Clinical Biomechanics 80 (2020) 105205

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Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

Review

Biomechanics of the posterior oblique ligament of the knee

Riccardo D’Ambrosi a, *, Katia Corona b, Germano Guerra b, Maurizio Rubino a, Fabrizio Di Feo a,
Nicola Ursino a
a
IRCCS Orthopedic Institute Galeazzi, Milan, Italy
b
Department of Medicine, Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The purpose of this systematic literature review is to analyse the isolated biomechanics of the
Posterior oblique ligament posterior oblique ligament of the knee. In the current literature, the biomechanical aspect of the posterior oblique
Posteromedial corner of the knee ligament was analysed in several articles, but this was always done in association with other capsuloligamentous
Biomechanics
structures.
Knee
Medial collateral ligament
Methods: A systematic review of the existing literature was performed to identify all studies dealing with the
biomechanics of the posterior oblique ligament. Two independent investigators performed the research using the
MEDLINE, CINAHL, Scopus, Embase and Cochrane databases.
Findings: A total of 10 articles analysed the biomechanics of the posterior oblique ligament, confirming the
importance of this ligament for the stability of the knee in different positions. The posterior oblique ligament is
the main stabiliser against internal rotation in early flexion angles (0◦ –30◦ ) and it is an important restraint to
posterior tibial translation in the posterior cruciate ligament deficient knee. Furthermore, the posterior oblique
ligament bears up to 47% of the force borne by the anterior cruciate ligament in resisting the internal rotation
loads when a pivot-shift maneuver is simulated.
Interpretation: This review confirms that the posterior oblique ligament is an anatomically well-defined and
distinct structure that plays a key role in stabilising the knee, especially in internal rotation. The posterior
oblique ligament is frequently injured along with other anatomical structures. Future studies should develop
clinical tests to evaluate the functionality and stability of the the posterior oblique ligament.

1. Introduction a distinct ligament and referred to all structures posterior to the super­
ficial MCL simply as the posteromedial joint capsule (Robinson et al.,
The posterior oblique ligament (POL) is the predominant ligamen­ 2004).
tous structure on the posterior medial corner of the knee joint (Lund­ The ligament is part of layer II, and its anterior margin blends with
quist et al., 2015). It is located at the posterior one-third of the medial the posterior margin of the superficial medial collateral ligament
capsular ligament, attaching proximally to the adductor tubercle of the (sMCL). The POL is a primary restraint to internal rotation (IR) and is a
femur and distally to the tibia and posterior aspect of the joint capsule secondary restraint to valgus translation and external rotation (Vieira
(Figs. 1 and 2) (Lundquist et al., 2015). Hughston and Eilers, in 1973, et al., 2019). Tibor et al. discussed how the POL helps stabilise IR at all
were the first to describe the POL and considered this ligament an knee flexion angles; however, the maximum load occurs at full extension
important medial stabiliser of the knee (Hughston & Eilers, 1973). In (Tibor et al., 2011). More recent works have studied the forces on intact
fact, the authors noted that with the knee at a 60◦ of flexion, the POL is knees, which has led to a better understanding of the biomechanical
relaxed and has no function as a true static stabiliser. However, when properties of the POL and its relationship with other medial structures in
there is a contraction of the semimembranosus (SM), it is possible to the knee.
note the kinetic and static function of the three arms of the POL The POL and sMCL were recently described as having a comple­
(Hughston & Eilers, 1973). Subsequently, in 2004, Robinson et al. in mentary relationship in resisting IR torque. Griffith et al. helped
their dissection study on the posterior medial corner (PMC) did not find demonstrate that the POL shares the load response against posterior and

* Corresponding author.
E-mail address: [email protected] (R. D’Ambrosi).

https://doi.org/10.1016/j.clinbiomech.2020.105205
Received 21 May 2020; Accepted 27 October 2020
Available online 2 November 2020
0268-0033/© 2020 Elsevier Ltd. All rights reserved.
R. D’Ambrosi et al. Clinical Biomechanics 80 (2020) 105205

