PCL Injury Tear – Causes, Symptoms, Diagnosis, Treatment

PCL Injury Tear/Posterior Cruciate Ligament Injury (PCL) is one of the four major ligaments of the knee joint that functions to stabilize the tibia on the femur. It originates from the anterolateral aspect of the medial femoral condyle in the area of the intercondylar notch and inserts onto the posterior aspect of the tibial plateau. It functions to prevent posterior translation of the tibia on the femur. To a lesser extent, the PCL functions to resist varus, valgus, and external rotation forces. It is approximately 1.3 to 2 times as thick and about twice as strong as the anterior cruciate ligament (ACL) and, consequently, less commonly subject to injury.[rx][rx][rx][rx]

The posterior cruciate ligament (PCL) is the largest and strongest ligament in the human knee, and the primary posterior stabilizer. Recent anatomy and biomechanical studies have provided an improved understanding of PCL function. PCL injuries are typically combined with other ligamentous, meniscal and chondral injuries. Stress radiography has become an important and validated objective measure in surgical decision making and post-operative assessment. Isolated grade I or II PCL injuries can usually be treated non-operatively. However, when acute grade III PCL ruptures occur together with other ligamentous injury and/or repairable meniscal body/root tears, surgery is indicated. Anatomic single-bundle PCL reconstruction (SB-PCLR) typically restores the larger anterolateral bundle (ALB) and represents the most commonly performed procedure.

Anatomy of PCL Injury

The PCL is the largest and strongest intraarticular ligament of the knee joint, comprising of 2 functional bundles: the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB) (rx). The size of the femoral attachment of the ALB is nearly twice the size of its tibial attachment and has been reported to range from 112 to 118 mm² (rx–rx). The center of the femoral ALB footprint is located 7.4 mm from the trochlear point, 11.0 mm from the medial arch point, and 7.9 mm from the distal articular cartilage. Furthermore, ALB tibial attachment center is located 6.1 mm posterior to the shiny white fibers of the posterior medial meniscus root, 4.9 mm from the bundle ridge (which separates both bundles), and 10.7 mm from the champagne glass drop-off of the posterior tibia (rx).

The area of the PMB femoral attachment is between 60 mm² and 90 mm² in size and is located between the anterior and posterior meniscofemoral ligaments. The femoral PMB center is located 11.1 mm from the medial arch point and 10.8 mm from the posterior point of the articular cartilage margin. Meanwhile, the PMB tibial attachment center is located 4.4 mm anterior to the champagne glass drop-off of the posterior tibia and 3.1 mm lateral from the medial groove of the medial tibial plateau articular surface (rx). These measures have biomechanical and surgical implications, because an anatomic reconstruction of the ALB and PMB better restores native knee kinematics and has been reported to improve clinical outcomes

Posterior Cruciate Ligament

• Origin – the posterior intercondylar region of the tibia
• Insertion – the anterolateral margin of the medial condyle of the femur
• Function – prevention of posterior translation of the tibia relative to the femur; generalized knee stability
• Blood Supply – middle geniculate artery
• Sensory Innervation – posterior articular nerve

The PCL is composed of two bundles: the anterolateral bundle and the posteromedial bundle

Anterolateral Bundle of the PCL

• Taut in knee flexion
• Lax in knee extension

Posteromedial bundle of the PCL

• Taut in knee extension
• Lax in knee flexion

Types of Posterior Cruciate Ligament Injury

Acute PCL injury

• Isolated injury – Symptoms are often vague and minimal, with patients often not even feeling or noticing the injury. Minimal pain, swelling, instability and full range of motion is present, as well as a near-normal gait pattern.
• Combination with other ligamentous injuries – Symptoms differ according to the extent of the knee injury. This includes swelling, pain, a feeling of instability, limited range of motion and difficulty with mobilisation. Bruising may also be present.

Chronic PCL injury

Patients with a chronic PCL injury are not always able to recall a mechanism of injury. Common complaints are discomfort with weight-bearing in a semi flexed position (e.g. climbing stairs or squatting) and aching in the knee when walking long distances. Complaints of instability are also often present, mostly when walking on an uneven surface. Retropatellar pain and pain in the medial compartment of the knee may also be present. Potential swelling and stiffness depend on the degree of associated chondral damage.

