PCL Injury

Author: Derek Moore

Topic updated on 04/20/13 7:56pm

Introduction
Mechanism direct blow to proximal tibia with flexed knee (dashboard injury) noncontact hyperflexion with plantar-flexed foot Chronic PCL deficiency PCL deficiency leads to increased contact pressures in the patellofemoral and medial compartments of the knee due to varus alignment whether late patellar and MFC chondrosis will develop remains controversial

Anatomy

Gross anatomy
- PCL extends from MFC to tibial sulcus
  - 38mm x 13mm in size
- PCL has two bundles
  - anterolateral bundle
    - is tight in flexion
  - posteromedial bundle
    - is tight in extension
- meniscofemoral ligaments (Humphrey, Wrisberg)
  - are variable
  - originate from the posterior horn of the lateral meniscus and insert into the substance of the PCL
Blood supply
- supplied by middle geniculate artery
Biomechanics
- strength is 2500 N (posterior)

Classification

Classification based on posterior subluxation of tibia relative to femoral condyles (with knee in 90° flexion)
- Grade I
  - 1-5mm posterior translation of tibia
- Grade II
  - 6-10 mm posterior translation of tibia
- Grade III
  - >10 mm posterior translation of tibia

Presentation

Symptoms
- history of a dashboard injury
- history of a hyperflexion athletic injury
Physical exam
- posterior drawer test
- quadriceps active test
- reverse pivot shift

Imaging

Radiographs
- AP and lateral
- kneeling stress radiographs of knee
MRI

Treatment

Nonoperative
- protected weight bearing & rehab
  - indications
    - isolated Grade I and II injuries
  - technique
    - follow with quadriceps rehabilitation
    - can return to sports within ~4 weeks
- extension brace for 2-4 weeks
  - indications
    - isolated Grade III injuries
  - technique
    - followed by quadriceps rehab
    - may choose surgery if bony avulsion or a young athlete
Operative
- PCL repair or reconstruction (ORIF for bony avulsion)
  - indications
    - combined ligament injury (PCL injury with with ACL or PLC injury)
    - isolated grade II or III with bony avulsion
  - postoperative rehabilitation
    - immobilize in extension early and protect against gravity
    - early motion should be in prone position
    - follow with quadriceps rehabilitation
- high tibial osteotomy
  - indications
    - chronic PCL deficiency
  - technique
    - consider medial opening wedge osteotomy to treat both varus malalignment and PCL deficiency
    - when performing a high tibial osteotomy in a PCL deficient knee, increasing the tibial slope helps reduce the posterior sag of the tibia

Surgical Techniques

Arthroscopic repair
- transtibial from front to back
- risk of popliteal vessels
- fix graft in flexion
Open (tibial Inlay)
- used for ORIF of bony avulsion
- uses posterior-medial approach between medial head of gastroc and semimembranosis
- biomechanic studies show less graft attrition and failure
Two bundle technique
- may be utilized in both arthroscopic and open techniques
- leads to improved stability in flexion and extension
- anterolateral graft tensioned in 90° of flexion
- posteromedial tensioned in 30° of flexion

Complications

Popliteal artery injury
- popliteal artery lies just posterior to the insertion of the PCLon the tibia, seperated only by the posterior capsule. Therefore care must be taken when drilling the tibial tunnel

Please Rate Educational Value!

3.0

Average 3.0 of 20 Ratings

Qbank (8 Questions)

TAG

(OBQ11.204) Which of the following should be avoided in early rehabilitation following posterior cruciate ligament (PCL) reconstruction? Topic

Review Topic

1. Quadcriceps muscle activation
2. Closed chain active terminal extension exercises
3. Prone passive flexion with active terminal extension
4. Prone hamstring curls
5. Active maximal ankle dosiflexion

PREFERRED RESPONSE ▶

DISCUSSION: Resisted hamstring strengthening exercises (ex. hamstring curls) are generally avoided in the early phase of rehabilitation following PCL reconstruction - this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft.

Kaufman et al studied the joint reactive forces during isokinetic exercises. They found that posterior shear forces exist during the flexion portion of isokinetic exercise and during extension exercises at knee joint angles greater than 40 degrees. The maximum posterior shear force was 1.7 body weight.

Incorrect Responses:
1. & 2. Progressively obtaining a full range of motion is an initial goal of rehabilitation. Quadriceps muscles help to obtain extension and near terminal extension actually decrease force on the graft. Non-weight-bearing resisted knee extension (60° to 0°) is an acceptable exercise in the initial stages following PCL reconstruction.
3. Prone positioning allows the weight of the leg to help maintain an anterior force on the tibia, while passive flexion minimizes hamstring pull.
5. Active ankle exercises such as ankle pumps are encouraged.

