When A Posterior Tibial Tendon Rupture Is Combined With A Spring Ligament Injury

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Author(s): 
Babak Baravarian, DPM, FACFAS, and Lindsay Mae Chandler, DPM

   Category two refers to cases of partial to compete tear of the spring ligament. In such cases, the tear is most often of the navicular tuberosity and there is an associated talar “unroofing” with medial protrusion. In category two cases, there is a substantial increase in the medial arch collapse. When the spring ligament is partially to completely torn, as in our second category, we have found that a direct repair is best with placement of one or two suture anchors into the navicular and imbrication of the spring ligament back into the navicular tuberosity under the proper tension. In cases that demonstrate a severe tear with shredding of the spring ligament with no primary repair possible, one should perform biotenodesis of the spring ligament with an allograft for greater strength and tension. One would anchor an allograft tendon strip with a biotenodesis screw into the talus and navicular.

   In our last category, category three, we have found that there is significant unroofing of the talus associated with arthritic changes. A talonavicular arthrodesis is the final resort in cases in which one finds the integrity spring ligament to be very poor and arthritic changes are present.

In Conclusion

More recently, we are regarding the function of the spring ligament complex as more essential than in the past and placing a significant amount of emphasis on its repair when it is ruptured. Traditionally, there had been a great deal of focus on rupture of the posterior tibial tendon because of its enhanced frequency. However, we have discovered that the pathology of the static stabilizers such as the spring ligament can play just as much a role as the posterior tibial tendon rupture on the adult-acquired flatfoot.

   Magnetic resonance imaging is a valuable modality for the diagnosis of injury to the posterior tibial tendon. With insufficiency and flatfoot deformity, a tear of either the posterior tibial tendon, spring ligament or both may cause collapse and pain. Researchers have acknowledged an increased incidence of abnormality of the spring ligament on MRI in patients with advanced posterior tibial tendon injury.5

   It is imperative to inspect and repair the spring ligament in conjunction with flatfoot reconstruction procedures. In following a classification system to aid in determining the surgical intervention warranted, our practice has had relatively great results and patient satisfaction. We have outlined that systematic approach above and hope it helps others with diagnosis and repair of the spring ligament complex.

   Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Chief of Podiatric Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and is the Director of the University Foot and Ankle Institute in Los Angeles.

   Dr. Chandler is a fellow at the University Foot and Ankle Institute in Los Angeles.

References
1. Key J. Partial rupture of the tendon of the posterior tibial muscle. J Bone and Joint Surg. 1935;35-A(4):1006-1008.
2. Gazdag AR, Cracchiolo A. Rupture of the posterior tibial tendon. J Bone Joint Surg Am. 1997;79(5):675-681.
3. Davis WH, Sobel M, DiCarlo EF, et al. Gross histological, and microvascular anatomy, and biomechanical testing of the spring ligament complex. Foot Ankle Int. 1996;17(2):95-102.
4. Yao L, Gentilli A, Cracchiolo A. MR imaging findings in spring ligament insufficiency. Skeletal Radiol. 1999;28(5):245-250.
5. 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):1137-1143.

Additional References
6. Pinney S, Lin S. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006;27(1):66-75.
7. Patil V, Ebraheim N, Frogameni A, Liu J. Morphometric dimensions of the calcaneonavicular (spring) ligament. Foot Ankle Int. 2007;28(8):927-932.

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Frank Caruso, CO/LOsays: April 2, 2013 at 7:54 am

Very good article. I present programs on managing the lower extremity. I plan to include some of this information into my lecture. PTTD is a common problem I treat weekly in my practice in TN. I like to use controlled motion bracing if possible with my patients. The traditional leather gauntlets immobilize. The dynamic suspension AFO (Revolution) has been very successful in pain relief and functional outcomes for PTTD referrals from docs. Some of my happiest clients have been former Arizona wearers.

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