Review Article

The Posteromedial Corner of the

Knee: Anatomy, Pathology, and
Management Strategies

Abstract
Andrew P. Dold, MD, FRCSC The posteromedial corner of the knee encompasses five medial
Stephanie Swensen, MD structures posterior to the medial collateral ligament. With modern
MRI systems, these structures are readily identified and can be
Eric Strauss, MD
appreciated in the context of multiligamentous knee injuries. It is
Michael Alaia, MD recognized that anteromedial rotatory instability results from an injury
that involves both the medial collateral ligament and the posterior
oblique ligament. Like posterolateral corner injuries, untreated or
concurrent posteromedial corner injuries resulting in rotatory
instability place additional strain on anterior and posterior cruciate
ligament reconstructions, which can ultimately contribute to graft
failure and poor clinical outcomes. Various options exist for
posteromedial corner reconstruction, with early results indicating that
anatomic reconstruction can restore valgus stability and improve
patient function. A thorough understanding of the anatomy, physical
examination findings, and imaging characteristics will aid the
physician in the management of these injuries.

From the Hospital for Joint Diseases,

New York, NY.
Dr. Strauss or an immediate family
member is a member of a speakers’
bureau or has made paid
presentations on behalf of Arthrex;
serves as a paid consultant to the
Joint Restoration Foundation, DePuy
Synthes Mitek Sports Medicine, and
Vericel; and has received research or
institutional support from Omeros and
Dynasplint. None of the following
authors or any immediate family
member has received anything of
value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Dold, Dr. Swensen, and Dr. Alaia.
J Am Acad Orthop Surg 2017;25:
752-761
DOI: 10.5435/JAAOS-D-16-00020
Copyright 2017 by the American
Academy of Orthopaedic Surgeons.
T he lateral side of the knee has
historically been considered the
“dark side of the knee” owing
primarily to our previous lack of
knowledge of both the complex
anatomy in this region and the
management of posterolateral
corner (PLC) pathology.1 Extensive
research has focused on the evalua-
tion and management of PLC
injuries, which has simplified our
approach to and improved our
understanding of this area of the
knee.2 Considerably less literature
has focused on the medial side of the
knee, specifically the posteromedial
corner (PMC), with some authors
labeling it “the neglected corner.”3
The relative oversight of the con-
tributing structures of the PMC may
be the result of early research and
subsequent functional studies that
focused predominantly on the role of
the superficial medial collateral liga-
ment (MCL), with little emphasis on
the supporting posteromedial struc-
tures.4 Thus, medial-sided knee injury
has become synonymous with injury
to the superficial MCL,5 with a lack
of appreciation for and understand-
ing of the other structures involved.
With modern MRI technology, the
major anatomic structures comprising
the PMC can be readily identified.
Recent anatomic and biomechanical
studies have expanded our under-
standing of these medial structures
and their contribution to the static and
dynamic stability of the knee, includ-
ing their supporting role in multi-
ligamentous knee injuries.6-9 It is now
recognized that anteromedial rota-
tory instability (AMRI) results from
injury to both the MCL and the
posterior oblique ligament (POL).
Like PLC injuries, untreated or

