52

The Collateral Ligaments and Posterolateral

Corner: What Radiologists Should Know
Violeta Vasilevska Nikodinovska, MD, PhD, MSc1 Lana H. Gimber, MD, MPH2 Jolene C. Hardy, MD3
Mihra S. Taljanovic, MD, PhD, FACR2

1 Department of Radiology, Musculoskeletal Radiology, Medical
Faculty, University “Ss. Cyril and Methodius” Skopje, University
Surgical Clinic “St. Naum Ohridski” Skopje, Republic of Macedonia
2 Department of Medical Imaging, The University of Arizona, College of
Medicine, Banner-University Medical Center, Tucson, Arizona
3 Department of Orthopaedic Surgery, The University of Arizona,
College of Medicine, Banner-University Medical Center,
South Campus, Sports Medicine Clinic, Tucson, Arizona
Address for correspondence Violeta Vasilevska Nikodinovska, MD,
PhD, MSc, Department of Radiology, Musculoskeletal Radiology,
Medical Faculty, University “Ss. Cyril and Methodius” Skopje, University
Surgical Clinic “St. Naum Ohridski” Skopje, 1000, Republic of
Macedonia (e-mail: v_vasilevska@yahoo.com).

Semin Musculoskelet Radiol 2016;20:52–64.

Abstract Ligamentous and tendinous structures of the posterolateral corner of the knee provide

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important static and dynamic stability to the knee joint and act in conjunction with
anterior and posterior cruciate ligaments. Injuries of these structures are not uncom-
Keywords mon. Failure to treat posterolateral corner injuries leads to posterolateral instability of
► posterolateral corner the knee and subsequently poor outcome of cruciate ligament reconstructions.
► knee Currently, MRI is the diagnostic modality of choice in the evaluation of posterolateral
► ligament corner injuries of the knee. We review normal MR imaging anatomy of the complex
► injury anatomical structures of the posterolateral corner of the knee, their biomechanical
► MR imaging function, injuries, and current treatment options.

The anatomy of the ligamentous and tendinous structures
of the posterolateral corner (PLC) of the knee is complex
(►Figs. 1–8).1 These structures contribute to static and
dynamic stability of the knee and resist varus angulation,
excessive external rotation, and posterior translation.2
Static stabilizers are the lateral collateral ligament (LCL)
(►Figs. 1–3), also known as the fibular collateral ligament,
popliteofibular ligament (PFL) (►Figs. 1, 2, 4a, and 8b),
arcuate ligament (AL) ( ►Figs. 1, 2, and 5), fabellofibular
ligament (FFL) (►Figs. 1, 2, 6, and 8b), and posterolateral
joint capsule. Dynamic stabilizers are the biceps femoris
tendon (BT) (►Figs. 1–3, and 8b), iliotibial band (ITB)
(►Figs. 1, 2, 3b, and 7a), and popliteus tendon (PT) muscle
complex (►Figs. 1, 2, 3a, 4a, 6, and 8a).
In acute injuries, clinical examination is often difficult due to
pain and soft tissue edema.3–5 MRI provides accurate evaluation
of frequently complex multistructural PLC injuries (►Figs. 8–12)
that are rarely isolated and occur in
5.7% of cases.6,7
Concomitant tears of the anterior cruciate ligament (ACL) are
as high as 10% (►Figs. 9d and 12c) and of the posterior cruciate
ligament (PCL) as high as 27%. Associated injuries of the peroneal
nerve (►Fig. 12c) are reported in
15% of patients.8,9
We review normal MRI anatomy of the complex anatomi-
cal structures of the PLC of the knee (►Figs. 1–7), their
biomechanical function, injuries (►Figs. 8–12), and current
treatment options (►Figs. 13 and 14).
Normal Anatomy
The major anatomical structures of the PLC of the knee include
the ITB (►Figs. 1, 2, 3b, and 7), LCL (►Figs. 1–3), the popliteus
complex (►Figs. 1, 2, 3a, 4a, 6, and 8a), the middle third of the
lateral capsular ligament, the FFL (►Figs. 1, 2, 6, and 8b), the AL
(►Figs. 1, 2, and 5), the posterior horn of the lateral meniscus,
the lateral coronary ligament, and the posterolateral joint
capsule.10–14 However, the anatomy may be variable.

