Joints of the lower limb pdf - Lower limb

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CHAPTER 10

the condyles of the tibia and their cartilaginous menisci

Above are the rounded condyles of the femur; below are

Articulation

Note that the fibula is not directly involved in the joint.

between the patella and the patellar surface of the femur.

the corresponding condyles of the tibia, and a gliding joint,

between the medial and lateral condyles of the femur and

in the body. Basically, it consists of two condylar joints

The knee joint is the largest and most complicated joint

The hip joint is fully described on page 467.

articular branches to the joints of the foot.

sor digitorum brevis muscle. Both terminal branches give

ond toes (Fig. 10.60). The lateral branch supplies the exten

supplies the skin of the adjacent sides of the big and sec

terminal, medial, and lateral branches. The medial branch

of the dorsalis pedis artery (see page 485). It divides into

The Lower Limb

-
-

Joints of the Lower Limb

Knee Joint

(Fig. 10.35); in front is the articulation between the lower

tellar bursa

suprapa

beneath the quadriceps tendon, forming the

permitting the synovial membrane to pouch upward

the joint. On the front of the joint, the capsule is absent,

surfaces and surrounds the sides and posterior aspect of

The capsule is attached to the margins of the articular

vial joint of the plane gliding variety.

possible. The joint between the patella and femur is a syno

the hinge variety, but some degree of rotatory movement is

The joint between the femur and tibia is a synovial joint of

Type

tibial plateaus

referred to clinically as the medial and lateral

faces of the medial and lateral condyles of the tibia are often

covered with hyaline cartilage. Note that the articular sur

The articular surfaces of the femur, tibia, and patella are

end of the femur and the patella.

Capsule

(Fig.

h side of the patella, the

10.35). On eac

above to the lateral condyle of the femur and below to the

is cordlike and is attached

lateral collateral ligament

The

the common tendon of the quadriceps femoris muscle.

10.35). It is, in fact, a continuation of the central portion of

der of the patella and below to the tuberosity of the tibia (Fig.

is attached above to the lower bor

ligamentum patellae

The

Extracapsular Ligaments

capsule and those that lie within the capsule.

The ligaments may be divided into those that lie outside the

Ligaments

permits the tendon of the popliteus to emerge (Fig. 10.35).

An opening in the capsule behind the lateral tibial condyle

(Fig. 10.35).

oblique popliteal ligament

muscle called the

is strengthened by an expansion of the semimembranous

vastus lateralis and medialis. Behind the joint, the capsule

capsule is strengthened by expansions from the tendons of

head of the fibula (Fig. 10.35). The tendon of the popliteus

and below to the medial surface of the shaft of the tibia

attached above to the medial condyle of the femur

medial collateral ligament

The

meniscus (Fig. 10.61).

muscle intervenes between the ligament and the lateral

is a flat band and is

(Fig. 10.35).

popliteal bursa

popliteus, forming the

longed downward on the deep surface of the tendon of the

At the back of the joint, the synovial membrane is pro

muscle (Fig. 10.35).

articularis genus

called the

ment of a small portion of the vastus intermedius muscle,

. This is held in position by the attach

suprapatellar bursa

cle for three fingerbreadths above the patella, forming the

which extends up beneath the quadriceps femoris mus

10.61). On the front and above the joint, it forms a pouch,

to the margins of the articular surfaces (Figs. 10.35 and

The synovial membrane lines the capsule and is attached

Synovial Membrane

it is relatively immobile.

meniscus is also attached to the medial collateral ligament,

tibia by anterior and posterior horns. Because the medial

Each meniscus is attached to the upper surface of the

cushions between the two bones.

to receive the convex femoral condyles; they also serve as

tion is to deepen the articular surfaces of the tibial condyles

surfaces are in contact with the tibial condyles. Their func

faces are in contact with the femoral condyles. The lower

forms a free edge (Figs. 10.35 and 10.61). The upper sur

capsule, and the inner border is thin and concave and

tilage. The peripheral border is thick and attached to the

The menisci are C-shaped sheets of fibrocar

Menisci

being pulled posteriorly.

