REVIEW ARTICLE
Physical Examination and Imaging of the Medial Collateral
Ligament and Posteromedial Corner of the Knee
Peter R. Kurzweil, MD and Steven T. Kelley, MD
Abstract: The medial side is one of the most commonly injured
areas of the knee. The anatomy, diagnosis, and treatment of
medial collateral ligament and posteromedial corner (PMC)
injuries can be challenging. Understanding the mechanism of
injury and performing a thorough physical examination and
radiographic evaluation is essential. Frequently, there are
concomitant meniscal and other ligament injuries associated
with medial-side injuries. Correct identification of all injured
structures is important, as missed diagnoses can lead to
significant disability. Unrecognized PMC injuries have been
implicated in anteromedial rotary instability and failed anterior
cruciate ligament reconstructions. Valgus stress testing is the
cornerstone for the identification of medial-side knee injuries.
Coronal sequences from magnetic resonance imaging are the
most useful tool to view the medial collateral ligament and
posteromedial structures. Stress x-rays and ultrasound may also
be helpful. Thorough physical examination and imaging of
injuries to the PMC should dictate the appropriate treatment for
optimal results.
Key Words: medial collateral ligament, posterior oblique
ligament, posteromedial corner, Pellegrini-Stieda lesion, knee
ligament injuries
(Sports Med Arthrosc Rev 2006;14:67–73)
T here has been a recent emphasis on the anatomy of the
posterolateral and, to a lesser extent, the postero-
medial corners (PMCs) of the knee. Investigators are
finding that injuries to either of these areas can produce
rotary instability that may need to be addressed during
the reconstruction of the multiple ligament-injured knee.
Robinson et al found that the PMC has 3 distinct
ligamentous components crossing the joint line: the
superficial MCL, the deep MCL, and the posteromedial
capsule. They did not find a discrete ligament where the
posterior oblique ligament had previously been de-
scribed—only capsular condensations, which seem to be
From the The Southern California Center for Sports Medicine, Long
Beach, CA.
No funding was received in support of this study. No author has
received anything of value from a commercial party related directly
or indirectly to the subject of the presentation.
Reprints: Peter R. Kurzweil, MD, Southern California Center for Sports
Medicine, 2760 Atlantic Avenue, Long Beach, CA 90266 (e-mail:
pkurzweil@aol.com).
Copyright r 2006 by Lippincott Williams & Wilkins
Sports Med Arthrosc Rev  Volume 14, Number 2, June 2006
a functional unit with links to the semimembranosus
tendon sheath. The authors found the posteromedial
capsule to be a passive restraint to internal rotation of the
tibia with the knee in extension.1
It is well known that the capsuloligamentous layers
of the medial side of the knee provide static stabilization
against a valgus force. The MCL is the primary restraint
to valgus force, but the PMC and anterior cruciate
ligament (ACL) increase their contribution to valgus
restraint with the knee in extension.2–4
The medial side is one of the most frequently injured
areas in the knee.2,5 Most medial-side knee injuries arise
from a valgus force applied to the lateral aspect of the
knee with the foot planted on the ground. This mechan-
ism of injury is common in contact sports such as
football, rugby, and hockey. A recent prospective study
of Division I collegiate hockey players found that damage
to the medial collateral ligament (MCL) was the most
common knee injury sustained, and second only to
concussions when considering all potential injuries.6
Although rare, complete disruption of the medial
structures of the knee can also occur from a rotational
force alone. Downhill skiing is one such activity that can
subject the knee to such external rotational forces. The
MCL is the most commonly injured knee ligament in
skiers, representing 60% of all skiing knee injuries.7 If a
valgus force is combined with external rotational, tears to
the medial structures and the ACL can occur. With these
combined injuries, there is a predilection for meniscal
injury as well with a 3- to 9-fold predominance of lateral
meniscus tears.8,9
Chronic medial laxity or combined valgus/external
rotational injury patterns can have an effect on other
structures in the knee, particularly the ACL and the
menisci. Therefore, it is important to perform a compre-
hensive physical examination when addressing a knee that
has sustained a valgus force injury. Understanding the
possible injury patterns will also help guide the physician
in evaluation of the injury.
PHYSICAL EXAMINATION
