REVIEW ARTICLE
Knee Ligament Anatomy and Biomechanics
Jeffrey D. Hassebrock, MD, Matthew T. Gulbrandsen, BS,
Walker L. Asprey, BS, Justin L. Makovicka, MD,
and Anikar Chhabra, MD, MS
Abstract: An understanding of knee ligament anatomy and bio-
mechanics is foundational for physicians treating knee injuries,
especially the more rare and morbid multiligamentous knee injuries.
This chapter examines the roles that the cruciate and collateral
anatomy and morphology play in their kinematics. Additionally,
the biomechanics of the ACL, PCL, MCL, and LCL are discussed
Downloaded from http://journals.lww.com/sportsmedarthro by BhDMf5ePHKbH4TTImqenVHSKDBWmBJlGl/SYjy0i3coenY5IqnhEuazeBoJ5aavp on 08/09/2020
as they have surgical and reconstructive implications.
Key Words: knee dislocation, MCL, LCL, ACL, PCL, anatomy,
biomechanics
(Sports Med Arthrosc Rev 2020;28:80–86)
M ultiple ligament knee injuries are rare, severe injuries
that commonly result in the loss of knee stability and
are often associated with damage to critical neurovascular
structures of the lower extremity. Even with modern advances
in surgical approaches and rehabilitation technology, surgical
outcomes are often poor, which has led to the controversy
around the treatment of these injuries. For optimal outcomes,
the timing of the surgery, surgical approach, tunnel prepara-
tion, and the anatomic placement of the grafts must all be
optimized. This requires the surgeons that perform the
reconstructions to have a thorough understanding of normal
knee anatomy and biomechanics. This chapter outlines the
anatomy, biomechanics, and surgical implications of the
cruciate and collateral ligaments of the knee.
ANATOMY OF THE CRUCIATES
Anterior Cruciate Ligament (ACL) Anatomy
The ACL originates from the tibial plateau, specifically,
anterior and between the intercondylar eminences. It courses
posteriorly to attach to the posteromedial portion of the lat-
eral femoral condyle. Prior research has found that up to 26%
of knees have single bundle ACLs and that there are also
knees that have a third intermediate bundle, however, it is
generally accepted that the ACL is composed of 2 bundles1,2
(Fig. 1). The 2 bundles, the anteromedial bundle and the
posterolateral bundle, are named for their relative attach-
ments on the tibia. Specifically, the medial and lateral inter-
condylar tubercles of the tibia have been described relative to
the distal attachment sites for both ACL bundles.3,4 On the
femur, the lateral intercondylar ridge (also referred to as the
residents ridge) and the lateral bifurcate ridge (also referred to
From the Department of Orthopedic Surgery, Mayo Clinic Arizona,
Phoenix, AZ.
Disclosure: The authors declare no conflict of interest.
Reprints: Anikar Chhabra, MD, MS, Department of Orthopedic Sur-
gery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix,
AZ 85054.
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as the cruciate ridge) can be used to identify the precise
attachment points for both bundles on the lateral femoral
condyle.3 The 2 ACL bundles’ attachment sites are separated
by the lateral bifurcate ridge, which is just posterior the lateral
intercondylar ridge. Anatomic studies of the ACL and its
2 bundles have shown that the ACL ranges from 31 to 38 mm
in length and 10 to 12 mm in width, whereas the anteromedial
and posterolateral bundles range from 6 to 7 mm and 5 to
6 mm in width, respectively.1,2,5
Functionally, the ACL serves a dual purpose; pre-
venting anterior translation of the tibia on the femur and
preserves normal biomechanical knee motion to prevent
meniscal damage. The 2 bundles that comprise the ACL
have unique functions that allow for the ACL’s normal
biomechanics. The anteromedial bundle is tight in flexion,
whereas the posterolateral bundle is tight in extension.6,7
The ACL has its own synovial membrane but is still
considered intra-articular. The middle genicular artery is the
primary blood supply to the ACL, while there is also some
contribution via diffusion through its synovial sheath.8,9 The
ACL is innervated by the tibial nerve which provides
mechanoreceptors that contribute to the ACL’s proprio-
ceptive function.10,11 There are minimal pain fibers in the
ACL, which explains why there is rarely pain after an acute
