A Lateral Collateral ligament injury is when the varus force (bowing) on the knee is too great for the ligament to resist. This occurs during activities like a sudden change in direction, twisting your knee while your foot is fixed, when your knee hyperextends, or if there is a direct hit to your knee. A Lateral Collateral ligament tear usually occur at speed, and if it coincides with muscle weakness or knee instability, because it increases your risk. Just like a Medial Collateral ligament sprain on the inside of the knee, the Lateral Collateral ligament on the outside needs to be strong enough & able to withstand different forces to your knee. Let’s discuss this in more detail.

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What is the Lateral Collateral Ligament made up of?

The Lateral Collateral ligament is a fibrous band on the outside of your knee. THe ligament is made up out of very strong cable-like collagen fibers. It originates from the lateral femoral epicondyle, this is the bony bump on the outside of your thigh just above the knee joint. It attaches to the head of the fibula which is the outside bone in your lower leg just below the knee joint.

It also forms part of the “posterolateral corner”. The biceps femoris tendon also anchors at this point.

What does Lateral Collateral Ligament do?

The Lateral Collateral ligament is one of the four ligaments that help stabilise your knee joint. Your Lateral Collateral ligament prevents excessive motion of your knee bowing inwards. While your knee is straight, your Lateral Collateral ligament stops our lower leg from collapsing inwards.  It also prevents excessive outward rotation of the tibial bone. The ligament takes up slack when your foot is forced inwards in relation to the knee, or when the foot is planted and the knee is twisted outwards.

For example, when you play soccer and run towards the ball, someone kicks it to your left, you have to very suddenly change direction, your foot stays on the ground while your body starts turning outwards, and your knee twists outwards over your foot.

An Lateral Collateral ligament sprain only accounts for about 2% of all knee injuries. Sometimes it happens in conjunction with injury to the other structures on the outside of your knee, such as the lateral meniscus tears, Anterior Cruciate ligament tears or hamstring tears in the bip femoris muscle.

How does Lateral Collateral Ligament sprain happen?

A ligament sprain is a form of overstretching of the ligament. There are several classifications in which ligament sprains can be divided, depending on the severity (Degree or Grade 1, 2 or 3). The fibrous band is like a pulley, which prevents the joint moving into extreme ranges. But when the force is too big for the ligament to resist, the fibers will tear.  Over stretching the Lateral Collateral ligament will result in tears & a sprain of your ligament.

It is very important to know and understand the difference and implications thereof. In the case of a tear, you may hear a snap or tearing sound. For example when a rugby player is tackled on his knee from the inside when his foot is firmly planted, the weight of the tackler will be in excess of what the Lateral Collateral ligament can resist. The force directed on the player’s knee is pushing his knee outwards. The Lateral Collateral ligament is at full stretch while a uncontrollable load is being forced on it, therefore this will thrust the ligament past its boundaries and cause the ligament to tear or completely rupture.

The collagen fibers tear like a rope. On a cellular level, injury will cause inflammation along the sheath of the ligament (a membrane that gives the ligament its nutrients – normal sustenance is disrupted). In turn, the inflammation causes swelling, pain and loss of function of the ligament, leaving the knee to buckle inwards. The swelling along the sheath contributes of loss of space around the ligament that restricts the normal slide of the ligament.

Ligament tears are indicated by Mucoid degeneration and fibrinoid necrosis (a type of cell death).

Lateral Colateral Ligament injury
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Causes of Lateral Collateral Ligament sprain

An Lateral Collateral ligament injury occurs mostly during sporting activities, but it doesn’t rule out the fact that it happen at work or just during a normal daily activity. For example, you are a soccer player, running towards the ball. An opponent comes from your left side, also running towards the ball, he collides with you and his knee hits you on the inside of your right knee. Your foot is planted in the ground at the time and thrusts your knee outwards. This puts the Lateral Collateral ligament at full strain. If the force exceeds the tension of the ligament the fibers start snapping & tearing, causing a Lateral Collateral ligament sprain.

When these mechanisms of injuries occur, they usually happen at speed, and if the knee stability muscles are not firing properly, the ligament will have to take up the slack, therefore it will increase your risk of an Lateral Collateral ligament sprain. If the ligament doesn’t get properly treated and rehabilitated, it could cause repetitive sprains.

A single, sudden, overload on the ligament will be classified as acute trauma, but repetitive straining of the ligament in excess of its abilities, will develop a persistent laxity of the ligament over and over again. The end result is a Chronic Lateral Collateral ligament injury. The ligament will end up in a cycle of constant damage leading from fatigue, strain and eventually tear or full rupture.

