REVIEW ARTICLE

Anatomy and Biomechanics of the Lateral Side

of the Knee and Surgical Implications
Evan W. James, BS,* Christopher M. LaPrade, BA,*
and Robert F. LaPrade, MD, PhD*w

ment, fabellofibular ligament, proximal tibiofibular liga-

Abstract: A detailed understanding of the anatomy and bio- ments, and coronary ligament of the lateral meniscus.11,12
mechanics of the lateral knee is essential for the clinical diagnosis Neurovascular structures such as the common peroneal
and surgical treatment of lateral-sided knee injuries. In the past, the nerve and lateral inferior genicular artery are also impor-
structure and function of the lateral and posterolateral knee was
poorly understood and was dubbed by some as “the dark side of
tant to evaluate during assessment and treatment of post-
the knee.” However, recent advances in quantitative anatomy and erolateral corner injuries.
biomechanics of this region have led to the development of ana-
tomic-based reconstruction techniques and improved objective and ANATOMY OF THE LATERAL KNEE
subjective patient-based outcomes. Although the lateral knee con- The lateral knee is comprised of 28 unique static and
sists of 28 unique structures, the primary lateral knee stabilizers dynamic stabilizers. The 3 primary stabilizers that are com-
include the fibular collateral ligament, popliteus tendon, and pop-
liteofibular ligament. Together, these structures function to resist
monly reconstructed surgically include the FCL, PFL, and
lateral compartment varus gapping and rotatory knee instability. PLT (Fig. 1).6 The peroneal nerve also courses through the
This work will summarize the current state of knowledge regarding posterolateral aspect of the knee. Avoiding iatrogenic injury
the anatomy and biomechanics of the lateral knee structures, while to the nerve is critical and is largely based on understanding
emphasizing implications for surgical treatment. its location relative to surgically relevant lateral knee struc-
tures. Many of the anatomic relationships in the lateral aspect
Key Words: lateral knee, posterolateral knee, anatomy, bio- of the knee are very small and therefore the quantitative
mechanics, surgical treatment descriptions are reported to a tenth of a millimeter. It should
(Sports Med Arthrosc Rev 2015;23:2–9) be noted that the size of knees are variable across a typical
population, and these reported numbers should be used as an
approximation of the average distance.

T he complexity of posterolateral corner knee anatomy

has been widely documented.1,2 Adding to the con-
fusion, posterolateral corner nomenclature has varied
Lateral Knee Bony Anatomy
The bony anatomy of the lateral knee is essential for
understanding not only key relationships of soft tissue
across studies in the anatomy and imaging literature. structures but also functions as a key determinant of the
However, over the past 2 decades, advancements in the inability of many lateral knee injuries to heal over time. Soft
understanding of lateral knee anatomy have led to more tissue structures of the lateral knee attach to the distal femur,
consistent definitions of structures, and biomechanical proximal tibia, and fibular head. The opposing bony surfaces
advances have led to clearer understanding of the func- of the tibiofemoral joint in the lateral knee articulate in a
tional contributions of individual posterolateral corner convex on convex manner, creating inherent instability in this
structures. Quantitative descriptions of posterolateral cor- region of the knee. Numerous animal model studies have
ner anatomic footprints enabled the development of ana- investigated the role of lateral knee bony geometry in the
tomic surgical techniques.3–8 In turn, these advances have natural history of lateral knee injuries, which revealed that
led to improved patient outcomes using anatomic principles lateral knee injuries rarely heal, leading to lateral compart-
for lateral knee repair and reconstruction techniques.9,10 ment gapping, medial compartment osteoarthritis, and
The lateral knee consists of numerous static and dynamic medial meniscus tears.13–15 In contrast, the medial tibiofe-
stabilizers that together provide lateral knee stability. The 3 moral joint articulation has a convex on concave bony
primary static stabilizers include the fibular collateral liga- geometry that confers an inherent stability to this region of
ment (FCL), popliteofibular ligament (PFL), and the pop- the knee, contributing to the propensity for many medial
liteus tendon (PLT). Other important structures include the knee injuries to heal over time. Other key bony landmarks of
iliotibial band, long and short heads of the biceps femoris the lateral knee include the lateral epicondyle, the fibular
muscle, lateral gastrocnemius tendon, anterolateral liga- head, the popliteal sulcus, and the Gerdy tubercle.
FCL
From the *Steadman Philippon Research Institute; and wThe Stead- The FCL originates on the lateral aspect of the femur
man Clinic, Vail, CO.
R.F.L. has received funding not in relation to this work through a
and inserts on the fibula. At its femoral attachment, the
Health East Norway Grant. FCL is located 1.4 mm proximal and 3.1 mm posterior to
Disclosure: R.F.L. is a paid consultant, lecturer, and receives royalties the lateral epicondyle in a small bony depression.6 This
from Arthrex and Smith & Nephew. The remaining authors declare attachment is approximately 18.5 mm proximal and poste-
no conflict of interest.
Reprints: Robert F. LaPrade, MD, PhD, The Steadman Clinic, 181 W.
rior to the PLT attachment, which represents an important
Meadow Drive, Suite 400, Vail, CO 81657. relationship in posterolateral anatomic reconstruction
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. techniques (Fig. 2). Using an open surgical approach