752 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

concurrent PMC injuries resulting in
rotatory instability place additional
strain on anterior cruciate ligament
(ACL) and posterior cruciate liga-
ment (PCL) reconstructions, which
can ultimately contribute to graft
failure and poor clinical outcomes. A
thorough understanding of the
structures comprising the PMC, the
examination findings associated with
PMC injuries, and the imaging
characteristics of PMC injuries
will aid the physician in managing
these injuries.
Anatomy
The anatomy of the medial side of
the knee has been described using
two different approaches. Initially,
Warren et al4 divided the medial side
into three layers from superficial to
deep. Layer I consists of the deep
fascia, layer II consists of the super-
ficial MCL, and layer III consists of
the joint capsule and the deep MCL.
In this layered approach, little
attention is given to the structures
lying posterior to the MCL.
A more recent description by
Robinson et al10 divides the medial
side of the knee into thirds—anterior,
middle, and posterior—extending
circumferentially from the medial
edge of the patellar tendon anteriorly
to the most medial edge of the medial
head of the gastrocnemius posteri-
orly. The anterior third extends from
the medial border of the patellar
tendon to the anterior border of the
longitudinal fibers of the superficial
MCL. The middle third is composed
of the width of the longitudinal
fibers of the MCL. The posterior
third, encompassing the PMC of the
knee, extends from the posterior
border of the longitudinal fibers of
the superficial MCL to the medial
edge of the medial head of the gas-
trocnemius muscle, which lies adja-
cent to the medial margin of the PCL
(Figure 1).
November 2017, Vol 25, No 11
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Andrew P. Dold, MD, FRCSC, et al
Figure 1
A, Illustration of the anterior, middle, and posterior divisions of the knee as
described by Robinson et al.10 The posterior third of the knee encompasses the
posteromedial corner, extending from the posterior border of the longitudinal
fibers of the superficial medial collateral ligament (MCL) to the medial edge of the
medial head of the gastrocnemius. B, Axial T2-weighted MRI demonstrating
normal posteromedial structures. The yellow arrow points to the superficial MCL,
the blue arrow points to the posterior oblique ligament, and the red arrow points
to the semimembranosus tendon.
Components of the POL originates just distal and poste-
Posteromedial Corner rior to the adductor tubercle, giving it
an origin distinct from that of the
The PMC of the knee has five major
superficial MCL, which originates just
components: the POL, the semi-
proximal and posterior to the medial
membranosus tendon and its expan-
femoral epicondyle.13-15
sions, the oblique popliteal ligament
Distally, the POL has three readily
(OPL), the posteromedial joint cap-
identifiable arms: the superficial, cen-
sule, and the posterior horn of the
tral, and capsular arms13 (Figure 2).
medial meniscus. The superficial and
The central, or tibial, arm is the largest
deep portions of the MCL occupy the
and thickest of the three arms and
middle third of the medial side of the
forms the main portion of the POL,
knee, and although they function in
comprising most of the ligament’s
close association with the structures
femoral attachment. Distally, the
of the PMC, they are not typically
central arm merges with and rein-
considered part of it.3
forces the posteromedial joint capsule,
adhering to the posteromedial aspect
Posterior Oblique Ligament of the medial meniscus and the adja-
The superficial MCL, as originally cent aspect of the tibia at the posterior
described by Brantigan and Voshell11 articular surface. LaPrade et al13 sug-
in 1943, consists of anterior fibers that gested that the central arm of the POL
run longitudinally across the joint line is the main structure in this area
and fan out as an oblique array of needing repair or reconstruction after
fibers posteriorly. This posterior por- injury to the PMC of the knee.
tion, running distally and posteriorly
at a 25° angle to the anterior fibers,
was later described as a ligament dis- Semimembranosus Tendon
tinct from the superficial MCL and and Its Expansions
was named the posterior oblique lig- The PMC was described by Müller16
ament by Hughston and Eilers.12 The as the “semimembranosus corner”
753
The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies
Figure 2
Illustration of the posteromedial aspect of the right knee demonstrating the three
arms of the posterior oblique ligament. MGT = medial gastrocnemius tendon,
OPL = oblique popliteal ligament, SM = semimembranosus muscle, sMCL =
superficial medial collateral ligament
because of the functionally relevant
contribution of the tendon to the
dynamic stability of the knee. Five
major arms or expansions have been
described: (1) the pars reflexa (ante-
rior arm), (2) the direct posteromedial
tibial insertion (primary attachment),
(3) the OPL insertion, (4) the POL
insertion, and (5) the popliteus apo-
neurosis expansion (Figure 3).
The main tendon bifurcates into
the direct and anterior arms just distal
to the joint line to insert on the
posteromedial and medial aspects of
the tibia, respectively. The direct arm is
the primary attachment of the tendon
754
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
to the tibia, inserting into a small
groove just distal to a tubercle on the
posteromedial part of the tibia called
the tuberculum tendinis, which lies
posterior to the medial tibial crest. The
anterior arm passes deep to the POL
and attaches to the tibia just distal to
the medial joint line, deep to the prox-
imal tibial attachment of the superficial
MCL in an oval pattern.13 The inser-
tion that blends with the POL, also
described as the capsular arm, is the
most anterior branch of the tendon,
merging with the posteromedial joint
capsule and the capsular portions of
the POL and OPL. The extension to
Journal of the American Academy of Orthopaedic Surgeons
the OPL arises approximately 2 cm
proximal to the main bifurcation. This
band passes posteriorly and obliquely
upward to blend with the OPL and
attach to the posterior lateral femoral
condyle, reinforcing the posterior
capsule. The popliteus aponeurosis
expansion represents the inferior arm,
which extends distally from the direct
and anterior arms and attaches to the
tibia just proximal to the insertion of
the superficial MCL.3,17
Oblique Popliteal Ligament
The OPL, a broad fascial band
crossing the posterior aspect of the
knee, is difficult to distinguish from
the posterior joint capsule. Arising
from the capsular arm of the POL and
the lateral expansion of the semi-
membranosus tendon, the OPL
extends from the main portion of the
semimembranosus tendon laterally
and proximally toward the lateral
femoral condyle. As a result, the lig-
ament is considered part of both the
PMC and the PLC. Laterally, the
OPL attaches to the meniscofemoral
portion of the posterior capsule, to an
osseous or cartilaginous fabella, and
to the plantaris muscle.18
Posteromedial Joint Capsule
According to the three-layered
approach to the medial structures of
the knee described by Warren et al,4
the joint capsule along with the
deep MCL comprises layer III.
LaPrade et al13 described the deep
MCL as a “thickening of the medial
joint capsule that is most distinct
along its anterior border, where it
approximately parallels the anterior
aspect of the superficial medial col-
lateral ligament.” Posteriorly, the
deep MCL blends with and becomes
inseparable from the central arm of
the POL, the distinct posterior aspect
of the superficial MCL. The central
arm forms a thick fascial reinforce-
ment of both the meniscofemoral
 Andrew P. Dold, MD, FRCSC, et al

and meniscotibial portions of the Figure 3

posteromedial capsule, with an
additional stout attachment to the
medial meniscus.