Fig. 1. Posteromedial corner of a left knee showing the bone insertions of the
relative structures. POL = posterior oblique ligament; AMT = adductor magnus
tendon; GT = gastrocnemius tubercle; MGT = medial gastrocnemius tendon; Fig. 2. The image shows the course of the POL and its relationship with the
AT = adductor tubercle; MPFL = medial patellofemoral ligament; ME = medial other structures in the posteromedial corner of the knee.
epicondyle; sMCL = superficial medial collateral ligament.
if: (1) reported biomechanical aspect on the surgery treatment of the
anterior tibial translation in an intact knee. The POL is an important POL (2) the articles were not in English; (3) a review article.
secondary stabiliser for rotation and valgus stress after an isolated MCL
injury (Griffith et al., 2009a). LaPrade et al. suggested that the central
2.2. Types of studies
arm of the POL is the main structure in this area, needing repair or
reconstruction after injury to the PMC of the knee (LaPrade et al., 2007).
We included in-vivo biomechanics studies in this systematic review.
The purpose of this systematic literature review is to analyse the
The assessment of the level of evidence of the selected article was per­
isolated biomechanics of the POL. In the current literature, there are
formed according to “The Oxford 2011 Levels of Evidence” (Marx et al.,
several articles that evaluate the biomechanical aspect of the POL, but
2015). We excluded animal studies and reviews, meta-analyses, expert
this is always done in association with other capsuloligamentous
opinions, case reports and editorials. Two independent reviewers ana­
structures. Knowledge of the primary and secondary function of the POL
lysed and evaluated all the information available in the articles. In cases
will assist in the interpretation of clinical examinations, and so provide
of a disagreement between the two reviewers, a third senior reviewer
guidance to improve diagnosis of this structure in a setting of multi­
was asked to evaluate and analyse the articles. Information regarding
ligamentous injuries.
the author, data, journal of publication, study design and level of evi­
dence was extracted and entered into a spreadsheet for analysis.
2. Methods
3. Results
A systematic review of the existing literature was undertaken to
identify all studies dealing with the biomechanics of the POL of the knee.
A total of 10 articles published between 2008 and 2019 met the in­
The Preferred Reporting Items for Systematic Reviews and Meta-
clusion criteria. All articles were in-vivo studies. The results reported
Analyses (PRISMA) guidelines were followed for the identification of
were subdivided in findings related to the effect of POL on knee kine­
the articles (Liberati et al., 2009). The review was registered on the
matics (internal and external rotation, valgus rotation, posterior and
PROSPERO database. Research was performed by two independent in­
anterior tibial translation, flexion) and mechanical properties (load to
vestigators using the MEDLINE, Scopus, Embase, CINAHL and Cochrane
failure). One study used a computation model while all the rest utilised a
databases (January 1999 to January 2020). For the research, the
mathematical model.
following terms were used: “posterior oblique ligament” OR “poster­
The detailed results are reported in Table 1.
omedial corner of the knee” AND “biomechanics” OR “cadaveric study”.
The research also included the references of all the articles identified
and the references of the systematic review. An eletronic search yielded 3.1. Internal rotation
257 studies. After 70 duplications were removed, 187 studies remained;
of these, 145 were excluded after review of the abstract and full-text 6 studies reported data regarding load response of the POL respect to
articles leaving 42 eligible studies. An additional 32 articles were then IR.
excluded based on additional inclusion and exclusion criteria. Finally, Vap et al. (Vap et al., 2017) assessed the effect of sequentially cutting
10 articles met the inclusion criteria (Fig. 3). of the POL on rotational stability in the setting of intact cruciate and
collateral ligament, reporting that it contributed significantly to
restraining IR of the tibia near full extension.
2.1. Eligibility and exclusion criteria Kittl et al. demonstrated that POL is the main stabiliser against IR in
early flexion angles (0◦ –30◦ ).
In order to be considered for inclusion, studies needed to include the Griffith et al. noted that the highest load response of the POL is in IR
biomechanical aspect (internal and external rotation, valgus rotation, with the knee at 0◦ (Griffith et al., 2009b). The POL IR torque load
posterior and anterior tibial translation, flexion) and mechanical prop­ response at 0◦ , 20◦ and 30◦ of flexion was significantly greater than at
erties (load to failure) on the anatomy of the POL. Studies were excluded both 60◦ and 90◦ of knee flexion (Griffith et al., 2009b). The same

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R. D’Ambrosi et al. Clinical Biomechanics 80 (2020) 105205

Fig. 3. A flowchart of the literature screening performed in this study.