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Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015 Anatomy and Biomechanics of the Lateral Knee

FIGURE 2. An illustration of the attachment locations of the

fibular collateral ligament (FCL), popliteofibular ligament (PFL),
and popliteus tendon (PLT) attachment sites. LGT indicates lat-
eral gastrocnemius tendon. Reprinted with permission from
LaPrade et al.6

FIGURE 1. The primary posterolateral corner static stabilizers

include the fibular collateral ligament, popliteofibular ligament, and
popliteus tendon. Reprinted with permission from LaPrade et al.6

through a laterally based hockey stick incision,12 the

proximal FCL attachment can be identified through a
longitudinal incision in the iliotibial band (Fig. 3). The
distal FCL attachment is located in a small depression on
the lateral aspect of the fibular head approximately 8.2 mm
posterior to the anterior margin of the fibular head and
28.4 mm distal to the fibular styloid tip. The distal FCL
attachment can be identified surgically through an incision
in the biceps bursa of the long head of the biceps femoris.
On average, the FCL measures 69.6 mm in length.
FIGURE 3. The distal attachment of the fibular collateral liga-
PLT ment (FCL) can be found by accessing the biceps bursa, whereas
The popliteus muscle originates at a tendon on the the proximal FCL attachment can be identified through a longi-
lateral aspect of the femur and inserts in a broad tudinal incision in the iliotibial band. BF indicates biceps femoris.

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James et al Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015

