Ankle and foot anatomy explained

The ankle and foot complex is a complicated matrix of bones and joints held together by ligaments and connective tissue. It consists of three sections – rearfoot, midfoot, and forefoot.

The traditional ankle joint comprises three bones – the tibia (shin bone), the fibula, and the talus. The tibia and fibula come together distally to form a mortise in which the talus fits. This structure allows for the up and down motion of our foot (dorsiflexion and plantarflexion).

Chronic or acute injuries in the ankle and foot complex can cause loss of the ability to walk, run, hike, or do many of the things we do to stay active.

Common ankle and foot injuries or conditions

Learn about common ankle and foot injuries and conditions below including sprains, strains, tendonitis, and more.

Ankle Sprain

An ankle sprain is one of the most common orthopedic injuries. It occurs when the ankle moves beyond its normal range of motion, stretching or tearing the ligaments that are in place to prevent excessive movement. When those ligaments are stretched beyond normal limits, the result is acute pain and swelling.

Ankle sprains are classified by grade (I-III), and grades are related to the amount of ligament damage. A grade III sprain refers to a complete tear of the ligament. Acute management of an ankle sprain is relatively straightforward. R.I.C.E is an acronym that stands for Rest, Ice, Compression, and Elevation.

With low-grade sprains, physical therapy treatment will focus initially on reducing swelling and pain. You may wear an air cast or other brace to help with stabilization while the ligament heals.

As symptoms resolve, your physical therapist will work on a range of motion and strengthening exercises as well as balance (proprioception) activities that will advance you towards a return to regular activity.

Chronic ankle sprains can become problematic and are often seen in patients with significant ligament laxity due to repeated microtrauma or an untreated grade 2 or 3 sprain. These patients will participate in aggressive strengthening and balance activities in therapy, along with sport-specific or functional activities.

• Ligament reconstruction: There are instances when the ligament damage is too severe. It is unable to support the ankle and prevent excessive movement despite conservative care such as physical therapy. In these cases, a surgeon will reconstruct the affected ligament using a tissue graft and anchors.

Following a reconstruction and immobilization period (surgeon dependent), physical therapists will protect the repair while regaining motion/strength through controlled ROM and strengthening exercises.

Since soft tissues like ligaments need time to heal, more aggressive therapy will begin approximately 6-8 weeks following surgery. This will include balance activities, strengthening, and a progression to sports specific/functional activities.

High Ankle Sprain

The term “high ankle sprain” has become more commonplace recently. A high ankle sprain refers to an injury to the syndesmotic tissue between the tibia and fibula above the ankle joint. Located in the lower leg, these ligaments hold the tibia and fibula together, creating a mortise in which the talus articulates.

High ankle sprains are rotational and occur when the lower leg and foot are forcefully rotated externally. High ankle sprains do not heal as quickly as a traditional ankle sprain and often need further evaluation by a physician.

For a less severe high ankle sprain, treatment will usually include a 6-week period of immobilization to allow the ligament time to heal, followed by a period of physical therapy.

For severe high ankle sprains with significant damage to the syndesmosis, surgery is often needed. The surgeon will stabilize the tibia and fibula using screws, allowing the ligament time to heal.

Physical therapy following a high ankle sprain will focus primarily on symptom management, protection, range of motion, strengthening, and balance (proprioceptive) activities. Functional transition to sport-specific or movement-specific exercises take some time and are dependent on how well the injury is healing.

Plantar Fasciitis

This is one of the most common causes of heel pain. It involves inflammation of the plantar fascia, a tough band of connective tissue that runs along the foot’s bottom and helps support the foot’s normal arch.

Typically, patients complain of severe, stabbing pain on the bottom of their foot, usually worse in the morning upon waking from the bed. Patients may also complain of increased symptoms with prolonged standing or activity, such as walking or running.

The plantar fascia acts like a bowstring that assists in supporting the normal arch of the foot. Many potential biomechanical breakdowns can occur, increasing the risk of repeated micro-trauma in the plantar fascia.

There is often localized micro-trauma and subsequent inflammation where the plantar fascia attaches to the calcaneus (heel bone). Most patients can point to this spot as a localized pain source.

Conservative treatment, including physical therapy, is most common. Patients will often attempt to self-treat using over-the-counter NSAIDs (such as Ibuprofen), arch supports, and night splints. Physical therapy treatment should include evaluating the entire patient and lower extremity kinetic chain along with symptom management.