REFERENCES:

1. Paine R. Section A: Language of exercise and rehabilitation. In: DeLee JC, Drez D, Miller MD, eds. Rehabilitation and Therapeutic Modalities: Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:221-237.

2. Kaufman KR, An KN, Litchy WJ, Morrey BF, Chao EY. Dynamic joint forces during knee isokinetic exercise. Am J Sports Med. 1991 May-Jun;19(3):305-16. PMID:1867339 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Robert Boykin MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 5 Ratings

TAG

(OBQ09.35) A 23-year-old collegiate soccer player sustained a right knee injury 6 months ago. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee "giving way." Physical exam reveals 10° varus alignment when standing and a varus thrust with walking. Strength is full compared to the other side. Ligamentous exam reveals a stable ACL and MCL, but opens to a varus stress and a 3+ posterior drawer and positive dial test at both 30° and 90° degrees of flexion. What is the best treatment option to allow this patient to return to competitive athletic activity? Topic

Review Topic

1. Functional bracing
2. Reconstruction of the PCL
3. Reconstruction of the ACL and PCL
4. High tibial osteotomy to decrease tibial slope and correct varus malalignment; reconstruction of the PCL & PLC
5. High tibial osteotomy to increase tibial slope and correct varus malalignment; reconstruction of the PCL & PLC

PREFERRED RESPONSE ▶

DISCUSSION: This patient sustained a combined posterior cruciate ligament (PCL) and posterolateral corner (PLC) injury. The 3+ posterior drawer indicates the PCL injury while the opening to varus stress indicates injury to the lateral collateral ligament (a component of the PLC). In addition, this patient has a positive dial test at both 30° (PLC tear) and 90° (PLC and PCL tear) degrees of flexion. Repair of the PCL alone and ignoring the PLC injury and/or varus malalignment will result in increased risk of failure of the reconstruction. Giffin et al in a recent cadaveric study showed the increasing the tibial slope in PCL deficient knees reduces the posterior tibial sag.

REFERENCES:

1. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 183-197

2. Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007 Sep;35(9):1443-9. Epub 2007 Jul 19. PMID:17641101 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD, Eric Shirley MD, Mark Miller MD,

Please Rate Educational Value!

3.0

Average 3.0 of 22 Ratings

TAG

(OBQ09.82) Which of the following rehabilitation principles is true regarding non-operative treatment of a grade II PCL tear? Topic

Review Topic

1. Quadriceps strengthening and prone range of motion should begin as tolerated
2. Hamstring strengthening and supine range of motion should begin as tolerated
3. Resisted quadriceps and hamstring strengthening, no early range of motion
4. No strengthening for 6 weeks
5. No range of motion for 6 weeks

PREFERRED RESPONSE ▶

DISCUSSION: Initial treatment for PCL tears is non-operative. Range of motion is typically initiated early. Flexion may be done in a prone position to limit posterior sag. While quadriceps strengthening is essential, resisted hamstring exercises are generally avoided initially because they pull the tibia in a relatively posterior position.

The references include two recent review articles on the evaluation and treatment of PCL tears. The Wind et al article reviews the evaluation and treatment of PCL tears and the Margheritini et al paper is a general review article on the PCL anatomy and injuries.

REFERENCES:

1. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 155-168

2. Margheritini F, Rihn J, Musahl V, Mariani PP, Harner C. Posterior cruciate ligament injuries in the athlete: An anatomical, biomechanical and clinical review. Sports Med 2002;32:393-408 PMID:11980502 (Link to Abstract)

3. Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med. 2004 Oct-Nov;32(7):1765-75. PMID:15494347 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Michael Hughes MD, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 10 Ratings

TAG

(OBQ07.4) At what angle of knee flexion should the graft be tensioned at during posterior cruciate ligament (PCL) reconstruction with a single bundle graft? Topic

Review Topic

1. 5 degrees hyperextension
2. 0 degrees flexion
3. 15 degrees flexion
4. 30 degrees flexion
5. 90 degrees flexion

PREFERRED RESPONSE ▶

DISCUSSION: For single bundle reconstructions, the PCL is usually tensioned in flexion and the ACL is tensioned in more extension. While not truly isometric, these positions are closest to the isometric points which means that the graft will not have excess strain or laxity as it is taken through a full range of motion. The Margheritini et al. paper describes 2 different methods of tibial fixation, but were performed at 90 degs of flexion. The Sekiya paper describes the technique and results of single bundle PCL reconstructions.

