M u s c u l o s k e l e t a l I m a g i n g R ev i ew

Linklater
Sports Injuries of the Foot

Musculoskeletal Imaging
Review
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FOCUS ON:

Imaging of Sports Injuries

in the Foot
James M. Linklater 1 OBJECTIVE. This article selectively reviews several areas in which imaging can play a
major role in the diagnosis and treatment of sports injuries of the foot.
Linklater JM CONCLUSION. Diagnostic imaging provides useful evaluation of capsuloligamentous
sports injuries and Morton neuroma in the foot and facilitates appropriate treatment. An un-
derstanding of the relevant anatomy, normal imaging appearance, and the spectrum of imag-
ing findings in the setting of injury is important for the practicing radiologist.

Keywords: Lisfranc ligament, Morton neuroma, plantar
plate, spring ligament, turf toe
DOI:10.2214/AJR.12.8547
Received January 9, 2012; accepted after revision
January 27, 2012.
1
Department of Musculoskeletal Imaging, Castlereagh
Sports Imaging, 60 Pacific Hwy, St. Leonards, NSW 2065,
Australia. Address correspondence to J. M. Linklater
(JamesLinklater@casimaging.com.au).
CME
This article is available for CME credit.
AJR 2012; 199:500508
0361803X/12/1993500
American Roentgen Ray Society
T
he foot is commonly injured at all
levels of sport and is particularly
vulnerable in agility sports. The
overriding concern in sports inju-
ries is early accurate diagnosis, appropriate
management, and early return to sport. The
complex anatomy in the foot and multiple sites
of potential injury can make clinical diagnosis
challenging. Early referral for diagnostic im-
aging can clarify diagnosis and guide treat-
ment. This article reviews several areas where
imaging can play a major role in diagnosis and
treatment of capsuloligamentous sports inju-
ries and Morton neuroma in the foot.
First Metatarsophalangeal Joint
Capsuloligamentous Injury
Clinical Analysis
Bowers and Martin [1] noted an increas-
ing incidence of first metatarsophalange-
al joint capsular injury in sports played on
an artificial surface, a condition known as
turf toe. The term covers a broad spec-
trum of capsuloligamentous injury, which
most commonly involves a valgus-hyperex-
tension mechanism, with disruption of the
first metatarsal head insertion of the medial
collateral ligament complex and acute hallux
valgus deformity [2]. Pure hyperextension
injuries may be associated with disruption
of the plantar plates and chondral injury at
the dorsal aspect of the joint due to a con-
comitant axial load, with resultant proximal
migration of the sesamoids. Less commonly,
there may be a varus mechanism with tear of
the lateral collateral ligament and hallux var-
us deformity [3]. Hyperflexion injuries sus-
tained while playing beach volleyball have
been termed sand toe and are usually asso-
ciated with dorsal capsular injury to the first
metatarsophalangeal joint [4]. Clanton and
Ford [5] advocated a 3-point clinical grading
system that may be useful in guiding man-
agement. Grade 1 injuries are thought to be
only a stretch injury, with the athlete often
being able to finish the game before present-
ing with low-grade pain and minimal swell-
ing. Most patients will return to sport early.
Grade 2 injuries manifest as swelling, pain,
and guarding against dorsiflexion and are
thought be partial tears. Management in a
walking boot and graduated return to activ-
ity may be required. Grade 3 injuries man-
ifest as severe pain and inability to bear
weight on the great toe and are thought to
reflect a complete tear. A significant propor-
tion of athletes with first metatarsophalange-
al joint capsuloligamentous injury will expe-
rience ongoing disabling symptoms that may
limit return to competition [6]. Selective ear-
ly surgical intervention with anatomic pri-
mary repair of the torn capsuloligamentous
structures would appear to generally result in
restoration of plantar stability and return to
full athletic activity [7].
Anatomy
The first metatarsophalangeal joint expe-
riences significant load with walking (0.4
0.6 times body weight) [8], running (23
times body weight), and jumping (8 times
body weight) [9]. The presence of a thick
plantar capsule with fibrocartilaginous me-
dial and lateral plantar plates and medial

