LIGAMENTS INURIES AROUND THE KNEE ARE ONE OF THE MOST IMPORTANT TOPICS TO UNDERSTAND WHICH CONTAIN ACL, PCL, MCL, LCL, PLC, MPFL, ALL ETC. IT IS IMPORTANT TO UNDERSTAND THE MECHANISM OF ACTION, RADIOLOGICAL PART, SIGNS AND SYMPTOMS, SPECIAL EXAMINATION TESTS, AND HOW TO TREAT THE PATIENT. THE BASIS OF THE INJURY, HOW ISOLATED INJURY CAN OCCUR AND HOW ONE LIGAMENT INJURY CAN LEAD TO OTHER LIGAMENT INJURIES.

1. LIGAMENTS INJURIES
AROUND KNEE
Dr. MIT PARIKH
RESIDENT ORTHOPEDICS
GEETANJALI MEDICAL COLLEGE AND HOSPITAL
UDAIPUR

2. KNEE STABILIZERS
STATIC
• Cruciate ligaments – 1. ACL
2. PCL
• Collateral ligaments – 1. MCL
2. LCL
• Meniscus – 1. Medial meniscus
2. Lateral meniscus
• ALL
• MPFL
DYNAMIC
• Muscle around the knee joint

4. ACL – Anterior cruciate ligament
• ATTACHMENT – 1. Tibia
2. Femur
• ACTION
• The length of the ACL is about 4 cm and
the average width is 11mm.
• TWO BUNDLE – 1. Antero medial
2. Postero lateral

5. ACL
Tight in flexion AM
Tight in extension PL

6. • EPIDEMIOLOGY
• MECHANISM OF INJURY
1. External rotation and abduction with the knee
at 90 degree flexion
2. Complete dislocation of the knee joint
3. Direct posterior force against the upper end of
the tibia
4. Internal rotation of the tibia while knee is
extended
5. O’Donoghue Triad

7. SIGN AND SYMTOMS
SYMPTOMS
• Extremely painful knee
• Knee Instability
• Poping sensation
• Difficulty in walking
• Difficulty in weight-bearing
SIGN
• swelling
• Knee effusion – A/C cases
• Quadriceps wasting – chronic
cases

8. SPECIAL TESTS
1. ANTERIOR DRAWER TEST –
• Position and procedure
• Range
• False negative test

9. 2. LACHMAN TEST –
• Position and procedure
• Most sensitive
3. PIVOT SHIFT TEST –
• Position and procedure

10. • GRADE 1 SPRAINS- The ligament is
slightly stretched, but still the knee
joint is stable.
• GRADE 2 SPRAINS- There is
moderate functional impairment.
There is tenderness, pain, swelling
• GRADE 3 SPRAINS- Unstable knee
joint. Severe swelling and mechanical
instability are seen. The patient is not
able to angulate and bear weight.

11. MRI
NORMAL ACL
The anterior cruciate ligament normally has a heterogeneous appearance and the
anteromedial and posterolateral bundles are defined by surrounding high-intensity structures
ACL TEAR
• Increased signal on T2 or fat-saturated PD
• fiber discontinuity
• abnormal anterior cruciate ligament orientation relative to intercondylar (Blumensaat) line
• ACL fibers are subjectively less steep than a line tangent to the intercondylar roof (Blumensaat line)

14. PCL- POSTERIOR CRUCIATE LIGAMENT
• ATTACHMENT – 1. Tibia
2. Femur
• ACTION
• The mean length of this ligament is
38mm and width 13 mm.
• TWO BUNDLE – 1. Ant Lateral
2. Post. Medial

16. • EPIDEMIOLOGY
• MECHANISM OF INJURY
1. Direct posterior trauma to the upper
tibia while knee flexed
2. Hyperextension injury
3. Dashboard Injury
4. Severe rotational injury
5. Complete dislocation

17. CLINICAL FEATURES
SIGN
• TENDERNESS OVER THE POPLITEAL
FOSSA AND SWELLING in almost every
case
• POSTERIOR SAG SIGN
SYMPTOMS
• Patient is usually able to walk
with mild tear but complain about
difficulty in weight-bearing
• Pop sound at the back of the knee
• Trouble going downstairs
• Pain worsens over time
• Feeling of instability of the knee
• Wobbly sensation

