Advanced Clinical Therapy-Plantar Foot Techniques-A Clinical Study
Copyright © Ted Nissen May 2004

SPEAKER: Ted Nissen Date

Phone: (562) 439-3803

Office:

Advanced Physiocare

440 Redondo Ave. # 201

Long Beach Calif. 90814

LECTURE/WORKSHOP NOTES ALL SESSIONS

1 Ted Nissen Background

Ø Ted Nissen has a successful private practice and has been in business as a massage therapist for over 30 years.

2 What you will Learn

1.) How to Test Massage Techniques on your clients.

2.) A unique view of why people hurt, the areas that pain can refer, and how to help them feel better.

3.) How to do pain rating using a scale

4.) The Histology, Myology, Neurology, Osteology, Arthrology, Vascular System, Surface Anatomy, Biomechanics and Pathology of the Plantar Foot

3 Agenda

1.) Single Case Single Visit Anecdotal Study Defined

2.) Why do a Study?

3.) What is a Theory and Why Have One?

4.) Oh, My Aching Feet-Why Do They Hurt?

5.) What is the Study Title & what does it mean?

6.) Who Should Be Excluded from and Included in the Study?

7.) What kind of Treatment will be used and how can we measure progress?

8.) What is the Anatomy and Physiology of the Foot?

9.) Question and Answer

4 Notes

v Single Case Single Visit Anecdotal Study

A simple way to learn about scientific method is to test the relative effectiveness of massage techniques on your clients. Single Case Study means you are testing the effectiveness of a technique on a single client. Single visit means you are doing the testing based on a single massage therapy session. It is called anecdotal because it is unscientific in that your data is based on observations of unscientific observers (Clients). You can apply statistical methods to your pre and post treatment ratings but your results don’t prove or disprove the effectiveness of the treatment. It is a way to learn about scientific method and the meaning of statistics. You will also learn how to conduct a study, gather information, and practice techniques.

v Rationale for Study

The massage therapy profession does not have a boatload, bundle or even a small packet of money for research relative to the pharmaceutical industry for example. Single case single visit out come studies are cheap and easy to do, don’t take a lot of time (15-20 Minutes) and although unscientific by definition (Anecdotal) provide an abundance of useful data which may direct more controlled scientific study. This is like the fashion model photographers’ Polaroid (To check lighting & photogenics before more expensive film is used) or the legal equivalent to prima facie inquiry when the rules of law are loosened to allow legally prohibitive facts in as evidence to assess criminality. Single case outcome studies don’t prove or disprove anything but protocols and statistical methods can be tested and may later serve as useful tools in subsequent more controlled scientific research. This project will further increase the body of knowledge necessary to establish a scientific basis for massage therapy treatments and act as a counterweight to the notion that massage treatment is palliative without curative value.

v Rational for the Theoretical Perspective and Study of Tendon and Ligament Trigger Points

Travell offers a theoretical perspective as to why muscle tissue and its associated deep fascia (FASH-ē-a; fascia=bandage) (Dense (Collagenous) Connective Tissue-Irregularly Arranged around muscles) develops a hyperirritable focal point (Trigger Point) within a taut band of skeletal muscle fibers. This theory, explains why Myofascial Trigger Points may develop in muscle tissue, but it does not explain how trigger points could develop in its associated fascia. Nor does her trigger point manual discuss the location or pain referral patterns of deep Fascial (surrounding muscles) trigger points. Although existence of tendon and ligament trigger points are acknowledged by Travell their location and pain referral patterns are only discussed in relation to the research of others and their location and pain referral patterns are never discussed in detail. The purpose of the following theoretical perspective and subsequent study is to explain the nature of tendon and ligament trigger points and examine the efficacy of clinical massage therapy as a viable curative treatment.

v Guessing about Nature

A theory begins with a question about why nature works the way it does. It is the analysis of a set of speculative facts in their relation to one another with the hope of answering the WHY questions. In the case of massage it begins with a client who experiences discomfort and the question is why do they hurt? A theory helps explain the why and gives us some clues as to what we can do about it.

v Theoretical Thinking-Why Do Our Feet Hurt? Illus.#1

The facial, Ligamentous, and tendon structures of the foot undergo enormous weight bearing forces especially for individuals who are on their feet a lot, engage in sports activities such as walking, running or hiking, or wear elevated heals. The forces of weight bearing also place pressure on the vessels that supply blood to the tissues. The transport of essential cell nutrition (O2, glucose and protein) to the tendon and connective tissue cells may be diminished and or interrupted. Cell stress and or death may ensue along with concomitant nerve irritation and referred sensory phenomena. With cell stress, enzymatic messengers may initiate a reflex arc (afferent and efferent sympathetic nerve fibres) causing vasoconstriction, increased metabolite concentration, and further nerve irritation. With cell death enzymatic messengers may initiate the production of inflammatory nerve irritants which refer sensory phenomena segmentally (Illus.#2.Illus#3, Illus#4) (Dermatomes ALL, Dermatomes L1-S3 Front, Dermatomes L1-S4 Back) and extra-segmentally (Illus#5) (Extrasegmental Referral). The tendon and connective tissue cells near the bone or at biomechanical stress points may be most affected due greater mechanical stresses and diminished blood supply. Hume’s Fork- The tendon and ligament cells near where they attach to the bone receive greater stress than the other cells of the tendon or ligament because of their proximity to the bone, which is being pulled by opposing muscles. In the tradition of analytic empiricism promulgated by the 18th century Scottish philosopher, David Hume (Hume’s Fork) the following simple experiment will reveal these stresses. If you cut a strip of paper ¼ to 1/3 of an inch thick and affix one end to a stable surface while pulling on the other end the following result should occur. Assuming the paper strip is equally strong in all its parts, the strip of paper will break more frequently on either end of the paper strip. That is near where your pinched fingers are pulling (the paper breaks more commonly at this site) or where you have affixed the other end. In the case of ligament cells, both ends of their attachments are vulnerable to the stresses of movement and receive greater metabolic demand. In the case of tendon cells only the cells near the bone seem prone to irritation probably because the tendon cells which interdigitate with the muscle cells have a better blood supply than the cells near the bone. Biomechanical stress points are usually areas of a tendon which receive greater stress because they are being pressed on by other structures such as bone and or soft tissue (this may occlude blood supply) or flexed repetitively (this may transfer mechanical stress to the apex of the flexing action). An example is at the Talocrural joint where the posterior tendons of plantar flexor muscles are repeatedly flexed and in the case of the tarsal canal muscles (flexor hallucis longus, tibialis posterior, flexor digitorum longus) pressed against the dome of the calcaneus. In the case of the Achilles tendon this biomechanical stress point is 3 to 5 cm proximal to the insertion onto the calcaneus as this is the most common site of Achilles tendonitis. Repetitive activities such as such as running and or walking repeatedly flex and straighten the tendon so that the cells in tendon and ligament cells (fibroblasts) in this area of the tendon receive greater stress in a similar manner to the cells near where the tendon and ligament attach to the bone. To demonstrate this principal with the above-defined strip of paper if you repeatedly flex and straighten the strip and then affix one end to a stable surface while pulling on the other end the following result should occur. The paper strip will break at the apex of the flexing action. This apex of the paper strip is the biomechanical stress point. (Illus#6, Illus#7, Illus#8, Illus#9, Illus#10) (Cell Stress/Death of Intrinsic Foot Structures-Direction of Pressure, Muscle Bone Attachments-Foot Plantar Right, Bones Foot Plantar Surface, Plantar Aponeurosis (Fascia) Illustrated, Plantar Aponeurosis (Fascia) Picture) These Pre-Acute, Acute, and or Chronic conditions if left untreated may have a cascading effect which contribute to clinical conditions e.g.; postural faults Trigger Points and or Plantar Fasciitis. It is unlikely that the usual laboratory measures eg sed rates, radiography, MRI, and or neurological testing will reveal these sub clinical phenomena. It is expected that a high percentage of active patient populations without lumbar or other pathology will present with these conditions and thus provide a fertile field of study. Ischemic compression and stretching have proven effective in the treatment of trigger points and may help re-establish circulation, help remove metabolic and or inflammatory irritants and improve the transport of essential cell nutrition (O2, glucose and protein) to the tendon and connective tissue cells aforementioned. Research Summary- Janet Travell Said in her 1983 book entitled 'Myofascial Pain And Dysfunction-the Trigger Point Manual' "These trigger points can exist in a latent form for decades, become periodically active restricting range of motion causing varying degrees of disability from mild to severe. One session using a variety of treatment modalities, which restore circulation to the ischemic area in the muscle, can eliminate the TP permanently" This may have a curative effect and help prevent potential clinical pathology (Plantar Fasciitis, postural faults, and or trigger points), athletic injuries, impaired activities of daily living (ADL), and or impaired athletic performance.

v Hypothesis

Hypothesis Defined- If a theory is the analysis of a set of speculative facts in their relation to one another with the hope of answering the WHY questions a hypothesis is concise statement in order to draw out and test the theories logical or empirical consequences. In this plantar foot study if the theory states that connective tissue cell stress/death produces neurological irritation and increasing circulation reduces that irritation and provides lasting curative relief then the referred Achilles tendon tenderness should decrease with treatments that increase circulation to these connective tissue structures. Further once circulation is re-established a lasting curative effect in the form of reduced Achilles tendon tenderness should persist without treatment. Plantar Foot Study Hypothesis-Compression and stretching of the connective tissue structures of the plantar foot will significantly reduce Achilles tendon tenderness as subjectively reported by clients. Plantar Foot Study Hypothesis-Multiple Visit-Subsequent treatment (Compression and stretching of plantar foot connective tissues) visits will continue to reduce Achilles tendon tenderness as subjectively reported by clients. This reduced Achilles tendon tenderness will persist even after treatment is discontinued.

v Illustration # 1-Why Do We Hurt?

v Illustration # 2- Dermatomes ALL

v Illustration # 3- Dermatomes L1-S3 Front

v Illustration # 4- Dermatomes L1-S4 Back

v Illustration # 5- Extrasegmental Referral

v Illustration # 6- Cell Stress/Death of Intrinsic Foot Structures-Direction of Pressure

v Illustration # 7- Muscle Bone Attachments-Foot Plantar Right

v Illustration # 8- Bones Foot Plantar Surface

v Illustration # 9- Plantar Aponeurosis (Fascia) Illustrated

v Illustration # 10- Plantar Aponeurosis (Fascia) Picture

v Study Title Single/Multiple Visit Study

Single Visit Study=The theory above tells us about Cell Stress/Death of Superficial & Intrinsic Foot Structures at Calcaneal & Metatarsal Attachments. We have already talked about what a single case single visit study is along with the meaning of anecdotal. An outcome is the rating scale you will use to determine sensitivity before and after treatment. The Plantar foot just means the bottom of the foot. In the following sections you will learn how to do the massage treatment which involves pressure and Dorsiflexion of the foot. The title of the study if you put all those factors together is “Single Case Single Visit Outcome (Anecdotal) Study-Plantar Foot-Superficial & Intrinsic Foot Structure Attachments -The Treatment Effects of Compression and Stretching.” Multiple Visit Study=With the addition of multiple visits the title becomes “Single Case Multiple Visit Outcome (Anecdotal) Study-Plantar Foot-Superficial & Intrinsic Foot Structure Attachments -The Treatment Effects of Compression and Stretching.”

v Pre-Screening

EXCLUDE-Persons with known lumbar pathology and or lumbar pain. These conditions can refer sensory phenomena including pain into the foot along the L4-5 and S1-2 dermatomes (Dermatomes ALL) and will not respond to treatment of the superficial & intrinsic structures. It would then be impossible to judge the effects of treatment, as referred pain from the lumbar region would persist. Persons with Early AM Heal Pain-This is a symptom marker for Plantar Fasciitis-classic symptoms of plantar fasciitis include severe pain which is worse in the morning/after rest and improves after moving around, Plantar Fasciitis is a clinical condition that underlies pathology that is more serious. Although this condition may respond to the compression and stretching treatments the focus of the current study is on the treatment effects on sub clinical conditions. Persons with Achilles Tendonitis-Persons who have a current or past Diagnosis of Achilles Tendonitis- will not respond to this treatment. You can suspect Achilles Tendonitis in persons who are overweight and flatfooted or who are long distance runners. These persons should also be excluded from this study. Sedentary (40-60 yr old) women recently engaged in novel, repetitive or over activity involving walking, standing and or running.- According to Travell sedentary, middle-aged women (40-60 years old) who have recently engaged in novel, repetitive or over activity (walking, standing, and or running) are prone to develop trigger points. Activities such as walking, standing and or running may cause injury to the muscle cells of the Soleus and Tibialis posterior, which can refer pain and tenderness into the Achilles tendon. Since Active patients can still develop trigger points in these lower leg muscles subsequent studies may help determine their numbers. CAN INCLUDE- Persons who engage in Frequent Weight Bearing Activities-These clients are more likely to place greater stress on the tissues in question and manifest sub clinical symptoms. Sedentary clients who have symptoms especially those clients who are overweight may have other conditions such as diabetes, deep vein thrombosis ect which will not respond to treatment. Persons who Wear Shoes w/ Elevated Heals-Greater stresses are placed on the plantar foot structures when clients wear high-healed shoes. Persons who have Plantar Foot Tenderness (Right Foot) (Illus#11) (Technique Plantar Foot)-This area may be palpated to establish connective tissue irritation near the Proximal Heads of the Metatarsal bones, which refers extrasegmentally and dermatomally into the plantar surface of the foot. MUST INCLUDE- Persons who have Achilles Tendon Tenderness (Right Foot) (Illus#12)(Palpation Achilles Tendon)-This area is palpated to determine pre and post treatment ratings. Generally, connective tissue attachments near Calcaneal Tuberosity (Medial Process) refer into the Achilles Tendon, extrasegmentally and dermatomally.

v Illustration # 11-Technique Plantar Foot

v Illustration # 12-Palpation Achilles Tendon

v Treatment Technique and Sensation Intensity Rating

Sensation Intensity-No Sensation 0 Mild Sensation 1-3 Discomforting 3-5 Distressing 5-7 Horrible 7-9 Excruciating 9-10 Pre-Treatment Rating-3 lbs pincer (pinching) pressure along Achilles Tendon. (Right Foot) (Illus.#12) (Palpation Achilles Tendon)- The amount of pressure can be roughly gauged by pinching a bathroom scale with your thumb and forefinger until you reach 3 lbs pressure. Then pinch the Achilles tendon (Right Foot) of the client and ask them to rate the sensation using the Sensation Intensity Rating Scale. (0-10) Sensation rating of above 1 will be selected for the study and those persons with ratings below 1 will be excluded from the study. Compression and Stretching Treatment (Illus#11) (Technique Plantar Foot)-Standard Technique- Pressure is directed against the Calcaneal Tuberosity and just anterior (Medial & Lateral Process), calcaneal plantar surface, base of the 5th metatarsal (Right Foot), with foot Dorsiflexion, and between the Proximal Heads of the Metatarsal bones, with toe extension. Treatment continues until Achilles Tendon tenderness subsides. Pressure may also be directed against the bases of the 2nd thru 5th metatarsal bones with foot dorsiflexion. (Illus#11) (Technique Plantar Foot) Alternate Technique Hand Position-The technique demonstrated in the picture (Technique Plantar Foot) can be altered to suit individual therapist preferences. For example separated fingers can be used against the bony processes while dorsiflexing the foot with the client is in the supine position. If the client is prone using the same or more comfortable finger position the foot is dorsiflexed while the leg is flexed at the knee. Post-Treatment Rating- 3 lbs pincer (pinching) pressure along Achilles Tendon. (Right Foot) (Illus.#12) (Palpation Achilles Tendon)-The amount of pressure can be roughly gauged by pinching a bathroom scale with your thumb and forefinger until you reach 3 lbs pressure. Then pinch the Achilles tendon (Right Foot) of the client and ask them to rate the sensation using the Sensation Intensity Rating Scale. (0-10) Sensation rating of above 1 will be selected for the study and those persons with ratings below 1 will be excluded from the study.

