MR diagnosis of traumatic tear of the spring ligament in a pole vaulter

Relationship Between Obesity and Medial Longitudinal Arch Bowing

BACKGROUND

There have been reports about the association between obesity and the medial longitudinal arch (MLA) of foot. The purpose of this study is to investigate the change of various parameters related to the MLA according to obesity classification severity by the World Health Organization using weightbearing computed tomography (WBCT).

METHODS

WBCT data of the noninvolved side of patients presenting with unilateral foot and ankle problems or healthy candidates from September 2014 to October 2022 were extracted from a single referral hospital. Forty-four cases in each of 5 obesity classes were selected sequentially. Two orthopaedic surgeons measured foot and ankle offset, forefoot arch angle (FAA), hindfoot moment arm, percentage of uncoverage of the middle facet of the subtalar joint, talonavicular angle (TNA), navicular-medial cuneiform angle, medial cuneiform-first metatarsal angle, talus-first metatarsal angle (TMT1A), first tarsometatarsal subluxation (TMT1S), talonavicular coverage angle, navicular floor distance (NFD), and NFD per height. Positive values indicate plantar collapse. Intra- and interobserver reliabilities were assessed using intraclass correlation coefficients. One-way analysis of variance tests were performed for parametric data with equal variances, and Welch's test for unequal variances. Kruskal-Wallis test was performed for nonparametric data. Post hoc analysis was performed for statistically significant parameters. Correlation analysis between body mass index (BMI) and 12 parameters were performed using Pearson test.

RESULTS

Intraobserver and interobserver reliability were excellent, except for TMT1S. The TNA and TMT1A showed a statistically significant difference. FAA (r = -0.2), TNA (r = 0.182), TMT1A (r = 0.296), and NFD (r = -0.173) showed a statistically significant correlation with BMI.

CONCLUSION

In nonsymptomatic feet, we found that the talonavicular joint, as measured by the TNA, to be influenced by obesity classification. Obesity and increased BMI was associated with a negative influence on the MLA.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Comparison of each bundle of the spring ligament complex between the standing and supine positions: A multiposture magnetic resonance imaging study

BACKGROUND

The spring ligament complex (SLC) supports the medial longitudinal arch of the foot, particularly in standing. We evaluated posture-related changes in the thickness and length of the three SLC bundles and their histology.

METHODS

The thickness and length of the supramedial calcaneonavicular ligament (smCNL), medioplantar oblique calcaneonavicular ligament (mpoCNL), and inferoplantar calcaneonavicular ligament (iplCNL) were measured in the supine and standing positions, using a multiposture magnetic resonance imaging system, in 72 healthy adult feet. Histological examination was performed for 10 feet from five cadavers.

RESULTS

The smCNL thickness decreased and its length increased from the supine to the standing position (P < 0.001); no other posture-related effects were noted. Histologically, smCNL fibers overlapped along multiple directions while mpoCNL and iplCNL, fibers were oriented horizontally along the longitudinal axis and vertically along the short axis, respectively.

CONCLUSION

The complex, multidirectional, orientation of the smCNL allows an adaptive response to changes in loading.

Injuries to the Spring Ligament: Nonoperative Treatment

The fibrocartilage within the superomedial calcaneonavicular (spring) ligament is part of an interwoven complex of ligaments that span the ankle, subtalar, and talonavicular joints. Acute isolated rupture of the spring ligament has been reported in association with an eversion ankle sprain. Attenuation and failure of the spring ligament causes complex 3D changes called the progressive collapsing foot deformity (PCFD). This deformity is characterized by hindfoot eversion, forefoot supination, collapse of the medial longitudinal arch, and forefoot abduction. Nonoperative treatment of an isolated spring ligament rupture and PCFD using various designs of orthoses have shown promising results.

The Spring Ligament Complex-Anatomy and Function

This article provides an overview of the soft tissue contributions to the normal structures that surround the talo-calcaneal-navicular (TCN) joint of the human arch. The TCN joint has a multiplanar range of motion that makes it essential to the kinetic coupling that links the forefoot and hindfoot. The soft tissue connection surrounding this joint is known as the spring ligament complex. More accurate knowledge of the anatomy of this complex will enhance the understanding of its role in the support of the head of the talus and, potentially, its critical interactions with the normal or abnormal function of the arch.

