ankle and foot


The ankle and foot


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Figure 14.1

The ankle and foot



The ankle is the second most common area to be affected by sport injuries after the knee (Fong et al 2007). Lateral ankle sprains are so common that in the United States they alone have an annual healthcare cost of $4 billion (Curtis et al 2008, Waterman et al 2010). Ankle sprains have been recorded to require more than 23,000 Americans to seek medical attention daily (Court-Brown & Caesar 2006). In addition, a recent study by You et al (2016) using MRI investigations found that between 15.8% and 20.5% of individuals who experienced ankle tendon and ligament injuries also had corresponding osteochondral lesions of the distal tibia and fibula and talus, thus leading to the possibility of recurrent issues.

As well as sports-related foot injuries, the increase in levels of obesity has been associated with an increase in foot and ankle complications including tendonitis, plantar fasciitis and osteoarthritic changes (Gross et al 2015, Mickle & Steele 2015). Nkhata et al (2015) postulated that obesity was one of the contributing factors in their investigation of work-related disorders among nurses when they discovered that the most commonly affected body parts were ankles and feet (54.8%). Biomechanical compensations from other joints can also lead to foot pain, as reported by Paterson et al (2015) who found that foot pain, both bilateral and ipsilateral, is commonly observed with osteoarthritic changes of the knee. For these reasons, it is important to investigate other joints rather than focus solely on the primary presentation when treating foot symptoms.

Martins et al (2012, 2013) found that 9 minutes of articulation based on a grade 3 articulation (Maitland scale) of the ankle joint over a period of 5 days decreased postoperative pain in the ankle. The effect is thought to be via both peripheral and central neurological receptors. Martins et al (2011) also found that ankle articulation helped produce ‘pronounced and long-lasting analgesic effects’ in rats with sciatic nerve crush causing neuropathic pain. Green et al (2001) performed passive articulation to ankle joints following an acute ankle sprain and found that it greatly improved the pain-free movement of the ankle when compared to a control group. Collins et al (2004) also found that articulation of the ankle joint with a sub-acute sprain helped improve the range of movement of the joint. Hoch et al (2012) performed anterior–posterior articulation of the talocrural joint over a period of 2 weeks on participants with a history of ankle sprains and found that it improved self-reported function of the ankle and foot, increased dorsiflexion and improved balance. This is also reported in Mulligan articulation of the ankle joint, where the talus is believed to be anteriorized and inverted following ankle sprains, therefore restricting dorsiflexion and making the ankle prone to respraining (Collins et al 2004).

Hallux limitus, or turf toe, causes loss of motion in the big toe joint and is the third most common injury reported to prevent participation in athletics (Adelaar & Anderson 1997), but it is a condition that can easily be overlooked. Being unable to push off properly with the foot can lead to further issues within not only the hallux (big toe) itself but also the ankle and knee, particularly in sportspeople (McCormick & Anderson 2009, Anderson et al 2010, Frimenko et al 2012). As with most sprains, the initial treatment suggestions are rest, ice, compression and elevation (RICE), with appropriate non-steroidal anti-inflammatory drugs (NSAIDs) and strapping of the joint when needed. In the sub-acute phase of turf toe, articulation of the hallux is recommended (Fritz 1999, Shamus et al 2004, McCormick & Anderson 2009). Shamus et al (2004) also looked at articulation of the sesamoid bones of the hallux with flexor hallucis strengthening and found a great improvement in symptoms with patients suffering with hallux limitus. In some circumstances surgery is needed for turf toe (VanPelt et al 2012), but not all evidence supports the overall effectiveness of surgery (Maffulli et al 2011). Evidence shows that post-surgical articulation of the hallux can be more beneficial than surgery alone (Grady et al 2013).

Plantar fasciitis (also known as plantar fasciosis or jogger’s heel) is one of the most common causes of heel and foot pain, affecting 10% of the general population in their lifetime (Li et al 2013, Beeson 2014), and classically originating from repetitive trauma to the calcaneus. Prakash and Misra (2014) found that manual therapy ‘is a superior approach in improving pain and disability in individuals with plantar fasciitis’, a finding supported by Cleland et al (2009). Patla et al (2015) suggested that articulation of the cuboid and exercise management can help with tibialis posterior tendinopathy, but the findings from this case report require further research.


