Sections

Sections Posterior Cruciate Ligament Pathology
Overview
Presentation
Workup
Treatment
Media Gallery
References

Workup

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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Harner CD, Janaushek MA, Kanamori A. Effect of knee flexion angle and tibial position during graft fixation on the biomechanics of a PCL reconstructed knee. Trans Orthop Res Soc. 1999. 24:23.
Jari S, Shelbourne KD. Natural history and nonoperative treatment of posterior cruciate ligament injuries. Oper Tech Sports Med. 2001. 9:53-9.
Seitlinger G, Scheurecker G, Högler R, Labey L, Innocenti B, Hofmann S. Tibial tubercle-posterior cruciate ligament distance: a new measurement to define the position of the tibial tubercle in patients with patellar dislocation. Am J Sports Med. 2012 May. 40(5):1119-25. [Medline].
Bach BR. Graft selection for posterior cruciate ligament surgery. Oper Tech Sports Med. 1993. 2:104-9.
Clendenin MB, DeLee JC, Heckman JD. Interstitial tears of the posterior cruciate ligament of the knee. Orthopedics. 1980 Aug 1. 3 (8):764-72. [Medline].
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Hughston JC, Bowden JA, Andrews JR, Norwood LA. Acute tears of the posterior cruciate ligament. Results of operative treatment. J Bone Joint Surg Am. 1980 Apr. 62(3):438-50. [Medline].
Hughston JC, Degenhardt TC. Reconstruction of the posterior cruciate ligament. Clin Orthop Relat Res. 1982 Apr. (164):59-77. [Medline].
Lipscomb AB, Johnston RK, Snyder RB. The technique of cruciate ligament reconstruction. Am J Sports Med. 1981 Mar-Apr. 9(2):77-81. [Medline].
Bergfeld JA. Diagnosis and nonoperative treatment of acute posterior cruciate ligament injury. Instr Course Lect. 1990. 208.
Panisset JC, Duraffour H, Vasconcelos W, Colombet P, Javois C, Potel JF, et al. [Clinical, radiological and arthroscopic analysis of the ACL tear. A prospective study of 418 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2008 Dec. 94(8 Suppl):362-8. [Medline].
Moore HA, Larson RL. Posterior cruciate ligament injuries. Results of early surgical repair. Am J Sports Med. 1980 Mar-Apr. 8(2):68-78. [Medline].
Savatsky GH, Marshall JL, Warren RF. Posterior cruciate ligament injury. Orthop Trans. 1980. 4:293.
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. 1983 Mar. 65(3):310-22. [Medline].
Noyes FR, Barber-Westin SD. Decision making and surgical treatment of posterior cruciate ligament ruptures. Scott WN, ed. Insall and Scott Surgery of the Knee. 6th ed. Philadelphia: Elsevier; 2018. 719-90.
Musahl V, Ayeni OR, Citak M, Irrgang JJ, Pearle AD, Wickiewicz TL. The influence of bony morphology on the magnitude of the pivot shift. Knee Surg Sports Traumatol Arthrosc. 2010 Sep. 18 (9):1232-8. [Medline].
Hewett TE, Noyes FR, Lee MD. Diagnosis of complete and partial posterior cruciate ligament ruptures. Stress radiography compared with KT-1000 arthrometer and posterior drawer testing. Am J Sports Med. 1997 Sep-Oct. 25(5):648-55. [Medline].
Gross ML, Grover JS, Bassett LW, et al. Magnetic resonance imaging of the posterior cruciate ligament. Clinical use to improve diagnostic accuracy. Am J Sports Med. 1992 Nov-Dec. 20(6):732-7. [Medline].
Patten RM, Richardson ML, Zink-Brody G, Rolfe BA. Complete vs partial-thickness tears of the posterior cruciate ligament: MR findings. J Comput Assist Tomogr. 1994 Sep-Oct. 18(5):793-9. [Medline].
Bellelli A, Mancini P, Polito M, David V, Mariani PP. Magnetic resonance imaging of posterior cruciate ligament injuries: a new classification of traumatic tears. Radiol Med (Torino). 2006 Sep. 111(6):828-35. [Medline].
Donell ST, Marshall TJ, Darrah C, Shepstone L. Cruciate ligament assessment in MRI scans: a pilot study of a static drawer technique. Knee. 2006 Mar. 13(2):137-44. [Medline].
Yoon YC, Chung HW, Ahn JH. MR imaging of stable posterior cruciate ligament grafts in 21 arthroscopically proven cases. Korean J Radiol. 2007 Sep-Oct. 8(5):403-9. [Medline].
Yoon JP, Chang CB, Yoo JH, Kim SJ, Choi JY, Choi JA, et al. Correlation of magnetic resonance imaging findings with the chronicity of an anterior cruciate ligament tear. J Bone Joint Surg Am. 2010 Feb. 92(2):353-60. [Medline].