authors in 2009 demonstrated that the initial sectioning of the POL 3.3. Valgus rotation
significantly increased IR at 0◦ of knee flexion compared to the intact
state (Griffith et al., 2009a). 3 studies assessed the effect of valgus load on the POL.
For an intact knee, Schafer et al. quantified loads on medial Kittl et al. noted that the valgus rotation increased at 0◦ and 30◦ after
compartment in response to internal rotation moments simulating POL sectioning, resulting in increases of 2.8 ± 1.9◦ and 3.4 ± 1.8◦ ,
important features of the pivot-shift maneuver at 5◦ , 15◦ and 30◦ . The respectively (Kittl et al., 2019).
load experienced by the POL decrease at the 30◦ of flexion while it in­ Griffith et al. (Griffith et al., 2009b) reported that the POL valgus
creases at the near full extension (Schafer et al., 2016). load response at 0◦ was significantly greater than that at 30◦ , 60◦ and
90◦ of flexion.
3.2. External rotation Wijdicks et al. (Wijdicks et al., 2009) tested the load responses of the
POL in isolated and multiple medial knee ligament injury states.
4 studies reported data regarding load response of the POL respect to Compared to the intact state, there was a significant load increase to an
ER. applied valgus moment on the POL after sectioning the proximal and
Vap et al. reported that a sequential cutting from PM to PL of the distal divisions of the sMCL and the meniscofemoral and meniscotibial
structures of the knee produced significant increases in the external divisions of the dMCL at 0◦ , 20◦ and 30◦ of knee flexion.
rotation of <0.3◦ at 0◦ through 90◦ of flexion. Meanwhile, a sequential
cutting from PL to PM of the structures of the knee produced significant 3.4. Posterior tibial translation
increases in the external rotation of <0.3◦ at flexion angles of 0◦ and 60◦
(Vap et al., 2017). Griffith et al. demonstrated that with an 88 N posterior drawer load,
Kitt et al. (Kittl et al., 2019) found that the POL also provided some there was a maximum load on POL at 0◦ of knee flexion. There were no
restraint to ER at all flexion angles (1.4◦ –1.8◦ ). Whereas Griffith et al. significant differences between any of the tested flexion angles.
(Griffith et al., 2009a; Vap et al., 2017) specified that the POL acts as Sectioning of the POL in PCL-deficient knees increased PTT significantly
secondary external rotation stabiliser at 30◦ of flexion. at 0◦ , 30◦ , 60◦ and 90◦ in comparison with the PCL/sMCL/dMCL-
Wijdicks et al. noted a significant increase in load on the POL with an deficient knee (Griffith et al., 2009b).
applied external rotation torque after sectioning both divisions of the Petersen et al. in 2008 evaluated the role of POL in concomitant
sMCL and the dMCL at 60◦ of knee flexion (Wijdicks et al., 2009). injuries of the PCL, demonstrating that cutting the POL after the MCL
section increased posterior tibial translation significantly at 0◦ , 30◦ , 60◦
and 90◦ of flexion under posterior tibial load and at all flexion angles

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Table 1
Summary data of the biomechanics studies included in the review.
Author Journal Type of article Biomechanics evaluation Number of Findings
specimens
Groups System evaluation Load Knee
applied flexion
angle (◦ )