The goal for this evaluation is to determine the
location and degree of injury to the MCL, and the
presence of any associated injuries. The examination can
be divided into 4 phases: (1) initial observation of the
patient’s gait, (2) documentation of the neurovascular
status of the leg, (3) observation and palpation of the
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Kurzweil and Steven
knee for tenderness, swelling, and ecchymosis, and (4)
testing for laxity of the MCL.
If possible, one should observe and examine the
knee with the patient in the standing, sitting, and supine
positions. A patient with a complete tear of the MCLs
may walk with a barely perceptible limp, although the
stride can be slightly shortened on the involved side. A
vaulting-type gait might be exhibited, where the quad-
riceps are acting to help stabilize the joint. This differs
from the patient with an acute ACL or meniscal injury
who typically walks with a bent-knee/equinus gait due to
the large joint effusion.10 If the clinician is unable to
observe the patient’s gait as he or she enters the
examination room, it should be performed at some point
during the examination.
As with all knee injuries in the acute setting, it is
essential to evaluate the neurovascular status of the
extremity. This is especially important after a high-energy
injury. The pedal pulses and sensation over the dorsum of
the foot, first web space, and plantar region are
documented. The ability to dorsiflex the great toe and
ankle should be recorded.
The third phase of the evaluation looks at specific
anatomic locations of the knee. The patient may have a
characteristic soft tissue bruising over the medial aspect of
the knee with an MCL injury (Fig. 1). Although rare,
medial skin dimpling has been associated with an
irreducible posterolateral knee dislocation.11 The entire
course of the MCL should be palpated from proximal to
distal. This is often best accomplished with the patient in
a supine position and the hip and knee comfortably
flexed. Tenderness usually indicates that some degree of
injury has occurred. In the authors’ experience, the
femoral origin of the MCL at the medial femoral condyle
is the most common site of maximal tenderness. Distal
tears of the MCL would result in tenderness along the
proximal tibia, often at or below the level of the pes
anserine tendons. Midsubstance tears may be associated
FIGURE 1. Inspection may show marked areas of ecchymosis
over the medial aspect of the knee.
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Sports Med Arthrosc Rev  Volume 14, Number 2, June 2006
with joint line tenderness, creating potential difficulty in
distinguishing meniscal tears from collateral ligament
injury. Even if convinced of an isolated MCL injury, it is
important not to ignore the lateral structures (Fig. 2). A
valgus knee injury that disrupts the MCL can lead to
bone contusions or damage to the meniscus in the lateral
compartment. This could result in significant tenderness
along the lateral joint line or lateral femoral condyle.
When examining medial-side knee injuries, it is
important to distinguish between localized soft tissue
swelling and an intra-articular effusion. The former is
commonly seen with an isolated MCL injury; the latter is
often associated with intra-articular pathology such as an
ACL or meniscal tear. However, when damage to both
the MCL and the ACL is present, the size of the
hemarthrosis may be minimal because of the extravasa-
tion of blood through the tear of the medial capsular
ligament.
Evaluating for fluid is best performed with the
patient in a supine position. The concavities on either side
of the patellar tendon were compared with the normal
knee. Isolated MCL injuries often produce no or minimal
effusion, so the findings can be subtle. One can check for
large effusions by assessing for fullness in the suprapa-
tellar pouch and the presence of a ballotable patella. With
more subtle effusions, it may be possible to demonstrate a
‘‘fluid wave.’’ By milking fluid with the heel of the hand
on the medial side of the knee from distal to proximal and
then immediately sweeping the lateral side from proximal
to distal using the fingertips of the opposite hand, an out-
pouching of the skin medially indicates the presence of
small effusion. Large effusions or a hemarthrosis may
occur with significant bone contusions in the lateral
compartment. In these situations a side-to-side difference
in the size of the knees is obvious (Fig. 3).
The final and perhaps most important phase of the
examination is testing the integrity of the MCL. Valgus
stress testing is the cornerstone to making the diagnosis
FIGURE 2. Note the contusion in the lateral femoral condyle.