With the knee joint flexed, the PCL prevents the tibia from

prevents anterior displacement of the femur on the tibia.

medial femoral condyle (Figs. 10.35 and 10.61). The PCL

be attached to the anterior part of the lateral surface of the

of the tibia and passes upward, forward, and medially to

ament (PCL) is attached to the posterior intercondylar area

The posterior cruciate lig

Posterior Cruciate Ligament

from being pulled anteriorly.

tibia. With the knee joint flexed, the ACL prevents the tibia

ACL prevents posterior displacement of the femur on the

the lateral femoral condyle (Figs. 10.35 and 10.61). The

be attached to the posterior part of the medial surface of

of the tibia and passes upward, backward, and laterally, to

ment (ACL) is attached to the anterior intercondylar area

The anterior cruciate liga

Anterior Cruciate Ligament

tibia throughout the joint’s range of movement.

ligaments are the main bond between the femur and the

to their tibial attachments (Fig. 10.61). These important

10.35). They are named anterior and posterior, according

ments that cross each other within the joint cavity (Fig.

are two strong intracapsular liga

cruciate ligaments

The

Intracapsular Ligaments

strengthens the posterior aspect of the capsule (Fig. 10.35).

sion derived from the semimembranosus muscle. It

is a tendinous expan

oblique popliteal ligament

The

(Fig. 10.61).

meniscus

It is firmly attached to the edge of the medial

. A bursa is

osed

interp

Basic Anatomy

501

infrapatellar pad of fat

infrapatellar fold

of synovial membrane

alar fold

anterior cruciate

ligament

medial

collateral

ligament

medial

meniscus

sartorius

gracilis

saphenous nerve

great saphenous vein

semimembranosus

semitendinosus

oblique popliteal ligament

gastrocnemius (medial head)

small saphenous vein

tibial nerve

popliteal artery

gastrocnemius (lateral head)

posterior cruciate ligament

popliteal vein

plantaris

common peroneal nerve

deep fascia

biceps femoris

popliteus

tendon

lateral collateral

ligament

lateral

meniscus

capsule

synovial membrane

transverse ligament

ligamentum patellae

prepatellar bursa

FIGURE 10.61

Relations of the right knee joint.

ceps muscle and communicates with the joint cavity

lies beneath the quadri

suprapatellar bursa

The

Anterior Bursae

may communicate with the joint.

membranosus bursa

semi

always communicate with the joint, and the

bursa

popliteal

suprapatellar bursa

behind the joint. The

Four are situated in front of the joint and six are found

found wherever skin, muscle, or tendon rubs against bone.

Numerous bursae are related to the knee joint. They are

Bursae Related to the Knee Joint

(Fig. 10.61).

alar folds

borders of the fold are termed the

the free

infrapatellar fold;

mentum patellae to form the

is reflected backward from the posterior surface of the liga

In the anterior part of the joint, the synovial membrane

behind the synovial cavity and are not bathed in synovial fluid.

ligaments (Fig. 10.61). As a result, the cruciate ligaments lie

posterior part of the capsule around the front of the cruciate

The synovial membrane is reflected forward from the

quently communicates with the synovial cavity of the joint.

and it fre

semimembranosus bursa,

this is termed the

medial femoral condyle and the semimembranosus tendon;

between the medial head of the gastrocnemius and the

and the

■

(Fig. 10.35). It is described above.

communicate with the joint cavity. It was described

insertion of the semimembranosus muscle and may

is found related to the

semimembranosus bursa

The

cavity. It was described previously.

don of the popliteus and communicates with the joint

is found in association with the ten

popliteal bursa

The

Posterior Bursae

tum patellae and the tibia (Fig. 10.35).

lies between the ligamen

deep infrapatellar bursa

The

part of the ligamentum patellae (Fig. 10.35).

neous tissue between the skin and the front of the lower

lies in the subcuta

superficial infrapatellar bursa

The

(Figs. 10.35 and 10.61).

patella and the upper part of the ligamentum patellae

between the skin and the front of the lower half of the

lies in the subcutaneous tissue

prepatellar bursa

The

■

previously.

nerves supply the knee joint.

