Clinical Skills - Foot - Distal

Handbook 5

Skeletal Anatomy:

Talus:

• Trochlea

• Head

• Neck

• Articular surfaces for: Medial malleolus + Lateral malleolus

• Posterior process and groove for FHL

Calcaneus:

• Calcaneal tuberosity – medial and lateral process

• Articular surface for talus

• Sustentaculum tali

• Surface for cuboid

• Groove for FHL and PL

• Fibular trochlea

Navicular:

• Tuberosity

• Groove for talus and cuneiforms

Cuboid:

• Tuberosity

• Groove for per. long.

• Articular surfaces for talus and cuneiforms

Metatarsals:

• Base, shaft and head

• Tuberosity of 5th MT

Phalanges:

• Base, shaft, head

• Proximal, middle and distal

Palpate the prominent bony landmarks at the level of the ankle.

Surface Anatomy:

Medial and lateral malleoli:

Palpate the medial and lateral malleoli with thumb and index finger. Move your fingers inferior and anterior in relation to the malleoli until they move into a depression behind the anterior compartment tendons. Your fingers should be on either side of the neck of talus. The head is the most anterior point, articulating with the navicular.

Head/Neck of talus and talocrural joint

With your thumb and index finger in position, move the ankle into full plantarflexion. The trochlea should roll forwards from underneath the tibia, so that you can now palpate over the anterior aspect of the trochlea.

Trochlea of talus

With the ankle in plantargrade (neutral), palpate the medial malleolus, and then move your fingers inferior until you palpate a small prominence (like a bony ledge). Inferior to the ledge, you will feel soft tissue only – this is how you know you are on the sustentaculum tali. Superior to the ledge, you are on the medial joint line of the subtalar joint.

Sustentaculum tali

Find the sustentaculum tali (calcaneus) and the navicular. Try to palpate where the bones meet on the medial foot.

Discuss the joint structure.

Talocalcaneonavicular joint

From the sustentaculum tali move your fingers anteriorly, the next bony prominence you feel on the medial aspect is the navicular tuberosity. Remember that the head of the talus should articulate with the navicular. Check that everything lines up.

Navicular tuberosity

Palpate between the sustentaculum tali and the navicular tuberosity.

Spring ligament (Talocalcaneonavicular ligament )

First palpate the 5^th metatarsal until you find the tuberosity on the proximal aspect. Move off the 5^th metatarsal onto the cuboid bone just proximal to it.

The cuboid is also located anterior/distal to the sinus tarsi.

Cuboid:

Try to palpate where the cuboid meets the calcaneus on the lateral foot and discuss the joint structure.

Calcaneocuboid joint

Like the cuboid, these are easiest to find by starting distally on the adjoining metatarsals and moving proximally from there:

·       Medial cuneiform sits proximally to the 1^st metatarsal

·       Intermediate cuneiform – second metatarsal

Lateral cuneiform – third metatarsal

Cuneiforms:

Draw a line along the bases of the metatarsals (Tarsometatarsal Joints)– note how the first metatarsal is shorter than the others.

The metatarsal heads are best found on the plantar surface and become visible in toe extension (metatarsophalangeal joints).

Metatarsals (Draw lines)

Identify the proximal, middle and distal phalanges by moving distally across each joint. The first toe has only proximal and distal phalanges (interphalangeal joints).

Phalanges:

Extend the toes and observe a small circular muscle belly on the dorsum of the foot, just anterior to the sinus tarsi.

Extensor digitorum and extensor hallucis brevis

Palpate the Achilles tendon of the gastrocnemius, soleus +/- plantaris

Achilles Tendon:

Palpate the attachment of the Achilles tendon to the posterior aspect of the calcaneus.

Calcaneal Tuberosity:

Palpate the strong fascia on the sole of the foot.

Note how the fascia becomes more taught when the toes extend at the metatarsophalangeal joints (Windlass mechanism).

Plantar fascia (including plantar aponeurosis)

Draw a line over the various arches. Observe the arches in non-weightbearing and weightbearing. Visualise the structures that support the arches.

Medial Longitudinal, lateral longitudinal and transverse arches

Extend the toes at the metatarsophalangeal joints and observe the prominent metatarsal heads on the plantar surface of the foot.

