Imaging the knee: Ligaments

Daniel B. Nissman, MD, R. Hal Hobbs, MD, Thomas L. Pope, MD,

C. David Geier, Jr., MD, and William F. Conway, MD

I
njuries of the knee are common. At participate in the magnetic moment of The anterior cruciate ligament
our institution, the Medical Univer- MRI. Therefore, under normal circum- The ACL extends in an inferior, ante-
sity of South Carolina, trauma and stances, ligaments show low signal rior, and medial direction from its origin
sports-related activities are the most fre- intensity on all pulse sequences. Injury on the inner surface of the posterior, lat-
quent causes of knee injuries. Second- allows loosely bound hydrogen atoms eral femoral condyle to its insertion on
ary to their role in maintaining stability, as well as infiltrating edema and hemor- the anterior tibial plateau anterior to the
the ligaments of the knee are commonly rhage to produce signal on the various tibial spines between the attachments of
involved in these injuries. To prevent pulse sequences used to evaluate these the medial and lateral menisci and be-
long-term sequelae, early diagnosis and structures.6 neath the transverse ligament.7 It consists
treatment—whether conservative or sur- MRI protocols for the knee vary by of 2 distinct bands—the anteromedial and
gical—are key in planning management magnet and interpreter preference. Pro- posterolateral bundles—according to
of these injuries. Because of its excellent tocols should include sequences ob- their distal attachment’s relationship to
soft-tissue contrast, magnetic resonance tained in the axial, coronal, and sagittal the tibial spine. These bands function to
imaging (MRI) has proven very useful for planes, with at least one fluid-sensitive resist anterior displacement of the tibia
identifying these important structures.1-4 sequence. In general, a high field- and hyperextension, respectively. Also,
In the immediate postinjury period, clini- strength magnet and a dedicated knee or because of these two separate compo-
cal assessment of the knee is unreliable, extremity coil is preferred, but adequate nents, the normal ACL is taut throughout
which accentuates the importance of MRI evaluation can be attained with mid- the full range of knee motion.8 Further,
as a diagnostic tool.5 This article reviews and low-field magnets. Patients are the posterolateral bundle provides an ele-
the MRI appearance of the knee liga- imaged supine with the knee in slight ment of rotational stability.
ments in their normal and injured states. external rotation both for better visual- The normal ACL is a low-signal-
ization of the anterior cruciate ligament intensity band that roughly parallels the
Basic imaging principles (ACL) and patient comfort. The authors intercondylar roof (Blumensaat’s line).
Because of the biochemical composi- do not use intravenous contrast unless Normal interspersed fat and connective
tion of ligaments, the tightly bound hy- evaluating for neoplasm or infection. tissue give the ACL a striated appear-
drogen molecules are unavailable to Intra-articular contrast is used primarily ance that should not be mistaken for
in the patient who has had prior surgical pathology. Usually, even with optimal
Dr. Nissman is a Resident and Dr. Hobbs
meniscal repair. positioning, the ACL is visualized on
was a Musculoskeletal Fellow in the
Department of Radiology and Radiologi- In general, the collateral ligaments ≥2 contiguous sagittal images rather
cal Science, Medical University of South are best evaluated in the coronal plane, than on a single image (Figures 1 and 2).
Carolina. Dr. Hobbs is now in private and the cruciate ligaments and exten- The ACL is commonly injured from
practice in Augusta, GA. Dr. Pope is a sor mechanism are best evaluated in excessive valgus stress, also called the
Professor of Radiology and Orthopedics
the sagittal plane. The coronal plane is “pivot-shift” mechanism. The classic ex-
and the Director of the Hollings Cancer
Center Breast Imaging Program; also an important projection for the ample of this is the clipping type of injury
Dr. Geier is an Assistant Professor of cruciate ligaments. However, visual- seen in American football. MRI signs of
Orthopaedic Surgery, Dr. Conway is a ization of all structures in all three ACL injury are a pseudomass in the nor-
Professor of Radiology and the Director of imaging planes is necessary for a com- mal location of the ACL, frank disconti-
Musculoskeletal Radiology, Medical Uni-
plete evaluation, which helps to avoid nuity of the ligament, wavy or irregular
versity of South Carolina, Charleston, SC.
misdiagnosis. course, or avulsion at either the femoral

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IMAGING THE KNEE: LIGAMENTS

A B

FIGURE 1. A normal anterior cruciate ligament FIGURE 2. The anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate lig-
(ACL). This sagittal T2-weighted image shows ament (ACL). (A) A coronal T1-weighted image through the anterior tibia shows the attach-
the normal appearance and course of the ACL ments of the AM (arrow) and PL (arrowhead) bundles of the ACL. (B) This axial T2-weighted
(arrow). Note the solid appearance anteriorly fat-suppressed image through the intercondylar notch shows the AM bundle in front and
and a striated appearance posteriorly. medial to the PL bundle (arrowhead).

