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
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 athlete or active adult with knee pain" and "General evaluation of the adult with 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 taught in flexion; the PM bundle is tight in extension but becomes progressively more slack in 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 .
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- 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