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Integrated functional anatomy of the ankle joint - Bones, joints, palpation, ligaments, nerves, joint anatomy, joint actions, arthrokinematics, muscles, fascia, and range of motion of the ankle joint. Highlighting the behaviors in postural dysfunction, pronation distortion syndrome, Achilles tendonitis, plantar fasciitis, shin splints, jumpers knee, runners knee, osteoarthritis, tarsal tunnel syndrome, and common interventions for the ankle joint.

Ankle Joint Anatomy: Talocrural, Subtalar and Tibiofibular Joints

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This course describes ankle/foot joint anatomy, which includes the talocrural, subtalar, and tibiofibular joints. This includes descriptions of the bones, synovial joints, joint actions, ligaments, bursae, relative location, the relationship between the bones of the foot and ankle, and the muscles that cross them. Further, this course discusses palpation and introduces ankle/foot joint specific exercises, manual techniques, and interventions for dysfunction, pain, posture, and movement impairment. The ankle joint is included in the common compensation patterns known as functional pes planus (flat feet), pronation distortion syndrome, functional valgus (knee bow in), asymmetrical weight shift (AWS), and 

. Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) with advanced knowledge of the ankle joint will improve their ability to analyze human movement and develop sophisticated exercise programs and therapeutic (rehabilitation) interventions. Further, this course is essential knowledge for future courses discussing injury prevention and physical rehabilitation/physical therapy (e.g. ankle pain, ankle arthritis, medial malleolus pain, ankle instability, chronic ankle sprain, ankle replacement surgery), the effect the ankle joint has on lower extremity alignment (e.g. the relationship between subtalar inversion and hip internal rotation), and ankle specific techniques for enhancing sports performance (e.g. lower body (leg) stability, strength, hypertrophy, agility, and power).

Brookbush Institute’s most recommended techniques for the Ankle Joint (see videos below):

Tibialis Anterior Isolated Activation (No Equipment)

Ankle (Talus) Manual Joint Mobilization – Anterior to Posterior

The bones and boney landmarks of the ankle/foot complex

Course Description: Ankle Joint Anatomy (Talocrural, Subtalar and Tibiofibular Joints)

Ankle Joint Anatomy: Talocrural, Subtalar, and Tibiofibular Joints

Course Study Guide Ankle Joint Anatomy: Talocrural, Subtalar, and Tibiofibular Joints

Study Guide: Ankle Joint Anatomy: Talocrural, Subtalar and Tibiofibular Joints

Introduction

: "Old English ancleow "ankle," from PIE root *ang-/*ank- "to bend" (see 

 (n.)). The modern form seems to have been influenced by Old Norse ökkla or Old Frisian ankel, which are immediately from the Proto-Germanic form of the root (source also of Middle High German anke "joint," German Enke "ankle"); the second element in the Old English, Old Norse and Old Frisian forms perhaps suggests claw (compare Dutch anklaauw), or it may be from the influence of cneow "knee," or it may be diminutive suffix -el. Middle English writers distinguished inner ankle projection (hel of the ancle) from the outer (utter or utward)." (

Joint (n): "c. 1300, "an (anatomical) joint, a part of a body where two bones meet and move in contact with one another, the structure that holds such bones together," from Old French joint "joint of the body" (12c.), from Latin iunctus "united, connected, associated," past participle of iungere "join" (see 

: "lower leg bone, 1726, from Latin tibia "shinbone," also "pipe, flute" (originally one of bone), in which sense it originally came into English (1540s). Of unknown origin. The Latin plural is tibiæ. (Related: 

 "1670s, "clasp, buckle, brooch," from Latin fibula "clasp, brooch; bolt, peg, pin," related to figere "to drive in, insert, fasten" (see 

 (v.)). In reference to brooches, the modern English word mostly is used in archaeology. As "smaller bone in the lower leg" from 1706, from a Latin loan-translation of Greek perone "small bone in the lower leg," originally "clasp, brooch; anything pointed for piercing or pinning;" the bone was so-called because it resembles a clasp such as that found in a modern safety pin. Related: Fibular." (

 " "anklebone," 1690s, from Latin talus "ankle, anklebone, knucklebone" (plural tali), related to Latin taxillus "a small die, cube" (they originally were made from the knucklebones of animals)." 