The femoral, obturator, common peroneal, and tibial

Nerve Supply

medial head of origin of the gastrocnemius muscle.

of origin of the gastrocnemius muscle; and beneath the

pass to their insertion on the tibia; beneath the lateral head

the sartorius, gracilis, and semitendinosus muscles as they

of insertion of the biceps femoris; related to the tendons of

The remaining four bursae are found related to the tendon

502

CHAPTER 10

sus muscles, assisted by the gracilis, sartorius, and popliteus

The biceps femoris, semitendinosus, and semimembrano

The following muscles produce movements of the knee joint.

especially the cruciate ligaments, are slack in this position.

on the femur. This is possible because the major ligaments,

the tibia can also be moved passively forward and backward

erable range of rotation is possible. In the flexed position,

When the knee joint is flexed to a right angle, a consid

being pulled backward also.

popliteus to the lateral meniscus results in that structure

ing contour of the femoral condyles. The attachment of the

again, the menisci have to adapt their shape to the chang

muscle, which laterally rotates the femur on the tibia. Once

ing or untwisting process is accomplished by the popliteus

permit movements between the joint surfaces. This unlock

tial that the major ligaments be untwisted and slackened to

Before flexion of the knee joint can occur, it is essen

The extended knee is said to be in the locked position.

rubber cushions between the femoral and tibial condyles.

rigid structure; the cartilaginous menisci are compressed like

ligaments of the joint, and the knee becomes a mechanically

the femur results in a twisting and tightening of all the major

medial rotation of

assumes the position of full extension,

The knee joint can flex, extend, and rotate. As the knee joint

Movements

The Lower Limb

Flexion

(Fig. 10.61)

Biceps femoris and common peroneal nerve

Laterally:

cles (Fig. 10.61)

Sartorius, gracilis, and semitendinosus mus

Medially:

taris (Fig. 10.61)

oris, the two heads of the gastrocnemius, and the plan

semimembranosus, the semitendinosus, the biceps fem

form the boundaries of the popliteal fossa, namely, the

peroneal nerves; lymph nodes; and the muscles that

The popliteal vessels; tibial and common

Posteriorly:

The prepatellar bursa (Fig. 10.61)

Anteriorly:

Important Relations

knee joint.

especially the quadriceps femoris, after injury to the

otherapist to build up the strength of these muscles,

cles is the most important, and it is the job of the physi

of the ligaments. Of these factors, the tone of the mus

the strong muscles acting on the joint and the strength

The stability of the knee joint depends on the tone of

The biceps femoris produces lateral rotation.

Lateral Rotation

rotation.

The sartorius, gracilis, and semitendinosus produce medial

Medial Rotation

limited by the tension of all the major ligaments of the joint.

The quadriceps femoris produces extension. Extension is

of the back of the leg with the thigh.

muscles, produce flexion. Flexion is limited by the contact

may be laterally rotated on the femur to lock the knee joint.

lize the knee joint. However, if the foot is raised off the ground, the tibia

is standing, the femur is medially rotated on the tibia to lock and stabi

Note that when the foot is firmly planted on the ground when a person

Extension

-
-

■

-
-

■

Strength of the Knee Joint

ligament in the body, for which surgery is performed. The condi

Tears of the ACL

Forced adduction of the tibia on the femur can result in injury

whereas sprains of the medial collateral ligament result in ten

femoral or tibial attachments. It is useful to remember that tears

of insertion of the vastus lateralis and medialis, respectively.

aged, the large synovial cavity becomes distended with fluid. The

the quadriceps femoris; provided that this is well developed, it is

muscles acting on the joint. The most important muscle group is

ligaments that bind the femur to the tibia and on the tone of the

The strength of the knee joint depends on the strength of the

capable of stabilizing the knee in the presence of torn ligaments.

Knee Injury and the Synovial Membrane

The synovial membrane of the knee joint is extensive, and if the

articular surfaces, menisci, or ligaments of the joint are dam-

wide communication between the suprapatellar bursa and the

joint cavity results in this structure becoming distended also. The

swelling of the knee extends three or four fingerbreadths above

the patella and laterally and medially beneath the aponeuroses

Ligamentous Injury of the Knee Joint

Four ligaments—the medial collateral ligament, the lateral col-

lateral ligament, the ACL, and the PCL—are commonly injured

in the knee. Sprains or tears occur depending on the degree of

force applied.

Medial Collateral Ligament
Forced abduction of the tibia on the femur can result in partial

tearing of the medial collateral ligament, which can occur at its

of the menisci result in localized tenderness on the joint line,

derness over the femoral or tibial attachments of the ligament.

Lateral Collateral Ligament

to the lateral collateral ligament (less common than medial liga-

ment injury).

