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Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved?

Jonathan T. Deland, Richard J. de Asla, Il-Hoon Sung, Lauren A. Ernberg and Hollis G. Potter
Foot Ankle Int 2005 26: 427
DOI: 10.1177/107110070502600601

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FOOT & ANKLE INTERNATIONAL
Copyright  2005 by the American Orthopaedic Foot & Ankle Society, Inc.
Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved?
Jonathan T. Deland, M.D.1 ; Richard J. de Asla, M.D.2 ; Il-Hoon Sung, M.D.3 ; Lauren A. Ernberg, M.D.1 ; Hollis G. Potter, M.D.1
ABSTRACT
Background: The pathology manifested in posterior tibial
tendon insufficiency (PTTI) is not limited to the poste-
rior tibial tendon. The association of ligament failure with
deformity has been discussed in numerous publications,
but extensive documentation of the structures involved
has not been performed. The purpose of this observational
study was to identify the pattern of ligament involvement
using standarized, high-resolution magnetic resonance
imaging (MRI) in a series of 31 consecutive patients diag-
nosed with PTTI compared to an age matched control
group without PTTI. Method: The structures evaluated
by MRI were the posterior tibial tendon, superomedial
and inferomedial components of the spring ligament
complex, talocalcaneal interosseous ligament, long and
short plantar ligaments, plantar fascia, deltoid ligament,
plantar naviculocuneiform ligament, and tarsometatarsal
ligaments. Structural derangement was graded on a five-
part scale (0 to IV) with level 0 being normal and level IV
indicating a tear of more than 50% of the cross-sectional
area of the ligament. Standard flatfoot measurements
taken from preoperative plain standing radiographs were
correlated with the MRI grading system. Results: Statisti-
cally significant differences in frequency of pathology in
the PTTI group and controls were found for the supero-
medial calcaneonavicular ligament (p < 0.0001), inferome-
dial calcaneonavicular ligament (p < 0.0001), interosseous
ligament (p = 0.0009), anterior component of the super-
ficial deltoid (p < 0.0001), plantar metatarsal ligaments
(p = 0.0002) and plantar naviculocuneiform ligament (p =
0.0006). The ligaments with the most severe involvement
were the spring ligament complex (superomedial and
1
Hospital for Special Surgery, New York, NY
2
Massachusetts General Hospital, Boston, MA
3
Hanyang University Hospital, Seoul, Korea
Corresponding Author:
Jonathan T. Deland, M.D.
Hospital for Special Surgery
535 East 70th Street
New York, NY 10021
E-mail: delandj@hss.edu
For information on prices and availability of reprints, call 410-494-4994 X226
427
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New York, NY
inferomedial calcaneonavicular ligaments) and the talo-
calcaneal interosseous ligament. Conclusion: Ligament
involvement is extensive in PTTI, and the spring ligament
complex is the most frequently affected. Because liga-
ment pathology in PTTI is nearly as common as posterior
tibial tendinopathy, treatment should seek to protect or
prevent progressive failure of these ligaments.
Key Words: Ligaments; Posterior Tibial Tendon
Insufficiency
INTRODUCTION
The pathology manifested in posterior tibial tendon
insufficiency (PTTI), also known as the adult acquired
flatfoot, is not limited to the posterior tibial tendon.
The association of ligament failure with deficiency
of the posterior tibial tendon has been discussed
in numerous publications.3,7,10,12,13,15,16,21,23 Although
posterior tibial tendon dysfunction is widely accepted as
a significant contributor to this deformity, the pathology
and deformity involve more than the posterior tibial
tendon.8 Basmajian and Stecko,2 in an EMG study of
standing patients, noted that no deformity occurred in
the arch when the posterior tibial tendon was inactive.
Other authors have produced deformities in vitro similar
to that found in PTTI by sectioning several ligaments in
addition to releasing the posterior tibial tendon.7,12
Studies have confirmed the accuracy of magnetic
resonance imaging (MRI) in evaluating posterior tibial
tendon pathology when compared to findings at
surgery, if proper MRI technique and an experienced
observer were used.4,20 Yao et al.25 found MRI to be
reliable in evaluating the medial portion of the spring
ligament. Furthermore, MRI has been shown to be
effective in detecting injury to other foot and ankle
ligaments.18,24
Gazdag and Cracchiolo9 noted involvement of the
superomedial portion of the spring ligament in most
operatively treated patients with PTTI and stressed the
428 DELAND ET AL.
importance of evaluating the status of the spring liga-
ment complex. In our experience, the superomedial
component of the spring ligament, as observed intraop-
eratively, ranges from appearing completely disrupted
to normal. The lateral side of the ligament and its
insertion under the navicular tuberosity usually cannot
be seen well with routine operative exposure. The
extent of pathology in the spring ligament complex
may not be fully appreciated. Most of the other liga-
ments that support the arch also may not be visible at