500 AJR:199, September 2012

 Sports Injuries of the Foot

and lateral sesamoid bones helps to withstand
these stresses. The sesamoids articulate with
articular facets at the plantar margin of the first
metatarsal head and are linked by the thick in-
tersesamoid ligament. The medial collateral
ligament complex provides stability to valgus
stress, consisting of the medial collateral liga-
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differs from that of the lesser metatarsophalan-
geal joints. Sagittal and long-axis (coronal)
images of the first metatarsophalangeal joint
must be plotted off a short-axis image per-
pendicular to the intersesamoid axis for the
sagittal sequence or parallel to the intersesa-
moid axis for the long-axis (coronal) sequenc-
Whenever a Morton neuroma is suspected in
the second web space, serious consideration
should be given to the alternate diagnosis of
a second metatarsophalangeal joint synovitis.
Athletes typically present with localized pain,
subtle dorsal swelling, tenderness localized
to the second metatarsophalangeal joint, and

ment proper and the medial sesamoid collat-
eral ligament (metatarsosesamoid ligament).
The latter is important in providing stability to
the medial sesamoidfirst metatarsal head ar-
ticulation during the toe-off phase of walking
and running. The lateral collateral ligament
complex provides stability during varus stress.
The sesamoid insertions of the two heads of
flexor hallucis brevis and abductor and adduc-
tor hallucis and linkage to the proximal pha-
lanx via the medial and lateral plantar plates
(sesamophalangeal ligaments) help provide
dynamic stability to dorsiflexion stress, to-
gether with the flexor hallucis longus tendon,
which inserts into the distal phalanx. The in-
sertion of the extensor hallucis brevis tendon
into the dorsal capsule helps provide dynamic
stability to plantar flexion stress, together with
the extensor hallucis longus tendon, which in-
serts into the distal phalanx.
Radiographs
A routine radiographic series of the great
toe should consist of weight-bearing antero-
posterior and lateral and nonweight-bear-
ing oblique views [3]. In acute trauma, it can
be helpful to include both the left and right
first metatarsophalangeal joints on the an-
teroposterior view, because subtle proximal
retraction of the sesamoids associated with
plantar plate disruption can be made more
conspicuous [10]. Radiographs provide as-
sessment for capsular avulsion fractures, im-
paction fractures of the metatarsal head, ses-
amoid fractures, and retraction. Commonly,
radiographs will be normal [3].
es. In the acute setting, complete ligament
tears are usually of fluid signal intensity (Fig.
1), whereas interstitial tears are of interme-
diate signal. Sagittal sequencing best depicts
tears of the medial and lateral plantar plate
(sesamophalangeal ligaments). Short-axis se-
quencing best reveals tears of the sesamoid
collateral (metatarsosesamoid) ligaments.
Long-axis sequencing best reveals tears of the
medial collateral ligament proper (metatar-
sophalangeal ligament). In late subacute and
chronic cases, scar response may obscure the
point of tear, making accurate diagnosis more
difficult (Fig. 2).
Lesser Metatarsophalangeal Joint
Plantar Plate Degeneration, Tear,
and Synovitis
Clinical Analysis
Second metatarsophalangeal joint synovitis
due to plantar plate degeneration and tear is
a common cause of forefoot pain that can be
easily misdiagnosed as Morton neuroma [13].
pain with forced second metatarsophalange-
al joint flexion [13]. There may be pain with
the drawer test, which consists of dorsoplantar
manipulation of the proximal phalanx while
fixating the second metatarsal head. Dorsal
subluxation may be elicited with the drawer
test if there is a plantar plate tear [14]. There
is increased interest in plantar plate tears in the
foot and ankle surgical community because of
the development of new techniques for plantar
plate repair [1517].
Anatomy
The plantar plate of the lesser metatarso-
phalangeal joints is a fibrocartilaginous thick-
ening of the plantar capsule, thickest at the at-
tachment on the base of the proximal phalanx
medial and lateral of midline and relatively at-
tenuated in the midline [18]. Proximally there
is a thin synovial attachment to the metatarsal
neck [19]. Although not strictly anatomically
correct, it can be useful to subdivide the plan-
tar plate into medial and lateral components.

