614 Section IV   Lower Extremity

Transverse tarsal joint: longitudinal axis

ABDUCTION/ADDUCTION DORSIFLEXION/PLANTAR FLEXION
(Vertical axis) (ML axis)

15
EVERSION/ 9 EVERSION/
INVERSION INVERSION
(AP axis) (AP axis)

A Medial view B Superior view

Neutral PRONATION: Main component SUPINATION: Main component

EVERSION INVERSION

C D E

Transverse tarsal joint: oblique axis

ABDUCTION/ADDUCTION DORSIFLEXION/PLANTAR FLEXION
(Vertical axis) (ML axis)

52

EVERSION/ EVERSION/
INVERSION INVERSION
(AP axis) (AP axis)
57

F Medial view G Superior view

Neutral PRONATION: Main components SUPINATION: Main components

ABDUCTION AND DORSIFLEXION ADDUCTION AND PLANTAR
FLEXION

H I J
FIG. 14.27 The axes of rotation and osteokinematics at the transverse tarsal joint. The longitudinal axis of rotation is
shown in red from the side (A and C) and from above (B). (The component axes and associated osteokinematics are
also depicted in panels A and B.) Movements that occur around the longitudinal axis are (D) pronation (with the
main component of eversion) and (E) supination (with the main component of inversion). The oblique axis of rotation
is shown in red from the side (F and H) and from above (G). (The component axes and associated osteokinematics
are also depicted in panels F and G.) Movements that occur around the oblique axis are (I) pronation (with main
components of abduction and dorsiflexion) and (J) supination (with main components of adduction and plantar
flexion). In (I) and (J), blue arrows indicate abduction and adduction, and green arrows indicate dorsiflexion and
plantar flexion.
 Chapter 14   Ankle and Foot 615

Medial
malleolus
FIG. 14.28 The medial side of a normal foot shows the medial longitu-
dinal arch (white) and the transverse arch (red).
v er s

e
Trans

arch
l longitudinal a
Media rc h

The previously described arthrokinematics of supination and provided by the connective tissues. Furthermore, significantly
pronation assume that the foot is unloaded, or off the ground. high levels of muscular force are required when the arch is stressed
The challenge is to understand these arthrokinematics when the by larger or dynamic loading scenarios, such as standing on
foot is on the ground, typically during the walking process. This tiptoes, walking, jumping, or running. The following section
topic is addressed later in this chapter. describes the passive support mechanism provided by the
medial longitudinal arch. The role of muscles in providing active
Medial Longitudinal Arch of the Foot support is described later, in the study of muscles of the ankle and
Fig. 14.28 shows the locations of the medial longitudinal and foot.
transverse arches of the foot. Both arches lend crucial elements of
stability and resiliency to the loaded foot. The structure and func- Passive Support Mechanism of the Medial Longitudinal Arch
tion of the medial longitudinal arch is addressed in this section. The talonavicular joint and associated connective tissues form the
The transverse arch is described later during the study of the distal keystone of the medial longitudinal arch. Additional nonmuscular
intertarsal joints. structures responsible for maintaining the height and general
The medial longitudinal arch follows the characteristic concave shape of the arch are the plantar fascia, spring ligament, and first
“instep” of the medial side of the foot. This arch is the primary tarsometatarsal joint. The plantar fascia of the foot provides the
load-bearing and shock-absorbing structure of the foot.190 The primary passive support to the medial longitudinal arch.45,79 This
bones that contribute structurally to the medial longitudinal arch dense connective tissue covers the sole and sides of the foot and
include the calcaneus, talus, navicular, cuneiforms, and associated is organized into superficial and deep fibers. The superficial fibers,
three medial metatarsals. Several connective tissues help maintain introduced earlier, blend primarily with the overlying thick dermis
the shape of the medial arch (described later in the chapter). of the plantar surface of the foot. The more extensive and thicker
Without this arched configuration, the large and rapidly produced deep plantar fascia (or aponeurosis) attaches posteriorly to the
forces applied against the foot during running and marching, for medial process of the calcaneal tuberosity (e-Fig. 14.1). This
examples, would likely exceed the physiologic weight-bearing tissue, 2 to 2.5 mm thick, consists of a series of longitudinal and
capacity of the bones. Additional structures that assist the arch in transverse bands of collagen-rich tissue.93,141 The fascia is extremely
absorbing loads are the plantar fat pads, sesamoid bones located strong, capable of resisting approximately 810 N (over 180 lb) of
at the plantar base of the great toe, and superficial plantar fascia tension before permanent elongation.141,207 From the tissue’s firm
(which attaches primarily to the overlying thick dermis, function- attachment to the calcaneus, lateral, medial, and central sets of
ing primarily to reduce shear forces). As will be described, the fibers course anteriorly, blending with and covering the first layer
medial longitudinal arch and associated connective tissues are the of the intrinsic muscles of the foot. The main, larger, central set
primary sources of mechanical support for the foot during rela- of fibers extends toward the metatarsal heads, where they eventu-
tively low-stress or near-static conditions—for example, while ally blend with the plantar plates (ligaments) of the metatarsopha-
standing at ease. Even after decades of research, however, the lit- langeal joints, fibrous sheaths of the flexor tendons of the digits,
erature remains mixed in regards to how much active muscular and fascia covering the plantar aspect of the toes. Extension of the
support is actually required to maintain the shape of the healthy toes therefore stretches the central fibers of the deep fascia, adding
arch while in relaxed standing.* Two conclusions that can be tension to the medial longitudinal arch. This mechanism is useful
drawn from the literature are that the muscle activity required to because it increases tension in the arch when one stands on
maintain the height of the normal arch during quiet standing is tiptoes, or during the late push off phase of gait.
highly variable, and is relatively small compared with the support When one stands normally, the weight of the body falls through
the foot near the region of the talonavicular joint.13 This load is
distributed anteriorly and posteriorly throughout the medial lon-
*References 10, 11, 49, 65, 72, 92, 114 gitudinal arch, ultimately passing to the fat pads and the thick
 Chapter 14   Ankle and Foot 615.e1

Lateral fibers
Medial fibers
Medial
malleolus Central fibers

Abductor Lateral
hallucis malleolus

Subcutaneous
calcaneal bursa

e-FIG. 14.1 The deep plantar fascia. Figure from Sobotta. Atlas of
Human Anatomy: Musculoskeletal System, Internal Organs, Head,
Neck, Neuroanatomy, 15e. Churchill Livingstone. 2011.
616 Section IV   Lower Extremity

Normal arch arch (see stretched spring in Fig. 14.29A). Acting like a truss, the
tie-rod supports and absorbs body weight. Experiments on cadav-
eric specimens indicate that the deep plantar fascia is the major
structure that maintains the height of the medial longitudinal
arch; cutting the fascia decreased arch stiffness by 25%.79
Body
weight As the arch is depressed, the rearfoot normally pronates a few
degrees. This is most evident from a posterior view as the calca-
neus everts slightly relative to the tibia. As the foot is unloaded,
such as when shifting body weight to the other leg during walking,
the naturally elastic and flexible arch returns to its preloaded raised
height. The calcaneus inverts slightly back to its neutral position,
allowing the mechanism to repeat its shock absorption function
once again.
As stated earlier, the height and shape of the medial longitudinal
arch are controlled primarily by passive restraints from the con-
A nective tissues depicted by the spring in Fig. 14.29A. Active
muscle support while quiet standing is relatively small and vari-
Dropped arch able, and may be considered as a “secondary line of support”—for
example, for controlling postural sway, switching from double to
single limb support, supporting relatively heavy loads, or when
the arch lacks inherent support because of overstretched or weak-
ened connective tissues.92,186