 " "slope," 1640s, from French talus (16c.), from Old French talu "slope, mound, small hill" (12c.), probably from Gallo-Roman *talutum, from Latin talutium "a slope or outcrop of rock debris," perhaps of Celtic origin (compare Welsh, Breton tal "forehead, brow")." (

 "from Latin (os) calcaneum "bone of the heel," from calcem (nominative calx (1)) "heel," a word of uncertain origin, perhaps from Etruscan. De Vaan lists as possible cognates Old Prussian culczi "hip," Lithuanian kulkšnis "ankle-(bone)" Bulgarian kalka "hip, thigh." " (

The ankle joint in a cadaver dissection showing the bones and ligaments of the ankle

Another depiction of a cadaver dissection of the ankle. More soft tissue than the previous image.
By Anatomist90 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=25274518[/caption]

The term "ankle joint" often haphazardly groups the tibiotalar (talocrural) and talocalcaneal (subtalar) joints together and considers the fibula a static structure that forms the lateral wall of the ankle joint mortise. A more accurate analysis of the ankle would include the tibiotalar and talocalcaneal joints separately and include glide of the fibula on the tibia at both proximal and distal ends (15).

The talocalcaneal joint is actually comprised of 3 joint surfaces, the anterior, middle, and posterior facets. The anterior and middle facets meet in some individuals. The posterior facet comprises nearly 70% of the articular surface of the talocalcaneal joint and receives approximately 75% of the force through the joint (2).

Included in this course, because the motion of the proximal tibiofibular joint is linked to the distal tibiofibular joint, and the distal tibiofibular joint plays a role in ankle mechanics. This joint must transfer the force imparted by the 

 and create a stable base for the lateral collateral ligament of the knee, so the small amount of motion that is allowed is likely to accommodate motion of the distal fibula (lateral malleolus).

This articulation, along with the lateral malleolus comprises the lateral wall of the mortise of the ankle (the ankle joint is often referred to as a "mortise" due to its resemblance to the rectangular wooden joint used by carpenters). Stability at this joint aids in the optimal transfer of force to and from the talus and up the kinetic chain, especially in the transverse and frontal planes. Approximately 90% of ground forces imparted on the lower extremity are transferred through the tibia, and no more than 10% through the fibula (1, 3, 16).

Synarthrosis: A joining of 2 bones with minimal motion, generally allowing a small amount of glide. This joint is either classified as a fibrous or cartilaginous joint.

Fibrous Syndesmosis Joint: Reinforced by the interosseous membrane

Articular Surfaces

A superior view of the talus with lateral and medial malleolus labeled

An image of the talus and calcaneus bones of the body

The ankle joint with the muscles and connective tissue labeled

The range of motion of the ankle joint with axis of rotations labeled

Illustration of the femoral torsion (anteversion) on the left, and tibial torsion angle on the right

Talus neck angle which depicts a slight medial angle of the talar neck

Introduction to Ankle Joint (Talocrural, Subtalar and Tibiofibular Joints) Anatomy

Palpation

The ankle joint is a great joint for sharpening your palpation skills. Although the bones and landmarks are fairly small and close to one another, they are mostly superficial.

Lateral and Medial Malleolus (fibular) - 

Palpation of the ankle is likely easiest if we start with the two large bumps on either side of the ankle. With your partner lying supine or seated, explore the size and shape of each malleolus (the large bumps). Notice how the lateral malleolus is larger, or at least longer, than the medial malleolus. Keep in mind, that the lateral malleolus is part of your fibula, and your medial malleolus is part of your tibia. You can trace the medial malleolus up the anterior tibia (shin), but tracing up your lateral malleolus results in the bone disappearing under your fibularis muscles. Palpate the ligaments projecting from the bottom of your malleoli - the fan-shaped deltoid ligaments projecting from the bottom of the medial malleolus, and the prominent calcaneofibular ligament projecting straight down from the end of the fibula.