Metatarsal heads

Abduct the big toe (+/- resistance)

Origin:

• Medial tubercle of calcaneal tuberosity

Insertion:

• Medial side of base of proximal phalanx 1^st digit

Nerve Supply:

• Medial Plantar Nerve (S2,S3)

Muscle Identification:

Abductor Hallucis:

• how to test +

  • Origin

  • Insertion

  • Nerve Supply

  • Function

Flex proximal interphalangeal joints.

Origin:

• Medial tubercle of calcaneal tuberosity

Insertion:

• Both sides of middle phalanges of lateral 4 digits

Nerve Supply:

• Medial Plantar Nerve (S2,S3)

Flexor Digitorum Brevis

• How to resist/activate

+

• Origin

• Insertion

• Nerve Supply

• Function

Abduct the little toe

Origin:

• Lateral tubercle of calcaneal tuberosity

Insertion:

• Base of proximal phalanx of 5th digit

Nerve Supply:

• Lateral plantar nerve (S2,3)

Function:

• Abduction + flexion of little toe at MTPJ

Abductor Digiti Minimi:

How to activate/test

+

• Origin

• Insertion

• Nerve Supply

• Function

Flex the distal interphalangeal joints – working through FDL

+

Origin:

• Plantar surfaces of calcaneus (Medial + Lateral tubercles)

Insertion:

• Posterolateral margin of tendon of FDL

Nerve Supply:

• Lateral Plantar Nerve (S2,3)

Function:

• Flexion of lateral 4 toes (through attachment to FDL)

• Assists in propulsion

Quadratus Plantae:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Flexion at the metatarsophalangeal joints and extension at the interphalangeal joints.

From Flexor to Extensor Compartment

Origin:

• Tendon of FDL

Insertion:

• Base of proximal phalanx and extensor hood

Nerve Supply:

• Medial (1st lumbrical) and lateral (Lateral 3 lumbricals) plantar nerves

Function:

MTP Flexion + IP extension

Lumbricals:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Flex the little toe at PIP

Origin:

• Base of 5th MT

Insertion:

• Base of proximal phalanx of 5th digit

Nerve:

• Lateral Plantar Nerve

Function:

• Little toe flexion @ MTPJ

Flexor digiti minimi

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Adduct big toe. Hold against resistance.

Origins:

• Oblique head MT’s 2-4

• Transverse head - MTP’s (plantar ligaments)

Insertion:

• Lateral side of base of proximal phalanx

Nerve Supply:

• Lateral Plantar Nerve

Function:

• Adduction of great toe

• Support of transverse arch

Adductor Hallucis:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Flex big toe at PIP.

Origin:

• Plantar surface of cuboid and lateral cuneiform

Insertions (2 heads):

• Base of proximal phalanx (Medial - abductor hallucis) (Lateral - adducotr hallucis - check)

Nerve:

• Medial Plantar Nerve

Function:

• Great toe flexion at MTPJ

• Aids in push off phase of gait.

Flexor hallucis brevis:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Adduct lateral toes

Origin:

• Medial side of plantar surface of proximal MT’s 3-5

Insertion:

• Medial side of base of proximal phalanx 3-5

Nerve Supply:

• Lateral Plantar Nerve

Function:

• Adduction of MTPJ’s 3-5 (PAD)

• Control during push off

Plantar Interossei:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Extend big toe at PIP

Origin:

• Calcaneus - floor of sinus tarsi

Insertion:

• Dorsal aspect of base of proximal phalanx of great toe

Nerve Supply:

• Deep peroneal nerves (L5, S1)

Function:

• Great toe extension at the MTP

Extensor Hallucis Brevis:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Extend big toe at PIP

Origin:

• Calcaneus - Floor of sinus tarsi

Insertion:

• extensor hoods of toes 2-4

Nerve Supply:

• Deep peroneal nerve

Function:

• Extension of toes 2-4

Extensor Digitorum Brevis:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function

Abduct lateral toes

---

Origin:

• Dorsal surface of proximal metatarsals (medial and lateral sides)

Insertion:

• Bases of proximal phalanges 2-4

Nerve Supply:

• Lateral Plantar Nerves

Function:

• Abduction of MTPJ’s 2-4 (DAB - dorsal interossei ABductor)

• Control of forefoot during pushoff

Dorsal Interossei:

How to activate/ test

+

• Origin

• Insertion

• Nerve Supply

• Function