Posterior cruciate ligament injury

Authors:
James MacDonald, MD, MPH, FAAFP, FACSM
Richard Rodenberg, MD
Section Editor:
Francis G O'Connor, MD, MPH, FACSM
Deputy Editor:
Jonathan Grayzel, MD, FAAEM
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2019. | This topic last updated: Sep 10, 2018.

INTRODUCTION The posterior cruciate ligament (PCL) is the primary

restraint to posterior translation of the tibia at the knee joint [1-4]. The bulk of
injuries to this ligament occur in combination with other internal derangements of
the knee in association with multi-ligament trauma; isolated PCL injuries are
uncommon [5,6]. The PCL is the knee ligament least frequently injured during
sports [5-7]. Over time, increasing knowledge of the anatomy and biomechanics of
this ligament has highlighted its importance with regard to knee stability and
function. As isolated injury is uncommon, the natural history of injury has yet to be
elucidated fully.

The presentation, evaluation, diagnosis, and nonoperative management of PCL

injuries are reviewed here. Other knee injuries and an overall approach to knee
complaints in active adults are discussed separately. (See "Anterior cruciate
ligament injury" and "Medial collateral ligament injury of the knee" and "Lateral
collateral ligament injury and related posterolateral corner injuries of the
knee" and "Approach to the adult with knee pain likely of musculoskeletal
origin" and "Approach to the adult with unspecified knee pain".)

ANATOMY AND BIOMECHANICS The posterior cruciate ligament

(PCL) is the largest and strongest of the intra-articular ligaments of the knee,
originating at the lateral border of the medial femoral condyle and inserting at the
posterior tibia in a depression called the PCL facet (fovea centralis) that lies
between the medial and lateral tibial plateaus (picture 1 and figure 1 and figure 2)
[1,2,8,9]. The PCL is considered an intra-articular but extrasynovial structure
because of the synovial sheath that lines the ligament [4]. The extrasynovial
location accounts for the limited swelling seen with isolated PCL injuries. Due to its
association with the posterior capsule, blood supply to the PCL is not permanently
lost with an intrasubstance tear. This permits primary surgical repair in some cases
of PCL injury [9].
The PCL is structurally divided into two distinct yet inseparable bundles identified
as the larger anterolateral (AL) and the smaller posteromedial (PM) bundles (figure
3). Classically, it was taught that, in addition to location, these bundles could be
distinguished by their function, with each bundle exhibiting different patterns of
tension and relaxation depending upon the degree of knee flexion [1,2,8,9].
However, subsequent biomechanical studies have demonstrated a more
synergistic "codominant relationship" between the AL and PM bundles, with both
contributing to knee stability throughout a full range of flexion (0 to 120 degrees)
[10].

The PCL works in concert with the meniscofemoral ligaments, which together
make up the PCL complex. The meniscofemoral ligaments originate from the
posterior horn of the lateral meniscus and insert on the medial femoral condyle
anterior to the PCL (ligament of Humphrey inserts anteriorly) and posteriorly to the
PCL (ligament of Wrisberg inserts posteriorly). While anchoring the lateral
meniscus, these ligaments also act as a secondary restraint to posterior tibial
translation [2,4,8,9].

The primary role of the PCL complex is to restrict posterior translation of the tibia
with respect to the femur, while also acting as a secondary restraint to external
rotation [2,8]. In addition, the PCL protects the extended knee from varus and
valgus stress. The role of the PCL in providing posterior knee stability increases as
the knee is brought into flexion. The PCL provides 95 percent of posterior stability
when the knee is flexed between 30 and 90 degrees [8]. Each bundle of the PCL
contributes to joint stability based upon its distinctive fiber orientation in relation to
the degree of knee flexion [1,2,8]. Essentially, tension in each bundle develops in a
reciprocal fashion during knee flexion and extension: The AL bundle becomes
slack in extension but progressively more taut with knee flexion; the PM bundle is
tight in extension but becomes progressively more slack with knee flexion [1,8].
Therefore, it may be more useful to consider the PCL as a single, complex
structure with a continuum of fibers of different lengths and varying tensions
depending on the degree of knee flexion [8].

The posterolateral complex, or PLC, (also referred to as the posterolateral corner)

consists of the lateral collateral ligament (LCL), iliotibial band, popliteus tendon,
popliteofibular ligament, arcuate ligament, and posterolateral joint capsule. The
PLC is an important secondary constraint against posterior tibial translation, with a
primary function of resisting varus and external rotational forces. The amount of
posterior tibial translation increases significantly when both the PCL and PLC are
injured. The clinician must be aware of this intimate anatomical relationship as an
injury to both structures suggests a need for prompt surgical treatment [1,2].
(See "Lateral collateral ligament injury and related posterolateral corner injuries of
the knee".)
 EPIDEMIOLOGY The incidence of posterior cruciate ligament (PCL)

injury is reported to range from 1 to 44 percent of all knee injuries [3,5,6,11]. This
wide variability in incidence probably exists because of the subtlety with which
isolated injuries can present. One report supports the notion that isolated PCL
injury is rare, comprising only 3.5 to 7.5 percent of trauma-related injury [5,6].
Common associated knee injuries involve the posterior lateral corner, anterior
cruciate ligament (ACL), and medial collateral ligament (MCL). Many individuals
who have sustained an isolated PCL injury continue to function at a high level in
sports and so may not present to clinicians, thus lowering the reported incidence.
Another study found a 2 percent incidence of asymptomatic PCL injury among
college American football players presenting for examination prior to the National
Football League (NFL) draft [2,3,12].

The main cause of PCL injury is high-energy trauma, most often involving motor
vehicle collisions (MVCs) [5,6,13]. Sporting activities are the second most common
cause of injury and are less likely to result in combined ligament injury. According
to a retrospective study of 19,530 sports-related injuries, the PCL is among the
least likely of structures to be injured in athletics, comprising up to 0.65 percent of
all athletic-related knee injuries [7]. Another large retrospective analysis found that
45 percent of PCL injuries were due to MVCs, while 40 percent were related to
athletic injury [13]. In this study, motorcycle accidents made up 28 percent of the
motor vehicle injuries, while football (soccer) was the sport most often associated
with PCL injury (25 percent). MVCs accounted for up to 63.8 percent of cases
involving combined ligamentous injuries of the knee, compared with athletic injury,
which accounted for 47.5 percent of such cases. Studies providing additional
insight into the rates of PCL injury in particular sports are not available.

MECHANISM OF INJURY Posterior cruciate ligament (PCL) injuries

may be sustained from high- or low-energy trauma. High-energy mechanisms,

primarily motor vehicle collisions (MVCs), may cause PCL injury when a posteriorly
directed sheer force is applied to a flexed knee (figure 4). One example is the
classic "dashboard injury" in which the anterior knee, including the proximal tibia, of
the driver or a front seat passenger collides with the car's dashboard. When such a
force is combined with varus rotation, the lateral or posterolateral structures of the
knee may be injured in addition to the PCL [2,3,13].