v Single Case Multiple Visit (Anecdotal) Studies Plantar Foot

If your class decides to continue the study past the first visit an additional research project will be completed. The title of the project will be “Single Case Multiple Visit Outcome (Anecdotal) Study-Plantar Foot-Superficial & Intrinsic Foot Structure Attachments -The Treatment Effects of Compression and Stretching.” The meaning of the title is the same as described above except you will be recording treatment effects for multiple visits. Protocol- There are 5 additional visits added to the Multiple visit outcome study. Four of these visits contain the same components as the single visit study e.g. Pre-Rating, Treatment, and Post-Rating. The time spacing between the first and subsequent visits (2-5) should be between 2 and 3 days with no more than 3 days between treatments. The last visit (Visit # 6) contains only a final rating with NO PRE-RATING or TREATMENT component. The time spacing between the fifth and sixth visit should be exactly 7 days. Rational for Subsequent Visits-The single case single visit study does not tell us the following; Gate Effect- since the treatment may be mildly or moderately discomforting to the client the strength of that signal may initiate a neurological gate (gate effect) which blocks any sensitivity from the Achilles’ tendon. My own anecdotal patient notes seem to indicate the Gate Effect lasts between 2-3 days. Placebo Effect- Since clients were expecting some type of treatment for their Achilles’ tendon tenderness that expectation (placebo effect) alone may be responsible for some or all of the treatment effect. My own anecdotal patient notes seem to indicate the Placebo Effect lasts between 2-3 days. Curative Effect-Depending on the severity of the pre-acute. Acute or chronic irritation it may take several treatments to re-establish circulation to the affected connective tissue cells. These treatment effects can only be measured with a multiple visit study. In addition, the 7 days between the 5th and 6th visit allows for the diminution of the Gate and Placebo effect so that the more lasting curative effect can be measured.

v Results of Study

The Results of this study will be posted at the following web site address: http://www.anatomyfacts.com/Muscle/researchpapers.htm

