Mysterious Coronary Ligaments

B y B e n E . B e n j a m i n

Illustrations provided by Putz/Pabst: Sobotta, Atlas der Anatomie des Menschen, 22nd edition © 2006 Elsevier GmbH, Urban & Fischer München

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How and Why These Ligaments Get InjuredInjury to the coronary ligaments is fairly com-

mon among athletes—particularly among dancersand tennis, football, soccer, and basketball play-ers. Ligament strain may develop slowly overtime through the constant pounding of run-ning, dancing, or jumping on hard surfaces,particularly if the person has poor knee orfoot alignment.

More often, however, the injuryis sudden and dramatic.Typically, the precipitatingincident is a sudden forcefulmedial or lateral twist of theknee that occurs while thefoot remains stationary onthe ground. (A lateral twiststresses the lateral coronary lig-ament, and a medial twist stressesthe medial coronary ligament.) Theknee isn’t designed to twist in that way. This type of injury can happen in a basketball game when aplayer turns in midair for a jump shot andlands before fully completing the turn. Or itcan happen when two soccer players kick aball simultaneously, forcefully rotating theirfeet medially or laterally.

Pain caused by a coronary ligament injurycan be sharp with sudden movement, butmore often it is dull and achy. The pain isfelt either laterally or medially and slightlyanteriorly. When the injury is severe, thereis swelling in the knee joint, making it diffi-cult to fully bend or straighten the knee.

Coronary ligament injuries are particular-ly frequent among people who have lax cru-ciate and collateral ligaments. The cruciateligaments are located in the center of theknee (see Figure 2). They stabilize the kneein anterior and posterior motions and limitthe range of movement in these directions.The medial and lateral collateral ligaments(see Figure 3) stabilize the knee in side-to-side motions. When one or both sets ofthese ligaments are loose—either from a

Despite their name, the coronary ligaments have nothing to do with a heart attack.These little-known ligaments are thin, flexible, wormlike structures located at themedial and lateral aspects of the knee.Their name is derived from the Latin word

corona, meaning crown, and refers to their crown-like shape (see Figure 1).They are respon-sible for limiting rotation of the knee and for stabilizing the menisci—the thick, spongy, halfmoon-shaped cushions that act as shock absorbers between the tibia and femur. (Note thatalthough the menisci are commonly referred to as cartilage, this type of cartilage is distinct-ly different from that of the Teflon-like articular cartilage that lines the articular surfaces ofthe femur and tibia).The coronary ligaments anchor the menisci to the tibia, while allowingthem to slide anteriorly and posteriorly.

A

B

C

D

Figure 1.The right knee, showing the medial meniscus(A), lateral meniscus (B), lateral coronary ligament(C), and medial coronary ligament (D).The medialcoronary ligament is highlighted here and shows atear at the anterior portion.

A

A

B

B

Figure 2.The anterior cruciateligament (A) and posteriorcruciate ligament (B).

Figure 3.The lateral collateralligament (A) and medial collateral ligament (B).

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prior trauma or as a result of hereditary fac-tors—the knee literally wobbles around whenplaced under stress through physical activity.This precondition makes it very likely that vigor-ous athletic activities involving turning and cut-ting movements will strain or tear the coronaryligaments.

Coronary ligament sprains frequently occurin conjunction with a more serious injury—atear of the meniscus, commonly referred to as atorn cartilage. When the meniscus is torn, theknee periodically gives way, generally locking ina bent position, andbecomes swollen. Oftena coronary ligament istorn without damage tothe meniscus, but if thisinjury goes untreated itcan lead to instabilityand a subsequentmeniscus tear, whichusually requires surgery.Another adjacent struc-ture that is vulnerableto injury is the medialcollateral ligament. Thisligament is contiguouswith the medial coro-nary ligament, and it’scommon for these twostructures to be injuredsimultaneously.

