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.^[15]

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.^[2]

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 subluxated 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%.^[16]

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.^[13]

Differential Diagnoses

Raj MA, Mabrouk A, Varacallo M. Posterior Cruciate Ligament Knee Injuries. StatPearls. 2021 Jan. [QxMD MEDLINE Link]. [Full Text].
Hughston JC, Norwood LA Jr. The posterolateral drawer test and external rotational recurvatum test for posterolateral rotatory instability of the knee. Clin Orthop Relat Res. 1980 Mar-Apr. 82-7. [QxMD MEDLINE Link].
Cosgarea AJ, Jay PR. Posterior cruciate ligament injuries: evaluation and management. J Am Acad Orthop Surg. 2001 Sep-Oct. 9(5):297-307. [QxMD MEDLINE Link].
MacLean CL, Taunton JE, Clement DB, et al. Eccentric and concentric isokinetic moment characteristics in the quadriceps and hamstrings of the chronic isolated posterior cruciate ligament injured knee. Br J Sports Med. 1999 Dec. 33(6):405-8. [QxMD MEDLINE Link]. [Full Text].
Cross MJ, Powell JF. Long-term followup of posterior cruciate ligament rupture: a study of 116 cases. Am J Sports Med. 1984 Jul-Aug. 12(4):292-7. [QxMD MEDLINE Link].
Dandy DJ, Pusey RJ. The long-term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surg Br. 1982. 64(1):92-4. [QxMD MEDLINE Link]. [Full Text].
Jung YB, Tae SK, Lee YS, et al. Active non-operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization. Knee Surg Sports Traumatol Arthrosc. 2008 Apr 17. [QxMD MEDLINE Link].
Fanelli GC, Stannard JP, Stuart MJ, Macdonald PB, Marx RG, Whelan DB, et al. Management of complex knee ligament injuries. Instr Course Lect. 2011. 60:523-35. [QxMD MEDLINE Link].
Edson CJ, Fanelli GC, Beck JD. Rehabilitation after multiple-ligament reconstruction of the knee. Sports Med Arthrosc. 2011 Jun. 19(2):162-6. [QxMD MEDLINE Link].
Edson CJ, Fanelli GC, Beck JD. Postoperative rehabilitation of the posterior cruciate ligament. Sports Med Arthrosc. 2010 Dec. 18(4):275-9. [QxMD MEDLINE Link].
Nicandri GT, Klineberg EO, Wahl CJ, et al. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. J Orthop Trauma. 2008 May-Jun. 22(5):317-24. [QxMD MEDLINE Link].
Deie M, Adachi N, Nakamae A, Takazawa K, Ochi M. Evaluation of single-bundle versus double-bundle PCL reconstructions with more than 10-year follow-up. ScientificWorldJournal. 2015. 2015:751465. [QxMD MEDLINE Link]. [Full Text].
Schulz MS, Russe K, Weiler A, et al. Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg. 2003 May. 123(4):186-91. [QxMD MEDLINE Link].
Jung YB, Jung HJ, Yang JJ, et al. Characterization of spontaneous healing of chronic posterior cruciate ligament injury: analysis of instability and magnetic resonance imaging. J Magn Reson Imaging. 2008 Jun. 27(6):1336-40. [QxMD MEDLINE Link].
Brown JR, Trojian TH. Anterior and posterior cruciate ligament injuries. Prim Care. 2004 Dec. 31(4):925-56. [QxMD MEDLINE Link].
Daniel DM, Stone ML, Barnett P, et al. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. J Bone Joint Surg Am. 1988 Mar. 70(3):386-91. [QxMD MEDLINE Link].
Otani T, Matsumoto H, Suda Y, et al. Proper use of MR imaging in internal derangement of the knee (orthopedic surgeon's view). Semin Musculoskelet Radiol. 2001 Jun. 5(2):143-5. [QxMD MEDLINE Link].
Theodorou DJ, Theodorou SJ, Fithian DC, et al. Posterolateral complex knee injuries: magnetic resonance imaging with surgical correlation. Acta Radiol. 2005 May. 46(3):297-305. [QxMD MEDLINE Link].
Veltri DM, Warren RF. Isolated and combined posterior cruciate ligament injuries. J Am Acad Orthop Surg. 1993 Nov. 1(2):67-75. [QxMD MEDLINE Link].
Hoit G, Rubacha M, Chahal J, Khan R, Ravi B, Whelan DB. Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial. Clin Orthop Relat Res. 2021 Aug 1. 479 (8):1725-36. [QxMD MEDLINE Link].
Bianchi M. Acute tears of the posterior cruciate ligament: clinical study and results of operative treatment in 27 cases. Am J Sports Med. 1983 Sep-Oct. 11(5):308-14. [QxMD MEDLINE Link].
Hughston JC, Degenhardt TC. Reconstruction of the posterior cruciate ligament. Clin Orthop Relat Res. 1982 Apr. 59-77. [QxMD MEDLINE Link].
Hayashi R, Kitamura N, Kondo E, et al. Simultaneous anterior and posterior cruciate ligament reconstruction in chronic knee instabilities: surgical concepts and clinical outcome. Knee Surg Sports Traumatol Arthrosc. 2008 Jun 7. [QxMD MEDLINE Link].
Owesen C, Sivertsen EA, Engebretsen L, Granan LP, Aroen A. Patients With Isolated PCL Injuries Improve From Surgery as Much as Patients With ACL Injuries After 2 Years. Orthop J Sports Med. 2015 Aug. 3 (8):2325967115599539. [QxMD MEDLINE Link]. [Full Text].
Fanelli GC, Edson CJ. Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy. 2004 Apr. 20(4):339-45. [QxMD MEDLINE Link].