PCL injuries sustained during athletics typically occur when an athlete falls on their
flexed knee while the foot is plantarflexed or from a direct blow to the anterior knee.
In addition, the PCL and posterior capsule can be torn by a hyperflexion or
hyperextension mechanism, with or without a posterior-directed force [2,3,13].
Valgus and varus forces applied to the knee can cause a PCL injury, but such
mechanisms typically involve injuries to multiple knee structures [13].

CLINICAL PRESENTATION The presentation of patients with a

posterior cruciate ligament (PCL) injury varies depending upon the nature of the
trauma involved (high- versus low-energy) and associated injuries and
comorbidities. PCL injuries sustained from high-energy trauma are frequently
associated with additional knee injuries, including damage to the posterolateral
corner (PLC), anterior cruciate ligament (ACL), and medial collateral ligament
(MCL) [6]. Particularly in cases of low-energy trauma, a careful history detailing the
mechanism of injury is important for identifying PCL injury. PCL injury can be
classified further based on the timing of injury (acute versus chronic) and severity
(isolated versus multiligamentous). These variables affect treatment and prognosis
[13].

As the large majority of PCL injuries are sustained during motor vehicle collisions
(MVCs), the clinician must maintain a high index of suspicion for ligamentous knee
injury, including complete knee (tibiofemoral) dislocation, for any patient
complaining of knee pain or dysfunction following high-energy trauma [1,3]. Knee
dislocation can cause severe morbidity from vascular disruption if not recognized
and treated immediately. Knee injuries associated with high-velocity trauma often
present with severe hemarthrosis, inability to bear weight, gross instability, and
decreased range of motion. Assessments of knee dislocation and of the patient
involved in major trauma are discussed separately. (See "Knee (tibiofemoral)
dislocation and reduction" and "Initial management of trauma in
adults" and "Trauma management: Approach to the unstable child".)

PCL injuries sustained from low-energy trauma (eg, sporting injuries) may present
with gross instability, particularly if associated with injuries to posterolateral knee
structures or with more subtle symptoms that can make diagnosis difficult. The
presentation of an isolated PCL injury is often subtle and quite different from that of
an injury to the ACL, which often involves an acute popping sensation perceived by
the athlete at the time of injury, typically while performing a quick pivoting
maneuver or landing from a jump, followed by the development of a large knee
effusion. Patients with an isolated PCL injury generally do not report feeling or
hearing such a "pop." They may have a mild to moderate knee effusion, a slight
limp, pain in the back of the knee (especially with squatting or kneeling), and loss
of terminal knee flexion (final 10 to 20 degrees). Complaints of joint instability are
more common with multiple knee ligament injuries than an isolated PCL injury [1-
3,11]. Acutely, many of these athletes may continue to play sports and not seek
medical attention [3,11]. An athlete's only complaint may be a sensation that
"something's not right" in the knee or of generalized knee pain; the patient may
have difficulty being more precise [11].
Patients suffering from a chronically injured PCL-deficient knee present more often
with generalized anterior knee pain that may localize to the medial compartment or
patellofemoral joint. According to an observational study of tibiofemoral motion
involving open-access magnetic resonance imaging of patients with a PCL-
deficient knee, altered kinematics related to PCL deficiency cause a fixed anterior
subluxation of the medial femoral condyle in relation to the medial tibial plateau
[14]. This appears to increase the risk for degenerative changes in the medial
knee. In this study, imaging was performed while patients performed several
weightbearing movements. The lateral compartment of the knee appears to be
unaffected by the compressive forces created by PCL deficiency.

Patients with a chronic PCL-deficient knee may complain more of disability than
instability that is most noticeable when negotiating inclines such as stairs or ramps
[2,3,11]. Athletes presenting with a chronic injury may complain of pain when
sprinting or decelerating and mild instability [3]. Many individuals with chronic PCL
insufficiency are found to have been injured in a previous MVC [13]. Such patients
often sustained life-threatening injuries that caused the knee injury to be
overlooked.

EXAMINATION FINDINGS

General knee examination — For patients presenting immediately following a

motor vehicle collision (MVC) or other high-energy trauma, a precise knee
examination may not be possible due to severe pain and swelling, or the need to
perform urgent diagnostic imaging (eg, assessment of the popliteal artery from
suspected knee dislocation) or more urgent interventions. Whenever possible, the
knee is thoroughly examined as part of the secondary trauma survey. Of crucial
importance is assessing for major vascular injury of the injured extremity.
(See "Knee (tibiofemoral) dislocation and reduction" and "Initial management of
trauma in adults".)

For patients presenting with knee pain following low-energy trauma or with chronic
complaints, it is important to perform a careful knee examination paying close
attention to joint stability and function. The knee examination is reviewed in detail
separately; elements of the examination of particular importance to the assessment
of posterior cruciate ligament (PCL) injury are discussed below. (See "Physical
examination of the knee".)

The knee examination begins with careful inspection, using the uninjured lower
extremity for comparison. Asymmetries can be appreciated by watching the
patient's stance and gait. Findings may include swelling, joint effusion, muscle
atrophy, malalignment (eg, varus or valgus), and ecchymosis or other skin
changes. In patients with a PCL injury, general inspection and palpation of the
knee while the patient is supine may reveal a mild to moderate effusion, or possibly
no effusion in case of chronic injury [1-3].
With acute isolated PCL injury, the patient may manifest an antalgic gait [15].
Depending upon the patient's anatomy and concomitant injuries, any of several
gait abnormalities may be present. Loss of restraints against external rotation of
the tibia (best evaluated by the dial test (picture 2)) in combination with tibia vara or
genu recurvatum can produce a varus thrust gait or knee hyperextension in
combination with a varus thrust gait, best noted during the stance phase of the gait
cycle [16,17]. The varus thrust pattern consists of a dynamic lateral bowing of the
knee during the weightbearing phase of gait, which places a greater load on the
medial knee. Other patients may walk with a slightly flexed knee in order to avoid
the pain and instability associated with a varus thrust or varus hyperextension gait
pattern [16,17]. These abnormal gait patterns are typically more pronounced with
combined PCL and posterolateral corner (PLC) injury [1,17-19]. (See "Clinical
assessment of walking and running gait".)

Examination findings in the patient with a chronically PCL-deficient knee are

generally more subtle. Suggestive findings may include tibia vara (bow legged) or
genu recurvatum (hyperextended knee) [1,15,16,18,20]. Comparison with the
uninjured extremity is often useful. Tibia vara, which may stem from progressive
incompetence of posterolateral knee structures injured at the same time as the
PCL, is best seen while inspecting the weightbearing patient from behind. Genu
recurvatum, which may develop from abnormal alignment due to posterior
subluxation of the tibia, is best evaluated by observing sagittal knee alignment
while the patient is weightbearing.

Following inspection, the knee is palpated for signs of injury, although with acute
PCL injuries, findings other than effusion may be scant. It is difficult to differentiate
using palpation the structures of the posterolateral complex (PLC), which is
commonly injured in association with the PCL. Few structures are palpable in the
posterior fossa, the space between the medial and lateral hamstring tendons, but
the area may be tender. The lateral collateral (LCL) and medial collateral (MCL)
ligaments should be palpated, and focal tenderness at these ligaments suggests
injury [1,2]. As it can be difficult to distinguish the LCL from the biceps femoris
tendon and iliotibial band at the joint line (picture 3), the examiner should begin
palpation at the lateral femoral condyle and follow the cordlike LCL distally as it
crosses over the joint line towards the fibular head (picture 4).

