Imaging of the Medial and Lateral Ligaments of the Knee

 

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ABSTRACT

The knee is an inherently unstable structure consisting of rounded femoral condyles articulating with a flat tibial plateau. Stability is provided by a complex system of intra-articular and extraarticular ligaments that resist anterior and posterior translation, abnormal tibial rotation, and varus and valgus stress. In this article, the anatomy and biomechanics of the medial and lateral stabilizers, as well as the mechanisms of injury, clinical examination, and radiographic and magnetic resonance imaging appearances of injury of these structures, are discussed.

REFERENCES

• 1 Warren L F, Marshall J L. The supporting structures and layers on the medial side of the knee: an anatomical analysis.  J Bone Joint Surg Am. 1979;  61(1) 56-62
  PubMedGoogle Scholar
• 2 Robinson J R, Sanchez-Ballester J, Bull A M, Thomas RdeW, Amis A A. The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee.  J Bone Joint Surg Br. 2004;  86(5) 674-681
  CrossrefPubMedGoogle Scholar
• 3 LaPrade R F, Engebretsen A H, Ly T V, Johansen S, Wentorf F A, Engebretsen L. The anatomy of the medial part of the knee.  J Bone Joint Surg Am. 2007;  89(9) 2000-2010
  CrossrefPubMedGoogle Scholar
• 4 De Maeseneer M, Shahabpour M, Van Roy F et al.. MR imaging of the medial collateral ligament bursa: findings in patients and anatomic data derived from cadavers.  AJR Am J Roentgenol. 2001;  177(4) 911-917
  PubMedGoogle Scholar
• 5 De Maeseneer M, Van Roy F, Lenchik L, Barbaix E, De Ridder F, Osteaux M. Three layers of the medial capsular and supporting structures of the knee: MR imaging-anatomic correlation.  Radiographics. 2000;  20(Spec No, Spec No) S83-S89
  CrossrefPubMedGoogle Scholar
• 6 Beltran J, Matityahu A, Hwang K et al.. The distal semimembranosus complex: normal MR anatomy, variants, biomechanics and pathology.  Skeletal Radiol. 2003;  32(8) 435-445
  CrossrefPubMedGoogle Scholar
• 7 Wymenga A B, Kats J J, Kooloos J, Hillen B. Surgical anatomy of the medial collateral ligament and the posteromedial capsule of the knee.  Knee Surg Sports Traumatol Arthrosc. 2006;  14(3) 229-234
  CrossrefPubMedGoogle Scholar
• 8 Mochizuki T, Akita K, Muneta T, Sato T. Pes anserinus: layered supportive structure on the medial side of the knee.  Clin Anat. 2004;  17(1) 50-54
  CrossrefPubMedGoogle Scholar
• 9 Robinson J R, Bull A M, Thomas R R, Amis A A. The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity.  Am J Sports Med. 2006;  34(11) 1815-1823
  CrossrefPubMedGoogle Scholar
• 10 Griffith C J, Wijdicks C A, LaPrade R F, Armitage B M, Johansen S, Engebretsen L. Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads.  Am J Sports Med. 2009;  37(1) 140-148
  PubMedGoogle Scholar
• 11 Petersen W, Loerch S, Schanz S, Raschke M, Zantop T. The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee.  Am J Sports Med. 2008;  36(3) 495-501
  CrossrefPubMedGoogle Scholar
• 12 Battaglia II M J, Lenhoff M W, Ehteshami J R et al.. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model.  Am J Sports Med. 2009;  37(2) 305-311
  CrossrefPubMedGoogle Scholar
• 13 Kurzweil P R, Kelley S T. Physical examination and imaging of the medial collateral ligament and posteromedial corner of the knee.  Sports Med Arthrosc. 2006;  14(2) 67-73
  CrossrefPubMedGoogle Scholar
