Arch Orthop Trauma Surg

DOI 10.1007/s00402-013-1854-y

Arthroscopy and Sports Medicine

Rehabilitation after posterior cruciate ligament reconstruction: a

review of the literature and theoretical support
Jin Goo Kim · Yong Seuk Lee · Byung Se Yang ·
Soo Jin Oh · Sang Jin Yang 

Received: 21 June 2013

© Springer-Verlag Berlin Heidelberg 2013

Abstract  used to prevent a posteriorly directed force. Most authors

Introduction  The purpose of this study was to conduct a
literature review of studies that have addressed rehabilita-
tion after posterior cruciate ligament (PCL) reconstruction.
In particular, we intended to perform categorical analysis
and discuss some critical points.
Materials and methods  A literature review of English
language articles was performed using the PubMed data-
bases. Our literature search was performed using the fol-
lowing text words: [posterior cruciate ligament OR PCL]
AND [reconstruction] AND [rehabilitation]. A total of 34
articles met our criteria and were included in the final sys-
tematic review. Rehabilitation protocols were reviewed and
tabulated according to main rehabilitation protocol catego-
ries [range of motion (ROM), weight bearing, bracing, and
strengthening].
Results Ranges of motion of 90° and 120° were allowed
at 4–8 and 6–12 weeks postoperatively in 70 % of studies.
Full weight bearing was delayed until 6 weeks postopera-
tively in 60 % of studies. Most studies (73 % of studies)
used a brace for 6–8 weeks and active hamstring exercise
was not allowed for 6–24 weeks postoperatively.
Conclusions  The review showed that flexion of 90° was
allowed at around 6 weeks and prone passive flexion exercise
or supine passive ROM exercise with posterior support was
J. G. Kim · B. S. Yang · S. J. Oh · S. J. Yang  tion, studies have revealed a reluctance to engage in daily
Department of Orthopedic Surgery, Seoul Paik Hospital, Inje
University, Seoul, Korea
Y. S. Lee (*)  ness at 2 years after surgery, although satisfactory clinical
Department of Orthopedic Surgery, Gil Hospital, Gil Medical
Center, Gachon University School of Medicine, Gachon
University, 1198 Guwol‑dong, Namdong‑gu, Incheon 405‑760,
Korea
e-mail: smcos1@hanmail.net
used non-weight bearing or partial weight bearing in their
rehabilitationprograms, however it may be possible to per-
form active weight bearing in fullextension or early flex-
ion grades as soon as the soft tissue situation allows. Co-
strengthening exercises could be recommended because
these exercises produce co-contraction between the quadri-
ceps and hamstring muscles with little posterior shear force.
Keywords Posterior cruciate ligament · Rehabilitation
protocol · Literature review · Theoretical support
Introduction
There is a paucity of information on rehabilitation after
reconstruction of the posterior cruciate ligament (PCL),
and there is a lack of consensus in the literature regard-
ing the rehabilitation protocol and different protocols have
been proposed [11, 14, 34, 41]. With regard to PCL out-
comes, an improved understanding of rehabilitation may
be a critical factor in terms of restoring knee function [14].
However, studies that have addressed to this topic rarely
provide a rationale for the protocols used [11, 26, 34]. This
implies that some review and discussion of current rehabili-
tation programs after PCL reconstruction is required.
In terms of functional analysis after PCL reconstruc-
activities that require rotation (cutting and turning) during
the early postoperative period and persistent muscle weak-
results could have been obtained using modern techniques
of PCL reconstruction [19, 34, 35]. In contrast to the PCL,
accelerated rehabilitation programs have been introduced
after anterior cruciate ligament (ACL) reconstruction

13
 Arch Orthop Trauma Surg

and these have resulted in some improvements in clinical
results and patient satisfaction [49, 50].
Major disabilities after ligament reconstruction are asso-
ciated with pain, swelling, loss of motion, weakness, joint
laxity, and loss of proprioception [24, 43]. Thus, it appears
that the critical points would be range of motion (ROM),
weight bearing, bracing, and strengthening in the rehabili-
tation. The purpose of this study was to conduct a review of
the literature of studies that have addressed rehabilitation
after PCL reconstruction. In particular, we intended to per-
form categorical analysis (ROM, weight bearing, bracing,
and strengthening) and discuss some critical points. The
main questions we sought to answer were: (1) How much
ROM should be performed at specific times during reha-
bilitation? (2) When is weight bearing allowed? (3) How
long should a patient wear a brace after surgery? (4) When
is hamstring exercise started?
were evaluated with a focus on active hamstring exercise,
and were categorized as >12 weeks hamstring inhibition,
12 weeks hamstring inhibition, and 6–8 weeks hamstring
inhibition.
Results
Using the above-mentioned search criteria, 1,720 articles
were initially identified for potential inclusion. Ninety-
eight articles met our inclusion criteria; however, we
excluded articles that did not include a rehabilitation pro-
tocol after PCL reconstruction. Finally, 34 articles that met
our criteria were included in our final systematic review
(Fig. 1). Frequency data for the categories of rehabilitation
protocol are summarized in Table 1.
Range of motion

