Anatomy and Function of the Anterolateral Capsule Structures

  • Daniel Guenther
  • Sebastián Irarrázaval
  • Chad Griffith
  • Volker MusahlEmail author
  • Richard Debski


The overall goal when treating athletes with high-grade rotatory knee laxity is to restore normal knee kinematics and joint function in order to facilitate a safe return to sports. Isolated ACL injuries do not require additional extra-articular tenodesis procedures. However, the current literature is unclear with regard to the more complex situation of chronic ACL tears, combined injuries, athletes with generalized joint hyperlaxity, and revision surgery.

The structures of the anterolateral capsule have held multiple names throughout history. To date, while there is no consensus in terms of the anatomy and biomechanical function of the anterolateral ligament, some researchers have proposed surgical treatment for anterolateral capsular injuries. Histologically, the organization of the anterolateral capsular structures is not as reproducible as the lateral collateral ligament. Moreover, an anterolateral ligament has not been observed during human fetal dissection. Nonetheless, studies have shown that the anterolateral capsule is an important restraint to anterior tibial loads and internal rotation torque in the ACL-deficient knee. This leads to the assumption that, in the majority of cases, capsular injuries appear secondary to chronic ACL tears. The role of additional procedures in addressing capsular injuries, such as extra-articular tenodesis or lateral plasty, requires definition based on the severity of the injury. The standardized pivot-shift test allows the determination of rotatory knee laxity and can be quantified using different customized tools. Treatment algorithms should be established based on each individual patient’s anatomy.


Lateral Collateral Ligament Iliotibial Band Rotatory Laxity Anterolateral Ligament Lateral Femoral Epicondyle 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 29(3):272–279PubMedGoogle Scholar
  2. 2.
    Araujo PH, Ahlden M, Hoshino Y, Muller B, Moloney G, Fu FH, Musahl V (2012) Comparison of three non-invasive quantitative measurement systems for the pivot shift test. Knee Surg Sports Traumatol Arthrosc 20(4):692–697. doi: 10.1007/s00167-011-1862-9 PubMedCrossRefGoogle Scholar
  3. 3.
    Arilla FV, Rahnemai Azar AA, Guenther D, Yacuzzi C, Engel B, Fu FH, Debski RE, Musahl V (2015) Effects of anterolateral capsular injury and extra-articular tenodesis on knee kinematics. Paper presented at the ISAKOS Biennial congress, LyonGoogle Scholar
  4. 4.
    Azar AARA JW, Costello J, Irrgang JJ, Hoshino Y, Samuelsson K, Fu FH, Musahl V (2014) The influence of the anterolateral capsular injury on knee laxity. Paper presented at the AOSSM annual meeting. Seattle, WA, USAGoogle Scholar
  5. 5.
    Bedi A, Musahl V, Lane C, Citak M, Warren RF, Pearle AD (2010) Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis. Knee Surg Sports Traumatol Arthrosc 18(9):1269–1276. doi: 10.1007/s00167-010-1160-y PubMedCrossRefGoogle Scholar
  6. 6.
    Bertoia JT, Urovitz EP, Richards RR, Gross AE (1985) Anterior cruciate reconstruction using the MacIntosh lateral-substitution over-the-top repair. J Bone Joint Surg Am 67(8):1183–1188PubMedGoogle Scholar
  7. 7.
    Campos JC, Chung CB, Lektrakul N, Pedowitz R, Trudell D, Yu J, Resnick D (2001) Pathogenesis of the segond fracture: anatomic and MR imaging evidence of an iliotibial tract or anterior oblique band avulsion. Radiology 219(2):381–386. doi: 10.1148/radiology.219.2.r01ma23381 PubMedCrossRefGoogle Scholar
  8. 8.
    Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A (2014) A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3517-8
  9. 9.
    Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223(4):321–328. doi: 10.1111/joa.12087 PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Cooper RR, Misol S (1970) Tendon and ligament insertion. A light and electron microscopic study. J Bone Joint Surg Am 52(1):1–20PubMedGoogle Scholar
  11. 11.
    Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA (2014) The anterolateral ligament: anatomy, length changes and association with the segond fracture. Bone Joint J 96-B(3):325–331. doi: 10.1302/0301-620X.96B3.33033 PubMedCrossRefGoogle Scholar
  12. 12.
    Dombrowski ME, Costello JM, Ohashi B, Murawski CD, Rothrauff BB, Arilla FV, Friel NA, Fu FH, Debski RE, Musahl V (2015) Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee. Knee Surg Sports Traumatol Arthrosc. Springer, Berlin, Heidelberg doi: 10.1007/s00167-015-3517-8
  13. 13.
    Duthon VB, Magnussen RA, Servien E, Neyret P (2013) ACL reconstruction and extra-articular tenodesis. Clin Sports Med 32(1):141–153Google Scholar
  14. 14.
    Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med 18(2):169–176PubMedCrossRefGoogle Scholar
  15. 15.
    Ferretti A, Conteduca F, Monaco E, De Carli A, D’Arrigo C (2006) Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. J Bone Joint Surg Am 88(11):2373–2379. doi: 10.2106/JBJS.F.00064 PubMedCrossRefGoogle Scholar
  16. 16.
    Guenther D, Griffith C, Lesniak B, Lopomo N, Grassi A, Zaffagnini S, Fu FH, Musahl V (2015) Anterolateral rotatory instability of the knee. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3616-6 Google Scholar
  17. 17.
    Guenther D, Rahnemai Azar AA, Fu FH, Debski RE (2015) The biomechanical function of the anterolateral ligament of the knee: letter to the editor. Am J Sports Med 43(8):NP21–NP22. doi: 10.1177/0363546515597217 PubMedCrossRefGoogle Scholar
  18. 18.
    Helito CP, Bonadio MB, Tirico LEP, Gobbi RG, Pecora JR, Camanho GL (2013) Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med 1(7):2325967113513546PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Hoshino Y, Araujo P, Ahlden M, Moore CG, Kuroda R, Zaffagnini S, Karlsson J, Fu FH, Musahl V (2012) Standardized pivot shift test improves measurement accuracy. Knee Surg Sports Traumatol Arthrosc 20(4):732–736. doi: 10.1007/s00167-011-1850-0 PubMedCrossRefGoogle Scholar
  20. 20.
    Hoshino Y, Araujo P, Ahlden M, Samuelsson K, Muller B, Hofbauer M, Wolf MR, Irrgang JJ, Fu FH, Musahl V (2013) Quantitative evaluation of the pivot shift by image analysis using the iPad. Knee Surg Sports Traumatol Arthrosc 21(4):975–980. doi: 10.1007/s00167-013-2396-0 PubMedCrossRefGoogle Scholar
  21. 21.
    Hoshino Y, Kuroda R, Nagamune K, Araki D, Kubo S, Yamaguchi M, Kurosaka M (2012) Optimal measurement of clinical rotational test for evaluating anterior cruciate ligament insufficiency. Knee Surg Sports Traumatol Arthrosc 20(7):1323–1330. doi: 10.1007/s00167-011-1643-5 PubMedCrossRefGoogle Scholar
  22. 22.
    Hughston JC, Andrews JR, Cross MJ, Moschi A (1976) Classification of knee ligament instabilities. Part I the medial compartment and cruciate ligaments. J Bone Joint Surg Am 58(2):159–172PubMedGoogle Scholar
  23. 23.
    Irvine GB, Dias JJ, Finlay DB (1987) Segond fractures of the lateral tibial condyle: brief report. J Bone Joint Surg Br 69(4):613–614PubMedGoogle Scholar
  24. 24.
    Lemaire M, Combelles F (1980) Plastic repair with fascia lata for old tears of the anterior cruciate ligament (author’s transl). Rev Chir Orthop Reparatrice Appar Mot 66(8):523–525PubMedGoogle Scholar
  25. 25.
