eMedicine Specialties > Radiology > Musculoskeletal

Knee, Collateral Ligament Injuries (MRI)

Alex Freitas, MD, Assistant Professor UCLA Department of Radiology, Assistant Chief of Musculoskeletal Radiology, Renaissance Imaging Medical Associates

Updated: Dec 15, 2008

Introduction

Grade I medial collateral ligament tear with surrounding intermediate signal consistent with edema (straight arrows) on a coronal proton density sequence. Note the normal thickness and signal of the medial collateral ligament and continued close apposition to the femoral and tibial cortices.

Corresponding fast spin-echo inversion recovery image demonstrates surrounding edema (white arrows).

Background

MRI has revolutionized the evaluation of musculoskeletal soft tissue injuries. Nowhere is this more evident than in the evaluation of internal derangements of the knee. MRI is an accurate and cost-effective means of evaluating a wide spectrum of knee injuries, ranging from cruciate-collateral ligament injuries to cartilage deficiencies. For interpreting radiologists and clinicians, evaluation of an injured knee using MRI requires knowledge of the proper imaging techniques, normal and aberrant anatomy, and the clinical significance of detected abnormalities.¹

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Knee Injury and Magnetic Resonance Imaging (MRI).

Pathophysiology

Both the medial and lateral supporting structures of the knee are complex arrangements of ligaments, fascial layers, and tendon insertions. For this reason, injuries may range from isolated single-element injuries to combined multiple-element injuries. In addition, injuries may range from strains or partial tears to complete disruptions.

Isolated medial collateral ligament (MCL) injuries result from a valgus stress without a rotary component. Biomechanical studies indicate that the primary function of the MCL as a limit to valgus is crucial only during flexion; therefore, most injuries occur when the knee is flexed.

MCL tears rarely are isolated. More commonly, they are associated with other soft tissue injuries of the knee, such as anterior cruciate ligament (ACL) tears and medial meniscal tears (O'Donoghue's unhappy triad). Of complete MCL tears, 73% are associated with additional significant knee injuries, usually an ACL tear. Other associations include meniscocapsular separations and bone bruises.

Isolated injuries of the lateral collateral ligament (LCL) result from the placement of an abnormal varus stress on an internally rotated knee. Posterior lateral corner (PLC) injuries may occur as a result of both direct and nondirect forces that cause hyperextension or hyperextension and external rotation. Similar to MCL tears, isolated injuries of the LCL are uncommon and typically occur in association with ACL or posterior cruciate ligament (PCL) tears. Injuries of the lateral compartment are complex, usually with injuries to multiple components; they are often more disabling than injuries of the medial structures because of the greater forces to which lateral structures are subjected during normal gait.²

The grading system for classifying both MCL and LCL tears is the same as that used for other ligaments evaluated by MRI as follows:

• Grade 1 — Microscopic tears
• Grade 2 — Partial tears
• Grade 3 — Complete tears

Frequency

United States

The medial collateral ligament (MCL) is the weakest of the 3 primary stabilizers of the knee (ACL, LCL, MCL); therefore, it is injured most commonly. Disruption of the MCL has been reported in as many as 61% of skiing injuries; it is reported to occur commonly as a result of clipping during football games (in clipping, one football players blocks an opponent from behind).

Injury of the LCL occurs significantly less commonly than injury of the MCL.

Mortality/Morbidity

Medial collateral ligament (MCL) tears are not associated with significant morbidity. Most MCL tears heal uneventfully with functional rehabilitation.

Chronic LCL and PLC tears can result in chronic instability, leading to buckling into hyperextension and subsequent injuries to additional ligaments. LCL and PLC instability eventually results in degenerative changes of the joint.

Anatomy

The medical collateral ligament (MCL) is a ligament measuring approximately 8-11 cm long by 10-15 mm wide. The MCL arises 5 cm above the joint from the medial femoral epicondyle and inserts 6-7 cm below the joint on the medial tibial metaphysis. Its insertion onto the tibia is covered by the muscle group of the pes anserinus. The MCL is considered to be a composition of the 2 deepest layers of the 3 layers forming the medial supporting structures of the knee.

