Clinical Orthopaedics and Related Research®

, Volume 475, Issue 10, pp 2401–2408 | Cite as

Rotational Laxity Control by the Anterolateral Ligament and the Lateral Meniscus Is Dependent on Knee Flexion Angle: A Cadaveric Biomechanical Study

  • Timothy Lording
  • Gillian Corbo
  • Dianne Bryant
  • Timothy A. Burkhart
  • Alan Getgood
Symposium: Improving Care for Patients With ACL Injuries: A Team Approach



Injury to the anterolateral ligament (ALL) has been reported to contribute to high-grade anterolateral laxity after anterior cruciate ligament (ACL) injury. Failure to address ALL injury has been suggested as a cause of persistent rotational laxity after ACL reconstruction. Lateral meniscus posterior root (LMPR) tears have also been shown to cause increased internal rotation of the knee.


The purpose of this study was to determine the functional relationship between the ALL and LMPR in the control of internal rotation of the ACL-deficient knee. Specifically: (1) We asked if there was a difference in internal rotation among: the intact knee; the ACL-deficient knee; the ACL/ALL-deficient knee; the ACL/LMPR-deficient knee; and the ACL/ALL/LMPR-deficient knee. (2) We also asked if there was a difference in anterior translation among these conditions.


Sixteen fresh frozen cadaveric knee specimens (eight men, mean age 79 years) were potted into a hip simulator (femur) and a 6 degree-of-freedom load cell (tibia). Rigid optical trackers were inserted into the proximal femur and distal tibia, allowing for the motion of the tibia with respect to the femur to be tracked during biomechanical tests. A series of points on the femur and tibia were digitized to create bone coordinate systems that were used to calculate internal rotation and anterior translation. Biomechanical testing involved applying a 5-Nm internal rotation moment to the tibia from full extension to 90° of flexion. Anterior translation was performed by applying a 90-N anterior load using a tensiometer. Both tests were performed in 15° increments tested sequentially in the following conditions: (1) intact; and (2) ACL injury (ACL−). The specimens were then randomized to either have the ALL sectioned (3) first (M+/ALL−); or (4) the LMPR sectioned first (M−/ALL+) followed by the other structure (M−/ALL−). A one-way analysis of variance was performed for each sectioning condition at each angle of knee flexion (α = 0.05).


At 0° of flexion there was an effect of tissue sectioning such that internal rotation of the M−/ALL− condition was greater than ACL− by 1.24° (p = 0.03; 95% confidence interval [CI], 0.16–2.70) and the intact condition by 2.5° (p = 0.01; 95% CI, 0.69–3.91). In addition, the mean (SD) internal rotations for the M+/ALL− (9.99° [5.39°]) and M−/ALL+ (12.05° [5.34°]) were greater by 0.87° (p = 0.04; 95% CI, 0.13–3.83) and by 2.15°, respectively, compared with the intact knee. At 45° the internal rotation for the ACL− (19.15° [9.49°]), M+/ALL− (23.70° [7.00°]), and M−/ALL− (18.80° [8.27°]) conditions was different than the intact (12.78° [9.23°]) condition by 6.37° (p = 0.02; 95% CI, 1.37–11.41), 8.47° (p < 0.01; 95% CI, 3.94–13.00), and 6.02° (p = 0.01; 95% CI, 1.73–10.31), respectively. At 75° there was a 10.11° difference (p < 0.01; 95% CI, 5.20–15.01) in internal rotation between the intact (13.96° [5.34°]) and the M+/ALL− (23.22° [4.46°]) conditions. There was also a 4.08° difference (p = 0.01; 95% CI, 1.14–7.01) between the intact and M−/ALL− (18.05° [7.31°]) conditions. Internal rotation differences of 6.17° and 5.43° were observed between ACL− (16.28° [6.44°]) and M+/ALL− (p < 0.01; 95% CI, 2.45–9.89) as well as between M+/ALL− and M−/ALL− (p = 0.01; 95% CI, −8.17 to −1.63). Throughout the range of flexion, there was no difference in anterior translation with progressive section of the ACL, meniscus, or ALL.


