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PCL Tear (Posterior Cruciate Ligament)

InjuriesKneePCL Tear


(Also known as a PCL Injury, Posterior Cruciate Ligament Tear, Torn PCL, PCL Sprain, Sprained PCL, Ruptured PCL)


What is a PCL tear?

A PCL tear is a relatively common sporting injury affecting the knee and is characterized by tearing of the Posterior Cruciate Ligament (PCL), an important stabilizing structure of the knee.

A ligament is a strong band of connective tissue which attaches bone to bone. The PCL is situated within the knee joint and is responsible for joining the front of the lower aspect of the thigh bone just above the knee joint (distal femur) to the back of the upper aspect of the shin bone just below the knee joint (proximal tibia) (figure 1).

Anatomy of a PCL tear and posterior cruciate ligament

(click to enlarge)

Figure 1 Anatomy of a PCL tear (rear view of the knee)

The PCL is one of the most important ligaments of the knee, giving it stability. The PCL achieves this role by preventing excessive twisting, straightening of the knee (hyperextension) and backward movement of the tibia on the femur. When these movements are excessive and beyond what the PCL can withstand, tearing to the PCL occurs. This condition is known as a PCL tear and may range from a small partial tear resulting in minimal pain, to a complete rupture of the PCL resulting in significant pain and disability. A PCL tear can be graded as follows:

  • Grade 1 tear: a small number of fibres are torn resulting in some pain but allowing full function
  • Grade 2 tear: a significant number of fibres are torn with moderate loss of function.
  • Grade 3 tear: all fibres are ruptured resulting in knee instability and major loss of function.With these injuries, other structures are also often injured, such as the menisci or collateral ligaments. Comprehensive rehabilitation is required to return to full sporting activity and surgery may be indicated to reconstruct the ligament, and/or repair other structures.
As with all ligament injuries in the knee, PCL tears tend to occur more frequently in female athletes compared to males.

Causes of a PCL tear

PCL tears typically occur during activities placing excessive strain on the PCL. This generally occurs suddenly due to a specific incident, however, occasionally may occur due to repetitive strain. There are three main movements that place stress on the PCL, these include:
  • twisting of the knee
  • hyperextension of the knee
  • backward movement of the tibia on the femur
When any of these movements (or combinations of these movements) are excessive and beyond what the PCL can withstand, tearing of the PCL may occur.

PCL tears are often seen in contact sports or sports requiring rapid changes in direction. These may include: football, netball, basketball and downhill skiing. The usual mechanism of injury for a PCL tear is either a hyperextension force (e.g. where a player falls across the front of the knee causing it to straighten excessively) or due to a direct blow to the front of the shin bone with the knee in a bent position. Occasionally a PCL tear may occur during twisting movements particularly when landing from a jump.

Signs and Symptoms of a PCL tear

Patients with a PCL tear may notice an audible snap or tearing sound at the time of injury. In minor cases, patients may be able to continue activity only to experience an increase in pain, swelling and stiffness in the knee after activity with rest (particularly first thing in the morning). Often the pain associated with a torn PCL is felt deep within the knee or at the back of the knee (sometimes involving the calf) and is poorly localized.

In cases of a complete rupture of the PCL, pain is usually severe at the time of injury, however, may sometimes quickly subside. Patients may also experience a feeling of the knee going out and then going back in. Patients with a complete PCL rupture generally cannot continue activity as the knee may feel unstable, or may collapse during certain movements. Swelling may develop immediately or over a number of hours, although the severity of swelling can vary from patient to patient. Occasionally, the patient may be unable to weight bear at the time of injury due to pain and may develop bruising and knee stiffness over the coming days. Patients with a complete PCL tear may also experience recurrent episodes of the knee giving way following the injury.

Diagnosis of a PCL tear

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a PCL tear. Investigations such as an X-ray, MRI scan or CT scan may be required to confirm diagnosis and determine the extent of damage or involvement of other structures within the knee.

Treatment for a PCL tear

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Surgery for a PCL tear

Surgical reconstruction of the PCL may be indicated in patients who have a complete rupture of the PCL and have not responded to a high quality physiotherapy rehabilitation program or patients who have a complete rupture of the PCL in combination with damage to other structures within the knee. Following PCL reconstruction surgery a lengthy period of rehabilitation of 6 12 months or longer is often required to gain an optimal outcome and return the patient to full activity or sport. Surgery for a PCL tear should be particularly considered in patients who have a complete tear and:
  • are < 40 years of age
  • need a high level of knee function for recreational, work or sporting activity
  • have associated damage to their menisci or collateral ligaments of the knee
  • are able to comply and commit to intensive rehabilitation
  • have ongoing knee pain, swelling or recurrent episodes of the knee giving way despite appropriate rehabilitation
In those patients who undergo surgical intervention, rehabilitation should commence from the time of injury, not from the time of surgery. This is essential to minimize swelling, improve range of movement and strength and ensure an optimal outcome following surgery.

