The proximal tibiofibular joint

The proximal tibiofibular joint is a synovial joint that is not directly connected with the knee joint. When the knee is flexed, this joint plays a part in rotation of the leg, allowing small degrees of supplementary abduction and adduction of the fibula (Lewit 1985) or, as Kuchera & Goodridge (1997) term it, ‘anterolateral and posteromedial glide of the fibular head’.

Greenman (1996) notes that the behavior of the fibular head is strongly influenced by the biceps femoris muscle, which attaches to it, suggesting that any dysfunction of the tibiofibular joint calls for assessment of this muscle, for length, strength and localized dysfunction (trigger points). Schiowitz (1991) notes that: ‘When evaluating or treating a fibular head dysfunction, the [practitioner] should completely examine the distal articulation as well, at the ankle joint’. Kuchera & Goodridge (1997) point out that functional movement of the distal tibiofibular joint is imperative as it allows the ankle mortise to accommodate the increased width of the posterior portion of the talus during dorsiflexion.

Proximal tibiofibular joint play

Lewit (1985) reports joint play at the proximal tibiofibular joint as involving an anteroposterior glide as well as some rotation potential of the fibular head on the tibia.

• When the tibia and ankle are externally rotated, the proximal fibular head elevates and glides (translates) anteriorly, to accommodate this movement (Kuchera & Goodridge 1997) (Fig. 14.3).

• Similarly, when the tibia and ankle are internally rotated, the proximal fibular head depresses and glides (translates) posteriorly, to accommodate this movement.

Figure 14.3 External rotation of the tibia (A) moves the distal fibula posteriorly (B) while the fibular head moves anteriorly (C). All these movements are reversed for internal rotation of the tibia (after Ward 1997).

Entrapment possibility

As observed above, care is required to avoid undue pressure on the posterior aspect of the fibula head due to neural structure proximity. Kuchera & Goodridge (1997) point out additionally that dysfunction that involves the fibular head being locked in a posteriorly translated direction ‘may cause symptoms related to entrapment neuropathy or compression of the common peroneal [fibular] nerve’ (see Box 14.9).

Box 14.9 Neural impingement and neurodynamic testing

Note: See Volume 1, Box 13.11 for additional information regarding the background to neural impingement.

Korr (1970, 1981) demonstrated that nerves transport vital biochemical substances throughout the body, constantly. The rate of axonal transport of such substances varies from 1 mm/day to several hundred mm/day, with ‘different cargoes being carried at different rates’. ‘The motor powers (for the waves of transportation) are provided by the axon itself’. Transportation is a two-way traffic, with retrograde transportation, ‘a fundamental means of communication between neurons and between neurons and non-neuronal cells’.

Korr (1981) believes this process to have an important role in maintenance of ‘the plasticity of the nervous system, serving to keep motor-neurons and muscle cells, or two synapsing neurons, mutually adapted to each other and responsive to each other’s changing circumstances’. The trophic influence of neural structures on the structural and functional characteristics of the soft tissues they supply can be shown to be vulnerable to disturbance. Korr (1981) explains:

Any factor which causes derangement of transport mechanisms in the axon, or that chronically alters the quality or quantity of the axonally transported substances, could cause the trophic influences to become detrimental. This alteration in turn would produce aberrations of structure, function, and metabolism, thereby contributing to dysfunction and disease.

Among the negative influences frequently operating on these transport mechanisms, Korr informs us, are deformations of nerves and roots, such as compression, stretching, angulation and torsion. Nerves are particularly vulnerable in their passage over highly mobile joints, through bony canals, intervertebral foramina, fascial layers and tonically contracted muscles (for example, posterior rami of spinal nerves and spinal extensor muscles).

Neurodynamic testing for and the treatment of ‘tensions’ in neural structures offer a means of dealing with some forms of pain and dysfunction.

Maitland (1986) suggested that assessment and treatment of ‘adverse mechanical tension’ (AMT) in the nervous system should be seen as a form of ‘mobilization’.

Any pathology in the mechanical interface (MI) between nerves and their surrounding tissues can produce abnormalities in nerve movement, resulting in tension on neural structures. Examples of MI dysfunction are nerve impingement by disc protrusion, osteophyte contact or carpal tunnel constriction. These problems may be regarded as mechanical in origin and symptoms will more easily be provoked by movement rather than passive testing.

Chemical or inflammatory causes of neural tension can also occur, resulting in ‘interneural fibrosis’, which leads to reduced elasticity and increased ‘tension’, which would become obvious with tension testing of these structures (see the discussion of Morton’s neuroma on p. 532). The pathophysiological changes resulting from inflammation, or from chemical damage (i.e. toxicity) lead to internal mechanical restrictions of neural structures, which are quite different from externally applied mechanical causes, such as would be produced by a disc lesion, for example.

When a neurodynamic test (see below) is positive (i.e. pain is produced by one or another element of the test – initial position alone or with ‘sensitizing’ additions) it indicates only that AMT exists somewhere in the nervous system and not that this is necessarily at the site of reported pain.

Petty (2006) suggests that in order to ‘ascertain the degree to which neural tissue is responsible for the production of the patient’s [ankle and foot] symptoms’ the tests that should be carried out are passive neck flexion, straight leg raising, passive knee flexion and slump. These tests are described below, with the exception of passive neck flexion, which is self-explanatory.

• A positive tension test is one in which the patient’s symptoms are reproduced by the test procedure and where these symptoms can be altered by variations in what are termed ‘sensitizing maneuvers’, which are used to ‘add weight to’, and confirm, the initial finding of AMT.

• Adding dorsiflexion during SLR is an example of a sensitizing maneuver.

• Precise symptom reproduction may not be possible, but the test is still possibly relevant if other abnormal symptoms are produced during the test and its accompanying sensitizing procedures. Comparison with the test findings on an opposite limb, for example, may indicate an abnormality worth exploring.

• Altered range of movement is another indicator of abnormality, whether this is noted during the initial test position or during sensitizing additions.

