Imaging of the Medial and Lateral Ligaments of the Knee

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.

KEYWORDS

MRI - knee - medial collateral ligament - posteromedial joint capsule - fibular collateral ligament - arcuate complex

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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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); 
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 27 House C V, Connell D A, Saifuddin A. Posteromedial corner injuries of the knee.  Clin Radiol. 2007;  62(6) 539-546
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 35 Watanabe Y, Moriya H, Takahashi K et al.. Functional anatomy of the posterolateral structures of the knee.  Arthroscopy. 1993;  9(1) 57-62
• 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
• 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
• 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
• 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
• 40 Bolog N, Hodler J. MR imaging of the posterolateral corner of the knee.  Skeletal Radiol. 2007;  36(8) 715-728
• 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
• 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
• 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
• 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
• 45 Veltri D M, Warren R F. Posterolateral instability of the knee.  J Bone Joint Surg Am. 1994;  76 460-472
• 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
• 47 Hughston J C, Jacobson K E. Chronic posterolateral rotatory instability of the knee.  J Bone Joint Surg Am. 1985;  67(3) 351-359
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 62 Covey D C. Injuries of the posterolateral corner of the knee.  J Bone Joint Surg Am. 2001;  83-A(1) 106-118
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 76 Westrich G H, Hannafin J A, Potter H G. Isolated rupture and repair of the popliteus tendon.  Arthroscopy. 1995;  11(5) 628-632
• 77 Conroy J, King D, Gibbon A. Isolated rupture of the popliteus tendon in a professional soccer player.  Knee. 2004;  11(1) 67-69
• 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