eMedicine Specialties > Sports Medicine > Knee

Posterior Cruciate Ligament Injury: Differential Diagnoses & Workup

Author: Charles S Peterson, MD, Consulting Staff, Arizona Sports Medicine Center
Coauthor(s): Thomas Agesen, MD, Assistant Clinical Professor, UMDNJ, New Jersey Medical School; Consulting Staff, Department of Physical Medicine and Rehabilitation, Mountainside Hospital, Summit Overlook Hospital; Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, Chief of Orthopedic Trauma, University of California at Davis; Director of Amputee Clinic, Kaiser Hospital; Gyorgy Kovacs, MD, Department of Orthopedic Surgery, Consulting Surgeon, GOC Clinic
Contributor Information and Disclosures

Updated: Dec 22, 2006

Differential Diagnoses

Anterior Cruciate Ligament Injury
Lateral Collateral Knee Ligament Injury
Medial Collateral Knee Ligament Injury
Meniscus Injuries
Talofibular Ligament Injury

Other Problems to Be Considered

Multiligamentous injury
Knee dislocation
Posterolateral instability

Workup

Laboratory Studies

  • Perform laboratory studies as indicated per patient age.

Imaging Studies

  • Radiographs
    • Acute injuries

      • Routine radiographs usually are negative in acute injuries.
      • Bony avulsions may be evident on lateral radiographs.
      • New radiological view: Axial radiograph as described by Puddu et al. Patient is supine with knees flexed to 70°, feet are plantigraded in moderate plantar flexion, and the tibia is in neutral rotation. With patient holding cassette, the radiographic beam is directed distal to proximal and parallel to the longitudinal axis of the patella. The length of the perpendicular line between the anterior tibial profile and the femoral groove is measured. If the side-to-side difference is >3 mm, posterior laxity is indicated.
         
    • Chronic lesions

      • Weight-bearing anteroposterior (AP) or Rosenberg view (posteroanterior [PA] with knees flexed) may demonstrate early medial joint arthrosis.
      • Tangential patellofemoral view (Laurin/Merchant view) may demonstrate patellofemoral arthrosis.
      • Long-film AP weight-bearing views are essential for preoperative alignment.
         
  • MRI
    • If physical examination reveals multiple injured ligaments, or if degree of injury is in question, an MRI may be justified.
    • MRI helps identify and confirm the location of the lesion; in addition, occult osteochondral lesion/fractures and meniscal lesions may be identified. MRI of acute injury is more accurate than for chronic injury, as the ligament may appear healed but be functionally deficient (Servant, 2004).

Other Tests

  • Occasionally, a patient with a posterior knee injury may present with calf pain and signs of an impending compartment syndrome, possibly due to soft tissue injury or signs of an occult vascular injury. The calf symptoms may be more pronounced than the knee symptoms. Compartment pressures need to be measured, and vascular surgery consultation must be considered for an arteriogram.

Procedures

  • Perform an arteriogram in patients with suspected vascular injury, such as an injury that might be seen with knee dislocation.

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
Multimedia: Posterior Cruciate Ligament Injury
References
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References

  1. Ahn JH, Nha KW, Kim YC, Lim HC, Nam HW, Wang JH. Arthroscopic femoral tensioning and posterior cruciate ligament reconstruction in chronic posterior cruciate ligament injury. Arthroscopy. Mar 2006;22(3):341.e1-4. [Medline].

  2. Ahn JH, Yoo JC, Wang JH. Posterior cruciate ligament reconstruction: double-loop hamstring tendon autograft versus Achilles tendon allograft--clinical results of a minimum 2-year follow-up. Arthroscopy. Aug 2005;21(8):965-9. [Medline].

  3. Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. Mar 2006;14(3):257-63. [Medline].

  4. Baker CL Jr, Norwood LA, Hughston JC. Acute combined posterior cruciate and posterolateral instability of the knee. Am J Sports Med. May-Jun 1984;12(3):204-8. [Medline].

  5. Bergfeld JA, McAllister DR, Parker RD, et al. The effects of tibial rotation on posterior translation in knees in which the posterior cruciate ligament has been cut. J Bone Joint Surg Am. Sep 2001;83-A(9):1339-43. [Medline].

  6. Browner BD. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, Pa: WB Saunders Co; 1998.

  7. Cain TE, Schwab GH. Performance of an athlete with straight posterior knee instability. Am J Sports Med. Jul-Aug 1981;9(4):203-8. [Medline].

  8. Clancy WG Jr, Shelbourne KD, Zoellner GB, et al. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. Mar 1983;65(3):310-22. [Medline].

  9. Cosgarea AJ, Jay PR. Posterior cruciate ligament injuries: evaluation and management. J Am Acad Orthop Surg. Sep-Oct 2001;9(5):297-307. [Medline].

  10. Cross MJ, Powell JF. Long-term followup of posterior cruciate ligament rupture: a study of 116 cases. Am J Sports Med. Jul-Aug 1984;12(4):292-7. [Medline].

  11. Daniel DM, Stone ML, Barnett P, Sachs R. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. J Bone Joint Surg Am. Mar 1988;70(3):386-91. [Medline].

