PCL

PCL - Posterior Cruciate Ligament Injury

Article by John Miller

What is a PCL (Posterior Cruciate Ligament) Injury?

One of the most common knee joint problems is a posterior cruciate ligament (PCL) tear.

The posterior cruciate ligament is one of four ligaments that are critical to the stability of the knee joint. Your PCL originates from the medial aspect of the medial femoral condyle and branches into two bundles. The posteromedial and anterolateral bundle before inserting into the posterior aspect of the tibia. (Margheritini et al., 2002)

The PCL is made of sturdy fibrous material and functions to control excessive motion by limiting joint mobility. In particular, it resists hyperextension, posterior tibial displacement and provides a rotational axis and stability. It prevents excessive tibial external rotation. (Magee D., 2008)

Of the knee’s four major ligaments, the PCL injury is the least common knee ligament injury. It is responsible for between 3% and 23% of knee injuries. It has a cross-sectional area 1.5 times that of your ACL. (DeBurca N. 2010, Brown JR, Trojian TH. 2004)

What Causes a PCL Injury?

A PCL injury usually occurs by forced hyperextension or a posterior translation of the tibia. It is common in motor vehicle accidents (knee into dashboard) and a sports-related injury (landing in a kneeling position or hyperextension). Your PCL can also be injured in high rotational injuries and associated with an ACL or MCL injury. (Margheritini et al., 2002)

What are the Symptoms of a PCL Tear?

Several methods make the diagnosis of a PCL injury. Patients who have a PCL injury can sometimes be unaware and may notice disability rather than instability. Symptoms are often vague. Unlike an ACL injury, when many hear or feel a “pop” in their knee, PCL injuries can be silent in isolation. (Brown JR, Trojian TH. 2004, Margheritini et al., 2002)

How is a PCL Tear Diagnosed?

On examination, your physiotherapist or sports doctor will look for clinical signs of posterior instability of the knee. These specialised tests place stress on the PCL and detect a torn ligament and the extent of the PCL tear.

An MRI may also be used to determine if the posterior cruciate ligament is ruptured or overstretched. And also to look for signs of any associated injuries in the knee, such as bone bruising, meniscus damage and other ligament damage.

How is a PCL Tear Treated?

Grade I / II

Researcher consensus is that mild and moderate PCL injuries (grades I and II) typically respond very well to non-operative physiotherapy treatment. Ideally, acute PCJ injuries should commence rehabilitation within four days of post-injury. (Wind W et al. 2004, Cross M et al., 1984)

The prognosis is good for grade I and II PCL injuries who follow a physiotherapist-supervised rehabilitation program. (Voos J et al., 2012)

Grade III

Grade III PCJ injuries may require surgery if your functional needs, e.g. sport, require an intact PCL. Many PCL injuries can go unrepaired if they are not showing signs of constant pain, swelling, instability or disability. Grade III PCL injuries in isolation can usually avoid surgery with the appropriate rehabilitation. (Maclean et al., 2001)

It is essential to exclude concomitant injuries such as the posterolateral corner or ACL. Each PCL case differs, and we recommend a professional opinion from your sports physiotherapist or knee surgeon.

There are several important factors to consider before deciding to undergo ACL surgery.

  1. Do you regularly perform activities that generally require a functional PCL?
  2. Do you experience knee instability?
  3. What other ligaments and structures did you damage?

If you don’t do multidirectional sports requiring a PCL, and you don’t have an unstable knee, you may not need PCL repair surgery.

Physiotherapy

Most patients with a PCL tear start to feel better within a few weeks of the injury. These individuals may feel as though their knee is pain-free, but the problems with knee instability and giving way may persist. It is also essential to allow at least six weeks for the natural ligament healing process to occur.

Whether or not you require PCL surgery or not, you should undertake a comprehensive knee rehabilitation program that involves strengthening, proprioception and high-level balance retraining, plus sport-specific agility and functional enhancement.

Your physiotherapy treatment will aim to:

  1. Reduce pain and inflammation.
  2. Normalise joint range of motion.
  3. Strengthen your knee: esp quadriceps (esp VMO) and hamstrings.
  4. Strengthen your lower limb, including your calves, hip and pelvis muscles.
  5. Improve patellofemoral (knee cap) alignment
  6. Normalise your muscle lengths
  7. Improve your proprioception, agility and balance
  8. Improve your technique and function, e.g. walking, running, squatting, hopping and landing.
  9. Minimise your chance of re-injury.

