The strongest ligament in the knee is the posterior cruciate ligament (PCL).  The function of the PCL is to prevent posterior movement of the tibia relative to the femur.  Injuries to the PCL frequently occur to other knee structures (meniscal ligaments) and rarely to the isolation.  PCL injuries occur in about 2 in 100,000 people per year. 
Injuries to the posterior cruciate ligament (PCL) can range from stretching to complete tearing or rupture of the ligament. These injuries are relatively uncommon.  They occur less frequently than injuries to the anterior cruciate ligament (ACL) because the PCL is wider and stronger. 
Clinically Relevant Anatomy
The PCL is one of the two cruciate ligaments in the knee. It acts as the main stabilizing ligament of the knee. and prevent excessive posterior displacement of the tibia relative to the femur. It also prevents hyperextension and limits internal rotation adduction and abduction knee joint.  The PCL is twice as thick as the ACL and causes less damage than the ACL due to its stronger nature. Therefore, PCL injuries are less common than ACL injuries.
It starts from the inner surface of the medial femoral condyle, ends at the center behind the tibial plateau, and is 1cm below the articular surface of the tibia. It forms an “X” across the ACL. PCL consists of two inseparable bundles: wide Anterolateral (AL) bundle and smaller posteromedial (PM) bundle.  The AL bundle is tightest during mid-flexion and internal rotation of the knee, while the PM bundle is tightest during extension and deep flexion of the knee. The orientation of the fibers varies from bundle to bundle. AL bundle is When the knee is bent beyond 30°, the extension is more horizontally oriented and becomes more vertical. The PM bundles are oriented vertically in knee extension and become more horizontal through a similar range of motion.  
Anterior view kneePosterior view knee
The average age of patients with acute PCL injury is between 20 and 30 years. Although PCL injuries occur primarily alone as a result of sports, they occur primarily in conjunction with other ligament injuries  (see Multiligamentous Knee Injuries), often resulting from motor vehicle accidents.  PCL injuries account for 44% of acute knee injuries , most commonly presenting as injuries to the posterolateral corner . Chronic asymptomatic PCL insufficiency has been estimated to occur in 2–3% of elite college football players .
Aetiology/Mechanism of Injury
The most common mechanism of injury is a direct impact on the anterior portion of the proximal tibia at the bent knee with the ankle in plantarflexion . This typically occurs when the dashboard is injured in a motor vehicle accident and causes the tibia to translate posteriorly. hyperextension and Rotation or varus/valgus stress mechanisms may also be the cause of a PCL tear.  These injuries mainly occur in sports such as football and skiing. Isolated PCL injuries are common in athletes, with hyperflexion the most common mechanism of injury Injured Athletes rarely report hearing a slam, and may be able to resume play immediately following an injury. Other mechanisms of PCL injury include jump mis-landings, simple mistakes, or rapid direction changes. 
There are varying degrees of PCL injury according to severity.
- Grade 1: Limited damage, with only minor tears in the ligament, mostly the result of overstretching. It is still able to function and stabilize the knee joint. 
- Grade 2: The ligament is partially torn. There is a sense of instability .
- Grade 3: Complete ligament tear or rupture. This type of injury is primarily associated with ACL and/or collateral ligament sprains. 
Symptoms of acute and chronic PCL injuries can be distinguished .
Acute PCL injury
- Isolated injury:
Symptoms are often vague and mild, and patients often don’t even feel or notice the injury.  There is minimal pain swelling instability and a full range of motion and a near normal gait pattern. 
- With other ligament injuries:
Symptoms vary with the degree of knee injury. This includes swelling pain, unsteadiness, limited range of motion, and difficulty moving. Bruising may also be present. 
Chronic PCL injury
Patients with chronic PCL injury do not always recall the mechanism of injury. Common complaints are discomfort with weight bearing in semi-flexed positions, such as climbing stairs or squatting, and knee pain when walking long distances. Unstable complaints are also often It occurs mainly when walking on uneven surfaces . Retropatellar pain and pain in the medial compartment of the knee may also be present . Potential swelling and stiffness depend on the extent of the associated cartilage damage. 