If you continue your palpation to the distal, posterior end of your malleoli and press a bit deeper into the tissue you will feel grooves in the back of each. The tendons of the 

 run in the groove of the medial malleolus, which then leads to the tarsal tunnel where you can find "Tom Dick And Very Nervous Harry" - 

, Posterior Tibial Artery, and Vein, Tibial Nerve, and 

 run in the groove in your lateral malleolus.

 - The fibular head (articulation of the proximal tibiofibular joint) can be palpated by tracing the fibularis muscles proximally from the lateral malleolus until your fingers get caught under the inferior portion of the fibular head. Or, you can fall off the tibial tuberosity (discussed in the 

 article) laterally 5 - 6 centimeters to end up on the anterior aspect of the fibular head. Continuing your palpation to fall off the top (superior/proximal) of the fibular head, you will find a depression (just inferior to the femoral condyle) where a little deeper palpation and exploration will reveal the knee joint line and lateral collateral ligament (LCL) Take the time to explore the shape, size, and depressions on the fibular head. This is an important palpation for manual therapists.

 - Walk your fingers down and back toward the heel and allow your fingers to sink into the soft tissue. The bone you are feeling is the calcaneus or "heel bone". Notice how the medial and lateral sides are rigid and cratered, compared to the round flat surface of the posterior and plantar aspects of the calcaneus (the tuberosity of the calcaneus). Consider how this is important to the function of the calcaneus and how this may be related to gait.

 - In seated or lying, passively invert your partner's foot and depress your thumb into the soft tissue just below the medial malleolus. About 2 centimeters inferior and slightly posterior to the medial malleolus you will feel a raised ridge. This ridge is your sustentaculum tali, the structure that supports the middle facet of the talus. (Note: ensure you are not anterior to the medial malleolus, as the ridge located there is the navicular tubercle)

 - In seated or lying, almost opposite the sustentaculum tali, on the lateral aspect of the calcaneus, about 2 centimeters inferior to the lateral malleolus is a raised ridge known as the "peroneal trochlea". Passively evert the foot to soften the tissues of the lateral ankle. The tendons of the 

 pass under this trochlea, but not the tendon of the 

The head of the talus can be located by first finding the navicular tubercle. The navicular tubercle is a raised bump about a centimeter inferior and 2 centimeters anterior to the distal end of the medial malleolus. (This was discussed above, as the sustentaculum tali is just inferior and posterior to the medial malleolus.) Once you have located the navicular tubercle, passively invert the foot to soften tissues and allow your thumb to depress between the navicular tubercle and medial malleolus. Moving your thumb back-and-forth in this depression, you should feel a ridge distally that is the head of the talus, and a flattened section of bone proximally that is the anterolateral aspect of the neck of the talus.

 - From the depression between the navicular tubercle, across the front of the ankle, to the anterior/inferior aspect of the lateral malleolus you can run your thumb over the neck of the talus. You can also find the neck of the talus by imagining a line through the medial and lateral malleoli and pressing your thumb in the center of that line, on the front of the ankle, deep to the tendons of the 

extensor hallucis longus, and extensor digitorum longus

- The trochlea of the talus can be felt using the same palpation as you used for the neck of the talus. Place your thumb in the center of a line between the malleoli, on the front of the ankle, and deep to the tendons of the 

. Now, with your other hand, pull your partner's foot into plantar flexion. As you pull the foot into plantarflexion, the talar dome will slide under your finger, and you should notice a mild depression, and/or two raised ridges move under your finger. You can imagine the trochlea as the "valley" between the two raised "ridges".

Illustration of the fibular, tibia, calcaneus, and talus and the connecting ligaments and tendons of the ankle joint

Simple Illustration of bones and ligaments of the ankle joint
By An svg version of image:Ankle.PNG by me (Jak). - A vector version of the original image found here [1], Public Domain, https://commons.wikimedia.org/w/index.php?curid=1981086

Ankle Joint Palpation

Capsule and Ligaments

The fibular, tibia, calcaneus, talus, bones of the foot, and interosseous membrane

Interosseous Membrane - By Anatomist90 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=25485637

Bursae

Muscles, tendons, and bursae of the lateral ankle joint

Ankle Joint Bursae

Ankle Joint Connective Tissues: Capsule, Ligaments, and Menisci

Nerves

Proximal Tibiofibular Joint Capsule: Innervated by branches from the common fibular and popliteal nerves (21).