Variations of passive motion of the nervous system during examination and treatment

1. An increase in tension can be produced in the interneural component, where tension is being applied from both ends, so to speak, as in the ‘slump’ test (Fig. 14.45).

2. Increased tension can be produced in the extraneural component, which then produces the maximum movement of the nerve in relation to its mechanical interface (such as in straight leg raising) with the likelihood of restrictions showing up at ‘tension points’.

Figure 14.45 The slump test places the entire neural network, from pons to the feet, under tension. Note the movement pattern of nerve roots and dura mater as indicated by the arrows. Also note that as the knee moves from flexion to extension the tibial nerve moves in two directions in relation to the tibia and femur. The fibular tension point is at the head of the fibula. No neural movement occurs behind the knee or at levels C6, T6 or L4

(Butler 1994).

3. Movement of extraneural tissues in another plane can be engineered.

CAUTION: General precautions and contraindications

• Care should be taken of the spine during the ‘slump test’ if disc problems are involved or if the neck is sensitive (or the patient is prone to dizziness).

• If any area is sensitive, care should be taken not to aggravate existing conditions during performance of tests.

• If obvious neurological problems exist, special care should be taken to avoid exacerbation that vigorous or strong stretching might provoke.

• Similar precautions apply to diabetic, MS or recent surgical patients or where the area being tested is affected by circulatory deficit.

• Tests of the sort described below should be avoided if there has been recent onset or worsening of neurological signs or if there is any cauda equina or cord lesion.

Straight leg raising (SLR) test

Note: See text relating to hamstring tests (for shortness) in Chapters 10 and 12. See Figure 12.46 in particular. In Chapter 10 Box 10.5, see discussion under the subheading: Protocol for assessment of symptoms caused by nerve root or peripheral nerve dysfunction (p. 237).

The leg is raised in the sagittal plane, knee extended.

It is suggested that this test should be used in all vertebral disorders, all lower limb disorders (and some upper limb disorders) to establish the possibility of abnormal mechanical tension in the nervous system in the lower back or limb.

Sensitizing additions to SLR

• Ankle dorsiflexion (this stresses the tibial component of the sciatic nerve).

• Ankle plantarflexion plus inversion (this stresses the common fibular nerve, which may be useful with anterior shin and dorsal foot symptoms).

• Passive neck flexion.

• Increased medial hip rotation.

• Increased hip adduction.

• Altered spinal position (for example, left SLR may be ‘sensitized’ by lateral flexion to the right of the spine).

The SLR test should be performed with the addition, one at a time, of each sensitizing maneuver, in order to assess changes in symptoms, new symptoms, restrictions, etc.

The question being asked is: ‘Can the leg be raised as far, and as easily, without force, and without symptoms (new or old) appearing, when the sensitizing additions are incorporated?’

Notes on SLR test

• During the SLR test there is caudad movement of the lumbosacral nerve roots in relation to interfacing tissue (which is why there is a ‘positive’ indication of pain and limitation of leg-raising potential when SLR is performed in the presence of a prolapsed intervertebral disc).

• The tibial nerve, proximal to the knee, moves caudad (in relation to the mechanical interface) during SLR, whereas distal to the knee it moves cranially. There is no movement of the tibial nerve behind the knee itself, which is therefore known as a ‘tension point’.

• The common fibular nerve is attached firmly to the head of the fibula (another ‘tension point’).

Prone knee bend test (PKB)

• The patient is prone and the knee is flexed, taking the heel toward the buttock to assess reproduction of existing symptoms, or other abnormal symptoms, or altered range of movement (heel should approximate buttock easily). See Figure 12.18 for positioning in prone position.

• During the test, the knee of the prone patient is flexed while the hip and thigh are stabilized, which moves the nerves and roots from L2, L3, L4 and, particularly, the femoral nerve and its branches.

• If, however, the test is conducted with the patient sidelying, the hip should be maintained in extension during the test (this alternative position is thought more appropriate for identifying entrapped lateral femoral cutaneous nerve problems).

• It is obvious that the PKB test stretches rectus femoris and rotates the pelvis anteriorly, thus extending the lumbar spine, which can confuse interpretation of nerve impingement symptoms. Care should be taken to avoid this by stabilizing the pelvis or by placement of a pillow under the abdomen to support the lumbar spine. A bodyCushion™ would most ideally achieve this goal.

• Sensitizing maneuvers include (in either prone or sidelying use of the test):

• introduction of cervical flexion

• adopting the ‘slump’ position (below) – but only in the sidelying variation of the test

• hip abduction, adduction, or rotation.

The ‘slump test’

Butler (1994) regards this as the most important test in this series. It links neural and connective tissue components from the pons to the feet and requires care in performance and interpretation (Fig. 14.45). The slump test is suggested for all spinal disorders, most lower limb disorders and some upper limb disorders (those that seem to involve the nervous system).

The test involves the seated patient introducing the following sequence of movements:

• thoracic and then lumbar flexion, followed by

• cervical flexion

• knee extension

• ankle dorsiflexion

• sometimes also hip flexion (produced by either bringing the trunk forward on the hips or by increasing SLR).

Additional sensitizing movements during slump testing are achieved by changes in the terminal positions of joints. Butler (1994) gives examples.

• If the test reproduces (for example) lumbar and radiating thigh pain, a change in head position – say into slight extension – could result in total relief of these symptoms (desensitizing).

• A change in ankle and knee positions could significantly change cervical, thoracic or head pain produced by the test.

• In both instances this would confirm that AMT was operating, although the site would remain obscure.

• Trunk sidebending and rotation or even extension, hip adduction, abduction or rotation and varying neck positions are all sensitizing movements.

Cadaver studies demonstrate that neuromeningeal movement occurs in various directions, with C6, T6 and L4 intervertebral levels being regions of constant state (i.e. no movement, therefore ‘tension points’). Butler (1994) reports that many restrictions identified during the slump test may only be corrected by appropriate spinal manipulation.

