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LCL Injury

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Other Names

  • LCL Tear
  • Lateral Collateral Ligament Tear
  • Lateral Collateral Ligament Injury
  • LCL Sprain
  • Fibular ligament injury

Background

History

  • Needs to be updated

Epidemiology

  • Second least frequent of all ligamentous knee injuries at 7.9% (behind PCL)[1]
  • Isolated knee injuries represent less than 2% of knee injuries[2]

Introduction

Lateral knee anatomy including the LCL[3]

Etiology

  • Contact sports
    • Commonly medial blow to knee while in full extension
  • Noncontact[4]
    • Varus bending
    • Hyperextension
  • Motor vehicle crashes

Anatomy

Associated Conditions

Risk Factors

  • Female gender
  • Sports that require high velocity pivoting, jumping
  • Sports[6]
    • Tennis
    • Gymnastics
    • Wrestling
  • Orthopedic history
    • History of knee, ankle or hip injury[7]

Differential Diagnosis

Clinical Features

Examination of the patient in the figure-of-four position. This allows the examiner to directly palpate the LCL (a, arrow)[8]
  • History
    • Generally patients will report an acute, traumatic event
    • Sudden onset lateral knee pain, swelling and bruising
    • Instability with knee in extension
    • Trouble with stairs, cutting or pivoting activities
    • Rarely weakness, parasthesia or foot drop (increase risk in PLC injuries)
    • Sensation of walking "bow legged" due to increase laxity
  • Physical Exam: Physical Exam Knee
    • Tenderness to palpation of the distal lateral femur and/or fibular head
    • Ecchymosis, swelling and warmth may be present
    • Effusion is typically absent in isolated injuries (due to extra-articular nature of LCL)
  • Special Tests
    • Varus Stress Test (Knee): one hand on lateral knee, other on leg applying varus stress at 0° and 30°
    • Posterolateral corner tests
    • Important to perform thorough structural knee exam on MCL, ACL, PCL, posterolateral corner, etc
Small avulsion fracture of the styloid process of the proximal fibula, with a defect in the fibular head noted. This is known as the arcuate sign.[9]
Full-thickness rupture (grade III) of the distal lateral collateral ligament.[10]

Evaluation

Radiographs

  • Standard Radiographs Knee
    • Routine screening
    • Typically normal
  • May demonstrate
    • Fibular head fractures/avulsions (arcuate sign)
    • Tibial spine avulsions
    • Lateral tibial plateau (i.e., Segond fracture)
  • Alternative views
    • Varus stress view
    • Kneeling posterior stress radiographs
    • Measure shortest distance between most distal aspect of lateral femoral condyle, associated tibial plateu

MRI

  • Gold standard for evaluating LCL
  • Best seen in axial, coronal views
  • Accuracy (need citation)
    • Sensitivity: 90%
    • Specificity: 90%
  • Primary findings
    • Majority of tears off fibular insertion
    • Medial compartment bone bruising (T2-weighted)
    • Varying amounts of peri-ligamentous edema, intra-substance signal
    • Discontinuity of LCL fibers in higher grade tears

US

  • Acute findings
    • Edema
    • Loss of fiber continuity
    • Dynamic laxity
  • Chronic findings
    • Thickened
    • Hypoechoic

Classification

LCL Tear Classification

  • Grade 1 (Mild)
    • Localized lateral knee tenderness
    • No instability or mechanical symptoms are present.
    • 0 to 4 mm of laxity
  • Grade 2 (Partial Tear)
    • Severe localized lateral and posterolateral knee pain, swelling.
    • 5 to 10 mm of laxity with a fixed endpoint
  • Grade 3 (Complete Tear)
    • Pain and swelling vary in patients
    • Usually associated with PLC and other related injuries
    • >10mm of laxity with no firm end point

LCL Tear MRI Classification

  • Grade 1
    • Subcutaneous fluid surrounding the midsubstance of the ligament at one or both insertions
  • Grade 2
    • Partial tearing of ligament fibers at either the midsubstance or one of the insertions
    • Increased edema
  • Grade 3
    • Complete tearing of ligament fibers at either the midsubstance or one of the insertions
    • Increased edema