18. SPECIAL TESTS
1. Posterior Drawer test
• Position and procedure
• Range
• False negative test
2. Posterior sag test
• Position and procedure

19. 3. Dial Test
• Position and procedure
4. Quadriceps active test
• Position and procedure

21. RADIOLOGY
MRI
• PCL is homogenously low in signal on T1 and T2-weighted sequences and demonstrates a
smooth convex posterior curve
TEAR
• Partial tears or degenerative changes of the PCL usually involve the central fibers of the
PCL without loss of PCL continuity.
• Complete PCL tears demonstrate focal interruption of the ligament fibers and alterations in
PCL contour .

24. MEDIAL COLLATERAL LIGAMENT
• Main stabilizer of the medial aspect of
knee
• Anatomy – 1. Origin
2. Attachment
• 8 – 10 cm in length
• Layers – 1. sMCL
2. dMCL
• Fibers – 1. Ant
2. post.

25. BIOMECHANICS
• Ant fibers – vertical and parallel
• Post fibers - oblique
• In complete extension – both fibers are taut
• In complete flexion – Ant fibers taut
Post fibers relaxed
• Restrain against ant displacement of the medial tibial condyle and external
rotation of tibia.

26. • EPIDEMIOLOGY
• MECHANISM OF INJURY
1. External Rotation beyond 45 degree
2. External Rotation beyond 45 degrees
plus Abduction
3. Violent Abduction when the knee is
fully extended

28. Grade 1
• Little or no joint effusion
• Mild to moderate joint stiffness
• Point tenderness just below medial
joint line
• Almost full movement
Grade 3
• Complete loss of medial stability
• Immediate severe pain
• Swelling
• Dull aching pain after initial episode
Grade 2
Mild to moderate swelling
Moderate to severe joint stiffness
Loss of passive range of motion
Weakness and instability

29. SPECIAL TESTS
1. Valgus stress test
• Position and procedure

30. RADIOLOGY
GRADE 1: intact ligament
normal in signal with
surrounding edema
and/or hemorrhage
GRADE 2: partial rupture
abnormal signal within the
ligament itself and/or fluid
surrounding the ligament in
MCL bursa
GRADE 3: complete
rupture, frank disruption
and discontinuity of
ligament

31. Grade I MCL Tear
• Rest and icing the injury
• Anti-inflammatory medications
• 1-2 weeks recovery time
Grade II MCL Tear
• Hinged knee brace
• 3-4 weeks recovery time
Grade III MCL Tear
• Knee immobilizer
• Crutches
• Knee brace (after the knee can bend)
• Regain strength in quadriceps
• 3-4 months recovery time
TREATMENT

32. POSTERO LATERAL CORNER LIGAMENT INJURY
• Posterolateral corner (PLC) injuries are
traumatic knee injuries that are
associated with lateral knee instability
and usually present with a concomitant
cruciate ligament injury (PCL > ACL)

33. STATIC STABILIZER
• Lateral collateral ligament
• Popliteus tendon
• Popliteofibular ligament
• Arcuate ligament
• Lateral capsule thickening
• Fabellofibular ligament
DYNAMIC STABILIZER
• Biceps femoris
• Popliteus muscle
• Iliotibial band
• lateral head of gastrocnemius

34. MECHANISM OF INJURY
• Blow to anteromedial knee
• Varus blow to flexed knee
• Contact and noncontact hyperextension injuries
• External rotation twisting injury
• Knee dislocation

35. SIGN AND SYMPTOMS
• ACUTE
1. Knee swelling and ecchymosis
2. contusion and abrasion on
anteromedial tibia
3. Antalgic gait.
• CHRONIC
1. Asymmetric pathologic varus
alignment on standing
2. Varus thrust gait
3. Motor and/or sensory deficit can be
present

36. SPECIAL TESTS
1. EXTERNAL ROTATION RECURVATUM TEST
• Position and Procedure
2. POSTEROLATERAL DRAWER TEST
• Position and procedure