A B

FIGURE 3. Complete tears of the anterior cruciate ligament (ACL) in 2 patients, which were
proven on arthroscopy. (A) This sagittal proton-density image shows thickening and complete FIGURE 4. “Kissing contusions.” This coronal
disruption of the ACL fibers proximally (arrows). (B) A sagittal T2-weighted image shows T2-weighted fat-saturated image through the
marked thickening of the ACL with intrasubstance edema, an example of the “pseudomass” anterior knee shows fluid signal in the medial
appearance (arrows). femoral condyle and tibial plateau that is com-
patible with bone marrow edema. This pattern
origin or tibial insertion. In the authors’ abnormal curvature of the posterior cru- represents the “kissing contusions” pattern of
experience, the mid-substance “pseudo- ciate ligament (PCL), which are related bone marrow edema seen in “pivot-shift”
mass” appearance resulting from edema findings, with the latter secondary to the injuries associated with anterior cruciate liga-
ment tears.
and hemorrhage is the most common former. However, buckling or increased
finding of an acute ACL tear. Occasion- curvature of the PCL may also be seen tears are also commonly associated find-
ally, the “pseudomass” appearance can be with hyperextension of the knee in the ings. The Segond fracture, an avulsion
caused by partial volume averaging on setting of a normal ACL. “Kissing con- fracture of the lateral joint capsule at its
the sagittal image. Apparent discontinu- tusions,” a commonly seen secondary insertion onto the lateral tibial plateau, is
ity on sagittal images can also lead to a sign of ACL injury caused by the previ- associated with an ACL tear in >90% of
misdiagnosis of an ACL tear. Correlation ously mentioned pivot-shift mechanism cases when it is present (Figure 5).10,11
with axial and coronal images is impera- of injury, occur on the posterior aspect of When any of these findings are seen at
tive to help radiologists avoid these imag- the tibial plateau and the mid to anterior MRI, a careful assessment of the ACL in
ing pitfalls.9 Two examples of complete aspect of the femoral condyle (Figure 4). all three imaging planes is essential.
ACL tears are shown in Figure 3. Medial and lateral meniscal tears usually In skeletally immature individuals,
Secondary signs of an ACL tear involving the posterior horns, and medial the injury pattern is somewhat different,
include anterior tibial translation and collateral ligament (MCL) sprains and with tibial spine avulsions and partial

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IMAGING THE KNEE: LIGAMENTS

A B

FIGURE 6. A partial anterior cruciate ligament (ACL) tear associated with tibial attachment avul-
FIGURE 5. An anteroposterior view of the sion. (A) This anteroposterior view of the knee shows a near-triangular–shaped fragment overly-
knee shows a lateral capsular avulsion frac- ing the tibial spines that represents an avulsion of the tibial attachment of the ACL. (B) A sagittal
ture on the lateral tibial plateau; this fracture T2-weighted image shows a thickened and edematous ACL. Note that some fibers can be fol-
is known as a Segond fracture. lowed from the tibial to the femoral attachment.

A B C

FIGURE 7. An isolated anteromedial bundle tear in a 15-year-old basketball player 2 weeks after the
injury. (A) An arthroscopic view of the intercondylar notch after clearance of a hemarthrosis reveals
torn anteromedial fibers still attached to the tibia with intact posterolateral fibers (arrow). (B) This
arthroscopic image shows the intact posterolateral bundle (arrows) after the torn anteromedial
fibers have been debrided. (C) A sagittal T2-weighted image shows an apparent complete tear of
the ACL (arrow). The intact posterolateral bundle was not identified even in retrospect.