Following palpation, active knee flexion is assessed by having the supine patient
flex the knee maximally, bringing the heel as close as possible to the gluteal fold.
Flexion can be measured in degrees using a goniometer or by the minimum
distance between the heels and the closest gluteal surface. Normal flexion is
approximately 130 degrees. If an effusion is present, as seen in acute PCL injury, it
is likely that active terminal flexion will be reduced by 10 to 20 degrees [1,2].

The clinician should determine the position of the tibia in relation to the femur with
the knee flexed to 90 degrees. This enables detection of asymmetries and allows
for correction of posterior subluxation of the tibia in the PCL-injured knee. In the
normal knee, the medial tibial plateau lies approximately 1 cm anterior to the
medial femoral condyle when the knee is flexed to 90 degrees. PCL injury should
be suspected if this step-off is absent [1,3,4]. As described below, it is important to
avoid confusing a PCL injury for an anterior cruciate ligament (ACL) injury when
performing an anterior drawer or Lachman test with the knee in this position [1,3].

As other knee ligaments are commonly injured along with the PCL, it is important
to test the joint for laxity. The ACL is best assessed using the Lachman and
anterior drawer maneuvers, while the MCL or LCL are assessed with the valgus
and varus stress tests respectively, at 0 and 30 degrees of flexion. (See "Physical
examination of the knee", section on 'Assessing joint stability'.)

Special tests for PCL injury — The primary tests used to assess the integrity of
the PCL and posterior knee include the posterior drawer test, posterior sag sign,
and quadriceps active test. The performance of these examination maneuvers is
described in detail separately. (See "Physical examination of the knee", section on
'Tests for PCL injury and posterior stability'.)
●Posterior drawer test – The posterior drawer test (figure 5) is generally
considered the most accurate examination maneuver for detecting PCL injury
[21]. Prior to performing the posterior drawer test, the clinician must ascertain
the position of the tibia relative to the femur. Posterior subluxation of the tibia
due to a loss of PCL integrity can compromise test results.
●Posterior sag sign (Godfrey test) – If a PCL injury is present, the tibia sags
below the level of the uninjured side (picture 5). This finding can be
appreciated in patients with acute or chronic PCL insufficiency [1,3].
●Quadriceps active test – In the PCL-deficient knee, the tibia starts in a
posteriorly subluxed position (as seen with the posterior sag sign), but with
contraction of the quadriceps the tibia translates anteriorly (movie 1 and figure
6).

Criteria for isolated PCL injury — When evaluating a patient for PCL injury, it is
important to rule out multiligamentous knee injury. An isolated PCL injury is likely if
the following criteria are met [11,22]:
●Posterior drawer test shows less than 10 mm laxity. In rare instances, an
isolated PCL injury can manifest >10 mm of laxity on posterior drawer testing.
In all cases, such a finding necessitates assessment of other knee structures,
particularly the PLC.
●Rotatory laxity of less than 5 to 10 degrees, performed with the knee in 30
degrees and 90 degrees of flexion (ie, negative dial test). (See "Physical
examination of the knee", section on 'Tests for PCL injury and posterior
stability'.)
●No sign of associated ligamentous injury (ie, negative testing for MCL, LCL,
and ACL injury).
The Lachman test and varus and valgus stress testing at 0 and 30 degrees of
knee flexion are effective examination maneuvers for diagnosing concomitant
ligament injury, but they may be ineffective immediately following acute injury
due to patient guarding. In these cases, magnetic resonance imaging (MRI) is
 effective at ruling out concomitant ligament or cartilage injury when an
immediate, definitive diagnosis is required. (See 'Diagnostic imaging' below.)

Classification of PCL injury — The magnitude of posterior knee translation as

measured during the posterior drawer test allows the examiner to grade a PCL
injury by comparing findings with the uninjured, contralateral knee [1-4,11].
Standard grading is as follows:
●Grade 1 – The anterior border of the medial tibial plateau can be displaced
posteriorly but remains anterior to the medial femoral condyle (0 to 5 mm
posterior displacement).
●Grade 2 – The anterior border of the medial tibia plateau can be displaced
posteriorly until it is flush with the medial femoral condyle (posterior
displacement of 5 to 10 mm).
●Grade 3 – The anterior border of the medial tibial plateau can be displaced
posteriorly beyond the anterior border of the medial femoral condyle (posterior
displacement >10 mm).

Grade 1 and Grade 2 injuries are considered partial PCL tears; Grade 3 injuries
represent complete PCL tears [1].

Associated injuries — When a Grade 3 injury is identified clinically, the clinician

must maintain a high index of suspicion for combined injury involving other
capsuloligamentous knee structures, primarily those of the PLC. It is important to
recognize these combined PCL and PLC injuries as management is more likely to
require surgery [1-3]. Assessment of the PLC includes four examination
maneuvers: the external rotation recurvatum test, posterolateral drawer test,
reverse pivot shift test, and dial test at 30 and 90 degrees. Examination of the PLC
is described in detail separately. (See "Lateral collateral ligament injury and related
posterolateral corner injuries of the knee", section on 'Clinical presentation and
examination'.)

DIAGNOSTIC IMAGING

Approach to diagnostic imaging

Suspected acute PCL injury — With any acute knee injury presenting after
moderate or severe trauma in which a posterior cruciate ligament (PCL) injury is
suspected and that is accompanied by concerning physical findings, such as joint
effusion, focal bony tenderness, decreased range of motion, or limp, we obtain
plain radiographs of the knee as part of the initial diagnostic imaging. Plain
radiographs may reveal fractures and avulsion injuries (image 1). If trauma is
relatively minor and concerning physical findings are absent, the Ottawa knee rules
can be used to guide decisions about plain radiographs. (See "Approach to the
adult with knee pain likely of musculoskeletal origin", section on 'Imaging'.)
We suggest obtaining magnetic resonance imaging (MRI) for all patients in whom a
PCL injury is suspected on clinical grounds (eg, blow to flexed knee with positive
posterior drawer test) following acute trauma involving the knee. (See 'Magnetic
resonance imaging' below.)

Suspected subacute or chronic PCL injury — Following a subacute or chronic

knee injury (time since injury greater than six weeks) in which a PCL tear is
suspected, we use the Ottawa knee rules to help determine whether plain
radiographs of the knee are needed as part of the initial diagnostic imaging in
adults. Although validated in children, the Ottawa knee rules were designed with
acute injuries such as fractures in mind [23]. Many pediatric and adolescent
patients present with subacute or chronic knee pain, and the authors generally
obtain plain knee radiographs in these cases to assess for conditions such as
avulsed apophyses or osteochondritis dissecans that may account for such
symptoms. If plain radiographs identify such conditions, workup proceeds as
indicated.

If plain radiographs are unrevealing or not indicated but chronic PCL injury is
suspected on clinical grounds, we suggest obtaining an MRI to assess both the
PCL and possible associated injury, although the sensitivity of MRI for chronic PCL
tears is limited. (See 'Magnetic resonance imaging' below.)

