Chapter 14: Ankle and Foot

Part 1 of 3: Anatomy, Biomechanics, and Functional Roles of the Ankle and Foot

Introduction to the Ankle and Foot

The ankle and foot are complex structures responsible for bearing the body’s weight,
providing stability, facilitating movement, and allowing for adaptation to different surfaces.
These structures play a significant role in standing, walking, running, and other functional
activities. Understanding their anatomy and biomechanics is essential for diagnosing and
treating foot and ankle pathologies.

Anatomy of the Ankle and Foot

The ankle and foot are composed of a variety of bones, joints, muscles, ligaments, and
tendons that allow for a range of movements. Their structure can be divided into several
key regions:

Bones of the Ankle and Foot

Tibia and Fibula: The tibia is the larger of the two bones in the lower leg and is primarily
responsible for bearing weight. The fibula, located on the outer side of the lower leg,
provides support and stability but is not weight-bearing.

Tibial Plafond: The bottom part of the tibia, known as the tibial plafond, articulates with the
talus bone to form the ankle joint.

Talus: The talus is the key bone of the ankle joint that connects the leg to the foot. It is
involved in plantarflexion and dorsiflexion of the foot and also serves as a pivot for
inversion and eversion movements of the foot.

Calcaneus: The calcaneus, or heel bone, is the largest bone in the foot. It provides support
for the body’s weight during standing and acts as the attachment site for the Achilles
tendon, the primary tendon for plantarflexion.

Navicular: The navicular bone sits in front of the talus and helps form the medial arch of the
foot.

Cuneiforms and Cuboid: These are the bones that help form the tarsal region of the foot.
The three cuneiform bones (medial, intermediate, and lateral) are located in the middle of
the foot, and the cuboid is on the lateral side.

Metatarsals and Phalanges: The metatarsals are the long bones of the foot, extending from
the midfoot to the toes. The phalanges are the toe bones, and they are structured similarly
to the fingers, with three segments (proximal, middle, and distal) except for the big toe,
which only has two segments.
Joints of the Ankle and Foot

The ankle and foot consist of numerous joints that work together to facilitate movement.
These joints can be classified into synovial joints (which allow free movement) and non-
synovial joints (which are more stable and less mobile).

Ankle Joint (Talocrural Joint)

The ankle joint, or talocrural joint, is a hinge joint formed between the talus, tibia, and
fibula. It allows for plantarflexion (pointing the toes downward) and dorsiflexion (lifting the
foot upward).

This joint is critical for walking, running, and standing, as it helps absorb shock and adapt
to uneven terrain.

Subtalar Joint

The subtalar joint lies between the talus and calcaneus and allows for inversion (turning
the sole inward) and eversion (turning the sole outward). This joint is crucial for maintaining
balance and adjusting the foot’s position during weight-bearing activities.

Midtarsal Joint

The midtarsal joint, formed by the talonavicular and calcaneocuboid joints, allows for the
rotation of the foot to accommodate uneven surfaces. The combined movement of the
subtalar and midtarsal joints helps the foot adjust to changes in terrain during walking and
running.

Metatarsophalangeal and Interphalangeal Joints

The metatarsophalangeal joints (MTP joints) connect the metatarsals to the toes, allowing
for flexion and extension of the toes. The interphalangeal joints (IP joints) are found
between the phalanges and allow for flexion and extension movements of the toes. These
joints are essential for activities like push-off during walking and running.

Biomechanics of the Ankle and Foot

The ankle and foot are integral to the body’s kinematic chain, influencing both lower
extremity function and overall body mechanics. These structures provide balance,
propulsion, and shock absorption.

Gait Cycle and Function of the Foot

The gait cycle consists of two phases: stance phase (when the foot is in contact with the
ground) and swing phase (when the foot is in the air). During the stance phase, the ankle
and foot play crucial roles in shock absorption, balance maintenance, and propulsion.

Heel Strike: The foot makes contact with the ground via the heel. At this stage, the foot is in
pronation (inward rolling), and the subtalar joint helps absorb shock.
Midstance: During midstance, the foot begins to transition into supination (outward rolling),
allowing the arch to become more rigid for push-off.

