Welcome to the introduction to the foot and ankle. There are 26 bones in this area (28 if you count the 2 sesamoid bones) of the body, 33 joints (which is a fair amount for such a small area), and over 100 soft tissues structures (muscle, tendons, and ligaments). The joints in the foot work in concert to allow for triplanar movement, meaning that movement within the foot and ankle can occur in the frontal or coronal plane, the sagittal plane, and the transverse plane. Some joints, such as the subtalar joint, allow movement in all of these planes at once. As with anything, you need a balance of mobility and stability for optimal function.
(Photo source: http://www.leadingmd.com/ankle_kalman/overview.asp)
Structure and Function
The foot is divided into 3 parts: the forefoot (metatarsals and phalanges), the midfoot (navicular, cuboid, and 3 cuneiform bones) and the hindfoot (the talus and calcaneus). The way these areas interact and your bones lay result in your arches. You have 4 arches in your foot: medial, lateral, fundamental longitudinal, and transverse. They allow for shock absorption with each step we take, and help to spring us forward into movement.
The “ankle” joint itself is where the talus articulates with the bottom of the tibia and fibula. Plantarflexion and dorsiflexion occur here, or the pointing and flexing of the foot. Your subtalar joint is between the talus and the calcaneus, or heel bone. This is where inversion and eversion occur. Inversion is the combination of plantarflexion, adduction, and internal rotation. Eversion is the combination of dorsiflexion, abduction, and external rotation. The tarsometatarsal joints are where the cuneiforms and cuboid articulate with the metatarsals. These bones mainly slide against each other, and don’t produce large movements. The toes (or phalanges) articulate with the metatarsals at the MTP joints (metatarsophalangeal), which is what you would consider the “knuckles” of your feet. The toes can flex and extend at these joints.
In terms of soft tissue, you have several ligaments, muscles, and tendons in this area of the body. Some of the muscles originate in the calf, and some muscles are intrinsic (originating within the foot itself). The muscles on the back of the calf (gastrocnemius, soleus, and plantaris) assist in plantar flexion. The muscles on the outside of the calf (the peroneals) assist in eversion. The muscles in the front of the shin (anterior tibialis) assist in dorsiflexion. The muscles in the medial part of the lower leg (posterior tibialis) assist in inversion. You also have intrinsic and extrinsic muscles that help to flex and extend the toes. While this is not an exhaustive list, it’s an easy way to look at certain compartments of the lower leg and see how they affect motion at the foot and ankle.
Some of the main ligaments and connective tissue structures in the foot are the deltoid ligament, the spring ligament, the calcaneofibular ligament (CFL), the anterior talofibular ligament (ATFL), and the plantar fascia. The deltoid and spring ligaments are on the medial side of the ankle. They help to stabilize the medial arch and keep you from hyperpronating, or rolling in too much. For those with flat feet, these ligaments are often stretched out and weak. The CFL and ATFL are on the lateral side of the ankle. They work to prevent inversion, or rolling your ankle out. Those with weak ligaments here are prone to ankle sprains. The plantar fascia is a band of soft tissue that connects your heel to your toes. It runs the length of your foot, and helps to support your arch. Athletes and those who are on their feet a lot (such as dancers) are more prone to small tears and irritation here, which results in plantar fasciitis. Again this list is not nearly exhaustive, but these are a few of the main connective tissue structures in your feet, which play an important role in injury and injury prevention.
Ankle sprains typically occur when you invert your foot (rolling your foot so that the outer part of your ankle over-stretches). It can occur the other way, but that typically results in a fracture due to the alignment of the bones in that are of the lower leg (how your tibia and talus line up). We that being said, we’ll focus on lateral ankle sprains. For dancers, this is very easy to do in pointe shoes, especially if you’re not keeping your heel forward, and fall into sickling. Often times though, we may get through dance class just fine, only to roll our ankles while walking to our cars. In either case, the CFL is the most commonly sprained ligament in lateral ankle sprains. The next most commonly affected ligament in sprains in this area is the ATFL. Sprains can vary in severity, from a grade I (microscopic tearing) to a grade III (complete tear) sprain. Swelling and bruising are quite common. Doctors may take x-rays to ensure no bones are broken. MRI’s may also be ordered, if complete tearing is suspected. Depending on the severity of your sprain, crutches and bracing or some sort of immobilization may be indicated.