Posterior Horn of the Medial

Meniscus
The posterior horn of the medial
meniscus is intimately linked to
various structures of the PMC,
including the posteromedial capsule
or deep MCL, the POL, and the
semimembranosus expansion. The
relationships among these structures
are critical to the dynamic stability of
the medial side of the knee and act as a
“cascade-type” system, in which the
function of each structure depends on
the surrounding structures to which is
it attached.5,17 Furthermore, the sta-
bilizing function of the medial
meniscus is of vital importance in the
setting of ACL and PCL insufficiency.
The meniscotibial portion of the
deep MCL is an important stabilizer
of the medial meniscus on the tibial
plateau, with the posterior horn act-
ing in a so-called brake stop function
to resist anterior tibial translation by
engaging the posterior femoral con-
dyle. Injury to the meniscotibial por-
tion of the deep MCL results in
meniscal instability and places the Illustration of the knee showing the semimembranosus expansions, with five
other structures of the PMC under insertions: (1) pars reflexa, (2) direct posteromedial tibial insertion, (3) oblique
increased stress and risk of injury popliteal ligament insertion, (4) expansion to posterior oblique ligament (POL),
and (5) popliteus aponeurosis expansion.
because the brake stop function has
been lost (Figure 4). MRI can readily
detect injury to both the meniscotibial “detachment of the ligament proba- structures within the PMC, are fre-
and meniscofemoral portions of the bly allows abnormal mobility of the quently associated with damage to
deep MCL.19 entire [posterior horn of the medial other knee ligaments, including the
A recent biomechanical cadaver meniscus], with a notable reduction MCL, ACL, and PCL.5,20-23
study illustrated the importance of in rotational stability.”20 Sims and Jacobson5 evaluated a
the meniscotibial ligament to the cohort of 93 patients with clinical
rotational stability of the knee and, or functional AMRI and described
along with the posterior horn of the Injury Patterns three major patterns of injury to the
medial meniscus, its support of the PMC: POL injury and associated
ACL.20 With the knee in an extended Although there is no commonly injury to the capsular arm of the
position, sectioning of the menisco- accepted classification scheme for semimembranosus tendon (70%),
tibial ligament increased internal and PMC injuries, recent studies have POL injury and complete periph-
external tibial rotation in both the demonstrated several basic injury eral meniscal detachment (30%),
native and ACL-deficient knee. The patterns.5,21,22 The injuries, which and POL injury and disruption of
authors of the study noted that include disruption of one or more the semimembranosus tendon and

November 2017, Vol 25, No 11 755

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies

Figure 4 common than lateral-sided injuries

in combined ACL-PCL ruptures.26
In a 2010 study, Chahal et al22
evaluated injury patterns in the PMC
in 27 knees with high-grade multi-
ligamentous injuries and demon-
strated that at least one structure
within the PMC was affected in 22
(81%) of the dislocated knees evalu-
ated. Interestingly, the authors of that
study found that injury to the PMC of
the knee occurred more frequently
than did MCL injury alone. Therefore,
the presence of multiligamentous knee
injuries should raise clinical suspicion
for PMC lesions.

Illustrations demonstrating the function of the medial meniscus and meniscotibial Clinical Evaluation
ligament in the brake stop mechanism, which prevents anterior tibial translation.
A, Intact brake stop function. B, Loss of brake stop function. The arrow signifies History
the disruption of the meniscotibial ligament.
A thorough history is essential to
determine the nature and mechanism
peripheral meniscal detachment suggested that avulsion fractures at of PMC injury, as well as to identify
(19%). Injury to the POL was this site may be predictive of con- concurrent pathology. Patients typi-
demonstrated in 99% of the knees comitant ACL injury. cally describe a valgus force to the
studied. The authors also found a Meniscocapsular injury can result affected knee, most commonly
high prevalence of associated knee in disruption, thickening, or bony occurring during athletic activ-
injuries, such as ACL and PCL avulsion of the meniscotibial and ity.27,28 Noncontact injuries usually
injuries. meniscofemoral attachments. These result in low-grade sprains, whereas
The POL is the most frequently lesions are most easily identified by a direct blow to the lateral leg pro-
injured structure of the PMC. Injury sagittal plane MRI.15 Escobedo duces a major valgus force and a
to the POL may include sprains, et al24 posited that the “reverse higher-grade injury.29 A pure valgus
partial tears, or complete tears and Segond fracture,” or bony avulsion force often causes an isolated MCL
may occur at the femoral attachment at the level of the meniscotibial injury.29,30 External rotation and
or tibial attachment or may be inter- ligament insertion, occurs in associ- valgus forces combined are most
stitial.3,5 House et al17 recommended ation with PCL rupture. These frac- likely to injure the POL and other
applying the MRI grading system for tures are rare, with the largest components of the PMC. In these
acute MCL injuries to POL injuries. published series to date reporting cases, patients may describe hearing
Injuries to the semimembranosus that the fracture was found in 0.64% a “pop” and experiencing a “side-to-
tendon include avulsion fractures, of multidetector row CT scans of side” sense of knee instability with
complete or partial tears of the ten- acute knee trauma managed in one subsequent ambulation.28 As pre-
don, and chronic insertional tendini- emergency department.25 viously stated, a report of knee dis-
tis. Avulsion of the posteromedial PMC injuries are most commonly location should also increase
plateau occurs during knee flexion associated with other ligamentous suspicion for injury to the PMC.
with abduction and external rotation knee injuries. In a study by
of the leg. The insertion site of the Halinen et al,21 22 of 23 patients
direct tibial arm of the tendon is most who underwent surgery for com- Physical Examination
commonly involved in posteromedial bined ACL and MCL injuries had The presence of AMRI on physical
tibial avulsion fractures. In a review POL tears, and 8 of 23 patients had examination is the hallmark of a
of 10 patients with posteromedial total PMC ruptures. In another PMC injury. Slocum and Larson31
plateau injuries, Chan et al23 found a study, medial-sided injuries, includ- first described AMRI in 1968 as
100% incidence of ACL tears and ing trauma to the PMC, were more excessive valgus motion with