The ALL and LMPR both play a role in aiding the ACL in controlling internal rotation laxity in vitro; however, these effects seem to be dependent on flexion angle. The ALL has a greater role in controlling internal rotation at flexion angles > 30o. The LMPR appears to have more of an effect on controlling rotation closer to extension.

Clinical Relevance

Injury to the ALL and/or LMPR may contribute to high-grade anterolateral laxity after ACL injury. The LMPR and the ALL, along with the iliotibial tract, appear to act in concert as secondary stabilizers of anterolateral rotation and could be considered as the “anterolateral corner” of the knee.


  1. 1.
    Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg Am. 2008;90:1922–1931.CrossRefPubMedGoogle Scholar
  2. 2.
    Bao HRC, Zhu D, Gong H, Gu GS. The effect of complete radial lateral meniscus posterior root tear on the knee contact mechanics: a finite element analysis. J Orthop Sci. 2012;18:256–263.CrossRefPubMedGoogle Scholar
  3. 3.
    Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A. A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Arthrosc. 2015;23:3186–3195.CrossRefPubMedGoogle Scholar
  4. 4.
    Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223:321–328.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Dennis DA, Mahfouz MR, Komistek RD, Hoff W. In vivo determination of normal and anterior cruciate ligament-deficient knee kinematics. J Biomech. 2005;38:241–253.CrossRefPubMedGoogle Scholar
  6. 6.
    Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA. The anterolateral ligament: anatomy, length changes and association with the Segond fracture. Bone Joint J. 2014;96:325–331.CrossRefPubMedGoogle Scholar
  7. 7.
    Dombrowski ME, Costello JM, Ohashi B, Murawski CD, Rothrauff BB, Arilla FV, Friel NA, Fu FH, Debski RE, Musahl V. Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee. Knee Surg Sports Traumatol Arthrosc. 2016;24:2854–2860.CrossRefPubMedGoogle Scholar
  8. 8.
    Elmansori A, Lording T, Dumas R, Elmajri K, Neyret P, Lustig S. Proximal tibial bony and meniscal slopes are higher in ACL injured subjects than controls: a comparative MRI study. Knee Surg Sports Traumatol Arthrosc. 2017 Feb 17. [Epub ahead of print]Google Scholar
  9. 9.
    Feucht MJ, Salzmann GM, Bode G, Pestka JM, Kühle J, Südkamp NP, Niemeyer P. Posterior root tears of the lateral meniscus. Knee Surg Sports Traumatol Arthrosc. 2014;23:119–125.CrossRefPubMedGoogle Scholar
  10. 10.
    Forkel P, Herbort M, Schulze M, Rosenbaum D, Kirstein L, Raschke M, Petersen W. Biomechanical consequences of a posterior root tear of the lateral meniscus: stabilizing effect of the meniscofemoral ligament. Arch Orthop Trauma Surg. 2013;133:621–626.CrossRefPubMedGoogle Scholar
  11. 11.
    Gadikota HR, Kikuta S, Qi W, Nolan D, Gill TJ, Li G. Effect of increased iliotibial band load on tibiofemoral kinematics and force distributions: a direct measurement in cadaveric knees. J Orthop Sports Phys Ther. 2013;43:478–485.CrossRefPubMedGoogle Scholar
  12. 12.
    Grood ES, Suntay WJ. A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng. 1983;105:136–144.CrossRefPubMedGoogle Scholar
  13. 13.
    Haimes JL, Wroble RR, Grood ES, Noyes FR. Role of the medial structures in the intact and anterior cruciate ligament-deficient knee. Limits of motion in the human knee. Am J Sports Med. 1994;22:402–409.CrossRefPubMedGoogle Scholar
  14. 14.
    Hein CN, Deperio JG, Ehrensberger MT, Marzo JM. Effects of medial meniscal posterior horn avulsion and repair on meniscal displacement. Knee. 2011;18:189–192.CrossRefPubMedGoogle Scholar
  15. 15.
    Helito CP, Demange MK, Bonadio MB. Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med. 2013;1:2325967113513546.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Iwaki H, Pinskerova V, Freeman MA. Tibiofemoral movement 1: the shapes and relative movements of the femur and tibia in the unloaded cadaver knee. J Bone Joint Surg Br. 2000;82:1189–1195.CrossRefPubMedGoogle Scholar
