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
our institution, the Medical Univer-
sity of South Carolina, trauma and
sports-related activities are the most fre-
quent causes of knee injuries. Second-
ary to their role in maintaining stability,
the ligaments of the knee are commonly
involved in these injuries. To prevent
long-term sequelae, early diagnosis and
treatment—whether conservative or sur-
gical—are key in planning management
of these injuries. Because of its excellent
soft-tissue contrast, magnetic resonance
imaging (MRI) has proven very useful for
identifying these important structures.1-4
In the immediate postinjury period, clini-
cal assessment of the knee is unreliable,
which accentuates the importance of MRI
as a diagnostic tool.5 This article reviews
the MRI appearance of the knee liga-
ments in their normal and injured states.
Basic imaging principles
Because of the biochemical composi-
tion of ligaments, the tightly bound hy-
drogen molecules are unavailable to
Dr. Nissman is a Resident and Dr. Hobbs
was a Musculoskeletal Fellow in the
Department of Radiology and Radiologi-
cal Science, Medical University of South
Carolina. Dr. Hobbs is now in private
practice in Augusta, GA. Dr. Pope is a
Professor of Radiology and Orthopedics
and the Director of the Hollings Cancer
Center Breast Imaging Program;
Dr. Geier is an Assistant Professor of
Orthopaedic Surgery, Dr. Conway is a
Professor of Radiology and the Director of
Musculoskeletal Radiology, Medical Uni-
versity of South Carolina, Charleston, SC.
December 2008
participate in the magnetic moment of
MRI. Therefore, under normal circum-
stances, ligaments show low signal
intensity on all pulse sequences. Injury
allows loosely bound hydrogen atoms
as well as infiltrating edema and hemor-
rhage to produce signal on the various
pulse sequences used to evaluate these
structures.6
MRI protocols for the knee vary by
magnet and interpreter preference. Pro-
tocols should include sequences ob-
tained in the axial, coronal, and sagittal
planes, with at least one fluid-sensitive
sequence. In general, a high field-
strength magnet and a dedicated knee or
extremity coil is preferred, but adequate
evaluation can be attained with mid-
and low-field magnets. Patients are
imaged supine with the knee in slight
external rotation both for better visual-
ization of the anterior cruciate ligament
(ACL) and patient comfort. The authors
do not use intravenous contrast unless
evaluating for neoplasm or infection.
Intra-articular contrast is used primarily
in the patient who has had prior surgical
meniscal repair.
In general, the collateral ligaments
are best evaluated in the coronal plane,
and the cruciate ligaments and exten-
sor mechanism are best evaluated in
the sagittal plane. The coronal plane is
also an important projection for the
cruciate ligaments. However, visual-
ization of all structures in all three
imaging planes is necessary for a com-
plete evaluation, which helps to avoid
misdiagnosis.
www.appliedradiology.com
The anterior cruciate ligament
The ACL extends in an inferior, ante-
rior, and medial direction from its origin
on the inner surface of the posterior, lat-
eral femoral condyle to its insertion on
the anterior tibial plateau anterior to the
tibial spines between the attachments of
the medial and lateral menisci and be-
neath the transverse ligament.7 It consists
of 2 distinct bands—the anteromedial and
posterolateral bundles—according to
their distal attachment’s relationship to
the tibial spine. These bands function to
resist anterior displacement of the tibia
and hyperextension, respectively. Also,
because of these two separate compo-
nents, the normal ACL is taut throughout
the full range of knee motion.8 Further,
the posterolateral bundle provides an ele-
ment of rotational stability.
The normal ACL is a low-signal-
intensity band that roughly parallels the
intercondylar roof (Blumensaat’s line).
Normal interspersed fat and connective
tissue give the ACL a striated appear-
ance that should not be mistaken for
pathology. Usually, even with optimal
positioning, the ACL is visualized on
≥2 contiguous sagittal images rather
than on a single image (Figures 1 and 2).
The ACL is commonly injured from
excessive valgus stress, also called the
“pivot-shift” mechanism. The classic ex-
ample of this is the clipping type of injury
seen in American football. MRI signs of
ACL injury are a pseudomass in the nor-
mal location of the ACL, frank disconti-
nuity of the ligament, wavy or irregular
course, or avulsion at either the femoral
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IMAGING THE KNEE: LIGAMENTS

A B

FIGURE 1. A normal anterior cruciate ligament
(ACL). This sagittal T2-weighted image shows
the normal appearance and course of the ACL
(arrow). Note the solid appearance anteriorly
and a striated appearance posteriorly.