Internal Rotation
Vap et al. Orthop J Controlled 1: sequential cutting Roboting system composed 5-N⋅m 0◦ 20 1: significant increase in IR of
(2017) Sports Laboratory from PM to PL by a universal force/torque 30◦ 2◦ at 0◦ of knee flexion.
Med Study 2: sequential cutting sensor (Delta F/T 60◦ Significant changes ≤1◦ were
from PL to PM Transducer, ATI Industrial 90◦ observed at flexion angles 30◦
Automation) and a 6 degrees through 90◦ .
of freedom robotic arm 2: produced significant IR
(KUKA KR-60-3, Kuka increases of <2◦ at 0◦ and 30◦
Robotics) of flexion.
Kittl et al. Am J Controlled Roboting testing setup 4-N⋅m with 0◦ 6 After the POL was cut,
(2019) Sports Laboratory composed by 6 degree of and 30◦ internal rotation instability
Med Study freedom industrial robot (KR without an 60◦ increased significantly at
125; KUKA Robotics) and a SM load of 90◦ early flexion angles (9.3◦
force/moment sensor (FTI 75 N ±3.2◦ at 0◦ ; 5.2◦ ±1.1◦ at
Theta 1500–240; Schunk) 30◦ ).
Griffith Am J Descriptive 100-N force model SM S- 5-N m 0◦ 24 The POL IR torque load
et al. Sports Laboratory type load cell 20◦ response at 0◦ of flexion (45.8
(2009b) Med Study 30◦ N) was significantly greater
60◦ than was the load response at
90◦ both 60◦ and 90◦ of knee
flexion. In addition, the load
response at 20◦ of flexion was
significantly greater than was
the load response at both 60◦
and 90◦ of knee flexion. There
was also a significantly larger
IR load response at 30◦ of
flexion than at 60◦ or 90◦ of
knee flexion.
Griffith Am J Descriptive 1: sequential cutting of 100-N force model SM S- 5-N m 0◦ 24 Sectioning of the POL
et al. Sports Laboratory the POL; type load cell 20◦ significantly increased IR at
(2009a) Med Study 30◦ 0◦ of knee flexion, 20◦ , 30◦ ,
2: sequential cutting of 60◦ 60◦ , and 90◦ , compared with
the sMCL (proximal 90◦ the intact state.
and distal divisions);
3: sequential cutting of
the deep MCL
(meniscofemoral and
meniscotibial
portions).
Schafer Am J Controlled Robotic manipulator 4-N⋅m 5◦ 12 At 5◦ , 15◦ and 30◦ of IR load
et al. Sports Laboratory 15◦ on POL increase respectively
(2016) Med Study 30◦ of 212%, 263% and 206%.

External Rotation
Vap et al. Orthop J Controlled 1: sequential cutting Roboting system composed 5-N m 0◦ 20 1: sectioning of the POL
(2017) Sports Laboratory from PM to PL by a universal force/torque 30◦ produced significant increases
Med Study 2: sequential cutting sensor (Delta F/T 60◦ in ER of <0.3◦ at flexion
from PL to PM Transducer, ATI Industrial 90◦ angles 0◦ through 90◦
Automation) and a 6 degrees 2: sectioning of the POL
of freedom robotic arm produced significant increases
(KUKA KR-60-3, Kuka in ER of <0.3◦ at flexion
Robotics) angles of 0◦ and 60◦
Kittl et al. Am J Controlled Roboting testing setup 4-N m with 0◦ 6 After the POL was cut, the
(2019) Sports Laboratory composed by 6 degree of and 30◦ effect on restraining ER was
Med Study freedom industrial robot (KR without an 60◦ not significant
125; KUKA Robotics) and a SM load of 90◦
force/moment sensor (FTI 75 N
Theta 1500–240; Schunk)
Griffith Am J Descriptive 1: sequential cutting of 100-N force model SM S- 5-N⋅m 0◦ 24 Initial sectioning of the POL
et al. Sports Laboratory the POL; type load cell 20◦ did not significantly increase
(2009a) Med Study 30◦ external rotation, compared
2: sequential cutting of 60◦ with the intact state at any
the sMCL (proximal 90◦ flexion angle
and distal divisions),
3: sequential cutting of
the deep MCL
(meniscofemoral and
meniscotibial
portions).
5-N⋅m 0◦ 24
(continued on next page)

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Table 1 (continued )
Author Journal Type of article Biomechanics evaluation Number of Findings
specimens
Groups System evaluation Load Knee
applied flexion
angle (◦ )

Griffith Am J Descriptive 100-N force model SM S- 20◦ The largest POL load response
et al. Sports Laboratory type load cell 30◦ to an applied internal rotation
(2009b) Med Study 60◦ torque was at 0◦ of knee
90◦ flexion (45.8 N). The POL IR
torque load response at 0◦ of
flexion (45.8 N) was
significantly greater than was
the load response at both 60◦
and 90◦ of knee flexion. In
addition, the load response at
20◦ of flexion was
significantly greater than was
the load response at both 60◦
and 90◦ of knee flexion. There
was also a significantly larger
IR load response at 30◦ of
flexion than at 60◦ or 90◦ of
knee flexion.
Wijdicks Am J Controlled 1: distal sMCL Instron 5865 5-N⋅m 0◦ 24 A significant increase in load
et al. Sports Laboratory attachment (Instron System, Norwood, on the POL with an applied
(2009) Med Study 2: POL Massachusetts) 20◦ external rotation torque after
3: Deep MCL 30◦ sectioning both divisions of
4: Proximal sMCL 60◦ the sMCL and the dMCL at 60◦
attachment 90◦ of knee flexion.

