 20 muscles in the foot and these are classified as intrinsic or extrinsic. The intrinsic muscles are those located in the foot and are responsible for toe movement. The extrinsic muscles are located outside the foot in the lower leg. The gastrocnemius or calf muscle is the largest of these and assists with movement of the foot. Muscle strains occur usually from overuse of the muscle in which the muscle is stretched without being properly warmed up.
  • Bursae: Bursae are small fluid filled sacs that decrease friction between tendons and bone or skin. Bursae contain special cells called synovial cells that secrete a lubricating fluid. When this fluid becomes infected, a common painful condition known as Bursitis can develop.

Biomechanics of Foot & Ankle

Biomechanics is a term to describe movement of the body. The ankle joint by itself permits two movements:

  • Plantar flexion: Pointing the foot downward. This movement is normally accompanied by inversion of the foot.
  • Dorsiflexion: Raising the foot upward. This movement is normally accompanied by eversion of the foot.

The foot (excluding the toes) also permits two movements:

  • Inversion: Turning the sole of the foot inward.
  • Eversion: Turning the sole of the foot outward

The toes allow four different movements:

  • Plantar flexion: Bending the toes towards the sole of the foot
  • Dorsiflexion: Bending the toes towards the top of the foot
  • Abduction: Spreading the toes apart. This movement normally accompanies plantar dorsiflexion.
  • Adduction: Bringing the toes together. This movement normally accompanies plantar flexion.

Ankle Arthroscopy

Arthroscopy is a surgical procedure during which the internal structure of a joint is examined for diagnosis and treatment of problems inside the joint. Ankle Arthroscopy includes the diagnosis and treatment of ankle conditions. In arthroscopic examination, a small incision is made in the patient’s skin through which pencil-sized instruments that have a small lens and lighting system (arthroscope) are passed. Arthroscope magnifies and illuminates the structures of the joint with the light that is transmitted through fiber optics. It is attached to a television camera and the interior of the joint is seen on the television monitor.

Arthroscopic examination of ankle joint is helpful in diagnosis and treatment of the following conditions:

  • Inflammation: Synovitis, the inflammation of the lining of the ankle joint
  • Acute or chronic injury
  • Osteoarthritis: A type of arthritis caused by cartilage loss in a joint

During arthroscopic ankle surgery, either a general or local anesthesia will be given depending on the condition. A small incision of the size of a buttonhole is made through which the arthroscope is inserted. Other accessory incisions will be made through which specially designed instruments are inserted. After the procedure is completed arthroscope is removed and incisions are closed. You may be instructed about the incision care, activities to be avoided and exercises to be performed for faster recovery.

Some of the conditions treated by ankle arthroscopy include:

  • Ankle Arthritis
  • Unstable ankle
  • Ankle fracture
  • Osteochondral Defects of the talus
  • Infection
  • Undiagnosed ankle pain

Some of the possible complications after arthroscopy include infection, phlebitis (clotting of blood in vein), excessive swelling, bleeding, blood vessel or nerve damage and instrument breakage.

Recovery

It may take several weeks for the puncture wounds to heal and the joint to recover completely. A rehabilitation program may be advised for a speedy recovery of normal joint function. Your child can resume normal activities and go back to school within a few days.

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Ankle Arthroscopy

Ankle Fracture

Ankle injuries are the most common sports-related injury. An ankle fracture is a break in one or more bones that make up the ankle joint. Sometimes ligaments may also be damaged. Ankle fractures are most often caused by motor vehicle accident, rolling or twisting of ankle, and by tripping or falling. People participating in sports such as basketball, football, soccer and skiing are at a high risk of developing ankle fractures.

Common symptoms of an ankle fracture include pain and swelling around the ankle, bruising, tender to touch, inability to walk on the leg, and deformity if the ankle is dislocated.

Following an ankle injury it is important to have the ankle evaluated by your doctor for proper diagnosis and treatment. Diagnosis is made based on the history of injury and physical examination of the ankle. In addition, the surgeon may order X-ray of the ankle to determine the extent of the injury.