Please discuss your knee injury after a thorough examination from a knee injury clinician such as a sports physiotherapist, sports physician or knee surgeon.

PCL Repair Surgery

Surgery for a PCL tear is called a PCL repair, but they often include repairs to other ligaments. A typical example of this is a posterolateral corner reconstruction.

Post-Surgical PCL Physiotherapy Rehabilitation

Post-operative PCL repair rehabilitation is one of the most critical aspects of PCL reconstruction surgery. The most successful and quickest outcomes result from the guidance and supervision of an experienced Sports Physiotherapist.

Your rehabilitation following PCL surgery focuses on restoring full knee motion, strength, power and endurance. While protecting the healing repaired ligament in the early phase, you’ll require proprioception, balance and agility training. Individualised exercises are focused on your specific sporting or functional needs.

As mentioned earlier, your sports physiotherapist is an expert in this field. Please get in touch with them for the best advice in your circumstances.

What Sports have a High Incidence of PCL Tears?

Many sports require a functioning PCL to perform manoeuvres such as landing, jumping, twisting and hyperextension.

These high demand sports include AFL, football, rugby, netball, touch, basketball, tennis, volleyball, hockey, dance, gymnastics, skiing and many more.

You may be able to function in your normal daily activities without a healthy PCL, but these high-demand sports may prove difficult. Athletes often face the decision to undergo reconstructive surgery to return to their previous level of competition. PCL injuries may curtail many promising sporting careers.

How to Prevent PCL Tears?

Preventing knee ligament injuries, including PCL tears, has been the focus of recent research for many years. Current investigations have focused on strengthening, dynamic, proprioceptive and neuromuscular training to prevent PCL tears. Prevention protocols are being improved and supported by researchers. For the latest advice, please ask your sports physiotherapist for prevention exercises and strategies. For more advice, please consult with your sports physiotherapist.

Braces for PCL Tears

Some patients will try a PCL brace. The brace required will need to stabilise your knee to avoid hyperextension and possibly multi-directionally if other ligaments are injured. While trialling a PCL brace is understandable, the success lies in the extent of your PCL instability.

In other words, highly unstable PCL’s may give out eventually regardless of the brace. However, mild instabilities may allow you to work and undertake non-directional change sport if you wear a PCL brace.

Return to Sports with a PCL Tear

Most athletes will typically have no significant trouble returning to sport following a PCL injury in isolation. However, an ACL or posterolateral corner injury complication will require special consideration depending upon your specific injury and the sport you wish to resume.

Knee Brace for a PCL Injury

Many patients will try a PCL brace. The knee brace required will need to stabilise your knee multi-directionally. While trialling a PCL brace is understandable, the success lies in the extent of your ACL instability.

In other words, highly unstable PCL tears will give out eventually regardless of the brace unless custom-made and moulded specially to your knee. However, mild instabilities may allow you to work and undertake non-directional change sport if you wear a PCL brace. These PCL braces are costly.

Common Causes - Knee Pain

Knee pain can have many origins from local injury, referred pain, biomechanical issues and systemic issues. While knee pain can appear simple to the untrained eye, a thorough assessment is often required to ascertain the origin of your symptoms. The good news is that once a definitive diagnosis is determined, most knee pain quickly resolves with the correct treatment and rehabilitation.

Knee Ligament Injuries

Knee Meniscus Injuries

Kneecap Pain

Knee Arthritis

Knee Tendon Injuries

Muscle Injuries

Knee Bursitis

Children’s Knee Conditions

Other Knee-Related Conditions

Knee Surgery

Knee FAQs

For specific information regarding your knee pain, please seek the assistance of a healthcare professional with a particular interest in knee condition, such as your knee physiotherapist.

Acute Injury Signs

Acute Injury Management.

Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.

For detailed information on specific injuries, check out the injury by body part section.

Don't Ignore these Injury Warning Signs

Joint Pain

Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.

Tenderness

If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.  

Swelling

Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.

Reduced Range of Motion

If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.

Weakness

Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.

Immediate Injury Treatment: Step-by-Step Guidelines

  • Stop the activity immediately.
  • Wrap the injured part in a compression bandage.
  • Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
  • Elevate the injured part to reduce swelling.
  • Consult your health practitioner for a proper diagnosis of any serious injury.
  • Rehabilitate your injury under professional guidance.
  • Seek a second opinion if you are not improving.