FIGURE 2. The anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate lig-
ament (ACL). (A) A coronal T1-weighted image through the anterior tibia shows the attach-
ments of the AM (arrow) and PL (arrowhead) bundles of the ACL. (B) This axial T2-weighted
fat-suppressed image through the intercondylar notch shows the AM bundle in front and
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 5. An anteroposterior view of the
knee shows a lateral capsular avulsion frac-
ture on the lateral tibial plateau; this fracture
is known as a Segond fracture.
FIGURE 6. A partial anterior cruciate ligament (ACL) tear associated with tibial attachment avul-
sion. (A) This anteroposterior view of the knee shows a near-triangular–shaped fragment overly-
ing the tibial spines that represents an avulsion of the tibial attachment of the ACL. (B) A sagittal
T2-weighted image shows a thickened and edematous ACL. Note that some fibers can be fol-
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-
tern is most likely secondary to the
greater ability of bone to deform under
stress in the immature skeleton and the
lack of osseous fusion of the tibial spine
prior to physeal closure. As the skeleton
matures, the patterns of ACL injury
approach that seen in adults.14
Partial tears of the ACL can be hard to
appreciate on MRI. Focal or diffuse sig-
nal alteration within an intact ligament,
abnormal thickening or thinning of the
ligament with abnormal intra-substance
signal, or abnormal angulation of the lig-
ament all can represent a partial tear
(Figure 6). The importance and treatment
of partial ACL tears is still debated, but
nonetheless, the diagnosis should be
sought and reported when seen.15,16
Recently, evidence suggests that
patients with isolated ACL bundle tears,
either anteromedial or posterolateral,
benefit from single bundle repairs.17,18
Additionally, complete tears may benefit
from so-called double-bundle recon-
struction, especially in light of the addi-
tional rotational stability provided by an
intact posterolateral bundle.19 Isolated
tears of the posterolateral bundle are dif-
ficult to appreciate using standard arthro-
scopic ports.17 On MRI, identification of
the individual bundles is complicated by
the oblique course of the ACL on all
imaging planes. Careful inspection of the
ACL in all projections may allow identi-
fication of an isolated bundle abnormal-
ity and help direct the orthopedic surgeon
to the area at arthroscopy. As more ortho-
pedic surgeons are performing these
operations, identification of isolated bun-
dle tears can be of great service to the
patient (Figure 7).
The appearance of chronic ACL tears
is highly variable. The fibrosis secondary
to healing of the ligament results in sig-
nal characteristics similar to that of a nor-
mal ligament. The most specific findings
of a chronic tear are an abnormal course

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FIGURE 8. A chronic anterior cruciate ligament
(ACL) tear. This sagittal T1-weighted image
shows the ACL lying inferiorly within the knee
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
The PCL extends in an inferior, poste-
rior, and lateral direction from its origin
on the inner surface of the anterior
aspect of the medial femoral condyle to
its insertion on the far posterior aspect of
the tibial plateau. Like the ACL, the
PCL is also composed of 2 bundles: the
anterolateral and posteromedial bundles.
The significance of these bundles in
terms of reconstruction is less clear than
for the ACL.21,22 The PCL functions to
resist posterior translation of the tibia
with respect to the femur, and portions
of this structure are taut throughout the
entire range of motion of the knee. The
normal PCL lacks the striations of the
ACL and can often be seen in its entirety
on a single sagittal image (Figure 9).
The meniscofemoral ligaments are inti-
mately associated with the PCL as they
pass from the posterior horn of the lat-
eral meniscus to the medial femoral
December 2008
IMAGING THE KNEE: LIGAMENTS
FIGURE 10. This sagittal T2-weighted
FIGURE 9. A normal posterior cruciate liga- image shows thickening of the posterior cru-
ment (PCL). This sagittal T2-weighted image ciate ligament (PCL) (arrows) and increased
shows the normal appearance and course of signal in the substance of the PCL that is
the PCL (arrow). compatible with a partial tear.
FIGURE 11. This sagittal T2-weighted fat-
saturated image shows a complete disconti- FIGURE 12. A normal medial collateral liga-
nuity of the posterior cruciate ligament (PCL), ment (MCL). This coronal T2-weighted fat-
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).
condyle. On coronal imaging, this struc-
ture can be mistaken for abnormal thick-
ening of the PCL, but correlation with
sagittal images can clarify this finding.
