Management of PCL Injuries in Handball

  • Markus WaldénEmail author
  • Lior Laver


Posterior cruciate ligament (PCL) injuries are rare injuries in sports compared with other acute knee ligament injuries such as medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injuries. The major function of the PCL is to provide a restraint to posterior displacement of the tibia on the femur. There are three dominating injury mechanisms described: hyperextension, hyperflexion and pretibial contact with a flexed knee such as in the dashboard injury or in a fall on the knee with a plantarflexed foot. It is paramount to distinguish early after the incident if the PCL injury is isolated or combined with other significant knee injuries. The most common treatment for an isolated PCL injury is a non-surgical protocol with bracing and stepwise rehabilitation. Return to handball and other similar knee-demanding sports can usually be expected within 5 months after such treatment. No firm conclusions can be drawn about the outcome and return to play rate after PCL reconstruction in handball players. All in all, the literature on PCL injuries is scarce compared with that on ACL injuries, and further studies on treatment and prevention are highly warranted.

Supplementary material

Video 21.1

Darko Martinovic PCL 1 (AVI 4110 kb)


  1. 1.
    Engebretsen L, Lew W. Injuries to the posterior cruciate ligament and posterolateral structures of the knee. Scand J Med Sci Sports. 1992;2:50–61.CrossRefGoogle Scholar
  2. 2.
    van Dommelen BA, Fowler PJ. Anatomy of the posterior cruciate ligament: a review. Am J Sports Med. 1989;17:24–9.CrossRefGoogle Scholar
  3. 3.
    Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med. 2004;32:1765–75.CrossRefGoogle Scholar
  4. 4.
    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;43:3077–92.CrossRefGoogle Scholar
  5. 5.
    Rosenthal MD, Rainey CE, Tognoni A, Worms R. Evaluation and management of posterior cruciate ligament injuries. Phys Ther Sport. 2012;13:196–208.CrossRefGoogle Scholar
  6. 6.
    Gupte CM, Bull AM, Thomas RD, Amis AA. The meniscofemoral ligaments: secondary restraints to the posterior drawer. Analysis of anteroposterior and rotary laxity in the intact and posterior-cruciate-deficient knee. J Bone Joint Surg. 2003;85-B:765–73.CrossRefGoogle Scholar
  7. 7.
    Kusayama T, Harner CD, Carlin GJ, Xerogeanes JW, Smith BA. Anatomical and biomechanical characteristics of human meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 1994;2:234–7.CrossRefGoogle Scholar
  8. 8.
    Fontbote CA, Sell TC, Laudner KG. Neuromuscular and biomechanical adaptations of patients with isolated deficiency of the posterior cruciate ligament. Am J Sports Med. 2005;33:982–9.CrossRefGoogle Scholar
  9. 9.
    Hooper DM, Morrissey MC, Crookenden R, Ireland J, Beacon JP. Gait adaptations in patients with chronic posterior instability of the knee. Clin Biomech (Bristol, Avon). 2002;17:227–33.CrossRefGoogle Scholar
  10. 10.
    Jonsson H, Kärrholm J. Three-dimensional knee kinematics and stability in patients with a posterior cruciate ligament tear. J Orthop Res. 1999;17:185–91.CrossRefGoogle Scholar
  11. 11.
    Kozanek M, Fu EC, Van de Velde SK, Gill TJ, Li G. Posterolateral structures of the knee in posterior cruciate ligament deficiency. Am J Sports Med. 2009;37:534–41.CrossRefGoogle Scholar
  12. 12.
    Owesen C, Sandven-Thrane S, Lind M, Forssblad M, Granan LP, Årøen A. Epidemiology of surgically treated posterior cruciate ligament injuries in Scandinavia. Knee Surg Sports Traumatol Arthrosc. 2017;25:2384–91.CrossRefGoogle Scholar
  13. 13.
    Schulz MS, Russe K, Weiler A, Eichhorn HJ, Strobel MJ. Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg. 2003;123:186–91.CrossRefGoogle Scholar
  14. 14.
    Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: a 10-year study. Knee. 2006;13:184–8.CrossRefGoogle Scholar
  15. 15.
    Sanders TL, Pareek A, Barrett IJ, Kremers HM, Bryan AJ, Stuart MJ, Levy BA, Krych AJ. Incidence and long-term follow-up of isolated posterior cruciate ligament tears. Knee Surg Sports Traumatol Arthrosc. 2017;25:3017–23.CrossRefGoogle Scholar
  16. 16.
    Granan LP, Inacio MC, Maletis GB, Funahashi TT, Engebretsen L. Sport-specific injury pattern recorded during anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:2814–8.CrossRefGoogle Scholar
  17. 17.
    Myklebust G, Maehlum S, Engebretsen L, Strand T, Solheim E. Registration of cruciate ligament injuries in Norwegian top level team handball. A prospective study covering two seasons. Scand J Med Sci Sports. 1997;7:289–92.CrossRefGoogle Scholar
  18. 18.
    Hewett TE. Neuromuscular and hormonal factors associated with knee injuries in female athletes. Strategies for Intervention Sports Med. 2000;29:313–27.PubMedGoogle Scholar
  19. 19.
    Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K. A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy. 2007;23:1320–5.CrossRefGoogle Scholar
  20. 20.
    Waldén M, Hägglund M, Werner J, Ekstrand J. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc. 2011;19:3–10.CrossRefGoogle Scholar
  21. 21.
    Renström P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, Georgoulis T, Hewett TE, Johnson R, Krosshaug T, Mandelbaum B, Micheli L, Myklebust G, Roos E, Roos H, Schamasch P, Shultz S, Werner S, Wojtys E, Engebretsen L. Non-contact ACL injuries in female athletes: An International Olympic Committee current concepts statement. Br J Sports Med. 2008;42:394–412.CrossRefGoogle Scholar
  22. 22.
    Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44:1861–76.CrossRefGoogle Scholar
  23. 23.
    Bencke J, Curtis D, Krogshede C, Jensen LK, Bandholm T, Zebis MK. Biomechanical evaluation of the side-cutting manoeuvre associated with ACL injury in young female handball players. Knee Surg Sports Traumatol Arthrosc. 2013;21:1876–81.CrossRefGoogle Scholar
  24. 24.
    Ebstrup JF, Bojsen-Møller F. Anterior cruciate ligament injury in indoor ball games. Scand J Med Sci Sports. 2000;10:114–6.CrossRefGoogle Scholar
  25. 25.
    Koga H, Nakamae A, Shima Y, Iwasa J, Myklebust G, Engebretsen L, Bahr R, Krosshaug T. Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball and basketball. Am J Sports Med. 2010;38:2218–25.CrossRefGoogle Scholar
  26. 26.
    Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med. 2004;32:1002–12.CrossRefGoogle Scholar
  27. 27.
    Hughston JC. Acute knee injuries in athletes. Clin Orthop. 1962;23:114–33.PubMedGoogle Scholar
  28. 28.
    Hughston JC. The absent posterior drawer test in some acute posterior cruciate ligament tears of the knee. Am J Sports Med. 1988;16:39–43.CrossRefGoogle Scholar
  29. 29.
    Tewes DP, Fritts HM, Fields RD, Quick DC, Buss DD. Chronically injured posterior cruciate ligament: magnetic resonance imaging. Clin Orthop Relat Res. 1997;335:224–32.Google Scholar
  30. 30.
    Mair SD, Schlegel TF, Gill TJ, Hawkins RJ, Steadman JR. Incidence and location of bone bruises after acute posterior cruciate ligament injury. Am J Sports Med. 2004;32:1681–7.CrossRefGoogle Scholar
  31. 31.
    Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg. 1999;12:209–13.PubMedGoogle Scholar
  32. 32.
    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. Bone Joint J. 2017;99-B:774–8.CrossRefGoogle Scholar
  33. 33.
    Dejour H, Walch G, Peyrot J, Eberhard P. The natural history of rupture of the posterior cruciate ligament. Rev Chir Orthop Reparatrice Appar Mot. 1988;74:35–43.PubMedGoogle Scholar
  34. 34.
    Jansson KS, Costello KE, O’Brien L, Wijdicks CA, LaPrade RF. A historical perspective on PCL bracing. Knee Surg Sports Traumatol Arthrosc. 2013;21:1064–70.CrossRefGoogle Scholar
