Lateral Collateral Ligament (LCL) Injury
1. Introduction
The Lateral Collateral Ligament (LCL), also known as the fibular collateral ligament, is on the outer side of your knee joint and connects the thigh bone (femur) to the shin (tibia). Its function, along with the Medial Collateral Ligament, is to provide stability to the knee joint by preventing too much sideways movement. The LCL itself prevents excessive outward movement of the knee (known as “Varus” stress). It also helps with stabilising the knee to prevent excessive forward/backward movement alongside the cruciate ligaments (1).
Frequently Asked Questions
- The lateral collateral ligament is a strong ligament on the outside of the knee which helps stabilise the knee. A tear will only occur during a high force impact or twisting motion.
- An isolated lateral collateral ligament injury is rare accounting for only 2% of all knee injuries (2).
- Injury of the lateral collateral ligament in most cases occurs in sporting activities such as basketball, tennis, football, gymnastics and skiing (2).
- No.
- With the right rehabilitation approach these types of injuries generally recover well.
- They are not linked to other serious pathology.
- Those who are in high contact sports or high velocity pivoting and jumping activities (2).
- Athletes in tennis and gymnastics have a higher likelihood to suffer from isolated lateral collateral ligament injury (2).
- People that have a history of hip, knee or ankle injuries are more prone to getting a lateral collateral ligament injury.
- Localised pain situated on the outside of the knee joint.
- Painful to touch the outside of the knee.
- Possible feeling of instability (knee giving way) when walking, running, or rapid change of direction.
- Potential swelling on the outside of the joint.
- Reduced movement or stiffness at the knee joint.
There are many things you can do to help recover (1):
- In the early stage of management good practice now involves use of the Peace & Love protocol- see below for more explanation.
- Reducing weight bearing on the injured knee by using crutches if needed.
- Over the counter anti – inflammatory medication, although it is best to discuss this with your GP for safe advice on pain relief.
- Specific exercise rehabilitation via a qualified physiotherapist will be helpful in most cases.
- This will depend upon several factors including medical/lifestyle factors, stage of injury and your ability to follow your rehabilitation plan (1,2).
- The estimated recovery time depends on the grade of the injury:
- Grade I (mild sprain) usually takes 2-4 weeks to return to normal activity.
- Grade II (moderate sprain) can take 4-6 weeks.
- Grade III (tear) may take more than 3 months to fully recover.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
Typically, patients with a Lateral Collateral Ligament injury will present with a history of an acute incident or trauma. Most patients will refer to a direct impact to the inside aspect of the knee joint while the knee is placed in a full straight and static position. Alternatively, an extreme outward bending of the joint without any direct impact may injury the ligament.
The immediate symptoms will be pain, swelling and bruising. It is possible a “pop” sound at the time of injury may be described (2). Difficulty weight bearing immediately after injury is common, and on some occasions limping and/or pins and needles / numbness sensation might be present. Further symptoms after an acute injury of the Lateral Collateral Ligament might be restriction in range of motion, “giving way”/instability while putting weight on the limb and difficulty to perform a straight leg raise from a position of lying. Also, its normal to expect some tenderness to the touch to the outside aspect of the knee.
3. Causes
Injury to the Lateral Collateral Ligament is rare in relation to other knee ligament injuries and accounts for only 2% of all knee injuries in isolation. Injuries of the LCL alongside other structures has been recorded in 7-16% of all knee injuries (2). Injury can occur due to a direct force/blow to the inside of the knee, or by forcing the knee outward and putting excessive load onto the LCL. These injuries are more common if the foot is planted at the time of impact, and can also occur without contact e.g., studs caught in turf/excessive movement skiing. Injury can also occur due to overextending of the knee (2).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone suffering a lateral collateral ligament injury. It does not mean everyone with these risk factors will develop symptoms (1,2).
- Occurs more often in female population
- In high contact sports
- Sports that require high velocity pivoting and jumping
- Football has the highest likelihood for knee injuries but tennis and gymnastics for the Lateral Collateral Ligament injury in isolation.
- Previous ankle, hip or knee injuries predispose higher rate of injuries for the Lateral Collateral Ligament.
5. Prevalence
The Lateral Collateral Ligament has a strong link with the rest of the knee ligaments PLC (posterolateral corner), PCL (posterior cruciate ligament) and ACL (anterior cruciate ligament) hence it rarely gets injured without injuring one of the other ligaments. The prevalence in high school athletes is calculated at 7.9% which accounts for the second to last in incidence followed by the PCL injuries which is the least common. The Lateral Collateral Ligament and PLC injuries are found most in contact sports with 40% rate. These injuries could also occur in instances that involve trauma, falls and motor vehicle accidents (2).
