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Injuries to the extra articular ligament and tendon structures on the medial aspect of the knee can be divided into tears of the medial collateral ligament, semimembranosus and per anserine insertions. The commonest is injury to the medial collateral ligament. The medial collateral ligament comprises two portions. The superficial component is stronger and runs from several centimetres above the knee joint to insert 5-6cm below. It is approximately 2.5cm anterior to posterior. Anteriorly it is related to the medial retinaculum and posterior to the capsule of the knee joint along with as specific condensation that runs posteriorly and obliquely to reinforce the posteromedial aspect of the joint along with the insertion of the semimembranosus tendon. This component is called the posterior oblique ligament (POL). The deep portion of the medial collateral ligament is composed of two rather weak ligaments. The meniscal femoral ligament runs between the femur and medial meniscus is the proximal portion with the meniscal tibial ligament distally. Between the two components lies the tibial collateral ligament bursa. The ligament is injured under two circumstances. The commonest injury is a valgus sprain which is associated with compression micro fracture in the lateral compartment. A second mechanism is less common where there is valgus translation of the proximal tibia. This is generally not associated with impaction micro fracture however medial meniscal extrusion may be observed. Injuries to the medial collateral ligament are most easily assessed using coronally orientated magnetic resonance imaging.
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The immediate external relation of the ligament is subcutaneous fat consequently and early sign is oedema infiltrating the fat. This is best appreciated on fat suppressed images. Injuries to the superficial component of the medial collateral ligament is classified by a three grade system. There is reasonably good correlation between the clinical grades and the MR findings. A grade one injury represents medial collateral ligament sprain. There is pain and focal tenderness clinically with a firm end point on valgus stress.The MR findings show oedema surrounding an otherwise intact ligament. A grade two injury clinically shows more valgus opening than grade one but once again a firm end point is reached. The MR findings in these cases show oedema surrounding the ligament with signal changes but not complete disruption of the ligament fibres themselves. Partial tears and occasionally a lamellated appearance described as onion skinning is identified. With grade three a complete ligament disruption, there is no end point to valgus stress on clinical examination. There was complete disruption to the ligament on MR imaging and the ligament will often appear wavy due to retraction. In many cases, the patient may also present with a locked knee. This is due pseudo locking due to muscles spasm related to pain and MR is efficient in excluding a mechanical block due to a displaced meniscal fragment, an osteochondral fragment or an impinging anterior cruciate ligament stump. The management of medial collateral ligament injuries is usually conservative. In most cases the ligament injury will heal without complication although ligament thickening may persist for considerable periods.
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