The ankle and foot are the most distal part of the lower limb of the appendicular skeleton. The bones, ligaments, tendons and muscles of the ankle and foot are highly developed, complex structures. The joints here are unlike many other joints in the body, because they are at times mobile and at other times quite stable. These structures articulate together to provide functional mobility and stability and enable us to perform diverse activities, including walking, running, standing and jumping (Riegger 1988).


In medical usage, the term ‘ankle’ usually refers specifically to the talocrural joint. However, in common usage, it often refers to the region or angle between the foot and leg. The ankle is made up of the articulation of three bones (the tibia, fibula and talus) and includes three joints (the talocrural, subtalar and inferior tibiofibular joints). The ankle allows dorsiflexion and plantar flexion movements of the foot (Moore et al 2013).


The foot, in contrast, is an intricate, biomechanically complex structure that supports the body weight, allows locomotion and withstands forces during propulsion. In addition to the tibia and fibula, there are 26 bones in each foot. These bones form a series of arches in the foot. They can be divided into three groups: the tarsal bones (7), the metatarsal bones (5), and the phalanges (14). The seven tarsal bones – the calcaneus, talus, navicular, cuboid bones and the medial, intermediate and lateral cuneiforms – are located at the proximal portion of the foot. The long metatarsals and the phalanges are located just anterior to the tarsals (OpenStax 2013).

The foot has a number of joints, which afford it stability and mobility. Although the total number of joints is not universally agreed, it is estimated that there are more than 30 in the foot. Some of the most important include the talocrural (ankle), subtalar, transverse tarsal, tarsometatarsal, metatarsophalangeal and interphalangeal joints (Tate 2009).

Structurally, the foot is subdivided into three main parts: the hindfoot, the midfoot and the forefoot. The hindfoot is the region closest to the center of the body. It is composed of three joints and contains two of the seven tarsal bones (the talus and the calcaneus). The midfoot constitutes the arches of the foot and works as a shock-absorber. This is made up of the remaining five tarsal bones (three cuneiform and the cuboid and navicular bones). The forefoot comprises five toes (phalanges), the corresponding five metatarsals and associated soft-tissue structures (Standring 2008).

Bony and joint anatomy


The tarsal bones, also known as the tarsus, are a cluster of seven articulating bones that form the posterior half of the foot. In a similar arrangement to the carpal bones of the wrist, tarsal bones are in proximal and distal rows; however, there is an extra element present medially in the tarsus – the navicular. The proximal row is composed of the talus and the calcaneus, and the distal row contains the three cuneiform and the cuboid (Moore et al 2013).

The talus is the most superior of the tarsal bones. It is an unusual bone, in that no muscle or tendon attaches with it. It forms the ankle joint, articulating with the tibia and fibula. The calcaneus is the largest bone of the foot. It forms the heel and serves as the attachment site for the large calf muscles. The cuboid is a relatively square-shaped bone located at the anterior end of the calcaneus. It articulates posteriorly with the calcaneus bone and medially with the navicular and lateral cuneiform bones. The navicular is a small bone that is located in front of the talus. It articulates posteriorly with the talus and anteriorly with the three cuneiforms. The cuneiforms are wedge-shaped bones that have an extensive superior surface but a narrow inferior surface (OpenStax 2013).


The metatarsal bones, also known as the metatarsus, are dorsally convex, elongated bones (numbered 1–5) that form the anterior half of the foot. The second of these bones is the longest of all; the first is thicker and shortest. They are located between the tarsus and the phalanges. Like the metacarpal bones of the hand, they have a shaft or body, proximal base and distal head. The shaft is prismatic in form, which tapers distally from the tarsal to the phalangeal extremity. The base is wedge-shaped and articulates with the cuboid or cuneiform bones. The head is the extended distal end of each metatarsal bone. It forms the ball of the foot and articulates with the proximal phalanx of a toe (Panchbhavi 2013).


The phalanges of the foot resemble those of the hand in number and structural arrangement. However, they are shorter than the finger phalanges and, those of the first row especially, are compressed laterally. The foot contains a total of 14 phalanx bones, which are distributed in five toes (numbered 1–5). The big toe (hallux) is analogous to the thumb, with two phalanx bones: the proximal and distal phalanges. The other toes contain three phalanx bones: proximal, middle and distal phalanges (Standring 2008).


Table 14.1 lists the major joints that provide the functional mobility and stability of the ankle and foot.



