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Persistent foot or ankle pain?

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Have you considered the talonavicular or calcaneocuboid joint elements?

Foot and ankle conditions such as a sprained ankle or ankle fracture are common. They are some of the most frequent injuries presenting to emergency departments and GPs across the country.

Most will resolve as expected within normal healing times for bones and ligaments but a percentage of complaints take longer to improve. One of the causes of this persistent pain to consider are the small joints of the foot. These often get forgotten in rehabilitation after foot and ankle injury. Treating them can make the difference to that last bit of pain or restriction sometimes felt.

The anatomy of the foot is complex. There are many small bones and joints within the foot held firm with many ligaments and surrounding muscles. The main ankle joint is termed the talocrural joint. This is the joint at the end of the shin bones (tibia and fibula) where it meets the first foot bone (talus). The majority of foot movement comes from this joint and most injury is to the ligaments that support it. If we move further into the foot, down from the talocrural (ankle) joint, we come to the small joints of the talonavicular and calcaneocuboid. There is naturally much less movement at these two joints in comparison to the talocrural joint.

Importantly though,  there should be some movement at these joints during walking and weight-bearing on the foot to allow for normal movement. The talonavicular joint is more towards the inside of the foot. There is a small amount of up and down movement and also some rotation in this joint when we put weight on to our foot during walking. This movement is variable from person to person and from left foot to right foot but an idea of the expected amount of movement can be assessed by your therapist. The calcaneocuboid joint is between the calcaneus bone and the cuboid bone. It is more towards the outer side of your midfoot. This joint has very little natural movement but does allow a small amount during walking.
These joints have developed and are important as they allow a flexible platform in which we can move and walk.  Our foot is impressively designed with many small interacting joints, muscles and ligaments in order that we can be both flexible and strong. These two joints, the talonavicular and calcaneocuboid and they particularly play an important role in the arches that form naturally in our foot as we weight bear.

A good case example of the contribution these small joints can make to recovery is presented here:

Mr X
31 year old male

Sprained his ankle badly playing football leaving to a small fracture of the ankle and significant swelling. He spent some time in a boot to help the bone heal and when he came out of the boot he found he had a stiff and sore ankle.

He was given some exercises to do and found that in general his ankle started to loosen up nicely and as he could get back to walking and things were improving he decided not to attend Physiotherapy.

8 weeks later Mr X found that although he had improved he still had problems when he was walking up hills or had been on his feet for a long time. Mr X was assessed by a physiotherapist who found that his main talocrural (ankle) joint was moving nicely but that on assessment his talonavicular joint didn’t have as much play and movement as his un-injured foot and that the up and downwards movement was slightly restricted. Mobilisation of this joint was performed and Mr X was shown how to do these mobilisations at home. He worked on these for several weeks and noted an improvement in his uphill walking.

In summary, these small midfoot joints do not provide a large percentage of the movement in the foot during walking but they do contribute. They also contribute to the arches that form a flexible but strong platform on which we are able to stand and move.

This allows us incredible mobility and function on two feet. After injury it is important to pay attention not only to the obvious main movers at the talocrural (ankle) and subtalar (hindfoot) joints but also to the midfoot joints of the talonavicular and calcaneocuboid joints. Their part to play is smaller but they work as a combined unit and so if problems are persisting, seek advice on whether they need to be assessed.

Leanne Plenge
Bristol Manager
Specialist MSK Physiotherapist 
Physiocomestoyou Ltd