- ACL injury
- Medial collateral ligament injury
- Talofibular ligament injury
- Menisci injuries
- Patellofemoral joint injuries
- Posterolateral knee injury and associated varus instability
- Multiligament knee injury
- Femoral condyle fracture
- Tibial plateau fracture
A detailed medical history is taken to understand the nature of symptoms and the mechanism of injury to distinguish different manifestations. Difficulty bearing weight and reduced range of motion are typical. Exclusion of fractures and dislocations will depend on symptoms and injury mechanism.
- Varus knee
- External rotation recurvatum
- Inversion thrust indicates instability 
- Neurovascular examination to rule out concurrent injury 
- Palpation: isolated injury minimal/no swelling 
- Muscle power
- Range of motion
- Posterior Drawer: This test has the highest sensitivity and specificity among clinical tests evaluating PCL.  Only performed if there is no swelling of the knee joint 
- Suspect a PCL injury if this 1 cm stride cannot be reached, or if the tip feels tender when the tibia is pushed posteriorly 
- > 10 mm posterior displacement may indicate injury to the posterolateral ligament complex 
- Posterior Lachmann test: a slight increase in posterior displacement indicates injury to the posterolateral ligament complex 
- Posterior droop sign: Posterior tibial droop indicates a positive test 
- Active quadriceps test : This test is helpful in diagnosing complete PCL tears .
- Dial Test or External Tibial Rotation Test: Tests for combined PCL and posterolateral corner (PLC) injury.  Increased external rotation by 30 degrees is only indicative of isolated PCL injury. A clear difference between 30 degrees and 90 degrees indicates combined PCL and PLC damage .
- Specific tests to rule out concurrent knee injury:
- Varus/Valgus stress tests
- External rotation recurvatum test
- Reverse pivot shift test
- AP tunnel sunrise stress and lateral view (best to detect lateral sag)
- X-rays can be taken in different positions such as standing with weight bearing with knees bent at 45°
- Assists in early identification of PCL avulsion fractures
- Chronic: Assess for joint space narrowing (preferably including weight bearing and sunrise view)
- MRI: the gold standard for diagnosing PCL and associated injuries 
- Acute: Determine injury grade and evaluate other structures that may be injured (eg, ligamentous menisci and/or cartilaginous structures of the knee). Increased signal or interruption of continuity of the ligament is expected .
- Chronic: MRI of grade I and II injuries may appear normal.
- Bone scan: Best used in chronic cases with recurrent pain, swelling, and instability.
- Detect early arthritic changes before an MRI or X-ray. These patients were at higher risk for degenerative changes in the articular cartilage, manifesting as areas of increased radiotracer uptake, most commonly in the medial and patellofemoral compartments.
- Ultrasound: more cost-effective than MRI for evaluation
- Arteriography: To assess the condition of blood vessels in an extremity
- Noyes knee score Questionnaire
- Lysholm score
- International knee dislocation score
- Multiligament Quality of Life Questionnaire
- International Knee Documentation Committee Subjective Knee Form
Nonoperative management of isolated PCL injuries has been shown to result in good subjective outcomes as well as high rates of motion recovery.  This approach is typically used for acute isolated grade I or II PCL sprains if the following criteria are met:
- Posterior drawer <10 mm
- Reduced Femoral Internal Rotation Drawer Offset
Grade I and II PCL tears usually heal quickly and most patients are satisfied with the results. Athletes are usually ready to return to competition within 2-4 weeks.  Management includes:
- Immobilize the knee in a range of motion brace in locked extension for 2-3 weeks
- Assisted weight bearing (partial to full) for 2 weeks
Acute grade III injuries can also be treated conservatively. Due to the high potential for injury to other posterolateral structures, immobilization in a series of sports braces in full extension for 2 to 4 weeks is recommended. Posterior tibial laxity caused by the hamstrings is Minimizes stretching forces on the damaged PCL and posterolateral structures.  This allows the soft tissue structures to heal. Physiotherapy is recommended as part of conservative treatment.  Conservative management of Grade III tears can usually resume play Between 3 and 4 months. 
Chronic isolated grade I and II PCL injuries are usually managed conservatively with physical therapy. For chronic cases of recurrent pain and swelling, activity modifications are recommended. 