Distal Tibiofibular Joint: (No Capsule) Innervated by branches of the sural, deep fibular, and tibial nerves.

Ankle (Tibiotalar) - Innervated by distal branches of all 5 major nerves of the lower leg, including the saphenous (medial ankle and malleolus), tibial (anterior, medial, and talocalcaneonavicular), sural (lateral), superficial peroneal (medial and ventral), and deep peroneal nerve (anterior ankle) (22, 23).

Talocalcaneal - The anterior facets are likely innervated by the deep peroneal nerve, the sural nerves have branches that penetrate the lateral joint line, this joint may also receive innervation from the tibial and medial plantar nerves (22, 24).

The muscular innervation of the nerves in the lower leg

Nerves of the Posterior Leg and Muscular Innervation

Ankle Joint Nerves

Osteokinematics

Included in this section are the osteokinematics of the talotibial (talocrural) and talocalcaneal (subtalar) joints. The distal and proximal tibiofibular joints are not included as they display a small amount of motion that would be best described as arthrokinematic motion.

Note: The axis of rotation for the ankle is not strictly parallel to the frontal or transverse planes of motion. It is not a simple frontal plane axis that results in the primary actions of the ankle running parallel to the sagittal plane. The true axis of the ankle can be imagined as a line through the distal tips of the malleoli; with the lateral malleolus extending further inferiorly and being slightly posterior to the medial malleolus. This creates an axis 10° from the frontal plane and 6° from the horizontal plane. Due to the slight obliquity of the axis of rotation of the tibiotalar joint, dorsiflexion along this axis would appear to include slight abduction and eversion (often referred to as pronation) whereas plantar flexion would appear to include slight adduction and inversion (often referred to as supination). Note, abduction and adduction are not active motions, and eversion and inversion of the tibiotalar joint are not active either. As these motions are not active, they are not included in the analysis below and are rather assumed as slight deviations from the sagittal plane during dorsiflexion and plantar flexion. Eversion and inversion of the talocalcaneal joint may be active and is included below. The Brookbush Institute prefers to use the terms "pronation" and "supination" to refer to a combination of joint actions that results in rotation of the forefoot (as the terms are commonly used by Podiatrists (DPM)), similar to how the terms are used for the forearm. Our decisions for how joint actions and terminology are used are not in defiance or disagreement of biomechanical principles, but they are based on function, clarity, and usefulness in practice. For example, although we may not be able to change the axis of rotation of the tibiotalar joint and affect the "abduction" component of "tibiotalar pronation", we can address excessive eversion of the talocalcaneal joint by addressing altered muscle activity and lengths of the muscles crossing the talocalcaneal joint, further, the talocalcaneal joint may be mobilized. The neutral position of the tibiotalar joint is considered 90° by convention when measured between the 5th metatarsal and center of the tibia, and the talocalcaneal joint is considered in a neutral position at 180° by convention, or when the Achilles tendon forms a straight line between the center of the calcaneus, talus, and tibia.

extensor digitorum longus, extensor hallucis longus, fibularis tertius

flexor hallucis longus, flexor digitorum longus

, fibularis longus, fibularis brevis, posterior capsule, inferior transverse ligament, calcaneofibular ligament (tibiotalar fibers), posterior tibiofibular ligament, interosseous ligament, deltoid ligament (tibiotalar fibers).

Optimal Range of Motion (AAROM): 15-20° (

Plantarflexors: Gastrocnemius, plantaris,

, anterior talofibular ligament, interosseous ligament, deltoid ligament (tibionavicular fibers).

