eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Posterior Cruciate Ligament Injury

Author: Jawad Bhatti, MD, Consulting Staff, Departments of Internal Medicine and Physical Medicine and Rehabilitation, Catahoula Parish District Hospital
Coauthor(s): Stephen Kishner, MD, Residency Program Director, Professor of Clinical Medicine, Department of Medicine, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine; Mahmoud Sarmini, MD, Department of Medicine, Section of Physical Medicine and Rehabilitation, Assistant Professor, Louisiana State University School of Medicine
Contributor Information and Disclosures

Updated: Jul 10, 2008

Introduction

Background

The posterior cruciate ligament (PCL) courses from the posterior intercondylar area of the tibia to the medial condyle of the femur. It gives dynamic stability to the knee by preventing posterior displacement of the tibia on the femur. The PCL is an extrasynovial structure composed of a large anterolateral portion and a small posteromedial portion.

The PCL resists 85-100% of posteriorly directed forces at 30 º and 90 º of knee flexion. The 2 bands of the PCL, the anterolateral band and the posteromedial band, have different tension patterns. The anterolateral band is under great tension during knee flexion, whereas the posteromedial band is under more tension during knee extension.

Related eMedicine topics:
Knee, Posterior Cruciate Ligament Injuries (MRI)
Posterior Cruciate Ligament Injury [Sports Medicine]
Posterior Cruciate Ligament Pathology

Related Medscape topic:
Resource Center Joint Disorders

Pathophysiology

Posterior cruciate ligament (PCL) injuries are usually the result of a direct blow to the anterior part of the tibia, with a hyperextension moment at the knee. Biomechanical studies have shown an increase in PCL force with knee flexion and the application of internal tibial torque, while other studies have shown that PCL-deficient knees have greater external tibial rotation. Several mechanisms have been implicated in PCL injury, including the following1 :

  • Posterior translation of the proximal tibia
  • Dashboard injuries in motor vehicle accidents (the most common mechanisms)
  • Falling on a flexed knee (the most common injury in sports, particularly in wrestling and football)
  • Forced hyperflexion of the knee joint
  • A posterior force applied against a hyperextended knee with the foot fixed
  • Forced hyperextension of the knee

Frequency

United States

There is a variable incidence of posterior cruciate ligament (PCL) injuries in the US population. In a retrospective study by Schulz and colleagues, 33% of the injuries were sports related.1 As many as 20% of all knee ligament injuries consisted of PCL trauma.

International

International data about posterior cruciate ligament (PCL) injuries are limited. In Germany, approximately 8-10% of all severe ligament injuries involve the PCL, which means that annually, 4000-5000 members of the German population suffer a PCL rupture.

Mortality/Morbidity

Chronic posterior cruciate ligament (PCL) deficiency can cause or predispose individuals to these pathologies: (1) medial compartment osteoarthritis of the knee, (2) increased risk for meniscal injury, and (3) patellofemoral osteoarthritis.2

Age

In Schulz's study, the mean age at which posterior cruciate ligament (PCL) injury occurred was 27.5 years ± 9.9 years.1

Clinical

History

Pain and limited range of motion (ROM) after an injury are the most common symptoms of posterior cruciate ligament (PCL) trauma with associated ligamentous injuries. The associated ligamentous injuries occur about 95% of the time. In isolated PCL injuries, patients may have symptoms of mild swelling, discomfort, and knee stiffness. Knee instability is uncommon in injuries isolated to the PCL. Patients with grade 2 injuries are able to perform gait and drop-landing activities.3

Physical

The posterior drawer test performed with the knee at 90 º is the most sensitive test for detecting posterior cruciate ligament (PCL) injury. The change in the step off from 1 cm (normal) from the medial tibial plateau anterior to the medial femoral condyle is absent, as compared with the healthy knee. This test is 90% sensitive and 99% specific in the diagnosis of PCL injury.4

Grading the injury on examination may be performed by using the following scale:

  • Grade I injury - Step off present but decreased (ie, 0-5 mm)
  • Grade II injury - 5-10 mm of posterior translation
  • Grade III injury - Greater than 10 mm of posterior translation

Decreased ROM may be observed, as compared with the ROM of the other knee. The injured knee may lack only 10-20 º of flexion.

Adjuvant tests can increase the sensitivity for diagnosis of PCL injuries. These include the quadriceps active test, the dynamic posterior shift test, the posteromedial and posterolateral instability test, the posterolateral drawer test, the reverse pivot shift test, and the Godfrey, or posterior sag, test.

In the posterior sag test, the patient is asked to flex both knees and hips at 90 º while lying in the supine position. The examiner holds both heels and legs. Posterior tibial translation is an indication of an injured or insufficient PCL.

In the quadriceps active test, the knee is flexed at 60 º and the foot is secured by the physician. The patient is asked to extend the knee isometrically, and if the PCL is injured or absent, the tibia translates anteriorly from a subluxed position. This motion creates a medial tibial plateau step off. The sensitivity of this test was reported to be 58%, with a specificity of 97%.5

In the dynamic posterior shift test, the patient is asked to extend the knee from 90 º of flexion to full extension. The patient is asked to keep his/her hip at 90 º of flexion. A positive result occurs when the tibia reduces with a click near full extension.

In the reverse pivot shift test, a valgus load is applied to the knee. The foot is also externally rotated while the knee is extended from a flexed position. If the posteriorly subluxated tibial plateau abruptly shifts back to the reduced position, the result is positive. This test is 95% specific but is only 26% sensitive.

Causes

In Schulz's study, the most common causes of posterior cruciate ligament (PCL) injury were motor vehicle accidents (45%) and athletic injuries (40%), with motorcycle accidents (28%) and soccer-related injuries (25%) making up the main specific causes of such trauma. Dashboard injuries (35%) and falls on a flexed knee with the foot in plantar flexion (24%) were the most common injury mechanisms.1

More on Posterior Cruciate Ligament Injury

Overview: Posterior Cruciate Ligament Injury
Differential Diagnoses & Workup: Posterior Cruciate Ligament Injury
Treatment & Medication: Posterior Cruciate Ligament Injury
Follow-up: Posterior Cruciate Ligament Injury
References
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References

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Further Reading

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Keywords

posterior cruciate ligament injury, PCL injury, ligamentum cruciatum posterius, knee ligament, tibia, medial condyle, femur, hyperextension, knee laxity

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Contributor Information and Disclosures

Author

Jawad Bhatti, MD, Consulting Staff, Departments of Internal Medicine and Physical Medicine and Rehabilitation, Catahoula Parish District Hospital
Jawad Bhatti, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, and American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen Kishner, MD, Residency Program Director, Professor of Clinical Medicine, Department of Medicine, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine
Stephen Kishner, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Mahmoud Sarmini, MD, Department of Medicine, Section of Physical Medicine and Rehabilitation, Assistant Professor, Louisiana State University School of Medicine
Mahmoud Sarmini, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Medical Editor

Curtis W Slipman, MD, Director, University of Pennsylvania Spine Center, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center
Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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