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Posterior Cruciate Ligament Injury

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Other Names

  • Posterior Cruciate Ligament Injury
  • Posterior Cruciate Ligament Tear
  • PCL Tear
  • PCL Injury
  • Posterior Cruciate Ligament Rupture
  • PCL Sprain

Background

History

  • Ernest Groves published description of PCL injuries and surgical treatment in 1917[1]

Epidemiology

  • 3% of outpatient knee injuries, 38% of acute traumatic knee hemarthroses[2]
  • 95% of PCL tears occur in combination with other ligament tears (need citation)
  • Schultz et al (2003)[3]
    • Mean age is 27
    • Etiology Traffic accidents (45%), athletic injuries (40%)

Pathophysiology

Schematic picture of PCL avulsion[4]
Schematic illustration of the anatomy of the posterior cruciate and the meniscofemoral ligaments. a Right knee from an antero-lateral view. b Right knee from a posterior view. ACL anterior cruciate ligament; ALB anterolateral bundle; aMFL anterior meniscofemoral ligament; LCL lateral collateral ligament; LM lateral meniscus; MCL medial collateral ligament; MM medial meniscus; PFL popliteofibular ligament; PMB posteromedial bundle; pMFL posterior meniscofemoral ligament; PT popliteus tendon[5]
Normal PCL in the sagittal plane of this knee MRI[6]
Ligamentous anatomy of the knee[7]

General

  • PCL injuries are much less common than other knee ligaments and meniscus injuries
  • Isolated injuries often go undiagnosed
  • Diagnosis can made based on physical exam and confirmed with MRI
  • Treatment for isolated PCL injuries is often non-surgical, but may require intervention if there are concomitant injuries

Pediatric Considerations

  • Rare, poorly described in pediatric population
  • Often associated with avulsion fracture (femoral or tibial)

Etiology

  • External trauma to tibia with posteriorly directed force
    • Knee vs dashboard in motor vehicle crash
    • In football, often blow to anterior tibia or fall onto knee with foot plantarflexed
  • Non-contact mechanism
    • Much less common
    • Can occur due to hyperextension or hyperflexion
    • E.g. falling off bicycle, knee hyperextension on trampoline, falling off playground equipment

Anatomy of the Posterior Cruciate Ligament

  • Originates on the lateral edge of the medial femoral condyle, inserts on the posterolateral surface of the tibia
  • Composed of both an anterolateral and a posteromedial bundle
  • Responsible for restraining anterior translation of the tibia relative to the femur

Associated Injuries

Risk Factors

Sports

  • Football
  • Soccer
  • Rugby
  • Skiing
  • Basketball
  • Track
  • Gymnastics

Differential Diagnosis

Differential Diagnosis Knee Pain

Clinical Features

Positive posterior sag sign on the right knee
Clinical demonstration of the posterior drawer test

History

  • Symptoms will vary due to acuity
  • Important to clarify mechanism, in chronic patients they may not be able to identify specific injury
    • Unlike ACL, no pop is typically reported
  • Acute: will report Stiffness, swelling and pain on the posterior knee
  • Chronic: anterior knee pain, instability when descending stairs, recurrent effusion
    • Trouble squatting, sitting cross legged on the ground

Physical Exam: Physical Exam Knee

  • On inspection, look for evidence of direct trauma (lacerations, abrasions, bruising)
  • Acutely: effusion
  • Clancy Sign: loss of the normal anteromedial, lateral prominences of the tibial plateau beneath the femoral condyles
  • Posterior Sag Sign: Supine, knee and hip flexed to 90°, look for posterior shift of tibia

Special Tests

Evaluation

Lateral X-ray view of the knee joint showing -A. PCL avulsion injury. B. Immediate postoperative showing reduction in the crater. C. At final follow up, a healed fracture. deterioration in the knee joint after fixation such as diminution of joint space or development of osteophytes[8]
Sagittal magnetic resonance imaging of a posterior cruciate ligament tear showing discontinuity of fibers (yellow arrow). An anterior cruciate ligament tear is also present[9]

Radiographs

  • Standard Radiographs Knee
    • Typically used as a screening tool in suspected PCL injuries
  • Potential findings
    • Tibial avulsion fractures at the PCL insertion on the posterior tibial plateau (best seen on lateral views)[10]
    • Reverse Segond fracture (avulsion of the medial tibial plateau) is a pathognomonic[11]
    • Posterior tibiofemoral subluxation
    • Arthrosis in chronic cases
  • Kneeling Stress Radiographs
    • Can be used to objectively quantify posterior knee laxity
    • Posterior tibial displacement can be used to classify injury compared to unaffected limb
    • Partial tear (0–7 mm), Complete tear (8–11 mm), additional injuries suspected if ≥12 mm
  • Posterior stress radiographs