37. 3. VARUS STRESS TEST
• Position and Procedure
4. REVERSE PIVOT SHIFT TEST
• Position and Procedure

39. XRAY
1. Arcuate Fracture
2. Abnormal widening of lateral joint space

40. INJURY TO THE PCL COMPLEX CAN BE GRADED ON MRI,
GRADE 1:- Edema surrounding an intact ligament .
GRADE 2:- Intrasubstance ligamentous signal, possibly with
ligamentous thickening or thinning and surrounding edema.
GRADE 3 :- Frank disruption and discontinuous fibers

42. MENISCAL INJURY
Two menisci(medial and lateral) exist
between the femoral and tibial
articulation.The femoral articulating
meniscal surface is concave,whereas
the tibial articulating surface is
convex.These surfaces conform to the
convex and concave opposing chondral
surfaces, respectively.

43. FUNCTION
1. Load distribution
2. Acts as joint filler compensating for the gross incongruity between tibial and
femoral articulating surfaces
3. Prevent capsular and Synovial impingement during flexion-extension
movements
4. Joint lubrication helps to distribute Synovial fluid through the joint and aids the
nutrition of articular cartilage.
5. Contribute to stability in all planes but are important rotatory stabilizers.
6. Shock absorption; the larger area provided by the meniscus reduces the
average contact stress between the bones.

44. MECHANISM OF INJURY
1. MEDIAL MENISCUS
• Internal rotation of the femur over the
tibia with the knee in flexion
• The posterior horn may be trapped in
this position by sudden extension of
the knee
2. LATERAL MENISCUS
• Vigorous external rotation of the femur
while the knee is flexed
• During sudden extension of the knee,
an anterioposterior distracting force
tends to straighten the cartilage and
imposes a strain on the medial concave
rim, which tears transversely and
obliquely

45. DESCRIPTIVE CLASSIFICATION –
LOCATION
• red zone (outer third, vascularized)
• red-white zone (middle third)
• white zone (inner third, avascular)

46. Type of tear Characteristics
Vertical longitudinal
– The most Common (especially in the setting of ACL
tears).
– It can be repaired if located in the peripheral third of
the meniscus.
Bucket handle meniscus tear
– A vertical longitudinal tear displaced into the notch.
– Double PCL sign.
Radial
– Starts centrally and proceeds peripherally.
– It’s not repairable because of loss of circumferential
fiber integrity.
Flap
– Begins as a radial tear and proceeds circumferentially.
– May cause mechanical locking symptoms.
Horizontal cleavage
– Occurs more frequently in the older population.
– May be associated with meniscal cysts.
Complex
– A combination of tear types.
– More common in the older population.

48. SIGN AND SYMPTOMS
• H/O twisting injury
• Pain
• LOCKING
• Effusion
• Clicks, snaps, or catches

49. SPECIAL TEST
1. MCMURRAY TEST
• Position and Procedure
2. APLEY’S GRINDING TEST
• Position and Procedure

50. 3. THESSALY TEST
• Position and Procedure

51. MRI

55. MEDIAL PATELLO-FEMORAL LIGAMENT INJURY
• ATTACHMENT
• FUNCTION
• MECHANISM OF INJURY
1. Outward torsion of the leg while the
knee is fully extended
2. Direct blow to the knee

56. SIGN AND SYMPTOMS
• A sense that the knee is buckling
and can no longer support your
weight
• The kneecap slips off to the side of
the joint and no longer feels as
though it is in the proper position
• Pain in the front of your knee that
increases with activity
• Knee pain while sitting
• Stiffness or swelling in the knee
• Creaking or cracking sounds when
you move your knee
• SILVER SIGN

57. MPFL injury patterns according to Balcarek et al.
SCHOTTLE POINT

59. TREATMENT
• INDICATION FOR MPFL RECONSTRUCTION
1. Recurrent patellar dislocation
2. Osteochondral injury at the time of dislocation
3. Failure of non-operative treatment for almost 3 months
4. High-level athletes that suffered a nontraumatic dislocation

60. RECENT ADVANCES
ANTEROLATERAL COMPLEX
• Superficial IT band
• Deep IT band
• Anterolateral ligament
ATTACHMENT -
FUNCTION –

61. THANK YOU