1. MOHAMED ELADL
01/02/2013

2. Dr M Eladl
Small joints of the foot
Forefoot Midfoot Hindfoot
1) IM joints
2) MP joints
3) IP joints
1) Tarsometatarsal joint
(Lis Franc Joint) Distally
2) Mid-tarsal Joint
(of chopart) Proximally
1) Subtalar Joint (Agility
joint)
2) Talocalcaneonavicular
Joint

3. Dr M Eladl
Forefoot

4. Dr M Eladl
Forefoot

5. Dr M Eladl
Midfoot
• Five bones with numerous articular
surfaces : Navicular, Cuboid & The 3
cuneiform bones
• Possesses little mobility
• Distally,
• The 1st MT with the medial
cuneiform (with 6 degrees mobility)
• The 2nd & 3rd MT with the
intermediate & lateral cuneiform
(firmly fixed).
• The 4th & 5th metatarsals articulate
with cuboid bone (Mobile).
• Each of these has an individual
joint capsule but all are wrapped
in one big capsule as well to form
the tarso-metatarsal joint
“LisFranc joint”.
1st, 2nd & 3rd
Metatarsals with
cuniform bones
4th & 5th
metatarsals
with cuboid
bone

6. Dr M Eladl
Midfoot
• Five bones with numerous articular
surfaces : Navicular, Cuboid & The 3
cuneiform bones
• Possesses little mobility
• Proximally,
Talonavicular & calcaneocuboid
joints, together form the
combined articulations of the
midtarsal joint (of
“Chopart”).
Talonavicular
joint
Calcaneocuboid
joint

7. Dr M Eladl
Lisfranc Joint
• The Lisfranc joint, or tarsometatarsal articulation of the foot, is
named for Jacques Lisfranc (1790–1847), a field surgeon in
Napoleon's army.

8. Dr M Eladl
Lisfranc Joint
• The Lisfranc joint, or tarsometatarsal articulation of the foot, is
named for Jacques Lisfranc (1790–1847), a field surgeon in
Napoleon's army.
• Lisfranc described an
amputation performed
through this joint because
of gangrene that developed
after an injury incurred
when a soldier fell off a
horse with his foot caught in
the stirrup.
• (their foot stuck in the
stirrup, they dislocated
portions of the mid-foot).

9. Dr M Eladl
Lisfranc Joint
• Some investigators have suggested
that the term “Lisfranc joint
complex” should be used to refer
to tarsometatarsal articulations
and that the term “Lisfranc
joint” should be applied to medial
articulation involving medial
(first) and middle (second)
cuneiforms with the first and
second metatarsals .*
• The Lisfranc joint complex has
three separate articular
capsules, creating three distinct
articular compartments: medial,
central, and lateral lacking
communication with one another
(**).

10. Dr M Eladl
Lisfranc’s Ligaments
• The joint capsule and TMT ligaments
provide limited soft-tissue support to the
Lisfranc joint.
• Ligaments are grouped according to
anatomic location (dorsal, plantar, and
interosseous)
The dorsal ligaments:
Are strong, flat bands.
• The medial cuneiform is joined to the 1st
metatarsal the by a broad, thin band;
• The 2nd metatarsal has 3 ligaments; one
from each cuneiform
• The 3rd metatarsal has one ligament from
the lateral cuneiform;
• The 4th has one from the cuboid; and
• The 5th has one from the cuboid.
Castro M et al. AJR 2010;195:W447-W455

11. Dr M Eladl
Lisfranc’s Ligaments
Castro M et al. AJR 2010;195:W447-W455
Dorsal ligaments of Lisfranc joint complex. Sagittal proton density MR image after
intraarticular injection of gadolinium solution (B) and photograph of
corresponding gross anatomic section (C) in cadaveric specimen show short and
flat dorsal tarsometatarsal ligament between medial cuniform and 1st metatarsal
(arrows). Note homogeneous low signal intensity at MR image.

