ANKLE AND FOOTDr. Michael P. Gillespie
ANKLE & FOOT
Walking and running require the foot to be both pliable and rigid.
It must be pliable to absorb stress and to conform to various configurations of the ground.
It must be rigid to withstand large propulsive forces.
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MEDIAL ASPECT
MEDIAL TENDONS
POSTERIOR TIBIAL ARTERY, TIBIAL NERVE
LATERAL MALLEOLUS & ATTACHED LIGAMENTS
PERONEUS LONGUS AND PERONEUS BREVIS TENDONS
ANTERIOR ASPECT
POSTERIOR ASPECT
OSTEOLOGY
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BONES, JOINTS, & REGIONS OF THE ANKLE
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NAMING THE JOINTS AND REGIONS
The term ankle refers primarily to the talocrural joint: the articulation among the tibia, fibula, and talus.
The term foot refers to all the tarsal bones, and the joints distal to the ankle.
Three regions of the foot: Rearfoot (hindfoot) – talus, calcaneus, and
subtalar joint Midfoot – remaining tarsal bones, transverse
tarsal joint, and smaller distal intertarsal joints Forefoot – metatarsals, phalanges, and all joints
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FIBULA
Long and thin Lateral and parallel to the tibia The shaft transfers only 10% of body weight
through the leg Fibular head – lateral to the lateral condyle of
the tibia Lateral malleolus – pulley for tendons of the
fibularis (peroneus) longus and brevis. Articular facet for the talus
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DISTAL TIBIA
The distal end of the tibia expands to accommodate loads transferred across the ankle
Medial malleolus Articular facet for the talus Fibular notch The distal end of the tibia is twisted
externally around the longitudinal axis by about 20 – 30 degrees – lateral tibial torsion
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OSTEOLOGIC FEATURES OF THE FIBULA AND DISTAL TIBIA
Fibula Head Lateral malleolus Articular facet (for the talus)
Distal Tibia Medial malleolus Articular facet (for the talus) Fibular notch
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DISTAL END OF THE RIGHT TIBIA, RIGHT FIBULA, AND TALUS
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TARSAL BONES
Seven tarsal bones Talus Calcaneus Navicular Medial, intermediate, and lateral cuneiform Cuboid
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OSTEOLOGIC FEATURES OF THE TARSAL BONES Talus
Trochlear surface Head Neck Anterior, middle, and posterior facets Talar sulcus Lateral and medial tubercles
Calcaneus Tuberosity Lateral and medial processes Anterior, middle, and posterior facets Calcaneal sulcus Sustentaculum talus
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OSTEOLOGIC FEATURES OF THE TARSAL BONES
Navicular Proximal concave (articular) surface Tuberosity
Medial, Intermediate, & Lateral Cuneiforms Transverse arch
Cuboid Groove (for the tendon of the fibularis longus)
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SUPERIOR (DORSAL) VIEW OF RIGHT FOOT
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INFERIOR (PLANTAR) VIEW OF RIGHT FOOT
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MEDIAL VIEW OF RIGHT FOOT
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LATERAL VIEW OF RIGHT FOOT
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TALUS
Most superiorly located bone of the foot Forms part of the talocrural joint 70% of the talus is covered with articular
cartilage
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SUPERIOR VIEW OF TALUS FLIPPED LATERALLY
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CALCANEUS
The largest of the tarsal bones Accepts the impact of heel striking the
ground during walking Calcaneal tuberosity – receives attachment
of the Achilles tendon Sustenaculum talus lies under and supports
the middle facet of the talus (shelf for the talus).