It is possible for SLR to be positive (e.g. symptoms are reproduced) and the slump test negative (no symptom reproduction) and vice versa, so both should always be performed.

The following findings have been reported in research using the slump test. Mid-thoracic to T9 are painful on trunk and neck flexion in 50% of ‘normal’ individuals. The following are considered normal responses if they are symmetrical.

• Hamstring and posterior knee pain occurring with trunk and neck flexion, when the knees are extended and increasing further with ankle dorsiflexion.

• Restrictions in ankle dorsiflexion during trunk/neck flexion while the knee is in extension.

• There is a common decrease in pain noted on release of neck flexion and an increase in range of knee extension or ankle dorsiflexion on release of neck flexion.

If the patient’s symptoms are reproduced by the slump position, altered or aggravated by sensitizing movements and can be relieved by desensitizing maneuvers, the test is regarded as positive.

Butler (1994) suggests that in treating adverse mechanical tensions in the nervous system, initial stretching of the tissues associated with neural restrictions should commence well away from the site of pain in sensitive individuals and conditions. It is not within the scope of this text to detail methods for releasing abnormal tensions, except to suggest that the treatment positions are commonly a replication of the test positions (as in shortened musculature, where MET is used).

We suggest that when the protocols outlined throughout the clinical applications segments are diligently carried out, including identifying and releasing tense and shortened musculature, releasing tense, indurated, fibrotic myofascial structures using NMT or other deep tissue methods as well as deactivating trigger points, where appropriate, mobilizing joints, including those aspects of movement that are involuntary (joint play), there will almost always be an improvement in abnormal neural restrictions.

Retesting restricted tissues regularly during treatment is important, in order to see whether gains in range of motion or lessening of pain noted during AMT testing are being achieved.

Mobilization with movement (MWM) to release the fibula head

If knee pain is reported in the posterolateral aspect of the knee joint and no internal knee dysfunction is apparent, joint play of the tibiofibular joint may be restricted.

MET for releasing restricted proximal tibiofibular joint

For anterior fibular head dysfunction (where posterior glide is restricted)

The ankle ligaments

The bones that make up the crural arch (the distal tibia and the medial and lateral malleoli) are connected to the talus by the joint capsule and powerful ligaments (Fig. 14.7ABC).

Figure 14.7 The ligaments of the A) medial ankle B) lateral ankle and C) posterior aspect of the ankle joint

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Movements of the ankle joint

Kuchera & Goodridge (1997) suggest that the ankle joint is in fact two joints, which should be considered together as a functional unit: the talocrural joint (ankle mortise) and the subtalar joint (described below). They point to the research of Inman (1976) who showed that during the gait cycle, as weight is taken on the foot, there is ‘visible medial rotation of the tibia [that] is greater than can be attributed to movement solely at the talocrural joint’. Inman demonstrated that the increased tibial rotation resulted from ‘relative calcaneal eversion about the subtalar axis’. As the stance phase progresses the tibia then externally (laterally) rotates, at the same time as calcaneal inversion occurs, again about the subtalar axis (see Box 14.1).

The motions of the ankle joint are as follows.

The talocalcaneal (subtalar) joint

The talocalcaneal (or subtalar) joint is a composite joint formed by the articulation of the talus (Fig 14.4) with the calcaneus (Fig. 14.8) at three surfaces. The largest of these three surfaces lies posterior to the tarsal canal while the anterior and middle facets lie anterior to it. These surfaces are further divided into anterior and posterior independent components by the interosseous talocalcaneal ligament, which lies obliquely between them, separating them into two compartments. The posterior portion has its own synovial cavity while the anterior and middle facets share one. These three articulating surfaces are collectively called the talocalcaneal joint, though it is helpful to consider the two different components of this joint separately. To distinguish them, the posterior component can be called the subtalar joint proper (or posterior subtalar joint) and the anterior component called the talocalcaneonavicular (TCN) joint.

Figure 14.8 The calcaneus: A) superior view; B) posterior view; C) lateral view

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

In collectively describing these surfaces, Cailliet (1997) writes:

The calcaneus is the largest tarsal bone, with the muscles of the calf attaching to its projecting posterior surface. In addition to the three articulations with the talus, its anterior surface offers a convex surface for articulation with the cuboid (Fig. 14.5A). The smooth facets contrast with the remaining rough surfaces of the calcaneus, where numerous ligaments and muscles attach. The sustentaculum tali projects medially from it and (dorsally) offers the middle facet, which articulates with the talus, making it also part of the TCN joint.

The posterior saddle-shaped (convex) articular surface of the calcaneus receives the concave talar facet. The middle and anterior articular surfaces include convex talar and concave calcaneal facets, therefore being the reverse of the posterior articulation. Since the talocalcaneal joint is composed of several joints lying in different planes, this unique configuration ‘permits simultaneous movement in different directions’ (Cailliet 1997). Triplanar movement around a single joint axis and functional weight-bearing at this joint are ‘critical for dampening the rotational forces imposed by the body weight while maintaining contact of the foot with the supporting surface’ (Levangie & Norkin 2005).

Levangie & Norkin (2005) explain:

Capsule and ligaments of the subtalar joint

The bones of the subtalar joint proper are connected by a fibrous capsule and by lateral, medial, interosseous talocalcaneal and cervical ligaments.

• The fibrous capsule envelops the joint, attaching via short fibers to its articular margins. The joint’s synovial membrane is separate from other tarsal joints (Gray’s anatomy 2005).

• Lateral talocalcaneal ligament: this descends obliquely posteriorly from the lateral talar process to the lateral calcaneal surface. It attaches anterosuperiorly to the calcaneofibular ligament.

• Medial talocalcaneal ligament: this joins the medial talar tubercle to the posterior aspect of the sustentaculum tali and the adjacent medial surface of the calcaneus. Its fibers become continuous with the medial (deltoid) ligament.

• Interosseous talocalcaneal ligament: this descends obliquely and laterally from the sulcus tali to sulcus calcanei.

