Posterior cruciate ligament injury
- James MacDonald, MD, MPH, FAAFP, FACSM
James MacDonald, MD, MPH, FAAFP, FACSM
- Nationwide Children's Hospital, Division of Sports Medicine
- Clinical Assistant Professor of Pediatrics and Family Medicine
- The Ohio State University
- Richard Rodenberg, MD
Richard Rodenberg, MD
- Associate Professor of Pediatrics
- Nationwide Children’s Hospital
- The Ohio State University
- Section Editor
- Francis G O'Connor, MD, MPH, FACSM
Francis G O'Connor, MD, MPH, FACSM
- Section Editor — Sports-Related Injuries; Symptom Assessment and Physical Examination; Medical Issues Related to Sports and Exercise
- Professor of Military and Emergency Medicine
- Uniformed Services University of the Health Sciences
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The posterior cruciate ligament (PCL) is the primary restraint to posterior translation of the tibia at the knee joint [1-4]. The bulk of injuries to this ligament occur in combination with other internal derangements of the knee in association with multi-ligament trauma; isolated PCL injuries are uncommon [5,6]. The PCL is the knee ligament least frequently injured during sports [5-7]. Over time, increasing knowledge of the anatomy and biomechanics of this ligament has highlighted its importance with regard to knee stability and function. As isolated injury is uncommon, the natural history of injury has yet to be elucidated fully.
The presentation, evaluation, diagnosis, and nonoperative management of PCL injuries are reviewed here. Other knee injuries and an overall approach to knee complaints in active adults are discussed separately. (See "Anterior cruciate ligament injury" and "Medial collateral ligament injury of the knee" and "Lateral collateral ligament injury and related posterolateral corner injuries of the knee" and "Approach to the adult with knee pain likely of musculoskeletal origin" and "Approach to the adult with unspecified knee pain".)
ANATOMY AND BIOMECHANICS
The posterior cruciate ligament (PCL) is the largest and strongest of the intra-articular ligaments of the knee, originating at the lateral border of the medial femoral condyle and inserting at the posterior tibia in a depression called the PCL facet (fovea centralis) that lies between the medial and lateral tibial plateaus (picture 1 and figure 1 and figure 2) [1,2,8,9]. The PCL is considered an intra-articular but extra-synovial structure because of the synovial sheath that lines the ligament . The extra-synovial location accounts for the limited swelling seen with isolated PCL injuries. Due to its association with the posterior capsule, blood supply to the PCL is not permanently lost with an intrasubstance tear. This permits primary surgical repair in some cases of PCL injury .
The PCL is structurally divided into two distinct yet inseparable bundles identified as the larger anterolateral (AL) and the smaller posteromedial (PM) bundles. These bundles are distinguished based on function, with each bundle exhibiting different patterns of tension and relaxation depending upon the degree of knee flexion [1,2,8,9]. The PCL works in concert with the meniscofemoral ligaments, which together make up the PCL complex. The meniscofemoral ligaments originate from the posterior horn of the lateral meniscus and insert on the medial femoral condyle anterior to the PCL (ligament of Humphrey inserts anteriorly) and posteriorly to the PCL (ligament of Wrisberg inserts posteriorly). While anchoring the lateral meniscus, these ligaments also act as a secondary restraint to posterior tibial translation [2,4,8,9].
The primary role of the PCL complex is to restrict posterior translation of the tibia with respect to the femur, while also acting as a secondary restraint to external rotation [2,8]. In addition, the PCL protects the extended knee from varus and valgus stress. The role of the PCL in providing posterior knee stability increases as the knee is brought into flexion. The PCL provides 95 percent of posterior stability when the knee is flexed between 30 and 90 degrees . Each bundle of the PCL contributes to joint stability based upon its distinctive fiber orientation in relation to the degree of knee flexion [1,2,8]. Essentially, tension in each bundle develops in a reciprocal fashion during knee flexion and extension: The AL bundle becomes slack in extension but progressively more taut with knee flexion; the PM bundle is tight in extension but becomes progressively more slack with knee flexion [1,8]. Therefore, it may be more useful to consider the PCL as a single, complex structure with a continuum of fibers of different lengths and varying tensions depending on the degree of knee flexion .