Treatment may consist of the following:

• Soft tissue mobilization
• Arch taping
• Ice
• Footwear recommendations
• Stretching/strengthening lower extremity muscles
• Activity modification
• Gait analysis *to identify biomechanical breakdown

Treatment and guidance may also include a discussion on shoe inserts or more permanent orthotic recommendations/fabrication.

Tendonitis

Tendonitis, simply put, is inflammation of a tendon. Tendons connect muscle to bone. Several lower extremity muscles in the foot and ankle serve to support and move the foot in different directions. These muscles become tendons that attach to individual bones in the foot.

For a variety of reasons, these tendons can become acutely inflamed and painful. Long term, chronic inflammation can lead to microscopic breakdown and degradation of the tendon tissue, a name referred to as tendinosis.

Below are descriptions of the three most common sites for tendonitis in the foot and ankle.

Achilles Tendonitis
The Achilles tendon is the largest in the body. It is formed by the distal ends of the calf muscles (gastrocnemius and soleus) coming together and inserting on the heel (calcaneus). When the calf muscle contracts, it causes ankle plantarflexion (foot pointing down, up onto toes).

This muscle is essential for walking, running, and jumping. Achilles Tendonitis typically develops over time due to overuse and repetitive stress. This can be caused by a sudden increase in activity, tight calf muscles, or a bone spur at the heel that irritates the calcaneus’ Achilles’ insertion.

Patients can suffer from “non-insertional tendonitis,” meaning that the inflammation is localized in the tendon’s mid-substance, or “insertional tendonitis,” meaning that the inflammation occurs at the point of insertion on the heel bone.

Both conditions are characterized by pain, point tenderness, swelling, pain with activity, and reduced ability to perform functional activities or sports. Conservative care is the most common intervention.

Depending on the length of time the symptoms have been occurring, recovery time can vary. With chronic, long-standing symptoms, recovery can take longer. Physical therapy can be highly effective in reducing symptoms and preventing recurrence.

Treatments will include ice massage, instrument-assisted soft tissue mobilization, stretching, eccentric strengthening program, and evaluation of lower extremity biomechanics, including gait analysis, footwear evaluation/recommendations, and orthotic consideration.

Posterior Tibialis Tendonitis
The posterior tibialis muscle originates on the mid-lower tibia in the posterior compartment. Its tendon runs medially behind the medial malleolus (inside ankle bone) and under the foot. It plays a crucial role in the passive stabilization of the arch.

Posterior Tibialis Tendonitis indicates acute inflammation of the posterior tibialis tendon. This can occur due to a sudden increase in activity level and will typically resolve with rest, anti-inflammatory medication, or modalities. Over time, chronic posterior tibialis dysfunction will result in excessive pronation (flat foot).

This condition is painful, and typically the pain worsens with activity such as standing and walking. Physical therapy plays a significant role in the management of symptoms and the prevention of further injury.

Immediate treatment includes activity modification and symptom reduction. This may consist of modalities or instrument-assisted soft tissue mobilization. Additionally, a physical therapist will strengthen the posterior tibialis and other lower extremity, hip, and core muscles.

It’s essential to identify through gait analysis where the breakdown occurs and address the breakdowns with a comprehensive exercise program, including the entire kinetic chain. Footwear changes and over-the-counter or custom arch supports (orthotics) can also reduce recurrence chances.

Peroneal Tendonitis
The peroneal tendons run along the outside of the foot and ankle. The peroneus longus tendon passes under the arch of the foot and inserts on the 1st metatarsal. Both muscles contract to cause ankle eversion (turning the foot outward).

Peroneal tendonitis would indicate acute inflammation of the peroneal tendons. This condition is typically caused by a sudden increase in activity associated with pain, tenderness, and swelling behind the outside ankle bone (distal fibula). There may also be pain with resisted eversion of the ankle (turning the foot outward) or ankle inversion (turning the foot inward).

Conservative care is most common in treating peroneal tendonitis. This may include a period of immobilization in a boot. Additionally, physical therapy is often needed and the go-to treatment for this condition. Activity modification, footwear recommendations, and patient education on return to activity will occur throughout your treatment.

Additionally, instrument-assisted soft tissue mobilization and exercises specific in addressing lower extremity kinetic chain mechanics will be prescribed. Gait and running analysis will help identify breakdowns that are occurring and help develop a treatment plan.

Tendon Rupture

All of the tendons listed above (Achilles, Posterior Tibialis, Peroneal) are subject to an acute rupture or a partial or complete tear due to chronic overuse.