MRI

  • Gold standard for diagnosiing PCL injuriees, characterizing morphology
  • Potential Findings[12]
    • Increased intrasubstance signal intensity
    • Ligament thickening
    • Focal fiber discontinuity
    • Redundancy or buckling of the ligament in avulsion injuries
  • MRI grading system[13]
    • Grade 0: Intact
    • Grade I: Injured but fibers intact (sprain) — predicts clinical stability at surgery 98.5% of the time
    • Grade II: Partial tear with some fiber disruption
    • Grade III: Complete tear with full discontinuity
  • Acute diagnostic value[14]
    • Sensitivity: 100%
    • Specificity: 100%
  • Chronic diagnostic value
    • Decreased sensitivity, specificity compared to acute injuries[15]
    • This is due to natural process of tissue healing after PCL tear mimicking the MRI appearance of a native, uninjured PCL
  • Also important to evaluate other ligaments, meniscus and cartilage

CT

  • Limited by emergening role
  • Standard single-energy CT has modest sensitivity for cruciate ligament injuries

Ultrasound

  • Screening tool with reasonable diagnostic accuracy for acute PCL injuries
  • Normal[16]
    • Homogeneously hypoechoic with a well-defined posterior border
    • Only the distal half is reliably visualized
  • Torn[17]
    • Heterogeneous echotexture, loss of the posterior border, and significant thickening
    • PCL thickness ≥6.5 mm on 2D ultrasound has 90.6% sensitivity and 86.7% specificity for PCL injury

Classification

PCL Tear Injury Classification

  • Grade 1 (partial)
    • Injury has 0 to 5 mm of displacement
    • Tibia remains anterior to the femoral condyles
  • Grade 2 (complete)
    • Injuries have 6 to 10 mm of displacement
    • Anterior tibia is flush with the femoral condyles
  • Grade 3 (posterolateral corner injury)
    • Injury would have greater than 10 mm of displacemt
    • Often ACL and/or PLC injury

Management

Example of PCL Brace

Nonoperative

  • Indications for protected weight bearing, rehab
    • Partial tear (grade I)
    • Complete (grade II) isolated
  • Indications for immobilization in extension for 4 weeks
    • Isolated (grade III) injuries
  • PCL Knee Brace
    • May help keep the tibia reduced during healing by avoiding posterior tibial sag[18]
    • Ideally, dynamic force brace which provide significantly greater applied force at 45º of flexion that increases with knee flexion angle
    • Note: indicated both for nonoperative treatment and postoperative rehabilitation of PCL tears
  • Physical Therapy
    • Emphasis on quadriceps strengthening

Operative

  • Indications - Acute
    • Symptomatic patients (pain, instability)
    • Tibial translation > 12 mm
    • Associated repairable meniscal tears
    • Knee dislocation or bony avulsions
    • Combined capsuloligamentous injuries
  • Indications - Chronic
    • Posterior tibial translation > 8 mm
    • Symptomatic patients (pain, instability)
    • Combined capsuloligamentous injuries.
  • Pediatric considerations
    • Avulsion fracture > 5-7 mm displacement
    • Crucial to preserve knee function to prevent future degenerative changes
  • Technique
    • PCL repair of bony avulsion fractures
    • PCL Reconstruction
    • High tibial osteotomy
    • Concurrent ligament, meniscus, posterolateral corner injuries
  • Surgical considerations
    • Open vs Arthroscopic with the later being preferred in most cases
    • Single vs double bundle technique
    • Autograft vs allograft
    • Tibial inlay vs Transtibial techniques

Rehab and Return to Play

Some exercises used in PCL rehab
PCL Rehab exercises

Phase 1: Acute Phase (Weeks 0–6)

  • Immobilize the knee in full extension[19]
    • Either: cylinder cast or long-leg brace with a posterior tibial support pad to prevent posterior tibial subluxation
  • Some protocols use cast immobilization for 4–6 weeks
    • With an attached tibial supporter maintaining an anteriorly directed force on the proximal tibia
  • Weight bearing as tolerated in the brace/cast with the knee in full extension
  • Begin isometric quadriceps sets and straight-leg raises immediately to prevent atrophy
  • Avoid isolated hamstring activation, resisted knee flexion, and any exercises promoting posterior tibial translation

Phase 2: Early Rehabilitation (Weeks 6–12)