Ligaments

• anterior cruciate ligament tear
  • • anterior tibial translocation sign
    • deep lateral sulcus sign
    • positive PCL line sign
    • reconstruction
      • radiographic evaluation
      • complications
        • cyclops lesion
        • tibial tunnel cyst
• anterior cruciate ligament ganglion cyst
• anterior cruciate ligament mucoid degeneration
• posterior cruciate ligament tear
• medial collateral ligament tear
• lateral collateral ligament tear
• medial patellofemoral ligament tear
• posterolateral corner injury
• posteromedial corner injury

Tendons

• patellar tendon rupture
• quadriceps tendon rupture

Meniscal lesions

• meniscal tear
  • • longitudinal tear
      • horizontal tear
      • longitudinal tear
        • Wrisberg rip
    • radial tear
      • ghost meniscus
    • root tear
    • displaced tear
      • flap tear
      • bucket-handle tear
      • parrot beak tear
    • signs
      • absent bow tie sign
      • double PCL sign
      • Jack and Jill lesion
      • two-slice-touch rule
    • MRI grading system for meniscal signal intensity
• meniscal contusion
• meniscal extrusion
• meniscal/parameniscal cyst
• meniscal flounce
• meniscal fraying
• meniscal maceration
• meniscocapsular separation
  • ramp lesion
  • floating meniscus
• bursosynovial lesions
  • infrapatellar bursitis
  • pes anserinus bursitis
  • prepatellar bursitis
  • medial patellar plica syndrome

Knee Joint Ligaments Anatomy Knee And Ankle Anatomy Musculoskeletal With Seegmiller At – Human Anatomy Library

Causes of Posterior Cruciate Ligament Injury

PCL tears are commonly seen in contact sports and non-contact sports. They often occur when:

• Motor vehicle accidents – A “dashboard injury” occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing the posterior cruciate ligament to tear.
• Contact sports – Athletes in sports such as football and soccer can tear their posterior cruciate ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
• The knee is hit directly – especially during sports like soccer, rugby, and football
• A person lands on a bent knee – such as during a fall or misstep
• Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
• A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
• A person lands on one leg – which can happen after a jump in basketball or volleyball
• A direct blow to the bent knee in an automobile injury
• A sports-related injury in which the knee bends
• Pulling on the ligament in a twisting injury or hyperextension
• A misstep on uneven terrain

Symptoms of Posterior Cruciate Ligament Injury/PCL Injury Tear

Diagnosis of PCL Injury Tear

History and Physical

Patients often will present with complaints of acute onset of posterior knee pain, swelling, and instability.  A thorough history includes the mechanism of injury, such as trauma from falling onto a flexed knee or recent motor vehicle accident.  There may or may not be a complaint of a “pop” with PCL tears like those frequently reported with ACL tears.

A thorough knee exam should be performed, including gait assessment. The neurovascular integrity of the lower extremity distal to the injury should also be assessed.

• Inspection – Affected knee will often present with mild to moderate joint effusion. Swelling is usually less than an ACL tear. Patients may present with antalgic gait on examination with obvious favoring of affected knee. They may have difficulty walking up or down stairs or at an incline. There may be a positive sag test; The sag test is performed with the patient supine, hip flexed to 45 degrees, and knee flexed to 90 degrees.  The tibia will be noted to sag distally relative to the femur as compared to the opposite knee.
• Palpation – There may be an effusion on physical exam.
• Muscle strength testing – Strength should be normal, but there may be weakness with knee extension and flexion secondary to guarding.
• ROM – The passive range of motion may be limited 10 to 20 degrees with flexion. It may be further decreased with other concomitant injuries such as meniscal, muscular, or ligamentous etiology.
• Special Testing – The posterior drawer test is the most accurate test for assessing PCL integrity.  It is performed with the patient in the supine position with the hip flexed to 45 degrees and knee flexed to 90 degrees. A posterior force is applied to the proximal tibia with one hand with stabilization of the femur with the other. Ligamentous and meniscal testing should be performed to assess the integrity of other structure of the knee. The Dial test can be performed to distinguish isolated PCL injuries with an associated posterolateral joint capsule, popliteus, medial collateral ligament, and posterior oblique ligament injuries.
• The posterolateral drawer test – external rotation recurvatum test, and reverse pivot shift test can also be used to assess injuries to the posterolateral structures. However, a positive external rotation recurvatum test is more indicative of an ACL injury than a PCL injury[rx] and the reverse pivot shift test should be used with care because the test may yield positive results in about 30% of normal knees[rx].