surgery. These additional soft-tissue longitudinal arch
supporters include the plantar fascia, the long and
short plantar ligaments, the talocalcaneal interosseous
ligament, and the plantar ligaments of the naviculo-
cuneiform and tarsometatarsal joints. The frequency
and extent of pathology affecting these ligaments in
patients with PTTI remain unclear. We attempted to
identify a pattern of structural derangement using clin-
ical MRI in 31 consecutive patients diagnosed with PTTI
and compared it to a control group without PTTI.
MATERIALS AND METHODS
Thirty-one consecutive patients (31 feet) diagnosed
with PTTI that was confirmed by both physical exam-
ination and operative evaluation were enrolled in this
study. Institutional Review Board approval was obtained
for this study. All patients had operatively documented
degeneration or a tear of the posterior tibial tendon.
The 31 patients in the control group were matched by
age and had MRI examination of the ankle and hindfoot
for reasons other than PTTI. The two most common
reasons for obtaining MRI in the control group were
osteochondral lesions of the talus and Achilles tendon
pathology. MRI examinations were done preoperatively
and were interpreted by a MRI radiologist specializing
in orthopaedic disorders. MRI assessment of the poste-
rior tibial tendon was done in both the control and
operative groups. The spring ligament complex was
assessed as separate components (the superomedial
calcaneonavicular ligament and the inferior calcaneon-
avicular ligament), as described by Davis et al.5 In
addition, the interosseous talocalcaneal ligament, long
and short plantar ligaments, plantar fascia, deltoid liga-
ment (anterior, posterior and deep components), plantar
naviculocuneiform ligament, and tarsometatarsal liga-
ments were evaluated by MRI in both groups.
Ligament pathology was graded on a five-part scale:
grade 0, an intact ligament with uniformly hypointense
signal intensity; grade I, degeneration, denoted on MRI
as increased signal intensity involving less than 50% of
the cross-sectional area of the ligament on axial images;
grade II, degeneration of more than 50%; grade III, a
partial tear with discontinuity of less than 50% of the
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Foot & Ankle International/Vol. 26, No. 6/June 2005
fibers discernible on MRI with both increased signal
intensity and abnormal morphology; and grade IV, a
tear involving abnormal morphology of more than 50%
of the cross sectional area. This same classification was
applied to the posterior tibial tendon. The classification
was not applied to the plantar fascia or the long and
short plantar ligaments, because these were noted to
have degeneration only and no tears (no grade III or
IV changes). To more precisely define the involvement
of these structures, signal change was classified on
a three-part scale, with mild being less than 25% of
the cross sectional area, moderate 25% to 50%, and
severe more than 50%. The presence of a tibial lip, a
ridge of bone just above the medial malleolus at the
anterior edge of the tendon, was recorded. We thought
that this finding is associated with PTTI and wanted to
determine its incidence. The presence of edema around
the calcaneocuboid joint also was noted. Measurements
on standing anteroposterior (AP) and lateral radiographs
of the feet included the lateral talometatarsal angle,
AP talonavicular coverage angle, calcaneal pitch angle,
and plantar medial cuneiform to the plantar fifth
metatarsal base distance. These measurements were
made independently by an orthopaedic surgeon with a
specialty knowledge of foot and ankle disorders who
was blinded to the MRI findings.
MRI Technique
MRI of the ankle was done with a 1.5 Tesla unit
(Signa, Horizon, General Electric Medical Systems,
Milwaukee, WI). All images were made with a linear
send-receive extremity coil (General Electric Medical
Systems, Milwaukee, WI). All ankles were positioned
neutrally, with the Achilles tendon parallel to the
long axis of the magnetic field and no plantarflexion.
Sagittal images were obtained with a fast spin echo
technique (repetition time {TR}/echo time {TE} msec
3000 – 5000/34 {Ef}) with a 3.5-mm slice thickness and
no gap, 512 × 384 matrix at 2 excitations, and field of
view of 14 cm to 16 cm. An additional sagittal pulse
sequence was obtained with fast inversion recovery
(TR/TE/TI 3500 – 5000/17/140), slice thickness of 4 mm
with no interslice gap, matrix 256 × 192 at 2 excitations,
and a field of view of 14 cm to 16 cm. Echo train
length varied between 8 and 16. Oblique coronal images
were obtained parallel to the subchondral plate of the
talonavicular joint from a sagittal image, obtained with
field of view of 11 cm to 12 cm, matrix 512 × 384 at 2
excitations, slice thickness of 4 mm with no gap and
TR/TE 3500 – 4000/34 (Ef). Axial images were obtained
parallel to the long axis of the foot, field of view of 12 cm
to 13 cm, matrix 512 × 256 – 384 at 2 excitations, and
slice thickness of 3.5 mm to 4 mm with no interslice gap.
Foot & Ankle International/Vol. 26, No. 6/June 2005 POSTERIOR TIBIAL TENDON INSUFFICIENCY 429