The 3 layers include (1) layer I, or the superficial layer, consisting of crural fascia, (2) layer II, or the intermediate layer, consisting of what classically is considered the superficial MCL, and (3) layer III, or the deep layer, consisting of the medial capsular ligament and meniscofemoral/meniscotibial ligaments. Fibrofatty tissue and a small bursa are interposed between layers II and III. Layers I and II fuse anteriorly to form the medial patellar retinaculum. Layers II and III fuse posteriorly to form the posterior oblique ligament (POL) component of the MCL (see top Image below and Image 1 in Multimedia). The MCL has 2 components including an anterior vertical component (layer II) and a POL component (fused layers II and III; see bottom Image below and Image 2 in Multimedia).

Coronal drawing shows the 3 layers of the medial supporting structures of the knee, including the medial collateral ligament.

Sagittal drawing of the medial supporting structures of the knee shows the anterior vertical and posterior oblique ligament components of the medial collateral ligament and their relationship to the pes anserinus and semimembranosus tendon.

The lateral supporting structures of the knee may be subdivided further into more functionally anatomic divisions that include a group of structures commonly and collectively referred to as the PLC or posterior lateral arcuate complex. The PLC includes the LCL, the popliteus tendon, the lateral head of the gastrocnemius, the arcuate ligament and, occasionally, the popliteofibular and fabellofibular ligaments.

The popliteus muscle/tendon arises from the posterior aspect of the tibia, extends laterally and superiorly deep to the LCL, traverses the popliteal hiatus, and inserts onto the popliteal groove of the lateral femoral condyle (see top Image below and Image 3 in Multimedia). The arcuate ligament is a Y-shaped thickening of the capsule in which the medial limb curves over the popliteus muscle and tendon to join the oblique popliteal ligament, and the lateral limb ascends to blend with the capsule near the lateral gastrocnemius muscle insertion (see bottom Image below and Image 4 in Multimedia).

Sagittal drawing of the lateral supporting structures of the knee, including the lateral collateral ligament.

Coronal drawing of the lateral supporting structures of the knee demonstrating the arcuate ligament's relationship to the popliteus muscle and the lateral collateral ligament.

Presentation

Individuals with medial collateral ligament (MCL) tears often report feeling a pop after a direct lateral blow to the knee. Clinicians should suspect concomitant cruciate ligament tears if the mechanism of injury was indirect. MCL tears may be classified according to physical examination.

• Grade I tears are not characterized by laxity, only by tenderness upon palpation of the MCL.
• In grade II tears, some laxity may be demonstrated upon valgus stress, but the endpoint is firm.
• In grade III tears, an increase in laxity is demonstrated and there is no identifiable endpoint.

Grade I, grade II, and isolated grade III tears are treated nonsurgically; treatment is limited to functional rehabilitation. Grade III tears with associated ACL tears are treated surgically by repairing the ACL only.

Individuals with LCL tears rarely report feeling a pop, because their symptoms usually are dominated by associated and more severe injuries. A hyperextension varus stress is the most common mechanism of isolated LCL tears, whereas hyperextension and external rotation is a common mechanism of PLC injuries. Patients present with instability, buckling into hyperextension, and posterior lateral pain. The LCL is a completely extracapsular structure; therefore, isolated injuries are associated with little swelling and no effusions. Treatment of injuries to the lateral supporting structures remains controversial, but surgical reconstruction is favored in athletes with significant instability or if an avulsion fracture of the fibular head is present.

Preferred Examination

MRI is the preferred modality for examining both MCL and LCL injuries. Detection of associated internal derangements of the knee makes MRI superior to ultrasonographic imaging; however, with isolated injuries, the accuracy of ultrasound is comparable to that of MRI.

Limitations of Techniques

The usual limitations of MRI pertain to MRI evaluation of the MCL and LCL. The usefulness of MRI is limited in patients with claustrophobia; in patients who are obese; in patients who have a pacemaker; and by the presence of artifacts created by nearby orthopedic hardware. The use of open MRI units, as well as dedicated extremity units, has decreased the number of patients for whom MRI cannot be used because of claustrophobia or obesity.

Differential Diagnoses

Other Problems to Be Considered

MCL tear
Medial meniscal tears
Medial tibial plateau or medial femoral condyle bone bruises/fractures
Pes anserinus bursitis/avulsions
Medial plica syndrome
MRI differential diagnosis (limited to interlayer [between layers II and III] bursitis)

LCL or PLC tear
Lateral meniscal tears
Lateral tibial plateau or medial femoral condyle bone bruises/fractures
Iliotibial band syndrome
MRI differential diagnosis (limited to iliotibial band syndrome)

Radiography

Findings

Calcification, particularly in its proximal portion, may be seen in persons with chronic tears of the MCL; it is termed Pellegrini-Stieda disease (see Image below and Image 5 in Multimedia).

