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Lateral Collateral Ligament Injury of the Knee

2014-10-05

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== Definition/Description ==

== Definition/Description ==

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An injury to the lateral collateral ligament of the knee can be caused by a varus stress, lateral rotation of the knee when weight-bearing or when the LCL loses it’s elasticity caused by repeated stress <ref name="[1]">Cedars Sinai. Health conditions. http://www.cedars-sinai.edu/Patients/Health-Conditions/Lateral-Collateral-Ligament-LCL-Tears.aspx (accessed 2 May 2011)</ref><ref name="[2]">Medscape reference. Drug, Conditions & Procedures.http://emedicine.medscape.com/article/307959-overview#showall (accessed 2 May 2011)</ref><ref name="[3]">J. A. K. Davies, P. Gayle, A. Brochert. LCL injury- Lateral Collateral Ligament Injury. http://www.medicineonline.com/articles/l/2/lcl-injury/lateral-collateral-ligament-injury.html (accessed 5 May 2011)</ref><ref name="[4]">PhysioAdvisor. LCL Tear (Lateral Collateral Ligament)http://www.physioadvisor.com.au/10196250/lcl-tear-lateral-collateral-ligament-lcl-injur.htm (accessed 6 May 2011)</ref>.The LCL can be sprained (grade I), partially ruptured (grade II) or completely ruptured (grade III) <ref name="[3]" />. Additional damage of the ACL, PCL and medial knee structures is possible when the lateral knee structures are injured <ref name="[5]">J. A. Recondo, E. Salvador, J.A. Villanúa, M.C. Barrera, C. Gervás, J.M. Alústiza. Lateral Stabilizing Structures of the Knee: Functional Anatomy and Injuries Assessed with MR Imaging. Radiographics 2000; 20 Spec No: S91-102. http://www.ncbi.nlm.nih.gov/pubmed/11046165 full text: http://radiographics.rsna.org/content/20/suppl_1/S91.full.pdf+html (accessed 2 May 2011)</ref>(A2). 

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An injury to the lateral collateral ligament of the knee can be caused by a varus stress, lateral rotation of the knee when weight-bearing or when the LCL loses it’s elasticity caused by repeated stress <ref name="[1]">Cedars Sinai. Health conditions. http://www.cedars-sinai.edu/Patients/Health-Conditions/Lateral-Collateral-Ligament-LCL-Tears.aspx (accessed 2 May 2011)</ref><ref name="[2]">Medscape reference. Drug, Conditions &
amp;
amp;amp; Procedures.http://emedicine.medscape.com/article/307959-overview#showall (accessed 2 May 2011)</ref><ref name="[3]">J. A. K. Davies, P. Gayle, A. Brochert. LCL injury- Lateral Collateral Ligament Injury. http://www.medicineonline.com/articles/l/2/lcl-injury/lateral-collateral-ligament-injury.html (accessed 5 May 2011)</ref><ref name="[4]">PhysioAdvisor. LCL Tear (Lateral Collateral Ligament)http://www.physioadvisor.com.au/10196250/lcl-tear-lateral-collateral-ligament-lcl-injur.htm (accessed 6 May 2011)</ref>.The LCL can be sprained (grade I), partially ruptured (grade II) or completely ruptured (grade III) <ref name="[3]" />. Additional damage of the ACL, PCL and medial knee structures is possible when the lateral knee structures are injured <ref name="[5]">J. A. Recondo, E. Salvador, J.A. Villanúa, M.C. Barrera, C. Gervás, J.M. Alústiza. Lateral Stabilizing Structures of the Knee: Functional Anatomy and Injuries Assessed with MR Imaging. Radiographics 2000; 20 Spec No: S91-102. http://www.ncbi.nlm.nih.gov/pubmed/11046165 full text: http://radiographics.rsna.org/content/20/suppl_1/S91.full.pdf+html (accessed 2 May 2011)</ref>(A2). 