Initially, your doctor will most likely advise you to follow the RICE protocol:
- Compression (with brace, kinesiotape, or an ace bandage)
- Elevation (keeping the foot above the height of the heart when reclined)
After the acute phase, you’ll begin to gently reintroduce movement and function again by focusing on increasing active range of motion (AROM) and strength. Your physical therapist will guide you in what’s appropriate to do and when. Some examples include writing the alphabet in the air with your foot, pumping your ankle (pointing and flexing it), and practicing inversion and eversion. It’s best to keep these motions in what physical therapists often refer to as “pain-free” range. If you already have pain at rest, then it’s best to do these movements in a range that will not make your pain levels spike. Once your able to do these without increased pain, you’re physical therapist will usually tell you you’re ready to move onto strengthening exercises. Here, you may use a theraband to do the above movements. You may begin doing elevés (lifting up on your toes, for the non-dancers out there) and toes raises (rocking back on your heels). You may also begin to incorporate some balance exercises here: first flat on the ground on two feet, then one foot, then on a softer surface, then on elevé. You’ll eventually progress to things like jumping and hopping again, or running, but these are final steps in your rehab. Again, your therapist will be able to guide you through your recovery.
The plantar fascia is a thick band of connective tissue that runs from your heel to your toes. As mentioned previously, it helps to support your arch. Those who are on their feet a lot, those with flat feet who tend to overpronate, those with high arches, runners, dancers, those who are overweight, and those with tight calf muscles and achilles tendons are more prone to injury here, commonly referred to as plantar fasciitis. Plantar fasciitis is considered an overuse injury, and refers to small tears and irritation that occur in the plantar fascia. People who suffer from this complain of intense pain in the feel of the foot that is worse in the morning (especially the first few steps out of bed), Pain that increases after sitting for a long time, pain in the bottom of the foot that increases with stair or ladder climbing, and pain that worsens after being on your feet for a long time. Diagnosis is usually done based on your symptoms, your foot structure, and your personal history, but a doctor may take an x-ray to confirm that there aren’t any stress fractures or heel spurs.
Recovering from plantar fasciitis is not an easy task. Initially, it will often involve ice to the bottom of the foot, stretching the calf and achilles, and possible taping techniques to help reduce the symptoms. You will alos most likely be advised to back off of some of the acitivites that have contributed to your condition. Supportive shoes and orthotics or heel cups may also be recommended (no flip flops if it’s summer). Night splints that keep the foot in a flexed position are sometimes helpful, as well. Your physical therapist may also include iontophoresis, a modality in which an electrical impulse is used to deliver anti-inflammatory medication through the skin into the heel. Once the pain starts to subside, your PT will guide you in strengthening and balance exercises depending on where you were weak. Dorsiflexion and eversion movements are often utilized before adding plantarfexion and inversion exercises, as these usually do not increase pain. Just be patient in your recovery here, as getting back to normal takes time.
The most common fractures in the foot for dancers are a fracture of the 5th metatarsal or stress fractures. One type of fracture of the 5th metatarsal is actually often referred to as a dancer’s fracture. This typically occurs when rolling the ankle outward, which leads to a strong ligament in the outer foot actually pulling a piece of the bone from the base of the 5th metatarsal away from the rest of the bone. This can usually be treated conservatively (or non-operatively) by having the person wear a CAM boot for about 6 weeks (guided by x-rays to confirm that the bone has properly healed before discontinuing use). A Jones fracture, which also occurs in the 5th metatarsal, occurs a little more distal to the avulsion fracture, and often results from repetitive motion, overuse, or trauma to the area. This injury also more commonly affects those with high arches and those prone to supination. This is more challenging to treat because the blood flow in this area of the foot is more limited, and more often requires surgery. Stress fractures occur from overuse or repetitive injuries and often occur with an increase in activity or a change in how things are being performed. They can also occur with different footwear (for dancers) or when exercising on a new surface. Most common areas for stress fractures in the foot and lower leg are the 2nd and 3rd metatarsals, the calcaneus, the fibula, the talus, and the navicular.
