Author(s): Ajay Patel, MD, Katherine Victoria Yao, MD
Originally published: January 30, 2014 Last updated: July 20, 2021
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Disease/ Disorder

Definition

The posterior cruciate ligament (PCL) is the largest and strongest intra-articular extrasynovial ligament of the knee. The PCL is the counterpart to the anterior cruciate ligament (ACL), and is one of the four main ligaments that stabilize the knee joint. The PCL tracks posteriorly and inferiorly and provides posterior stability of the tibia on the femur, and acts as a secondary restraint to resist varus, valgus, and external rotation movements at the knee.1

Etiology

Injury to the PCL may be the result of direct trauma. Motor vehicle collisions (MVC) account for 45% of injuries while 40% are attributed to athletic injuries.2 The PCL functions to prevent the femur from continuing to move anteriorly on the tibia and prevent the tibia from moving posteriorly on the femur.3 Thus, PCL injuries tend to occur with a sudden posterior tibial translation mechanism. The PCL also functions to limit external rotation of the tibia. PCL tears that result from an MVC are typically due to the knee striking the dashboard-knee bar.4 In sports activities, injury to the PCL usually occurs when the knee strikes the ground in a hyperflexed position. This is commonly seen in football, soccer, rugby, and skiing.5 In contact or combat sports, the PCL may be injured with a posteriorly directed blow to the proximal tibia when the foot is flexed on the ground. Many individuals who have sustained an isolated PCL injury often continue to participate in sports without functional limitations, thus lowering the reported incidence.6 Knee injuries associated with rotation and a concomitant varus or valgus force may also injure the PCL.7

Epidemiology including risk factors and primary prevention

PCL injuries occur less commonly than ACL injuries; PCL injuries occur in only about 3% of all knee injuries.8 Up to 95% of PCL tears occur in combination with other ligament tears.5 Isolated PCL injuries are rare and comprise only 3.5-7.5% of trauma related injury.9,10

PCL injuries are most seen in men between the ages of 18 and 44 years old.7 The type of injury that occurs to the PCL appears to be patient- and activity-dependent. Universally, a high velocity activity or trauma is more likely to result in injury to the PCL than at a lower velocity.3

There is some evidence that PCL injury can be prevented with proper warm-up and stretching. Proper aerobic and weight training, with proprioceptive training, can assist in avoiding these types of injuries.11

Patho-anatomy/physiology

The PCL attaches to the anterolateral aspect of the medial femoral condyle and the posterior tibial surface. The PCL is composed of anterolateral and posteromedial components. The anterolateral component is the larger and stronger of the two. Historically, the anterolateral component and posteromedial component were thought to function independently in a reciprocal nature, with the anterolateral component taut during flexion and posteromedial component taut in extension. However, recent studies have shown that both components play a significant role in resisting posterior tibial translation at all flexion angles.5

The vascular supply for the PCL is provided by the middle genicular artery, a branch of the popliteal artery. Secondary blood supply is derived from the inferior medial and lateral genicular arteries.12 Innervation is provided by the posterior articular nerve, which is a branch of the tibial nerve.13

The PCL functions to resist posterior displacement of the tibia in relation to the femur, prevent hyperextension, and limit varus/valgus rotation. The PCL also resists external rotation of the tibia on the femur.1 This combination of support by the PCL accounts for 85% to 100% of the restraint of tibial translation of the knee in flexion.14

PCL injuries can occur in isolation but are more often a component of multi-ligament knee injuries.15 PCL injuries are associated with ACL injuries in 46% of cases, medial collateral ligament injuries in 31% of cases, and injuries to the posterolateral corner in 62% of cases.10 The posterolateral corner of the knee is made up of the popliteus muscle, the posterior capsule fibers, the lateral meniscus, lateral cruciate ligament, and iliotibial band.1,16

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

In most cases of PCL injury, trauma is the cause. The patient may describe an event such as an MVC or sports contact injury to the knee that leads to a physical examination and/or imaging of the joint.10

In some cases, a PCL injury may go undiagnosed. A patient may present months after an injury with mild symptoms of pain and knee instability.9,10

Specific secondary or associated conditions and complications

When an isolated PCL tear diagnosis is missed, a chronic PCL tear may persist and result in secondary problems in the knee joint. Symptoms include ongoing pain and instability in the joint, as well as an alteration in gait pattern. The natural history of a chronic PCL tear is increased pain, arthrosis in the medial and patellofemoral compartments, and meniscal breakdown.16

