Posterior Cruciate Ligament (PCL)

Where is it painful for a client with a PCL lesion?


Classical patient features for a PCL lesion

Age: Average age is 32.7 years

Gender: Male incidence is higher than female 2: 1

Activities / Sport: Football, soccer, skiing, motor vehicle racing, motor vehicle accidents

Area of symptoms for a PCL lesion

– Widespread around the knee as injury does not commonly occur in isolation

– Feelings of unsteadiness or discomfort // for both acute and idiopathic injuries

– Common to report anterior knee pain whilst completing functional activities

– Less common however patients can report pain in the back of the knee

– Retropatellar knee pain

Characteristics of symptoms for a PCL lesion

– Tightness and restriction // likely due to the mild/moderate effusion

– Patient reports vague symptoms compared to other ligamentous structures at the knee

– Knee stiffness (depending on the level of chondral injury)

– Deep aching pain // often low in intensity

– intermittent symptoms

Typical activity capability/restriction for a client with a PCL lesion

– Pain and discomfort when descending stairs, ramps and decelerating.

– Difficulty with weight-bearing in a semi-flexed position e.g. squatting and walking long distances

– Walking on uneven surfaces // patient will often complain of knee instability or feelings of giving way

Behaviour of symptoms for a a PCL lesion

Aggs: Hyper-extension, kneeling (posterior knee pain), deceleration, going downstairs, running.

Ease: Pillow under the knee, bracing, rest, ice

24-hour pattern: Mechanically related

Typical history of a client with a PCL lesion

– Patient reports a traumatic blow most commonly to the anterior portion of the proximal tibia

– Will have an acute onset of pain following the trauma

– Mechanism commonly a direct blow to the proximal tibia, a fall on the knee with the foot in plantarflexion and hyperextension with combined rotational forces

– 50% of positive tests occur secondary to sporting injuries

– PCL implicated in 40% of acute knee instability presentations

– Another common mechanism are motor vehicle accidents (impact on the tibia forcing it posteriorly)

– 2-3% of chronic PCL presentations with unknown mechanism of injury

Pathobiological mechanisms underlying a PCL lesion

– Nociceptive pain mechanism at initial presentation

– Due to commonly reported instability at the knee it is important to understand patients confidence levels especially with loaded activities in aggravating position

– If a patient feels like a knee is going to give way or not support they will alter their behaviour accordingly. This pathway will lead to increased nociplastic influences on the patient’s presentation.

Proposed pathology for a PCL lesion

– PCL can be compromised at the mid substance, or there may be an avulsion from the anterior aspect

– Isolated PCL damage occurs in athletics, multiple structures may be involved if there is high energy trauma.

-Typically PCL injuries are combined with other ligamentous, chondral (52%) and meniscal injuries (16-28%).

Grading of injury (posterior translation in relation to the femur)

– Grade 1 (0-5mm)

– Grade 2 (5-10mm)

– Grade 3 (>10mm)

Physical impairments & associated structure/tissue sources (ie P/E findings)


– Symptoms are vague and minimal.

– Minimal pain

– Minimal swelling // intraarticular

– Full ROM into flexion

– 5 to 10 degrees deficit into extension // likely full ROM if an isolated injury

– reduced strength if chronic or pain inhibition

– bruising

– reduced gastrocnemius strength

Special tests

– Posterior drawer at 90 deg knee flexion (sensitivity 0.22-1.00; specificity 0.98)

– Posterior sag test (sensitivity 0.46-1.00; specificity 0.89)

– Quadriceps active test (sensitivity 0.53-0.98; specificity 0.96-1.00)

– Reverse pivot shift test (sensitivity 0.19-0.26; specificity 0.95)


– unlikely to have any changes if acute


– adaptive gait changes

– reduced confidence with landing and change of direction

– feelings of giving way or instability

Typical contributing factors for a PCL lesion

Intrinsic – reduced gastrocnemius activation

Extrinsic – Reduced dynamic control, poor performance with jumping/landing etc

General – hypermobility and ligament laxity

Relevant precautions/ contraindications to P/E and treatment

– Depending on severity and irritability

– If acute, encourage RICER and limit assessment to P1

– Screen for a contusion of the tibia / popliteal ecchymosis

– Screen for DVT

– Screen for boney injuries

Relevant diagnostic imaging for a PCL lesion

X-rays – bony avulsion may be observed however won’t show any findings regarding the integrity of the ligament

Stress radiographs – may be used to correlate clinical findings

MRI (97% sensitive) – Gold standard, recommended if evidence of ligamentous injury

Typical prognosis for a PCL lesion

Return to play rate up to 67% of patients with grade 1 & 2 tears

Return to play rate 58-63% with operated tears grade 2 and above

– Long term consequences of isolated injury is unknown // mid-level evidence for the increased prevalence of meniscal injury, 80% of follow up group reported pain and 50% reported occasional swelling

– graft failure rate of 11% in isolated PCL reconstruction

– 7 years follow up // 23% of patients had arthritic changes

– 14 year follow up // 41% of patients had arthritic changes, of the 41%, 11% had moderate to severe OA

– noted that there was no control group so no comparison to normal age-related changes

Management/treatment selection for a PCL lesion

Isolated grade I or II PCL tears are most commonly managed conservatively. When a grade III tear is sustained acutely, along with other ligamentous injuries and/or with meniscus tears, surgery review is indicated.

Indications for surgery // or surgical review

– Grade III PCL injury WITH pain and instability

– Or instability and a failed conservative trial of management

Sample Rehabilitation outline from Brukner and Khan:

Phase 1

Duration: 6 weeks

Bracing: 2-4/52 -brace 0 ; then as below

NWB – WBAT – PWAB (1-4)

Exercises: ROM in prone; symptom Mx; isometric quads; SLR; weight shift; proprioception; DL strengthening (knee < 70 degrees flex)

Phase 2

Duration:6 to 12 weeks

Bracing: next 12-14/52 brace 0 – 110;


DL strengthening (knee < 70 degrees flex) ; SL proprioception;

Phase 3

Duration: 12 to 16 weeks

DL strengthening past 70 degrees; SL strengthening; jogging; agility

Phase 4

16 to 24 weeks

unrestricted strengthening; plyometrics; return to sport

Differential diagnosis for a PCL lesion

LCL/MCL // Will present with additional valgus/varus laxity

Posterolateral corner

ACL // Positive Lachmann’s Test, positive anterior drawer test, positive pivot shift test

Neural (tibial/peroneal nerve) // differentiated by a neuro exam

Vascular (popliteal vein + artery) // differentiated by a vascular exam, Doppler Ultrasound

Tib Plateau/fibula/shaft/Segond fracture // differentiated imaging

Meniscal injury // Positive Thessaly / McMurray’s Test / Appleys

Pes anserine // Tenderness over insertion, RSC of adductors

S1/S2 Nerve Root // Slump, Neurological, Reflexes

Plica // Pain with patella compression and medial glide

Baker’s Cyst // Palpation, area of swelling

Osteochondritis Dessicans // Stiffness through ROM

Biceps Femoris Tendon Injury // Focal tenderness, pain with hamstring RSC, reduced hamstring length

Popliteus, plantaris muscle injuries // Tenderness in popliteal space, dynamic assessment


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In association with Peter Migliore and Sanjana Soni