ACL tear until the development of a hemarthrosis.9,12
Posterior Cruciate Ligament (PCL) Anatomy
The PCL originates on the lateral aspect of the medial
femoral condyle and inserts posterior and lateral the artic-
ular plateau of the tibia. Its average length is 38 mm while
its width at the midportion is 13 mm on average.13,14 The
PCL is generally larger than the ACL with a 20% larger
surface area at the tibial attachment and a 50% greater
surface area at the femoral attachment. Unlike the ACL, the
PCL is larger at its femoral insertion than its tibial
insertion.15,16 Like the ACL, the PCL consists of 2 bundles,
however, the PCL’s bundles are named the anterolateral and
posteromedial bundles. Recent studies have allowed for a
greater understanding of the PCL’s specific attachment sites
on the femur and tibia and how they vary between indi-
viduals. The femoral footprint for the PCL measured
209 mm2 on average with the anterolateral and poster-
omedial bundles measuring 118 and 90 mm2, respectively.14
Osseous landmarks for the attachment of the PCL on the
femur include the medial intercondylar wall and medial
bifurcate ridge (Fig. 1). The surface area for the attachment
of the PCL to the tibia is 244 mm2 with the anterolateral and
posteromedial bundle attachments measuring 93 and
151 mm2, respectively. Specifically, the tibial attachment site
is on the posterior intercondylar fossa between the tibial
plateaus 1 cm distal to the joint surface.17
The posterior compartment of the knee is also where
the ligaments of Humphrey and Wrisberg are located. These
Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
FIGURE 1. Anterior view of the cruciate ligaments of a right knee
visualizing both the anteromedial (AM) and posterolateral (PL)
bundles of the anterior cruciate ligament as well as the femoral
insertion of the posterior cruciate ligament.
accessories, intra-articular ligaments are known as the
meniscofemoral ligaments and are not present in all indi-
viduals. The ligaments of Humphrey and Wrisberg originate
from the posterior horn of the lateral meniscus and insert
onto the medial femoral condyle anterior and posterior the
PCL. The ligaments average ∼22% of the cross-sectional
area of the PCL.15,16
The primary function of the PCL is to prevent poste-
rior translation of the tibia relative to the femur. The larger
anterolateral bundle is tight in flexion, while the smaller
posteromedial bundle is tight in extension.15,16,18 When
present, the ligament of Humphrey and Wrisberg serve as
secondary stabilizers to posterior tibial translation.15,16
The PCL is intra-articular and extra synovial, like the
ACL, however, a much larger part of the PCL exists
extrasynovially. Further, the PCL’s primary vascular supply
is also from the middle genicular artery. The PCL’s blood
supply is primarily soft tissue-based rather than osseous
based.19 As with the ACL, the PCL’s nerve function is
primarily proprioceptive, however, it is innervated by both
the tibial and obturator nerves.10
The Medial Compartment of the Knee
In 1979, Warren and Marshall20 described extensively
the 3 (superficial, middle, and deep) layers to the medial
compartment of the knee. The superficial layer contains the
sartorius muscle and deep fascia.21 The middle layer con-
tains the superficial medial collateral ligament (MCL),
posterior oblique ligament, medial patellofemoral ligament,
medial patellar retinaculum, and the semimembranosus.21
The deep compartment contains the deep MCL, the capsule
of the knee joint, and the coronary ligaments.21
The MCL, measuring 8 to 10 cm in length, is the largest
structure found on the medial aspect of the knee joint.22 The
MCL is composed of 2 components, superficial and deep.
The superficial MCL is located in the middle layer of the
medial compartment of the knee, while the deep MCL aptly
located in the deep layer. To locate and identify both
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Knee Ligament Anatomy and Biomechanics
FIGURE 2. View of the medial structures of a right knee high-
lighting the MCL as well as the POL. AMT indicates adductor
magnus tendon; AT, adductor tubercle; GT, gastrocnemius
tubercle; MCL, medial collateral ligament; ME, medial epicondyle;
MGT, medial gastronomies tubercle; POL, posterior oblique
ligament.