== [[Image:LCL physiopedia.jpg|right|3x8px|LCL physiopedia.jpg]]Clinically Relevant Anatomy ==

== [[Image:LCL physiopedia.jpg|right|3x8px|LCL physiopedia.jpg]]Clinically Relevant Anatomy ==

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The lateral collateral ligament is a structure of the arcuate ligament complex, together with the biceps femoris tendon, popliteus muscle and tendon, popliteal meniscal and popliteal[[Image:LCL physiopedia.jpg|right|167x246px|LCL physiopedia.jpg]] 

The lateral collateral ligament is a structure of the arcuate ligament complex, together with the biceps femoris tendon, popliteus muscle and tendon, popliteal meniscal and popliteal[[Image:LCL physiopedia.jpg|right|167x246px|LCL physiopedia.jpg]] 

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fibular ligaments, oblique popliteal, arcuate and fabellofibular ligaments and lateral gastrocnemius muscle<ref name="[5]" />(A2). The lateral collateral ligament is a strong connection between the lateral epicondyle of the femur and the head of the fibula, with the function to resist varus stress on the knee and tibial external rotation and thus a stabilizer of the knee. When the knee is flexed to more than 30°, the LCL is loose. The ligament is strained when the knee is in extension.<ref name="[3]" /><ref name="[6]">Medscape reference. Drugs, Conditions &amp;amp;amp;amp;amp; Procedures. http://emedicine.medscape.com/article/89819-overview#showall (accessed 4May 2011)</ref><ref name="[7]">eOrif. Lateral Collateral Ligament Tear. http://www.eorif.com/KneeLeg/LCL.html (accessed 8 May 2011)</ref> 

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fibular ligaments, oblique popliteal, arcuate and fabellofibular ligaments and lateral gastrocnemius muscle<ref name="[5]" />(A2). The lateral collateral ligament is a strong connection between the lateral epicondyle of the femur and the head of the fibula, with the function to resist varus stress on the knee and tibial external rotation and thus a stabilizer of the knee. When the knee is flexed to more than 30°, the LCL is loose. The ligament is strained when the knee is in extension.<ref name="[3]" /><ref name="[6]">Medscape reference. Drugs, Conditions &
amp;
amp;amp;amp;amp;amp;amp;amp; Procedures. http://emedicine.medscape.com/article/89819-overview#showall (accessed 4May 2011)</ref><ref name="[7]">eOrif. Lateral Collateral Ligament Tear. http://www.eorif.com/KneeLeg/LCL.html (accessed 8 May 2011)</ref> 

 

 

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== Epidemiology /Etiology ==

== Epidemiology /Etiology ==

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Injuries to the lateral and medial collateral ligaments are common, but the MCL injuries occur more often than the LCL injuries. 25% of the patients in the United States with an acute knee injury in the emergency rooms, have a collateral ligament injury. Adults of 20-34 and 55-65 years old have the highest incidence. LCL (and MCL) injuries occur equally for men and women as for different races. These injuries are succesfully treated with conservative methods. Even when surgery is necessary, there is normally a good prognosis. <ref name="[2]" /><ref name="[8]">M.Majewski, H. Susanne, S. Klaus. Epidemiology of athletic knee injuries: a 10-year study.The knee Volume 13, Issue 3, 2006, pages 184-188 http://www.sciencedirect.com.ezproxy.vub.ac.be:2048/science/article/pii/S0968016006000032, full text in pdf: http://www.sciencedirect.com.ezproxy.vub.ac.be:2048/science?_ob=MImg&amp;_imagekey=B6TCJ-4JRKCV4-1-1&amp;_cdi=5172&amp;_user=1011600&amp;_pii=S0968016006000032&amp;_origin=gateway&amp;_coverDate=06%2F30%2F2006&amp;_sk=999869996&amp;view=c&amp;wchp=dGLbVtz-zSkzV&amp;md5=2e67d2c214e0fac0b96730da4a77a107&amp;ie=/sdarticle.pdf (accessed 10 May 2011)</ref>(A2)<ref name="[9]">Knee Pain Info. Collateral ligament injuries.http://www.kneepaininfo.com/kneecollateral.html (accessed 9 May 2011)</ref> 