MRI
MRI of the first metatarsophalangeal joint is
the preferred imaging modality for the assess-
ment of capsuloligamentous trauma, chondral
and osteochondral abnormalities, and sesamoid
injuries [3, 11, 12]. Dedicated imaging of the
first metatarsophalangeal joint with appropriate
surface coils facilitates a high-resolution tech- A B
nique, with slice thickness of approximately 2 Fig. 124-year-old male professional cricketer who presented with right hallucal pain, swelling, and inability
mm for sagittal and long-axis images and in- to weight bear on hallux following acute injury sustained while batting, pivoting on foot with resultant
plane resolution of approximately 0.3 mm for hyperextension mechanism.
proton-density sequencing and 0.6 mm for fat- A, Sagittal proton-density image shows distal avulsion (arrow) of lateral plantar plate (sesamophalangeal
ligament), with retracted proximal stump.
suppressed proton-density sequencing. The ori- B, Sagittal proton-density MRI shows proximal avulsion (arrow) of medial plantar plate (sesamophalangeal
entation of the first metatarsophalangeal joint ligament), with retracted proximal stump.

AJR:199, September 2012 501

 Linklater

Ultrasound
The plantar plate is best evaluated sonogra-
phically utilizing an oblique plantar parasag-
ittal approach, directing attention to the lat-
eral plantar plate insertion on the base of the
proximal phalanx, the most common site of
abnormalities. The plantar plate should also
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be assessed in the transverse plane [20]. The

normal plantar plate is a mildly hyperechoic
structure with a somewhat granular echotex-
ture [20]. Dynamic assessment of the integ-
rity of the plantar plate can be performed by
applying a dorsiflexion stress. Color or power
Doppler ultrasound should be used to assess
for hyperemia. Plantar plate degeneration is
A B manifest as hypoechoic echotextural change
Fig. 222-year-old male professional rugby league player who had hyperextension valgus injury to great toe 6 [20]. Partial tears of the plantar plate may
months prior. vary in appearance, sometimes seen as a hy-
A, Long-axis (axial) proton-density MRI shows nonacute complete tear (arrow) of medial collateral ligament at poechoic or anechoic cleft and sometimes as
first metatarsal head insertion, with ineffective subsequent scar response.
a heterogeneous echotexture [20] (Fig. 3A).
B, Short-axis (coronal) proton-density MRI shows nonacute complete tear (arrow) of medial sesamoid
collateral (metatarsosesamoid) ligament at first metatarsal head insertion, with ineffective subsequent scar Complete tears may be seen as a complete
response. defect (Fig. 3B) and may be evident only on
dorsiflexion of the metatarsophalangeal joint.
The plantar plate imparts sagittal plane sta- ond metatarsal head relative to the first meta- Attention should also be directed to the dor-
bility to the metatarsophalangeal joint and tarsal head. In the setting of tear of the lateral sal recess of the second metatarsophalangeal
helps prevent mechanical overload of the plantar plate of the second metatarsophalangeal joint to assess for effusion, capsulosynovial
metatarsal heads [15]. joint, there may be varus drift of the second toe. thickening, and hyperemia. Medial sublux-
ation of the flexor tendon complex in the set-
Pathologic Analysis Arthrography ting of plantar plate tear is best appreciated
Attritional mechanical overload of the lat- Arthrography can be used to show plantar on short-axis imaging.
eral plantar plate of the second metatarso- plate tears [21, 22]. However, it has the dis-
phalangeal joint at the proximal phalangeal advantage of being invasive, having the po- MRI
insertion is a common cause of metatarsalgia tential to increase the extent of a tear by hy- In 1994, Yao et al. [21] demonstrated the
in athletes. The abnormality seen in this set- draulic distention of the joint, and not being utility of sagittal high-resolution MRI in visual-
ting encompasses a spectrum from degenera- able to show plantar plate degeneration. izing the normal plantar plate and plantar plate
tion without tear, to partial thickness tear, to
complete tear [15, 20]. In more severe cas-
es, there may be attritional tear of the later-
al collateral ligament, varus drift of the sec-
ond toe, and medial subluxation of the flexor
tendon complex. Entheseal bony irregular-
ity and spurring may develop at the proxi-
mal phalangeal base adjacent to the plantar
plate degeneration [20]. Coughlin et al. [15]
proposed a 5-point grading system based on
the shape of the plantar plate tear, ranging
from attenuation without tear, transverse dis-
tal tear (< 50% thickness or > 50% thick-
ness), transverse and longitudinal tear (with
or without collateral ligament), to extensive
complete tear.
A B
Radiographs Fig. 3Ultrasounds shows degeneration and tear of lateral plantar plate of second metatarsophalangeal joint
Radiographs should be performed with in two different patients.
weight bearing to better assess functional align- A, Oblique sagittal image shows degeneration and partial thickness tear (arrow) of lateral plantar plate of
ment. Attention should be directed to the rela- second metatarsophalangeal joint manifesting as hypoechoic echotextural change, with adjacent entheseal
bony irregularity (arrowhead) at proximal phalangeal insertion.
tive length of the first and second metatarsals B, Oblique sagittal image shows degeneration and complete tear (arrow) of lateral plantar plate at proximal
and the extent, if any, of protrusion of the sec- phalangeal insertion.