Calcification of the proximal portion of the medial collateral ligament (arrow) consistent with a chronic medial collateral ligament tear and Pellegrini-Stieda disease.

Fibular head avulsion fracture (arrow).

Lateral, tibial-metaphyseal, capsular avulsion fracture, termed a Segond fracture (white arrow). Segond fractures are highly associated with anterior cruciate ligament tears. Note the avulsion of the tibial spines (black arrow), indicating an anterior cruciate ligament injury.

Computed Tomography

Findings

Findings similar to those observed on plain radiographs may be seen on CT. In addition, soft tissue injuries of the MCL and LCL may be detected, although not with the accuracy or contrast resolution of MRI.

Magnetic Resonance Imaging

Findings

Routine MRI sequences for the evaluation of the knee vary among institutions and scanners. The knee should be imaged in all 3 planes — sagittal, coronal, and axial. At a minimum, scans should include sequences to define anatomy, edema, and cartilage.^{3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18}

Sequences for anatomic definition include spin-echo (SE) and fast spin echo (FSE) proton density (PD) sequences. Fluid-sensitive sequences, such as SE/FSE PD fat-suppressed or short tau inversion recovery (STIR), detect edema. Cartilage may be characterized by fat suppressed FSE PD sequences, fat-suppressed gradient-echo (GRE) sequences, or spoiled gradient fat-suppressed sequences.

Coronal images with anatomy-defining and fluid-sensitive sequences optimally demonstrate the medial and lateral supporting structures. Additional useful information may be gleaned from sagittal and axial images of these structures.

Both the anterior vertical component and the posterior oblique component of the MCL are depicted consistently on coronal T1-weighted or SE/FSE T2-weighted sequences. The MCL is seen as a thin, taut, well-defined, low T1/T2-signal structure extending from the medial femoral epicondyle to the medial tibial metaphysis. Surrounded by high T1-weighted signal fibrofatty tissue throughout its full extent, it is parallel to and closely applied to the medial femoral epicondyle and medial tibial metaphysis. The anterior vertical or superficial component is best visualized at the level of the intercondylar notch in the vicinity of the distal insertion of the ACL (see Image below and Image 8 in Multimedia).

Proton density coronal image shows the anterior vertical portion of the medial collateral ligament as a thin, taut, well-defined, low-signal structure extending from the medial femoral epicondyle to the medial tibial metaphysis (straight arrows). Distal insertion of the anterior cruciate ligament is visualized (curved arrow).

• With grade I, or microscopic ligamentous tears, an intact ligament of normal thickness surrounded to a variable degree by intermediate T1-weighted and high T2-weighted signals (indicative of surrounding edema) is seen. The ligament remains closely applied to the underlying cortical bone (see Images below and Images 9-10 in Multimedia).

Grade I medial collateral ligament tear with surrounding intermediate signal consistent with edema (straight arrows) on a coronal proton density sequence. Note the normal thickness and signal of the medial collateral ligament and continued close apposition to the femoral and tibial cortices.

Corresponding fast spin-echo inversion recovery image demonstrates surrounding edema (white arrows).

• With grade II tears, thickening and/or partial disruption of the fibers of the MCL is demonstrated, along with an increase in the amount of surrounding intermediate T1-weighted and high T2-weighted signals, indicative of increased edema and concomitant hemorrhage (see Images below and Images 11-12 in Multimedia).

Grade II medial collateral ligament tear seen on a coronal proton density image shows slight thickening of the medial collateral ligament and separation from the underlying cortices (arrows).

Corresponding coronal fast spin-echo inversion recovery image shows surrounding edema (small arrows). Note bone bruise of the lateral tibial plateau (large arrow), another sequela of the valgus stress.

• With grade III tears, complete disruption of the ligament with corresponding surrounding hemorrhage and edema is seen (see Images below and Images 13-15 in Multimedia).

Grade III medial collateral ligament tear on a coronal fast spin-echo T2-weighted image demonstrates a disrupted ligament that is thickened and retracted, with surrounding edema (black arrow).

Acute grade III tear with a folded ligament (arrow) and surrounding edema on a coronal proton density image.

Corresponding coronal fast spin-echo inversion recovery image.