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NAVICULAR
Named for its resemblance to a ship Proximal surface articulates with the talus Distal surface articulates with the three
cuneiform bones
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MEDIAL, INTERMEDIATE, AND LATERAL CUNEIFORMS
Cuneiform (Latin root meaning “wedge”) Spacer between the navicular and bases of
the three medial metatarsal bones Contribute to the transverse arch of the foot
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CUBOID
Six surfaces, three of which articulate with adjacent tarsal bones
Articulates with 4th and 5th metatarsal bones
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RAYS OF THE FOOT
A ray of the foot is functionally defined as one metatarsal and its associated set of phalanges
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METATARSALS
Five metatarsal bones link the distal tarsal bones with the phalanges
Numbered 1 – 5 starting with the medial side Plantar surface of the 1st metatarsal has two
facets for sesamoid bones Fifth metatarsal bone has a styloid process
for attachment of the fibularis brevis muscle
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OSTEOLOGIC FEATURES OF A METATARSAL
Base (with articular facets for articulation with the bases of adjacent metatarsals)
Shaft Head Styloid process (on the fifth metatarsal only)
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PHALANGES
The foot has 14 phalanges The first toe, great toe or hallux has two
phalanges
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OSTEOLOGIC FEATURES OF A PHALANX
Base Shaft Head
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ARTHROLOGY
Major joints of the ankle Talocrural Subtalar Transverse tarsal joints
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JOINTS OF THE ANKLE AND FOOT
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TERMS THAT DESCRIBE MOVEMENTS AND DEFORMITIES OF THE ANKLE & FOOT
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Motion Axis of Rotation
Plane of Motion
Example of Fixed Deformity or Abnormal Posture
Plantar flexionDorsiflexion
Medial-lateral Sagittal Pes equinusPes calcaneus
InversionEversion
Anterior-posterior Frontal Varus Valgus
AbductionAdduction
Vertical Horizontal Abductus Adductus
SupinationPronation
Oblique (varies by joint)
Varying elements of inversion, adduction, and plantar flexionVarying elements of eversion, abduction, and dorsiflexion
Inconsistent terminology – usually implies one or more components of supinationInconsistent terminology – usually involves one or more components of pronation
FUNDAMENTAL MOVEMENT DEFINITIONSAPPLIED MOVEMENT DEFINITIONS
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STRUCTURE AND FUNCTION OF THE JOINTS ASSOCIATED WITH THE ANKLE
From an anatomic perspective, the ankle includes one articulation: the talocrural joint.
An important structural component of this joint is the articulation formed between the tibia and fibula. This articulation is reinforced by the proximal and distal tibiofibular joints and the interosseous membrane of the leg.
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PROXIMAL TIBIOFIBULAR JOINT
Located lateral to and immediately inferior to the knee.
Synovial joint (diarthrosis)
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DISTAL TIBIOFIBULAR JOINT
The articulation between the medial surface of the distal fibula and the fibular notch of the tibia.
Syndesmosis Interosseus ligament is an extension of the
interosseus membrane and forms the strongest bond between these bones.
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ANTERIOR-LATERAL VIEW RIGHT DISTAL TIBIOFIBULAR JOINT
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POSTERIOR VIEW RIGHT ANKLE
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TALOCRURAL JOINT
The articulation of the trochlea (dome) and the sides of the talus with the cavity formed from the distal end of the tibia and both malleoli.
Called the mortise joint due to its resemblance to the wood joint used by carpenters.
90 – 95% of the forces pass through the talus and tibia. 5 – 10% pass through the talus and fibula.
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LIGAMENTS OF THE DISTAL TIBIOFIBULAR JOINT
Interosseous ligament Anterior tibiofibular ligament Posterior tibiofibular ligament
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LIGAMENTS
A thin capsule surrounds the talocrural joint. Reinforced by collateral ligaments. Medial collateral (deltoid) ligament – broad
and expansive Lateral collateral ligament
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DISTAL ATTACHMENTS OF THE THREE SUPERFICIAL SETS OF FIBERS WITHIN THE DELTOID LIGAMENT
Tibionavicular fibers attach to the navicular, near its tuberosity.
Tibiocalcaneal fibers attach to the sustentaculum talus.
Tibiotalar fibers attach to the medial tubercle and adjacent part of the talus.
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MEDIAL COLLATERAL (DELTOID) LIGAMENT
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THREE MAJOR LIGAMENTS OF THE LATERAL COLLATERAL LIGAMENTS OF THE ANKLE
Anterior talofibular ligament Calcaneofibular ligament Posterior talofibular ligament
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LATERAL COLLATERAL LIGAMENTS
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MOVEMENTS THAT STRETCH AND ELONGATE THE MAJOR LIGAMENTS OF THE ANKLE
Ligaments Crossed Joints Movements That Stretch or Elongate Ligaments
Deltoid Ligament (Tibiotalar fibers)
Talocrural Joint Eversion, dorsiflexion with associated posterior slide of talus
Deltoid ligament (tibionavicular fibers)
Talocrural jointTalonavicular joint
Eversion, plantar flexion with associated anterior slide of talus
Deltoid ligament (tibiocalcaneal fibers)
Talocrural joint and subtalar joint
Eversion
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MOVEMENTS THAT STRETCH AND ELONGATE THE MAJOR LIGAMENTS OF THE ANKLE
Ligaments Crossed Joints Movements That Stretch or Elongate Ligaments
Anterior talofibular ligament
Talocrural joint Plantar flexion with associated anterior slide of the talus
Calcaneofibular ligament
Talocrural jointSubtalar joint
Dorsiflexion with associated posterior slide of the talus
Posterior talofibular ligament
Talocrural joint Dorsiflexion with associated posterior slide of the talus
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LIGAMENTOUS INSTABILITY
Ligaments Anterior and posterior talofibular, anterior
tibiofibular, and deltoid ligaments. If any of these ligaments are torn, the tibia
can separate from the fibula and the talus may become unstable.