ACL tears predominating.12-14 This pat- of partial ACL tears is still debated, but the oblique course of the ACL on all
tern is most likely secondary to the nonetheless, the diagnosis should be imaging planes. Careful inspection of the
greater ability of bone to deform under sought and reported when seen.15,16 ACL in all projections may allow identi-
stress in the immature skeleton and the Recently, evidence suggests that fication of an isolated bundle abnormal-
lack of osseous fusion of the tibial spine patients with isolated ACL bundle tears, ity and help direct the orthopedic surgeon
prior to physeal closure. As the skeleton either anteromedial or posterolateral, to the area at arthroscopy. As more ortho-
matures, the patterns of ACL injury benefit from single bundle repairs.17,18 pedic surgeons are performing these
approach that seen in adults.14 Additionally, complete tears may benefit operations, identification of isolated bun-
Partial tears of the ACL can be hard to from so-called double-bundle recon- dle tears can be of great service to the
appreciate on MRI. Focal or diffuse sig- struction, especially in light of the addi- patient (Figure 7).
nal alteration within an intact ligament, tional rotational stability provided by an The appearance of chronic ACL tears
abnormal thickening or thinning of the intact posterolateral bundle.19 Isolated is highly variable. The fibrosis secondary
ligament with abnormal intra-substance tears of the posterolateral bundle are dif- to healing of the ligament results in sig-
signal, or abnormal angulation of the lig- ficult to appreciate using standard arthro- nal characteristics similar to that of a nor-
ament all can represent a partial tear scopic ports.17 On MRI, identification of mal ligament. The most specific findings
(Figure 6). The importance and treatment the individual bundles is complicated by of a chronic tear are an abnormal course

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 IMAGING THE KNEE: LIGAMENTS

FIGURE 10. This sagittal T2-weighted

FIGURE 9. A normal posterior cruciate liga- image shows thickening of the posterior cru-
FIGURE 8. A chronic anterior cruciate ligament ment (PCL). This sagittal T2-weighted image ciate ligament (PCL) (arrows) and increased
(ACL) tear. This sagittal T1-weighted image shows the normal appearance and course of signal in the substance of the PCL that is
shows the ACL lying inferiorly within the knee the PCL (arrow). compatible with a partial tear.
with a normal tibial attachment and an absent
femoral attachment. The proximal aspect has
fused to the posterior cruciate ligament.

or angulation of the ACL without other

abnormalities normally associated with
an acute tear.20 In some cases of complete
tears, the ACL will settle on top of the
posterior cruciate ligament and, over
time, will adhere by fibrosis to this liga-
ment (Figure 8). The edema seen around
and within an acutely torn ACL will be
absent in a chronic tear.

Posterior cruciate ligament FIGURE 11. This sagittal T2-weighted fat-

The PCL extends in an inferior, poste- saturated image shows a complete disconti- FIGURE 12. A normal medial collateral liga-
rior, and lateral direction from its origin nuity of the posterior cruciate ligament (PCL), ment (MCL). This coronal T2-weighted fat-
on the inner surface of the anterior with surrounding increased signal,which is saturated image shows the normal appear-
compatible with a complete tear of the PCL. ance and course of the MCL (arrow).
aspect of the medial femoral condyle to
its insertion on the far posterior aspect of condyle. On coronal imaging, this struc-
the tibial plateau. Like the ACL, the ture can be mistaken for abnormal thick-
PCL is also composed of 2 bundles: the ening of the PCL, but correlation with
anterolateral and posteromedial bundles. sagittal images can clarify this finding.
The significance of these bundles in The PCL is less frequently injured
terms of reconstruction is less clear than than the ACL, and such injuries require a
for the ACL.21,22 The PCL functions to greater force. Therefore, there is often
resist posterior translation of the tibia associated injury to other structures of
with respect to the femur, and portions the knee (usually the ACL and MCL)
of this structure are taut throughout the when PCL injuries are encountered.
entire range of motion of the knee. The Mechanisms of injury to the PCL include
normal PCL lacks the striations of the hyperflexion, hyperextension, and dislo-
ACL and can often be seen in its entirety cation. Posterior cruciate ligament tears
on a single sagittal image (Figure 9). are often difficult to diagnose clinically
FIGURE 13. A grade 1 medial collateral liga-
The meniscofemoral ligaments are inti- in the acute setting and can be difficult to
ment (MCL) injury. A coronal T2-weighted
mately associated with the PCL as they evaluate at arthroscopy secondary to its fat-saturated image shows fluid signal adja-
pass from the posterior horn of the lat- far posterior location. Therefore, MRI is cent to the MCL (arrows) without intrasub-
eral meniscus to the medial femoral critical in the diagnosis of this entity. stance signal or discontinuity.