Toe-off: As the body moves forward, the foot prepares for push-off, primarily using the
plantarflexors like the gastrocnemius and soleus to propel the body forward.

Role of the Arches of the Foot

The foot has three primary arches: the medial longitudinal arch, the lateral longitudinal
arch, and the transverse arch. These arches are important for distributing weight and
providing shock absorption.

Medial Longitudinal Arch: The most prominent arch, running from the heel to the first
metatarsal. It plays a critical role in shock absorption and supports the body’s weight.

Lateral Longitudinal Arch: Located on the outer side of the foot, it provides stability and
assists with balance.

Transverse Arch: This arch runs across the foot from side to side and helps with foot
stabilization and balance.

Muscles Involved in Ankle and Foot Function

Numerous muscles around the ankle and foot are involved in movement and stabilization.
These muscles can be divided into flexors, extensors, inverters, and everters.

Plantarflexors

The gastrocnemius and soleus are the primary plantarflexors, working together to elevate
the heel and push off the ground during activities like walking, running, and jumping.

Dorsiflexors

The tibialis anterior is the main dorsiflexor, responsible for lifting the foot upward. It plays a
crucial role in controlling foot movement during the swing phase of walking.

Inverters

The tibialis posterior and flexor hallucis longus are the primary inverters of the foot. They
help stabilize the medial arch and control inward foot motion.

Everters

The peroneus longus and peroneus brevis are the main everters, responsible for turning the
foot outward and helping with balance and lateral stability.
Conclusion: Functional Roles of the Ankle and Foot

The ankle and foot are fundamental to many of the body’s functional tasks. They not only
serve as the foundation for weight-bearing but also provide necessary shock absorption,
balance control, and propulsion during dynamic movements such as walking, running, and
jumping. Their complex anatomy and biomechanics are critical for effective and efficient
movement, making them central to lower extremity function.

Chapter 14: Ankle and Foot

Part 2 of 3: Common Pathologies, Clinical Assessment, and Treatment Strategies

Common Pathologies of the Ankle and Foot

The ankle and foot are subject to various injuries and conditions due to their critical role in
weight-bearing, mobility, and adaptation to surfaces. Common pathologies include
ligamentous injuries, tendinopathies, fractures, and degenerative conditions.
Understanding these pathologies helps in diagnosis and treatment planning.

Ankle Sprains

Mechanism of Injury: Ankle sprains commonly occur when the foot is subjected to an
excessive inversion or eversion force, leading to stretching or tearing of the ligaments. The
most common sprains involve the lateral ligaments of the ankle, specifically the anterior
talofibular ligament (ATFL) and calcaneofibular ligament (CFL).

Symptoms and Diagnosis: Symptoms include pain, swelling, bruising, and difficulty
bearing weight on the affected leg. The Ottawa Ankle Rules can help determine the need
for imaging in cases of suspected sprains. The anterior drawer test and inversion stress test
are commonly used to assess the integrity of the ankle ligaments.

Treatment: Acute treatment follows the R.I.C.E. method (Rest, Ice, Compression,
Elevation). For more severe sprains, bracing or a walking boot may be required to stabilize
the joint. Rehabilitation focuses on restoring range of motion, strength, and proprioception,
using exercises that target the peroneal muscles and ankle stabilizers.

Achilles Tendonitis and Tendon Ruptures

Achilles Tendonitis: This overuse injury is characterized by inflammation of the Achilles

tendon, which connects the gastrocnemius and soleus muscles to the calcaneus. It is
often caused by repetitive stress from activities such as running or jumping.

Symptoms and Diagnosis: Patients typically experience pain in the posterior ankle,
especially during activities that require plantarflexion. The Thompson test can assess for
Achilles tendon rupture by squeezing the calf muscle and checking for plantarflexion
movement.

