Revista de Medicina Desportiva (English) November 2018 | Page 22

and ecchymosis, and it might be
found paresthesia and some motor
deficit on the foot due to the injury
of the superficial peroneal nerve.
Later the patient can complain of
instability and show hyperextension
when standing. 6 On the chronic
injuries the instability is the most
important. The march with hyper-
extension and a big varus, known
as varus thrust gait, is typical. 6 The
symptoms related to the peroneal
nerve may remain unchanged and
they may occur in the 20% of the
patients. 18,20
Physical exam
The physical exam is fundamental
for the diagnosis of the PLC injury.
Unser suspicion, there should be
done the varus stress test, the dial test
and the reverse pivot shif. 1,7,21-23
The varus laxity evaluation should
be performed at full extension and
at 30° flexion. The force must be
applied at the patient’s foot or at
the ankle to increase an eventual
rotatory instability. If the opening
during this stress is similar both in
full extension and at 30° flexion it
must be assumed that all primary
restrictors are injured. If the opening
is only at 30° flexion and it can be
reversed at full extension it is pre-
sumed only an injury of the LCL. 1,21,22
The dial test evaluates the rotation
of the tibia over the femur. It is exe-
cuted with the patient on decubitus
and the knees at 30° and 90° of flex-
ion. The occurring external rotation
A
B
must be compared with the one on
the contralateral side using the end
of the foot as the reference mark in
relation to the femur. The test is pos-
itive if the difference between both
sides is bigger than 10°: if it is posi-
tive at 30° the injury of PCL must be
suspected; if it is positive both at 30
and 90° there must be a combined
injury of PLC and of the PCL.
The reverse pivot-shift has a lower
positive predictive value in relation
to the other tests. With the patient
on supine and the knee at 90° of
flexion it is applied simultaneously
a valgus force at the level of the
interarticular line with the tibia on
external rotation. The test is positive
if during the extension movement
the previous sub-dislocated tibia
return to the normal position at 40°
of flexion. 1,7,21-23
Complementary diagnostic exams
The simple X-ray is the more acces-
sible and practical image exam,
although in the contest of acute
injuries is quite often normal without
any significant information. 24,25 On
the chronic cases, the X-ray per-
formed with a stress in varus has
been shown a reliable and reproducible
method for the PLC injuries. 24,25 There
should be made a bilateral varus
stress X-ray with the knee at 30° of
flexion. LaPrade describes an opening
of the outer compartment of 2,7mm
on isolated ruptures of LCL and on
the ruptures of the posterior-lateral
complex the opening is 4 or more
C
Figure 2 – A: Arciero’s technique; B: Larson’s technique; C: LaPrade’s technique
20 november 2018 www.revdesportiva.pt
millimeters when comparing with
the contralateral side. 24,25
The magnetic resonance is the
elected exam for the ligament inju-
ries 26,27 , and it can identify the other
injured structures. However, it must
be done during the 12 weeks after
the injury because if it is performed
after this period there is the risk of
only 26% injured patients can be
diagnosed. 27,28
Treatment
For a correct treatment approach, it
is considered the evolution time, the
associated injuries and the residual
instability.
The conservative treatment is
only adequate for the isolated grade I
and grade II injuries. 8,20 However, for
type II multi-ligament injuries (with
PCL or ACL) or ruptures grade II the
results of the conservative treatment
are frankly insufficient, with persis-
tent instability and early degenera-
tive changes. 29,30 Surgical treatment
has better clinical results. 29,30
The surgical procedure varies
according the evolution time of the
injury. On the acute injury, with less
than three weeks before the pro-
cedure, the reparation is possible,
although with doubtful results. 31-35
When the treatment is performed
after three weeks, the ligaments are
already with retraction with fibrotic
scar and the results are unsatisfac-
tory and similar to treatment on
the chronic phage. There are 31-35 two
cohort studies (level of evidence II)
comparing reparation versus recon-
struction on the acute stages of PLC
injuries. Stannard et al 32 and Levy et
al 33 both documents very high fail-
ure rates on the reparation group,
about 40%, comparing with the 10%
on the reconstruction group.
There are several techniques for
ligament reconstruction, both ana-
tomic and non-anatomic (Figure 2).
Larson 37 described a non-anatomic
reconstruction isometric technique
with a tunnel at the fibular head
and anchorage of the graft at
femoral insertion of the LCL. He
presented 14 cases that were able to
stabilize the varus forces.
As previously indicated, due to the
distance between the LCL insertion
and popliteus muscle tendon, it is