PCL Tear (Posterior Cruciate Ligament)
(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 of the knee (PCL).
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 femur (thigh bone) to the back of the tibia (shin bone) (figure 1).
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. Often other structures are also injured such as the menisci or collateral ligaments. Surgery may be required.
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 can not 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
Most patients with a PCL tear heal well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. A vital aspect of treatment is that the patient rests sufficiently from any activity that increases their pain (crutches may be required). Activities placing large amounts of stress on the PCL should also be minimized, particularly twisting and hyperextension of the knee. Resting from aggravating activities ensures the body can begin the healing process in the absence of further damage. Once the patient can perform these activities pain free a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with a PCL tear is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence or PCL surgery.
Patients should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following a PCL tear or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities (this may include the use of crutches or a protective brace), regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
Patients with this condition should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. One of the key components of PCL rehabilitation is pain-free strengthening of the quadriceps, hamstring, gluteal and calf muscles to improve the control of the knee joint with weight-bearing activities. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
Surgery for an 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
Following a complete PCL rupture, patients who choose not to have surgery may suffer from ongoing knee instability and recurrent episodes of the knee collapsing or giving way with certain movements (particularly twisting or hyperextension). Patients with a complete PCL rupture may also have an increased likelihood of developing knee osteoarthritis due to excessive movement and subsequent wear and tear of the knee.
In the case of surgery, rehabilitation for a PCL injury 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.
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. 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.
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:
- soft tissue massage
- joint mobilization
- ice or heat treatment
- electrotherapy (e.g. ultrasound)
- anti-inflammatory advice
- exercises to improve flexibility, strength and balance
- activity modification advice
- crutches prescription
- biomechanical correction
- a gradual return to activity program
Other intervention for a PCL tear
Despite appropriate physiotherapy management, a small percentage of patients with a PCL tear 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, 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 this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Knee Bend to Straighten
Begin this exercise by lying on your back as demonstrated (figure 2). Bend and straighten your knee as far as possible without increasing your pain. Repeat 20 times.
Figure 2 – Knee Bend to Straighten (left 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 to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible without increasing your symptoms.
Figure 3 – Static Quadriceps Contraction (left leg)
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:
- Knee Braces
- Ice packs or hot packs
- Protective Tape
- Foam Rollers (For self massage)
- Spikey Massage Balls (For self massage)
- Resistance Band (For strengthening exercises)
To purchase physiotherapy products for a PCL tear click on one of the above links or visit the PhysioAdvisor Shop.
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