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 Sports Injuries of the Foot
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A B
Fig. 428-year-old male triathlete who presented with metatarsalgia.
A, Sagittal fat-suppressed proton densityweighted MRI of second metatarsophalangeal joint shows subtle signal hyperintensity (arrow) in lateral plantar plate laterally,
consistent with myxoid degeneration, without tear.
B, Short-axis (coronal) T1-weighted image shows corresponding signal hyperintensity (arrow) in lateral plantar plate of second metatarsophalangeal joint.

degeneration and tear. Umans and Elsinger [23]
emphasized the role of short-axis coronal imag-
ing in this context. Plantar plate degeneration
manifests on MRI as mild signal hyperintensi-
ty on short TE sequences, becoming less con-
spicuous on long TE sequences (Fig. 4). Plantar
plate tears have greater signal hyperintensity on
proton-density sequences, becoming more con-
spicuous on fat-suppressed proton-density and
T2-weighted sequences (Fig. 5). Occasionally,
bone marrow edema may be seen at the proxi-
mal phalanx adjacent to the plantar plate abnor-
mality. Infiltration of the fat plane at the plan-
tar margin of the plantar plate tear can mimic a
Morton neuroma. Care should be taken not to
misinterpret the normal attenuation of the plan-
tar plate at the proximal phalangeal insertion in
the midline at the level of the flexor tendon.
Morton Neuroma
Clinical Analysis
Symptomatic Morton neuroma is relatively
common in athletes and can mimic plantar plate
injuries of the lesser metatarsals. Morton neuro-
ma symptoms typically include gradual onset of
shooting pain, numbness, and tingling in the
third and fourth toes; a burning sensation;
cramping; and a sensation of walking on a
lump in the ball of the foot [24]. The symp-
toms are often relieved by removal of shoe wear.
Mulder click may be elicited by simultaneous
dorsoplantar and mediolateral compression of
the web space and is thought to be due to plantar
displacement of the neuroma [25]. Imaging stud-
ies have found a relatively high incidence of
asymptomatic Morton neuroma [26, 27].

Anatomy and Pathologic Analysis

The common plantar digital nerve nor-
mally has a diameter of less than 2 mm and
is accompanied by the plantar metatarsal ar-
tery. It divides into medial and lateral plan-
tar digital nerves. The intermetatarsal bursa
lies predominantly dorsal and proximal to
the deep transverse metatarsal ligament, be-
ing closely applied to the neurovascular bun-
dle at the distal margin of the ligament. A
small amount of fluid is commonly present in
the asymptomatic intermetatarsal bursa [27].
Morton neuroma refers to an entrapment
neuropathy caused by repetitive compression
of the common plantar digital nerve against
the transverse metatarsal ligament. This con-
dition most often affects the 34 web space
A B and, to a lesser extent, the 23 web space.
Fig. 528-year-old male professional rugby player who presented with chronic pain and swelling in second
Morton neuroma change virtually never oc-
metatarsophalangeal joint. curs in the 12 or 45 web space. The disor-
A, Sagittal proton densityweighted MRI shows extensive full thickness tear (arrow) of lateral plantar plate. der is characterized by nonneoplastic swell-
Note moderate joint effusion and mild synovial thickening in dorsal recess. ing, myxoid degeneration, and perineurial
B, Long-axis fat-suppressed proton densityweighted MRI shows high-grade tear (arrow) of lateral collateral
ligament of second metatarsophalangeal joint at metatarsal head insertion. Note normal lateral collateral and endoneurial fibrosis and demyelination
ligament (arrowhead) of third metatarsophalangeal joint. of the common plantar digital nerve [28].