756 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

external rotation of the leg. AMRI is
clinically characterized by anterior
subluxation of the anteromedial
tibial plateau on the femoral con-
dyle.7,32 AMRI can be identified by
applying a valgus stress at 30° of
knee flexion while the foot is con-
comitantly externally rotated.
Holding the limb by the plantar
surface of the foot instead of the
distal leg allows appreciation of the
rotatory component.27 A positive
test result occurs with medial joint
space gapping and anterior sub-
luxation of the medial tibial plateau
relative to the femur and correlates
with a combined PMC and MCL
injury.
The anterior drawer test is also
used to evaluate suspected AMRI.
This test is performed by flexing the
knee to 90° while externally rotat-
ing the foot 10° to 15° and applying
an anterior force to the knee.
Anteromedial tibial plateau sub-
luxation is a positive test result and
indicates injury to the PMC.
Additional ligamentous examina-
tions should include valgus stress
testing and posterior drawer testing.
Valgus stress testing should be per-
formed at 0° and 30° of knee flexion
to assess the integrity of the MCL. It
is important to differentiate isolated
MCL injury from AMRI by assessing
for valgus laxity associated with
anterior rotatory subluxation of the
medial tibial plateau on the medial
femoral condyle with the AMRI
pattern.29 In addition, valgus open-
ing at full extension should raise
suspicion not only for cruciate liga-
ment injuries but also for damage to
the PMC.
For suspected PCL injury, the pos-
terior drawer examination should be
performed with the tibia in neutral
and internal rotation. In an isolated
PCL injury, there will be decreased
posterior tibial translation with the
tibia in internal rotation because the
POL and posteromedial capsule
function as secondary stabilizers to
November 2017, Vol 25, No 11
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
this translation.26,33,34 Therefore, in
combined PCL-PMC injuries, there
will be equal posterior translation of
the tibia relative to the femur with
the tibia in both neutral and internal
rotations.
Imaging
Imaging studies are critical for the
diagnosis of PMC injuries, particu-
larly in the setting of an acute injury
when a thorough examination is not
possible or is equivocal because
of patient guarding. Obtaining a
standard radiographic series is the
initial step in the evaluation of sus-
pected PMC injuries. The series
should include AP, lateral, and
oblique views. Standing radio-
graphs are useful to assess overall
limb alignment, but they are not
always practical because of pain
with weight bearing. Although
plain radiographs are frequently
normal, they may demonstrate
avulsion fractures or osteochondral
defects. Radiographs should be care-
fully evaluated for any evidence of
joint space narrowing or asymmetry,
raising suspicion for knee dislocation
and multiligamentous injuries.
Objective evaluation of knee laxity
may be performed with stress radio-
graphs of the knee. LaPrade et al35
developed a quantitative method of
analyzing valgus knee radiographs.
In a biomechanical study, the
authors found that, compared with
the contralateral knee, .3.2 mm of
laxity at 20° of flexion is indicative
of a grade III MCL lesion. Sub-
stantial gapping at 0° and 20° (up to
9.8 mm) was correlated with com-
plex knee injuries involving the
MCL, PMC, and cruciate ligaments.
Posterior stress radiographs can
also detect combined injuries.
Garavaglia et al36 found that .9 mm
of posterior tibial translation on
posterior stress views at 30° of knee
flexion and .12 mm at 80° of knee
flexion were indicative of PCL and
Andrew P. Dold, MD, FRCSC, et al
associated lesions (ie, lateral collat-
eral ligament, MCL, PMC, PLC).
The current imaging modality of
choice for diagnosing complex
injuries of the PMC is MRI. The
normal anatomic components of the
PMC are difficult to visualize with
standard imaging technology; how-
ever, certain techniques may facilitate
evaluation of these structures on
MRI. In a cadaver study, Loredo
et al37 found these structures chal-
lenging to identify on MRI but re-
ported improvement in visualization
with contrast-enhanced sequences
and coronal oblique images. Edema
and soft-tissue thickening can be
used to identify many injuries of the
PMC. In addition, MRI allows the
evaluation of associated injuries
within the knee and assists with
preoperative planning.
Management
To our knowledge, there is a paucity
of literature regarding nonsurgical
management of PMC injuries. Nev-
ertheless, in our opinion, isolated
grade I and II injuries to the MCL
complex that extend posteromedially
can be treated nonsurgically with a
short course of bracing and physical
therapy, allowing patients to return
to sport.
In our experience, injuries that
involve the PMC typically occur in
patients with multiligamentous
injuries or knee dislocations. Most
grade III MCL and PMC injuries
are associated with substantial
multiligamentous instability and often
require surgical intervention to improve
valgus, rotational, and sagittal stability.
Various techniques for repair or
reconstruction of the posteromedial
structures of the knee have been
described, each demonstrating
acceptable clinical results.38-41
Despite the number of different
surgical techniques, however, there
are still no clear-cut, agreed-upon
757
The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies
indications for surgical management
of a PMC injury. In our experience,