The Lateral Collateral ligament rarely ever gets injured in isolation, therefore it is important to consult with your physiotherapist in order to assess the surrounding structures as well.

How bad is it?

The symptoms of an Lateral Collateral ligament injury depend on the degree of stretch that is put on the ligament.

Grade 1 LCL sprain (mild)

Small amount of fibers torn, some discomfort and pain. The ligament only has a slight stretch. No swelling or much pain, but you may run into trouble if this starts happening over and over again. Recurrence of micro tears in the ligament could lead to more severe tears. You will have no loss of function or range of movement of your knee, but may be painful at some point during the movement. You will be able to continue playing.

Symptoms of a 1st degree LCL sprain

  • Light stretch, no tear
  • About 5/10 pain on the VAS scale
  • Could get slightly swollen on the outside of the knee
  • Mild tenderness over the area
  • No instability/giving way of the knee
  • No discolouration

Medical treatment

You will need to consult with a Physio to establish the extent of damage and accurate diagnosis. Physio treatment of a Gr 1 LCL sprain is very successful.

What you should do during this time:

  • Rest from any activity that causes your pain
  • Ice your knee

Recovery Time

Grade 1 – 2 to 4 weeks. An LCL sprain heal within a few weeks (anything between 2-4 weeks). However , the collagen fibers only align after 6 weeks (maximal ligament strength), so it is advisable to not return to sport too soon.

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Grade 2 LCL tear (moderate)

Partial tear with some swelling and bruising. Pain level increases quite a bit from a grade I, and moving the knee will not occur without pain. It may feel uncomfortable to bend or straighten the knee and your knee may feel unstable and like it wants to “give way”. 20% to 80% of the fibers torn. You will not be able to put weight through the leg. Even if you try to continue playing, you will have considerable amount of pain and limping. The pain will not allow you to straighten your knee or lift your leg forward (knee to chest).

Symptoms of a 2nd degree LCL tear

  • Partial tear of the ligament
  • Swelling common
  • Bruising (discolouration)
  • High pain level
  • Difficulty bending or straightening (flexing and extending) the knee
  • Feeling of instability (giving way) when full weight bearing on injured side
  • Fearful of putting full weight on affected side

Medical treatment

Contact us A.S.A.P. The faster we have a look at it before the swelling and bleeding sets in, the better. You have to consult with a Physio to establish the extent of damage and determine the most appropriate course of action. We can successfully restore your ligament without any surgical intervention.

  • Use of a weight-bearing brace or supportive strapping will be used during this phase. This aids in avoiding overuse of the ligament and puts some pressure on the ligament to ease the pain.
  • Physiotherapy management during this grade will be the same as with a grade I, progression will be expected to be slower.
  • Comprehensive rehabilitation program addressing all the stages of recovery
  • Expect return to activity to be no sooner than 6 weeks.

Recovery Time

Grade 2 – 6 to 8 weeks (With early treatment, we try to get you jogging at 6 weeks)

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Grade 3 LCL tear (severe)

Complete tear. Swelling and discolouration (bleeding under the skin) is visible. The knee feels like it wants to give way completely. Bearing full weight is almost impossible. Bleeding and swelling will definitely be present.

The main concern with a Gr 3 tear, is the ligament’s ability to stabilize the knee joint,  if the ligament tears into two separate flaps, there is no way the ligament can ‘heal’ or re-attach without surgery. A Sonar or Diagnostic Ultrasound will show the full extent of the damage. Surgery is the best option to re-connect the separated segments of the torn muscle.

Often there will be no pain, but the disfigurement is quite obvious, since all the fibers are torn. It is important to know that there could be other structures involved with such an injury, but we will discuss this in more detail with our differential diagnosis later.

Symptoms of a 3rd degree LCL tear

  • Complete ligament rupture
  • Swelling
  • Bleeding under skin (red and blue discolouration)
  • Unstable joint
  • Can’t bear full weight on affected side
  • Feeling of knee wanting to give way
  • Either no pain, or severe pain that subsides quickly
  • This injury usually increase the risk of other structures being injured as well (ACL, meniscus)

Medical treatment

Contact us immediately! The faster we have a look at it before the swelling and bleeding sets in, the better.
You have to consult with a Physio to establish the extent of damage and determine the most appropriate course of action.

What you should do during this time:

  • You will be on crutches for up to 6 weeks, during which
  • You will wear a hinged brace up to 6 weeks
  • It is essential to see your physiotherapist for full rehabilitation of the knee, as it will become a very unstable joint if left untreated.

Recovery Time

Will depending on conservative or surgery treatment option. Conservative may be more than 8 weeks with intensive rehab.
If you have completely ruptured your medial collateral ligament you will need surgery and may take 4 – 6 months to full recovery.