components of the MCL during surgical procedures, it is
advantageous to know the origins and insertions of each
component. The superficial MCL originates as an ovoid
semicircular portion 3.2 mm proximal and 4.8 mm posterior
to the medial epicondyle21,23,24 (Fig. 2). It has 2 distinct
insertions on the tibia, one portion inserting primarily into
soft tissue 12.2 mm distal to the joint line and a second
insertion point into cortical bone ∼61.2 mm from the joint
line.21,23,24 The deep MCL is divided into 2 segments, the
meniscotibial and meniscofemoral. The meniscotibial por-
tion attaches the meniscus to a point 3 mm distal to the
articular cartilage of the tibia and the meniscofemoral
connects the meniscus to a point 1 mm distal and posterior
to the medial epicondyle of the femur.21,23
The MCL is innervated by the medial articular nerve, a
branch of the saphenous nerve.25 The innervation is greatest
near the epiligament and near the insertions. The ligament
can perceive pain and process proprioception through
Ruffini endings, Pacinian corpuscles, Golgi receptors, and
bare nerve endings.25 Complete MCL tears will disrupt this
innervation. The blood supply to the MCL comes from the
branches of the superior and inferior genicular arteries.25
The Lateral Compartment of the Knee
The lateral aspect of the knee also contains 3 layers
referred to as the superficial, middle, and deep layers.26 The
iliotibial band and biceps femoris make up the superficial
layer.26 The lateral patellofemoral ligament and lateral
patellar retinaculum make up the middle layer, while the
lateral (fibular) collateral ligament (LCL), fabellofibular liga-
ment, popliteus tendon, politeofibular ligament, joint capsule,
and arcuate ligament make up the deep layer.26 The LCL,
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Hassebrock et al
politeofibular ligament and popliteus tendon are the 3 primary
stabilizers that are commonly reconstructed surgically.26
The LCL has a width of 4 to 5 mm and a thickness of
2.6 mm with a length of 69.9 mm.27,28 The origin is located
1.4 mm proximal and 3.1 mm posterior to the lateral epi-
condyle of the femur within an osseous depression, the
insertion is 8.2 mm posterior to the anterior aspect of the
fibular head.27,28
The innervation of the LCL has been proposed to
include 3 distinct patterns. A branch of the tibial nerve
branching from the innervation of biceps femoris, a branch
of the common fibular nerve adjacent to the popliteal fossa,
and a separate branch of the common fibular nerve at the
level of the head of the fibula.29 The blood supply to the
LCL comes from branches of the inferior lateral genicular
artery and the anterior tibial recurrent artery.30
BIOMECHANICS
Biomechanics of the Knee Joint
Healthy joints serve a dual purpose; allowing bones that
surround the joint to move while bearing the loads against
gravity caused by movement. Biomechanics is defined as the
science of the action of forces on the living body. The knee is
able to withstand tremendous forces during normal phases of
ambulation as a result of the interactions between the femur,
tibia, and patella. Kinematics is defined as the study of body
motion without regard for the cause of that motion.31 The knee
has the following planes of motion: anterior/posterior trans-
lation, medial/lateral translation, cephalad/caudad translation,
flexion/extension, internal/external rotation, and varus/valgus
angulation.32 The knee joint is responsible for providing motion
while maintaining stability during static and dynamic activities.
The balance between motion and stability is provided by the
interaction of osseous anatomy, articular surface, ligaments,
menisci, and surrounding musculature.33 Alterations or injury to
any one of these variables can alter the knee joint’s biomechanics
and increase the loads and functional stress placed on the healthy
structures. For reconstructive procedures, it is necessary to
understand the normal interaction of the structures of the knee,
so that normal structure and function can be preserved.
Flexion and extension are the primary motions of the
knee. The anatomy of the knee’s articular surfaces, surrounding
soft tissue capsule, and ligaments contribute to the passive
motion of the knee joint.34 In the sagittal plane, the knee joint
averages 0 to 135 degrees of flexion.7 The medial and lateral
femoral condyles are asymmetrical distally which leads to the
lateral femoral condyle rolling more posteriorly than the medial
condyle between full extension and 20 degrees of flexion. This
posterior rolling allows the femur and tibia to unlock without
the assistance of the surrounding musculature.33 Passive flexion
of the knee occurs via a sliding motion, with relative tibial
movement on the femur, past 20 degrees of flexion.7
The Functional Biomechanics of the Cruciate
Ligaments
The cruciate ligaments are responsible for limiting
excess anterior/posterior knee motion. In the case of a tear
or rupture to one of the cruciate ligaments, ambulatory
biomechanics can be altered. Because of their asymmetric
attachment sites, the length and tension of the ACL and
PCL vary throughout the varying degrees of flexion and
extension. This interplay, which is often referred to as the
4-bar cruciate linkage system, provides dynamic stability to
the knee joint.35
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Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
When a person stands with their knees at full extension,
the ACL is under tension while the PCL is lax and the joint
is passively stable with minimal muscular support. With
flexion, the posterolateral bundle of the ACL becomes lax
and the PCL, and specifically its anterolateral bundle,
tighten. From 20 to 50 degrees of flexion, there is less sta-
bility across the knee joint as both cruciate ligaments are
fairly lax. As flexion increases, the ACL becomes more
horizontal relative to the joint line while the PCL becomes
more vertical. This change in orientation between the ACL
and PCL provides the knee dynamic stability in the sagittal
plane. With increasing flexion, the PCL is increasingly
engaged which prevents posterior distraction of the tibia
from the joint.33,36 The center of joint rotation moves pos-
teriorly with flexion, which is demonstrated by the inter-
section of the ACL and PCL, and this allows for the sliding
and rolling movements of the femur during flexion while
preventing the femur from rolling off the tibial plateau
during deep flexion.7
As a result of changing force vectors from throughout
the gait cycle and altered mechanical loads from changing
foot position, a joint reactive force that is 2 to 5 times a
person’s body weight is produced during normal ambulation.
