Ankle and Foot: Arches, Tendons, Balance, and Common Overuse Patterns

Foot structure as a load-management system in gait

The ankle–foot complex behaves like a variable-stiffness platform: it must be compliant for shock absorption and terrain adaptation, then stiffen to transmit force for push-off. Load distribution is shaped by (a) the longitudinal and transverse arches, (b) rearfoot–midfoot coupling, and (c) tendon-driven “tie-rods” that support the arch under body weight. Clinically, many overuse complaints reflect a mismatch between tissue capacity (tendon/plantar fascia/bone) and repeated loading (steps, hills, speed, footwear, surface).

Arches in function (not just shape): the medial longitudinal arch deforms under load and recoils for propulsion; the lateral column provides a stable lever; the transverse arch helps distribute forefoot pressures. The plantar fascia and intrinsic foot muscles contribute to arch stiffness, especially during late stance when the toes extend and the fascia tightens (windlass effect), helping convert the foot into a rigid lever.

(1) Landmarks to orient assessment and load lines

Malleoli (medial and lateral)

Use the malleoli as reference points for ankle mortise alignment and swelling patterns. The lateral malleolus sits more distal and posterior than the medial malleolus, which matters when interpreting inversion sprain tenderness and syndesmotic involvement. Observe whether swelling is localized anterior to the lateral malleolus (often ATFL region) versus higher and more diffuse (possible syndesmosis).

Navicular region

The navicular region is a practical proxy for medial arch behavior and posterior tibial tendon (PTT) demand. A prominent or tender navicular area can reflect increased midfoot loading or PTT overload (especially with prolonged standing/walking, hills, or new footwear). Compare side-to-side for navicular “drop” in relaxed stance and during single-leg tasks.

Base of the 5th metatarsal

The base of the 5th metatarsal is a key lateral column landmark. Tenderness here may reflect peroneal tendon traction/overuse, lateral foot overload, or post-sprain guarding. It is also a useful reference when observing whether the patient avoids loading the lateral forefoot during push-off.

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Calcaneus

The calcaneus is the rearfoot load receiver. Note heel fat pad sensitivity (central plantar heel) versus medial calcaneal tubercle region (often plantar fascia-related). Rearfoot position during stance (relative eversion/inversion) influences midfoot motion and tendon demands.

Achilles tendon

The Achilles transmits calf force to the calcaneus and stores elastic energy during gait. Differentiate mid-portion symptoms (2–6 cm above insertion) from insertional symptoms (at the calcaneus), as compression and footwear effects differ. Observe tendon thickening, focal tenderness, and pain with loading tasks (heel raises, hopping if appropriate).

(2) Subtalar and talocrural roles in pronation/supination and dorsiflexion

Talocrural joint: tibial progression and dorsiflexion

The talocrural joint primarily allows dorsiflexion/plantarflexion and is central to how the tibia advances over the foot in mid-stance. If dorsiflexion is limited, common compensations include early heel rise, midfoot collapse, toe-out, or increased pronation to “borrow” motion from adjacent joints. These strategies redistribute load toward the plantar fascia, forefoot, and calf–Achilles complex.

Subtalar joint: pronation/supination as a tri-planar adapter

Subtalar pronation (eversion with associated motions) helps the foot adapt and absorb load; subtalar supination helps create a stiffer lever for push-off. Clinically, focus less on “pronation is bad” and more on timing and control: rapid or prolonged pronation can increase strain on the plantar fascia and PTT, while insufficient pronation can reduce shock absorption and shift stress laterally (peroneals, 5th metatarsal region).

Rearfoot–midfoot coupling and arch stiffness

During late stance, the foot should transition toward a more rigid lever: heel rises, toes extend, plantar fascia tension increases, and the midfoot stiffens. If the midfoot remains compliant (persistent pronation), the calf must work harder to achieve propulsion, often increasing Achilles load and reducing efficiency.

(3) Typical patterns and what to look for

Achilles tendinopathy (mid-portion vs insertional)

• Typical story: gradual onset with running, hills, speed work, or increased walking; morning stiffness; pain that “warms up” then returns after activity.
• Mid-portion features: pain/thickening 2–6 cm above insertion; often sensitive to tensile load; may tolerate some compression.
• Insertional features: pain at the calcaneal insertion; often aggravated by end-range dorsiflexion and compression (e.g., uphill walking, deep squat, rigid heel counters).
• Movement clues: early heel rise, reduced tibial progression, or excessive pronation prolonging calf demand; asymmetry in heel raise endurance.

Plantar heel pain (common plantar fascia-related presentation)

• Typical story: first-step pain in the morning or after sitting; pain with prolonged standing; may ease with initial walking then worsen with volume.
• Location: often medial plantar heel region; differentiate from diffuse heel fat pad sensitivity (more central) and from nerve-related symptoms (burning/tingling patterns).
• Load drivers: sudden increase in steps, new minimalist footwear, long standing, reduced ankle dorsiflexion, high forefoot loading, or reduced intrinsic foot endurance.
• Functional clue: pain provoked by repeated heel raises or prolonged single-leg stance if arch control is limited.