Joint actions of the foot, including dorsiflexion and plantar flexion

Dorsiflexion and Plantarflexion of the Tibiotalor (Talocrural) Joint
By Connexions - http://cnx.org, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=29624326

Limited by: Fibularis longus, fibularis brevis, 

, lateral collateral ligaments (anterior talofibular, posterior talofibular, calcaneal fibular ligaments), talocalcaneal ligaments (medial, posterior, lateral), interosseous ligament and cervical ligament

Evertors: Fibularis longus, fibularis brevis, 

medial gastrocnemius, deltoid ligament (all fibers), talocalcaneal ligaments (medial, posterior, lateral), interosseous ligament, cervical ligament

 may be biased toward contributing to inversion; however, may also contribute to eversion when the attachment of the Achilles tendon on the calcaneus is lateral to the talocalcaneal axis of rotation (roughly the midline of the calcaneus) (25, 26)

Further, the medial and lateral gastrocnemius may be biased toward eversion due to a 90° rotation of the Achilles tendon that places the fibers that invest in the gastrocnemius muscles lateral to the center of the calcaneus (25, 27)

An example of subtalar inversion and eversion

Talocalcaneal (subtalor) Inversion and Eversion

Arthrokinematics

Image of a cross section of the muscles of the lower leg

Ankle Joint Actions

Regional Interdependence

Motion of the ankle is influenced by muscles, fascia, and the mobility of nerves that cross multiple joints, a concept often referred to as "regional interdependence". Further, the motion of proximal joints may influence the position of bones, force vectors, moment arms, and the dissipation of force. 

A strong argument can be made that all muscles crossing the joints of the lower extremity (from the sacroiliac joint to phalanges) may affect ankle motion.

Those with the largest influence likely include muscles that contribute to: 

Plantarflexion: Gastrocnemius, plantaris,

, vastus lateralis (iliotibial band complex)

Note: All of the invertors and evertors of the talocalcaneal joint also either plantarflex or dorsiflex the ankle.

Iliotibial Band: by attachment to the fibular head and its influence on proximal tibiofibular joint motion.

Ankle (Tibiotalar) - Discussed above, the 5 major nerves of the lower leg both cross the ankle and innervate the joint capsules, saphenous nerve, tibial nerve, sural nerve superficial fibular nerve, and deep fibular nerve (22, 23).

Femoral and Sciatic Nerves - The saphenous nerve departs from the femoral nerve, the sciatic nerve splits into the tibial nerves and the common fibular nerve, the common fibular nerve splits again into the superficial and deep fibular nerves and the sural is comprised of branches of the tibial and common fibular nerves (1 - 4).

Common Fibular Nerve - The common fibular nerve deserves an additional mention, as this nerve may become irritated or trapped as a result of proximal tibiofibular joint dysfunction. Although this dysfunction is often treated as knee impairment, it is likely the ankle plays a significant role.

Postural Dysfunction

The ankle has a propensity toward a compensation pattern often described as "flat feet," "feet turn out," "functional pes planus," or "pronation distortion"(1, 7-10). This movement impairment is a combination of joint restrictions and actions - 

excessive eversion, and potentially excessive tibial external rotation at the knee

 (which is discussed further in the article - 

excessive anterior glide/inadequate posterior glide

 of the talus commonly accompanies this dysfunction (1, 7, 9, 10). Clinically, the Brookbush Institute has also noted stiffness and arthrokinematic dyskinesis of the talocalcaneal and proximal and distal tibiofibular joints that match the arthrokinematic motions that one would expect to find accompanying excessive plantarflexion, eversion, and talar anterior glide.

excessive medial glide of the calcaneus on the talus, excessive anterior glide of the distal fibula, and excessive posterior glide of the proximal tibiofibular joint

. Again, this may be further accompanied by arthrokinematic dyskinesis of the 

. These changes may result in, or be the result of altered length and activity of one, or many of the muscles crossing the ankle joint and/or proximal tibiofibular joint, and further, result in maladaptive changes in length and/or extensibility of passive soft tissues (capsule, ligaments and fascial structures). Although this section will describe dysfunction from the perspective of the ankle; the ankle could be viewed as the "keystone" of 

. That is lower extremity alignment and optimal muscular recruitment are dependent on optimal function of the ankle during gait from heel strike to push off. Further, maladaptation of the structures associated with the 

 may alter heel placement during heel strike and initiate compensatory patterns of motion during the gait cycle. Careful assessment of the 

 (and perhaps the sacroiliac joint) should be included for every patient/client exhibiting dysfunction of the ankle. It should also be noted that additional compensatory patterns exist and are relevant to practice; however, in this article, focus will be given to this pattern, which is presumed to be "most common."