Spring and Deltoid Ligament Insufficiency in the Setting of Progressive Collapsing Foot Deformity. An Update on Diagnosis and Management

The spring ligament and deltoid ligament are important stabilizers of the medial ankle. Together, they form a complex along the medial ankle and foot that is critical to stability of both the ankle and the medial longitudinal arch. Incompetence of the spring and deltoid ligament is a component of both the early and late stages of progressive collapsing foot deformity. As the importance of this medial ligament complex has been recognized, repair and reconstruction of these ligaments have progressively evolved, initially as separate reconstructions, and more recently as combined techniques.

Painful Accessory Navicular and Spring Ligament Injuries in Athletes

Painful accessory navicular and spring ligament injuries in athletes are different entities from more common posterior tibialis tendon problems seen in older individuals. These injuries typically affect running and jumping athletes, causing medial arch pain and in severe cases a pes planus deformity. Diagnosis requires a detailed physical examination, standing radiographs, and MRI. Initial treatment focuses on rest, immobilization, and restriction from sports. Orthotic insoles may alleviate minor pain, but many patients need surgery to expedite recovery and return to sports. The authors review their approach to these injuries and provide surgical tips along with expected rehabilitation to provide optimal outcomes.

MRI evaluation of ligaments and tendons of foot arch in talar dome osteochondral lesions

Background There are no publications in literature describing an association between disorders of the ligaments and tendons supporting the foot arch and osteochondral lesions of the talus (OCLT). We believe there may be a correlation between the damage of these structures. Purpose To investigate the pathologies of main ligaments and tendons that support the foot arch in sprained ankles, by reviewing magnetic resonance imaging (MRI) studies and comparing the results in two groups of patients, with and without OCLT. Material and Methods MR images from 316 patients examined in the orthopedic clinic for ankle sprain were evaluated for pathologic findings of the plantar fascia, short and long plantar ligaments, spring ligament, sinus tarsi, and ankle tendons supporting the foot arch. Findings were compared between two groups of patients: 158 patients with OCLT and 158 patients without OCLT. Results Plantar fascia, short plantar ligament, and spring ligament abnormalities were seen in 50 (31.6%), 28 (17.7%), and 60 (38%) patients with OCLT, and in nine (5.6%), three (1.9%), and 18 (11.4%) patients without OCLT, respectively ( P < 0.05). Sinus tarsi and tendon abnormalities were seen in 11 (6.7%) and nine (5.7%) patients with OCLT, and in eight (5%) and eight (5%) patients without OCLT, respectively ( P > 0.05). Two or more associated abnormalities were present in 50 (31.6%) patients with OCLT and in 11 (6.7%) without OCLT ( P < 0.05). Conclusion Plantar fascia, short plantar ligament, and spring ligament abnormalities were commonly seen in patients with OCLT on MRI, while sinus tarsi and tendon abnormalities were not. Concomitant pathologies have an increased incidence in patients with OCLT.

Arthroscopic approach to the spring (calcaneonavicular) ligament

BACKGROUND

This research studied the safety and efficacy of a new portal to the spring ligament. This portal is located just plantar to the insertion of the posterior tibial tendon and above the fibrous septum between the posterior tibial and the flexor digitorum longus tendons.

METHODS

Twelve fresh frozen foot and ankle specimens were used. The distance between the accessory medial portal and the medial plantar nerve was measured. The relation between the medial plantar nerve and the spring ligament was studied. The depth that can be reached through the portal was also assessed.

RESULTS

The average distance between the insertion point of the 3mm diameter metal rod and the medial plantar nerve was 20(6-27)mm. The medial plantar nerve located at lateral third of the ligament in 8 specimens (67%), middle third in 2 specimens (17%) and medial third in 2 specimens (17%). The tip of rod can reach Zone A in all specimens.

