Basic Science of Foot

Prof. P. Bala subramaniam

Singapore

Basic Science of Foot

New knowledge has come into diagnosis
and surgery of ankle and foot
Arthroscopic and endoscopic anatomy,
joint replacement, sports medicine and
sports injuries
Unlearn and relearn new knowledge.
some old knowledge and concepts still
important

Pathological conditions of the foot

Foot : general principles

Highly specialized for weight bearing,
shock absorption and locomotion.
Arches of foot built on structural
engineering principles for transmission
of forces and shock absorption.

Foot : general principles

Two extreme modes of function
1. as a rigid structure when the 26 bones
of the foot are converted into a single unit
eg. ballet dance on point , kicking
2. as a supple structure. eg. climbing a
tree

Foot: general principles

Speed and power push the feet to extreme
limits.
Kinematic chain with the leg powered by
extrinsic and intrinsic muscles
loss of kinematic and structural
restraints affect ankle and foot stability
Dynamic & static stability of feet
The whole foot is wrapped up in specialized
skin and deep fascia

Skin of foot
on dorsum : lax and thin, poor blood
supply.
Sole :a weight bearing cushion for
toes, MT heads, and heel : fat pads
Heel structure : 18mm thick padding cover
the tuber calcaneus
Heel pads contain specialized fat in
MICRO and MACRO chambers

Skin of foot: dorsum & sole

Heel structure
The cup ligament attached to periosteal
layer of calcaneum by a series of tough
septa that form a U-system.
Septa seal off chambers with fat
Flow of fat within chambers for shock
absorption; running , jumping 10x BW
Aging & overuse : septa breakdown to
confluent cavities loss of shock
absorption , painful heel

Heel structure

Deep fascia of foot

Special arrangements
a. planter aponeurosis :truss & windlass
b. 9 compartments of foot
c. retinacula to strap tendons
Planter aponeurosis extends from
calcaneum to planter aspect of p.phalanx
Is a truss-like structure across longitudinal
arch . A cable between heel & toes

Planter aponeurosis ctd

It locks tarsal joints together
by a windlass mechanism
at the MTP attachment of the fascia
when the proximal phalanx is dorsiflexed.
Combined truss and windlass mechanism
raise the arches of foot , lock the
joints and make a single unit of multiple
bones and joints

Deep fascia: Retinacula of foot

Superior extensor retinaculum

Inferior extensor retinaculum
Flexor retinaculum
Superior peroneal retinaculum
Inferior peroneal retinaculum
Thickened restraining bands that hold
tendons in position and form pulleys within
which tendons slide when they change
direction at ankle

Deep fascia:Peroneal retinacula

Deep fascia of foot

Muscles of the foot

Foot :a jointed / lever system powered
by muscles --- the extrinsic and intrinsic
muscles.
Extrinsic muscles are in extensor,
flexor and lateral compartments of leg.
Intrinsic muscles: 4 layers of muscles
A balanced plantigrade foot necessary
to achieve its functions

4 layers of muscles of sole

First layer: : abdh,fdb,abddm, pl apon,
lat & medial pl digital nerves ( med& lat
planter nerve & vessels)
Second layer: quadratus planti from fdl, 4
lumbr, fdl crosses fhl, tib post to navicular
Third layer : fhb, addh, fdm, lat pl art &
nerve
Fourth layer : 3 pl interossei , 4 dorsal int

Muscles of the foot

extrinsic and intrinsic

Dorsum of foot

Extensor digitorum brevis muscle & ehb

Absent in 10%
L5 nerve root supply, PID wasting of edb
Anatomic door to bony structures
Elevate its origin, sinus tarsi TC,TN,CC jt
Tib ant, EHL, artery & nerve, EDL ,PT
Surgical approach to ankle & foot

Blood supply and venous drainage

Arterial supply very peripheral
From anterior tibial & posterior tibial
Ant. tibial gives rise to dorsalis pedis,
ant & lat maleolar arteries
Arterial supply of foot from dorsalis pedis,
arcuate artery, dorsal metarsal arteries ,
digital arteries , lateral pl artery, medial
plantar artery

Venous drainage

Superficial and deep group

Deep veins accompany the arteries
Most of them contain valves
Perforating veins connect both
Blood flow is from superficial to deep
Muscle pump
DVT ---incompetence
Long saph to femoral, short to popliteal

Nerve supply of foot

Peroneal nerve to extensor and lateral
compartments
Tibial nerve to flexor compartment
Has a neuromuscular mechanism for
posture & balance even with a small
base of support
Cutaneous supply saphenus, ant tibial ,
musculocutaneus & sural nerve
Root value : L4,L5,S1, S2, referred pain

Nerve supply of foot

Biomechanics of foot
Complex and different from those of ankle.
The necessity of foot- to- floor stability
dictates that the foot itself must
independently adapt a variety of
conditions
Loss of kinematic & structural restraints
affect ankle & foot stability & produce
malalignment of ankle joint surfaces

Biomechanics of foot
Its intricate construction, complex dynamic
organization provide for shock absorption,
stability and propulsion of body.
It successfully performs this task by forming a
kinematic chain with the leg
Foot must be stable for function. Stability
mechanism of foot depends on arches of the
foot, muscle control and sensory feed back.