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Injuries to the lateral and medial collateral ligaments are common, but the MCL injuries occur more often than the LCL injuries. 25% of the patients in the United States with an acute knee injury in the emergency rooms, have a collateral ligament injury. Adults of 20-34 and 55-65 years old have the highest incidence. LCL (and MCL) injuries occur equally for men and women as for different races. These injuries are succesfully treated with conservative methods. Even when surgery is necessary, there is normally a good prognosis. <ref name="[2]" /><ref name="[8]">M.Majewski, H. Susanne, S. Klaus. Epidemiology of athletic knee injuries: a 10-year study.The knee Volume 13, Issue 3, 2006, pages 184-188 http://www.sciencedirect.com.ezproxy.vub.ac.be:2048/science/article/pii/S0968016006000032, full text in pdf: http://www.sciencedirect.com.ezproxy.vub.ac.be:2048/science?_ob=MImg&
amp;
amp;amp;amp;_imagekey=B6TCJ-4JRKCV4-1-1&
amp;
amp;amp;amp;_cdi=5172&
amp;
amp;amp;amp;_user=1011600&
amp;
amp;amp;amp;_pii=S0968016006000032&
amp;
amp;amp;amp;_origin=gateway&
amp;
amp;amp;amp;_coverDate=06%2F30%2F2006&
amp;
amp;amp;amp;_sk=999869996&
amp;
amp;amp;amp;view=c&
amp;
amp;amp;amp;wchp=dGLbVtz-zSkzV&
amp;
amp;amp;amp;md5=2e67d2c214e0fac0b96730da4a77a107&
amp;
amp;amp;amp;ie=/sdarticle.pdf (accessed 10 May 2011)</ref>(A2)<ref name="[9]">Knee Pain Info. Collateral ligament injuries.http://www.kneepaininfo.com/kneecollateral.html (accessed 9 May 2011)</ref> 

An injury of the lateral collateral ligament most often occurs from a varus force or by twisting the knee. Such an injury occurs in sports with a lot of quick changes in direction or with violent collusions. Examples are soccer, basketbal, skiing, footbal or hockey. An LCL injury can also be caused by repeated stress or when an elderly person falls. <ref name="[1]" /><ref name="[3]" /><ref name="[4]" /> 

An injury of the lateral collateral ligament most often occurs from a varus force or by twisting the knee. Such an injury occurs in sports with a lot of quick changes in direction or with violent collusions. Examples are soccer, basketbal, skiing, footbal or hockey. An LCL injury can also be caused by repeated stress or when an elderly person falls. <ref name="[1]" /><ref name="[3]" /><ref name="[4]" /> 

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The LCL is not connected with the lateral meniscus, so it is not automatically associated with a meniscal tear. However, an LCL injury often occurs along with other ligament injuries, including [http://www.physio-pedia.com/index.php5?title=Anterior_Cruciate_Ligament_Injury ACL], [http://www.physio-pedia.com/index.php5?title=Posterior_Cruciate_Ligament_Injury PCL], and [http://www.physio-pedia.com/index.php5?title=Medial_Collateral_Ligament_Injury_of_the_Knee MCL], and is frequently seen along with [http://www.physio-pedia.com/index.php5?title=Knee_Dislocation knee dislocations]. 

The LCL is not connected with the lateral meniscus, so it is not automatically associated with a meniscal tear. However, an LCL injury often occurs along with other ligament injuries, including [http://www.physio-pedia.com/index.php5?title=Anterior_Cruciate_Ligament_Injury ACL], [http://www.physio-pedia.com/index.php5?title=Posterior_Cruciate_Ligament_Injury PCL], and [http://www.physio-pedia.com/index.php5?title=Medial_Collateral_Ligament_Injury_of_the_Knee MCL], and is frequently seen along with [http://www.physio-pedia.com/index.php5?title=Knee_Dislocation knee dislocations]. 

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== Differential Diagnosis <ref name="[7]" /><ref name="[10]">Medscape reference. Drugs, Conditions & Procedures. http://emedicine.medscape.com/article/89819-differential (accessed 12 May 2011)</ref><ref name="[11]">Medscape reference. Drugs, Conditions & Procedures. http://emedicine.medscape.com/article/89819-clinical#showall (accessed 12 May 2011)</ref> ==

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== Differential Diagnosis <ref name="[7]" /><ref name="[10]">Medscape reference. Drugs, Conditions &
amp;
amp;amp; Procedures. http://emedicine.medscape.com/article/89819-differential (accessed 12 May 2011)</ref><ref name="[11]">Medscape reference. Drugs, Conditions &
amp;
amp;amp; Procedures. http://emedicine.medscape.com/article/89819-clinical#showall (accessed 12 May 2011)</ref> ==

- Injury at the posterolateral corner - PCL tear - MCL tear - ACL tear - Meniscus tear/ injuries - Chondral injury - Tibial Plateau Fractures - Patellar/ knee dislocation - Popliteus avulsion - Iliotibial Band Syndrome - Biceps femoris tendinitis 

- Injury at the posterolateral corner - PCL tear - MCL tear - ACL tear - Meniscus tear/ injuries - Chondral injury - Tibial Plateau Fractures - Patellar/ knee dislocation - Popliteus avulsion - Iliotibial Band Syndrome - Biceps femoris tendinitis 