• Cervical ligament: this is attached to the superior calcaneal surface and ascends medially to an inferolateral tubercle on the talar neck.

Between the posterior and middle articulations lies a deep groove, which forms the obliquely oriented tarsal tunnel (canal). The larger end of this tunnel, the sinus tarsi, lies just anterior to the lateral malleolus, while its smaller end emerges between the medial malleolus and the sustentaculum tali (medially projecting ledge on the calcaneus). Within the tunnel resides the interosseous talocalcaneal ligament, which divides the subtalar from the TCN joint.

The subtalar joint has been described as a ‘shock absorber’ by Kuchera & Kuchera (1994), a designation earned, they say, because ‘in coordination with the inter-tarsal joints, it determines the distribution of forces upon the skeleton and soft tissues of the foot’.

Kapandji (1987) calls the talus ‘an unusual bone’ (due to the fact that it has no muscular attachments) and in view of its role as a ‘distributor’ of loads over the entire foot (Fig. 14.9); also, because ‘it is entirely covered by articular surfaces and ligamentous insertions; hence its name of “relay station”’.

Figure 14.9 The distribution of body weight through the talus

(reproduced with permission from Kapandji 1987).

Mennell (1964) graphically describes this shock-absorbing potential.

Its most important movement is a rocking movement of the talus upon the calcaneus, which is entirely independent of voluntary muscle action. It is this movement which takes up all the stresses and strains of stubbing the toes and that spares the ankle from gross trauma, both on toe-off and at heel-strike, in the normal function of walking and when abnormal stresses …are inflicted on the ankle joint. If it were not for the involuntary rocking motion at the subtalar joint, fracture dislocations would be more commonplace.

Gray’s anatomy (2005) notes that there are anterior and posterior articulations between the calcaneus and talus as described above. However, the subtalar joint, as described in Gray’s anatomy, relates only to the posterior articulation, which has its own joint capsule. The anterior articulation between the talus and calcaneus is then seen to be part of the TCN joint, a viewpoint that has merit and is discussed later in this chapter. As mentioned elsewhere, there is value in considering these joints individually as well as collectively with regard to foot movements.

Schiowitz (1991) describes the major motions of the subtalar joint as:

• calcaneal abduction (valgus), which creates foot eversion (involving fibularis longus and brevis)

• adduction (varus), which creates foot inversion, in relation to the talus (involving tibialis anterior and posterior).

It is worth remembering that these movements cannot occur in isolation but are mandatory simultaneous movements in the three planes of space. The terms used to describe these movements are subject to confusion (see Box 14.1) based on lack of agreement; however, regardless of the term chosen, they move the foot simultaneously in its vertical, horizontal and longitudinal axes. As the medial aspect of the foot is elevated, it is simultaneously adducted and plantarflexed. As the lateral aspect of the foot is elevated, it is simultaneously abducted and dorsiflexed. These movements cannot happen in isolation but instead are triaxial.

Kuchera & Goodridge (1997) describe the joint’s action as being ‘like a mitred hinge’ in which movements of the calcaneus induce rotation of the tibia.

Inversion of the calcaneus produces external rotation of the tibia and the talus glides posterolaterally over the calcaneus. Eversion of the calcaneus produces medial rotation of the tibia and anteromedial glide of the talus on the calcaneus.

Levangie & Norkin (2005) note that:

Although the triplanar motions of pronation/supination can be described by its three componenet (cardinal) motions, these subtalar component motions are coupled and cannot occur independently. The coupled motions must occur simultaneously as the calcaneus (or talus) twists across the subtalar joint’s three articular surfaces.

Ankle sprains

Note: See also the notes in the previous section of this chapter that discuss the relationship between the proximal and distal tibiofibular joints and ankle sprain. See also Box 14.3.

Plantarflexion is the position in which ankle sprains are most likely to occur. Schiowitz (1991) reports that: ‘The most common [ankle] sprain represents an inversion and is usually caused by a combination of plantarflexion, internal rotation and inversion. The lateral ligaments sustain the initial impact’ (Fig. 14.10).

Figure 14.10 Structural stress occurring in common supination ankle sprain

(after Ward 1997).

Gray’s anatomy (1995) clarifies the mechanisms of ankle sprain.

Merck (2001) report that in ankle sprain, the anterior talofibular ligament (ATL) usually ruptures first after which the fibulocalcaneal ligament (FCL) may separate. Merck suggest that if the ATL is ruptured, examination for associated trauma to the lateral FCL should be carried out. Palpation of the lateral ankle usually rapidly determines the site of the ligamentous injury. If ATL is ruptured during a sprain, anterior displacement of the talus becomes possible. To test this, the patient sits on the side of a table with legs hanging freely. The practitioner places one hand in front of the patient’s leg, while the other hand grasps the patient’s heel posteriorly and attempts to move the talus anteriorly.

MET treatment of dorsiflexion restriction at the talotibiofibular joint

PRT treatment of medial (deltoid) ligament dysfunction

MWM treatment of restricted talotibiofibular joint and for postinversion sprain

Mulligan (1999) suggests that this joint may display loss of joint play following inversion (lateral ligament) sprains of the ankle. He describes a slightly different hold, when using MWM, from that outlined in the assessment above, although that hold is also effective.

MWM for eversion ankle sprains

In the case of this less common injury, a ventral glide of the fibula is performed while the patient performs repetitions of slow and painless eversions of the foot.

Calcaneal spur syndrome (and plantar fasciitis)

The calcaneal spur syndrome is characterized by the presence of a benign growth extending away from the bone and often accompanied by extreme heel pain in the area of the inferior calcaneus, caused by the pull of the plantar fascia (and sometimes by the insertion of the Achilles tendon) on the periosteum. There may be no obvious evidence of a heel spur on X-ray (Merck 2001). Note: A negative X-ray for bone spur is not conclusive, as in the early stages visual evidence is often minimal.