The primary goals during PCL reconstruction are to restore normal knee mechanics and dynamic knee stability, thereby correcting posterior tibial laxity.   There are several options for the optimal surgical approach to PCL reconstruction. Controversy exists about the best graft type or source Placement of the tibiofemoral tunnel Number of graft bundles and tension on the bundles. 
Both bundles of the PCL can be reconstructed when a double bundle graft is used. Single-bundle grafts reconstruct only the stronger anterolateral bundle. Dual bundle approach can restore normal full range of motion knee motion whereas single bundle can only restore 0°-60° knee range. 
Types of grafts include:
- Allografts (mainly Achilles tendon): Reduced operative time and without iatrogenic trauma to the harvest site. The Achilles tendon graft produces a lot of collagen and ensures complete filling of the tunnel. This is often used to reconstruct AL bundles. AL grafts are Tensioned and secured at 90° knee flexion. 
- Autologous tissue:
- Bone-patellar tendon-bone: Most common because bone plugs adequately immobilize the tissue. Disadvantages of this graft are morbidity at the harvest site, and due to the rectangular form of the graft, the tunnel is not completely filled with collagen.
- Quad Hamstrings: Reduces morbidity, but results in poorer fixation methods. Double semitendinosus tendon autografts are commonly used for PM bundle reconstruction. The PM graft was tensioned and fixed at 30° of knee flexion.
- Quadriceps tendon: with morbidity and adequate biomechanical properties.
Acute PCL injury
Surgical reconstruction of the PCL is recommended for acute injuries with severe subluxation and instability of the posterior tibia if the posterior displacement is greater than 10mm or if there are multiple ligamentous injuries. PCL avulsion fracture injury healed well during early surgery In high-need populations such as young athletes  surgery is often performed as soon as possible to increase the chance of regaining full functional capacity.  PCL grade III injuries are often combined with other injuries, and the ligaments should be reconstructed surgically Must often be done within 2 weeks of injury. This time frame provides optimal anatomic ligament repair of the PCL with less capsular scarring.
Chronic PCL injury
Surgical intervention is recommended in chronic cases considering the following (mainly grade III injuries):
- Recurrent pain and swelling
- Positive bone scan, patient unable to alter his/her activities
- Surgery is essential in the presence of combined injuries
- Tibial inlay surgery: Starts with diagnostic arthroscopy, but inlay itself is an open surgery. The femoral tunnel was created using an outside-in technique to closely replicate the femoral insertion of the PCL-meniscofemoral ligament complex. Grafts are prepared during exposure. It is then placed in a graft conveyor and passed through the femoral tunnel that is tensioned and screwed to the bone.
- A brace that limits the range of motion of the knee is needed after surgery (see Physical Therapy Management).
- The tibial tunnel method: an arthroscopic approach. Drill a guide wire from a point distal and medial to the tibial tubercle, aiming distal and lateral to the PCL imprint. The femoral tunnel should be placed just below the subchondral bone to reduce the risk of osteonecrosis. The direction of the graft channel depends on the type of graft used. Tibial inlay surgery avoids this difficult part. The graft is placed in 70° to 90° flexion. In single-bundle reconstructions, only 1 tunnel was drilled. In a double bundle reconstruction, two tunnels are drilled This is more technically challenging. 
Complications that may arise after or during PCL reconstruction include:
- Popliteal artery injury
- Deep vein thrombosis
- Residual laxity (possibly due to undiagnosed nonisolated PCL injury)
- Reduced range of motion (possibly caused by improper placement or overtension of the graft).
- If physical therapy is unsuccessful, manipulation under anesthesia may be considered to improve range of motion
Medical Management Biomechanics
bundle reconstruction or conservative management
The primary function of the posterior cruciate ligament in the knee is to prevent the tibia from moving backward over the femur. It consists of 2 main bundles: the anterolateral bundle (ALB) and the posteromedial bundle (PMB). These parts work together to provide all-around comprehensive protection Bend and rotate. ALB prevents external rotation and PMB prevents internal rotation. Together they prevent forward and backward translation through a codominant relationship. Their medial portion is valuable in protecting the knee from varying degrees of rotational force buckling. The ALB is tensed in flexion and the PMB is tensed in extension . Although the tension is different at different degrees of flexion, their co-dominance relationship is achieved according to their spatial orientation. As flexion increases, the ALB tightens and becomes more vertically aligned. Due to this orientation, it is less resistant to back translation. However, the greater the knee flexion, the stronger the horizontal orientation of the PMB, increasing its resistance to posterior translation .