Patients who chose not to have surgery to repair their PCL can still have a very good outcome with physiotherapy and rehabilitative exercises alone. Some may experience ongoing knee instability or recurrent episodes of the knee collapsing or giving way, in which case the option of delayed PCL surgery can then be considered.

It is important to note, that patients who chose not to have surgery and those who do undertake surgery both have an increased risk of developing early onset knee osteoarthritis.

Prognosis of a PCL tear

With appropriate management, most patients with a minor to moderate PCL tear (grades 1 and 2) can return to sport or normal activity within 2 8 weeks. Patients with a complete rupture of the PCL are likely to require an extended rehabilitation period (regardless of whether surgery is undertaken or not). In patients who undergo surgical reconstruction of the PCL, a lengthy rehabilitation period of 6 - 12 months or longer may be required to gain optimum function. Patients who also have damage to other structures of the knee such as the meniscus or collateral ligaments are likely to have an extended rehabilitation period.

Contributing factors to a PCL tear

There are several factors which can increase the likelihood of sustaining a PCL injury. These factors need to be assessed and (where possible) corrected with direction from a physiotherapist. Some of these factors include:
  • sex (more common in females)
  • past history of a previous PCL injury
  • lower limb posture (increased Q angle, genu valgum, pronated feet)
  • muscle tightness (particularly the hamstrings or calf)
  • muscle weakness (particularly the quadriceps (VMO) or hip abductors/external rotators)
  • poor pelvic or core stability
  • poor coordination or jumping and landing strategies
  • joint stiffness (particularly the ankle, knee or hip)
  • inadequate rehabilitation following a previous PCL injury
  • abnormal running biomechanics/technique
  • inappropriate footwear or surfaces
  • being overweight, deconditioned or fatigued
  • generalized ligament laxity (hypermobile)
  • pregnancy (increased ligament laxity)
  • mid menstrual cycle (increased risk at ovulation due to hormonal changes causing increased ligament laxity)

Physiotherapy for a PCL tear

Physiotherapy for patients with a PCL tear is vital to hasten healing, ensure an optimal outcome and reduce the likelihood of future recurrence. Treatment may comprise:


Other intervention for a PCL tear

Despite appropriate physiotherapy management, a small percentage of patients with a minor to moderate PCL tear and some patients with a complete PCL rupture do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigation such as an X-ray, CT scan or MRI, pharmaceutical intervention, or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. Surgical reconstruction of the PCL is occasionally required in cases of a complete PCL rupture particularly when other structures are damaged or conservative measures fail.

Exercises for a PCL tear

The following exercises are commonly prescribed to patients with a PCL tear. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should commence once the physiotherapist has indicated it is safe to do so and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.


Initial Exercises

These initial exercises should generally be performed 3 times daily:

Knee Bend to Straighten  

Begin this exercise by lying on your back as demonstrated (figure 2). Bend and straighten your knee as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 - 20 times.

Exercises for a PCL Tear - Knee Bend to Straighten
 
Figure 2 - Knee Bend to Straighten (right leg)

Static Quadriceps Contraction  

Begin this exercise in the position demonstrated (figure 3). Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel. Put your fingers on your inner quadriceps (VMO) to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible without increasing your symptoms.

Exercises for a PCL Tear - Static Quadriceps Contraction
 
Figure 3 - Static Quadriceps Contraction (left leg)


Intermediate Exercises

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Advanced Exercises

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Other Exercises

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Rehabilitation Protocol for a PCL Tear

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Physiotherapy Products for a PCL Tear   Physiotherapy products for a PCL tear

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with a PCL tear include:
  1. Knee Braces
  2. Crutches
  3. Ice packs or hot packs
  4. Compression Bandages
  5. Protective Tape
  6. Foam Rollers (For self massage)
  7. Spikey Massage Balls (For self massage)
  8. Resistance Band (For strengthening exercises)
  9. Wobble Boards or Dura Discs
  10. Swiss Balls for strengthening exercises
To purchase physiotherapy products for a PCL tear click on one of the above links or visit the PhysioAdvisor Shop.

Find a Physio   Find a Physio for a PCL tear

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More Physiotherapy Exercises

 

   More Exercises

 


Recommended Reading

 

   Recommended Reading

 


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A PCL tear is a relatively common sporting injury affecting the knee and is characterized by tearing of the Posterior Cruciate Ligament (PCL), an important stabilizing structure of the knee.



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