Materials and methods A ROM exercise program was declared in the 21 studies

listed in Table 2. In four (19 %) studies, less than 45° flex-
A systematic review of English language articles was per- ion was allowed until 6 weeks [17, 20, 27, 53]. Jung et al.
formed using the PubMed databases. Our literature search [27] used most delayed ROM and limited to full exten-
was performed using the following text words: [posterior sion until 6 weeks postoperatively. In seven (33 %) stud-
cruciate ligament OR PCL] AND [reconstruction] AND ies, 90° ROM was allowed from 6 to 8 weeks and 120°
[rehabilitation]. This search was conducted from January ROM was allowed at 12 weeks [2, 18, 33, 36, 42, 57, 59].
2000 to December 2011. Articles were only included if the In eight (38 %) studies, 90° ROM was allowed at 4 weeks
following criteria were satisfied: combined posterolateral and 120° ROM at 6–8 weeks [4, 5, 7, 30, 32, 46, 56, 58].
rotatory instability (PLRI) was only included among multi- In two (10 %) studies, 120° ROM was allowed at 4 weeks
ligament injuries that require surgical correction. Less than and 120° ROM at 6–8 weeks [38, 39]. In 70 % of studies,
grade II concomitant ligamentous laxity that did not require 90° ROM was allowed at 4–8 weeks and 120° ROM at
surgical procedure or combined meniscal (partial-, subto- 6–12 weeks.
tal meniscectomy, and repair) or focal cartilage procedures
were included, an original article was only included and we
excluded case reports, pure surgical technique, and review
articles; the series require more than 2 years follow-up after
the reconstruction of the PCL; we did not limit the kind of
operation. Rehabilitation protocols were reviewed and tab-
ulated according to main rehabilitation protocol categories,
that is, ROM, weight bearing, bracing, and strengthening
and we presented the tendency of each category by dividing
into delayed- and relatively accelerated rehabilitation.
Categorical analysis was performed to determine the
influence of each category. The level of evidence was com-
pared between delayed- and relatively accelerated reha-
bilitation using a Chi square test. ROM was analyzed by
90° and 120° of flexion. Weight bearing was analyzed with
respect to non-weight bearing (NWB), partial weight bear-
ing (PWB), and full weight bearing (FWB). NWB was
defined as only a toe touch was allowed. PWB was defined
as tolerable FWB was not allowed and FWB meant a tol-
erable FWB. The bracing was analyzed by categorizing its
duration as <6, 6–8, or >8 weeks. Strengthening programs Fig. 1  Schematic of the literature search

13
Arch Orthop Trauma Surg

Table 1  Frequency data for

the categories of rehabilitation ROM 2–6 weeks limit 6–8 weeks: 90° 4 weeks: 90° 4 weeks: 120°
protocol (%) 19 33 38 10
Weight Bearing 10–12 weeks: PWB 6 weeks: PWB Tolerable FWB, 3–4 weeks: PWB
(%) 19 59 22
Bracing 10–12 weeks 6–8 weeks 6 weeks No brace
(%) 18 32 41 9
Strengthening More than 12 weeks 12 weeks 6–8 weeks hamstring inhibition
(%) 26 37 37

Table 2  ROM protocols after PCL reconstruction

ROM
Delayed Relatively accelerated

Freeman et al. [17] Ahn et al. [2] Chen et al. [5] MacGillivray et al. [38]
→ 2–6 weeks: 30° → 2–3 weeks limit, 8 weeks: 90° → 4 weeks: 90° → Early period: 90°
Jung et al. [27] Lee et al. [33] Wu et al. [56] McGuire [39]
→ 6 weeks: limit → 6 weeks: 90° → 4 weeks: 90°, 8 weeks: 120° → 2 weeks: 60°
→ 3 weeks: 90°
→ 4 weeks: 120°
Wang et al. [53] Zhang et al. [59] Jung et al. [30]
→ 6 weeks: limit, less than 45° → 4 weeks limit, 8 weeks: 90°, 12 weeks: → 4 weeks: 90°, 6 weeks: 140°
initially 120°
Chen et al. [6] Li et al. [36] Chan et al. [4]
→ 6 weeks: limit, less than 45° → 8 weeks: 90°, 12 weeks: 120° → 4 weeks: 90°, 8 weeks: 120°
initially
Min et al. [42] Chuang [7]
→ 8 weeks: 90°, 12 weeks: 120° → 4 weeks: 90°, 10 weeks: 135°
Yoon et al. [57] Zayni et al. [58]
→3 weeks limit 6 weeks : 90°, 12 weeks: → 4 weeks: 90°, 8 weeks: 120°
135°
Garofalo et al. [18] Nyland [46]
→ CPM started at 24 h postoperatively → 4 weeks: 90°, 8 weeks: 130°
→ 4 weeks: 70°
Kim [32]
→ 2–4 weeks start, 6–8 weeks: 110°
→ full flexion limit until 3 months
2–6 weeks : limit 6–8 weeks : 90° 4 weeks : 90° 4 weeks: 120°