Data Analysis
Table 1: Comparison of structures involved and
Grading is an ordinal measurement and the data
degree of involvement between control and PTTI
were analyzed using the non-parametric statistics,
group
Mann-Whitney tests for differences between groups. A
modified Bonferroni correction for multiple comparisons
was applied, so alpha was set to 0.005 for each test. Number of
Number of Patients:
RESULTS
Structure Patients: Control
& Level PTTI Group Group
The ligament most commonly involved in the Posterior tibial
PTTI group was the superomedial component of the tendon
calcaneonavicular ligament, which demonstrated MRI 0 0 21
evidence of a tear (grades III or IV) in 23 of 31 feet (74%) I 2 10
(Table 1 and Figure 1). All patients with MRI evidence of II 6 0
grade IV tears of the superomedial spring ligament had III 11 0
splits in the ligament or severe attenuation at surgery. If IV 12 0
signal change of more than 50% of the ligament (grade
II) is added to this subgroup, then 27 of 31 feet (87%) Superomedial
met these criteria. In comparison, grades II, III, and spring ligament∗
IV changes in the posterior tibial tendon were noted 0 0 18
in 29 of 31 feet (94%). No patient in the PTTI group I 4 9
demonstrated a level 0 superomedial spring ligament. II 4 4
The next most commonly involved ligament in the III 7 0
PTTI group was the inferior calcaneonavicular compo- IV 16 0
nent of the spring ligament complex (Figure 2). Grade (p < 0.0001)
III or IV changes were observed in 12 patients (39%)
Inferomedial
and grades II, III, or IV changes in 23 patients (74%)
spring ligament∗
(see Table 1). The talocalcaneal interosseous ligament
0 5 19
I 3 6
II 11 6
III 3 0
IV 9 0
(p < 0.0001)
Talocalcaneal
interosseus
ligament∗
0 6 12
I 10 17
II 2 2
III 6 0
IV 7 0
(p = 0.0009)

∗ indicates a significant difference between control and PTTI group.

also was commonly involved in this group, demon-

Fig. 1: Oblique coronal MRI of a 70-year-old man with PTTI
demonstrates severe degeneration and attenuation (grade III) of the
superomedial fibers of the spring ligament (arrow).
strating grade III or IV in 13 feet (42%), and grade II,
III or IV in 15 patients (48%) (Table 1 and Figure 3).
The anterior superficial deltoid was involved in more
feet than the deep or posterior superficial deltoid, with
grade III or IV changes in six feet and grade II, III or IV
changes in 10 feet (Table 3). This is compared to level

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430 DELAND ET AL. Foot & Ankle International/Vol. 26, No. 6/June 2005

Fig. 3: Sagittal MRI of a 69-year-old woman with PTTI demonstrates

a thickened, hyperintense, torn (grade III) interosseous ligament (long
arrow). Of note, the long plantar ligament is maintained (short arrow).