Illustrations: A

REFERENCES:

1. OKU: Sports Medicine 3, 2004 pg 155-168.

2. Margheritini F, Rihn JA, Mauro CS, et al. Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction. Arthroscopy. 2005 Oct;21(10):1164-71. PMID:16226642 (Link to Abstract)

3. Sekiya JK, West RV, Ong BC, et al. Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy. 2005 Sep;21(9):1042-50. PMID:16171628 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

TAG

(OBQ07.15) Strengthening of what muscle group most effectively counteracts the deficit seen with an incompetent PCL? Topic

Review Topic

1. Hip flexors
2. Hip abductors
3. Gastroc-soleus
4. Quadriceps
5. Hamstrings

PREFERRED RESPONSE ▶

DISCUSSION: The primary function of the PCL complex is to restrict posterior tibial translation. After acute PCL rupture or PCL reconstruction, resisted hamstring strengthening is avoided as it pulls the tibia posteriorly. Therefore, therapy should focus on quadriceps strengthening which pulls the tibia anteriorly. The Irrgang paper describes rehabilitation principles for multi-ligament knee injuries. The Wind Article is a review which includes rehabilitation priciples for both non-op and operative PCL treatment. The Harner paper is a similar but earlier review.

REFERENCES:

1. Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: Revisited. Am J Sports Med 2004;32:1765-75. PMID:15494347 (Link to Abstract)

2. Harner CD, Hoher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-82. PMID:9617416 (Link to Abstract)

3. Irrgang JJ, Fitzgerald GK. Rehabilitation of the multiple-ligament-injured knee. Clin Sports Med. 2000 Jul;19(3):545-71. PMID:10918965 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ06.55) A football player sustains an isolated posterior cruciate ligament (PCL) tear. Which of the following mechanisms is most likely to have caused this injury? Topic

Review Topic

1. Fall on the flexed knee with the foot in plantarflexion
2. Fall on the flexed knee with the foot in dorsiflexion
3. Non-contact twist causing knee external rotation and valgus
4. Non-contact twist causing knee internal rotation and varus
5. Direct contact blow to the posterior knee

PREFERRED RESPONSE ▶

DISCUSSION: Overall the most common mechanism of PCL injury is a direct blow to the proximal aspect of the tibia. The most common mechanism of PCL injury in athletes is a fall onto the flexed knee with the foot in plantarflexion, which places a posterior forces on the tibia and leads to rupture of the PCL.

Schulz et al retrospectively analyzed 494 patient with PCL injuries. Traffic accidents (45%) and athletic injuries (40%) were the most common causes. The most common injury mechanisms were dashboard injuries (35%) and falls on the flexed knee with the foot in plantarflexion (24%). Multiligament injuries involving the PCL occurred in 64% of patients injured in traffic accidents vs. 48% of those with athletic injuries (p<0.0001).

Janousek found similar results showing that MVA was more likely to result in multi-ligament injuries, while a fall on the knee with the foot plantarflexed is most likely to result in an isolated PCL injury in athletic activities.

REFERENCES:

1. Janousek AT, Jones DG, Clatworthy M, Higgins LD, Fu FH. Posterior cruciate ligament injuries of the knee joint. Sports Med 1999;28:429-441. PMID:10623985 (Link to Abstract)

2. Schulz MS, Russe K, Weiler A, Eichhorn HJ, Strobel MJ. Epidemiology of posterior cruciate ligament injuires. Arch Orthop Trauma Surg 2003;123:186-191. PMID:12734718 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Jeremy Stern MD, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

TAG

(OBQ06.99) A 35-year-old construction worker presents with medial-sided knee pain. He has no instability complaints but at age 18, he sustained a complete PCL injury that was treated non-operatively. A radiograph is shown in Figure A. What surgical treatment is the best option given his age and occupation? Topic

Review Topic

FIGURES: A

1. PCL reconstruction
2. Unicompartmental knee replacement
3. Total knee replacement
4. Lateral closing wedge osteotomy of the proximal tibia
5. Medial opening wedge osteotomy of the proximal tibia

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs show a knee with significant medial compartment narrowing. A frequently tested fact is that wear associated with chronic PCL instability occurs most commonly in the patellofemoral joint and the medial compartment of the knee. A young laborer is not an ideal candidate for arthroplasty because of early wear and loosening concerns. In addition, cruciate ligaments are required for the insertion of a unicompartmental knee replacement. Isolated PCL reconstruction would not be recommended as he already has arthritis and cruciate reconstruction in a mal-algined knee is at increased risk of failure. Either valgus producing osteotomy is reasonable, but the opening wedge tends to increase posterior tibial slope which is helpful in PCL-deficient knees. The article by Giffin et al described that by performing an opening medial wedge osteotomy, the slope of the knee is effectively increased by about 3 degrees and this reduces posterior subluxation or sag of the tibia on the femur. This helps to accommodate for the deficient ligamentous restraint posteriorly, whereas decreasing slope may be protective in an ACL-deficient knee.

