Posterior Cruciate Ligament (PCL) Injuries

Although the knee may look like a simple joint, it is one of the more intricate and most likely to be injured. It is estimated that there are 676 000 knee injuries in Australia each year. Injury may occur from a work place incident, from sport activity or direct/indirect trauma to the knee. Posterior cruciate ligament injuries often go undiagnosed as physicians may be unfamiliar with posterior cruciate ligament (PCL) injuries since the PCL injuries occur less often than the anterior cruciate ligament (ACL) and the injury may have little presentation. Recent developments in understanding of PCL anatomy, biomechanics and imaging have started a shift in the paradigm of PCL injuries and reconstruction. These injuries may actually be more common than originally thought, accounting for an estimated 3% of all knee injuries and 37% of soft-tissue knee injuries.

Posterior cruciate ligament (PCL) is taught (tight) when the knee is flexed, resulting in most PCL injuries occurring in flexion. The most common cause of PCL tears are sports injuries (37%) and trauma (56%) often involving a forceful blow to the front of a bent knee or a hyperextension of the knee. Damage to the posterior cruciate ligament results in the posterior instability of the knee joint. Clinical presentation can vary extensively, depending on the level of severity, type of injury and associated trauma. Knee pain, swelling and stiffness might be the only presenting symptoms. The traditional feeling of a ‘pop’ associated with anterior cruciate ligament (ACL) injuries is unlikely to be evident at the time of injury. Similarly, signs of mechanical instability may not be obvious or identified.

The rehabilitation life cycle for a PCL injury is dependent on the degree of injury (grade I, II or III tear) and type of treatment received (conservative or surgical intervention). According to the study of Rosenthal et al isolated PCL injuries of all degrees can be managed without surgical interventions, whereas Fanelli et al. only treat grade I or II PCL injuries in their practice without surgical intervention.

Non-operative management goals for rehabilitation include reducing pain and inflammation, restoring range of motion, early weightbearing and regaining strength, especially of the quadriceps muscle group. Strengthening the quadriceps is a key factor in a successful recovery because the quadriceps can take the place of the PCL to a certain extent, helping to prevent the femur from moving too far forward over the tibia. Strengthening hamstrings and posterior chain should also be incorporated.

Closed chain exercises are recommended for grade I and II PCL injuries. They do not only increase muscle strength, but also have a positive effect on balance, proprioception and coordination. Once the strength and endurance has been regained, the patient can move on to an agility-based program. Patients that are not able to progress to functional exercises and continue to have pain may need surgical intervention. For a tailored pre-habilitation and/or rehabilitation programme, please contact the Exercise Physiologists at Absolute Balance today.

Victoria Bago (B.Sc-ExSportsSc, GraddipSc – ExRehab, GraddipEd-Sec)

Accredited Exercise Physiologist (AEP) (ESSAM)

Reference

Tarek Boutefnouchet and Ayaz Lakdawala (2015). Posterior cruciate ligament avulsion injury. Review current concepts and surgical approaches to deal with PCL avulsion injury

R.Sivakumar and  P.Kuma (2017). Tibial avulsion fractures of pcl—A comparison of outcomes between isolated, associated and missed injuries

Hiroyasu Ogawa (2015). Posterior cruciate ligament mediated avulsion fracture of the lateral tibial condyle: a case report. Journal of Orthopaedic Surgery and Research

Charles S Peterson, MD; Chief Editor: Craig C Young (2017). Posterior Cruciate Ligament Injury Treatment & Management. Journal of Orthopaedic Surgery and Research