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Sports Med Arthrosc Rev  Volume 14, Number 2, June 2006
FIGURE 3. A large hemarthrosis can occur with significant
bone contusions.
and grading the injury. A pillow under the affected knee
will generally make the patient more comfortable. It is
often beneficial to examine the normal knee first, which
may also make the patient less apprehensive. The authors
have found that patients are less apprehensive when they
know what physical examination maneuvers they can
expect when the side in pain is later examined. In
addition, the contralateral knee serves as a control to
determine the presence and degree of asymmetrical
medial joint opening.
The examination is conducted at both 0 and 30
degrees of knee flexion, and the amount of ‘‘opening’’ at
the medial joint line is evaluated. A 30-degree test isolates
the MCL, and is typically performed first. It is usually
performed with the hip slightly abducted and flexed, with
the lower leg cradled securely between the examiner’s
waist and elbow (Fig. 4). The opposite hand can be used
to help suspend and stabilize the leg as it applies a valgus
force. When examining a larger patient or one with
significant guarding, let the thigh rest on the table
FIGURE 4. Technique of stressing the MCL.
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MCL Exam and Imaging of the Knee
allowing the lower leg to drop off to the side while
supporting the foot and ankle. This position will help
keep the thigh musculature relaxed and the patient
comfortable.
When applying the valgus stress, place a finger on
the medial joint line to help assess the amount of medial
joint opening. According to the American Medical
Association guidelines, the injury is graded as to how
much more the injured side opens compared with the
uninjured side.12 A grade I injury allows 0 to 5 mm of
opening with a firm end point, a grade II injury allows 5
to 10 mm with a firm end point, and a grade III injury, or
a ‘‘complete’’ tear of the superficial and deep portions of
the ligament allows greater than 10 mm of opening and
the end point is usually soft. One can also get a sensation
of the knee opening and reducing with more significant
injuries. It is worth emphasizing that a difference of only 5
to 8 mm can be indicative of significant structural damage
to the MCL. Injuries to the MCL will often result in pain
over the ligament during valgus stress testing.
It may be helpful, when performing a valgus stress
at 30 degrees of knee flexion, to hold the lower extremity
by the plantar surface of the foot rather than the distal
portion of the leg during abduction. This may allow for
appreciation of a rotary component by placing a slight
rotary stress on the foot and observing for any
anteromedial rotation of the tibial plateau on the medial
femoral condyle. A positive finding of rotary instability
may suggest damage to the PMC of the knee. Although
an injury to the posterolateral corner and anteromedial
corner may both result in increased external rotation
during rotatory testing manuevers, only the latter will
cause the medial tibial to sublux anteriorly. Injury to this
meniscocapsular complex is believed to interrupt the
static and dynamic resistance to anteromedial rotary
instability throughout the normal range of motion.13 This
finding may represent a subset of patients in whom the
medial-side injury requires surgical repair, especially in
the face of a concomitant ACL rupture.
Valgus stress testing in full extension is the second
part of this evaluation. Once again, the degree of medial
laxity is compared with the uninjured knee. Opening in
full extension is a much more ominous sign and is
indicative of a complete MCL rupture (grade III) and
PMC damage. It may also be associated with ACL or
posterior cruciate ligament (PCL) injury. Other injuries
reported with medial laxity in full extension include
tearing of the vastus medialis obliquus and patellar
instability.14 There have been recent case reports of lateral
patellar dislocations associated with avulsion of the
femoral origin of the MCL and the medial patellofemoral
ligaments.11,15
The external rotation anterior drawer test is another
provocative test to determine the degree of injury. This
maneuver assesses the amount of anterior translation of
the tibia with the knee flexed at 80 degrees and the tibia
externally rotated at 15 degrees (Fig. 5). The examiner
will notice more translation of the medial tibial condyle,
which seems to be fuller and more prominent. The test is
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Kurzweil and Steven Sports Med Arthrosc Rev  Volume 14, Number 2, June 2006