Management

Nonoperative

  • Indications[11]
    • Grade I, II
    • Stable varus stress test at 0°
  • Hinged Knee Brace
    • Should restrict varus motion
    • Discontinue after pain, sensation of instability resolve
  • Early Mobilization
  • Physical Therapy
    • Not always necessary in isolated injuries
    • May be needed in cases of prolonged immobilization

Operative

  • Indications
    • Grade III injuries (controversial)
    • Co-occuring injuries such as posterolateral corner, multiligament injuries
  • Technique
    • Repair
    • Reconstruction

Rehab and Return to Play

Rehabilitation

  • General
    • Limited immobilization with progression range of motion
    • functional rehabilitation
    • Emphasis on quadriceps, hamstring strengthening

Return to Play/ Work

  • Grade I and II
    • Can often return to sport in 6-8 weeks

Complications and Prognosis

Prognosis

  • Bushnell at al looked at NFL players with isolated grade III LCL injuries[2]
    • Nonsurgically managed injuries were as likely as those with surgically managed injuries to return to professional play
    • They did so more quickly
  • Krukhuag et al found surgically managed isolated grade III LCL injuries did better than nonsurgical counterparts[12]
  • Kannus found nonoperative management of isolated grade III injuries did not do as well as surgically managed patients[11]
    • Findings: severe or gross lateral laxity, insufficiency of the ACL, muscle weakness, and posttraumatic osteoarthritis
  • Studies show that the LCL does not heal as well as the MCL (need citation)

Complications

  • Common Peroneal Nerve Injury
    • Occurs in up to 44% of LCL/PLC combined injuries[4]
  • Persistent varus or hyperextension laxity
  • Stiffness
    • Tends to occur following prolonged immobilization with nonoperative management
  • Physeal arrest
    • Can be seen in skeletally immature patient with errant lateral condylar LCL fixation

See Also

Internal

External

References

  1. ↑ Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-2010/2011. Med Sci Sports Exerc. 2013 Mar;45(3):462-9.
  2. ↑ 2.0 2.1 Bushnell BD, Bitting SS, Crain JM, Boublik M, Schlegel TF: Treatment of magnetic resonance imaging-documented isolated grade III lateral collateral ligament injuries in National Football League athletes. Am J Sports Med 2010;38(1):86-91.19966106
  3. ↑ LaPrade RF, Spiridonov SI, Coobs BR, Ruckert PR, Griffith CJ (2010) Fibular collateral ligament anatomical reconstructions: a prospective outcomes study. Am J Sports Med 38(10):2005–2011
  4. ↑ 4.0 4.1 Chahla, Jorge, et al. "Posterolateral corner of the knee: current concepts." Archives of Bone and Joint Surgery 4.2 (2016): 97.
  5. ↑ Wilson WT, Deakin AH, Payne AP, Picard F, Wearing SC: Comparative analysis of the structural properties of the collateral ligaments of the human knee. J Orthop Sports Phys Ther 2012;42(4):345-351.22030378
  6. ↑ Grawe, Brian, et al. "Lateral collateral ligament injury about the knee: anatomy, evaluation, and management." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 26.6 (2018): e120-e127.
  7. ↑ Hill OT, Bulathsinhala L, Scofield DE, Haley TF, Bernasek TL. Risk factors for soft tissue knee injuries in active duty U.S. Army soldiers, 2000-2005. Mil Med. 2013 Jun;178(6):676-82
  8. ↑ Jain, Rajat K. "Lateral collateral ligament injury." Common Pediatric Knee Injuries: Best Practices in Evaluation and Management (2021): 225-232.
  9. ↑ Case courtesy of Haytham Mohamed Assayed Bedier, Radiopaedia.org, rID: 56857
  10. ↑ Case courtesy of Henry Knipe, Radiopaedia.org, rID: 62164
  11. ↑ 11.0 11.1 Kannus, Pekka. "Nonoperative treatment of grade II and III sprains of the lateral ligament compartment of the knee." The American Journal of Sports Medicine 17.1 (1989): 83-88.
  12. ↑ Krukhaug Y, Mølster A, Rodt A, Strand T. Lateral ligament injuries of the knee. Knee Surg Sports Traumatol Arthrosc. 1998;6(1):21-5.
Created by:
John Kiel on 7 July 2019 05:43:53
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Last edited:
16 March 2023 16:21:57
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