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Normal Anatomy

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The Anatomy of foot and ankle is complex, they both work in unity to provide balance, stability, movement and Propulsion.

It consists of 26 bones, 33 joints, Muscles, Tendons, Ligaments, Blood vessels, nerves, and soft tissue.


The ankle joint consists of three bones that connect the leg to the foot. The tibia (shin bone) and the fibula, articulate (connect) to the talus (ankle bone) at the Tibiotalar joint (ankle joint) allowing the foot to move up and down.

The bony protrusions that we can see and feel on the ankle are:

  • Lateral Malleolus – the outer ankle bone formed by the distal end of the fibula.
  • Medial Malleolus – the inner ankle bone formed by the distal end of the tibia.


The foot can be divided into three anatomical sections called the hindfoot, midfoot and forefoot. The hindfoot consists of the Talus bone (ankle bone) and the Calcaneus bone (heel bone). The Calcaneus bone is the largest bone in your foot and joins the Talus bone at the subtalar joint. The hindfoot connects the midfoot to the ankle at the transverse tarsal joint.

The midfoot contains five tarsal bones – the navicular bone, the cuboid bone, and 3 cuneiform bones. The midfoot is responsible for forming the arches of your feet and acts as a shock absorber when walking or running. The midfoot connects to the forefoot at the five tarsometatarsal joints.

The forefoot consists of your toe bones (phalanges), and metatarsal bones (long bones) in your feet. Phalanges connect to metatarsals at the ball of the foot by joints called metatarsophalangeal joints. Each toe has three phalange bones and two joints, while the big toe contains two phalanges bones, one joint, and two tiny, round sesamoid bones that enable the toe to move up and down. Sesamoid bones are bones that develop inside of a tendon over a bony prominence. The first metatarsal bone connected to the big toe is the shortest and thickest of the metatarsals. This bone is important for its role in propulsion and weight bearing.

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Ankle Sprain

Ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear.

Most sprained ankles occur in the ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibres that make up the ligament to complete tears through the tissue.

If there is a complete tear of the ligaments, the ankle may become unstable. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.

Ankle sprains are common injuries that occur among people of all ages. They range from mild to severe depending upon the damage to the ligaments. Ankle sprain can be sustained by walking or exercising on an uneven surface, falls, sports that require cutting actions or rolling and twisting of the foot or during sports someone else may step on your foot while you are running, causing your foot to twist or roll to the side.

Most sprains are minor injuries that heal with home treatments (RICE treatment) rest, applying ice, compression and elevation. However, if your ankle is very swollen and painful to walk on or if you are having trouble putting weight on your ankle then you need to see the doctors.

Almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.

A three-phase program guides treatment for all ankle sprains from mild to severe

  • Phase 1 includes resting, protecting the ankle and reducing the swelling.
  • Phase 2 includes restoring range of motion, strength and flexibility.
  • Phase 3 includes maintenance exercises and the gradual return to activities that do not require turning or twisting the ankle. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities).

This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.

Without proper treatment and rehabilitation, a more severe sprain can weaken your ankle making it more likely that you will injure it again. Repeated ankle sprains can lead to long-term problems, including chronic ankle pain, arthritis, and ongoing instability.

Ankle Arthritis

Arthritis is inflammation of the joints

It can cause symptoms of pain, swelling and stiffness. It commonly affects the small joints of foot and ankle.

There are several different forms of arthritis, many of which affect the foot and ankle. All types can make it difficult to walk and perform activities you enjoy.

Although there is no cure for arthritis, there are many treatment options available in form of either non-surgical or surgical treatment to slow the progress of the disease and relieve symptoms. With proper treatment, many people with arthritis are able to manage their pain, remain active, and lead fulfilling lives.

Ankle Arthroscopy

Arthroscopy is a surgical procedure during which the internal structures of a joint are examined using small incisions (key hole procedure).

