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)
Local
– 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)
Remote
– unlikely to have any changes if acute
General
– 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;
FWB
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
References
Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.
Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.
Castro, C & João, T 2019, ‘Intrinsic and Extrinsic Risk Factors for Lateral Ankle Sprain: A Literature Review’, Archives of Sports Medicine, vol. 3, 09/14.
D’Amato, M 2018 ‘Posterior Cruciate Ligament Injuries’ in C Giangarra & R Manske (eds) Clinical Orthopaedic Rehabilitation, Elsevier, Philadelphia, PA, pp – 359-367
Fowler, PJ & Messieh, SS 1987, ‘Isolated posterior cruciate ligament injuries in athletes’, The American Journal of Sports Medicine, vol. 15, no. 6, 1987/11/01, pp. 553-57.
Heyworth, J 2003, ‘Ottawa ankle rules for the injured ankle’, BMJ (Clinical research ed.), vol. 326, no. 7386, pp. 405-06.
Schüttler, KF, Ziring, E, Ruchholtz, S & Efe, T 2017, ‘[Posterior cruciate ligament injuries]’, Unfallchirurg, vol. 120, no. 1, Jan, pp. 55-68.
Sheng, A 2019, ‘Postereior Cruciate Ligament Sprain’ in Walter F, Julie K.S, Thomas D.R (eds) Essentials of Physical Medicine and Rehabilitation Musculoskeletal Disorders, Pain and Rehabilitation, Elsevier, Philadelphia PA, pp – 424 – 430
In association with Peter Migliore and Sanjana Soni