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Spring Ligament Injury

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Other Names

  • Spring Ligament Insufficiency
  • Spring ligament complex injury

Background

History

Epidemiology

  • Unknown as the disease is rarely reported in the literature
  • Most commonly seen in middle aged women (need citation)

Pathophysiology

  • General
    • Overall rare disease poorly described in the literature
    • Can be acute and seen in athletes
    • The chronic, degenerative form is often seen along with Posterior Tibial Tendon Dysfunction

Etiology

  • Chronic
  • Acute
    • Associated with running and jumping sports
    • Often results from an abduction or eversion type mechanism during sports[1]
    • An awkward landing from a fall can also injure the spring ligament[2]
    • Many athletes have an unclear mechanism of injury and describe a sprain injury.

Associated Conditions

Pathoanatomy

  • Spring Ligament Complex
    • Originates on the calcaneus, inserts into the navicular
    • Consists of
      • Superomedial calcaneonavicular ligament (SmCNL)
      • Medioplantar oblique calcaneonavicular ligament (MpoCNL)
      • Inferoplantar longitudinal calcaneonavicular ligament (IplCNL)
    • Function: stabilize the talonavicular joint, longitudinal arch of the foot

Risk Factors

  • Sports (case reports only)
    • Track and Field
    • Soccer
    • Cricket
    • Tennis[5]
    • Hiking[6]

Differential Diagnosis


Clinical Features

  • History
    • Inability to bear weight immediately following injury may correlate to degree or severity of injury
    • Pain along arch extending towards medial malleolus and retromalleolus
    • Some patients may have lateral pain, impingement in the sinus tarsi region[7]
    • Patients may report early vague activity-related medial ankle and foot pain, difficulties walking on uneven ground, and/or balance problems
  • Physical Exam: Physical Exam Foot
    • Medial arch swelling, tenderness are typically present
    • Tenderness between the sustentaculum tali and the navicular
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Useful to exclude evidence of deltoid injury
  • Potential findings
    • Abduction and uncoverage of the talonavicular joint
    • Loss of the medial longitudinal arch
    • Dorsal subluxation of the navicular
  • Meary's Angle[8]
    • Lateral talo-1st metatarsal angle is used to assess flatfoot deformity
    • Normal: lateral talo-1st metatarsal angle less than 4°
    • Abnormal: large angle often indicates flatfoot deformity

MRI

  • Gold standard diagnostic imaging modality
  • Useful to evaluate
    • Spring Ligament
    • Posterior Tibial Tendon
  • Findings
    • Edema of navicular, talar head
  • Findings for superomedial calcaneonavicular ligament (SmCNL)[9]
    • Best seen on axial and coronal cuts
    • Abnormally high signal intensity on T2-weighted or proton density (PD) images
    • Thickening (>5–6 mm), thinning (<2 mm), waviness, and discontinuity
  • ICN Bundle
    • Best seen on axial and coronal images
    • Intermediate signal intensity on T1, low intensity on T2 images
  • MPO bundle
    • Harder to visualize
    • Has a striated appearance on the axial and coronal images
  • Diagnostic accuracy[9]
    • Sensitivity: 55%
    • Specificity: 100%

Ultrasound

  • Utility
    • Visualize the superior medial bundle
    • Can indicate disruption or thickening of the ligament fibers
    • Allows visualization of the distal aspect of the posterior tibialis tendon

Classification

Gazdag and Cracchiolo Classification

  • General[10]
    • Describes spring ligament disease in the setting of posterior tibial tendon dysfunction
    • Currently, no classification system exists for isolated spring ligament injury
  • Grade 1
    • Longitudinal tear within the midsubstance
    • OR partial tears at the ligament’s insertion on the sustentaculum tali or the navicular
    • OR a single longitudinal tear or several small tears at the ligament insertion.
    • No apparent ligamentous laxity
  • Grade 2
    • Loose ligament that appears stretched, with or without visible tears
  • Grade 3
    • Complete rupture of the ligament.

Management

Nonoperative

  • Indications
    • First line treatment for vast majority of cases
    • Partial injury without arch collapse or pes planus
  • RICE Therapy initially
  • Immobilization/ Protection
    • Individual should be in Short Walking Boot with non weight bearing status (NWB) until definitive diagnosis is made[11]
    • Once diagnosis is confirmed, NWB status should be maintained for 6 weeks
    • Subsequently, patient can be weened out of boot over 3-4 weeks
    • As the patient is weened, a custom Orthotic Arch Support should be prescribed
  • Weight bearing status
    • Most patients should be NWB for about 6 weeks
    • Following, they can initiate weightbearing progression along with physical therapy
  • Physical Therapy

Operative

  • Indications
    • Complete tear of the ligament complex
    • Resultant foot deformity
    • Consider in all young or competitive athletes
  • Technique
    • Spring Ligament Reconstruction
    • Spring Ligament Repair
    • Posterior Tibial Tendon as indicated

Rehab and Return to Play

Rehabilitation

  • Postoperative
    • Weeks 3-4: Begin heavier training, simulated sports activities
    • Can initiate running protocol with pain free ambulation, restored strength, stability
    • Interval jogging followed by longer jogging, sprinting and explosive movements
    • Agility training, plyometrics and cutting maneuvers come later
    • Sports specific drills can then be incorporated such as throwing, catching

Return to Play/ Work

  • General RTP
    • Requires ongoing monitoring by physician, staff and coaches

Complications and Prognosis

Prognosis

  • Unknown

Complications


See Also


References

  1. Borton DC, Saxby TS. Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot. A case report. J Bone Joint Surg Br 1997;79(4):641–3.
  2. Shuen V, Prem H. Acquired unilateral pes planus in a child caused by a ruptured plantar calcaneonavicular (spring) ligament. J Pediatr Orthop B 2009;18(3): 129–30.
  3. Chen JP, Allen AM. MR diagnosis of traumatic tear of the spring ligament in a pole vaulter. Skeletal Radiol 1997;26(5):310–2.
  4. Borton DC, Saxby TS. Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot: a case report. J Bone JointSurg Br. 1997;79:641-643.
  5. Masaragian, Héctor José, Hugo Osvaldo Ricchetti, and Cynthia Testa. "Acute isolated rupture of the spring ligament: a case report and review of the literature." Foot & ankle international 34.1 (2013): 150-154.
  6. Kann JN, Myerson MS. Intraoperative pathology of the posterior tibial tendon. Foot Ankle Clin. 1997;2:343-355.
  7. Gazdag AR, Cracchiolo A 3rd. Rupture of the posterior tibial tendon. Evaluation of injury of the spring ligament and clinical assessment of tendon transfer and ligament repair. J Bone Joint Surg Am 1997;79(5):675–81.
  8. Ikoma K, Hara Y, Kido M, et al. Relationship between grading with magnetic resonance imaging and radiographic parameters in posterior tibial tendon dysfunction. J Foot Ankle Surg 2017;56:718–723.
  9. 9.0 9.1 Yao L, Gentili A, Cracchiolo A. MR imaging findings in spring ligament insufficiency. Skeletal Radiol 1999;28:245–250.
  10. Gazdag AR, Cracchiolo A. Rupture of the tibial tendon: evaluation of injury of the spring ligament and clinical assessment of tendon transfer and ligament repair. J Bone Joint Surg Am. 1997;79:671-681.
  11. Shuen V, Prem H. Acquired unilateral pes planus in a child caused by a ruptured plantar calcaneonavicular (spring) ligament. J Pediatr Orthop B 2009;18(3): 129–30.
Created by:
John Kiel on 29 January 2022 04:12:55
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Last edited:
4 October 2022 12:40:48
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