Pes Planus—“Abnormally Dropped” Medial Longitudinal Arch

Body
Pes planus or “flatfoot” describes a chronically dropped or abnor-
Extrinsic
weight muscles
mally low medial longitudinal arch. This condition is often the
result of joint laxity within the midfoot or proximal forefoot
regions, typically combined with an overstretched, torn, or weak-
ened plantar fascia, spring ligament, and tibialis posterior
tendon.137,190,200,205 As a consequence, the subtalar joint is exces-
sively pronated causing the rearfoot to assume an exaggerated
valgus posture (calcaneus everted away from the midline).74,168
In addition, the forefoot is often in excessive abduction.38 Often
the depressed talus and navicular rub against the inside of the
B Intrinsic muscles footwear, forming a callus on the adjacent skin.
FIG. 14.29 Models of the foot show a mechanism of accepting body
Fig. 14.29B shows the foot of a person with pes planus. The
weight during standing. (A) With a normal medial longitudinal arch, abnormally wide midfoot region evident in the footprint is indica-
body weight is accepted and dissipated primarily through elongation of tive of excessive laxity within the joints that normally support the
the plantar fascia, depicted as a red spring. The footprint illustrates the arch.123 A person with moderate or severe pes planus typically has
concavity of the normal arch. (B) With an abnormally dropped medial a compromised ability to support and dissipate loads through the
longitudinal arch, the overstretched and weakened plantar fascia, depicted foot. Significant active forces from intrinsic and extrinsic muscles
as an overstretched red spring, cannot adequately accept or dissipate body may be required to compensate for the lack of tension produced
weight. As a consequence, various extrinsic and intrinsic muscles are in overstretched or weakened connective tissues. Significant mus-
active as a secondary source of support to the arch. The footprint illus- cular activity may be needed even during quiet standing, which
trates the dropped arch and loss of a characteristic instep. may contribute to fatigue and various overuse symptoms, includ-
ing general foot and leg pain, bone spurs, and a thickened and
inflamed plantar fascia.
dermis over the heel and ball (metatarsal head region) of the foot Pes planus is often described as being either a rigid or a flexible
(Fig. 14.29A). Normally the rearfoot receives about twice the deformity, although many conditions are not as extreme as these
compressive load as the forefoot.27 The mean pressure under the terms imply. The foot with rigid pes planus (as shown in Fig.
forefoot is usually greatest in the region of the heads of the second 14.29B) demonstrates a dropped arch even in non–weight-bear-
and third metatarsal bones. ing positions. This deformity is often congenital, secondary to
During standing, body weight pushes the talus inferiorly, bony or joint malformation, such as a tarsal coalition (i.e., partial
slightly lowering the medial longitudinal arch. The amount of fusion of the calcaneus with the talus fixed in eversion). Pes planus
depression of the arch while weight bearing can be measured may also occur from spastic paralysis and the resultant over-pull
clinically by the distance between the ground and the navicular from certain muscles. Because of the fixed nature and potential
tuberosity, a static measurement referred to as the “navicular drop for producing painful symptoms, rigid pes planus in the child may
test.” The drop of the arch (on average about 7 mm in healthy require surgical correction.
adult males) increases the distance between the calcaneus and Flexible pes planus is the more common form of a dropped arch.
metatarsal heads.13 Tension in stretched connective tissues, espe- The medial longitudinal arch appears essentially normal when
cially the deep plantar fascia, acts as a semi-elastic tie-rod that unloaded but drops excessively on weight-bearing. Flexible pes
“gives” slightly under load,141 allowing only a slight drop in the planus is often associated with laxity of local supporting
 Chapter 14   Ankle and Foot 617

S PE C I A L F O C U S 1 4 . 4

Pes Cavus—Abnormally Raised Medial Longitudinal Arch

W hile under the load of body weight, the alignment and

associated height of the arch of the foot can be broadly
categorized as either pes planus, pes rectus (normal or optimal
Furthermore, a foot with a chronically raised (and relatively rigid)
arch cannot, in theory, optimally absorb the repeated impacts of
walking and running.61,74,204 A person with significant pes cavus
alignment), or pes cavus. This categorization can be determined may therefore be at a higher risk of developing stress-related
through measurements of goniometry (standing rearfoot varus, for injuries within the foot and lower limb.61,90
example), height and flexibility of the medial longitudinal arch, or More severe cases of pes cavus also exist—many of which are
static or dynamic plantar loading patterns while walking. Pes associated with a known cause. Pes cavus may be posttraumatic,
cavus is less common than pes planus, occurring in about 20% caused by, for example, severe fracture, crush injury, or burn. An
of the asymptomatic, healthy population.74 In its least complicated unresolved congenital “clubfoot” in childhood may persist later in
form, pes cavus describes an abnormally raised medial longitudi- life as pes cavus.128 Perhaps the most involved and debilitating
nal arch, often associated with excessive rearfoot varus (inversion) cases of pes cavus have a neurologic origin, such as Charcot-
(Fig. 14.30). Excessive forefoot valgus (eversion) may also be Marie-Tooth disease, poliomyelitis, cerebral palsy, or peripheral
present, often as a compensation mechanism used to keep the nerve injury.154 Although usually for a variety of reasons, these
medial forefoot firmly in contact with the ground. neurogenic disorders often result in an imbalance of muscular
Pes cavus may be fixed or progressive and may manifest in forces within the foot, ultimately causing the pes cavus deformity.
infancy, early childhood, or later in life. Many relatively mild forms For example, spastic or otherwise overpowering tibialis posterior
of pes cavus are considered idiopathic with a strong genetic and fibularis longus muscles combined with a weakened or para-
predisposition, such as the subject depicted in Fig. 14.30. Func- lyzed tibialis anterior muscle eventually favor development of a
tional limitations associated with mild or subtle pes cavus vary rearfoot varus and forefoot valgus deformity. The weakened tibi-
from nonexistent to marked. The chronically raised arch reduces alis anterior muscle may also allow the fibularis longus to overpull
the area of contact between the plantar surface of the foot and the first metatarsal into excessive plantar flexion. A combined
the floor,47 and also shifts the center of plantar pressure laterally rearfoot varus, forefoot valgus, and excessively plantar flexed first
while walking.74,123 As depicted in Fig. 14.30, the abnormally high metatarsal are often the more prominent features of a neurogenic
arch also places the metatarsal bones at a greater angle with the pes cavus. Mechanical-based treatment options vary based on
ground. When combined with the reduced area of plantar contact, age and the organic cause and degree of involvement, but may
plantar pressures typically rise and shift anteriorly over the fore- combine physical therapy, the use of braces, or tendon transfer
foot (compared with pes rectus or planus).47 For this reason, surgery.
persons with marked pes cavus may have pain (metatarsalgia) THE PONSETI METHOD
and callous formation over the region of the metatarsal heads. Conservative management of non-neurogenic, congenital pes
cavus (clubfoot) may include utilizing physical therapy, stretching
of tight muscles (including the typically tight gastrocnemius and
Pes cavus soleus), and using specialized footwear or orthotic devices. In
infants and children, these methods have been used in conjunction
Talonavicular joint with the Ponseti method,116,128,172,173 based on the original work of
Medial Ignacio V. Ponseti, a Spanish orthopedic surgeon who did much
malleolus of his work at the University of Iowa. This highly respected method
of treatment typically requires a series of 5–7 plaster casts applied
to the relatively malleable clubfoot of the infant, with each suc-
cessive cast holding the foot in a position closer to normal.8 The
application of the casts and the gentle (and very specific) manipu-
lation of the foot need to be performed by a trained individual,
because this process requires knowledge of the anatomy and
basic pathokinesiology of the clubfoot.6,87,210 In addition, a percu-
First tarsometatarsal taneous tenotomy of the tightened Achilles tendon is typically
joint required. The success of this relatively conservative method of
treatment is predicated on the prolonged nightly use of an “exter-
First metatarsophalangeal joint nal rotation” (Denis Browne type) brace to maintain the correction.
In more severe or complicated cases, extensive surgery may be
FIG. 14.30 A photograph of a right foot of a man with idiopathic pes indicated if the conservative approaches by trained personal are
cavus. unsuccessful.78
618 Section IV   Lower Extremity

connective tissues, generalized weakness or pain in muscles that 100

can support the arch, or compensatory mechanisms that cause

Height of medial arch

excessive pronation of the foot. Surgical intervention is rarely 90
indicated for flexible pes planus. Treatment is usually in the form

(percent)
of providing orthosis, using specialized footwear, and performing
strengthening exercises of muscles in the foot and throughout the 80
lower limb.74,102,104
In closing, it should be noted that although the image depicted 70
in Fig 14.29B provides useful insight into the overall pathome-
chanics associated with pes planus, it offers limited functional
information because the subject is simply standing at ease—
placing relatively low stress on the foot. A more detailed and
realistic appreciation of how pes planus affects the mechanics of
the foot requires a dynamic, three-dimensional analysis of the
foot-floor interface throughout the entire stance phase of A
walking.54,74,122 This assessment involves a relatively elaborate 0 10 20 30 40 50 60 70 80 90 100
measurement system, which necessitates that the subject walk
across a specialized mat or floor that has been instrumented with

Frontal plane subtalar joint motion

6
force or pressure-sensitive sensors, typically involving a concur-
rent method for collecting three-dimensional kinematic data on 4
the lower extremity. This system can collect data on the subject’s INVERSION
path of the “center of pressure” across the plantar surface of the 2

(degrees)
foot (Chapter 15), overall ground reaction force, instantaneous
height of the medial longitudinal arch, and the eversion and 0
inversion kinematics of the rearfoot as well as other regions of –2
the lower limb. In theory, this type of information can help
determine the functional impact that the pes planus condition EVERSION
may have on the subject’s local tissues in the ankle and foot, PUSH
OFF
and, indirectly, on other regions of the body. Although this more
elaborate measurement system is not typically available in most 0 10 20 30 40 50 60 70 80 90 100
clinical settings, the data produced in research settings may be
Heel contact