Spurs may result from excessive traction on the calcaneal periosteum by the plantar fascia. The stretching may lead to pain along the inner border of the plantar fascia (plantar fasciitis). It is considered that flat feet and contracted heel cords may contribute to the development of spurs through increased plantar fascial tension (Merck 2001).

First aid involves the RICE protocol and introducing mild antiinflammatory strategies (see Chapters 6 and 7). Treatment may involve methods that release excessive tension in the plantarflexors and fascia and deactivate associated trigger points. Attention should also focus on achieving normal muscle tone, strength and length, with particular focus on the individual’s gait cycle, with use of rehabilitation exercises to counteract any compensation habits acquired during periods of pain. Orthotic control and strapping may be useful in rehabilitation. Short-term use of NSAID medication and, in extreme circumstances, steroid injections and/or surgery may be called for. Habits of use regarding the feet (such as hooking them on a chair rung when working) should be considered as should overall postural positioning.

Epiphysitis of the calcaneus (Sever’s disease)

This condition involves painful cartilage break in the heel, affecting children.

Usually, before age 16, when ossification of the calcaneus (which develops from two centers of ossification) is incomplete, excessive strain involving vigorous activities may cause a break in the cartilage that connects the two, as yet non-united bones. Diagnosis is based on the patient’s age, the identification of pain along the heel growth centers on the margins of the heel and a history of vigorous activity. Warmth and swelling may occasionally be present. The condition cannot be diagnosed radiographically.

Heel pads may be helpful in reducing the pull of the Achilles tendon on the heel, as might treatment of the triceps surae. Immobilization in a cast is usually required and recovery may take several months. Subsequent attention should focus on achieving normal muscle tone, strength and length, with particular focus on the individual’s gait cycle, with use of rehabilitation exercises to counteract the compensation habits acquired during immobilization.

Posterior Achilles tendon bursitis (Haglund’s deformity)

This condition, which occurs mostly in young women, involves an inflamed bursa overlying the Achilles tendon attachment associated with a prominent bony enlargement of the calcaneus. It commonly results from variations in heel position and function and inappropriate footwear, particularly high heels. Merck (2001) states:

Early signs include increased redness and induration, often ‘protected’ by adhesive tape to ease shoe pressure. If the inflamed bursa enlarges, a painful red lump develops over the tendon. In time, the bursa may become fibrotic and calcium may further enlarge the process.

Treatment might involve foam rubber or felt heel pads, in order to elevate the heel (as well as padding around the bursa initially), plus ensuring that shoe pressure is minimized. Use of an orthotic to prevent abnormal heel motion may also be helpful. Antiinflammatory medication offers short-term benefit only. Medical treatment might involve infiltration of a soluble corticosteroid to ease inflammation. Excision of the posterolateral aspect of the calcaneus is sometimes suggested by surgeons in severe recurrent cases.

Adjunctive care should include ensuring normal muscle tone, strength and length, with attention to the gait cycle, with use of rehabilitation exercises to counteract the compensation habits that may have been acquired. When inflammation is active, hydrotherapy and nutritional strategies, as outlined in Chapters 6 and 7, may be useful for symptom relief.

Anterior Achilles tendon bursitis (Albert’s disease)

The bursa, which lies anterior to attachment of the Achilles tendon to the calcaneus, may become inflamed due to injury or in association with inflammatory arthritis. It would be aggravated by anything that added strain to the Achilles tendon, including inappropriately high or rigid shoes.

Symptoms may arise suddenly in case of trauma, whereas if the bursa is being irritated by a systemic problem, such as arthritis, a slow evolution is likely. Swelling and heat, together with pain, will be noted in the retrocalcaneal space. Walking and tight shoes are likely to aggravate the symptoms, which over time extend medially and laterally, beyond the area anterior to the tendon.

Differential diagnosis is necessary to distinguish bursitis from a fractured posterolateral tubercle (see below and Box 14.5) or degenerative changes to the calcaneus (as may occur in rheumatoid arthritis). These conditions would be confirmed by X-ray, whereas the bursitis is characterized by warmth and swelling contiguous to the tendon, with pain noted mainly in the soft tissues. Rest and hydrotherapy may offer relief but when inflammation is severe, an intrabursal injection of a soluble corticosteroid is commonly helpful. Subsequent attention should focus on achieving normal muscle tone, strength and length, with particular focus on the individual’s gait cycle, with use of rehabilitation exercises to counteract the compensation habits acquired during immobilization.

Achilles tendinitis and rupture (clement 1984, rolf & movin 1997, teitz et al 1997)

Athletic overuse, change of terrain such as unaccustomed running up hill, a sudden increase in distance covered or the wearing of inappropriate shoes can all cause extreme stress to the Achilles tendon. Tendinitis is characterized by persistent pain and swelling and often by grating or crackling sensations as the ankle is moved into flexion and extension.

There may be clinical evidence of inflammation (redness, swelling, etc.) without histological evidence, in which case the correct term is tendinosis rather than tendinitis. Tendinosis may be related to localized areas of diminished blood supply just above the tendon insertion and may remain subclinical until a rupture occurs. Heel cord contractures may be present. Training errors in adults in their 30s and 40s, most commonly associated with running, are major contributory features.

Antiinflammatory strategies (RICE, etc.) are called for as well as avoiding undue pressure on the tendon. Use of cushioned shoes, and sometimes raising the heel to ease tendon stress, may help. Careful stretching is necessary and diligent warm-up protocols should be followed if active exercise is continued. There remains a risk of tendon rupture. If this occurs pain may be marked and there will be an inability to stand on tiptoe on the injured foot. Surgery or a cast is required. Any massage applied should be careful to avoid actively inflamed tissue but manual lymphatic drainage and gentle massage and stretching of healing tissue (after the first 2 weeks or so) may reduce scar tissue formation.

Posterior tibial nerve neuralgia

The posterior tibial nerve passes through a canal (tarsal tunnel) at the level of the ankle, where it divides into the medial and lateral plantar nerves. Fibroosseous compression of the nerve within the canal (tarsal tunnel syndrome), synovitis involving the flexor tendons of the ankle or inflammatory arthritis creating pressure on the nerve may all induce neuralgia. If swelling accompanies the neuralgia its source should be established (venous, inflammatory, rheumatic, traumatic, etc.).