12. Dr M Eladl
Lisfranc’s Ligaments
The plantar ligaments:
• They are stronger than on the dorsal
aspect.
• Consist of longitudinal and oblique
bands, disposed with less regularity
than the dorsal ligaments.
• Those for the 1st & 2nd metatarsals
are the strongest;
• The 2nd & 3rd metatarsals are joined
by oblique bands to the medial
cuneiform;
• The 4th & 5th metatarsals are
connected by a few fibers to the
cuboid
• Note that there is no transverse
metatarsal ligament from 1 to 2
Castro M et al. AJR 2010;195:W447-W455

13. Dr M Eladl
Lisfranc’s Ligaments
• The relative importance of the
different ligaments of the Lisfranc
complex to the overall stability has
been discussed in many reports.*
• There is a general consensus that the
most important ligaments are the
ones coursing from the medial
cuneiform to the 2nd metatarsal
base; these are also the ones most
often disrupted in midfoot
injuries.**
• Secondary stabilizers of the joint are
the insertions of the peroneus
longus, tibialis anterior and tibialis
posterior tendons and plantar
ligaments, and plantar fascia.* Castro M et al. AJR 2010;195:W447-W455

14. Dr M Eladl
Mechanism of injury of Lisfranc joint
Direct Indirect
- High energy blunt
trauma to the
dorsum of the foot.
- Poorer clinical
outcomes Motor car accidents
High energy Low energy
During athletic
competition
With direct injuries, the force vector dictates
the fracture pattern and direction of
dislocation. The more predictable indirect
injuries most commonly involve failure of the
weaker dorsal TMT ligaments in tension
with subsequent dorsal or dorsolateral
metatarsal dislocation*

15. Dr M Eladl
Mechanism of injury of Lisfranc joint
• Smith et al (2005) performed
impact testing on postmortem
human lower legs and feet. The
authors determined that Lisfranc
injuries result from the forefoot
being forcefully plantar flexed, as
occurs during sudden braking in a
car accident
• Axial loading of a plantar
flexed foot causes indirect
injuries, such as those incurred in
football players when one player
falls onto the heel of another
whose foot is in equinus and
planted.

16. Dr M Eladl
Midtarsal joint (of “Chopart”).
Is a compound joint formed by 2
separate joints aligned
transversely:
1) Talonavicular part of the
talo-calcaneo-navicular joint
(Ball & Socket) and
2) Calcaneo-cuboid joint
(Saddle).

17. Dr M Eladl
Midtarsal joint (of “Chopart”).
- At this joint, the midfoot and
forefoot rotate as a unit on the
hindfoot around a longitudinal
(AP) axis, augmenting the
inversion and eversion
movements occurring at the
clinical subtalar joint.
- Transection across the transverse
tarsal joint is a standard method
for surgical amputation of the
foot.
- The complex anatomy of the
Chopart joint, optimally adapting
to uneven surfaces upon first heel
contact & forcefully pushing the
foot off the ground at the end of
the walk cycle.

18. Dr M Eladl
Subtalar Joint
• known as the “Agility joint”.
• Is between: the large posterior
calcaneal facet on the inferior
surface of the talus & the
corresponding posterior talar
facet on superior surface of
calcaneus
• The articular cavity is enclosed by
synovial membrane, which is
covered by a fibrous capsule.
• Allows gliding and rotation, which
are involved in inversion and
eversion of the foot.

19. Dr M Eladl
Subtalar Joint ligaments
Lateral, medial, posterior, and interosseous talocalcaneal ligaments
stabilize the joint.
Daftary A et al. Radiographics 2005;25:1215-1226
Drawing of the lateral surface of the calcaneus shows the peroneal tubercle (P), as well as the
lateral talocalcaneal (LTL), interosseous (IOL), and bifurcate (B) ligaments.

20. Dr M Eladl
TaloCalcaneoNavicular Joint
• A complex joint in which the head of
talus articulates with calcaneus &
plantar calcaneonavicular ligament
(spring ligament) below & the
navicular in front

21. Dr M Eladl
TaloCalcaneoNavicular Joint
• A complex joint in which the head of
talus articulates with calcaneus &
plantar calcaneonavicular ligament
(spring ligament) below & the
navicular in front
• Allows gliding & rotation movements,
which together with subtalar joint are
involved with inversion & eversion
of the foot.