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== Diagnostic Procedures ==

== Diagnostic Procedures ==

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The elements that occur when there is a lateral collateral ligament injury are: <ref name="[1]" /><ref name="[13]">Medscape reference. Drugs, Conditions &amp; Procedures. http://emedicine.medscape.com/article/307959-clinical (accessed 12 May 2011)</ref> 

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The elements that occur when there is a lateral collateral ligament injury are: <ref name="[1]" /><ref name="[13]">Medscape reference. Drugs, Conditions &
amp;
amp;amp;amp; Procedures. http://emedicine.medscape.com/article/307959-clinical (accessed 12 May 2011)</ref> 

- Ask if the patient felt or heard a ‘pop’ in the knee and have an ustable feeling in the knee<ref name="[B]">FRANK R. NOYES, MD, LONNIE PAULOS, MD, LISA A. MOOAR, BA, and BEN SIGNER, BA Knee Sprains and Acute ; Knee Hemarthrosis ,Misdiagnosis of Anterior Cruciate Ligament Tears, Physical Therapy December 1980 vol. 60 no. 12 1596-1601</ref> - Look for swelling, bruising, stiffnes, erythema (after several days) or deformity of the knee<ref name="[A]">Hai-ning Zhang, Jie Zhang, Cheng-yu Lv, Ping Leng, Ying-zhen Wang, Xiang-da Wang, and Chang-yao Wang Modified biplanar open-wedge high tibial osteotomy with rigid locking plate to treat varus knee J Zhejiang Univ Sci B. 2009 September; 10(9): 689–695</ref> - Palpate the knee and serach for tenderness, warmth, swelling, etc. - No significicant joint effusion, unless there is also a cruciate ligament or meniscal rupture 

- Ask if the patient felt or heard a ‘pop’ in the knee and have an ustable feeling in the knee<ref name="[B]">FRANK R. NOYES, MD, LONNIE PAULOS, MD, LISA A. MOOAR, BA, and BEN SIGNER, BA Knee Sprains and Acute ; Knee Hemarthrosis ,Misdiagnosis of Anterior Cruciate Ligament Tears, Physical Therapy December 1980 vol. 60 no. 12 1596-1601</ref> - Look for swelling, bruising, stiffnes, erythema (after several days) or deformity of the knee<ref name="[A]">Hai-ning Zhang, Jie Zhang, Cheng-yu Lv, Ping Leng, Ying-zhen Wang, Xiang-da Wang, and Chang-yao Wang Modified biplanar open-wedge high tibial osteotomy with rigid locking plate to treat varus knee J Zhejiang Univ Sci B. 2009 September; 10(9): 689–695</ref> - Palpate the knee and serach for tenderness, warmth, swelling, etc. - No significicant joint effusion, unless there is also a cruciate ligament or meniscal rupture 

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The lateral collateral ligament injury can be a grade I, II or III and these can be distinguished by the symptoms. <ref name="[1]" /><ref name="[7]" /><ref name="[11]" /><ref name="[12]">Sports Injury Clinic. Knee Pain, Lateral Ligament Sprain. http://www.sportsinjuryclinic.net/cybertherapist/front/knee/ilateralligament.html (accessed 12 May 2011)</ref> Grade I: - Mild tenderness and minor pain over the lateral collateral ligament - Usually no swelling - The varustest in 30° is painful but doesn’t show any laxity (< 5 mm laxity) Grade II: - Significant tenderness and pain on the lateral collateral ligament and on medial side of the knee - Swelling in the area of the ligament - The varustest is painful and there is laxity in the joint with a clear endpoint. (5 -10mm laxity) Grade III: - The pain can vary and can be less than in grade II - Tenderness and pain at the medial side of the knee and at the injury - The varustest shows a significant joint laxity (>10mm laxity) - The feeling of having a very unstable knee - Swelling 

The lateral collateral ligament injury can be a grade I, II or III and these can be distinguished by the symptoms. <ref name="[1]" /><ref name="[7]" /><ref name="[11]" /><ref name="[12]">Sports Injury Clinic. Knee Pain, Lateral Ligament Sprain. http://www.sportsinjuryclinic.net/cybertherapist/front/knee/ilateralligament.html (accessed 12 May 2011)</ref> Grade I: - Mild tenderness and minor pain over the lateral collateral ligament - Usually no swelling - The varustest in 30° is painful but doesn’t show any laxity (< 5 mm laxity) Grade II: - Significant tenderness and pain on the lateral collateral ligament and on medial side of the knee - Swelling in the area of the ligament - The varustest is painful and there is laxity in the joint with a clear endpoint. (5 -10mm laxity) Grade III: - The pain can vary and can be less than in grade II - Tenderness and pain at the medial side of the knee and at the injury - The varustest shows a significant joint laxity (>10mm laxity) - The feeling of having a very unstable knee - Swelling 