Symptoms include pain (sometimes of a burning or tingling nature) in and around the ankle, which commonly reaches the toes. The pain is worse on walking (and sometimes on standing) and eased by rest.

When the nerve is irritated, tapping or applying light pressure to the posterior tibial nerve below the medial malleolus, at a site of compression or injury, often produces distal tingling (Tinel’s sign). Confirmation of the diagnosis of posterior tibial nerve neuralgia is by electrodiagnostic testing.

Treatment is commonly by means of strapping the foot into a neutral or slightly inverted position or may involve the wearing of orthotic supports that maintain inversion, so reducing tension on the nerve. If there is no neural compression within the canal, corticosteroid injections or, in severe unremitting cases, surgery may be suggested. Subsequent attention should focus on achieving normal muscle tone, strength and length, with particular focus on the individual’s gait cycle, with use of rehabilitation exercises to counteract the compensation habits acquired during immobilization.

Talocalcaneonavicular (TCN) joint

The talonavicular joint is the most anterior part of a more complex joint, the talocalcaneonavicular (TCN) joint (Fig. 14.17). Like the subtalar joint, it is a triplanar joint producing simultaneous movements across longitudinal, vertical and horizontal axis (supination/pronation, inversion/eversion). Because the TCN joint is a compound joint, having several articular surfaces in different planes, any movement produced by the talus results in mandatory motion at each of these surfaces.

Figure 14.17 The ‘socket’ of the talocalcaneonavicular joint

(adapted from Platzer 1992).

In a previous edition of their work, Levangie & Norkin (2001) described the TCN as the ‘key to foot function’, skillfully illustrating an interesting view with their description of this joint.

The talonavicular articulation is formed proximally by the anterior portion of the head of the talus and distally by the concave posterior navicular. The talar head, however, also articulates inferiorly with the anterior and medial facets of the calcaneus and with the plantar calcaneonavicular [spring] ligament, that spans the gap between the calcaneus and navicular below the talar head. Consequently, we can visualize the TCN as a ball and socket joint where the large convexity of the head of the talus is received by a large ‘socket’ formed by the concavity of the navicular, the concavities of the anterior and medial calcaneal facets, by the plantar calcaneonavicular ligament and by the deltoid ligament medially and the bifurcate ligaments laterally.

All of this is enclosed by a single capsule, hence the description of this complex as being a ‘joint’. The TCN joint capsule is reinforced by ligamentous support from the superomedial portion of the cartilage covered calcaneonavicular ligament (forming a sling for the head of the talus, which articulates with it), the inferior calcaneonavicular ligament, the medial and lateral collateral ligaments, inferior extensor retinacular structures, cervical ligament and the dorsal talocalcaneal and interosseous ligaments. Additionally, it gains support from related ligaments associated with the adjacent calcaneocuboid joint.

In a subsequent edition of their textbook, Levangie and Norkin (2005) put less emphasis on consideration of the TCN structure as a joint. ‘…it might be argued that even this compound term is incomplete. The talus in weight-bearing also can be considered to act as a ballbearing between three joints: (1) the tibiofibular mortise (the ankle joint) superiorly, (2) the calcaneus (the subtalar joint) inferiorly, and (3) the navicular bone (talonavicular joint) anteriorly. In weight-bearing supination/pronation, the talus dorsiflexes and plantarflexes within the mortise, as well as on the calcaneus and the navicular bone. Abduction/adduction of the talus during supination/pronation not only occurs on the calcaneus and the navicular bone but also affects the position of the mortise as the body of the talus laterally and medially rotates.’ It should also be borne in mind that each of these movements translates forces to all surrounding structures that must interact with weight distribution from above (influenced by balance, objects being carried, etc.) and ground reaction forces from below (influenced by terrain, speed, etc.). It is not surprising that anatomical terminology fails miserably in describing the complexities of the foot.

Transverse tarsal joint

The talonavicular and calcaneocuboid joints together form the compound transverse tarsal joint, an ‘S’-shaped joint that divides the hindfoot from the midfoot (Fig. 14.18). Forefoot range of movement in triaxial rotation (supination/pronation) is thereby increased by simultaneous gliding of the talonavicular and calcaneocuboid joints. As the medial edge of the foot is lifted (supinated, inverted) the talar head rotates on the navicular while cuboid glides down the calcaneus in an opposite movement. This transverse tarsal movement adds to the supination/pronation ranges occurring as a result of subtalar movement, and allows ‘the forefoot to remain flat on the ground (relatively immobile) while the hindfoot (talus and calcaneous) pronates or supinates in response to the terrain or the rotations imposed by the leg.’ (Levangie & Norkin 2005).

An important function of this joint is allowing tibial rotation to be absorbed by the hindfoot, without translating these destabilizing forces into the forefoot, a response that is critical to stability of the gait foot. The converse is also true, especially when on rough terrain. That is, if the forefoot must adjust to a rocky surface, the transverse tarsal joint absorbs forefoot rotation, reducing the translation of these forces into the hindfoot and subsequently, through the ankle joint, into the leg, knee and hip.

Tarsometatarsal (TMT) joints

The tarsometatarsal joints, composed of the articulation of the distal surface of the three cuneiforms and cuboid with the bases of the five metatarsals, have varying mobility (least mobile is the second metatarsal) and some shared capsules (2 and 3 share, 4 and 5 share).

In the medial column, the navicular articulates with the three wedge-like cuneiform bones, which in turn articulate with the first three metatarsals. Laterally, the cuboid articulates directly with the last two metatarsal bones. The cuneiform bones wedge together to form a transverse arch (see Box 14.6). Additionally, the medial and lateral cuneiforms project distally beyond the middle one, which forms a recess for the second metatarsal base and stabilizes it against motion.

