Clinical Anatomy of The Foot

By Dr.Sanaa Alshaarawy

After the end of this lecture you should able to :•Know the Function of foot arches.•Describe the Medial, Lateral longitudinal and Transverse arches.•Know Maintenance of the longitudinal arches.•Describe Applied anatomy regarding the arches.•Describe Clinical Anatomy regarding deep fascia,muscles,joints,nerves and vessels.• Describe the Tarsal Tunnel Syndrome.

OBJECTIVES OF Clinical Anatomy Of FOOT

Arches of the Foot•The foot arches are formed by the bones, ligaments, and tendons of the foot.

Function :

They act as a weight bearing.

They act as a locomotive part of the body in walking & running.

They provide space in the sole of foot to contain and protect the muscles, nerves and blood vessels of the sole.

They provide support and flexibility to the foot.

Medial Longitudinal Arch•The "medial longitudinal arch" is the most prominent foot arch.

• It runs from front to back along the inner edge of the foot.

•This arch absorbs the majority of the shock of impact while walking, jumping or running.

•This arch is very tall and is extremely flexible due to its large number of component bones.•Its apex (the trochlear surface of the talus) and its two extremities which are the medial tubercle of the calcaneum and the heads of 1st -3rd metatarsals..• It is formed of calcaneum, talus, navicular, 3 cuneiform bones, and first medial 3 metatarsal bones.

Medial Longitudinal Arch

Lateral Longitudinal ArchIt runs along the outer edge of the foot.It is most visible in people with very high arches.It is difficult to define its apex because although body weight is transmitted into it via the talus, the talus is not part of the arch.The extremities are the lateral tubercle of the calcaneum and the heads of 4th -5th metatarsals.This arch is flat and contains relatively few bones.It is formed of calcaneum, cuboid and lateral 4th & 5th metatarsal bones.

Transverse Arch• It runs across the midfoot.• Lies at the level of tarso-metatarsal joints.• It provides support and flexibility to the foot.• This arch is maintained by the same muscles and ligaments as the longitudinal arches. •Formed of bases of all metatarsal bones, cuboid and 3 cuneiform bones.

Factors Maintaining Foot ArchesThese arches are maintained by :•The shape of the foot bones which allows them to interlock. •The activity of muscles.• A wide variety of ligaments (plus the tendons of muscles acting as ligaments) play an important role in supporting the arches..

Maintenance of the longitudinal arches

•The longitudinal arches are supported and stabilised by :•The shape of the bones which allows them to interlock•The muscles whose tendons run into the apex of the arches and tend to increase their height (e.g. tibialis anterior) •The muscles whose tendons run into the sole of the foot where they have a longitudinal course. They prevent the extremities separating (e.g. peroneus longus and small intrinsic muscles which also run longitudinally).

•A variety of longitudinally arranged ligaments which prevent the extremities separating, for example the long and short plantar ligaments and by the plantar calcaneonavicular ("spring") ligament.

ligaments

The plantar aponeurosis arises posteriorly from calcaneus and distally divides into five bands that become continuous with the fibrous digital sheaths that enclose the flexor tendons of the toes.• It has slips to the toes, Extending (raising) the toes and heightening the longitudinal arches.

Maintenance of the longitudinal arches

Applied Anatomy of Foot

BIRTH DEFECTS (Clubfoot).High Arches.Flat Foot.

BIRTH DEFECTS :Clubfoot is a common congenital deformity involving one foot or both.The affected foot appears to have been rotated internally at the ankle.In babies with clubfoot the ligaments and tendons of muscles are shorter than usual causing their feet to be twisted.In many cases, the defect can be corrected using casts on the childs's feet and legs but some cases may require surgery.Without treatment, people with club feet often appear to walk on their ankles or on the sides of their feet. However with treatment, the majority of patients recover completely during early childhood and are able to walk.

Pes Cavus (High Foot Arch)

• Cavus foot is a condition in which the foot has a very high arch.• It is the opposite of flat foot.• It is much less common than flat foot.• There is a fixed plantar flexion deformity of the foot.

Causes : It may be hereditary or acquired, They are more associated with an orthopedic, neurological or neuromuscular conditions. Neuromuscular diseases that cause changes in muscle tone (shortening of muscles or tendons of leg or sole), in most cases due to poliomyelitis.It usually need foot support. A high arch may cause significant disability.