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To determine the severity and laxity of the knee the therapist can carry out a [http://www.physio-pedia.com/index.php5?title=LCL_Test varustest]. To determine whether it is a grade 2 sprain or 3, you can take the test in extension. When the patient has a severe grade 3 sprain, the knee will show laxity, while a grade 2 sprain won’t. Also the grade 3 sprain will not have a demonstrable endpoint at 30 degree flexion.<ref name="[D]">Reider B Medial collateral ligament injuries in athletes. Sports Med 21(2): 147- 156, 1996</ref>When the varustest is done in extension, there is also an evaluation of the posterolateral corner structures and cruciate ligaments. <ref name="[11]" /> You can also take an MRI scan of the knee. It is an accurate way to see how badly the lateral collateral ligament has been torn and to detect other injuries to the knee. Noticing a partial rupture with an MRI scan is difficult. To make sure that the bones of the knee are not broken, you can take an X-ray.<ref name="[1]" /><ref name="[5]" />(A2)<ref name="[9]" /><ref name="[14]">UCSF Medical Center. Conditions &amp; Treatments, Orthopedics, LCL Tear. http://www.ucsfhealth.org/conditions/lcl_tear/ (accessed 12 May 2011)</ref> The peroneal nerve can also be injured. This type of injury requires surgical repair because of the complex structures which are involved. Damage is easily spotted if you see a foot drop of the patient while he is walking or when the patient feels a numbness or weakness in the foot. <ref name="[1]" /><ref name="[C]">Jennifer Baima , Lisa Krivickas Evaluation and treatment of peroneal neuropathy Curr Rev Musculoskelet Med. 2008 June; 1(2): 147–153</ref> 

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To determine the severity and laxity of the knee the therapist can carry out a [http://www.physio-pedia.com/index.php5?title=LCL_Test varustest]. To determine whether it is a grade 2 sprain or 3, you can take the test in extension. When the patient has a severe grade 3 sprain, the knee will show laxity, while a grade 2 sprain won’t. Also the grade 3 sprain will not have a demonstrable endpoint at 30 degree flexion.<ref name="[D]">Reider B Medial collateral ligament injuries in athletes. Sports Med 21(2): 147- 156, 1996</ref>When the varustest is done in extension, there is also an evaluation of the posterolateral corner structures and cruciate ligaments. <ref name="[11]" /> You can also take an MRI scan of the knee. It is an accurate way to see how badly the lateral collateral ligament has been torn and to detect other injuries to the knee. Noticing a partial rupture with an MRI scan is difficult. To make sure that the bones of the knee are not broken, you can take an X-ray.<ref name="[1]" /><ref name="[5]" />(A2)<ref name="[9]" /><ref name="[14]">UCSF Medical Center. Conditions &
amp;
amp;amp;amp; Treatments, Orthopedics, LCL Tear. http://www.ucsfhealth.org/conditions/lcl_tear/ (accessed 12 May 2011)</ref> The peroneal nerve can also be injured. This type of injury requires surgical repair because of the complex structures which are involved. Damage is easily spotted if you see a foot drop of the patient while he is walking or when the patient feels a numbness or weakness in the foot. <ref name="[1]" /><ref name="[C]">Jennifer Baima , Lisa Krivickas Evaluation and treatment of peroneal neuropathy Curr Rev Musculoskelet Med. 2008 June; 1(2): 147–153</ref> 

== Outcome Measures ==

== Outcome Measures ==

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29. Michael P Nogalski et al. , Collateral Ligament Pathology Treatment & Management, Medscape, 2012 (5) 

29. Michael P Nogalski et al. , Collateral Ligament Pathology Treatment & Management, Medscape, 2012 (5) 

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[[Category:Condition]][[Category:Knee]][[Category:Musculoskeletal/
orthopaedics
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orthopaedics
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[[Category:Condition]][[Category:Knee]][[Category:Musculoskeletal/
Orthopaedics
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Orthopaedics
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