High Yield Topics

Lateral Collateral Ligament Tear

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Lateral Collateral Ligament Tear
Brent S. E. Rich
Mitchell Pratte
Basics
Description
  • Partial or complete sprain of the lateral collateral ligament (LCL) owing to an acute force, usually from a medial direction
  • Consists of a cordlike fiber bundle that runs from the lateral femoral condyle to the lateral aspect of the fibular head about 1 cm anterior to the apex: discrete extracapsular structure.
  • Primary restraint to varus stress with the knee in extension
  • Isometric between 0 and 70 degrees of flexion, followed by slackening trend with deeper flexion
Epidemiology
  • Least commonly injured knee ligament; isolated injuries are rare.
  • Infrequent site of overuse injury or rupture
  • Wrestling is the most likely associated sport.
  • May be associated with injury to other ligaments [anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL)] or structures of the posterolateral corner (popliteus tendon, biceps femoris, iliotibial band, popliteofibular ligament) and peroneal nerve injuries
Risk Factors
  • Unclear if previous LCL injuries predispose to recurrent injury
  • Varus knee, otherwise normal, does not seem to be predisposed to LCL injury.
  • PCL deficiency may increase risk of LCL injury.
Diagnosis
History
  • Contact or noncontact varus stress to partially flexed knee in internal tibial rotation from direct force or, more rarely, distal indirect stress (eg, stepping into a hole) with fixed foot
  • Acute lateral knee pain
  • Many hear/feel an associated “pop.”
  • LCL is extraarticular; mild to moderate swelling is associated with isolated injury.
  • Mild disability with low-grade injury; difficult weight bearing with high-grade injury/associated injuries owing to pain and instability
  • Instability with high-grade or moderate injury
  • Check for possible peroneal nerve symptoms.
Physical Exam
  • Signs and symptoms:
    • Acute lateral knee pain associated with a mechanism of varus stress with knee in flexion of 25–30 degrees
    • Patient may feel or hear a “pop” at time of injury.
    • Swelling variable, effusion not common with low-grade injuries; associated ligamentous injuries may cause significant effusion.
    • Instability symptoms in high-grade injury or with associated underlying varus knee
    • Possible peroneal nerve symptoms
  • Physical examination:
    • Local swelling over ligament
    • Tender to palpation over ligament
    • Readily palpated in “figure-of-4 position”: Normally a pencil-like structure but less distinct with partial tears (grade II) or complete tears (grade III)
    • Varus stress testing: Grade I sprain, no increased laxity; grade II sprain, increase in laxity with semifirm endpoint at 25–30 degrees of flexion isolates the LCL; grade III sprain, increase in laxity with soft or no endpoint compared with the uninjured knee indicates injury.
    • Careful assessment of ACL (Lachman test) and PCL (posterior drawer test), posterolateral structures (external rotation recurvatum test, external rotation roll-out test at 90 and 30 degrees, posterolateral drawer sign), and pivot shift if possible. Grade I injuries may be confused with lateral meniscal tears.
    • Peroneal nerve sensory and motor function should be checked as well.
Diagnostic Tests & Interpretation
Imaging
  • Plain films to rule out occult fracture of tibial plateau, lateral femoral condyle, or fibular head on all patients
  • MRI to better assess integrity of LCL and associated knee structures (ACL, PCL, lateral meniscus, popliteus tendon, posterolateral corner)

P.355


Differential Diagnosis
  • Proximal fibula avulsion fracture
  • Biceps femoris strain
  • Iliotibial band strain
  • Popliteus strain/tear
  • Associated anterior or posterior cruciate injury
  • Lateral meniscus tear
  • Lateral compartment chondral/osteochondral injury
  • Tibial plateau fracture
  • Associated loose body
  • Peroneal nerve injury
Treatment
  • Acute treatment
  • Analgesia:
    • Ice and compression in acute setting
    • NSAIDs until acute pain subsides
    • Narcotics appropriate for 24–72 hr for grade II or III injuries or combined ligamentous injuries
  • Immobilization:
    • Grade I injury: No immobilization needed, but hinged bracing limiting flexion to 45–60 degrees is beneficial.
    • Grade II or III: Limited short-term use of knee immobilizer (<1 wk) followed by hinged brace, progressing through to full ROM over 4–6 wks
    • Bracing continues for contact or collision sport for the remainder of that season.
Additional Treatment
Additional Therapies
  • May consider more prolonged immobilization and bracing in varus knee, which is thought to increase stress on the injured ligament. This is somewhat controversial.
  • Rehabilitation:
    • In the acute setting, start isometric quadriceps exercises and straight-leg lifts.
    • Electrical stimulation/biofeedback to VMO quads
    • Gentle hamstring and calf strengthening in protective ROM
    • ROM exercises with progression to full ROM over 4–8 wks to allow ligament to heal without too much stress
    • Stair stepper or similar for CV conditioning can be added, limiting knee flexion to 45–60 degrees when tolerated.
    • Stationary bike later in rehabilitation when able to flex knee to 115 degrees without pain or residual swelling afterwards
    • When gait is normal, begin jogging and enhanced resistance exercises.
    • Progress to half sprints, full sprints, and cutting maneuvers once ligament fully healed.
Surgery/Other Procedures
Surgery is considered for grade III/combined ligamentous injuries.
Ongoing Care
Follow-Up Recommendations
  • Referral to orthopedic surgery for any fracture, associated ligament injury, complex meniscal tear, or grade III injury that is not amenable to the initial 2–4 wks of rehabilitation
  • Associated neurovascular injuries should be considered emergent, and appropriate surgical/radiographic consultations should be initiated and performed on the same day.
Additional Reading
Kozanek M, et al. Posterolateral structures of the knee in posterior cruciate ligament deficiency. Am J Sports Med. 2009;3.
Van de Velde S, et al. The effect of anterior cruciate ligament deficiency on the in vivo elongation of the medial collateral and lateral collateral ligament. Am J Sports Med. 2007;35.
Victor J, et al. How isometric are the medial patellofemoral, superficial medial collateral, and lateral collateral ligaments of the knee? Am J Sports Med. 2009;37.
Wheeless' Textbook of Orthopaedics, Duke University, 2009, http://www.wheelessonline.com/ortho/lateral/collateral/ligament
Codes
ICD9
844.0 Sprain of lateral collateral ligament of knee
Clinical Pearls
  • Average return to play for grade I injury is 1–2 wks; grade II, 4–6 wks. Return to play is greatly dependent on the type of activity.
  • Once healed, there are no data to suggest that the ligament is more predisposed to recurrent injury.


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More