Valgus Rotation
Kittl et al. Am J Controlled Roboting testing setup 8-N⋅m with 0◦ 6 After the POL was cut, the
(2019) Sports Laboratory composed by 6 degree of and 30◦ increase in valgus rotation
Med Study freedom industrial robot (KR without an 60◦ was most pronounced at
125; KUKA Robotics) and a SM load of 90◦ 0◦ and 30◦ , resulting in
force/moment sensor (FTI 75 N increases of 2.8◦ ±1.9◦ and
Theta 1500–240; Schunk) 3.4◦ ±1.8◦
Griffith Am J Descriptive 100-N force model SM S- 10-N⋅m 0◦ 24 The POL valgus load response
et al. Sports Laboratory type load cell 20◦ at 0◦ was significantly greater
(2009b) Med Study 30◦ than at 30◦ , 60◦ , and 90◦ of
60◦ flexion. The maximum load
90◦ on the POL for an applied
valgus load was at 0◦ of knee
flexion.
Wijdicks Am J Controlled 1: distal sMCL Instron 5865 (Instron 10-N m 0◦ 24 Compared with the intact
et al. Sports Laboratory attachment System, Norwood, state, there was a significant
(2009) Med Study 2: POL Massachusetts) 20 ◦
load increase to an applied
30◦ valgus moment on the POL
3: Deep MCL 60◦ after sectioning the proximal
4: Proximal sMCL 90◦ and distal divisions of the
attachment sMCL and the meniscofemoral
and meniscotibial divisions of
the dMCL at 0◦ , 20◦ , and 30◦ .

Posterior Tibial Translation

Griffith Am J Descriptive 100-N force model SM S- 88 N 0◦ 24 There was a maximum load of
et al. Sports Laboratory type load cell 20◦ 6.9 N at 0◦ of knee flexion.
(2009b) Med Study 30◦ There were no significant
60◦ differences between any of
90◦ the tested flexion angles.
Petersen Am J Controlled 1: intact, Robotic/universal force- 134 N 0◦ 10 Additional cutting of the POL,
et al. Sports Laboratory 2: PCL–deficient, moment sensor testing 30◦ in PCL deficient knees, after
(2008) Med Study 3: PCL/superficial system 60◦ sMCL and dMCL sectioning,
MCL–deficient, 90◦ increased posterior tibial
4: PCL/sMCL/dMCL/ translation significantly at 0◦ ,
POL–deficient; 30◦ , 60◦ , and 90◦ of flexion
5: PCL/sMCL/dMCL/ under posterior tibial load
POL/posteromedial and at all flexion angles tested
capsule–deficient knee. under valgus or internal tibial
load.

Anterior Tibial Translation

Griffith Am J Descriptive 100-N force model SM S- 88 N 0◦ 24 There was a maximum load of
et al. Sports Laboratory type load cell 20◦ 10.3 N at 20◦ of knee flexion
(2009b) Med Study 30◦ on the POL. Despite the fact
60◦ that there was an anterior
90◦ drawer load response on the
POL at all tested flexion

(continued on next page)

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Table 1 (continued )
Author Journal Type of article Biomechanics evaluation Number of Findings
specimens
Groups System evaluation Load Knee
applied flexion
angle (◦ )

angles, there were no

significant differences
between any of the individual
flexion angles.
Flexion
Guess J Knee Computational Subject-specific computational knee models: The knee 2 The POL produces a
et al. Surg Models models produced passive ligament lengthening patterns. maximum constraining force
(2016) The biomechanics of the POL and the ACL bundles during when the knee is at full
combined tibia internal–external rotation torque and extension. It constrains
anterior–posterior forces through deep flexion were then internal tibial rotation and
examined posterior tibial translation at
extension.
Schafer Am J Controlled Robotic manipulator 4-N⋅m 5◦ 12 Load in the POL was 47% of
et al. Sports Laboratory 15◦ the ACL. At 15◦ of flexion, the
(2016) Med Study 30◦ POL carried 45% of the load
in the ACL. At 30◦ of flexion,
the load in the POL was 35%
of the ACL.

