Ankle Joint

Original Editor - Naomi O'Reilly

Lead Editors - Naomi O'Reilly, Kim Jackson, Lucinda hampton, Joanne Garvey, Rachael Lowe, Ewa Jaraczewska, Vidya Acharya, Admin, WikiSysop, Simisola Ajeyalemi, Rucha Gadgil, Jess Bell, Khloud Shreif, Kirenga Bamurange Liliane, Olajumoke Ogunleye, Evan Thomas, Sona Eyobe, Oyemi Sillo and Tarina van der Stockt

Description

The Ankle Joint, also known as the Talocrural Articulation, is a synovial hinge joint connecting the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus. The ankle joint is maintained by the shape of the talus and its tight fit between the tibia and fibula. In the neutral position, there are strong bony constraints. With increasing plantar flexion, the bony constraints are decreased and the ligaments are more susceptible to strain and injury. The articulation between the tibia and the talus bears more weight than that between the smaller fibula and the talus. 

Anatomy

Articulating Surfaces

• Trochlea of Talus
• Malleolar Mortis formed by Tibia & Fibula
• Lateral & Medial Malleolus
  

Joint Capsule

The articular capsule surrounds the joints, and is attached, above, to the borders of the articular surfaces of the tibia and malleoli; and below, to the talus around its upper articular surface. The joint capsule anteriorly is a broad, thin, fibrous layer, posteriorly the fibres are thin and run mainly transversely blending with the transverse ligament and laterally the capsule is thickened, and attaches to the hollow on the medial surface of the lateral malleolus. The synovial membrane extends superiorly between Tibia & Fibula as far as the Interosseous Tibiofibular Ligament.

Ligaments

Lateral Ligaments of Ankle

Lateral ligament

Reinforce Joint Laterally through three ligaments. These ligaments stabilize the ankle, and serve as a guide to direct ankle motion by attaching the lateral malleolus to the bones below the ankle joint. They are responsible for resistance against inversion and internal rotation stress.

LIGAMENT	DESCRIPTION	PROXIMAL ATTACHMENT	DISTAL ATTACHMENT	ROLE
Anterior Talofibular Ligament (ATFL)	Flat Weak Band that extends Anteriomedially. Most commonly damaged ligament of the ankle.	Lateral Malleolus	Neck of Talus	Restrain anterior displacement of the talus in respect to the fibula and tibia. Resists Inversion in planterflexion.
Posterior Talofibular Ligament (PTFL)	Thick, fairly strong band that runs horizontally medially. This ligament is under greater strain in full dorsiflexion of ankle. Rarely injured because bony stability protects ligaments when ankle in dorsiflexion.	Malleolar Fossa of Fibula	Lateral Tubercle of Talus	Forms the back wall of the recipient socket for the talus' trochlea. Resists posterior displacement of the talus.
Calcaneofibular Ligament (CFL)	Round cord that passes posterioinferiorly	Tip of Lateral Malleolus	Lateral Surface of Calcaneus	Aids Talofibular stability during Dorsiflexion. Restrain inversion of the calcaneus with respect to the fibula. Prevent Talar tilt into Inversion.

Medial Ligaments of Ankle

Medial ligament

Known collectively as the Deltoid Ligament the medial ligaments of the ankle attaches proximally to the Medial Malleolus and fan out to attach distally to the Talus, Calcaneus and Navicular via four adjacent and continuous parts. The deltoid ligament is triangular in shape and consists of a superficial and deep layer which connect the talus to the medial malleolus. It reinforces the joint capsule medially. Stabilise’s the ankle joint during eversion of the foot and prevents subluxation of the ankle joint.

LIGAMENTS	DESCRIPTION	PROXIMAL ATTACHMENT	DISTAL ATTACHMENT	ROLE
Anterior Tibiotalar Ligament		Medial Malleolus	Head of Talus	Reinforces Ankle Joint. Control Plantarflexion & Eversion
Posterior Tibiotalar Ligament			Talus Posteriorly	Control Dorsiflexion
Tibionavicular Ligament	Forms most anterior part of the Deltoid Ligament		Dorsomedial Aspect of Navicular	Reinforces Ankle Joint
Tibiocalcaneal Ligament	Very thin ligament		Sustentaculum Tali	Reinforces Ankle Joint

