PCL Injury – Posterior Cruciate Ligament Tear

The posterior cruciate ligament or otherwise known as PCL is one of the four ligaments of the knee which provide a knee joint stability and flexibility. PCL is located on the back of the knee. It connects the femur and the tibia, and its role is to prevent the tibia from moving backward too far, stabilizing the knee joint this way.

PCL injuries are not that common and they occur in about 20 % of cases. This is because this ligament is much stronger and broader than other knee ligaments. Often PCL injuries are accompanied by injuries of other knee ligaments and structures, which complicates the situation even more. Evaluating PCL injuries is more difficult, compared to other knee ligament injuries.

What Causes PCL Injury?

A PCL injury - you can see there is a full thickness tear of the posterior cruciate ligament shown from the back of the knee

PCL is the strongest ligament of the knee, meaning that a great force is required to lead to an injury. Common ways how PCL injuries occur include:

  • Falling on a bent knee,
  • In a car accident when the knee gets smashed against the dashboard,
  • While skiing,
  • While playing baseball, football, or soccer,
  • A simple misstep, etc.

Types of PCL Injury

The severity of PCL injuries varies from mild, moderate, or severe, depending on how many ligament fibers are damaged. PCL ligament can either be torn partially or totally. PCL injuries are grades as follows:

Grade 1 – is characterized by a minor damage to the ligament fibers where less than 10 % of ligament fibers are affected. The ligament is only stretched more than it should but can provide knee joint stability still.  

Grade 2 – is characterized by a partial damage to the ligament fibers, anywhere between 10 to 90 % of ligament fibers are affected. The PCL becomes loose.

Grade 3 – is characterized by a complete tear of the PCL. 100 % of the ligament fibers are damaged and normally it is a severe injury to the knee. The knee joint becomes unstable as the posterior cruciate ligament is split into two pieces.

As mentioned, PCL injuries are often accompanied by damages to the other knee ligaments or knee structures, presenting a real severe knee injury.

PCL injuries can also be classified as acute or chronic problems. Acute PCL problems occur after a sudden injury, while chronic PCL problems develop over a long period of time.

What Does it Feel Like When You Tear PCL?

How a PCL injury will feel like depends on the severity of the injury.

Most patients refer knee stiffness and some swelling. Often a feeling of insecurity while walking or giving away of the knee, are reported. This is more likely to occur when trying to change the knee direction.

Knee pain is also common, present immediately after the knee injury or within the first couple of weeks. Even though the pain, knee swelling and other symptoms may resolve within four weeks, the knee may still feel unstable.

Posterior Cruciate Ligamet Tear: Symptoms

Common PCL injury symptoms include:

  • Knee pain, especially while squatting
  • Knee swelling, but calf swelling is also possible if there is a synovial tear as well,
  • Pain while walking,
  • Difficulty to walk,
  • A wobbly sensation in the knee, and knee instability,
  • Osteoarthritis, which develops over time, etc.

Knee pain and swelling are noticeable quickly after the ligament injury. The knee can become stiff due to the swelling and sometimes even a limp is noticeable. Because of the PCL injury, the knee becomes unstable in grade 2 and above, making even walking difficult or impossible.

In chronic PCL injuries, the patient might not recall a knee injury. However, complaints of knee pain and discomfort while lifting things, especially when the knee is in a semi – flexed position are common.

Walking for a long distance will also lead to knee pain and discomfort as well. Instability is also possible, mostly when walking on an uneven surface. Retropatellar pain, swelling, and knee stiffness are also possible in chronic PCL injuries, normally depending on the severity of associated chondral damage.

PCL Injury Diagnosis

When diagnosing a PCL injury your healthcare provider will need a detailed anamnesis and history, including how you ended up with a knee injury. You will need to tell your doctor if you injured your knee while playing sports, falling off, in a car accident, etc.

Physical Examination 

A physical examination is also very important in order to diagnose a PCL injury. For this purpose, you will need to lie down on your back while keeping the knees bent. If there is any abnormal knee movement during a physical examination, it can signify a PCL injury.

