Research Article

Return to Sport following a Spring Ligament Reconstruction in a Division I Collegiate Jumper: a Case Report

Feigenbaum LA1*, Steinlauf SD2, Carlston M3, Cruz-Niklas C3, Price K3, Reddy M3, Negishi N4 and Scavo VA4
1Department of Physical Therapy, University of Miami (FL) Miller School of Medicine, USA
2Orthopaedic Associates of South Broward, USA
3Department of Physical Therapy, University of Miami (FL) Miller School of Medicine, USA
4Department of Athletics, University of Miami (FL), USA


*Corresponding author: Luis A Feigenbaum, Department of Physical Therapy, University of Miami (FL) Miller School of Medicine, 5915 Ponce de Leon Blvd, 5th Floor, Coral Gables, FL 33146, USA


Published: 30 May, 2016
Cite this article as: Feigenbaum LA, Steinlauf SD, Carlston M, Cruz-Niklas C, Price K, Reddy M, et al. Return to Sport Following a Spring Ligament Reconstruction in a Division I Collegiate Jumper: A Case Report. Remed Open Access. 2016; 1: 1002.

Abstract

Introduction: Isolated spring ligament ruptures and reconstructions are rare. To date, there are no published studies documenting the rehabilitation of a spring ligament surgical reconstruction. The purpose of this case report is to describe the surgical reconstructions, post-operative rehabilitation, and outcome in a spring ligament tear.
Materials and Methods: A 21 year-old male Division I collegiate track athlete who competes in the long and high jumps sustained a noncontact foot injury. The injury occurred during take-off while planting on his foot. The subject was diagnosed with an isolated tear of the spring ligament without arch collapse. After failed conservative treatment, he underwent surgical reconstruction with a peroneus longus tendon allograft. A four-phased individualized treatment program was initiated following surgery. Outcomes were tracked using the FADI and FADI-S. The rehabilitation goal was to return to his sport.
Results and Discussion: At 5 months, the athlete was discharged with all objective measures normalized to pre-injury levels. FADI scores improved to 99% and FADI-S to 87.5%. At 6 months postoperatively, the athlete was cleared to return to sport by his surgeon. At final follow-up 30 months after the surgery, the patient continued to participate as an elite level collegiate athlete, without issues related to the operative foot.
Conclusion: Despite the lack of an established rehabilitation protocol for spring ligament reconstructions, surgery coupled with a criterion based progressive rehabilitation program can lead to a successful return to sport outcome. The use of evidence-based practice and clinical practice guidelines can help clinicians navigate the rehabilitation of novel injuries and surgeries, as was the case with the spring ligament reconstructions.

Keywords: Sport; Reconstruction; Spring ligament; Collegiate athlete

Introduction

Injury to the plantar calcaneonavicular (spring) ligament rarely occurs in isolation [1]. It most commonly occurs in conjunction with posterior tibialis tendon (PTT) dysfunction or injury. Studies have found that between 82-92% of patients with PTT dysfunction also sustained an injury to the spring ligament[2-4]. The spring ligament is one of the primary static stabilizers of the medial arch of the foot, while the PTT is the primary dynamic stabilizer [5-11]. The spring ligament serves two primary functions: 1) supports the head of the talus and 2) stabilizes the longitudinal arch of the foot with the PTT [9]. It is most commonly injured through excessive pronation of the foot, causing a stretch to the ligament [9]. Spring ligament tears may also occur secondary to a deficient PTT with adult-acquired flatfoot deformity [1]. Damage to either of these structures can result in flat foot deformity [6,9,11,12]. When injury to the spring ligament occurs, it is most often the superomedial calcaneonavicular ligament (SMCNL) portion that is affected.
The severity of a spring ligament tear and its related dysfunction determine the course of treatment [9]. Conservative treatment is commonly reserved for partial and acute tears [9]. The patient will be non-weight bearing (NWB) for approximately six weeks with immobilization. Once pain and inflammation decrease, the patient begins therapy and is guided through a progressive rehabilitation program [9]. A chronically injured spring ligament will commonly occur in conjunction with posterior tibialis tendinopathy (PTT), often requiring surgery for patients who are competitive athletes [2,4,9,13]. However, spring ligament tears leading to flat foot deformity can occur in isolation [14,15]. If they are diagnosed prior to arch collapse, they can be reconstructed in an attempt to prevent a more significant flat foot deformity. Surgical treatment is determined by the extent of the tear and the function of the surrounding structures.
Reconstruction surgeries of the spring ligament have been performed with autograft and allograft techniques using the flexor digitorum longus tendon, and more commonly, the peroneus longus and flexor hallucis longus tendons [11,16-18].
Despite the lack of evidence-based and objective guidelines on spring ligament reconstructions, the goal of rehabilitation in an athlete is to return to previous activity and function as quickly as possible [19]. The rehabilitation process should focus on, but is not limited to, range of motion, proprioception, strength and conditioning, speed and agility, and performance based activities. The purpose of this case report is to summarize the findings, surgery, rehabilitation, and outcomes of an elite athlete who suffered an isolated spring ligament tear.