CONCLUSION

This study demonstrated that arthroscopic approach and repair of the spring ligament can injure the medial plantar nerve.

CLINICAL RELEVANCE

The clinical relevance of this cadaver study is that it confirmed the feasibility of arthroscopic approach to the whole span of the spring ligament and alerted the potential risk of injury to the medial plantar nerve during arthroscopic assisted repair of the ligament.

Spring ligament complex: Illustrated normal anatomy and spectrum of pathologies on 3T MR imaging

The spring (plantar calcaneonavicular) ligament complex connects the calcaneus and navicular bone of the foot and serves as the primary static stabilizer of the medial longitudinal arch of the foot. In this article, we describe the normal anatomy of the spring ligament complex, illustrate 3T magnetic resonance imaging appearances in its normal and abnormal states, and discuss the pathological associations with relevant case examples.

Isolated spring ligament failure as a cause of adult-acquired flatfoot deformity

BACKGROUND

Adult-acquired flatfoot deformity is usually secondary to failure of the tibialis posterior tendon, with secondary injury to the surrounding osseous-ligamentous complex. Rarely, patients may present with a normal tibialis posterior tendon and an isolated injury of the plantar calcaneonavicular, or spring, ligament. The current study describes the clinical presentation and operative management of 6 patients with isolated spring ligament ruptures who presented with symptomatic flexible flatfoot deformities.

METHODS

Six consecutive patients with unilateral flatfoot deformities secondary to spring ligament failure were operatively treated at one institution between 2003 and 2010. All patients presented with symptomatic flatfoot deformities recalcitrant to conservative management. No patients had previous flatfoot reconstructive surgery, but all had undergone some combination of orthotic use, immobilization, or activity modifications prior to operative treatment. In each case, intraoperative findings demonstrated a tear of the spring ligament complex with a normal tibialis posterior tendon. To address the deformities, spring ligament repairs and adjunctive flatfoot reconstructions were performed. A retrospective chart study was performed to document patient presentation, demographics, and outcomes.

RESULTS

Average patient age was 42 years. All 6 patients were female. All patients presented with medial foot pain for a mean of 27 months prior to presentation. Spring ligament abnormality was demonstrated in all 5 patients who received preoperative magnetic resonance imaging. Intraoperatively, all 6 patients demonstrated spring ligament tears and no significant tibialis posterior tendon abnormality. All 6 patients underwent spring ligament repairs with or without adjunctive flatfoot reconstructions. At mean follow-up of 13 months, all but 1 patient were pain-free without orthotics, and all patients were without residual deformity. There was a single patient with delayed bone graft healing and no other minor or major complications in this series.

CONCLUSIONS

Adult-acquired flatfoot deformity is usually secondary to tibialis posterior tendon failure but in rare cases may be secondary to isolated spring ligament injury without tibialis posterior tendon abnormality. This unique clinical entity should be considered in patients who present with flatfoot deformities. In this study, although preoperative magnetic resonance imaging was not required, it identified a suspected spring ligament tear in all cases in which it was used. Thorough intraoperative exploration can identify an injury to the spring ligament and a normal tibialis posterior tendon. Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Tibialis posterior tendon and deltoid and spring ligament injuries in the elite athlete

The tibialis posterior tendon and the spring and deltoid ligament complexes combine to provide dynamic and passive stabilization on the medial side of the ankle and hindfoot. Some of the injuries will involve acute injury to previous healthy structures, but many will develop insidiously. The clinician must be aware of new treatment strategies and the level of accompanying scientific evidence regarding injuries sustained by athletes in these areas, while acknowledging that more traditional management applied to nonathletic patients is still likely to be appropriate in the setting of treatment for elite athletes.