attachment at the posterior aspect of the tibia.16 The PLT anterior division (2.6 mm). Anatomic total posterolateral
attachment has a relatively broad footprint (0.59 cm2) corner reconstructions reproduce the PFL using a graft
located just posterior to the margin of the lateral femoral extending from the posteromedial aspect of the fibular head
condyle articular cartilage.6 This attachment is found at the to a transtibial tunnel beginning posteriorly 1 cm medial
anterior fifth and proximal half of the popliteal sulcus and and distal to the fibular tunnel and exiting anteriorly at the
can be visualized arthroscopically or through an arthrot- flat spot near the Gerdy tubercle.5,8
omy incision in the anterolateral joint capsule. From this
attachment, the tendon courses obliquely in the posterior Iliotibial Band
and inferior directions and becomes extra-articular near the The iliotibial band is a broad fascial structure that
popliteal hiatus before wrapping around the posterior connects the pelvis to the tibia and covers the lateral thigh.
capsule in the medial direction (Fig. 4). As the tendon Interestingly, humans are the only species with an iliotibial
passes through the popliteal hiatus, it is anchored to the band over the anterolateral aspect of the knee.1 The ilioti-
lateral meniscus by 3 popliteomeniscal fascicles. These bial band originates at the anterolateral external lip of the
consist of the anteroinferior, posterosuperior, and poster- iliac crest and has a primary insertion on the anterolateral
oinferior fascicles, or bundles.17–19 Together, these struc- aspect of the tibia at Gerdy’s tubercle. In addition to its
tures form the boundaries of the popliteal hiatus, which attachment at Gerdy’s tubercle, the iliotibial band also
averages 1.3 cm in length.17 attaches distally via an iliopatellar band and deep and
From full extension to approximately 112 degrees of capsulo-osseous layers. The iliopatellar band is an anterior
flexion, the PLT rests proximal to the popliteal sulcus on extension of the iliotibial band that extends to the patella.1
the lateral femoral condyle.6 Beginning at 112 degrees and Fulkerson and Gossling20 have also described this band as
higher knee flexion angles, the PLT engages in the popliteal the “superficial oblique retinaculum.” The deep layer
sulcus. Just medial to the posteromedial aspect of the fib- attaches the iliotibial band to the distal femur, whereas the
ular head in the posterior knee, the PLT connects to the capsule-osseous layer has attachments to the lateral head of
popliteus muscle belly at its musculotendinous junction. As the gastrocnemius, the short head of the biceps femoris, and
previously stated, the PLT attachment is separated from the the tibia posterior to Gerdy’s tubercle.1 During open
proximal FCL attachment by approximately 18.5 mm posterolateral corner surgical procedures, the iliotibial band
(Fig. 2). This represents a key anatomic relationship that is must be incised longitudinally to identify the femoral FCL
important to reproduce during anatomic total postero- and PLT attachments.
lateral reconstructions.
Long Head of the Biceps Femoris Muscle
PFL
The biceps femoris consists of a long and short head.
The PFL consists of distinct anterior and posterior The long head of the biceps femoris originates at the ischial
divisions and anchors the musculotendinous junction of the tuberosity of the pelvis and courses laterally through the
popliteus muscle to the fibular head.6 At its junction with posterior and lateral aspect of the thigh.21 The long head
the PLT, the PFL forms an 83-degree angle to the PLT. The attaches using a direct and anterior arm. In addition, 3
anterior division of the PFL attaches 2.8 mm distal to the fascial connections also contribute to the distal attachment:
tip of the fibular styloid process, whereas the posterior the reflected arm, lateral aponeurosis, and anterior apo-
division attaches 1.6 mm distal to the tip of the fibular neurosis. The direct arm attaches lateral to the fibular sty-
styloid process. Overall, it is a thin, stout attachment loid on the lateral aspect of the fibular head. The anterior
between the PLT and the fibular styloid (Fig. 4). Both arm attaches lateral to the FCL fibular attachment on the
attachments wrap along the posteromedial downslope of fibular head. A bursa called the biceps bursa, or the FCL-
the fibular styloid process. The posterior division has a biceps bursa, is formed between the anterior and direct arms
consistently larger width (5.8 mm) than the width of the of the long head of the biceps distal attachment.22 This
interval must be accessed through a small longitudinal inci-
sion in the distal long head of the biceps femoris during an
FCL repair or reconstruction or total posterolateral corner
reconstruction to identify the distal FCL attachment.3,5

Short Head of the Biceps Femoris Muscle

The short head of the biceps femoris muscle originates
medial to the linea aspera on the distal femur, traverses in
the distal and lateral direction, and attaches distally
through several connections. Distal attachments include
connections to the anteromedial side of the long head of the
biceps tendon, posterolateral aspect of the joint capsule,
capsulo-osseous layer of the iliotibial band, a lateral apo-
neurosis, and a direct and anterior arm.21 The capsular
attachment is typically located in the region between the
lateral head of the gastrocnemius and the FCL. The most
prominent attachment is a direct arm located at the fibular
FIGURE 4. The popliteofibular ligament connects the popliteus head between the fibular styloid and the distal FCL
musculotendinous junction to the fibular head (left knee). The attachment. In addition, there is an anterior arm of the
popliteus muscle and tendon can be seen coursing proximally short head of the biceps femoris, which attaches 1 cm pos-
and laterally. terior to Gerdy’s tubercle.

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Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015 Anatomy and Biomechanics of the Lateral Knee