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Selftest

If this position is painful going into it, the test is positive meaning you may have some degree of Lateral Collateral ligament tear.

Standing

  • Stand on one leg
  • Do a small squat (bend the knee slowly)
  • You will either feel pain on the outside of your knee, or you wouldn’t want to stand on one leg, depending on the severity of your sprain

Kneeling

  • Kneel with both knees on a mat or on the ground.
  • Sit back onto your heels, you may only feel the pain when all of your weight is shifted backwards.

Stepping

  • Stand on a step
  • Step down with the affected leg staying on the step
  • Your knee will feel like it wants to give way outwards or you’d have pain if there is a sprain
  • Gently repeat trying to hold your knee inwards, and then repeat holding it outwards. Any difference?

Twisting

  • Stand on your affected leg
  • Bend it slightly
  • Twist your body towards your knee
  • Then twist your body away from the knee
  • Either direction of twisting may cause pain
  • Pain and/or instability will indicate a possible sprain

Diagnosis

Our Physiotherapists diagnose a ligament tear and sprain by placing stress on each individual ligament during our testing. Our physiotherapists are experts at detecting a Lateral Collateral ligament tear because we develop a fine dexterity for this type of injury. We test it by doing a few specific stretch and stress tests, after which we test the knee’s ability to bear Weight, Balance, Range of movement, Stability and Endurance of your knee. Other diagnostic tests:

X-ray

In this case, it is unnecessary to perform an x-ray, as the ligament will not show up on an x-ray and pathology will go undetected.

MRI

An MRI may be useful to rule out other injuries to the knee, for example, a meniscus injury, bursitis, ACL, Tendonitis’. But when a pure Lateral Collateral ligament injury is suspected, it is an unnecessary and expensive thing to do an MRI.

Sonar (Diagnostic Ultrasound)

This is the most cost effective diagnostic tool to determine an LCL sprain. The width of the ligament can be compared to that of the opposite side, and the degree of the tear is determined through a diagnostic ultrasound. We refer mostly for this type of diagnostic tool when it comes to ligament sprains, however, we can usually tell through our clinical tests whether we suspect a ligament injury or not.

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Why is my knee pain not going away?

Maximal ligament strength will only return after about 6 weeks, when the collagen fibers have rearranged and matured.

Before this, the ligament can be prone to re-occurring injury or progression of the injury from a grade I to II or III. For example, if you sustained a grade I injury this past weekend during a soccer match, you have rested and iced it well. It feels better this week, and now, a few days later, you run onto the field. A player from your team kicks the ball to you, but just a few meters too wide, and at speed. You have to suddenly change direction. Your knee twists outwards while your foot stays in the ground for that second. The ligament is not ready to handle the load at this stage. At this point, you may have overloaded and overstretched the ligament to worsen your condition from a sprain to a tear.

It is always better to allow the full time for a ligament to heal until it is back to its normal state before getting back onto the sports field. Your physiotherapist will be able to assess and tell you exactly when this moment of readiness is.

A big problem we see with a Lateral Collateral ligament injury these days:

If you are asking yourself ‘why is it taking so long for the pain to go away’ then you might want to consider the following.

When a ligament tears, the body reacts similar to repairing an open wound. Let’s say for example, you have a cut on your thumb, but you keep writing with that hand. At this rate you are shearing away the cells that are closing the wound. The same principle applies. The more you put strain on the ligament, the longer it takes to heal.

Patients generally start running again because the pain “feels better” within 3 days. However, within these three days, you are disrupting the most vital part of the healing when participating too soon again, because you are “ripping the wound right open again”. This causes even more damage and will take even longer to heal. This is also the most common reason why patients consult us.

What makes Lateral Collateral ligament injury worse

  • Straightening the knee through the pain
  • Bending or ‘forcing ‘ the knee to bend
  • Running – especially trail running (uneven surfaces)
  • Climbing stairs (up and down)
  • Jumping – especially on the landing
  • Kneeling to fix the sink or getting something from the bottom drawer
  • In the gym: leg press, knee extensions, side leg raises, squats, lunges.
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Lateral Collateral ligament injury, Lateral Collateral ligament sprain, Lateral Collateral ligament tear, knee LCL injury

Anti-inflammatories: to take them or not to take them?

If you are taking anti-inflammatory medication for your ligament tear, STOP taking them. Inflammation is the body’s natural way of healing the injured collagen fibers. The medication is preventing this process from taking place, not to mention, masking the effect of the trauma on the tissue if you return to running while still taking anti-inflammatory medications.

