Review Question - QID 219477

This athlete has a chronic, isolated grade 3 lateral collateral ligament (LCL) tear with peroneal nerve symptoms and should be treated with LCL reconstruction and peroneal nerve neurolysis.

Injuries to the lateral side of the knee can be difficult to diagnose and treat, given the complex anatomy involved. Three primary structures are involved in providing stability to the lateral side of the knee including the LCL, popliteus, and popliteofibular ligament. The LCL is primarily responsible for providing varus restraint at 30° of flexion, while the popliteus and popliteofibular ligaments provide external rotation control as well as control of posterior tibial translation. Injury to the lateral side of the knee can also cause direct injury to the peroneal nerve or a stretch injury over time if there is excess laxity. Most isolated LCL injuries can be treated non-operatively, but grade 3 injuries with evidence of excess clinical laxity in high-level athletes may benefit from operative management, especially in the setting of nerve symptoms. Repair and reconstruction of the injured ligament are both options, but repair has been shown to have a higher rate of failure in more chronic (>3 weeks) settings.

Grawe et al. published a review article in JAAOS discussing the evaluation and management of LCL injuries. They discuss the different grades of LCL injury and subsequent management strategies. They note that a torn LCL does not heal as well as a torn MCL and they have a lower threshold for intervention, especially in grade 3 injuries.

Moulton et al. looked at outcomes following LCL reconstruction in 43 patients using a semitendinosus graft. They found that Lysholm and WOMAC scores improved significantly postoperatively, as did patient satisfaction scores. They concluded that, when indicated, these patients had a high level of success with reconstruction of their LCL.

Incorrect Answers:
Answer 1: Physical therapy with the initial assistance of bracing would be appropriate in patients with an isolated grade 1 or 2 LCL injury, but not in a high-level athlete hoping to return to contact sports. Additionally, the contribution of symptoms from his peroneal nerve would be an indication for operative intervention.
Answer 2: PRP injection would not be appropriate in the setting of a complete ligament rupture with high-grade clinical laxity and would not restore the ligament's integrity.
Answer 3: Ligament repair has a higher rate of failure in the setting of subacute or chronic injuries and given this injury occurred during the prior football season, this option would not be appropriate.
Answer 5: Reconstruction of the popliteus and popliteofibular ligament would not be necessary as this appears clinically to be an isolated LCL injury without concomitant posterolateral corner injury.