Symptoms :•Shortened length of foot.•Difficulty fitting shoes.•Hammertoes (bent toes) or claw toes.•Foot pain associated with walking, standing, and running.

Pes Cavus (High Foot Arch)

Pes planus (Flat Foot)The medial longitudinal arch is depressed, so the foot is displaced laterally and everted.

Causes of flat foot :

• Congenital.• Stretched or torn tendons.• Damage or inflammation of the tibialis posterior tendon, which connects from your lower leg, along your ankle, to the middle of the arch• Broken or dislocated bones.• Some health conditions, such as rheumatoid arthritis.• Nerve problems.• So weak muscles & ligaments are stretched and pain is produced after walking for a short distance.

Other factors that can increase your risk include:ObesityDiabetesPregnancyLong standing or Long walking.

Anatomical Importance of the Deep Fascia Of Foot

• The deep fascia is thin on the dorsum of the foot.•The plantar fascia, the deep fascia of the sole, is thicker in the central part (plantar aponeurosis) and weaker medial and lateral parts.• The plantar fascia holds parts of the foot together, helps protect the sole from injury, and helps support the longitudinal arches of the foot.

The Anatomical Importance of the Muscles of the Foot

• Of the 20 individual muscles of the foot, 14 are located on the plantar aspect, 2 are on the dorsal aspect, and 4 are intermediate in position. • On the dorsum of the foot, there are two closely connected muscles: the extensor digitorum brevis (EDB) and extensor hallucis brevis (EHB). These muscles form a fleshy mass on the lateral part of the dorsum of the foot, they aid the extensor digitorum and extensor hallucis longus to extend digits.

The Anatomical Importance of the Muscles of the Foot

Most of the muscles are lying in the sole.The plantar muscles (muscles of the sole) are located in four layers. They don’t work as complicated as the small muscles in the hands; they mostly work together to support the arches of the foot.

•Rather than producing actual movement, they are most active in fixing the foot or to maintain balance.• Plantar interossei ADduct and arise from a single metatarsal as unipennate muscles.• Dorsal interossei ABduct and arise from two metatarsals as bipennate muscles.

The Anatomical Importance of the Muscles of the Foot

Joints of the Foot

Articulation : • Inferior surface of body of talus. • Upper surface of calcaneum. • It is a talocalcaneal part of talocalcaneonavicular joint.Movements : • Inversion. • Eversion.

Subtalar (talocalcaneal) Joint :

Nerves and Arteries Of Foot•The tibial nerve and posterior tibial artery divide posterior to the medial malleolus into the medial and lateral plantar nerves and arteries.•These nerves & arteries supply the intrinsic muscles of the sole of foot.

Clinical Anatomy of the Dorsal venous arch of Foot Is a superficial vein that connects the small saphenous vein and the great saphenous vein. It drains deoxygenated blood from the foot.It lies superior to the metatarsal bones.Clinical significance :Varicose veins: The great saphenous vein, like other superficial veins, can become varicose; swollen, twisted and lengthened. • Elevating the legs provides temporary symptomatic relief.• Advice about regular exercise.• Wearing of compression stockings.Venous Thrombosis : if the blood clot is located near the sapheno-femoral junction , a clot fragment can migrate to the deep venous system and to the pulmonary circulation. Also it can be associated with, or progress to a deep vein thrombosis which must be treated immediately.

Dorsalis Pedis ArteryIt supplies the dorsum of the foot. It arises at the anterior aspect of ankle joint as a continuation of the anterior tibial artery. It terminates at the first intermetatarsal space, where it divides into two branches, the first dorsal metatarsal artery and the deep plantar artery.

Clinical Anatomy of the dorsalis pedis arteryThe dorsalis pedis artery pulse can be palpated lateral to the extensor hallucis longus tendon on the dorsum of the foot.

It is often examined, by physicians, in cases of peripheral vascular disease.

Recently, MR angiography has been reported as an accurate technique for analyzing the foot arteries in diabetic patients referred for surgical revascularization.

What are the symptoms of tarsal tunnel syndrome?When the tibial nerve is compressed in the tarsal tunnel, patients commonly complain of numbness over the bottom of the foot, as well as complaints of burning pain, and tingling over the base of the foot and heel.

What is the cause of tarsal tunnel syndrome?Unknown in most cases, but can be the result of fractures, benign tumors, muscle injury, or foot deformities.

What is the tarsal tunnel?It is a space in the foot located between bones and the flexor retinaculum .

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