eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Medial Collateral and Lateral Collateral Ligament Injury

Author: Adam B Agranoff, MD, Physiatrist and Partner, Chelsea Back Care, Chelsea Community Hospital
Coauthor(s): Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center
Contributor Information and Disclosures

Updated: Jul 9, 2008

Introduction

Background

Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries of the knee are common. In fact, injury to the MCL is the most common ligamentous knee injury.

The MCL and LCL provide restraint to valgus and varus angulation of the knee, respectively. The MCL has superficial and deep components. The superficial MCL fibers attach proximally to the medial femoral epicondyle and distally to the medial aspect of the tibia, approximately 4 cm distal to the joint line. The deep MCL fibers originate from the medial joint capsule and are attached to the medial meniscus.

The LCL is part of a complex of ligaments collectively named the posterolateral corner (PC). The structures in the PC include the LCL, the popliteofibular ligament, the popliteus ligament, the arcuate ligament, the short lateral ligament, and the posterolateral joint capsule. The LCL is separated from the lateral meniscus by a fat pad (see Image 1).1,2,3,4

Related eMedicine topics:
Collateral Ligament Pathology, Knee
Knee, Collateral Ligament Injuries (MRI)
Lateral Collateral Knee Ligament Injury
Medial Collateral Knee Ligament Injury

Related Medscape topic:
Resource Center Joint Disorders

Pathophysiology

Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries are caused primarily by valgus and varus stress (respectively) to the knee joint. Injuries also can occur to both ligaments with excessive lateral rotation of the knee.

Frequency

United States

The annual incidence of acute knee injury in the United States is estimated to be 300 cases per 100,000 population. Collateral ligament injuries account for 25% of patients presenting to emergency rooms with acute knee injury. Peak incidence of collateral ligament injuries occurs in adults aged 20-34 years. The National Collegiate Athletic Association (NCAA) injury surveillance system reported 2.1 medial or lateral collateral injuries per 1000 player exposures in games across all NCAA sports over 1 year.5 Even noncontact sports, such as gymnastics and swimming, can lead to collateral ligament injuries.6

Mortality/Morbidity

Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries can in most individuals be treated successfully with conservative methods. Severe injuries may require surgical intervention and tend to have good outcomes.2,7

Race

There is no known racial predilection for medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries.

Sex

Unlike anterior cruciate ligament (ACL) injuries, which occur at a higher rate in women, medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries occur at equal rates in men and women.6,8

Related eMedicine articles:
Anterior Cruciate Ligament Pathology
Anterior Cruciate Ligament Injury [Physical Medicine and Rehabilitation]
Anterior Cruciate Ligament Injury [Sports Medicine]
Knee, Anterior Cruciate Ligament Injuries (MRI)

Age

Age patterns for medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries are bimodal, with the highest incidence rates found in individuals aged 20-34 years and in persons aged 55-65 years. Nonetheless, MCL and LCL injuries can occur at any age.

Clinical

History

Listen to the patient's description of the injury event. The force vector of injury to the knee indicates the most likely site of pathology.9 For example, a football player who complains of medial knee pain after a valgus stress on the knee is likely to have an injury to the medial collateral ligament (MCL). Have the patient use the uninjured knee to explain precisely what he/she was doing when the incident occurred.

  • MCL injury
    • Patients commonly have had recent excessive valgus force applied to a partially flexed knee (eg, a clipping injury in football). A common triad of injury (particularly in athletes) when a valgus force is applied to the knee involves injury to the MCL, the medial meniscus, and the anterior cruciate ligament.
    • Most patients are able to continue ambulating after an acute injury.
    • Pain and stiffness are localized to the medial knee.
    • Erythema may appear after several days.
    • The location of pain and swelling can be good indicators of which structure(s) may be damaged in the knee.
    • Instability or mechanical symptoms (eg, a locking or popping sensation) are uncommon.
  • Lateral collateral ligament (LCL) injury
    • The patient commonly reports a history of varus force applied to the knee.
    • Most patients are able to continue ambulating after an acute injury.
    • Pain and stiffness are localized to the lateral knee.
    • Erythema may appear after several days.
    • Swelling is often present.
    • Instability or mechanical symptoms (eg, a locking or popping sensation) are uncommon.

Physical

Recognize that collateral ligament injuries often are seen in association with injury to other knee structures. A comprehensive musculoskeletal knee examination should be completed to direct further diagnostic testing and therapeutic interventions. A systematic review of the available literature revealed no articles that adequately assessed the diagnostic sensitivity and specificity of a physical examination in detecting medial and lateral collateral ligamentous injuries.