Plain radiography — Plain radiographs are the initial studies obtained in most

patients with an acute knee injury and suspected PCL tear. Anteroposterior (AP)
and lateral views are used to rule out fracture of the tibial plateau, femoral
condyles, and patella. The lateral view should be examined carefully looking for
bony avulsion of the tibial PCL insertion (image 1) and posterior sag of the tibia,
which suggest a PCL injury (image 2) [1-3,11]. A cortical avulsion off the medial
tibial plateau has been described as a medial "Segond-type" fracture that may be
associated with tears of the PCL and medial meniscus, but further research is
needed [24].

In the patient with a suspected chronic PCL-deficient knee, weightbearing AP

views of the knee should be obtained, as well as a lateral view and sunrise views
of the patella (image 3). These images should be examined for posterior sag of the
tibia, avulsion fracture of the PCL insertion, and degenerative changes in the
medial and patellofemoral compartments [1-3,11]. Posterolateral or posteromedial
subluxation may be apparent if the posterolateral or posteromedial compartments
have been disrupted [11].

Stress radiographs — More clinicians are using stress radiographs to diagnose

and grade PCL injuries [3,10,13]. Stress radiographs enable the clinician to obtain
objective measurements of tibial translation in the sagittal plane noninvasively and
to compare measurements in injured and uninjured knees [2]. Stress radiographs
can be performed manually or with the aid of a mechanical device, which may
allow for more consistent measurements. Some experts endorse the single-leg
kneeling technique, obtaining a view of the injured and uninjured knees to compare
posterior tibial translation [10]. This technique is thought to be more cost effective
and accessible.

A retrospective study comparing findings from stress radiographs of 1041

consecutive patients with PCL tears to findings from cadaveric dissection studies
found that posterior translation of the tibia in excess of 8 mm was associated with
complete insufficiency of the PCL, while translation exceeding 12 mm was
indicative of additional injury to secondary restraining structures, such as those of
the posterolateral complex (PLC) [25]. Similar results have been reported in
cadaver studies [26].

Magnetic resonance imaging — In most cases of suspected PCL injury,

magnetic resonance imaging (MRI) is obtained to assess both the PCL and other
soft tissue knee structures. MRI is highly sensitive and specific for acute PCL tears
but much less accurate for detecting chronic tears.

Studies using arthroscopy as the gold standard have found the sensitivity and
specificity of MRI for diagnosing acute PCL injury to approach 100 percent [27-29].
The PCL is best seen on the sagittal view with a normal ligament appearing as a
dark, curvilinear structure on T1 and T2 sequences (image 4 and image 1) [2,11].
The clinician must be mindful that a clinical Grade 3 injury significantly raises the
likelihood for more severe damage involving other capsuloligamentous knee
structures, primarily those of the PLC.

In many instances of chronic injury, the PCL appears relatively normal due to the
ability of the ligament to heal [30,31]. A systematic review of follow-up studies of
posttraumatic PCL injuries revealed that 77 to 93 percent of partial or complete
PCL tears regained continuity [31]. Thus, the accuracy of MRI in diagnosing
chronic PCL injury is relatively low, with one small retrospective study reporting 57
percent [30]. Of note, the MRI appearance of the PCL following chronic injury has
not been shown to correlate with clinical stability; in other words, a continuous
ligament does not imply a stable knee [3,30,31].

Radionuclide imaging (bone scan) — For a patient with chronic PCL deficiency

associated with pain and instability, bone scan may be able to identify early
degenerative changes in the patellofemoral or medial compartments of the knee
[1,2]. The decision about whether to obtain a bone scan in the setting of possible
chronic PCL injury is best left to an orthopedic specialist. Results of the study can
help to determine whether reconstruction of the PCL will be undertaken. Bone scan
is not used in the assessment of suspected acute PCL injury.

Ultrasound — Ultrasound can assess the PCL only to a limited extent, but it may
reveal changes consistent with PCL injury, such as enlargement of the ligament
compared with the contralateral knee or in some cases a focal disruption in
ligament continuity [32,33]. MRI is superior for evaluation of acute PCL injury and
for identifying concomitant injury of menisci, ligaments, and articular cartilage.
More research is needed to determine the capacities of ultrasound for identifying
PCL injury. Ultrasound may offer a viable alternative for diagnosing suspected
chronic PCL injuries not appreciated on MRI due to elongated healing.

DIAGNOSIS Definitive diagnosis of an acute or subacute posterior

cruciate ligament (PCL) injury can be made with magnetic resonance imaging
(MRI) or arthroscopy (although arthroscopy is not performed for the purpose of
diagnosis). A presumptive clinical diagnosis can often be made based upon the
mechanism of injury and examination findings. A direct blow to the anterior portion
of a flexed knee from a car dashboard, an opponent, or the ground is the most
common mechanism, while a positive posterior drawer test, posterior sag sign, and
quadriceps active test are highly suggestive findings. (See 'Mechanism of
injury' above and 'Clinical presentation' above and 'Examination findings' above.)

Establishing a definitive diagnosis of chronic PCL injury can be difficult as both MRI
and direct visualization using arthroscopy have limitations. As PCL tears can heal
over time, MRI studies of chronic injuries may fail to identify such injuries, although
degenerative changes found in the medial and patellofemoral compartments of the
knee are suggestive. A PCL tear may be difficult to detect using arthroscopy
because the PCL is partially obscured by the anterior cruciate ligament (ACL) and
may appear intact despite clinical laxity and the existence of a partial tear [21,34].

INDICATIONS FOR ORTHOPEDIC CONSULT OR

REFERRAL Based upon our clinical experience and that of our surgical

colleagues, and the limited available published evidence, we suggest that the
following injuries be referred to a knowledgeable orthopedic surgeon:
●Grade 3 posterior cruciate ligament (PCL) injuries – Anterior border of medial
tibial plateau can be displaced posteriorly beyond the anterior border of the
medial femoral condyle (posterior displacement >10 mm [35] ).
●PCL injuries associated with any fracture or any additional soft tissue injuries
of significance (eg, injury of the posterolateral complex [PLC], anterior cruciate
ligament [ACL] injury, meniscal tear).
●PCL disruption involving avulsion of the ligamentous insertion at the tibia
[35,36].

In addition, if the clinical picture is unclear or the patient is a high-level athlete, it is

reasonable to obtain orthopedic consultation. We suggest that acute isolated PCL
injuries (ie, Grade 1 and 2 injuries) be managed nonoperatively, as outlined below.
Should appropriate nonoperative management of a Grade 1 or Grade 2 PCL injury
be unsuccessful (eg, patient experiences persistent pain or instability), orthopedic
consultation should be obtained. However, given the limitations of surgical
interventions, we adhere to a course of physical therapy and nonoperative
management for as long as possible, and we generally wait up to 12 months before
referring patients with lower grade PCL injuries. We refer patients with a chronic,
isolated PCL injury to a knowledgeable orthopedic surgeon if they have developed
functional instability or symptoms such as recurrent effusions or worsening pain
[36]. Otherwise, we begin treatment with an appropriate physical therapy program.
(See 'Follow-up care' below.)