Treatment varies with the type and severity of the injury. The common method of treatment of ankle fractures is adequate rest, ice application, leg elevation, and medications to reduce swelling and pain. A short leg cast or a brace may be applied over the fractured ankle to provide support. If there is severe injury, excessive swelling or severe pain, you should seek immediate medical treatment.

Some ankle fractures are treated with a splint, which is placed on the ankle for few days until the swelling subsides. Once the swelling decreases a cast may be placed on the ankle to hold the broken bone in a specific place. Surgery may be needed to realign the bones before placing the splint. During surgery, your doctor may place metal screws, plates, or rods to hold the broken bone intact until the healing happens. In some cases, crutches may be used to prevent the ankle from bearing weight.

It is important to use proper fitting shoes for the particular sports activity to reduce the chances of injury.

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Ankle Fracture

Bunion Surgery

Bunion is a foot deformity that changes the shape of the foot causing the big toe to turn inward, towards the second toe leading to pain and inflammation. A bunion is caused by incorrect footwear, joint damage, arthritis, and genetic disposition. Some of the commonly observed symptoms are pain, inflammation, bony bump on the side of the foot.

Bunion may be corrected with conservative treatment or surgery. If the conservative treatment does not treat the bunion pain, then your surgeon may recommend bunionectomy, surgical removal of a bunion. The main goal of the surgery is to remove painful deformities, restore normal bone alignment, and prevent recurrence.

This surgery involves shaving the inflamed tissue around the big toe joint using a shaving drill. A part of the bone in big toe is cut to straighten the toe (osteotomy). Ligaments are tightened and adjusted in a proper direction. Screws and pins are used to fuse the bones together. After the surgery, your surgeon may instruct you to wear crutches to prevent weight bearing. Some of the complications of the surgery include infection, stiffness of the toe, loss of blood supply to the toe, and over-correction. Over-correction leads to turning of the big toe outward (Hallux varus). However, these complications can be corrected.

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Bunion Surgery

Achilles Tendon Rupture

Achilles tendon is a strong fibrous cord present behind the ankle that connects the calf muscles to heel bone. It is used when you walk, run and jump. When the Achilles tendon becomes thin, weak, or if it is not used, it may be susceptible to injury or damage. Achilles tendon rupture occurs most often in middle-aged athlete participating in sports that involve running, pivoting, and jumping. Recreational sports that may cause Achilles rupture include tennis, racquetball, basketball, and badminton.

If Achilles tendon is ruptured you will experience severe pain in the back of your leg, swelling, stiffness, and difficulty to stand on tiptoe and push the leg when walking. A popping or snapping sound is heard when the injury occurs. You may also feel a gap or depression in the tendon, just above heel bone.

Your doctor diagnoses the rupture based on symptoms, history of the injury and physical examination. Your doctor will gently squeeze the calf muscles, if the Achilles tendon is intact, there will be flexion movement of the foot, if it is ruptured, there will be no movement observed.

Achilles tendon rupture is treated using non-surgical method or surgical method. Non-surgical treatment involves wearing a cast or special brace which is changed after some period of time to bring the tendon back to its normal length. Along with cast or brace, physical therapy may be recommended to improve the strength and flexibility of leg muscles and Achilles tendon. Surgical procedure involves opening the skin and suturing the torn tendon together. Surgery helps to decrease the recurrence of the Achilles tendon in comparison to the non-surgical treatment.

To help prevent an Achilles tendon injury, it is a good practice to perform stretching and warm-up exercises before any participating in any activities. Gradually increase the intensity and length of time of activity. Muscle conditioning may help to strengthen the muscles in the body.

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Achilles Tendon Rupture

Ankle Sprain

A sprain is stretching or tearing of ligaments, which connect adjacent bones in a joint and provides stability to the joint. An ankle sprain is a common injury and occurs when you fall or suddenly twist the ankle joint or when you land your foot in an awkward position after a jump. It most commonly occurs when you participate in sports or when you jump or run on a surface that is irregular. Ankle sprains can cause pain, swelling, tenderness, bruising, and stiffness, numbness in the toes, and inability to walk or bear weight on the ankle.