Issue Theme Knee and Ankle Imaging; Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/
Guest Editor, Marco Zanetti, MD Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1579677.
New York, NY 10001, USA. ISSN 1089-7860.
Tel: +1(212) 584-4662.
 Collateral Ligaments and Posterolateral Corner
Fig. 1 Axial proton-density-weight fat-saturated MR image with
superimposed illustration of the layers of the lateral ligamentous
structures of the knee. Green ¼ layer 1; yellow ¼ layer 2; red ¼ layer
3; white ¼ other structures of the knee. ACL, anterior cruciate liga-
ment; AL, arcuate ligament; BT, biceps femoris tendon; C, postero-
lateral joint capsule; FFL, fabellofibular ligament; G, gracilis tendon;
ITB, iliotibial band; LCL, lateral collateral ligament; LG, lateral head of
the gastrocnemius muscle; LR, lateral retinaculum; MCL, medial
collateral ligament; MG, medial head of the gastrocnemius muscle;
MR, medial retinaculum; OPL, oblique popliteal ligament; P, patellar
tendon; PCL, posterior cruciate ligament; POL, posterior oblique
ligament; PT, popliteus tendon; S, sartorius muscle and tendon; SM,
semimembranosus tendon; ST, semitendinosus tendon.
Three-Layer Approach
Seebacher et al introduced a three-layered approach in the
complex anatomical description of the lateral supporting
structures of the knee (►Fig. 1).12
Anatomical structures of layer 1 include the lateral fas-
cia,15 the ITB (►Figs. 1, 2, 3b, and 7a), and the long and short
heads of the BT (►Figs. 1–3, and 8b), with each head having
two distal arms. The ITB (►Figs. 1, 2, 3b, and 7a) represents
the bandlike distal continuation of the tensor fascia lata that
inserts onto the Gerdy tubercle of the anterolateral proximal
tibia. The long and short heads of BT are located posteriorly
with most of the distal fibers inserting on the fibular head/
styloid (►Figs. 1–3, and 8b).16 The direct arm of the long head
of the BT attaches to the anterior and posterolateral aspects
of the fibular head while the anterior arm inserts slightly
anterior to this region. The direct arm of the short head of the
BT inserts just anterior to the fibular styloid process and
medial to the anterior arm of the long head of BT; the anterior
arm inserts onto the superolateral edge of the lateral tibial
plateau.17 A recent cadaveric study revealed four footprints
of the distal BT insertion including tibial, distal fibular head,
medial fibular head (styloid), and proximal fibular head
(styloid).18 The tibial insertion footprint was seen distal to
the tibial insertion of the anterolateral ligament (ALL)
(►Fig. 7b), the distal fibular head insertion footprint at the
Vasilevska Nikodinovska et al. 53
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Fig. 2 Illustration of the main posterolateral capsular supporting structures
of the knee superimposed on reconstructed three-dimensional computed
tomography image. The BT (1) and the LCL (2) form a conjoined tendon that
inserts onto the fibula. The BT and myotendinous junction are located
superficial and posterior to the LCL. The LCL is the most important structure in
the posterolateral corner in limiting varus stress. The AL (3) is Y-shaped with
medial and lateral limbs that run in close relationship with the posterolateral
joint capsule and attach onto the fibular styloid. The FFL (4) is seen originating
from the fabella and inserting onto the fibular head. The PT (5) inserts onto the
lateral femoral condyle and is deep to the LCL. The PFL (6) arises from the PT
about its myotendinous junction and connects the PT to the fibular head. Also
depicted is the ITB (7), which is an extension of the tensor fascia lata and
inserts on the Gerdy tubercle at the proximal tibia.
anterior aspect of the fibular head anterior to the LCL
insertion, the proximal fibular head insertion footprint at
the lateral aspect of the fibular head and styloid posterior to
the LCL insertion, and the medial fibular insertion footprint
on the fibular head and styloid process base, proximal to the
LCL and adjacent anterior and proximal fibular footprints.18
In this study we focused on quantitative evaluation of
tendinous insertions of the BT without determining which
of the heads specifically contributes to each of the footprints
and without quantitative evaluation of the fascial compo-
nents of the BT. The common peroneal nerve courses poste-
rior and deep to the BT.14
Anatomical structures of layer 2 include the lateral patellar
retinaculum that is located anteriorly and the patellofemoral
ligament located posteriorly. At the lateral margin of the
patella, layers 1 and 2 adhere to each other (►Fig. 1).
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54 Collateral Ligaments and Posterolateral Corner Vasilevska Nikodinovska et al.

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Fig. 3 Conjoined BT and LCL tendons at the lateral aspect of the knee. (a) Coronal proton-density-weighted (PD-w) fat-saturated MR image and (b)
sagittal PD-w MR image show the BT (solid arrows) that is part of layer 1 of the posterolateral corner of the knee, and the LCL (white arrowheads)
that is part of layer 3, forming a conjoined tendon (dashed arrow) about their fibular attachments. Also note the PT (open arrow) in (a) and ITB
(black arrowheads) in (b).

Fig. 4 PT and PMFs at the posterolateral aspect of the knee. (a) Coronal proton-density-weighted (PD-w) fat-saturated MR image shows the PT
(curved arrow) with myotendinous junction (solid arrows), which are part of layer 3 of the posterolateral corner of the knee and insert onto the
lateral femoral condyle (not shown). Note the PFL (dashed arrow) that arises from the PT about its myotendinous junction and inserts onto the
fibular styloid. (b, c) Sagittal PD-w fat-saturated MR images show the popliteomeniscal fascicles (PMFs) that represent meniscocapsular
extensions of the PT with attachment onto the lateral meniscus. The anteroinferior (open arrow) and posterosuperior (solid arrowhead) PMFs are
always present; however, posteroinferior PMF (open arrowhead) is variably present.