  17. 17.
    Jakob RP, Hassler H, Staeubli HU. Observations on rotatory instability of the lateral compartment of the knee. Experimental studies on the functional anatomy and the pathomechanism of the true and the reversed pivot shift sign. Acta Orthop Scand Suppl. 1981;191:1–32.CrossRefPubMedGoogle Scholar
  18. 18.
    Kennedy MI, Claes S, Fuso FAF, Williams BT, Goldsmith MT, Turnbull TL, Wijdicks CA, LaPrade RF. The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med. 2015;43:1606–1615.CrossRefPubMedGoogle Scholar
  19. 19.
    Kittl C, Daou El H, Athwal KK, Gupte CM, Weiler A, Williams A, Amis AA. The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. Am J Sports Med. 2016;44:345–354.CrossRefPubMedGoogle Scholar
  20. 20.
    Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:629–634.CrossRefPubMedGoogle Scholar
  21. 21.
    Kocher MS, Steadman JR, Briggs K, Zurakowski D, Sterett WI, Hawkins RJ. Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2002;84:1560–1572.CrossRefPubMedGoogle Scholar
  22. 22.
    Lerer DB, Umans HR, Hu MX, Jones MH. The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol. 2004;33:569–574.CrossRefPubMedGoogle Scholar
  23. 23.
    Macchi V, Porzionato A, Morra A, Stecco C, Tortorella C, Menegolo M, Grignon B, De Caro R. The anterolateral ligament of the knee: a radiologic and histotopographic study. Surg Radiol Anat. 2016;38:341–348.CrossRefPubMedGoogle Scholar
  24. 24.
    Maher JM, Markey JC, Ebert-May D. The other half of the story: effect size analysis in quantitative research. Cell Biol Educ. 2013;12:345–351.CrossRefGoogle Scholar
  25. 25.
    Marzo JM, Gurske-DePerio J. Effects of medial meniscus posterior horn avulsion and repair on tibiofemoral contact area and peak contact pressure with clinical implications. Am J Sports Med. 2008;37:124–129.CrossRefPubMedGoogle Scholar
  26. 26.
    Monaco E, Ferretti A, Labianca L, Maestri B, Speranza A, Kelly MJ, D’Arrigo C. Navigated knee kinematics after cutting of the ACL and its secondary restraint. Knee Surg Sports Traumatol Arthrosc. 2011;20:870–877.CrossRefPubMedGoogle Scholar
  27. 27.
    Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2010;38:1591–1597.CrossRefPubMedGoogle Scholar
  28. 28.
    Musahl V, Rahnemai-Azar AA, Costello J, Arner JW, Fu FH, Hoshino Y, Lopomo N, Samuelsson K, Irrgang JJ. The influence of meniscal and anterolateral capsular injury on knee laxity in patients with anterior cruciate ligament injuries. Am J Sports Med. 2016;44:3126–3131.CrossRefPubMedGoogle Scholar
  29. 29.
    Musahl V, Rahnemai-Azar AA, van Eck CF, Guenther D, Fu FH. Anterolateral ligament of the knee, fact or fiction? Knee Surg Sports Traumatol Arthrosc. 2015;24:2–3.CrossRefGoogle Scholar
  30. 30.
    Noyes FR, Jetter AW, Grood ES, Harms SP, Gardner EJ, Levy MS. Anterior cruciate ligament function in providing rotational stability assessed by medial and lateral tibiofemoral compartment translations and subluxations. Am J Sports Med. 2015;43:683–692.CrossRefPubMedGoogle Scholar
  31. 31.
    Parsons EM, Gee AO, Spiekerman C, Cavanagh PR. The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med. 2015;43:669–674.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Peltier A, Lording T, Maubisson L, Ballis R, Neyret P, Lustig S. The role of the meniscotibial ligament in posteromedial rotational knee stability. Knee Surg Sports Traumatol Arthrosc. 2015;23:2967–2973.CrossRefPubMedGoogle Scholar
  33. 33.
    Perez-Blanca A, Espejo-Baena A, Amat Trujillo D, Prado Nóvoa M, Espejo-Reina A, Quintero López C, Ezquerro Juanco F. Comparative biomechanical study on contact alterations after lateral meniscus posterior root avulsion, transosseous reinsertion, and total meniscectomy. Arthroscopy. 2016;32:624–633.CrossRefPubMedGoogle Scholar