The PCL is less frequently injured
than the ACL, and such injuries require a
greater force. Therefore, there is often
associated injury to other structures of
the knee (usually the ACL and MCL)
when PCL injuries are encountered.
Mechanisms of injury to the PCL include
hyperflexion, hyperextension, and dislo-
cation. Posterior cruciate ligament tears
are often difficult to diagnose clinically
FIGURE 13. A grade 1 medial collateral liga-
in the acute setting and can be difficult to
ment (MCL) injury. A coronal T2-weighted
evaluate at arthroscopy secondary to its fat-saturated image shows fluid signal adja-
far posterior location. Therefore, MRI is cent to the MCL (arrows) without intrasub-
critical in the diagnosis of this entity. stance signal or discontinuity.
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IMAGING THE KNEE: LIGAMENTS
FIGURE 14. A grade 2 medial collateral liga-
ment (MCL) injury. This coronal T2-weighted
fat-saturated image shows fluid signal adja-
cent to the MCL and within the substance of
the MCL but without discontinuity (arrow).
FIGURE 17. A normal fibular collateral liga-
ment (FCL). This coronal proton-density image
shows the normal appearance and course of
the fibular collateral ligament (arrows), a com-
ponent of the lateral collateral ligament com-
plex. Note the biceps femoris tendon merging
with the FCL near its fibular attachment to form
the conjoined tendon (inferior-most arrow).
Signs of injury include frank disrup-
tion of the ligament, diffuse midsub-
stance widening with increased signal in-
tensity on T1- and T2-weighted images,
or an avulsion of either its femoral origin
or tibial insertion.23 Partial tears are rec-
ognized by abnormal signal intensity
within an intact ligament. Of note, if the
PCL appears higher in signal intensity
than the ACL on any imaging sequence,
it is considered abnormal. See Figures 10
and 11 for an example of a partial and a
complete tear.
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FIGURE 15. A grade 3 medial collateral liga-
ment (MCL) injury. This coronal T2-weighted
fat-saturated image shows a distal discontinuity
of the MCL and waviness of the ligament that is
compatible with a complete tear of the MCL
(arrow). More commonly, the proximal attach-
ment of the MCL is involved in a complete tear.
FIGURE 18. A normal biceps femoris tendon.
This coronal T1-weighted image shows the
normal appearance and course of the biceps
femoris tendon (arrows).
Medial collateral ligament
The MCL arises from the medial
femoral condyle approximately 5 cm
above the joint line and extends to insert
on the medial tibia approximately 6 to
7 cm below the joint line posterior to the
insertion of the pes anserinus.24 The
MCL actually consists of 2 layers sepa-
rated by a small bursae and minimal
peribursal fat. The superficial MCL is
the true tibial collateral ligament. The
deep layer is contiguous with the menis-
cofemoral and meniscotibial ligaments
FIGURE 16. A normal iliotibial band. This
coronal proton-density image shows the nor-
mal appearance and course of the iliotibial
band (arrows).
FIGURE 19. Normal conjoined tendon. This
coronal T2-weighted fat-saturated image
shows the normal course and appearance of
the conjoined tendon, which is composed of
the biceps femoris tendon (arrow) and the
fibular collateral ligament (arrowhead). (See
Figure 16, illustrating a normal iliotibial band.)
of the medial meniscus. The MCL func-
tions as the chief valgus stabilizer of the
knee and is therefore most commonly
injured with abnormal valgus angula-
tion of the knee.
As mentioned, the MCL is best visual-
ized in the coronal plane, where it is
normally seen as a linear, low-signal-
intensity structure (Figure 12). Meniscal
injuries are graded as 1 through 3 based
on imaging findings. Adjacent edema
with no signal abnormality within the
ligament is characterized as a sprain, or
December 2008
 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
at its fibular attachment. Note the wavy
appearance of the biceps femoris tendon and
the fibular collateral ligament (arrows).