Weight bearing Protective bracing

A weight bearing program was declared in the 27 studies
listed in Table 3, and these could be subdivided into three
groups (PWB for 10–12 weeks, PWB for 6 weeks, and
PWB for 3–4 weeks or tolerance FWB). In five (19 %)
studies, FWB was delayed until 10–12 weeks [2, 19, 36, 48,
59]. In 16 (59 %) studies, FWB was delayed until 6 weeks
[4, 7, 8, 17, 18, 21, 23, 30, 32, 33, 38, 53, 56–58, 60]. In six
(22 %) studies, FWB was started at least for 3–4 weeks [5,
10, 26, 39, 42, 46]. In three studies, FWB was performed
from immediate postoperatively [5, 10, 26]. In 60 % of
studies, FWB was delayed until 6 weeks postoperatively.
A bracing program was declared in 22 studies (Table 4). No
study declared specific type of brace. However, all braces were
thought to be hinged type braces allowing ROM of certain
degrees because they described that braces were worn during
ROM exercise or activities. In four (18 %) studies, the knee
was protected with a brace for 10–12 weeks [2, 36, 48, 59],
in seven (32 %) studies, a brace was used for 6–8 weeks [4,
5, 7, 27, 38, 45, 58], and in nine (41 %) studies [8, 17, 19–21,
23, 30, 33, 55], a brace was used for 6 weeks; no brace was
used in two (9 %) studies [10, 26]. In the majority of studies
(approximately 73 %) a brace was used for 6–8 weeks.

13
 Arch Orthop Trauma Surg

Table 3  Weight bearing Weight bearing

protocols after PCL
reconstruction Delayed Relatively accelerated

Seon et al. [48] MacGillivray et al. [38] Inoue [23] Chen et al. [5]
→ NWB: 8 weeks → PWB: 6 weeks → PWB: 6 weeks → Tolerance FWB
→ FWB: 12 weeks
Ahn et al. [2] Wu et al. [56] Chan et al. [4] Deehan et al. [10]
→ PWB: 3 months → PWB: 6 weeks → PWB: 6 weeks → FWB without brace
Zhang et al. [59] Jung et al. [30] Zhao et al. [60] Jackson et al. [26]
→ NWB:12 weeks → PWB: 6 weeks →PWB: 6 weeks → FWB: tolerated
Li et al. [36] Hermans et al. [21] Zayni et al. [58] McGuire [39]
→ PWB: 10 weeks → PWB: 4 weeks →PWB: 6 weeks → NWB: 1 weeks
→ FWB: 8 weeks → PWB: 3 weeks
Goudie et al. [19] Freeman [17] Cooper [8] Min et al. [42]
→ PWB: 10 weeks → PWB: 6 weeks → PWB: 6 weeks → PWB: 4 weeks
Lee [33] Garofalo [18] Nyland et al. [46]
→ PWB: 6 weeks → PWB: 6 weeks → PWB: 3 weeks
Chuang [7] Kim et al. [32]
→ PWB: 6 weeks → PWB: 6 weeks
Wang et al. [53] Yoon et al. [57]
→ PWB: 6 weeks → NWB: 3 weeks
→ FWB: 6 weeks
NWB non-weight bearing, PWB 10–12 weeks: PWB 6 weeks: PWB Tolerance FWB
partial weight bearing, FWB full 3–4 weeks: PWB
weight bearing

Table 4  Protective bracing after PCL reconstruction

Brace
Delayed Relatively accelerated

Seon et al. [48] Chen et al. [5] Jung et al. [30] Jackson et al. [26]
→ 4 weeks: full extension, 12 weeks: → 6 weeks: full extension, 8 weeks: off → 0–3 weeks: full extension → No brace
off → 3–6 weeks: off
Ahn et al. [2] MacGilliuray et al. [38] Herman et al. [21] Deehan et al. [10]
→ 2 weeks: full extension, 12 weeks: → 6 weeks: full extension → 4 weeks: 15° fix, after 4 weeks: → No brace
off loose
Zhang et al. [59] Jung et al. [27] Freeman et al. [17]
→ 12 weeks: off → 6 weeks: splint → 2 weeks: full extension
Li et al. [36] Chuang et al. [7] Lee et al. [33]
→ 3 weeks: full extension, 10 weeks: → 8 weeks: full extension → 2–3 weeks: full extension
off → 6 weeks: off
Chan et al. [4] Wong et al. [55]
→ 8 weeks: full extension → 4–6 weeks: full extension
→ 6 weeks: off
Zayni et al. [58] Inoue [23]
→ 8 weeks: off → 2 weeks splint
Noyes et al. [45] Cooper [8]
→ 8 weeks: off → 6 weeks: off
Chen et al. [4]
→ 6 weeks: off
Goudie et al. [19]
→ 6 weeks: off
10–12 weeks brace 6 ~ 8 weeks brace 6 weeks brace No brace