• 14 Robinson J R, Bull AMJ, Amis A A. Structural properties of the medial collateral ligament complex of the human knee.  J Biomech. 2005;  38(5) 1067-1074
  CrossrefPubMedGoogle Scholar
• 15 Quinlan J F, Farrelly C, Kelly G, Eustace S. Co-existent medial collateral ligament injury following transient patellar dislocation—observations at MRI.  Br J Sports Med. 2008 November 19 (Epub ahead of print); 
  PubMedGoogle Scholar
• 16 Alioto R J, Browne J E, Barnthouse C D, Scott A R. Complete rupture of the distal semimembranosus complex in a professional athlete.  Clin Orthop Relat Res. 1997;  336(336) 162-165
  CrossrefPubMedGoogle Scholar
• 17 Kaplan P A, Gehl R H, Dussault R G, Anderson M W, Diduch D R. Bone contusions of the posterior lip of the medial tibial plateau (contrecoup injury) and associated internal derangements of the knee at MR imaging.  Radiology. 1999;  211(3) 747-753
  CrossrefPubMedGoogle Scholar
• 18 Sims W F, Jacobson K E. The posteromedial corner of the knee: medial-sided injury patterns revisited.  Am J Sports Med. 2004;  32(2) 337-345
  CrossrefPubMedGoogle Scholar
• 19 Fanelli G C, Harris J D. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee.  Sports Med Arthrosc. 2006;  14(2) 78-83
  CrossrefPubMedGoogle Scholar
• 20 Hall F M, Hochman M G. Medial Segond-type fracture: cortical avulsion off the medial tibial plateau associated with tears of the posterior cruciate ligament and medial meniscus.  Skeletal Radiol. 1997;  26(9) 553-555
  CrossrefPubMedGoogle Scholar
• 21 Escobedo E M, Mills W J, Hunter J C. The “reverse Segond” fracture: association with a tear of the posterior cruciate ligament and medial meniscus.  AJR Am J Roentgenol. 2002;  178(4) 979-983
  CrossrefPubMedGoogle Scholar
• 22 Yao L, Lee J K. Avulsion of the posteromedial tibial plateau by the semimembranosus tendon: diagnosis with MR imaging.  Radiology. 1989;  172(2) 513-514
  PubMedGoogle Scholar
• 23 Chan K K, Resnick D, Goodwin D, Seeger L L. Posteromedial tibial plateau injury including avulsion fracture of the semimembranous tendon insertion site: ancillary sign of anterior cruciate ligament tear at MR imaging.  Radiology. 1999;  211(3) 754-758
  PubMedGoogle Scholar
• 24 Vanek J. Posteromedial fracture of the tibial plateau is not an avulsion injury. A case report and experimental study.  J Bone Joint Surg Br. 1994;  76(2) 290-292
  PubMedGoogle Scholar
• 25 Yao L, Dungan D, Seeger L L. MR imaging of tibial collateral ligament injury: comparison with clinical examination.  Skeletal Radiol. 1994;  23(7) 521-524
  PubMedGoogle Scholar
• 26 Schweitzer M E, Tran D, Deely D M, Hume E L. Medial collateral ligament injuries: evaluation of multiple signs, prevalence and location of associated bone bruises, and assessment with MR imaging.  Radiology. 1995;  194(3) 825-829
  CrossrefPubMedGoogle Scholar
• 27 House C V, Connell D A, Saifuddin A. Posteromedial corner injuries of the knee.  Clin Radiol. 2007;  62(6) 539-546
  CrossrefPubMedGoogle Scholar
• 28 Rasenberg E I, Lemmens J A, van Kampen A et al.. Grading medial collateral ligament injury: comparison of MR imaging and instrumented valgus-varus laxity test-device. A prospective double-blind patient study.  Eur J Radiol. 1995;  21(1) 18-24
  CrossrefPubMedGoogle Scholar
• 29 Bergin D, Keogh C, O'Connell M et al.. Atraumatic medial collateral ligament oedema in medial compartment knee osteoarthritis.  Skeletal Radiol. 2002;  31(1) 14-18