Injury Verification

The coronary ligamentsare not clearly described

in most anatomy texts, and as a result mostmassage therapists and other health profes-sionals are unaware of their significance.Injuries to these ligaments are often confusedwith injuries to other parts of the knee. Forinstance, an injury to the medial coronary liga-ment may be misidentified as a meniscus tearor a medial collateral ligament injury. Aninjury to the lateral coronary ligament may bemisidentified as a strain of the iliotibial band(ITB) at the lateral attachment to the knee(which is located just a half-inch away).

Making assessment even more difficult is therange of different symptom profiles that coro-nary ligament injuries can cause. In someinstances, the origin of the injury is obvious—there is a sudden trauma in which the kneetwists while the foot remains stationary (aspreviously described). This is followed by

buckling and a feeling of weakness with painand/or swelling that persists for several days orweeks. In other cases, however, the onset can-not be traced to a specific incident. The clientmay report constant pain that is intensified bywalking just a few blocks, or else the pain maycommence only after three or four miles of run-ning or forty-five minutes of a vigorous sport.

The best way to reliably identify injuries tothe coronary ligaments is to perform preciseorthopedic assessment tests that isolate thesestructures. Pain felt on passive lateral rotation

of the knee indicates a medial coronary liga-ment injury, and pain on passive medial rota-tion indicates a lateral coronary ligament injury.

Test 1. Passive lateral rotation (stresses themedial coronary ligament).

Standing at the client’s knee while facing ina footward direction, lift the leg in the air sothat it is bent at about a 90° angle. Place yourmedial hand on the lateral portion of the heel,cradling and supporting the knee with yourforearm, and place your lateral hand on themedial aspect of the forefoot. Laterally rotatethe foot to the end of its range while keeping itin dorsiflexion. If there is no discomfort orpain, give it a little extra rotation pressure. Ifthe medial coronary ligament is injured, therewill be pain at the anterior-medial aspect ofthe knee just on top of the tibia.

e s s e n t i a l s k i l l s


Test 1. Passive lateral rotation

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Test 2. Passive medial rotation (stresses thelateral coronary ligament).

Standing in the same position as for passivelateral rotation (see above), switch your handsso that your medial hand is on the medialaspect of the heel and your lateral hand is onthe lateral forefoot. Now, medially rotate thefoot to the end of its range, keeping the foot indorsiflexion. If this causes no pain or discom-fort, give it a slight overpressure.

Note: when performing these test motions,be careful not to twist the ankle. A client willoften say, “That hurts!” without specifyingexactly what hurts. You may assumeit’s the knee, but the client may bereferring to the ankle. So be sure tocheck to see where the client feels thepain from each test.

Treatment Options

The first step is to be sure that theclient has seen an orthopedic

physician to check for a tear in themeniscus. Once a meniscus tear hasbeen ruled out, the treatment optionswill depend on the severity and loca-tion of the injury.

Self-TreatmentMild coronary ligament injuries

often resolve on their own after aperiod of rest that includes somequadriceps-strengthening exercises—provided that the person avoids anyactivities that cause pain.

It’s important to watch for involuntary col-lapsing of the leg or locking of the knee, whichwould indicate an injury to the meniscus. Ifthis begins to happen, send the client back tothe doctor.

Friction TherapyThis hands-on treatment is effective only

when the lesion is located in the anterior por-tion of the ligament. In these cases, the clientgenerally feels pain at the anterior-medial oranterior-lateral edge of the tibial condyle, andone of those areas is tender on palpation. Ifthe client experiences pain near the posterioredge of the tibial condyle, this suggests thatthe injured portion of the ligament cannot beaccessed manually.

The techniques described here require ahighly skilled action, so follow these instruc-tions as precisely as you can.

Friction of the medial coronary ligament.Stand at the side of the table near the kneeyou’ll be working on. Have the client’s leg bentat a 90° angle with the foot on the table. Nowturn the foot laterally; this makes the ligamentmore accessible. Stabilize the leg by placingyour headward hand on top of the knee with adownward pressure. Place the index finger ofyour footward hand on the medial tibial shelfwith the middle finger on top of it for support.Friction toward or away from you, while press-ing very firmly down onto the tibial shelf, forfive or six minutes. Be sure to bring the client’s



Test 2. Passive medial rotation

Friction of the medial coronary ligament.