Arthroscopic examination of ankle joint is helpful in diagnosis and treatment of many ankle conditions. Some of the conditions treated by ankle arthroscopy include arthritis, unstable ankle, osteochondral defects of the talus, loose bodies, soft tissue (scar) impingement, infection and undiagnosed ankle pain.

Arthroscopic ankle surgery is performed under either a general anaesthesia or regional anaesthesia depending on the medical condition. A small incision of the size of a key hole is made through which the arthroscope is inserted. Other accessory incisions will be made through which specially designed instruments are inserted. The incisions are closed at the end of the procedure and instructions are provided about the incision care, activities to be avoided and exercises to be performed for faster recovery.

Some of the possible complications after arthroscopy include infection, thrombosis (clots in the veins), excessive swelling, bleeding, blood vessel or nerve damage and instrument breakage.

It may take several weeks for the surgical incision to heal and the joint to recover completely. A physiotherapy program may be advised for a speedy recovery of the ankle joint function.

Ankle Reconstruction

Surgical treatment for ankle sprains is rare.

Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability (giving away) after months of rehabilitation and nonsurgical treatment.

Surgical options may include

  1. Arthroscopy – Use a small camera, called an arthroscope, to look inside your ankle joint. Miniature instruments are used to remove any loose fragments of bone or cartilage, or parts of the ligament that may be caught in the joint.
  2. Reconstruction – Can be either repair the torn ligament with stitches or sutures or in some cases, reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and/or tendons found in the foot and around the ankle.

There is typically a period of immobilization following surgery for an ankle sprain. A cast or protective boot is applied to protect the repaired or reconstructed ligament.

If removed too soon, a simple misstep can re-tear the fixed ligaments.

Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of recovery time depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.

Arthrodesis Joint Fusion Procedure

Arthrodesis is fusion of the bones in the joint completely, making one continuous bone out of two or more bones. The goal of the procedure is to reduce pain by eliminating motion in the arthritic joint.

During arthrodesis, the damaged cartilage is removed and then with use of pins, plates and screws, or rods the joint is fixed in a permanent position. Over time, the bones fuse or grow together, just like two ends of a broken bone grow together as it heals. The pain disappears due to removal of the arthritic joint.

Arthrodesis is typically quite successful, although there can be complications. In some cases, the joint does not fuse together (non-union), and the hardware may break. This can happen if you put weight on your foot before the fusion is complete. While the broken hardware does not cause pain, the non-union of the fusion can lead to pain and swelling. If non-union occurs, a second operation to place bone graft in the joint and place new hardware may be needed. However, repeated fusions are not as likely to be successful, so it is best to closely follow guidelines during the recovery period of the original operation.

In most cases, surgery relieves the pain of arthritis and makes it easier to perform daily activities. Full recovery can take from 4 to 12 months, depending on the severity of your condition before surgery and the complexity of your procedure.

Foot and ankle surgery can be painful. Advancements in pain control now make it easier to manage and relieve pain.

You will most likely have a plaster cast after surgery to limit movement in your foot and ankle and to prevent non-union. To reduce swelling, it is important to keep your foot elevated above the level of your heart for up to 2 weeks after surgery.

Later in the recovery period, physiotherapy may be recommended to help regain strength in your foot or ankle and to restore range of motion.

In most cases, you will be able to resume your daily activities in 3 to 4 months although, for a period of time, you may need to wear supportive shoes or a brace.

A small percentage of patients have problems with wound healing, but these problems can usually be addressed by bracing or by an additional surgery. In some cases, loss of motion in the joint after a fusion causes the joints adjacent to the one fused to bear more stress than they did before the surgery. This can lead to arthritis in the adjacent joints years after the surgery.


Bunion is a bony bump that develops on the inside of the forefoot at the big toe joint and can be painful. They are often referred to as hallux valgus.

Bunions develop slowly and due to the pressure the big toe can drift toward the second toe. The deformity will gradually increase and may make it painful to wear shoes or walk.