This changes with varying types and levels of movement and
can be as much as 24 times an individual’s body weight when
running. Muscles engage and add dynamic forces to aid in
balancing the functional loads and joint reactive forces, which
becomes especially important as the weight-bearing axis shifts
posteriorly in the knee joint.34,37 When a ligament, muscle or
bony injury occurs that affects this balance of forces, the
joint’s ability to withstand loads and forces lessens which can
lead to degeneration of the knee joint.33
The cruciate ligaments restrain the dynamic actions of
the musculature surrounding the knee during flexion and
extension. During extension, the ACL limits anterior
translation of the tibia relative to the femur, which occurs as
a result of the action of the quadriceps muscle pulling on its
insertion site at the anterior tibia. When there is a deficiency
in the ACL, anterior translation in the sagittal plane can
occur during ambulation. When this happens, the center of
rotation changes, leading to increased stress across the other
supporting structures of the knee. Further, this leads to a
decrease in the moment arm of the extensor apparatus of the
knee, which leads to an increased need for muscle forces to
maintain balance. The increased muscle forces further con-
tribute to the increased joint reactive forces and stress placed
on the supporting structures.38 Specifically, the menisci and
soft tissue capsule provide secondary support to restrain
anterior translation and experience increase stress when
there is an ACL defect. The extra stress placed on secondary
structures is corrected by quadriceps atrophy, which com-
monly occurs after an ACL rupture, as decreased muscle
strength leads to less extensor pull on the tibia.
The importance of the dynamic muscle in knee motion
is demonstrated by the screw home mechanism. During
flexion, the moment arm of the extensor apparatus of the
knee increases as the lateral femoral condyle rolls posteri-
orly. The increased moment arm provides a mechanical
advantage to the knee during running or stair climbing when
demand on the joint is greatest.36
Biomechanics of the ACL
The primary function of the ACL is to prevent anterior
translation of the tibia. It acts as a secondary stabilizer
against the internal rotation of the tibia and valgus
Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
angulation at the knee.39,40 In full extension, the ACL
absorbs 75% of the anterior translation load and 85%
between 30 and 90 degrees of flexion.41 Loss of the ACL
leads to a decreased magnitude of this coupled rotation
during flexion and an unstable knee. Many studies have
been performed to determine the biomechanical properties
of the ACL. However, uniform testing with regard to strain
rates and orientation is impossible. Several recent studies
have demonstrated that the anterior bundle has higher
maximum stress and strain than the posterior bundle.42 The
tensile strength of the ACL is ∼2200 N but is altered with
age and repetitive loads.31,43,44 As the magnitude of the
anterior drawer force increases, the in situ force of the ACL
also increases.5
Biomechanics of the PCL
The primary function of the PCL is to resist posterior
translation of the tibia on the femur at all positions of knee
flexion.45,46 It is a secondary stabilizer against the external
rotation of the tibia and excessive varus or valgus angula-
tion at the knee.47 The anterolateral band is tight in flexion
and is most important in resisting posterior displacement of
the tibia in 70 to 90 degrees of flexion. The posteromedial
portion is tight in extension; thus, it resists the posterior
displacement of the tibia in this position. Although the PCL
is the primary restraint to posterior translation of the tibia,
this function is greatly enhanced by other structures.46,48
Recent cadaveric studies have suggested that excessive
posterior translation of the tibia requires injury to 1 or more
secondary structures in addition to the PCL.49
Isolated PCL ruptures may cause a mild increased in
external rotation at 90 degrees of knee flexion, however,
they do not greatly alter tibial rotation or varus/valgus
angulation because of the intact extracapsular tissues and
ligaments. With both PCL and posterolateral corner (PLC)
injuries, there is a marked increase in tibia external rotation
because of the lack of supporting restraints.50 Harner et al15
demonstrated that the anterolateral component had a
greater stiffness and tensile strength than the posteromedial
bundle and the meniscofemoral ligaments.51 Furthermore,
Fox and colleagues demonstrated that at varying degrees of
knee flexion, different in situ forces existed. At 0 degrees, the
PCL had an average tensile strength of 6.1 N, whereas at 90
degrees, it had a tensile strength of 112.3 N. The poster-
omedial bundle attained a maximum force of 67.9 N at 90
degrees of knee flexion, whereas the anterolateral bundle
reached a maximal force of 47.8 N at 60 degrees.52 Under-
standing these relationships is critical in reconstructive sur-
gery to ensure that the grafts are tensioned properly.
