PCL Injuries: Evaluation and Management

The posterior cruciate ligament (PCL) is the strongest and largest ligament in the knee and functions as the primary posterior stabilizer. It is mainly comprised of the posteromedial bundle (PMB) and anterolateral bundle (ALB), which work together in both flexion and extension to prevent posterior translation of the tibia relative to the femur. In addition to these two bundles, the menisco femoral ligament acts as a third source to resist posterior translation. In addition to these three components providing stability to posterior directed forces, they also provide significant secondary backup for posterior lateral rotation. It is estimated that the age and sex-adjusted annual incidence of isolated complete PCL tears in the United States is 1.8 per 100,000. However, injury to the PCL typically occurs in conjunction with other ligamentous, meniscal, and chondral injuries (up to 95%). There are numerous physical examination tests that are helpful in the evaluation of patients with a suspected PCL injury, including the posterior drawer test, quadriceps active test, and the Dial test. The contralateral knee is an excellent resource and should be examined for comparison. An MRI is critical in the evaluation of the PCL and also other associated structures such as articular and meniscal cartilage and the other knee ligaments. Treatment of both isolated and combined PCL injuries includes both non-operative and operative management decisions. In general, partial and complete isolated PCL injuries are treated with physical therapy and complete combined injuries are treated with carefully timed and skillful surgical intervention. Partial tears (grade I) are typically managed non-operatively, and nonoperative management has historically been pursued for isolated complete PCL tears as well. However, recent evidence suggests long-term benefits after operative management, specifically regarding the development of osteoarthritis (OA). Multi-ligamentous tears and avulsion injuries should be treated operatively. Surgical considerations include open versus arthroscopic approaches, as well as repair versus reconstruction. If reconstruction is pursued, the surgeon must decide between single-bundle versus double-bundle reconstruction, allograft versus autograft, and transtibial tunnel versus tibial inlay surgical technique. Regardless of the treatment method utilized, postoperative rehabilitation is important for regaining quad strength, knee range of motion, and overall knee function. Evaluation and management of complete PCL injuries continue to evolve over time, with an increasing trend towards surgical management in order to prevent future meniscal injury and progression of osteoarthritis. Patient evaluation should include a comprehensive history and physical, weight-bearing and stress radiographs, as well as MRI. Numerous surgical techniques have been utilized to repair or reconstruct the PCL with satisfactory results, but there is no consensus as to which method or technique is superior. Postoperative rehabilitation is critical in regaining knee strength, function, and range of motion.