Your healthcare provider will probably measure the tightness of the knee ligaments using an arthrometer.

Imaging Examination

Imaging examinations like X-ray of the injured knee, CT-scan, and MRI, are also necessary tests in PCL injury diagnosis. With the help of knee X-ray, your healthcare provider may detect any pieces of broken bones which might have occurred during the injury.

CT-scan is also necessary to look for any damage to the bones and other knee structures, especially in cases of chronic PCL injuries. MRI imaging is a great method which will help your healthcare provider visualize and determine the exact location of the PCL tear.

Arthroscopy can be used as a diagnostic method in cases when it is hard to determine the severity of the knee injury. With the help of this surgical technique, the doctors will be able to visualize the inner of your knee joint with a small camera, which is inserted into the knee joint through a small incision.

Unlike ACL injuries that are characterized by a popping sound when the injury occurs, PCL injuries will not produce such a sound.

PCL Injury Tests

The posterior drawer test is one of the best ways to diagnose a PCL injury, especially its severity.  The patient should lie on the back while keeping the foot flat on the table and the knee bent at a right angle. The examiner will push back the tibia as far as possible. The severity of a PCL injury is diagnosed this way.

Lachman test is a good alternative to the drawers test as the knee only needs to be flexed at a 30 degree angle when diagnosing PCL injuries. During the examination, the tibia should be in a neutral position while the knee is flexed at a 30 degree angle. A posteriorly directed force on the tibia is exerted to check if there is a PCL injury.

The posterior sag sign is perhaps the most sensitive test as part of the physical examination. A sagging of the tibia can be noticed when the patient is lying down on the examination table with the injured knee flexed at a 90 degree angle.

The quadriceps active test is another test which can help your doctor diagnose a PCL injury. During this test, the injured knee should be flexed at a 90 degree angle while the foot is stabilized. The patient is then asked to slide the foot down on the examination table, during which a reduction of the posteriorly subluxated tibia can be visualized in cases when there is a PCL injury.

Treatment Options

P.R.I.C.E.

PRICE – which stands for protect, rest, ice, compression, and elevation is the initial treatment you can do at home or at the place where the injury occurred.

First of all, you will need to protect the injured knee in order to avoid any further damage, which will, of course, complicate things and make the situation even worse. If the injured knee is not protected correctly, then a partial tear can easily progress into a total tear of the posterior cruciate ligament. Once your knee is well protected, you should rest it.

Often after the injury, bearing weight with the injured knee is impossible. If it is too painful to land on your foot then use the help of your friends and family to walk and take you to a medical professional for the necessary help and treatment. Ice packs are also part of the at home treatment in cases of a PCL injury.

However, make sure not to apply ice directly on the skin as you will end up with an ice burn. Also, don’t apply the ice packs more than 10 to 15 minutes, every two hours. Compression is also important after a PCL injury as it will prevent further swelling of the affected knee.

Elevating the injured knee above the heart level is also necessary as it will help the blood flow and circulation, preventing knee swelling, pain, and discomfort after a PCL injury. PRICE method should be used a couple of days for minor PCL injuries until your condition gets better, or until you seek professional medical help in cases of severe PCL injuries

Medical Treatment

Pain relieving medications are also necessary to help you relieve the pain and discomfort. Sometimes, over the counter medications will help you a lot, while in severe cases of PCL injury, even prescribed pain relieving medications might be needed.

Rehab

Rehabilitation after a PCL injury is often needed, regardless if your knee problem required surgical treatment or not.

Specific physical exercises will help you restore the function of your knee, strengthening the leg muscles, making them more flexible at the same time, which will provide the necessary support to your knee joint.

It is especially important to strengthen the quadriceps muscles of your thigh for a successful recovery. If you need surgical treatment then you will be able to start with rehabilitation, about 1 to 4 weeks after the surgical procedure.