  34. 34.
    Rasmussen MT, Nitri M, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF. An in vitro robotic assessment of the anterolateral ligament, part 1: secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury. Am J Sports Med. 2016;44:585–592.CrossRefPubMedGoogle Scholar
  35. 35.
    Ristanis S, Stergiou N, Patras K, Vasiliadis HS, Giakas G, Georgoulis AD. Excessive tibial rotation during high-demand activities is not restored by anterior cruciate ligament reconstruction. Arthroscopy. 2005;21:1323–1329.CrossRefPubMedGoogle Scholar
  36. 36.
    Saiegh YA, Suero EM, Guenther D, Hawi N, Decker S, Krettek C, Citak M, Omar M. Sectioning the anterolateral ligament did not increase tibiofemoral translation or rotation in an ACL-deficient cadaveric model. Knee Surg Sports Traumatol Arthrosc. 2015;21:257.Google Scholar
  37. 37.
    Shybut TB, Vega CE, Haddad J, Alexander JW, Gold JE, Noble PC, Lowe WR. Effect of lateral meniscal root tear on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2015;43:905–911.CrossRefPubMedGoogle Scholar
  38. 38.
    Simon RA, Everhart JS, Nagaraja HN, Chaudhari AM. A case-control study of anterior cruciate ligament volume, tibial plateau slopes and intercondylar notch dimensions in ACL-injured knees. J Biomech. 2010;43:1702–1707.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Spencer L, Burkhart TA, Tran MN, Rezansoff AJ, Deo S, Caterine S, Getgood AM. Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med. 2015;43:2189–2197.CrossRefPubMedGoogle Scholar
  40. 40.
    Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:975–983.CrossRefPubMedGoogle Scholar
  41. 41.
    Van Dyck P, Clockaerts S, Vanhoenacker FM, Lambrecht V, Wouters K, De Smet E, Gielen JL, Parizel PM. Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries. Eur Radiol. 2016;26:3383–3391.CrossRefPubMedGoogle Scholar
  42. 42.
    Vedi V, Williams A, Tennant SJ, Spouse E, Hunt DM, Gedroyc WM. Meniscal movement. An in-vivo study using dynamic MRI. J Bone Joint Surg Br. 1999;81:37–41.CrossRefPubMedGoogle Scholar
  43. 43.
    Vincent J-P, Magnussen RA, Gezmez F, Uguen A, Jacobi M, Weppe F, Al-Saati MF, Lustig S, Demey G, Servien E, Neyret P. The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc. 2011;20:147–152.CrossRefPubMedGoogle Scholar
  44. 44.
    West RV, Kim JG, Armfield D, Harner CD. Lateral meniscal root tears associated with anterior cruciate ligament injury: classification and management (SS-70). Arthroscopy. 2004;20:e32–e33.CrossRefGoogle Scholar
  45. 45.
    Wroble RR, Grood ES, Cummings JS, Henderson JM, Noyes FR. The role of the lateral extraarticular restraints in the anterior cruciate ligament-deficient knee. Am J Sports Med. 1993;21:257–263.CrossRefPubMedGoogle Scholar
  46. 46.
    Zens M, Niemeyer P, Ruhhammer J, Bernstein A, Woias P, Mayr HO, Sudkamp NP, Feucht MJ. Length changes of the anterolateral ligament during passive knee motion: a human cadaveric study. Am J Sports Med. 2015;43:2545–2552.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2017

Authors and Affiliations

  • Timothy Lording
    • 1
  • Gillian Corbo
    • 2
  • Dianne Bryant
    • 3
  • Timothy A. Burkhart
    • 4
    • 5
  • Alan Getgood
    • 6
  1. 1.Melbourne Orthopaedic GroupWindsorAustralia
  2. 2.Anatomy and Cell Biology, Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  3. 3.Faculty of Health SciencesWestern UniversityLondonCanada
  4. 4.Lawson Health Research InstituteLondonCanada
  5. 5.Departments of Surgery and Mechanical EngineeringWestern UniversityLondonCanada
  6. 6.Fowler Kennedy Sport Medicine ClinicWestern UniversityLondonCanada

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