This is a bit of a “catch-22” situation. During healing, inflammation is necessary for the healing process to take place. But inflammation causes swelling, pain and discomfort in the joint. If your goal is to just have less pain, take the anti-inflammatories. If the goal is to heal the ligament quicker, leave the anti-inflammatories and allow the natural process of healing to take place.

Physio treatment for a LCL tear

Grade 1 Lateral Collateral Ligament sprain

Phase 1 (Week1)

Goals:

  • To reduce swelling
  • To get the knee to fully extend (straighten)
  • To get the knee flexed (bent) more than 90 degrees
  • Start pain free strengthening exercises

Rehabilitation:

  • Pain free Passive stretches of the quads and hamstring muscles
  • Static quad and hamstring strengthening exercises
  • Isometric quad, hamstring, glute and calf exercises.
  • Examples: calf raises, quads contractions on pillow, theraband resistance exercises- but come see us for a more specific exercise protocol and put us to the test!

Phase 2 (Week 1-2)

Goals:

  • Get rid of swelling completely
  • Restore full range of motion (ROM)
  • Start jogging

Rehabilitation:

  • Dynamic strengthening exercises introduced here
  • Examples: knee flexions, extensions, step ups, half squats, single leg calf raises, bridging exercises

Phase 3 (Week 2-4)

Goals:

  • Regain full strength
  • Maintain Full ROM
  • Introduce sport specific exercises/ exercises that allow you to get back to your daily activities completely like driving, climbing stairs and running

Rehabilitation:

  • Adding more load/weight to activities
  • Increasing the speed and agility of movements
  • Examples: weighted squats, leg presses, plyometrics, sideways running drills

Phase 4 (week 3-6)

Goals:

  • Maintaining full ROM, strength, agility, speed
  • Adding endurance
  • Performance based when dealing with a sports person (full time training and competition based)

Rehabilitation:

  • Finally hopping, bouncing or jumping activities can be included here

Grade 2 or 3 Medial Collateral Ligament tear

Phase 1 (Week 1-4)

Goals:

  • Control swelling
  • Maintain full extension of knee
  • Gain range to more than 90 degrees flexion
  • Introduce strengthening exercises
  • Maintain fitness (best suggestion would be a stationary bike).

Rehabilitation:

  • Non weight bearing week 1-2 (use crutches)
  • Partial weight bearing week 3-4
  • Full weight bearing week 4 onwards
  • Wear a brace that is set at 30 degrees
  • Stretching, strengthening and mobility exercises will be done in the brace (knee extension should not be more than 30 degrees)
  • Examples of exercises: static quads, hamstrings, calf raises, hip abductions

Phase 2 (Week 4-6)

Goals:

  • Completely eliminate swelling
  • Full weight bearing
  • Full ROM
  • Injured leg as strong as uninjured leg

Rehabilitation:

  • Week 5: Knee brace set to 60 degrees
  • Week 6: Remove knee brace (other knee support can be used at this time for compression, for example a knee guard, only to support knee during this transition phase for a week, no longer than that because we don’t want the knee to become dependent on external support)
  • Examples of exercises: Quads and hamstring stretches, along with static and isometric quad exercises: leg presses, hamstring curls, step ups, calf raises. Upper body strength and endurance should be maintained, and general fitness kept by swimming or stationary bike. No breastroke though!

Phase 3 (Week 6-10)

Goals:

  • Full ROM
  • Strength
  • Return to light jogging
  • Return to sport specific exercises at week 10
  • Return to full activities of daily living (walking, driving, getting in and out of bed without pain)

Rehabilitation:

  • Light jogging after week 6
  • Sideways running after week 8

Phase 4 (Week 10+)

Goals:

  • Performance based when dealing with a sports person (full time training and competition based)

Rehabilitation:

  • Plyometrics, hopping, jumping, agility, speed by week 10

What else could the condition be?

  • ITB syndrome – Its a sharper pain that only comes on during running, and subsides.
  • Pesa serines Bursitis – Pain on the insertion site of the Bicep Femoris muscle
  • Lateral meniscus tear – This involves the disc on the outside of the knee joint.
  • Peroneal nerve entrapment – nerve type pain radiating down the outside of the lower leg.
  • Tibial plateau fracture – Fractures or avution may happen with a direct impact to your knee
  • Head of fibula immobility – Superior Tibiofibular joint that helps turning the lower leg outwards.
  • Popliteal muscle strain – A muscle controlling the knee to lock and unlock at the back of your knee.
  • Peroneal sprain or tendinitis – A muscle in the lower leg that controls the foot movement anchors on the outside of your knee.

Lateral Collateral ligament injury, Lateral Collateral ligament sprain, Lateral Collateral ligament tear, knee LCL injury

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