v Functional Anatomy and Physiology

Histology (hiss’-TOL-ō-jē; histio=tissue; logos=study of)- Connective Tissue-Introduction(Illus # 14) (Tendon, Ligament, Muscle Tissue and Cells)-This is the most abundant tissue in the body and serves a binding and supporting function. With the exception of cartilage, which is Avascular, connective tissue is highly vascular with a rich blood supply. The cells of connective tissue are widely scattered as opposed to closely packed and there is considerable intercellular substance (matrix). In contrast to Epithelium, connective tissues do not occur on free surfaces, such as the surfaces of a body cavity or the external surface of the body. The general functions of connective tissues are protection, support, binding together various organs, separating structures such as skeletal muscles, and storage of reserve energy. The tissue qualities are largely determined by the intercellular substance in a connective tissue. This tissue is a non-living substance and may consist of fluid, semi fluid, gel like, or fibrous material. The intercellular material found in cartilage is firm but pliable. The intercellular material found in bone is considerably harder and not pliable. Fibroblast (FĪ-brō-blast)= A large, flat cell that forms collagenous and elastic fibers and intercellular substance of loose connective tissue The intercellular substances are produced by the cells of connective tissue (Fibroblasts). These cells may also store fat, ingest bacteria and cell debris, form anticoagulants, or give rise to antibodies that protect against disease. Connective Tissue Proper- Dense (Collagenous) Connective Tissue- Dense (Collagenous) Connective Tissue has fibers that are closely packed than found in loose connective tissue and the fibers are irregularly or regularly arranged. These fibers are made up of collagen. Collagen (KOL-a-jen)=A protein that is the main organic constituent of connective tissue. Irregularly Arranged=When the tensions on the connective tissue are exerted in various directions, the fiber bundles are interwoven and without regular orientation. It forms most fasciae, the reticular (deeper) region of the dermis of the skin, the periosteum of bone, and the perichondrium of cartilage, and the membrane (fibrous) capsules around organs, such as the kidneys, liver, testes, and lymph nodes. Regularly Arranged=This tissue is adapted for tension in one direction, and the fibers have an orderly, parallel arrangement. The most common variety of dense regularly arranged connective tissue has a predominance of collagenous fibers arranged in bundles. Fibroblasts are placed in rows between the bundles. The tissue is silvery white, tough, yet somewhat pliable. Because of its great strength, it is the principal component of tendons, which attach muscles to bones, aponeurosis (ap’-o-noo-RO-sez), which are sheet like tendons connecting one muscle with another or with bone; and many ligaments (collagenous ligaments), which hold bones together at joints. Plantar Aponeurosis (a-paw-neurosis) (PA) (Illus #9)(Plantar Aponeurosis (Fascia) Illustrated) (Illus #10)(Plantar Aponeurosis (Fascia) Picture) -The plantar aponeurosis is Dense (Collagenous) Connective Tissue, which is regularly arranged and stretches across the sole of the foot similar to the palmar aponeurosis in the hand. It is a thickened layer of deep fascia, which serves both a protective and supportive function to the underlying muscles, vessels and nerves. The fibers are oriented longitudinally and attached to the Calcaneal tuberosity and over its surface. The aponeurosis divides distally into five digital slips, one of which courses to each toe. Fibers extend from the margins of the aponeurosis divide again to cover partially both the medial and lateral plantar eminences attaching on either side of the plantar ligament of the MP joint. Functionally and histologically the plantar aponeurosis is tendon like and acts as an extension of the Achilles tendon. During the push off it is tightened along with the other plantar flexors, which pull on the Achilles tendon whose fibers may interdigitate with the PA. As push off progresses and the toes are extended the PA is further tightened. The tautness of the PA helps maintain the arch during running and walking activities. During stance phase the PA is less tight as intrinsic foot structures such as the long and short plantar ligament assume the burden of arch support. Lateral Cord of the Plantar Aponeurosis-Helps support the lateral longitudinal arch. It is attached to the lateral Calcaneus blending with the plantar aponeurosis. Distally this structure attaches to the base of the 5th metatarsal bone. Plantar Fascia (fā-si-ă) (PF)-Extends over the medial and lateral side of the PA and covers the abductor Hallucis (hǎ-li-cis) on the medial side and abductor Digiti Minimi (dĭgĭtĭ mĭnĭmĭ) on the lateral side. Plantar Ligaments (Illus # 14) (Tendon, Ligament, Muscle Tissue and Cells)-Long Plantar Ligament- The long plantar ligament is the longest of all the ligaments of the tarsus. It is attached behind to the plantar surface of the calcaneus in front of the tuberosity, and in front to the tuberosity on the plantar surface of the cuboid bone, the more superficial fibers being continued forward to the bases of the (sometimes second), third, fourth and fifth metatarsal bones. This ligament converts the groove on the plantar surface of the cuboid into a canal for the tendon of the Peroneus longus. Plantar Calcaneocuboid Ligament (Short Plantar Ligament)-The plantar Calcaneocuboid ligament lies nearer to the bones than the preceding, from which it is separated by a little Areolar (ă-realer) tissue. It is a short but wide band of great strength, and extends from the tubercle and the depression in front of it, on the forepart of the plantar surface of the calcaneus, to the plantar surface of the cuboid behind the peroneal groove. Plantar Calcaneonavicular (Spring) Ligament-The plantar Calcaneonavicular ligament is a broad and thick band of fibers, which connects the anterior margin of the Sustenaculum tali of the calcaneus to the plantar surface of the Navicular. This ligament not only serves to connect the calcaneus and Navicular, but also supports the head of the talus, forming part of the articular cavity in which it is received. Retinaculum of foot/Fascia Around the Ankle (Illus #28- Synovial (Mucous) Sheaths of the Tendons & Retinaculum (Ligaments) Around the Ankle (Lateral & Medial))-Three ligaments bind down the tendons in front of and behind the ankle in their passage to the foot as follows; Transverse Crural, Cruciate Crural and the Laciniate, and the Superior and Inferior Peroneal Retinacula. For the purposes of this study the following will examine the Laciniate and Superior and Inferior Peroneal Retinacula. Laciniate Ligament=The laciniate ligament is a strong fibrous band, extending from the tibial malleolus above to the margin of the calcaneus below, converting a series of bony grooves in this situation into canals for the passage of the tendons of the Flexor muscles and the posterior tibial vessels and tibial nerve into the sole of the foot. It is continuous by its upper border with the deep fascia of the leg, and by its lower border with the plantar aponeurosis and the fibers of origin of the Abductor hallucis muscle. Enumerated from the medial side, the four canals which it forms transmit the tendon of the Tibialis posterior; the tendon of the Flexor digitorum longus; the posterior tibial vessels and tibial nerve, which run through a broad space beneath the ligament; and lastly, in a canal formed partly by the talus, the tendon of the Flexor hallucis longus. Peroneal Retinacula=The peroneal Retinacula are fibrous bands, which bind down the tendons of the Peronei longus and brevis as they run across the lateral side of the ankle. The fibers of the superior retinaculum (external annular ligament) are attached above to the lateral malleolus and below to the lateral surface of the calcaneus. The fibers of the inferior retinaculum are continuous in front with those of the cruciate crural ligament; behind they are attached to the lateral surface of the calcaneus; some of the fibers are fixed to the peroneal trochlea, forming a septum between the tendons of the Peronei longus and brevis. Synovial (Mucous) Sheaths of the Tendons Around the Ankle(Illus #28)-All the tendons crossing the ankle-joint are enclosed for part of their length in mucous sheaths, which have an almost uniform length of about 8 cm. each. On the front of the ankle the sheath for the Tibialis anterior extends from the upper margin of the transverse crural ligament to the interval between the diverging limbs of the cruciate ligament; those for the Extensor digitorum longus and Extensor hallucis longus reach upward to just above the level of the tips of the malleoli, the former being the higher. The sheath of the Extensor hallucis longus is prolonged on to the base of the first metatarsal bone, while that of the Extensor digitorum longus reaches only to the level of the base of the fifth metatarsal. On the medial side of the ankle the sheath for the Tibialis posterior extends highest up—to about 4 cm. above the tip of the malleolus—while below it stops just short of the tuberosity of the navicular. The sheath for Flexor hallucis longus reaches up to the level of the tip of the malleolus, while that for the Flexor digitorum longus is slightly higher; the former is continued to the base of the first metatarsal, but the latter stops opposite the first cuneiform bone. On the lateral side of the ankle (Fig. 441) a sheath which is single for the greater part of its extent encloses the Peronei longus and brevis. It extends upward for about 4 cm. above the tip of the malleolus and downward and forward for about the same distance. Foot and Toe Muscles-Introduction-The muscles of the leg can be divided into three compartments according to deep facial divisions, nerve supply, and muscular action. The three compartments are; Anterior Compartment, Lateral (Peroneal) Compartment and the Posterior Compartment. This type of categorization is similar to the divisions found in the thigh muscles. For the purposes of this study we will detail the Lateral (Peroneal) Compartment and the Posterior Compartment. Lateral (Peroneal) Compartment=These muscles plantar flex and evert the foot and are supplied by the superficial peroneal nerve. Peroneus Brevis=This muscle plantar flexes and everts the foot. Its origin is on the body of the fibula and it inserts on the base of the fifth metatarsal. It is supplied by the superficial peroneal nerve with nerve roots of L5, S1, and S2. Peroneus Longus=This strap muscle along with the Tibialis posterior help support the medial transverse arch of the foot. This muscle plantar flexes and everts the foot. Its origin is on the head and body of the fibula and lateral condyle of the tibia and it inserts at the first metatarsal and first cuneiform. It is supplied by the superficial peroneal nerve with nerve roots of L5, S1, and S2. Posterior Compartment=These muscles are divided into superficial and deep groups and the tibial nerve innervates all. Most of these muscles plantar flex the foot except one muscle in the deep compartment the Popliteus that flexes and medially rotates the leg. The muscles contained in the superficial grouping share a common tendon of insertion, the Calcaneal (Achilles) tendon that is attached to the calcaneus bone of the ankle. The Calcaneal (Achilles) tendon is the strongest tendon of the body and is able to withstand a 1000-pound force without tearing. Despite this, however, the calcaneal tendon ruptures more frequently than any other tendon because of the tremendous pressures placed on it during competitive sports. Posterior Superficial Compartment-Gastrocnemius=This muscle plantar flexes the foot and flexes the leg. Its origin is on the lateral and medial condyles of the femur and capsule of the knee and it inserts on the calcaneus by way of the calcaneal (Achilles) tendon. It is supplied by the tibial nerve with nerve roots of S1-2. Plantaris=This muscle plantar flexes the foot. Its origin is on the femur above the lateral condyle and it inserts onto the calcaneus by way of the calcaneal (Achilles) tendon. It is supplied by the tibial nerve and its nerve roots are S1-2. Soleus=This muscle attaches to the upper portion of the lower leg and to the Achilles tendon. During the stance phase of gate, it checks the forward motion of the lower leg and plantar flexes the foot during the gate phase of push-off. While seated this one joint muscle is a strong plantar flexor while the gastrocnemius is mechanically disadvantaged due to its lengthened position. It is supplied by the tibial nerve with nerve roots of S1-2. Posterior Deep Compartment-Flexor Digitorum Longus=This muscle plantar flexes and inverts the foot and flexes the toes. Its origin is the posterior surface of the tibia and it inserts onto the distal phalanges of the four outer toes. It is supplied by the tibial nerve with nerve roots of S2-3. Flexor Hallucis Longus=This muscle plantar flexes and inverts the foot and flexes the big toe. Its origin is on the lower two-thirds of the fibula and it inserts onto the distal phalanx of the big toe. It is supplied by the tibial nerve and its nerve roots are S2-3. Tibialis Posterior=This strap muscle along with the Peroneus longus and brevis help support the medial transverse arch of the foot. The Tibialis posterior is the deepest posterior lower leg muscle attaching to the Interosseous Membrane (fibrous connective tissue which binds the tibia and fibula) and to both the tibia and fibula covering a major portion of the lower leg. This muscle also attaches to many of the bones that wedge together in forming the Roman style arch of the foot including the bases of the middle three metatarsal bones. This muscle plantar flexes and inverts the foot. Its origin is on the tibia, fibula, and interosseous membrane and it inserts onto the second, third, and fourth metatarsals; navicular, all three cuneiforms, and cuboid. It is supplied by the tibial nerve and its nerve roots are L4-5. Intrinsic Foot Muscles (Illus#13) (Foot Plantar Intrinsic Superficial & Deep View) -The intrinsic muscles of the foot are similar to the hand muscles, which are specialized for intricate and precise movements where as the foot muscles are specialized for support and locomotion. The deep fascia of the foot joins with the plantar aponeurosis, which attaches to the calcaneus and the metatarsophalangeal (MP) joints providing longitudinal arch support. The intrinsic foot muscles are divided into two groups; Dorsal, which includes only two muscles (see below) and the plantar muscles, which include several layers as, outlined below. Of particular interest to this study are the Abductor Hallucis, Flexor digitorum Brevis, Abductor digiti minimi and the quadratus plantae all of which have their origin on the calcaneus. Dorsal Muscles-Extensor Digitorum Brevis=This muscle extends the first through fourth toes. Its origin is on the dorsal aspect of the calcaneus and it inserts on the tendon of the extensor Digitorum longus and proximal phalanx of the great toe. It is supplied by the Deep peroneal nerve with nerve roots of S1 and S2. Extensor Hallucis Brevis=This muscle extends the proximal phalanx of the Hallux. Its origin is on the dorsal aspect of the calcaneus and it inserts on the dorsal surface of the base of proximal phalanx of Hallux. It is supplied by the deep peroneal nerve with nerve roots of S1 and S2. Plantar Muscles-Plantar First Superficial Layer-Abductor Digiti Minimi (Foot)=The action of this muscle is to abduct the fifth toe away from the fourth toe. This muscle has its origin on the calcaneus and it inserts onto the little toe. It is supplied by the lateral plantar nerve with nerve roots of S2 and S3. Abductor Hallucis=The action of this muscle is to abduct the big toe from the mid line of the foot. This muscle has its origin on the calcaneus and it inserts onto the big toe. It is supplied by the medial plantar nerve with nerve roots of S2 and S3. Flexor Digitorum Brevis=The action of this muscle is to flex the second through fifth toes. This muscle has its origin on the calcaneus and plantar aponeurosis ant it inserts onto the middle phalanx of the second through fifth toes. It is supplied by the medial plantar nerve with nerve roots of S2 and S3. Plantar Second Layer-Lumbricals=This muscle extends the second through fifth toes. Its origin is on the tendons of the flexor Digitorum longus and it inserts onto the tendons of the extensor Digitorum longus. It is supplied by the medial and lateral plantar nerves with nerve roots of S2 and S3. Quadratus Plantae=This muscle flexes the second through fifth toes. Its origin is on the calcaneus and it inserts onto the tendons of the flexor Digitorum longus. It is supplied by the lateral plantar nerve with nerve roots of S2 and S3. Plantar Third Layer-Adductor Hallucis=The adductor hallucis adducts the big toe towards the 2nd toe and Flexes the big toe towards plantar surface. The oblique head attaches (origin) to the bases of the 2nd, 3rd and 4th metatarsals. The transverse head attaches (origin) to the Plantar Metatarsophalangeal ligaments of the 3rd, 4th and 5th toes. Both heads insert into the lateral side of base of proximal phalanx of big toe. This muscle is supplied by the lateral plantar nerve and its nerve roots are S2 and S3. Flexor Digiti Minimi Brevis=This muscle flexes the small toe. Its origin is on the fifth metatarsal and it inserts on the proximal phalanx of the small toe. It is supplied by the lateral plantar nerve and its roots are S2 and S3. Flexor Hallucis Brevis=This muscle flexes the great toe. Its origin is on the cuboid and third (lateral) cuneiform with insertion onto the proximal phalanx of the great toe. It is supplied by the medial plantar nerve with nerve roots of S2 and S3. Plantar Fourth Deep Layer-Dorsal Interossei=This muscle abducts the toes and flexes the proximal phalanges. Its origin is on the adjacent side of the metatarsals and it inserts onto the proximal phalanges, both sides of the second toe, and the lateral side of the third and fourth toes. It is supplied by the lateral plantar nerve and its nerve roots are S2 and S3. Plantar Interossei=This muscle adducts the third, fourth, and fifth toes and flexes the proximal phalanges. Its origin is on the third, fourth and fifth metatarsals and it inserts onto the proximal phalanges of the same toes. It is supplied by the lateral plantar nerve with nerve roots of S2 and S3. Neurology (Illus # 2) (Dermatomes ALL) (Illus # 3) (Dermatomes L1-S3 Front) (Illus # 4) (Dermatomes L1-S4 Back) (Illus # 15) (Exit of Spinal Nerves) – Posterior RAMI=Dermatomes-The Fetal stem cells form the organs, bones, muscles, nerves and fascia. The specialized set of cells that form the fascia including the skin is called a dermatome. The word dermatome has also come to mean the area of the skin supplied by the dorsal RAMI of the spinal nerves. Each dermatome is named after a spinal level from which the nerve originates. For example, the L 1 dermatome is supplied by the first lumbar nerve. The L5 dermatome is supplied by the 5th lumbar nerve. The dermatomal levels of concern for this study are the spinal levels and dermatomal areas which refer into the Achilles tendon. These are; 1.) S1-Refers to the lateral tissue around the Achilles tendon. 2.) L5-Refers to the posterior later Achilles Tendon 3.) S2-refers to the medial tissue and medial posterior aspect of the Achilles Tendon. Anterior RAMI=Major Nerve Supply (Illus # 24A-Lumbar Plexus) (Illus # 24B-Sacral Plexus) (Illus # 25-Nerve Distribution (Lumbar and Sacral Plexus))-The Sciatic is the major nerve which forms from the sacral plexus. Its nerve roots are L4-S3.. Composed of two nerves: tibial and common peroneal, bound together by common sheath of connective tissue. It splits into its two divisions, usually at knee where the tibial nerve descends through the middle of the popliteal fossa, to the lower part of the Popliteus muscle, where it passes with the popliteal artery beneath the arch of the Soleus. It then runs along the back of the leg with the posterior tibial vessels to the interval between the medial malleolus and the heel, where it divides beneath the laciniate ligament into the medial and lateral plantar nerves. Additional branches of the tibial nerve are the Medial Sural Cutaneous Nerve and the medial Calcaneal (Tibial) nerve. The Common Peroneal Nerve descends obliquely along the lateral side of the popliteal fossa to the head of the fibula, close to the medial margin of the Biceps femoris muscle. It lies between the tendon of the Biceps femoris and lateral head of the Gastrocnemius muscle, winds around the neck of the fibula, between the Peroneus longus and the bone, and divides beneath the muscle into the superficial and deep peroneal nerves. Cutaneous branches of this nerve supply the skin of the dorsal foot. The Femoral Nerve the largest branch of the lumbar plexus runs beneath the inguinal ligament, into the medial thigh, and splits into an anterior and a posterior division. The Saphenous Nerve is a cutaneous branch of the posterior division of the femoral nerve. Cutaneous Nerves (Illus # 16) (Cutaneous Nerve Distribution Plantar Foot & Posterior Lower Leg)-1.) Saphenous-cutaneous branch of the femoral;post div(fem n.) With nerve roots of L3-4 originating from the lumbar plexus. Supplies the skin over the medial tibial border to the ankle and medial side of the foot. 2.) Medial plantar(tibial)-Cutaneous branch of the tibial(sciatic) nerve with nerve roots of L4-5 originating from the sacral plexus. Supplies the skin of the medial side of the sole of the foot; common and proper plantar digital nerves supply the plantar skin on both sides of 1^st through 3^rd digits and the medial 4^th digit. Dorsal branches supply skin around the nail of the same aforementioned digits. 3.) Lateral plantar-Cutaneous branch of the tibial(sciatic) nerve with nerve roots of L4-S3 arising from the sacral plexus. Supplies skin over the lateral part of the sole; common and proper plantar digital nerves supply the plantar skin on the lateral side of the 4th and both sides of the 5th digit. Dorsal branches supply skin around the nail of the same aforementioned digits. 