Lateral Collateral Ligament of the Knee: Difference between revisions
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'''Original Editors '''- [[User:Dorien Scheirs|Dorien Scheirs]], [[User:Joris De Pot|Joris De Pot]]  
'''Original Editors '''- [[User:Dorien Scheirs|Dorien Scheirs]], [[User:Joris De Pot|Joris De Pot]]  


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== Description  ==
The fibular or lateral collateral ligament (LCL) is a cord-like band and acts as 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.]]


== Definition/Description  ==
=== Anatomy ===
[[Image:Knee ligaments.png|250x250px|lateral collateral ligament|right|frameless]]'''Origin''': Lateral epicondyle of the [[femur]]


On this page you will find some information about the fibular collateral ligament of the knee. Functional anatomy, technique and the different grades of injury from the LCL will be explained. More information about the ligament can be founded at the page of Wouter Claesen. An injury at the Lateral Collateral Ligament is an injury at the lateral side of the knee. There are several tests for testing the Lateral Collateral Ligament. ‘The 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;
'''Insertion''': Fibula head


== Clinically Relevant Anatomy  ==
<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>


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.  
At the proximal level this ligament is closely related to the joint capsule, without having direct contact, as it is separated by fat pad, The insertion is augmented by the [[Iliotibial Band Syndrome|iliotibial band]].<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> The [[Popliteus Muscle|popliteus]] tendon is deep to the LCL, seperating it from the [[lateral meniscus]].<ref name=":3">Moore KL, Dalley AF, Agur AMR. Clinial oriented anatomy. Philadelphia: Wolters Kluwer, 2010.</ref> The LCL further splits the [[Biceps Femoris|biceps femoris]] into two parts.<ref name=":3" />
== Function ==
The LCL stabilizes the lateral side of the knee joint, mainly in varus stress and posterolateral rotation of the tibia relative to the femur. The LCL acts as a secondary stabilizer to anterior and posterior tibial translation when the cruciate ligaments are torn. <ref name=":0" /> 


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>
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, 2016; 2121-2297.
</ref> When the knee is extended, the LCL is stretched.  


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 has no direct contact with the joint capsule or lateral meniscus, it’s separated from it by a small fat pad.  
== Clinical relevance  ==
The incidence of [[Lateral Collateral Ligament Injury of the Knee|LCL injuries]] are relatively low (6%) when compared to other knee injuries.<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> It is commonly associated with other knee ligament injuries, thus LCL tear can be easily overlooked as a result of that.<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>


There are different grades for the LCL, they will be classified as follows:<ref name="three" /><ref name="three" />  
'''Mechanism of injury:''' (for more information, see the page on [[Lateral Collateral Ligament Injury of the Knee|LCL injuries]])<ref name=":1" />
* A direct blow to the anteromedial knee and posterolateral corner
* Non-contact hyperextension
* Non-contact varus stress<ref name=":1" />  


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.
== Assessment ==


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>
=== Palpation ===
Patient position: Legs crossed with ankle resting on opposite knee (90° knee flexion, hip abduction and external rotation)


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" />  
In this position the iliotibial band 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 unaffected side.


 For grade 1 and 2 the suggested treatment includes rest, ice, compression, elevation (RICE)  
=== Special tests ===
'''Adduction (varus) stress test'''


<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 20-30°, so the knee joint is in the closed packed position. The physiotherapist stabilize the knee with one hand, while the other hand adducts the ankle.<ref name=":4">Petty NJ. Neuromusculoskeletal examination assessment: A handbook for therapists. 3rd edition. Edinburgh: Elsevier, 2006.</ref>


<br>
''Interpretation:''  If the knee joint adducts greater than normal (compared to the unaffected leg), the test is positive. This an indication of a LCL 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>  
''Other structures involved:''<ref name=":4" />
* 0°: Posteriolateral capsule, arcuate-popliteus complex, anterior and posterior cruciate ligaments, lateral gastrocnemius
* 20-30°: Posteriolateral capsule, arcuate-popliteus complex, iliotibial band, biceps femoris tendon
''Reliability and validity:''
* 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>
* 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>
* If the varus stress test is positive at 20°, but negative at 0°, only the LCL is torn. A positive result at both 0° and 20° indicate cruciate ligament involvement.<ref>Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.</ref>
<clinicallyrelevant id="84562015" title="Varus stress test" />


<br>  
'''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]]


== Purpose<br>  ==
== Resources  ==
* [[Lateral Collateral Ligament Injury of the Knee|Lateral collateral ligament injuries]]


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.
== References  ==
 
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.
 
<br>
 
== Technique<br>  ==
 
&nbsp;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>
 
<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>
 
<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|kZm5VEHKMPQ}}
 
<br>
 
== Resources <br>  ==
 
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.
 
{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.
 
{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.
 