AJR:199, September 2012 503

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A B C
Fig. 644-year-old woman training for her first marathon who presented with metatarsalgia.
A, Longitudinal image of second web space using plantar approach shows fusiform hypoechoic thickening (arrows), consistent with Morton neuroma change along line
of 23 common plantar digital nerve, with normal-appearing nerve (arrowheads) evident more proximally.
B, Short-axis T1-weighted MRI shows intermediate signal (arrow) at plantar aspect of second web space, consistent with Morton neuroma.
C, Short-axis T2-weighted image shows slightly reduced conspicuity of Morton neuroma margins (arrow) compared with T1-weighted image.

Ultrasound
Although ultrasound does not have the con-
trast resolution of MRI in assessing the inter-
face between a Morton neuroma and the adja-
cent fat plane, it does have the advantage of a
virtually unlimited multiplanar capability,
which facilitates demonstration of the com-
mon plantar digital nerve in long-axis sagittal
imaging with a plantar approach using high-
quality contemporary ultrasound machines.
The normal nerve is seen as a hypoechoic
structure adjacent to the common plantar
metatarsal artery. Color or power Doppler ul-
trasound may be required to differentiate the
artery from the nerve. The web space can also
be assessed in the short-axis coronal plane and
with a dorsal approach in the sagittal plane.
Morton neuroma change is typically man-
ifest as fusiform-ovoid hypoechoic thicken-
ing along the line of the common plantar dig-
ital nerve toward the distal margin of the web
space [29, 30] (Fig. 6A). Size criteria for a di-
agnosis of symptomatic Morton neuroma are
of limited utility, given the relatively high in-
cidence of asymptomatic Morton neuromas.
Although one study reported a mean diame-
ter of 5.3 mm in symptomatic cases, the mean
diameter in asymptomatic cases was 4.1 mm
[26]. Vascularity is usually not evident on
color power Doppler ultrasound assessment.
MRI
Dedicated high-resolution MRI of the cen-
tral forefoot (second to fourth metatarsopha-
langeal joints) provides accurate diagnosis of
Morton neuroma. Key points include use of
a slice thickness of 2 mm or less in all im-
age planes. Optimal MRI assessment of the
common plantar digital nerves and the meta-
tarsophalangeal joint is provided by oblique
short-axis coronal T1- and T2-weighted se-
quencing perpendicular to the long axis of the
proximal phalangeal shafts (plotted off sagit-
tal images) [3133]. This is particularly im-
portant in the setting of hyperextension de-
formities of the metatarsophalangeal joints.
Oblique sagittal sequencing perpendicular
to the transverse axis of the central forefoot
(plotted off short axis-coronal images) may
allow long axis visualization of the neuro-
vascular bundle. Scanning the patient prone
may increase the conspicuity of a Morton
neuroma [34]. On MRI, Morton neuroma
is often most conspicuous on the short-axis
T1-weighted sequence [33], usually of inter-
mediate signal (Fig. 6B). Signal intensity on
proton-density and T2-weighted sequencing
may be variable, depending on the extent of
fibrosis within the lesion, being of low sig-
nal if fibrosis predominates (Fig. 7). In le-
sions with higher water content, the margins
may be less conspicuous on T2-weighted im-
ages [33] (Fig. 7C). Fat suppression of T2-
weighted images may reduce lesion conspi-
cuity because of the similar low signal of a
fibrotic Morton neuroma and adjacent sup-
pressed fat. Contrast enhancement is often
not present, and routine administration of IV
contrast agent is not recommended [32].
Lisfranc Ligament Complex Injury
Clinical Analysis
Lisfranc ligament complex sprain injuries
in the athlete are relatively common, particu-
larly among those who play football, basket-
ball, and gymnastics [3537], and can be a
cause of substantial time off sport [38, 39].
The typical mechanism of injury involves an
axial longitudinal force applied to the foot in
a plantar-flexed and slightly rotated position
[40]. Associated injury to the first tarsometa-
tarsal joint capsule or the medial intercune-
iform ligament and naviculocuneiform joint
capsule may result in first ray instability [40].
Athletes often describe a pop in the foot at
the time of injury and midfoot pain aggravat-
ed by weight bearing [41]. At times, the clini-
cal findings may be quite subtle, contributing
to the relatively high rate of delayed diagno-
sis. There is some variation in the approach
to the imaging assessment and management
of subtle Lisfranc ligament complex injuries
in which there is no or minimal displacement
on weight-bearing radiographs. Some sur-
geons find stress radiography under anesthe-
sia useful in determining whether to internal-
ly fix the midfoot [42]. Others advocate the
use of MRI in determining the extent of cap-
suloligamentous injury and using this to de-
termine whether to proceed to examination
under anesthesia. Some surgeons use the in-
creased sensitivity of CT to detect subtle dis-
placement not evident on plain x-rays.
Anatomy
The Lisfranc ligament complex constitutes
an oblique linkage between the medial cunei-
form and the base of the second metatarsal. It
is biomechanically important because of the
large axial load transmitted through the sec-
ond metatarsal during walking and running and