Foot flat

Heel off

Toe off
Swing phase
very enlightening. For example, even if the arch appears com-
pletely flat while standing, certain muscular or kinematic altera- B
tions during the gait process may compensate for some of the Percent of gait cycle
otherwise potential deleterious effects of the pes planus. These
natural compensations may partially explain why some healthy FIG. 14.31 (A) The percent change in height of the medial longitudinal
arch throughout the stance phase (0% to 60%) of the gait cycle. On the
persons who meet the criteria of having pes planus exhibit no vertical axis, the 100% value is the height of the arch when the foot is
painful symptoms while walking.74 These compensations may, unloaded during the swing phase. (B) Plot of frontal plane range of
however, be exceptions rather than the rule, because when studied motion at the subtalar joint (i.e., inversion and eversion of the calcaneus)
across a very large population, pes planus and excessive foot throughout the stance phase.34 The 0-degree reference for frontal plane
pronation while walking have been statistically correlated with motions is defined as the position of the calcaneus (observed posteriorly)
pain in the foot and low back.101,122 while a subject stands at rest. The push off phase of walking is indicated
by the darker shade of purple.
COMBINED ACTION OF THE SUBTALAR AND TRANSVERSE
TARSAL JOINTS
During the first 30% to 35% of the gait cycle, the subtalar joint
When the foot is unloaded (i.e., not bearing weight), pronation pronates (everts), adding an element of flexibility to the midfoot
twists the sole of the foot outward, whereas supination twists the (see Fig. 14.31B).34 By late stance, the arch rises sharply as the
sole of the foot inward. While the foot is under load during the now supinating subtalar joint adds rigidity to the midfoot.13 The
stance phase of walking, however, pronation and supination rigidity prepares the foot to support the large loads produced at
permit the leg-and-talus to rotate in all three planes relative to a the peak of the push off phase. The ability of the foot to repeat-
comparatively fixed calcaneus. This important mechanism is edly transform from a flexible and shock-absorbent structure to a
orchestrated primarily through an interaction among the subtalar more rigid lever during each gait cycle is one of the most impor-
joint, transverse tarsal joint, and medial longitudinal arch. Much tant and clinically relevant actions of the foot. As subsequently
remains to be learned about this complex topic. described, the subtalar joint is the principal joint that directs the
In the healthy foot, the medial longitudinal arch rises and pronation and supination kinematics of the foot.
lowers cyclically throughout the gait cycle. During most of the
stance phase, the arch lowers slightly in response to the progressive Early to MidStance Phase of Gait: Kinematics of Pronation at the
loading of body weight (Fig. 14.31A).13,83 Structures that resist Subtalar Joint
the lowering of the arch absorb local stress as the foot is progres- Immediately after the heel contact phase of gait, the dorsiflexed
sively compressed by body weight. This load attenuation mecha- talocrural joint and slightly supinated subtalar joint rapidly
nism offers essential protection to the foot and lower limb against plantar flex and pronate, respectively (consult Figs. 14.19 and
stress-related, overuse injury.61,90,204 14.31B).34 Although the data plotted in Fig. 14.31B show only
 Chapter 14   Ankle and Foot 619

TABLE 14.5 Selected Actions That May Be Associated with

Exaggerated Pronation of the Subtalar Joint during Weight
Bearing

INTERNAL
Joint or Region Action
ROTATION
Hip Internal rotation, flexion, and
adduction
Valgus Knee Increased valgus stress
stress
Rearfoot Pronation (eversion) with a lowering
of medial longitudinal arch
Midfoot and forefoot Supination (inversion)

S PE C I A L F O C U S 1 4 . 5

Example of the Kinematic Versatility of the Foot

D
E arlier in this section, the point was made that pronation of
the unloaded foot occurs primarily as a summation of the
pronation at both the subtalar and the transverse tarsal joints
AN ION REARFOOT
OT
E FO PINAT EVERSION (review Fig. 14.26B). This summation of motion does not neces-
R
FO OT SU
FO sarily occur, however, when the foot is under the load of body
MID REARFOOT
Lowering weight. With the foot loaded or otherwise fixed to the ground,
PRONATION
of arch pronating the rearfoot may cause the midfoot and forefoot
regions, which are receiving firm upward counterforce from the
floor, to twist into relative supination (see Fig. 14.32). This
FIG. 14.32 With the foot fixed, full internal rotation of the lower limb reciprocal kinematic relationship between the rearfoot and more
is mechanically associated with rearfoot pronation (eversion), lowering anterior regions of the foot demonstrates the versatility of the
of the medial longitudinal arch, and valgus stress at the knee. Note that
foot, either amplifying the other region’s action when the foot
as the rearfoot pronates, the floor “pushes” the forefoot and midfoot into
a relatively supinated position. is unloaded (see Fig. 14.26B) or counteracting the other region’s
action when the foot is loaded (see Fig. 14.32).

about 4 degrees of movement towards eversion (pronation)

between 0 and 30 degrees of the gait cycle, other data sources
using asymptomatic subjects (with normal medial arch heights) The amplitude of pronation at the subtalar joint during the
report values in the range of 5 to 9 degrees.83,190,200,208 Differ- early to midstance phase of walking is indeed relatively small,
ences in defining the 0-degree position of the subtalar joint, occurring for only one-quarter of a second during average-speed
dissimilar sample sizes and foot types, and the varying measure- walking. The amount and the speed of the pronation nevertheless
ment techniques account for much of this inconsistency within influence the kinematics of the more proximal joints of the lower
the literature. For this reason, it is often difficult to specifically extremity. These effects can be readily appreciated by exaggerating
define “abnormal” eversion (pronation) during walking. and dramatically slowing the pronation action of the rearfoot
The pronation (eversion) at the subtalar joint during stance during the initial loading phase of gait. Consider the demonstra-
occurs primarily by two mechanisms. First, the calcaneus tips into tion depicted in Fig. 14.32. While standing over a loaded and
slight eversion in response to the ground reaction force passing fixed foot, forcefully but slowly internally rotate the lower limb
upward and just lateral to the midpoint of the posterior calcaneus. and observe the associated pronation at the rearfoot (subtalar
The simultaneous impact of heel contact also pushes the head of joint) and simultaneous lowering of the medial longitudinal arch.
the talus medially in the horizontal plane and inferiorly in the If sufficiently forceful, this action also tends to internally rotate,
sagittal plane. Relative to the calcaneus, this motion of the talus slightly flex, and adduct the hip and create a valgus stress on the
abducts and (slightly) dorsiflexes the subtalar joint. These motions knee (Table 14.5). These mechanical events are indeed exagger-
are consistent with the formal definition of pronation. A loosely ated and do not all occur to this degree and pattern during
articulated skeletal model aids in the visualization of this motion. walking at normal speed. Nevertheless, because of the linkages
Second, during the early stance phase, the tibia and fibula, and to throughout the lower limb, excessive or uncontrolled pronation
a lesser extent the femur, internally rotate after initial heel of the rearfoot could exaggerate one or more of these mechanically
contact.84,148,150 Because of the embracing configuration of the related joint actions. Clinically, a person who excessively pronates
talocrural joint, the internally rotating lower leg steers the subtalar during early stance may complain of medial knee pain, possibly
joint into further pronation. The argument is often made that with from excessive valgus stress placed on the knee and subsequent
the calcaneus in contact with the ground, pronation at the sub- overstretching of the medial collateral ligament. Whether the
talar joint causes, rather than follows, internal rotation of the leg; overpronation causes excessive strain on the medial collateral liga-
either perspective is valid. ment or vice versa is not always obvious.
620 Section IV   Lower Extremity