  CrossrefPubMedGoogle Scholar
• 30 Niitsu M, Ikeda K, Iijima T, Ochiai N, Noguchi M, Itai Y. MR imaging of Pellegrini-Stieda disease.  Radiat Med. 1999;  17(6) 405-409
  PubMedGoogle Scholar
• 31 Miller T T, Gladden P, Staron R B, Henry J H, Feldman F. Posterolateral stabilizers of the knee: anatomy and injuries assessed with MR imaging.  AJR Am J Roentgenol. 1997;  169(6) 1641-1647
  PubMedGoogle Scholar
• 32 Harish S, O'Donnell P, Connell D, Saifuddin A. Imaging of the posterolateral corner of the knee.  Clin Radiol. 2006;  61(6) 457-466
  CrossrefPubMedGoogle Scholar
• 33 Stannard J P, Brown S L, Robinson J T, McGwin Jr G, Volgas D A. Reconstruction of the posterolateral corner of the knee.  Arthroscopy. 2005;  21(9) 1051-1059
  CrossrefPubMedGoogle Scholar
• 34 Raheem O, Philpott J, Ryan W, O'Brien M. Anatomical variations in the anatomy of the posterolateral corner of the knee.  Knee Surg Sports Traumatol Arthrosc. 2007;  15(7) 895-900
  CrossrefPubMedGoogle Scholar
• 35 Watanabe Y, Moriya H, Takahashi K et al.. Functional anatomy of the posterolateral structures of the knee.  Arthroscopy. 1993;  9(1) 57-62
  CrossrefPubMedGoogle Scholar
• 36 Maynard M J, Deng X, Wickiewicz T L, Warren R F. The popliteofibular ligament. Rediscovery of a key element in posterolateral stability.  Am J Sports Med. 1996;  24(3) 311-316
  CrossrefPubMedGoogle Scholar
• 37 Sudasna S, Harnsiriwattanagit K. The ligamentous structures of the posterolateral aspect of the knee.  Bull Hosp Jt Dis Orthop Inst. 1990;  50(1) 35-40
  PubMedGoogle Scholar
• 38 Seebacher J R, Inglis A E, Marshall J L, Warren R F. The structure of the posterolateral aspect of the knee.  J Bone Joint Surg Am. 1982;  64(4) 536-541
  PubMedGoogle Scholar
• 39 Hughston J C, Andrews J R, Cross M J, Moschi A. Classification of knee ligament instabilities. Part II. The lateral compartment.  J Bone Joint Surg Am. 1976;  58(2) 173-179
  PubMedGoogle Scholar
• 40 Bolog N, Hodler J. MR imaging of the posterolateral corner of the knee.  Skeletal Radiol. 2007;  36(8) 715-728
  CrossrefPubMedGoogle Scholar
• 41 Grood E S, Stowers S F, Noyes F R. Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures.  J Bone Joint Surg Am. 1988;  70(1) 88-97
  CrossrefPubMedGoogle Scholar
• 42 Gollehon D L, Torzilli P A, Warren R F. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study.  J Bone Joint Surg Am. 1987;  69(2) 233-242
  CrossrefPubMedGoogle Scholar
• 43 Veltri D M, Deng X H, Torzilli P A, Warren R F, Maynard M J. The role of the cruciate and posterolateral ligaments in stability of the knee. A biomechanical study.  Am J Sports Med. 1995;  23(4) 436-443
  CrossrefPubMedGoogle Scholar
• 44 Wroble R R, Grood E S, Cummings J S, Henderson J M, Noyes F R. The role of the lateral extraarticular restraints in the anterior cruciate ligament-deficient knee.  Am J Sports Med. 1993;  21(2) 257-262 discussion 263
  CrossrefPubMedGoogle Scholar
• 45 Veltri D M, Warren R F. Posterolateral instability of the knee.  J Bone Joint Surg Am. 1994;  76 460-472
  PubMedGoogle Scholar
• 46 Baker Jr C L, Norwood L A, Hughston J C. Acute posterolateral rotatory instability of the knee.  J Bone Joint Surg Am. 1983;  65(5) 614-618
  PubMedGoogle Scholar
• 47 Hughston J C, Jacobson K E. Chronic posterolateral rotatory instability of the knee.  J Bone Joint Surg Am. 1985;  67(3) 351-359
  PubMedGoogle Scholar