504 AJR:199, September 2012


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A B
Fig. 7Man with interosseous Lisfranc ligament injury, with spectrum of imaging findings seen on long-axis
fat-suppressed proton-density MRI sequencing.
A, Low-grade interstitial sprain (arrow) manifests as subtle signal hyperintensity.
B, Complete midsubstance tear (arrow) is seen as discrete fluid signal midsubstance defect.
the absence of a transverse ligamentous linkage
between the first and second metatarsal bases
[43]. The interosseous Lisfranc ligament is the
strongest constituent of the Lisfranc ligament
complex [44]. The plantar oblique C1M2,M3
ligament between the medial cuneiform and the
bases of the second and third metatarsals is the
second strongest constituent of the Lisfranc lig-
ament complex [44]. It is of particular interest
because of recent cadaveric and clinical studies
showing that injury to the ligament in combi-
nation with interosseous Lisfranc ligament in-
jury is the strongest predictor of instability on
abduction stress radiographic examination un-
der anesthesia [42, 45]. The plantar oblique lig-
ament consists of a strong superficial band that
inserts broadly on the base of the third metatar-
sal and a less substantial deep band that inserts
on the base of the second metatarsal [46]. The
dorsal oblique Lisfranc ligament is the least
substantial component of the Lisfranc ligament
complex [44].
Radiographs
Radiographic diagnosis of Lisfranc injury
relies on findings of abnormality in midfoot
alignment or entheseal Lisfranc ligament flake
avulsion fractures (fleck sign). Comparison
with an anteroposterior view of the contralat-
AJR:199, September 2012 505
Sports Injuries of the Foot
eral foot is helpful. Radiographic studies are
more sensitive when performed during weight
bearing [47]. The ability to bear weight in the
acute setting is often limited, potentially ex-
plaining the still limited sensitivity of weight-
bearing x-rays compared with abduction stress
radiography under anesthesia [42, 45]. The
key criterion for normal alignment on an an-
A B
Fig. 8Man with interosseous Lisfranc ligament injury, with spectrum of imaging findings seen on long-axis
fat-suppressed proton-density MRI sequencing.
A, Low-grade interstitial sprain (arrow) manifests as subtle signal hyperintensity.
B, Complete midsubstance tear (arrow) is seen as discrete fluid signal midsubstance defect.
teroposterior view is that the medial borders
of the second metatarsal and intermediate cu-
neiform are colinear [48]. Widening of the in-
terval between the medial cuneiform and sec-
ond metatarsal base and between the bases of
the first and second metatarsals are other cri-
teria [40]. Attention should also be directed to
the medial intercuneiform interval on the an-
teroposterior view and sagittal plane malalign-
ment on the lateral view. A side-to-side differ-
ence of greater than 2 mm has been suggested
as an indication for surgical midfoot reduction
and stabilization [40].
CT
CT is more sensitive than radiography at
revealing midfoot fractures and subtle ab-
normalities in alignment associated with
Lisfranc ligament injury [49].
MRI
Proton-density and fat-suppressed proton-
density or STIR sequencing in the long axis of
the midfoot will reliably reveal both the interos-
seous Lisfranc ligament and the plantar oblique
ligament between the medial cuneiform and
the second and third metatarsal bases [5052].
Although the entire length of the interosseous
ligament will usually be seen on a single im-
age, the plantar oblique C1M2,M3 ligament
often needs to be pieced together on several
consecutive long-axis images. In the acute set-
ting, an interstitial strain injury of the interos-
seous Lisfranc ligament will manifest as mild
signal hyperintensity on proton-density and
fat-suppressed proton-density MRI sequenc-
ing (Fig. 8A). Partial volume artifact associated
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A B C
Fig. 9Man with plantar oblique medial cuneiform-base third metatarsal (C1M3) ligament injury. Spectrum of imaging findings is seen on long-axis proton-density MRI
sequencing.
A, Normal ligament (arrow) is seen, with predominant low signal and minimal striation.
B, Low-grade interstitial strain injury (arrow) is seen as moderate-signal hyperintensity.
C, Complete distal tear (arrow) is manifest as discrete ligament fiber discontinuity and redundant proximal stump.