4.) Medial Sural Cutaneous Nerve-Cutaneous branch of the tibial nerve (Sciatic) with nerve roots of L5-S2 arising from the sacral plexus. Supplies the posterolateral skin of the distal third of the calf and the lateral side of the foot and little toe. 5.) Medial Calcaneal (Tibial)-Cutaneous branch of the tibial nerve (Sciatic) with nerve roots of S1-S2 arising from the sacral plexus. Supplies the skin of the medial side of the plantar surface of the foot and heel. Motor Nerves-The medial and lateral plantar motor nerves, which arise from the tibial nerve with nerve roots of S2-S3, supply all of the intrinsic muscles of the plantar foot. Articular Branches-Medial Plantar Nerve=This nerve has articular branches to all of the tarsal joints and branches to the metatarsal and Phalangeal joints of the first three digits. Lateral Plantar Nerve=This nerve has articular branches to the metatarsophalangeal and Interphalangeal joints of the 4^th and 5^th digits. Osteology-Tarsals, Metatarsals, and Phalanges-Tarsus (Tarsals) (7) (Illus # 8) (Bones Foot Plantar Surface) (Illus # 17) (Right Foot Dorsal/Plantar) (Illus # 18) (Left Talus) (Illus # 19) (Calcaneus) (Illus # 20) (Navicular and Cuboid Bones) (Illus #20A-1st & 2nd Cuneiform Bones) (Illus #20B-3rd Cuneiform Bone) (Illus #20C-1st & 2nd Metatarsal Bones) (Illus #20D-3rd & 4th Metatarsal Bones) (Illus #20E-5th Metatarsal Bone)=The tarsus is a collective designation for the seven bones of the ankle called tarsals. The term tarsos pertains to a broad, flat surface. Posterior Tarsus-The posterior tarsus contains the talus and calcaneus. Talus (Illus #18)=The talus, the uppermost tarsal bone, is the only bone of the foot that articulates with the fibula and tibia. It is surrounded on one side by the medial Malleolus of the tibia and on the other side by the lateral Malleolus of the fibula. The talus is the second largest of the tarsal bones. It occupies the middle and upper part of the tarsus, resting upon the calcaneus below, articulating in front with the navicular. It consists of a body, a neck, and a head. During walking, the talus initially bears the entire weight of the body. About half the weight is then transmitted to the calcaneus. The remainder is transmitted to the other tarsal bones. The shape of the talus is as follows; The Body; The trochlea is broader in front than behind, convex from before backward, slightly concave from side to side: in front it is continuous with the upper surface of the neck of the bone.The inferior surface presents two articular areas, the posterior and middle calcaneal surfaces, separated from one another by a deep groove, the sulcus tali. The groove runs obliquely forward and lateralward, becoming gradually broader and deeper in front: in the articulated foot it lies above a similar groove upon the upper surface of the calcaneus, and forms, with it, a canal (sinus tarsi) filled up in the fresh state by the interosseous talocalcaneal ligament. It articulates with the corresponding facet on the upper surface of the calcaneus, and is deeply concave in the direction of its long axis, which runs forward and lateralward at an angle of about 45° with the median plane of the body. The posterior surface is narrow, and traversed by a groove running obliquely downward and medialward, and transmitting the tendon of the Flexor hallucis longus. Lateral to the groove is a prominent tubercle, the posterior process, to which the posterior talofibular ligament is attached; this process is sometimes separated from the rest of the talus, and is then known as the os trigonum. Medial to the groove is a second smaller tubercle. The Neck; The neck is directed forward and medialward, and comprises the constricted portion of the bone between the body and the oval head. Its upper and medial surfaces are rough, for the attachment of ligaments; its lateral surface is concave and is continuous below with the deep groove for the interosseous talocalcaneal ligament. The Head; The head looks forward and medialward; its anterior articular or navicular surface is large, oval, and convex. Its inferior surface has two facets, which are best seen in the fresh condition. The medial, situated in front of the middle calcaneal facet, is convex, triangular, or semi-oval in shape, and rests on the plantar calcaneonavicular ligament; the lateral, named the anterior calcaneal articular surface, is somewhat flattened, and articulates with the facet on the upper surface of the anterior part of the calcaneus. Calcaneus (kal-KĀ-nē-us) (Illus #19)=The calcaneus, or heel bone, is the largest and strongest tarsal bone. The calcaneus articulates with two bones: the talus and cuboid. It is situated at the lower and back part of the foot, serving to transmit the weight of the body to the ground, and forming a strong lever for the muscles of the calf. It is irregularly cuboidal in form, having its long axis directed forward and lateralward; it presents for examination six surfaces. Superior Surface; This varies in length in different individuals, is convex from side to side, concave from before backward, and supports a mass of fat placed in front of the tendo calcaneus. In front of this area is a large usually somewhat oval-shaped facet, the posterior articular surface, which looks upward and forward; it is convex from behind forward, and articulates with the posterior calcaneal facet on the under surface of the talus. In front and to the medial side of this groove is an elongated facet, concave from behind forward, and with its long axis directed forward and lateralward. This facet is frequently divided into two by a notch: of the two, the posterior, and larger is termed the middle articular surface; it is supported on a projecting process of bone, the sustentaculum tali, and articulates with the middle calcaneal facet on the under surface of the talus; the anterior articular surface is placed on the anterior part of the body, and articulates with the anterior calcaneal facet on the talus. Inferior or Plantar surface; The inferior or plantar surface is uneven, wider behind than in front, and convex from side to side; it is bounded posteriorly by a transverse elevation, the calcaneal tuberosity, which is depressed in the middle and prolonged at either end into a process; the lateral process, small, prominent, and rounded, gives origin to part of the Abductor digiti quinti; the medial process, broader and larger, gives attachment, by its prominent medial margin, to the Abductor hallucis, and in front to the Flexor digitorum brevis and the plantar aponeurosis; the depression between the processes gives origin to the Abductor digiti quinti. The rough surface in front of the processes gives attachment to the long plantar ligament, and to the lateral head of the Quadratus plantae while to a prominent tubercle nearer the anterior part of this surface, as well as to a transverse groove in front of the tubercle, is attached the plantar calcaneocuboid ligament. Medial Surface; The medial surface is deeply concave; it is directed obliquely downward and forward, and serves for the transmission of the plantar vessels and nerves into the sole of the foot; it affords origin to part of the Quadratus plantae. The anterior or cuboid articular surface is of a somewhat triangular form. Its medial border gives attachment to the plantar calcaneonavicular ligament. The lowest of these is rough, and covered by the fatty and fibrous tissue of the heel; the middle, also rough, gives insertion to the tendo calcaneus and Plantaris; while the highest is smooth, and is covered by a bursa which intervenes between it and the tendo calcaneus. Anterior Tarsus=The anterior tarsus contains the cuboid, Navicular, and three cuneiform (cuneiform=wedge-shaped) bones called the first (medial), second (intermediate), and third (lateral) cuneiform. Cuboid Bone (Illus # 20)=The cuboid bone is placed on the lateral side of the foot, in front of the calcaneus, and behind the fourth and fifth metatarsal bones. It is of a pyramidal shape, its base being directed medialward. The cuboid articulates with four bones: the calcaneus, third cuneiform, and fourth and fifth metatarsals; occasionally with a fifth, the navicular. Dorsal Surface; The dorsal surface, directed upward and lateralward, is rough, for the attachment of ligaments. Plantar Surface; The plantar surface presents in front a deep groove, the peroneal sulcus, which runs obliquely forward and medialward; it lodges the tendon of the Peroneus longus, and is bounded behind by a prominent ridge, to which the long plantar ligament is attached. Lateral Surface; The lateral surface presents a deep notch formed by the commencement of the peroneal sulcus. Posterior Surface; The posterior surface is smooth, triangular, and concavo-convex, for articulation with the anterior surface of the calcaneus; its inferior-medial angle projects backward as a process, which underlies and supports the anterior end of the calcaneus. Anterior Surface; The anterior surface, of smaller size, but also irregularly triangular, is divided by a vertical ridge into two facets: the medial, quadrilateral in form, articulates with the fourth metatarsal; the lateral, larger and more triangular, articulates with the fifth. Medial Surface; The medial surface is broad, irregularly quadrilateral, and presents at its middle and upper part a smooth oval facet, for articulation with the third cuneiform; and behind this (occasionally) a smaller facet, for articulation with the navicular; it is rough in the rest of its extent, for the attachment of strong interosseous ligaments. Navicular Bone (Illus # 20)=The navicular bone is situated at the medial side of the tarsus, between the talus behind and the cuneiform bones in front. The navicular articulates with four bones: the talus and the three cuneiforms; occasionally with a fifth, the cuboid. Anterior Surface; The anterior surface is convex from side to side, and subdivided by two ridges into three facets, for articulation with the three cuneiform bones. Posterior Surface; The posterior surface is oval, concave, broader laterally than medially, and articulates with the rounded head of the talus. Dorsal Surface; The dorsal surface is convex from side to side, and rough for the attachment of ligaments. Plantar Surface; The plantar surface is irregular, and also rough for the attachment of ligaments. Medial Surface; The medial surface presents a rounded tuberosity, the lower part of which gives attachment to part of the tendon of the Tibialis posterior. Lateral Surface; The lateral surface is rough and irregular for the attachment of ligaments, and occasionally presents a small facet for articulation with the cuboid bone. First Cuneiform Bone (Illus 20a)=The first cuneiform bone is the largest of the three cuneiforms. It is situated at the medial side of the foot, between the navicular behind and the base of the first metatarsal in front. The first cuneiform articulates with four bones: the navicular, second cuneiform, and first and second metatarsals. The medial surface is subcutaneous, broad, and quadrilateral; at its anterior plantar angle is a smooth oval impression, into which part of the tendon of the Tibialis anterior is inserted; in the rest of its extent it is rough for the attachment of ligaments. Second Cuneiform Bone (Illus 20a)=The second cuneiform bone, the smallest of the three, is of very regular wedge-like form, the thin end being directed downward. It is situated between the other two cuneiforms, and articulates with the navicular behind, and the second metatarsal in front. The second cuneiform articulates with four bones: the navicular, first and third cuneiforms, and second metatarsal. Third Cuneiform Bone (Illus 20b)=The third cuneiform bone, intermediate in size between the two preceding, is wedge-shaped, the base being uppermost. It occupies the center of the front row of the tarsal bones, between the second cuneiform medially, the cuboid laterally, the navicular behind, and the third metatarsal in front. The third cuneiform articulates with six bones: the navicular, second cuneiform, cuboid, and second, third, and fourth metatarsals. Metatarsus (5) (Illus # 20c,d&e)=The metatarsus consists of five metatarsal bones numbered 1-5 from the medial to lateral position. Like the metacarpals of the palm of the hand, each metatarsal consists of a proximal base, a shaft, with a distal head. The metatarsals articulate proximally with the first, second and third cuneiform bones and with the cuboid. Distally, they articulate with the proximal row of phalanges. The first metatarsal is thicker than the others because it bears more weight. Phalanges (14)=The phalanges of the foot resemble those of the hand both in number and arrangement. Each also consists of a proximal base, a middle shaft, and a distal head. The Hallux (great or big toe), has two large, heavy phalanges called proximal and distal phalanges. The other four toes each have three phalanges, proximal, middle, and distal. Total Bones of Foot=26 Arches of the Foot-The bones of the foot are arranged in two arches. These arches enable the foot to support the weight of the body, provide an ideal distribution of body weight over the hard and soft tissues of the foot, and provide leverage while walking. The arches are not rigid. They yield as weight is applied and spring back when the weight is lifted, thus helping to absorb shocks. The fundamental longitudinal arch is contributed to by both the medial and lateral arch, and consists of the calcaneus, cuboid, third cuneiform, and third metatarsal: all the other bones of the foot may be removed without destroying this arch. Longitudinal Arch-The longitudinal arch has two parts. Both consist of tarsal and metatarsal bones arranged to form an arch from the anterior to the posterior part of the foot. Medial Longitudinal Arch-Originates at the calcaneus rises to the talus and descends through the Navicular, the three cuneiforms, and the heads of the three medial metatarsals. The talus is the keystone of the arch. The two piers of this arch are the tuberosity on the plantar surface of the calcaneus posteriorly and the heads of the first, second, and third metatarsal bones anteriorly. The weakest part of this arch is the Talonavicular joint which is supported by the calcaneonavicular (spring) ligament and its elasticity helps restore the arches integrity against compressive forces. This arch is further supported by the deltoid ligament, the tendons of the Tibialis posterior/anterior and Peroneus Longus and associated ligaments along with the plantar aponeurosis and intrinsic foot muscles. Lateral Longitudinal Arch-Begins at the calcaneus, rises at the cuboid and descends to the heads of the two lateral metatarsals. The cuboid is the keystone of this arch. This arch is supported by the long plantar and the plantar calcaneocuboid ligaments. Transverse Arch-The Navicular, three cuneiforms, cuboid, and the bases of the five metatarsals form the transverse arch. The transverse arches are strengthened by the interosseous, plantar, and dorsal ligaments, by the short muscles of the first and fifth toes (especially the transverse head of the Adductor hallucis), and by the Peroneus longus, whose tendon stretches across between the piers of the arches. Arthrology (ar-THROL-ō-jē; arthro=joint; logos=sturdy of) (Illus # 21) (Right Foot Lateral & Medial Ligaments) (Illus # 22) (Plantar Ligaments & Joints) (Illus # 23) (Right Foot Synovial Joint Cavities) Introduction-Bones are too rigid to bend without causing damage. All movements that change the positions of the bone parts of the body occur at joints. An articulation (joint) is a point of contact between bones between cartilage and bones, or between teeth and bones. The scientific study of joints is referred to as Arthrology (ar-THROL-ō-jē; arthro=joint; logos=sturdy of). The joint’s structure determines how it functions. Some joints permit no movement, others permit slight movement, and still others afford considerable movement. In general, the closer the fit at the point of contact, the stronger the joint. At tightly fitted joints, however, movement is restricted. The looser the fit, the greater the movement. Unfortunately, loosely fitted joints are prone to dislocation. Movement at joints is also determined by the structure (shape) of the articulation bones, the flexibility (tension or tautness) of the connective tissue ligaments and joint capsules that bind the bones together, and the position of ligaments, muscles, and tendons. Classification of Joints-Functional- The functional classification of joints takes into account the degree of movement they permit. 1.) Synarthroses (sin-ar-THRŌ-sēz))-Immovable 2.) Amphiarthroses (am-fē –ar-THRŌ-sēz)-Slightly moveable 3.) Diarthroses-Freely movable Structural- The structural classification of joints is based on the presence or absence of a synovial (joint) cavity (a space between the articulating bones) and the kind of connective tissue that binds the bones together. Structurally, joints are classified as Fibrous Joints, in which there is no synovial cavity and the bones are held together by fibrous connective tissue. Cartilaginous Joints have no synovial cavity and the bones are held together by cartilage. Synovial Joints have a synovial cavity and the bones forming the joint are united by a surrounding articular capsule and frequently by accessory ligaments (described later). We will discuss the joints of the body based upon their structural classification, but with reference to their functional classification as well. For the purpose of this study we will discus fibrous and synovial joints in detail. Fibrous Joints- Fibrous joints lack a synovial cavity, and the articulating bones are held very closely together by fibrous connective tissue. They permit little or no movement. The three types of fibrous joints are Sutures, Syndesmoses, and gomphoses. For the purposes of this study we will discuss Syndesmosis. Syndesmosis (Sin’-dez-MŌ-sis)=This is a fibrous joint in which the uniting fibrous connective tissue is present in a much greater amount than in a suture, but the fit between the bones is not quite as tight. The fibrous connective forms an interosseous membrane or ligament. A Syndesmosis is slightly movable because the bones are separated more than in a suture and some flexibility is permitted by the interosseous membrane or ligament. Syndesmoses are functionally classified as amphiarthrotic and typically permit slight movement. An example of a Syndesmosis is the distal articulation of the fibia and fibula. Synovial Joints- Structure (Illus #30- Generalized Synovial Joint Capsule Frontal Section)=A joint in which there is a space between articulating bones is called a synovial joint. The space is called a synovial (joint) cavity. Because of this cavity and because of the arrangement of the articular capsule and accessory ligaments, synovial joints are freely movable. Thus, synovial joints are functionally classified as diarthrotic. Synovial joints are different from the other joint types in the following ways. 1.) Synovial Joint Cavity 2.) Hyaline (Articular) Cartilage 3.) Articular Capsule Accessory Ligaments= There are two kinds of accessory ligaments (ligare= to bind) one which is on the outside of the joint capsule is named the extracapsular ligament and another is named the intracapsular ligament because it is on the inside of a joint capsule. Bursae=Bursae help reduce friction between moving parts. Bursae are saclike structures whose walls consist of connective tissue similar to the fibrous tissue around the joint capsule. Bursae are lined with a synovial membrane and filled with fluid similar to synovial fluid. Bursae cushion movement of one part of a body over another and repetitive stress can inflame them. This inflammation is called bursitis. Bursae are found between the following structures; Skin and bone in places where the skin rubs over the bone, Tendons and bones, Muscles and bones, and Ligaments and bones. Types of Synovial Joints (Illus #29- Synovial Joint Types)=The shape of the articulating bones determines the type of movement that can be performed. The structure of synovial joints although similar differ in articular shape and can be divided into six sub-types as follows; Gliding, Hinge, Pivot, Ellipsoidal, Saddle, and Ball and Socket. For the purpose of this study a selected sample of these joint types will be discussed in detail. Gliding=The bones of gliding joints (arthrodia (ar-THRŌ-dē-a)) form a flat surface so that only side-to-side and back and fourth movements are possible. The ligaments or adjacent bones limit twisting and rotation movements. Gliding joints are nonaxial because there's no axis around which they move. Examples of these joints are; Joints between the carpal bones, Tarsal bones, Sternum and clavicle, and Scapula and clavicle. Hinge=The hinge or ginglymus (JIN-gli-mus) joint is one in which the concave surface of one bone fits into the convex surface of another bone. This joint is monaxial or uniaxial because its movement is primarily a single plane. A door hinge is a good example of this type of joint. Movements include; Flexion & Extension. Examples include; Elbow, Ankle, and Interphalangeal joints. Ellipsoidal=An ellipsoidal or condyloid (KON-di-loyd) joint, an oval-shaped condyle of one bone fits into an elliptical cavity of another bone. Since the joint permits side-to-side and back-and-forth movements, it is biaxial. The joint at the wrist between the radius and carpals is ellipsoidal. The movement permitted by such a joint is illustrated when you flex and extend and abduct and adduct and circumduct the wrist. Examples of this joint type are; Metatarsophalangeal Joints (MP) and wrist joint. Saddle (Reciprocal Reception)=In a saddle or sellaris (sel-A-ris) joint, the articular surface of one bone is saddle-shaped and the articular surface of the other bone is shaped like a rider sitting in the saddle. Essentially, the saddle joint is a modified ellipsoidal joint in which the movement is somewhat freer. Movements at a saddle joint are side to side and back and forth. Thus, the joint is biaxial. Examples of this joint are; Trapezium of the carpus and the metacarpal of the thumb and the Calcaneocuboid Joint of foot. Ball and Socket=A ball and socket or spheroid (SFĒ-royd) joint consists of a ball-like surface of one bone fitted into a cuplike depression of another bone. Such a joint permits triaxial movement, or movement in three planes of motion: flexion-extension, abduction-adduction, and rotation-Circumduction. The range of movement at a ball-and-socket joint is illustrated by Circumduction of the arm. Movements of this joint include; Flexion-extension, Abduction-adduction, Rotation-Circumduction. Examples of this joint are; Shoulder Joint, Coxal (hip) Joint, and Talocalcaneonavicular (TCN) of the foot. Tibiofibular Joint-The superior and inferior tibiofibular joints are separate from the ankle joint but must provide accessory movements