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skin with you as you move; don’tslide over the skin. Then take arest and do it again.

Friction of the lateral coro-nary ligament. Stand on the sideof the table opposite the kneeyou’ll be working on. Bend theclient’s leg to a 90º angle withthe foot on the table, and thenturn it medially. Stabilize the legby placing your headward handon top of the knee. Now reachacross the table and place theindex finger of your footwardhand on the lateral tibial shelf,with the middle finger on top ofit for support. Friction towardor away from you, while press-ing firmly down onto the tibialshelf, for five or six minutes. Besure to bring the skin with you


Guidelines for Friction Therapy

Here are some guidelines for effective applica-tion of friction therapy.

Options for hand positioning. If you’re usingyour index finger to perform the friction, placeyour middle finger on top for reinforcement andwrap your thumb medially around the knee in agripping action to offer an opposing force. Sometherapists prefer to use the middle finger to fric-tion. In that case, the middle finger can be rein-forced by the index finger of the other hand.Other practitioners are more comfortable usingthe tip of their thumb. Experiment to find outwhich position is most comfortable for you.

Applying pressure appropriately. Be surethat the work involved in doing these techniquesis shared by the muscles of your forearm, hand,and shoulder, or you will end up injuring yourself.While maintaining a downward pressure with yourfingers and hand, move your entire arm—not justyour fingers—to perform the friction.

Apply pressure in one direction only (eithertoward you or away from you) so you give your-self and your client a momentary rest with eachstroke.After two or three minutes, switch thedirection in which you apply the pressure.Then,after five or six minutes, take a break and repeat

the same procedure. Doing it in this way makes itless likely that you will need friction of the liga-ments and tendons of your wrist and hand whenyou’re finished helping the client.

Begin by using relatively little pressure andincrease the pressure very gradually so that theclient feels the least possible discomfort.As youwork, the tissues will become slightly numb andless sensitive to the touch.

Massage. After you’ve performed friction therapy for ten to twelve minutes, massage all the surrounding tissues to increase the circulationin these areas as much as possible. I suggest working on the thigh, shin, calf, and buttock.Also massage the other leg, since it is probablyunder extra stress from compensating for theinjured leg.

Frequency and duration of treatment. Inmy experience, friction therapy for a coronary lig-ament injury generally takes between four andeight weeks—depending on the seriousness of theinjury and the general health of the client. Start byhaving the client come for two or three sessionsper week, with each session including ten totwelve minutes of frictioning.As the clientimproves, taper off the treatment to once a week,then twice a month.


Friction of the lateral coronary ligament.

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as you move. Then take arest and do it again.

Exercise to AccompanyTreatment

As with many otherinjuries, exercise therapyis an important adjunct tofriction and massage ther-apy when you’re treatingthe coronary ligaments. Advise the client touse a stationary bike for fifteen minutes eachday to keep the ligament mobile. The bikeshould be kept in a low gear, requiring mini-mal effort.

Prognosis

With appropriate treatment, the prognosisfor clients with injured coronary liga-

ments is very good. I’ve worked with manyindividuals who have made a full recovery fromthese injuries. What’s often missing for peopleis the essential first step toward recovery—

accurate identification ofthe injury. Because thecoronary ligaments are notwidely known, they areoften overlooked as asource of knee pain. If youwere unfamiliar with thembefore, then just by readingthis article you’veenhanced your ability to

help clients who have injured these structures.I hope that the anatomical details, assessmentprotocols, and treatment techniques you’velearned have helped to take some of the mys-tery out of these common and commonly mis-understood injuries.

Ben E. Benjamin, PhD, holds a doctorate in educationand sports medicine. He is senior vice president of strategicdevelopment for Cortiva Education and founder of theMuscular Therapy Institute. He has been in private practicefor more than forty years and is the author of Listen to YourPain, Are You Tense? and Exercise Without Injury andcoauthor of The Ethics of Touch. He can be contacted [email protected].

M&B

With appropriatetreatment, the prognosisfor clients with injured

coronary ligamentsis very good.

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Mysterious Coronary Ligaments