Video: Ligaments of the foot
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Yo VIP! Let's kick it. RICE, RICE, baby. RICE, RICE, baby. Okay, stop! Concentrate and listen. Kenhub’s here. Nobody better miss it. You're walking down the street and your foot starts twisting. Yo... Read more
Yo VIP! Let's kick it. RICE, RICE, baby. RICE, RICE, baby. Okay, stop! Concentrate and listen. Kenhub’s here. Nobody better miss it. You're walking down the street and your foot starts twisting. You’re in a lot of pain and your words are stitchin’. You looked at your foot and you start yelling. That ligament sprain and the foot is swellin’. It's painful. Your foot got a problem. How you gonna solve it? I know a way, just gotta involve it. Use RICE, RICE, baby. You just need RICE, RICE baby.
Okay, I'll stop rapping, if I really have to. I was just brushing up on my clinical skills when dealing with the ligaments of the foot.
So, the ligaments of the foot are very numerous, so it's no wonder learning about them seems daunting. Trust me, I've been there. Spraining a ligament in your foot is almost less painful than trying to learn them all by heart. If only there was a way to be more systematic about it, that would make it all easier.
Well, that's what we've done for you in this tutorial. We've categorized the ligaments into more manageable subgroups based on which joint they're associated with to make things a little easier. We'll cover all of the ligaments associated with the joints between the tarsal bones, any joints associated with the metatarsal bones, and interphalangeal joints. And we'll finish the tutorial with some clinical notes.
Before you continue with me though, I need to first double check that you're up to speed on the bones at the foot. You're going to need to know all about these before learning about the ligaments here. So, if you need a refresher, why not first check out our tutorial on the bones of the foot, which will remind you everything you need to know. If you're ready, let's get started with the ligaments of the foot.
First up are the ligaments associated with the talocalcaneal joint. The talocalcaneal joint, also known as the subtalar joint, is the joint between the talus and the calcaneus bones of the foot. We have four ligaments here – the lateral, medial, posterior, and interosseous talocalcaneal ligaments. You'll notice that quite conveniently most ligaments of the foot are named after the bones they connect. Maybe, they're not so bad after all.
The lateral talocalcaneal ligament is a short flat and slim band which extends downwards and posteriorly from the lateral process of the talus to the lateral surface of the calcaneus just lateral to its posterior articular surface. On the opposite side, we have the medial talocalcaneal ligament and this is also a short strong ligament which connects the medial tubercle of the talus to the posterior talar shelf or the sustentaculum tali of the calcaneus, and the adjacent medial surface of the calcaneus. It often blends with the tibiocalcaneal ligament of the ankle joint. Together, the medial and lateral talocalcaneal ligaments act to reinforce the talocalcaneal joint capsule.
The short flat posterior talocalcaneal ligament is, of course, located at the posterior aspect of the foot. It connects the lateral tubercle of the talus to the superomedial aspect of the posterior calcaneus. Occasionally, this ligament consists of two separate fascicles appearing as a split tendon. While the medial and lateral ligaments are somewhat superficial, the interosseous talocalcaneal ligament is located deeper in the foot in what's known as the talar sinus – a space between the talus and the calcaneus. It is a broad, flat, and obliquely-oriented ligament which connects the sulcus tali to the calcaneal sulcus. In less than half the population, a cervical talocalcaneal ligament is also present, just lateral to the talar sinus.
One group down, we're now moving on to the ligaments which cross the talocalcaneonavicular joint.
As the name suggests, the talocalcaneonavicular joint involves three bones and describes the articulation of the talus with the navicular bone and another articulation of the talus with the calcaneus. We have three ligaments here – the dorsal talonavicular, the calcaneonavicular, and the plantar calcaneonavicular ligaments.
The name of the dorsal talonavicular ligament tells you exactly where it is. It connects the talus to the navicular and is found at the top or the dorsum of the foot. This broad, thin band stretches between the dorsal surface of the neck of the talus and the dorsal surface of the navicular bone.
The calcaneonavicular ligament is found on the dorsolateral aspect of the hindfoot. Due to its position, it is sometimes referred to as the lateral calcaneonavicular ligament. The ligament attaches to the dorsal aspect of the calcaneus, specifically, to the anteromedial border of the hollow contributing to the talar sinus. Its other attachment is at the posterodorsal part of the lateral aspect of the navicular bone.