Cruciate Ligaments
Injury to the cruciate ligaments can occur when excessive force

is applied to the knee joint.

are common. It is the most frequently injured

tion is more common in women and this may be explained by the

different alignment of the thigh on the leg in women associated

with the wider pelvis. There is also an increased risk in women

during the preovulatory phase of the menstrual cycle, possibly

C L I N I C A L N O T E S

(continued)

Basic Anatomy

503

due to the influence of the female sex hormones.

such as the cruciate ligaments and the menisci, for diagnostic

This technique permits the direct visualization of structures,

into the synovial cavity of the knee joint through a small incision.

Arthroscopy involves the introduction of a lighted instrument

wedged between the articular surfaces, further movement is

length (Fig. 10.63). When the torn part of the meniscus becomes

being subjected to a severe grinding force, and it splits along its

sudden movement between the condyles results in the meniscus

position between the femoral and tibial condyles (Fig. 10.62A). A

the femur, and the medial meniscus is pulled into an abnormal

taking the weight of the body. The tibia is usually abducted on

is rotated on the femur, with the knee joint partially flexed and

injury occurs when the femur is rotated on the tibia, or the tibia

eral ligament of the knee joint, which restricts its mobility. The

probably because of its strong attachment to the medial collat

damaged much more frequently than the lateral, and this is

Injuries of the menisci are common. The medial meniscus is

however, the capsule of the joint and the collateral ligaments be

on the quadriceps femoris muscle is begun at once. Should,

immobilized in slight flexion in a cast, and active physiotherapy

torn cruciate ligaments is not always attempted. The knee is

integrity of the collateral ligaments, operative repair of isolated

largely on the tone of the quadriceps femoris muscle and the

(Fig. 10.62). Because the stability of the knee joint depends

tibia can be made to move excessively backward on the femur

on the femur; with rupture of the posterior cruciate ligament, the

ligament shows that the tibia can be pulled excessively forward

len. Examination of patients with a ruptured anterior cruciate

commonly torn, or the capsule may be damaged. The joint cavity

damage to other knee structures; the collateral ligaments are

Injury to the cruciate ligaments is always accompanied by

Tears of the

PCL are rare.

quickly fills with blood (hemarthrosis) so that the joint is swol-

torn in addition, early operative repair is essential.

Meniscal Injury of the Knee Joint

impossible, and the joint is said to “lock.”

Injury to the lateral meniscus is less common, probably

because it is not attached to the lateral collateral ligament of

the knee joint and is consequently more mobile. The popliteus

muscle sends a few of its fibers into the lateral meniscus, and

these can pull the meniscus into a more favorable position dur-

ing sudden movements of the knee joint.

Pneumoarthrography

Air can be injected into the synovial cavity of the knee joint so

that soft tissues can be studied. This technique is based on

the fact that air is less radiopaque than structures such as the

medial and lateral menisci, so their outline can be visualized on

a radiograph (Fig. 10.76).

Arthroscopy

purposes.

cruciate ligament

ruptured posterior

cruciate ligament

ruptured anterior

cruciate ligament

test for posterior

cruciate ligament

r anterior

foot on ground

of fall

direction of impact

direction

medial
meniscus

test fo

FIGURE 10.62

posterior cruciate ligament (PCL).

Test for integrity of the

Test for integrity of the anterior cruciate ligament (ACL).

ground between the femur and the tibia.

of the tibia on the femur, and the medial meniscus is pulled into an abnormal position. The cartilaginous meniscus is then

right knee joint is semiflexed and that medial rotation of the femur on the tibia occurs. The impact causes forced abduction

Mechanism involved in damage to the medial meniscus of the knee joint from playing football. Note that the

504

CHAPTER 10

The Lower Limb

medial meniscus

FIGURE 10.63

Tears of the medial meniscus of the knee

10.65). The opposed bony surfaces are roughened.

of the tibia and the lower end of the fibula (Figs. 10.64 and

Articulation is between the fibular notch at the lower end

Articulation

Distal Tibiofibular Joint

movements at the ankle joint.

A small amount of gliding movement takes place during

Movements

The common peroneal nerve supplies the joint.

Nerve Supply

the margins of the articular surfaces.

The synovial membrane lines the capsule and is attached to

Synovial Membrane

the tibia and fibula together, also greatly strengthens the joint.

which connects the shafts of

interosseous membrane,

The

strengthen the capsule.

posterior ligaments

Anterior

Ligaments

gins of the articular surfaces.

