Ankle Joint

Description

The Ankle Joint, also known as the Talocrural Articulation, is a synovial hinge joint connecting the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus. The ankle joint is maintained by the shape of the talus and its tight fit between the tibia and fibula. In the neutral position, there are strong bony constraints. With increasing plantar flexion, the bony constraints are decreased and the ligaments are more susceptible to strain and injury. The articulation between the tibia and the talus bears more weight than that between the smaller fibula and the talus. [1]

[2]
[3]

Anatomy

Articulating Surfaces

  • Trochlea of Talus
  • Malleolar Mortis formed by Tibia & Fibula
  • Lateral & Medial Malleolus

Joint Capsule

The articular capsule surrounds the joints, and is attached, above, to the borders of the articular surfaces of the tibia and malleoli; and below, to the talus around its upper articular surface. The joint capsule anteriorly is a broad, thin, fibrous layer, posteriorly the fibres are thin and run mainly transversely blending with the transverse ligament and laterally the capsule is thickened, and attaches to the hollow on the medial surface of the lateral malleolus. The synovial membrane extends superiorly between Tibia & Fibula as far as the Interosseous Tibiofibular Ligament.[4]

Ligaments

Lateral Ligaments of Ankle

Lateral ligament

Reinforce Joint Laterally through three ligaments. These ligaments stabilize the ankle, and serve as a guide to direct ankle motion by attaching the lateral malleolus to the bones below the ankle joint. They are responsible for resistance against inversion and internal rotation stress. [4]

LIGAMENT

DESCRIPTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT ROLE

Anterior Talofibular Ligament (ATFL)

Flat Weak Band that extends Anteriomedially.

Most commonly damaged ligament of the ankle.

Lateral Malleolus Neck of Talus

Restrain anterior displacement of the talus in respect to the fibula and tibia.

Resists Inversion in planterflexion.

Posterior Talofibular Ligament

(PTFL)

Thick, fairly strong band that runs horizontally medially.

This ligament is under greater strain in full dorsiflexion of ankle.

Rarely injured because bony stability protects ligaments when ankle in dorsiflexion.

Malleolar Fossa of Fibula Lateral Tubercle of Talus

Forms the back wall of the recipient socket for the talus' trochlea.

Resists posterior displacement of the talus.

Calcaneofibular Ligament (CFL)

Round cord that passes posterioinferiorly Tip of Lateral Malleolus Lateral Surface of Calcaneus

Aids Talofibular stability during Dorsiflexion.

Restrain inversion of the calcaneus with respect to the fibula.

Prevent Talar tilt into Inversion.

Medial Ligaments of Ankle

Medial ligament

Known collectively as the Deltoid Ligament the medial ligaments of the ankle attaches proximally to the Medial Malleolus and fan out to attach distally to the Talus, Calcaneus and Navicular via four adjacent and continuous parts. The deltoid ligament is triangular in shape and consists of a superficial and deep layer which connect the talus to the medial malleolus. It reinforces the joint capsule medially. Stabilise’s the ankle joint during eversion of the foot and prevents subluxation of the ankle joint. [4]

LIGAMENTS

DESCRIPTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT ROLE

Anterior Tibiotalar

Ligament

Medial Malleolus
Head of Talus

Reinforces Ankle Joint.

Control Plantarflexion & Eversion

Posterior Tibiotalar

Ligament

Talus Posteriorly Control Dorsiflexion

Tibionavicular

Ligament

Forms most anterior part of the Deltoid Ligament

Dorsomedial Aspect of Navicular Reinforces Ankle Joint

Tibiocalcaneal

Ligament

Very thin ligament Sustentaculum Tali Reinforces Ankle Joint

Muscles

Plantarflexion

Muscles which contribute to Plantarflexion

MUSCLE

ACTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERVATION

POSTERIOR COMPARTMENT

SUPERFICIAL

Gastrocnemius

Plantarflexion when Knee Extended

Flexion Knee

Raises Heel during Walking

Lateral Head: Lateral Aspect of Lateral Femoral Condyle

Medial Head: Popliteal Surface of Femur Superior to Medial Femoral Condyle

Posterior Surface Calcaneus via Calcaneal Tendon (Achilles Tendon)

