Hindfoot and midfoot components are easily delineated. The former is largely composed of its two bony structures, the talus and calcaneus, while the latter is composed of the navicular, the three cuneiforms, and the cuboid. Anatomically, the boundaries of the hindfoot region begin at the subtalar joint and extend to the Chopart (or transverse-tarsal) joint; the midfoot begins at this joint and extends to the Lisfranc (or tarsometatarsal joint) complex. The subtalar articulation links the talus and calcaneus via three articular facets. The Chopart joint comprises the talonavicular and calcaneocuboid joints. The term subtalar joint complex refers to both the subtalar and Chopart joints. In addition to osseous and chondral injuries, soft-tissue structures such as the capsule, tendon, ligament, nerve, and heel pad may be injured in isolation or combinations during competitive sport.
The biomechanics of the subtalar joint complex remain poorly understood; in fact, the joint complex is perhaps the most poorly understood articulation. Efficient locomotion requires alternating flexibility and rigidity of the foot. Flexibility is necessary for shock absorption, while rigidity is required for propulsive activities. The alternating inversion-eversion of the subtalar joint within the gait cycle is necessary for efficient locomotion.1 Subtalar motion is intimately linked to the adduction/abduction and pronation/supination movements of the talonavicular joint.
Due to skeletal alignment, natural hindfoot alignment is valgus; therefore, normal hindfoot function is dependent on voluntary control of hindfoot inversion. A competent posterior tibial tendon is, therefore, essential for regulation of subtalar joint control.
Midfoot architecture comprises the longitudinal and transverse arches. Bone stability is enhanced by its unique structural design. The second metatarsal base insets into the adjacent cuneiforms in mortise-and-tenon fashion (Fig. 70-1). A dense network of stout, plantar ligaments secure the metatarsal bases to the cuneiforms. The plantar fascia supplies supplemental longitudinal arch support. If midfoot integrity is disrupted, force transmission from the hindfoot to the forefoot (and vice versa) is impaired. If injury is not diagnosed in a timely manner, continued weight bearing may result in midfoot collapse.2
Significant hindfoot or midfoot injury sustained during an athletic injury may result in considerable dysfunction. Overuse injury involving bone and tendon is commonly present in runners and dancers. Periarticular fractures are not infrequent; they are difficult to detect due to intricate three-dimensional foot anatomy. Injury sequelae, especially stiffness and pain, result in impairment in select abilities, such as jumping and ballistic motions, preventing return to elite competition. Therefore, prompt diagnosis, appropriate intervention, and aggressive rehabilitation are essential to optimize outcomes.
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