posterior CRUCIATE LIGAMENT (pCL) REHABILITATION

Basic Structure and Function

The PCL is a very large ligament located behind the ACL and consists of 2 bundles:[1]

1. Anterior and Lateral: Tightness when the knee is bent
2. Posterior Medial Beam: Tighten when the knee is extended

The two bundles work together to create stability within the knee.

Functions:

• PCL is the primary constraint on posterior translation of the tibia relative to the femur
• Auxiliary stabilizer resists tibial external rotation and valgus/varus stress

PCL is rarely injured alone. [2] They usually occur with other ligamentous meniscal or cartilage injuries. [3] They are far less common than ACL or other knee ligament injuries. [2][4]

The injury mechanism involves some type of varus or valgus force combined with the posterior tibial force.

Decision Making and Physical Examination

Positive posterior drawer and tibial retropituitary signs are the most important tests for diagnosing PCL and determining treatment planning. [5]

The decision about conservative or surgical management depends on the extent of the injury and associated soft tissue damage.

Grades:[6]

• Level 1: 0-5 mm posterior tibial translation
• Grade II: 5-10 mm posterior translation
• Grade III: > 10 mm posterior translation

Surgery is indicated for:

• All grade III combined PCL and posterolateral corner injuries. The combination of posterior laxity and rotational instability can lead to poor outcomes as the joint fails to regain stability that is essential for active work and life or to resume movement when it resumes.
• Grade II and III isolated PCL failed conservative treatment, reported recurrent instability and/or tibial displacement with activity
• Multi-ligamentous injury

Conservative management can be considered for isolated PCL injuries, regardless of grade.

[7]

[8]

Conservative Management Outcomes

When considering nonoperative management of PCL, it is important to discuss short- and long-term goals with the patient to make the best decision.

One study looked at 46 patients with MRI-confirmed grade II and III PCL injuries, treated conservatively from the time of injury until they returned to sports, and reviewed them again 5 years after injury. The study reported that it took an average of 16 weeks from injury to recovery. competitive sports. 91% of returners were able to achieve the same or higher levels at 2 years, while 69% achieved the same levels at 5 years of follow-up. This suggests that non-surgical treatment has achieved good results in restoring high levels of play and function. [9]

Despite a successful return to sports, the development of osteoarthritis following non-surgical PCL management is evident.

A study investigating 14 patients with PCL injuries found that the anteromedial location of peak cartilage deformation was increased, reflecting higher than normal loads on the medial compartment of the knee. Another study in 2003 looked at 181 patients with PCL injuries who were treated conservatively after five years Degenerative changes have been reported in 77% of the medial femoral condyle and in 47% of the trochlea after injury [10][11].

Rehabilitation

There is no difference between the person in charge of rehabilitation and the person in charge of surgical management.

Basically, few precautions/restrictions are necessary to allow the ligament to heal in a neutral position [12]:

1. Limit gravity to create more posterior tibial sag by encouraging your patient to avoid positions where tibial sagging (such as wall sliding) occurs for the first 6 weeks. You may also suggest sleeping with a pillow under the proximal tibia to keep the tibia in better shape position and reduce back pull.
2. Dynamic PCL braces are considered one of the great advances in PCL management. It acts as a spring to apply a constant force to pull the tibia forward and reduce tibial sagging. Ideally, a PCL brace should be worn for 24 hours (excluding bathing) for 16 weeks. A 2010 study [13] analyzed The one-year effect of the PCL dynamic brace in 21 patients found a 2.3 mm reduction in posterior tibial pull at 12 months. This reflects the inherent healing capacity of the PCL and the role of the PCL brace in reducing the level of injury. If the patient cannot afford the cost An acute knee immobilizer can be an alternative. This is followed by a hinged exercise brace with PCL straps for 12 months or more, depending on knee stability.
3. As you work to improve your ROM, start in a prone position to limit the effects of gravity.
4. If the injury is accompanied by effusion and joint hemorrhage, initially limit WB to restore joint homeostasis.
5. Restrict isolated hamstring contractions at knee flexion greater than 15 degrees for at least 16 weeks, as it has been found to increase PCL loading [14]. Instead, you can suggest exercises such as the Romanian deadlift, which has a small knee flexion to avoid excessive shin strength.

[15]

Acute Rehabilitation:

Aims:

• Restore ROM
• Reduce swelling
• Manage the inflammatory process
• Restore muscle function

ROM: (0-4 weeks)[12]

1- Assisted prone ROM exercises

2- When the knee is bent 115 degrees or when the ROM allows the bike to rotate, enter the stationary bike.

Swelling management:

• Ice
• Elevation
• Load management by limiting weight bearing to allow healing.

Muscle Function: Teaching quadriceps activation is critical, as the quadriceps pull the tibia forward for stability. Encourage isolated quadriceps contraction by pulling the patella up.

Weight-bearing exercise can be performed when the patient meets the following conditions:

• 130 degrees knee flexion
• Terminally knee extension
• Able to walk comfortably a distance in the brace

Late Rehabilitation

1. Muscular Endurance (Weeks 5-10): Low loads and high repetitions. For example; 3-4 sets of 15 reps, 40 seconds rest. Exercise example:
   • Go forward and backward with Theraband
   • Bilateral squat
   • Do eccentric exercises, such as stepping down from a 1-inch box
   • Single leg Romanian deadlift or deadlift
2. Muscle Strength (Weeks 11-16): Low repetitions and high loads. For example; 3 sets of 10-12 repetitions, 1 minute rest. You can adjust the same exercises you use for endurance training and adjust the parameters or suggest higher-load exercises, such as overhead splint squats. In addition, the lumbar-pelvic rhythm Exercise is important for improving stability
3. Strength Agility and Running (Weeks 17-20/22) [12]

Return to Sports

It is recommended to complete an appropriate strength program before returning to sports.

Criteria for promotion or return to play:

There are criteria available in the evidence, but the symmetry of the following measurements reflects strength and stability [12]:

• Quadriceps strength
• Y balance anterior reach distance
• Power test such as hop test