A tear or stretch occurs when the external force exceeds the capacity of these tendons. The most common mechanism of injury is a motor vehicle accident, called a “dashboard injury,” in which the tibia is forced to move backward over the femur. This usually results in Multiple ligament injuries usually require surgical intervention , but there are cases of acute injuries. Mild acute injuries are treated conservatively.
Conservative treatment has been a common option for PCL tear rehabilitation, especially in grade I and II acute tears, due to the strong intrinsic healing capacity of the ligament . During conservative treatment, the general rehabilitation program will focus on building weight-bearing capacity and Quadriceps strengthening . The initial phase of healing focuses on maintaining range of motion and reducing swelling and edema while protecting the PCL. To protect the PCL during the later stages of healing, begin quadriceps training and avoid hamstring training. Quadriceps function is to extend the knee, and since its attachment point is anterior to the bottom of the tibial plateau; its secondary motion pulls the tibia anteriorly on the femur when the knee is pulled in the opposite direction of the PCL function. In contrast, the hamstrings are responsible for Flexion of the knee increases the posterior shear from the tibia, which can stress or re-tear the healing PCL. Walking is often included early in the rehabilitation phase, using a dynamic brace that allows the knee to flex but supports the tibia backward.
Conservative management is also indicated in the postoperative regimen for reconstructed patients, but is usually of shorter duration .
Several studies have found long-term negative effects of conservative management on PCL, such as higher degrees of laxity and a higher incidence of degenerative changes in the medial and patellofemoral compartments. Increased slack means the PCL is not taut where it should be, and The femur will translate farther, especially in the posterior direction. This imbalance affects the articular cartilage, increasing shear and compression forces on the tibial plateau. Degeneration of articular cartilage leads to increased incidence of osteoarthritis over time and meniscal tears. The structure of the posterolateral horn also increases the risk of injury due to PCL deficiency. Laxity alters knee kinematics and loading during functional activities. In one study, fluoroscopy of a single-leg lunge was performed on a person with flaccid muscles. PCL and PCL complete person. It was shown that tibial cartilage deformation was increased in PCL-deficient knees , suggesting that tibial mechanics were also altered.
Single Bundle Reconstruction
When the tear is grade II or higher, reconstructive surgery may be required. Single Bundle Reconstruction (SBR) reconstructs the largest and stronger bundle of the two – the ALB. ALB is the stronger bundle and is the main constraint for post-translation. Ultimate load failure ALB is almost twice that of PMB: 1120±362 N and 419±128 N, respectively . For most people, this treatment is good enough to allow them to continue their activities as before. However, without these two bundles, they don’t have as much support when fully flexed Compared to double-bundle reconstruction. The SBR provides full anteroposterior support from 0-60° of flexion . Most people don’t need as much flexion in their daily activities.
In the long term, SBR has been problematic; many subsequent studies have shown persistent posterior laxity of the knee joint and increased patellofemoral stress . This laxity means that the movement of the femur along the tibial plateau is less predictable, increasing the risk of osteoarthritis and the posterolateral corner Injury due to increased pressure .
Double Bundle Reconstruction
Dual-bundle reconstruction (DBR) is a relatively new method that attempts to better reconstruct native PCL with ALB and PMB. Evidence suggests that this approach better reestablishes their co-dominant relationship, thereby restoring the knee to greater stability against tibial posterior Translation than SBR. Some studies have shown that it has less posterior laxity compared with SBR and conservative treatment due to a co-dominant relationship . In a randomized controlled trial comparing SBR and DBR allografts, they found that DBR had better outcomes in terms of Loose than SBR. This was tested by a subjective test (International Knee Documentation Committee (IKDC) Subjective Knee Form Lysholm Score Tegner Activity Scale) and an objective test (reduction of knee laxity) .
