Lateral Collateral Ligament of the Knee: Difference between revisions

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== Description  ==
== Description  ==
[[Image:Knee ligaments.png|250x250px|lateral collateral ligament|right|frameless]]The lateral or fibular collateral ligament is the primary varus stabilizer of the knee.<ref>R.F. LAPRADE, Journal of sports medicine, 2005, July the first 2010</ref>&nbsp;
[[Image:Knee ligaments.png|250x250px|lateral collateral ligament|right|frameless]]The fibular or lateral collateral ligament (LCL) is the primary varus stabilizer of the knee. <ref name=":0">LaPrade, R. F., Macalena, J. A. [https://www.researchgate.net/publication/309550053_Fibular_Collateral_Ligament_and_the_Posterolateral_Corner Fibular collateral ligament and the posterolateral corner.] Insall & Scott Surgery of the Knee. 5th ed. Philadelphia, PA: Elsevier/Churchill Livingstone, 2012; 45: 592-607.
</ref> It is one of 4 critical ligaments involved in stabilizing the [[Knee|knee joint.]]


=== Attachments ===
=== Attachments ===
The lateral collateral ligament or fibular collateral ligament has its origin on the lateral epicondyle of the femur and runs to the fibular head. <ref name="two">M.shünke, E.S (2005). Anatomische atlas prometheus, algemene anatomie en bewegingsapparaat. Bohn Stafleu van Loghum</ref><ref name="nine">William C.Whiting, R.F. (2008). Biomechanics of musculoskeletal injury. Second Edition</ref>The LCL has no direct contact with the joint capsule or lateral meniscus, it’s separated from it by a small fat pad.
The lateral collateral ligament, a cordlike band, has its origin on the lateral epicondyle of the [[femur]] and extends to the fibular head. <ref name="two">Schünke M, Schulte E, Schumacher U. Prometheus deel 1: Algemene anatomie en bewegingsapparaat. Houten: Bohn Stafleu Van Loghum, 2005.</ref><ref name="nine">Whiting WC, Zernicke RF. Biomechanics of musculoskeletal injury. 2nd ed. Human Kinetics, 2008.</ref>  
 
At the proximal level the ligament is closely related to the joint capsule, but has no direct contact with the joint capsule, it is separated by fat pad, Its distal insertion is augmented by the [[Iliotibial Band Syndrome|iliotibial tract]]. <ref name=":1">Malagelada F, Vega J, Golano P, Beynnon B, Ertem F. Knee Anatomy and Biomechanics of the Knee. In: DeLee & Drez's Orthopaedic Sports Medicine. 4th ed.  Elsevier Health Sciences, 2014.
</ref>


== Function ==
== Function ==
The lateral collateral ligament (LCL) is one of four critical ligaments involved in stabilizing the knee joint.&nbsp;The medial collateral ligament, the anterior cruciate ligament and the posterior cruciate ligament are the other stabilizers of the knee. When the knee is extended the LCL is stretched and it is loose when the knee is flexed (more than 30°).<ref name="three">eMedicine on Medscape, Sherwin SW Ho, MD. Lateral Collateral Knee Ligament Injury, Updated: Feb 28, 2010 http://emedicine.medscape.com/article/89819-overview</ref> The fibular collateral ligament is primary restraint to varus rotation from 0-30° of knee flexion, varus rotation is when the distal part of the leg below the knee is deviated inward, resulting in a bowlegged appearance. Secondarily it also acts to resist internal rotation forces of the tibia.  
The LCL stabilizes the lateral side of the knee joint, mainly in varus stress and posterolateral rotation of the tibia relative to the femur. LCL is one of the structures that are important as secondary stabilizers to anterior and posterior tibial translation when the cruciate ligaments are torn.  <ref name=":0" /> 
 
It is primary restraint to varus rotation from 0-30° of knee flexion. As the knee goes into flexion, the LCL loses its significance and influence as a varus-stabilizing structure.<ref name=":2">Miller RH, Azar FM. Knee injuries. In: Campbell's Operative Orthopaedics. 13th ed. Philadelphia: Elsevier, 201; 2121-2297.
</ref> When the knee is extended, the LCL is stretched.  