Inadequate dorsiflexion (excessive plantar flexion), excessive eversion, and potentially excessive tibial external rotation at the knee

Excessive anterior glide of the talus on the tibia

Excessive medial glide of the calcaneus on the talus

Excessive anterior glide of the lateral malleolus

Excessive posterior glide of the fibular head on the tibia

Maladaptive Decrease In Length/Extensibility 

Restricts dorsiflexion and posterior glide of talus on tibia - posterior capsule of tibiotalar joint, inferior transverse ligament, calcaneofibular ligament (tibiotalar fibers), posterior tibiofibular ligament

Restricts talocalcaneal inversion and medial glide of calcaneus on talus - lateral collateral ligaments (anterior talofibular, posterior talofibular, calcaneal fibular ligaments), talocalcaneal ligaments (medial, posterior, lateral), interosseous ligament and cervical ligament

Flexor Hallucis Longus and Flexor Digitorum Longus

Relative to posterior glide of the proximal fibula (and potentially tibial external rotation)

(Synergistically Dominant - Release Only)

Extensor Hallucis Longus and Extensor Digitorum Longus

Relative to posterior glide of the proximal fibula (and potentially tibial external rotation) 

Ankle Dysfunction

The various arches of the foot, inlcuding normal, high arch, and flat foot

Signs of Dysfunction

Signs of Dyfunction

Postural Dysfunction and the Ankle Joint

Self-administered Ankle Joint Mobilization

Videos

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition 

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Phillip Page, Clare Frank, Robert Lardner, 

Assessment and Treatment of MuscleImbalance: The Janda Approach

NASM Essentials of Corrective Exercise Training

Movement Impairment Syndromes of the Extremities, Cervical and Thoracic Spine,

Manipulative Therapy: Musuloskeletal Medicine

Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004

Ankle Joint Anatomy: Talocrural, Subtalar and Tibiofibular Joints

Related Courses:

Course Description: Ankle Joint Anatomy (Talocrural, Subtalar and Tibiofibular Joints)

Study Guide: Ankle Joint Anatomy: Talocrural, Subtalar and Tibiofibular Joints

Introduction to Ankle Joint (Talocrural, Subtalar and Tibiofibular Joints) Anatomy
1 Sub Section

Ankle Joint Palpation

Ankle Joint Connective Tissues: Capsule, Ligaments, and Menisci
1 Sub Section

Ankle Joint Nerves

Ankle Joint Actions
1 Sub Section

Regional Interdependence

Postural Dysfunction and the Ankle Joint
2 Sub Sections

Videos
1 Sub Section

Bibliography

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Ankle Joint Anatomy: Talocrural, Subtalar and Tibiofibular Joints

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Course Description: Ankle Joint Anatomy (Talocrural, Subtalar and Tibiofibular Joints)

Study Guide: Ankle Joint Anatomy: Talocrural, Subtalar and Tibiofibular Joints

Introduction to Ankle Joint (Talocrural, Subtalar and Tibiofibular Joints) Anatomy1 Sub Section

Ankle Joint Palpation

Ankle Joint Connective Tissues: Capsule, Ligaments, and Menisci1 Sub Section

Ankle Joint Nerves

Ankle Joint Actions1 Sub Section

Regional Interdependence

Postural Dysfunction and the Ankle Joint2 Sub Sections

Videos1 Sub Section

Bibliography

Related Courses:

Comments

Guest

Introduction to Ankle Joint (Talocrural, Subtalar and Tibiofibular Joints) Anatomy
1 Sub Section

Ankle Joint Connective Tissues: Capsule, Ligaments, and Menisci
1 Sub Section

Ankle Joint Actions
1 Sub Section

Postural Dysfunction and the Ankle Joint
2 Sub Sections

Videos
1 Sub Section