Talocrural joint

A synovial hinge joint that joins the upper surface (trochlea) of the talus with the tibia and fibula

Permits dorsiflexion and plantar flexion movements via axis in the talus

Subtalar joint

A modified multiaxial joint, allowing anterior and posterior articulations between the talus and the calcaneus

Permits inversion and eversion motions of the foot

Talocalcaneonavicular joint

A compound multiaxial joint, which forms when the rounded head of the talus connects with the navicular and the calcaneus

Allows plantar flexion of talus on the navicular

Calcaneocuboid joint

A biaxial joint formed by the articulation between the heel bone (calcaneus) and the cuboid bone

Allows a movement that is best referred to as obvolution–involution

Interphalangeal joints

Ginglymoid (hinge) joints formed by the articulations between the superior surfaces on the phalangeal heads and the adjacent phalangeal bases

Permit flexion and extension movements


Table 14.1
Important joints of the ankle and foot complex

Data from Riegger (1988), Standring (2008), Norkin & White (2009)



The ligaments of the ankle and foot complex can be divided into a number of groups, depending on their anatomical position. They include the lateral and medial collateral ligaments, the tibiofibular syndesmotic ligaments, the ligaments of the subtalar and talocalcaneal joints, the talonavicular and plantar calcaneonavicular ligaments, the ligaments of the calaneocuboid joint, the intermetatarsal ligaments, and many more (Standring 2008, Golanó et al 2010). The most important are summarized in Table 14.2. These ligaments primarily serve to hold the tendons in place and stabilize the joints of the foot and ankle (Standring 2008).



Lateral collateral ligament (complex)

Consists of the anterior and posterior talofibular ligaments and the calcaneofibular ligament

Originates from the lateral malleolus of the fibula to the talus and calcaneus

Serves to stabilize the ankle joint

Medial collateral ligament

A fan-shaped, multifascicular ligament that is composed of a superficial and deep layer

Commonly known as the deltoid ligament

Originates from the medial malleolus (the bottom portion of the tibia) to the talus, calcaneus and navicular bone

Stabilizes the inside of the ankle

Tibiofibular syndesmotic ligament (complex)

Consists of four ligaments: the anterior tibiofibular, posterior tibiofibular, inferior transverse and interosseous

Serves to stabilize the tibiofibular syndesmosis

Provides stability between the distal tibia and the fibula

Fights forces (e.g. axial, translational or rotational) that attempt to separate the distal (inferior) tibiofibular joint

Cervical ligament

Also known as the subtalar ligament

Originates from the superior calcaneal surface to the inferolateral tubercle of the talus

Serves to hold the calcaneous in order to stabilize the subtalar joint

Bifurcate ligament

Originates from the anterior aspect of the calcaneus to the dorsomedial surface of the cuboid and navicular bones

Serves to stabilize the calcaneocuboid joint

Intermetatarsal interosseus ligaments

Run between the lateral four metatarsal bones

Serve to stabilize the intermetatarsal joints

Hold together the metatarsals so that they can move in sync


Table 14.2
Important ligaments of the ankle and foot complex

Data from Milner & Soames (1998), Standring (2008), Boonthathip et al (2010), Golanó et al (2010), Moore et al (2013)


Range of motion


The axis of rotation of the ankle is dynamic because of the complex morphology of the talocrural joint. The ankle shifts during dorsi- and plantar flexion, but there is a wide range of variability in reported values of normal dorsiflexion and plantar flexion (see Tables 14.3 and 14.4).


The range of motion of the foot joints is complex. The motion of the subtalar joint is triplanar, providing pronation and supination. The joint allows 1° of freedom. The transverse tarsal joint is reported to permit some degrees of inversion and eversion, but it mainly serves to amplify the motions of the talocrural joint and the subtalar joint (Oatis 1988). The motion of the tarsometatarsal joints is translatory or planar. They are presumed to continue the compensating movement produced at the transverse tarsal joint when it reaches its maximum range of motion. The metatarsophalangeal joints allow 2° of freedom, providing motion in the sagittal and transverse planes. The interphalangeal (IP) joints permit motion in the sagittal plane, allowing pure flexion and extension (Norkin & White 2009). The range of motion of the joints of the foot is summarized in Table 14.5.