The plantar calcaneonavicular ligament is a Y-shaped structure found on the plantar medial aspect of the foot. It connects the anterior margin of the sustentaculum tali of the calcaneus to the plantar surface of the navicular bone. This ligament is often described as having two separate bands – a superomedial part and an inferior part. Occasionally, the superomedial band is described as a separate ligament while the lateral part is considered as the plantar calcaneonavicular ligament proper.
The interesting thing about the calcaneonavicular and the plantar calcaneonavicular ligaments is that they connect two bones which do not have a direct articulation with one another. Aside from anchoring these bones together, the plantar calcaneonavicular ligament supports the head of the talus and is the strongest and most important stabilizers of the longitudinal arches of the foot. It contains a considerable amount of elastic fibers so as to give elasticity to the arch and spring to the foot, and for this reason, it's often referred to as the spring ligament.
It's time to move on to the next joint in our list and the ligaments associated with it – the calcaneocuboid joint.
The calcaneocuboid joint is an articulation between the calcaneus and the cuboid. The joint is strengthened by four different ligaments – the calcaneocuboid, the dorsal calcaneocuboid, the plantar calcaneocuboid, and the long plantar ligaments. Let's take a look at each of them separately.
We'll start with the calcaneocuboid ligament, which is also sometimes referred to as the medial calcaneocuboid ligament. It attaches to the anterior aspect of the anterior process of the calcaneus and the dorsal aspect of the cuboid bone. Remember the calcaneonavicular ligament which we mentioned a few moments ago? Well, this and the calcaneocuboid ligament are often coupled together and collectively known as the bifurcate ligament due to their combined fork-like appearance. To make matters even more complicated, it's also known as Chopart’s ligament.
We're now moving on to our next ligament, which is the dorsal calcaneocuboid ligament. Now, I know what you're thinking. There's already a calcaneocuboid ligament on the dorsum of the foot. Confusing, right? Well, the dorsal calcaneocuboid ligament is located inferolateral to the calcaneocuboid ligament. It's also sometimes known as the dorsolateral or lateral calcaneocuboid ligament. The easy way to tell these two apart is that the calcaneocuboid ligament forms a V shape with the calcaneonavicular ligament while the dorsal calcaneocuboid ligament is a single band. Their ligament links the dorsolateral corner of the anterior process of the calcaneus to the dorsolateral aspect of the cuboid bone.
We're flipping over to the plantar surface of the foot now where we have two more ligaments to look at. The first is the long plantar ligament. It's the longest of the tarsal ligaments, so it may not be immediately obvious that it is one of the major ligaments connecting the calcaneus to the cuboid bone. It proximally attaches to the plantar surface of the calcaneus. Its deep fibers then insert into the ridge and tuberosity on the plantar surface of the cuboid bone. The superficial fibers, however, go on to extend as far as the bases of the second to fourth, and sometimes, fifth metatarsal bones.
Deep to the long plantar ligament hides the plantar calcaneocuboid ligament. It is much shorter, and therefore, occasionally gets referred to as the short plantar ligament. The two ligaments are separated by areolar connective tissue. The plantar calcaneocuboid ligament is attached to the plantar aspect of the anterior process of the calcaneus and extends to the plantar surface of the cuboid bone just proximal to the groove for the tendon of the fibularis longus.
We're making progress! Next up, we're looking at the cuboideonavicular joint and the ligaments associated with it. The cuboideonavicular joint, quite unsurprisingly, refers to the articulation between the cuboid and the navicular bones. There are three ligaments we need to discuss in association with this joint – the dorsal cuboideonavicular, the plantar cuboideonavicular, and the interosseous cuboideonavicular ligaments. Be aware that occasionally the terms cubonavicular or naviculocuboid may alternatively be used in naming all of these ligaments.
The dorsal cuboideonavicular ligament is a triangular structure found on the dorsum of the foot. Its medial apex attaches to the dorsal aspect of the navicular bone anteromedial to the attachment of the calcaneonavicular ligament, which we said is part of the bifurcate ligament. The lateral base inserts into the dorsal distal half of the cuboid with some fibers extending onto the lateral cuneiform bone.
