Year : 2017 | Volume
: 17 | Issue : 1 | Page : 45--49
Rehabilitation of posterolateral corner injuries of knee
Hariharasudhan Ravichandran1, Balamurugan Janakiraman2, Asmare Yitayeh2, Berihu Fisseha2, Subramanian Sundaram3,
1 Orthopedic and Sports Physiotherapist, Department of Physiotherapy, Global Hospitals and Health City, Chennai, Tamil Nadu; Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India
2 Faculty, Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
3 Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India
Dr. Hariharasudhan Ravichandran
Global Hospitals and Health City, 439, Cheran Nagar, Chennai - 600 100, Tamil Nadu
Injuries to the posterolateral corner (PLC) of the knee pose a significant challenge in sports rehabilitation due to their complex nature. Identifying PLC injuries are paramount in preventing chronic pain, instability, and/or surgical failure. To educate health professionals and athlete about posterior lateral corner injuries of the knee. Mr. X, 28-year-old badminton coach have been assessed with PLC injury with lateral collateral ligament (LCL) injury have been, clinically evaluated and rehabilitated efficiently. Mr. X was diagnosed with LCL injury and PLC injury, the treatment program provided for him on aspects of pain management, strengthening dynamic posterolateral structures, and increasing flexibility so he could continue his services pain-free. Cryotherapy was done before strengthening and stretching exercises. Very often PLC is forgotten during the assessment and rehabilitation of knee injuries. This study throws light into posterolateral aspect of the knee in preventing future complication of the instability of knee which may lead to disability.
|How to cite this article:|
Ravichandran H, Janakiraman B, Yitayeh A, Fisseha B, Sundaram S. Rehabilitation of posterolateral corner injuries of knee.Saudi J Sports Med 2017;17:45-49
|How to cite this URL:|
Ravichandran H, Janakiraman B, Yitayeh A, Fisseha B, Sundaram S. Rehabilitation of posterolateral corner injuries of knee. Saudi J Sports Med [serial online] 2017 [cited 2019 Jul 19 ];17:45-49
Available from: http://www.sjosm.org/text.asp?2017/17/1/45/197470
Posterolateral corner (PLC) injuries of knee often remained as the "dark side of knee", which denotes the fact that little is known about it. There are about 28 described structures that comprise the PLC of the knee. Recent biomechanical studies have simplified the description to three main anatomic structures; the popliteus tendon, popliteofibular ligament (PFL), and lateral collateral ligament (LCL). These three have been identified as the most important structures for posterolateral knee instability. PLC injuries account for 16% of knee ligament injuries. PLC of the knee consists of a number of static and dynamic restraints. Despite increasing awareness of the importance of early recognition of injury to the PLC, these injuries remain under-reported. Hence, the purpose of this paper is to describe the assessment and rehabilitation methods on PLC injury. The effect of rehabilitation was measured in terms of visual analog scale (VAS) and manual muscle testing procedures during rehabilitation.
Mr. X 28-year-old badminton coach was referred to our institute with complaints of pain in the right knee due to twist and fall while playing badminton 3 weeks ago. He had a swelling, and there is no active bleeding except mild abrasions over anterior aspect of knee. Mr. X suffered no other joint injuries, and he does not suffer from any other comorbid illness. Initially, after the fall he applied ice packs to the knee and rested from aggressive physical activities. Initially after the fall, he was managing to do most of his daily activities except squatting or sitting in floor. At around the end of 2nd week, pain was aggravated even after walking for about 20-30 m. Due to which he was referred to a medical officer elsewhere in a private clinic and advised to undergo radiograph of the right knee (Anteroposterior and lateral view) which revealed that there is no bony injuries. He had severe pain in the knee, 8/10 according to the VAS. In addition to constant knee pain, Mr. X had frequent episodes of sharp pain in the lateral aspect of knee while walking which was relieved on walking cessation. Mr. X was worried and emotionally disturbed due to his discontinuance from the training session. He was eagerly waiting to prepare his students for the national level badminton competition which was going to be held after 8 months. With all these goals in view, Mr. X was referred to our physiotherapy department after 21 days of injury.