Distinguishing between MRI grade II and grade III tears is difficult. Clinical evaluation of the presence (grade II) or absence (grade III) of an end point to valgus laxity is helpful. As discussed earlier, the presence of a concomitant ACL tear is suggestive of a complete disruption of the MCL.

A chronic MCL tear is seen as an ill-defined, thickened ligament with both low T1-weighted and T2-weighted signals. Occasionally, the MCL ossifies, and normal bone marrow signal may be seen within its proximal portion (see top Image below and Image 16 in Multimedia). With healing of subacute tears, a thickened low T1/T2-signal ligament is demonstrated; the ligament reaches approximately 50% of its original strength at 12 months (see lower Image below and Image 17 in Multimedia).

Coronal proton density image demonstrating ossification of the proximal portion of the medial collateral ligament, as evidenced by normal bone marrow signal within (arrow).

MRI 7 months following functional rehabilitation demonstrating a thickened scarred medial collateral ligament without surrounding edema.

Coronal proton density image demonstrating the lateral collateral ligament in its entirety, from the femoral condyle origin to the fibular head insertion.

Peripheral sagittal proton density image demonstrates the lateral collateral ligament as an obliquely oriented low-signal structure (white arrows). Note its insertion onto the fibular head conjointly with the biceps femoris tendon (black arrow).

Acute tear of the proximal portion of the lateral collateral ligament is seen on this coronal proton density image (white arrow). Note the associated grade II medial collateral ligament tear (black arrows).

Corresponding coronal fast spin-echo inversion recovery image. Note the relative lack of accumulated edema/free fluid around the lateral collateral ligament tear, as compared with the associated grade II medial collateral ligament tear.

The lateral collateral ligament is lax and its fibers are interrupted at its origin (white arrow) on this coronal fast spin-echo T2-weighted image. Note the associated anterior cruciate tear (black arrow).

Chronic lateral collateral ligament tear appearing as a thickened low-signal ligament on coronal fast spin-echo T2-weighted image (arrowheads).

Degree of Confidence

The degree of confidence is high with MRI of tears of the collateral ligaments and rises with increasing grade of the tear. A prospective study of normal knees and knees with surgically verified grade III LCL injuries demonstrated a sensitivity, specificity, and accuracy of 94.4%, 100%, and 95%, respectively. The sensitivity, specificity, and accuracy of MRI for MCL injuries are less well established because of the nonsurgical nature of the injury but may be assumed to be similar to those of the LCL.

False Positives/Negatives

Loose high T1-weighted areolar tissue interposed between the 2 layers of the MCL is a normal finding that may mimic disease.

Ultrasonography

Findings

The normal MCL appears as two parallel hyperechoic bands with loose hypoechoic areolar tissue imposed between them. Its thickness varies from approximately 2-4 mm along its length in the average individual.^19,20

An MCL tear appears as a thickened ligament with decreased echogenicity. A complete disruption appears as a discontinuity in the ligament.

The normal LCL appears as a single hyperechoic band just deep to the biceps femoris tendon. Similarly, tears appear as a discontinuity in the ligament or as thickening and loss of echogenicity.

Degree of Confidence

Sonography is approximately 94% sensitive for MCL tears.

Multimedia

Media file 1: Coronal drawing shows the 3 layers of the medial supporting structures of the knee, including the medial collateral ligament.

Media file 2: Sagittal drawing of the medial supporting structures of the knee shows the anterior vertical and posterior oblique ligament components of the medial collateral ligament and their relationship to the pes anserinus and semimembranosus tendon.

Media file 3: Sagittal drawing of the lateral supporting structures of the knee, including the lateral collateral ligament.

Media file 4: Coronal drawing of the lateral supporting structures of the knee demonstrating the arcuate ligament's relationship to the popliteus muscle and the lateral collateral ligament.

Media file 5: Calcification of the proximal portion of the medial collateral ligament (arrow) consistent with a chronic medial collateral ligament tear and Pellegrini-Stieda disease.

Media file 6: Fibular head avulsion fracture (arrow).

Media file 7: Lateral, tibial-metaphyseal, capsular avulsion fracture, termed a Segond fracture (white arrow). Segond fractures are highly associated with anterior cruciate ligament tears. Note the avulsion of the tibial spines (black arrow), indicating an anterior cruciate ligament injury.

