Radiology Teaching Files > Case 27481

Contributed by: Stan Cheng, Radiologist, Seattle Children's Hospital & Regional Medical Center, Washington, USA.
Patient: 11 year old male
History: 11 yo male with knee pain following a football injury.

Fig. 1: Coronal PD

Fig. 2: Coronal PD

Fig. 3: Coronal STIR

Fig. 4: Coronal STIR

The medial collateral ligament is completely disrupted. There is a moderate size joint effusion, with fluid surrounding the disrupted medial collateral ligament.

There is abnormal increased STIR signal within the epiphysis of the medial and lateral femoral condyles, greater medially, most likely bone contusions.

Other ligamentous structures and menisci were normal.


1. Complete tear of medial collateral ligament
2. Femoral condyle bone contusions


- MCL is composed of superficial & deep portions;
- superficial MCL:
- anatomically this is the second (middle) layer of the medial compartment;
- proximal attachment: posterior aspect of medial femoral condyle;
- distal attachment: metaphyseal region of the tibia, up to 4-5 cm distal to the joint, lying beneath the pes anserinus;
- Function: provides primary restraint to valgus stress at knee
- superficial ligament can be divided into anterior & posterior portions;
- anterior fibers of superficial portion of ligament appear to tighten w/ knee flexion of 70 to 105 deg;
- posterior fibers form the posterior oblique ligament:
- Deep MCL:
- anatomically this is the third (deep) layer of the medial compartment, which in many cases will be separated from the superficial MCL (layer II) by a bursa (which allows sliding of the tissues during flexion);
- divided into meniscofemoral and meniscotibial ligaments;
- inserts directly into edge of tibial plateau & meniscus;
- firmly attaches to the meniscus but does not provide significant resistance to valgus force;

Location of Tears:
- Femoral tear:
- if ligament is avulsed from medial epicondyle, the ligament may elevate a small bony fragment with it, in which case the point of origin becomes tender to palpation;
- Mid substance tear:
- if ligament is torn at its midpoint, tendon and overlying soft tissue may be shredded;
- Tibial tear:
- tenderness may be felt 6-8 cm down medial tibial shaft (along length of the ligament insertion);
- when distal end of MCL is torn in area of pes anserinus, one may restore normal tension to this portion of MCL by securing the lower end to freshened area of bone w/ sutures or a staple advanced distally;

Clinical Exam Findings:
Valgus stress test--
- clinical findings may be subtle even with complete injury;
- it is helpful to anchor the thigh on the table w/ the knee and leg off the the edge of the table;
- opening of 5-8 mm compared to opposite knee may indicate complete tear;
- instability in slight flexion:
- anterior portion of the medial capsular is primary stabilizer at 30 deg of flexion;
- hence at 30 flexion, testing is specific for just MCL;
- instability in extension:
- posterior portion of the MCL, posterior oblique ligament, ACL, medial portion of posterior capsule & possibly PCL;

Radiographic findings:

- Pellegrini-Stieda Phenomenon:
- w/ chronic injury, it is common to see calcification at origin of MCL;

- MRI:
- helpful for delineating of disruption of the collateral complex;
- collateral ligament is best visualized on T2 weight images:
- as a high signal of edema and hemorrhage in the substance of the low signal ligament;
- look for concomitant meniscal tear

References: on 10/1/02

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Additional Details:

Case Number: 27481Last Updated: 10-02-2002
Anatomy: Skeletal System   Pathology: Trauma
Modality: MRExam Date: 09-30-2002Access Level: Readable by all users
Keywords: knee, medial collateral ligament, tear

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