for full ankle function. The superior Tibiofibular is formed between the proximal ends of the tibia and fibula when the fibular head joins with a facet on the Posterolateral aspect of the rim of the tibial condyle forming a plane synovial joint. The inferior Tibiofibular joint is formed between the distal ends of the tibia and fibula forming a Syndesmosis with fibroadipose tissue, and bound together by the Crural Tibiofibular interosseous ligament and the anterior and posterior Tibiofibular ligaments. With Dorsiflexion, plantarflexion, inversion, and Eversion there are slight accessory movements of the fibula. Talocrural (Ankle) Joint (ta’’lo-krōōr’al)-This Synovial Hinge (Ginglymus) Type joint is formed by the congruous union of the distal end of the tibia and its medial Malleolus and the Lateral Malleolus of the fibula both forming the concave articulating surface of the mortice with the convex talar surface. The fibrous capsule is lined by a synovial membrane throughout its entirety and well supported by the deltoid ligament medially and the lateral collateral ligaments (Anterior Talofibular, Posterior Talofibular, and Calcaneofibular). Since the axis of movement, (20º Dorsiflexion and 45º plantarflexion) is near the tip of both malleoli these ligaments are not pulled tight during normal movement at the Talocrural joint. Subtalar/Talocalcaneal (ta’’lo-kal-ka-ne-al)-This synovial modified plane or gliding joint is uniaxial and is formed by the union of the talus and calcaneus at two separate articular capsules (Posterior & Anterior) separated by the tarsal canal which divides the two joint cavities. The Subtalar joint allows the movements of inversion and eversion. This joint is supported by several external ligaments (Medial and Lateral Collateral Ligaments (Talocrural), Extensor Retinaculum, Posterior and Lateral Talocalcaneal) and internal ligaments (Interosseous Talocalcaneal (Tarsal Canal) & Cervical Talocalcaneal Ligament). Talocalcaneonavicular (TCN)-This Synovial, compound ball & socket joint with the Navicular forming the socket and the talus forming the ball. The talus articulates with the calcaneus at anterior and medial facets. All of the above articulations are enclosed in the same fibrous capsule. The joint is supported by the calcaneonavicular (Spring) ligament, Bifurcate Ligament (Calcaneonavicular Portion), Deltoid Ligament (Tibionavicular Portion), and Dorsal Talonavicular ligament. The joint assists in inversion and eversion. Calcaneocuboid-This synovial, sellar (saddle) joint between the calcaneus (convex in a dorsal to plantar direction and concave in a medial to lateral direction) and the cuboid (reciprocally concave and convex) This joint is supported by the Calcaneocuboid (Short Plantar) Ligament, Long Plantar ligament and the Bifurcate Ligament (Calcaneocuboid Band). Metatarsophalangeal Joints (MP)-This synovial, Condyloid (KON-di-loyd) joint is formed between the distal ends of the metatarsals with the adjacent end of the proximal phalanges and supported by the medial and lateral collateral ligaments and the plantar ligaments. The joint movements are flexion, extension, abduction, and adduction. Interphalangeal Joints of Toes (IP)-This synovial, hinge joint is formed between the adjacent surfaces of the phalanges and its movements are flexion and extension. Intercuneiform and Cuneocuboid-These synovial gliding joints are formed between the cuneiform bones and between the cuneiform and cuboid bones. These joints permit minimal gliding movements and are supported by dorsal, plantar and Interosseous Ligaments. Tarsometatarsal-These synovial gliding joints are formed between the cuneiform, cuboid and bases of the five metatarsal bones. These joints permit minimal gliding movement and are supported by dorsal, plantar and Interosseous Ligaments. Intermetatarsal-These synovial gliding joints are formed between the adjacent surfaces of the heads and bases of the five metatarsal bones. The joints permit minimal gliding movement and are supported by dorsal, plantar, Interosseous Ligaments and Transverse Metatarsal Ligaments. Synovial Membranes of Foot (Review)-There are nine synovial membranes in the foot enclosing both single and multiple articulations in the foot. 1.) Subtalar/Talocalcaneal 2.) Talocalcaneal 3.) Talocalcaneonavicular 4.) Calcaneocuboid 5.) Cuneonavicular 6.) Intercuneiform, Cuneocuboid, and cuneiform (2nd & 3rd)/metatarsal (2nd, 3rd, & 4th) 7.) 1st cuneiform with great toe 8.) Cuboid & Metatarsal (4th & 5th) 9.) Navicular & Cuboid (Rare) Achilles Tendon Bursa-Introduction-The Retrocalcaneal & Calcaneal Bursa bursae can become inflamed because of either damage to the Achilles tendon or excessive pressure upon the area. Retrocalcaneal Bursa=The retro Calcaneal bursa lies between the anterior surface of the tendon of Achilles and the bare posterior superior angle of the calcaneus. Calcaneal Bursa=This bursa lies between the insertion of the Achilles tendon and the overlying skin. These bursae are more commonly enlarged a condition usually due to oversized or tight shoes and particularly to high heels. Vascular-Arteries of the Foot (Illus # 26- Arteries Of Pelvis & Right Lower Extremity Anterior/Posterior)-Dorsalis Pedis Artery (Dŏr-sălis Pēdĭs)=A branch of the anterior tibial artery provides arterial circulation to the dorsum of the foot. The pulse of the dorsalis pedis artery can best be palpated over the dorsum of the foot, at about the level of the Navicular and first cuneiform bones. If the pulses can be felt it is an indication that the blood supply to the leg is good. Medial And Lateral Plantar Arteries=A branch of the posterior tibial artery which provides arterial circulation to the plantar foot. The pulse of the Posterior Tibial artery can be felt by pressing gently into the soft tissue space behind the Tibialis posterior and the flexor digitorum longus tendons between the Calcaneal tendon and the posterior tibia. Veins of the Foot (Illus # 27- Veins Of Pelvis & Right Lower Extremity Anterior/Posterior)-Dorsal Venous Arch (Medial)=The superficial veins of the medial aspect of the foot join together to form the great (long) Saphenous vein and provide venous circulation to the medial dorsum of the foot. Locate the medial Malleolus and palpate the long Saphenous vein, which is often visible immediately anterior to the medial Malleolus. When veins in the upper extremity cannot be located, this vein is usually an accessible site for intravenous infusion. Varicosity in the lower extremity frequently involves the long Saphenous vein. Dorsal Venous Arch (Lateral)=The superficial veins of the lateral aspect of the foot join together to form the Small (short) Saphenous vein. Both the great and small Saphenous veins are connected by the dorsal venous arch (medial and Lateral). Medial & Lateral Plantar Veins and Plantar Arch=Drains into Posterior Tibial Vein and provides venous circulation to the plantar foot. Examination-Surface Anatomy-Bony Palpation (Illus # 31- Bony Anatomy of the Foot and Ankle (Medial & Lateral Aspect))-Head of the First Metatarsal Bone and the Metatarsophalangeal Joint=The head of the first metatarsal bone and the metatarsophalangeal joint are palpable at the ball of the foot. Note any associated bone excrescences involving the head of the metatarsal. The metatarsophalangeal joint is the joint most frequently involved in gout and bunions. From the joint, probe proximally along the medial shaft of the first metatarsal bone. First Metatarsocuneiform=The metatarsal flares slightly at its base, and meets the first cuneiform bone to form the first metatarsocuneiform joint. The first cuneiform bone projects distally nearly half an inch further than the other cuneiform bones. It articulates with the base of the first metatarsal in a simple plane joint, providing gliding movement. Navicular Tubercle=As you continue moving proximally along the medial border of the foot, the next large bone prominence you encounter is the navicular tubercle. The navicular articulates with five other bones. Proximally with the talar head, distally with the three cuneiforms, and laterally with the cuboid bone. Aseptic necrosis of the navicular, characterized by local tenderness and a limping gait, is sometimes found in children. Further, if the tubercle is too prominent, it may press against the medial counter of the shoe and become painful. Head of the Talus=The medial side of the talar head is immediately proximal to the navicular. You can find it by inverting and everting the forefoot; the resultant motion between the talus and navicular is palpable. Eversion causes the head to become more prominent as it juts out from under the navicular. If the talar head is difficult to find, draw a line between the medial malleolus and the navicular tubercle, bisect the line, and probe that area. The head of the talus lies directly under your fingers; when the foot is in the neutral position, it feels like a slight depression. In pes planus, the head becomes prominent on the medial side. Medial Malleolus=From the head of the talus, probe proximally until you come to the prominent medial malleolus (the distal end of the tibia). The malleolus embraces the medial aspect of the talus, adding bone stability to the ankle joint. It articulates with one-third of the medial side of the talus. Sustentaculum Tali=Move plantarward approximately a finger’s breadth from the distal end of the malleolus until you find the sustentaculum tali. The sustentaculum tali is small, and may not be palpable at all, but it has anatomic significance. Clinically, it supports the talus and serves as an attachment for the spring ligament; problems within this anatomic alignment may well lead to pes planus. Medial Tubercle of the Talus=The medial tubercle of the talus, which is small and barely palpable, lies immediately posterior to the distal end of the medial malleolus. It is the point of insertion for the posterior aspect of the ankle’s medial collateral ligament. Fifth Metatarsal Bone; Fifth Metatarsophalangeal Joint=These are situated at the lateral side of the ball of the foot. Note that the first and fifth metatarsal heads are normally the most prominent. Probe proximally along the lateral shaft of the fifth metatarsal to its flared base, the styloid process. Notice that the Peroneus brevis inserts into the process. Directly behind the flare of the process and in front of the cuboid lies a depression, which is further accentuated by the groove in the cuboid itself. The Peroneus longus muscle tendon creates this groove as it runs to the medial plantar surface of the foot. Calcaneus=Move proximally along the foot’s lateral border to the calcaneus, which is subcutaneous and easily palpable. Peroneal Tubercle=The peroneal tubercle lies on the calcaneus, distal to the lateral malleolus. Normally, it is about a quarter of an inch in length; however, its size may vary somewhat in different patients. The tubercle is a significant landmark because it separates the Peroneus brevis and longus tendons at the point where they pass around the lateral calcaneus. Lateral Malleolus=The lateral malleolus, located at the distal end of the fibula extends further distally and is more posterior than the medial malleolus. Its configuration permits the ankle mortise to point 15° laterally, and its additional distal extension acts as a deterrent to eversion ankle sprains. The medial malleolus, have less distal extension, does not enjoy this mechanical advantage, and is less effective in preventing the inversion type of sprain that is so commonly seen. These differences in length and position of the malleoli can be more readily appreciated if you place your fingers on the anterior portion of both malleoli. The incidence of Malleolar fracture due to trauma is relatively high. If you place your thumb on the most anterior portion of the lateral malleolus and plantar flex your patient’s foot, the Anterolateral portion of the talar dome becomes palpable as it rotates out from under the ankle mortise. Dome of the Talus=Keep the patient’s foot in inversion and plantar flex it. A small portion of the dome of the talus becomes palpable; a greater portion of its surface is palpable on its lateral side than on the medial side adjacent to the medial malleolus. Occasionally, a defect is palpable in the articulating surface of the dome. Inferior Tibiofibular Joint=This joint lies immediately proximal to the talus. Since the anterior inferior tibiofibular ligament overlies this joint, clear palpation of the joint itself is impossible; however, you can feel a slight depression directly over it. The bones of the joint may separate (diastasis) following injury to the ankle. Dome of the Calcaneus-At the posterior aspect of the heel is prominent crest running horizontally between the upper and lower posterior Calcaneal surfaces. The Achilles tendon gains attachment to the upper surface. Medial Tubercle of Calcaneus-The lower surface of the calcaneus is covered by a fat pad, slopes forward to the medial and lateral tubercles on the inferior aspect of the calcaneus. Palpation of the inferior aspect of the calcaneus is made difficult by the thick skin and fat pad that cover it. The weight-bearing medial tubercle can be vaguely distinguished posteriorly in most persons. Traction osteophytes (heel spurs) occasionally develop just anterior to the Calcaneal tubercles where the long plantar ligament attaches. The medial tubercle lies on the medial plantar surface of the calcaneus. It is rather broad and large, and gives attachment to the abductor hallucis muscle medially and to the flexor digitorum brevis muscle and the plantar aponeurosis anteriorly. The medial tubercle is not really sharp and distinct unless it is associated with a heel spur, when it becomes tender to palpation. The medial tubercle is weight bearing, whereas the lateral tubercle of the calcaneus is not. Most of the muscles of the plantar surface of the foot originate from this bone. Their origins are not palpable because of the thick pad of fat covering the bone. This area should be palpated because of the possibility of a heel spur protruding from the medial tubercle and its attendant bursa, both of which cause tenderness and affect the heel strike phase of gait. Metatarsal Heads-Palpate each metatarsal head by placing your thumb upon the plantar surface and your index finger upon the dorsal surface. The transverse arch of the forefoot is located immediately behind the metatarsal heads.; it is this arch that makes the first and fifth metatarsal heads most prominent. As you palpate the heads, try to determine if any one is disproportionately prominent. If one is, it must bear an unaccustomed amount of weight and is subject to a variety of problems. This pathology occurs most often to the second metatarsal head; Callosities that have formed because of the increased pressure may obscure the head completely. Occasionally, the fifth metatarsal head exhibits excessive callosity. Pain in the second, third, or fourth metatarsal heads may be secondary to aseptic necrosis (lack of blood supply), which, in turn, creates an antalgic gait. Soft Tissue Palpation (Illus # 32-Tarsal Tunnel Soft Tissue, Achilles Tendon & Calcaneal Bursa)- Head of the First Metatarsal Bone=The area surrounding the prominent head of the first metatarsal bone and the first metatarsophalangeal joint is the site of that common pathologic condition, Hallux valgus. Hallux valgus is a deformity characterized by lateral deviation of the great toe. In many cases, the deviation is so excessive that it causes the big toe to overlap the second toe. The first metatarsal shaft may be medially angulated (metatarsus primus varus) as well. Under such circumstances, an excrescence of bone may grow over the medial aspect of the first metatarsal head and cause the surrounding soft tissue to swell. The resultant increased pressure and friction against the shoe can cause the development of a bursa, which frequently becomes tender and inflamed. Characteristically, the surrounding area appears reddened (bunion formation). The medial aspect of the first metatarsal head is also a common site for gout. Tophi (deposits of urate crystals in the tissues about the joints) often develop at the first metatarsophalangeal joint and cause pain as well as deformity. Take care not to confuse such tophi deposits with the bunion formation associated with Hallux valgus. Navicular Tubercle and the Talar Head=The plantar portion of the talar head articulates with the sustentaculum tali and the anterior portion with the posterior aspect of the navicular. The talar head lacks bony support between these two articulations. The tibialis posterior tendon and the spring ligament, which runs from the sustentaculum tali to the navicular, support this gap. In pes planus (flat feet), the talar head displaces medially and plantarward from under cover of the navicular and stretches the spring ligament and the tibialis posterior, resulting in the loss of the medial longitudinal arch. A callosity may develop over the now prominent talar head at the point where the skin presses against the shoe’s medial counter. Because of the callosity, the stretched soft tissue structures, and the valgus angle of the os Calcis (when viewed from the posterior aspect of the foot), the area may be exceedingly tender to palpation. Medial Malleolus Structures=The order of the structures in this area can be remembered by the mnemonic “Tom, Dick, an’ Harry”: Tibialis Posterior, flexor Digitorum longus, Artery (tibial artery), Nerve (tibial nerve), flexor Hallucis longus. Tibialis Posterior Tendon=This tendon is most prominent when the patient inverts and plantar flexes his foot. It is both palpable and visible where it passes immediately behind and inferior to the medial malleolus. If spasticity, meningomyelocele, or poliomyelitis have weakened the other muscles around the ankle, the relatively strong tibialis posterior may, as a consequence, cause plantar flexion and an inversion deformity of the foot. Flexor Digitorum Longus Tendon=This muscle lies just behind the tibialis posterior tendon. To palpate it, have the patient flex his toes while you resist his motion. Although the muscle’s tendon does not become very prominent, you should be able to feel its motion immediately behind the tibialis posterior, just above the medial malleolus. Flexor Hallucis Longus Tendon=This tendon actually lies on the posterior aspect of the ankle joint, rather than around the medial malleolus. It runs along the posterior aspect of the fibia and grooves the posterior aspect of the talus between its medial and lateral tubercles as it crosses the ankle joint. Because it is deep to other muscles, the tendon of the flexor hallucis longus muscle cannot be palpated. All of these tendons pass so closely around the posterior aspect of the medial malleolus (particularly the tibialis posterior) that they groove the bone and must be protected by a synovial lining. When this lining becomes inflamed (Synovitis), the patient complains of pain behind the medial malleolus and the area is tender to palpation. Posterior Tibial Artery=The posterior tibial artery lies between the tendons of the flexor digitorum longus and the flexor hallucis longus muscles. Its pulse is not always easy to find. IT is easier to palpate when the foot is relaxed in a non-weight-bearing position and the tendons in the area are slack. The pulse can be felt by pressing gently into the soft tissue space behind the Tibialis posterior and the flexor digitorum longus tendons. After you have felt it, compare it to the opposite side. A diminution of this pulse may indicate arterial occlusion. The posterior tibial artery has clinical significance because it provides the main blood supply to the foot. Tibial Nerve=The tibial nerve is located immediately posterior and lateral to the posterior tibial artery, and follows the artery’s course into the foot. The nerve is difficult to palpate as an isolated structure, but, since it is the main nerve supply to the sole of the foot, its anatomic position should be noted. The neurovascular bundle is bound to the tibia by a ligament, creating a tarsal tunnel, which, if it is too small or too tight, can cause Neurovascular problems in the foot. Although its incidence is less frequent, this syndrome is similar to that of the carpal tunnel syndrome in the hand. Long Saphenous Vein=Locate the medial Malleolus and palpate the long Saphenous vein, which is often visible immediately anterior to the medial Malleolus. When veins in the upper extremity cannot be located, this vein is usually an accessible site for intravenous infusion. Varicosity in the lower extremity frequently involves the long Saphenous vein. Peroneus Longus and Brevis Tendons=These tendons pass immediately behind the lateral malleolus as they cross the ankle joint. The brevis is closer to the malleolus, grooving the bone as it passes, while the longus lies just posterior to the brevis. The Peronei are the primary foot everters, and they assist in plantar flexion. To palpate them, have the patient actively evert and plantar flex his foot. Occasionally, the retinaculum (facial band), which holds the tendons to the lateral malleolus, may be incomplete, and the tendons may dislocate from behind the lateral malleolus. This situation produces the snapping tendon syndrome; the snap of the dislocating tendons may be both audible and palpable. As they pass the calcaneus, the Peronei tendons are separated by the peroneal tubercle. They are held to the tubercle by a retinaculum and are surrounded by synovium. They are, therefore, subject to Tenosynovitis. In addition, the tunnel through which they run may narrow, causing stenosing Tenosynovitis. In that event, the area of the peroneal tubercle fells thick and is tender to palpation. Palpate the Peroneus brevis to its insertion into the styloid process. Tenderness in this area may be due to an avulsion or a fracture of the tip of the styloid process in association with an ankle sprain, or to an inflamed bursa over the process itself. Head of Fifth Metatarsal=Overlying the lateral side of the head of the fifth metatarsal bone, there is a bursa, which is subject to inflammation. Excessive friction or pressure upon this bursa can cause both bursitis and the development of an associated excrescence of bone over its lateral aspect with subsequent redness, swelling, and tenderness. This condition is know as “tailor’s bunion.” (Traditionally, tailors crossed their legs and held their feet in such a way that the lateral aspect of the fifth metatarsal head rested against the floor). Achilles Tendon=The gastrocnemius and the soleus muscles form a