  12. Delee JC. Orthopaedic Sports Medicine, Principles and Practice. Vol 2. Philadelphia, Pa: WB Saunders Co; 1994.

  13. Donovan. Posterior cruciate ligament injury on artificial turf. Orthop. 1977;1:20.

  14. Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med. Nov-Dec 1987;15(6):553-7. [Medline].

  15. Harner, Miller. Complex topics in knee surgery. Clin Sports Med. 1999;18(1).

  16. Janousek AT, Jones DG, Clatworthy M, et al. Posterior cruciate ligament injuries of the knee joint. Sports Med. Dec 1999;28(6):429-41. [Medline].

  17. Jung TM, Höher J, Weiler A. Screw fixation of a 4 1/2-year-old PCL avulsion injury. Knee Surg Sports Traumatol Arthrosc. May 2006;14(5):469-72. [Medline].

  18. Jung YB, Jung HJ, Tae SK, Lee YS, Yang DL. Tensioning of remnant posterior cruciate ligament and reconstruction of anterolateral bundle in chronic posterior cruciate ligament injury. Arthroscopy. Mar 2006;22(3):329-38. [Medline].

  19. Lenschow S, Zantop T, Weimann A, Lemburg T, Raschke M, Strobel M. Joint kinematics and in situ forces after single bundle PCL reconstruction: a graft placed at the center of the femoral attachment does not restore normal posterior laxity. Arch Orthop Trauma Surg. May 2006;126(4):253-9. [Medline].

  20. Margheritini F, Rihn J, Musahl V, Mariani PP, Harner C. Posterior cruciate ligament injuries in the athlete: an anatomical, biomechanical and clinical review. Sports Med. 2002;32(6):393-408. [Medline].

  21. Ogata K, McCarthy JA, Dunlap J, Manske PR. Pathomechanics of posterior sag of the tibia in posterior cruciate deficient knees. An experimental study. Am J Sports Med. Nov-Dec 1988;16(6):630-6. [Medline].

  22. Paddu G, Gianni E, Chambat P. The axial view in evaluating tibial translation in cases of insufficiency of the posterior cruciate ligament. Arthroscopy. 2000;16(2):217-220.

  23. Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. Jan-Feb 1986;14(1):35-8. [Medline].

  24. Safran MR, Allen AA, Lephart SM, et al. Proprioception in the posterior cruciate ligament deficient knee. Knee Surg Sports Traumatol Arthrosc. 1999;7(5):310-7. [Medline].

  25. Sekiya JK, West RV, Ong BC, Irrgang JJ, Fu FH, Harner CD. Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy. Sep 2005;21(9):1042-50. [Medline].

  26. Servant CT, Ramos JP, Thomas NP. The accuracy of magnetic resonance imaging in diagnosing chronic posterior cruciate ligament injury. Knee. Aug 2004;11(4):265-70. [Medline].

  27. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. May-Jun 1999;27(3):276-83. [Medline].

  28. Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg. 1999;12(4):209-13. [Medline].

  29. Sheps DM, Otto D, Fernhout M. The anatomic characteristics of the tibial insertion of the posterior cruciate ligament. Arthroscopy. Jul 2005;21(7):820-5. [Medline].

  30. Siliski JM. Traumatic Disorders of the Knee. New York, NY: Springer-Verlag; 1994.

  31. St Pierre P, Miller MD. Posterior cruciate ligament injuries. Clin Sports Med. Jan 1999;18(1):199-221, vii. [Medline].

  32. Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. Mar 2003;19(3):262-8. [Medline].

  33. Veltri DM, Warren RF. Isolated and combined posterior cruciate ligament injuries. J Am Acad Orthop Surg. Nov 1993;1(2):67-75.

  34. Wang CJ. Injuries to the posterior cruciate ligament and posterolateral instabilities of the knee. Chang Gung Med J. May 2002;25(5):288-97. [Medline].

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Further Reading

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Keywords

posterior cruciate ligament, PCL injury, PCL tear, posterior knee instability, posterior laxity of the knee

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Contributor Information and Disclosures

Author

Charles S Peterson, MD, Consulting Staff, Arizona Sports Medicine Center
Charles S Peterson, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Agesen, MD, Assistant Clinical Professor, UMDNJ, New Jersey Medical School; Consulting Staff, Department of Physical Medicine and Rehabilitation, Mountainside Hospital, Summit Overlook Hospital
Thomas Agesen, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, and Physiatric Association for Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, Chief of Orthopedic Trauma, University of California at Davis; Director of Amputee Clinic, Kaiser Hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Gyorgy Kovacs, MD, Department of Orthopedic Surgery, Consulting Surgeon, GOC Clinic
Disclosure: Nothing to disclose.

Medical Editor

Gerard A Malanga, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, New Jersey Medical School; Director of Pain Management, University of Medicine and Dentistry at New Jersey, Overlook Hospital; Director of Sports Medicine, Mountainside Hospital
Gerard A Malanga, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association for Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Consulting Staff, Rockford Orthopedic Associates
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical College of Wisconsin
Craig C Young is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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