The diagnosis of an ankle sprain is usually made by asking the history of injury and physical examination of the ankle. X-ray of your ankle may be needed to confirm if a fracture is present.

The most common treatment recommended for ankle sprains is rest, ice, compression and elevation (RICE).

  • Rest: You should not move or use the injured part to help to reduce pain and prevent further damage. Crutches may be used that help in walking
  • Ice: An ice-pack should be applied over the injured area up to 3 days after the injury. You can use a cold pack or crushed ice wrapped in a towel. Ice packs helps to reduce swelling and relieve pain. Never place ice directly over the skin
  • Compression: Compression of the injured area helps to reduce swelling and bruising. This is usually accomplished by using an elastic wrap for few days to weeks after the injury
  • Elevation: Place the injured part above heart level to reduce swelling. Elevation of an injured leg can be done for about 2 to 3 hours a day

The doctor may also use a brace or splint to reduce motion of the ankle. Anti-inflammatory pain medications may be prescribed to help reduce the pain and control inflammation.

You may need to use an ankle brace or wrap to support and protect your ankle during sports activities. Avoid pivoting and twisting movements for 2 to 3 weeks.

To prevent further sprains or re-injury you may need to wear a semi-rigid ankle brace during exercise, special wraps, and high-top tennis shoes. A program of ankle exercises will also help to prevent re-injury by making the ankles strong and flexible.

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Ankle Sprain

Common Toe Deformities

Toes are the digits in your foot and are associated with walking, providing balance, weight-bearing and other activities. A variety of toe deformities occur in children’s feet. They are as follows:

  • Hallux Valgus: Hallux valgus is a common toe deformity in which the child’s great toe is shifted laterally and lies over the second toe. The first metatarsal bone is deviated towards the medial side causing a prominence over the medial aspect of the metatarsophalangeal (MTP) joint. A fluid filled sac (bursa) may form over this prominence which may result in a painful bunion caused by continuous irritation and inflammation. Foot pronation (flat feet) may sometimes be associated with this condition.
    The factors that cause hallux valgus include structural foot anomaly that may or may not be hereditary and use of narrow shoes that curl or fold the toes. Children having hallux valgus may not have any symptoms most of the times and do not require any treatment. Your doctor may advise shoes that have good amount of space for the toes and no heels. If there is flat foot then a shoe insert may help to prevent its progression. Surgery may be recommended only in severe cases.
  • Hammertoe: Hammertoe is a deformity in which there is downward bending of the middle joint of the toe or the proximal interphalangeal joint (PIP). Although it can affect the other toes, it most commonly affects the second toe. It may be present at birth or may result from wearing shoes that are too tight which forces the toe to bend forward. It causes no pain and does not require any specific treatment. Hammer toe can be treated by ensuring that your child wears well-fitting shoes that has enough space for the toes to stretch.
  • Mallet Toe: Mallet toe refers to the downward bending of the third joint or distal interphalangeal joint (DIP) giving it a mallet-like appearance. Corns or calluses may develop over the deformity as a result of constant friction against the footwear. Mallet toe can be inherited or may develop from wearing shoes that are too tight or high-heeled.
  • Claw Toe: Claw toe is a rare deformity but occurs in association with cavus foot, Charcot-Marie-Tooth disease or myelomeningocele. It affects all the toe joints and results from hyperextension of the metatarsophalengeal (MTP joint or 1st joint) and flexion at the PIP (2nd joint), and DIP (3rd joint) joints. It results from altered structural anatomy and /or neurologic disorder that cause muscle imbalances.
  • Curly Toe: Curly toes are present at birth and affect the third, fourth and fifth toes of one or both the feet. It is caused by tightening of the tendon that runs below the toe which results in pulling of the tip of the toe under the next toe towards the sole. Your child may develop areas of hard skin on the sole of the foot and may have difficulty in selecting suitable shoes that fit properly.
    Generally, no treatment is needed if curly toes do not cause any symptoms but if the condition becomes severe and causes irritation, then surgery may be performed to release and transfer of toe flexor.
  • Polydactyly: It is a condition in which there is an extra digit present in the feet. The great toe or the fifth toe is usually affected. It may occur in association with other congenital anomalies or as an isolated problem. If the extra digit does not cause any problem, it may be left alone without any treatment. Surgical excision of the extra digit will be done in cases where there is an extra little or big toe that is prominent causing difficulty in wearing shoes. Surgery is usually done after the age of 9-12 months.
  • Syndactyly: Syndactyly is the presence of fused digits and may occur along with other congenital anomalies or as an isolated problem. It rarely causes any problems and does not need any treatment. The connection between two or more toes varies from a thin skin attachment to a bony attachment (synostosis) between the phalanges.
  • Bunionette (Tailor Bunion): Bunionette is less common and occurs at the fifth MTP joint. When this occurs, the fluid sac over the lateral side of the fifth MTP joint becomes prominent and inflamed causing pain. Padding is done to relieve the discomfort. If this does not help, surgical correction will be needed.