The capsule surrounds the joint and is attached to the mar

This is a synovial, plane, gliding joint.

Type

flattened and covered by hyaline cartilage.

the head of the fibula (Fig. 10.35). The articular surfaces are

Articulation is between the lateral condyle of the tibia and

Articulation

Proximal Tibiofibular Joint

Tear of the anterior portion of

Tear of the posterior

torn from its peripheral attachment.

The meniscus is

Complete bucket handle tear.

joint. A.

portion of the meniscus. D.

the meniscus.

Capsule

and

posterior ligament of distal tibiofi

posterior talofibular ligament

calcaneofibular ligament

anterior talofi

anterior ligament of distal tibiofi

fibula

tuberosity of navicular

calcaneonavicular

tibia

medial malleolus

medial (deltoid) ligament

calcaneum

sustentaculum tali

plantar

ligament

talus

tibia

bular joint

talus

bular ligament

bifurcated ligament

dorsal tarsal ligaments

cuboid

dorsal tarsometatarsal ligaments

calcaneum

lateral malleolus

bular joint

FIGURE 10.64

The right ankle joint as seen from the medial aspect (A) and the lateral aspect (B).

Basic Anatomy

505

calcaneofibular ligament

peroneus brevis

lateral plantar vessels and ner

flexor digitorum brevis

flexor digitorum longus

tibialis posterior

posterior tubercle of talus

posterior talofi

calcaneofibular ligament

inferior transverse ligament

posterior tibiofibular ligament

tibia

interosseous membrane

fibula

lateral malleolus

calcaneum

sustentaculum tali

bular ligament

medial tubercle of talus

medial (deltoid) ligament

capsule

medial malleolus

tibia

medial malleolus

medial (deltoid) ligament

medial plantar vessels and nerve

abductor hallucis

quadratus plantae

abductor digiti minimi

peroneus longus

lateral malleolus

talus

interosseous membrane

fibula

flexor hallucis longus

sustentaculum tali

FIGURE 10.65

The right ankle joint as seen from the posterior aspect

near their articular margins.

The capsule encloses the joint and is attached to the bones

The ankle is a synovial hinge joint.

Type

covered with hyaline cartilage.

the body of the talus fits snugly. The articular surfaces are

the lower end of the tibia, deepens the socket into which

between the lateral malleolus and the posterior border of

The inferior transverse tibiofibular ligament, which runs

malleoli, and the body of the talus (Figs. 10.64 and 10.65).

Articulation is between the lower end of the tibia, the two

Articulation

rounding tendons make this joint strong and stable.

of the bones and the strength of the ligaments and the sur

move on a transverse axis in a hingelike manner. The shape

upper part of the body of the talus. The talus is able to

lower ends of the tibia and fibula, into which is fitted the

The ankle joint consists of a deep socket formed by the

ments at the ankle joint.

A small amount of movement takes place during move

Movements

Deep peroneal and tibial nerves supply the joint.

Nerve Supply

terior border of the lower end of the tibia.

surface of the upper part of the lateral malleolus to the pos

runs from the medial

inferior transverse ligament

The

and behind the interosseous ligament.

fibrous tissue connecting the two bones together in front

are flat bands of

posterior ligaments

anterior

The

and fibula together, also greatly strengthens the joint.

which connects the shafts of the tibia

osseous membrane,

inter

fibrous tissue that binds the two bones together. The

is a strong, thick band of

interosseous ligament

The

Ligaments

There is no capsule.

The distal tibiofibular joint is a fibrous joint.

Type

(A) and in coronal section (B).

Capsule

and

Ankle Joint

Capsule

506

CHAPTER 10

The Lower Limb

Ankle Joint Stability

transversely. Overinversion (without rotation), in which the talus

by forced overeversion (without rotation), in which the talus

still farther, its rotary movement results in its violent contact with

off the tip of the medial malleolus. If the talus is forced to move

fracture spirally. If the force continues, the talus moves laterally,

by forced external rotation and overeversion of the foot. The

Fracture dislocations of the ankle are common and are caused

deep mortise formed by the lower end of the tibia and the medial

The ankle joint is a hinge joint possessing great stability. The

and lateral malleoli securely holds the talus in position.

Acute Sprains of the “Lateral Ankle”

Acute sprains of the lateral ankle are usually caused by exces-

sive inversion of the foot with plantar flexion of the ankle. The

anterior talofibular ligament and the calcaneofibular ligament

are partially torn, giving rise to great pain and local swelling.

