Foot & Ankle

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

This complex anatomy consists of:

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

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

Ankle

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

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

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

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

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

Hind foot

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

The hind foot connects the mid foot to the ankle at the transverse tarsal joint.

• Talus
• Calcaneus

Mid foot

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

The mid foot connects to the forefoot at the five tars metatarsal joints.

• Navicular
• Cuboid
• Cuneiform Bones

Forefoot

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

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

• Phalanges
• Metatarsal

Soft Tissue Anatomy

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

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

Biomechanics of Foot & Ankle

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

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

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

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

The toes allow four different movements:

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

Ankle arthroscopy is a minimally invasive surgical procedure in which an arthroscope, a small, soft, flexible tube with a light and video camera at the end, is inserted into the ankle joint to evaluate and treat a variety of conditions.

An arthroscope is a small, fiber-optic instrument consisting of a lens, light source, and video camera. The camera projects an image of the inside of the joint onto a large screen monitor allowing the surgeon to look for any damage, assess the type of injury, and repair the problem.

Indications

Ankle Arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, has proved to be highly effective in managing various ankle disorders including ankle arthritis, unstable ankle, ankle fracture, osteochondral defects of the talus, infection, and undiagnosed ankle pain.

The benefits of arthroscopy compared to the alternative, open ankle surgery, include:

• Smaller incisions
• Minimal soft tissue trauma
• Less pain
• Faster healing time
• Lower infection rate
• Less scarring
• Earlier mobilization
• Shorter hospital stay

Procedure

Your surgeon will make 2 or 3 small incisions around the ankle joint. Through one of the incisions an arthroscope is inserted. Along with it, a sterile solution is pumped into the joint to expand the joint area and create room for the surgeon to work.

The larger image on the television monitor allows the surgeon to visualize the joint directly to determine the extent of damage so that it can be surgically treated. Surgical instruments will be inserted through the other tiny incisions to assess and treat the problem.

After the surgery, the instruments are removed, and the incisions are closed and covered with a bandage.

Post-surgical care

After the procedure, you will be taken to a recovery room. The ankle joint will be immobilized with a splint or cast. The nature and duration of immobilization will depend on the type of repair performed and the preference of the surgeon. The surgical site should be kept clean and dry during the healing process. Patients may be prescribed pain medication for the management of pain. Elevation of the ankle and ice application helps to reduce pain and swelling. Follow your post-operative instructions for the best outcome.

Risks and complications

Ankle arthroscopy is a safe procedure and the incidence of complications is low. However, as with any surgery, risks and complications can occur. Some associated risks with ankle surgery can include infection, damage to blood vessels or nerves, bleeding, and compartment syndrome.

Conclusion

Ankle arthroscopy is a less invasive surgical procedure than traditional open surgery for the management of various ankle disorders. Benefits of arthroscopy include faster healing, less pain, and less complications.

Ankle instability is a chronic condition characterized by a recurrent slipping of the outer side of the ankle. It usually results from repeated ankle sprains. It is generally noticed during movement of the ankle joint but can also occur during standing as well.

Causes

Repetitive injury of the ankle ligaments on the same side is the most common cause of ankle instability. Inadequate healing of the sprained ligament or incomplete rehabilitation of the affected ligament can result in instability of the ankle. Recurrent injury of the ligaments further weakens them and aggravates the instability which predisposes to the development of additional ankle problems.

Symptoms

Pain is the most common symptom and is associated with swelling and tenderness of the ankle. There may be a persistent discomfort and instability in the affected ankle joint. The ankle is unstable and may turn repeatedly while walking on uneven surfaces or during a sporting activity.

Diagnosis

A complete medical history, including a history of any previous ankle injuries, and a physical examination is essential for an accurate diagnosis of the condition. An X-ray may be ordered to confirm the diagnosis. Other imaging tests may also be used to evaluate the injury.

Treatment

The management of ankle instability depends on the findings of physical examination and the activity level of the patient.

Conservative treatment

Conservative treatment includes physical therapy for improving the strength, balance and range of motion of the joint, bracing to support the affected ankle and prevent further sprain, and non-steroidal anti- inflammatory (NASAIDs) to reduce the pain and inflammation.