common tendon, the tendon of Achilles, which inserts into the calcaneus. The Achilles tendon id the thickest and strongest tendon in the body. It is palpable from about the lower on-third of the calf to the calcaneus. It can be ruptured from a sharp blow or from an abrupt strain caused by a moment of sudden excess activity. A sharp blow may produce a transverse laceration, whereas a sudden strain may cause a shredding of the tendon. Should the tendon be ruptured, the resulting defect is palpable, although swelling in the period between injury and presentation may have obscured it. Initially, the area is quite painful and tender, and powerful plantar flexion of the foot is usually impossible. If the patient can still walk, he will exhibit accompanying gait abnormalities, such as absence of “toe-off” (push –off) from the stance phase and a flat-footed gait. To test the continuity of the gastrocnemius and soleus muscles, have the patient lie prone on the examination table, and squeeze the calf of his leg to determine if there is any resultant plantar flexion of the foot. Normally, there is such motion. However, if the Achilles tendon is ruptured, the motion is markedly decreased or absent. The tendon may also develop Tenosynovitis, and palpation may elicit tenderness and Crepitation upon motion. Retrocalcaneal Bursa=Locate this bursa by pinching the soft tissue, anterior to the tendon of Achilles. Calcaneal Bursa=Locate this bursa by lifting the skin posterior to the tendon-the bursa lies directly between your fingers. Plantar Aponeurosis=Palpate the plantar surface of the foot. It should feel smooth, nontender, and nonnodular. Point tenderness may indicate plantar Fasciitis, while discrete palpable nodules in the fascia indicate Duputyren’s contracture. Most often, nodules found on the skin of the sole (particularly on the ball of the foot) are plantar warts, which are more tender when pinched than when under direct pressure. Palpate the soft tissues between each of the metatarsal heads for tenderness and swelling. It is not uncommon to find painful neuromas in the space between the third and fourth metatarsal heads (Morton’s neuroma). Palpate the base of the 5th metatarsal bone as the lateral cord of the plantar aponeurosis attaches here. Callosities on the plantar surface, unlike warts, are tender to pressure but not to pinching. Biomechanics-Introduction-Problems in the biomechanics of the foot ankle complex are likely to cause abnormal stresses to the joints of the foot and ankle, as well as to the other weight-bearing joints such as the knee, hip, or lower spine. The foot/ankle as a movable pivot helps in the maintenance of balance and economy of energy consumption, which are adversely affected by inadequate mobility, and improper structural alignment of the foot/ ankle complex. Planes (Illus # 33-Planes of Reference)-The three basic planes of reference are derived from the dimensions in space and are at right angles to each other. Sagittal Plane=The Sagittal plane is vertical and extends from front to back, deriving its name from the direction of the Sagittal suture of the skull. It may also be called an anterior-posterior plane. The median Sagittal plane, midsagittal, divides the body into right and left halves. Coronal (Frontal) Plane=The coronal plane is vertical and extends from side to side, deriving its name from the direction of the coronal suture of the skull. It is also called the frontal or lateral plane, and divides the body into an anterior and a posterior portion. Transverse (Horizontal) Plane=A transverse plane is horizontal and divides the body into upper (cranial) and lower (caudal) portions. Axes-An axis is a straight line about which the joint rotates. The three basic axes described below are at right angles to each other. Sagittal axis=Placed on the Sagittal plane it runs horizontally from anterior to posterior. The movements of abduction and adduction occur around this axis in a coronal plane. Coronal (Frontal) Axis=A horizontal line in the coronal plane situated from side to side. Flexion and extension occur about this axis in the Sagittal plane. Longitudinal Axis=This is a vertical line extending in a superior –inferior direction. Medial and lateral rotation, and horizontal abduction and adduction occur in the transverse plane. Exceptions=These exceptions are explained in the sections for the thumb and scapula. Center of Gravity-The point at which the three midplanes of the body intersect is the center of gravity, which in an ideally aligned posture in a so-called average adult human being, slightly anterior to the first or second sacral segment. Line of Gravity-The line of gravity is a vertical line through the center of gravity. Lever Systems and Leverage (Illus # 34-Classes of Levers)-In producing a body movement, bones act as levers and joints function as fulcrums of these levers. A lever may be defined as a rigid rod that moves about on some fixed point called a fulcrum. A fulcrum may be symbolized as F. A lever is acted on at two different points by two different forces: the resistance R and the Effort E. The resistance may be regarded as a force (load) to be overcome, whereas the effort is the force exerted to overcome the resistance. The resistance may be the weight of a part of the body that is to be moved. The muscular effort (contraction) is applied to the bone at the insertion of the muscle and produces motion if the effort exceeds the resistance (load). Levers are categorized into three types according to t he positions of the fulcrum, the effort, and the resistance. First-class Levers=In first-class levers, the fulcrum is between the effort and resistance. This is symbolized EFR. An example of a first-class lever is a seesaw. There are not many first-class levers in the body. One example is the head resting on the vertebral column. When the head is raised, the facial portion of the skull is the resistance. The joint between the atlas and occipital bone (Atlanto-occipital joint) is the fulcrum. The contraction of the muscles of the back is the effort. Second-class levers=Second-class levers have the fulcrum at one end, the effort at the opposite end, and the resistance between them. This is symbolized FRE. They operate like a wheelbarrow. Most authorities agree that there are very few examples of second-class levers in the body. One example is raising the body on the toes. The body is the resistance, the ball of the foot is the fulcrum, and the contraction of the calf muscles to pull the heel upward is the effort. Third-class Levers=Consist of the fulcrum at one end, the resistance at the opposite end, and the effort between them. This is symbolized FER. They are the most common levers in the body. One example is adduction of the thigh, in which the weight of the thigh is the resistance, the hip joint is the fulcrum, and contraction of the adductor muscles is the effort. Another example is flexing the forearm at the elbow. As we have seen, the weight of the forearm is the resistance, the contraction of the biceps brachii is the effort, and the elbow joint is the fulcrum. Leverage=Muscles attached further from the joint produce greater strength but muscles attached closer to the joint produce greater range of motion. Since strength increases with distance from the joint and range of movement decreases, maximal strength and maximal range are incompatible; strength and range vary inversely. Gait Analysis (Illus # 35-Phases of Gait)-Pathology that affects the lower extremity often manifests itself most clearly in gait, and analysis of gait’s normal and abnormal parameters will help identify and treat characteristic pathologies when they occur. There are two phases to the normal walking cycle; stance phase, when the foot is on the ground; and swing phase, when it is moving forward. Sixty percent of the normal cycle is spent in stance phase (25 percent in double stance, with both feet on the ground) and 40 percent in swing phase. Each phase, in turn, is divided into its smaller components. Stance Phase=Heel Strike, Foot Flat, Midstance, and Push-Off (Toe-Off). Swing Phase=Acceleration, Midswing and Deceleration. Most problems become apparent in stance phase since, because it bears weight and constitutes the major portion of gait, it undergoes the greater stress. The following normal parameters can facilitate identification of abnormal gait patterns and suggested pathology. Width of the base (2”-4”)=Should not be more than two to four inches from heel to heel. If you note that the patient is walking with a wider base, you should suspect pathology. Patients usually widen their base if they feel dizzy or unsteady as a result, perhaps, of cerebellar problems or decreased sensation the sole of the foot. Patients with decreased sensation of the soles of their feet (caused by diabetes, syphilis, or any peripheral neuropathy) broaden their gait to gain stability. In addition, they may look at their feet to orient themselves in relation to space and the ground. Patients with cerebellar problems may have difficulty in maintaining their balance, and, as a result, may widen their base. Body’s center of gravity (2” S2) (Oscillates vertically 2”)=Lies two inches in front of the second sacral vertebra. In normal gait it oscillates no more than two inches in a vertical direction. Controlled vertical oscillation maintains the smooth pattern of gait as the body advances. Increased vertical motion may indicate pathology. Knee remains flexed during all components of stance phase (except heel strike)=This prevents excessive vertical displacement of the center of gravity. For example, in toe-off, when the ankle, with 20° of plantar flexion, tends to cause the center of gravity to rise, the knee flexes to approximately 40° to counterbalance it. Patients with their knees fused in extension may be unable to counteract excesses of ankle motion, losing the normal smooth pattern of gait. Pelvis and trunk shift laterally (1” Laterally))=Approximately one inch to the weight-bearing side during gait to center the weight over the hip. If the patient has gluteus medius weakness, this lateral shift of trunk and pelvis is markedly accentuated. Average length of a step is approximately 15 inches=With pain, advancing age, fatigue, or pathology within the lower extremity, the length of the steps may decrease. Average adult walks at a cadence of approximately 90 to 120 steps per minute=The average energy cost at this rate is only 100 calories per mile. Changes in this smooth, coordinated pattern markedly reduce efficiency and greatly increase the energy cost. With advancing age, fatigue, or pain, the number of steps per minute decreases. If the surface on which the patient is walking is slick, and if his footing is unsure, the number of steps per minute also decreases. During swing phase, the pelvis rotates 40° forward=While the hip joint of the opposite extremity (which is in stance phase) acts as the fulcrum for rotation. Patients do not rotate normally around a hip joint that is stiff or painful. The following problems pertinent to this study are identified according to the phase of gait in which they occur. Stance phase=Heel Strike-Foot=Foot pains may be a result of a heel spur, a spike of bone that protrudes from the medial tubercle on the plantar surface of the os calcis (calcaneus). It usually causes a very sharp pain as the patient brings his heel down hard on the floor. In time, a protective bursa may develop over the spur; bursitis may follow, causing increased pain. To relieve the pain, the patient may try to hop onto the involved foot in an attempt to avoid heel strike completely. Midstance=Foot-Normally, weight is borne evenly on all aspects of the foot. Patients with rigid pes planus and subtalar arthritis may develop pain when walking on uneven ground; those with fallen transverse arches of the forefoot may develop painful calluses over the metatarsal heads. Corns formed on the dorsum of the toes may also become painful in midstance, since they may rub against the shoe as the toes begin to grip the ground. Push-Off=Foot-If the patient has Osteoarthritis or a partially or fully fused metatarsophalangeal joint (Hallux Rigidus), he may be unwilling or unable to hyperextend the metatarsophalangeal joint of his great toe, and may be forced to push off from the lateral side of his forefoot, a manoeuvre which eventually causes pain. Pain may be increased as a result of the increased pressure on the metatarsal heads if callosities have developed secondary to a dropped head (Metatarsalgia). Soft corns between the fourth and fifth toes may also become excessively painful as a result of the added pressure. You can often diagnose this condition by examining the shoe, instead of the normal transverse crease over the toes, an oblique crease, cutting across the toes and forefoot, may develop. Patients with muscle weakness of the gastroc-soleus group (S!,S2) may have a flat foot gait with no forceful toe-off. Movements of Specific Joints-Ankle Joint-The ankle joint is a ginglymus or hinge joint formed by the articulation of the tibia and fibula with the talus. The axis about which motion takes place extends obliquely from the posterolateral aspect of the fibular malleolus to the Anteromedial aspect of the tibial malleolus. Flexion (Plantar Flexion) and Extension (Dorsiflexion)=These movements occur about the oblique axis. Flexion (plantarflexion) is movement of the foot in which the plantar surface moves in a caudal and posterior direction. Extension (dorsiflexion) is movement of the foot in which the dorsal surface moves in an anterior and cranial direction. The knee should be flexed when measuring dorsiflexion. With the knee flexed, the ankle joint can be dorsiflexed about 20°. If the knee is extended, the gastrocnemius will limit the range of motion to about 10° of dorsiflexion. The range of motion in plantar flexion is approximately 45°. Subtalar Joint and Transverse Tarsal Joints-The subtalar joint is a modified plane or gliding joint formed by the articulation of the talus and the calcaneus. The talus also articulates with the navicular, and the talonavicular joint is involved in the movements ascribed to the subtalar joint. Supination and Pronation=Movements permitted by the subtalar and talocalcaneonavicular joints. Supination is rotation of the foot in which the sole of the foot moves in a medial direction; pronation is rotation in which the sole of the foot moves in a lateral direction. Transverse Tarsal Joints-The transverse tarsal joints are formed by the articulations of the talus with the navicular, and the calcaneus with the cuboid. Adduction and Abduction=Movements of the forefoot permitted by the transverse tarsal joints, adduction is movement of the forefoot in a medial direction and abduction is movement in a lateral direction. Inversion=A combination of supination and forefoot adduction. It is more free in plantar flexion than in dorsiflexion. Eversion=A combination of pronation and forefoot abduction. It is more free in dorsiflexion than in plantar flexion. Metatarsophalangeal Joints-The metatarsophalangeal joints are condyloid, formed by the articulation of the distal ends of the metatarsals with the adjacent ends of the proximal phalanges. Flexion and extension=Movements about a coronal axis. Flexion is movement in a caudal direction, extension is movement in a cranial direction. The range of motion in adults is variable, but 30° flexion and 40° extension may be considered an average range for good function of the toes. Adduction and Abduction=Movements about a Sagittal axis. The line of reference for adduction and abduction of the toes is the axial line projected distally in line with the second metatarsal and extending through the second digit. Adduction is movement toward the axial line, and abduction is movement away from it, as in spreading the toes apart. Because abduction of the toes is restricted by the wearing of shoes, this movement is markedly limited in most adults and little attention is paid to the ability to abduct. Interphalangeal Joints of toes-The Interphalangeal joints are ginglymus or hinge joints formed by the articulations of adjacent surfaces of phalanges. Flexion and extension=Movements about a coronal axis with flexion being movement in a caudal direction and extension movement in a cranial direction. Structural Alignment-In the normal standing position, the patella faces straight forward, the knee joint axis lies in the frontal plane and the tibial tubercle is in line with the midline or lateral half of the patella and a line passing through the tips of the of the malleoli should be 20° to 25° with the frontal plane. The lateral Malleolus is positioned inferiorly with respect to the medial Malleolus such that the intermalleolar line makes an angle of about 10° with the transverse plane. With the patellae facing straight forward, the feet should be pointed outward about 5° to 10°. A Valgus positioning of the calcaneus on the talus is associated with pronation at the Subtalar joint, whereas a varus hind-foot involves supination. When considering the structure of the foot as a whole, it is helpful to compare it to a twisted plate; the calcaneus, at one end, is positioned vertically when contacting the ground, whereas the metatarsal heads are positioned horizontally when making contact with a flat surface. The medial arch is dependent almost entirely on the twisted configuration of the foot, which is maintained statically by the short and long plantar ligaments and dynamically by the anterior and posterior tibialis muscles. Referring back to the cardboard model, notice that when the cardboard is allowed to untwist by inclining the vertical end in one direction and keeping the other end flat on the table the arch flattens. In the foot, inclination of the vertical component of the structure, the calcaneus, will result in similar untwisting or twisting; this results in a respective decrease or increase in the arching of the foot, if the metatarsal heads remain in contact with the ground. The person who stands with the heel in a valgus position will have a relatively "flat" or untwisted foot, whereas a person whose heel is in a varus position when standing will appear to have a "high" arch because of increased twisting between hindfoot and forefoot. Arthrokinematics of the Ankle-Foot Complex-Ankle Mortise Joint=The anterior talus is 6mm wider than the posterior talus yet dorsiflexion does not separate the tibia and fibula more than 2 mm if at all. Both the anterior and posterior aspects of the talus are in a close, fit with tibial and fibular malleoli. How does such a wide anterior bone fit into a smaller posterior articular space? It is because the axis of talar motion is more medial than lateral, the lateral talar articulation is longer than the medial articulation, which means it moves a greater distance than the medial talus. The lateral talus rotates in a helical movement and there is movement of combined rolling and sliding which also changes the axis of movement positionally. Thus the final close packed position of full dorsiflexion results in only minimal tibular/fibular displacement. Subtalar Joint=From the outset, movement at this joint is somewhat difficult to conceptualize because the posterior articulation between the talus and calcaneus is concave superiorly on convex inferiorly, while the Anteromedial articulation is convex on concave. The posterior Calcaneal facet moving against the opposing concave talar surface can be compared with the radial head moving within the radial notch of the ulna. In at least some persons, this type of movement at the Subtalar joint is accompanied by a slight forward displacement of the talus during pronation and a backward displacement on supination, thus making the total movement a helical, or screw like motion. Neutral Position of a Joint-The neutral position of the first ray is that position in which the first metatarsal head lies in the same transverse plane as the central three metatarsal heads when they are at their most dorsiflexed position. Root and co-workers describe a neutral position of the Subtalar joint that is that position of the joint in which the foot is neither pronated nor supinated. From this position, full supination of the normal Subtalar inverts the calcaneus twice as many degrees as full pronation everts it. When the Subtalar joint is held in its neutral position there is no longer the ability for the midtarsal joint to pronate. According to James, the talar head in a pronated foot can be palpated as a medial bulge; in a supinated foot the talar head bulges laterally. The neutral position is usually present when the longitudinal axis of the lower limb and the vertical axis o f the calcaneus are parallel. A second method that is useful in the open-chain position involves visualizing and feeling the Subtalar joint as it moves through its range of motion. To begin, the examiner should place the ulnar surface of the thumb into the Sulcus of the patient's foot from pronation to supination and back again. This can be confirmed visually by observing the lateral curves above and below the Malleolus. Transverse Tarsal Joints: Talonavicular and Calcaneocuboid Joints- Although the talonavicular joint is a ball and socket joint with potential multidirectional movement because the navicular is closely bound to the cuboid bone laterally, the movement allowed at the calcaneocuboid joint largely governs its freedom of movement. The axis of motion of most concern is the axis of pronation and supination. Such an orientation allows a movement of inversion-adduction-plantar flexion (supination) and eversion-abduction-dorsiflexion (pronation) of the forefoot. In the standing position, movement and positioning of the transverse tarsal joint occurs in conjunction with subtalar joint movement; when the subtalar joint pronates, the transverse tarsal joint supinates and vice versa. Osteokinematics of the Ankle-Foot Complex-Terminology=1.) Inversion-Eversion=Movement about a horizontal axis lying in the Sagittal plane. Functionally pure inversion and eversion rarely occur at any of the joints of ankle or foot. More often they occur as a component of supination or pronation. 2.) Abduction-Adduction=Movement of the forefoot about a vertical axis or the movement of the forefoot that results from internal or external rotation of the hindfoot with respect to the leg. 3.) Internal-External Rotation=Movement between the leg and hindfoot occurring about a vertical axis. Pure rotations do not occur functionally but rather occur as components of pronation and supination. 