Physical Medicine and Rehabilitation for Posterior Cruciate Ligament Injury Treatment & Management

Updated: Nov 29, 2021
  • Author: Jawad Bhatti, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
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Treatment

Rehabilitation Program

Physical Therapy

The top priority in the rehabilitation of posterior cruciate ligament (PCL) injury is the restoration of knee function to normal or to as close to normal as possible.

The treatment of PCL injury depends on the grade of the injury. An isolated injury of grade I or grade II may be treated with physical therapy. [19] A grade I or grade II injury is usually treated with a brief period of knee splinting in extension, followed by early ROM therapy and a quadriceps-and-hamstring–strengthening program (that is particularly eccentric). [3, 4, 5, 6, 7] Recovery is quick, and many patients are able to return to normal function in about 4 weeks. Closed kinetic chain exercises and open kinetic chain exercises are recommended. The use of continuous passive motion (CPM) machines for early knee mobilization is an option. A good outcome is correlated with the maintenance of good quadriceps strength.

The postoperative protocol includes the use of a knee brace in extension, with weight bearing as tolerated for 4 weeks, as well as the use of quadriceps-strengthening exercises. Later, closed chain exercises are performed at 6 weeks, and proprioceptive training is carried out at 12 weeks. Hamstring exercises are delayed for 4 months to decrease the posterior load on the tibia. Patients can begin light jogging at 6 months. Cycling and aerobic exercise can also benefit the patient and can help to restore function. [8, 9, 10]

A study by Hoit et al of patients who underwent repair or reconstruction for injury to the PCL and at least one other ligament found no significant difference in outcomes between patients who were treated with “early” or “late” knee rehabilitation. Early physical therapy began the first day after surgery, with removal of the extension splint so that quadriceps activation and ROM exercises could be carried out. Late physical therapy did not begin until the patient had undergone 3 weeks of extension splinting. Results with regard to knee stiffness, laxity, and patient-reported quality of life were comparable between the two groups. [20]

With a multidisciplinary approach and the use of various modalities, such as ice and heat therapy, a good outcome is expected. Weight training and proprioceptive techniques also show good results in rehabilitative treatment.

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Medical Issues/Complications

Patients with chronic posterior cruciate ligament (PCL) injury can develop medial compartment osteoarthritis and patellofemoral osteoarthritis of the knee. Arterial injury is possible during PCL reconstruction.

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Surgical Intervention

Grade III posterior cruciate ligament (PCL) injuries may need surgical intervention. Tibial avulsion fractures with a PCL injury also require such intervention. [3, 11] Because of the complexity of biomechanical tensions, reproducing the function of the PCL complex is difficult. [21, 22, 23, 24]

Suture repair of insertion site avulsions is effective if it is performed less than 3 weeks after the injury. Nonabsorbable sutures are placed through the avulsed ligament and tied over the bone bridge. Unfortunately, the results are often unsatisfactory.

Other surgical techniques can rely on a single or a double reconstruction technique. [12] In the single bundle reconstruction technique, a hamstring patellar tendon or Achilles allograft is passed through the tibial tunnel into the femoral tunnel in single bundle technique. Studies have shown that this technique can result in an improvement in the patient's symptoms. In one study, statistically significant improvement (P = .001) from the preoperative condition was found at 2- to 10-year follow-up evaluations. [25]

In the double bundle reconstruction technique, 2 femoral patellar tunnels are used to recreate the functional activity of the 2 bands in the injured PCL. Two grafts are placed. A larger anterolateral graft is placed at 90º of flexion. A posteromedial graft is placed in knee extension to provide posterior stability. [26]

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Consultations

An orthopedic surgeon should be consulted for grade III posterior cruciate ligament (PCL) injuries or for poorly recovering grade II injuries.

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Other Treatment

If patients who develop knee pain are willing to try acupuncture treatment, this therapy may be considered. However, data do not show long-term relief from acupuncture use. More research into this modality, including the conduction of double blind, placebo-controlled studies, is needed. [27] Studies have shown that transcutaneous electrical nerve stimulation (TENS) units and ultrasonographic treatment are effective in pain management. [28]

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