Collateral Ligament Pathology Workup
- Author: Michael P Nogalski, MD; Chief Editor: Thomas M DeBerardino, MD more...
Radiography and a physical examination usually suffice for grade 1 collateral ligament injuries in which the diagnosis appears straightforward. With more pain, larger effusions, or if the diagnosis is unclear, MRI may be of value. Examination findings may be more accurate with a repeat evaluation 2 weeks after the injury.
MRI is very sensitive and specific for MCL injuries; however, only a physical examination can quantitate or grade the injury. Meniscal, other ligamentous, patellofemoral, and possibly chondral injuries can be identified. In addition to a careful and thorough physical examination, grade 3 MCL injuries may be associated with other concomitant injuries, and if suspicion exists, MRI is helpful in evaluation.
In lateral collateral ligament injuries, plain radiographic findings may be normal or, in bony avulsions of the LCL, show a fibular head avulsion fracture. MRI is the optimal test to demonstrate the lateral structures. MRI can also be used to evaluate the other structures in the knee, such as the PCL, ACL, MCL, and menisci.
Examination under anesthesia has some value, especially in combined ligament injuries when evaluation of the knee would be painful and less accurate. Arthroscopy has little value in the evaluation of these specific injuries but does aid in the evaluation of associated ligamentous, chondral, and meniscal injuries.
In the posterolateral drawer test, the examiner supports the patient's foot and, with the knee first at 30 degrees and then at 90 degrees of flexion, places a posterolateral spin on the tibia by pushing laterally on the medial anterior tibia. Findings should ideally be compared with a normal opposite knee. The angle of the foot with respect to the midsagittal plane can be used to gauge the amount of spin that the tibia has with respect to each femur. If the posterolateral spin of the tibia is greatest at 30 degrees and minimal at 90 degrees, then a posterolateral complex injury is likely. If the posterolateral spin is larger at 90 degrees, then PCL injury associated with a lateral complex injury is likely.
In the external recurvatum test, both legs are raised off the examination table with the examiner grasping the great toe while the patient is supine. If the tibial tubercle rotates outward and the knee goes into recurvatum, laxity of the posterolateral corner is present. Comparison with the opposite lower extremity can help identify normal versus abnormal rotation and recurvatum.
The posterolateral spin test at 30 and 90 degrees uses the same principle as the posterolateral spin test above but uses the thigh-foot angle, as measured with an external rotation on the tibia exerted on the feet with the knees at 30 and 90 degrees. Having an assistant hold the knees together and performing this test with the patient supine is helpful. The patient is asked to place his or her knees at positions of 30 and 90 degrees as set by the examiner. With an assistant holding the knees together, the thigh-foot angle is assessed after exerting an external rotation force on both feet simultaneously. Side-to-side differences of greater than 10 degrees are thought to be significant. Significantly increased external rotation at 30 degrees indicates a posterolateral complex injury. If the spin is also increased at 90 degrees, then likely both the PCL and posterolateral complex are injured.
Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc. 2006 Jun. 14(2):84-90. [Medline].
Wilson WT, Deakin AH, Payne AP, Picard F, Wearing SC. Comparative Analysis of the Structural Properties of the Collateral Ligaments of the Human Knee. J Orthop Sports Phys Ther. 2011 Oct 25. [Medline].
Roach CJ, Haley CA, Cameron KL, Pallis M, Svoboda SJ, Owens BD. The epidemiology of medial collateral ligament sprains in young athletes. Am J Sports Med. 2014 May. 42(5):1103-9. [Medline].
Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-2010/2011. Med Sci Sports Exerc. 2013 Mar. 45(3):462-9. [Medline]. [Full Text].
Liu F, Gadikota HR, Kozánek M, Hosseini A, Yue B, Gill TJ, et al. In vivo length patterns of the medial collateral ligament during the stance phase of gait. Knee Surg Sports Traumatol Arthrosc. 2011 May. 19(5):719-27. [Medline]. [Full Text].
Kitayama S, Onodera S, Kondo E, Kobayashi T, Miyatake S, Kitamura N, et al. Deficiency of macrophage migration inhibitory factor gene delays healing of the medial collateral ligament: a biomechanical and biological study. J Biomech. 2011 Feb 3. 44(3):494-500. [Medline].
Grana WA, Janssen T. Lateral ligament injury of the knee. Orthopedics. 1987 Jul. 10(7):1039-44. [Medline].
Baker CL, Liu SH. Collateral ligament injuries of the knee: operative and non-operative approaches. In: Fu FH, et al, eds. Knee Surgery. Baltimore, Md:. Lippincott Williams & Wilkins. 1994.
Griffin LY. Orthopedic Knowledge Update-Sports Medicine. Rosemont, Ill:. American Academy of Orthopedic Surgeons. 1994.