Fig. 1036-year-old female orienteer who sustained

ankle sprain while running through bushland and
presented with persistent medial ankle pain and
valgus hindfoot deformity 12 months after injury,
having previously undergone ankle arthroscopy.
A, Coronal proton-density MRI shows mixed pattern
of thickening and attenuation, signal hyperintensity,
and ill definition of superomedial fibers of spring
ligament (long arrow). Note concomitant poorly
remodeled scar (short arrow) along line of tibial-
spring component of superficial deltoid ligament.
B, Axial proton-density image shows frank
tear (arrow) toward navicular insertion. Patient
underwent spring ligament repair, calcaneal
osteotomy, and insertion of arthroereisis screw into
sinus tarsi.

A B

with oblique sampling of a bifascicular interos-
seous Lisfranc ligament may simulate a low-
grade strain injury. A complete tear of the inter-
osseous Lisfranc ligament will usually be seen
as a fluid signal intensity defect in the ligament,
often more conspicuous on fat-suppressed pro-
ton-density MRI sequencing (Fig. 8B). Flake
avulsion fracture fragments at the medial cune-
iform or second metatarsal base are often diffi-
cult to perceive. A similar spectrum of findings
may be seen in relation to the plantar oblique
C1M2,M3 ligament (Fig. 9). Injury to the dor-
sal oblique C1M2 ligament is often best ap-
preciated on short-axis fat-suppressed proton-
density MRI sequencing.
ly highly significant injury [53]. Hintermann
et al. [53] popularized the concept of medial
ligament injury and resultant medial ankle in-
stability characterized by a feeling of giving
way, medial ankle pain, and plano-valgus de-
formity that can be corrected by tibialis poste-
rior activation [54]. Although more commonly
associated with injuries to the deltoid ligament
complex, 25% of the patients in the study by
Hintermann et al. [53] had spring ligament
rupture. Untreated medial ankle instability
may result in overload of the posterior tibial
tendon and tendon degeneration and elonga-
tion [53]. Early surgical correction may pre-
vent this progression [53].
calcaneonavicular ligament, the medioplan-
tar oblique calcaneonavicular ligament, and
the inferoplantar longitudinal calcaneonavicu-
lar ligament [56]. It may be simpler to refer
to these ligaments as the superomedial, plantar
oblique, and plantar longitudinal fibers of the
spring ligament [31].
Pathologic Analysis
Isolated spring ligament tears usually in-
volve the superomedial fibers and range from
interstitial sprain injury to frank tear, often cor-
onal in orientation, adjacent to the navicular in-
sertion [53], sometimes extending to involve
the dorsal talonavicular joint capsule [57].

Spring Ligament Injury Anatomy Radiographs

Clinical Analysis The spring ligament complex is the ma- Weight-bearing radiographs may show nor-
Injuries to the spring ligament in the ath- jor static stabilizer of the arch during mid- mal findings or lateral peritalar subluxation of
lete are an uncommon but potentially clinical- stance [55]. It consists of the superomedial the navicular insertion [58].

506 AJR:199, September 2012

 Sports Injuries of the Foot

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