Muscles

Plantarflexion

Muscles which contribute to Plantarflexion

MUSCLE	ACTION	PROXIMAL ATTACHMENT	DISTAL ATTACHMENT	INNERVATION
POSTERIOR COMPARTMENT
SUPERFICIAL
Gastrocnemius	Plantarflexion when Knee Extended Flexion Knee Raises Heel during Walking	Lateral Head: Lateral Aspect of Lateral Femoral Condyle Medial Head: Popliteal Surface of Femur Superior to Medial Femoral Condyle	Posterior Surface Calcaneus via Calcaneal Tendon (Achilles Tendon)	Tibial Nerve S1-S2
Soleus	Plantarflexion Steadies Leg on Foot	Posterior Aspect of Head Fibula Superior ¼ Posterior Surface Tibia Soleal Line & Medial Border Tibia
Plantaris	Weakly Assists Gastrocnemius in Plantarflexion	Inferior end Lateral Supracondylar Line of Femur Oblique Popliteal Ligament
DEEP
Tibialis Posterior	Plantarflexion Inversion Supports Medial Longitudinal Arch	Interosseous Membrane Posterior Surface Tibia inferior to Soleal Line Posterior Surface Fibula	Navicular Tuberosity Cuneiform Cuboid Bases of Metatarsals 2-4	Tibial Nerve L4-L5
Flexor Digitorum Longus	Plantarflexion Flexion Lateral Four Digits Supports Longitudinal Arch	Medial Part Posterior Surface Tibia inferior to Soleal Line Broad Tendon to Fibula	Base Distal Phalanges Digits 2-4	Tibial Nerve S2-S3
Flexor Hallucis Longus	Weak Plantarflexion Flexion Big Toe at all Joints Supports Medial Longitudinal Arch	Inferior 2/3 Posterior Surface Fibula Inferior Part Interosseous Membrane	Base Distal Phalanx of Big Toe
LATERAL COMPARTMENT
Peroneus Brevis	Weak Plantarflexion Eversion	Inferior 2/3 of Lateral Surface Tibia	Dorsal Surface Tuberosity of Base 5th Metatarsal	Superficial Peroneal Nerve (Superficial Fibular Nerve) L5 - S2
Peroneus Longus	Weak Plantarflexion Eversion Supports Transverse Arch	Head & Superior 2/3 of Lateral Surface Tibia	Base 1st Metatarsal Medial Cuniform

Dorsiflexion

Muscles which contribute to Dorsiflexion

MUSCLE	ACTION	PROXIMAL ATTACHMENT	DISTAL ATTACHMENT	INNERVATION
ANTERIOR COMPARTMENT
Tibialis Anterior	Dorsiflexion Inversion Supports Medial Longitudinal Arch	Lateral Condyle Tibia Superior ½ Lateral Surface Tibia Interosseous Membrane	Medial & Inferior Surfaces Medial Cuniform Base of 1st Metatarsal	Deep Peroneal Nerve (Deep Fibular Nerve) L4-L5
Extensor Digitorum Longus	Dorsiflexion Extends Lateral Four Digits	Lateral Condyle Tibia Superior ¾ Anterior Surface Interosseous Membrane	Middle & Distal Phalanges of Lateral Four Digits	Deep Peroneal Nerve (Deep Fibular Nerve) L5-S1
Extensor Hallucis Longus	Dorsiflexion Extends Big Toe	Middle Part Anterior Surface Fibula Interosseous Membrane	Dorsal Aspect of Base Distal Phalanx of Big Toe
Peroneus Tertius	Dorsiflexion Aids Eversion	Inferior 1/3 Anterior Surface Fibula Interosseous Membrane	Dorsum Base 5th Metatarsal

Blood Supply

Derived from Malleolar Branches of:

• Peroneal Artery
• Tibial Artery

Nerve Supply

• Common Peroneal Nerve
• Tibial Nerve

Function

Motions Available

• Talocrural Joint is a uniaxial hinge joint which has just 1° of Motion
• Dorsiflexion 0° - 20° 
• Plantarflexion 0° - 50°

Closed Packed Position

• Maximum Dorsiflexion

Open Packed Position

• 10° Plantarflexion

Structures Limiting Movement

Movement	Limiting Structures
Plantarflexion Posterior & Lateral Compartment	Anterior Talofibular Ligamanet Anterior Part of Medial Ligament Anterior Joint Capsule Tension Contact of Talus with Tibia Dorsiflexor Tension
Dorsiflexion Anterior Compartment	Medial Ligament Calcaneofibular Ligament Posterior Talofibular Ligament Posterior Joint Capsule Tension Contact of Talus with Tibia Plantarflexors Tension

Clinical Examination

Assessment

• Ankle & Foot Examination
• Ankle Joint Assessment Video
  

Special Tests

• Kaltenborn Ankle & Foot Examination
  
• Anterior Drawer of the Ankle
• Ligament Tests
• Squeeze Test
• Talar Tilt Test
• Kleiger Test

Clinical Predicition Rules

• Ottawa Ankle Rules to rule in/out radiography of the ankle after trauma

Outcome Measures

• Foot and Disability Index&is a 34-item self report questionnaire divided into two subscales: the Foot and Ankle Disability Index and the Foot and Ankle Disability Index Sport

Pathology/Injury

• Ankle Arthrodesis
• Ankle Impingement
• Ankle Osteoarthritis
• Ankle Osteochondral Lesions
• Ankle Sprain
• Ankle and Foot Fractures
• Ankle and Foot Arthropathies
• Chronic Ankle Instability

Physiotherapeutic Techniques

Manual Therapy

• Talocrural Joint Posterior Glide to Promote Dorsiflexion
• Talocrural Joint Anterior Glide to Promote Plantarflexion
• Talocrural Joint Distal Distraction [5][5]
  

Balance Retraining

• Balance
• Proprioception
• Perturbation Techniques

Procedures

• Ankle Arthroplasty

Resources

• Anatomy of the Ankle Ligaments: A Pictorial Essay - In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.