Anatomical structures of the deepest layer 3 attach to
the edges of the proximal tibia and fibula and distal femur.
The layer 3 structures include the PT, LCL (►Figs. 1–3), PFL
(►Figs. 1, 2, 4a, and 8b), and the posterolateral joint
capsule is reinforced by the AL (►Figs. 1, 2, and 5) and
FFL (►Figs. 1, 2, 6, and 8b). The coronary ligament, also
known as the meniscotibial ligament, extends from the
lateral joint capsule to the inferior peripheral margin of the
lateral meniscus.19,20 The coronary ligament contributes to
the formation of the popliteus hiatus through which the PT
courses. Superficial and deep divisions of the lateral joint
capsule are separated by the lateral geniculate artery,

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 Collateral Ligaments and Posterolateral Corner
Fig. 5 Arcuate ligament (AL) at the lateral aspect of the knee. Sagittal proton-
density-weighted fat-saturated MR image shows the Y-shaped AL that is part
of layer 3 of the posterolateral corner of the knee. The AL has medial (dashed
arrows) and lateral (solid arrows) limbs that attach to the fibular styloid
process. This ligament runs in close relationship with the posterolateral joint
capsule superficial to the PT (open arrow).
Fig. 6 FFL at the posterolateral aspect of the knee. Coronal proton-
density-weighted fat-saturated MR image shows the FFL (solid arrow),
which is part of layer 3 of the posterolateral corner of the knee. The
ligament originates from the fabella within the lateral head of the
gastrocnemius muscle or the posterolateral capsule of the knee and
the lateral femoral condyle and inserts onto the fibular head. Also
included is the PT myotendinous junction (dashed arrows).
Vasilevska Nikodinovska et al. 55
which is a branch of the popliteal artery. The superficial
lateral capsular division encompasses the LCL, terminating
posteriorly at the FFL. The deep lateral capsular division
forms the coronary ligament that terminates posteriorly at
the AL.
Specific Anatomical Structures
The LCL (►Figs. 1–3) originates at the lateral aspect of the
lateral femoral condyle with distal insertion on the upper
facet of the fibular head anterior and lateral to the FFL and AL.
The length of the LCL, as measured with the extended knee, is

6 cm and the mean width is 3–5 mm.21–23 The LCL and BT
appear as V-shaped structures forming a distal conjoined
tendon with an intervening bursa (►Fig. 3).16,24,25
The PT courses between the lateral meniscus and the
posterolateral joint capsule (►Figs. 1, 2, 3a, and 4a). The
intra-articular portion of this tendon originates from
the anterolateral aspect of the lateral femoral condyle at
the popliteal sulcus and descends inferiorly and medially,
becoming extra-articular while passing the posterior horn of
the lateral meniscus at the popliteal hiatus.22 At the popliteus
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hiatus, the PT sends off two to three popliteomeniscal
fascicles (PMFs) (►Fig. 4b, c) including the anteroinferior
(►Fig. 4c), posterosuperior (►Fig. 4b), and variably present
posteroinferior (►Fig. 4b) that represent the meniscocapsu-
lar extensions with attachment onto the lateral menis-
cus.8,21,24,26,27 Distal to the popliteus hiatus, the PT
continues through the myotendinous junction into the pop-
liteus muscle that resides at the posteromedial surface of the
proximal tibia (►Figs. 4a, 6, and 8a). There is normal ana-
tomical communication of the PT sheath with the knee joint.
The PFL is located deep to the AL (►Figs. 1, 2, 4a, and 8b). This
ligament originates from the PT proximal to its myotendinous
junction and inserts at the posterior aspect of the fibular
styloid.21–23 Three different morphologies of the PFL have
been described including single, double, and Y-shaped types.
The mean length of the PFL measures between 10 mm and
14 mm with a mean anteroposterior diameter between
7 mm and 9 mm.28–30 The PT and PFL create an inverted
Y-shaped structure that contributes significantly to PLC
stability.2,11,29–31
Additional two ligaments that reinforce the posterolateral
capsule of the knee joint are the AL (►Figs. 1, 2, and 5) and
the FFL (►Figs. 1, 2, 6, and 8b).12 The AL is a variably present
Y-shaped structure that arises from the posterior aspect of the
joint capsule and has medial and lateral limbs that both attach to
the apex of the fibular styloid process (►Fig. 5). The medial
(arcuate) limb courses superficial to the PT and attaches to the
posterior knee capsule. The lateral (upright) limb extends from
the apex of the fibular styloid process to its proximal attachment
on the lateral femoral condyle while coursing in close relation-
ship with the lateral joint capsule.32 The FFL originates from the
fabella, a small sesamoid bone within the lateral head of the
gastrocnemius muscle, and attaches onto the fibular styloid
process (►Figs. 1, 2, 6, and 8b).21 In cases with a congenital
absence of the fabella, the FFL originates from the posterolateral
aspect of the lateral femoral condyle.14,23 Seebacher et al
reported an inverse relationship between the size of the
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56 Collateral Ligaments and Posterolateral Corner Vasilevska Nikodinovska et al.