22. Dr M Eladl
TALOCALCANEONAVICULAR JOINT
LIGAMENTS
• Talonavicular ligament: superiorly, which passes between the
neck of the talus and adjacent regions of the navicular;
• Interosseous talocalcaneal ligament: posteriorly;

23. Dr M Eladl
TALOCALCANEONAVICULAR JOINT
LIGAMENTS
• Talonavicular ligament: superiorly by the, which passes between
the neck of the talus and adjacent regions of the navicular;
• Interosseous talocalcaneal ligament: posteriorly;
• Plantar calcaneonavicular ligament (Spring): inferiorly

24. Dr M Eladl
Spring ligament
- Called plantar
calcaneonavicular
ligament
- Extends across and
fills a wedge-shaped
gap between the talar
shelf and the inferior
margin of the posterior
articular surface of the
navicular
- It supports the head of
the talus

25. Dr M Eladl
Short plantar ligament
- Called Plantar
calcaneocuboid
ligament
- Located on a plane
between the plantar
calcaneonavicular and
the long plantar
ligaments.
- Extends from the
anterior aspect of the
inferior surface of the
calcaneus to the
inferior surface of
cuboid.

26. Dr M Eladl
Long Planter ligament
- Passes from the
plantar surface of
the calcaneus to the
groove on the
cuboid.
- Some of its fibers
extend to the bases
of the metatarsals,
thereby forming a
tunnel for the
tendon of the
peroneus longus.
- Important in
maintaining the
longitudinal arch of
the foot.

27. Dr M Eladl
Plantar Fascia
• Is an important stabilizer in the foot
where a great deal of foot pathology
begins.
• It originates from the plantar surface of
the calcaneus and attaches to the plantar
surfaces of the five metatarsal heads and
proximal phalanges of the toes.
• Acts as a major stabilizer of the foot.
It helps maintain the arch of the foot and
is an antipronator.
• In its function of maintaining the
congruity of the relationship between the
calcaneus and the metatarsal heads, it
resists the torsion movement of the
forefoot in relation to the hindfoot
during pronation. Most of the eversion of
pronation occurs in the mid and forefoot
while the calcaneus remains stable in the
hindfoot.

28. Dr M Eladl
References
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2) Castro, M., L. Melao, et al.(2010) "Lisfranc joint ligamentous complex: MRI with anatomic correlation in
cadavers." AJR Am J Roentgenol 195(6): W447-55.
3) Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J
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4) Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the
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5) Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North
Am. 1989;20:655–64.
6) Burroughs, K. E., C. D. Reimer, et al. (1998). "Lisfranc injury of the foot: a commonly missed diagnosis." Am
Fam Physician 58(1): 118-24.
7) Schulze, W; Richter, J; Russe, O; Ingelfinger, P; Muhr, G: Surgical treatment of talus fractures: a retrospective
study of 80 cases followed for 1–15 years. Acta Orthop. Scand. 73:344 –351, 2002.
8) Suckel, A., O. Muller, et al. (2007). "Changes in Chopart joint load following tibiotalar arthrodesis: in vitro
analysis of 8 cadaver specimens in a dynamic model." BMC Musculoskelet Disord 8: 80.
9) http://www.sportsinjuryclinic.net/anatomy/ankle-anatomy
10) http://www.footeducation.com/ligaments-of-foot-and-ankle-overview
11) Preidler KW, Wang YC, Brossmann J, Trudell D, Daenen B, Resnick D. Tarsometatarsal joint: anatomic details
on MR images. Radiology 1996; 99:733–736
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13) Chiodo CP, Myerson M. Developments and advances in the diagnosis and treatment of injuries to the
tarsometatarsal joint. Orthop Clin North Am 2001; 32:11–20
14) Kura H, Luo Z, Kitaoka HB, Smutz WP, An K. Mechanical behavior of Lisfranc and dorsal cuneometatarsal
ligaments: in vitro biomechanical study. J Orthop Trauma 2001; 15:107–110