Posterior drawer test

• The test is performed with the person lying on his or her back.
• The examiner will ask the person to bend their hip to 45º with foot flat) and knee to 90º.
• He or she will lean lightly on the person’s foot to stabilize the leg.
• The examiner will wrap both hands around the joint line of the knee and attempt to move the tibia (shin bone) backwards.
• This movement may be done several times to confirm the diagnosis.

By putting pressure on the shin bone, the doctor will be able to gauge resistance from the PCL; an injured PCL will have less resistance than an uninjured ligament, causing the tibia to move backwards.

Treatment of Posterior Cruciate Ligament Injury/PCL Injury Tear

Nonsurgical Treatment Options for PCL Injuries

Less severe posterior cruciate ligament (PCL) tears of the knee generally heal well without surgery. Immediately after the injury, management consists of the RICE method:

• Rest – Any activities that causes knee pain, such as running or walking, should be avoided until symptoms are relieved.
• Ice – A person may be advised to apply ice to the area to help reduce pain and swelling. Ice can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected knee.
• Elevation – Keeping the knee supported above the waist can help with swelling.
• Wear a knee brace – A knee brace provides stability and restricts side-to-side movement. Some people may choose to wear a functional knee brace, which allows for more movement, when they return to activity.
• Use crutches – Crutches may be recommended to keep weight off the injured knee.

Physical therapist

• A physical therapist will focus on improving mobility, strength, flexibility, and balance, which can help speed up recovery time and improve performance once the injury has healed.
• Walking (weight-bearing) is initiated as soon as possible.
• Knee straightening (extension) and bending (flexion) are encouraged. Pool therapy is helpful.
• Stationary cycling is initiated as soon as adequate motion is achieved.
• Quadriceps strengthening exercises are started, such as standing squats with toe raises and leg press.
• Hamstring exercise may be modified for 6 months.
• Surgery is avoided in most cases unless other major ligaments are disrupted.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic PCL injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee PCL injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of  PCL injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgery

Arthroscopic transtibial technique

• standard arthroscopic portals with an accessory posteromedial portal posteromedial portal is placed 1 cm proximal to the joint line posterior to the MCL avoid injury to branches of the saphenous nerve during placement.
• posteromedial corner of the knee is best visualized with a 70° arthroscope either through the notch (modified Gillquist view) or using a posteromedial portal transtibial drilling anterior to posterior
• fix graft in 90° flexion with an anterior drawer results in knee biomechanics similar to native knee risk to popliteal vessels

Open (tibial inlay)

• uses a posteromedial incision between medial head of gastrocnemius and semimembranosus used for ORIF of bony avulsion biomechanical advantage with a decrease in the “killer turn” with less graft attenuation and failure  screw fixation of the graft bone block is within 20 mm of the popliteal artery.

Single-bundle technique

• arthroscopic or open reconstruct the anterolateral bundle tension at 90° of flexion

Double-bundle technique

• arthroscopic or open techniques may be utilized anterolateral bundle tensioned in 90° of flexion posteromedial bundle tensioned in extension biomechanical advantage with knee function in flexion and extension clinical advantage has yet to be determined may be advantageous to perform with combined PCL/PLC injuries for better rotational control as PLC reconstructions typically loosen over time.

Rehabilitation of PCL Injury Tear

Conservative management with Physiotherapy management

Grade 1 & II injuries

Two weeks of relative immobilisation of the knee (in a locked range of motion brace) is recommended by orthopaedic surgeons. Physiotherapy in this time period includes

• Partial to full weight-bearing mobilisation
• Reduce pain and inflammation
• Reducing knee joint effusion
• Restore knee range of motion
• Knee strengthening (especially protective quadriceps rehabilitation)
  • Strengthening the quadriceps is a key factor in a successful recovery, as the quadriceps can take the place of the PCL to a certain extent to prevent the femur from moving too far forward over the tibia.
  • Hamstring strengthening can be included
  • Important to incorporate eccentric strengthening of the lower limb muscles
  • Closed chain exercises
• Activity modification until pain and swelling subsides

After 2 weeks (on the orthopaedic surgeon’s recommendation)

• Progress to full weight-bearing mobilisation
• Weaning of range of motion brace
• Proprioception, balance and coordination
• Agility programme when strength and endurance has been regained and the neuromuscular control increased
• Return to play between 2 and 4 weeks of injury

Grade III injuries

The knee is immobilised in range of motion brace, locked in extension, for 2-4 weeks. Physiotherapy management in this time includes:

• Activity modification
• Quadriceps rehabilitation
  • Initially isometric quadriceps exercises and straight-leg raises (SLR)

After 2-4 weeks

• Avoid isolated hamstring strengthening
• Active-assisted knee flexion <70°
• Progress weight-bearing within pain limits
• Quadriceps rehabilitation: Promote dynamic stabilisation and counteract posterior tibial subluxation
  • Closed chain exercises
  • Open kinetic chain eccentric exercises and eventually
  • Progress to functional exercises such as stationary cycling, leg press, elliptical exercises and stair climbing

Return to play is sport specific, and only after 3 months.