Mr. X complains that his pain was worse while walking and relieved by lying in bed or sitting with right leg supported. Mr. X was a badminton coach by profession and was playing with his trainee while getting injured. He was moving quickly toward left side and suddenly he forced his right foot against the ground while moving and forgot to clear his right foot from the ground while trying to do overhead hit. As because of his right foot struck firmly against the ground while creating an aggressive force to move toward left side he fell down with pain in the outer aspect of knee. Moreover, Mr. X revealed that he was trying for an overhead hit; he might have kept his knee in extension at least. This mechanism of injury suggests that Mr. X could have injured his lateral structures of knee, say lateral collateral with probability of lateral meniscal injury. On observation, he had mild edema along lateral aspect of knee and there is no ecchymosis. Knee is partially in flexed posture while walking to the treatment room. Mr. X made slight facial expressions with difficulty in bearing weight on the right knee while walking that indicated some discomfort or pain in his right lower limb. Mr. X was palpated and there was mild grade warmth evident over lateral aspect of the knee joint. Diffuse tenderness was present over the posterolateral aspect of the knee joint, and he complained of local pain at the fibular head and the joint line on palpation. Mr. X was assessed for his knee range of motion in supine with a universal goniometer. His left knee range was assessed to have 0°-134° of active flexion without lag. His right knee flexion range of motion was 5°-125° actively and 0°-125° passively. This was accompanied by empty or painful end feel at the end of knee flexion range of motion. Muscle test was assessed manually as described by, Kendall et al. His left hip, knee, and ankle musculatures had a power of around 5/5 with no discomfort. In right knee flexion and extension power was 4/5, and Mr. X complained of pain at the end ranges of movement at the lateral aspect of knee. Hip flexion, ankle dorsiflexion and on the right lower limb was 4/5 and Mr. X experienced no pain while testing hip and ankle. Mr. X had no complains of numbness or paraesthesia or any other sensory deficits in the right lower limb. Moreover, his distal dorsalis pedis artery pulsations were felt bilaterally. Lachman and anterior drawer test were negative as there is no excessive translation of tibia. Posterior drawer test was negative at both 30° and 90° of knee flexion. Varus stress test on the right knee was positive for pain and increased excursion with a distinct end feel with a consistent Grade II LCL sprain. McMurray test and Apley's test for Mr. X was negative suggestive of the intact meniscus. Dial test was done for Mr. X by positioning him in supine lying with both knees together, and external rotation force was applied to the feet at 30° and 90° of knee flexion. In this test right, lower limb of Mr. X had more external rotation compared to the left side. The same test is repeated with knee flexed to 90° and 30° and we found that he had more external rotation at 30° than at 90°. This suggests that posterolateral ligament has injured with intact popliteus. In Figure of four test Mr. X was positioned in supine and his right knee was flexed to approximately 90° then crossing it over the other knee with the right foot across the left knee and the hip externally rotated. In this position, a varus stress was applied on the right knee joint by pushing it toward the examination table. Mr. X complained of pain and discomfort in the outrer aspect of knee indicating injury to posterolateral structures of the knee, especially the popliteus complex and popliteomeniscal fascicles. If these structures have been disrupted by injury, there is no tension to stabilize the lateral meniscus, and the lateral meniscus can displace medially into the joint causing pain and reproducing their symptoms at the lateral joint line. Posterolateral drawer test was performed to determine the integrity of the PLC. In supine position, right knee of Mr. X was flexed to 90° with foot externally rotated to 15°. A gentle combined posterior drawer and external rotation force is then applied, and there is mild posterolateral translation noted excessively when compared to the left knee. Valgus stress test was not done as there is no history suggestive of pain in medial aspect of knee. Mr. X complains of a sharp pain during terminal stance and push off resulting in decreased stance time in the right lower limb, and he was presented with antalgic gait pattern. He denied sharp pain during the swing phase of gait. And, whenever he stands his knee is not completely extended or neutral, instead it still remained in flexed posture.
From all the above-mentioned histories and examination, we provisionally diagnose that there is LCL sprain and PLC injury of the right knee. Diagnosing LCL injury is not an uphill task for sports rehabilitation Personnel as because of its prevalence among the commonly injured ligament. To conclude PLC injury we put forward the following reasons. Mr. X had tenderness in lateral and posterolateral aspect of knee with local pain in fibular head. This was correlated to DeLee et al. who found that patients with acute PLC injury had diffuse tenderness over the posterolateral joint region, with point tenderness localized over the fibular head or at the joint line in patients with arcuate. The mechanism of injury which Mr. X had undergone is a varus stress and a posteriorly directed force in the extended knee suggesting damage to lateral and posterolateral structures of knee. According to Cooper et al., in noncontact injury to the posterolateral structures, the mechanism often includes a combination of lateral and posterior forces on an extended knee, resulting in hyperextension of the knee and external rotation of the tibia. During the physical examination, it is imperative to assess for signs of nerve injury as up to 15% of PLC injuries have associated nerve damage. Hence, Mr. X was assessed and found to be have no nerve injuries. While analyzing gait pattern of Mr. X, partial flexed knee during stance phase and reduced stance duration in the right knee with sharp pain in posterior knee indicated that there is posterior complex injury has occurred. From the dial test, posterolateral drawer test and Figure of four test it is confirmed that Mr. X had injured his posterolateral complex and graded as I. And to rule out bony injuries X-ray was taken earlier and Mr. X was found to have no abnormal findings radiologically. Hence, we conclude that PLC complex injury was accompanied with LCL injury.