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IMAGING THE KNEE: LIGAMENTS

FIGURE 15. A grade 3 medial collateral liga-

ment (MCL) injury. This coronal T2-weighted
FIGURE 14. A grade 2 medial collateral liga- fat-saturated image shows a distal discontinuity
ment (MCL) injury. This coronal T2-weighted of the MCL and waviness of the ligament that is FIGURE 16. A normal iliotibial band. This
fat-saturated image shows fluid signal adja- compatible with a complete tear of the MCL coronal proton-density image shows the nor-
cent to the MCL and within the substance of (arrow). More commonly, the proximal attach- mal appearance and course of the iliotibial
the MCL but without discontinuity (arrow). ment of the MCL is involved in a complete tear. band (arrows).

FIGURE 17. A normal fibular collateral liga-

ment (FCL). This coronal proton-density image FIGURE 19. Normal conjoined tendon. This
shows the normal appearance and course of coronal T2-weighted fat-saturated image
the fibular collateral ligament (arrows), a com- shows the normal course and appearance of
ponent of the lateral collateral ligament com- FIGURE 18. A normal biceps femoris tendon. the conjoined tendon, which is composed of
plex. Note the biceps femoris tendon merging This coronal T1-weighted image shows the the biceps femoris tendon (arrow) and the
with the FCL near its fibular attachment to form normal appearance and course of the biceps fibular collateral ligament (arrowhead). (See
the conjoined tendon (inferior-most arrow). femoris tendon (arrows). Figure 16, illustrating a normal iliotibial band.)

Signs of injury include frank disrup- Medial collateral ligament of the medial meniscus. The MCL func-
tion of the ligament, diffuse midsub- The MCL arises from the medial tions as the chief valgus stabilizer of the
stance widening with increased signal in- femoral condyle approximately 5 cm knee and is therefore most commonly
tensity on T1- and T2-weighted images, above the joint line and extends to insert injured with abnormal valgus angula-
or an avulsion of either its femoral origin on the medial tibia approximately 6 to tion of the knee.
or tibial insertion.23 Partial tears are rec- 7 cm below the joint line posterior to the As mentioned, the MCL is best visual-
ognized by abnormal signal intensity insertion of the pes anserinus.24 The ized in the coronal plane, where it is
within an intact ligament. Of note, if the MCL actually consists of 2 layers sepa- normally seen as a linear, low-signal-
PCL appears higher in signal intensity rated by a small bursae and minimal intensity structure (Figure 12). Meniscal
than the ACL on any imaging sequence, peribursal fat. The superficial MCL is injuries are graded as 1 through 3 based
it is considered abnormal. See Figures 10 the true tibial collateral ligament. The on imaging findings. Adjacent edema
and 11 for an example of a partial and a deep layer is contiguous with the menis- with no signal abnormality within the
complete tear. cofemoral and meniscotibial ligaments ligament is characterized as a sprain, or

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 IMAGING THE KNEE: LIGAMENTS

A B

FIGURE 20. A complete tear of the conjoined

tendon. This coronal T2-weighted fat-saturated
image depicts a complete tear of the con-
joined tendon with discontinuity of the tendon FIGURE 21. A normal transverse meniscal ligament. These sagittal T2-weighted images reveal
at its fibular attachment. Note the wavy the transverse meniscal ligament. (A) This image reveals a clear separation between the anterior
appearance of the biceps femoris tendon and horn of the medial meniscus and the transverse meniscal ligament (arrow). (B) In this image, the
the fibular collateral ligament (arrows). minimal separation between these structures could be mistaken for a meniscal tear (arrow).

FIGURE 22. This coronal proton-density

image shows the oblique course of the menis- FIGURE 23. Ligament of Humphrey. This FIGURE 24. Ligament of Wrisberg. This
cofemoral ligament (arrow) from the medial sagittal T2-weighted image depicts the menis- sagittal T2-weighted image reveals the
aspect of the medial femoral condyle to the cofemoral ligament (arrow) anterior to the meniscofemoral ligament (arrow) posterior
lateral meniscus (not seen in this image). posterior cruciate ligament . to the posterior cruciate ligament.

