The purpose of this study was to provide an anatomical explanation for the presence of medial proximal tibial pain in patients with patellar mal-tracking without identifiable medial tibio-femoral compartment or proximal tibial pathology.

Using cadaveric dissection we were consistently able to identify a connection between the medial patella and the medial proximal tibia including the medial hamstrings and the posterior oblique expansion. This connection is independent of the inferior patello-tibial ligament and has not previously been described in either anatomical or orthopaedic literature. The dimensions of this medial patello-tibial connection were measured using a digital microscribe. This technique also facilitated the creation of a three dimensional virtual representation of the patello-tibial connection.

In the clinical setting, patients presenting with medial proximal tibial pain who had patellar mal-tracking as identified by clinical examination and merchant radiographs underwent MRI scanning of the knee to exclude any intraarticular or proximal tibial pathology. In those patients with patellar mal-tracking that had no evidence of proximal tibial or medial compartment pathology identified, we were able to correlate the MRI finding of oedema based at the proximal medial aspect of the tibia with the cadaveric dissection findings mentioned previously. In such cases we would recommend that treatment of the medial proximal tibial pain should focus on managing the primary pathology of patella mal-tracking.

In conclusion we present a newly identified medial patello-tibial ligamentous complex that can explain the presence of medial proximal tibial pain in patients with patellar mal-tracking and no other proximal tibial or medial compartment pathology.

We present a simple seated dial test that can be used by a single examiner in the acute or chronic situation to diagnose posterolateral corner knee injury.

In the acute setting a traditional prone dial test can be cumbersome and painful for patients. Therefore a supine technique can be utilised, however this requires an assistant in order to hold the knees together with the tibia in a reduced position. We therefore utilise a seated technique in which the patient sits with their knees flexed over the edge of the examination couch. The patient is then able to hold their knees together, negating the need for an assistant. The sensitivity of a dial test is improved if the knee is reduced and so with this technique the tibia will be held in the anatomical position by the examination couch.

The patients' feet are grasped with both medial malleoli together and then an external rotation moment is exerted at 30 and 90 degrees of flexion measuring the thigh-foot angle or visualising the tibial tuberosities. A positive test being 10 degrees or more of increased external rotation in the affected knee.

This test is similar to the Spin test however it relies on the tactile sensation of posterolateral tibial rotation. This can be difficult to elicit in the acute situation due to haemarthrosis. Simultaneous side-to-side comparison is also not possible. A further disadvantage of the Spin test is that it can only be performed at 90 degrees of flexion and so only applies in combined PCL and posterolateral corner repair.

In conclusion we believe that this modification of the standard dial test is a simple to perform accurate method for assessing posterolateral corner knee injury in the acute and chronic setting.

Injuries of the posterolateral corner (PLC) of the knee are uncommon, but can lead to chronic disability from persistent instability and resultant articular cartilage degeneration if not appropriately treated. Although numerous reconstructive techniques have been described in the literature, there is no consensus on a single surgical approach due to a lack of consistent, long-term clinical outcomes. Nonanatomic reconstructions, in particular, have produced variable results, while anatomic reconstructions offer the most promise by restoring normal knee stability and kinematics and are now favoured by most.

We describe the novel use of the BICEPTOR™ Tenodesis screw (Smith & Nephew) as an effective and technically straight forward means of performing a PLC reconstruction. We describe the technique and present the first 10 consecutive cases from a single surgeon series. All of the patients had a positive dial test pre-operatively with increased external rotation of 10 degrees or more at 30 degrees of knee flexion indicating clinical PLC injury. They all had the PLC reconstructed at the same time as an arthroscopic ACL reconstruction. Mean time from injury to surgery was 4 months (range 2–12). Patients were seen in clinic at maximum follow-up (11.1 months mean, range 6–24 months) and assessed clinically using the dial test at 30 and 90 degrees of knee flexion. Lysholm Knee Questionnaire and Tegner Activity Scale were also performed at maximum follow-up. Mean Lysholm Score was 68 (range 32–96). Mean Tegner Score pre-operatively was 3.5 (range 3–6) and at maximum follow-up was 4.5 (range 3–7). Of particular note only one patient reported any symptoms at all of giving way at maximum follow-up. Dial test was negative on all patients.

Further work is warranted but we describe this as an effective and straight forward means of performing a PLC reconstruction.