Surgical treatment

Surgery is recommended in patients with a high degree of instability and in those who have failed to respond to non-surgical treatments. Commonly used surgical procedures involve repair or reconstruction of the damaged ligament.

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

The diagnosis of an ankle sprain is usually made by evaluating the history of injury and physical examination of the ankle. X-ray of your ankle may be needed to confirm if a fracture is present. The most common treatment recommended for ankle sprains is rest, ice, compression and elevation (RICE).

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

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

During your recovery, rehabilitation exercises are recommended to strengthen and improve range of motion in your foot. You may need to use a brace or wrap to support and protect your ankle during sports activities. Avoid pivoting and twisting movements for 2 to 3 weeks. To prevent further sprains or re-injury you may need to wear a semi-rigid ankle brace during exercise, special wraps and high-top lace shoes.

Ankle ocd (osteochondritis dissecans) is a condition in which the bone located underneath the articulating cartilage surfaces of the ankle joint undergoes degeneration due to lack of blood supply. Fragments of bone and cartilage may then break loose causing restricted range of motion and pain.

Ankle OCD commonly occurs in the talus, one of the large bones in the ankle. It may be caused by a twisting injury of the ankle and may result in a chip-type fracture or impairment of blood supply to the joint with subsequent necrosis and fragmentation of the bone.

Initially, you will have pain and swelling, with difficulty bearing weight on the ankle. The symptoms will persist due to degeneration and fragmentation of the bone. The bone fragments may produce a catching sensation and restrict range of motion of the ankle.

Your doctor will take a complete medical history and perform a physical examination to evaluate for signs and symptoms of ankle OCD. Radiographs of the ankle are obtained to identify the bone fragments. Special imaging techniques such as computerized tomography or magnetic resonance imaging are performed to get a detailed view of the area including the surrounding soft tissues.

The type of treatment depends on the time elapsed since injury. If ankle OCD is diagnosed immediately following the injury, cast immobilization along with non-weight bearing may be recommended for a period of 6 weeks. This allows the bone to heal and prevent further injury.

Surgery is usually recommended to remove the devitalized bone in cases of chronic infections. Surgery may be performed using an arthroscope through very small incisions in the joint or by making a large open incision. Small holes may be drilled into the bone after removal of the necrotic material to stimulate increased blood supply to the area and promote healing. Following surgery, physical therapy is recommended to regain range of motion and strength of the ankle.

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

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

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

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

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

The ankle joint is composed of three bones: the tibia, fibula, and talus which are articulated together. The ends of the fibula and tibia (lower leg bones) form the inner and outer malleolus, which are the bony protrusions of the ankle joint that you can feel and see on either side of the ankle. The joint is protected by a fibrous membrane called a joint capsule, and filled with synovial fluid to enable smooth movement.

Ankle injuries are very common in athletes and in people performing physical work, often resulting in severe pain and impaired mobility. Pain after ankle injuries can either be from a torn ligament and is called ankle sprain or from a broken bone which is called ankle fracture. Ankle fracture is a painful condition where there is a break in one or more bones forming the ankle joint. The ankle joint is stabilized by different ligaments and other soft tissues, which may also be injured during an ankle fracture.

Causes

Ankle fractures occur from excessive rolling and twisting of the ankle, usually occurring from an accident or activities such as jumping or falling causing sudden stress to the joint.

Symptoms

With an ankle fracture, there is immediate swelling and pain around the ankle as well as impaired mobility. In some cases, blood may accumulate around the joint, a condition called hemarthrosis. In cases of severe fracture, deformity around the ankle joint is clearly visible where bone may protrude through the skin.

Types of fractures

Ankle fractures are classified according to the location and type of ankle bone involved. The different types of ankle fractures are:

• Lateral Malleolus fracture in which the lateral malleolus, the outer part of the ankle is fractured.
• Medial Malleolus fracture in which the medial malleolus, the inner part of the ankle, is fractured.
• Posterior Malleolus fracture in which the posterior malleolus, the bony hump of the tibia, is fractured.
• Bimalleolar fractures in which both lateral and medial malleolus bones are fractured
• Trimalleolar fractures in which all three lateral, medial, and posterior bones are fractured.
• Syndesmotic injury, also called a high ankle sprain, is usually not a fracture, but can be treated as a fracture.