Fig. 2: Axial MRI of a 51-year-old woman with PTTI demonstrates a

severely frayed and degenerated (grade IV) inferomedial spring liga-
ment (arrow) with an intact adjacent bifurcate ligament (arrowhead).

II, III, or IV involvement of the deep deltoid in four feet

and the posterior superficial deltoid in six feet (Table 3
and Figure 4). The plantar fascia showed mild signal
change in 13 feet (42%), moderate degeneration in four
feet (13%), and grade III degeneration in only four feet
(13%) (Table 2). Level II or more signal change of the
plantar fascia was present in only 26% of the feet, and
no partial or complete tears of the plantar fascia were
present. The metatarsotarsal ligaments demonstrated
mild or more signal change in six feet, while the navicu-
locuneiform ligament was similarly involved in four feet
(Table 2). The long and short plantar ligaments were the
least involved structures with mild changes in just two
patients (Table 2) and no tears observed.
There were no level III or IV tears in any ligament
studied in the control group (Figures 5 and 6). Further-
more, there were no MRI changes in the posterior
tibial tendon greater than level I in this group. Although Fig. 4: Oblique coronal MRI of a 64-year-old woman with PTTI
these patients did not have surgical exploration of their demonstrates the deep fibers of the deltoid to be hyperintense and
tendons, the level 0 or I changes make it unlikely that torn (grade IV) off the talus (arrow).
patients in the control group had PTTI. Also, these
patients had no clinical symptoms referable to the A tibial lip was present in 17 PTTI group patients
posterior tibial tendon. The talocalcaneal interosseous (Figure 7) and edema at the calcaneocuboid joint was
ligament was the most commonly involved ligament in present in six. Nine of 30 control patients were found to
the control group, with 19 (61%) grade I or II changes have a tibial lip (one central MRI was not available when
(Table 1). this portion of this study was done). Seven of these

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Foot & Ankle International/Vol. 26, No. 6/June 2005 POSTERIOR TIBIAL TENDON INSUFFICIENCY 431

Table 2: Comparison of structures involved and Table 3: Comparison of structures involved and
degree of involvement between control and PTTI degree of involvement between control and PTTI
group group

Number of Number of
Number of Patients: Number of Patients:
Structure Patients: Control Structure Patients: Control
& Level PTTI Group Group & Level PTTI Group Group
Plantar fascia Deep deltoid
0 10 21 ligament
I 13 6 0 23 21
II 4 3 I 4 9
III 4 1 II 2 1
III 0 0
Plantar metatarso- IV 2 0
cuneiform
ligaments∗ Anterior superficial
0 17 30 deltoid
I 8 0 ligament∗
II 3 1 0 2 21
III 2 0 I 19 9
IV 1 0 II 4 1
(p = 0.0002) III 4 0
IV 2 0
Plantar naviculo- (p < 0.0001)
cuneiform
ligament∗ Posterior
0 19 30 superficial
I 8 1 deltoid ligament
II 3 0 0 20 24
III 1 0 I 5 6
IV 0 0 II 5 1
(p = 0.0006) III 1 0
IV 0 0
Long and short
plantar ∗ indicates a significant difference between control and PTTI group
ligaments∗
0 29 31
I 2 0 were found in the superomedial spring (p < 0.0001),
II 0 0 inferomedial spring (p < 0.0001), interosseous (p =<
III 0 0 0.0009), anterior superficial deltoid (p < 0.0001), plantar
(p = 0.2) metatarsocuneiform (p = 0.0002), and plantar naviculo-
cuneiform ligaments (p = 0.0006).
∗ indicates a significant difference between control and PTTI group
DISCUSSION

nine patients were found to have some form of medial
pathology: one with grade I posterior tibial tendon signal
change only, one with mild medial ankle joint wear and
grade I posterior tibial tendon changes, and five with
some degree of deltoid ligament signal alteration with
or without grade I posterior tibial tendon changes.
Statistically significant differences in the frequency
of pathology between the PTTI and control groups
This study documents the frequency and degree
of ligament involvement in PTTI. The spring ligament
complex was most frequently involved. This ligament
complex consists of two anatomic components: the
superomedial calcaneonavicular ligament and the infer-
omedial calcaneonavicular ligament.5,6 The supero-
medial component includes the medial talonavicular
capsule and is the largest and strongest portion of the