Despite decades of research, a predictable kinematic relation- a “chain reaction” of kinematic disturbances and compensations
ship between the magnitude and timing of excessive pronation throughout the entire limb, such as those depicted in Fig. 14.32.181
and excessive internal rotation throughout the lower limb has For example, as described in Chapter 13, the abnormal kinematic
not been established conclusively. Additional studies are needed sequence between the tibia and femur may alter the contact area
in this area before definite cause-and-effect relationships are at the patellofemoral joint, potentially increasing stress at this
known. These relationships are important, because they serve as joint. Furthermore, excessive rearfoot eversion may create an
the basis for many exercises and for the use of orthotics to increased valgus stress on the medial side of the knee. These situ-
reduce painful conditions related to excessive or poorly con- ations may predispose a person to patellofemoral joint pain syn-
trolled pronation. drome or instability.9 For these reasons, clinicians often note the
position of the subtalar joint while the patient stands and walks
Biomechanical Benefits of Controlling Pronation during the as part of an evaluation for a mechanical cause of patellofemoral
Stance Phase joint pain or other overuse syndromes throughout the lower limb,
A controlled and limited amount of pronation of the subtalar including the hip and spine.54,126,181,202
joint through the mid stance phase of walking has several useful The underlying pathomechanics of excessively pronated feet are
biomechanical effects. Pronation at the subtalar joint permits the a concern for both running and non–running populations. Repet-
talus and entire lower extremity to rotate internally slightly after itive impact from high-intensity and high-volume running and
the calcaneus has contacted the ground. The strong horizontal marching is a risk factor for sustaining a stress fracture, most often
orientation of the facets at the subtalar joint certainly facilitates involving the navicular and tibia.22,71,124 Research on civilian
this action. Without such a joint mechanism, the plantar surface female distance runners has shown that those with a history of a
of the calcaneus would otherwise “spin” like a child’s top against previous tibial stress fracture exhibit greater rearfoot eversion
the walking surface, along with the internally rotating leg. Eccen- during the stance phase while running compared with a control
tric activation of supinator muscles, mainly the tibialis posterior, group.125 Whether the excessive eversion at heel contact ultimately
can help to decelerate the pronation and resist the lowering of the caused the increased likelihood of having a stress fracture cannot
medial longitudinal arch.131 Controlled pronation of the subtalar be stated with certainty, although the possibility should be
joint favors relative flexibility of the midfoot, allowing the foot to respected.
accommodate to the varied shapes and contours of walking In summary, the pathomechanics of overpronation can involve
surfaces. many dynamic kinematic relationships within the joints of the
foot and between the foot and the joints in the lower limb and
Biomechanical Consequences of Excessive Pronation during the low back region.123,126 The origin of the pathomechanics may be
Stance Phase related to interactions between the hip and knee (described in
Innumerable examples exist on how malalignment within the foot Chapter 13) and expressed distally as impairments at the sub-
affects the kinematics of walking. One common scenario results talar joint. Even if the pathomechanics are obviously located
from excessive, prolonged, or poorly controlled pronation at the within the foot, abnormal motion in the forefoot may be com-
subtalar joint (rearfoot) during the stance phase. As a conse- pensated by abnormal motion in the rearfoot and vice versa.
quence, the path of the center of plantar pressure falls more medi- Furthermore, extrinsic factors, such as footwear, orthotics, terrain,
ally on the sole of the foot than in a rectus or high arch.74 After and speed of walking and running alter the kinematic relation-
many repetitions of the gait cycle, cumulative stress may build ships within the foot and lower extremity. An understanding
within the medial foot and ultimately result in local inflammation of the complex kinesiology of the entire lower extremity is a
and pain. Stressed local regions of the foot include the plantar definite prerequisite for the effective treatment of the painful or
fascia, talonavicular joint (keystone of the medial arch), and tibi- misaligned foot.
alis posterior tendon.122
The pathomechanics of pes planus may include weakness of Mid-to-Late Stance Phase of Gait: Kinematics of Supination at
muscles throughout the lower extremity, laxity or weakness in the the Subtalar Joint
mechanisms that normally support and control the medial longi- At about 15% to 20% into the gait cycle, the entire stance limb
tudinal arch, or abnormal shape or mobility of the tarsal bones. reverses its horizontal plane motion from internal to external
Regardless of cause, the rearfoot falls into excessive valgus (ever- rotation.85,148,150 External rotation of the leg while the foot
sion) after heel contact, in some cases doubling the normal remains planted coincides roughly with the beginning of the
amount.200 Excessive subtalar joint pronation may be a compensa- swing phase of the contralateral lower extremity. With the stance
tion for excessive or restricted motion throughout the lower foot securely planted, external rotation of the femur, followed
extremity, particularly in the frontal and horizontal planes. by the tibia, gradually reverses the horizontal plane direction of
Paradoxically, one of the most common structural deformities the talus from internal to external rotation. As a result, at about
within an overpronated foot is a relatively fixed rearfoot varus. 30% to 35% into the gait cycle, the pronated (everted) subtalar
(Varus describes a segment of the foot that is inverted toward the joint starts to move sharply toward supination (inversion) (see
midline.) As a response to rearfoot varus, the subtalar joint often Fig. 14.31B). As demonstrated in Fig. 14.33, with the rearfoot
overcompensates by excessively pronating, in speed and/or mag- supinating, the midfoot and forefoot must simultaneously twist
nitude, to ensure that the medial aspect of the forefoot contacts into relative pronation in order for the foot to remain in full
the ground during the stance phase.119,150 Similar compensations contact with the ground. By late stance, the supinated subtalar
may occur with a forefoot varus deformity.126 Whether the forefoot joint and the elevated and tensed medial longitudinal arch
varus deformity causes or results from excessive pronation of the convert the midfoot (and ultimately the forefoot) into a more
rearfoot is not always clear. rigid lever. Muscles such as the gastrocnemius and soleus use
As described previously, excessive rearfoot pronation is typically this stability to transfer forces from the Achilles tendon, through
associated with excessive (horizontal plane) internal rotation of the midfoot, to the metatarsal heads during the push off phase
the talus and leg during walking.150 Such a movement may create of walking or running.
 Chapter 14   Ankle and Foot 621

S PE C I A L F O C U S 1 4 . 6

The Use of a Foot Orthosis for Controlling Excessive Pronation

V arying levels of evidence exist that support the therapeutic

value of using a foot orthosis for persons with pes planus or
other conditions that cause excessive pronation during walking or
average of about 2 degrees.29 This kinematic change does not
however necessarily explain how the orthosis moderates existing
painful syndromes or prevents overuse injuries throughout the
running.4,53,102,130,153 Evidence is even stronger for using a foot lower limb. Perhaps the presence of the foot orthosis reduces
orthosis as a preventive measure, such as to reduce the frequency the demand on muscles (such as the tibialis posterior), optimizes
of overuse injuries in the lower limb from high-intensity physical the alignment of the bones and joints, produces a subtle change
training, typically experienced by military recruits.30,54 Some of in the kinematic sequencing in the joints proximal to the foot, or
these overuse injuries purported to be associated with excessive simply provides physical support to the plantar medial aspect of
pronation include inflammation of the iliotibial tract, patellofemoral the foot.132 Although not thoroughly understood, it is likely that the
pain syndrome, plantar fasciitis, stress fractures, and Achilles and therapeutic benefit arises as a combination of these and other yet
patellar tendinopathy.9,54 identified factors.17,46,111,152
In its very basic form, a pronation-controlling orthosis incorpo- As an adjunct to using a foot orthosis to control excessive
rates medial wedging (or posting) in specific regions of the foot pronation, clinicians typically stress the need to improve the
and a contoured in-step that fits inside of a shoe. In simple terms, strength and control of the intrinsic and extrinsic muscles of the
the orthosis “brings the floor up to the foot.” Orthoses may be foot.4 Greater “eccentric” control over the muscles that decelerate
prefabricated or highly customized to accommodate the unique pronation and other associated motions mechanically linked to
shape of the foot, body weight, and arch dynamics, or as a hybrid pronation (such as those listed in Table 14.5) may reduce the rate
of the two.54 It is not possible to unequivocally determine which of loading of tissues throughout the lower limb. Some of these
type of orthosis is most effective given its many design options extrinsic muscles include the supinators of the foot (notably the
and clinical uses.30,54,132,133,183 Each type likely has its advantages tibialis posterior) and the more proximal external rotators and
and disadvantages as far as cost and function. abductors of the hip.
A properly fit and well-designed foot orthosis can reduce peak
rearfoot pronation during standing, walking, and running by an

EXTERNAL
ROTATION

EXTERNAL
ROTATION
D
T AN
R E FOO NATION
FO T PRO
O
M IDFO

REARFOOT
SUPINATION
Raising REARFOOT
of arch INVERSION

FIG. 14.33 With the foot fixed to the ground, full external rotation of the lower limb is mechanically associated with
rearfoot supination (inversion) and raising of the medial longitudinal arch. Note that as the rearfoot supinates, the
forefoot and midfoot pronate to maintain contact with the ground.
622 Section IV   Lower Extremity

