Differential Diagnoses

Workup

Wang CJ. Injuries to the posterior cruciate ligament and posterolateral instabilities of the knee. Chang Gung Med J. 2002 May. 25(5):288-97.
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.
Sanders TL, Pareek A, Barrett IJ, Kremers HM, Bryan AJ, Stuart MJ, et al. Incidence and long-term follow-up of isolated posterior cruciate ligament tears. Knee Surg Sports Traumatol Arthrosc. 2016 Feb 27. [Medline].
Sheps DM, Otto D, Fernhout M. The anatomic characteristics of the tibial insertion of the posterior cruciate ligament. Arthroscopy. 2005 Jul. 21(7):820-5.
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar. 14(3):257-63.
Servant CT, Ramos JP, Thomas NP. The accuracy of magnetic resonance imaging in diagnosing chronic posterior cruciate ligament injury. Knee. 2004 Aug. 11(4):265-70.
Nha, KW, Bae, JH, Kwon, JH, et al. Arthroscopic posteromedial drive-through test in posterior cruciate ligament insufficiency: a new diagnostic test. Knee Surg Sports Traumatol Arthrosc. February 2014. [Medline].
[Guideline] Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2012 Apr 8. [Medline].
[Guideline] Lee BK, Nam SW. Rupture of posterior cruciate ligament: diagnosis and treatment principles. Knee Surg Relat Res. 2011 Sep. 23(3):135-41. [Medline]. [Full Text].
Chen B, Gao S. Double-bundle posterior cruciate ligament reconstruction using a non-hardware suspension fixation technique and 8 strands of autogenous hamstring tendons. Arthroscopy. 2009 Jul. 25(7):777-82. [Medline].
Lim HC, Bae JH, Wang JH, et al. Double-bundle PCL reconstruction using tibial double cross-pin fixation. Knee Surg Sports Traumatol Arthrosc. 2010 Jan. 18(1):117-22. [Medline].
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. 2006 May. 126(4):253-9.
Kim SJ, Kim TE, Jo SB, et al. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. 2009 Nov. 91(11):2543-9. [Medline].
Jung TM, Höher J, Weiler A. Screw fixation of a 4 1/2-year-old PCL avulsion injury. Knee Surg Sports Traumatol Arthrosc. 2006 May. 14(5):469-72.
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. 2005 Aug. 21(8):965-9.
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. 2006 Mar. 22(3):341.e1-4.
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. 2006 Mar. 22(3):329-38.
Sekiya JK, West RV, Ong BC, Irrgang JJ, Fu FH, Harner CD. Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy. 2005 Sep. 21(9):1042-50.
Goudie EB, Will EM, Keating JF. Functional outcome following PCL and complex knee ligament reconstruction. Knee. 2009 Sep 29. [Medline].
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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].
Cosgarea AJ, Jay PR. Posterior cruciate ligament injuries: evaluation and management. J Am Acad Orthop Surg. 2001 Sep-Oct. 9(5):297-307. [Medline].
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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. 1988 Mar. 70(3):386-91. [Medline].
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Donovan. Posterior cruciate ligament injury on artificial turf. Orthop. 1977. 1:20.
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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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Media Gallery

A normal lateral radiograph of a knee. In a normal knee, a line drawn along the posterior femoral condyle will not intersect the posterior tibial condyle.
A lateral radiograph of a knee with a posterior cruciate ligament injury. Note that the same line as in the above image will bisect the posterior tibial condyle due to a posterior sag and an incompetent posterior cruciate ligament.
The posterior tibial sag sign. The photo on the left demonstrates the clinical finding of the posterior tibial sag sign. A line drawn parallel to the patella accentuates the posterior tibial 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.
A close-up view of a posterior tibial sag with an incompetent posterior cruciate ligament.
This MRI of the knee shows a torn posterior cruciate ligament.
This MRI (coronal section) shows a posterior cruciate ligament tear.
This transverse MRI shows edema to the torn posterior cruciate ligament.
A view of the broad origin of the posterior cruciate ligament (PCL) on the medial femoral condyle of a left knee. The anterior cruciate ligament has been removed for surgical reconstruction.
An additional view of the posterior cruciate ligament broad origin and insertion in a knee pending anterior cruciate ligament reconstruction.
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 2 bundles of the PCL.
The 2 tunnels are created by reaming from outside in; 8- to 9-mm tunnels are made depending on patient size and the graft that will be used.
Two red Robinson catheters are advanced through the femoral tunnels.
The catheters have premade holes, which are used for suture retrieval.
The catheters are advanced and threaded out the posterior knee. In this case, a posterior tibial onlay graft from an Achilles tendon allograft is used. The 2 bundles are secured to the catheters and advanced into the joint through the tunnels.
The 2 Achilles tendon bundles are secured with a baseball whipstitch, are threaded through the catheter holes, and are advanced into the femoral condyle tunnels.
Additional view of the placement and advancement of the Achilles allograft.
Completion and seating of the femoral allograft reconstruction. The 2 bundles are secured or stabilized by suturing over a post and washer. Note the reestablishment of the broad surface area for the reconstructed posterior cruciate ligament origin.
Completion of the tibial onlay, 2-bundle Achilles tendon allograft/posterior cruciate ligament (PCL) reconstruction. The bony calcaneus remnant is secured to the posterior tibia with 1 or 2 interfragmentary compression screws into a trough into the posterior tibia at the level of the PCL insertion. Care is taken to not penetrate the anterior tibial cortex with these screws. Note the intact original anterior cruciate ligament.

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Author

Charles S Peterson, MD Consulting Staff, Arizona Sports Medicine Center; Instructor in Family Medicine, Mayo Clinic College of Medicine; Clinical Instructor, Midwestern University Medical School

Charles S Peterson, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Agesen, MD Assistant Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Consulting Staff, 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, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Gyorgy Kovacs, MD Consulting Surgeon, Department of Orthopedic Surgery, GOC Clinic

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.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD 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

Disclosure: Nothing to disclose.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Sections Posterior Cruciate Ligament Injury
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Posterior Cruciate Ligament Injury Differential Diagnoses

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