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432 DELAND ET AL.
Fig. 5: Sagittal MRI of a 39-year-old female control patient with no
evidence of PTTI demonstrates intact interosseous (arrow) and long
plantar (arrowhead) ligaments.
spring ligament complex.5 This component contains not
only fibrous tissue but also fibrocartilaginous tissue that
likely results from the compression between the talar
head and the adjacent posterior tibial tendon. The infe-
rior calcaneonavicular ligament is a narrower, entirely
fibrous structure that lies in the plantar most aspect
of the acetabular pedis. The superomedial component
is more easily seen at operative inspection and has
been more commonly implicated in operatively defined
spring ligament ‘‘ruptures.’’ Because of the inability to
see both sides of this ligament and because it can be
A B
Fig. 6: A, Oblique coronal MRI of a 72-year-old female control patient demonstrates intact superomedial fibers of the spring ligament (arrow). B,
Axial MRI in the same patient demonstrates intact inferomedial fibers of the spring ligament (arrow).
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Foot & Ankle International/Vol. 26, No. 6/June 2005
lax or torn at the recesses of the talonavicular joint,
partial tears or degeneration of the ligament may not be
readily appreciated in the operating room.
All patients in the PTTI group had some degree of
MRI abnormality of the superomedial calcaneonavicular
ligament. MRI evidence of pathology in this component
of the spring ligament complex was nearly as severe
as that in the posterior tibial tendon. The next most
frequently involved were the inferior calcaneonavicular
ligament and the talocalcaneal interosseous ligament.
Frequent involvement of the inferior calcaneonavicular
ligament, which is part of the acetabulum pedis and
spring ligament complex, is not surprising. Nearly half
(15) of the PTTI patients demonstrated grade II, III, or IV
involvement of the talocalcaneal interosseous ligament.
This ligament helps maintain the alignment of the
calcaneus relative to talus and, therefore, abnormality of
this ligament is expected, although the frequency was
higher than anticipated.11
The anterior deltoid was not commonly involved
(although statistically significant at p < 0.0001 for six
patients), and the deep deltoid was affected even less
frequently (one patient). This correlates with the lack of
gross clinical failure of the ankle alignment until very end
stage PTTI (stage IV).14 Surprisingly, the plantar fascia
did not show significant involvement as compared to
controls. No demonstrable tears were seen in any
patient. This raises questions about biomechanical
models that release the plantar fascia to simulate the
deformity seen in PTTI.10,15,22
The superomedial calcaneonavicular ligament is an
important restraint to the development of flatfoot
Foot & Ankle International/Vol. 26, No. 6/June 2005
A B
Fig. 7: A, Axial image of a 69-year-old woman with PTTI demonstrates severe degeneration and enlargement (grade II) of the posterior tibial
tendon (arrow). B, Axial image obtained at a more proximal level in the same patient demonstrates a tibial lip (arrow).
deformity. Based on biomechanical and clinical stu-
dies,3,6,7,9 the spring ligament complex, particularly the
superomedial calcaneonavicular ligament component,
could be considered a primary static restraint to
deformity of the talonavicular joint. However, it is not the
only restraint, as release of this ligament does not create
immediate deformity without cyclic loading. With cyclic
loading, however, other ligamentous restraints are likely
to attenuate, causing the development of deformity
once the primary restraint has been lost. Biomechanical
models that apply cyclic loading following release of
the spring ligament seem logical according to our study
and have produced deformities similar to that seen in
PTTI.12,13,19
As the most commonly involved ligament, the spring
ligament complex is the one ligamentous structure
that should be protected or successfully reconstructed.
Degeneration of the tissue, just like degeneration of the
posterior tibial tendon, often precludes direct repair.
Reconstruction or repair alone is not likely to be
adequate; a calcaneal osteotomy may be needed for
correction of bony alignment that may have contributed
to the ligament’s initial failure and the deformity
that occurs after cyclic loading. Calcaneal osteotomy
has been shown to provide stress relief for the
superomedial calcaneonavicular ligament17 and may
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POSTERIOR TIBIAL TENDON INSUFFICIENCY 433