• 48 Yoon K H, Bae D K, Ha J H, Park S W. Anatomic reconstructive surgery for posterolateral instability of the knee.  Arthroscopy. 2006;  22(2) 159-165
  CrossrefPubMedGoogle Scholar
• 49 Theodorou D J, Theodorou S J, Fithian D C, Paxton L, Garelick D H, Resnick D. Posterolateral complex knee injuries: magnetic resonance imaging with surgical correlation.  Acta Radiol. 2005;  46(3) 297-305
  CrossrefPubMedGoogle Scholar
• 50 Malone A A, Dowd G S, Saifuddin A. Injuries of the posterior cruciate ligament and posterolateral corner of the knee.  Injury. 2006;  37(6) 485-501
  CrossrefPubMedGoogle Scholar
• 51 LaPrade R F, Wentorf F A, Fritts H, Gundry C, Hightower C D. A prospective magnetic resonance imaging study of the incidence of posterolateral and multiple ligament injuries in acute knee injuries presenting with a hemarthrosis.  Arthroscopy. 2007;  23(12) 1341-1347
  CrossrefPubMedGoogle Scholar
• 52 Simonsen O, Jensen J, Mouritsen P, Lauritzen J. The accuracy of clinical examination of injury of the knee joint.  Injury. 1984;  16(2) 96-101
  CrossrefPubMedGoogle Scholar
• 53 Bahk M S, Cosgarea A J. Physical examination and imaging of the lateral collateral ligament and posterolateral corner of the knee.  Sports Med Arthrosc. 2006;  14(1) 12-19
  CrossrefPubMedGoogle Scholar
• 54 Ranawat A, Baker III C L, Henry S, Harner C D. Posterolateral corner injury of the knee: evaluation and management.  J Am Acad Orthop Surg. 2008;  16(9) 506-518
  PubMedGoogle Scholar
• 55 Sekiya J K, Whiddon D R, Zehms C T, Miller M D. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency.  J Bone Joint Surg Am. 2008;  90(8) 1621-1627
  CrossrefPubMedGoogle Scholar
• 56 Hughston J C, Norwood Jr L A. The posterolateral drawer test and external rotational recurvatum test for posterolateral rotatory instability of the knee.  Clin Orthop Relat Res. 1980;  147(147) 82-87
  PubMedGoogle Scholar
• 57 Bae J H, Choi I C, Suh S W et al.. Evaluation of the reliability of the dial test for posterolateral rotatory instability: a cadaveric study using an isotonic rotation machine.  Arthroscopy. 2008;  24(5) 593-598
  CrossrefPubMedGoogle Scholar
• 58 Kannus P. Nonoperative treatment of grade II and III sprains of the lateral ligament compartment of the knee.  Am J Sports Med. 1989;  17 83-88
  CrossrefPubMedGoogle Scholar
• 59 Oberlander M A, Shalvoy R M, Hughston J C. The accuracy of the clinical knee examination documented by arthroscopy. A prospective study.  Am J Sports Med. 1993;  21(6) 773-778
  CrossrefPubMedGoogle Scholar
• 60 Harner C D, Vogrin T M, Höher J, Ma C B, Woo S L. Biomechanical analysis of a posterior cruciate ligament reconstruction. Deficiency of the posterolateral structures as a cause of graft failure.  Am J Sports Med. 2000;  28(1) 32-39
  PubMedGoogle Scholar
• 61 Cooper D E. Tests for posterolateral instability of the knee in normal subjects. Results of examination under anesthesia.  J Bone Joint Surg Am. 1991;  73(1) 30-36
  PubMedGoogle Scholar
• 62 Covey D C. Injuries of the posterolateral corner of the knee.  J Bone Joint Surg Am. 2001;  83-A(1) 106-118
  PubMedGoogle Scholar
• 63 Shindell R, Walsh W M, Connolly J F. Avulsion fracture of the fibula: the ‘arcuate sign’ of posterolateral knee instability.  Nebr Med J. 1984;  69(11) 369-371
  PubMedGoogle Scholar