Lateral Gastrocnemius Tendon There has been some debate regarding the correlation
The gastrocnemius muscle is anchored laterally and between anterolateral ligament injury and the Segond
proximally by the lateral gastrocnemius tendon. The gas- avulsion fracture, which has been widely correlated with
trocnemius tendon emerges from the far lateral portion of anterior cruciate ligament injuries.23,29 Some have
the gastrocnemius muscle belly in the region of the poste- hypothesized that the presence of a Segond fracture, indi-
rior fibular head. The tendon first attaches to either a bony cative of injury to the anterolateral ligament, in patients
or cartilaginous fabella and continues to attach to the with concurrent anterior cruciate ligament injury contrib-
femur near the supracondylar process.12 In a study by utes to the presence of chronic rotatory stability and a
LaPrade et al,6 the lateral gastrocnemius tendon attached residual positive pivot shift test following anterior cruciate
on the supracondylar process in 80% of specimens studied. ligament reconstruction.11,30,31 In light of this, some are
The femoral attachment is located approximately 13.8 mm now advocating for repair or reconstruction of the ante-
posterior to the proximal FCL attachment and 28.4 mm rolateral ligament in these patients.
from the PLT attachment. In the region between the
fabellar and femoral attachments, the gastrocnemius Fabellofibular Ligament
adheres to the meniscofemoral portion of the posterolateral The fabellofibular ligament is defined as the distal edge
joint capsule. During some surgical procedures, the tendon of the capsular arm of the short head of the biceps femo-
must be separated from the posterior capsule and this can ris.1,6,12,21 The fabellofibular ligament has been reported to
be accomplished using sharp dissection. The gastrocnemius exist both only in the presence of a fabella by some
muscle and tendon are also important landmarks for iso- authors32,33 and in cases of either the presence or absence of
lated PLT and total posterolateral corner reconstructions. a fabella by other authors.12,34,35 The fabella is a sesamoid
Using blunt dissection after a common peroneal neurolysis, structure located in the lateral head of the gastrocnemius
the interval between the lateral gastrocnemius (posterior) muscle. However, fabellae have also been documented in
and soleus muscle (anterior) can be expanded through with the medial head of the gastrocnemius muscle in approx-
the musculotendinous junction of the popliteus muscle is imately 2% to 10% of individuals.36,37 The fabella is found
readily visualized. in most, but not all, individuals and can be comprised
of either cartilaginous or bony tissue.36–38 Zeng et al37
reported in a cadaveric study that presence of a fabella was
Anterolateral Ligament not predictive of presence of a fabellofibular ligament. The
The anterolateral ligament12,23–25 has been previously fabellofibular ligament originates at the fabella proximally,
called the mid-third lateral capsular ligament1,26,27 and the coursing distally in a vertical orientation, before attaching
capsule-osseous later of the iliotibial band. According to just lateral to the lateral aspect of the fibular styloid proc-
Claes and colleagues, the anterolateral ligament was first ess.1,39 In the absence of a fabella, the fabellofibular
described by French surgeon Segond as a “pearly, resistant, ligament often is less substantial, originating on the
fibrous band” along the anterolateral aspect of the posterolateral lateral femoral condyle and inserting lateral
knee.11,28 Claes et al11 dissected 41 unpaired formalin pre- to the lateral fibular styloid process.39
served cadaveric knees and reported the ligament to be
present in 97% of specimens. The ligament originates on Proximal Tibiofibular Joint Ligaments
the prominence of the lateral femoral epicondyle, courses The proximal tibiofibular joint is comprised of ante-
obliquely in the anteroinferior direction, and inserts on the rior and posterior tibiofibular joint ligaments.40 These
proximal tibia between Gerdy’s tubercle and the fibular structures connect the proximal aspect of the medial fibular
head (Fig. 5). Along its course, it encases the lateral inferior head and the lateral aspect of the tibia and confer stability
genicular artery and attaches to the peripheral rim of the to the joint. See and colleagues reported that the anterior
lateral meniscus. tibiofibular ligament attaches 15.6 mm posterolateral to
Gerdy’s tubercle on the tibia and 17.3 mm anteroinferior to
the fibular styloid. The posterior tibiofibular ligament
attaches 15.7 mm interior to the lateral tibial plateau
articular cartilage and 14.2 mm medial to the fibular styloid.
These structures are important for tibiofibular joint stabil-
ity and isometric reconstruction techniques have been
developed to reconstruct the tibiofibular ligament complex
in cases of significant acute or chronic tibiofibular joint
instability.4

Coronary Ligament of the Lateral Meniscus

The coronary ligament of the lateral meniscus is
defined as a meniscotibial portion of the posterolateral joint
capsule that connects the lateral meniscus to the lateral
edge of the tibial plateau distal to the articular cartilage.1,12
The medial aspect of the coronary ligament begins laterally
FIGURE 5. The anterolateral ligament (anterior to scissors), also
called the midthird lateral capsular ligament, is believed to pro- at the tibial attachment of the posterior cruciate ligament
vide rotatory stability to the knee and a distal avulsion fracture of and forms the medial border of the popliteal hiatus as it
the ligament has been correlated with the Segond fracture continues laterally to the lateral meniscus. The coronary
commonly seen with anterior cruciate ligament injuries (right ligament of the lateral meniscus is best visualized arthro-
knee). scopically by elevating the lateral meniscus with a probe.