FIGURE 21. A normal transverse meniscal ligament. These sagittal T2-weighted images reveal
the transverse meniscal ligament. (A) This image reveals a clear separation between the anterior
horn of the medial meniscus and the transverse meniscal ligament (arrow). (B) In this image, the
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-
sive edema with abnormal signal inten-
sity, thickening, or thinning of the lig-
ament signifies grade 2 injury, or partial
tear (Figure 14), and complete disruption
of the ligament or its attachments quali-
fies as a grade 3 injury (Figure 15).25,26
Injuries of the MCL are commonly asso-
ciated with medial meniscal tears and
meniscocapsular separation. Menisco-
capsular separation is defined as disrup-
tion of the normal tight attachment of the
MCL to the medial meniscus and joint
capsule. It is recognized on MRI as fluid
signal interspersed between the MCL
and medial meniscus. A potential pitfall
in this diagnosis is fluid in the deep MCL
bursae separating the superficial and
deep components as mentioned above.
The characteristic appearance and loca-
tion of this bursa helps the radiologist
avoid this error.
Lateral collateral
ligamentous complex
Laterally, the knee is stabilized by a
group of structures, collectively known
as the lateral collateral ligamentous com-
plex (LCLC), which resist varus stress
and external rotation.27 The most impor-
tant of these structures, from anterior to
posterior, are the iliotibial band (ITB), a
continuation of the tensor fascia lata
inserting on Gerdy’s tubercle on the
anterolateral tibia (Figure 16), the fibular
or true lateral collateral ligament (Fig-
ure 17), and the tendon of the biceps
femoris muscle that converges with the
fibular collateral ligament to form the
conjoined tendon prior to inserting on the
fibular head (Figures 18 and 19). The
popliteus tendon also contributes to lat-
eral stability and should be evaluated for
injury on knee MRI, but will not be dis-
cussed further in this article.
Because of the numerous contributors
to the lateral complex, increased force is
required to cause injury in this location.

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IMAGING THE KNEE: LIGAMENTS
MRI findings of injury here are similar to
those seen with the MCL: surrounding
soft tissue edema and hemorrhage, in-
creased signal intensity within these nor-
mally low-signal-intensity structures, or
frank discontinuity of the individual com-
ponents. Figure 20 shows a complete tear
of the conjoined tendon. Inflammation
adjacent to the structures of the LCL can
also have clinical significance. The most
common of these conditions involves
inflammation adjacent to the iliotibial
band (ITB) and distension of an adjacent
bursae associated with ITB syndrome.28
Other ligaments
The transverse meniscal ligament and
the meniscofemoral ligaments are other
commonly visualized knee ligaments on
MRI. The transverse meniscal ligament
is a thin, fibrous band that connects the
anterior horns of the menisci.29 The liga-
ment is occasionally misdiagnosed on
sagittal images as a tear of either of the
anterior meniscal horns where it inserts
on these structures. Knowledge of this
structure’s normal appearance and fol-
lowing it across the joint space on con-
tiguous sagittal images will help radiol-
ogists avoid this pitfall (Figure 21).
The meniscofemoral ligaments have
already been briefly mentioned in terms
of their relationship to the PCL. These
structures extend from the posterior horn
of the lateral meniscus superomedially
to the inner aspect of the medial femoral
condyle (Figure 22). If the ligament is
anterior to the PCL, it is referred to as
Humphry’s ligament (Figure 23), and if
it is posterior to the PCL, it is referred to
as Wrisberg’s ligament (Figure 24).
Rarely, the ligament will bifurcate, sur-
rounding the PCL and giving the appear-
ance of both.29 Some individuals do not
have an identifiable meniscofemoral lig-
ament.30 The function of the menis-
cofemoral ligament is to stabilize the
lateral meniscus against the pull of the
popliteus muscle.29 In the PCL-deficient
knee, the meniscofemoral ligament re-
sists posterior drawer.31
Again, these structures are important
primarily in that knowing their normal
32 ■ APPLIED RADIOLOGY ©
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appearance and position can help a radi-
ologist avoid pitfalls in diagnosis. A
prominent Humphry’s ligament can
occasionally mimic a flipped meniscal
fragment from a bucket-handle tear or a
loose body in the intercondylar notch.
Also, similar to the transverse meniscal
ligament, the attachment of the menisco-
femoral ligament to the lateral meniscus
can occasionally mimic a meniscal tear.
Conclusion
Injury to the knee ligaments is rela-
tively common. MRI is the best imaging
technique available to identify these
abnormalities and to plan arthroscopic
or open surgical repair. Knowledge of
the normal MRI appearance of the major
knee ligaments and the most common
findings seen following injury to these
structures is critical for the interpreting
radiologist to be a successful imaging
consultant.
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