most high-energy multiligamentous
knee injuries, especially those with a
true knee dislocation, warrant con-
siderable attention to the PMC.
In our practice, candidates for sur-
gical repair or reconstruction include
patients with multiligamentous
injuries with AMRI, those who
experience medial gapping or insta-
bility with valgus stress at full exten-
sion, and patients in whom the
posterior drawer test with internal
rotation produces posterior trans-
lation equal to that of a posterior
drawer done with neutral rotation.
All of these scenarios demonstrate
the relative incompetence of the
posteromedial structures and warrant
surgical attention in the context of a
knee with multiligamentous injuries.
Distally based tibial-sided MCL
and PMC tears that are avulsed as a
sleeve may benefit from early fixa-
tion, especially when they are asso-
ciated with Stener-type lesions or
demonstrate incarceration in the
knee joint. In the acute care setting, if
a robust tissue sleeve is present, we
consider PMC repair with or without
augmentation to be a viable option.
However, in patients with a sub-
stantially attenuated ligamentous
complex (especially those with mid-
substance tears), reconstruction and/
or augmentation should be consid-
ered. Chronic, symptomatic PMC
injuries are treated only with surgical
reconstruction.
In patients who require concomi-
tant ACL and PCL reconstructions,
we assess the overall quality of the
knee before deciding whether to stage
the procedure or perform it in one
stage. In the setting of chronic ACL/
PCL/PMC injuries, we typically find
that patients have uncompromised
motion; we prefer to perform the
procedure in one setting in these
patients. However, in the acutely
injured knee, we pay careful attention
to the type of medial-sided injury as
758
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
well as the overall quality of the knee
joint. High-energy injuries and dis-
locations often have major capsular
detachments and have an increased
risk for arthrofibrosis. In patients
with these injuries, we typically stage
the procedures and perform the
medial procedure in isolation, espe-
cially when the ligamentous struc-
tures are torn off the tibia. After the
patient has successfully completed
rehabilitation and regained full, pain-
less motion, we perform the second
stage. Thought can also be given to
performing the PMC and PCL proce-
dures concurrently because the reha-
bilitation protocols may be similar;
doing both procedures minimizes any
extra stress on the PMC by ensuring
that the PCL is competent. However,
no consensus as to the timing and
potential staging of these procedures
currently exists.
We recommend performing a
thorough examination under anes-
thesia and diagnostic arthroscopy
regardless of the method of surgical
management. During the initial
arthroscopy, meniscal pathology
should be addressed, the articular
cartilage should be assessed, and an
intraoperative stress examination
should be performed. When the soft
tissues allow, our preferred approach
is to perform an acute reconstruction
of the cruciate ligaments (ie, in the
case of a combined ACL/PCL injury)
with medial repair versus recon-
struction, depending on the quality of
the medial tissues.
Repair
Surgical repair of PMC injuries has
been effective in restoring knee sta-
bility and improving functional out-
comes.6,42 Often, the MCL must be
repaired in conjunction with the
PMC. A medially based longitudinal
incision extending from the level of
the superior patella to 6 to 8 cm
distal to the joint line should be used,
and soft-tissue dissection should
Journal of the American Academy of Orthopaedic Surgeons
extend down to the superficial MCL
and posteromedial structures. Care
is required to protect the hamstring
insertions at the pes anserine.
Fixation can be accomplished with
several options, including suture
anchors, staples, or screw-and-
washer2type constructs. Whichever
fixation method is chosen, we rec-
ommend approaching these injuries
in a deep-to-superficial fashion. The
medial meniscus and meniscocap-
sular attachments should be ap-
proached first. The meniscotibial
attachments can be repaired with
small suture anchors placed around
the surface of the tibia from posterior
to anterior, just distal to the tibial
articular surface, with care taken to
avoid violating the articular cartilage.
Suture anchor repair can be used for
tibial- or femoral-sided avulsions of
the POL if the tissue is of robust
quality. Advancement of the tissue
and reapproximation into the
superficial MCL have also been
described.43
The semimembranosus tendon
should be evaluated. When torn, this
tendon can be advanced and sutured
into the superficial MCL tissue in a
pants-over-vest fashion or reattached
with a suture anchor. We think this is
important given the role of this tendon
in dynamic stabilization of the knee.
In general, the clinical results of
surgical repair have been good.
DeLong and Waterman42 recently con-
ducted a meta-analysis of patients
who underwent repair of MCL and
PMC injuries and found that in 93
knees, the mean side-to-side differ-
ence in medial joint space opening
was 1.25 mm. In total, 13 of 212
knees (6.1%) met the criteria for
failure of the repair. Because of the
inherent limitations in systematic
reviews, only 63% of the patients in
this study had documented measures
of valgus laxity, and only 26% of
patients had quantifiable side-to-side
differences in postoperative medial
joint space opening.