13
Arch Orthop Trauma Surg

Table 5  Strengthening after PCL reconstruction

Strengthening
Delayed Relatively accelerated

Fanelli [15] Jung [27] Wang [53]

→ Progressive closed kinetic chain (CKC) → 12 weeks: active hamstring inhibition → 6 weeks: active hamstring inhibition
exercise
Freeman [17] Chuang [7] Chen [20]
→ CKC encouraged → 12 weeks: CKC → 4 weeks: CKC
→ Aggressive hamstring strengthening
Lee [33] Nyland [46] Chen [5]
→ 16 weeks: active hamstring inhibition → 4–8 weeks: standing balance → 8 weeks: aggressive hamstring and quadriceps
→ 8–12 weeks: mini-squatting exercise
Zhang [59] Kim [32] Wu [56]
→ 24 weeks: inhibition of active flexion and → 6 weeks: CKC → 4 weeks: CKC
squatting → 8 weeks: active hamstring and quadriceps
exercise
Zayni [58] Garofalo [18] Wong [55]
→ 24 weeks; active hamstring exercise → 4 weeks: CKC → 6 weeks: hamstring inhibition
→ Progress open kinetic chain (OKC)
→ 12 weeks: active hamstring inhibition
Goudie [19] Chan [4]
→ 6 weeks: CKC → 4 weeks: CKC
→ Progress OKC → 8 weeks: hamstring and quadriceps exercise
→ 12 weeks: active hamstring inhibition
Ahn [2] Noyes [45]
→ 6 weeks: CKC → Progressive CKC
→ 8 weeks: hamstring isotonic exercise

Strengthening hamstring exercise was started at from 6 to 24 weeks.

A strengthening program was declared in 19 studies
(Table 5). In five (26 %) studies [15, 17, 33, 58, 59], active
hamstring exercise was delayed for more than 12 weeks,
in seven (37 %) studies [2, 7, 18, 19, 30, 32, 46] for
12 weeks, in seven (37 %) studies [4, 5, 20, 45, 53, 55, 56]
for 6–8 weeks. Isometric quadriceps exercise and straight
leg raising training were started during the immediate post-
operative period in most studies, and closed kinetic chain
(CKC) exercise was initially started and followed by open
kinetic chain (OKC) exercise in most studies [18, 19].
However, the starting point of CKC exercise varied from
the immediate postoperative period to 6 weeks postopera-
tively, but was started at 12 weeks in one study [7].
Discussion [34]
The principal findings of this literature review were that
(1) 90° and 120° ROM were usually allowed by 4–8 and
6–12 weeks postoperatively, respectively; (2) FWB was
usually delayed until 6 weeks postoperatively; (3) in most
studies, a brace was used for 6–8 weeks; and (4) active
Although most studies used different rehabilitation proto-
cols, they showed good stability and functional improve-
ments. PCL injuries are frequently combined with PLRI
and it is counted as approximately 43–80 % [16, 28]. In
this series, the incidences of combined injury were also
variable, and there were few studies (less than 10 articles)
that only included isolated PCL injury. Therefore, it was
difficult to perform a separate analysis between isolated
and combined injures. In addition, great variety of graft
selection, tensioning, tunnel anatomy, and combined injury
makes true comparison difficult and a lack of extensive
study regarding the rehabilitation and long-term follow-up
data are lacking. Therefore, it must be considered in the
evaluation of the rehabilitation after PCL reconstruction.
The major focus of rehabilitation programs after liga-
ment reconstruction should be on impairment following
knee ligament surgery with the aim of restoring function
and minimizing disability associated with pain, swelling,
loss of motion, weakness, joint laxity, and loss of proprio-
ception [24, 43]. Of these, pain and swelling are associated
with initial management. Therefore, the critical aspects of
rehabilitation program are based on loss of motion, weak-
ness, joint laxity, and loss of proprioception, which are

13

all somewhat controllable. Loss of motion is reflected
by ROM, and weakness and joint laxity could be associ-
ated with strengthening and bracing, respectively. Loss of
proprioception could be matched with weight bearing and
strengthening although it is difficult to define and evaluate
improvements. Thus, it appears that the critical points were
ROM, weight bearing, bracing, and strengthening.
Range of motion
First, accelerated rehabilitation does not mean rapid
increase of ROM. An ROM from 0° to 30° is permissible
from immediately after surgery, because this range of ROM
exercise involves little posteriorly directed force [1, 37].
However, to protect against gravity, prone exercise or pos-
terior support is recommended. From 2 weeks postopera-
tively, ROM usually increases by 15° per week until week
6, which means that 90° of flexion is achieved at around
6 weeks [2]. To increase ROM, prone passive flexion exer-
cise and supine passive ROM exercise with the support of
both hands should be performed to prevent a posteriorly
directed force [2, 29]. Further increases in ROM depend on
several other factors, such as, fixation strength, graft mate-
rial, pre-injury activity, expected time to return, and indi-
vidual requirements [34].
Weight bearing
A more conservative approach has traditionally been
used for PCL rehabilitation. First, early weight bearing
is believed to be deleterious to the PCL because it is con-
sidered to be the primary static stabilizer of the knee [52].
Second, a PCL reconstruction is often associated with
either a medial or lateral repair or reconstruction, and the
cyclic motion of the knee during ambulation needs to be
minimized to avoid over-stressing these structures [11, 12].
Third, there is a lack of empirical research on the effects
of exercise and daily activities on the reconstructed PCL.
However, the tibial plateau is inclined posteriorly and an
axial load placed on the tibia by weight bearing in rela-
tively extended positions produces an elemental force
in the anterior direction. Therefore, the joint is stabilized
somewhat by weight bearing in the fully extended position
[22, 25]. Weight bearing has several benefits and could be
encouraged as early as possible [11, 12]. The reasons are
as follows. First, patients have better static stability when
standing on both legs, thereby minimizing the risk of falls.
Second, weight bearing could stimulate tunnel healing
and graft incorporation. Third, it promotes the production
of synovial fluid, which bathes articular cartilage. Fourth,
weight bearing itself can be viewed as a co-strengthening
exercise and a form of proprioceptive training [11, 12, 31].
Finally, most patients have a tendency to flex their operated
13
Arch Orthop Trauma Surg
knee to prevent weight bearing, which means that a posteri-
orly directed force can be avoided if weight bearing is per-
formed. Therefore, active weight bearing in full extension
beyond that used in current protocols may be beneficial.
Strengthening
Quadriceps exercise is strongly encouraged because the
quadriceps is an agonistic muscle of the PCL. Daniel et al.
described the concept of quadriceps neutral angle [9],
which occurs at approximately 60°–75° of flexion. Quadri-
ceps strengthening extension exercise at angles less than
the quadriceps neutral angle produce anterior tibial transla-
tion, which is antagonistic to the ACL but synergistic to the
PCL. On the other hand, quadriceps strengthening exten-
sion exercises at angles greater than the quadriceps neutral
angle cause posterior translation of the tibia, which is syn-
ergistic to the ACL but antagonistic to the PCL. Therefore,
after PCL reconstruction, quadriceps strengthening knee
extension should be restricted to between 60° of flexion
and full extension of the knee [9, 24].
Within 0°–30° of flexion, the hamstring cannot produce
a posterior shear force and the anterior angle of the patel-
lar tendon is always larger than that of the hamstring ten-
dons [1, 37]. Therefore, active flexion exercise is permis-
sible within this range of flexion. Active flexion exercise
above 30° is unfavorable because a posterior shear force
can occur above this angle [1, 37]. Therefore, inhibition of
active hamstring exercise should only be done above 30°
of flexion. However, hamstring strengthening could be pos-
sible by co-strengthening (co-contraction exercise) of the
quadriceps and hamstring.
Co-strengthening is performed by calf raising, short
arc leg press, and mini-squatting exercises. Calf raising is
a strengthening exercise of the gastrocnemius that is ago-
nistic to the PCL. During short arc leg press, maximal co-
contractions of quadriceps and hamstring occur from 30°
to 60° flexion and posterior shear force can be lessened
by CKC exercise rather than OKC exercise (Fig. 2) [37].
Squatting promotes co-contraction of the quadriceps and
hamstring. During vertical squatting, the body is positioned
only slightly posterior to the knee, which results in more
co-contraction of the quadriceps and hamstring muscles
and less posterior shear force (Fig. 3) [24, 44, 47].
OKC and CKC exercises generate different patterns of
muscle activities and ligament forces [13, 37, 54]. CKC
programs activate antagonistic muscle groups across mul-
tiple joints and cannot be used to isolate or examine a
single muscle group. On the other hand, OKC exercises
isolate specific muscle groups for strengthening and evalu-
ation purposes [40]. Three prevalent assumptions have led
to the popularity of CKC exercises over OKC exercises
[3, 54]. However, OKC exercises are used throughout the
Arch Orthop Trauma Surg
Fig. 2  Courtesy of Lutz et al., average tibiofemoral shear forces
observed during closed kinetic chain leg press, open kinetic chain
extension, and open kinetic chain flexion exercises
Fig. 3  Courtesy of Ohkoshi et al., calculated shear force (kg) per
body weight (kg) while standing on both legs at various flexion
angles of the knee and trunk
rehabilitation period because they challenge the quadriceps
more effectively than CKC [11]. One possible problem is
patellofemoral pain. To minimize patellofemoral contact
stress, CKC exercises are recommended from 0° to 45° of
flexion and OKC exercises should be performed from 90°
to 50° of flexion [51]. Therefore, CKC extension exercise
of quadriceps ranging from 0° to 60°–75° of flexion is pre-
ferred after PCL reconstruction because it does not produce
posterior shear force or patellofemoral pain.
This study has some limitations that must be considered.
First, it was impossible to evaluate the isolated and com-
bined PCL injury independently because most studies did
not declare the difference of rehabilitation between isolated
and combined PCL injury. Second, we could not validate
or access any particular rehabilitation protocol for use in
clinical practice. Third, since a myriad of different aspects
needs to be considered depending on many things such as
the used technique and concomitant injuries, a systematic
review to draw conclusions appears difficult.
Conclusion
The consensus of our analysis was that flexion of 90° is
allowed at around 6 weeks and prone passive flexion exer-
cise or supine passive ROM exercise with posterior sup-
port is used to prevent a posteriorly directed force. Most
authors used NWB or PWB in their rehabilitation programs
although it appears possible increasing active weight bear-
ing in full extension and early flexion grades as soon as the
soft tissue situation allows. Co-strengthening exercises,
such as, calf raising, short arc leg press, and mini-squatting,
could be recommended because these exercises produce
co-contraction of the quadriceps and hamstring muscles
with little posterior shear force.
Acknowledgments  This work was supported by the National
Research Foundation of Korea Grant funded by the Korean Govern-
ment (2012000971).
Conflict of interest None.
References
1. Aalbersberg S, Kingma I, Ronsky JL, Frayne R, van Dieen JH
(2005) Orientation of tendons in vivo with active and passive
knee muscles. J Biomech 38:1780–1788
2. Ahn JH, Yang HS, Jeong WK, Koh KH (2006) Arthroscopic tran-
stibial posterior cruciate ligament reconstruction with preserva-
tion of posterior cruciate ligament fibers: clinical results of mini-
mum 2-year follow-up. Am J Sports Med 34:194–204
3. Bynum EB, Barrack RL, Alexander AH (1995) Open versus
closed chain kinetic exercises after anterior cruciate ligament
reconstruction. A prospective randomized study. Am J Sports
Med 23:401–406
4. Chan YS, Yang SC, Chang CH, Chen AC, Yuan LJ, Hsu KY,
Wang CJ (2006) Arthroscopic reconstruction of the posterior
cruciate ligament with use of a quadruple hamstring tendon graft
with 3- to 5-year follow-up. Arthroscopy 22:762–770
5. Chen CH, Chen WJ, Shih CH, Chou SW (2004) Arthroscopic
posterior cruciate ligament reconstruction with quadriceps ten-
don autograft: minimal 3 years follow-up. Am J Sports Med
32:361–368
6. Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH (2006)
Arthroscopic posterior cruciate ligament reconstruction with
hamstring tendon autograft: results with a minimum 4-year fol-
low-up. Knee Surg Sports Traumatol Arthrosc 14:1045–1054
7. Chuang TY, Ho WP, Chen CH, Shieh MH, Liau JJ, Huang CH
(2011) Non-hardware posterior cruciate ligament reconstruction
using knot/press-fit technique with periosteum-enveloped ham-
strings tendon autograft. Am J Sports Med 39:1081–1089
8. Cooper DE, Stewart D (2004) Posterior cruciate ligament recon-
struction using single-bundle patella tendon graft with tibial inlay
fixation: 2- to 10-year follow-up. Am J Sports Med 32:346–360
9. Daniel DM, Stone ML, Barnett P, Sachs R (1988) Use of the
quadriceps active test to diagnose posterior cruciate-ligament dis-
ruption and measure posterior laxity of the knee. J Bone Jt Surg
Am 70:386–391
10. Deehan DJ, Salmon LJ, Russell VJ, Pinczewski LA (2003) Endo-
scopic single-bundle posterior cruciate ligament reconstruction:
results at minimum 2-year follow-up. Arthroscopy 19:955–962
13

11. Edson CJ, Fanelli GC, Beck JD (2010) Postoperative rehabili-
tation of the posterior cruciate ligament. Sports Med Arthrosc
18:275–279
12. Edson CJ, Fanelli GC, Beck JD (2011) Rehabilitation after mul-
tiple-ligament reconstruction of the knee. Sports Med Arthrosc
19:162–166
13. Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE,
Andrews JR (1998) Biomechanics of the knee during closed
kinetic chain and open kinetic chain exercises. Med Sci Sports
Exerc 30:556–569
14. Fanelli GC (2008) Posterior cruciate ligament rehabilitation: how
slow should we go? Arthroscopy 24:234–235
15. Fanelli GC, Edson CJ (2002) Arthroscopically assisted combined
anterior and posterior cruciate ligament reconstruction in the
multiple ligament injured knee: 2- to 10-year follow-up. Arthros-
copy 18:703–714
16. Fanelli GC, Larson RV (2002) Practical management of postero-
lateral instability of the knee. Arthroscopy 18:1–8
17. Freeman RT, Duri ZA, Dowd GS (2002) Combined chronic pos-
terior cruciate and posterolateral corner ligamentous injuries: a
comparison of posterior cruciate ligament reconstruction with
and without reconstruction of the posterolateral corner. Knee
9:309–312
18. Garofalo R, Jolles BM, Moretti B, Siegrist O (2006) Double-
bundle transtibial posterior cruciate ligament reconstruction with
a tendon-patellar bone-semitendinosus tendon autograft: clini-
cal results with a minimum of 2 years’ follow-up. Arthroscopy
22:1331–1338 (e1331)
19. Goudie EB, Will EM, Keating JF (2010) Functional outcome fol-
lowing PCL and complex knee ligament reconstruction. Knee
17:230–234
20. Hankemeier S, Hufner T, Wang G, Kendoff D, Zeichen J, Zheng
G, Krettek C (2006) Navigated open-wedge high tibial oste-
otomy: advantages and disadvantages compared to the conven-
tional technique in a cadaver study. Knee Surg Sports Traumatol
Arthrosc 14:917–921
21. Hermans S, Corten K, Bellemans J (2009) Long-term results of
isolated anterolateral bundle reconstructions of the posterior cru-
ciate ligament: a 6- to 12-year follow-up study. Am J Sports Med
37:1499–1507
22. Higgins H (1896) Geniculate articular surfaces of the femur and
tibia. J Anat Physiol 30:292–295
23. Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M (2004) Primary
repair of posterior cruciate ligament avulsion fracture: the effect
of occult injury in the midsubstance on postoperative instability.
Am J Sports Med 32:1230–1237
24. Irrgang JJ, Fitzgerald GK (2000) Rehabilitation of the multiple-
ligament-injured knee. Clin Sports Med 19:545–571
25. Iwamoto J, Takeda T, Suda Y, Otani T, Matsumoto H (2004) Con-
servative treatment of isolated posterior cruciate ligament injury
in professional baseball players: a report of two cases. Knee
11:41–44
26. Jackson WF, van der Tempel WM, Salmon LJ, Williams HA,
Pinczewski LA (2008) Endoscopically-assisted single-bundle
posterior cruciate ligament reconstruction: results at minimum
ten-year follow-up. J Bone Jt Surg Br 90:1328–1333
27. Jung TM, Lubowicki A, Wienand A, Wagner M, Weiler A (2011)
Knee stability after posterior cruciate ligament reconstruction in
female versus male patients: a prospective matched-group analy-
sis. Arthroscopy 27:399–403
28. Jung YB, Jung HJ, Kim SJ, Park SJ, Song KS, Lee YS, Lee SH
(2008) Posterolateral corner reconstruction for posterolateral
rotatory instability combined with posterior cruciate ligament
injuries: comparison between fibular tunnel and tibial tunnel
techniques. Knee Surg Sports Traumatol Arthrosc 16:239–248
13
Arch Orthop Trauma Surg
29. Jung YB, Jung HJ, Tae SK, Lee YS, Lee KH (2005) Reconstruc-
tion of the posterior cruciate ligament with a mid-third patellar
tendon graft with use of a modified tibial inlay method. J Bone Jt
Surg Am 87(suppl 1):247–263
30. Jung YB, Jung HJ, Tae SK, Lee YS, Yang DL (2006) Tension-
ing of remnant posterior cruciate ligament and reconstruction of
anterolateral bundle in chronic posterior cruciate ligament injury.
Arthroscopy 22:329–338
31. Katonis P, Papoutsidakis A, Aligizakis A, Tzanakakis G, Kontakis
GM, Papagelopoulos PJ (2008) Mechanoreceptors of the poste-
rior cruciate ligament. J Int Med Res 36:387–393
32. Kim SJ, Jung M, Moon HK, Kim SG, Chun YM (2011) Ante-
rolateral transtibial posterior cruciate ligament reconstruction
combined with anatomical reconstruction of posterolateral corner
insufficiency: comparison of single-bundle versus double-bundle
posterior cruciate ligament reconstruction over a 2- to 6-year fol-
low-up. Am J Sports Med 39:481–489
33. Lee KH, Jung YB, Jung HJ, Jang EC, Song KS, Kim JY, Lee
SH (2011) Combined posterolateral corner reconstruction with
remnant tensioning and augmentation in chronic posterior cruci-
ate ligament injuries: minimum 2-year follow-up. Arthroscopy
27:507–515
34. Lee YS, Kim NK (2011) Rehabilitation after posterior cruciate
ligament reconstruction. Minerva Orthop Traumatol 62:291–295
35. Lee YS, Lim BO, Kim JG, Lee KK, Park HO, An KO, Ryew CC,
Kim JH (2011) Serial assessment of knee joint moments in pos-
terior cruciate ligament and posterolateral corner reconstructed
patients during a turn running task. Arch Orthop Trauma Surg
131:335–341
36. Li B, Wen Y, Wu H, Qian Q, Wu Y, Lin X (2009) Arthroscopic
single-bundle posterior cruciate ligament reconstruction: retro-
spective review of hamstring tendon graft versus LARS artificial
ligament. Int Orthop 33:991–996
37. Lutz GE, Palmitier RA, An KN, Chao EY (1993) Comparison of
tibiofemoral joint forces during open-kinetic-chain and closed-
kinetic-chain exercises. J Bone Jt Surg Am 75:732–739
38. MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL,
Warren RF (2006) Comparison of tibial inlay versus transtibial
techniques for isolated posterior cruciate ligament reconstruction:
minimum 2-year follow-up. Arthroscopy 22:320–328
39. McGuire DA, Hendricks SD (2010) Comparison of anatomic ver-
sus nonanatomic placement of femoral tunnels in Achilles dou-
ble-bundle posterior cruciate ligament reconstruction. Arthros-
copy 26:658–666
40. Mesfar W, Shirazi-Adl A (2008) Knee joint biomechanics in
open-kinetic-chain flexion exercises. Clin Biomech (Bristol,
Avon) 23:477–482
41. Miller MD, Cooper DE, Fanelli GC, Harner CD, LaPrade RF
(2002) Posterior cruciate ligament: current concepts. Instr Course
Lect 51:347–351
42. Min BH, Lee YS, Jin CZ, Son KH (2011) Evaluation of transti-
bial double-bundle posterior cruciate ligament reconstruction
using a single-sling method with a tibialis anterior allograft. Am J
Sports Med 39:374–379
43. Nagi SZ, Marsh J (1980) Disability, health status, and utilization
of health services. Int J Health Serv 10:657–676
44. Ninos JC, Irrgang JJ, Burdett R, Weiss JR (1997) Electromyo-
graphic analysis of the squat performed in self-selected lower
extremity neutral rotation and 30 degrees of lower extremity turn-
out from the self-selected neutral position. J Orthop Sports Phys
Ther 25:307–315
45. Noyes FR, Barber-Westin SD (2005) Posterior cruciate ligament
revision reconstruction, part 2: results of revision using a 2-strand
quadriceps tendon-patellar bone autograft. Am J Sports Med
33:655–665
Arch Orthop Trauma Surg
46. Nyland J, Hester P, Caborn DN (2002) Double-bundle posterior
cruciate ligament reconstruction with allograft tissue: 2-year
postoperative outcomes. Knee Surg Sports Traumatol Arthrosc
10:274–279
47. Ohkoshi Y, Yasuda K, Kaneda K, Wada T, Yamanaka M (1991)
Biomechanical analysis of rehabilitation in the standing position.
Am J Sports Med 19:605–611
48. Seon JK, Song EK (2006) Reconstruction of isolated posterior
cruciate ligament injuries: a clinical comparison of the transtibial
and tibial inlay techniques. Arthroscopy 22:27–32
49. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo MS
(1995) Ligament stability two to six years after anterior cruci-
ate ligament reconstruction with autogenous patellar tendon graft
and participation in accelerated rehabilitation program. Am J
Sports Med 23:575–579
50. Shelbourne KD, Nitz P (1990) Accelerated rehabilitation after
anterior cruciate ligament reconstruction. Am J Sports Med
18:292–299
51. Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman
KR (1993) Biomechanical considerations in patellofemoral joint
rehabilitation. Am J Sports Med 21:438–444
52. Van Dommelen BA, Fowler PJ (1989) Anatomy of the posterior
cruciate ligament. A review. Am J Sports Med 17:24–29
53. Wang CJ, Chen HS, Huang TW, Yuan LJ (2002) Outcome of
surgical reconstruction for posterior cruciate and posterolateral
instabilities of the knee. Injury 33:815–821
54. Wilk KE (1994) Rehabilitation of isolated and combined poste-
rior cruciate ligament injuries. Clin Sports Med 13:649–677
55. Wong T, Wang CJ, Weng LH, Hsu SL, Chou WY, Chen JM, Chan
YS (2009) Functional outcomes of arthroscopic posterior cruci-
ate ligament reconstruction: comparison of anteromedial and
anterolateral trans-tibia approach. Arch Orthop Trauma Surg
129:315–321
56. Wu CH, Chen AC, Yuan LJ, Chang CH, Chan YS, Hsu KY, Wang
CJ, Chen WJ (2007) Arthroscopic reconstruction of the posterior
cruciate ligament by using a quadriceps tendon autograft: a mini-
mum 5-year follow-up. Arthroscopy 23:420–427
57. Yoon KH, Bae DK, Song SJ, Cho HJ, Lee JH (2011) A prospec-
tive randomized study comparing arthroscopic single-bundle and
double-bundle posterior cruciate ligament reconstructions pre-
serving remnant fibers. Am J Sports Med 39:474–480
58. Zayni R, Hager JP, Archbold P, Fournier Y, Quelard B, Chambat
P, Sonnery-Cottet B (2011) Activity level recovery after arthro-
scopic PCL reconstruction: a series of 21 patients with a mean
follow-up of 29 months. Knee 18:392–395
59. Zhang H, Hong L, Wang XS, Zhang J, Geng XS, Liu X, Feng
H (2010) Single-bundle posterior cruciate ligament reconstruc-
tion and mini-open popliteofibular ligament reconstruction in
knees with severe posterior and posterolateral rotation instabil-
ity: clinical results of minimum 2-year follow-up. Arthroscopy
26:508–514
60. Zhao J, Huangfu X (2007) Arthroscopic single-bundle posterior
cruciate ligament reconstruction: retrospective review of 4- ver-
sus 7-strand hamstring tendon graft. Knee 14:301–305
13