- Allen CR, Kaplan LD, Fluhme DJ, Harner CD. Posterior cruciate ligament injuries. Curr Opin Rheumatol 2002; 14:142.
- Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med 2004; 32:1765.
- McAllister DR, Petrigliano FA. Diagnosis and treatment of posterior cruciate ligament injuries. Curr Sports Med Rep 2007; 6:293.
- Voos JE, Mauro CS, Wente T, et al. Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med 2012; 40:222.
- Fanelli GC. Posterior cruciate ligament injuries in trauma patients. Arthroscopy 1993; 9:291.
- Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: Part II. Arthroscopy 1995; 11:526.
- Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. Knee 2006; 13:184.
- Bowman KF Jr, Sekiya JK. Anatomy and biomechanics of the posterior cruciate ligament, medial and lateral sides of the knee. Sports Med Arthrosc 2010; 18:222.
- Flandry F, Hommel G. Normal anatomy and biomechanics of the knee. Sports Med Arthrosc 2011; 19:82.
- Lopez-Vidriero E, Simon DA, Johnson DH. Initial evaluation of posterior cruciate ligament injuries: history, physical examination, imaging studies, surgical and nonsurgical indications. Sports Med Arthrosc 2010; 18:230.
- Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986; 14:35.
- Schulz MS, Russe K, Weiler A, et al. Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg 2003; 123:186.
- Logan M, Williams A, Lavelle J, et al. The effect of posterior cruciate ligament deficiency on knee kinematics. Am J Sports Med 2004; 32:1915.
- Harner CD, Höher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998; 26:471.
- Malone AA, Dowd GS, Saifuddin A. Injuries of the posterior cruciate ligament and posterolateral corner of the knee. Injury 2006; 37:485.
- Davies H, Unwin A, Aichroth P. The posterolateral corner of the knee. Anatomy, biomechanics and management of injuries. Injury 2004; 35:68.
- Fleming RE Jr, Blatz DJ, McCarroll JR. Posterior problems in the knee. Posterior cruciate insufficiency and posterolateral rotatory insufficiency. Am J Sports Med 1981; 9:107.
- Chen FS, Rokito AS, Pitman MI. Acute and chronic posterolateral rotatory instability of the knee. J Am Acad Orthop Surg 2000; 8:97.
- Kozanek M, Fu EC, Van de Velde SK, et al. Posterolateral structures of the knee in posterior cruciate ligament deficiency. Am J Sports Med 2009; 37:534.
- Rubinstein RA Jr, Shelbourne KD, McCarroll JR, et al. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med 1994; 22:550.
- Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc 2013; 21:1071.
- Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee Rule in children: a multicenter study. Ann Emerg Med 2003; 42:48.
- Hall FM, Hochman MG. Medial Segond-type fracture: cortical avulsion off the medial tibial plateau associated with tears of the posterior cruciate ligament and medial meniscus. Skeletal Radiol 1997; 26:553.
- Schulz MS, Steenlage ES, Russe K, Strobel MJ. Distribution of posterior tibial displacement in knees with posterior cruciate ligament tears. J Bone Joint Surg Am 2007; 89:332.
- Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am 2008; 90:1621.
- Polly DW Jr, Callaghan JJ, Sikes RA, et al. The accuracy of selective magnetic resonance imaging compared with the findings of arthroscopy of the knee. J Bone Joint Surg Am 1988; 70:192.
- Fischer SP, Fox JM, Del Pizzo W, et al. Accuracy of diagnoses from magnetic resonance imaging of the knee. A multi-center analysis of one thousand and fourteen patients. J Bone Joint Surg Am 1991; 73:2.
- Gross ML, Grover JS, Bassett LW, et al. Magnetic resonance imaging of the posterior cruciate ligament. Clinical use to improve diagnostic accuracy. Am J Sports Med 1992; 20:732.
- Servant CT, Ramos JP, Thomas NP. The accuracy of magnetic resonance imaging in diagnosing chronic posterior cruciate ligament injury. Knee 2004; 11:265.
- Boks SS, Vroegindeweij D, Koes BW, et al. Follow-up of posttraumatic ligamentous and meniscal knee lesions detected at MR imaging: systematic review. Radiology 2006; 238:863.