In contrast, Stannard et al6
described a cohort of patients who
sustained knee dislocations with
multiligamentous injuries and re-
ported a lower failure rate in patients
who underwent reconstruction than
in those who underwent repair. The
authors reported that 96% of those
treated with surgical reconstruction
achieved postoperative valgus sta-
bility compared with 80% of
patients treated with direct repair of
the PMC.
Reconstruction
Surgical reconstruction should be
considered in cases of chronic,
symptomatic rotatory instability (ie,
AMRI), valgus instability (ie, espe-
cially in full extension), and posterior
instability with PMC and PCL insuf-
ficiency. Multiple methods of recon-
struction have been described in the
literature, and choice of graft is based
on the surgeon’s preference and
experience. Generally, in cases of
multiligamentous knee injuries, we
prefer the use of allograft tissue to
limit donor site morbidity.
Various PMC reconstruction tech-
niques have had promising
results.38,40,41,44 We prefer the
technique described by LaPrade and
Wijdicks,41 which is an anatomic
reconstruction of the proximal and
distal divisions of the superficial
MCL and the POL using two sepa-
rate grafts (Figure 5). An ante-
romedial longitudinal incision
beginning 4 cm medial to the patella
and extending 8 cm distal to the joint
line is used to expose both the fem-
oral and the distal tibial attachment
sites of the superficial MCL. The
sartorial fascia is incised to expose
the gracilis and semitendinosus ten-
dons. The semimembranosus tendon
can be harvested for autograft de-
pending on surgeon preference.
Deep within the pes anserine bursa,
the distal tibia attachment of the
superficial MCL can be identified
November 2017, Vol 25, No 11
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Andrew P. Dold, MD, FRCSC, et al
Figure 5
Illustrations of the posteromedial aspect of the left knee before (A) and after (B) a
posteromedial corner reconstruction using two separate grafts to reconstruct the
superficial medial collateral ligament (sMCL) and the posterior oblique ligament
(POL), as described by LaPrade and Wijdicks.41
6 cm distal to the joint line. First, a sites should be identified before
reconstruction tunnel is created for reaming—rather than reaming each
the superficial MCL. A guide pin is tunnel individually—to decrease the
placed from medial to lateral at the possibility of reaming a tunnel out-
posterior aspect of the superficial side the ideal location. Guide pins
MCL tibial insertion, and a 6- or are placed across the femur, and
7-mm tunnel is reamed to a depth of once the tunnel position is confirmed
25 mm. A reconstruction tunnel for as acceptable, a 6- or 7-mm reamer is
the central arm of the POL is then used to drill each reconstruction
placed just anterior to the direct arm tunnel to a depth of 25 mm. The
attachment of the semimembranosus femoral ends of the grafts are first
tendon. A guidewire is placed, fixed with interference screws. The
directed toward the Gerdy tubercle, POL graft is then placed into its
and overreamed with a 6- or 7-mm tibial tunnel and tensioned in full
reamer to a depth of 25 mm. extension and neutral rotation. The
Attention is then turned toward the superficial MCL is woven under the
femoral tunnel sites. When the fem- sartorial fascia and fixed in its tibial
oral attachment sites of the native tunnel with the knee held in neutral
POL and MCL are not readily visu- rotation and 20° of flexion, and with
alized because of the injury pattern, a slight varus reduction force to
the tunnel locations can be estimated ensure no medial compartment
by using bony topography. The gapping.
superficial MCL tunnel is placed Attention is then directed toward
slightly proximal and anterior to the recreating the proximal tibial
medial epicondyle. The femoral POL attachment site of the superficial
tunnel is placed approximately 8 mm MCL graft. A suture anchor is placed
distal and 3 mm anterior to the 12 to 13 mm distal to the medial joint
gastrocnemius tubercle. Both tunnel line, just anterior to the anterior arm
759
The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies
of the semimembranosus tendon
attachment. The superficial MCL
graft is secured to this site with the
anchor, restoring the native proximal
tibial attachment.
In patients undergoing concomi-
tant PCL reconstruction via femoral
bone tunnels, it is important to angle
the superficial MCL and POL tunnels
30° proximally and anteriorly (ie, in
the coronal and axial planes,
respectively). Tunnels drilled at 0° in
the axial plane may result in shorter
tunnels and may increase the risk of
intersection with a PCL femoral
tunnel.45 In the setting of multi-
ligamentous reconstruction, we typ-
ically tension the cruciate ligaments
before tensioning the collateral
ligaments.
In a series of 28 patients who
underwent anatomic reconstruction
with this technique, LaPrade and