Zhao J, Xiaoqiao H, He Y, et al. Sandwich-style posterior cruciate ligament reconstruction. Arthroscopy. 2008 Jun. 24(6):650-9. [QxMD MEDLINE Link].
Wang SM, Kain ZN, White PF. Acupuncture analgesia: II. Clinical considerations. Anesth Analg. 2008 Feb. 106(2):611-21, table of contents. [QxMD MEDLINE Link].
Eyigör S, Karapolat H, Ibisoglu U, et al. [Does transcutaneous electrical nerve stimulation or therapeutic ultrasound increase the effectiveness of exercise for knee osteoarthritis: a randomized controlled study.]. Agri. 2008 Jan. 20(1):32-40. [QxMD MEDLINE Link].
Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, et al. Accelerated Versus Nonaccelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized, Double-Blind Investigation Evaluating Knee Joint Laxity Using Roentgen Stereophotogrammetric Analysis. Am J Sports Med. 2011 Sep 27. [QxMD MEDLINE Link].
DeLee JC, Bergfeld JA, Drez D. The posterior cruciate ligament. Ortho Sports Med. 1994. 2:1374-400.
Fontboté CA, Sell TC, Laudner KG, et al. Neuromuscular and biomechanical adaptations of patients with isolated deficiency of the posterior cruciate ligament. Am J Sports Med. 2005 Jul. 33(7):982-9. [QxMD MEDLINE Link].
Gill TJ, DeFrate LE, Wang C, et al. The effect of posterior cruciate ligament reconstruction on patellofemoral contact pressures in the knee joint under simulated muscle loads. Am J Sports Med. 2004 Jan-Feb. 32(1):109-15. [QxMD MEDLINE Link].
Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am. 1987 Feb. 69(2):233-42. [QxMD MEDLINE Link].
Kannus P, Jarvinen M. Nonoperative treatment of acute knee ligament injuries. A review with special reference to indications and methods. Sports Med. 1990 Apr. 9(4):244-60. [QxMD MEDLINE Link].
Markey KL. Functional rehabilitation of the cruciate-deficient knee. Sports Med. 1991 Dec. 12(6):407-17. [QxMD MEDLINE Link].
Matava MJ, Sethi NS, Totty WG. Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction. Arthroscopy. 2000 Nov. 16(8):796-804. [QxMD MEDLINE Link].
Miller MD, Bergfeld JA, Fowler PJ, et al. The posterior cruciate ligament injured knee: principles of evaluation and treatment. Instr Course Lect. 1999. 48:199-207. [QxMD MEDLINE Link].
Morgan EA, Wroble RR. Diagnosing posterior cruciate ligament injuries. Physician Sports Med. Nov 1997. 25(11):1-9.
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. [QxMD MEDLINE Link].
Senter C, Hame SL. Biomechanical analysis of tibial torque and knee flexion angle: implications for understanding knee injury. Sports Med. 2006. 36(8):635-41. [QxMD MEDLINE Link].
Shelbourne KD, Muthukaruppan Y. Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries. Arthroscopy. 2005 Apr. 21(4):457-61. [QxMD MEDLINE Link].
Tegner Y. Strength training in the rehabilitation of cruciate ligament tears. Sports Med. 1990 Feb. 9(2):129-36. [QxMD MEDLINE Link].
Tibone JE, Antich TJ, Perry J, et al. Functional analysis of untreated and reconstructed posterior cruciate ligament injuries. Am J Sports Med. 1988 May-Jun. 16(3):217-23. [QxMD MEDLINE Link].
Torg JS, Barton TM, Pavlov H, et al. Natural history of the posterior cruciate ligament-deficient knee. Clin Orthop Relat Res. 1989 Sep. 208-16. [QxMD MEDLINE Link].
Van Dommelen BA, Fowler PJ. Anatomy of the posterior cruciate ligament. A review. Am J Sports Med. 1989 Jan-Feb. 17(1):24-9. [QxMD MEDLINE Link].
Winters K, Tregonning R. Reliability of magnetic resonance imaging of the traumatic knee as determined by arthroscopy. N Z Med J. 2005 Feb 11. 118(1209):U1301. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Jawad Bhatti, MD Consulting Staff, Departments of Internal Medicine and Physical Medicine and Rehabilitation and Pain Management, 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, American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Stephen Kishner, MD, MHA Clinical Professor, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Mahmoud Sarmini, MD Assistant Professor, Department of Medicine, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine

Mahmoud Sarmini, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Society of Physical and Rehabilitation 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.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

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, North American Spine Society

Disclosure: Nothing to disclose.

Sections Physical Medicine and Rehabilitation for Posterior Cruciate Ligament Injury
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Follow-up
References

Physical Medicine and Rehabilitation for Posterior Cruciate Ligament Injury Clinical Presentation

History

Physical

Causes

References

Tables

Contributor Information and Disclosures

What would you like to print?