- Lee MJ, Chow K. Ultrasound of the knee. Semin Musculoskelet Radiol 2007; 11:137.
- Miller TT. Sonography of injury of the posterior cruciate ligament of the knee. Skeletal Radiol 2002; 31:149.
- Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med 1987; 15:553.
- Bedi A, Musahl V, Cowan JB. Management of Posterior Cruciate Ligament Injuries: An Evidence-Based Review. J Am Acad Orthop Surg 2016; 24:277.
- Fanelli GC, Beck JD, Edson CJ. Current concepts review: the posterior cruciate ligament. J Knee Surg 2010; 23:61.
- Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med 1993; 21:846.
- Mair SD, Schlegel TF, Gill TJ, et al. Incidence and location of bone bruises after acute posterior cruciate ligament injury. Am J Sports Med 2004; 32:1681.
- Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. J Orthop Sports Phys Ther 2010; 40:383.
- Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am 1995; 77:1166.
- Quelard B, Sonnery-Cottet B, Zayni R, et al. Isolated posterior cruciate ligament reconstruction: is non-aggressive rehabilitation the right protocol? Orthop Traumatol Surg Res 2010; 96:256.
- Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go? Arthroscopy 2008; 24:234.
- Edson CJ, Fanelli GC, Beck JD. Postoperative rehabilitation of the posterior cruciate ligament. Sports Med Arthrosc 2010; 18:275.
- Lee BK, Nam SW. Rupture of posterior cruciate ligament: diagnosis and treatment principles. Knee Surg Relat Res 2011; 23:135.
- Rosenthal MD, Rainey CE, Tognoni A, Worms R. Evaluation and management of posterior cruciate ligament injuries. Phys Ther Sport 2012; 13:196.
- Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train 2012; 47:339.
- Shelbourne KD, Clark M, Gray T. Minimum 10-year follow-up of patients after an acute, isolated posterior cruciate ligament injury treated nonoperatively. Am J Sports Med 2013; 41:1526.
- Patel DV, Allen AA, Warren RF, et al. The nonoperative treatment of acute, isolated (partial or complete) posterior cruciate ligament-deficient knees: an intermediate-term follow-up study. HSS J 2007; 3:137.
- Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med 1999; 27:276.
- Agolley D, Gabr A, Benjamin-Laing H, Haddad FS. Successful return to sports in athletes following non-operative management of acute isolated posterior cruciate ligament injuries: medium-term follow-up. Bone Joint J 2017; 99-B:774.
- Hammoud S, Reinhardt KR, Marx RG. Outcomes of posterior cruciate ligament treatment: a review of the evidence. Sports Med Arthrosc 2010; 18:280.
- Jacobi M, Reischl N, Wahl P, et al. Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report. J Bone Joint Surg Br 2010; 92:1381.
- Strobel MJ, Weiler A, Schulz MS, et al. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy 2003; 19:262.
- Wang D, Berger N, Cohen JR, et al. Surgical treatment of posterior cruciate ligament insufficiency in the United States. Orthopedics 2015; 38:e281.
- ANATOMY AND BIOMECHANICS
- MECHANISM OF INJURY
- CLINICAL PRESENTATION
- EXAMINATION FINDINGS
- General knee examination
- Special tests for PCL injury
- Criteria for isolated PCL injury
- Classification of PCL injury
- Associated injuries
- DIAGNOSTIC IMAGING
- Approach to diagnostic imaging
- - Suspected acute PCL injury
- - Suspected subacute or chronic PCL injury
- Plain radiography
- Stress radiographs
- Magnetic resonance imaging (MRI)
- Radionuclide imaging (bone scan)
- INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL
- DIFFERENTIAL DIAGNOSIS
- Anterior cruciate ligament (ACL) injuries
- Lateral collateral ligament (LCL) and posterolateral corner (PLC) injuries
- Meniscal injuries (lateral and medial)
- Proximal tibia fractures
- Knee (tibiofemoral) dislocation
- Bone contusion
- Patellar and quadriceps tendon tears
- INITIAL TREATMENT
- FOLLOW-UP CARE
- Early rehabilitation
- Later rehabilitation
- RETURN TO SPORT OR WORK
- COMPLICATIONS AND PROGNOSIS
- SUMMARY AND RECOMMENDATIONS