Wijdicks41 noted an average improve-
ment of 33 points in International
Knee Documentation Committee
scores, elimination of side-to-side
instability in all patients, and an
average of 1.3 mm of increased medial
compartment gapping postoperatively
(versus 6.2 mm preoperatively) on
stress radiographs compared with the
contralateral knee. Although the
authors reported considerable
improvement on stress radiographs
compared with the contralateral side,
they did not break down these values
by 20° of flexion versus full extension.
Two alternative techniques that use
the native semitendinosus tendon and
keep the distal insertion of the tendon
intact have been described.38,40 Both
techniques have demonstrated
promising results.
Summary
Our understanding of the PMC—
both its anatomic features and its
contribution to knee stability—has
increased substantially in recent
years. With modern MRI systems,
760
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
the major anatomic structures com-
prising the PMC can be readily
identified and appreciated in the
context of multiligamentous injuries.
Novel anatomic and biomechanical
studies demonstrated that the PMC
is an important primary stabilizer of
valgus laxity and a secondary stabi-
lizer of anterior tibial translation and
external rotation. AMRI is the hall-
mark of PMC injuries. In the setting
of a possible multiligamentous or
medial-sided injury, a high index of
suspicion for a PMC injury must be
maintained; when unrecognized, this
injury can result in chronic valgus
laxity and late graft failure after ACL
reconstruction. Limited studies of
PMC injuries treated with primary
repair or reconstruction of the
superficial MCL and POL have re-
ported good functional outcomes
and low failure rates. Further
research regarding short- and long-
term outcomes after surgical treat-
ment of PMC injuries is warranted to
further expand our knowledge about
the management of these injuries.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, reference 1 is
a level I study. References 6, 39, and
42 are level III studies. References 5,
22, 38, 40, and 41 are level IV
studies.
References printed in bold type are
those published within the past 5
years.
1. Andrews JB, Baker CL, Curl WW: Surgical
repair of acute and chronic lesions of the
lateral capsular ligamentous complex of
the knee, in Fergin JA Jr, ed: Injuries About
the Knee. New York, NY, Churchill
Livingstone, 1988, pp 425-438.
2. Ranawat A, Baker CL III, Henry S,
Harner CD: Posterolateral corner injury of
the knee: Evaluation and management. J
Am Acad Orthop Surg 2008;16(9):
506-518.
3. Lundquist RB, Matcuk GR Jr,
Schein AJ, et al: Posteromedial corner of the
Journal of the American Academy of Orthopaedic Surgeons
knee: The neglected corner. Radiographics
2015;35(4):1123-1137.
4. Warren LA, Marshall JL, Girgis F: The
prime static stabilizer of the medical side of
the knee. J Bone Joint Surg Am 1974;56(4):
665-674.
5. Sims WF, Jacobson KE: The posteromedial
corner of the knee: Medial-sided injury
patterns revisited. Am J Sports Med 2004;
32(2):337-345.
6. Stannard JP, Black BS, Azbell C, Volgas DA:
Posteromedial corner injury in knee
dislocations. J Knee Surg 2012;25(5):
429-434.
7. Engebretsen L, Lind M: Anteromedial
rotatory laxity. Knee Surg Sports
Traumatol Arthrosc 2015;23(10):
2797-2804.
8. Pedersen RR: The medial and
posteromedial ligamentous and capsular
structures of the knee: Review of
anatomy and relevant imaging findings.
Semin Musculoskelet Radiol 2016;20(1):
12-25.
9. Griffith CJ, LaPrade RF, Johansen S,
Armitage B, Wijdicks C, Engebretsen L:
Medial knee injury: Part 1, static function
of the individual components of the main
medial knee structures. Am J Sports Med
2009;37(9):1762-1770.
10. Robinson JR, Sanchez-Ballester J, Bull AM,
Thomas Rde W, Amis AA: The
posteromedial corner revisited: An
anatomical description of the passive
restraining structures of the medial aspect
of the human knee. J Bone Joint Surg Br
2004;86(5):674-681.
11. Brantigan OC, Voshell AF: The tibial
collateral ligament: Its function, its
bursae, and its relation to the medial
meniscus. J Bone Joint Surg Am 1943;25:
121-131.
12. Hughston JC, Eilers AF: The role of the
posterior oblique ligament in repairs of
acute medial (collateral) ligament tears of
the knee. J Bone Joint Surg Am 1973;55(5):
923-940.
13. LaPrade RF, Engebretsen AH, Ly TV,
Johansen S, Wentorf FA, Engebretsen L:
The anatomy of the medial part of the knee.
J Bone Joint Surg Am 2007;89(9):
2000-2010.
14. Bauer KL, Stannard JP: Surgical
approach to the posteromedial corner:
Indications, technique, outcomes. Curr
Rev Musculoskelet Med 2013;6(2):
124-131.
15. Wijdicks CA, Griffith CJ, LaPrade RF, et al:
Radiographic identification of the primary
medial knee structures. J Bone Joint Surg
Am 2009;91(3):521-529.
16. Müller W: The Knee: Form, Function, and
Ligament Reconstruction. Berlin,
Germany, Springer Verlag, 1983.

