Hythem Omar, MD
Mina Hanna, MD
Lena Omar, MD
Daniel Moore, MD
Gina Cho Sims, MDGeorge Liu, DPM
Avneesh Chhabra, MD

Objectives
I.

Normal anatomy of the spring ligament complex

II.

Injury patterns
o Sample cases

III. Treatment algorithm

I. Normal Anatomyo Description
oSpring ligament is composed of thick bands of tissue
connecting the sustentaculum talus to the plantar aspect of thenavicular.

o Functions
ooImportant support structure and stabilizer of the medial arch ofthe foot.
Supports the talar head as part of the anterior
talocalcaneonavicular joint.Bandso Superomedial (SM)o Medial plantar oblique (MPO)o Inferoplantar longitudinal (IPL)o Tibial Spring (TS)oPart of the superficial deltoidligament.

Superomedial (SM) Bando Attachments
oooMedial sustentaculum talus
to superomedial navicularbone over a broad
attachment.
Forms the sling that
articulates with talar head.
Deep to posterior tibialis
tendon (PTT).

o Thicknesso< 4mmo Optimal planes forvisualizationso Axial & coronal

Axial proton density (PD) Weighted Image

Superomedial (SM) Bando Readily seen between thetalar head/neck and PTT.

Axial PD Weighted Imageo Forms a sling to support
the talar head.

Coronal PD Weighted Image

Gliding Zoneo Region between the SM bandand PTT lined by synovial cells
and containing fibrocartilage.

Coronal PD Weighted Image

Medial plantar oblique(MPO) Bando Attachments
oCoronoid fossa of calcaneus
to medial plantar navicularbone adjacent to navicular
tuberosity.

o Thickness
oNavicular tuberosity< 4mmo Optimal plane for visualization
oCoronoid fossa

Axial

Axial PD Weighted Image

Medial plantar oblique(MPO) Bando Calcaneal coronoid process to medial plantar navicular.

Coronoid fossa

Axial PD Weighted Image

Sagittal PD Weighted Image

Inferoplantar longitudinal(IPL) Bando AttachmentsooCoronoid fossa of calcaneus
to navicular bone inferiorbeak.
Arises anterior to the MPO
band in the coronoid fossa.

Navicular beako Thicknesso< 4mmo Optimal planes forCoronoid fossa

visualizationo Axial & sagittal

Axial PD Weighted Image

Inferoplantar longitudinal(IPL) Bando Calcaneal coronoid process to inferior navicular beak.

Coronoid fossa

Axial PD Weighted Image

Sagittal PD Weighted Image

Tibial Spring (TS) Bando Attachments
oFrom medial malleolus
blending inferiorly with SMband.

o Optimal planes forvisualizationo Axial & coronalo Part of superficial deltoidligament.

Coronal PD Weighted ImageSpring Ligament Recesso Potential space between MPO
and IPL bands.

o Lined by synovium.
o Communicates withtalocalaneonavicular joint.

o Should not be mistaken for atear.

SMMPO

IPL

Spring Ligament Recess

Coronal proton density Fat Saturation (PDFS) Weighted Image

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II. Spring Ligament Injury
o MRI FindingsooThickening > 4mm
Increased Signaloo

IPL band can normally have intermediate intrasubstance signal
due to interposed fat.

Gap/nonvisualizationo Associationsooo

PTT pathology in >90%
Pes planovalgus
Sinus tarsi syndromeo SM band is most commonly injured.

SM BandThickeningo Axial PDFS showing

thickening of the SM bandand PTT tenosynovitis.

Torn TS and SM bando Coronal (left) & axial (right) PDFS showing
complete tears of TS and SM.

Torn MPOo Axial PDFS showing a partiallytorn MPO band with reactive
navicular bone marrow edema.

Associations:
PTTo Axial PD showing PTT split tear.
o Thickened SM band with someintermediate increased signal.

Associations:
Acquired Pes Planovalguso Mechanism
oPTT pathology leads to abnormal loading of the spring
ligament by the talar head. This results in:
oSpring ligament failure.

oTalar head rotation in a plantar and medial direction.
Calcaneus undergoing progressive valgus alignment.

oAssociations:
Acquired Pes Planovalgus
o Radiographic Signs
oAP talocalcaneal angle > 45degrees.
ooAngle formed by lines
parallel to medial borderof talus and parallel tolateral border ofcalcaneus.

Measured on weight bearingviews.