Acute Sprains of the “Medial Ankle”

Acute sprains of the medial ankle are similar to but less com-

mon than those of the lateral ankle. They may occur to the medial

or deltoid ligament as a result of excessive eversion. The great

strength of the medial ligament usually results in the ligament

pulling off the tip of the medial malleolus.

Fracture Dislocations of the Ankle Joint

talus is externally rotated forcibly against the lateral malleolus of

the fibula. The torsion effect on the lateral malleolus causes it to

and the medial ligament of the ankle joint becomes taut and pulls

the posterior inferior margin of the tibia, which shears off.

Other less common types of fracture dislocation are caused

presses the lateral malleolus laterally and causes it to fracture

presses against the medial malleolus, produces a vertical frac-

ture through the base of the medial malleolus.

C L I N I C A L N O T E S

Ligaments

tial position for major thrusting movements in walking,

the stability of the ankle joint when the foot is in the ini

distal tibiofibular joint. This arrangement greatly increases

them to separate slightly and tighten the ligaments of the

forced between the medial and lateral malleoli, causing

wider anterior part of the articular surface of the talus is

Note that during dorsiflexion of the ankle joint, the

talofibular ligament.

the anterior fibers of the medial ligament, and the anterior

gus. It is limited by the tension of the opposing muscles,

posterior, flexor digitorum longus, and flexor hallucis lon

soleus, plantaris, peroneus longus, peroneus brevis, tibialis

is performed by the gastrocnemius,

Plantar flexion

the calcaneofibular ligament.

calcaneus, the posterior fibers of the medial ligament, and

peroneus tertius. It is limited by the tension of the tendo

extensor hallucis longus, extensor digitorum longus, and

is performed by the tibialis anterior,

Dorsiflexion

at the ankle joint

inversion and eversion take place at the tarsal joints and

(toes pointing downward) are possible. The movements of

Dorsiflexion (toes pointing upward) and plantar flexion

Movements

Deep peroneal and tibial nerves supply the ankle joint.

Nerve Supply

The synovial membrane lines the capsule.

Synovial Membrane

talus.

from the lateral malleolus to the posterior tubercle of the

(Fig. 10.64) runs

posterior talofibular ligament

The

the lateral surface of the calcaneum.

the tip of the lateral malleolus downward and backward to

(Fig. 10.64) runs from

calcaneofibular ligament

The

talus.

from the lateral malleolus to the lateral surface of the

(Fig. 10.64) runs

anterior talofibular ligament

The

and consists of three bands.

is weaker than the medial ligament

lateral ligament

The

navicular bone.

calcaneonavicular ligament, and the tuberosity of the

side of the talus, the sustentaculum tali, the plantar

the talus; the superficial fibers are attached to the medial

nonarticular area on the medial surface of the body of

(Fig. 10.65). Below, the deep fibers are attached to the

attached by its apex to the tip of the medial malleolus

is strong and is

deltoid, ligament

medial,

The

not

running, and jumping.

longus (Fig. 10.48)

rior tibial vessels, the tibial nerve, and the flexor hallucis

tibialis posterior, the flexor digitorum longus, the poste

The

Posteromedially (behind the medial malleolus):

peroneus longus and brevis (Fig. 10.46)

The

Posterolaterally (behind the lateral malleolus):

The tendo calcaneus and plantaris (Fig.

Posteriorly:

tertius (Fig. 10.48)

nerve, the extensor digitorum longus, and the peroneus

longus, the anterior tibial vessels, the deep peroneal

The tibialis anterior, the extensor hallucis

Anteriorly:

Important Relations

possible.

small amounts of rotation, abduction, and adduction are

the ligaments of the distal tibiofibular joint are less taut and

Note also that when the ankle joint is fully plantar flexed,

■

10.48)

■

Basic Anatomy

is con

joint cavity

by dorsal and plantar ligaments. The

is strengthened

capsule

vial joint of the gliding variety. The

navicular bone and the three cuneiform bones. It is a syno

between the

articulation

The cuneonavicular joint is the

Cuneonavicular Joint

extensor digitorum longus also assist.

brevis, and peroneus tertius; the lateral tendons of the

Eversion is performed by the peroneus longus, peroneus

digitorum longus; the tibialis posterior also assists.