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common toe deformitiesHip Surgery

Plantar Fasciitis

Plantar fasciitis is a common problem that causes pain under the heel bone often with lengthy walks and prolonged standing. It is most often seen in middle-aged men and women.

Plantar fascia is a thick band of tissue that lies at the bottom of the foot. It runs from the heel bone to the toe and forms the arch of the foot. The plantar fascia functions as a shock absorber and also supports the arch of the foot.

Causes

Too much of pressure over the fascia may damage or tear away the tissue and can be a cause of heel pain. It is also possible that when the plantar fascia gets overstretched or overused repeatedly, there may be irritation or inflammation of the fascia. Inflammation of the plantar fascia causes plantar fasciitis.

The risk factors that can make you more prone to develop plantar fasciitis include obesity, foot arch problems such as flat feet and high arch, activities such as long-distance running, ballet dancing and dance aerobics, occupations that necessitate walking or standing on hard surfaces for long period of time and wearing shoes with poor arch support or thin-soled shoes.

Symptoms

The most common symptom of plantar fasciitis is stabbing pain on the bottom of the foot near the heel. The pain develops gradually and may involve either one or both feet at the same time. Pain is usually worse in the morning or may aggravate after standing up for a long time.

Diagnosis

Your doctor will examine your foot and will check for the signs of flat feet or high arches, tenderness, swelling and redness of the foot and stiffness or tightness of the arch in the bottom of your foot.

Your doctor may suggest an X-ray or MRI scan to rule out other causes of heel pain such as a stress fracture or pinched nerve.

Treatment

Most patients with plantar fasciitis are effectively treated with the following measures:

  • Medications: Your doctor may prescribe non-steroidal anti-inflammatory drugs (NSAIDs) as they can reduce your pain and inflammation. Corticosteroids can be injected directly into the plantar fascia which may offer pain relief and reduce inflammation.
  • Rest: Decrease or avoid the activities that worsen the pain.
  • Ice: Apply ice pack over the painful area for at least twice a day for 10 – 15 minutes, for the first few days.
  • Night splints: Use of night splints is beneficial as it stretches the plantar fascia and allows it to heal.
  • Supportive shoes and orthotics: Your doctor may recommend you to wear shoes with good support and cushioning. Custom orthotics (shoe inserts) may also be helpful.
  • Physical therapy: Your physical therapist may suggest you an exercise program that focuses on stretching your plantar fascia and Achilles tendon. These exercises may help to strengthen the muscles of lower leg. In addition to exercises application of athletic taping to support the bottom of your foot is also taught.
  • Extracorporeal shock wave therapy: During this procedure, sound waves are targeted to the painful area to stimulate the healing process in the damaged plantar fascia tissue.

Surgery: Rarely, surgery to release the tight plantar fascia may be needed. However it is recommended only after all nonsurgical measures have failed.

Preventive measures such as stretching exercise programs and footwear modifications can help prevent plantar fasciitis. But if it occurs proper treatment is essential as otherwise it can become a long-term problem.

Hip Anatomy

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