== Clinical relevance  ==
== Clinical relevance  ==
From all knee injury’s the Lateral Collateral Ligament Injury only takes 6%.<ref>H.B.TANDETER, P.SHVARTZMAN, ‘Acute knee injuries: Use of decision rules for selective radiograph ordering’, 1999</ref>
From all knee injury’s the incidence of LCL is not as high as for the medial collateral ligament and it takes only 6%.<ref>Tandeter HB., Shvartzman, P. [https://www.ncbi.nlm.nih.gov/pubmed/10605994 Acute knee injuries: use of decision rules for selective radiograph ordering.] Am Fam Physician 1999; 60(9): 2599-2608.</ref> [[Lateral Collateral Ligament Injury of the Knee|Injuries to the LCL]] are commonly associated with other knee ligament injuries, thus LCL tear can be overlooked because of other concomitant injuries, and the difficulty is in the proper diagnosis. <ref>Kane PW et al. [https://www.ncbi.nlm.nih.gov/pubmed/29884567 Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears.] Arthroscopy, 2018.
</ref>
 
A direct blow to the anteromedial knee is a common mechanism of injury to the LCL and posterolateral corner account, although noncontact hyperextension and noncontact varus stress injuries have also been well described.<ref name=":1" />  


== Assessment ==
== Assessment ==


=== Palpation ===  
=== Palpation ===
 
To palpate LCL, have the patient cross his legs so that his ankle rests upon the opposite knee. When the knee is flexed to 90 degrees and the hip is abducted and externally rotated, the iliotibial tract relaxes and makes the LCL easier to isolate. The ligament lies laterally and posteriorly along the joint line. Ocassionally, the LCL is congenitally absent. <ref>Hoppenfeld S, Hutton R, Hugh T. Physical examination of the spine and extremities. 1st ed. New York: Appleton-Century-Crofts, 1976.</ref> When LCL is injured or torn, this cordlike band is not as noticeable as on the undamaged side.
=== Special test ===
<u>The Varus stress test</u>:&nbsp;
 
The Varus stress test shows a lateral joint line gap. It is possible that the ligament is damaged. The patients legg is abducted and the knee is flexed in about 30°, so the knee joint is in the closed packed position.<ref>DEMOS MEDICAL PUBLISHING, 2004</ref> The sensitivity of the test is 25% . the reliability of this test in extension is 68% and in 30° flexion it is only 56%. The test is fairly solid.<ref>L. MERRIMAN, W.TURNER, ‘Assessment of the lower limb’, Elsevier health sciences, 2002</ref> The lateral collateral ligament stress test (varus stress test) is used to estimate the integrity&nbsp;of the lateral collateral ligament, to see whether it is this ligament that causes the instability in the knee. The purpose of this test is to determine if there is looseness in the ligament and if an MRI would be necessary. Serious tears or ruptures of the lateral collateral ligament may require surgery.<br>
 
The varus or adduction stress test evaluates the lateral collateral ligament. To perform this test, the physiotherapist has to place the knee in thirty degrees of flexion. While he is stabilizing the knee, he adducts the ankle. If the knee joint adducts greater than normal (compare with the uninjured leg), the test is positive. This is indicative of a lateral collateral ligament tear.
 
<u>How to do the Varus test?</u>
 
The test can be executed in 0° en 30 ° flexion. The physiotherapist puts one hand on the end of the femur at the medial side of the knee. His other hand is placed on the lateral side on the tibia. The practitioner is trying to stress the lateral collateral ligament by pushing the knee with both hands. It looks like he is going to break the leg. The patient has to rotate the hip maximally.<ref>L. MERRIMAN, W.TURNER, ‘Assessment of the lower limb’, Elsevier health sciences, 2002</ref>&nbsp;When the therapist feels a soft spot, the ligament is injured.<ref>.P. NOGALSKI, ‘Collateral ligament pathology, knee’, 2009</ref>
 
<br> {{#ev:youtube|sg1gk6QKARw}} <ref>Physiotutors. Varus Stress Test of the Knee⎟Lateral Collateral Ligament. Available from: https://www.youtube.com/watch?v=sg1gk6QKARw </ref>
== LCL Injuries  ==
 
There are different grades for the LCL injuries, they will be classified as follows:<ref name="three" /><ref name="three" />
 
Grade 1: Some tenderness and minor pain at the lateral side of the knee, pain when the distal part of the leg below the knee is deviated inward (varus stress). This means there have been small tears in the ligament.
 