    Lopomo N, Signorelli C, Bonanzinga T, Marcheggiani Muccioli GM, Neri MP, Visani A, Marcacci M, Zaffagnini S (2014) Can rotatory knee laxity be predicted in isolated anterior cruciate ligament surgery? Int Orthop 38(6):1167–1172. doi: 10.1007/s00264-014-2287-0 PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Lopomo N, Zaffagnini S, Signorelli C, Bignozzi S, Giordano G, Marcheggiani Muccioli GM, Visani A (2012) An original clinical methodology for non-invasive assessment of pivot-shift test. Comput Methods Biomech Biomed Engin 15(12):1323–1328. doi: 10.1080/10255842.2011.591788 PubMedCrossRefGoogle Scholar
  27. 27.
    Marcacci M, Zaffagnini S, Giordano G, Iacono F, Presti ML (2009) Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: a prospective clinical and radiographic evaluation with 10- to 13-year follow-up. Am J Sports Med 37(4):707–714. doi: 10.1177/0363546508328114 PubMedCrossRefGoogle Scholar
  28. 28.
    Marcacci M, Zaffagnini S, Iacono F, Neri MP, Loreti I, Petitto A (1998) Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons. Knee Surg Sports Traumatol Arthrosc 6(2):68–75. doi: 10.1007/s001670050075 PubMedCrossRefGoogle Scholar
  29. 29.
    Merida-Velasco JA, Sanchez-Montesinos I, Espin-Ferra J, Merida-Velasco JR, Rodriguez-Vazquez JF, Jimenez-Collado J (1997) Development of the human knee joint ligaments. Anat Rec 248(2):259–268PubMedCrossRefGoogle Scholar
  30. 30.
    Merida-Velasco JA, Sanchez-Montesinos I, Espin-Ferra J, Rodriguez-Vazquez JF, Merida-Velasco JR, Jimenez-Collado J (1997) Development of the human knee joint. Anat Rec 248(2):269–278PubMedCrossRefGoogle Scholar
  31. 31.
    Monaco E, Ferretti A, Labianca L, Maestri B, Speranza A, Kelly MJ, D’Arrigo C (2012) Navigated knee kinematics after cutting of the ACL and its secondary restraint. Knee Surg Sports Traumatol Arthrosc 20(5):870–877. doi: 10.1007/s00167-011-1640-8 PubMedCrossRefGoogle Scholar
  32. 32.
    Monaco E, Labianca L, Conteduca F, De Carli A, Ferretti A (2007) Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 15(10):1168–1174. doi: 10.1007/s00167-007-0368-y PubMedCrossRefGoogle Scholar
  33. 33.
    Moore SM, Ellis B, Weiss JA, McMahon PJ, Debski RE (2009) The glenohumeral capsule should be evaluated as a sheet of fibrous tissue: a validated finite element model. Ann Biomed Eng 38(1):66–76Google Scholar
  34. 34.
    Muller B, Hofbauer M, Rahnemai-Azar AA, Wolf M, Araki D, Hoshino Y, Araujo P, Debski RE, Irrgang JJ, Fu FH, Musahl V (2016) Development of computer tablet software for clinical quantification of lateral knee compartment translation during the pivot shift test. Comput Methods Biomech Biomed Engin 19(2):217–228. doi: 10.1080/10255842.2015.1006210
  35. 35.
    Parsons EM, Gee AO, Spiekerman C, Cavanagh PR (2015) The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med 43(3):669–674. doi: 10.1177/0363546514562751 PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Parsons EM, Gee AO, Spiekerman C, Cavanagh PR (2015) The biomechanical function of the anterolateral ligament of the knee: response. Am J Sports Med 43(8):NP22. doi: 10.1177/0363546515597218 PubMedCrossRefGoogle Scholar
  37. 37.
    Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P (2010) Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med 38(6):1094–1102. doi: 10.1177/0363546509361018 PubMedCrossRefGoogle Scholar
  38. 38.