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James et al Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015

Neurovascular Structures BIOMECHANICS OF THE LATERAL KNEE

Common Peroneal Nerve Recent biomechanical studies have demonstrated the
The common peroneal nerve provides innervation to importance of 3 essential structures of the lateral side of the
the lower extremity and is supplied by branches of L4-S2 knee: the FCL, PLT, and PFL. As demonstrated in early
spinal nerve roots. The common peroneal nerve emerges biomechanical cutting studies, the lateral structures of the
from a bifurcation of the sciatic nerve in the posterior knee function as the primary stabilizers against varus gap-
aspect of the thigh, courses along the biceps femoris and ping, external rotation, and coupled posterolateral tibial
around the neck of the fibula, and splits into the superficial translation.43,44 In addition, these lateral knees structures
and deep peroneal nerves. Sensory divisions of the common also perform an important role in stabilizing against internal
peroneal nerve include 2 articular branches, 1 recurrent rotation.3,45 Overall, the 3 primary lateral knee stabilizers
articular nerve, and the lateral sural cutaneous nerve. and other lateral knee structures function to preserve nor-
Motor function of the nerve includes foot eversion and mal knee kinematics and, therefore, the health of the entire
plantar flexion via innervation of the peroneus longus and knee. Furthermore, preservation or restoration of lateral
peroneus brevis muscles, foot dorsiflexion and toe extension knee stability is especially important in patients who
via the tibialis anterior, extensor hallucis longs, and received anterior cruciate ligament and posterior cruciate
extensor digitorum longus muscles, and intrinsic foot ligament reconstructions, as chronic lateral knee instability
movements via the intrinsic muscles of the foot. During has been associated with increase strain on cruciate ligament
posterolateral corner procedures, a common peroneal nerve grafts and an increased risk of graft failure.46–48 This section
neurolysis is typically performed to minimize the risk of will review the individual and collective functions of the
foot drop postoperatively due to swelling (Fig. 6). Common FCL, PLT, and PFL along with an emphasis on the bio-
peroneal nerve neuropraxia has been reported due to mechanics of grade III (complete) lateral knee injury.
hematoma formation at the fibular head after primary FCL
injury and is also a concern in cases where a postoperative
The FCL is the primary restraint to varus instability in
hematoma leads to nerve compression.41
the knee.3,43,44 In response to applied loads, the FCL is
loaded by varus-directed forces and internal and external
Lateral Inferior Genicular Artery rotational torques, of the tibia on the femur, whereas
The lateral inferior genicular artery emerges from the anterior and posterior drawer forces and valgus stress do
popliteal artery in the posterior aspect of the knee and not load the FCL (Fig. 7).45 The highest forces exerted on
courses extra-articularly along the joint capsule. At the the FCL reportedly occur with the knee in full extension
lateral knee, the artery winds anteriorly, anterior to the coupled with external rotation. In a sectioning study per-
fabellofibular ligament, and posterior to the PFL.1,12,19,33,42 formed by Coobs et al,3 the function of the FCL was
Along the anterior aspect of the knee, the artery travels investigated by comparing intact knees to FCL-sectioned
anterior either within or just adjacent to the anterolateral knees by applying a varus moment and internal and
ligament.1,11 During lateral knee surgery, identification of external torques. Results demonstrated that sectioning the
the lateral inferior genicular artery serves a dual purpose. FCL resulted in significantly increased varus rotation and
For one, it can help differentiate between the fabellofibular internal rotation at all tested flexion angles (0, 15, 30, 60,
ligament and the PFL intraoperatively or on imaging and 90 degrees). Conversely, external rotation was only
examinations.1,29 In addition, it is important to stop significantly increased at 60 and 90 degrees of knee flexion.
bleeding from the artery before closing of a lateral knee Lateral compartment gapping of 2.7 mm to 4.0 mm on
surgical incision site as hematoma formation at the fibular stress radiographs taken at 20 degrees of knee flexion is
head has been reported to cause transient peroneal neuro- commonly seen in FCL-deficient knees (Table 1).49 In an
praxia secondary to hematoma formation.41 ACL-deficient knee, the FCL has been reported to function
as a primary restraint to varus gapping and a secondary
restraint to anterior translation and internal rotation.50
Thus, the functional contributions of the FCL are depend-
ent on both knee flexion angle and the presence of other
knee stabilizers including the anterior cruciate ligament.
Furthermore, understanding of the functional contributions
of the FCL have laid the groundwork against which ana-
tomic FCL reconstruction techniques have been evaluated
for their ability to restore normal knee kinematics.3
As for the structural properties of the FCL, LaPrade
et al51 reported the FCL has a mean ultimate failure
strength of 295 N and a stiffness of approximately 33.5 N/m.
However, as noted in the study, these loads are much lower
than the failure loads for the cruciate ligaments and,
therefore, the FCL likely functions in combination with the
other main lateral knee structures in resisting load.51 Inju-
ries to the FCL also place other ligament reconstructions at
FIGURE 6. A peroneal neurolysis is performed to gently release risk of failure. In several studies simulating FCL tears, lat-
and retract the peroneal nerve during a posterolateral corner eral knee instability after FCL injury resulted in increased
reconstruction (arrow). The popliteus musculotendinous junction strain on anterior cruciate ligament and posterior cruciate
can be readily visualized through the interval between the lateral ligament reconstruction grafts.46–48 LaPrade et al48 reported
gastrocnemius tendon and soleus (star) (left knee). that FCL sectioning resulted in increased forces on the

