The Posterior Cruciate Ligament (PCL) is one of the four major ligaments of the knee joint that functions to stabilize the tibia on the femur. It originates from the anterolateral aspect of the medial femoral condyle in the area of the intercondylar notch and inserts onto the posterior aspect of the tibial plateau. It functions to prevent posterior translation of the tibia on the femur. To a lesser extent, the PCL functions to resist varus, valgus, and external rotation forces. It is approximately 1.3 to 2 times as thick and about twice as strong as the anterior cruciate ligament (ACL) and, consequently, less commonly subject to injury.
Injuries to the PCL are caused by an extreme anterior force applied to the proximal tibia of the flexed knee. Common causes include dashboard injuries where the knee is forced into the dashboard during a motor vehicular collision. The PCL also can be injured secondary to falling forward onto a flexed knee. The most common sports where PCL injuries occur are football, skiing, soccer, and baseball. Less commonly, damage can occur due to a rotational hyperextension injury to the knee joint.
According to a 2003 study by Schulz et al., the mean age of PCL injuries was 27 years. The two most common causes of PCL injury were car accidents (45%) and athletic injuries (40%). Specifically, the two most common causes of injury are motorcycle accidents (28%) and soccer-related injuries (25%). The most common injury mechanism was dashboard injuries (35%) and falls on a flexed knee with the foot in plantar flexion (24%). The male to female ratio is 2:1.
The PCL originates from the anterolateral aspect of the medial femoral condyle in the area of the intercondylar notch and inserts extra-articularly onto the posterior aspect of the tibial plateau. It is 1.3 to 2 times as thick and about two times the strength of the ACL. It can be further separated into anterolateral and posteromedial bundles. The anterolateral and posteromedial bands are respectively 65% and 35% of the body of the PCL. The anterolateral bundle is taught in knee flexion and lax in knee extension where the posteromedial bundle is tight in knee extension and lax in knee flexion. The function of the PCL is to prevent posterior translation of the tibia on the femur. Because a majority of the injuries occur in knee flexion, the anterolateral portion is more commonly injured. The PCL is the primary restraint to posterior tibial translation between 30 degrees and 90 degrees. At 90 degrees, the PCL accepts 95% of posterior translational forces. It resists posterior translation with the assistance of the posterolateral joint capsule, popliteus, medial collateral ligament, and posterior oblique ligament.
The Posterior cruciate ligament receives blood supply from the middle geniculate artery and is innervated by the tibial nerve.
Patients often will present with complaints of acute onset of posterior knee pain, swelling, and instability. A thorough history includes the mechanism of injury, such as trauma from falling onto a flexed knee or recent motor vehicle accident. There may or may not be a complaint of a “pop” with PCL tears like those frequently reported with ACL tears.
A thorough knee exam should be performed, including gait assessment. The neurovascular integrity of the lower extremity distal to the injury should also be assessed.
Initial imaging should be limited to plain X-rays. Include ipsilateral standing AP, 45 degree flexion, weight bearing, and merchant patellar views with contralateral views to assess for associated fractures, arthritis, joint effusion, and the 45-degree flexion view may show a positive sag compared to the contralateral knee.
MRI is the gold standard for evaluation of a PCL injury. It has been reported to have accuracy in the range of 96% to 100%. It can also assess for concomitant injuries such as meniscal, Ligamentous, posterolateral joint capsule, popliteus, medial collateral ligament, and posterior oblique ligament injuries.
PCL injuries are graded on a scale of I-III.
Non-operative treatments are indicated for acutely isolated grade I and II injuries. Acute treatment involves RICE (rest, ice, compression, and elevation). Rehabilitation is important with a focus on knee extensor strengthening. Estimated return to play is 2 to 4 weeks. Grade III injuries can be treated with knee immobilization x 4 weeks with a transition to rehabilitation focusing initially on passive range of motion to knee extensor strengthening.
Operative treatment is reserved for combined capsuloligamentous injuries, grade II or grade III injuries with bony avulsion, or chronic PCL injuries with instability.
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