Imaging Studies

Radiography

Initial radiographs should include weightbearing 45° posteroanterior (PA), lateral, and Merchant views. (See the images below.)

Lateral radiograph of a normal knee. In a normal knee, a line drawn along the posterior femoral condyle does not intersect the posterior tibial condyle. Image courtesy of Janos P. Ertl, MD.

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Lateral radiograph of a knee with a posterior cruciate ligament injury. Note that the same line as in the image above bisects the posterior tibial condyle due to a posterior sag and an incompetent PCL. Image courtesy of Janos P. Ertl, MD.

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An avulsion fracture from the origin of the posterior cruciate ligament (PCL) may be seen with hyperextension injuries. Avulsion fractures from the insertion of the PCL are associated with flexion injuries.^[2] (See the images below.)

Radiograph depicting a chronic avulsed posterior cruciate ligament (PCL). Image courtesy of Mervyn J. Cross, MBBS, FRACS.

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Sagittal view radiograph showing a posterior cruciate ligament (PCL) rupture. Note the posterior positioning of the tibia in relation to the femur. Image courtesy of Mervyn J. Cross, MBBS, FRACS.

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Stress views are more sensitive than physical examination for diagnosing PCL tears. Posterior tibia translation of more than 8 mm on stress radiographs is consistent with a complete PCL tear, and translation of less than 8 mm suggests a partial tear.^[42]

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is 97-100% sensitive for PCL injuries.^{[43, 44, 45, 46, 47, 48, 49, 50, 51]} (See the image below.) However, MRI is only 67% sensitive in distinguishing between partial and complete PCL tears.^{[52, 53]}

An MRI showing a torn posterior cruciate ligament (PCL). Image courtesy of Mervyn J. Cross, MBBS, FRACS.

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Bone scanning

A bone scan can be used to evaluate patients with chronic PCL insufficiency for early chondrosis. Increased signal at the medial femoral condyle and the patellofemoral compartment suggests degenerative changes secondary to PCL insufficiency.^{[2, 54]}

Treatment & Management

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Media Gallery

Lateral radiograph of a normal knee. In a normal knee, a line drawn along the posterior femoral condyle does not intersect the posterior tibial condyle. Image courtesy of Janos P. Ertl, MD.
Lateral radiograph of a knee with a posterior cruciate ligament injury. Note that the same line as in the image above bisects the posterior tibial condyle due to a posterior sag and an incompetent PCL. Image courtesy of Janos P. Ertl, MD.
The photo on the left demonstrates the clinical finding of the posterior tibia sag sign. A line drawn parallel to the patella accentuates the posterior tibia sag. The photo on the right demonstrates the quadriceps active drawer test described by Daniels; with the knee in 70-90° of flexion, the extensor mechanism is contracted, pulling the tibia anteriorly into a reduced position. Image courtesy of Janos P. Ertl, MD.
Close-up view of a posterior tibia sag with an incompetent posterior cruciate ligament (PCL). Image courtesy of Janos P. Ertl, MD.
A view of the broad origin of the posterior cruciate ligament (PCL) on the medial femoral condyle of a left knee. The anterior cruciate has been removed for surgical reconstruction. Image courtesy of Janos P. Ertl, MD.
An additional view of the posterior cruciate ligament (PCL) broad origin and insertion in a knee pending anterior cruciate ligament (ACL) reconstruction. Image courtesy of Janos P. Ertl, MD.
A right knee pending posterior cruciate ligament (PCL) reconstruction. A minimal notchplasty is completed. Two guide pins are advanced into the medial femoral condyle for tunnel placement to reconstruct the two bundles of the PCL. Image courtesy of Janos P. Ertl, MD.
The two femoral tunnels are created by reaming from outside in; 8- to 9-mm tunnels are made depending on the patient size and graft used. Image courtesy of Janos P. Ertl, MD.
Two red Robinson catheters are advanced through the femoral tunnels. Image courtesy of Janos P. Ertl, MD.
The catheters have premade holes that are used for suture retrieval. Image courtesy of Janos P. Ertl, MD.
The catheters are advanced and threaded out the posterior knee. In this case, a posterior tibial inlay graft from an Achilles tendon allograft is used. The two bundles are secured to the catheters and advanced into the joint through the tunnels. Image courtesy of Janos P. Ertl, MD.
The two Achilles tendon bundles are secured with a baseball whipstitch, threaded through the catheter holes, and advanced into the femoral condyle tunnels. Image courtesy of Janos P. Ertl, MD.
Additional view of the placement and advancement of the Achilles allograft. Image courtesy of Janos P. Ertl, MD.
Completion and seating of the femoral allograft reconstruction. The two bundles are secured or stabilized by suturing over a post and washer. Note the re-establishment of the broad surface area for the reconstructed posterior cruciate ligament (PCL) origin. Image courtesy of Janos P. Ertl, MD.
Completion of the tibial inlay two-bundle Achilles tendon allograft/posterior cruciate ligament (PCL) reconstruction. The bony calcaneus remnant is secured to the posterior tibia with one or two interfragmentary compression screws into a trough into the posterior tibia at the level of the PCL insertion. Care is taken not to penetrate the anterior tibial cortex with these screws. Note the intact original anterior cruciate ligament (ACL). Image courtesy of Janos P. Ertl, MD.
Posterior sag of the left posterior cruciate ligament–deficient knee in comparison to the right knee. Note the posterior subluxation of the tibia relative to the femur of the left knee. Image courtesy of Robert Bronstein, MD.
Clinical examination photograph of a ruptured posterior cruciate ligament (PCL) confirmed on a posterior sagittal radiograph. Image courtesy of Mervyn J. Cross, MBBS, FRACS.
Radiograph depicting a chronic avulsed posterior cruciate ligament (PCL). Image courtesy of Mervyn J. Cross, MBBS, FRACS.
An MRI showing a torn posterior cruciate ligament (PCL). Image courtesy of Mervyn J. Cross, MBBS, FRACS.
Sagittal view radiograph showing a posterior cruciate ligament (PCL) rupture. Note the posterior positioning of the tibia in relation to the femur. Image courtesy of Mervyn J. Cross, MBBS, FRACS.

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Author

Matthew Lawless, MD Assistant Professor of Orthopedic Surgery, Wright State University School of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Miami Valley Hospital and Dayton Veterans Affairs Medical Center

Matthew Lawless, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Damian M Andrisani, MD Staff Physician, Department of Orthopedic Surgery, Wright State University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Professor of Orthopedic Surgery, Baylor College of Medicine as Co-Director, Combined Baylor College of Medicine-The San Antonio Orthopaedic Group, Texas Sports Medicine Fellowship; Medical Director, Burkhart Research Institute for Orthopaedics (BRIO) of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; The Foundry, Cotera; ABMT; Conmed; <br/>Received research grant from: Arthrex, Inc.; MTF.

Additional Contributors

Phillip J Marone, MD, MSPH Clinical Professor, Department of Orthopedic Surgery and Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University

Phillip J Marone, MD, MSPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Philadelphia County Medical Society

Disclosure: Nothing to disclose.