Fig. 7 ITB and ALL at the lateral aspect of the knee. (a) Coronal proton-density-weighted (PD-w) fat-saturated MR image demonstrates the ITB

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(arrows), which is part of layer 1 of the lateral supporting ligamentous structures of the knee. It is a continuation of the tensor fascia lata and
inserts onto the proximal tibia at the Gerdy tubercle. (b) PD-w fat-saturated MR image of the knee in a different patient demonstrates the ALL
originating from the lateral femoral condyle and bifurcating superior to the lateral inferior geniculate artery (dotted arrow) into a meniscal branch
(solid black arrow) and tibial branch (solid white arrow).

Fig. 8 Coronal proton-density-weighted fat-saturated MR images of the knee show grade 1 strain of the PT and sprain of the PFL in two different
patients. (a) Note edema in the PT myotendinous junction compatible with grade 1 strain (arrows). (b) In another patient, the PFL (dashed arrow)
also demonstrates increased signal consistent with grade 1 sprain although without tear. Note associated mild bone marrow edema within the
fibular head (asterisk). Note normal FFL (solid arrowhead) and BT (open arrowhead).

fabella and the FFL in relation to the size of AL.12 The AL
(►Figs. 1, 2, and 5), the PFL (►Figs. 1, 2, 4a, and 8b), and the
FFL (►Figs. 1, 2, 6, and 8b) are termed the arcuate complex.
In 2007, the ALL was described at the lateral aspect of the
knee joint capsule by Vieira and collaborators (►Fig. 7b).
This ligament originates at the lateral femoral condyle
between the LCL and PT, courses anteriorly and inferiorly,
and then bifurcates just above the lateral inferior geniculate
artery. The ALL divides into meniscal and tibial branches,
with the meniscal branch inserting onto the lateral menis-
cal body and the tibial branch inserting onto the lateral
tibial condyle just below the plane of the lateral tibial
plateau in the vicinity of the ITB.33
It is worth mentioning that the oblique popliteal ligament
(OPL) (►Fig. 1) is the largest ligamentous structure at the
posterior aspect of the knee.34 This ligament is formed medially
by an expansion of the semimembranosus tendon and capsular
arm of the posterior oblique ligament. From its medial origin
sites, the OPL extends laterally in a broad fashion with two lateral
attachments. The proximal lateral attachment of the OPL in-
cludes the osseous or cartilaginous fabella, meniscofemoral
portion of the posterolateral joint capsule, and plantaris muscle
with the fibrous distal lateral attachment on the lateral aspect of
the PCL facet at the posterior aspect of the tibia. The main role of
this ligament, which is primarily a posteromedial corner struc-
ture, is to prevent hyperextension of the knee.1

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Fig. 9 Acute PLC Injury. Proton-density-weighted fat-saturated MR images of the knee in a patient with acute posterolateral corner injury and ACL
tear. (a) Coronal image demonstrates full-thickness tear with proximal retraction of the ITB (arrowheads) from its tibial attachment site. (b)
Sagittal and (c) axial images show full-thickness tear of the LCL (solid arrows) and BT (dashed arrows). In (a) and (c), note bone marrow edema of
the medial femoral condyle. (d) The patient also had an associated full-thickness tear of the ACL (open arrow).

MR Imaging Routine MR imaging protocols vary between different

In our experience, with advances of high-resolution MRI
( 1.5 T) in dedicated knee coils and with thin cuts
( 3 mm), most of ligamentous and tendinous structures of
the PLC can be visualized on routine MRI examinations
(►Figs. 1, 7).21,25,35–40
Normal ligaments and tendons show low signal intensity
on all imaging sequences (►Figs. 1, 7). Sprained or partially
torn ligaments and tendons typically display increased
signal intensity that is more obvious on fluid-sensitive
sequences with fat saturation or inversion recovery imag-
ing with thinning or thickening of the affected structures
(►Figs. 8 and 11). Complete ligamentous or tendon tears
are characterized by discontinuity of fibers with an
associated gap, waviness, and frequently abnormal orien-
tation (►Figs. 9 and 12).
On MRI, injuries of the ligamentous structures of the PLC of
the knee are usually graded using the same semiquantitative
grading system that can be applied to any injured ligament
about the large or small joints in the extremities. Grade I
injury corresponds to sprain (►Fig. 8), grade II to a partial-
thickness tear (►Fig. 11b), and grade III to a complete tear
(►Figs. 9 and 12). Grade III injuries of the PLC structures
typically require surgery.41
institutions, but most include fluid-sensitive sequences
with fat saturation in three imaging planes (axial, coronal,
and sagittal), and T1-weighted sequence and/or conventional
proton-density-weighted sequence in the sagittal or coronal
plane. In some institutions isotropic tridimensional fluid-
sensitive sequences with fat saturation are performed with
images reconstructed in the other two imaging planes to
substitute imaging in three planes.21,36
Yu et al suggested the use of coronal oblique plane MRI to
improve visualization of some of the obliquely oriented
ligamentous structures of the PLC, such as the FFL, PFL, and
AL.36 However, this has not been used in routine practice in
most institutions.
Biomechanics
As previously mentioned, the anatomical structures of the
PLC of the knee contribute to static and dynamic stability of
the knee and resist varus angulation, excessive external
rotation, and posterior translation.2 The LCL (►Figs. 1–3),
PFL (►Figs. 1, 2, 4a, and 8b), AL (►Figs. 1, 2, and 5), FFL
(►Figs. 1, 2, 6, and 8b), and the posterolateral joint capsule are
the static stabilizers and the BT (►Figs. 1–3, and 8b), ITB

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58 Collateral Ligaments and Posterolateral Corner Vasilevska Nikodinovska et al.

