PCL - Posterior Cruciate Ligament Injury
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 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.
- Do you regularly perform activities that generally require a functional PCL?
- Do you experience knee instability?
- 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.
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:
- Reduce pain and inflammation.
- Normalise joint range of motion.
- Strengthen your knee: esp quadriceps (esp VMO) and hamstrings.
- Strengthen your lower limb, including your calves, hip and pelvis muscles.
- Improve patellofemoral (knee cap) alignment
- Normalise your muscle lengths
- Improve your proprioception, agility and balance
- Improve your technique and function, e.g. walking, running, squatting, hopping and landing.
- 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 Ligament Injuries
- ACL Injury
- PCL Injury
- MCL Sprain
- LCL Sprain
- Posterolateral Corner Injury
- Superior Tibiofibular Joint Sprain
Knee Meniscus Injuries
- Chondromalacia Patella
- Fat Pad Syndrome
- Patella Dislocation
- Patellofemoral Pain Syndrome
- Osgood Schlatter’s Disease
- Sinding Larsen Johansson Syndrome
Knee Tendon Injuries
- Corked Thigh
- Thigh Muscle Strain
- Hamstring Strain
- ITB Syndrome
- Popliteus Syndrome
- Muscle Strain (Muscle Pain)
- DOMS – Delayed Onset Muscle Soreness
Children’s Knee Conditions
Other Knee-Related Conditions
- Runner’s Knee
- Plica Syndrome
- Stress Fracture
- Overuse Injuries
- Restless Legs Syndrome
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 physiotherapist.
Individuals who experience ACL tears describe a feeling of the joint giving out or buckling. You'll commonly hear a "pop."
Signs You May Have Sustained an ACL Tear:
- Sudden giving way of the knee
- Hearing a 'pop' at the time of injury
- Sudden swelling of the knee joint
- Pain in the knee when walking
How is an ACL Tear Diagnosed?
A well trained Sports Physiotherapist, Sports Physician or Orthopaedic Surgeon will generally be able to confirm the diagnosis of an ACL tear within the clinic and from your injury history.
An MRI scan can confirm your ACL tear and identify other knee injuries that may have occurred when your ACL was ruptured. These accessory injuries commonly include meniscal tears, bone bruising and collateral ligament injuries.
Confirmation of an ACL tear is essential since the treatment differs from a common knee ligament strain or a meniscus tear.
What to do if you have a Ruptured ACL?
Please be guided by your trusted healthcare practitioner for an ACL tear. Successful rehabilitation options vary depending on your age, activity level and extent of the injury. For specific advice, please consult an experienced knee physiotherapist, knee surgeon or sports doctor.
Why are ACL Tears Such a Big Problem?When an ACL injury occurs, the knee becomes less stable. The ACL injury is a problem because this instability can make sudden, pivoting movements difficult, and it may make the knee more prone to developing arthritis and cartilage tears. If your knee is unstable, a common complaint of a sensation that the knee will 'give out' from under them. When this giving way sensation is because of an ACL injury, the knee joint is sliding too much. Joint sliding can be a problem because each episode of instability (the 'giving way' sensation) can cause damage to the knee cartilage. Therefore an ACL injury makes patients more prone to developing arthritis and meniscus tears. Athletes often have particular difficulty once they have sustained an ACL injury. Many sports require a functioning ACL to perform common manoeuvres such as cutting, pivoting, and sudden turns. These high demand sports include, but are not limited to:
- Snow Skiing
- Hockey (Ice and Field)