It is vitally important that the treating clinician has, by examination and imaging,
confirmed the diagnosis of isolated PCL injury, and determined its grade, before
making a determination about the need for consultation. A multiligamentous knee
injury is vastly different than an isolated PCL injury, with far greater associated
morbidity, and surgical consultation is required for all these injuries.

DIFFERENTIAL DIAGNOSIS Posterior cruciate ligament (PCL)

injuries, particularly those sustained in high-energy trauma, are often associated

with other injuries of the knee and elsewhere. Important injuries to consider when
PCL tear is suspected include the following:

ACL injuries — The mechanisms of injury associated with PCL trauma may also
injure the anterior cruciate ligament (ACL). However, the history and examination
findings associated with ACL tears are generally distinct from those of PCL tears.
Athletes who sustain an ACL injury often hear or feel an acute "pop" at the time of
injury, and the mechanism generally involves a quick pivoting maneuver or landing
from a jump, followed acutely by the development of a large knee effusion. The
knee often feels unstable and a Lachman test is positive. It is important that the
Lachman maneuver be performed correctly to avoid a false positive result. Should
a definitive diagnosis be required, magnetic resonance imaging (MRI) readily
distinguishes between these two acute injuries. (See 'General knee
examination' above and "Anterior cruciate ligament injury".)

LCL and PLC injuries — Lateral collateral ligament (LCL) and posterolateral

corner (PLC) injuries are often sustained in combination with PCL injury,
particularly following high-energy trauma, and must be distinguished from isolated
PCL injuries as multi-ligament trauma typically requires surgical intervention. In the
presence of an LCL injury, a varus stress maneuver reveals abnormal widening
and pain at the lateral joint line; the maneuver does not provoke such widening or
pain with an isolated PCL injury. Likewise, the examination maneuvers commonly
used to assess the PLC (ie, external rotation recurvatum test, posterolateral drawer
test, reverse pivot shift test, and dial test at 30 and 90 degrees) are unlikely to be
positive in the setting of an isolated PCL injury. MRI is highly accurate for
identifying injury to the LCL and PLC in addition to the PCL, but the radiologist
must be consulted to ensure that the appropriate imaging protocol is used.
(See "Lateral collateral ligament injury and related posterolateral corner injuries of
the knee", section on 'Clinical presentation and examination' and "Lateral collateral
ligament injury and related posterolateral corner injuries of the knee", section on
'Imaging' and "Physical examination of the knee", section on 'Tests for PCL injury
and posterior stability'.)

Meniscal injuries (lateral and medial) — There can be significant overlap in the

clinical presentation of PCL and meniscal injuries, and these injuries may be
sustained simultaneously [37]. Meniscal injuries often present with nonspecific
mechanical symptoms, such as popping, locking, or catching of the knee joint, and
functional instability, which may also be present with PCL injuries. Pain and
disability are comparable, and signs such as mild to moderate effusions may be
similar. Differences in the physical examination include joint line tenderness and
positive McMurray and Thessaly maneuvers, which are often present with meniscal
injury, and the posterior sag and posterior drawer tests, which are positive in the
presence of PCL injury but not with isolated meniscal injuries. Diagnostic imaging
may be needed to distinguish these two injuries. (See "Meniscal injury of the
knee".)

Proximal tibia fractures — Fracture of the proximal tibia can occur in the same
setting where one might see a PCL injury. Motor vehicle collisions (MVCs) causing
direct trauma to the knee or hyperextension injuries sustained on the athletic field
are common mechanisms for both types of injury. Typically, a tibial fracture
presents with a hemarthrosis, which manifests as a larger effusion than is typically
seen with PCL injury, and substantial pain, which is also uncharacteristic of an
isolated PCL injury. Pain and guarding from a tibial fracture are likely to prevent the
clinician from performing examination maneuvers that can distinguish between the
two injuries. Plain radiographs usually reveal a tibial fracture. (See "Proximal tibial
fractures in adults".)

Knee (tibiofemoral) dislocation — A knee (tibiofemoral) dislocation is a limb-

threatening injury requiring emergent evaluation. The clinician must maintain a high
index of suspicion for such injury in any patient complaining of knee pain or
dysfunction following significant knee trauma. Knee dislocation is typically
sustained through high-energy trauma (eg, MVC) and causes severe pain and
gross instability of the knee. Swelling is generally severe, and there may be
obvious deformity, assuming the dislocation does not reduce spontaneously.
(See "Knee (tibiofemoral) dislocation and reduction".)

Bone contusion — The mechanisms commonly associated with many PCL

injuries, such as direct knee trauma and knee hyperextension, can also cause a
bone contusion of the tibia, and the two injuries may coexist [38]. Bone contusions
can cause significant pain and disability, causing restrictions in knee motion and
possibly an effusion. However, the posterior sag and posterior drawer tests are
negative in the patient with an isolated bone contusion. In difficult cases where the
examination is limited and a definitive diagnosis is required, MRI readily
distinguishes between these two acute injuries.
Patellar and quadriceps tendon tears — Both tendon tears and PCL injuries can
occur with a fall onto a flexed knee. However, when such trauma causes a patellar
or quadriceps tendon tear, the patient often reports feeling a "pop" in their knee
along with some degree of immediate disability and a knee effusion. These
presenting symptoms and signs are highly atypical of a PCL injury. Patients with
tendon tears are generally unable to bear weight on the injured leg or to perform a
straight leg raise, whereas patients with a PCL injury are usually able to do both,
although posterior sag of the tibia may be noted during the straight leg raise. Often,
there is a palpable defect and reproducible tenderness when examining a torn
patellar or quadriceps tendon, while such findings are not found with PCL injuries.
On plain radiographs, the height of the patella may be altered (patella alta or baja)
or signs of a patellar avulsion injury may be present in patients with tendon tears. If
obtained, an MRI clearly distinguishes between these two injury types.
(See "Quadriceps muscle and tendon injuries", section on 'Quadriceps and patellar
tendon tears'.)

INITIAL TREATMENT Once the treating clinician has established that

there is no need for referral, initial treatment of an isolated posterior cruciate

ligament (PCL) injury involves standard management of pain and functional
disability if present. The basic principles of protection, rest, ice, compression,
elevation, and medications (PRICE-M) apply.

We suggest maintaining the affected knee in hinged knee brace locked in full
extension for approximately two weeks in order to reduce posterior lag in the
acutely injured knee. Alternatively, a standard knee immobilizer may be used. After
two weeks, the brace is unlocked to allow progressive range of motion exercises.
There is no high-quality evidence supporting this approach, but we and some
others consider immobilization in extension to be an important part of initial
treatment [11]. Chronic PCL-deficient knees do not require bracing unless the
patient reports a high degree of functional instability; if a brace is used in this
setting, it should be unlocked.

PCL injuries themselves generally do not cause significant pain or joint effusion,
but these may develop due to associated bone contusions. Therefore, appropriate
rest may require a period of limited weightbearing using crutches. The use of
crutches is intended for pain control and is not mandatory. Ice applied to the knee,
elastic compression wraps (eg, ACE wraps), and elevation of the affected extremity
above heart level may be needed to reduce swelling and discomfort. Analgesic
medications may be needed for pain. Options may include a short course
of acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs). Opioids are
typically unnecessary. Usually, patients are able to resume school or desk-type
work soon after an isolated PCL injury.
 FOLLOW-UP CARE There is a dearth of high-quality evidence and

currently no consensus about what constitutes optimal nonoperative rehabilitation

and management of an isolated posterior cruciate ligament (PCL) injury [22,35].
Rehabilitation of the conservatively treated, isolated PCL injury can resemble that
of the surgically reconstructed PCL, for which there is better evidence [39]. The
approach described below is based upon our experience and our interpretation of
the available literature. Rehabilitation of a PCL injury can be difficult and the
authors strongly prefer that rehabilitation be supervised by a knowledgeable
physical therapist.