17. House CV, Connell DA, Saifuddin A:
Posteromedial corner injuries of the knee.
Clin Radiol 2007;62(6):539-546.
18. LaPrade RF, Morgan PM, Wentorf FA,
Johansen S, Engebretsen L: The anatomy of
the posterior aspect of the knee: An
anatomic study. J Bone Joint Surg Am
2007;89(4):758-764.
19. De Maeseneer M, Shahabpour M,
Vanderdood K, Van Roy F, Osteaux M:
Medial meniscocapsular separation: MR
imaging criteria and diagnostic pitfalls. Eur
J Radiol 2002;41(3):242-252.
20. Peltier A, Lording T, Maubisson L, Ballis R,
Neyret P, Lustig S: The role of the
meniscotibial ligament in posteromedial
rotational knee stability. Knee Surg Sports
Traumatol Arthrosc 2015;23(10):2967-2973.
21. Halinen J, Lindahl J, Hirvensalo E,
Santavirta S: Operative and nonoperative
treatments of medial collateral ligament
rupture with early anterior cruciate
ligament reconstruction: A prospective
randomized study. Am J Sports Med 2006;
34(7):1134-1140.
22. Chahal J, Al-Taki M, Pearce D, Leibenberg
A, Whelan DB: Injury patterns to the
posteromedial corner of the knee in high-
grade multiligament knee injuries: A MRI
study. Knee Surg Sports Traumatol
Arthrosc 2010;18(8):1098-1104.
23. Chan KK, Resnick D, Goodwin D, Seeger
LL: Posteromedial tibial plateau injury
including avulsion fracture of the
semimembranous tendon insertion site:
Ancillary sign of anterior cruciate ligament
tear at MR imaging. Radiology 1999;211
(3):754-758.
24. Escobedo EM, Mills WJ, Hunter JC: The
“reverse Segond” fracture: Association
with a tear of the posterior cruciate
ligament and medial meniscus. AJR Am J
Roentgenol 2002;178(4):979-983.
25. Peltola EK, Lindahl J, Koskinen SK: The
reverse Segond fracture: Not associated
with knee dislocation and rarely with
posterior cruciate ligament tear. Emerg
Radiol 2014;21(3):245-249.
26. Shelbourne KD, Carr DR: Combined
anterior and posterior cruciate and medial
collateral ligament injury: Nonsurgical and
November 2017, Vol 25, No 11
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
delayed surgical treatment. Instr Course
Lect 2003;52:413-418.
27. Craft JA, Kurzweil PR: Physical
examination and imaging of medial
collateral ligament and posteromedial
corner of the knee. Sports Med Arthrosc
2015;23(2):e1-e6.
28. Wijdicks CA, Griffith CJ, Johansen S,
Engebretsen L, LaPrade RF: Injuries to the
medial collateral ligament and associated
medial structures of the knee. J Bone Joint
Surg Am 2010;92(5):1266-1280.
29. Stannard JP: Medial and posteromedial
instability of the knee: Evaluation,
treatment, and results. Sports Med Arthrosc
2010;18(4):263-268.
30. Fanelli GC, Harris JD: Surgical treatment of
acute medial collateral ligament and
posteromedial corner injuries of the knee.
Sports Med Arthrosc 2006;14(2):78-83.
31. Slocum DB, Larson RL: Rotatory
instability of the knee: Its pathogenesis and
a clinical test to demonstrate its presence. J
Bone Joint Surg Am 1968;50(2):211-225.
32. Slocum DB, James SL, Larson RL,
Singer KM: Clinical test for anterolateral
rotary instability of the knee. Clin Orthop
Relat Res 1976;118:63-69.
33. Ritchie JR, Bergfeld JA, Kambic H,
Manning T: Isolated sectioning of the
medial and posteromedial capsular
ligaments in the posterior cruciate ligament-
deficient knee: Influence on posterior tibial
translation. Am J Sports Med 1998;26(3):
389-394.
34. Tibor LM, Marchant MH Jr, Taylor DC,
Hardaker WT Jr, Garrett WE Jr,
Sekiya JK: Management of medial-sided
knee injuries, part 2: Posteromedial corner.
Am J Sports Med 2011;39(6):1332-1340.
35. LaPrade RF, Bernhardson AS, Griffith CJ,
Macalena JA, Wijdicks CA: Correlation of
valgus stress radiographs with medial knee
ligament injuries: An in vitro biomechanical
study. Am J Sports Med 2010;38(2):
330-338.
36. Garavaglia G, Lubbeke A, Dubois-Ferrière V,
Suva D, Fritschy D, Menetrey J: Accuracy
of stress radiography techniques in grading
isolated and combined posterior knee
Andrew P. Dold, MD, FRCSC, et al
injuries: A cadaveric study. Am J Sports
Med 2007;35(12):2051-2056.
37. Loredo R, Hodler J, Pedowitz R, Yeh LR,
Trudell D, Resnick D: Posteromedial corner
of the knee: MR imaging with gross
anatomic correlation. Skeletal Radiol 1999;
28(6):305-311.
38. Kim SJ, Lee DH, Kim TE, Choi NH:
Concomitant reconstruction of the medial
collateral and posterior oblique ligaments
for medial instability of the knee. J Bone
Joint Surg Br 2008;90(10):1323-1327.
39. DeLong JM, Waterman BR: Surgical
techniques for the reconstruction of medial
collateral ligament and posteromedial
corner injuries of the knee: A systematic
review. Arthroscopy 2015;31(11):2258-
2272.e1.
40. Lind M, Jakobsen BW, Lund B, Hansen MS,
Abdallah O, Christiansen SE: Anatomical
reconstruction of the medial collateral
ligament and posteromedial corner of the
knee in patients with chronic medial
collateral ligament instability. Am J Sports
Med 2009;37(6):1116-1122.
41. LaPrade RF, Wijdicks CA: Surgical
technique: Development of an anatomic
medial knee reconstruction. Clin Orthop
Relat Res 2012;470(3):806-814.
42. DeLong JM, Waterman BR: Surgical repair
of medial collateral ligament and
posteromedial corner injuries of the knee: A
systematic review. Arthroscopy 2015;31
(11):2249-2255.e5.
43. Lubowitz JH, MacKay G, Gilmer B: Knee
medial collateral ligament and
posteromedial corner anatomic repair with
internal bracing. Arthrosc Tech 2014;3(4):
e505-e508.
44. Weimann A, Schatka I, Herbort M, et al:
Reconstruction of the posterior oblique
ligament and the posterior cruciate
ligament in knees with posteromedial
instability. Arthroscopy 2012;28(9):
1283-1289.
45. Gelber PE, Masferrer-Pino À,
Erquicia JI, et al: Femoral tunnel drilling
angles for posteromedial corner
reconstructions of the knee. Arthroscopy
2015;31(9):1764-1771.
761