6. Assessment & Diagnosis
An MSK physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your Physiotherapist will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent re-assessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scan are usually not required to achieve a working diagnosis, but in unusual presentations such as Grade III they may be warranted.
Grade of LCL sprains, as with any other ligament injury, are divided into 3 categories of severity:
- Grade 1: The least severe. A mild sprain involving less than 10% of the ligament fibres. You are likely to feel discomfort and possibly mild swelling but will not have laxity/instability of the joint and may even feel able to continue most normal activities. Typically return to full sport is within few weeks.
- Grade 2: An increased portion of the ligament fibres will be ruptured compared to grade 1, and you will have pain, with possible swelling, and some instability. Typically return to sport is around 4-6 weeks.
- Grade 3: Most severe. A full rupture (tear) of the ligament. Severe pain. Likely to involve instability of the knee joint. Difficulty moving the knee. Return to sports can be 3 months +.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your Lateral Collateral Ligament injury. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
The rehabilitation approach is different on each stage of recovery and depends on the severity of the injury. However, in conservative management, strengthening exercises for the quadriceps, gluteal, gastrocnemius, and hamstrings and acquiring full range of motion in the knee joint will be crucial for the long-term benefits. In later stages of recovery, closed chain strengthening exercises, proprioception exercises and plyometric work are important to prepare the knee for returning to sport and preventing from future injuries.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing Lateral Collateral Ligament injury. In some instances, a one-to-one assessment is appropriate to tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Lateral Collateral Ligament (LCL) Injury
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining a range of movement within the knee, appropriate activation of quadriceps muscle and maintenance of lower limb strength and stability. We suggested you carry this out once a day over for approximately 2-3 weeks as pain allows.
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This is the next progression. More focus is given to closed chain strength work, training proprioception and lower limb strengthening.
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This programme is a further progression with challenging plyometric exercises of the affected knee, strengthening of whole kinetic chain and aerobic conditioning.
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10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, you should be able to comfortably do the advanced Lateral Collateral Ligament injury rehabilitation plan.
As part of a multi-modal treatment approach, your Physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
Surgery is rarely required for Lateral Collateral Ligament injuries, but it may be an option particularly if more than one ligament of the knee is affected and if the knee joint remains significantly unstable after a period of physiotherapy. The decision on if surgery is the best management will also dependent on the desired level of function or return to sport. Surgery to reconstruct the LCL ligament after a grade III injury shows significant improved patient function and satisfaction (3).
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References
- Grawe, Brian MD; Schroeder, Amanda J. MD; Kakazu, Rafael MD; Messer, Malynda S. BS Lateral Collateral Ligament Injury About the Knee: Anatomy, Evaluation, and Management, Journal of the American Academy of Orthopaedic Surgeons: March 15, 2018 – Volume 26 – Issue 6 – p e120-e127 doi: 10.5435/JAAOS-D-16-00028
- Yaras RJ, O’Neill N, Yaish AM. Lateral Collateral Ligament Knee Injuries. [Updated 2020 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
- Moulton SG, Matheny LM, James EW, LaPrade RF. Outcomes following anatomic fibular (lateral) collateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):2960-6. doi: 10.1007/s00167-015-3634-4. Epub 2015 May 19. PMID: 25986095.
Other Conditions in
Knees
Patellofemoral Pain Syndrome (PFPS)
Knee pain around the kneecap usually worse in static positions, squatting or kneeling.
Patellar Tendinopathy
Knee pain at the lower border of the kneecap which is also known as ‘jumper’s knee’.
Osgood-Schlatter Disease
Pain in an area just below the knee on the shin bone, often with a lump.
Meniscus Injury
Structural knee injury, triggered either by a tear or through wear and tear.
Medial Collateral Ligament Sprain
Knee Replacement Surgery
Replacement of the knee hinge joint, typically as a result of severe osteoarthritis or trauma.
Knee Osteoarthritis
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Hamstring Strain/Tear
An over-stretch or tear to one or more of the muscles located at the back of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Fat Pad Impingement
A rare condition affecting the adipose (fat) tissue that sits under the kneecap (patella) between the joint spaces of the knee.
Degenerative Meniscus
Seen to be normal as we age, but in some situations can result in knee aches, pain or joint swelling.
Bowed Knees
A condition in which the legs are bowed outwards leaving a greater space in between your knees.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.
Anterior Cruciate Ligament (ACL) Injury
Injury to a major stability ligmant in the knee, normally occuring following a significant twisting injury.