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Fig. 10 Patient with ITB and arcuate complex avulsion fractures. Frontal (a) and lateral (b) radiographs of the knee demonstrate displaced avulsion fractures of
the anterolateral aspect of the proximal tibia (dashed black arrows) consistent with avulsion fracture of the Gerdy tubercle. There is also an avulsion fracture at the
level of the fibular head/styloid (solid black arrows) consistent with an arcuate fracture/sign. (c) Coronal proton-density-weighted (PD-w) fat-saturated MR image
at the posterior aspect of the knee shows the avulsion fracture of the fibular head (solid black arrow) with avulsion tears of the BT (solid white arrow) and LCL (open
arrow). Note the PFL (arrowhead) attached to the avulsed fracture fragment and the PT (curved arrows). (d) Coronal PD-w fat-saturated MR image at the anterior
aspect of the knee demonstrates the avulsion fracture of the Gerdy tubercle (dashed black arrow) with attached ITB (dashed white arrows). There is overlying soft
tissue edema. (e) Sagittal PD-w fat-saturated MR image demonstrates associated full-thickness tear of the PCL (arrowheads). Note bone marrow edema in the
medial femoral condyle.

(►Figs. 1, 2, 3b, and 7a), and the popliteus muscle complex
(►Figs. 1, 2, 3a, 4a, 6, and 8a) are the dynamic stabilizers. The
LCL is a major structure that provides varus stability of the
knee joint. The LCL has limited ability in resisting external
rotation forces and posterior translation of the tibia in the
flexed knee.42 Additional structures that to a lesser extent
contribute to varus stability include the PCL and the postero-
lateral joint capsule. The ACL is considered a minor secondary
contributor to varus stability of the knee. The PLC structures
that resist external rotation forces are the PFL (►Figs. 1, 2, 4a,
and 8b), FFL (►Figs. 1, 2, 6, and 8b), capsular attachment of
the short head of the BT, and the PT (►Figs. 1, 2, 3a, 4a). The
PT and muscle (►Figs. 1, 2, 3a, 4a, 6, and 8a), together with
the PFL (►Figs. 1, 2, 4a, and 8b) and the PMFs (►Fig. 4b, c),
represent a functional unit that prevents the posterior trans-
lation, varus angulation, and excessive external rotation and
stabilizes the lateral meniscus.24
In a cadaveric study, after transection of all other PLC
ligamentous structures, the PT and muscle continue to main-
tain neutral tibial rotation.43 With varus stress, the LCL fails
first, followed by the PFL and later on by the PT. Isolated
transection of the LCL, PT, AL, FFL, and the posterolateral joint
capsule cause increased varus angulation, internal transla-
tion, and external rotation. The combined transection of the
LCL and posterolateral joint capsule including the AL increase
external rotation with all degrees of knee flexion.44

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 Collateral Ligaments and Posterolateral Corner Vasilevska Nikodinovska et al. 59

Fig. 11 Segond fracture. (a) Frontal radiograph of the knee shows a small osseous fragment at the periphery of the lateral tibial plateau consistent with a Segond
fracture (solid arrow). (b) Coronal and (c) axial proton-density-weighted fat-saturated MR images of the knee demonstrate the Segond fracture (solid arrows) with
surrounding bone marrow edema (asterisk). Also seen is a high-grade partial-thickness tear of the LCL (open arrow) in (b). There is edema and thickening involving
the posterolateral capsular structures (arrowhead). In (b), note an associated ACL tear (open arrowhead).

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Fig. 12 Chronic untreated grade III PLC Injury. (a) Axial and (b) coronal proton-density-weighted (PD-w) fat-saturated images demonstrate
complete tear of all PLC structures with gaping of the lateral joint space (solid black arrow in [b]) including disruption of the ITB, PT, BT, LCL, AL,
FFL, and posterolateral joint capsule. (c) Sagittal PD-w fat-saturated image shows associated tear of the ACL (arrowheads). The peroneal nerve
(dotted arrows) is also markedly enlarged with increased signal secondary to partial injury.