Movement type

Range of motion (°)


Normal dorsiflexion


Clarkson (2000)

Normal plantar flexion


Dorsiflexion, knee extended


Spink et al (2011)

Dorsiflexion, knee flexed



Table 14.3
Approximate range of motion of the ankle


Movement type

Reported variation in range of motion (°)




Oatis (1988)

Plantar flexion




Roaas & Andersson (1982), Lindsjo et al (1985), Lundberg et al (1989), Valderrabano et al (2003)

Plantar flexion



Table 14.4
Variation in reference values reported for range of motion of the ankle



Movement type

Range of motion (°)

Subtalar joint





Metatarsophalangeal joints

Flexion (big/great toe)


Flexion (lesser toes)


Extension (big/great toe)


Extension (lesser toes)


Interphalangeal joints

Flexion (big/great toe)


Flexion (lesser toes)


Extension (big/great toe and other toes)



Table 14.5
Range of motion of the foot joints

Data from Oatis (1988), Norkin & White (2009)



Ankle injuries

Ankle injury is a very common musculoskeletal injury, accounting for 25% of all sports-related injuries, and it can affect anyone, regardless of age and sex (Fong et al 2007). The most common type of ankle injury is the sprain of the lateral ligament complex, involved in up to 80% of all ankle sprains (O’Loughlin et al 2009). These injuries can occur when participating in athletic activities such as running or jumping sports, or when simply stepping down at an angle or onto an uneven surface. In the UK, the incidence of ankle sprain is roughly 61 per 10,000 individuals. This equates to a total of about 302,000 people and 42,000 (severe) new ankle sprain patients visiting accident and emergency departments every year (Bridgman et al 2003). The main precursor for ankle sprains is a history of sprains (Noronha et al 2013), but a restriction in dorsiflexion of the talocrural joint can also predispose a person to ankle sprains and fractures of the ankle (Tabrizi et al 2000, Willems et al 2005).

Ankle sprain can happen to both non-athletes and athletes. People of all ages, including children, adolescents and older adults, are all at risk of ankle sprains. Overall, males of 15–24 years of age and females over 30 years of age come in the highest-risk category. However, females have a greater risk of spraining their ankle than males (13.6 versus 6.94 per 1000 exposures), and children are more likely than teenagers and older adults (2.85, 1.94 and 0.72 per 1000 exposures, respectively) (Waterman et al 2010, Doherty et al 2014).




Tibial posterior tendonitis

The most common cause of ankle pain of the medial portion

Causes acquired flatfoot deformity in adults

Seriously affects gait and balance

Occurs because of prolonged stretching into eversion

Often linked to extreme subtalar pronation

Most commonly affects women over 40 years of age

Symptoms include flattening of the foot, change in foot shape, pain and swelling at the medial hindfoot, an abducted forefoot and a valgus heel

Kohls-Gatzoulis et al (2004), Trnka (2004)

Peroneal tendonitis

The most common overuse injury that causes ankle pain of the lateral portion

Causes inflammation of the peroneal tendons

Often occurs as a result of excessive eversion and pronation

Commonly affects sport athletes, particularly those whose sport involves repetitive ankle motion

Wang et al (2005)

Hallux valgus (bunion)

Progressive and commonest forefoot deformity, also called a bunion

Causes a valgus angulation of the proximal phalanx of the big toe

Often leads to painful motion of the joint (pronation problems), trouble with footwear, and painful swelling on the big toe during weight-bearing

Occurs most commonly in adolescents, particularly in girls

Estimated prevalence: 23–35%

Hartley (1995), Nix et al (2010)

Plantar fasciitis

A degenerative disease of the plantar fascia

The most common cause of stabbing pain in the heel and bottom of the foot

Commonly affects middle-aged people

About 10% of individuals develop it at some time during their lives

Risk factors include leg length inconsistency, nerve entrapment, muscle tightness, excessive pronation, over-training and using ill-fitting footwear

Li et al (2013), Beeson (2014)

Tarsal tunnel syndrome

Occurs due to compression of the posterior tibial nerve in the tarsal tunnel (canal formed between the flexor retinaculum and the medial malleolus)

Often occurs because of having flat feet or fallen arches, trauma, an underlying disease (such as diabetes or arthritis) or excessive pronation

Symptoms include shooting pain radiating into the heel, toes and arch of the foot, tingling or burning sensation and numbness on the plantar aspect