  • Progressive ROM and Strengthening[20]
  • Initiate prone passive flexion (gravity assists anterior tibial translation in the prone position, protecting the healing PCL)
  • Progress flexion gradually: target 90° by 8 weeks and full flexion by 12 weeks
  • Begin progressive closed-chain quadriceps exercises (leg press 0–60°, mini-squats), core strengthening, and hip stabilization
  • Open-chain knee extension (90–0°) is permitted as it generates an anteriorly directed tibial force
  • Continue to avoid open-chain hamstring curls and deep squats beyond 70–90° of flexion

Phase 3: Advanced Strengthening (Weeks 12–16)

  • Begin an interval running program at approximately 12 weeks[21]
    • If adequate quadriceps strength is present and no effusion
  • Increase resistance in closed-chain exercises
  • Add stationary cycling and pool-based activities
  • Progress to sport-specific movement patterns

Phase 4: Sport-Specific Training and Return to Play (Weeks 16+)

  • Introduce agility drills, cutting, and plyometric training progressively
  • In a prospective study of 45 athletes[22]
    • Mean time to sports-specific training was 10.6 weeks
    • Full competitive sport was 16.4 weeks in a prospective series of 46 athletes
    • At 2 years, 91.3% were playing at the same or higher level
    • at 5 years, 82.6% remained competitive
  • Suggested return-to-sport benchmarks
    • Quadriceps strength ≥90% limb symmetry index
    • Hop test ≥90% LSI
    • Full ROM, and minimal or no pain

PCL Injury Rehab Exercise PDFs

Return to Play: Nonoperative

  • Timeline
    • Mean return to full competitive sport is 16.4 weeks (range 10 to 40 weeks)[23]
    • Most athletes return to sport specific training at 10.6 weeks
  • Requirements
    • Full painless range of motion
    • Restoration of quadriceps strength
    • Absence of swelling and instability

Return to Play: Operative

  • Timeline
    • Mean return to full sports after isolated PCL reconstruction is 9.7 months[24]
    • Factors associated with delayed return to play include extensor or flexor deficits, limb asymmetry, meniscal or posteromedial corner (PMC) lesions, and higher number of surgical procedure[25]
  • Requirements
    • Restoration of limb symmetry in strength and functional hop tests
    • No pain or instability with sports-specific activities
    • Satisfactory patient-reported outcome measures (e.g., Lysholm, KOOS, Tegner score)

Complications and Prognosis

Prognosis

  • General
    • Degree of PCL Laxity does not predict who will develop deteriorating knee function[26]
  • Nonoperative management
    • Parolie found 80% of patients satisfied, 84% returned to sport with isolated PCL injuries[27]
    • Shelbourne found 50% returned to same or higher level of sport, 33% returned to the same or lower level[28]
    • Shino found 14/15 athlete were able to return to sport, 1 developed medial femoral chondral changes[29]
    • Some studies report increase medial, patellofemoral degeneration, poor function[30][31]
    • Rates of return to play following non surgical management are up to 91% at 2 years[32]