Diagnosis

The diagnosis of the ankle injury starts with a physical examination, followed by X-rays and CT scan of the injured area for a detailed view. Usually it is very difficult to differentiate a broken ankle from other conditions such as a sprain, dislocation, or tendon injury without having an X-ray of the injured ankle. In some cases, pressure is applied on the ankle and then special X-rays are taken. This procedure is called a stress test. This test is employed to check the stability of the fracture to decide if surgery is necessary or not. In complex cases, where detail evaluation of the ligaments is required an MRI scan is recommended.

Treatments

Immediately following an ankle injury and prior to seeing a doctor, you should apply ice packs and keep the foot elevated to minimize pain and swelling.

The treatment of ankle fracture depends upon the type and the stability of the fractured bone. Treatment starts with non-surgical methods, and in cases where the fracture is unstable and cannot be realigned, surgical methods are employed.

In non-surgical treatment, the ankle bone is realigned and special splints or a plaster cast is placed around the joint, for at least 2-3 weeks.

With surgical treatment, the fractured bone is accessed by making an incision over the ankle area and then specially designed plates are screwed onto the bone, to realign and stabilize the fractured parts. The incision is then sutured closed and the operated ankle is immobilized with a splint or cast.

Post-operative care

After ankle surgery, you will be instructed to avoid putting weight on the ankle by using crutches while walking for at least six weeks.

Physical therapy of the ankle joint will be recommended by the doctor. After 2-3 months of therapy, the patient may be able to perform their normal daily activities.

Risks and complications

Risks and complications that can occur with ankle fractures include improper casting or improper alignment of the bones which can cause deformities and eventually arthritis. In some cases, pressure exerted on the nerves can cause nerve damage, resulting in severe pain.

Rarely, surgery may result in incomplete healing of the fracture, which requires another surgery to repair.

Introduction

The plantar fascia is a long, thin ligament present along the bottom of the foot that creates the arch of the foot. It extends from the heel bone, and then splits and fans out to attach itself to the toes.

Plantar fasciitis is a condition where the plantar fascia becomes inflamed from overstretching or overuse, causing pain in the heel and bottom of the foot. It can occur in one or both feet due to excessive standing and is one of the most common orthopaedic complaints, especially in active men between 40 and 70 years of age.

Causes

Plantar fasciitis occurs when you strain or irritate the plantar fascia ligament. Repeated strain can result in tiny tears in the ligament, leading to pain and swelling, which can make walking difficult.

Strains can occur due to:

• High or low foot arch
• Obesity or sudden weight gain
• Tight Achilles tendon which connects the calf muscles to the heel
• Starting a new activity or increasing the intensity of an activity
• Wearing improper shoes with soles that are too soft, do not fit well or offer poor arch support

Symptoms

The major complaint of plantar fasciitis is pain and stiffness in the heel and foot. The pain associated with this condition becomes more intense:

• In the morning when you step out of bed
• Walking after sitting or standing for some time
• Climbing stairs
• After exercise

Diagnosis

Your doctor diagnoses plantar fasciitis after reviewing your medical history and conducting a physical examination of the foot to check for tenderness, stiffness or redness of the sole. Your doctor may watch how you stand and walk, and evaluate related conditions such as high arches.

X-rays of the foot can be taken if your doctor suspects a stress fracture, a hairline fracture in the bone, or other related conditions such as a heel spur, which is extra calcium deposit on the heel bone.