Box 14.6 The plantar vault

The plantar vault is a structure that uses concepts of triangular equilibrium, with the anterior aspect of the triangle being a ‘floating’ component, which is bound somewhat at the posterior tarsus. The vault provides a dynamic component to gait while functional arches act as elastic shock absorbers. Unless exercised on actual ground surfaces (beaches, rocky slopes), the ability of the arches to ‘hollow’ and to adapt to ever-changing terrain is often lost to the town dweller, who almost always walks on even, firm ground.

Regarding the plantar vault, Kapandji (1987) eloquently states:

The plantar vault is an architectural structure which blends all the elements of the foot – joints, ligaments and muscles – into a unified system. Thanks to its changes of curvature and its elasticity, the vault can adapt itself to unevenness of the ground, and can transmit to the ground the forces exerted by the weight of the body and its movements. This it achieves with the best mechanical advantage under the most varied conditions. The plantar vault acts as a shock-absorber essential for the flexibility of the gait. Any pathological conditions, which exaggerate or flatten its curvatures, interfere seriously with the support of the body on the ground and necessarily with running, walking and the maintenance of the erect posture.

The plantar aponeurosis, which arises from superficial fascia and sometimes from the plantaris muscle (Cailliet 1997, Gray’s 2005), provides a substantial structural component for the plantar vault of the foot. Levangie & Norkin (2001) simplify this concept.

From the beginning to the end of the stance phase of gait, tension on the platar aponeurosis increases…For this reason, the function of the aponeurosis in supporting the arches has been compared to the function of a tie-rod on a truss. The truss and the tie-rod form a triangle; the two struts of the truss form the sides of the triangle and the tie-rod is the bottom. The talus and calcaneus form the posterior strut, and the remaining tarsal and the metatarsals form the anterior strut. The plantar aponeurosis, as the tie-rod, holds together the anterior and posterior struts when the body weight is loaded onto the triangle. This structural design is efficient for the weight-bearing foot because the struts (bones) are subjected to compression forces, whereas the tie-rod (aponeurosis) is subjected to tension forces. Bending moments to the bone that can cause injury are minimized.

The functional anatomy of the foot is commonly described in terms of its longitudinal and transverse arches, which help compose the ‘vault’ (Fig. 14.19). The longitudinal arch (or curve) can be divided into medial and lateral constituents and is accompanied by a transverse curvature.

Figure 14.19 The plantar vault from a medial perspective, with its three support points occurring at the calcaneus and the first and fifth metatarsal heads

(reproduced with permission from Kapandji 1987).

The medial longitudinal (‘spring’) arch has bony components (pillars) composed of the calcaneus, talus, navicular, the cuneiforms and the first three metatarsals (Fig. 14.20). This arch is designed to transmit and absorb force. Gray’s anatomy (2005) summarizes:

The bones themselves contribute little to the stability of the arch, whereas the ligaments contribute significantly. The most important ligamentous structure is the plantar aponeurosis, which acts as a tie beam between the supporting pillars. Dorsiflexion, especially of the hallux, draws the two pillars [calcaneous and three metatarsal heads] together, thus heightening the arch.

Figure 14.20 The medial longitudinal arch. A: first metatarsal contact; C: calcaneal contact; PL: fibularis (peroneus) longus; TP: tibialis posterior; FHL: flexor hallucis longus; Ab HL: abductor hallucis longus; 1: plantar calcaneonavicular ligament; 2: talocalcanean ligament; 3: tibialis posterior attachment, which blends with plantar ligaments

(reproduced with permission from Kapandji 1987).

The medial longitudinal arch is higher, more mobile and resilient than the lateral and, as it flattens, there is a progressive tightening of the plantar calcaneonavicular ligament and plantar fascia. Active support of the medial arch is primarily supplied by tibialis posterior (the tendon of which has attachments on the navicular, first cuneiform and the bases of the second, third and fourth metatarsals), fibularis (peroneus) longus, flexor hallucis longus, flexor digitorum longus and abductor hallucis.

The lateral longitudinal arch comprises the calcaneus, cuboid and the fourth and fifth metatarsals (Fig. 14.21). This arch is low, has limited mobility and is designed for transmission of force to the walking surface rather than for the absorption of weight and thrust (Gray’s anatomy 2005, Schiowitz 1991). Muscles acting to tighten it include fibularis brevis and longus, and abductor digiti minimi.

The transverse arch is best described as an almost full-length transverse curvature of the tarsals and metatarsals, giving a ‘vaulted’ appearance to the foot. It can be examined at several locations along its length (Fig. 14.22). The flexible anterior aspect includes the metatarsal heads. The fixed metatarsal arch includes the bases of the metatarsals. The fixed posterior aspect includes the cuboid and the cuneiforms, resting on the ground only at the laterally placed cuboid while the neighboring navicular is ‘slung above the ground and overhangs the medial surface of the cuboid’ (Kapandji 1987). The muscular support for the transverse arch includes fibularis longus (which acts on all three components of the arch system), adductor hallucis running transversely and tibialis posterior, which runs (from beneath the medial malleolus) obliquely anterolaterally.

Figure 14.21 The lateral longitudinal arch. B: fifth metatarsal contact; C: calcaneal contact; PL: fibularis (peroneus) longus; PB: fibularis (peroneus) brevis; Ab 5: abductor digiti minimi; 4: long plantar ligament deep; 5: long plantar ligament superficial; 6: peroneal tubercle of calcaneus

(reproduced with permission from Kapandji 1987).

Figure 14.22 The ‘vaulted’ appearance of the foot is in part due to an almost full-length transverse curvature of the tarsals and metatarsals. The degree of transverse arching will vary at different points of the foot, as shown here by considering the metatarsal heads, metatarsal bases and the tarsals

(adapted from Cailliet 1997).

The intrinsic muscles are significant contributors to the muscular support of the arches. Their line of pull lies essentially in the long arch of the foot and perpendicular to the transverse tarsal joints; thus they can exert considerable flexion force on the forefoot and are also the principal stabilizers of the transverse tarsal joint.