Complications

See Also

Internal

References

  1. ↑ Groves, ErnestW Hey. "Operation for the repair of the crucial ligaments." The Lancet 190.4914 (1917): 674-676.
  2. ↑ Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: Part II. Arthroscopy. 1995; 11(5):526–9.
  3. ↑ Schulz, M. S., et al. "Epidemiology of posterior cruciate ligament injuries." Archives of orthopaedic and trauma surgery 123.4 (2003): 186-191.
  4. ↑ Rhatomy, Sholahuddin, et al. "Posterior Cruciate Ligament reconstruction augmentation on avulsion PCL: A case series." International Journal of Surgery Open 20 (2019): 15-19.
  5. ↑ Winkler, Philipp W., et al. "Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics." Knee Surgery, Sports Traumatology, Arthroscopy 29 (2021): 672-681.
  6. ↑ Case courtesy of Andrew Dixon, Radiopaedia.org, rID: 22993
  7. ↑ Rohen, Johannes Wilhelm, Chihiro Yokochi, and Elke Lütjen-Drecoll. Color atlas of anatomy: a photographic study of the human body. Schattauer Verlag, 2006.
  8. ↑ Madi, Sandesh, et al. "Clinical and radiological outcomes following arthroscopic dual tibial tunnel double sutures knot-bump fixation technique for acute displaced posterior cruciate ligament avulsion fractures." Archives of Bone and Joint Surgery 9.1 (2021): 50.
  9. ↑ Wang, Dean, et al. "Nonoperative treatment of PCL injuries: goals of rehabilitation and the natural history of conservative care." Current reviews in musculoskeletal medicine 11.2 (2018): 290-297.
  10. ↑ Katsman, Anna, et al. "Posterior cruciate ligament avulsion fractures." Current reviews in musculoskeletal medicine 11.3 (2018): 503-509.
  11. ↑ Gottsegen, Christopher J., et al. "Avulsion fractures of the knee: imaging findings and clinical significance." Radiographics 28.6 (2008): 1755-1770.
  12. ↑ Patten, Randall M., et al. "Complete vs partial-thickness tears of the posterior cruciate ligament: MR findings." Journal of computer assisted tomography 18.5 (1994): 795-799.
  13. ↑ Nicandri, Gregg T., et al. "Can magnetic resonance imaging predict posterior drawer laxity at the time of surgery in patients with knee dislocation or multiple-ligament knee injury?." The American Journal of Sports Medicine 39.5 (2011): 1053-1058.
  14. ↑ Gross, Michael L., et al. "Magnetic resonance imaging of the posterior cruciate ligament: clinical use to improve diagnostic accuracy." The American journal of sports medicine 20.6 (1992): 732-737.
  15. ↑ Pache, Santiago, et al. "Posterior cruciate ligament: current concepts review." Archives of Bone and Joint Surgery 6.1 (2018): 8.
  16. ↑ Cho, Kil-Ho, et al. "Normal and acutely torn posterior cruciate ligament of the knee at US evaluation: preliminary experience." Radiology 219.2 (2001): 375-380.
  17. ↑ Wang, Lin-Yi, et al. "Evaluating posterior cruciate ligament injury by using two-dimensional ultrasonography and sonoelastography." Knee Surgery, Sports Traumatology, Arthroscopy 25.10 (2017): 3108-3115.
  18. ↑ Jacobi, M., et al. "Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report." The Journal of Bone and Joint Surgery. British volume 92.10 (2010): 1381-1384.
  19. ↑ Ahn, Jin Hwan, et al. "Evaluation of clinical and magnetic resonance imaging results after treatment with casting and bracing for the acutely injured posterior cruciate ligament." Arthroscopy: The Journal of Arthroscopic & Related Surgery 27.12 (2011): 1679-1687.
  20. ↑ Pierce, Casey M., et al. "Posterior cruciate ligament tears: functional and postoperative rehabilitation." Knee Surgery, Sports Traumatology, Arthroscopy 21.5 (2013): 1071-1084.
  21. ↑ Wang, Dean, et al. "Nonoperative treatment of PCL injuries: goals of rehabilitation and the natural history of conservative care." Current reviews in musculoskeletal medicine 11.2 (2018): 290-297.
  22. ↑ Agolley, D., et al. "Successful return to sports in athletes following non-operative management of acute isolated posterior cruciate ligament injuries: medium-term follow-up." The bone & joint journal 99.6 (2017): 774-778.
  23. ↑ Pierce, Casey M., et al. "Posterior cruciate ligament tears: functional and postoperative rehabilitation." Knee Surgery, Sports Traumatology, Arthroscopy 21.5 (2013): 1071-1084.
  24. ↑ Lee, Dhong Won, et al. "Return to sports and clinical outcomes after arthroscopic anatomic posterior cruciate ligament reconstruction with remnant preservation." Arthroscopy: The Journal of Arthroscopic & Related Surgery 35.9 (2019): 2658-2668.
  25. ↑ Pizza, Nicola, et al. "Good long-term patients reported outcomes, return-to-work and return-to-sport rate and survivorship after posterior cruciate ligament (PCL)-based multiligament knee injuries (MLKI) with posteromedial corner tears as significant risk factor for failure." Knee Surgery, Sports Traumatology, Arthroscopy 31.11 (2023): 5018-5024.
  26. ↑ Shelbourne KD, Muthukaruppan Y. Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries. Arthroscopy. 2005;21(4):e457–61.
  27. ↑ Parolie, James M., and John A. Bergfeld. "Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete." The American journal of sports medicine 14.1 (1986): 35-38.
  28. ↑ Shelbourne, K. Donald, Thorp J. Davis, and Dipak V. Patel. "The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries." The American journal of sports medicine 27.3 (1999): 276-283.
  29. ↑ Shino K, Horibe S, Nakata K, Maeda A, Hamada M, Nakamura N. Conservative treatment of isolated injuries to the posterior cruciate ligament in athletes. J Bone Joint Surg Br. 1995;77(6):e895–900.
  30. ↑ Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996;24(3):e306–10.
  31. ↑ Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med. 1993;21(6):e846–9
  32. ↑ Agolley, D., et al. "Successful return to sports in athletes following non-operative management of acute isolated posterior cruciate ligament injuries: medium-term follow-up." The bone & joint journal 99.6 (2017): 774-778.
Created by:
John Kiel on 7 July 2019 05:43:47
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