Common mechanism of injury is a supination or inversion force.
LIGAMENTOUS INSTABILITY
The foot turns under the ankle after walking or running on uneven surfaces or when landing on an inverted foot after a jump.
The most common injured ligament is the anterior talofibular ligament.
Ligament laxity can lead to chronic ankle sprains.
LIGAMENTOUS INSTABILITY
Clinical Signs and Symptoms Ankle swelling Static ankle pain Pain on passive motion Tenderness over affected ligament
LIGAMENTS
Drawer’s Foot Sign
Procedure: Patient supine. Stabilize ankle with one hand. Press posterior on tibia with the other hand. Next, grasp anterior aspect of the foot with one hand and the posterior aspect of the tibia with the other. Pull anterior.
Rationale: Gapping with posterior push – tear anterior
talofibular Gapping with anterior pull – tear posterior
talofibular
Drawer’s Foot Sign
Drawer’s Foot Sign
LATERAL STABILITY
Procedure: Patient supine. Passively invert foot.
Rationale: Gapping secondary to trauma. Suspect tear of anterior talofibular ligament or calcaneofibular ligament.
LATERAL STABILITY
LATERAL STABILITY
MEDIAL STABILITY
Procedure: Patient supine. Passively evert foot.
Rationale: Gapping secondary to trauma. Suspect tear of deltoid ligament.
MEDIAL STABILITY
MEDIAL STABILITY
SUPERIOR VIEW RIGHT TALOCRURAL JOINT
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THE AXIS OF ROTATION AND OSTEOKINEMATICS TALOCRURAL JOINT
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NEUTRAL
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DORSIFLEXION
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PLANTAR FLEXION
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ARTHROKINEMATICS TALOCRURAL JOINT
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ROM TALOCRURAL JOINT DURING GAIT
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FACTORS THAT INCREASE THE MECHANICAL STABILITY OF DORSIFLEXED TALOCRURAL JOINT
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SUBTALAR JOINT
Resides under the talus Grasp the unloaded calcaneus and twist it
from side to side and rotary fashion Pronation and supination occur at this joint During walking the talus moves over a
relatively fixed calcaneus
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AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
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AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
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AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
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AXIS OF ROTATION AND OSTEOKINEMATICS AT THE SUBTALAR JOINT
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BONES & JOINTS OF THE RIGHT FOOT
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TRANSVERSE TARSAL JOINT (TALONAVICULAR AND CALCANEOCUBOID JOINTS)
The transverse tarsal joint, also known as the midtarsal joint, consists of two anatomically distinct articulations: the talonavicular joint and the calcaneocuboid joint.
These joints connect the rearfoot and midfoot.
Pronation and supination occurs at this joint to a great extent.
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TRANSVERSE TARSAL JOINT
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PLANTAR ASPECT RIGHT FOOT
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AXES OF ROTATION & OSTEOKINEMATICS TRANSVERSE TARSAL JOINT
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AXES OF ROTATION & OSTEOKINEMATICS TRANSVERSE TARSAL JOINT
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MEDIAL LONGITUDINAL ARCH OF THE FOOT
This arch is evident as the “instep” of the medial side of the foot.
This arch is the primary load bearing and shock absorbing structure of the foot.
The bones that form the arch are the calcaneus, talus, navicular, cuneiforms, and associated three medial metatarsals.
Additional supports include plantar fat pads, plantar fascia, and sesamoid bones.
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MEDIAL LONGITUDINAL ARCH
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ACCEPTING BODY WEIGHT DURING STANDING
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PES PLANUS – “ABNORMALLY DROPPED” MEDIAL LONGITUDINAL ARCH
Pes planus or “flatfoot” describes a chronically dropped or abnormally low medial longitudinal arch.
Often results from joint laxity and an overstretched or weak plantar fascia.
Flexible ples planus appears normal when unloaded, but drops when loaded.
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PES CAVUS – ABNORMALLY RAISED MEDIAL LONGITUDINAL ARCH
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CHANGE IN HEIGHT IN THE MEDIAL LONGITUDINAL ARCH
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ACTIONS ASSOCIATED WITH EXAGERRATED PRONATION OF THE SUBTALAR JOINT DURING WEIGHT BEARING
Joint of Region Action
Hip Internal rotation, flexion, and adduction
Knee Increased valgus stress
Rearfoot Pronation (eversion) with a lowering of medial longitudinal arch
Midfoot and Forefoot Supination (inversion)
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OSTEOKINEMATICS OF FIRST TARSOMETATARSAL JOINT
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METATARSOPHALANGEAL JOINT
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HALLUX VALGUS
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COMMON FIBULAR (PERONEAL) NERVE
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TIBIAL NERVE
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TARSAL TUNNEL SYNDROME
Tarsal tunnel syndrome occurs when the posterior tibial nerve becomes entrapped in its tunnel as it passes behind the medial malleolus to enter the foot.