PLC Injuries hyperextension injury to the externally rotated knee.24 PLC

PLC injuries are less common when compared with postero-
medial corner injuries but tend to be more disabling
(►Figs. 8–12). These injuries are rarely isolated, and there
is commonly an association with PCL (►Fig. 10e) more often
than ACL (►Figs. 9d, 11b, and 12c) injuries.10,35 Associated
injuries of the menisci, medial supporting structures, bones
(►Figs. 10 and 11), and adjacent soft tissues are encountered
as well.4,5
Common causes of PLC injury include athletic trauma,
motor vehicle accidents, and falls. The most common mecha-
nism of injury is a direct blow to the anteromedial aspect of
the proximal tibia with full extension of the knee joint and a
force directed posterolaterally.10 Another possibility is
injuries are commonly associated with posterior rotatory
dislocation that occurs with varus stress and a posteriorly
directed blow to the proximal tibia of the flexed knee. This is
frequently associated with dashboard injuries. PLC injuries
also occur with anterior rotatory dislocations of the knee with
varus stress applied to the hyperextended knee.45,46
Acute PLC injuries can be difficult to diagnose on clinical
examination (►Figs. 9–11).47,48 With careful specific clinical
examination, diagnosis of the posterolateral instability of the
knee can be made. However, pain and guarding during the
examination, soft tissue edema, and the presence of multi-
ligamentous injury may cause a delay in diagnosis.3,44
Unrecognized injuries of the PLC of the knee can lead to
chronic instability (►Fig. 12)45,49 and failure of the cruciate

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60 Collateral Ligaments and Posterolateral Corner Vasilevska Nikodinovska et al.

ligament reconstruction secondary to the inability of the

deficient PLC structures to resist biomechanical stress.3,6,10,31
These injuries can further cause severe disability and devel-
opment of secondary osteoarthritis.10

Clinical Testing and Grading

With clinical suspicion for PLC injuries, testing for varus and
external rotation instability is performed at various degrees
of knee flexion in comparison with the contralateral unaf-
fected side.10 The posterolateral rotation or dial test is one of
the standard methods used to assess posterolateral rotatory
instability of the knee joint evaluating for increased external
rotation of the tibia with respect to the femur at 30 degrees of
knee flexion.50
On clinical examination, the following scale is frequently used
qualitatively to address the degree of ligamentous instability: 1þ
(mild), 2þ (moderate), and 3þ (severe). A similar scale is used to
evaluate abnormal lateral compartment joint space opening at
opening 30 degrees of knee flexion; stage I with a 0- to 5-mm
opening, stage II with a 5- to 10-mm opening, and stage III with
a > 10-mm opening.10,51 Stage III corresponds to extensive

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injury of all major PLC structures including the LCL, PT, and
PFL that indicates varus laxity in complete knee extension and
requires operative treatment.51

Ligamentous Injuries of the PLC

Fig. 13 Illustration of the Arciero’s reconstruction technique super-
imposed on reconstructed three-dimensional computed tomography
image. The LCL (1) and PFL (2) are reconstructed using a double
femoral tunnel with interference screws. The transfibular tunnel is
depicted (dotted lines).
LCL: LCL injuries can occur at the proximal aspect, in the
midsubstance or at the fibular attachment site (►Figs. 9b, c,
10c, 11b, 12a, b).16 These include proximal or distal avulsions or
intrasubstance tears that may be partial or full thickness. Distal
injuries may be associated with an avulsed fracture fragment off
the fibular styloid (►Fig. 10a–d).12,52,53 Associated LCL and PCL
(►Fig. 10e) injuries with a torn posterolateral joint capsule
cause a significant increase of varus opening of the knee joint

Fig. 14 PLC reconstruction failure and revision. (a) Initial frontal radiograph of a knee status post PLC reconstruction using Aciero’s technique
shows the double lateral femoral condyle tunnel with radiolucent interference screws (solid arrows) and transfibular tunnel used for
reconstruction of the PFL and LCL and with anchor screw placement (open arrowhead) for fixation of BT avulsion. Also seen are postsurgical
changes related to ACL reconstruction (solid arrowheads) with EndoButton on the lateral femoral condyle. (b) Follow-up knee radiograph
demonstrates displacement of the anchor screw (open arrowhead). (c) Radiograph following reconstruction revision demonstrates two headless
screws reinforcing the double lateral femoral condyle tunnel (dotted arrows) and transfibular tunnels with radiolucent screws for the PFL and LCL
reconstruction (dotted arrowheads). (d) Coronal proton-density-weighted image shows proximal lateral femoral condyle tunnel related to LCL
reconstruction (dotted arrow), transfibular tunnels with screw fixation for PFL and LCL reconstruction (dotted arrowheads), and hamstring
allograft for LCL reconstruction (open arrows). Portion of the PFL reconstruction graft is seen underneath the LCL graft.