When the PCL injury is more complex, other structures in the knee may also be damaged. This commonly involves the PCL and the posterolateral corner of the knee.3 This is more common in a high velocity trauma to the knee. Often, with PCL tears and trauma, a contusion of the proximal anterior tibial surface will be seen on magnetic resonance imaging (MRI). Other structures of the posterolateral corner that may be involved include the lateral meniscus, articular cartilage surfaces on the tibia and femur, lateral cruciate ligament, and iliotibial band.17

Essentials of Assessment

History

In an acute injury, it is important to focus on the mechanism of action of the injury and the type of trauma to the knee. In the case of trauma, such as a MVC, knowing that the knee bar was struck can help. In sports-related injuries, the act is often witnessed and thus the mechanism can often be described. It is important to consider concurrent damage to other ligaments as isolated PCL injuries are rare.

Patients may describe an audible pop at the time of injury, but this is less common with PCL injuries compared to ACL injuries. Typically, patients will complain of a mild to moderate knee effusion, pain in the back of the knee aggravated by squatting or kneeling, and loss of terminal knee flexion. Complaints of joint instability are more common with multiple knee ligament injuries. Antalgic gait is frequently present, with significant guarding of the knee with ambulation.3,4

In the patient with a chronic PCL tear, complaints of pain and aching are localized to the anterior knee, in particular the medial compartment or patellofemoral joint. Patients will notice disability more so than instability that is prevalent when maneuvering incline surfaces, such as stairs or ramps.5 In some cases, patients may describe a feeling of give-way or instability.3

Physical examination

On inspection, look for clues of trauma, such as contusions or lacerations. Other findings may include swelling, effusions, muscle atrophy, malalignment, and ecchymosis. Presence of an effusion is more likely to be present following acute injuries rather than chronic injuries. This should be followed by palpation of the joint, evaluation of range of motion which may be reduced by 10-20 degrees, neurovascular testing, special tests, and gait assessment.

Multi-ligament knee injuries are associated with vascular compromise, and the popliteal artery is at greatest risk. Concurrent damage to the ACL, PCL, and LCL is associated with a 32% incidence of vascular compromise, while posterior dislocation injuries are associated with vascular compromise 25% of the time.35 For this reason, it is imperative that immediate vascular assessment is performed by assessing distal pulses. If abnormalities are found, then an ankle-brachial index and further radiographic imaging should be considered.35

Special tests that can be done to assist with PCL evaluations include the following:

  1. Posterior Drawer Test: The patient lies supine with hips flexed to 45 degrees and knees flexed to 90 degrees. A posterior force is applied to the proximal tibia, while stabilizing the foot. When the PCL is torn, laxity will be apparent as compared to the contralateral knee. Sensitivity for this test varies from 0.22-1.00, while specificity is 0.98.33
  2. Posterior Sag Sign: The patient lies supine with hips flexed to 45 degrees and knees flexed to 90 degrees. Sagging of the tibia compared to the contralateral side suggests a PCL tear. Sensitivity ranges from 0.46-1.00, while specificity is 1.00.33
  3. Quadriceps Active Test: The patient lies supine with hips flexed to 45 degrees and knees flexed to 90 degrees. The foot and thigh are stabilized, and the patient is asked to contract the quadriceps muscles.  With a PCL tear, anterior tibial translation may be seen. Sensitivity is between 0.53-0.98, while specificity is 0.96-1.00.33
  4. Dial test: The patient lies prone. The relative degree of external rotation is compared side-to-side with the knees flexed to 30 and subsequently to 90 degrees. An increase in more than 10 degrees of external rotation at both positions suggests a possible posterolateral corner injury and PCL injury, while an increase only at 30 degrees suggests that the PCL is intact, but an isolated posterolateral corner injury exists.18 Sensitivity is 0.20 and specificity is 1.00.34

An antalgic gait pattern is common in patients with acute PCL injury. Patient’s may also have a varus thrust of the affected leg during mid-stance, which would suggest instability.