Chronic injuries

• Chronic PCL injuries can be adequately treated with physiotherapy. A range of motion brace is used, initially set to prevent the terminal 15° of extension. After a while the brace is opened to full extension.

Post-operative rehabilitation

Post-operative rehabilitation typically lasts 6 to 9 months. The duration of each of the five phases and the total duration of the rehabilitation depends on the age and physical level of the patient, as well as the success of the operation. Also see page on PCL reconstruction.

General Guidelines for the post-operative PCL rehabilitation

• Mobility should be restricted from 0-90 degrees in the first two weeks then facilitated gradually to full ROM.
• Involved leg should be in non-weight bearing for the first 6 weeks then placed in mobilizer brace and progressed to rebound PCL brace for 6 months.
• Avoid isolated hamstrings contraction for 4 months due to the hamstrings force in drawing tibia posteriorly which can apply an elongation force on the PCL graft causing instability
• Avoid unsupported knee flexion for 4 months to prevent any posterior drawing forces on tibia.

Phase I: Early Post-operative phase

Early mobilisation and placing sub-maximal strain on graft lead to better outcomes.

Objectives of maximal protection and early rehabilitation:

• Restore joint homeostasis
• Scar tissue management
• Restore joint ROM
• Re-train quadriceps
• Create an effective plan for your patient

Strategies of rehabilitation:

• Perform ROM exercises from prone position to avoid posterior tibial sag and graft elongation
• Teach patient to perform Quadriceps contraction/sets from day 1 post surgery if the patient is not on strong pain medications.
• Patellofemoral mobilisation is important to prevent scarring and preserve joint volume for full range of flexion and extension
• Ice and elevation for swelling and inflammation management
• Progressing by applying strategies for increasing ROM and terminal knee extension

One of the huge advancement of PCL management is the utilisation of Dynamic PCL braces. This option may not always be available but if found make sure to utilise it. It’s a spring loaded brace aiming to place an anterior force on the tibia preventing posterior tibial sag and graft elongation by placing the graft in a shortened position. Immediately after surgery, it is recommended to place the leg in a mobiliser braces then progress to a dynamic brace once swelling is subsided. It should be used all the time and only taken off to perform exercises for 6 months. Then move into more functional bracing, worn all the time for 12 months.

Building weight bearing tolerance after 6 weeks of non weight bearing (NWB) should take place gradually and progressively between week 7-8 .

Phase II: Later Post-operative Rehabilitation

Begins 8 weeks after surgery. The aim is to create a plan for the patient to prepare them for returning to pre-operative functional capacity by addressing all MSK deficits.

Areas to address in late post-operative rehabilitation and suggested time-frames:

• Muscular endurance (weeks:9-16)
• Strength (weeks 17-22)
• Power (weeks 23-28) with running progression if it needed (weeks 25-28)
• Speed and agility (weeks 29-32 )
• Return to training (week 33).
• Return to sport : It varies from a sport to another but on average takes about with 3-4 weeks of training. Return to play around 36th week.

How can you care for yourself at home?

• Put ice or a cold pack on your knee for 10 to 20 minutes at a time. Try to do this every 1 to 2 hours (when you’re awake) for the first 3 days after your injury or until the swelling goes down. Put a thin cloth between the ice and your skin.
• Prop up your leg on a pillow when you ice it or anytime you sit or lie down. Do this for about 3 days after your injury. Try to keep your knee above the level of your heart. This will help reduce swelling.
• Take anti-inflammatory medicines to reduce pain and swelling. These include ibuprofen (Advil, Motrin) and naproxen (Aleve). Be safe with medicines. Read and follow all instructions on the label.
• Follow instructions about how much weight you can put on your leg and how to walk with crutches, if your doctor recommends them.
• Wear a brace, if your doctor recommends it, to protect and support your knee while it heals. Wear it as directed.
• Do stretches or strength exercises as your doctor suggests.

References

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