>45˚

AP radiograph of the footAssociations:
Acquired Pes Planovalgus
o Radiographic SignsoLateral talocalcaneal
angle > 50 degrees.
ooAngle formed by lines
bisecting the talus
and parallel to theinferior border ofthe calcaneus.

>50˚

Measured on weightbearing views.
Lateral radiograph of the footAssociations:
Acquired Pes
Planovalgus
o MRI Signs
o Axial PD weighted image

showing medial rotation with
uncovering of the talar head.

Associations:
Acquired Pes
Planovalgus
o MRI Signs
o Hindfoot valgus angleoThe angle between lines
drawn through the long axisof the tibia and along theborder of the calcaneal
medial cortex.

ooooNormal: 0-6°
Mild: 7-16°
Moderate: 17-26°
Severe: >27°

Coronal PDFS Weighted Image

Associations:Sinus Tarsi Syndromeo Related to progressive failure of PTT and spring ligament.
o MRI Signs
ooo

Obliteration of normal tarsal sinus fat.
Increased tarsal sinus T2 signal.
Thickened or attenuated tarsal sinus ligaments.

Associations:Sinus Tarsi Syndrome
o MRI signs: Sagittal T1 showing normal (left) and obliterated(right) sinus tarsi fat.

Treatment Algorithm:
Non-operative Managemento Reserved for cases with low likelihood of worsening pes
planovalgus.

o Medial longitudinal arch support is emphasized.
oOrthotics/boots play a central role.

Treatment Algorithm:
Operative Managemento Primarily for cases with high likelihood of progression of pes
planovalgus.

o Restore medical arch support.
ooooo

Repair of associated PTT injuries
Imbrication/augmentation/reconstruction of the SM band
Calcaneal osteotomy
Lateral column lengthening procedure
Arthrodesis

Treatment Algorithm:
Operative Managemento Procedural overview
oooMedial incisionoImbricate theattenuated component
Reconstruct/augment
as necessaryoRetract PTT
Identify SM band
deep to PTT

Summaryo Knowledge of spring ligament anatomy and associatedinjury patterns is imperative.
o Evaluate for associated PTT injury
o Evaluate for pes planovalgus
o Evaluate for sinus tarsi syndromeo Of all spring ligament components, integrity of the SM bandis the most important.

o Both non-operative and operative managements are viable
depending on risk of pes planovalgus progression.

References
1.

Bergman, A. G. “Lateral Hindfoot Impingement." MRI Web Clinic - December 2011. Web. 25 Oct. 2013.
(www.radsource.us/clinic/1112).

2.

Bernard Mengiardi, Marco Zanetti, Philip B. Scho¨ttle, Patrick Vienne, Beata Bode, Juerg Hodler, Christian W.
A. Pfirrmann. Spring Ligament Complex: MR Imaging–Anatomic Correlation and Findings in asymptomaticSubjects. Radiology 2005; 237:242–249.

3.

Kiley D. Perrich, Douglas W. Goodwin, Paul J. Hecht, Yvonne Cheung. Ankle Ligaments on MRI: Appearanceof Normal and Injured Ligaments. AJR 2009; 193:687–695.

4.

Kapil R. Desai, Luis S. Beltran, Jenny T. Bencardino, Zehava S. Rosenberg, Catherine Petchprapa, German
Steiner. The Spring Ligament Recess of the Talocalcaneonavicular Joint: Depiction on MR Images withcadaveric and histologic correlation. AJR 2011; 196:1145–1150.

5.

Leon R. Toye, Clyde A. Helms, Brian D. Hoffman, Mark Easley, James A. Nunley. Original report: MRI ofSpring Ligament Tears. AJR 2005;184:1475–1480.

6.

Manaster, Betty J. Diagnostic Imaging. Musculoskeletal: Non-traumatic Disease. Salt Lake City, Utah: Amirsys,
2010; 4:56-61. Print.

7.

Manaster, Betty J., David G. Disler, and David A. May. Musculoskeletal Imaging: The Requisites. Philadelphia,
PA: Elsevier, Saunders, 2013; 523-526. Print.

8.

Resnick, Donald, Heung Sik. Kang, and Michael L. Pretterklieber. Internal Derangements of Joints.
Philadelphia, PA: Saunders/Elsevier, 2007; 2100-2104. Print.

9.

Wheeless C. Wheeless’ Textbook of Orthopaedics. www.wheelessonline.com. Updated February 8, 2013.
Accessed October 21, 2013.

The authors would like to thank Townsend Majors fromRadiology Illustrative Services for her assistance in illustrations,animations, and graphics for this presentation.