0:00

We have a patient with medial knee joint pain.

0:06

And the main findings are located

0:09

in the medial compartment.

0:12

I like to draw your attention to.

0:15

the medial collateral ligament

0:18

proximal insertion.

0:20

So, we have the insertion into the

0:22

medial femoral epicondyle.

0:25

And then, as we know,

0:27

there is this superficial layer of the MCL,

0:31

that in this patient, if you pay attention

0:35

to the proximal origin,

0:37

there is a partial thickness tear right there.

0:40

So, let's draw that again.

0:43

Right there.

0:44

So, we have partial thickness tear of the

0:48

under surface fibers of the MCL.

0:52

And this would be a grade two medial

0:55

collateral ligament sprain.

0:57

So, the sprains are divided into three grades

1:01

for the medial collateral ligament.

1:03

This is based on orthopedic classification.

1:08

Grade one is when we have fluid.

1:12

About the fibers, but the fibers are intact.

1:15

There is no discontinuity of the ligament.

1:20

Grade two, there is partial thickness tear.

1:23

And grade three, there is full thickness tear.

1:26

Now, we need to remember that the medial

1:28

collateral ligament has two layers.

1:31

So, we already drew over the superficial layer.

1:36

There is a deep layer composed by

1:39

the meniscocapsular ligaments.

1:41

And we have those ligaments coming from

1:43

the meniscus to attach to the adjacent femur.

1:47

So that would be the meniscofemoral ligament.

1:50

And here we have the meniscotibial ligament.

1:53

In this patient,

1:54

both ligaments appear to be edematous.

1:59

So, that is a sprain also of the deep layer

2:02

of the medial collateral ligament.

2:05

In addition,

2:06

this patient has an associated medial

2:10

meniscus tear.

2:12

The tear is complex.

2:14

It has a dominant oblique configuration

2:18

propagating from the posterior horn,

2:20

involving the zone of the posterior horn,

2:24

extending into the body segment

2:27

and surfacing inferiorly.

2:29

So, we have a flap tear of the medial meniscus

2:34

that is migrated into the medial joint gutter

2:39

in this patient with a complex tear.

2:42

Now, I like to also draw your attention to the

2:45

presence of fluid between the two layers

2:48

of the medial collateral ligament.

2:50

You see, the superficial layer that we know

2:53

is partly torn proximally.

2:55

And the meniscofemoral ligament,

2:58

this space is occupied by the medial collateral

3:02

ligament semimembranosus versa.

3:05

And the fluid that we're seeing there

3:07

is splitting the two layers in that virtual

3:11

space that in this patient

3:12

has been filled with fluid

3:14

given the presence of the grade two sprain.

3:18

So in summary,

3:20

grade two MCL sprain

3:22

with partial proximal disruption of the superficial

3:28

layer of the medial collateral ligament.

Wk 5, Case 5 - Review

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Pro Tip: Click on a word in the transcript to jump to that point in the video

0:00

We have a patient with medial knee joint pain.

0:06

And the main findings are located

0:09

in the medial compartment.

0:12

I like to draw your attention to.

0:15

the medial collateral ligament

0:18

proximal insertion.

0:20

So, we have the insertion into the

0:22

medial femoral epicondyle.

0:25

And then, as we know,

0:27

there is this superficial layer of the MCL,

0:31

that in this patient, if you pay attention

0:35

to the proximal origin,

0:37

there is a partial thickness tear right there.

0:40

So, let's draw that again.

0:43

Right there.

0:44

So, we have partial thickness tear of the

0:48

under surface fibers of the MCL.

0:52

And this would be a grade two medial

0:55

collateral ligament sprain.

0:57

So, the sprains are divided into three grades

1:01

for the medial collateral ligament.

1:03

This is based on orthopedic classification.

1:08

Grade one is when we have fluid.

1:12

About the fibers, but the fibers are intact.

1:15

There is no discontinuity of the ligament.

1:20

Grade two, there is partial thickness tear.

1:23

And grade three, there is full thickness tear.

1:26

Now, we need to remember that the medial

1:28

collateral ligament has two layers.

1:31

So, we already drew over the superficial layer.

1:36

There is a deep layer composed by

1:39

the meniscocapsular ligaments.

1:41

And we have those ligaments coming from

1:43

the meniscus to attach to the adjacent femur.

1:47

So that would be the meniscofemoral ligament.

1:50

And here we have the meniscotibial ligament.

1:53

In this patient,

1:54

both ligaments appear to be edematous.

1:59

So, that is a sprain also of the deep layer

2:02

of the medial collateral ligament.

2:05

In addition,

2:06

this patient has an associated medial

2:10

meniscus tear.