Figure 1

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Figure 1
Non-contrast MRI of spring ligament tear. Arrow indicates the tear.

Materials and Methods

A healthy 21 year-old male Division I collegiate track athlete (long and high jump competitor) was injured during take-off during the long jump. The subject reported immediate pain in the medial hindfoot. After competing in two subsequent track meets, he continued to have significant pain while jumping.
The subject was evaluated by an Orthopaedic Surgeon when he did not respond to rest and conservative measures. On examination tenderness and swelling were isolated to the spring ligament region of the hindfoot. Weight bearing radiographs revealed no arch collapse. MRI revealed a tear of the spring ligament without associated pathology to the posterior tibial tendon (Figure 1). Further conservative treatment was initiated by the Orthopaedist.
Preoperative
The surgeon instructed the subject to maintain toe-touch weight bearing (TTWB) with crutches in a CAM walking boot. After 6 week of immobilization, the subject still presented with pain and an inability to advance his activity level without significant symptomatology. In an effort to prevent eventual arch collapse in a high level athlete, surgical intervention was elected.
Surgical intervention
The subject underwent a left spring ligament repair with allograft reconstruction using an allograft peroneus longus tendon. The surgery was performed under a regional block in the supine position with tourniquet control.
An incision was made from posterior to the tip of the medial malleolus to distal to the navicular. The PTT and the flexor digitorum longus tendon were found to be normal in appearance. The spring ligament was noted to have very good tissue proximally; however, a few millimeters proximal to the insertion of the navicular, there was full thickness tearing noted (Figure 2). The spring ligament was repaired primarily with sutures and was then augmented with the allograft (Figure 3). The augmentation was performed to assist with stability and healing in the setting of intense strain that was expected to occur in this collegiate athlete. The pre-tensioned allograft was placed into a tunnel created in the sustentaculum-tali and then anchored into a tunnel running from plantar to dorsal through the navicular. Fixation was obtained with interference screws. The ankle was immobilized for 2 weeks in a splint. A timeline of relevant events is described in Table 1.

Figure 2

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Figure 2
Clinical picture of spring ligament tear and normal posterior tibial tendon. Block arrow indicates tear, Arrow indicates the posterior tibial tendon.

Figure 3

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Figure 3
Clinical pictures of allograft placement: A. Tensioning of the graft B. Final after fixation of the graft and suture of the spring ligament. Arrow indicates the allograft.

Table 1

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Table 1
Timeline of Events.