Early rehabilitation — Rehabilitation may begin when swelling has diminished

and pain is well controlled; practically, for many patients that means immediately
after presentation. Early rehabilitation following an acute, isolated PCL injury
consists primarily of general mobility and open-chain quadriceps exercises. These
include ankle pumps (active dorsiflexion and plantarflexion of the ankles) and quad
sets (active contraction of the quad with the knee in extension). The goal of early
rehabilitation is to prevent joint stiffness and encourage recruitment of the
quadriceps, which the patient may have difficulty activating due to pain or joint
effusion. Full strength and function of the quadriceps are needed for full recovery,
and thus addressing this muscle group early in the course of treatment is
important. The authors avoid open-chain hamstring exercises (eg, heel slides) to
prevent unopposed hamstring activation, which may accentuate posterior sag of
the tibia, contribute to joint irritation, and delay recovery.

Supervision by a knowledgeable physical therapist, athletic trainer, or comparable

professional during this early stage of recovery is not mandatory but can be helpful
to ensure that pain and swelling (if present) are manageable and the prescribed
exercises are being performed correctly. Modalities often available through
physical therapy, such as neuromuscular electrical stimulation, can help with
quadriceps activation even if the patient is unable to perform simple open-chain
exercises [40,41].

During rehabilitation, some patients may benefit from additional support of the
posterior knee, which can be provided by the taping method pictured in the
following graphic (picture 6). Note that the support provided by this method
would not be adequate for a patient returning to full sport. Ideally, such patients
should have developed sufficient strength of the muscles supporting the knee that
extraneous support is unnecessary, or barring that should use a robust functional
PCL brace.

Later rehabilitation — The advanced stage of rehabilitation typically commences

four to six weeks after the initial injury, when pain and disability have subsided.
Although several rehabilitation protocols for surgically treated PCL injuries have
been published, there is relatively little evidence available to guide the
rehabilitation of PCL injuries managed nonoperatively [3,11,42-44]. An example of
a properly designed, nonoperative PCL rehabilitation protocol for an isolated,
uncomplicated, acute PCL injury can be found in the attached table and reference
(table 1) [22]. Initially, the goals of this stage of rehabilitation are to continue to
protect the knee, regain full knee motion, and strengthen the muscles primarily
responsible for supporting the PCL-deficient knee (ie, quadriceps). Depending on
patient goals, more challenging exercises are gradually introduced that enable the
patient ultimately to regain full function.

Typically, rehabilitation for PCL injuries takes longer than that for ACL injuries [45].
Rehabilitation protocols following PCL reconstruction range from 26 to 52 weeks
[43,46], whereas rehabilitation of the nonoperatively treated PCL-deficient knee is
typically completed in half that time. It is important to note that rehabilitation
protocols are function based and not time based.

RETURN TO SPORT OR WORK Decisions concerning return to

sport or heavy labor are necessarily multifactorial and entail balancing patient
preference, subjective assessments of persistent pain and functional limitations,
and objective evaluations of strength and performance. There is no single "gold
standard" for determining return to sport [44].

The authors make their determination in concert with the physical therapists who
have been conducting the patient's rehabilitation. The athlete is expected to
demonstrate symmetric strength and proprioception in the affected and the
uninvolved extremities. Strength can be assessed with single leg presses using
resistance machines; proprioception may be determined by standing on one leg
and maintaining balance and a level pelvis for 30 seconds. Plyometric and other
functional tests are commonly used by physical therapists for these assessments,
especially in athletes, and these may include timed single-leg hops for distance,
shuttle runs, single-leg vertical jumps for height, and the Star Excursion Balance
Test [47]. As a general rule of thumb, performance of the injured leg should be
within 10 percent of that of the uninjured leg prior to return to sport [44].

For patients who do desk work or do not engage in vigorous activity, return to work
can typically be achieved as soon as pain and functional disability have abated
sufficiently. The time needed for a return to this sort of work is generally within two
to four weeks and can commence while the patient is still undergoing rehabilitation.

Beyond the period of early rehabilitation, there is no evidence to support functional

knee bracing in patients with isolated posterior cruciate ligament (PCL) injuries.
When returning patients to sport, the authors do not routinely use functional knee
braces, although these may be used for activities that are considered high-risk (eg,
American football linemen). Following surgical reconstruction, such knee bracing
may be used during sport for up to 18 months postoperatively [44].
 COMPLICATIONS AND PROGNOSIS The natural history of

isolated, nonoperatively treated posterior cruciate ligament (PCL) tears continues

to be a source of debate. Some authors believe that the natural history of PCL
tears entails inevitable degenerative changes and have argued that this supports
the need for surgical intervention [36]. Others have noted that the prevalence of
knee osteoarthritis after PCL reconstruction appears to be similar or worse than
that seen in knees treated conservatively [48,49]. There is insufficient high-quality
evidence to determine the true prognosis or the best approach to treatment.

Based on limited evidence, it appears that most patients can expect to have good
subjective and functional results with nonoperative management of isolated PCL
tears. One prospective study of 133 patients reported that the majority had good
subjective results at five-year follow-up, with half able to return to sport at the same
or a higher level [50]. Smaller studies of similar design report comparable results
[49,51]. However, premature osteoarthritis is a long-term concern, as it is with any
internal derangement of the knee. According to a case series of 44 patients
managed nonoperatively and followed for a mean of 14.3 years, the prevalence of
moderate to severe knee osteoarthritis was 11 percent [48].

No factors have been identified that accurately predict which patients will develop
complications, such as osteoarthritis, instability, or chronic pain. As an example,
the grade of PCL injury does not correlate with the development of degenerative
joint disease [3].

Historically, the results of surgical repair of isolated PCL injuries have been less
satisfactory than comparable repairs of anterior cruciate ligament (ACL)
reconstructions [52]. In addition, the PCL has greater natural healing ability than
the ACL, with one study demonstrating continuity of the disrupted PCL in 20 of 21
patients six months after injury with conservative treatment [53].

Nevertheless, PCL repair and reconstruction are becoming more common,

although high-quality evidence pertaining to the surgical treatment of isolated PCL
injuries is lacking, and controversy exists about appropriate management
[36,48,50,54]. The sources of controversy encompass a number of issues related
to PCL surgery, including: repair versus reconstruction, single-bundle versus
double-bundle reconstruction techniques, preferred graft options (eg, Achilles
allograft versus hamstring autograft), whether any PCL remnant should be
preserved in reconstruction, and the best surgical approach (eg, tibial tunnel
versus tibial inlay) [52]. In the United States, many if not most Grade 3 injuries are
currently managed nonoperatively, with surgery primarily reserved for acute,
multiligamentous knee injuries [55].
 SOCIETY GUIDELINE LINKS Links to society and government-

sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Meniscal injury".)