DBR was also superior to SBR when comparing tibial posterior translation. When tested at a tibial posterior load of 134N in 30° 45° 60° 75° 90° 105° and 120° flexion, DBR had significantly less tibial posterior translation than SBR. The most notable difference is At 105° of flexion, the SBR knee translated 5.3 mm more than the DBR. DBR has more tibial posterior translation compared with intact knees in flexion from 0° to 15° . This indicates that the DBR method cannot fully reconstruct the kinematics of the native knee joint. also In terms of rotational resistance, DBR outperforms SBR  .
Clinical and patient-reported outcomes did not show any significant difference between DBR and SBR  . However, the results for most patients only compare their postoperative state to their injured state, not their pre-injury state. This will be an area that requires further research.
DBR provides more biomechanical support and has fewer negative outcomes in the long run than SBR or conservative treatments. DBRs are often considered for high performance athletes as they may require stability in all degrees of flexion. However, according to the findings Biomechanical studies DBR should be considered as a treatment for the common man. There are some reasons why DBR may not be considered, for example, if the bone density is too low, it may not be safe to create a tunnel in the tibia for the attachment of the graft. low person BMD or osteoporosis would be safer with SBR or conservative treatment, as fewer tunnels would reduce fracture risk in this group.
It is important to know that neither SBR nor DBR methods fully reconstruct native knee kinematics, and there is currently no agreement on which method is better. Disagreement arises from variability in other aspects of PCL reconstruction such as graft tension angle implemented by graft type Graft tensioning and surgical technique (tibial inlays and transtibial). Future studies should compare knees under similar conditions and larger sample sizes for optimal results. However, clinical outcomes remain difficult to understand because it is difficult to relate Pre-injury or pre-flax state.
Conservative treatment approaches are also very effective postoperatively, reducing the risk of future injury and reducing residual laxity long-term. Knee immobilization for 3 days, then transition to a dynamic knee brace and progressive weighting to avoid hyperextension and strengthen the quadriceps is a common postoperative approach . and recommended for quick recovery
Grade 1 & II injuries
Orthopedic surgeons recommend immobilizing the knee for two weeks (within a locked range of motion). Physiotherapy during this period included:
- partial to full weight bearing activity
- Reduce pain and inflammation
- Reducing knee joint effusion
- Restore knee range of motion
- Knee strengthening (particularly protective quadriceps rehabilitation)
- Strengthening the quadriceps is a key factor in successful recovery because the quadriceps can replace the PCL to some extent to prevent the femur from moving forward over the tibia.
- Hamstring strengthening can be included
- It is important to combine the eccentric forces of the lower body muscles
- Closed chain exercises
- changing activities until the pain and swelling subside
After 2 weeks (as recommended by plastic surgeon):
- progress to full weight bearing mobilization
- Weaning of range of motion brace
- proprioceptive balance and coordination
- Agility program when strength and endurance have been restored and neuromuscular control has increased
- Returning to play 2 to 4 weeks after injury
Grade III injuries
Knee is immobilized in a range of motion brace and locked in extension for 2-4 weeks. Physiotherapy management at this time includes:
- Activity modification
- Quadriceps rehabilitation
- Start with isometric quadriceps exercises and straight leg raises (SLR)
After 2-4 weeks:
- Avoid isolated hamstring strengthening
- Active-assisted knee flexion <70°
- Loading within pain limits
- Quadriceps Rehabilitation: Promoting Dynamic Stability and Counteracting Posterior Tibial Subluxation
- Closed chain exercises
- Open Kinetic Chain Centrifugal Exercises, Ultimate
- Do functional exercises, such as stationary bike leg press elliptical exercises and stair climbing
Return to play is sport specific and only after 3 months. 
Physical therapy can adequately treat chronic PCL injuries. The range of motion brace is initially set to prevent extension of the distal 15°. After a while, the brace opens and fully extends. 
Postoperative recovery usually lasts 6 to 9 months. The duration of each of the five stages and the total duration of rehabilitation depends on the age and fitness level of the patient and the success of the surgery. See also the PCL rebuild page.
General guidelines for postoperative PCL rehabilitation:
- Activity should be limited to 0-90 degrees for the first two weeks, then gradually promoted to full ROM.
- The affected leg should be non-weight bearing for the first 6 weeks, then placed in a mover brace and progressed to a rebound PCL brace for 6 months.
