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Injuries to the Posterior Cruciate Ligament of the Knee

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Summary

The posterior cruciate ligament (PCL) is the strongest ligament about the knee and is approximately twice as strong as the anterior cruciate ligament. Its main function is to prevent the posterior dislocation of the tibia in relation to the femur, providing 95% of the strength to resist the tibial posterior displacement. Along with the anterior cruciate ligament (ACL) the PCL controls the passive ‘screw home’ mechanism of the knee in terminal knee extension. It also provides mechanical support for the collateral ligaments during valgus or varus stress of the knee.

PCL ruptures are uncommon apparently due to its strong fibre structure. The most frequent injury mechanism in isolated PCL tears is a direct blow on the anterior tibia with the knee flexed thus driving the tibia posteriorly. Automobile accidents (in which the knee hits the dashboard) and soccer injuries (in which an athlete receives a blow to the anterior surface of the tibia during knee flexion) characteristically produce this type of injury. In other PCL injury mechanisms (hyperextension, hyperflexion or rotational injuries with associated valgum/varum stress), other knee structures are also often damaged.

The most characteristic diagnostic finding in a knee with a PCL rupture is the ‘posterior sag sign’ meaning the apparent disappearance of the tibial tubercle in lateral inspection when the knee is flexed 90°. This is due to gravity-assisted posterior displacement of the tibia in relation to the femur. A positive posterior drawer test performed at 90° of flexion and a knee hyperextension sign are sensitive but nonspecific tests. False negative findings are frequent, especially in acute cases. If necessary, the clinical diagnosis of the PCL tear can be verified by magnetic resonance imaging, examination under anaesthesia, arthroscopy, or a combination of these modalities.

If a PCL avulsion fragment has been dislocated, surgical treatment is recommended. In isolated, complete midsubstance tears of the PCL the majority of the recent studies recommend conservative treatment, since abnormal residual posterior laxity in most of these knees is consistent with functional stability and minimal symptoms. This has been the case even in athletes. In isolated PCL tears, the outcome seems to depend more on the muscular (quadriceps) status of the knee than on the amount of residual posterior laxity. Therefore, the conservative treatment protocol emphasises intensive quadriceps exercises, and only a short (under 2 weeks) immobilisation period followed by early controlled activities and early weightbearing.

According to the current concept, acute phase surgery (primary PCL repair with augmentation, or primary PCL reconstruction) is indicated in fresh injuries of the PCL associated with disruptions of other major ligaments or capsular structures. Simultaneously with the PCL surgery, all the other damaged structures should also be repaired. Even with surgery, however, the prognosis is poorer than in isolated PCL tears. In chronic PCL insufficiency a reconstruction with bone-patella tendon-bone autograft or allograft can be considered, if the patient suffers from repeated giving way symptoms which are not resolved by rehabilitation.

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Authors and Affiliations

  1. McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont, USA

    Pekka Kannus, Robert J. Johnson, Malcolm Pope, Per Renström & Kazunori Yasuda

  2. Tampere Research Station of Sports Medicine, The UKK-Institute for Health Promotion Research, Tampere, Finland

    Pekka Kannus & Markku Järvinen

  3. Department of Surgery, Section of Orthopaedics, University Central Hospital, Tampere, Finland

    Markku Järvinen

  4. Department of Orthopaedic Surgery, Section of Sports Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

    John Bergfeld

  5. Department of Orthopaedic Surgery, Section of Knee Joint Surgery and Sports Medicine, School of Medicine, Hokkaido University, Sapporo, Japan

    Kazunori Yasuda

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  1. Pekka Kannus
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Throughout this article the term ‘abnormal posterior laxity’ refers to an increased posterior displacement of the tibia in relation to the femur due to the PCL injury. If the ligaments are intact, the knee is determined to be ‘statically stable’ when compared with the other knee, allowing no tibial displacement beyond physiological limits. The term ‘functional instability’ refers to a patient’s feeling of giving way of the injured knee during activity. This may occur if there is an abnormal ligamentous laxity which cannot be compensated by thigh muscle activity.

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Kannus, P., Bergfeld, J., Järvinen, M. et al. Injuries to the Posterior Cruciate Ligament of the Knee. Sports Med 12, 110–131 (1991). https://doi.org/10.2165/00007256-199112020-00004

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