SUMMARY AND RECOMMENDATIONS

●The posterior cruciate ligament (PCL) is the largest and strongest of the intra-
articular ligaments of the knee, and the primary restraint to posterior
translation of the tibia at the knee joint. PCL injuries are usually sustained from
high-energy trauma (eg, motor vehicle collision [MVC]) in association with
damage to other knee structures. Sporting activities are the second most
common cause of PCL injury. Isolated PCL injuries are relatively uncommon,
and athletes with such injuries may continue to function at a high level.
(See 'Anatomy and biomechanics' above and 'Epidemiology' above.)
●High-energy mechanisms of PCL injury typically involve a posteriorly directed
sheer force is applied to a flexed knee, as might occur when a knee strikes a
dashboard during a MVC. PCL injuries sustained during athletics typically
occur when an athlete falls on their flexed knee while the foot is plantarflexed
or from a direct blow to the anterior knee.
●The presentation of patients with a PCL injury varies depending upon the
nature of the trauma and associated injuries and comorbidities. PCL injuries
sustained from high-energy trauma are frequently associated with damage to
the posterolateral corner (PLC), anterior cruciate ligament (ACL), medial
collateral ligament (MCL), or a combination of these structures. The possibility
of a complete knee (tibiofemoral) dislocation, a limb-threatening injury, must
be considered for any patient complaining of knee pain or dysfunction
following high-energy trauma. (See 'Clinical presentation' above and "Knee
(tibiofemoral) dislocation and reduction".)
●PCL injuries sustained from low-energy trauma (eg, sporting injuries) may
present with gross instability, particularly if associated with injuries to
posterolateral knee structures, but typically present with more subtle
symptoms, particularly in the case of an isolated PCL injury. Patients with such
injuries may present with a mild to moderate knee effusion, a slight limp, pain
in the back of the knee (especially with squatting or kneeling), and loss of
terminal knee flexion (final 10 to 20 degrees). Patients suffering from a
chronically injured PCL-deficient knee present more often with generalized
anterior knee pain that may localize to the medial compartment or
patellofemoral joint. (See 'Clinical presentation' above.)
●Following major trauma, the knee examination may be limited by pain,
swelling, or the need to perform more urgent interventions. Gross instability
due to multiple ligament disruptions (eg, knee dislocation) can damage the
popliteal artery, putting the limb at risk, and this must be assessed. For
patients assessed following low-energy trauma or with chronic complaints, it is
important to perform a careful knee examination paying close attention to joint
stability and function. Findings with an acute PCL injury often include gait
abnormalities, a knee joint effusion, tenderness in the posterior fossa, and loss
of terminal knee flexion. The most useful tests for detecting PCL injury are the
posterior drawer test (figure 5), posterior sag sign (picture 5), and quadriceps
active test (movie 1 and figure 6). Given the frequency of injury to other knee
ligaments in patients with PCL damage, the stability of the ACL, MCL, and
lateral collateral ligament (LCL) should be assessed. (See 'Examination
findings' above.)
●With any acute knee injury presenting after moderate or severe trauma in
which a PCL injury is suspected and that is accompanied by concerning
physical findings, such as joint effusion, focal bony tenderness, decreased
range of motion, or limp, we suggest obtaining plain radiographs of the knee
as part of the initial diagnostic imaging. If trauma is relatively minor and
concerning physical findings are absent, the Ottawa knee rules can be used to
guide decisions about plain radiographs. The Ottawa knee rules are reviewed
separately. (See "Approach to the adult with knee pain likely of
musculoskeletal origin", section on 'Imaging'.)
●We suggest obtaining magnetic resonance imaging (MRI) for all patients in
whom a PCL injury is suspected on clinical grounds (eg, blow to flexed knee
with positive posterior drawer test) following acute trauma involving the knee.
In addition, for patients with a chronic PCL injury suspected on clinical grounds
and unrevealing plain radiographs, we suggest obtaining an MRI. MRI is the
preferred method for establishing a definitive diagnosis in the acute or
subacute setting, but its accuracy is more limited with chronic PCL injuries.
(See 'Approach to diagnostic imaging' above and 'Magnetic resonance
imaging'above.)
●PCL injuries that meet any of the following criterial should be referred to a
knowledgeable orthopedic surgeon:
•Grade 3 PCL injuries: Anterior border of medial tibial plateau can be
displaced posteriorly beyond the anterior border of the medial femoral
condyle (posterior displacement >10 mm)
•PCL injuries associated with any fracture or any additional soft tissue
injuries of significance (eg, injury of the PLC, ACL, or meniscus)
•PCL disruption involving avulsion of the ligamentous insertion at the tibia
(see 'Indications for orthopedic consult or referral' above)
●When evaluating the patient with a possible PCL injury, other conditions to
consider include: ACL injury, PLC and LCL injury, meniscal injury, proximal
tibia fracture, knee (tibiofemoral) dislocation, bone contusion, and patellar and
quadriceps tendon tear. (See 'Differential diagnosis' above.)
●Initial treatment of a PCL injury involves standard management of pain and
functional disability, if present. The basic principles of protection, rest, ice,
compression, elevation, and medications (PRICE-M) apply. Knee injuries
involving multiple structures are referred as detailed above, but the
management of isolated PCL injuries consists primarily of a progressive
physical therapy program, which is discussed in the text. For isolated acute
 PCL injuries, we suggest maintaining the affected knee in full extension for
approximately two weeks initially in order to reduce posterior lag. (See 'Initial
treatment'above and 'Follow-up care' above and 'Return to sport or
work' above and 'Complications and prognosis' above.)
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REFERENCES
1. Allen CR, Kaplan LD, Fluhme DJ, Harner CD. Posterior cruciate ligament injuries.
Curr Opin Rheumatol 2002; 14:142.
2. Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior
cruciate ligament injuries: revisited. Am J Sports Med 2004; 32:1765.
3. McAllister DR, Petrigliano FA. Diagnosis and treatment of posterior cruciate
ligament injuries. Curr Sports Med Rep 2007; 6:293.
4. Voos JE, Mauro CS, Wente T, et al. Posterior cruciate ligament: anatomy,
biomechanics, and outcomes. Am J Sports Med 2012; 40:222.
5. Fanelli GC. Posterior cruciate ligament injuries in trauma patients. Arthroscopy
1993; 9:291.
6. Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: Part
II. Arthroscopy 1995; 11:526.
7. Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year
study. Knee 2006; 13:184.
8. Bowman KF Jr, Sekiya JK. Anatomy and biomechanics of the posterior cruciate
ligament, medial and lateral sides of the knee. Sports Med Arthrosc 2010; 18:222.
9. Flandry F, Hommel G. Normal anatomy and biomechanics of the knee. Sports Med