Posterior-superior view

Metatars
al
s

AR FLEXION
A

NT
A
C PL
nei forms
Navic
ula Cu N

IO
r

RS
EVE
IF
IF LF
LF
MF MF
Cuboid
FIG. 14.35 Structural and functional features of the midfoot and forefoot.
Styloid (A) The transverse arch is formed by the intercuneiform and cuneocuboid
Cuneonavicular joint process
joint complex. (B) The stable second ray is reinforced by the recessed
MF Medial facet
Facet for second tarsometatarsal joint. (C) Combined plantar flexion and eversion
IF Intermediate facet
LF Lateral facet calcaneocuboid of the left tarsometatarsal joint of the first ray allow the forefoot to better
joint conform to the surface of the rock.
Cuboideonavicular joint
Intercuneiform and
cuneocuboid joint complex
these articulations. The slightly concave facets (lateral, intermedi-
FIG. 14.34 A posterior-superior view of the right foot is shown with the
talus and calcaneus removed. The navicular bone has been flipped medi-
ate, and medial) on each of the three cuneiforms fit into one of
ally, exposing its anterior surface and the many articulations within the three slightly convex facets on the anterior side of the navicular.
distal intertarsal joints. Articular surfaces have been colored-coded as The major function of the cuneonavicular joint is to help transfer
follows: cuneonavicular joint in light purple; the small cuboideonavicular components of pronation and supination distally from the talo-
joint in green; and the intercuneiform and cuneocuboid joint complex in navicular toward the forefoot.
blue. Replacing the navicular to its natural position would join the three
sets of articular facets within the cuneonavicular joint—medial facet Cuboideonavicular Joint
(MF), intermediate facet (IF), and lateral facet (LF). Replacing the navic- The small synarthrodial (fibrous) or sometimes synovial cuboideo­
ular would also rearticulate the cuboideonavicular joint (green). navicular joint is located between the lateral side of the navicular
and a proximal region of the medial side of the cuboid (see Fig.
14.34, green). This joint provides a relatively smooth contact
point between the lateral and medial longitudinal columns of the
A person who, for whatever reason, remains relatively pronated foot. Observations on cadaver specimens show that the articular
late into stance phase may have difficulty stabilizing the midfoot surfaces slide slightly against each other during movements of the
at a time when it is naturally required.120 Consequently, excessive midfoot, most notably during inversion and eversion.
activity may be required from extrinsic and intrinsic muscles of
the foot to reinforce the medial longitudinal arch. Over time, Intercuneiform and Cuneocuboid Joint Complex
hyperactivity may lead to generalized muscle fatigue and painful The intercuneiform and cuneocuboid joint complex consists of
“overuse” syndromes throughout the lower limb and foot. three articulations: two between the set of three cuneiforms, and
one between the lateral cuneiform and medial surface of the
DISTAL INTERTARSAL JOINTS cuboid (see Fig. 14.34, blue). Articular surfaces are essentially flat
and aligned nearly parallel with the long axis of the metatarsals.
The distal intertarsal joints are a collection of three joints or joint Plantar, dorsal, and interosseous ligaments strengthen this set of
complexes, each occupying a part of the midfoot (review organiza- articulations.
tion of joints of the foot; see Fig. 14.23). The articular surfaces The intercuneiform and cuneocuboid joint complex forms the
of the distal intertarsal joints are shown exposed and color-coded transverse arch of the foot (Fig. 14.35A). This arch provides trans-
in Fig. 14.34. verse stability to the midfoot. Under the load of body weight, the
transverse arch depresses slightly, allowing body weight to be
Basic Structure and Function shared across all five metatarsal heads. The transverse arch receives
As a group, the distal intertarsal joints (1) assist the transverse support from intrinsic muscles; extrinsic muscles, such as the
tarsal joint in pronating and supinating the midfoot and (2) tibialis posterior and fibularis longus; connective tissues; and the
provide stability across the midfoot by forming the transverse arch keystone of the transverse arch: the intermediate cuneiform (see
of the foot. Motions at these joints are small and typically not IF in Fig. 14.34).
specifically measured clinically.
TARSOMETATARSAL JOINTS
Cuneonavicular Joint
Three articulations are formed between the anterior side of the Anatomic Considerations
navicular and the posterior surfaces of the three cuneiform bones The tarsometatarsal joints are frequently called Lisfranc’s joints,
(see Fig. 14.34, purple). Plantar and dorsal ligaments surround after Jacques Lisfranc, a French field surgeon in Napoleon’s army
 Chapter 14   Ankle and Foot 623

who described an amputation in this region of the foot. As a

group, the five tarsometatarsal joints separate the midfoot from
the forefoot (review organization of joints in Fig. 14.23). The
joints consist of the articulation between the bases of the meta-
tarsals and the distal surfaces of the three cuneiforms and cuboid.
Specifically, the first (most medial) metatarsal articulates with the
medial cuneiform, the second with the intermediate cuneiform, EVERSION
and the third with the lateral cuneiform. The bases of the fourth
and fifth metatarsals both articulate with the distal surface of the
cuboid.
The articular surfaces of the tarsometatarsal joints are generally
flat, although the medial two show slight, irregular curvatures. Tarsometatarsal
Dorsal, plantar, and interosseous ligaments add stability to these joint
articulations. Only the first tarsometatarsal joint has a well- PLANTAR
developed capsule.175 A FLEXION

Kinematic Considerations
The tarsometatarsal joints are the basilar joints of the forefoot.
Mobility is least at the second and third tarsometatarsal joints, in
part because of strong ligaments and the wedged position of the
base of the second ray between the medial and lateral cuneiforms
(see Fig. 14.35B). Consequently, the second and third rays DORSIFLEXION
produce an element of longitudinal stability throughout the foot,
similar to the second and third rays in the hand. This stability is
useful in late stance as the forefoot prepares for the dynamics of
push off.
Overall mobility is greatest in the first, fourth, and fifth tarso-
metatarsal joints, most notably in the first (most medial) joint.35,55 Tarsometatarsal
During the early to midstance phase of walking, the first tarso- joint
metatarsal joint (or entire medial column of the foot) dorsiflexes B INVERSION
about 5 degrees.33,42 This motion occurs as body weight depresses
the cuneiform region downward as the ground simultaneously FIG. 14.36 The osteokinematics of the first tarsometatarsal joint. Plantar
pushes the distal end of the first ray upward. This movement is flexion occurs with slight eversion (A), and dorsiflexion occurs with slight
associated with a gradual lowering of the medial longitudinal inversion (B).
arch64—a previously described mechanism that helps absorb the
stress of body weight acting on the foot. At the late stance (push
off ) phase of gait, however, the first tarsometatarsal joint rapidly
plantar flexes about 5 degrees.33 The plantar flexion of the first ray, of the thumb metacarpal as the pronated hand grasps a large
controlled in part by pull of the fibularis longus, effectively “short- spherical object.) Exactly how these atypical movement combina-
ens” the medial column of the foot slightly, thereby helping to tions relate functionally to the overall kinematics of the foot
raise the medial longitudinal arch. This mechanism increases the during walking remains uncertain.
stability of the arch (and medial column of the foot) at a time in
the gait cycle when the midfoot and forefoot are under higher INTERMETATARSAL JOINTS
loads.
The overall functional stability of the first tarsometatarsal joint Structure and Function
is considered an important mechanism that assists the medial Plantar, dorsal, and interosseous ligaments interconnect the bases
longitudinal arch in safely accepting and sharing the loads incurred of the four lateral metatarsals. These points of contact form three
while walking. Instability or excessive mobility of the joint (usually small intermetatarsal synovial joints. Although interconnected by
clinically assessed in the sagittal plane) has been associated with ligaments, a true joint does not typically form between the bases
several pathologies of the foot, including hallux valgus (bunion), of the first and second metatarsals. This lack of articulation
local osteoarthritis, and pes planus.35,42,142 The pathomechanics increases the relative movement of the first ray, in a manner similar
underlying these associations are not clear and difficult to study. to the hand. Unlike in the hand, however, the deep transverse
Most literature describes a natural mechanical coupling of the metatarsal ligaments interconnect the distal end of all five meta-
kinematics at the first tarsometatarsal joint: specifically, plantar tarsals. Slight motion at the intermetatarsal joints augments the
flexion occurs with slight eversion, and dorsiflexion with slight inver- flexibility at the tarsometatarsal joints.
sion.63,64,105 Such passive mobility does indeed appear to occur
naturally when assessed in a non–weight-bearing condition (Fig. METATARSOPHALANGEAL JOINTS
14.36). Although these movement combinations do not fit the
standard definitions of pronation or supination, they nevertheless Anatomic Considerations
provide useful functions. Combining plantar flexion and eversion, Five metatarsophalangeal joints are formed between the convex
for example, allows the medial side of the foot to better conform head of each metatarsal and the shallow concavity of the proximal
around irregular surfaces on the ground (see Fig. 14.35C). (This end of each proximal phalanx (see Fig. 14.23). These joints are
motion of the first metatarsal is generally similar to the movement located about 2.5 cm proximal to the “web spaces” of the toes.
624 Section IV   Lower Extremity

Epicondyle Medial capsular Superior view

ligament (cord portion) Distal attachment
Interphalangeal of extensor digitorum
joint longus and brevis (cut)
Distal
interphalangeal
Extensor joint
hallucis Proximal
longus (cut) interphalangeal
joint
Extensor
Plantar plate Dorsal
digitorum
and sesamoids digital
brevis (cut)
expansion
FIG. 14.37 A medial view of the first metatarsophalangeal joint showing Plantar plate
the cord and accessory portions of the medial (collateral) capsular liga- Dorsal
Sesamoid
ment. The accessory portion attaches to the plantar plate and sesamoid bones interossei
bones. (Redrawn from Haines R, McDougall A: Anatomy of hallux
valgus, J Bone Joint Surg Br 36:272, 1954.) Flexor
hallucis Extensor
brevis digitorum
brevis
Abductor
hallucis Extensor