Imaging

After completion of the physical examination, if there is suspicion of a PCL tear, or bony fracture, x-rays with weight bearing A/P, lateral, sunrise, and tunnel views should be obtained.19 More recently, kneeling stress radiography of the joint has been incorporated to evaluate for knee instability; with PCL laxity, posterior tibial subluxation may be demonstrated on stress views.5 The bony anatomy and alignment of the tibia, femur, and patella can be evaluated with x-ray to assess for fractures and avulsion injuries. More detail about the soft tissues, ligaments, and menisci can be obtained from an MRI of the knee. MRI has a high sensitivity and specificity for diagnosing acute PCL tears20; however, it should be cautioned that 57% of chronic PCL tears may appear nearly normal on MRI due to ability of the ligament to heal.21 Degenerative changes in the medial and patellofemoral compartment can be suggestive of chronic PCL tears if ligament appears intact on MRI.38 This should be clinically correlated with signs and symptoms of instability, difficulty decelerating, or instability when ambulating inclined services like stairs and ramps to help determine if a PCL injury could be present.38

Supplemental assessment tools

PCL tears can be graded based on the type and quality of tear:

  1. Grade I – sprain with preservation of knee stability
  2. Grade II – partial tear with laxity on examination
  3. Grade III – complete tear with knee instability
  4. Grade IV – complete tear of PCL combined with other ligamentous damage and knee instability

Environmental

An injury to the PCL is commonly associated with a trauma or sports activity. Many times, in the case of trauma, an MVC is the cause, with the result of contact to the knee bar.

As for patients who are involved in sporting activities, those who participate in contact sports are more likely to sustain an injury to the PCL. High velocity activities with contact place a higher risk on PCL injury.

Professional Issues

Return-to-play will be the first question from most patients, followed by treatment options, and how much time is required for rehabilitation. It may be necessary for the physician to manage player, coach, therapist, and trainer.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Management of PCL injuries is dependent on first identifying if the injury is acute or chronic. Grade I and II acute injuries with posterior tibial translation between 8mm and 12mm suggests an isolated ligament injury and can be managed non-operatively.39 Grade III injuries who are mildly symptomatic or participate in low demand activities can also forego surgical intervention.39 Posterior tibial translation >12mm is concerning for a combined injury, which is managed surgically.39 Chronic PCL tears are treated surgically only in cases of posterior tibial translation > 8mm, the presence of PCL related symptoms, such as difficulty with deceleration or difficulty negotiating inclines such as stairs or ramps.39

Because the PCL requires a prolonged time for healing, as compared with the ACL, appropriate and timely rehabilitation is crucial for successful recovery. Although different rehabilitation programs exist, key elements of the course should include progressive weight bearing, prevention of posterior tibial subluxation, and early quadriceps strengthening.5

With grade I and II PCL tears, physical therapy and rehabilitation programs focus on proprioception and quadriceps and hamstring strengthening. Eccentric quadriceps muscle contractions with lunges and squats can be initiated.22,23 A core strengthening program should be started, and assessment of the kinetic chain should be completed. Knee braces, which provide anterior and posterior support, may be utilized.24,25

The rehabilitative course for a non-operative approach to PCL tears has three phases.

Phase I (initial 6 weeks post-injury): consists of early passive mobilization, partial weight bearing, and hamstring, quadriceps, and gastrocnemius stretching.

Phase II (6-12 weeks post-injury): emphasizes quadriceps strengthening, range of motion, and proprioceptive training.

Phase III (13-18 weeks post-injury: the patient eases into running and sport-specific training.

In the final phase, the patient usually will return to sport about 4 to 8 months after the initial injury, marked by full quadriceps strength.26

For grade II, III and IV tears of the PCL, surgical options should be considered in the active high-functioning patient and athlete.3,4,24 Complete PCL tears, grade III and IV, treated non-operatively have been reported to increase the long-term risk of degenerative changes of the medial and patellofemoral compartment, and were associated with poor function.5

A PCL tear is more likely to be treated surgically when it is a component of a multi-ligament knee injury, though repair versus reconstruction and optimal timing of surgery remain unclear.27

PCL tears with avulsions from either the femoral or tibial surface should be repaired with a pinning surgical process.3,4

Surgical repair of a PCL injury has several benefits as well as associated risks. Benefits include improvement in instability symptoms including, but not limited to, difficulty with deceleration and descending stairs.36 Surgical repair can also help decrease risk of long-term changes such as subsequent meniscal injuries and articular cartilage degeneration.36 Risks associated with surgical repair of the PCL, as seen with other surgeries, include infection and pain at the surgical site. Residual posterior laxity is the most common risk associated with PCL repair.37 Bleeding and motor or sensory deficits can occur due to popliteal artery laceration and tibial nerve injury respectively.37 Osteonecrosis of the medial femoral condyle and fracture of the tibia are rare but may occur following surgery.37