Again, your doctor may begin my ordering RICE. Certain fractures will also require immobilization by things such a CAM boot. You may not be able to participate in dancing or other activities for 6 weeks, while the bone is healing (This will vary depending on the type and severity of the fracture). Once you’re ready to begin more active rehabilitation, your physical therapist will guide you through AROM exercise first (Do you see a trend here?). Once your ROM activities are pain-free, you’ll begin to incorporate strengthening and balance exercises before including agility training (running, jumping, etc), and returning to dancing or other activities as normal.
Hallux Limitus or Rigidus and Hallux Vaglus
(Photo credit: http://www.drwolgin.com/Pages/HalluxRigidus.aspx)
Hallux limitus is a condition in which the ROM at your first MTP joint (where your big toe attaches to your foot) is limited. It’s the beginning stages of arthritis in this joint, and bone spurs begin to form, which limit mobility. Hallux rigidus is a more advanced form of this condition, resulting in very limited motion at this joint (hence, the toes is fairly rigid). Here, your cartilage erodes and the joint itself starts to fuse. As movement at the big toe is vital for walking and all weight bearing activities, these conditions can be very limiting. They can also be very painful. Most note pain and swelling around the 1st MTP joint, and state that pushing off while working is difficult and uncomfortable. For a dancer, going up onto elevé or relevé without sickling or compromising heel height would be restricted and painful, if not impossible.
Hallux valgus occurs when the big toe begins to angle towards the 2nd toe, resulting in a bunion. Technically speaking, it’s when the 1st ray (or 1st metatarsal) begins to deviate medially while the 1st toe begins to deviate laterally. Those with flat feet, tight calves, lax ligaments, and forefoot varus are more prone to this condition, as are those with a longer 1st ray. This imbalance often occurs when the lateral muscles that pull the big toe out towards the 2nd toe are overly developed or stronger than the ones that would pull the big toe medially. In addition, having a lax medial capsule at the 1st MTP also contributes to the dysfunction and imbalance here. While there is no conclusive evidence that female dancers get bunions more than non-dancers, hallux valgus is certainly a condition that rears its ugly head in the dance world (Davenport et al). Conservative treatment may include things such as taping, use of spacers, and use of supportive and proper footwear (with a broad toe box to decease pain and pressure), but this is often not enough to reverse hallux valgus. This may allow the dancer to finish her career before having surgery, but does not usually allow her to avoid surgery completely.
RICE, shoe modifications, and anti-inflammatories are often the first line of defense when hallux limitus or rigidus appear. Rehab with a physical therapist will often focus on restoring ROM to the 1st MTP joint (or retaining what’s still there) through ROM activities, gentle stretching, and manual therapy such as soft tissue mobilization and joint mobilizations/distraction to address tight muscles and soft tissue structures as well as improve the roll and glide that occurs in a healthy, functioning joint. Modalities will be utilized to decrease pain. Orthotics may be prescribed to limit great toe extension. Stretching the muscles of the calf will also be incorporated. If certain muscles are weak, they will then be addressed through a strengthening program, as will balance by exercises on two feet or one foot on varying surfaces to improve proprioception. If this fails, surgical procedures such as a cheilectomy or fusion may be indicated. For hallux valgus, most treatment occurs after surgical intervention, and will also include the aforementioned, (managing pain though use of modalities, restoring ROM, increasing strength, improving gait, and improving balance).
I hope you enjoyed this week’s look into the foot and ankle. Next up: the knee. Stay tuned!
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