Exten
digitorum
With the joints flexed, the prominent heads of the metatarsals are longus

so
easily palpable on the dorsum of the distal foot.

r ha
lluc
Articular cartilage covers the distal end of each metatarsal head Fibularis

is
(Fig. 14.37). A pair of collateral ligaments spans each metatarso-

lon
tertius

gu
phalangeal joint, blending with and reinforcing the capsule. As in r

s
ula

Fibularis brevis
(c u
the hand, each collateral ligament courses obliquely from a dorsal- ic

t)
v
proximal to a plantar-distal direction, forming a thick cord

Na
portion and a fanlike accessory portion. s
lu

Ta
The accessory portion attaches to the thick, dense plantar plate,
located on the plantar side of the joint. The plate, or ligament, is
grooved for the passage of flexor tendons. Fibers from the deep
plantar fascia attach to the plantar plates and sheaths of the flexor FIG. 14.38 Muscles and joints of the dorsal surface of the right forefoot.
The distal half of the first metatarsal is removed to expose the concave
tendons. Two sesamoid bones located within the tendon of the
surface of the first metatarsophalangeal joint. A pair of sesamoid bones
flexor hallucis brevis rest against the plantar plate of the first is located deep within the first metatarsophalangeal joint. The proximal
metatarsophalangeal joint (Fig. 14.38). Connective tissue attach- phalanx of the second toe is removed to expose the concave side of the
ments between the sesamoid bones and the collateral ligaments proximal interphalangeal joint.
help stabilize the position of the pair of bones relative to the head
of the first metatarsal bone.142 Although not depicted in Fig.
14.38, four deep transverse metatarsal ligaments blend with and
join the adjacent plantar plates of all five metatarsophalangeal hand is the third or middle digit.) The axes of rotation for all
joints. By interconnecting all five plates, the transverse metatarsal volitional movements of the metatarsophalangeal joints pass
ligaments help maintain the first ray in a similar plane as the lesser through the center of each metatarsal head.
rays, thereby adapting the foot for propulsion and weight bearing Most people demonstrate limited dexterity in active movements
rather than manipulation. In the hand, the deep transverse meta- at the metatarsophalangeal joints, especially in abduction and
carpal ligament connects only the fingers, freeing the thumb for adduction. From a neutral position, the toes can be passively
opposition. extended about 65 degrees and flexed about 30 to 40 degrees. The
A fibrous capsule encloses each metatarsophalangeal joint and great toe typically allows greater extension, to near 85 degrees.194
blends with the collateral ligaments and plantar plates. A poorly This magnitude of extension is readily apparent as one stands up
defined dorsal digital expansion covers the dorsal side of each on “tiptoes.”
metatarsophalangeal joint. This structure (analogous to the exten-
sor mechanism in the digits of the hand) consists of a thin layer Deformities or Trauma Involving the Metatarsophalangeal Joint
of connective tissue that is essentially inseparable from the dorsal of the Great Toe
capsule and extensor tendons. Hallux Limitus
Hallux limitus, or “rigidus” in its less severe form, is primarily a
Kinematic Considerations posttraumatic condition characterized by gradual marked limita-
Movement at the metatarsophalangeal joints occurs in two degrees tion of motion, articular degeneration, and pain at the metatar-
of freedom. Extension (dorsiflexion) and flexion (plantar flexion) sophalangeal joint of the great toe. Although any trauma or sprain
occur approximately in the sagittal plane about a medial-lateral of the great toe can progress to hallux limitus, the mechanism of
axis; abduction and adduction occur in the horizontal plane about injury frequently involves forceful hyperextension of the metatar-
a vertical axis. The second digit serves as the reference digit for sophalangeal joint. More severe injuries may involve complete or
naming the movements of abduction and adduction of the toes. incomplete tears of the plantar ligaments, capsule, and associated
(The reference digit for naming abduction and adduction in the tendons, as well as fracture of the sesamoid bones.21
 Chapter 14   Ankle and Foot 625

Injury caused by forced hyperextension of the great toe is often the body and not the second digit) about its tarsometatarsal
called “turf toe” and occurs relatively frequently in American joint.42,63,98 The adducted position of the first metatarsal can even-
football players. Historically, the term turf toe originated from the tually lead to lateral dislocation of the metatarsophalangeal joint,
increase in this injury after the replacement of natural grass with thereby completely exposing the metatarsal head as a lump or
artificial turf and the use of lighter-weight shoes.19 Regardless of “bunion.” The deformed metatarsophalangeal joint often becomes
the initiating trauma, a diagnosis of hallux limitus is often made inflamed and painful, and potentially osteoarthritic.142 If the
if pain persists along with reduced range of extension, usually to proximal phalanx laterally deviates in excess of about 30 degrees,
less than 55 degrees.194 In some cases the condition will progress the proximal phalanx often begins to evert about its long axis. The
to osteoarthritis; excessive osteophyte formation may then limit bunion deformity is also referred to as “hallux abducto-valgus” in
motion in all directions. order to account for the deviations in both horizontal and frontal
The impairments associated with hallux limitus can have sig- planes.
nificant impact on walking. Normally, walking requires about 45 The progressive medial deviation (adduction) of the first meta-
degrees of extension at the first metatarsophalangeal joint as the carpal coupled with the axial rotation of the laterally deviated
heel rises at late stance phase. A person with hallux limitus may proximal phalanx of the hallux creates a muscular imbalance in
attempt to avoid extending the painful great toe during the late the forces that normally align the metatarsophalangeal joint.5,142
stance phase of walking. Often this is accomplished by walking The abductor hallucis muscle (normally located medial to the first
on the outer surface of the affected foot, or by walking with the metatarsophalangeal joint) may gradually shift toward the plantar
foot pointed outward and “rolling over” the medial arch of the side of the joint. The subsequent unopposed pull of the adductor
foot. hallucis and lateral head of the flexor hallucis brevis progressively
Those affected may be advised to wear stiff-soled shoes (or stiff increases the lateral deviation posture of the proximal phalanx. As
inserts placed within the shoes) and to avoid inclines or declines. the lateral deviation of the hallux progresses, the tendons of the
Physical therapy has been shown to be effective in restoring range flexor and extensor hallucis longus become displaced lateral to the
of motion and reducing pain.166 Surgery may be recommended in vertical axis at the metatarsophalangeal joint. Forces in these
more severe cases. tendons therefore create an additional valgus torque to the under-
ling joint. In time, the overstretched medial collateral ligament
Hallux Valgus and capsule may weaken or rupture, removing the primary source
The central feature of hallux valgus (or bunion) is a progressive of reinforcement to the medial side of the joint.142 The deformity
lateral deviation of the great toe relative to the midline of the also positions the pair of sesamoids laterally relative the metatar-
body. Although the deformity appears to involve primarily the sophalangeal joint (see Fig. 14.39B).
metatarsophalangeal joint, the pathomechanics of hallux valgus Persons with marked hallux valgus typically limit placing weight
usually involve the entire first ray (Fig. 14.39A,B). As depicted in over the first metatarsophalangeal joint while walking, causing the
the radiograph, hallux valgus is typically associated with excessive lateral metatarsal bones to accept a greater proportion of the
adduction of the first metatarsal (defined in this case relative to load.98 The pathomechanics of marked hallux valgus involve a

FIG. 14.39 Hallux valgus. (A) Multiple features of

hallux valgus (bunion) and associated deformities.
(B) Radiograph shows the following pathomechanics
often associated with hallux valgus: (1) adduction of
52
the first metatarsal (toward the midline of the body),
evidenced by the increased angle between the first and
second metatarsal bones (normally 11 degrees63); (2)
lateral deviation of the proximal phalanx (normally
<15 degrees63) with dislocation or subluxation of the
first metatarsophalangeal joint; (3) visible lateral sesa-
moid between first and second metatarsals; (4) dis-
placement of the lateral sesamoid; (5) rotation
(eversion) of the phalanges of the great toe; and (6)
exposed first metatarsal head, forming the so-called
20 “bunion.” (A, From Richardson EG: Disorders of the
hallux. In Canale ST, Beaty JH: Campbell’s operative
orthopaedics, vol 4, ed 11, St Louis, 2008, Mosby; B,
From Richardson EG: Disorders of the hallux. In
Canale ST, Beaty JH: Campbell’s operative orthopaedics,
vol 4, ed 12, St Louis, 2012, Mosby.)
A B
626 Section IV   Lower Extremity