Grade 2: Noticeable looseness in the knee, a joint space opening of about 5-10mm is present when moved by hand. There have been larger tears in the ligament = Joint instability of the knee. Major pain and tenderness at the inner side of the knee and some swelling is a consequence.<ref name="ten">Schoen, D.C.(2000). Adult orthopaedic nursing. Lippincott</ref>


Grade 3: Noticeable looseness in the knee, a joint space opening of &gt;10mm is present when moved by hand. This means the ligament is completely torn. Considerable pain and tenderness at the inner side of the knee and some swelling are also noted. There may also be a tear of the anterior cruciate ligament.<ref name="ten" />
=== Special tests ===


 For grade 1 and 2 the suggested treatment includes rest, ice, compression, elevation (RICE)  
==== <u>Adduction (Varus) stress test</u> ====


<br> Grade 3 is best treated with surgical intervention<br>
===== Purpose =====
The Varus stress test shows a lateral joint line gap.


These injuries are much less common than medial collateral ligament (MCL) injuries because the opposite leg usually guards against direct blows to the medial side of the knee. <br>
===== Performance =====
A varus stress test is performed by stabilizing the femur and palpating the lateral joint line. The other hand provides a varus stress to the ankle. The test is performed at 0 and 30 degrees, so the knee joint is in the closed packed position. While the physiotherapist with one hand is stabilizing the knee, the other hand adducts the ankle.  


<br>
===== Interpretation =====
If the knee joint adducts greater than normal (compare with the uninjured leg), the test is positive. This is indicative of a lateral collateral ligament tear.


Symptoms of a tear in the lateral collateral ligament are:<ref name="seven">Medlineplus, Linda J. Vorvick, MD. Lateral collateral ligament (LCL) injury, Update Date: 6/13/2010 http://www.nlm.nih.gov/medlineplus/ency/article/001079.htm</ref><br>o Knee swelling outside the joint. This symptom occurs also in bursitis, [[Patellar tendinopathy|patellar tendonitis and]] growth plate injury. The swelling may cause the joint to appear larger or abnormally shaped.<br>o Locking or catching of the knee with movement<br>o Pain or tenderness along the outside of the knee<br>o Knee gives way, or feels like it is going to give way, when it is active or stressed in a certain way<br>
===== Reliability and Validity =====
== Resources <br>  ==
* Sensitivity: 25%. Specificity: not reported. Varus stress testing was performed in 20° of flexion, and testing in extension was not done. <ref>Malanga GA, Andrus S, Nadler SF, McLean J. [https://www.archives-pmr.org/article/S0003-9993%2802%2904844-X/pdf Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests.] Arch Phys Med Rehabil, 2003; 84(4): 592-603.</ref>


Books:<br>{1}M.shünke, E.S. (2005). Anatomische atlas prometheus, algemene anatomie en bewegingsapparaat. Bohn Stafleu van Loghum<br>{2}William C.Whiting, R.F. (2008). Biomechanics of musculoskeletal injury. Second Edition <br>{4}Schoen, D.C.(2000). Adult orthopaedic nursing. Lippincott <br><br>Sites:<br>{3.0}Sherwin SW Ho, MD. Lateral collateral knee ligament injury, Updated: Feb 28, 2010 http://emedicine.medscape.com/article/89819-overview (secondary source)<br>Primary source: LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. Jul-Aug 1997;25(4):433-8.
* Sensitivity: 25% . The reliability of this test in extension is 68% and in 30° flexion only 56%. The test is fairly solid.<ref>Merriman L, Turner W. Assessment of the Lower Limb. 2nd ed. Churchill Livingstone, 2002.</ref>
{{#ev:youtube|sg1gk6QKARw}} <ref>Physiotutors. Varus Stress Test of the Knee⎟Lateral Collateral Ligament. Available from: https://www.youtube.com/watch?v=sg1gk6QKARw </ref>


{3.1}Sherwin SW Ho, MD. Lateral collateral knee ligament injury, Updated: Feb 28, 2010 http://emedicine.medscape.com/article/89819-overview (secondary source)<br>Primary source: Griffin LY. Acute knee injuries. Sports Medicine. New York, NY: John Wiley &amp; Sons, Inc; 1994:2255-60.
==== Additional tests for detecting LCL injury with other knee ligaments: <ref name=":2" /> ====
* External Rotation-Recurvatum Test
* Reverse Pivot Shift Sign of Jakob, Hassler, and Stäubli
* [[Dial Test]]


