Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Spring Ligament Injury: The Underdiagnosed Cause of Flat Foot Pain

The spring ligament (plantar calcaneonavicular ligament) is one of the most important static stabilizers of the medial longitudinal arch — and one of the most underdiagnosed sources of arch and ankle pain. At Balance Foot & Ankle, we see spring ligament injuries regularly, often in patients who’ve been treated for “plantar fasciitis” or “tendinitis” without improvement.

What Is the Spring Ligament?

The spring ligament is a complex of three ligament bands connecting the sustentaculum tali of the calcaneus (heel bone) to the navicular bone. It supports the head of the talus from below — essentially acting as a hammock for the talus that prevents the arch from collapsing. It works in conjunction with the posterior tibial tendon (the main dynamic arch stabilizer) to maintain foot alignment.

The spring ligament is the key static restraint of the medial arch. When it fails, the arch collapses — and the posterior tibial tendon (now working harder to compensate) is put at higher risk for injury as well.

How Do Spring Ligament Injuries Occur?

• Chronic attenuation: Most spring ligament insufficiency develops gradually from repeated overloading in flat-footed individuals. The ligament stretches over years of arch collapse.
• PTTD association: Spring ligament insufficiency is closely associated with posterior tibial tendon dysfunction (PTTD) — the two conditions frequently coexist, and treating PTTD without addressing spring ligament pathology leads to poor outcomes.
• Acute trauma: Can rupture acutely from a forceful inversion-plantar flexion injury or a Lisfranc injury mechanism
• Obesity and diabetes: Both increase the chronic load on the arch structures

Symptoms

• Medial arch and ankle pain, often worse with prolonged standing or walking
• Progressive flat foot deformity — the arch appears to be flattening over time
• Pain and tenderness below and slightly anterior to the medial ankle (the spring ligament location)
• Associated posterior tibial tendon symptoms (medial ankle pain behind the medial malleolus)
• The “too many toes” sign: from behind, more toes are visible on the outer aspect of the affected foot

Diagnosis

Spring ligament injury is frequently missed because:

• The spring ligament is not well visualized on standard foot X-rays
• Clinical symptoms overlap with PTT dysfunction and plantar fasciitis
• Not all clinicians include spring ligament assessment in their evaluation

MRI is essential for diagnosing spring ligament tears — it shows ligament discontinuity, edema, and thinning. A skilled musculoskeletal radiologist familiar with spring ligament anatomy is important for accurate interpretation. Ultrasound can also show spring ligament pathology in experienced hands.

Weight-bearing X-rays assess arch height and hindfoot valgus, informing treatment planning.

Non-Surgical Treatment

• Custom orthotics with aggressive medial posting: UCBL-type devices or high-profile arch support orthotics; must adequately support the arch to unload the spring ligament
• Arizona brace or similar: For more severe cases requiring rigid hindfoot control
• Activity modification: Reducing impact loading during acute phases
• Physical therapy: Posterior tibial tendon strengthening; intrinsic foot muscle activation
• Immobilization: Short-term walking boot for acute spring ligament tears or significant pain

Surgical Treatment

Spring ligament repair is typically performed as part of flatfoot reconstruction surgery when conservative care fails. Current techniques include:

• Direct spring ligament repair with suture anchor fixation
• Augmentation with FHL (flexor hallucis longus) tendon graft or synthetic ligament
• Combined with calcaneal osteotomy and PTT transfer for comprehensive flatfoot reconstruction

Addressing the spring ligament during flatfoot surgery significantly improves long-term outcomes compared to addressing the tendon alone.

Ready to Get Relief? We’re Here to Help.

Board-certified podiatrists Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients daily at our Howell and Bloomfield Township, MI offices.

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📞 (810) 206-1402

Related Conditions

• Flat Feet Treatment
• Custom Orthotics
• Plantar Fasciitis

Expert Spring Ligament Repair

Spring ligament injuries are a hidden cause of progressive flatfoot. Our podiatrists diagnose and treat this critical stabilizer to prevent arch collapse and long-term disability.

Learn About Flat Foot Treatment | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Deland JT, et al. Spring ligament failure as a cause of flatfoot deformity. Foot Ankle Clin. 2001;6(3):569-579.
2. Gazdag AR, et al. The spring ligament complex: anatomy, biomechanics, and clinical relevance. Foot Ankle Int. 2014;35(8):834-842.
3. Williams G, et al. MRI findings in spring ligament injury. AJR Am J Roentgenol. 2014;203(5):1120-1127.

Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.