Association of tibialis posterior tendon pathology with other radiographic findings in the foot: a case-control study

The purpose of this study was to analyze the prevalence of spring ligament pathology and other radiographic changes related to flatfoot deformity in the presence of different degrees of tibialis posterior tendon pathology. A total of 72 patients (24 with tibialis posterior tendon abnormality and 48 sex- and age-matched controls) were evaluated for tibialis posterior tendon pathology, spring ligament pathology, and plain pedal radiographic angles, including cuboid abduction, talar declination, calcaneal inclination, and Meary's angles. The patients with tibialis posterior tendon pathology were subdivided into either minor (Type I) or severe (Type II/III), according to the Conti classification of tibialis posterior tendon pathology on MRI. All the continuous data of radiographic angles were dichotomized into either a flatfoot group or normal/cavus foot group. Associations between these nominal variables were analyzed. There was no association between Type I tibialis posterior tendon pathology and spring ligament pathologies (OR = 0.8, 95% CI = 0.15-4.65). Conversely, every patient with Type II/III tibialis posterior tendon pathology had spring ligament abnormality. Type II/III group also showed statistically significant associations with both increased talar declination angle (OR = 10.4, 95% CI = 1.62-109.22) and Meary's angle (OR = 7.5, 95% CI = 1.35-51.12), while no such associations were found with Type I tibialis posterior tendon pathology (OR = 1.0, 95% CI = 0.18-6.18 with talar declination angle; OR = 3.9, 95% CI = 0.65-27.71 with Meary's angle). In this investigation, only advanced tibialis posterior tendon pathology was statistically significantly associated with adult-acquired flatfoot deformity and spring ligament pathology.

Comparison of sonography and magnetic resonance imaging for spring ligament abnormalities: preliminary study

OBJECTIVE

The purpose of this study was to determine whether sonography is as accurate as magnetic resonance (MR) imaging for depicting abnormalities of the spring ligament in patients with symptomatic posterior tibial tendon (PTT) dysfunction.

METHODS

Sixteen patients (18 ligaments) with symptomatic PTT dysfunction were prospectively evaluated with sonography and MR imaging.

RESULTS

Magnetic resonance imaging showed spring ligament tears in 8 of 18 feet, including 6 incomplete tears and 2 complete tears. Sonography showed spring ligament tears in 7 of 18 feet, including 6 incomplete tears and 1 complete tear. The findings of sonography and MR imaging were concordant in 17 of 18 feet (94%). Six of the 8 spring ligament tears on MR imaging were associated with posterior tibial tendinosis or tears.

CONCLUSIONS

Sonography is an effective imaging option in assessing spring ligament abnormalities in patients with symptomatic PTT dysfunction.

A prospective study of injury patterns in high school pole vaulters

BACKGROUND

The pole vault is a track and field event that has witnessed a large increase in participants during the past 5 years. Currently there are no prospective studies that have evaluated injury patterns in pole vaulters.

OBJECTIVES

To determine the injury rate and to describe injury patterns in high school pole vaulters.

STUDY DESIGN

Descriptive epidemiological study.

METHODS

This was a prospective cohort study of 140 Wisconsin high school athletes who participated in pole vaulting during the 2005 and 2006 track and field seasons. Baseline athlete information was obtained at the beginning of each season. When an injury occurred, an injury report form was completed to document diagnosis and circumstances of the incident. Injury rates were expressed as injuries per 100 athletes per season as well as injuries per 1000 athletic exposures. Risk factors were analyzed by calculating relative risks for baseline athlete variables.

RESULTS

The injury rates were 26.4 injuries per 100 athletes per season (95% confidence interval, 18.6-36.4) and 7.1 injuries per 1000 athletic exposures (95% confidence interval, 5.0-9.8). Trauma to the lower extremities accounted for 71.5% of injuries. The most common injury types were ligament sprains (31.6%). Landing incorrectly was the most frequent mechanism of injury (26.3%). A history of pole-vault injury was associated with increased risk of injury (relative risk, 2.4; 95% confidence interval, 1.4-4.1).

CONCLUSION

Injuries are common in young vaulters. Injury mechanisms indicate that many could be avoided by using proper technique, particularly during the landing phase. Coaches should focus on vaulters with prior injuries to identify risky behavior and to help correct poor technique.

Morphometric dimensions of the calcaneonavicular (spring) ligament

BACKGROUND

The spring ligament complex (SLC) is a static support of the head of the talus and a major anatomical contributor to the integrity of the medial longitudinal arch, particularly if the dynamic support of the posterior tibial tendon is compromised. For this reason, we sought to further elucidate the anatomical components and dimensions of this ligamentous complex.