{3.2}Sherwin SW Ho, MD. Lateral collateral knee ligament injury, Updated: Feb 28, 2010 http://emedicine.medscape.com/article/89819-overview (secondary source)<br>Primary source: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2000:336-8.<br>{5}Linda J. Vorvick, MD. Lateral collateral ligament (LCL) injury, Update Date: 6/13/2010 http://www.nlm.nih.gov/medlineplus/ency/article/001079.htm (secondary source)<br>Primary source: De Carlo M, Armstrong B. Rehabilitation of the knee following sports injury. Clin Sports Med. 2010;29:81-106.
== Resources  ==


Articles:<br>- Robert F. LaPrade, Spiridonov SI, Coobs BR, Ruckert PR, Griffith CJ. Fibular collateral ligament anatomical reconstructions: a prospective outcomes study. Am J Sports Med. 2010; 38: 2005-2012<br>- Benjamin R. Coobs, Robert F. LaPrade, Chad J. Griffith, Bradley J. Nelson. Biomechanical Analysis of an Isolated Fibular (Lateral) Collateral Ligament Reconstruction Using an Autogenous Semitendinosus Graft. Am J Sports Med. 2007; 35: 1521-1527<br>- DE Cooper. Tests for posterolateral instability of the knee in normal subjects. Results of examination under anesthesia. J bone Joint Surg Am. 1991; 73: 30-36<br>  
Articles:<br>- Robert F. LaPrade, Spiridonov SI, Coobs BR, Ruckert PR, Griffith CJ. Fibular collateral ligament anatomical reconstructions: a prospective outcomes study. Am J Sports Med. 2010; 38: 2005-2012<br>- Benjamin R. Coobs, Robert F. LaPrade, Chad J. Griffith, Bradley J. Nelson. Biomechanical Analysis of an Isolated Fibular (Lateral) Collateral Ligament Reconstruction Using an Autogenous Semitendinosus Graft. Am J Sports Med. 2007; 35: 1521-1527<br>- DE Cooper. Tests for posterolateral instability of the knee in normal subjects. Results of examination under anesthesia. J bone Joint Surg Am. 1991; 73: 30-36<br>  


== References<br> ==
== References  ==


<references />  
<references />  


[[Category:Knee_Anatomy]] [[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Sports_Injuries]][[Category:Musculoskeletal/Orthopaedics]] [[Category:Knee]] [[Category:Assessment]] [[Category:Ligaments]]
[[Category:Knee_Anatomy]] [[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Sports_Injuries]][[Category:Musculoskeletal/Orthopaedics]] [[Category:Knee]] [[Category:Assessment]] [[Category:Ligaments]]

Revision as of 20:43, 9 July 2018

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Description[edit | edit source]

lateral collateral ligament

The fibular or lateral collateral ligament (LCL) is the primary varus stabilizer of the knee. [1] It is one of 4 critical ligaments involved in stabilizing the knee joint.

Attachments[edit | edit source]

The lateral collateral ligament, a cordlike band, has its origin on the lateral epicondyle of the femur and extends to the fibular head. [2][3]

At the proximal level the ligament is closely related to the joint capsule, but has no direct contact with the joint capsule, it is separated by fat pad, Its distal insertion is augmented by the iliotibial tract. [4]

Function[edit | edit source]

The LCL stabilizes the lateral side of the knee joint, mainly in varus stress and posterolateral rotation of the tibia relative to the femur. LCL is one of the structures that are important as secondary stabilizers to anterior and posterior tibial translation when the cruciate ligaments are torn.  [1] 

It is primary restraint to varus rotation from 0-30° of knee flexion. As the knee goes into flexion, the LCL loses its significance and influence as a varus-stabilizing structure.[5] When the knee is extended, the LCL is stretched.

Clinical relevance[edit | edit source]

From all knee injury’s the incidence of LCL is not as high as for the medial collateral ligament and it takes only 6%.[6] Injuries to the LCL are commonly associated with other knee ligament injuries, thus LCL tear can be overlooked because of other concomitant injuries, and the difficulty is in the proper diagnosis. [7]

A direct blow to the anteromedial knee is a common mechanism of injury to the LCL and posterolateral corner account, although noncontact hyperextension and noncontact varus stress injuries have also been well described.[4]

Assessment[edit | edit source]

Palpation[edit | edit source]

To palpate LCL, have the patient cross his legs so that his ankle rests upon the opposite knee. When the knee is flexed to 90 degrees and the hip is abducted and externally rotated, the iliotibial tract relaxes and makes the LCL easier to isolate. The ligament lies laterally and posteriorly along the joint line. Ocassionally, the LCL is congenitally absent. [8] When LCL is injured or torn, this cordlike band is not as noticeable as on the undamaged side.