Seminars in Musculoskeletal Radiology Vol. 20 No. 1/2016

 Collateral Ligaments and Posterolateral Corner
with marked posterolateral rotatory instability when compared
with LCL injury alone.32,54 Reported sensitivity, specificity, and
accuracy of MRI in the identification of LCL injuries is 94.4%,
100%, and 95%, respectively.21
BT: The PLC injuries are often associated with injuries to the
distal BT including myotendinous junction tears, or soft tissue or
bone avulsions from the fibular head (►Figs. 9b, c, 10c, 12a, and
12b).16,21 These injuries can be partial or full thickness. Disrup-
tion of the conjoined tibial attachment of the anterior arm of the
short head of the BT and the meniscotibial portion of the mid
third of the lateral capsular ligament represents a soft tissue
Segond injury (lateral meniscotibial capsular avulsion injury)
with associated proximal retraction or thickening. The soft tissue
Segond injury was described by LaPrade and collaborators.21
ITB: Injuries of the ITB are rarely isolated. These injuries are
usually associated with injuries of other multiple knee liga-
ments and may present as complete transection or avulsion of
the tibial insertion of the ITB (►Figs. 9a, c, 10d, and 12a).16
PT complex: PT injuries can be intra-articular including
the femoral insertion site and the level of popliteus hiatus
or extra-articular that includes injuries of the popliteus
muscle or more frequently of the myotendinous junction
(►Figs. 8a, 12a, b).25,26,55 These injuries can be partial or
full thickness. PT injuries are commonly associated with
injury of other ligaments and/or menisci, and only 8% of the
cases are isolated.24,56 MRI plays an important role in the
diagnosis of popliteus muscle and tendon injuries,
particularly parts that are inaccessible to arthroscopy.20,41
Reported sensitivity, specificity, and accuracy of MR imag-
ing in identification of the femoral origin injury of the PT is
93.3%, 80%, and 90%, respectively.21
PFL: The PFL may be degenerated, partially or completely
torn, or avulsed from its fibular insertion site in association
with injuries of the other PLC structures (►Figs. 8b and 10c).
AL: The MR imaging diagnosis of AL injuries may be
challenging due to its variable presence and anatomical
variations.31,32,57 This ligament may also be considered as a
thickening of the posterolateral knee joint capsule.15 On MRI,
AL injuries present as edema in the posterolateral joint
capsule (►Fig. 12a, b). Disruption of this ligament in associa-
tion with PLC injuries may cause lack of joint effusion.41
FFL: The FFL may be degenerated, partially or completely
torn, or avulsed from its fibular styloid insertion site
(►Fig. 12a, b). Fibular avulsion of the FFL can be associated
with an avulsion injury of the short head of the BT.16,41,58
Lateral head of gastrocnemius: The lateral head of the
gastrocnemius muscle is usually not considered a part of
PLC structures and is rarely injured.12 However, it serves as an
important secondary stabilizer of the PCL of the knee and is
evaluated with the PLC structures.22
Osseous Injuries Associated with PLC Injuries
Anteromedial Femoral Condyle Bone Contusion and
Fracture of the Anterior Peripheral Margin of the Medial
Tibial Plateau
Bone contusions of the anteromedial femoral condyle
(►Figs. 9a, c, and 10e) have a strong association with PLC
Vasilevska Nikodinovska et al. 61
injuries in combination with cruciate ligament tears
(►Figs. 9d and 10e). These are associated with varus stress
and hyperextension of the knee.39 Additionally, fractures of the
peripheral margin of the anterior aspect of the medial tibial
plateau can occur in association with the PLC and PCL injuries.59
Arcuate Fracture
Different types of fibular head bony avulsion (arcuate) frac-
tures (arcuate sign) are seen in association with PLC injuries
(►Fig. 10a–c).12,52,53 The avulsed bone fragments are easily
depicted on radiographs (►Fig. 10a, b) and computed tomo-
graphy studies. Small avulsed bone fragments may be over-
looked on MRI that reveals associated bone marrow edema in
the fibular head.52,53 Avulsion fracture at the lateral aspect of
the fibular styloid process suggests an avulsion injury of the
conjoined tendon; the more medial avulsion injuries that
involve the posterosuperior apex of the fibular styloid process
suggest an avulsion of the AL, FFL, and the PFL. Arcuate
fractures are commonly associated with injuries of the pos-
terolateral joint capsule in
67% of cases and cruciate
ligaments in
89% of cases.52 There is a less common
Downloaded by: Universite Laval. Copyrighted material.
association with meniscal tears and popliteus muscle inju-
ries.52,53 Additional bone contusions are commonly present
with most common involvement of the anteromedial femoral
condyle followed by the anteromedial tibial plateau.53
Segond Fracture
The Segond fracture is a small flake-like bony avulsion off the
lateral tibial plateau posterior to the Gerdy tubercle (►Fig. 11).16
Thus injury was first described in 1879 by Paul Ferdinand
Segond, a French surgeon, as a small avulsion bone injury at
the tibial attachment of the mid third lateral capsular ligament.60
LaPrade and collaborators described the mid third lateral capsu-
lar ligament as a thickening of the lateral joint capsule, with
attachment to the lateral femoral condyle and lateral tibia, with
capsular attachment to the lateral meniscus that represents the
lateral equivalent of the deep medial collateral ligament.61 There
may be associated avulsion of the anterior arm of the short head