In addition to its known role in the sagittal plane, the
PCL influences knee motion in the frontal plane. This occurs
because the PCL inserts onto the lateral aspect of the medial
femoral condyle and is oriented obliquely. This orientation
of the PCL aids in the articular asymmetry between the
medial and lateral femoral condyles and permits adequate
tensioning of the PCL during the rolling of the lateral
femoral condyle posteriorly in early flexion.
The popliteus muscle aids the PCL in resisting poste-
rior tibial translation and enhancing stability. Harner et al53
demonstrated that in a PCL-deficient knee, the popliteus
muscle reduced posterior translation of the tibia by 36%.
Biomechanics of the LCL
The LCL functions as the primary stabilizer to prevent
varus angulation of the knee. When isolating various
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Knee Ligament Anatomy and Biomechanics
ligaments of the posterior lateral knee, Grood et al47 deter-
mined that varus angulation was normal as long as the LCL
was intact. However, when the LCL was cut, the limit of
angulation increased by 4.5 degrees (or 4.5 mm additional
opening of the joint). The LCL also aids the PCL in resisting
external rotation of the tibia. Furthermore, current research
suggests that the LCL, as part of the posterior lateral com-
partment, aids in the prevention of anterior motion of the
tibia.54
Biomechanics of the MCL
The functions of the superficial and deep MCL differ.
The superficial MCL functions as the main contributor in
preventing valgus displacement of the knee and works in
conjunction with the ACL in preventing anterior translation
and internal rotation.21,23 The deep MCL functions as a
meniscus stabilizer and helps stabilize internal rotation of
the knee from full extension through 90 degrees flexion.24,25
INJURY PATTERNS AND SURGICAL
IMPLICATIONS OF CRUCIATE/COLLATERAL
INJURIES
Although there is limited high-level evidence for the
optimal treatment for multiligament knee injuries, there are
some studies that have shown that surgical management
improves outcome.55,56 However, in certain patients, such as
those that are elderly, inactive with comorbidities, and
others that are not surgical candidates, nonoperative treat-
ment is a viable option.55
Injury Patterns of the Cruciates and their Surgical
Implications
There is persistent controversy around the order and
necessity of reconstruction of the ACL, PCL, and PLC in
combined injuries. In isolated PCL injuries, Harner and col-
leagues showed that reconstruction led to an average posterior
tibial translation of 1.5 and 2.4 mm at 30 and 90 degrees,
respectively. In a combined PCL-PLC injury, the average
posterior translation increased to 6.0 and 4.6 mm at 30 and 90
degrees when only the PCL was reconstructed. Further, the
varus angulation increased 7 degrees and external rotation
increased 14 degrees. These results support the reconstruction
of both ligaments in combined PCL-PLC injuries.52,53 When
the ACL is torn in addition to a PCL-PLC injury, it should be
reconstructed primarily or in a staged procedure, but the PCL
and PLC should be prioritized.43 Specific surgical treatments
and treatment approaches of ACL-based and PCL-based
multiple ligaments injured knees are reviewed in the following
chapters.
Injury Patterns of the MCL and Their Surgical
Implications
The MCL is the most frequently injured ligament of the
knee and has been reported as being injured in 7.9% of all
knee injuries.22 Injuries are common in athletes and occur
during trauma or sudden changes in direction that cause
increased valgus stress. The gold standard for diagnosing
MCL injury is through arthroscopic exploration, though
this is rarely done. Consequently, a focused history and
thorough physical examination play vital roles in the eval-
uation of possible MCL injuries. Positive findings include
tenderness to palpation over the medial aspect of the knee
and increased medial opening during the valgus stress test.