  35. 35.
    Jacobi M, Reischl N, Wahl P, Gautier E, Jakob RP. Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report. J Bone Joint Surg. 2010;92-B:1381–4.CrossRefGoogle Scholar
  36. 36.
    LaPrade RF, Smith SD, Wildon KJ, Wijdicks CA. Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation. Knee Surg Sports Traumatol. 2015;23:3070–6.CrossRefGoogle Scholar
  37. 37.
    Pierce CM, O’Brien L, Griffin LW, LaPrade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol. 2013;21:1071–84.CrossRefGoogle Scholar
  38. 38.
    Zhao JX, Zhang LH, Mao Z, Zhang LC, Zhao Z, Su XY, Zhang LN, Gao Y, Sun Y, Tang PF. Outcome of posterior cruciate ligament reconstruction using the single- versus double bundle technique: a meta-analysis. J Int Med Res. 2015;43:149–60.CrossRefGoogle Scholar
  39. 39.
    Owesen C, Sivertsen EA, Engebretsen L, Granan LP, Årøen A. Patients with isolated PCL injuries improve from surgery as much as patients with ACL injuries after 2 years. Orthop J Sports Med. 2015;3(8). Doi: Scholar
  40. 40.
    Chahla J, von Bormann R, Engebretsen L, LaPrade RF. Anatomic posterior cruciate ligament reconstruction: state of the art. J ISAKOS. 2016;1:292–302.CrossRefGoogle Scholar
  41. 41.
    Ardern C, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, Gojanovic B, Griffin S, Khan KM, Moksnes H, Mutch SA, Phillips N, Reurink G, Sadler R, Silbernagel KG, Thorborg K, Wangensteen A, Wilk KE, Bizzini M. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016;50:853–64.CrossRefGoogle Scholar
  42. 42.
    Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20:379–85.CrossRefGoogle Scholar
  43. 43.
    Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986;14:35–8.CrossRefGoogle Scholar
  44. 44.
    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;27:276–83.CrossRefGoogle Scholar
  45. 45.
    Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S, Zarins B, Li G. The effect of posterior cruciate ligament reconstruction on patellofemoral contact pressures in the knee joint under simulated muscle loads. Am J Sports Med. 2004;32:109–15.CrossRefGoogle Scholar
  46. 46.
    Ahrend M, Ateschrang A, Döbele S, Stöckle U, Grünwald L, Schröter S, Ihle C. Return to sport after surgical treatment of a posterior cruciate ligament injury: a retrospective study of 60 patients. Orthopade. 2016;45:1027–38.CrossRefGoogle Scholar
  47. 47.
    Myklebust G, Engebretsen L, Braekken IH, Skjølberg A, Olsen OE, Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;12:71–8.CrossRefGoogle Scholar
  48. 48.
    Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ. 2005;330:449.CrossRefGoogle Scholar
  49. 49.
    Petersen W, Braun C, Bock W, Schmidt K, Weimann A, Drescher W, Eiling E, Stange R, Fuchs T, Hedderich J, Zantop T. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg. 2005;125:614–21.CrossRefGoogle Scholar
  50. 50.
    Wedderkopp N, Kaltoft M, Lundgaard B, Rosendahl M, Froberg K. Prevention of injuries in young female players in European team handball. A prospective intervention study. Scand J Med Sci Sports. 1999;9:41–7.CrossRefGoogle Scholar
  51. 51.
    Orchard JW, Seward H. Decreased incidence of knee posterior cruciate ligament injury in Australian Football League after ruck rule change. Br J Sports Med. 2009;43:1026–30.CrossRefGoogle Scholar

Copyright information

© ESSKA 2018

Authors and Affiliations

  1. 1.Football Research Group, Division of Community Medicine, Department of Medical and Health SciencesLinköping UniversityLinköpingSweden
  2. 2.Department of Trauma and OrthopaedicsUniversity Hospitals Coventry and WarwickshireCoventryUK
  3. 3.Department of ArthroscopyRoyal Orthopaedic HospitalBirminghamUK

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