Posterolateral corner (PLC) injury of the knee

What is it?

Posterolateral corner (PLC) injuries are commonly associated with ACL or

PCL tears, justifying close examination for a PLC injury for every cruciate
ligament tear. Only 28% of all PLC injuries occur in isolation.
Failing to address a PLC injury may compromise concurrent cruciate
ligament reconstructions. It could furthermore derive in altered knee
biomechanics, which ultimately can lead to early degenerative changes of
the joint.
Common mechanism of injury to the PLC is a direct blow to the
anteromedial knee hyperextension. Non-contact varus stress injuries can
also damage the PLC.

What structures are involved?

1. The posterolateral ligamentous complex three major static stabilizers

Fibular (lateral) collateral ligament (FCL) the primary restraint to varus
stress across the knee
Popliteus tendon (PLT) minor primary stabilizer (the ACL is the main
stabilizer in lower flexion angles and ALL in higher flexion angles) in
preventing internal rotation
Popliteofibular ligament (PFL)

2. Secondary structures that help stabilize the knee in a static and dynamic
manner
Lateral capsular ligament
Coronary ligament
Lateral gastrocnemius tendon
Fabellofibular ligament
Long head of the biceps femoris
Iliotibial band (ITB)
3. What are the functions of the PLC structures?

Provide the primary restraint to varus forces of the knee and

postero-lateral rotation of the tibia relative to the femur.
In cruciate deficient knees, these structures are also important secondary
stabilizers to anterior and posterior tibial translation.
In regards to tibial external rotation, the FCL and the popliteus
complex are the primary restraints, especially between 30 and
40 of flexion. Posterior cruciate ligament (PCL) acts as a secondary
restraint. Thus, combined PCL and PLC injuries are more susceptible to
external rotation forces
Other PLC structures are secondary restraints to internal rotation.
Minimal contribution of the PLC has been reported for anteroposterior tibial
translation (popliteus tendon), specifically in full extension and with ACL or
PCL deficient knees.

How to identify PLC injuries?

1. Symptoms

Pain, perceived side-to-side instability near extension, increased difficulty

walking on uneven ground or up and down stairs, ecchymosis and swelling.
This instability and difficulty walking can present as a varus thrust gait
seen during the initiation of the stance phase.
It is not uncommon for the patient to complain of paresthesia of the
common peroneal nerve distribution or foot drop. Common peroneal nerve
injury has been reported to occur in up to one third of PLC injuries.

2. Physical examination

Varus stress testing

Dial test
Reverse pivot shift test
External rotation recurvatum test
All tests should be performed bilaterally to compare to the uninjured knee.

3. Radiological examination

Standard antero-posterior (AP), lateral and bent knee patella-femoral

(sunrise) view radiographs of the knee should be obtained
For chronic PLC injuries, a standing long-leg AP alignment radiograph is a
requirement because mal-alignment needs to be recognized and corrected
with a bi-planar osteotomy prior to, or at the time of, surgical PLC
reconstruction
Varus stress radiographs for the objective diagnosis of PLC injuries
reported to be a reliable and reproducible objective method to evaluate the
severity of these lesion
4. Classification

They are classified depending on the degree of joint gapping when the therapist
manually stresses the lateral joint, as well as the end feel when performing this
movement.
Grade 1 injuries demonstrate a 3-5 mm gap with a clear end point.
Grade 2 injuries demonstrate 5-10mm gaps, still with a clear end point.
Grade 3 injuries demonstrate more than a 10mm gap, with a very soft or
even nonexistent end-feel.

What are the treatment options?

1. Conservative

Grade 1 and lesser grade 2 injuries may be treated conservatively with good
results. The knee should firstly be stabilized in a hinged brace (permitting full
range of motion) and controlled weight bearing (using a crutch or stick) for 2-4
weeks. Following this, a progressive rehabilitation programme, which concentrates
on regaining full knee motion and building the strength in the quads in particular.

However, poor functional outcomes for non-operatively treated grade III PLC
injuries with persistent instability and degenerative changes have been reported.
Increased forces on the PCL and ACL reconstruction grafts have been reported if
concurrent PLC injuries are not addressed.

2. Surgical

Grade 2 and grade 3 injuries require surgical treatment.

Repair
Acute treatment, within 3 weeks, is reported to have improved outcomes,
while treatment after 3 weeks has been reported to have similar outcomes
to chronic injuries.
Acute injuries (within 3 weeks) can often be treated with a repair, whereas
more chronic injuries require surgical reconstruction. Repair is not possible
after the acute period has passed due to the development of scar tissue as
well as joint misalignment.

Reconstruct
A graft may be taken from the achilles tendon, IT band, patella tendon,
semitendinosus tendon (one of the hamstring muscles) or the anterior or
posterior tibialis tendon. This is used to recreate the ruptured structures.
What is the rehabilitation process like post-operation?

Following PLC reconstruction, patients utilize a knee immobilizer and stay

non-weight bearing for 6 weeks.
Formal rehabilitation begins immediately postoperatively and focuses on
restoration of tibio-femoral and patella-femoral range of motion,
edema and pain management, and restoration of quadriceps
function.
Passive range of motion 0-90 for the first 2 weeks and then progressed to
full range of motion as tolerated.
At 6 weeks, patients are permitted to begin spinning on a stationary bike
and begin to wean off crutches.
Once full weight bearing, patients begin closed chain strength exercises
with training parameters focused on first developing a muscular endurance
base before progressing to muscular strength and power development.
Isolated hamstring strengthening is limited to avoid stressing the
reconstruction until a minimum of 4 months postoperatively.
A running progression and speed and agility work may begin once
appropriate strength and power characteristics have been developed,
typically around 6 months post-surgery.
Return to sports or activity is allowed when normal strength, stability, and
knee range of motion comparable to the contralateral side has been
achieved (usually between 6 to 9 months and based on concurrent cruciate
ligament or other ligament surgery).
Resources

Chahla, J., Moatshe, G., Dean, C. S., & LaPrade, R. F. (2016). Posterolateral Corner
of the Knee: Current Concepts. Archives of Bone and Joint Surgery, 4(2), 97103.

Vinson, E. N., Major, N. M., & Helms, C. A. (2008). The posterolateral corner of the
knee. American Journal of Roentgenology, 190(2), 449-458.

http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/posterolateral-corner-
injury

http://www.orthobullets.com/sports/3012/posterolateral-corner-injury