provide additional relief for the other ligaments on the
medial side of the foot. It is important to note that the
four most commonly involved ligaments (both portions
of the spring ligament complex, the interosseous
ligament and the anterior deltoid ligament) are located
in the medial half of the foot. We believe that calcaneal
osteotomy (or another method to correct alignment) is
indicated for valgus malalignment that causes increased
strain on the medial side of the foot and places the
ligamentous structures at risk for further deterioration.
Radiographs were taken preoperatively in an attempt
to correlate deformity measurements with ligamentous
involvement. The absolute values of flatfoot measure-
ments did not correlate with the degree of ligament
involvement. We theorize two reasons for this lack of
correlation. First, it is paramount to have radiographic
measurements before the development of the PTTI, so
that progressive deformity as a result of posterior tendon
dysfunction is known. This point is particularly true in
patients with pre-existing pes planus. Second, radio-
graphic measurements may not be sufficiently accurate
to reliably detect small but significant changes in the
medial longitudinal arch.
The presence of a tibial lip was found nearly twice
as often in the PTTI group (p = 0.07) than in the
control group. When identified in the control group,
434 DELAND ET AL.
it usually was associated with MRI evidence of medial
side overload. While this finding is likely more of a
general interest than a significant clinical finding, it may
represent evidence of a fatigued posterior tibial tendon
or deltoid ligament. We are unaware of any reports that
describe such a finding.
MRI gives an indication of the presence and degree
of pathology affecting the ligaments. It does not provide
a direct measurement of the ligament’s functional
capacity. Some correlation is likely, but it cannot
be confirmed by our data. This study indicates a
pattern of ligament involvement without giving an
absolute indication of the strength of these ligaments.
MRI findings of grade IV ligament involvement of
the superomedial ligament and the posterior tibial
tendon correlated well with findings at surgery. This is
consistent with our previous conclusions concerning the
accuracy of MRI in assessing the Lisfranc ligament.18
It is important to note that the type of MRI unit
and the pulse sequence parameters used, including
the orientation of the acquisition (ankle in neutral
position), plane resolution, and slice thickness, as well
as the experience of the radiologist are all essential
in obtaining accurate assessment of the ligaments.
Clinicians should, therefore, view MRI reports with
caution unless the physician has had experience with
that specific MR unit and radiologist. We frequently see
MRI scans obtained for PTTI in which the interpretation
of these ligaments or even the posterior tibial tendon is
not possible because of poor technique.
Numerical image analysis is a possible addition to
interpretation of image of a ligament by a radiologist.
While a large project, this could have made the project
more accurate and is a potential weakness of the
study. However, we are confident of the quality of
the images and the interpretation. There also is the
issue that the reading of the ligament by MRI may
be more difficult (therefore possibly more ‘‘subjective’’)
than reading the tendon. While this reading of ligament
involvement becomes more of a problem with less
experience and a lesser quality scan, we have found
that careful interpretation of good quality scans give a
good indication of the condition of the ligaments found
at surgery.
In summary, an MRI of the pattern of ligament
involvement in PTTI identified the superomedial calca-
neonavicular ligament as the most commonly involved,
followed by the inferomedial calcaneonavicular and talo-
calcaneal interosseous ligaments, indicating that repair
or reconstruction needs to consider both components
of the spring ligament complex. Furthermore, a medial
calcaneal osteotomy seems appropriate not only to aid
in the tendon transfer but also to take strain off the
medial ligaments. Various medial ligaments were noted
to have some degree of pathology, including in this
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Foot & Ankle International/Vol. 26, No. 6/June 2005
study and included the ligamentous supports of joints
involved in PTTI, such as the talonavicular, subtalar,
metatarsocuneiform, and naviculocuneiform joints.
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