sor hallucis longus, and the medial tendons of extensor

Inversion is performed by the tibialis anterior, the exten

movement of inversion is more extensive than eversion.

the foot so that the sole faces in the lateral direction. The

is the opposite movement of

Eversion

sole faces medially.

is the movement of the foot so that the

Inversion

joints.

of the foot take place at the subtalar and transverse tarsal

The important movements of inversion and eversion

sal joints

transverse tar

midtarsal

are together referred to as the

The talocalcaneonavicular and the calcaneocuboid joints

and Calcaneocuboid Joints

Movements in the Subtalar, Talocalcaneonavicular,

The synovial membrane lines the capsule.

Synovial Membrane

bone (Fig. 10.59).

of the calcaneum and to the adjoining part of the cuboid

that is attached to the anterior tubercle on the undersurface

is a wide, strong ligament

short plantar ligament

The

into a tunnel.

the groove for the peroneus longus tendon, converting it

fourth, and fifth metatarsal bones in front. It bridges over

to the undersurface of the cuboid and the bases of the third,

attached to the undersurface of the calcaneum behind and

the lower surface of the joint (Figs. 10.58 and 10.59). It is

is a strong ligament on

long plantar ligament

The

the navicular bone.

of the cuboid, and the medial limb to the upper surface of

calcaneum. The lateral limb is attached to the upper surface

is attached to the upper surface of the anterior part of the

surface of the joint (Fig. 10.64). It is Y shaped, and the stem

is a strong ligament on the upper

bifurcated ligament

The

Ligaments

The capsule encloses the joint.

The calcaneocuboid joint is synovial, of the plane variety.

Type

articular surfaces are covered with hyaline cartilage.

and the posterior surface of the cuboid (Fig. 10.37). The

Articulation is between the anterior end of the calcaneum

Articulation

Calcaneocuboid Joint

Gliding and rotatory movements are possible.

Movements

The synovial membrane lines the capsule.

Synovial Membrane

cartilage and supports the head of the talus.

The superior surface of the ligament is covered with fibro

the inferior surface and tuberosity of the navicular bone.

runs from the anterior margin of the sustentaculum tali to

is strong and

plantar calcaneonavicular ligament

The

Ligaments

The capsule incompletely encloses the joint.

The joint is a synovial joint.

Type

faces are covered with hyaline cartilage.

concave surface of the navicular bone. The articular sur

upper surface of the sustentaculum tali, and the posterior

Articulation is between the rounded head of the talus, the

Articulation

navicular bone (Fig. 10.37).

between the talus and the calcaneum and also involves the

The talocalcaneonavicular joint is the anterior joint

Talocalcaneonavicular Joint

Gliding and rotatory movements are possible.

Movements

The synovial membrane lines the capsule.

Synovial Membrane

tali and below to the sulcus calcanei.

between the two bones. It is attached above to the sulcus

(Fig. 10.65) is strong and is the main bond of union

interosseous (talocalcaneal) ligament

the capsule. The

strengthen

lateral (talocalcaneal) ligaments

Medial

Ligaments

gins of the articular areas of the two bones.

The capsule encloses the joint and is attached to the mar

These joints are synovial, of the plane variety.

Type

ered with hyaline cartilage.

the calcaneum (Fig. 10.37). The articular surfaces are cov

the talus and the facet on the middle of the upper surface of

Articulation is between the inferior surface of the body of

Articulation

and the calcaneum.

The subtalar joint is the posterior joint between the talus

Subtalar Joint

Tarsal Joints

507

Capsule

and

Capsule

and 4th metatarsal bones.

sal joints, between the bases of the 2nd and 3rd and the 3rd

joints and also with the cuneometatarsal and intermetatar

tinuous with those of the intercuneiform and cuneocuboid

508

CHAPTER 10

third, as in the hand.

take place from the midline of the second digit and not the

toes, performed by the interossei muscles, are minimal and

The movements of abduction and adduction of the

verse ligaments connect the joints of the five toes.

resemble those of the hand (see page 412). The deep trans

The metatarsophalangeal and interphalangeal joints closely

sal joint of the big toe has a separate joint cavity.

sal, plantar, and interosseous ligaments. The tarsometatar

joints of the plane variety. The bones are connected by dor

The tarsometatarsal and intermetatarsal joints are synovial

Tarsometatarsal and Intermetatarsal

ligaments.