Regarding the arches, though there are some shared philosophies, there is little agreement, especially concerning the ‘transverse arch’.

• Schiowitz (1991) suggests that although: ‘many authors describe a number of transverse arches, with the exception of the metatarsal heads, these arches do not transmit force to the ground’.

• Gray’s anatomy (2005), in partial agreement with Schiowitz, states that: ‘Transmission of force occurs at the metatarsal heads, to some degree along the lateral border of the foot, and through subjacent soft tissues.’

• Regarding the anterior metatarsal transverse arch comprising the five metatarsal heads, Greenman (1996) suggests that: ‘The metatarsal arch is not a true arch, but refers to the relation of the heads of the five metatarsals’. He notes that restrictions of the metatarsal heads are usually secondary to dysfunctional patterns involving the other arches of the foot and are likely to be associated with soft tissue changes, especially involving the plantar fascia (see below). Joint play here includes dorsal and plantar glide, as well as rotation (Greenman 1996). If restriction is noted it is commonly between the second and third metatarsals, with associated tenderness in the interosseous musculature.

Gray’s anatomy (1995) observes that:

The human foot, alone among primates, is normally arched in its skeletal basis, usually with visible concavity in the sole. The word ‘arch’ so applied has perhaps become too architectural, imposing rigidity on classical descriptions of curved pedal form and differences of interpretation more linguistic than factual. The word has several meanings and doubtless ‘arches of the foot’ has various implications. As a start, at simplest, the term implies little more than a curved form, concave on the plantar aspect. Such an arch should not be compared with static masonry, with pediments on terra firma and an intermediate keystone structure. The pedal arch is dynamic; muscles and ligaments are functionally inseparable. Moreover, its heel is often off the ground. In this account, therefore, ‘arch’ denotes no more than curved form, just as the back is merely curved when ‘arched’.

It should be borne in mind that the plantar vault, whether considered as a twisted osteoligamentous plate (Gray’s anatomy 2005, Levangie & Norkin 2005) or as an architectural wonder, is an integral component of whole-body health, its influences being felt both locally and throughout the body. The health and integrity of this dynamic system should be a priority component of most therapeutic interventions.

The articular surfaces with adjoining metatarsals allow a little movement between them. Stability is reinforced by numerous ligaments, including the deep transverse metatarsal ligament, which helps prevent excessive movement and splaying (spreading apart) of the metatarsal heads (Levangie & Norkin 2005).

The function of the TMT joints is to continue the movements of the transverse tarsal joint when needed, while retaining ground contact of the forefoot. Levangie & Norkin (2005) note:

As the weight-bearing hindfoot moves in inversion and eversion patterns, the midfoot and forefoot move in the opposite direction to counterrotate the forefoot, in order to maintain plantar contact. This compensation usually occurs first in the transverse tarsal joint and, if necessary, further compensation occurs at the TMT joints, including varying dorsiflexion and plantarflexion of the rays of the foot. For example, if the calcaneus inverts (supinates), the forefoot must produce relative pronation in order to maintain contact with the ground, otherwise the medial aspect would lift from the ground and create instability. Most of the forefoot pronation will occur at the transverse tarsal joint but, if calcaneal movement is extreme, then tarsometatarsal joints must also compensate, which may include dorsi- and plantarflexion as well as rotational movements of the rays about the second toe, commonly referred to as a supination twist (Levangie & Norkin 2005). This rotation about the second ray (longitudinal axis) will increase or decrease the curvature of the anterior arch (Kapandji 1987). The configuration of the forefoot will vary depending upon the surface to which the foot is adjusting.

The arches of the foot

The midfoot region of the foot is usually associated with the arch system. Although the plantar vault truly span over almost the full length of the foot, dysfunction of the medial longitudinal arch is usually most visible in the midfoot region. The plantar vault, with its longitudinal and transverse arches, is more fully discussed in Box 14.6.

Pes planus (flat foot)

If the medial longitudinal arch is lost this is known as pes planus or flat footed, and can be either flexible or rigid. Flexible flat foot, which is marked by the reappearance of the arch when the foot is non-weight-bearing, may be correctable, whereas rigid flat foot does not usually respond to manual therapies or exercise. Mechanically, collapse of this arch may occur because of hyperpronation or from increased eversion of the subtalar joint. This leads to the calcaneus lying in valgus and external rotation relative to the talus. It is most noticeable in the midfoot region where associated sagging or medial excursion of the midfoot occurs when the talus moves anteriorly, medially and inferiorly, the navicular slides inferiorly, and the calcaneus pronates (Levangie & Norkin 2005).

The incidence of pes planus is approximately 20% in adults, the majority of which are flexible. Flat feet are not necessarily uncomfortable, as long as there is no heel cord contracture, but flat feet associated with heel cord contracture may limit function and lead to discomfort when walking. Heel cord contracture is associated with lateral deviation of Achilles when weight bearing (Staheli et al 1987).

Evidence suggests that flat feet protect against metatarsal stress fractures but the feet offer poor shock absorption with regard to the lower back, leading to a higher incidence of low back pain. In contrast, a pes cavus foot (high arch) may actually be somewhat protective of stress-related low back pain (Ogon 1999). Although associated foot dysfunction (hammer toe, claw toe) may result, the consequences of pes cavus are not usually as far-reaching as pes planus.

It is important to distinguish between flexible flat foot and rigid (or spastic) flat foot. Surgical intervention is only called for if there is a rigid flat foot (seldom in flexible flat foot) and only when pain, deformity (midfoot breakdown) or severe contracture are factors. A small number of flexible flat feet do not correct with growth and eventually become rigid due to adaptive changes (Lau & Daniels 1998).

Sesamoid bones of the lower extremity

Non-articular sesamoid bones or cartilages are frequently found in the lower limb (Gray’s anatomy 2005) and bursal arrangements may also occur at such sites. Those muscles in the lower limb in which these minute bones are commonly found include: