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PCL Tears and Treatment

Patient Testimonial: "I injured my knee playing High School Football in November of 2018. I had never been injured before, and I immediately knew by the pain and swelling that this was serious. I saw Dr. Ziegler a week later and he was able to immediately diagnose my injury, a ruptured PCL in my right knee. That same day he took x-rays and scheduled an MRI to confirm his diagnosis. The MRI clearly showed my PCL was torn in half. Within a week of the MRI Dr. Ziegler made sure to see us again and schedule my surgery. The time period between suffering the injury and then getting scheduled for surgery was no more than two weeks. Dr. Ziegler was fast, efficient, patient, and on task. There was no long waits, lies, or messing around. Dr. Ziegler gets to the point and likes to take action. The surgery was a complete success, and Dr. Ziegler made sure to check with me every week for the next 3 weeks after surgery. The physical Therapy was very well organized as well. Dr. Ziegler has his own protocol for each individual injury. Because of this my physical therapy was all PCL specific and very well run. The process was long and tedious, as Dr. Ziegler is a very attentive person. At times I was frustrated with this because I was a 17 year old just trying to play football again, but I couldn't be more thankful he made me take it slow. I was injured on Thanksgiving of 2018, and was cleared ten months later in September 2019. Dr. Ziegler's work has allowed me to make a full recovery to the point where my knee feels exactly the same as my other, and I am able to play the sport I love with no brace or issues at all. I couldn't be more thankful for Dr. Ziegler and everything he did for me, I highly recommend this Doctor to anyone, especially anyone with a sports related injury."   - AS

What is the PCL (Posterior Cruciate Ligament)?
The posterior cruciate ligament (PCL) is the ligament that crosses the more commonly torn anterior cruciate ligament (ACL). It is one of several ligaments that connect the femur (thighbone) to the tibia (shinbone). The PCL sits in the center and back of the knee (“posterior” implies back of the knee) and prevents the knee from slipping backwards.  It is most important for function on a bent knee, usually when the knee is bent to about 90 degrees. The PCL is the strongest ligament of the knee and is, therefore, less commonly injured. A PCL injury is often caused by a powerful force—in many cases from sports trauma. This may include a bent knee hitting something very hard (for example, a dashboard in a car accident or a hockey player hitting the goalpost) or a football player falling on a knee while it is in the bent position. PCL tears can also occur in hyperextension injuries.

 

What does a PCL tear feel like?
Most athletes who tear their PCL describe a tearing sensation within their knee.  Most do not describe a “pop”, which is commonly associated with an ACL tear. A PCL tear commonly causes just a little bit of swelling in the knee, and when it occurs by itself (that is without any other ligaments torn), there may not be much swelling within the knee. PCL pain has been described as deep within the knee and dull.  There is not usually a sharp pain described with an isolated PCL tear. In some circumstances, such as with football lineman, the dull ache can be difficult to determine from wear and tear from normal sports activity and the PCL tear may go unrecognized until being properly evaluated.

 

PCL Tear Symptoms
Posterior cruciate ligament tears can cause:
•    Problems decelerating
•    Problems going down stairs and inclines
•    Problems twisting, turning, or pivoting
•    Pain over the anterior aspect of the knee

PCL Tear Diagnosis
Dr. Ziegler will assess for signs of a torn PCL with a detailed clinical exam, x-rays, kneeling posterior knee stress x-rays, and almost always, an MRI scan to determine the extent of the injury and other injuries to determine a treatment plan. In general, an isolated, partial PCL injury will heal over time. It is important to diagnose a PCL tear early in order get the knee appropriately braced and prevent the PCL from healing in an elongated and nonfunctional position. While the results of an MRI scan are helpful for an acute injury evaluation, they are not very useful in the case of a chronic PCL injury, which can often look relatively normal on MRI, but actually be stretched out causing persistent knee instability. In this case, physical examination and stress x-rays are required to diagnose the extent of the tear.

PCL Injury Testing
The diagnosis of a torn PCL depends upon assessment of the patient’s posterior knee translation. PCL injury test involves examining the patient from the side to see if there is any posterior step off, performing a quadriceps active test and also performing the posterior drawer test in neutral rotation. In addition, a patient should have bilateral posterior knee stress radiographs to objectively determine the amount of increased posterior translation on the injured knee compared to the normal knee.

PCL stress XRs in a 16 yo male football player who sustained a Grade 3 PCL tear to his Right knee during a football game. Image on Right shows increased posterior translation of the tibia (shin bone) relative to the femur (thigh bone).

PCL Tear Grading
Posterior cruciate ligament injuries are classified according to the amount of injury to the ligament:

Grade 1 PCL injury: A small partial tear
Grade 2 PCL injury: A near complete tear
Grade 3 PCL Tear: A complete tear whereas the ligament becomes non-functional; usually this occurs with injuries to other knee ligaments (most commonly the posterolateral knee structures) or in those with a flat posterior tibial slope.

 

Most isolated grade 1 and 2 PCL sprain injuries can be treated with a non-operative program to include functional rehabilitation of the quadriceps mechanism and the use of a PCL brace to help reduce the knee into a normal (neutral) position.

 

PCL Tear Treatment
Patients who have a PCL tear with less than 8 mm of posterior translation measured on stress X-rays can be considered for a non-operative rehabilitation program in special circumstances. However, in most patients who have 8 mm or more of increased posterior knee translation, there is a much higher likelihood that these patients will need a PCL reconstruction surgery to improve their knee function and decrease the chances of developing knee arthritis. Thus, in a higher-level athlete, it is usually recommended to proceed with the PCL knee reconstruction because results of acute reconstructions are much better than chronic reconstructions.

When Dr. Ziegler makes the determination that a patient requires a PCL reconstruction, he thoroughly assesses the patient to see if there is any concurrent injury. Approximately 90% of patients who have persistent PCL tear symptoms limiting their function also have a other associated ligament injury. Thus, the incidence of isolated PCL reconstructions is approximately 10% of the total PCL reconstructions performed.

Dr. Ziegler’s surgical technique for a PCL reconstruction is an arthroscopically-assisted double bundle reconstruction with allograft tendon. It utilizes minimal incisions and does not violate the quadriceps mechanism like conventional posterior cruciate ligament reconstruction surgery techniques. The double bundle PCL reconstruction has been extremely effective in restoring knee stability back to the patient both objectively with PCL stress x-rays and subjectively based on patients independently evaluating their outcome scores.

PCL Surgery Recovery
PCL surgery recovery involves patients initiating prone knee flexion from 0-90° beginning within 1-2 days of surgery. Patients will also use of a PCL brace for 6-9 months postoperatively to reduce the posterior gravitational stress to the knee. Patients are non-weight-bearing for the first 6 weeks and then initiate a protective weight-bearing program weaning off of crutches when they can walk without a limp. Patients may initiate the use of a stationary bike to a maximum of 70° of knee flexion at 6 weeks postoperatively. Beginning therapy promptly after surgery allows for quicker return of knee motion, decreased risk of knee stiffness and high level function.