Outcome of treatment
As both LCL and PLC injured for Mr. X was Grade I he was advised for conservative treatment of physiotherapy. Our goal of treatment started with three phases of interventions. During the initial phase of rehabilitation, we intended to reduce pain, increase knee range of motion and to strengthen knee musculatures. To avoid further strain, Mr. X was advised to wear a knee brace while walking. He was advised partial weight bearing with elbow crutch. Mr. X received transverse friction massage over LCL to decrease sensitivity and to increase blood flow for the healing tissue. Therapeutic ultrasound with intermittent mode of 1:1 was applied over posterior and lateral aspect of knee for about 8 min at an intensity of 0.8 W/cm2 at a frequency of twice a day. Therapeutic exercises prescribed for Mr. X was intended to protect the healing tissues hence, it included straight leg raises, isometric contractions of the quadriceps, hamstrings and gastrocnemius, terminal knee extensions, hip flexion isometrics, and sagittal plane exercises including gait training and stationary bike under the supervision of therapist. The purpose of the initial treatment was to enable Mr. X to walk without pain. Posterior fibular translation was common following PLC injuries; hence we aimed at maintaining the normal alignment or positioning of fibular head. Mr. X also complained of sharp pain during the stance phase on the affected leg, and our palpation though revealed tenderness in the fibular head region. Taping and positioning the fibular head is the method to control it. We followed a unique taping method that is preferred to reduce posterior fibular translation. Mr. X was made to stand with knee flexed at 15° and the fibular head was manually glided (Grades II and III) anteriorly, taping was applied from posterior fibular head to mid-patellar region. This taping helped to reposition fibular head which controlled or restrained posterior translation of fibula during gait activities. After 10 sessions of physiotherapy (2 weeks) knee extensor lag of 5° was reduced. Now, Mr. X could do 134°-0° of knee extension without pain or lag actively.
In the second phase, we focused on gait rehabilitation and improving posterolateral stability of knee: strengthening hamstrings, popliteus, gastrocnemius, and quadriceps musculatures. Mr. X was taught exercises to control and maintain Frontal and multiple plane right lower limb activities were encouraged. Muscle energy technique (MET) of postisometric relaxation was provided to hamstrings and gastrocnemius, with a frequency of ten repetitions per session, three sessions per day, and five sessions per week. MET helps to relieve pain, increases ROM and hence, therefore, reduces disability. Strengthening exercise for lateral hamstrings and gastrocnemius was done under the supervision of a therapist. This is to improve posterolateral stability of knee joint.
We found that Mr. X was able to tolerate increased duration, repetition, and intensity of therapeutic exercise workouts and home exercise program (HEP). Gradually, he was allowed full weight-bearing gait and knee brace was discontinued at the end of this phase. Now, he could walk without pain during the stance phase. The HEP performed 3-4 time per week consisted of 10-20 min of stationary bike exercise, stairmaster/elliptical machine exercise, treadmill walking (with progression to jogging), stretching (quadriceps, IT band, adductors), and strengthening (squats, knee extensions and curls, calf raises, and leg press). At the end of 4 weeks, he was comfortable in his gait and able to perform his ADL activities comfortable.
Rehabilitation of posterolateral corner differs from the rehabilitation of other conditions of knee
In case of PLC injuries, emphasis to reduce varus angulation of knee by increasing the stability of lateral hamstrings and gastrocnemius and controlling tibial external rotation at angles <45°, particularly in weight-bearing. Functionally, Mr. X was able to walk throughout campus and had returned to badminton court to coach his students without pain after 3 weeks of LCL and PLC rehabilitation from our institute.
Isolated injuries of PLC of knee are less common. Injuries to PLC of the knee are usually associated with cruciate ligament injuries (anterior/posterior). Injuries to the PLC of the knee are infrequent but can cause severe disability due to both instability and articular cartilage degeneration. The incidence of isolated PLC injuries has been reported to be between 13% and 28%. Most PLC injuries accompany an ACL or PCL tear, and can contribute to ACL or PCL reconstruction graft failure if not recognized and treated., It is necessary to know the PLC injuries because the knee anatomy and mechanics are so complex, which makes it so hard to diagnose the PLC injuries pathology. Most physician or orthopedician tend to forget the PLC anatomy and start treating the cruciates or collaterals. Mr. X was treated only for his LCL sprain and missed to diagnose or rehabilitate with PLC injury pathology after the initial stage of injury (i.e., for about 3 weeks after injury), which made him to suffer restriction from essential physical activities of daily living and leading to temporary disability. Apart from rehabilitation, prehabilitation is also essential in preventing risk of fall and injuries.