Reade et al (2001), Franson & Baravarian (2006)

Morton’s neuroma (Morton’s metatarsalgia or interdigital neuroma)

Commonly affects one foot, but can occasionally be both feet

Normally affects the nerve between the third and fourth metatarsals, but occasionally the second and third toes

Can occur at any age, but most often affects middle-aged women (perhaps because of footwear)

Higher incidence in runners

Symptoms initially start with tingling that gradually gets worse, developing to a sharp, shooting pain

Owens et al (2011), Pastides et al (2012)

Turf toe (hallux limitus)

Involves the metatarsophalangeal joint of the hallux (big toe)

Chronic pain and loss of strength when pushing off

Can lead to joint degeneration

Loss of range of movement can lead to lack of ability to push off in gait cycle and eventually lead to ankle and knee issues

Common in sports such as, soccer, American football and athletics

Can be divided into three categories: hyperextension, hyperflexion and dislocation

McCormick & Anderson (2009), Anderson et al (2010), Frimenko et al (2012)


Table 14.6
Common disorders of the ankle and foot


As discussed in Chapter 1, meniscoids can develop in the embryo or after trauma to the ankle joint (Lahm et al 1998, Baums et al 2006, Glazebrook et al 2009). This can lead to long-term symptoms such as locking, decreased range of movement and pain in the ankle. In a similar way to plica in the knee (see Chapter 13, The knee), meniscoids can only be fully diagnosed after imaging or arthroscopy (Valkering et al 2013). Also like plica, although manual therapy can be effective in treating the area, surgery may also be a viable treatment mode (Brennan et al 2012).

Foot pain

Foot pain is an extremely common problem. It is associated with balance and gait problems, high risk of falls, and reduced ability to execute activities of daily living. Risk factors for foot pain include age, sex, heredity, obesity, generalized osteoarthritis, intrinsic foot conditions (such as toe deformity, hallux valgus, calluses and corns), extreme exercise and ill-fitting footwear (Menz et al 2006). Foot pain is highly prevalent in elderly people and is estimated to affect around 20–30% of adults aged 65 and over (Benvenuti et al 1995, Dunn et al 2004, Thomas et al 2004). The prevalence of foot pain in other age groups, however, has not been so widely studied to date. Nevertheless, women are known to be 40% more likely than men to have foot pain (Hill et al 2008). The prevalence of disabling foot pain in subjects reporting foot pain in the past month is about 9.5% (Garrow et al 2004). Common disorders of the ankle and foot are described in Table 14.6.

Ankle and foot examination

Medical history

During the ankle and foot examination, a detailed medical history of the patient should be taken to characterize the severity of the pain, narrow down the differential diagnosis, and facilitate the physical examination. While interviewing the patient, the ankle and foot must be exposed as much as possible, so that visual observation can be made. The examiner should review prior injuries and/or surgeries, past medical history, previous diagnostic reports, recreational and occupational activities, medications, allergies and social history. The patient should also be asked about the severity and location of pain, presence of swelling, duration of symptoms, exacerbating and relieving factors, and functional difficulty, such as inability to walk, run and jump.

Red flags

Table 14.7 details the red flag conditions that the examiner should note in particular from the patient’s narrative and examination.


Signs and symptoms


History of recent trauma such as a crush injury, an ankle injury or a fall from height

Pain, bruising or swelling on affected leg

Persistent synovitis

Point tenderness over involved tissues

Inability to walk or bear weight on involved leg

Deep vein thrombosis (DVT)

History of recent surgery

Calf pain

Redness of the skin

Swelling and tenderness on affected leg

Pain intensified with walking or standing and reduced by elevation and rest

Septic arthritis

Fever, chills

History of recent bacterial infection

Constant aching and/or throbbing pain

Coexisting immunosuppressive disorder

Red, swollen joint with no history of trauma

Compartment syndrome

History of trauma or crush injury

Pain with dorsiflexion of toes

Pain intensified with stretch applied to affected muscles

Swelling, tightness and bruising of involved compartment


Previous history of cancer (e.g. prostate, breast or any reproductive cancer)

Systemic symptoms such as fever, chills, malaise and weakness

Sudden loss of weight with no valid reason

Suspected malignancy

Unexplained deformity, mass, or swelling

Feb 5, 2018 | Posted by in MANUAL THERAPIST | Comments Off on ankle and foot
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