Treatment: Treatment includes rest, ice, and anti-inflammatory medications. Physical

therapy focuses on eccentric strengthening exercises for the calf muscles to promote
tendon healing. In cases of severe rupture, surgical repair may be necessary.
Plantar Fasciitis

Mechanism of Injury: Plantar fasciitis is an overuse injury involving the plantar fascia, a
thick band of tissue that runs along the bottom of the foot. It is often caused by repetitive
stress on the fascia, especially in people who are overweight or engage in high-impact
activities.

Symptoms and Diagnosis: The hallmark symptom is heel pain, particularly in the morning
when the foot is first weight-bearing. The pain often improves as the person walks but can
return after prolonged standing or exercise. Diagnosis is often clinical, but X-rays can help
rule out bone spurs or other conditions.

Treatment: Conservative treatments include stretching exercises for the gastrocnemius

and soleus, night splints to maintain the foot in a dorsiflexed position overnight, and
orthotic insoles to provide support to the arch. If conservative measures fail, corticosteroid
injections or shockwave therapy may be considered.

Tarsal Tunnel Syndrome

Mechanism of Injury: Tarsal tunnel syndrome occurs when the tibial nerve is compressed
as it passes through the tarsal tunnel, located behind the medial malleolus. This
compression can be caused by trauma, inflammation, or structural abnormalities in the
foot.

Symptoms and Diagnosis: Symptoms include pain, tingling, and numbness along the
medial side of the foot and the plantar surface. The Tinel’s sign can be used to diagnose
this condition by tapping over the tarsal tunnel and assessing for tingling sensations.
Treatment: Treatment includes reducing inflammation, using foot orthoses to support the
arch, and avoiding activities that exacerbate symptoms. In some cases, surgery may be
necessary to release the nerve compression.

Fractures of the Ankle and Foot

Mechanism of Injury: Fractures in the ankle and foot can occur due to direct trauma,
twisting injuries, or overuse. The most common fractures include lateral malleolus
fractures, medial malleolus fractures, and fractures of the metatarsals or phalanges.

Symptoms and Diagnosis: Symptoms include severe pain, swelling, bruising, and difficulty
moving the affected foot. Imaging studies like X-rays or CT scans are used to confirm
fractures and assess their severity.

Treatment: Treatment varies depending on the location and severity of the fracture. Non-
displaced fractures may require immobilization with a cast or boot, while displaced
fractures may require surgical intervention to realign the bones. Post-surgical rehabilitation
focuses on restoring mobility and strength, especially for weight-bearing exercises.

Clinical Assessment of the Ankle and Foot

A thorough clinical assessment is essential for diagnosing ankle and foot injuries. The
assessment typically includes a combination of history taking, physical examination, and
imaging studies to accurately diagnose the condition and determine the appropriate
treatment.
History Taking

The clinician should gather information about the patient’s symptoms, including the onset,
duration, and aggravating factors. Important questions include whether the patient has
experienced any trauma, whether there are associated swelling or bruising, and whether
they have any history of previous foot or ankle injuries.

Physical Examination

The physical examination begins with inspection of the foot and ankle for signs of swelling,
deformity, or discoloration. The clinician should palpate for tenderness over specific
structures, such as the Achilles tendon, plantar fascia, or malleoli. Joint stability and range
of motion (ROM) are assessed, and special tests are used to evaluate ligamentous integrity,
such as the anterior drawer test for the ankle or the Thompson test for Achilles tendon
rupture.

Imaging Studies

X-rays: X-rays are essential for identifying fractures, joint dislocations, and the presence of
bone spurs or signs of degenerative conditions like osteoarthritis. They can also rule out
other conditions like stress fractures.

MRI: MRI is a valuable tool for assessing soft tissue injuries, such as ligament sprains,
tendonitis, and tears in the meniscus or cartilage. It provides a detailed view of the soft
tissues and can help guide treatment.
Ultrasound: In certain cases, ultrasound imaging is used to assess soft tissue injuries,
particularly for evaluating tendonitis or muscle strains. It allows for real-time assessment
of tendon movement and inflammation.