The tunnel can be compressed either intrinsically or extrinsically.
Space-occupying lesions account for 50% of the cases.
TARSAL TUNNEL SYNDROME
Direct trauma and repetitive dorsiflexion account for a significant portion of the remaining cases.
A severe flat foot can unduly stretch the posterior tibial nerve.
Other possible causes include: fracture callus, ganglion of the tendon sheath, lipoma, engorged venus plexus, and excessive pronation of the hind foot.
TARSAL TUNNEL SYNDROME
Clinical Signs and Symptoms Intermittent paresthesia of plantar aspect of foot Pain on foot inversion and / or eversion of the
foot Pain radiating to posterior / medial aspect of the
leg Pain made worse by activity and improved by
rest
TARSAL TUNNEL
Tinel’s Foot Sign
Procedure: Tap over the posterior tibial nerve with a neurological reflex hammer.
Rationale: Paresthesias radiating to the foot indicate irritation of the posterior tibial nerve that may be caused by constriction at the tarsal tunnel.
Tinel’s Foot Sign
ACHILLES TENDON RUPTURE
Achilles tendon rupture generally occurs in adults aged 30 to 50.
It is usually spontaneous in athletes who account for most of these injuries.
Decreased vascularity of the Achilles tendon as the patient ages may contribute.
ACHILLES TENDON RUPTURE
Mechanism of injury - forced dorsiflexion of the foot as the soleus and gastrocnemius contract.
Rupture occurs 2 to 6 cm from the insertion of the Achilles tendon into the calcaneus.
As the proximal aspect of the tendon retracts, there is usually a palpable defect of the tendon.
ACHILLES TENDON RUPTURE
Clinical Signs and Symptoms Severe posterior ankle pain Inability to stand on toes Posterior leg and heel swelling Posterior leg and heel ecchymosis
Thompson’s Test
Procedure: Patient prone. Flex knee. Squeeze the calf muscles against the tibia and fibula.
Rationale: The the gastrocnemius and soleus are squeezed, they mechanically contract. They are attached to the Achilles tendon, which plantar-flexes the foot. If the tendon is ruptured, contraction of the gastrocnemius and soleus muscles will NOT plantar-flex the foot.
Thompson’s Test
ACTIONS ACROSS TALOCRURAL AND SUBTALAR JOINTS
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MUSCLES OF THE ANTERIOR COMPARTMENT OF THE LEG (PRETIBIAL “DORSIFLEXORS”)
Muscles Tibialis anterior Externsor digitorum longus Extensor hallucis longus Fibularis tertius
Innervation Deep branch of the fibular nerve
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PRETIBIAL MUSCLES
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LATERAL COMPARTMENT MUSCLES
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LATERAL COMPARTMENT OF THE LEG (“EVERTORS”)
Muscles Fibularis longus Fibularis brevis
Innervation Superficial branch of the fibular nerve
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MUSCLES OF THE POSTERIOR COMPARTMENT OF THE LEG
Superficial Group (“Plantar Flexors”) Gastrocnemius Soleus Plantaris
Deep Group (“Invertors”) Tibialis posterior Flexor digitorum longus Flexor hallucis longus
Innervation Tibial nerve
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POSTERIOR COMPARTMENT MUSCLES: SUPERFICIAL
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POSTERIOR COMPARTMENT MUSCLES: DEEP
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NERVE INJURY AND RESULTING DEFORMITIES OR ABNORMAL POSTURES
Nerve Injury / Associated Paralysis
Deformity or Abnormal Posture
Common Clinical Name
Deep branch of fibular nerve / paralysis pretibial muscles
Plantar flexion of talocrural joint
Drop-foot or pes equinus
Superficial branch fibular nerve / paralysis of fibularis longus and brevis
Inversion of the foot Pes varus
Common fibular nerve / paralysis of all dorsiflexor and evertor muscles
Plantar flexion of the talocrural joint and inversion of the foot
Pes equinovarus
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NERVE INJURY AND RESULTING DEFORMITIES OR ABNORMAL POSTURES
Nerve Injury / Associated Paralysis
Deformity or Abnormal Posture
Common Clinical Name
Proximal portion of tibial nerve / paralysis of all plantar flexor and supinator muscles
Dorsiflexion of the talocrural joint and eversion of the foot
Pes calcaneovalgus
Middle portion of the tibial nerve / paralysis of supinator muscles
Eversion of the foot Pes valgus
Medial and lateral plantar nerves
Hyperextension of the metatarsalphalangeal joints and flexion of the interphalnageal joints
Clawing of the toes
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PROPRIOCEPTIVE TRAINING
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