The cuboideonavicular joint is reinforced on the plantar surface by the plantar cuboideonavicular ligament. This rectangular band attaches to the plantar surface of the cuboid bone along the medial border and plantar surface of the navicular bone close to its lateral edge. The interosseous cuboideonavicular ligament is a very short, strong band connecting the non-articular surfaces of the cuboid and navicular bones. As the ligament lies between the two bones, it is hidden by the plantar cuboideonavicular ligament when looking from the plantar aspect. It attaches to the medial surface of the cuboid bone and anteroinferior part of the lateral surface of the navicular bone.
We're moving on to the cuneiform bones now, and looking at the cuneonavicular joint ligaments.
The cuneonavicular or naviculocuneiform joint, whichever you prefer to call it, is formed by the articulation of the navicular bone and the three cuneiform bones of the midfoot. We're looking at seven ligaments here altogether – three dorsal, three plantar, and one medial cuneonavicular ligament.
The three dorsal cuneonavicular ligaments connect each of the cuneiform bones to the navicular bone. Each of the three ligaments arise at the distal dorsal surface of the navicular bone. The first band extends anteriorly straight over the joint and inserts into the dorsal surface of the medial cuneiform bone. It is the strongest of the three ligaments. The second and third dorsal bands are oblique, inserts in the dorsal surfaces of the intermediate and lateral cuneiform bones.
If we turn to the opposite side of the foot, we find three corresponding plantar cuneonavicular ligaments. The first band is broad and flat. It attaches to the anterior and plantar surfaces of the navicular tuberosity and the plantar tuberosity of the medial cuneiform bone. The second and third ligaments arise at the plantar surface of the navicular bone. Each of these inserts into the posterior aspect of the cuneiform crest of the intermediate and lateral cuneiform bones.
The final member of this group of ligaments is the medial cuneonavicular ligament. It is a strong ligament on the medial aspect of the foot. It stretches between the medial aspect of the tuberosity of the navicular bone and the medial aspect of the medial cuneiform bone.
Moving over to the lateral aspect of the foot, let's have a quick look at some ligaments associated with the cuneocuboid joint.
Unlike the cuneonavicular joint where all three cuneiform bones are involved, this articulation only involves the cuboid and the lateral cuneiform bones. In the literature, the ligaments associated with the joint are not well described compared to the other ligaments at the foot; however, at Kenhub, we don't discriminate, so let's talk about the three cuneocuboid ligaments which are the dorsal, plantar, and interosseous cuneocuboid ligaments.
The dorsal cuneocuboid ligaments is a broad and flat band which connects the dorsal aspect of the cuboid bone to the dorsal surface of the lateral cuneiform bone. It's described as forming a roughly triangular arrangement with the dorsal cuboideonavicular and dorsal cuneonavicular ligaments.
Supporting the cuneocuboid joint on the plantar surface of the foot, we find the plantar cuneocuboid ligament. It's a short ligament stretching between the medial aspect of the crest of the cuboid bone and the lateral plantar surface of the lateral cuneiform bone.
The interosseous cuneocuboid ligaments is a tiny, but strong band which anchors these bones within the joint. It attaches anterior to the articular surfaces of the lateral aspect of the lateral cuneiform and medial aspect of the cuboid.
We're moving into the last group of ligaments which link together the tarsal bones. So, let's talk about the intercuneiform ligaments.
So, we have two intercuneiform joints, one between the medial and intermediate cuneiform bones and another between the intermediate and lateral cuneiform bones. There are five to six intercuneiform ligaments to look at here – two dorsal, two interosseous, and one to two plantar intercuneiform ligaments.
The dorsal ligaments are really straightforward. They are two little transverse bands which bind the dorsal surfaces of adjacent cuneiform bones. Just like the other interosseous ligament of the foot, the interosseous cuneiform ligaments are short strong bands located deep within the foot.
The plantar intercuneiform ligaments are another group of structures where textbooks can't seem to reach an agreement. Almost all texts uniformly describe a plantar intercuneiform ligament between the medial and intermediate cuneiform bones; however, some texts also describe a second ligament located between the intermediate and lateral cuneiform bones.
Well, that was a big section. If you feel like a breather, why don't we take a short intermission to look at this cat.
Now, that we’ve taken a little break, we’ll dip our toes into the tarsometatarsal joints and ligaments which hold them together.