Treatment Strategies for Ankle and Foot Injuries

Treatment for ankle and foot injuries focuses on reducing pain, promoting healing, and
restoring function. Approaches vary based on the severity of the injury and the patient’s
activity level.

Conservative Treatments

Rest and Ice: For acute injuries, rest and ice are the first steps in reducing inflammation
and pain. Ice is applied for 15-20 minutes every 2-3 hours during the first 48 hours after the
injury.

Compression and Elevation: Compression with an elastic bandage or ankle wrap can help
control swelling, and elevating the foot above heart level reduces edema.

Physical Therapy: Once the acute phase has passed, physical therapy is essential to regain
strength and mobility. Therapy may include range of motion exercises, strengthening
exercises, and balance training to restore normal function. For tendon injuries, eccentric
strengthening is often employed.

Surgical Treatments
In cases of severe fractures, ligament tears, or tendon ruptures, surgical intervention may
be necessary. The goal of surgery is to restore anatomical alignment and allow the injured
structures to heal properly. Following surgery, rehabilitation is crucial to restore strength,
flexibility, and functional capacity.

Chapter 14: Ankle and Foot

Part 3 of 3: Rehabilitation Protocols, Injury Prevention, and Advanced Treatment Strategies

Rehabilitation Protocols for Ankle and Foot Injuries

Rehabilitation plays a crucial role in the recovery of ankle and foot injuries, ensuring that
the affected structures regain their strength, flexibility, and functional capacity. A well-
designed rehabilitation program helps reduce the risk of re-injury and enables the
individual to return to their regular activities, including sports or work-related tasks.

Initial Phase (Acute Phase)

Goals: The primary goal during the acute phase (first 48-72 hours) is to reduce pain,
swelling, and inflammation. This phase focuses on protecting the injured area and
preventing further damage to the tissues.

R.I.C.E. Protocol: The R.I.C.E. (Rest, Ice, Compression, Elevation) method is the
cornerstone of the acute treatment phase. Ice should be applied to the injured area to
decrease inflammation, while compression and elevation help reduce swelling. Rest is
important to avoid placing unnecessary stress on the injured structures.

Immobilization: In some cases, immobilization with a cast or walking boot may be

recommended to protect the injury and prevent further movement during the early stages
of healing.

Subacute Phase (Recovery Phase)

Goals: The goal during the subacute phase (typically 3-6 weeks after injury) is to restore
range of motion, begin weight-bearing exercises, and prevent muscle atrophy. The focus is
on gentle mobility exercises and the gradual introduction of more challenging activities.

Range of Motion (ROM) Exercises: The ankle and foot should be gradually moved through
their normal range of motion, ensuring that the joint is not stiffening. Therapeutic exercises
include dorsiflexion, plantarflexion, eversion, and inversion movements, as well as circles
and toe curls.

Strengthening Exercises: As pain decreases and range of motion improves, strengthening

exercises targeting the calf muscles, peroneals, tibialis anterior, and flexors can be added.
Resistance bands and thera-bands can be used for controlled strengthening.

Proprioception Training: Proprioception exercises are crucial during this phase to improve
the patient’s ability to maintain balance and body position during dynamic activities.
Exercises such as single-leg stands, balance boards, and foam pads can enhance
proprioception.

Late Stage (Functional Phase)

Goals: The functional phase focuses on returning the injured individual to their normal
activities, including sports, walking, or running. The objective is to gradually increase the
intensity of functional and sport-specific exercises while minimizing the risk of re-injury.

Plyometric Exercises: Plyometrics involve dynamic movements such as hopping, bounding,

and jumping exercises that challenge the strength, power, and coordination of the ankle
and foot. These exercises enhance the individual’s ability to generate force quickly and
efficiently.

Sport-Specific Training: For athletes, sport-specific training is essential. This may involve
practicing movements such as cutting, lateral movements, and agility drills that mimic the
demands of the sport. The rehabilitation program should also include running drills,
sprinting, and other activities that focus on improving cardiovascular fitness while
minimizing stress on the injured foot.