METHODS

Dissection was performed on 30 adult cadaver feet disarticulated at the ankle joint that were preserved by embalming technique.

RESULTS

The superomedial ligament (SML) averages 42.51 +/- 3.93 mm and 33.44 +/- 3.34 mm at the superomedial and inferolateral borders, respectively. The width at the level of sustentaculum tali and navicular tuberosity averaged 20.00 +/- 2.35 mm and 10.26 +/- 2.05 mm, respectively. The medioplantar oblique (MPO) ligament averaged 23.56 +/- 2.15 mm and 21.20 +/- 1.42 mm at the medial and the lateral borders, respectively. The widths at the navicular and calcaneal side were 2.71 +/- 0.39 mm and 8.14 +/- 0.56 mm, respectively. The inferoplantar longitudinal (IPL) ligament measured 4.26 +/- 0.43 mm and 2.66 +/- 0.42 mm at the medial and lateral borders, respectively. The width at the calcaneal and navicular insertions measured 5.21 +/- 0.53 mm and 3.39 +/- 0.39 mm, respectively.

CONCLUSIONS

The distinction between the SML and MPO components of the spring ligament complex is difficult. This study tried to clarify the dimensions and configurations of these components of the SLC.

CLINICAL RELEVANCE

This effort may aid surgeons who wish to repair this ligament with more precision.

MRI of rupture of the spring ligament complex with talo-cuboid impaction

The spring ligament complex is essential for the stability of the longitudinal arch of the foot and includes the ligaments between the calcaneus and the talus at the superomedial to inferoplantar aspect of the foot. Tears of the spring ligament complex are most commonly degenerative in etiology and secondary to concomitant abnormality of the posterior tibial tendon. We report MRI findings in a 30-year-old man who presented with traumatic rupture of the spring ligament complex, seen following dislocation of the talonavicular joint. We also describe the previously unreported MRI features of talo-cuboid impaction secondary to disruption of the spring ligament complex.

Sonography of the superomedial part of the spring ligament complex of the foot: a study of cadavers and asymptomatic volunteers

OBJECTIVE

To evaluate the ability of high-resolution sonography for assessing the thickness and echogenicity of the superomedial part of the normal spring ligament in the foot in cadavers and asymptomatic volunteers.

MATERIALS AND METHODS

The superomedial part of the normal spring ligament of four cadaveric feet was imaged with a high-resolution linear array transducer. Upon localization, the ligament was injected with 0.1% methylene blue with sonographic guidance. A posteromedial approach was used to dissect the feet immediately following injection to confirm accurate identification of the ligament. The bilateral ligaments in 40 asymptomatic adult volunteers were subsequently imaged.

RESULTS

Surgical dissection confirmed the accurate injection of methylene blue into all four cadaveric ligaments. The superomedial part of the normal spring ligament was identified bilaterally in all of the 40 asymptomatic volunteers, with a mean thickness of 3 mm in longitudinal short axes. The ligament was echogenic relative to surrounding fat, and it was thinner in women. Differences in ligament measurements with respect to age, sex, side (left vs. right) and foot dominance were not significant. The volunteers' height, weight and body mass index had a weakly positive correlation with ligament thickness.

CONCLUSION

High-resolution ultrasound can be used to identify and measure the thickness of the superomedial part of the normal spring ligament. The provided baseline measurements for the normal ligament could prove valuable when assessing the abnormal ligament.

Spring Ligament Complex: MR Imaging–Anatomic Correlation and Findings in Asymptomatic Subjects

PURPOSE

To use magnetic resonance (MR) imaging to assess the anatomy of the spring ligament complex (SLC) in cadaveric feet and to prospectively evaluate the MR imaging depiction of this complex in asymptomatic subjects.