Knee joint is a complex body part that is commonly injured in athletics. PLC injuries are far too commonly missed. Accurate diagnosis depends on thorough knowledge of PLC anatomy and also an astute clinical assessment. Since they are missed easily in acute cases, they end up resulting in chronicity which may be disabling and many ends up requiring surgical correction.
Even early recognition of PLC injury is essential before treating cruciates or collaterals either conservative or by surgery. Often with an LCL injury, other injuries occur, such as PLC injury. This is commonly forgotten while assessing and treating an athlete or nonathlete. In case of athletic rehabilitation compromising in diagnosis or rehabilitation will leads to failure of the athlete in the event in which he is going to participate. We recommend that clinical assessment of the PLC should be routinely undertaken if there is any suspicion that this injury could be present.
We have not taken stress X-ray and magnetic resonance imaging in diagnosing this condition, as because of the special tests we used have clearly indicated PLC injury and ruled out other conditions. These are the limitations in this study.
The authors wish their gratitude to and Dr. Clement Joseph (MS Ortho) full fledge to complete this study. We are thankful to all the therapist of Global Hospitals and Health City for their support. We also wish to express our gratitude for our family members and friends.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Hughston JC, Jacobson KE. Chronic posterolateral rotatory instability of the knee. J Bone Joint Surg Am 1985;67:351-9.|
|2||Veltri DM, Deng XH, Torzilli PA, Maynard MJ, Warren RF. The role of the popliteofibular ligament in stability of the human knee. A biomechanical study. Am J Sports Med 1996;24:19-27.|
|3||LaPrade RF, Wentorf FA, Fritts H, Gundry C, Hightower CD. A prospective magnetic resonance imaging study of the incidence of posterolateral and multiple ligament injuries in acute knee injuries presenting with a hemarthrosis. Arthroscopy 2007;23:1341-7.|
|4||Terry GC, LaPrade RF. The posterolateral aspect of the knee. Anatomy and surgical approach. Am J Sports Med 1996;24:732-9.|
|5||Laprade RF. Introduction and incidence of posterolateral knee injuries. In: Posterolateral Knee Injuries: Anatomy, Evaluation and Treatment. New York: Thieme; 2006. p. 1-8.|
|6||Kendall FP, McCreary EK, Provance PG. Muscles, Testing and Function. 4 th ed. Baltimore, MD: Williams and Wilkins; 1993.|
|7||Magee DJ. Orthopaedic Physical Assessment. 3 rd ed. Philadelphia, PA: WB Saunders; 1997.|
|8||Stäubli HU, Birrer S. The popliteus tendon and its fascicles at the popliteal hiatus: Gross anatomy and functional arthroscopic evaluation with and without anterior cruciate ligament deficiency. Arthroscopy 1990;6:209-20.|
|9||Hughston JC, Norwood LA Jr. The posterolateral drawer test and external rotational recurvatum test for posterolateral rotatory instability of the knee. Clin Orthop Relat Res.1980;147:82-7.|
|10||DeLee JC, Riley MB, Rockwood CA Jr. Acute posterolateral rotatory instability of the knee. Am J Sports Med 1983;11:199-207.|
|11||Shindell R, Walsh WM, Connolly JF. Avulsion fracture of the fibula: The ′arcuate sign′ of posterolateral knee instability. Nebr Med J 1984;69:369-71.|
|12||Cooper JM, McAndrews PT, LaPrade RF. Posterolateral corner injuries of the knee: Anatomy, diagnosis, and treatment. Sports Med Arthrosc 2006;14:213-20.|
|13||Hughston JD. Knee Ligaments, Injury and Repair. St. Louis, MO: Mosby; 1993.|
|14||LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med 1997;25:433-8.|
|15||Tappan FM, Benjamin PJ. Tappan′s Handbook of Healing Massage Techniques. Classic Holistic and Energing Methods. 3 rd ed. Stamford, CT: Appleton and Lange; 1998.|
|16||Hariharasudhan R, Balamurugan J. A randomized double-blinded study of effectiveness of strain counter-strain technique and muscle energy technique in reducing pain and disability in subjects with mechanical low back pain. Saudi J Sports Med 2014;14:83-8.|
|17||Wascher DC, Grauer JD, Markoff KL. Biceps tendon tenodesis for posterolateral instability of the knee. An in vitro study. Am J Sports Med 1993;21:400-6.|
|18||LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of Grade III posterolateral knee complex injuries on anterior cruciate ligament graft force. A biomechanical analysis. Am J Sports Med 1999;27:469-75.|