zigzag-like collapse of the first ray, similar to the “ulnar drift” of All interphalangeal joints of the foot possess similar anatomic
the metacarpophalangeal joint in the hand with rheumatoid features. The joint consists of the convex head of the more proxi-
arthritis (see Chapter 8). mal phalanx articulating with the concave base of the more distal
Although the cause and underlying pathomechanics of hallux phalanx. The proximal phalanx of the second toe is removed in
valgus are not totally clear, several factors appear to be associated Fig. 14.38 to expose the concave side of the proximal interpha-
with either the initiation or the progression of the disorder. Some langeal joint. The structure and function of the connective tissues
of these factors include genetics, sexual dimorphism, incorrect at the interphalangeal joints are generally similar to those described
footwear,142 abnormal alignment of the lower limb,177 excessive for the metatarsophalangeal joints. Collateral ligaments, plantar
rearfoot valgus and associated altered axis of rotation at the base plates, and capsules are present but smaller and less defined.
of the first ray,63 tightness of the Achilles tendon,142 and instability Mobility at the interphalangeal joints is limited primarily to
of the base of the first ray.35 The full spectrum of severe hallux flexion and extension. The amplitude of flexion generally exceeds
valgus often includes dislocation and osteoarthritis of the meta- extension, and motion tends to be greater at the proximal than
tarsophalangeal joint, metatarsus varus, valgus (lateral deviation) the distal joints. Extension is limited primarily by passive tension
of the great toe, bunion formation (and bursitis) over the medial in the toe flexor muscles and plantar ligaments.
metatarsophalangeal joint, hammer toe of the second digit, cal-
luses, and metatarsalgia. As advocated by Glasoe and colleagues,63 ACTION OF THE JOINTS WITHIN THE FOREFOOT DURING
a pronation controlling foot orthosis may be helpful in slowing THE LATE STANCE PHASE OF GAIT
the progression of the deformity. Surgical intervention is often
indicated in cases of marked deformity and dysfunction. The joints of the forefoot include the articulations associated
with each ray, from the tarsometatarsal joint to the distal inter-
INTERPHALANGEAL JOINTS phalangeal joints of the toe. Depending on the phase of gait, these
joints provide an element of flexibility or stability to the
As in the fingers, each toe has a proximal interphalangeal and a forefoot.
distal interphalangeal joint. The great toe, or hallux, being analo- At the end of stance phase, the midfoot and forefoot must
gous to the thumb, has only one interphalangeal joint. become relatively stable to accept the stress associated with

Normal foot Foot with pes planus

Extrinsic
muscles

Intrinsic muscles

A B
FIG. 14.40 The “windlass effect” of the plantar fascia is demonstrated while a subject stands on tiptoes. (A windlass
is a hauling or lifting device consisting of a rope wound around a cylinder that is turned by a crank. The rope is analo-
gous to the plantar fascia, and the cylinder is analogous to the metatarsophalangeal joint.) (A) In the normal foot,
contraction of the extrinsic plantar flexor muscles lifts the calcaneus, thereby transferring body weight forward over
the metatarsal heads. The resulting extension of the metatarsophalangeal joints (shown collectively as the white disk)
stretches (or winds up) the plantar fascia within the medial longitudinal arch (red spring). The increased tension from
the stretch raises the arch and strengthens the midfoot and forefoot. Contraction of the intrinsic muscles provides
additional reinforcement to the arch. (B) The foot with pes planus (flat foot) typically has a poorly supported medial
longitudinal arch. During an attempt to stand up on tiptoes, the forefoot sags under the load of body weight. The
reduced extension of the metatarsophalangeal joints limits the usefulness of the windlass effect. Even with strong
activation of the intrinsic muscles, the arch remains flattened and the midfoot and forefoot unstable.
 Chapter 14   Ankle and Foot 627

TABLE 14.6 Major Actions at Regions of the Ankle and Foot during the Stance Phase of Walking*
Early Stance Mid to Late Stance
Region Representative Joint Action Desired Function Action Desired Function

Ankle Talocrural Plantar flexion Allows rapid foot Continued dorsiflexion Produces a stable mortise
contact with the followed by rapid (ankle) to accept body
ground plantar flexion weight, followed by
thrust needed for push
off
Rearfoot Subtalar Pronation and Permits internal Continued pronation Permits external rotation of
lowering of the rotation of lower changing to lower limb
medial limb supination, followed Converts the midfoot to a
longitudinal Allows the foot to by a raising of the rigid lever for push off
arch function as a medial longitudinal
shock absorber arch
Produces a pliable
midfoot
Midfoot Transverse tarsal Relative inversion Allows full extent of Relative eversion Allows the midfoot and
as a response to subtalar joint forefoot to maintain firm
counterforce pronation contact with the ground
from the ground
Forefoot Metatarsophalangeal Insignificant — Extension Through the windlass
effect, raises the medial
longitudinal arch and
stabilizes the midfoot
and forefoot for push off

*Each region of the foot is represented by only one joint.

terminal push off. In addition to activation of local intrinsic and individual has no neuromuscular pathology, there is significant
extrinsic muscles (notably the tibialis posterior), a rising of the loss in the lift of the heel, even on maximal muscular effort.
medial longitudinal arch further stabilizes the foot. Although the Without an effective medial longitudinal arch, the unstable,
rise of the arch is highly variable, it averages 6 mm during the late unlocked midfoot and forefoot sag under body weight. This typi-
push off phase.163 One of the primary mechanisms used to lift the cally causes a movement toward dorsiflexion of the tarsometatarsal
arch has been historically described as the “windlass effect,” which joints (in contrast to normal slight plantar flexion). This kine-
can be demonstrated by standing on tiptoes (Fig. 14.40A). Because matic response may stretch the extrinsic toe flexor muscles and,
of the indirect attachments between the deep plantar fascia and if significant, limit toe extension. Regardless of the specific cause-
the toes, full extension of the metatarsophalangeal joints increases and-effect relationship, the reduced extension of the metatarso-
the tension throughout the medial longitudinal arch. In theory, phalangeal joints reduces the effectiveness of the windlass effect
the increased tension stabilizes the arch. As the heel and most for stabilizing the foot.
of the foot are lifted, body weight shifts anteriorly toward the The final section on kinematics closes with Table 14.6, which
more medial metatarsal heads. Local fat pads reduce potentially summarizes the important functions of the ankle and foot during
damaging stress to the bone, and the sesamoid bones protect the the entire stance phase of walking.
long flexor tendon of the great toe. Once stabilized by the stretched
plantar fascia and a reinforced arch, the second and third rays act
as rigid levers capable of withstanding the large bending moments MUSCLE AND JOINT INTERACTION
created by the contracting gastrocnemius and soleus muscles. The
tensile force within the stretched plantar fascia during very late Innervation of Muscles and Joints
stance phase has been estimated to be near 100% of body weight.45
Failure of the plantar fascia to transmit this force from the calca- INNERVATION OF MUSCLES
neus to the base of the toes would limit the effectiveness of the
windlass mechanism in raising the arch. This, indeed, is often Extrinsic muscles of the ankle and foot have their proximal attach-
observed by noting the guarded or ineffective manner of “push ments in the leg, and a few extend as far proximal as the femur.
off ” in a person who has had a plantar fasciotomy or is experienc- Intrinsic muscles, in contrast, have both their proximal and distal
ing painful plantar fasciitis. attachments within the foot.
In contrast to the healthy foot, consider the pathomechanics The extrinsic muscles are arranged in three compartments
involved as a person with an unstable “flat foot” (pes planus) of the leg: anterior, lateral, and posterior. A different motor
attempts to rise up on tiptoes (see Fig. 14.40, B). Although the nerve innervates the muscles within each compartment (see
628 Section IV   Lower Extremity

cross-sections in Figs. 14.41 and 14.42). Each motor nerve is a set includes the calf muscles: the gastrocnemius and soleus
branch of the sciatic nerve, formed from the L4–S3 spinal nerve (together known as the triceps surae) and the small plantaris. The
roots of the sacral plexus. deep set includes the tibialis posterior, flexor hallucis longus, and
Lateral to the head of the fibula, the common fibular (peroneal) flexor digitorum longus. As the tibial nerve approaches the medial
nerve (L4–S2) divides into a deep and a superficial branch (see Fig. side of the ankle, it sends a sensory branch to the skin over the
14.41). The deep branch of the fibular nerve innervates the muscles heel.
within the anterior compartment: the tibialis anterior, extensor Just posterior to the medial malleolus, the tibial nerve bifurcates
digitorum longus, extensor hallucis longus, and fibularis (pero- into the medial plantar nerve (L4–S2) and the lateral plantar nerve
neus) tertius. The deep branch continues distally to innervate the (L5–S3). The plantar nerves supply sensation to the skin on most
extensor digitorum brevis (an intrinsic muscle located within the of the plantar surface of the foot and motor innervation to all
dorsum of the foot). It also supplies sensory innervation to a trian- intrinsic muscles, except the extensor digitorum brevis. The
gular area of skin in the web space between the first and second general organization of the innervation of the intrinsic muscles of
toes. The superficial branch of the fibular nerve innervates the fibu- the foot is similar to that in the hand. The medial plantar nerve
laris longus and fibularis brevis within the lateral compartment. is analogous to the median nerve, whereas the lateral plantar nerve
The nerve then continues distally as a sensory nerve to much of is analogous to the ulnar nerve.
the skin on the dorsal and lateral aspects of the leg and foot. The spinal nerve roots that supply the muscles of the lower
The tibial nerve (L4–S3) and its terminal branches innervate extremity are listed in Appendix IV, Part A. Part B of this appendix
the remainder of the extrinsic and intrinsic muscles of the foot lists key muscles typically used to test the functional status of the
and ankle (see Fig. 14.42). The muscles within the posterior com- L2–S3 spinal nerve roots. Part C shows a dermatome map of the
partment are divided into superficial and deep sets. The superficial lower extremity.