Load to Failure
Wijdicks Am J Controlled 100-N force model SM S- Loaded to failure at 20 20 The mean load at failure for
et al. Sports Laboratory type load cell mm per minute was the central arm of the POL
(2010) Med Study evaluted for medial was 256.2 ± 29.5 N. The
structures. Tested were mean stiffness was 38.6 ±
the sMCLwith intact 16.0 N/mm. The mean
femoral and detached displacement at failure for the
proximal tibial POL attachment was 6.6 ±
attachments, the sMCL 2.9 mm.
with intact femoral and Failures occurred most
detached distal tibial commonly midsubstance (n =
attachments, the central 4), followed by the femoral (n
arm of the POL, and the = 2) and tibial (n = 2)
isolated deep MCL. Load attachment sites.
was recorded as a
function of
displacement.

tested under valgus or internal tibial load (Petersen et al., 2008). 4. Discussion

The aim of the study was to analyse in detail the biomechanics of the
3.5. Anterior tibial translation
POL. Currently, in the literature, this ligament is largely analysed in
association with other capsuloligamentous structures and our review is
Griffith et al. reported that with an 88 N anterior drawer load, there
the first to focus solely on the POL.
was a maximum load on POL at 20◦ of knee flexion. Despite the fact that
The review confirms the importance of this ligament for knee sta­
there was an anterior drawer load response on the POL at all tested
bility in different positions; first, Kittl et al. (Kittl et al., 2019) found that
flexion angles, there were no significant differences between any of the
the POL is the main stabiliser against IR in early flexion angles (0◦ –30◦ )
individual flexion angles (Griffith et al., 2009b).
on the medial side of the knee (Liberati et al., 2009). Previous biome­
chanical studies confirm this by reporting that IR increased by 6◦ after
3.6. Flexion POL sectioning. POL also plays a role in ER, providing restraint. Previous
studies reported the “wheel brake” mechanism of the POL-medial
A recent study evaluated by computation models showed the meniscus functional unit when the tibia is moved anteriorly (Kittl
biomechanics of the POL during different knee movements and noted et al., 2019).
that POL experienced a dramatic decrease in length with flexion and was The importance of POL during IR has also been reported by Griffith
only about 65% of its maximum length at approximately 130◦ of knee et al., who indicated a complementary relationship between the POL and
flexion. For passive knee motion, the POL was longest at 0◦ (Guess et al., the sMCL in resisting IR torque (Griffith et al., 2009a). This is confirmed
2016). by a subsequent study by the same authors, which showed a significant
Schafer et al. demonstrated that the POL bore about 50% of the load primary stabilisation role played by the POL in IR at all tested flexion
carried by the ACL in response to the combined torques at 5◦ and 15◦ of angles (Griffith et al., 2009b).
flexion (Schafer et al., 2016). Further, Vap and Schafer confirmed in their biomechanical study the
role of POL during IR, showing how the ligament acts as a stabiliser to
prevent excessive IR (Schafer et al., 2016; Vap et al., 2017).
3.7. Load to failure However, not only is POL a stabiliser preventing IR but also, Petersen
et al. in 2008, reported that it is an important restraint to posterior tibial
Wijdicks et al. in 2010 reported that the mean load to failure for the translation in the PCL-deficient knee, supporting the theory that un­
central arm of the POL was 256.2 ± 29.5 N. The mean stiffness was 38.6 treated injuries to the POL may contribute to PCL graft failure (Petersen
± 16.0 N/mm. Failures occurred most commonly midsubstance, fol­ et al., 2008).
lowed by the femoral and tibial attachment sites (Wijdicks et al., 2010).