Tibial Nerve

S1-S2

Soleus

Plantarflexion

Steadies Leg on Foot

Posterior Aspect of Head Fibula

Superior ¼ Posterior Surface Tibia

Soleal Line & Medial Border Tibia

Plantaris

Weakly Assists Gastrocnemius in Plantarflexion

Inferior end Lateral Supracondylar Line of Femur

Oblique Popliteal Ligament

DEEP

Tibialis Posterior

Plantarflexion

Inversion

Supports Medial Longitudinal Arch

Interosseous Membrane

Posterior Surface Tibia inferior to Soleal Line

Posterior Surface Fibula

Navicular Tuberosity

Cuneiform

Cuboid

Bases of Metatarsals 2-4

Tibial Nerve
L4-L5
Flexor Digitorum Longus

Plantarflexion

Flexion Lateral Four Digits

Supports Longitudinal Arch

Medial Part Posterior Surface

Tibia inferior to Soleal Line

Broad Tendon to Fibula

Base Distal Phalanges Digits 2-4

Tibial Nerve

S2-S3

Flexor Hallucis Longus

Weak Plantarflexion

Flexion Big Toe at all Joints

Supports Medial Longitudinal Arch

Inferior 2/3 Posterior Surface Fibula

Inferior Part Interosseous Membrane

Base Distal Phalanx of Big Toe

LATERAL COMPARTMENT

Peroneus Brevis

Weak Plantarflexion

Eversion

Inferior 2/3 of Lateral Surface Fibula

Dorsal Surface Tuberosity of Base

5th Metatarsal

Superficial Peroneal Nerve

(Superficial Fibular Nerve)

L5 - S2

Peroneus Longus

Weak Plantarflexion

Eversion

Supports Transverse Arch

Head & Superior 2/3 of Lateral Surface Fibula

Base 1st Metatarsal

Medial Cuniform

Dorsiflexion

Muscles which contribute to Dorsiflexion

MUSCLE

ACTION PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERVATION

ANTERIOR COMPARTMENT

Tibialis Anterior

Dorsiflexion

Inversion

Supports Medial Longitudinal Arch

Lateral Condyle Tibia

Superior ½ Lateral Surface Tibia

Interosseous Membrane

Medial & Inferior Surfaces

Medial Cuniform

Base of 1st Metatarsal

Deep Peroneal Nerve

(Deep Fibular Nerve)

L4-L5

Extensor Digitorum

Longus

Dorsiflexion

Extends Lateral Four Digits

Lateral Condyle Tibia

Superior ¾ Anterior Surface

Interosseous Membrane

Middle & Distal Phalanges of Lateral Four Digits

Deep Peroneal Nerve

(Deep Fibular Nerve)

L5-S1

Extensor Hallucis

Longus

Dorsiflexion

Extends Big Toe

Middle Part Anterior Surface Fibula

Interosseous Membrane

Dorsal Aspect of Base Distal

Phalanx of Big Toe

Peroneus Tertius

Dorsiflexion

Aids Eversion

Inferior 1/3 Anterior Surface Fibula

Interosseous Membrane

Dorsum Base 5th Metatarsal

Blood Supply

Derived from Malleolar Branches of:

  • Peroneal Artery
  • Tibial Artery

Nerve Supply

  • Common Peroneal Nerve
  • Tibial Nerve

Function

Motions Available

  • Talocrural Joint is a uniaxial hinge joint which has just 1° of Motion
  • The reported normal available range for dorsiflexion varies in the literature between 0-16.5o[5] and 0-25o[6]. This changes in weight bearing.
  • The normal range of Plantarflexion has been reported to be around 0°- 50°

Closed Packed Position

  • Maximum Dorsiflexion

Open Packed Position

  • 10° Plantarflexion

Structures Limiting Movement

Movement Limiting Structures
Plantarflexion
Posterior & Lateral Compartment
Anterior Talofibular Ligamanet
Anterior Part of Medial Ligament
Anterior Joint Capsule Tension
Contact of Talus with Tibia
Dorsiflexor Tension
Dorsiflexion
Anterior Compartment
Medial Ligament
Calcaneofibular Ligament
Posterior Talofibular Ligament
Posterior Joint Capsule Tension
Contact of Talus with Tibia
Plantarflexors Tension

Clinical Examination

Assessment

Special Tests

Clinical Predicition Rules

Outcome Measures

  • Foot and Disability Index&is a 34-item self report questionnaire divided into two subscales: the Foot and Ankle Disability Index and the Foot and Ankle Disability Index Sport

Pathology/Injury

Physiotherapeutic Techniques

Manual Therapy

Balance Retraining

Procedures

Resources

References

  1. Allen F. Anderson Sports Medicine. Anatomy Ankle Available from: http://www.drallenfanderson.com/ankle/anatomy [last accessed 20/03/2015]
  2. Anatomy Zone. Ankle Joint - 3D Anatomy Tutorial. Available from: https://www.youtube.com/watch?v=lPLdoFQlZXQ [last accessed 19/03/2015]
  3. AnimatedBiomedical. Ankle Joint, Bones of the Foot - 3D Medical Animation. Available from: https://www.youtube.com/watch?v=X-eAXKS4pJM [last accessed 19/03/2015]
  4. 4.0 4.1 4.2 Moore KL, Agur AMR, Dalley AF. Essential Clinial Anatomy. Baltimore: Lippincott Williams and Wilkins, 2011.
  5. Baggett BD, Young G. Ankle joint dorsiflexion. Establishment of a normal range. Journal of the American Podiatric Medical Association. 1993 May;83(5):251-4.
  6. CDCP. Normal joint range of motion study. Acceessed https://www.cdc.gov/ncbddd/jointrom/
  7. PT Haven. Talocrural Joint Distal Distraction. Available from: http://www.pthaven.com/page/show/162347-talocrural-joint-distal-distraction [last accessed 19/03/2015]