FIGURE 6. Supine AP radiograph of patient with grade 1 MCL

on right and grade 3 on left. Note the significant medial joint
space widening on the left.
FIGURE 5. Slocum’s modified anterior drawer.

positive if there is a side-to-side difference with the A technique of stress radiography to help evaluate
contralateral knee. This indicates disruption of the and document laxity has been proposed by Sawant et al.17
meniscotibial ligaments that allows the meniscus to move In this study, the authors performed comparative stress
freely. If these ligaments are intact, the meniscus remains radiographs of the injured and uninjured knees with the
firmly seated on the tibia, providing a buttress against patients under general anesthesia before arthroscopy.
the posterior femoral condyle and thus resisting anterior With the knees bound together and a cassette placed
translation of the tibia.16 under both knees, the examiner stands at the foot of the
table between the patient’s legs and applies simultaneous
valgus forces to each knee until the end points have been
IMAGING reached. A single radiograph is taken and the opening of
Although the history and physical examination are the medial joint space is compared. The authors of that
critical to determining the type and degree of ligamentous study found that opening of the medial joint space to
damage to the knee, it may be difficult to perform the twice or more of that of the normal knee was indicative of
appropriate examination due to pain, swelling, and ACL/PCL damage in addition to MCL rupture. It
muscle spasm. Repeat examination at a later date when remains to be determined how clinically useful this test
the inflammation is reduced can be important. Through could be, and is not something we have routinely used.
the use of a number of imaging modalities, the location
and extent of damage to the MCL and other structures
MAGNETIC RESONANCE IMAGING
can be determined.
Magnetic resonance imaging (MRI) has become the
imaging modality of choice when investigating injuries
RADIOGRAPHS that may involve damage to the ligaments, menisci,
A standard radiographic knee series is indicated in
all cases of suspected MCL injuries. As with all injuries,
we recommend a complete ‘‘knee series,’’ which includes
anterior-posterior (AP) and 45 degrees flexion (tunnel)
views, a lateral and sunrise view. Although standing views
are often desired to demonstrate limb alignment and
narrowing of the joint space, they may not be practical in
patients with significant pain when weight bearing. High-
grade MCL sprains, especially when combined with a
cruciate injury, may show medial joint space widening on
a supine AP view (Fig. 6). Avulsions or osteochondral
fragments seen on x-ray could significantly affect the
treatment plan. Any young patient with increased laxity
to valgus stress and open physes should have stress views
to rule out a fracture through the growth plate. In chronic
cases with instability, long-standing cassette radiographs
of both lower extremities should be obtained to assess
limb alignment. Chronic injuries may have calcification at
the medial femoral condyle insertion known as the FIGURE 7. Pellegrini-Stieda lesion indicating chronic MCL
Pellegrini-Stieda lesion (Fig. 7). insufficiency.

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Sports Med Arthrosc Rev  Volume 14, Number 2, June 2006 MCL Exam and Imaging of the Knee

physes, or other key structures about the knee.18–20 The

presence of meniscal tears, the location of the MCL tear,
and any concomitant injuries can be accurately
diagnosed.21 This study is particularly useful when the
physical examination is compromised. MRI can also
reveal pivotal information that may alter an operative
plan, such as the presence of an entrapped MCL lesion,
even in apparently straightforward cases.11,22
The MCL is best visualized on the coronal imaging
sequences, where it is normally visualized as a taut black
structure on both T1-weighted and T2-weighted images.
It extends from the medial femoral epicondyle to the
medial tibial metaphysis and is typically 8 to 10 cm long.
This uniformly low-signal-intensity line extends 5 to 7 cm
distal to the joint line, deep to the pes anserinus
insertion.23
When the MCL is injured, the fiber continuity and
the amount of edema on T2-weighted images helps to
determine the radiographic grade of injury. The classic
method of grading MCL injuries by MRI is to divide
them into 3 grades. Grade I is characterized by
periligamentous swelling with minor tearing of the
ligament fibers. Grade II displays complete disruption
of the superficial layer but the deep fibers remain intact.
Grade III shows complete disruption of both the super-
ficial and deep layers with fluid extravasation from the
joint into the periligamentous tissue24 (Fig. 8). Restora-
tion of valgus stability clinically has been significantly
correlated with the location and amount of superficial
MCL fiber damage on MRI.25
Lateral compartment injuries are commonly asso-
ciated with MCL tears and are easily assessed with MRI.
Miller et al26 showed that 45% of all isolated MCL tears
have evidence of bone contusion in the lateral femoral
condyle, lateral tibial plateau, or both. Evaluation of the
lateral meniscus is also important, especially in the
multiple ligament-injured knee, as the incidence of
meniscal injury increases significantly.
Despite the multitude of magnetic resonance
sequences that are available, it remains difficult to
delineate the posteromedial capsule even in uninjured
knees. Demonstration of posteromedial capsule tears with
MRI may be useful in the preoperative planning of repair
and restoration of normal knee stability. Loredo27
performed an anatomic-MRI correlative study to inves-
tigate the posteromedial corner of the knee. Even using
uninjured cadaveric knees, an atypical coronal oblique
plane and intra-articular administration of gadolinium,
the authors still concluded assessment of the PMC of the
knee to be difficult.