bones are connected by dorsal, plantar, and interosseous

continuous with that of the cuneonavicular joint. The

vial joints of the plane variety. Their joint cavities are

The intercuneiform and cuneocuboid joints are syno

Intercuneiform and Cuneocuboid Joints

ous ligaments.

the two bones connected by dorsal, plantar, and interosse

The cuboideonavicular joint is usually a fibrous joint, with

Cuboideonavicular Joint

The Lower Limb

Joints

-
-

Metatarsophalangeal and

Interphalangeal Joints

Later, osteoarthritic changes occur in the metatarsophalan

which is a lateral deviation of the great toe

Metatarsophalangeal Joint of the Big Toe

Hallux valgus,

at the metatarsophalangeal joint, is a common condition. Its

incidence is greater in women than in men and is associated

with badly fitting shoes. It is often accompanied by the pres-

ence of a short 1st metatarsal bone. Once the deformity is

established, it is progressively worsened by the pull of the

flexor hallucis longus and extensor hallucis longus muscles.

geal joint, which then becomes stiff and painful; the condition

is then known as hallux rigidus.

C L I N I C A L N O T E S

The Foot as a Functional Unit

assist the forward propulsive action of the gastrocnemius

and toes (i.e., the takeoff point of the foot) and greatly

exert their action on the bones of the forepart of the foot

long flexor muscles and the small muscles of the foot can

able and can adapt itself to uneven surfaces. Moreover, the

the lever is segmented with multiple joints, the foot is pli

activities of the gastrocnemius and soleus muscles. Because

forward propulsive action would depend entirely on the

the foot could not adapt itself to uneven surfaces, and the

pulsion (Fig. 10.66). However, with such an arrangement,

body weight and serve well as a rigid lever for forward pro

bone instead of a series of small bones, it could sustain the

walking and running. If the foot possessed a single strong

weight and to serve as a lever to propel the body forward in

The foot has two important functions: to support the body

The Foot as a Weight Bearer

and a Lever

and soleus muscles (Fig. 10.66).

the following engineering methods used for its support

Examination of the design of any stone bridge reveals

Mechanisms of Arch Support

bones (Fig. 10.67).

atarsal bones and the cuboid and the three cuneiform

This consists of the bases of the met

Transverse arch:

(Fig. 10.67).

neum, the cuboid, and the 4th and 5th metatarsal bones

This consists of the calca

Lateral longitudinal arch:

bones, and the first three metatarsal bones (Fig. 10.63).

neum, the talus, the navicular bone, the three cuneiform

This consists of the calca

Medial longitudinal arch:

graph of the foot shows the bones that form the arches.

An examination of an articulated foot or a lateral radio

The Bones of the Arches

metatarsals.

of the first metatarsal and the heads of the remaining four

in front, namely, the two sesamoid bones under the head

the heel behind and six points of contact with the ground

body weight on standing is distributed through a foot via

From this description, it can be understood that the

the two feet are placed together, a complete dome is formed.

likened to a half-dome, so that when the medial borders of

its summit on the foot’s medial border. The foot has been

an arch, with its base on the lateral border of the foot and

the cuboid and cuneiform bones. This is, in fact, only half

transverse arch involves the bases of the five metatarsals and

the presence of the low-lying lateral longitudinal arch. The

5th metatarsal head and least between these areas because of

the lateral margin of the foot is greatest at the heel and the

longitudinal arch. The pressure exerted on the ground by

arched above the ground because of the important medial

gin of the foot, from the heel to the 1st metatarsal head, is

are in contact with the ground (Fig. 10.67). The medial mar

the metatarsal heads, and the pads of the distal phalanges

that the heel, the lateral margin of the foot, the pad under

made with the person in the standing position, one can see

On examination of the imprint of a wet foot on the floor

a large amount of subcutaneous fat on the sole of the foot.

child, the foot appears to be flat because of the presence of

(Fig. 10.67). In the young

transverse arches

and

medial longitudinal, lateral longi

are present at birth: the

in the form of an arch. The foot has three such arches, which

A segmented structure can hold up weight only if it is built

The Arches of the Foot

tudinal,

■

(Fig. 10.68):

with the thin edge of the wedge lying inferiorly. This

porting the arch is to make the stones wedge shaped,

The most effective way of sup

The shape of the stones:

■