A tendon rupture may occur acutely due to a sudden contraction, like jumping, or a sudden overstretching of the tissue that causes it to fail. An Achilles tendon rupture is most common.

This is seen in sports such as football, basketball, baseball, or soccer, often early in the season or after a period of deconditioning. A complete tendon rupture requires surgical repair. Depending on the injury, the damaged tissue, and the surgeon, techniques for repair may vary.

Following surgery, protecting the repair is most important. This will require immobilization of the foot and ankle and weight-bearing restrictions to allow the damaged/repaired tissue to heal for approximately 6-8 weeks.

Physical therapy will begin at varying times in the recovery (surgeon dependent). Depending on timing post-surgery, physical therapy interventions will vary depending on the rate of tissue healing.

Early in recovery, protecting the repair while gradually restoring range of motion (ROM) is the primary goal. ROM, strength, scar mobility, and a gradual return to function will become the most important objectives as time progresses.

Later in the recovery period, physical therapy will focus on proprioception (balance), more aggressive strengthening throughout the entire kinetic chain, and functional activities such as running, jumping, and cutting.

As with any post-operative status, communication between the physical therapist and physician is essential to align goals and manage patient expectations.

Fractures

There are many possible bones in the foot and ankle that can be fractured.

• An ankle fracture refers to a break in one or more bones that make up the ankle joint – tibia, fibula, or talus. Depending on the number of fractures and the structures involved, treatment will range from immobilization in a cast or boot to surgical reconstruction using screws and plates. Physical therapy following an ankle fracture will focus on restoring ROM, restoring strength and proprioception, and returning the patient to functional weight-bearing activities, including walking, stair climbing, and moving from sit to stand. Some patients may require desensitization techniques following surgery on the ankle joint.

• A calcaneus fracture refers to a break of the calcaneal bone, and these injuries are often quite severe and debilitating. Usually, calcaneus fractures result from a high-energy event, such as an automobile accident or a fall from height. Most of the time, surgery is required to restore the calcaneus’s normal anatomy, although sometimes immobilization in a cast is prescribed. Whether your treatment is surgical or non-surgical, physical therapy will be very similar. The time it takes to return to daily activities will vary depending on the fracture’s type and severity and whether you have other injuries. Physical therapy following a calcaneus fracture/repair will include exercises that help improve your foot and ankle range of motion and strengthen supporting muscles. Your physical therapy will focus on regaining motion, strength, and proprioception (when appropriate), as well as a gradual return to functional activities as appropriate. Aquatic therapy can be an excellent resource for these patients as the water buoyancy helps reduce weight-bearing.

Osteoarthritis

At the lower end of the kinetic chain, the foot and ankle provide support, shock absorption, and accommodation to the stresses of walking, running, jumping, and so on. With over 30 joints and 28 bones in the foot, it is remarkably stable and mobile simultaneously.

Osteoarthritis (OA), or “wear and tear” arthritis, occurs when the articular cartilage, the slippery substance that covers most bones’ ends, becomes worn and degenerative. This can occur as a function of the normal aging process because of excess wear and tear on a particular joint or an injury (post-traumatic arthritis) that disrupted normal joint kinematics.

OA can be painful and results in the inability to perform functional activities. Although arthritis cannot be reversed, its progression and symptoms can be addressed with proper treatment.

Physical therapy can help patients with activity modification and patient education on assistive devices, footwear, inserts, and bracing. Additionally, exercises to improve muscular strength and flexibility can help improve function and perform functional activities safely.

• Total Ankle Arthroplasty: Not as common as a total knee, hip or shoulder replacement, a total ankle replacement can assist patients with advanced arthritis, pain, and loss of function. Physical therapy following a total ankle replacement will focus on ROM, strength, and safe return to functional activities.
• Ankle Arthrodesis: An arthrodesis is a fusion of one or more joints in the foot and ankle, thus eliminating motion and pain at that joint.

Balance Disorders

Whether a function of aging or other medical conditions, balance can be affected in patients and increase the risk of falls. The foot and ankle complex plays a crucial role in balance and foot accommodation during functional activities such as walking.

For many patients, a loss of balance becomes a significant issue over time. The inability to react to a change in walking surface or a change in direction can result in a fall that can have disastrous consequences, such as a hip fracture.

Physical therapy can be helpful for patients suffering from reduced functional mobility due to balance concerns. First and foremost, your physical therapist will address your safety and your ability to move safely. Physical therapy will work on functional activities, balance activities, assistive devices to improve safety and patient/family education.

If you are experiencing chronic ankle or foot pain,  Schedule an in-clinic consultation today.