4.) Plantar flexion-Dorsiflexion=Movement about a horizontal axis lying in the plane corresponding to the intermalleolar line. Functionally, these usually occur in conjunction with other movements. 5.) Pronation-Supination=Functional movements occurring around the obliquely situated subtalar or transverse tarsal joint axis. At both of these joints, pronation involves abduction, eversion and some dorsiflexion; supination involves adduction, inversion, and plantar flexion of the distal segment on the proximal segment. This is because these joint axes are inclined backward, downward, and laterally. It must be appreciated that when the metatarsals are fixed to the ground, pronation of the hindfoot (subtalar joint) involves supination of the forefoot (transverse tarsal joint). 6.) Pronated Foot-Supinated Foot=Traditionally, a pronated foot (in the standing position) is one in which the arched configuration of the foot is reduced; the hindfoot is pronated while the forefoot is supinated. In a supinated foot (standing) the arch is high, the hindfoot is supinated, and the forefoot is pronated. 7.) Valgus-Varus=Terms used for alignment of parts. Valgus denotes inclination away from the midline of a segment with respect to its proximal neighbor, whereas varus is inclination toward the midline. At the hindfoot and forefoot, valgus refers to alignment in a pronated position and varus to alignment in a supinated position. Orientation of Joint Axes and the Effect on Movement-In the normal standing position, the axis of movement for the knee joint is horizontal and in a frontal plane. The ankle mortise joint axis is directed backward mediolaterally about 25° from the frontal plane and downward from medial to lateral about 10° to 15° from horizontal. Movement of the free foot about this axis results in combined plantar flexion, adduction, and inversion or combined dorsiflexion, abduction, and eversion. Note that the above statements relate the movements at the respective joints to the orientations of the joint axes when the foot and leg are swing feely. The obvious question in this regard would be; How is it possible to move both the tibia and femur in the Sagittal plane such as when performing a knee bend with the knee pointed forward, when movement is occurring at the ankle and knee about two nonparallel axes? Since the knee joint axis lies horizontally in the frontal plane, no problem would be expected there, since it is ideally oriented to allow rotation of the bones in the Sagittal plane. It would seem, then, that by performing such a knee bend an internal rotatory movement must be applied to the ankle, since the ankle joint axis I externally rotated with respect to the frontal plane. This apparent problem can be resolved by considering the orientation of the joint axis and associated movements at the subtalar joint. The average deviation from the midline of the foot is 23°, whereas the average deviation from the horizontal is 42°. Because the axis of motion for the subtalar joint deviates from the Sagittal plane and from the horizontal plane, movement at this joint involves combined eversion, dorsiflexion, and abduction or combined inversion, plantar flexion, and adduction. Subtalar movement is essentially uniaxial, so that any movement occurring at the joint may occur only in conjunction with its component movements, that is, abduction can only occur in conjunction with eversion and dorsiflexion the three together constituting pronation at the subtalar. Supination causes the calcaneus to assume a varus position, which, since the metatarsals remain flat on the ground, increases the twist in the foot and raises the arch. Ankle and Foot During Gait-Clinicians must be concerned with the function of the joints of the ankle and foot during normal daily activities. The prime consideration here, of course, is walking. Again, because these are weight-bearing joints and because the foot becomes fixed to the ground during the stance phase, an understanding of the biomechanical interrelationships between these joints and the other joints of the lower extremity is necessary. During the gait cycle, the leg progresses through space in a Sagittal plane. Minimization of vertical displacement of the center of gravity is largely accomplished by angular movement of the lower extremity components in the Sagittal plane, that is, flexion-extension at the hip, knee, and ankle complex. The hip has no trouble accommodating such movement since it is multiaxial, allowing some movement in all vertical planes. The knee, although essentially uniaxial, allows flexion and extension in the Sagittal plane because its axis of movement is perpendicular to this plane and horizontally oriented. Movement of the tibia in a parasagittal plane over a fixed foot requires simultaneous movement at the subtalar and ankle mortise joints. Those muscles that affect movement at the ankle mortise joint also cross the subtalar joint, moving it as well. During the first interval, each of the segments of the lower extremity rotates internally with respect to its more proximal neighboring segment; the pelvis rotates internally in space, the femur rotates internally on the pelvis, and the tibia rotates internally on the femur. Much of this internal rotation is absorbed at the subtalar joint as pronation. Internal rotation of the leg with respect to the foot, occurring at the subtalar joint, makes the axis o the ankle mortise joint more perpendicular to the plane of progression. This is because the obliquity of the ankle axis, in the coronal plane, imposes a component of adduction of the foot during plantar flexion. At heel-strike, a moment-arm equal to the distance between the point of heel contact and the ankle joint develops. This results in some flexion at the knee, which is consistent with the fact that the tibia is rotating internally with respect to the femur. Through the early period of foot-flat, during which most of dorsiflexion occurs, the segments of the lower extremity continue to rotate internally. This occurs as supination at the subtalar joint. Consistent with this, the Peroneus longus muscle contracts, maintaining a pronated twist of the metatarsals and bring the foot as a whole toward its twisted configuration. Internal rotation of the talus with respect to the calcaneus occurs as pronation, while external rotation results in supination at the subtalar joint. Also, once the foot becomes flat on the ground, the metatarsal heads become fixed and the twisting and untwisting of the foot becomes dependent on the position of the hind foot. A relatively common condition that illustrates the biomechanical interdependency of the weight-bearing joints is femoral anteversion. Pathology-Achilles Tendonitis-This condition is a chronic, painful inflammation of the achilles tendon and its sheath, the fibrous terminal attachment of the gastrocnemius and Soleus muscles into the calcaneus and associated structures. It is also known as Achilles or calcaneal paratenonitis. It is prevalent among runners, middle aged individuals, and proportionally distributed among men and women. The causes include; Overuse, Rough terrain, improper shoe wear, Cold weather, Biomechanical foot problems, Sudden increase in training, and absent warm-up. Typical signs include; A gradual increase in painful swelling and warmth occurs at any point along the tendon substance most commonly 3 to 5 cm proximal to the insertion onto the calcaneus. Arthritis=The term arthritis refers to many different diseases, the most common of which are rheumatoid arthritis (RA), Osteoarthritis, and gouty arthritis. All are characterized by inflammation of one or more joints. Inflammation, pain, and stiffness may also be present in adjacent parts of the body, such as the muscles near the joint. Bursitis=An acute chronic inflammation of a bursa is called bursitis. The condition may be caused by trauma, by an acute or chronic infection (including syphilis and tuberculosis), or by rheumatoid arthritis. Repeated excessive friction often results in a bursitis with local inflammation and the accumulation fo fluid. Bunions are frequently associated with a friction bursitis over the head of the first metatarsal bone. Symptoms include pain, swelling, tenderness, and the limitation of motion involving the inflamed bursa. The prepatellar or subcutaneous Infrapatellar bursae may become inflamed in individuals who spend a great deal of time kneeling. This bursitis is usually called “housemaid’s knee” (“carpet layer’s knee”) Calcaneal Spur Syndrome (Traction osteophytes (heel spurs))=Calcaneal heel spurs (Traction Osteophytes) are the growth of new bone, which develops in the area of the inferior calcaneus probably caused by the pull of the plantar fascia on the periosteum. Although X-Ray evidence of calcaneal osteophytes confirms the diagnosis a negative x-ray cannot rule out early heel spur onset as infrequently, calcaneal spurs may appear ill defined exhibiting fluffy new bone formation. Flatfeet and contracted heel cords may contribute to the development of heel spurs because of increased plantar fascial tension. When firm thumb pressure is applied to the center of the heel further pain is elicited. Inferior calcaneal pain without X-Ray evidence may be a sign of the early heel spur formation but as the spur enlarges pain often diminishes possibly because of adaptive changes in the foot and an asymptomatic period ensues. After the heel spur enlarges sudden painful onset may occur often following local trauma (sports injury). An adventitious bursa may develop and become inflamed causing the bottom of the heel to become swollen, warm, painful, and throbbing. Calf-stretching, night splinting, strapping, Oral NSAIDs, anaesthetic and or a mixture of soluble and insoluble corticosteroids injection may be effective in reducing or eliminating symptoms. Dislocation=A dislocation, or luxation (luks-Ā-shun), is the displacement of a bone from a joint with tearing of ligaments, tendons, and articular capsules. A partial or incomplete dislocation is called a Subluxation. The most common dislocations are those involving a finger or shoulder. Those of the mandible, elbow, knee, or hip are less common. Symptoms include loss of motion, temporary paralysis of the involved joint, pain k, swelling, and occasionally shock. A dislocation is usually caused by a blow or fall., although unusual physical effort may lead to this condition. Flexor Hallucis Longus (FHL) Tendonitis/Tenosynovitis=This condition is a chronic, painful inflammation of the Flexor Hallucis Longus tendon and its sheath, the fibrous terminal attachment of the Flexor Hallucis Longus muscle to the planar surface of the base of the distal phalanx of the big toe. This condition is rarely seen except in ballet dancing because of their extreme plantar flexion when going from flat foot to the en pointe position (extreme plantar flexion). Lesions develop in the tendon posterior to the medial Malleolus (tarsal tunnel) where swelling, pain, and tenderness triggering pain along tendon sheath may occur with toe flexion. Dorsiflexion of the great toe may be reduced when the ankle is placed in dorsiflexion. Gouty Arthritis (GOW-tē)=Uric acid (a substance that gives urine its name) is a waste product produced during the metabolism of nucleic acids. The person who suffers from gout either produces excessive amounts of uric acid or is not able to excrete normal amounts. The result is a build-up of uric acid in the blood. This excess acid then reacts with sodium to form a salt called sodium urate. Crystals of this salt are deposited in soft tissues. Typical sites are the kidneys, first metatarsal Phalangeal joint and the cartilage of the ears and other joints. Metatarsalgia=Metatarsalgia is a general term meaning pain over the ball of the foot caused by Interdigital nerve irritation, interdigital Perineural Fibrosis (Morton’s Neuroma between 3rd & 4th MP joint), or disease of the metatarsophalangeal articulations. Interdigital neuralgia presents with sudden pain onset along one or multiple interdigital nerve pathways (common and proper plantar digital nerves) radiating to the ball of the foot or the toes. Interdigital neuralgia may be caused by loss of the fat pad protecting the nerves of the foot, low-grade repetitive trauma, or improper footwear. Interdigital Perineural Fibrosis is described in the section of this text on Morton's Neuroma. MP joint disease results from misalignment of the joint surfaces, causing Subluxation and capsular and synovial impingement with eventual destruction of joint cartilage (degenerative joint disease). Predisposing factors include; Rigidity and stiffness of the forefoot, hammertoe deformities, cavus (highly arched) feet, excessive eversion of the subtalar joint (rolling-in of the ankles [pronation]), and Hallux valgus deformity (bunion). Morton's Neuroma: Interdigital Perineural Fibrosis=It is not a neuroma (type of tumor composed of nerve cells) but a Perineural fibrosis (a fibrous thickening develops around the nerve covering) characterized by a sudden onset of burning/tingling pain most commonly between the 3rd & 4th MP joint (80-85%), 2nd & 3rd (15-20%) (Does not occur between the 1st & 2nd or 4th & 5th MP joints) results in compression of the common digital nerves of the foot radiating to the ball or the toes. It is most often unilateral, found in only one MP joint (3rd & 4th MP), and occurs most often in women (78%). It is made worse by walking in high-heeled shoes with a narrow toe box, is relieved by rest and shoe removal. Vague pain may radiate up the leg including the achilles tendon. Lower heels, wider toe box, metatarsal pads, metatarsal bar, stiff soled shoe, orthosis, and rest may help reduce symptoms. Osteoarthritis (os’-tē-ō-ar-THRĪ-tis)=A degenerative joint disease far more common than rheumatoid arthritis, and usually less damaging, is Osteoarthritis. It apparently results from a combination of aging, irritation of the joints and wear and abrasion. Degenerative joint disease is a non-inflammatory, progressive disorder of movable joint, particularly weight-bearing joints. It is characterized by the deterioration of articular cartilage and by formation of new bone in the subchondral areas and at the margins of the joint. The cartilage slowly degenerates, and as the bone ends become exposed, small bumps, or spurs, of new osseous tissue are deposited on them. These spurs decrease the space of the joint cavity and restrict joint movement. Unlike rheumatoid arthritis, Osteoarthritis usually affects only the articular cartilage. The synovial membrane is rarely destroyed, and other tissues are unaffected. The main distinction between Osteoarthritis and rheumatoid arthritis is that the former strides the big joints (knees, hips) first, whereas the latter strikes the small joints first. But Osteoarthritis may affect the fingers, and when this is the case, the distal phalanges show the most prominent changes. The effect of rheumatoid arthritis on the fingers is most pronounced proximally, in the wrists and in the Metacarpophalangeal, and proximal Interphalangeal joints. Also, rheumatoid arthritis is more likely to be bilaterally symmetrical than is the case for Osteoarthritis. Peroneal Tendonitis/ Tenosynovitis=The synovial sheath (secretes fluid which allows the tendon to slide up and down without friction) and tendon become inflamed due to excessive pronation. Symptoms include; pain and swelling at the 1.) Base of the 5th metatarsal 2.) Cuboid tunnel (groove for the Peroneus longus tendon) near the proximal prominence of the 5th metatarsal. 3.) Behind the outer ankle bone (lateral malleoli). Pain is increased with inward movement of the foot (inversion and with resistance to outward movement (ankle eversion). Peroneal Tendon Dislocation/Subluxation=The Peroneus longus and brevis snap in and out of their groove behind the fibula when the retinaculum is torn or stretched due to traumatic injury (skiing injuries). Symptoms include; Lateral ankle pain with activity that does not resolve, Snapping of the peroneal tendons over the fibula, Tenderness behind the lateral Malleolus along the Peroneus brevis muscle; Subluxation elicited with the patient attempting to dorsiflex the affected foot from a plantar flexed, everted position. Pes Cavus (High Arch-Cavus Foot)=A high arched foot with or without symptoms as follows; Calluses on forefoot or hind foot, May have weak push-off, May be asymptomatic, May have pain under forefoot, and Difficulty in fitting or tolerating shoes. Pes Planus (Flat Foot)=The normal longitudinal arch of the foot is lost with effects to the foot, ankle, and, in some cases the heel cord. This condition can be acquired or congenital. A flexible flatfoot lacks an arch only when the foot is weight bearing but not when the foot is in a dependent position or when the patient toe-stands. A rigid flatfoot lacks an arch at all times, even when the foot is dependent or when the patient toe-stands. Plantar Fasciitis=Experts disagree as to the cause of plantar Fasciitis some hypothesizing that microadhesions form around the plantar fascia, especially during sleep and the first step most painful symptom is associated with tears of these microadhesions and other experts believe that chronic inflammation of the plantar fascia is the cause of plantar Fasciitis. In either case chronic inflammation is noted at the base of the plantar fascia insertion near the medial calcaneal tuberosity. Patients will complaint of heel pain that is worse in the morning or after prolonged sitting with the “first step” and lessens in severity with walking. Stretching exercises, Nonsteroidal anti-inflammatory agents, Orthoses, and when all else fails corticosteroid Injections. Surgical intervention is rarely indicated. Running and jumping Sports may cause or exacerbate the problem. Posterior Tibial Tendon Rupture=Because the posterior tibial tendon inverts the subtalar joint during heel rise and locks the transverse tarsal joint facilitating weight transfer to the lateral foot border tendon rupture is the major cause of adult (affects adults 40-60 years old) acquired flat foot. Its causes may be tenuous blood supply and chronic tendonitis. Patients complain of a painful medial foot and ankle subsequent to a specific traumatic episode which increases along with an evident progressive flatfoot deformity marked by clinically observable “Too many toes” sign: visualizing three or more toes lateral to the lateral Malleolus when viewed from posterior. Posterior Tibial Tendonitis (Posterior Tibial Tendon Dysfunction (PTTD))=Leading causes of acquired flatfoot in adults whose onset may be gradual or abrupt. Abrupt onset may be related to trauma e.g. stepping down off a curb or ladder, falling from a height or an automobile accident. PTTD increases with age and rarely seen in children. Signs include; Loss of medial arch height, Edema (swelling) of the medial ankle, Loss of the ability to resist force to abduct or push the foot out from the midline of the body, Pain on the medial ankle with weight bearing, Inability to raise up on the toes without pain, Too many toes sign, and Lateral subtalar joint (outside of the ankle) pain. Rheumatism (rheumat=Subject to flux)=Refers to any painful state of the supporting structures of the body- its bones, ligaments, joints, tendons, or muscles. Arthritis is a form of rheumatism in which the joints have become inflamed. Rheumatoid Arthritis (RA) (ROO-ma-toyd)=This is an autoimmune disease in which the body attacks its own tissues; in this case its own cartilage and joint linings. It is characterized by inflammation of the joint, swelling, pain, and loss of function. Usually, this form occurs bilaterally-if your left wrist is affected; your right wrist may also be affected, although usually not to the same degree. Sever's Disease=Avascular necrosis (AVN) (Sever's Disease) is the in situ death of a segment of cancellous bone from lack of circulation caused by trauma which injures arterial vessels or a non traumatic origin possibly related to Corticosteroids and or Ethanol use. Most commonly found in the 30 to 40 year old age range, equally divided between males and females, with pain of insidious onset, described as aching, and is minimally relieved by anti-inflammatory medications. Pain increases with time and is worsened by weight bearing. Shin Splints / Medial Tibial Stress Syndrome=Pain over the Posteromedial border of the middle to distal thirds of the tibia, at the periosteal/fascial junction attributed to Periostitis (Inflammation of the periosteum covering a bone) but may involve tendonitis of tibialis posterior/flexor digitorum longus/flexor hallucis longus. Causes include; improper gait, wearing old shoes, tight soleus muscle, improper muscle balance between gastroc-soleus/tibialis anterior, and improper training habits. Sprain and Strain=A sprain is the forcible wrenching or twisting of a joint with partial rupture or other injury to its attachments without luxation. It occurs when the attachments are stressed beyond their normal capacity. There may be damage to the associated blood vessels, muscles, tendons, ligaments, or nerves. A sprain is more serious than a strain, which is the overstretching of a muscle. Severe sprains may be so painful that the joint cannot be moved. There is considerable swelling and pain may occur owing to underlying hemorrhage from ruptured blood vessels. The ankle joint is most often sprained; the low back area is another frequent location for sprains. Tarsal Tunnel Syndrome=The posterior tibial nerve becomes entrapped by the flexor retinaculum posterior to the medial Malleolus and anterior to the Achilles tendon in an area known as the tarsal tunnel and causing referred Paresthesia and pain along the medial & lateral plantar nerves and calcaneal nerves. This condition affects middle aged to elderly men and women equally. No known causes are definitive but In general, tarsal tunnel syndrome usually results from specific injury or a space-occupying lesion within the tarsal tunnel. Characteristically, patients find it difficult to describe the pain. Complaints usually are burning; tingling, and numbness of toes and plantar aspect of the foot. Symptoms are often aggravated with activity and improve with rest, although some patients feel worse at rest and better while on their feet. Approximately 33% of patients have radiation of their pain proximally along the medial aspect of the leg to the level of the midcalf. Tendinitis or Tenosynovitis=The synovial sheath surrounding some tendons secretes fluid, which allows the tendon to slide up and down without friction. Inflammation of the tendon is known as tendonitis and often includes inflammation of the surrounding sheath known as Tenosynovitis.