Orakzai SH, Egan CM, Eustace S, Kenny P, O'flanagan SJ, Keogh P. Correlation of intra-articular osseous measurements with posterior cruciate ligament length on MRI scans. Br J Radiol. 2010 Jan. 83(985):23-7. [Medline].
Espregueira-Mendes J, Pereira H, Sevivas N, Passos C, Vasconcelos JC, Monteiro A, et al. Assessment of rotatory laxity in anterior cruciate ligament-deficient knees using magnetic resonance imaging with Porto-knee testing device. Knee Surg Sports Traumatol Arthrosc. 2012 Apr. 20(4):671-8. [Medline].
Okazaki K, Tashiro Y, Izawa T, Matsuda S, Iwamoto Y. Rotatory laxity evaluation of the knee using modified Slocum's test in open magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc. 2012 Apr. 20(4):679-85. [Medline].
Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg. 1999 Fall. 12(4):209-13. [Medline].
Tewes DP, Fritts HM, Fields RD, et al. Chronically injured posterior cruciate ligament: magnetic resonance imaging. Clin Orthop. 1997 Feb. (335):224-32. [Medline].
Bisson LJ, Clancy WG. Posterior cruciate ligament. Garrett WE, Speer KP, Kirkendall DT, eds. Principles and Practice of Orthopaedic Sports Medicine. Philadelphia: Lippincott Williams & Wilkins; 2000. 763-86.
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Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986 Jan-Feb. 14(1):35-8. [Medline].
Torg JS, Barton TM, Pavlov H, Stine R. Natural history of the posterior cruciate ligament-deficient knee. Clin Orthop. 1989 Sep. (246):208-16. [Medline].
Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med. 1987 Nov-Dec. 15(6):553-7. [Medline].
Dejour H, Walch G, Peyrot J, Eberhard P. [The natural history of rupture of the posterior cruciate ligament]. Rev Chir Orthop Reparatrice Appar Mot. 1988. 74(1):35-43. [Medline].
Keller PM, Shelbourne KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med. 1993 Jan-Feb. 21(1):132-6. [Medline].
Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med. 1993 Nov-Dec. 21(6):846-9. [Medline].
Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996 May-Jun. 24(3):306-10. [Medline].
Skyhar MJ, Warren RF, Ortiz GJ, et al. The effects of sectioning of the posterior cruciate ligament and the posterolateral complex on the articular contact pressures within the knee. J Bone Joint Surg Am. 1993 May. 75(5):694-9. [Medline].
MacDonald P, Miniaci A, Fowler P, et al. A biomechanical analysis of joint contact forces in the posterior cruciate deficient knee. Knee Surg Sports Traumatol Arthrosc. 1996. 3(4):252-5. [Medline].
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. 1999 May-Jun. 27(3):276-83. [Medline].
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Chan YS, Yang SC, Chang CH, Chen AC, Yuan LJ, Hsu KY, et al. Arthroscopic reconstruction of the posterior cruciate ligament with use of a quadruple hamstring tendon graft with 3- to 5-year follow-up. Arthroscopy. 2006 Jul. 22(7):762-70. [Medline].
Paulos LE, Bair BA. Transosseous reconstruction of the posterior cruciate ligament: single- and double-tunnel techniques. Oper Tech Sports Med. 2001. 9:60-8.
McAllister DR, Bergfeld JA, Kambic H. A biomechanical comparison of posterior cruciate ligament reconstruction techniques. Presented at the AAOS 66th Annual Meeting. Anaheim, CA. February 1999.
Bergfeld JA, Graham SM. Tibial inlay procedure for PCL reconstruction: One tunnel and two tunnel. Oper Tech Sports Med. 2001. 9:69-75.
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Race A, Amis AA. The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech. 1994 Jan. 27(1):13-24. [Medline].
Harner CD, Hoher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med. 1998 May-Jun. 26(3):471-82. [Medline].
Lipscomb AB Jr, Anderson AF, Norwig ED, et al. Isolated posterior cruciate ligament reconstruction. Long-term results. Am J Sports Med. 1993 Jul-Aug. 21(4):490-6. [Medline].
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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.

Sections Posterior Cruciate Ligament Pathology
Overview
Presentation
Workup
Treatment
Media Gallery
References

Posterior Cruciate Ligament Pathology Workup

Imaging Studies

Radiography

Magnetic resonance imaging

Bone scanning

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