Biomechanics Therapy PR

The Deltoid Ligament Complex 🦶

👉 The deltoid ligament is a group of ligaments that derives its origin from the medial malleolus, where 2 colliculi (1 anterior and 1 posterior) can be found, separated by an intercollicular sulcus. This ligament complex has insertions at talus, calcaneus, and navicular bones, as well as into the superomedial calcaneonavicular ligament, acquiring a delta shape. https://link.springer.com/article/10.1007/s00167-012-2159-3

👉 Cadaveric studies reported that the deltoid ligament has multiple compositions along with variations. https://pubmed.ncbi.nlm.nih.gov/33990250/

👉 Components of the deltoid ligament consist of SUPERFICIAL and DEEP layers and each layer of the deltoid ligament complex provides a specific supportive function to the ankle joint, and collectively to prevent lateral subluxation of the talus in severe ankle fractures. https://www.sciencedirect.com/science/article/abs/pii/S1083751513000582

👉 The superficial layer consist of the following ligaments: (1) tibiospring ligament, (2) tibionavicular ligament, (3) superficial tibiotalar, and (4) tibiocalcaneal ligament (s. figure, https://pubmed.ncbi.nlm.nih.gov/24740670/ & figure in comments, https://pubmed.ncbi.nlm.nih.gov/27133289/)

🟥 Tibionavicular ligament: originates from the anterior border of the anterior colliculus and extends to the dorso medial corner of the anterior margin of the navicular, making it the most anterior aspect of the superficial deltoid ligaments. https://pubmed.ncbi.nlm.nih.gov/24740670/

🟧 Tibiospring ligament: originates from the anterior segment of the anterior colliculus and travels plantar to insert on the superior border of the superomedial calcaneo-navicular ligament. This ligament has also been described as tibioligamentous fascicle. https://pubmed.ncbi.nlm.nih.gov/33990250/

🟧 Superficial posterior tibiotalar: originates from the posterior-medial part of the anterior colliculus and the medial surface of the posterior colliculus and inserts on the posteromedial talus. https://www.tandfonline.com/doi/abs/10.3109/17453677908989759

🟩 Tibiocalcaneal ligament: originates from the medial aspect of the anterior colliculus of the medial malleolus and inserts on the medial border of the sustentaculum tali of the talus and the superomedial calcaneonavicular ligament.

📌 The superficial ligaments provide resistance against valgus and external rotation of talus in the tibiotalar joint. https://www.sciencedirect.com/science/article/pii/S1060187209001233

The deep layer consists of the following ligaments:

🟫 Posterior tibiotalar ligament: originates from the intercollicular sulcus, the entire anterior surface of the posterior colliculus, and the upper segment of the posterior surface of the anterior colliculus. The fibers divide into 2 bands with an intraarticular one reaching the posteromedial tubercle of the talus and an extrasynovial one inserting into the talus posteriorly. https://pubmed.ncbi.nlm.nih.gov/33990250/

🟦 Anterior tibiotalar ligament: originates from the tip of the anterior colliculus and the anterior part of the intercollicular groove and inserts on the medial surface of the talus distal to the anterior segment of the comma-shaped talar articular surface. https://www.tandfonline.com/doi/abs/10.3109/17453677908989759

📌 The deep layer of the deltoid complex provides stabilization to the ankle joint against plantarflexion by preventing lateral displacement of the talus along with restraint against external rotation of the talus. https://pubmed.ncbi.nlm.nih.gov/8653970/

Figure 1: Illustration of the medial view of a left ankle showing the anatomical attachment sites of the ligamentous bands of the deltoid ligament and their spatial relationships to surgically relevant osseous landmarks: (A) distal center of the intercollicular groove, (B) posteromedial talar tubercle, (C) posterior point of the sustenaculum tali, (D) tuberosity of the navicular, and (E) anteromedial corner of the trochlea. https://pubmed.ncbi.nlm.nih.gov/24740670/

Coracoclavicular (CC) Ligament 🤓

👉 The coracoclavicular ligament comprises 2 stout ligaments (conoid and trapezoid) that span from the base of the superior coracoid to the undersurface of the clavicle (s. figure, https://link.springer.com/chapter/10.1007/978-3-030-23029-6_1)

👉 The trapezoid ligament is oriented from its origin on the coracoid in a superior, anterior, and lateral direction to its insertion on the clavicle. The trapezoid ligament has a broad insertion into the trapezoid line at the undersurface of the clavicle.

👉 The conoid origin is posterior and medial to the trapezoid from the coracoid angle and is oriented superiorly and medially toward its clavicular attachment. The conoid ligament inserts at a boney prominence on the undersurface of the clavicle posterior to the midline termed the conoid tubercle.
https://www.sciencedirect.com/science/article/pii/S1060187214000276

👉 The conoid and trapezoid function differently in resisting applied loads, depending on the direction of the applied load. After transection of the AC joint capsule, the conoid served as the primary restraint against anterior and superior loading, while the trapezoid functioned as the primary restraint against posterior loading. The relative orientation of these two ligaments has been suggested to account for their different functions. https://pubmed.ncbi.nlm.nih.gov/3949839/,

👉 The AC joint capsule is quite thin, but has considerable ligamentous support; there are four AC ligaments: superior, inferior, anterior and posterior. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295671/, https://pubmed.ncbi.nlm.nih.gov/3618870/, https://pubmed.ncbi.nlm.nih.gov/10983707/, https://pubmed.ncbi.nlm.nih.gov/20810076/

👉 Dawson et al. showed that the AC ligaments offer three times more stability in the anteroposterior plane than in the supero inferior plane. https://pubmed.ncbi.nlm.nih.gov/19111475/

👉 This finding agrees with the generally accepted principle that horizontal stability is mediated by the AC ligaments while vertical stability is mediated by the CC ligaments. https://pubmed.ncbi.nlm.nih.gov/25606549/.

👉 Load-to-failure test results confirmed that the conoid ligament fails first when a load is applied to the CC complex in a superior direction. https://pubmed.ncbi.nlm.nih.gov/14507296/, https://pubmed.ncbi.nlm.nih.gov/18375786/) The most common site of rupture was the midsubstance region, followed by rupture about the origin (https://pubmed.ncbi.nlm.nih.gov/12825527/, https://pubmed.ncbi.nlm.nih.gov/15572323/).

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