Anyone can get a bunion, but they are more common in women. Women who wear a tight, narrow shoe that squeeze the toes together are more likely to develop bunion, increased risk of bunion worsening and also have more commonly painful symptoms.

In most cases, pain is relieved by wearing wider shoes with adequate toe room and using other simple treatments to reduce pressure on the big toe.

Surgery may be recommend for a bunion if you have pain and difficulty walking despite changes in footwear and other nonsurgical treatments. Bunion surgery realigns bone, ligaments and tendons so that the big toe can be brought back to its correct position.

There are several surgical procedures to correct bunions. Although most procedures are done with overnight hospital stay, longer recovery time after surgery is common.

Surgery to remove an adolescent bunion is not recommended unless the bunion causes extreme pain that does not improve with a change in footwear or addition of orthotics. If an adolescent has bunion surgery, particularly before reaching skeletal maturity, there is a strong chance of recurrence of the bunion.


A bunionette, or “tailor’s bunion,” occurs on the outside of the foot near the base of the little toe.

Although it is in a different spot on the foot, a bunionette is very much like a bunion of the big toe. You may develop painful bursitis and a hard corn or callus over the bump.

Treatment is similar to treatment of the Bunion.

Claw / Hammer Toe

Claw Toe

A Claw toe is a deformity of lesser toes which cause the toes to dig down into the soles of the shoes and create painful calluses. It is common to blame the toe deformity to wearing shoes that are too tight, too short or high heels. However, it is often the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Claw toe gets worse without treatment and may become a permanent deformity over time.

Claw toe deformities are usually flexible at first, but they fix into place over time. Early claw toe can be treated with splint or tape to hold your toes in correct position. Wearing shoes with soft, roomy toe boxes and avoid tight shoes and high-heels, use your hands to stretch your toes and toe joints toward their normal positions and exercise your toes by using them to pick up marbles or crumple a towel laid flat on the floor.

If you have claw toe in later stages and your toes are fixed in position a special pad can redistribute your weight and relieve pressure on the ball of your foot. Extra depth shoe can be used to accommodate the deformity.

If these treatments do not help, you may need surgery to correct the problem.

Hammer Toe

A hammer toe is a deformity of the second, third or fourth toes. The toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.

People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.

Hammer toe results from shoes that don’t fit properly or muscle imbalance and usually combination of one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the muscles tighten and cannot stretch out.

Initial treatment starts with new shoes that have soft, roomy toe boxes. Sandals may help, as long as they do not pinch or rub other areas of the foot.

Hammer toe can be corrected by surgery if conservative measures fail. The actual procedure will depend on the type and extent of the deformity. After the surgery, there may be some stiffness, swelling and redness and the toe may be slightly longer or shorter than before. You will be able to walk, but should not plan any long hikes while the toe heals, and should keep your foot elevated as much as possible.

Achilles Tendon Rupture

The Achilles tendon is the largest tendon in the body and it connects your calf muscles to your heel bone.

Achilles tendon rupture or tear is the separation of the tendon fibres so that the tendon can no longer perform its normal function.

Achilles tendon rupture occurs most often in middle-aged athlete participating in sports that involve running, pivoting and jumping. Recreational sports can also cause Achilles rupture.

If Achilles tendon is ruptured you will experience severe pain in the back of your leg, swelling and difficulty to stand on tiptoe and push the leg when walking. A popping or snapping sound is heard when the injury occurs. You may also feel a gap or depression in the tendon, just above heel bone.

Achilles tendon rupture can be treated using either non-surgical method or surgical method. Non-surgical treatment involves wearing a cast or special brace boot which is changed after period of time to bring the tendon back to its normal length. Surgical procedure involves opening the skin and suturing the torn tendon together. Surgery helps to decrease the recurrence of the Achilles tendon rupture in comparison to the non-surgical treatment.

Achilles tendon injury can be prevented by performing stretching and warm-up exercises before sports participation.