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Hassebrock et al
MCL injuries are classified based on adaptations to the
Hughston grading method.
 Grade I: A few fibers of the MCL are torn, the patient
has localized tenderness to palpation, a solid endpoint is
felt, and 5 mm or less of valgus opening can be elicited.
 Grade II: More fibers of the MCL are torn, the patient
has more generalized tenderness, a perceptible endpoint is
felt, and 6 to 10 mm of valgus opening can be elicited.
 Grade III: Complete MCL tears with considerable
tenderness, no perceptible endpoint, and > 10 mm of
valgus opening can be elicited.
Surgery for MCL tears is rarely necessary, no matter the
grade of injury. Historically, studies have suggested that early
range of motion exercises and strengthening results in return
to sports and exceptional outcomes.57–66 However, surgery
should be considered in patients who have MCL tears with
complete ligament disruption. Specific indications for oper-
ative management include when the injury occurs with bony
avulsion, tibial plateau fracture, or associated anteromedial
rotary instability.67–71 Although the treatment of acute MCL
tears is debated, chronic valgus laxity after MCL injury
indicates the need for surgical intervention.67
In instances where concomitant tears occur to the ACL
and MCL, the treatment is still debated. Shelbourne and
Porter72 showed that patients were able to return to previous
activity levels after repairing the ACL without repairing the
MCL. Although Nakamura et al73 suggested that depending
on the grade of the MCL injury, it can be advantageous to
surgically repair it when reconstructing the ACL. Hughston
and Barrett74 reported good long-term results after repairing
the MCL but not the ACL.
Injury Patterns of the LCL and Their Surgical
Implications
Isolated LCL injuries are rare and can be misdiagnosed.
It is important to have a detailed history and thorough
physical examination in diagnosing LCL injuries. Injuries can
be contact or noncontact force causing varus, rotational,
extension, and/or translational force.54 Subjectively, patients
often describe feelings of instability or dull pain.
During the physical examination, swelling is often
evident, and point tenderness is commonly located directly
over the area of injury. Although a similar grading system,
identical to the grading system for MCL, found above in the
Injury patterns of the MCL and their surgical implications
section, can be used to describe LCL injuries, LCL injuries
are typically graded based on MRI results. Grade I shows
subcutaneous fluid, grade II shows morphologic disruption
of the ligament involving partial tearing of ligament fibers,
and grade III shows complete tearing of the ligament.54
As multiple injuries to the PLC occur contiguously
with LCL injuries, it is important to assess the integrity of
other components of the PLC through various maneuvers
including the recurvatum test, dial test, and posterolateral
drawer test.
Grade I and II LCL injuries without additional knee
injuries are typically managed nonsurgically. Because of the
rarity for isolated grade III LCL tears, little literature exists
to determine if surgical management provides improved
outcomes. Studies by Kannus75 and Krukhaug et al76 sug-
gested that nonoperative management of grade III injuries
results in poor outcomes; however, Bushnell et al77 showed
that NFL players who were managed nonoperatively for
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Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
grade III LCL tears recovered similarly to those treated
operatively. It has also been demonstrated that LCL tears
do not heal as well as MCL tears,27 suggesting a lower
threshold for surgical treatment. In general, the common
practice is to treat grade I and II LCL tears nonoperatively
and to treat grade III LCL tears operatively.
However, when LCL injuries occur in the setting of
multiligamentous knee injuries, early surgical intervention is
advantageous.78 When comparing repair versus recon-
struction for LCL tears in multiligamentous knee injuries,
repairs were found to have much higher rates of failure.79,80
CONCLUSIONS
Knee dislocations are severe injuries that can com-
promise multiple ligaments, the surrounding musculature,
and critical neurovascular structures.81 The damage to lig-
aments and other surrounding soft tissue can lead to bio-
mechanical deficiencies in the knee before and after recon-
struction is attempted. To prevent loss of biomechanical
function, surgeons performing reconstructions of multiple
ligament knee injuries must have a thorough understanding
of normal anatomy and biomechanics of the entire knee.
Although acute diagnosis and treatment can be difficult and
are controversial, a strong foundational knowledge of the
knee joint and its biomechanics helps optimize a surgeon’s
decisions about when surgery is performed, the order that
ligaments are reconstructed, and the rehabilitation of the
associated musculature.
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