Lateral ankle sprain patterns (and why symptoms persist)

• Typical mechanism: inversion with plantarflexion; common tenderness/swelling anterior to the lateral malleolus.
• Common persistent issues: reduced confidence, delayed peroneal activation, impaired proprioception, and avoidance of lateral column loading.
• Movement clues: cautious gait with reduced stance time, limited push-off, or excessive toe-out; difficulty controlling frontal-plane sway in single-leg stance.

Posterior tibial tendon overload (medial ankle/arch load intolerance)

• Typical story: medial ankle/arch ache with walking/standing; worse with hills or prolonged time on feet; may report “arch collapsing” fatigue.
• Observable signs: increased midfoot pronation during single-leg tasks; reduced ability to perform controlled single-leg heel raises; medial tenderness along tendon course and near navicular region.
• Functional clue: symptoms reproduced by repeated heel raises or by walking with increased step length (higher tibial progression demand).

(4) Balance and proprioception considerations

The foot and ankle provide rapid sensory feedback for postural control. After pain or sprain, proprioceptive acuity and reactive stability can be reduced, leading to higher re-injury risk and compensatory strategies (stiffening, toe gripping, reduced push-off). Balance work should be specific: start with stable surfaces and progress to perturbations and task demands that resemble the patient’s sport/work.

• Key idea: balance is not only “standing still”; it is the ability to control the center of mass over a changing base of support while the foot transitions from mobile adapter to rigid lever.
• Common compensations: excessive toe clawing, knee valgus collapse, hip hiking, or trunk lean to avoid ankle strategy.
• Clinical link: persistent lateral ankle symptoms often correlate with poor single-leg balance and delayed peroneal response; medial arch symptoms often correlate with fatigue-related loss of midfoot control.

Functional assessment series (practical, step-by-step)

Use the following sequence to connect structure, movement, and symptom behavior. Keep the patient’s main aggravating activity in mind (running, long standing, stairs, sport cutting) and aim to reproduce and then modify symptoms.

1) Gait observation (barefoot if appropriate, then in shoes)

Goal: identify load distribution and timing issues (pronation/supination transition, tibial progression, push-off strategy).

• Step 1: observe from behind: rearfoot motion (eversion/inversion), heel whip, and whether the heel stays everted late into stance.
• Step 2: observe from the side: tibial progression over the foot, timing of heel rise, stride length, and whether push-off is through the hallux/1st ray versus lateral forefoot.
• Step 3: observe from the front: foot progression angle (toe-out), medial arch collapse timing, and knee tracking relative to foot.
• Step 4 (symptom link): ask when symptoms appear during walking (first steps, after 5 minutes, hills). Note whether speed or step length changes symptoms.

2) Single-leg balance (static to dynamic)

Goal: screen proprioception, foot intrinsic strategy, and frontal-plane control.

• Step 1: single-leg stance 20–30 seconds, eyes open. Record: number of foot taps, trunk sway, toe gripping, and whether the arch collapses over time.
• Step 2: repeat with head turns or eyes closed (if safe). Increased sway suggests reliance on vision and reduced ankle/foot sensory control.
• Step 3: add a small reach task (e.g., reach forward/diagonal with the free foot). Watch for medial arch drop (PTT demand) or lateral instability (sprain pattern).
• Symptom note: medial ankle/arch pain during balance tasks often implicates load intolerance of the PTT/plantar structures; lateral pain with wobble suggests residual instability or peroneal overload.

3) Heel raise profile (capacity and control)

Goal: assess calf–Achilles capacity, rearfoot control, and symptom reproduction.

• Step 1: double-leg heel raises x 10. Note symmetry, speed, and whether the heels drift inward/outward.
• Step 2: single-leg heel raises to fatigue (or a set number such as 10–15 depending on irritability). Record: height, tempo, quality, and pain location.
• Step 3: observe rearfoot: does the heel move toward inversion at the top (expected supination component) or remain everted (persistent pronation)?
• Interpretation cues: mid-portion Achilles pain with loading suggests tensile sensitivity; insertional pain aggravated at end-range dorsiflexion suggests compression sensitivity; medial ankle pain/poor control suggests PTT overload; cramping/toe clawing suggests over-reliance on intrinsics due to calf weakness or instability.

4) Dorsiflexion screen (weight-bearing lunge)

Goal: estimate functional dorsiflexion and identify compensations that shift load.

• Step 1: in a split stance facing a wall, keep heel down and move knee toward the wall over the 2nd–3rd toe.
• Step 2: find the maximum distance where the knee touches the wall without heel lift. Compare sides.
• Step 3: watch for compensations: arch collapse, knee diving inward, foot turning out, or heel lift.
• Clinical link: limited dorsiflexion often correlates with early heel rise and increased forefoot/plantar fascia load; excessive pronation during the lunge may indicate the patient is “buying” dorsiflexion through midfoot motion.

5) Symptom modification trials (quick, reversible tests)

Goal: determine whether changing load distribution or joint position reduces symptoms during a comparable task (walk, heel raise, lunge, step).

How to use results: choose one modification that meaningfully reduces symptoms (e.g., ≥30% improvement) and integrate it into early management (temporary support, gait cue, graded loading). If no trial changes symptoms, reconsider the primary driver (irritability, neural sensitivity, bone stress, or non-foot contributors) and adjust the assessment focus.