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>
 
<br>
 
== Clinical Bottom Line  ==
 
The lateral collateral ligament, located on the lateral side of the knee has its origin on the lateral epicondyle of the femur and his insertion on the fibular head. It is the primary varus stabilizer of the knee. This ligament is restraint to varus rotation from 0-30° of knee flexion and it also acts to resist internal rotation forces of the tibia.<br>
 
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1PcHN4WG_Qm8BIdC8G4f2aWWSFanY4flre3ZOPxxSBfR8-VQBr|charset=UTF­8|short|max=10</rss>
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== References<br> ==


<references />  
<references />  


[[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Musculoskeletal/orthopaedics|orthopaedics]] [[Category:Knee]] [[Category:Assessment]]
[[Category:Knee - Anatomy]]  [[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Sports_Injuries]][[Category:Musculoskeletal/Orthopaedics]] [[Category:Knee]] [[Category:Assessment]] [[Category:Ligaments]] [[Category:Knee - Ligaments]]

Latest revision as of 01:04, 29 August 2019

Original Editors - Dorien Scheirs, Joris De Pot

Top Contributors - Saimat Lachinova, Admin, Joris De Pot, Dorien Scheirs, Kim Jackson, Rachael Lowe, Leana Louw, Oyemi Sillo, WikiSysop, Tony Lowe, Derycker Andries, Naomi O'Reilly, George Prudden and Kai A. Sigel  

Description[edit | edit source]

The fibular or lateral collateral ligament (LCL) is a cord-like band and acts as the primary varus stabilizer of the knee.[1] It is one of 4 critical ligaments involved in stabilizing the knee joint.

Anatomy[edit | edit source]

lateral collateral ligament

Origin: Lateral epicondyle of the femur

Insertion: Fibula head

[2][3]

At the proximal level this ligament is closely related to the joint capsule, without having direct contact, as it is separated by fat pad, The insertion is augmented by the iliotibial band.[4] The popliteus tendon is deep to the LCL, seperating it from the lateral meniscus.[5] The LCL further splits the biceps femoris into two parts.[5]

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. The LCL acts as a secondary stabilizer 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.[6] When the knee is extended, the LCL is stretched.

Clinical relevance[edit | edit source]

The incidence of LCL injuries are relatively low (6%) when compared to other knee injuries.[7] It is commonly associated with other knee ligament injuries, thus LCL tear can be easily overlooked as a result of that.[8]

Mechanism of injury: (for more information, see the page on LCL injuries)[4]

  • A direct blow to the anteromedial knee and posterolateral corner
  • Non-contact hyperextension
  • Non-contact varus stress[4]

Assessment[edit | edit source]

Palpation[edit | edit source]

Patient position: Legs crossed with ankle resting on opposite knee (90° knee flexion, hip abduction and external rotation)

In this position the iliotibial band relaxes and makes the LCL easier to isolate. The ligament lies laterally and posteriorly along the joint line. Ocassionally, the LCL is congenitally absent. [9] When LCL is injured or torn, this cordlike band is not as noticeable as on the unaffected side.

Special tests[edit | edit source]

Adduction (varus) stress test

Purpose: The varus stress test shows a lateral joint line gap.

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 20-30°, so the knee joint is in the closed packed position. The physiotherapist stabilize the knee with one hand, while the other hand adducts the ankle.[10]

Interpretation: If the knee joint adducts greater than normal (compared to the unaffected leg), the test is positive. This an indication of a LCL tear.

Other structures involved:[10]

  • 0°: Posteriolateral capsule, arcuate-popliteus complex, anterior and posterior cruciate ligaments, lateral gastrocnemius
  • 20-30°: Posteriolateral capsule, arcuate-popliteus complex, iliotibial band, biceps femoris tendon

Reliability and validity:

  • Sensitivity: 25%. Specificity: not reported. Varus stress testing was performed in 20° of flexion, and testing in extension was not done.[11]
  • Sensitivity: 25% . The reliability of this test in extension is 68% and in 30° flexion only 56%. The test is fairly solid.[12]
  • If the varus stress test is positive at 20°, but negative at 0°, only the LCL is torn. A positive result at both 0° and 20° indicate cruciate ligament involvement.[13]

Varus stress test video provided by Clinically Relevant

Additional tests for detecting LCL injury with other knee ligaments:[6]

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

Resources[edit | edit source]

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 4.2 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 Moore KL, Dalley AF, Agur AMR. Clinial oriented anatomy. Philadelphia: Wolters Kluwer, 2010.
  6. ↑ 6.0 6.1 Miller RH, Azar FM. Knee injuries. In: Campbell's Operative Orthopaedics. 13th ed. Philadelphia: Elsevier, 2016; 2121-2297.
  7. ↑ Tandeter HB., Shvartzman, P. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician 1999; 60(9): 2599-2608.
  8. ↑ Kane PW et al. Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears. Arthroscopy, 2018.
  9. ↑ Hoppenfeld S, Hutton R, Hugh T. Physical examination of the spine and extremities. 1st ed. New York: Appleton-Century-Crofts, 1976.
  10. ↑ 10.0 10.1 Petty NJ. Neuromusculoskeletal examination assessment: A handbook for therapists. 3rd edition. Edinburgh: Elsevier, 2006.
  11. ↑ 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.
  12. ↑ Merriman L, Turner W. Assessment of the Lower Limb. 2nd ed. Churchill Livingstone, 2002.
  13. ↑ Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.
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