McDougall JJ, Yeung G, Leonard CA, et al. Adaptation of post-traumatic angiogenesis in the rabbit knee by apposition of torn ligament ends. J Orthop Res. 2000 Jul. 18(4):663-70. [Medline].
Lyon RM, Akeson WH, Amiel D, et al. Ultrastructural differences between the cells of the medical collateral and the anterior cruciate ligaments. Clin Orthop. 1991 Nov. (272):279-86. [Medline].
Woo SL, Chan SS, Yamaji T. Biomechanics of knee ligament healing, repair and reconstruction. J Biomech. 1997 May. 30(5):431-9. [Medline].
Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983 Mar. 65(3):323-9. [Medline].
Inoue M, McGurk-Burleson E, Hollis JM, et al. Treatment of the medial collateral ligament injury. I: The importance of anterior cruciate ligament on the varus-valgus knee laxity. Am J Sports Med. 1987 Jan-Feb. 15(1):15-21. [Medline].
Rettig A. Medial and lateral ligament injuries. In: Scott W, ed. Ligament and Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, Mo:. Mosby. 1991.
Shelbourne KD, Porter DA. Anterior cruciate ligament-medial collateral ligament injury: nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction. A preliminary report. Am J Sports Med. 1992 May-Jun. 20(3):283-6. [Medline].
DeHaven KE. Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med. 1980 Jan-Feb. 8(1):9-14. [Medline].
Hunter SC, Marascalco R, Hughston JC. Disruption of the vastus medialis obliquus with medial knee ligament injuries. Am J Sports Med. 1983 Nov-Dec. 11(6):427-31. [Medline].
Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop. 1978 May. (132):206-18. [Medline].
Hughston JC, Andrews JR, Cross MJ. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976 Mar. 58(2):159-72. [Medline].
Grood ES, Noyes FR, Butler DL, Suntay WJ. Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. J Bone Joint Surg Am. 1981 Oct. 63(8):1257-69. [Medline].
Reider B, Sathy MR, Talkington J. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med. 1994 Jul-Aug. 22(4):470-7. [Medline].
Ross G, Chapman AW, Newberg AR, Scheller AD Jr. Magnetic resonance imaging for the evaluation of acute posterolateral complex injuries of the knee. Am J Sports Med. 1997 Jul-Aug. 25(4):444-8. [Medline].
Miyamoto RG, Bosco JA, Sherman OH. Treatment of medial collateral ligament injuries. J Am Acad Orthop Surg. 2009 Mar. 17(3):152-61. [Medline].
Ranawat A, Baker CL 3rd, Henry S, Harner CD. Posterolateral corner injury of the knee: evaluation and management. J Am Acad Orthop Surg. 2008 Sep. 16(9):506-18. [Medline].
Ricchetti ET, Sennett BJ, Huffman GR. Acute and chronic management of posterolateral corner injuries of the knee. Orthopedics. 2008 May. 31(5):479-88; quiz 489-90. [Medline].
Swenson TM, Harner CD. Knee ligament and meniscal injuries. Current concepts. Orthop Clin North Am. 1995 Jul. 26(3):529-46. [Medline].
Elsasser JC, Reynolds FC, Omohundro JR. The non-operative treatment of collateral ligaments of the knee in professional football players. J Bone Joint Surg. 1974. 56A:1185-1190.
Jokl P, Kaplan N, Stovell P, et al. Non-operative treatment of severe injuries to the medial and anterior cruciate ligaments of the knee. J Bone Joint Surg Am. 1984 Jun. 66(5):741-4. [Medline].
Lind M, Jakobsen BW, Lund B, Hansen MS, Abdallah O, Christiansen SE. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med. 2009 Mar 31. [Medline].
Clancy WG. Repair and reconstruction of the posterior cruciate ligament. In: Chapman MW, ed. Operative Orthopedics. Philadelphia, Pa:. WB Saunders Co. 1993.
Noyes FR, Barber-Westin SD. Reconstruction of the lateral collateral ligament of the knee with patellar tendon allograft. Report of a new technique in combined ligament injuries. Am J Sports Med. 1999 Mar-Apr. 27(2):269-70. [Medline].
Schechinger SJ, Levy BA, Dajani KA, Shah JP, Herrera DA, Marx RG. Achilles tendon allograft reconstruction of the fibular collateral ligament and posterolateral corner. Arthroscopy. 2009 Mar. 25(3):232-42. [Medline].
Kitamura N, Ogawa M, Kondo E, Kitayama S, Tohyama H, Yasuda K. A novel medial collateral ligament reconstruction procedure using semitendinosus tendon autograft in patients with multiligamentous knee injuries: clinical outcomes. Am J Sports Med. 2013 Jun. 41(6):1274-81. [Medline].
Harner CD, Irrgang JJ, Paul J, et al. Loss of motion following anterior cruciate ligament reconstruction. Am J Sports Med. 1992. 20:507-515.