REFERENCES:

1. Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med 2004;32:376-382 PMID:14977661 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

TAG

(OBQ04.161) A 35-year-old male sustained an isolated PCL injury over 5 years ago which was treated non-operatively. If his follow-up radiographs show degenerative changes related to his PCL-deficiency, the changes are likely to be present in which of the following knee compartments? Topic

Review Topic

1. medial and patellofemoral
2. medial only
3. lateral
4. lateral and patellofemoral
5. patellofemoral only

PREFERRED RESPONSE ▶

DISCUSSION: A PCL deficient knee has an increased risk of early onset of degenerative changes in the medial and patellofemoral compartments.

Strobel et al conducted a retrospective arthroscopic review of 181 PCL-deficient knees that were treated nonoperatively initially but later underwent knee arthroscopy. They found that PCL insuffiency significantly increased the risk of developing medial femoral condyle and patellar cartilage degeneration over time. Of the patients whose PCL-deficiency was present for more than 5 years, 77.8% showed degenerative cartilage lesions of the medial femoral condyle and 46.7% showed cartilage degeneration of the patella. After 1 year of PCL insufficiency, the number of medial femoral cartilage lesions increased threefold (13.6% v 39.1%).

REFERENCES:

1. Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003 Mar;19(3):262-8. PMID:12627150 (Link to Abstract)

Question Authors:

Paul D. Kim MD, Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

4.0

Average 4.0 of 9 Ratings

Videos

	Arthroscopic PCL Repair with Repair of Meniscal Root Avulsion - Dr. Dean Taylor Sports - Surgical Techniques - PCL Injury View this video on arthroscopic repair of the PCL by Dean Taylor, MD, Col (ret)...	9/22/2012 85 views 4
	Arthroscopic PCL Reconstruction Sports - Surgical Cases - PCL Injury PCL reconstruction in 26-year-old male with posterior knee instability Stanley T...	3/1/2012 99 views 4

See More Videos

Posts

Importance of Tibial Slope for Stability of the Posterior Cruciate Ligament Deficient Knee. Includes Poll

Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD
Am J Sports Med. 2007 Sep;35(9):1443-9. PMID: 17641101 (Link to Pubmed)

Sports - Journal Club - PCL Injury

4/18/2013

11 responses

See More Posts

Groups

ABOS II: PCL Injury

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 4 (Case Series)

Kaufman KR, An KN, Litchy WJ, Morrey BF, Chao EY. Dynamic joint forces during knee isokinetic exercise. Am J Sports Med. 1991 May-Jun;19(3):305-16. PMID:1867339 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Margheritini F, Rihn J, Musahl V, Mariani PP, Harner C. Posterior cruciate ligament injuries in the athlete: An anatomical, biomechanical and clinical review. Sports Med 2002;32:393-408 PMID:11980502 (Link to Abstract)
Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med. 2004 Oct-Nov;32(7):1765-75. PMID:15494347 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Paine R. Section A: Language of exercise and rehabilitation. In: DeLee JC, Drez D, Miller MD, eds. Rehabilitation and Therapeutic Modalities: Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:221-237.

Undefined

Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 183-197
Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance of tibial slope for stability of the posterior cruciate ligament deficient knee. Am J Sports Med. 2007 Sep;35(9):1443-9. Epub 2007 Jul 19. PMID:17641101 (Link to Abstract)
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 155-168
OKU: Sports Medicine 3, 2004 pg 155-168.
Margheritini F, Rihn JA, Mauro CS, et al. Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction. Arthroscopy. 2005 Oct;21(10):1164-71. PMID:16226642 (Link to Abstract)
Sekiya JK, West RV, Ong BC, et al. Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy. 2005 Sep;21(9):1042-50. PMID:16171628 (Link to Abstract)
Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: Revisited. Am J Sports Med 2004;32:1765-75. PMID:15494347 (Link to Abstract)
Harner CD, Hoher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-82. PMID:9617416 (Link to Abstract)
Irrgang JJ, Fitzgerald GK. Rehabilitation of the multiple-ligament-injured knee. Clin Sports Med. 2000 Jul;19(3):545-71. PMID:10918965 (Link to Abstract)
Janousek AT, Jones DG, Clatworthy M, Higgins LD, Fu FH. Posterior cruciate ligament injuries of the knee joint. Sports Med 1999;28:429-441. PMID:10623985 (Link to Abstract)
Schulz MS, Russe K, Weiler A, Eichhorn HJ, Strobel MJ. Epidemiology of posterior cruciate ligament injuires. Arch Orthop Trauma Surg 2003;123:186-191. PMID:12734718 (Link to Abstract)
Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med 2004;32:376-382 PMID:14977661 (Link to Abstract)
Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003 Mar;19(3):262-8. PMID:12627150 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

PCL Injury

Qbank (8 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Videos

Posts

Groups

Evidence & References Show References

Topic Comments