of the BT. Additional ligamentous structures that may play a role
in the pathogenesis of the Segond fracture include the anterior
oblique band of the LCL and the anterior oblique band of the ITB
(now referred as the ALL) (►Fig. 7b). An association of Segond
fractures with PLC injuries has been reported in 31 to 35% of
cases62,63 and with the ACL injuries in 94 to 100% of cases.63,64
Gerdy Tubercle Avulsion Fracture
Gerdy tubercle bony avulsion fracture of the iliotibial band
(►Fig. 10a, b, d) can be associated with PLC injuries. The
mechanism of injury can be related to pure varus force and
medial tibia and medial femoral condyle “coup-contrecoup”
impactions with associated ITB and LCL injuries or to a direct
blow to the medial aspect of the knee.39,65,66
Treatment Options
There is general consensus that both the isolated and com-
bined high-grade injuries of the PLC structures of the knee are
best treated with reconstruction surgery rather than repair
Seminars in Musculoskeletal Radiology Vol. 20 No. 1/2016
62 Collateral Ligaments and Posterolateral Corner
along with reconstruction of frequently associated cruciate
ligament injuries. The commonly proposed methods of PLC
reconstruction focus on reconstruction of the LCL, the PT, and
the PFL (►Figs. 13 and 14).51
Management of the PLC injuries depends on the injury
grade, chronicity, acute versus chronic nature, and the coex-
istence of associated injuries. Acute grade I and II PLC injuries
are usually treated with a knee brace in extension for 4 to 6
weeks (►Figs. 8 and 11) followed by physical therapy and
delayed ACL or PCL reconstruction as soon as the knee
regains mobility. Acute grade III injuries are treated with
prompt reconstruction of the cruciate ligaments and recon-
struction or repair of the PLC structures (►Fig. 14).51 Acute
surgical treatment within the first 3 weeks after injury
improves outcomes. Nonoperatively treated grade III injuries
have poor functional outcomes and persistent instability
(►Fig. 12) with subsequent osteoarthritis. Femoral, fibular,
and tibial ligamentous avulsion injuries are repaired direct to
bone.67 Primary repairs of the LCL and PT avulsions without a
coexisting midsubstance tear may be performed within 2 to 3
weeks after injury. Later on, scarring and tissue retraction of
the torn PLC structures precludes primary repair. Midsub-
stance tears require reconstruction, regardless of their
chronicity.67 A higher success rate has been reported with
the reconstruction of the PLC structures compared with
repair.68,69
Chronic injuries are more difficult to treat than acute. In
addition to ligamentous reconstruction, varus deformity
must be corrected, preferentially through high tibial medial
open osteotomy.51
Several reconstruction techniques of the PLC we described
can be classified as nonanatomical and anatomical with
regard to the reconstructed ligaments and positioning of
the reconstruction tunnels. A variety of allografts or auto-
grafts can be used including patellar, Achilles, hamstring, BT,
or tibialis tendons.10,50,70–73
Some of the nonanatomical reconstruction techniques
include the Clancy procedure74 that consists of tenodesis of
the distal BT to mimic the LCL, the Larson procedure that is
performed by reconstructing the LCL with a vertical graft limb
from the anterior aspect of the fibular head to the lateral
femoral condyle, while adding an oblique graft limb from the
posterior aspect of the fibular head to the femoral condyle,50
the modified Larsen technique by Fanelli et al who use a
washer lock at the midpoint between the LCL and PT with a
figure-of-eight graft configuration,70 and modified Larsen
technique by Arciero with two drill holes on the femoral
site to reconstruct the PT and the LCL footprints.71 Arciero’s
technique is used at the senior author’s institution. Stannard’s
nonanatomical reconstruction technique utilizes the anterior
or posterior tibial allograft that must be a minimum of 2.4 cm
in length to reconstruct the LCL, the PT, and the PFL, but the
reconstruction tunnels are not at the location of native foot-
prints.68 LaPrade’s anatomical reconstruction technique
comprises reconstruction of the LCL, PT, and PFL with two
free graft reconstructions through two femoral tunnels, one
tibial and one femoral tunnel. These authors prefer the split
Achilles allograft.28,67,72,73
Seminars in Musculoskeletal Radiology Vol. 20 No. 1/2016
Vasilevska Nikodinovska et al.
Conclusion
The complex ligamentous and tendinous structures of the PLC
of the knee resist varus angulation, posterior translation, and
excessive external rotation. Injuries of the PLC of the knee are
frequently complex and may represent diagnostic and thera-
peutic challenges. They are rarely isolated and frequently
occur in association with injuries of the cruciate ligaments,
menisci, bones, and adjacent soft tissues. With acute injuries,
a clinical examination may be difficult due to pain and soft
tissue edema. MRI imaging is presently the diagnostic study
of choice in the evaluation of PLC injuries and is frequently
helpful in surgical treatment guidance. Knowledge of normal
MRI anatomy and biomechanics of the PLC of the knee is
important for correct diagnosis of its injuries. Acute grade III
PLC injuries require surgical treatment with ligamentous
reconstruction favored over primary repair. Unrecognized
PLC injuries may result in early failure of cruciate ligament
reconstruction with continued instability of the knee joint
and development of secondary osteoarthritis.
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