ULTRASOUND FIGURE 8. Grade 1 lesions show periligamentous swelling

Ultrasound is increasingly being used to assess
superficial soft tissue structures and injuries to the
knee.28,29 Few studies, however, have addressed the
anatomy of the normal knee collateral ligaments
or injuries to these structures sonographically.30–32
Ultrasound can be somewhat dependent on a technician
with interstitial fiber tears but maintenance of continuity of the
ligament (A). Grade 2 lesions show disruption of the superficial
portion of the ligament (B). Grade 3 lesions have disruption of
both elements. Also note the significant lateral compartment
edema in all 3 images and a concomitant lateral meniscal tear
in grade 3 (C).

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Kurzweil and Steven
or center, making it often difficult for even an experienced
radiologist to identify the medial and lateral collateral
ligaments in every patient. A recent study demonstrated
that by identifying 2 bony landmarks, the medial femoral
epicondyle and the sulcus of the semimenbranous tendon,
the superficial portion of the MCL could be reliably
identified in most patients. However, the deep portion of
the MCL and the PMCs were more difficult to identify.33
Although ultrasound provides a less expensive method
for evaluation of the anatomy of the knee, it remains
operator dependent and thus far fails to reliably provide
the anatomic detail needed to evaluate the severity of
injury and any concomitant injuries.
ANGIOGRAM
In cases of disruption of the MCL associated with
tearing of the ACL or PCL, or a known knee dislocation,
careful consideration must be given to evaluating the
lower limb vasculature with an angiogram. The incidence
of vascular injury associated with knee dislocation has
been reported as high as 30%.34 If diminished distal
pulses are palpated, then an angiogram is indicated.
However, if the pedal pulses are normal and the arterial-
brachial index is >0.9, then observation with repeat
examinations is the appropriate course of action.
CONCLUSIONS
Injuries to the medial side of the knee are relatively
common and may cause significant disability especially if
the PMC is involved in conjunction with other ligament
ruptures. Correct identification of all injured anatomic
structures is important when deciding between conserva-
tive and operative treatments. The determination of the
severity of the injury must rely on the summation of clues
from a detailed patient history, physical examination, and
combined radiographic studies. Missed anteromedial
rotary instability may affect the long-term viability of
an ACL graft or the long-term function of the knee
especially with respect to compromising the integrity of
the medial meniscus.
The phrase ‘‘medial-side knee injury’’ has unfortu-
nately become synonymous with an MCL sprain or tear.
However, it is important to recognize that more extensive
injury involving the PMC and the meniscus may exist and
deserve further evaluation. Failure to consider the
possible functional contribution that the PMC structures
lend to dynamic stability may lead to more serious long-
term consequences. Unrecognized and unaddressed PMC
injuries have been implicated in some ACL reconstruction
failures.35–37 The dynamic stability provided by an intact
PMC may also explain why some ACL disruptions can
have excellent functional outcomes without surgical
intervention. Further studies of injuries to the PMC and
its functional significance to the long-term performance of
the knee are needed.
Sims et al13 summed up 3 concepts they deemed
important with regard to medial-side knee injuries: (1) not
all medial-side knee injuries are created equal, (2) the
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Sports Med Arthrosc Rev  Volume 14, Number 2, June 2006
PMC structures act in dynamic fashion to resist
anteromedial rotary instability, and (3) although less
anatomically complex as the posterolateral corner, the
PMC is no less important functionally.
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