Anterior view

Sciatic nerve Anterior compartment

COMMON Tibialis anterior
FIBULAR Extensor hallucis
NERVE (L4-S2) Deep branch— longus
fibular nerve Extensor
Recurrent articular nerve Tibia digitorum
longus
DEEP BRANCH— Superficial branch—
FIBULAR NERVE fibular nerve

Lateral
Tibialis anterior
compartment
Common Fibularis
SUPERFICIAL fibular longus
BRANCH— nerve
FIBULAR NERVE Fibularis
Extensor digitorum brevis
longus
Fibularis longus
Fibula
Extensor hallucis Interosseous
longus membrane
Fibularis brevis Superficial
fibular
Fibularis nerve
Sensory nerve tertius
(superficial branch—
fibular nerve) Deep fibular
nerve
Extensor digitorum
brevis
Sural nerve
(sensory) Sensory nerve
(deep branch— SENSORY DISTRIBUTION
fibular nerve)

FIG. 14.41 The path and general proximal-to-distal order of muscle innervation for the deep and superficial branches
of the common fibular (peroneal) nerve. The primary spinal nerve roots are in parentheses. The general sensory distri-
bution of this nerve (and its branches) is highlighted along the dorsal-lateral aspect of the leg and foot. The dorsal
“web space” of the foot is innervated solely by sensory branches of the deep branch of the fibular nerve. The cross-
section highlights the muscles and nerves located within the anterior and lateral compartments of the leg. (Modified
with permission from deGroot J: Correlative neuroanatomy, ed 21, Norwalk, Conn, 1991, Appleton & Lange.)
 Chapter 14   Ankle and Foot 629

Posterior view

Sciatic nerve

Common
fibular
TIBIAL NERVE nerve
(L4-S3) Sural nerve

Tibial nerve
Gastrocnemius Lateral plantar
nerve

Popliteus Medial plantar

nerve
Plantaris SENSORY DISTRIBUTION

Soleus
Deep posterior compartment Tibia
Tibialis posterior
Tibialis posterior
Sural nerve Fibula
Flexor digitorum (sensory)
longus Flexor digitorum
longus
Flexor hallucis Tibial nerve
longus
Flexor hallucis
longus

Plantaris tendon

TERMINAL BRANCHES
Superficial
Medial posterior
plantar nerve compartment Soleus Gastrocnemius
Lateral
plantar nerve
FIG. 14.42 The path and general proximal-to-distal order of muscle innervation for the tibial nerve and its branches.
The primary spinal nerve roots are in parentheses. The general sensory distribution of this nerve is highlighted along
the lateral and plantar aspects of the leg and foot. The cross-section highlights the muscles and nerves located within
the deep and superficial parts of the posterior compartment of the leg. (Modified with permission from deGroot J:
Correlative neuroanatomy, ed 21, Norwalk, Conn, 1991, Appleton & Lange.)

SENSORY INNERVATION OF THE JOINTS where the tendons cross the axes of rotation at the talocrural and
subtalar joints (see ahead Fig. 14.43). Although Fig. 14.43 is
The talocrural joint receives sensory innervation from the deep oversimplified (by lacking the transverse tarsal joint as well as
branch of the fibular nerve. In general, the sensory innervation to other components of pronation and supination of the foot), it can
the other joints of the foot is supplied by nerve branches that cross nevertheless serve as a useful guide to understanding many of the
the region. Each major joint receives multiple sources of sensory actions of the extrinsic muscles.
innervation, traveling to the spinal cord primarily through S1 and Throughout the remainder of this chapter, it may be helpful to
S2 nerve roots.175 consult Appendix IV, Part D for a summary of the attachments
and nerve supply to the muscles of the ankle and foot. Also, as a
Anatomy and Function of the Muscles reference, a list of cross-sectional areas of selected muscles of these
regions is provided in Appendix IV, Part E.
The muscles of the ankle and foot not only control the specific
actions of the underlying joints, but also provide the stability, EXTRINSIC MUSCLES
thrust, and shock absorption necessary for locomotion. Both
intrinsic and extrinsic muscles perform these functions. Addi- Anterior Compartment Muscles
tional discussion of the muscular interactions during walking and Anatomy
running follows in Chapters 15 and 16. The four muscles of the anterior compartment are listed in the
Because all extrinsic muscles cross multiple joints, they possess box. As a group, these “pretibial” muscles have their proximal
multiple actions. Many of these actions are evident by noting attachments on the anterior and lateral aspects of the proximal
630 Section IV   Lower Extremity

Anterior view

DORSIFLEXION DORSIFLEXION
INVERSION EVERSION

Extensor hallucis longus

Tibialis anterior
Tibialis anterior Fibularis longus
Extensor digitorum longus
Talocrural
Fibularis tertius
joint axis
Tibia Fibula

Tibialis posterior Fibularis brevis

Flexor digitorum longus
Fibularis longus Extensor digitorum longus
Flexor hallucis longus and fibularis tertius
Subt
joint

Achilles tendon
Extensor
alar

Superior extensor
axis

PLANTAR FLEXION PLANTAR FLEXION hallucis longus

INVERSION EVERSION retinaculum
FIG. 14.43 The multiple actions of muscles that cross the talocrural and Inferior extensor
subtalar joints, as viewed from above. The actions of each muscle are retinaculum
based on its position relative to the axes of rotation at the joints. Note
that the muscles have multiple actions.
Extensor digitorum
brevis

half of the tibia, the adjacent fibula, and the interosseous mem-
brane (Fig. 14.44). The tendons of these muscles cross the dorsal
side of the ankle, restrained by a synovial-lined superior and infe-
rior extensor retinaculum. Located most medially is the prominent FIG. 14.44 The pretibial muscles of the leg: tibialis anterior, extensor
tendon of the tibialis anterior, coursing distally to attach to digitorum longus, extensor hallucis longus, and fibularis tertius. All four
the medial-plantar surface of the first tarsometatarsal joint muscles dorsiflex the ankle.
(Fig. 14.45). The tendon of the extensor hallucis longus passes just
lateral to the tendon of the tibialis anterior as it courses toward
the dorsal surface of the great toe (see Fig. 14.44). Progressing subtalar joint by passing just medial to the axis of rotation. The
laterally across the dorsum of the ankle are the tendons of the tibialis anterior inverts and adducts the talonavicular joint,
extensor digitorum longus and the fibularis tertius (or “third” fibu- and, when the demand arises, supports the medial longitudinal
laris muscle). The four tendons of the extensor digitorum longus arch.
attach to the dorsal surface of the middle and distal phalanges via The primary actions of the extensor hallucis longus are dorsiflex-
the dorsal digital expansion. The fibularis tertius is part of the ion at the talocrural joint and extension of the great toe. Inversion
extensor digitorum longus muscle and may be considered as this at the subtalar joint is negligible because of its small moment arm,
muscle’s fifth tendon. The fibularis tertius attaches to the base of at least when analyzed from the anatomic position. In addition
the fifth metatarsal bone. to dorsiflexion of the ankle, the extensor digitorum longus and fibu-
laris tertius evert the foot.
Muscles of the Anterior Compartment of the Leg The previously stated muscular actions of the pretibial
(Pretibial “Dorsiflexors”) muscles are based on the assumption that the muscles are acti-
vated while the joints in question are in the anatomic, or
MUSCLES neutral, position. It is likely however that the potential torque
• Tibialis anterior (or possibly even action) of some of the muscles changes when
• Extensor digitorum longus
the joints are moved well outside the anatomic position. This
• Extensor hallucis longus
• Fibularis tertius change may have important functional implications. Consider,
for example, that the inversion moment arm of the tibialis
INNERVATION anterior may actually increase in a position of extreme inversion
• Deep branch of the fibular nerve (consult Fig. 14.43 as a visual guide). Such a biomechanical
scenario may at times be counterproductive, theoretically
Joint Action increasing the muscle’s inversion torque potential at a time
All four pretibial muscles are dorsiflexors because they cross ante- when evertor muscles (such as the fibularis longus and brevis)
rior to the axis of rotation at the talocrural joint (see Fig. 14.43). are attempting to resist this primary component of the classic
From the anatomic position, the tibialis anterior also inverts the ankle sprain.59,76