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Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015 Anatomy and Biomechanics of the Lateral Knee

torque was the only applied load that substantially loaded

the PLT, with the highest load seen at 60 degrees of knee
flexion (Fig. 8). In a later sectioning study, LaPrade et al7
studied the effect of internal and external rotation torques,
a varus moment, and anterior and posterior forces following
sectioning of the PLT. Significant differences compared with
the intact state were found for external rotation at 30, 60, and
90 degrees of flexion, internal rotation at 0, 20, 30, 60, and 90
degrees of flexion, varus angulation at 20, 30, and 60 degrees
of flexion, and anterior translation at 0, 20, and 30 degrees of
flexion. No significant differences in posterior translation
were found between the intact knee and PLT-sectioned knee.
The authors concluded that the PLT has a primary role in
external stability, with smaller, significant roles as a stabilizer
to internal rotation, varus angulation, and anterior trans-
lation. These findings have since been used to develop and
validate anatomic-based PLT reconstruction techniques for
their ability to restore normal knee kinematics.
With respect to structural properties, the PLT report-
edly has the highest ultimate failure and stiffness of the pri-
FIGURE 7. Forces on the fibular collateral ligament (FCL) during mary 3 lateral knee structures.51 With ultimate failure
a 6 N m external rotation moment, 6 N m internal rotation strength of 700 N and a stiffness of 83 N/m, the PLT seems
moment, and 12 N m varus moment. Results demonstrate con-
sistent loading of the FCL with a varus moment and greater
particularly able to withstand large loads. However, when
loading at 0 and 30 degrees of flexion with an external rotation injuries do occur, unrecognized PLT injuries combined with
moment compared with higher knee flexion angles. Reproduced injury to other lateral knee structures results in significantly
with permission from LaPrade et al.45 increased forces on ACL or PCL reconstruction grafts47,48
and increased posterior translation, external rotation, and
anterior cruciate ligament graft under varus loading at 0 and varus rotation in PCL-reconstructed knees.46 Therefore,
30 degrees of knee flexion. Similar increased forces on the restoration of PLT function either via primary repair in acute
posterior cruciate ligament reconstruction graft47 and cases of PLT avulsion fractures or reconstruction for mid-
increased posterior translation, external rotation, and varus substance tears or chronic injuries is required.
rotation46 have been reported after combined injury to lat-
eral knee structures. Therefore, in cases of combined lateral PFL
knee and cruciate ligament injury, it is essential to surgically Although the functions of the FCL and PLT have
repair or reconstruct lateral knee injuries, such as injury to historically been appreciated as essential for preserving
the FCL, in addition to performing a cruciate ligament lateral knee stability, the PFL has received comparatively
reconstruction. little attention.43,44,46 Despite this, the PFL nevertheless
plays an important role in lateral knee stability. The PFL
PLT reportedly undergoes substantial loading with applied
The PLT has been reported to perform a similar role
to the FCL as a restraint to internal and external rotation
of the tibia on the femur. In a cadaveric cutting study
performed by Ferrari et al,52 internal and external rotation
were measured in intact knees and knees with partial and
complete PLT detachment at 0, 30, 60, and 90 degrees of
flexion. Results demonstrated increased internal and
external rotation after internal and external moments were
applied in knees where the PLT had been partially or
completely detached at its femoral insertion. In a similar
study, LaPrade et al45 reported that an external rotation