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Furthermore, Schafer et al. demonstrated that POL bears up to 47% superficial medial collateral ligament proximal and distaldivisions to applied loads.
Am. J. Sports Med. 37 (1), 140–148.
of the force borne by the ACL in resisting the internal rotation aspect of
Guess, T.M., Razu, S., Jahandar, H., 2016. Evaluation of knee ligament mechanics using
the combined rotatory loads comprising critical features of the clinical computational models. J. Knee Surg. 29 (2), 126–137.
pivot-shift examination. The authors underlined that the POL plays a Hughston, J.C., Eilers, A.F., 1973. The role of the posterior oblique ligament in repairs of
greater role in resisting these loads in extension and has a minimal role acute medial (collateral) ligament tears of the knee. J. Bone Joint Surg. Am. 55 (5),
923–940.
in resisting isolated valgus loads (Schafer et al., 2016). Kittl, C., Becker, D.K., Raschke, M.J., Müller, M., Wierer, G., Domnick, C.,
All reported biomechanical studies confirm the importance of POL in Glasbrenner, J., Michel, P., Herbort, M., 2019. Dynamic restraints of the medial side
knee stability although in the current literature, adequate attention has of the knee: the semimembranosus corner revisited. Am. J. Sports Med. 47 (4),
863–869.
not been paid at these anatomic structures. In fact, despite most of the LaPrade, R.F., Engebretsen, A.H., Ly, T.V., Johansen, S., Wentorf, F.A., Engebretsen, L.,
biomechanical studies agreeing that POL loading is maximal during IR 2007. The anatomy of the medial part of the knee. J. Bone Joint Surg. Am. 89 (9),
in full extension, during clinical examinations, hip rotation affects POL 2000–2010.
Liberati, A., Altman, D.G., Tetzlaff, J., Mulrow, C., Gøtzsche, P.C., Ioannidis, J.P.,
testing. Further analysis should be conducted to define proper tests. Clarke, M., Devereaux, P.J., Kleijnen, J., Moher, D., 2009. The PRISMA statement for
Future studies should also analyse and develop clinical tests to evaluate reporting systematic reviews and meta-analyses of studies that evaluate health care
both isolated and associated POL lesions. In clinical practice, however, interventions: explanation and elaboration. J. Clin. Epidemiol. 62 (10), e1–34.
Lundquist, R.B., Matcuk Jr., G.R., Schein, A.J., Skalski, M.R., White, E.A., Forrester, D.
several studies have already evaluated the short- to medium-term results M., Gottsegen, C.J., Patel, D.B., 2015. Posteromedial corner of the knee: the
of associated POL reconstructions, with excellent results, confirming neglected corner. Radiographics. 35 (4), 1123–1137.
that this ligament should always be taken into consideration in multi- Marx, R.G., Wilson, S.M., Swiontkowski, M.F., 2015. Updating the assignment of levels of
evidence. J. Bone Joint Surg. Am. 97 (1), 1–2.
ligament knee injuries.
Petersen, W., Loerch, S., Schanz, S., Raschke, M., Zantop, T., 2008. The role of the
posterior oblique ligament in controlling posteriortibial translation in the posterior
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Robinson, J.R., Sanchez-Ballester, J., Bull, A.M., Thomas Rde, W., Amis, A.A., 2004. The
posteromedial corner revisited. An anatomical description of the passive restraining
This review confirms that POL is an anatomically well-defined and structures of the medial aspect of the human knee. J. Bone Joint Surg. (Br.) 86 (5),
distinct structure that plays a key role in stabilising the knee, especially 674–681.
in IR. The POL is frequently injured along with other anatomical Schafer, K.A., Tucker, S., Griffith, T., Sheikh, S., Wickiewicz, T.L., Nawabi, D.H.,
Imhauser, C.W., Pearle, A.D., 2016. Distribution of force in the medial collateral
structures. Future studies should develop clinical tests to evaluate the ligament complex during simulated clinical tests of knee stability. Am. J. Sports Med.
functionality and stability of the POL. 44 (5), 1203–1208.
Tibor, L.M., Marchant Jr., M.H., Taylor, D.C., Hardaker Jr., W.T., Garrett Jr., W.E.,
Sekiya, J.K., 2011. Management of medial-sided knee injuries, part 2: posteromedial
Disclosure corner. Am. J. Sports Med. 39 (6), 1332–1340.
Vap, A.R., Schon, J.M., Moatshe, G., Cruz, R.S., Brady, A.W., Dornan, G.J., Turnbull, T.L.,
None. LaPrade, R.F., 2017. The role of the peripheral passive rotation stabilizers of the
knee with intact collateral and cruciate ligaments: a biomechanical study. Orthop. J.
Sports Med. 25 (5), 2325967117708190.
Funding Vieira, T.D., Pioger, C., Frank, F., Saithna, A., Cavaignac, E., Thaunat, M., Sonnery-
Cottet, B., 2019. Arthroscopic dissection of the distal semimembranosus tendon: an
anatomical perspective on posteromedial instability and ramp lesions. Arthrosc.
None.
Tech. 8 (9), e987–e991.
Wijdicks, C.A., Griffith, C.J., LaPrade, R.F., Spiridonov, S.I., Johansen, S., Armitage, B.
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