The tarsometatarsal joints are located between the cuboid and cuneiform bones of the tarsus and the bases of the five metatarsal bones found distal to them. It's commonly referred to as Lisfranc's joint. The joints themselves are covered by capsules which are reinforced by several ligaments. There are dorsal and plantar tarsometatarsal ligaments and cuneometatarsal interosseous ligaments.
With five metatarsal bones, you might expect there to be five ligaments, but actually, we have seven to nine dorsal tarsometatarsal ligaments here. The first band is thick and strong. It anchors the base of the first metatarsal bone to the medial cuneiform bone. We have three ligaments attached to the bases of the second metatarsal, one to each of the cuneiform bones. The third metatarsal base is only connected to the dorsum of the lateral cuneiform bone. The fourth metatarsal has a ligament anchoring it to the cuboid bone, and sometimes, the bands to the lateral cuneiform bone, too.
The fifth metatarsal is connected by a ligament to the cuboid bone, and occasionally, to the dorsum of the lateral cuneiform bone. Unfortunately, the plantar tarsometatarsal ligaments aren’t too straightforward either, mostly due to the anatomical variation due to lots of inconsistencies between different texts. All texts report a strong ligament between the plantar aspect of the medial cuneiform bone and the base of the first metatarsal bone. Some sources also mention ligaments joining the medial cuneiform bone to the bases of the second and third metatarsal bones.
There is disagreement about the existence of the ligaments between the intermediate cuneiform bone and the second and third metatarsal bones. We've added these ligaments to our illustration to show you where they would be if present.
The ligaments associated with the lateral aspect of the foot are subject to a lot of anatomical variation. There is a varied presence of ligaments between the lateral cuneiform and cuboid bones and the metatarsal bases three to five.
There are three interosseous ligaments between the cuneiform and metatarsal bones. The first ligament connects the medial cuneiform bone to the second metatarsal bone and is known as Lisfranc’s ligament as it is the main anchoring ligament for the tarsometatarsal joint. The second ligament connects the lateral cuneiform bone to the adjacent angle of the second metatarsal base. The third and last of the interosseous ligament connects the lateral angle of the lateral cuneiform to the base of the fourth metatarsal bone.
As well as being anchored to the tarsal bones, the metatarsals are joined to each other, so, let's look at the intermetatarsal joints and ligaments.
We have four intermetatarsal joints between metatarsals one through five. Similarly, to the cuneometatarsal joints, we have dorsal, plantar, and interosseous ligament here, too. We have no dorsal or plantar ligaments between metatarsals one and two. The dorsal metatarsal ligaments are actually really straightforward. There are three thin flat bands linking the dorsal surfaces of the bases of the second to fifth metatarsal bones.
The plantar ligaments are, fortunately, very similar to the dorsal ligaments except they are notably stronger due to their greater role in joint integrity. So just like before, we have three ligaments one between the bases of the second through fifth metatarsal bones.
We also have three interosseous metatarsal ligaments between the bases of the metatarsal bones two through five. Just like many other interosseous ligaments we've seen, these bands are really short and strong. There are also some weak fibers between the first and second metatarsals binding non-articular surfaces together.
Bear with me, because we only have two more sets of ligaments to go. So, let's dive into the metatarsophalangeal joints and their ligaments.
There are five metatarsophalangeal joints in the foot, one between each metatarsal bone and the proximal phalanx of the same digit. Each joint is covered with a fibrous capsule. There are several ligaments associated with the metatarsophalangeal joints which both reinforce the capsule and anchor the adjacent bones to each other. These ligaments are the plantar and collateral metatarsophalangeal ligaments as well as the deep transverse metatarsal ligaments.
This time, we're starting on the plantar aspect of the foot as we take a look at the plantar ligaments of the metatarsophalangeal joints, sometimes known as the plantar plates. These ligaments form thickened plates on the plantar surface of the foot. They blend with the joint capsule and the collateral ligaments. These ligaments are loosely attached to the metatarsal bones and firmly attached to the phalangeal bases. These ligaments have grooves on their plantar surfaces for the tendons of flexor muscles of the digits which gives them their distinct appearance.
On either side of the plantar ligaments, we find the collateral ligaments of the metatarsophalangeal joints. These strong cords attach the dorsal tubercles of each metatarsal head with the bases of the corresponding proximal phalanx. Just like the plantar ligaments, the collateral ligaments blend well with the joint capsule.