Special tests[edit | edit source]

Adduction (Varus) stress test[edit | edit source]

Purpose[edit | edit source]

The Varus stress test shows a lateral joint line gap.

Performance[edit | edit source]

A varus stress test is performed by stabilizing the femur and palpating the lateral joint line. The other hand provides a varus stress to the ankle. The test is performed at 0 and 30 degrees, so the knee joint is in the closed packed position. While the physiotherapist with one hand is stabilizing the knee, the other hand adducts the ankle.

Interpretation[edit | edit source]

If the knee joint adducts greater than normal (compare with the uninjured leg), the test is positive. This is indicative of a lateral collateral ligament tear.

Reliability and Validity[edit | edit source]
  • Sensitivity: 25%. Specificity: not reported. Varus stress testing was performed in 20° of flexion, and testing in extension was not done. [9]
  • Sensitivity: 25% . The reliability of this test in extension is 68% and in 30° flexion only 56%. The test is fairly solid.[10]

[11]

Additional tests for detecting LCL injury with other knee ligaments: [5][edit | edit source]

  • External Rotation-Recurvatum Test
  • Reverse Pivot Shift Sign of Jakob, Hassler, and Stäubli
  • Dial Test

Resources[edit | edit source]

Articles:
- Robert F. LaPrade, Spiridonov SI, Coobs BR, Ruckert PR, Griffith CJ. Fibular collateral ligament anatomical reconstructions: a prospective outcomes study. Am J Sports Med. 2010; 38: 2005-2012
- Benjamin R. Coobs, Robert F. LaPrade, Chad J. Griffith, Bradley J. Nelson. Biomechanical Analysis of an Isolated Fibular (Lateral) Collateral Ligament Reconstruction Using an Autogenous Semitendinosus Graft. Am J Sports Med. 2007; 35: 1521-1527
- DE Cooper. Tests for posterolateral instability of the knee in normal subjects. Results of examination under anesthesia. J bone Joint Surg Am. 1991; 73: 30-36

References[edit | edit source]

  1. ↑ 1.0 1.1 LaPrade, R. F., Macalena, J. A. Fibular collateral ligament and the posterolateral corner. Insall & Scott Surgery of the Knee. 5th ed. Philadelphia, PA: Elsevier/Churchill Livingstone, 2012; 45: 592-607.
  2. ↑ Schünke M, Schulte E, Schumacher U. Prometheus deel 1: Algemene anatomie en bewegingsapparaat. Houten: Bohn Stafleu Van Loghum, 2005.
  3. ↑ Whiting WC, Zernicke RF. Biomechanics of musculoskeletal injury. 2nd ed. Human Kinetics, 2008.
  4. ↑ 4.0 4.1 Malagelada F, Vega J, Golano P, Beynnon B, Ertem F. Knee Anatomy and Biomechanics of the Knee. In: DeLee & Drez's Orthopaedic Sports Medicine. 4th ed. Elsevier Health Sciences, 2014.
  5. ↑ 5.0 5.1 Miller RH, Azar FM. Knee injuries. In: Campbell's Operative Orthopaedics. 13th ed. Philadelphia: Elsevier, 201; 2121-2297.
  6. ↑ Tandeter HB., Shvartzman, P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician 1999; 60(9): 2599-2608.
  7. ↑ Kane PW et al. Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears. Arthroscopy, 2018.
  8. ↑ Hoppenfeld S, Hutton R, Hugh T. Physical examination of the spine and extremities. 1st ed. New York: Appleton-Century-Crofts, 1976.
  9. ↑ Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil, 2003; 84(4): 592-603.
  10. ↑ Merriman L, Turner W. Assessment of the Lower Limb. 2nd ed. Churchill Livingstone, 2002.
  11. ↑ Physiotutors. Varus Stress Test of the Knee⎟Lateral Collateral Ligament. Available from: https://www.youtube.com/watch?v=sg1gk6QKARw
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