Biomechanics of foot
Stability of foot depends on the 3 arches
Lateral arch , lower and shorter composed
of calcaneum, cuboid and lateral 2 rays.
This system is the more stable and weight
bearing portion of the arches
It carries the larger & higher medial arch
consisting of calcaneus, talus, navicular,
cuneiforms and 3 medial rays

Biomechanics of foot
Transverse arch : configured by the
shape of midtarsal bones cuneiforms, &
cuboid and the bases of metatarsals.
Longitudinal arch is not intrinsically
stable owing to the shape of bones .
Stabilized by heavy ligamentus structures
surrounding the joint

Biomechanics of foot

Biomechanics of foot

Planter aponeurosis and

biomechanics of foot
Truss like structure across the
longitudinal arch; like a cable between
heel and toes.
windlass mechanism through proximal
phalanx attachment of fascia;
dorsiflexion of toes shortens the truss ,
raises the arch and making it a single unit
of multiple bones & joints

Foot functionally divided into

three sections
Hind foot talus & calcaneus. Responsible for
most of motion in foot
Midfoot -- navicular, cuneiforms & cuboid.
Responsible for medial & lateral column stability
Forefoot 5MT , 6 weight bearing contacts
Competing issues of stability & mobility
Load evenly distributed over the foot during
weight bearing
50% thru subtalar joint to calcaneum
50% equally among the 6 points of contact of ff

Fore foot

1st ray:
halux valgus
Intermetatarsal angle 8-9 degrees
valgus angle of 1st MTP jt 30-35 degrees
Adductor hallucis Mcbride procedure
sesamoid ridge on the planter surface
Displacement into inter-metatarsal space
Less weight bearing on 1st ray transfer
metatarsalgia

Fore foot ctd

2nd ray: base of MT recessed in between
the cuneiforms rigid , stress #
3rd web space: planter digital neuroma
5th metatarsal: stress fracture ,
peroneous brevis inserted into base
Soft tissue support for forefoot alignment
mainly of dense ligaments between the
lesser metatarsals

Hind foot

Calcaneum: articular surface for talus & cuboid

Sustentaculum tali supports neck of talus
FHL courses beneath sustentaculum tali
Achilles tendon inserted into posterior aspect of
tuberosity.
Bohlers angle 20-40 deg. assess the
posterior facet in calcaneal #s
Gissanes angle
CT anatomy in calcaneal #s

Talus

Body, neck and head.60% articular, vas access

Defines ankle & subtalar motion
Anchors medial column of foot
talar dome articulates with tibial plafond
Inferiorly with the calcaneus
Laterally with malleoli
Has no muscle attachment
Two bony processes. Posterior & lateral #

Foot disorders : hind foot

Midfoot

Navicular, cuneiforms and cuboid

Talonavicular & calcaneocuboid joints
Tarsometatarsal jt (Lisfrancs injury)
Functionally the weight bearing position of
forefoot depends on proper alignment of
this joint complex
Tib post inserted to tuberosity of navicular
Tib ant inserted to medial cuneiform

Foot: tarsal coalition

Special anatomy for

Ankle arthroscopy : portals: anterior,
lateral, middle, ?posterior.
Impingement, osteophytes, loose bodies,
arthroscopic arthrodesis
Anatomy thru the scope: looking at
structures within the jt from inside
Hindfoot endoscopy: ostrigonum,
posteroir impingement

Basic science of foot for sports

Walk, run, jump, hop, dance, kick, forward
movement, side to side movement.
Subject to great ground reaction forces
Speed & power , overuse soft tissues &
bones
Normal, rigid, or floppy feet. arch
Tendons & bursae, bones joints, ligaments

Summary basic science of foot

General principles of foot structure & function

Skin of foot: sole a weight bearing cushion
Deep fascia specialization 3
Powered by extr and intr muscles: Balance
Vascular and nerve supply
Biomechanics of foot
Arthroscopic & endoscopic anatomy
Anatomy for sports medicine & sp. injuries