  • Medial collateral ligament (MCL) injury
    • Palpate with the knee in 25-30 º of flexion.
    • Tenderness may be noted anywhere along the course of the MCL.
    • Isolated tenderness at the proximal or distal insertion sites may indicate an avulsion-type injury.
    • Swelling often is present and should alert the examiner to possible intra-articular injury.
  • Lateral collateral ligament (LCL) injury
    • Palpate with the knee in 20 º of flexion.
    • Tenderness may be noted anywhere along the course of the LCL.
    • Isolated tenderness at the proximal or distal insertion sites may indicate an avulsion-type injury.
    • Swelling is common.
  • Evocative testing of collateral ligaments
    • Valgus stress testing of the MCL
      • The patient is in the supine position with the knee flexed 25-30 º. The examiner places one hand on the lateral knee and grasps the medial ankle with the other hand. Then the knee is abducted. Pain and excessive laxity indicate stretching or tearing of the MCL.
      • Perform the same technique as above with the knee extended. If excessive knee joint laxity and pain are still noted, injury to the anterior cruciate ligament also may be present.
    • Varus stress testing of the LCL
      • The patient is in the supine position with the knee flexed 20-25 º. The examiner places one hand on the medial knee and grasps the lateral ankle with other hand. The knee is adducted. Pain and excessive laxity indicate injury to the LCL.
      • Then perform the same technique as above with the knee extended. If pain and laxity are still present, injury to the posterior capsule may be present.
  • Injury severity
    • Grade I - Less than 5 cm laxity (partial tear)
    • Grade II - 5-10 cm laxity
    • Grade III - More than 10 cm laxity (complete tear)
  • Physical examination under general anesthesia may be indicated if the patient is guarding due to pain symptoms.

Causes

  • Injury to the medial collateral ligament (MCL) or lateral collateral ligament (LCL) may be caused by the following:
    • Trauma
      • Acute varus or valgus stress on the knee joint
      • Sports related (younger population)
      • Falls (elderly)
      • Other trauma
    • Overuse syndromes (for example, swimmers who use the breaststroke may repetitively stretch the MCL, leading to injury)

More on Medial Collateral and Lateral Collateral Ligament Injury

Overview: Medial Collateral and Lateral Collateral Ligament Injury
Differential Diagnoses & Workup: Medial Collateral and Lateral Collateral Ligament Injury
Treatment & Medication: Medial Collateral and Lateral Collateral Ligament Injury
Follow-up: Medial Collateral and Lateral Collateral Ligament Injury
Multimedia: Medial Collateral and Lateral Collateral Ligament Injury
References
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References

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  2. Swenson TM, Harner CD. Knee ligament and meniscal injuries. Current concepts. Orthop Clin North Am. Jul 1995;26(3):529-46. [Medline].

  3. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:783-812.

  4. Amiri S, Cooke D, Kim IY, et al. Mechanics of the passive knee joint. Part 2: interaction between the ligaments and the articular surfaces in guiding the joint motion. Proc Inst Mech Eng [H]. Nov 2007;221(8):821-32. [Medline].

  5. National Collegiate Athletic Association. NCAA Injury Surveillance System. 1999-2000;[Full Text].

  6. Yawn BP, Amadio P, Harmsen WS, et al. Isolated acute knee injuries in the general population. J Trauma. Apr 2000;48(4):716-23. [Medline].

  7. Quarles JD, Hosey RG. Medial and lateral collateral injuries: prognosis and treatment. Prim Care. Dec 2004;31(4):957-75, ix. [Medline].

  8. Dugan SA. Sports-related knee injuries in female athletes: what gives?. Am J Phys Med Rehabil. Feb 2005;84(2):122-30. [Medline].

  9. El-Dieb A, Yu JS, Huang GS, et al. Pathologic conditions of the ligaments and tendons of the knee. Radiol Clin North Am. Sep 2002;40(5):1061-79. [Medline].

  10. Pimentel L. Orthopedic trauma: office management of major joint injury. Med Clin North Am. Mar 2006;90(2):355-82. [Medline].

  11. Strayer RJ, Lang ES. Evidence-based emergency medicine/systematic review abstract. Does this patient have a torn meniscus or ligament of the knee?. Ann Emerg Med. May 2006;47(5):499-501. [Medline].

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  13. Beall DP, Googe JD, Moss JT, et al. Magnetic resonance imaging of the collateral ligaments and the anatomic quadrants of the knee. Radiol Clin North Am. Nov 2007;45(6):983-1002, vi. [Medline].

  14. Hastings DE. The non-operative management of collateral ligament injuries of the knee joint. Clin Orthop. Mar-Apr 1980;(147):22-8. [Medline].

  15. Bin SI, Nam TS. Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy. Oct 2007;23(10):1066-72. [Medline].

  16. Wahl CJ, Nicandri G. Single-Achilles allograft posterior cruciate ligament and medial collateral ligament reconstruction: a technique to avoid osseous tunnel intersection, improve construct stiffness, and save on allograft utilization. Arthroscopy. Apr 2008;24(4):486-9. [Medline].

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  18. Yoshiya S, Kuroda R, Mizuno K, et al. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med. Sep 2005;33(9):1380-5. [Medline].

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Further Reading

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Keywords

medial collateral ligament injury, lateral collateral ligament injury, MCL injury, LCL injury, tibial collateral ligament, fibular collateral ligament

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Contributor Information and Disclosures

Author

Adam B Agranoff, MD, Physiatrist and Partner, Chelsea Back Care, Chelsea Community Hospital
Adam B Agranoff, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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