2:12

The tear is complex.

2:14

It has a dominant oblique configuration

2:18

propagating from the posterior horn,

2:20

involving the zone of the posterior horn,

2:24

extending into the body segment

2:27

and surfacing inferiorly.

2:29

So, we have a flap tear of the medial meniscus

2:34

that is migrated into the medial joint gutter

2:39

in this patient with a complex tear.

2:42

Now, I like to also draw your attention to the

2:45

presence of fluid between the two layers

2:48

of the medial collateral ligament.

2:50

You see, the superficial layer that we know

2:53

is partly torn proximally.

2:55

And the meniscofemoral ligament,

2:58

this space is occupied by the medial collateral

3:02

ligament semimembranosus versa.

3:05

And the fluid that we're seeing there

3:07

is splitting the two layers in that virtual

3:11

space that in this patient

3:12

has been filled with fluid

3:14

given the presence of the grade two sprain.

3:18

So in summary,

3:20

grade two MCL sprain

3:22

with partial proximal disruption of the superficial

3:28

layer of the medial collateral ligament.

Report

Patient History
General left knee after physical activity for two weeks. Suspect medial meniscus tear or MCL sprain. Prior arthroscopy 15-20 years ago.
Findings
Menisci:

Medial Meniscus: Chronic undersurface body to posterior horn conversion signal related to previous meniscectomy/chronic horizontal cleavage tear of the rim. Mild associated extrusion of the undersurface indicating rim or meniscal fragment instabilty.

Lateral Meniscus: Chronic horizontal cleavage type intrameniscal signal.

Ligaments:

Anterior Cruciate Ligament: Intact but demonstrates diffuse myxoid degeneration. Diffuse notch synovitis is incidentally noted due to notch stenosis with impingement.

Posterior Cruciate Ligament: Intact.

Medial Collateral Ligament: Thickened intact proximal to mid tibial collateral ligament with extensive diffuse periligamentous edema, consistent with an intermediate grade (grade 2) MCL sprain. Meniscotibial and meniscofemoral ligaments remain intact but swollen.

Lateral Collateral Ligament: Intact.

Posterolateral Corner Structures: Intact.

Posteromedial Corner Structures: Intact.

Extensor Mechanism:

Patellar Tendon: Intact.

Distal Quadriceps Tendon: Intact.

Medial Patellofemoral Ligament: Markedly attenuated and edematous at its femoral origin, anterior to the proximal tibial collateral ligament and adjacent to the adductor tubercle, consistent with at least a grade 2-3 (intermediate to high-grade) sprain/tear.
Medial and Lateral Patellar Retinacula: Lax edematous medial patellar retinaculum. Intact lateral retinaculum.

Hoffa’s Fat Pad: Curvilinear scar within the right inferomedial patellar fat pad, consistent with previous arthroscopy.

Articulations:

Patellofemoral Compartment: Penetrating grade 4 chondromalacia with penetrating osteochondral erosions involving the mid to upper patella apex. Diffuse grade 2-3 chondromalacia involving the lateral patellar facet and trochlear sulcus.

Medial Compartment: Diffuse grade 2-3 medial tibiofemoral chondromalacia with a more focal area of high-grade penetrating chondromalacia (grade 4) on the posterior aspect of the medial femoral condyle.

Lateral Compartment: Diffuse grade 2-3 lateral tibiofemoral chondromalacia. No penetrating high-grade chondromalacia.

General:

Bones: Incidental notch dysplasia with notch stenosis and impingement.

Effusion: Moderate-sized suprapatellar effusion.

Baker’s Cyst: None.

Loose Bodies: None.

Soft tissue and Neurovascular: Unremarkable.

Conclusion

1. Intermediate (grade 2) MCL sprain.
2. Suspect intermediate to high-grade (grade 2-3) MPFL injury at its femoral origin.
3. Early medial compartment failure with meniscal and chondral insufficiency (diffuse grade 2-3 chondromalacia), with chronic undersurface medial meniscus conversion signal/horizontal cleavage tear and partial extrusion.
4. Grade 4 penetrating chondromalacia middle to upper patellar ridge and grade 2-3 chondromalacia trochlear sulcus lateral trochlear facet.
5. ACL myxoid degeneration and notch synovitis.

Case Discussion

Faculty

Omer Awan, MD, MPH, CIIP

Associate Professor of Radiology

University of Maryland School of Medicine

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Jenny T Bencardino, MD

Vice-Chair, Academic Affairs Department of Radiology

Montefiore Radiology

Edward Smitaman, MD

Clinical Associate Professor

University of California San Diego

Practice Cases

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Wk 5, Case 5 - Review