- Avoid isolated hamstring contractions at 4 months, as hamstring forces pull the tibia posteriorly, which may exert elongation forces on the PCL graft, causing instability
- Avoid unsupported knee flexion for 4 months to prevent any posterior pull on the tibia.
Phase I: Early Post-operative phase
Early mobilization and submaximal strain on the graft lead to better outcomes .
Goals for maximum protection and early recovery:
- Restore joint homeostasis
- Scar tissue management
- Restore joint ROM
- Re-train quadriceps
- Create effective plans for your patients
Strategies of rehabilitation:
- Perform ROM exercises from the prone position to avoid posterior tibial prolapse and graft elongation
- If the patient is not taking strong pain medication, teach the patient quadriceps contractions/sets beginning postoperative day 1.
- Patellofemoral joint mobilization is important to prevent scarring and preserve joint volume for full range of flexion and extension
- Ice and elevation for swelling and inflammation management
- Progress is made by applying strategies to increase ROM and distal knee extension
One of the great advances in PCL management has been the use of dynamic PCL braces. This option may not always be available, but be sure to use it if you find it. It is a spring-loaded brace designed to prevent posterior tibial prolapse and graft elongation by exerting an anterior force on the tibia Place the graft in a shortened position. Immediately after surgery, it is recommended to place the leg in a mover brace and then transition to a dynamic brace after the swelling subsides. It should be used all the time and only removed for exercise within 6 months. then enter more The functional brace was worn for 12 months.
Building weight bearing tolerance after 6 weeks of non-weight bearing (NWB) should be done gradually between weeks 7-8.
Phase 2: Post-operative rehabilitation
Started 8 weeks after surgery. The goal is to develop a plan for the patient that will prepare them for the return of preoperative functional capacity by addressing all MSK deficits.
Areas to be addressed and suggested time frames for post-operative rehabilitation:
- Muscular endurance (weeks:9-16)
- Strength (weeks 17-22)
- Strength training (weeks 23-28), running if needed (weeks 25-28)
- Speed and agility (weeks 29-32 )
- Return to training (week 33).
- Return to Sport: This varies by sport, but takes about 3-4 weeks of training on average. Return to play around week 36.
There are no specific exercises for PCL rehab, but generally we should consider the whole leg after a period of NWB. Combine different exercises for the quadriceps and hamstrings and combine them into functional exercises. Adjusting training parameters to achieve goals; endurance strength or reinforcement.
Examples of exercises: would look like
Muscle ExamplesQuadriceps Dominant Leg PressGluteus Dominant Single Leg BridgeHamstring DominantRomanian DeadliftQuadriceps Dominant SquatQuadriceps Dominant Single Leg SquatHamstring Dominant Hamstring Lean/North European Hamstring Curl
Return to Sport Criteria:
The evidence does not provide specific criteria for return to sport after PCL reconstruction, but logically we could apply the same criteria after ACL reconstruction :
- Quadriceps index of 90 or higher – less than 10% of quadriceps strength between the affected and non-involved sides. The strength of the hamstrings should also be considered.
- Less than 15% lower extremity symmetry in hop tests (single hops, triple hops, interleaved and timed hops)
Clinical bottom line
PCL injuries are mostly caused by excessive flexion, and injuries do not occur frequently. This is due to the strength of the ligaments and the fact that hyperflexion that may occur through forces on the proximal anterior portion of the tibia is not common. PCL injuries occur mainly in Sports like football and skiing. Another possible mechanism of injury is a car accident resulting in a “dashboard injury”. There are three levels of severity, and there is a distinction between acute and chronic injuries. Clinical manifestations will depend on the degree and Injury situation. If symptoms can be observed, they usually include swelling pain, unsteadiness, limited range of motion, and difficulty moving. Treatment depends on grade and individual patient. Grade I and II injuries are usually treated nonoperatively Unless it happens to young athletes or high demanding individuals. Grade III injuries are usually treated surgically, but can also be managed nonsurgically. Physiotherapy plays an important role in conservative treatment and postoperative rehabilitation. recovered Plan to focus on the quadriceps as it partially takes over the function of the PCL. The structure and establishment of a rehabilitation program depends on the extent of the individual patient’s injury and the success of the procedure (if applicable).
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