In post-surgical PCL repair, the purpose of the rehabilitation course is to establish a return to full range of motion of the knee. Phase 1 timeline varies from 0 to 6 weeks with a focus on protecting the integrity of the graft while introducing passive ROM and muscle firing. Phase 2 varies from 4 weeks to 3 months and focuses on return to full ROM, recovery of a normal gait pattern, full weight bearing and practice of ADLs. Phase 3 occurs between 3 to 6 months and focuses on strengthening and straight line running. Phase 4 varies from 6 to 12 months with a focus on higher level activities including jumping, agility, and lateral movements. Phase 5 occurs after 9 months and focuses on sport specific objective goals and return to play.28 One functional marker that is used to establish return to full function is quadriceps strength. Once quadriceps muscle strength is greater than 90% of the contralateral side, full level activity may be initiated.9

Patient & family education

When discussing treatment options, whether conservative or surgical, the risks and benefits should be explained to the patient. Patient education regarding the injury and process of injury is important. This will allow the patient to develop goals and motivation for the rehabilitative process, whether surgical correction is needed or not. Discussing the biomechanics of the PCL and knee joint with the patient, family, trainers, etc., may also help to prevent future injury. Stressing the importance of a rehabilitation program for the patient is key. Developing a home exercise program and routine to strengthen the knee will also play a key role.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Patients with PCL injury most often will present with a history of trauma. Whether they undergo conservative or surgical treatment, they need to complete a rehabilitation program to re-establish strength and range of motion.

A focus on the kinetic chain and core strengthening should also be discussed and established. Working on the core muscles, incorporating plyometics, and understanding the concept of kinetic chain theory can help advance a patient’s rehabilitation.

Patients with previous PCL injury are prone to knee problems such as meniscal breakdown, patellofemoral syndrome, and arthrosis. Being aware of these problems and educating patients may help prevent such complications.

Chronic PCL injuries can result in complications such as residual laxity and loss of range of motion, most notable with knee flexion.27

Cutting Edge/ Emerging and Unique Concepts and Practice

Ultrasound is limited in its ability to assess the PCL, but it may reveal changes such as enlargement of the ligament compared with the contralateral knee or focal disruption in ligament continuity. Ultrasound may offer a viable alternative for diagnosing chronic PCL tears not seen on MRI due to healing, but more research is needed to determine the capacities of ultrasound in assessment of PCL injury. 

There have been reports of regenerative medicine being used to treat type 1 and 2 ligament injuries of the knee, particularly the ACL. However, this has not been well studied regarding the PCL. Further studies are needed to assess the efficacy of orthobiologic agents to heal partial PCL tears.

At present, repair of the PCL can be done with an autograft or allograft. The Achilles tendon is the most commonly used allograft.15 Autograft is typically harvested from the patellar tendon or hamstrings.15 Controversy exists regarding taking an autograft, when harvested from the patellar tendon, as harvesting from the patellar tendon may weaken the quadriceps muscle group and inhibit rehabilitation.9 Bone-patellar tendon-bone autografts are also being used, but it is unclear if there is any benefit to use of remnant-bone technique as compared to conventional techniques.

Techniques for surgical replacement of the PCL are debatable. Four techniques are currently used: trans-tibial, tibial inlay, single bundle, and double bundle approaches. The single bundle technique is considered the “classic” approach to the PCL reconstruction. One prospective study comparing single bundle and double bundle techniques revealed statistically significant improvements in posterior stability with the double bundle technique when compared to single bundle; however, the remainder of the data did not clearly establish superiority of the double bundle technique over the single bundle technique.29 Further studies are needed to evaluate differences in outcomes amongst the techniques used for PCL reconstruction.

Gaps in the Evidence- Based Knowledge

Additional research is needed to compare outcomes of surgical versus conservative management of PCL injuries, particularly with respect to different populations based on age and activity levels. Studies have demonstrated that degenerative wear after PCL reconstruction occurs regardless of posterior knee stability30; given these outcomes and both the risk of limb-length imbalance after reconstruction in immature populations31 and the possible need of revision procedures32, surgical interventions should be rigorously compared to non-operative approaches.

References

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Original Version of the Topic

Steve M. Aydin, DO. Posterior cruciate ligament (PCL) injuries. 1/30/2014

Original Version of the Topic

Steve M. Aydin, DO. Posterior cruciate ligament (PCL) injuries. 2/13/2017

Author Disclosure

Ajay Patel, MD
Nothing to Disclose

Katherine Victoria Yao, MD
Nothing to Disclose