Media file 8: Proton density coronal image shows the anterior vertical portion of the medial collateral ligament as a thin, taut, well-defined, low-signal structure extending from the medial femoral epicondyle to the medial tibial metaphysis (straight arrows). Distal insertion of the anterior cruciate ligament is visualized (curved arrow).

Media file 9: Grade I medial collateral ligament tear with surrounding intermediate signal consistent with edema (straight arrows) on a coronal proton density sequence. Note the normal thickness and signal of the medial collateral ligament and continued close apposition to the femoral and tibial cortices.

Media file 10: Corresponding fast spin-echo inversion recovery image demonstrates surrounding edema (white arrows).

Media file 11: Grade II medial collateral ligament tear seen on a coronal proton density image shows slight thickening of the medial collateral ligament and separation from the underlying cortices (arrows).

Media file 12: Corresponding coronal fast spin-echo inversion recovery image shows surrounding edema (small arrows). Note bone bruise of the lateral tibial plateau (large arrow), another sequela of the valgus stress.

Media file 13: Grade III medial collateral ligament tear on a coronal fast spin-echo T2-weighted image demonstrates a disrupted ligament that is thickened and retracted, with surrounding edema (black arrow).

Media file 14: Acute grade III tear with a folded ligament (arrow) and surrounding edema on a coronal proton density image.

Media file 15: Corresponding coronal fast spin-echo inversion recovery image.

Media file 16: Coronal proton density image demonstrating ossification of the proximal portion of the medial collateral ligament, as evidenced by normal bone marrow signal within (arrow).

Media file 17: MRI 7 months following functional rehabilitation demonstrating a thickened scarred medial collateral ligament without surrounding edema.

Media file 18: Coronal proton density image demonstrating the lateral collateral ligament in its entirety, from the femoral condyle origin to the fibular head insertion.

Media file 19: Peripheral sagittal proton density image demonstrates the lateral collateral ligament as an obliquely oriented low-signal structure (white arrows). Note its insertion onto the fibular head conjointly with the biceps femoris tendon (black arrow).

Media file 20: Acute tear of the proximal portion of the lateral collateral ligament is seen on this coronal proton density image (white arrow). Note the associated grade II medial collateral ligament tear (black arrows).

Media file 21: Corresponding coronal fast spin-echo inversion recovery image. Note the relative lack of accumulated edema/free fluid around the lateral collateral ligament tear, as compared with the associated grade II medial collateral ligament tear.

Media file 22: The lateral collateral ligament is lax and its fibers are interrupted at its origin (white arrow) on this coronal fast spin-echo T2-weighted image. Note the associated anterior cruciate tear (black arrow).

Media file 23: Coronal (A), sagittal (B), proton density, and coronal fast spin-echo inversion recovery (C) images demonstrating an acute fibular head avulsion fracture (arrows; same patient as Image 5).

Media file 24: Chronic lateral collateral ligament tear appearing as a thickened low-signal ligament on coronal fast spin-echo T2-weighted image (arrowheads).

References

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15. Ikuma H, Abe N, Uchida Y, Furumatsu T, Fujiwara K, Nishida K, et al. Novel magnetic resonance imaging evaluation for valgus instability of the knee caused by medial collateral ligament injury. Acta Med Okayama. Jun 2008;62(3):185-91. [Medline].

16. Bergin D, Hochberg H, Zoga AC, Qazi N, Parker L, Morrison WB. Indirect soft-tissue and osseous signs on knee MRI of surgically proven meniscal tears. AJR Am J Roentgenol. Jul 2008;191(1):86-92. [Medline].

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Keywords

knee collateral ligament injury, collateral ligament injury of knee, medial collateral ligament injury of knee, knee medial collateral ligament injury, medial collateral ligament, MCL, lateral collateral ligament, LCL, anterior cruciate ligament, ACL, medial supporting structures of the knee, lateral supporting structures of the knee, posterior lateral corner

Contributor Information and Disclosures

Author

Alex Freitas, MD, Assistant Professor UCLA Department of Radiology, Assistant Chief of Musculoskeletal Radiology, Renaissance Imaging Medical Associates
Alex Freitas, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, Radiological Society of North America, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Medical Editor

David S Levey, MD, PhD, Orthopedic/Spine MRI TeleRadiologist, Radsource, LLC
David S Levey, MD, PhD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Javier Beltran, MD, Chair, Department of Radiology, Maimonides Medical Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

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