TABLE 1. Mean Side-to-Side Difference in Varus Gapping on

Varus Stress Radiographs and the Corresponding Injury Pattern48
Lateral Compartment
Gapping* Injury
0-2.4 mm Physiologic laxity or grade I or II
sprain
2.4-4 mm Isolated grade III FCL tear
> 4 mm Complete grade III PLC tear
*Thresholds in lateral compartment gapping are determined by
obtaining a varus stress radiographs with a clinician applied force with the FIGURE 8. Forces measurements in response to a 6 N m external
knee in 20 degrees of flexion. rotation torque in the fibular collateral ligament (FCL), pop-
FCL indicates fibular collateral ligament. liteofibular ligament (PFL), and popliteus tendon (PLT). Repro-
duced with permission from LaPrade et al.45

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James et al Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015

external rotation torques, with the highest forces on the turn led to improved patient outcomes following lateral
ligament observed with the knee at 60 degrees of flexion knee injuries.
(Fig. 8).45 Therefore, the ligament offers substantial con-
tributions to lateral knee stability as a primary stabilizer REFERENCES
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and colleagues determined that reconstructing the PFL is J Sports Med. 2007;35:1521–1527.
4. Horst PK, LaPrade RF. Anatomic reconstruction of chronic
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5. LaPrade RF, Johansen S, Wentorf FA, et al. An analysis of an
Grade III Injury to Posterolateral Structures anatomical posterolateral knee reconstruction: an in vitro
As described above, the FCL, PLT, and PFL all per- biomechanical study and development of a surgical technique.
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Therefore, grade III injury to the posterolateral knee, defined
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as complete tears of each of these 3 structures, profoundly morphologic analysis of the fibular collateral ligament,
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a grade III posterolateral injury resulted in significantly 7. LaPrade RF, Wozniczka JK, Stellmaker MP, et al. Analysis of
increased external rotation after an applied external rotation the static function of the popliteus tendon and evaluation of an
torque and increased varus rotation after an applied varus anatomic reconstruction: the “fifth ligament” of the knee. Am J
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posterolateral knee reconstructions require a popliteofibular
applied internal rotation torque at 60 and 90 degrees of knee
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flexion.8 A grade III posterolateral injury has been reported Med. 2010;38:1674–1681.
to significantly increase the force on reconstructed anterior 9. LaPrade RF, Johansen S, Engebretsen L. Outcomes of an
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degrees of knee flexion, as well as with coupled varus loading que. J Bone Joint Surg Am. 2011;93(suppl 1):10–20.
and internal rotation at 0 and 30 degrees of knee flexion.48 10. LaPrade RF, Johansen S, Agel J, et al. Outcomes of an
Lateral compartment gapping of 4.0 mm or greater on varus anatomic posterolateral knee reconstruction. J Bone Joint Surg
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12. Terry GC, LaPrade RF. The posterolateral aspect of the knee.
result in significantly increased force on posterior cruciate Anatomy and surgical approach. Am J Sports Med. 1996;24:
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cruciate ligament reconstruction grafts was seen under an 14. LaPrade RF, Wentorf FA, Crum JA. Assessment of healing of
external rotation torque at 60 degrees of knee flexion.47 grade III posterolateral corner injuries: an in vivo model.
As reviewed above, the individual and collective J Orthop Res. 2004;22:970–975.
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standing of lateral knee anatomy and biomechanics have in the knee. Its anatomy and injury patterns associated with acute

8 | www.sportsmedarthro.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sports Med Arthrosc Rev ! Volume 23, Number 1, March 2015 Anatomy and Biomechanics of the Lateral Knee

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