Treatment

Treatment involves conservative measures to resolve the condition. Conservative treatment measures include:

• Rest: Rest is the first step that is considered for reducing pain and preventing further damage to the ligament.
• Ice: Rolling your foot over ice can be very effective in reducing swelling, and is recommended for 20 minutes, 3-4 times a day
• Medications: NSAIDs (non-steroidal anti-inflammatory drugs) may be prescribed for relief of pain and inflammation
• Exercise: calf stretches and plantar fascia stretches are effective in relieving pain
• A steroid injection may be administered into the plantar fascia for reducing pain and inflammation
• Supportive shoes and orthotics may also be recommended to reduce the pain while walking or standing
• Night splints can be suggested by your doctor to help stretch the plantar fascia while sleeping
• Physical therapy may be recommended for instruction on stretching exercises, massage and ice treatments
• PT may use extracorporeal shockwave therapy (ESWT), which uses high-energy shockwave impulses to stimulate healing of the damaged plantar fascia tissues

Surgery

Surgical treatment is considered only if conservative therapy does not provide effective relief after 12 months.  There are two surgeries your surgeon may perform and will depend on your particular situation.

• Gastrocnemius recession- Tight calf muscles or gastrocnemius muscles can strain the plantar fascia. To release this stress, your surgeon will surgically lengthen the calf muscle, and increase the motion of the ankle. The surgery can be performed by open incision or endoscopically through a small incision by using an endoscope, which is a long instrument with a small camera attached.
• Plantar fascia release- If you have normal range of ankle motion, but continue to have heel pain, a partial release procedure is recommended. Your surgeon will partially cut the plantar fascia ligament to relieve the tension. The surgery can be performed endoscopically but open incision is easier to perform and is associated with lower risk of nerve damage.

Risks and Complications

Complications are rare following surgery to treat plantar fasciitis, but as with any surgical procedure, they can occur.  Some complications include:

• Infection
• Nerve Damage
• Unresolved Pain

The foot has 26 bones, and can be divided into 3 parts:

The Hindfoot is comprised of two bones, the talus bone which connects to the bones of the lower leg, and the calcaneus bone which forms the heel.

The Midfoot is comprised of the navicular, cuboid, and three cuneiform bones.

The forefoot is made up of five metatarsal bones and 14 toe bones called phalanges.

The hindfoot is separated from the midfoot by the mediotarsal joint and the midfoot is separated from the forefoot by the Lisfranc joint.

Muscles, tendons and ligaments support the bones and joints of the feet enabling them to withstand the entire body’s weight while walking, running and jumping. Despite this, trauma and stress can cause fractures in the foot. Extreme force is required to fracture the bones in the hindfoot. The most common type of foot fracture is a stress fracture, which occurs when repeated activities produce small cracks in the bones.

Types of foot fractures

Foot fractures can involve different bones and joints and are classified into several types:

• Calcaneal fractures:

This type affects the heel bone and occurs mostly as a result of high-energy collisions. It can cause disabling injuries and if the subtalar joint is involved it is considered a severe fracture.

• Talar fractures:

The talus bone helps to transfer weight and forces across the joint. Talus fractures usually occur at the neck or mid portion of the talus.

• Navicular fractures:

Navicular fractures are rare and include mostly stress fractures that occur with sports activities, such as running and gymnastics, as a result of repeated loading on the foot.

• Lisfranc fractures:

This type of fracture occurs due to excessive loading on the foot, which leads to stretching or tearing of the midfoot ligaments.

Causes

Foot fractures commonly occur as a result of a fall, motor vehicle accident, dropping a heavy object on your foot, or from overuse such as with sports.

Symptoms

The common symptoms of a foot fracture include:

• Pain
• Bruising
• Tenderness
• Swelling
• Deformity
• Inability to bear weight

Diagnosis

Your doctor diagnoses a foot fracture by reviewing your medical history and performing a thorough physical examination of your foot. Imaging tests such as X-rays, MRI or CT scan may be ordered to confirm the diagnosis.

Navicular fractures can be especially difficult to diagnose without imaging tests.

Treatment

Treatment depends on the type of fracture sustained. For mild fractures, nonsurgical treatment is advised and includes rest, ice, compression, and elevation of the foot. Your doctor may suggest a splint or cast to immobilize the foot. For more severe fractures, surgery will be required to align, reconstruct or fuse the joints. Bone fragments may be held together with plates and screws.

Physical therapy may be recommended to improve range of motion and strengthen the foot muscles. Weightbearing however should be a gradual process with the help of a cane or walking boot.