Arthrosc 2011; 19:82.
10. LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging Updates on
the Posterior Cruciate Ligament: A Review of the Current Literature. Am J Sports
Med 2015; 43:3077.
11. Lopez-Vidriero E, Simon DA, Johnson DH. Initial evaluation of posterior cruciate
ligament injuries: history, physical examination, imaging studies, surgical and
nonsurgical indications. Sports Med Arthrosc 2010; 18:230.
12. Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated
posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986; 14:35.
13. Schulz MS, Russe K, Weiler A, et al. Epidemiology of posterior cruciate ligament
injuries. Arch Orthop Trauma Surg 2003; 123:186.
14. Logan M, Williams A, Lavelle J, et al. The effect of posterior cruciate ligament
deficiency on knee kinematics. Am J Sports Med 2004; 32:1915.
15. Harner CD, Höher J. Evaluation and treatment of posterior cruciate ligament
injuries. Am J Sports Med 1998; 26:471.
16. Malone AA, Dowd GS, Saifuddin A. Injuries of the posterior cruciate ligament and
posterolateral corner of the knee. Injury 2006; 37:485.
17. Davies H, Unwin A, Aichroth P. The posterolateral corner of the knee. Anatomy,
biomechanics and management of injuries. Injury 2004; 35:68.
18. Fleming RE Jr, Blatz DJ, McCarroll JR. Posterior problems in the knee. Posterior
cruciate insufficiency and posterolateral rotatory insufficiency. Am J Sports Med
1981; 9:107.
19. Chen FS, Rokito AS, Pitman MI. Acute and chronic posterolateral rotatory
instability of the knee. J Am Acad Orthop Surg 2000; 8:97.
20. Kozanek M, Fu EC, Van de Velde SK, et al. Posterolateral structures of the knee in
posterior cruciate ligament deficiency. Am J Sports Med 2009; 37:534.
21. Rubinstein RA Jr, Shelbourne KD, McCarroll JR, et al. The accuracy of the clinical
examination in the setting of posterior cruciate ligament injuries. Am J Sports Med
1994; 22:550.
22. Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears:
functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc
2013; 21:1071.
23. Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee Rule in children: a
multicenter study. Ann Emerg Med 2003; 42:48.
24. Hall FM, Hochman MG. Medial Segond-type fracture: cortical avulsion off the
medial tibial plateau associated with tears of the posterior cruciate ligament and
medial meniscus. Skeletal Radiol 1997; 26:553.
25. Schulz MS, Steenlage ES, Russe K, Strobel MJ. Distribution of posterior tibial
displacement in knees with posterior cruciate ligament tears. J Bone Joint Surg Am
2007; 89:332.
26. Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of
posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated
and combined deficiency. J Bone Joint Surg Am 2008; 90:1621.
27. Polly DW Jr, Callaghan JJ, Sikes RA, et al. The accuracy of selective magnetic
resonance imaging compared with the findings of arthroscopy of the knee. J Bone
Joint Surg Am 1988; 70:192.
28. Fischer SP, Fox JM, Del Pizzo W, et al. Accuracy of diagnoses from magnetic
resonance imaging of the knee. A multi-center analysis of one thousand and
fourteen patients. J Bone Joint Surg Am 1991; 73:2.
29. 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; 20:732.
30. Servant CT, Ramos JP, Thomas NP. The accuracy of magnetic resonance imaging
in diagnosing chronic posterior cruciate ligament injury. Knee 2004; 11:265.
31. Boks SS, Vroegindeweij D, Koes BW, et al. Follow-up of posttraumatic ligamentous
and meniscal knee lesions detected at MR imaging: systematic review. Radiology
2006; 238:863.
32. Lee MJ, Chow K. Ultrasound of the knee. Semin Musculoskelet Radiol 2007;
11:137.
33. Miller TT. Sonography of injury of the posterior cruciate ligament of the knee.
Skeletal Radiol 2002; 31:149.
34. Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am
J Sports Med 1987; 15:553.
35. Bedi A, Musahl V, Cowan JB. Management of Posterior Cruciate Ligament Injuries:
An Evidence-Based Review. J Am Acad Orthop Surg 2016; 24:277.
36. Fanelli GC, Beck JD, Edson CJ. Current concepts review: the posterior cruciate
ligament. J Knee Surg 2010; 23:61.
37. Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior
cruciate ligament injuries. Am J Sports Med 1993; 21:846.
38. Mair SD, Schlegel TF, Gill TJ, et al. Incidence and location of bone bruises after
acute posterior cruciate ligament injury. Am J Sports Med 2004; 32:1681.
39. Senese M, Greenberg E, Todd Lawrence J, Ganley T. REHABILITATION
FOLLOWING ISOLATED POSTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION: A LITERATURE REVIEW OF PUBLISHED PROTOCOLS.
Int J Sports Phys Ther 2018; 13:737.
40. Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation
after anterior cruciate ligament reconstruction on quadriceps strength, function, and
patient-oriented outcomes: a systematic review. J Orthop Sports Phys Ther 2010;
40:383.
41. Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps
femoris muscle and functional recovery after reconstruction of the anterior cruciate
ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone
Joint Surg Am 1995; 77:1166.
42. Quelard B, Sonnery-Cottet B, Zayni R, et al. Isolated posterior cruciate ligament
reconstruction: is non-aggressive rehabilitation the right protocol? Orthop
Traumatol Surg Res 2010; 96:256.
43. Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go?
Arthroscopy 2008; 24:234.
44. Edson CJ, Fanelli GC, Beck JD. Postoperative rehabilitation of the posterior
cruciate ligament. Sports Med Arthrosc 2010; 18:275.
45. Lee BK, Nam SW. Rupture of posterior cruciate ligament: diagnosis and treatment
principles. Knee Surg Relat Res 2011; 23:135.
46. Rosenthal MD, Rainey CE, Tognoni A, Worms R. Evaluation and management of
posterior cruciate ligament injuries. Phys Ther Sport 2012; 13:196.
47. Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess
dynamic postural-control deficits and outcomes in lower extremity injury: a
literature and systematic review. J Athl Train 2012; 47:339.
48. Shelbourne KD, Clark M, Gray T. Minimum 10-year follow-up of patients after an
acute, isolated posterior cruciate ligament injury treated nonoperatively. Am J
Sports Med 2013; 41:1526.
49. Patel DV, Allen AA, Warren RF, et al. The nonoperative treatment of acute,
isolated (partial or complete) posterior cruciate ligament-deficient knees: an
intermediate-term follow-up study. HSS J 2007; 3:137.
50. 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; 27:276.
51. Agolley D, Gabr A, Benjamin-Laing H, Haddad FS. Successful return to sports in
athletes following non-operative management of acute isolated posterior cruciate
ligament injuries: medium-term follow-up. Bone Joint J 2017; 99-B:774.
52. Hammoud S, Reinhardt KR, Marx RG. Outcomes of posterior cruciate ligament
treatment: a review of the evidence. Sports Med Arthrosc 2010; 18:280.
53. Jacobi M, Reischl N, Wahl P, et al. Acute isolated injury of the posterior cruciate
ligament treated by a dynamic anterior drawer brace: a preliminary report. J Bone
Joint Surg Br 2010; 92:1381.
54. Strobel MJ, Weiler A, Schulz MS, et al. Arthroscopic evaluation of articular
cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy 2003;
19:262.
55. Wang D, Berger N, Cohen JR, et al. Surgical treatment of posterior cruciate
ligament insufficiency in the United States. Orthopedics 2015; 38:e281.