Gradual Return to Activity: The final phase involves a progressive return to full activity.
During this time, the patient is encouraged to increase their activity level slowly, keeping
track of any signs of discomfort or swelling. It is important for patients to avoid returning to
high-intensity sports or physical activity too soon, as this could increase the risk of re-
injury.

Prevention of Ankle and Foot Injuries

Ankle and foot injuries are common, particularly in individuals who engage in high-impact
sports or occupations. Preventing these injuries is crucial for maintaining long-term joint
health and avoiding the need for extensive rehabilitation. Effective prevention strategies
focus on strengthening, flexibility, proprioception, and proper footwear.
Strengthening Exercises

Strengthening the muscles that support the foot and ankle is key to preventing injuries.
Regular strengthening exercises for the calf, tibialis anterior, peroneals, and flexors can
help provide the necessary support to the joints, reducing the risk of sprains, strains, and
other injuries.

Exercises such as toe raises, heel drops, and ankle circles should be incorporated into a
balanced workout routine to enhance both strength and flexibility.

Flexibility and Stretching

Tight muscles, particularly in the calves and Achilles tendon, are major contributors to foot
and ankle injuries. Regular stretching of the gastrocnemius, soleus, and plantar fascia can
help maintain flexibility and prevent muscle imbalances.

Stretching should be performed before and after exercise or physical activity. Static
stretches, such as calf stretches and Achilles tendon stretches, as well as dynamic
stretches, like walking lunges and leg swings, can help maintain adequate flexibility in the
lower extremities.

Proprioceptive Training

Enhancing proprioception can reduce the risk of ankle sprains and other injuries. Balance
training is one of the most effective methods to improve proprioception, as it helps
individuals react to uneven surfaces or sudden changes in direction.
Using balance equipment such as BOSU balls, balance boards, and foam pads can help
improve the body’s awareness of its position in space. Proprioceptive training should be
incorporated into strength and conditioning programs for athletes and individuals engaging
in physical activity.

Footwear and Orthotics

Proper footwear plays a critical role in injury prevention. Shoes that provide adequate arch
support, heel cushioning, and ankle stability can help prevent plantar fasciitis, shin splints,
and other lower limb injuries.

Athletes or individuals with specific foot mechanics may benefit from custom orthotic
insoles designed to improve alignment, distribute forces more evenly, and correct
abnormal foot movements. It is important to replace shoes regularly to ensure continued
support and cushioning.

Taping and Bracing

For individuals who are at risk of repeated ankle sprains, taping or bracing may be a
preventive measure. Ankle braces can provide additional support during high-risk activities,
such as running, jumping, or playing sports that involve quick direction changes. Similarly,
kinesiology tape may be used to support injured structures while allowing for some
mobility during rehabilitation.
Advanced Treatment Strategies

In some cases, ankle and foot injuries may require advanced treatments, especially if
conservative approaches do not yield satisfactory results. These treatment options aim to
accelerate recovery and enhance the healing process.

Corticosteroid Injections

In cases of persistent inflammation, corticosteroid injections may be used to reduce pain

and swelling in the injured area. These injections are particularly useful for conditions like
plantar fasciitis, Achilles tendonitis, and tarsal tunnel syndrome.

While corticosteroids provide short-term relief, they should be used cautiously, as

prolonged use can weaken tendons and other soft tissues, increasing the risk of further
injury.

Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) is an advanced treatment that uses high-energy

sound waves to promote healing in damaged tissues. This therapy is particularly effective
for conditions like Achilles tendonitis and plantar fasciitis, where traditional treatments
have not been successful.

Shockwave therapy helps stimulate blood flow to the injured area, accelerate tissue repair,
and reduce pain.

Surgical Intervention
In cases of severe fractures, ligament tears, or tendon ruptures, surgery may be required.
Surgical procedures, such as ankle arthroscopy or open reduction and internal fixation
(ORIF), may be used to restore joint function and correct structural abnormalities.

Post-surgical rehabilitation is essential to regain strength, flexibility, and functional

capacity. A progressive rehabilitation program is required to restore mobility and prevent
complications such as joint stiffness or muscle atrophy.