The final group of ligaments associated with the metatarsophalangeal joints are the deep transverse metatarsal ligaments. These are four short, wide, flat bands, which extend between the plantar ligaments of adjacent joints.
Alright, folks, we're at our last joints of the foot, and therefore, our last ligaments. We're now looking at the interphalangeal joints and their ligaments.
There are nine interphalangeal joints at the foot – one in the big toe and two each in the lateral four toes. Each of these joints is covered with the fibrous joint capsule. Associated with these joints are the plantar and collateral interphalangeal ligaments. The plantar interphalangeal ligaments are very much like the metatarsophalangeal in that they form thickened plates on the plantar surfaces of the joints. The collateral interphalangeal ligaments also follow the same pattern. There are two ligaments on either side of each joint.
Whoo! Take a breath. We've covered all the ligaments of the foot. You certainly deserve an A for getting through this long tutorial. But how about we make it an A+ with some quick clinical notes?
Today for our clinical notes section, we're talking about turf toe. If you're unfamiliar with this term, it may sound quite fun. However, if you're the footballer with this injury, you certainly won't enjoy it. As far as foot injuries go, turf toe is definitely not the most serious. It's simply a sprain of the ligaments associated with the first metatarsophalangeal joint. The term sprain refers to stretching or tearing of the ligaments. The term comes from American football, when grass became more commonly replaced with artificial turf, this type of injury increased. That's because when football players prepare to run or jump, they push forcefully off their big toe and artificial turf has much less give which puts more pressure on the big toe. That can cause hyperextension of the toe and results in injury.
This injury is obviously not limited to American football players. Other active profession such as ballet dancers, gymnasts, and basketball players are at high risk, too, as well as high-heeled wearers. It can be an immediate injury or happen over time due to repetitive movement. The symptoms include pain upon extension of the big toe, swelling, and stiffness. Sometimes, there's a popping sensation in the foot at the time of injury. A physician would diagnose it with a simple physical examination and may suggest an x-ray to rule out a fracture.
Turf toe is graded based on its severity. Grade one turf toe is when the ligaments are merely stretched. The treatment is resting, putting icing and compression on the joint, and keeping it elevated. Grade two includes partial tearing of ligaments. This type of injury may require wearing a special boot to allow the ligaments to heal. Grade three is a complete tear of the plantar ligament complex around the first metatarsophalangeal joint. It needs to be immobilized for up to a few months and may require surgery.
And that concludes today's tutorial. But before we finish up, let's have a look over what we looked at today.
We started at the back of the foot where the talocalcaneal joint. Here we had lateral, medial, interosseous, and cervical ligaments contributing to the strength of the joint. At the talocalcaneonavicular joint, we have three ligaments associated with it – the dorsal talonavicular, the calcaneonavicular, and the plantar calcaneonavicular. At the calcaneocuboid joint, we found the calcaneocuboid, dorsal, plantar calcaneocuboid, and long plantar ligaments. The cuboideonavicular joint is reinforced by dorsal, plantar, and interosseous ligaments.
There were seven ligaments associated with the cuneonavicular joint - three dorsal, three plantar, and one medial ligament. At cuneocuboid joint, we had three ligaments again – the dorsal, plantar, and interosseous cuneocuboid ligaments and we also had the intercuneiform joints with five to six ligaments between them. We had two dorsal, two interosseous, and one or two plantar intercuneiform ligaments.
We then moved into the tarsometatarsal joints and their ligaments, which included the dorsal, interosseous, and plantar tarsometatarsal ligaments. The metatarsal bones also articulate with each other and these intermetatarsal joints are held together with three dorsal, three plantar, and three interosseous ligaments between the metatarsals two to five.
We then took a look at the metatarsophalangeal joints, and here we saw thickened plantar ligaments which formed plates on the plantar aspect of each of the MTP joints. There were four deep transverse ligaments stretching between the plantar ligaments and two collateral ligaments on the sides of each of the joints. The interphalangeal ligaments followed a similar pattern with thickened plantar ligaments and two collateral ligaments on each of the joints. And we finished up by talking about a condition called turf toe, which refers to a strain of ligaments in the first metatarsophalangeal joint.
And that's it. I hope you enjoyed this tutorial. See you next time!