Spring ligament complex injury
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Spring ligament complex injuries or calcaneonavicular ligament injuries refer to stretching sprains, tears, or ruptures of the plantar calcaneonavicular ligament complex and can affect one or more of the three portions.
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Spring ligament complex injuries are most commonly associated with posterior tibial tendon dysfunction and are rare in isolation. Middle-aged women are most commonly affected 1,2.
The following associated conditions might be seen in the setting of a spring ligament complex injury 1:
Characteristic imaging findings in the setting of medial ankle pain and the absence of other significant injuries indicate the diagnosis 1-3.
The following MR criteria for a clinically relevant superomedial calcaneonavicular ligament injury have been suggested 1:
abnormal thickening or thinning of the superomedial ligament (>5 mm or <2 mm)
intrinsic signal changes
partial or complete ligament discontinuity
posterior tibial tendon dysfunction (tenosynovitis, tendinosis, partial or complete tears)
Clinical symptoms are vague and similar to posterior tibial tendon insufficiency 1. They include early vague activity-related medial ankle and foot pain, difficulties walking on uneven ground, and/or balance problems. At later stages, patients might complain about lateral ankle pain related to the sinus tarsi and the lateral malleolus.
If untreated spring ligament injuries can result in the following 1-3:
subtalar joint osteoarthritis
A spring ligament injury refers to stretching, partial or complete tear of the spring ligament complex that acts as a static stabilizer of the medial longitudinal arch 1. It can affect one or more of the following ligamentous portions 1-3:
superomedial calcaneonavicular ligament (clinically most relevant)
Functional deficits of the posterior tibial tendon lead to a lack in hindfoot inversion and thus to the abnormal medial transmission of forces across the talonavicular joint from the contracting soleus and gastrocnemius muscles 1-4.
Spring ligament complex injury can be caused by the following 2:
acute injury (rare)
overuse injury and chronic degeneration in the setting of posterior tibial tendon dysfunction
Spring ligament injuries can theoretically occur in any of the three ligaments.
The superomedial ligament is the most important component for providing functional stability. It is the most frequently affected component with tears usually occurring at the superior and distal portion at the junction to the tibiospring ligament 1,2. Of the other two ligaments, the medioplantar oblique ligament is more commonly affected then the inferoplantar longitudinal ligament 2.
Plain radiographs may show flat foot deformity or evidence of hindfoot valgus. Weight-bearing x-rays of the foot can be used to assess the lateral talo-first metatarsal angle to assess for flat foot deformity 3.
The superomedial calcaneonavicular ligament might be thickened and demonstrate a loss of the normal fibrillar echo pattern and increased vascularity. There might be associated signs of posterior tibial tendinopathy 6.
As in other ligament injuries, imaging features in a plantar calcaneonavicular injury include ligament thickening or thinning, contour irregularities, inhomogeneity, partial or complete discontinuity as well as signal intensity changes especially on fat-suppressed T2-weighted or intermediate weighted sequences of one or more of the three ligamentous components 1-3.
There might be also indirect signs such as direct contact of the posterior tibial tendon with the talar head 1.
The radiological report should include a description of the following features:
type of calcaneonavicular ligament injury (sprain, partial tear, complete tear, avulsion)
affected components (superomedial, medioplantar oblique, inferoplantar longitudinal)
posterior tibial tendon abnormalities (tenosynovitis, tendinopathy, longitudinal tear)
associated injuries (deltoid ligament injury, midtarsal sprain, flat foot)
Treatment and prognosis
Management depends on clinical symptoms and the severity of the injury. Conservative treatment is indicated in patients with a low-grade sprain or partial tears with no or minimal foot deformities and a low risk of further progression and consists of boots or orthotic devices with medial longitudinal arch support.
Surgical options include direct repair with sutures or spring ligament reconstruction techniques with anterior deltoid ligament graft, the use of a posterior tibial tendon stump, peroneal or split tibialis anterior tendon graft, and reconstruction of the posterior tibial tendon if applicable 1,2.
The differential diagnosis of spring ligament complex injuries consist of the following:
posterior tibial tendon injury without spring ligament complex injury
- 1. Pinto C, Zanetti M, Mengiardi B. Spring Ligament Complex and Posterior Tibial Tendon: MR Anatomy and Findings in Acquired Adult Flatfoot Deformity. Semin Musculoskelet Radiol. 2016;20(01):104-15. doi:10.1055/s-0036-1580616 - Pubmed
- 2. Stadnick ME. Spring Ligament Tear. Radsource – January 2008MRI Web Clinic
- 3. Kimura Y, Yamashiro T, Saito Y, Kitsukawa K, Niki H, Mimura H. MRI Findings of Spring Ligament Injury: Association with Surgical Findings and Flatfoot Deformity. Acta Radiologica Open. 2020;9(12):205846012098014. doi:10.1177/2058460120980145 - Pubmed
- 4. Balen P & Helms C. Association of Posterior Tibial Tendon Injury with Spring Ligament Injury, Sinus Tarsi Abnormality, and Plantar Fasciitis on MR Imaging. AJR Am J Roentgenol. 2001;176(5):1137-43. doi:10.2214/ajr.176.5.1761137 - Pubmed
- 5. Flores D, Mejía Gómez C, Fernández Hernando M, Davis M, Pathria M. Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings. Radiographics. 2019;39(5):1437-60. doi:10.1148/rg.2019190046 - Pubmed
- 6. Mansour R, Teh J, Sharp R, Ostlere S. Ultrasound Assessment of the Spring Ligament Complex. Eur Radiol. 2008;18(11):2670-5. doi:10.1007/s00330-008-1047-1 - Pubmed