• 64 Lee J, Papakonstantinou O, Brookenthal K R, Trudell D, Resnick D L. Arcuate sign of posterolateral knee injuries: anatomic, radiographic, and MR imaging data related to patterns of injury.  Skeletal Radiol. 2003;  32(11) 619-627
  CrossrefPubMedGoogle Scholar
• 65 Cohen A P, King D, Gibbon A J. Impingement fracture of the anteromedial tibial margin: a radiographic sign of combined posterolateral complex and posterior cruciate ligament disruption.  Skeletal Radiol. 2001;  30(2) 114-116
  CrossrefPubMedGoogle Scholar
• 66 Bennett D L, George M J, El-Khoury G Y, Stanley M D, Sundaram M. Anterior rim tibial plateau fractures and posterolateral corner knee injury.  Emerg Radiol. 2003;  10(2) 76-83
  CrossrefPubMedGoogle Scholar
• 67 Yu J S, Salonen D C, Hodler J, Haghighi P, Trudell D, Resnick D. Posterolateral aspect of the knee: improved MR imaging with a coronal oblique technique.  Radiology. 1996;  198(1) 199-204
  CrossrefPubMedGoogle Scholar
• 68 Munshi M, Pretterklieber M L, Kwak S, Antonio G E, Trudell D J, Resnick D. MR imaging, MR arthrography, and specimen correlation of the posterolateral corner of the knee: an anatomic study.  AJR Am J Roentgenol. 2003;  180(4) 1095-1101
  CrossrefPubMedGoogle Scholar
• 69 Pacholke D A, Helms C A. MRI of the posterolateral corner injury: a concise review.  J Magn Reson Imaging. 2007;  26(2) 250-255
  CrossrefPubMedGoogle Scholar
• 70 Malone W J, Koulouris G. MRI of the posterolateral corner of the knee: normal appearance and patterns of injury.  Semin Musculoskelet Radiol. 2006;  10(3) 220-228
  Article in Thieme ConnectPubMedGoogle Scholar
• 71 Recondo J A, Salvador E, Villanúa J A, Barrera M C, Gervás C, Alústiza J M. Lateral stabilizing structures of the knee: functional anatomy and injuries assessed with MR imaging.  Radiographics. 2000;  20(special issue) S91-S102
  CrossrefPubMedGoogle Scholar
• 72 LaPrade R F, Gilbert T J, Bollom T S, Wentorf F, Chaljub G. The magnetic resonance imaging appearance of individual structures of the posterolateral knee. A prospective study of normal knees and knees with surgically verified grade III injuries.  Am J Sports Med. 2000;  28(2) 191-199
  CrossrefPubMedGoogle Scholar
• 73 Brown T R, Quinn S F, Wensel J P, Kim J H, Demlow T. Diagnosis of popliteus injuries with MR imaging.  Skeletal Radiol. 1995;  24(7) 511-514
  PubMedGoogle Scholar
• 74 Juhng S K, Lee J K, Choi S S, Yoon K H, Roh B S, Won J J. MR evaluation of the “arcuate” sign of posterolateral knee instability.  AJR Am J Roentgenol. 2002;  178(3) 583-588
  PubMedGoogle Scholar
• 75 Huang G S, Yu J S, Munshi M et al.. Avulsion fracture of the head of the fibula (the “arcuate” sign): MR imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament.  AJR Am J Roentgenol. 2003;  180(2) 381-387
  CrossrefPubMedGoogle Scholar
• 76 Westrich G H, Hannafin J A, Potter H G. Isolated rupture and repair of the popliteus tendon.  Arthroscopy. 1995;  11(5) 628-632
  CrossrefPubMedGoogle Scholar
• 77 Conroy J, King D, Gibbon A. Isolated rupture of the popliteus tendon in a professional soccer player.  Knee. 2004;  11(1) 67-69
  CrossrefPubMedGoogle Scholar
• 78 Guha A R, Gorgees K A, Walker D I. Popliteus tendon rupture: a case report and review of the literature.  Br J Sports Med. 2003;  37(4) 358-360
  CrossrefPubMedGoogle Scholar

Theodore T MillerM.D. 

Department of Radiology and Imaging, Hospital for Special Surgery

535 E. 70th St., New York, NY 10021

Email: millertt@hss.edu