v Illustration # 13-Foot Plantar Intrinsic Superficial & Deep View

v Illustration # 14-Tendon, Ligament, Muscle Tissue and Cells

v Illustration # 15-Exit of Spinal Nerves

v Illustration # 16-Cutaneous Nerve Distribution Plantar Foot & Posterior Lower Leg

v Illustration # 17-Right Foot Dorsal/Plantar

v Illustration # 18-Left Talus

v Illustration # 19-Calcaneus

v Illustration # 20-Navicular and Cuboid Bones

v Illustration # 20A-1^st & 2^nd Cuneiform Bones

v Illustration # 20B-3^rd Cuneiform Bone

v Illustration # 20C-1^st & 2^nd Metatarsal Bones

v Illustration # 20D-3^rd & 4^th Metatarsal Bones

v Illustration # 20E-5^th Metatarsal Bones

v Illustration # 21-Right Foot Lateral & Medial Ligaments

v Illustration # 22-Plantar Ligaments & Joints

v Illustration # 23-Right Foot Synovial Joint Cavities

v Illustration # 24A-Lumbar Plexus

v Illustration # 24B-Sacral Plexus

v Illustration # 25-Nerve Distribution (Lumbar and Sacral Plexus)

v Illustration # 26-Arteries Of Pelvis & Right Lower Extremity Anterior/Posterior

v Illustration # 27-Veins Of Pelvis & Right Lower Extremity Anterior/Posterior

v Illustration # 28-Synovial (Mucous) Sheaths of the Tendons & Retinaculum (Ligaments) Around the Ankle (Lateral & Medial)

v Illustration # 29-Synovial Joint Types

v Illustration # 30-Generalized Synovial Joint Capsule Frontal Section

v Illustration # 31-Bony Anatomy of the Foot and Ankle (Medial & Lateral Aspect)

v Illustration # 32-Tarsal Tunnel Soft Tissue, Achilles Tendon & Calcaneal Bursa

v Illustration # 33-Planes of Reference

v Illustration # 34-Classes of Levers

v Illustration # 35-Phases of Gait

v Summary

Single Case Single Visit Anecdotal Study- These studies help you determine the relative effectiveness of massage technique for various conditions by applying scientific method to a single case on a single visit. They are easy to do & give you practice with the process steps involved in research. However, they don’t prove or disprove anything conclusively. Rationale for Study- Since their aren’t large research grants for massage therapy single case studies provide the sole practitioner quick and cheap methodology for analytical inquiry. Statistical tools and research design and methodology can be tested for later use in larger studies. Rational for the Theoretical Perspective-The purpose of the theoretical perspective and subsequent study is to explain the nature of tendon and ligament trigger points and examine the efficacy of clinical massage therapy as a viable curative treatment. Guessing about Nature- Theory, helps explain the questions our current understanding does not readily answer and provides clues to effective treatment. Theoretical Thinking-Why Do Our Feet Hurt?- (Illus.#1)The feet bear the weight of our bodies under enormous pressure to the connective tissue structures which support the arch. The cells of these structures need 02, glucose & protein to thrive & survive. Active persons engaged in frequent weight bearing activity are likely to stress these structures beyond the circulatory supply of essential nutrients. Connective tissue cells near bone attachments or at biomechanical stress points become stressed causing vasoconstriction and metabolite irritation. Cells may die producing inflammatory chemicals, which further irritate afferent nerve supply. Pain is referred distally into the plantar surface of the foot and the Achilles tendon. (Illus.#5) Compression and stretching may help re-establish circulatory supply, increase nutrition to connective tissue cells and disperse irritants. Hypothesis-Compression and stretching of the connective tissue structures of the plantar foot will significantly reduce Achilles tendon tenderness as subjectively reported by clients. Subsequent treatment (Compression and stretching of plantar foot connective tissues) visits will continue to reduce Achilles tendon tenderness as subjectively reported by clients. This reduced Achilles tendon tenderness will persist even after treatment is discontinued. Study Title- Single Visit Study=“Single Case Single Visit Outcome (Anecdotal) Study-Plantar Foot-Superficial & Intrinsic Foot Structure Attachments -The Treatment Effects of Compression and Stretching.” Multiple Visit Study=“Single Case Multiple Visit Outcome (Anecdotal) Study-Plantar Foot-Superficial & Intrinsic Foot Structure Attachments -The Treatment Effects of Compression and Stretching.” Pre-Screening- EXCLUDE-Lumbar Pathology, Lumbar Pain, Early AM Heal Pain, Achilles Tendonitis and Sedentary (40-60 yr old) recently active women. CAN INCLUDE-Frequent Weight Bearing Activities, Wear Shoes w/ Elevated Heals, and Plantar Foot Tenderness (Right Foot) (Illus.#11) (Technique Plantar Foot) MUST INCLUDE-Achilles Tendon Tenderness (Right Foot) (Illus.#12) (Palpation Achilles Tendon) Treatment Technique and Sensation Intensity Rating- Pre-Treatment Rating (0-10) (Sensation Intensity Rating Scale) using 3 lbs pincer (pinching) pressure along Achilles Tendon (Right Foot) (Illus.#12) (Palpation Achilles Tendon) Compression and Stretching Treatment at (Right Foot) Calcaneal Tuberosity (Medial & Lateral Process), base of the 5th metatarsal and between the Proximal Heads of the Metatarsal bones. Both a standard technique using thumbs to compress the connective tissue attachments at the bone (Illus.#11) (Technique Plantar Foot) or alternate techniques with the client prone can be used. (Alternate Technique) Post-Treatment Rating (0-10) (Sensation Intensity Rating Scale) using 3 lbs pincer (pinching) pressure along Achilles Tendon (Right Foot) (Illus.#12) (Palpation Achilles Tendon). Single Case Multiple Visit Study-Subsequent visits (2-5) are from 2-3 days apart and the final visit is 7 days exactly from the 5^th visit. Pre and Post ratings and the date of the visit are recorded for each session. The rational for multiple visits helps determine the relative influence of the Gate, Placebo, and Curative effects. Functional Anatomy and Physiology-The histology of connective tissue reveals that tendons and ligaments are dense (Collagenous) Connective Tissue composed of widely scattered cells (fibroblasts) that produce regularly arranged fibers composed of the collagen protein. An example of this connective tissue is the plantar aponeurosis (sheet like tendon) (Illus #9&10), which attaches distally to each toe and proximally to the Calcaneal tuberosity. The plantar ligaments and fascia of the foot include the, Lateral Cord of the Plantar Aponeurosis, Plantar Fascia (fā-si-ă) (PF), Long Plantar Ligament, Plantar Calcaneocuboid Ligament (Short Plantar Ligament), and Plantar Calcaneonavicular (Spring) Ligament. The retinaculum (ligaments) of interest which bind down the tendons in front of and behind the ankle are the laciniate and peroneal Retinacula. (Illus #28) The mucous sheaths of the tendons around the ankle can become inflamed at biomechanical stress points. The intrinsic muscles (Illus #13) of the foot are specialized for support and locomotion, provided longitudinal arch support by the plantar aponeurosis and divided into two groups dorsal and plantar, which include four layers. The Abductor Hallucis, Flexor digitorum Brevis, Abductor digiti minimi and the quadratus plantae all attach to the calcaneus and are of special interest to this study. The dermatome is an area of skin supplied by supplied by the dorsal RAMI of the spinal nerves and of concern for this study are the L5, S1, and S2 Dermatomes. (Illus #2-4 & #15). The anterior rami of the spinal cord form the sacral plexus whose largest nerve is the sciatic (L4-S3) which in turn supplies the motor and cutaneous nerves of the foot. The Femoral nerve (anterior rami) is the largest branch of the lumbar plexus, which also supplies motor and cutaneous branches to the foot. (Illus #24A&B & #25) The cutaneous nerves of the foot are; Saphenous, Medial plantar (tibial), Lateral plantar, Medial Sural Cutaneous Nerve, and Medial Calcaneal (Tibial). The motor nerves of the foot are the lateral and medial plantar, derive from the tibial nerve, and supply all of the intrinsic plantar foot muscles. The Articular branches are the medial and lateral plantar nerves and supply all the joints of the foot. (Illus #16) There are 26 bones in the foot; Tarsals=7, Metatarsals=5, Phalanges=14. The calcaneus is the most important bone for the purpose of this study as the connective tissues, which attach to it are treated with compression and stretching. The foot also has two arches; Longitudinal and Transverse (Illus # 8). All of the joints of the foot are synovial which means they have a synovial joint cavity, hyaline (articular) cartilage and an articular capsule. (Illus # 30) There are several different types of joints represented in the foot namely; Gliding, Hinge, Ellipsoidal, Saddle, and Ball and Socket. (Illus # 30) The joints of the foot include the following; 1.) Talocrural (Ankle) 2.) Subtalar/Talocalcaneal 3.) Talocalcaneonavicular (TCN) 4.) Calcaneocuboid 5.) Metatarsophalangeal (MP) 6.) Interphalangeal (IP) 7.) Intercuneiform and Cuneocuboid 8.) Tarsometatarsal 9.) Intermetatarsal. The Tibiofibular Joint is also included in the Arthrology of the foot because it provides accessory movements for full ankle function. The two bursa of the foot of importance in this study are the Calcaneal and Retrocalcaneal bursa. Vascular-The arterial supply to the foot is provided by the Dorsalis Pedis Artery (Dorsum of foot) and the Medial And Lateral Plantar Arteries (Plantar Foot). The veins of the foot are the Dorsal (Medial & lateral) Venous Arch (Dorsal Foot) & Medial & Lateral Plantar Veins and Plantar Arch (Plantar Foot). The examination of the foot includes bony palpation (Illus #31) of the Head of the First Metatarsal Bone and the Metatarsophalangeal Joint, First Metatarsocuneiform, Navicular Tubercle, Head of the Talus, Medial Malleolus, Sustentaculum Tali, Medial Tubercle of the Talus, Fifth Metatarsal Bone; Fifth Metatarsophalangeal Joint, Calcaneus, Peroneal Tubercle, Lateral Malleolus, Dome of the Talus, Tibiofibular Joint, Dome of the calcaneus, medial tubercle of calcaneus, and metatarsal heads. Examination of the soft tissue (Illus #32) of the foot includes; Head of the First Metatarsal Bone, Navicular Tubercle and the Talar Head, Tom, Dick, an’ Harry, Tibialis Posterior Tendon, Flexor Digitorum Longus Tendon, Flexor Hallucis Longus Tendon, Posterior Tibial Artery, Tibial Nerve, Long Saphenous Vein, Peroneus Longus and Brevis Tendons, Head of Fifth Metatarsal, Achilles Tendon, Retrocalcaneal bursa, Calcaneal bursa and plantar aponeurosis. Biomechanical problems in the foot ankle complex cause abnormal stresses to the joints of the foot and ankle, as well as to the other weight-bearing joints such as the knee, hip, or lower spine. The study of foot pathology illustrates biomechanical problems and highlights functional anatomy as they manifest in clinical entities.

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