grade 1 injury (Figure 13). More exten- in this diagnosis is fluid in the deep MCL continuation of the tensor fascia lata
sive edema with abnormal signal inten- bursae separating the superficial and inserting on Gerdy’s tubercle on the
sity, thickening, or thinning of the lig- deep components as mentioned above. anterolateral tibia (Figure 16), the fibular
ament signifies grade 2 injury, or partial The characteristic appearance and loca- or true lateral collateral ligament (Fig-
tear (Figure 14), and complete disruption tion of this bursa helps the radiologist ure 17), and the tendon of the biceps
of the ligament or its attachments quali- avoid this error. femoris muscle that converges with the
fies as a grade 3 injury (Figure 15).25,26 fibular collateral ligament to form the
Injuries of the MCL are commonly asso- Lateral collateral conjoined tendon prior to inserting on the
ciated with medial meniscal tears and ligamentous complex fibular head (Figures 18 and 19). The
meniscocapsular separation. Menisco- Laterally, the knee is stabilized by a popliteus tendon also contributes to lat-
capsular separation is defined as disrup- group of structures, collectively known eral stability and should be evaluated for
tion of the normal tight attachment of the as the lateral collateral ligamentous com- injury on knee MRI, but will not be dis-
MCL to the medial meniscus and joint plex (LCLC), which resist varus stress cussed further in this article.
capsule. It is recognized on MRI as fluid and external rotation.27 The most impor- Because of the numerous contributors
signal interspersed between the MCL tant of these structures, from anterior to to the lateral complex, increased force is
and medial meniscus. A potential pitfall posterior, are the iliotibial band (ITB), a required to cause injury in this location.

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IMAGING THE KNEE: LIGAMENTS

MRI findings of injury here are similar to appearance and position can help a radi- 12. Stanitski CL, Harvell JC, Fu F. Observations on
those seen with the MCL: surrounding ologist avoid pitfalls in diagnosis. A acute knee hemarthrosis in children and adolescents.
J Pediatr Orthop. 1993;13(4):506-510.
soft tissue edema and hemorrhage, in- prominent Humphry’s ligament can 13. Shea KG, Apel PJ, Pfeiffer RP. Anterior cruciate
creased signal intensity within these nor- occasionally mimic a flipped meniscal ligament injury in paediatric and adolescent patients:
mally low-signal-intensity structures, or fragment from a bucket-handle tear or a A review of basic science and clinical research.
Sports Med. 2003;33(6):455-471.
frank discontinuity of the individual com- loose body in the intercondylar notch. 14. Prince JS, Laor T, Bean JA. MRI of anterior cruci-
ponents. Figure 20 shows a complete tear Also, similar to the transverse meniscal ate ligament injuries and associated findings in the
of the conjoined tendon. Inflammation ligament, the attachment of the menisco- pediatric knee: Changes with skeletal maturation.
AJR Am J Roentgenol. 2005;185:756-762.
adjacent to the structures of the LCL can femoral ligament to the lateral meniscus 15. Bak K, Scavenius M, Hansen S, et al. Isolated
also have clinical significance. The most can occasionally mimic a meniscal tear. partial rupture of the anterior cruciate ligament: Long-
common of these conditions involves term follow-up of 56 cases. Knee Surg Sports Trau-
matol Arthrosc. 1997;5(2):66-71.
inflammation adjacent to the iliotibial Conclusion 16. Lamar DS, Bartolozzi AR, Freedman KB, et al.
band (ITB) and distension of an adjacent Injury to the knee ligaments is rela- Thermal modification of partial tears of the anterior
bursae associated with ITB syndrome.28 tively common. MRI is the best imaging cruciate ligament. Arthroscopy. 2005;21(7):809-814.
17. Petersen W, Zantop T. Partial rupture of the anterior
technique available to identify these cruciate ligament. Arthroscopy. 2006;22:1143-1145.
Other ligaments abnormalities and to plan arthroscopic 18. Yagi M, Kuroda R, Nagamune K, et al. Double-
The transverse meniscal ligament and or open surgical repair. Knowledge of bundle ACL reconstruction can improve rotational
stability. Clin Orthop Relat Res. 2007;454:100-107.
the meniscofemoral ligaments are other the normal MRI appearance of the major 19. Zelle BA, Brucker PU, Feng MT, Fu FH. Anatomi-
commonly visualized knee ligaments on knee ligaments and the most common cal double-bundle anterior cruciate ligament recon-
MRI. The transverse meniscal ligament findings seen following injury to these struction. Sports Med. 2006;36(2):99-108.
20. Vahey TN, Broome DR, Kayes KJ, Shelbourne
is a thin, fibrous band that connects the structures is critical for the interpreting KD. Acute and chronic tears of the anterior cruciate
anterior horns of the menisci.29 The liga- radiologist to be a successful imaging ligament: Differential features at MR imaging. Radiol-
ment is occasionally misdiagnosed on consultant. ogy. 1991;181(1):251-253.
21. Markolf KL, Feeley BT, Tejwani SJ, et al.
sagittal images as a tear of either of the
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