Recovery Exercises

Recovery exercises are an important part of the treatment. PCL injury recovery is a long process which requires tremendous patience and endurance.

However, you should not get demotivated as a person can fully recover from a PCL injury. Once you are able to put about ½ of the body weight on your leg and if the swelling has subsided, then you are ready to start with recovery exercises.

Here are some of the most recommended strengthening and stretching exercises during a PCL injury recovery:

Wall squat with a ball – for this exercise you will need a ball. Stand against the wall with your feet shoulder width apart.

Place the ball behind your back. You can use a soccer ball or basketball sized ball for this wall squat exercise. While keeping your back against the wall, start squatting down to a 45 – degree angle. Remain in this position for a couple of seconds and slowly return to the starting position.

Repeat this exercise 10 to 15 times.

Step up – for this exercise you will need a small step on which you will put your injured leg, while your other foot is flat on the floor.

Start shifting your body weight slowly onto your injured leg. As your other leg comes off the floor start straightening the knee of your injured leg slowly. Return to the starting position slowly.

Repeat this exercise 10 to 15 times.

Seated quad sets – sit on a chair and keep your injured knee bent to a 90 – degree angle. Tighten the quadriceps muscle of the injured leg without moving the leg at all. Remain in this position for a couple of seconds and slowly relax your muscle.

 Repeat this exercise 10 to 15 times.

Quad sets – sit on the floor while keeping one leg bent and the injured one straight.

Start pressing the back of the injured knee against the floor while tightening the quadriceps muscle at the same time. Remain in this position for a couple of seconds and slowly return to the starting position.

Repeat this exercise 10 to 15 times.

Straight leg raise – lie on your back on the floor, while keeping your legs in a straight position. B

end the healthy knee and place the foot on the floor. Tighten the thigh muscles and lift the injured leg slowly from the floor. Remain in this position for a couple of seconds. Slowly get your leg back to the starting position.

Repeat this exercise 10 to 15 times.

Knee Braces for PCL Injuries

Knee braces are recommended during the recovery period after a PCL injury as it will help stabilize the knee and prevent further damage to the knee structures at the same time.

Check Out: The best knee braces for support

Surgery

In severe PCL damages, surgical treatment is often necessary. Patients who are more likely to require surgical treatment of a PCL injury include:

  • PCL injuries where there are broken bone as well and pieces of bones have become loose,
  • PCL injuries accompanied by injuries of other knee ligaments, or
  • Chronic PCL which becomes loose.

Rebuilding the PCL is usually necessary, as sewing, the ligament back as it was before often did not lead to healing.

A tissue graft is used during the surgical procedure to replace the ligament that has been damaged. The graft is either taken from your own body or from a donor. After the surgery, it will take several months to fully recover.

Treatment of PCL injuries is important as long term knee instability will lead to an early onset of knee arthritis.

How Long Does it Take to Recover from PCL Injury?

Recovering from PCL injury depends on the severity of the injury.

Minor PCL injuries have a better outlook and faster recovery period. On the other hand, moderate to severe PCL injuries, especially PCL injuries accompanied with broken bones or damage to other knee structures (ligaments, tendons, soft tissue) are normally harder to treat and a full recovery takes weeks and several months.

In cases when surgical treatment was necessary to repair a damaged PCL, then a full recovery can be expected after at least 6 to 12 months.

The recovery from a PCL injury is very slow. However, you should be committed to achieving your goal in order to return back as soon as possible to your daily life activities and for athletes to playing sports again.

How to Prevent PCL Tear?

PCL injuries are hard to prevent as they usually occur because of an accident, car accident for example or unforeseen injuries during contact sports.

However, in order to prevent any knee ligament injury, including PCL injuries you should strengthen and stretch the leg muscles. Muscles strength  can be achieved by doing regular physical exercise like stretching.

You can prevent tear by using caution when playing contact sports as there is a greater risk of ending up with a knee injury and using proper technique when playing sports, exercising, and even while walking.

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