    Ralphs JR, Benjamin M (1994) The joint capsule: structure, composition, ageing and disease. J Anat 184(Pt 3):503–509PubMedPubMedCentralGoogle Scholar
  39. 39.
    Segond P (1879) Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. Progrés Méd 7:297–299, 319–321, 340–341Google Scholar
  40. 40.
    Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S (2015) Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. doi: 10.1177/0363546515571571 Google Scholar
  41. 41.
    Stijak L, Bumbasirevic M, Radonjic V, Kadija M, Puskas L, Milovanovic D, Filipovic B (2014) Anatomic description of the anterolateral ligament of the knee. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-014-3422-6 Google Scholar
  42. 42.
    Terry GC, Hughston JC, Norwood LA (1986) The anatomy of the iliopatellar band and iliotibial tract. Am J Sports Med 14(1):39–45PubMedCrossRefGoogle Scholar
  43. 43.
    Vieira EL, Vieira EA, da Silva RT, Berlfein PA, Abdalla RJ, Cohen M (2007) An anatomic study of the iliotibial tract. Arthroscopy 23(3):269–274. doi: 10.1016/j.arthro.2006.11.019 PubMedCrossRefGoogle Scholar
  44. 44.
    Vincent JP, Magnussen RA, Gezmez F, Uguen A, Jacobi M, Weppe F, Al-Saati MF, Lustig S, Demey G, Servien E, Neyret P (2012) The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc 20(1):147–152. doi: 10.1007/s00167-011-1580-3 PubMedCrossRefGoogle Scholar
  45. 45.
    Wahl CJ, Westermann RW, Blaisdell GY, Cizik AM (2012) An association of lateral knee sagittal anatomic factors with non-contact ACL injury: sex or geometry? J Bone Joint Surg Am 94(3):217–226. doi: 10.2106/JBJS.K.00099 PubMedCrossRefGoogle Scholar
  46. 46.
    Woo SL-Y, Maynard J, Butler D, Lyon R, Torzilli P, Akeson W et al (1988) Ligament, tendon, and joint capsule insertions to bone. In: WSL-YBJ A (ed) Injury and repair of the musculoskeletal soft tissues. American Academy of Orthopedic Surgeons, Park Ridge, pp 133–166Google Scholar
  47. 47.
    Wroble RR, Grood ES, Cummings JS, Henderson JM, Noyes FR (1993) The role of the lateral extraarticular restraints in the anterior cruciate ligament-deficient knee. Am J Sports Med 21(2):257–262; discussion 263PubMedCrossRefGoogle Scholar
  48. 48.
    Zaffagnini S, Marcacci M, Lo Presti M, Giordano G, Iacono F, Neri MP (2006) Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 years follow-up. Knee Surg Sports Traumatol Arthrosc 14(11):1060–1069. doi: 10.1007/s00167-006-0130-x PubMedCrossRefGoogle Scholar
  49. 49.
    Zens M, Ruhhammer J, Goldschmidtboeing F, Woias P, Feucht MJ, Mayr HO, Niemeyer P (2014) A new approach to determine ligament strain using polydimethylsiloxane strain gauges: exemplary measurements of the anterolateral ligament. J Biomech Eng 136(12):124504. doi: 10.1115/1.4028837 PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Daniel Guenther
    • 1
    • 2
  • Sebastián Irarrázaval
    • 3
  • Chad Griffith
    • 3
  • Volker Musahl
    • 4
    Email author
  • Richard Debski
    • 3
  1. 1.Department of Orthopaedic SurgeryUniversity of Pittsburgh, Kaufman Medical BuildingPittsburghUSA
  2. 2.Trauma DepartmentHannover Medical School (MHH)HannoverGermany
  3. 3.Department of Orthopaedic SurgeryUniversity of Pittsburgh, Kaufman Medical BuildingPittsburghUSA
  4. 4.Department of Orthopaedic SurgeryUPMC Center for Sports MedicinePittsburghUSA

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