Rehabilitation
Phase 1: Immediate postoperative phase: restrictive motion (weeks 0-4): The goals of this phase were to protect the anatomic reconstruction, prevent the negative effects of immobilization, and restore/maintain full ROM at the knee and hip. The subject was instructed to remain NWB with crutches for 2 weeks. During weeks 3-4, the subject was TTWB with crutches in a fiberglass short leg cast (Table 2).
Phase 2: Intermediate phase: moderate protection phase (weeks 5-11): This phase focused on protecting the anatomic reconstruction, continuing to diminish pain and inflammation, achieving satisfactory muscle strength, gaining full active plantarflexion and dorsiflexion, and normalizing gait. During this phase, no impact activities were performed and postoperative swelling was managed. The short leg cast was removed and replaced with a CAM boot at week 5 with partial (25%) weight bearing. Weight bearing was advanced to full as tolerated with the use of the CAM walking boot and crutches week 6. During postoperative week 7, the subject discontinued use of the crutches but continued in the CAM walking boot only for longer distances until week 12. The subject used a regular sneaker with an over-the-counter arch support while walking around his dorm room during this time.
Phase 3: Advanced strengthening phase (weeks 12-20): During this phase, the subject discontinued bracing, began jog-run-sprint progressions, initiated higher-level strengthening and athletic maneuvers, and returned to full weight room activities. During postoperative week 12 weight bearing radiographs were performed, confirming adequate maintenance of arch alignment. At this time, no significant pain or tenderness was reported. The subject approached full, pain-free ankle range of motion and strength. The subject was also prescribed a custom fit orthotic. During postoperative week 19, the subject reported painless running during short sprints and 400m runs.
Phase 4: Return-to-sport phase (months 4-6): During postoperative week 28 the subject was cleared by the physician to return to all activities as tolerated. Rehabilitation focused on returning to full activity, continuing to progress weight room activities, and educating the subject on a maintenance program.
Outcome measure
The FADI is a subjective self-report measure of function with two components [20]. The traditional FADI consists of 26-items related to activities-of-daily living (ADL); in addition, the FADI Sport (-S) subscale consists of 8-items that are specifically designed for an athletic population [21]. It is scored for activity and pain items on a 0 to 4 scale: 0 representing unable to do or unbearable pain and 4 representing no difficulty or no pain, respectively. The scores for the FADI and FADI-S are calculated into separate percentages with 100% representing no dysfunction. The FADI (ICC = 0.89) and FADI-S (ICC = 0.84) have both been shown to be reliable outcome measures used to detect functional limitations in patients with CAI [21,22]. The FADI-S is more sensitive in detecting limitations among highfunctioning individuals and therefore may be more practical for use in an athletic population. Construct validity has been demonstrated as these measures were found to have good sensitivity to detect change in function between healthy subjects and patients with CAI [21,22]. Both measures have demonstrated responsiveness to improvements in function following rehabilitation. Minimal clinically important difference (MCID) has yet to be determined for both the FADI and FADI-S.

Results and Discussion

The subject initially presented with significant pain in his medial hindfoot without visible collapse of the arch. After 6 weeks of conservative treatment without improvements, reconstructive surgery was performed. The subject’s early rehabilitation consisted of exercises focusing on achieving normal ankle ROM and muscle strength while maintaining normal mobility at proximal joints. As goals were met, the program advanced, consisting of more sport specific exercises. Once the subject was cleared by the physician and there were sufficient improvements with the FADI and FADI-S, the subject was able to return to sport pain-free. At the subject’s 30 month follow-up evaluation, he was noted to be competing at an elite level as a college track athlete. He reported no pain at the operative site, exam demonstrated normal strength without atrophy, full range of motion, and a maintained arch. He was subjectively pleased with the result.
Implementation of a rehabilitative protocol that incorporated a criterion-based progressive plan of care was key in the subject’s recovery and ultimately in his return to sport. Caution was taken throughout the course of his care to avoid overly tensioning the reconstruction while still providing adequate stresses for soft tissue adaptations. Monitoring signs and symptoms of associated with these stresses was especially important considering the lack of literature concerning spring ligament reconstructions.
The subject’s FADI scores improved from 66.3% to 99% and the FADI-S improved from 0% to 87.5% (Table 3). The FADI and FADI-S were the outcome measures used to assess the subject’s level of dysfunction and responsiveness to treatment. The FADI is an outcome tool because it has a sport component in order to analyze tasks that are more sport specific [21,22]. While it has been found to be a reliable outcome tool, it was only assessed in one study which analyzed the FADI and FADI-S in patients with CAI [21]. Further research needs to be conducted to assess their reliability with other foot and ankle pathologies.

Table 2

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Table 2
Rehabilitation Protocol.

Table 3

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Table 3
FADI and FADI-S Scores.

Conclusion

This study outlines a subject’s return to pain-free sport activity following a spring ligament reconstruction. The results suggest that a multimodal approach to rehabilitation will lead to a successful outcome in post-surgical rehabilitation of a spring ligament reconstruction. This may help guide clinicians with their return to sport progressions for patients with similar presentations. Future studies should be conducted following these guidelines in order to confirm successful post-surgical reconstruction outcomes.

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