MATERIALS AND METHODS

Cadaveric feet were obtained and used according to institutional guidelines and with institutional approval and consent from the donors (before death) or the appropriate family members. Healthy volunteers were examined, with institutional review board approval and informed consent from each volunteer. MR imaging findings of the SLC in five cadaveric feet were analyzed and correlated with the findings in dissected foot specimens. Then, the MR imaging findings in the feet of 78 asymptomatic subjects were analyzed. For all three parts of the SLC, visibility, optimal imaging plane, and signal intensity characteristics were analyzed. The thicknesses of all SLC parts were measured. The measurements obtained in men and women were compared by using the Mann-Whitney U test, and Pearson correlation coefficients for associations between ligament thickness and subject age and sex were calculated.

RESULTS

In the cadaveric feet, MR imaging enabled differentiation of all three parts of the SLC. The superomedial calcaneonavicular ligament (CNL) was visible in all; the medioplantar oblique CNL, in 60; and the inferoplantar longitudinal CNL, in 71 volunteers. The superomedial CNL had a mean thickness of 3.2 mm, was best seen on transverse oblique or coronal MR images, and had mainly intermediate signal intensity on T1-weighted images and low signal intensity on T2-weighted images. The medioplantar oblique CNL had a mean thickness of 2.8 mm, was best seen on transverse oblique MR images, and had mainly a typical striated appearance on T1- and T2-weighted images. The inferoplantar longitudinal CNL was the thickest (mean thickness, 4.0 mm), was best seen on coronal MR images, and had mainly intermediate signal intensity on T1-weighted images and variable signal intensity on T2-weighted images. Women had significantly thinner superomedial (mean thickness, 3.3 vs 3.5 mm; P = .015, Mann-Whitney U test) and inferoplantar longitudinal (mean thickness, 3.8 vs 4.2 mm; P = .02) CNLs than men. There was no significant correlation between ligament thickness and subject age.

CONCLUSION

The superomedial and inferoplantar longitudinal CNLs are consistently visible portions of the SLC. The medioplantar oblique ligament is thinner, is seen less consistently, and has mainly a characteristic striated MR imaging appearance.

MRI of Spring Ligament Tears

OBJECTIVE

Surgical repair of the spring ligament is becoming recognized as an important management component of adult-acquired flatfoot, yet little literature exists on the MRI appearance of spring ligament abnormalities. In this article, we describe the MRI appearance of surgically proven spring ligament tears.

CONCLUSION

MRI findings present in surgically proven spring ligament tears include an abnormal spring ligament caliber, signal intensity, waviness, a full-thickness gap, and posterior tibial tendonopathy. The finding unique to cases with surgically proven tears is a full-thickness gap in the ligament, seen in 79% of the cases in our series. When multiple abnormalities are seen in the spring ligament in conjunction with a full-thickness gap, the diagnosis of a tear can be made with confidence.

The anatomy of the navicular and periarticular structures

The navicular bone, located in the midfoot, articulates with the head of the talus, cuboid, and the three cuneiform bones that are involved in the acetabulum pedis. It gives attachment to the spring ligament (superomedial and inferior calcaneonavicular ligament)that can be injured in a failure of the posterior tibialis tendon and cause an adult acquired flatfoot deformity. The navicular bone provides insertion for the posterior tibialis tendon. Some pathologies can be related to the presence of an accessory navicular bone. Osteonecrosis or stress fractures can affect the navicular bone because of its poor vascularization, especially in its central portion.

The talonavicular and calcaneocuboid joints: anatomy, biomechanics, and clinical management of the transverse tarsal joint

The transverse tarsal plays a critical role in allowing the foot to transition from a flexible structure that dissipates impact as the foot strikes the ground and accepts the body's weight to the rigid structure that is required for efficient propulsion during toe off.Similarly, the medial longitudinal arch of the foot is controlled by the supportive structures of the talonavicular joint. A fine balance exists between muscular control and static support structures of the talonavicular joint. Failure of one support structure is often followed by fatigue of the remaining support and loss of function of the entire joint complex. This article describes the osseous and ligamentous anatomy of the talonavicular and calcaneocuboid joints and describes the biomechanical role of the transverse tarsal joint in standing and gait. Biomechanical principles are used to illustrate orthotic management of diseases that affect the transverse tarsal joint.