Physical Therapy in Sport 13 (2012) 196e208

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Physical Therapy in Sport

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Masterclass

Evaluation and management of posterior cruciate ligament injuries

Michael D. Rosenthal a, b, *, Charles E. Rainey a, Angela Tognoni a, Robert Worms a
a
34800 Bob Wilson Drive, Naval Medical Center, San Diego, CA, USA
b
Rocky Mountain University of the Health Professions, Provo, UT, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Posterior cruciate ligament injuries are increasingly recognized, the result of various sports
Received 17 October 2011 activities, and while most athletes return to sports the development degenerative joint changes is
Received in revised form common.
27 March 2012
Objective: To provide a synopsis of the current best evidence regarding the recognition and treatment of
Accepted 28 March 2012
posterior cruciate ligament injuries.
Design: Structured narrative review.
Keywords:
Methods: Keyword search of Medline, CINAHL, and PEDro databases for studies published in English from
Knee injuries
Posterior cruciate ligament
January 1975 to July 2011. Additionally, the reference lists from articles obtained were manually searched
Rehabilitation for relevant literature.
Review Summary: The manuscript provides an overview of posterior cruciate ligament injury, discusses diag-
nostic methods to include radiographic examination techniques, and presents information on surgical
and conservative management of PCL injuries.
Conclusion: Understanding the mechanism of injuries and most effective examination methods can aide
in effective early recognition of PCL injuries. Appropriate management of the patient with PCL deficiency
or reconstructed knee will optimize outcomes and potentially affect long term knee function.
Published by Elsevier Ltd.

1. Introduction operative management of PCL tears. Additionally, once the treat-

Posterior cruciate ligament (PCL) injuries are increasingly
recognized and most often occur due to athletic or motor vehicle
related trauma. While not as prevalent as ACL injuries, reports
suggest a prevalence of 2e3% in athletic knee injuries and up to 40%
incidence in trauma patients with knee effusion (e.g. motor vehicle
accidents) (Fanelli & Edson, 1995; Shelbourne, Thorp, & Patel 1999).
Mechanisms of injury include hyperextension, posterior directed
force to the proximal tibia on a flexed knee, forced hyperflexion of
the knee, rotation combined with varus or valgus force, and knee
dislocation (Fanelli, 2008; Fowler & Messieh, 1987). Clinical
research devoted to this key ligament lags far behind that of the ACL
injured knee. Posterior cruciate ligament injuries may occur in
isolation or as one of a multitude of soft tissue injured structures in
the case of a knee dislocation. The management of PCL injuries
varies widely and there is limited well designed research to guide
practitioners in pursuit of best practices for operative or non-
* Corresponding author. Naval Medical Center, PT Department, 34800 Bob Wilson
Drive, San Diego, CA 92134, USA. Tel.: þ1 619 865 8611.
E-mail addresses: mikerosenthal@ymail.com (M.D. Rosenthal), Charles.rainey@
med.navy.mil (C.E. Rainey), Angela.tognoni@med.navy.mil (A. Tognoni),
Robert.worms@med.navy.mil (R. Worms).
ment approach has been determined (operative or non-operative)
there remains a dearth of information on the best operative tech-
nique, optimal post-operative rehabilitation, and optimal conser-
vative management. Therefore, evidence based treatment decisions
are at best based upon expert opinion and research with limited
scientific rigor. This overview of the PCL injured knee will cover the
spectrum of anatomy, biomechanics, evaluation, treatment, and
outcomes.
2. Anatomy/biomechanics
The PCL serves as one of four major ligaments of the knee. It has
been reported to have twice the strength of any other knee liga-
ment and consists of two major bundles, the anterior-lateral bundle
(ALB) and the posterio-medial bundle (PMB) (Kennedy, Hawkins,
Willis, & Danylchuck, 1976). The PCL originates on the femur in
the anterolateral aspect of the medial femoral condyle in the area of
intercondylar notch, and is anatomically anterior to the anterior
cruciate origin. It has been shown to extend roughly 30 mm ante-
riorly into the intercondylar notch, primarily on the medial aspect
but also into the roof of the notch. The anterior-lateral bundle runs
in a sagittal plane and it is this component that inserts into the roof,
compared to the PMB that inserts medially in the medial femoral

1466-853X/$ e see front matter Published by Elsevier Ltd.

doi:10.1016/j.ptsp.2012.03.016
 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
condoyle and runs in an oblique pattern towards the tibial insertion
point. Edwards et al. described a wide variation in regards to the
shape and size of the femoral origin amongst 39 cadavers studied;
however there was strong consistency with the tibia insertion
anatomy (Edwards, Bull, & Amis, 2007). The distal aspect of the PCL,
both ALB and the PMB, insert into the tibial region in the posterior
tibial plateau outside of the intra-articular structure and along the
posterior intercondylar fossa. The ALB insertion is about the root of
the posterior horn of the medial meniscus, while the PMB has an
average insertional point 7 mm distal to the joint line posteriorly.
This distal insertion point tends to anchor directly into the peri-
osteum and in close proximity to the origin of the popliteus tendon.
Of the two bundles, the ALB has been noted to comprise roughly
65% of the total PCL while the PMB comprises 35% of the total mass.
Two meniscofemoral ligaments (MFLs) also compliment the PCL
complex, the anterior meniscofemoral ligament of Humphrey
(aMFL) and the posterior meniscofemoral ligament of Wrisberg
(pMFL) (Gupte, Bull, Thomas, & Amis, 2003). Both ligaments origi-
nate from the posterior horn of the lateral meniscus and insert onto
the lateral aspect of the medial femoral condoyle in close proximity
to the distal articular cartilage, thus blending into the PCL fibers.
The aMFL runs anteriorly to the PCL from the posterior horn of the
lateral meniscus and inserts into the lateral aspect of medial
femoral condoyle in close proximity to the distal articular cartilage.
The ligament of Wrisberg, found posterior to the PCL, also extends
from the lateral meniscus posterior horn and inserts in the central
aspect of intracondylar notch.
Anatomically, the ligaments of Humphrey and/or Wrisberg are
not present in all knees. A cadaveric study reported 49% of knees
having both aMFL and pMFL, 19% showed only an aMFL, 25% only
a pMFL, and in 7% neither was present. When both are in place, they
provide a sling mechanism in support of the PCL. According to Gupte
et al., the meniscofemoral ligaments provide 28% of the posterior
translation stability in intact PCL knees and 70.1% in the PCL deficient
knee (Gupte et al., 2003). Gupte et al. concluded that the menisco-
femoral ligaments, when present, contribute a significant amount of
torque resistance to posterior tibial translation, particularly
between 60 and 90 of flexion (Gupte et al., 2003). Gupte et al.
demonstrated that there was a greater amount of posterior trans-
lational instability without rotational instability with in vitro exci-
sion of the MFLs. A limitation of the study was that testing was done
on each specimen in the order of intact knee, PCL deficient knee, and
combined PCL and MFL deficiency. The clinical relevance of the MFLs
is yet to be determined. There have been no clinical reports indi-
cating isolated ligamentous injury of one structure (e.g. PCL tear and
intact MFL or MFL sprain with intact PCL).
The PCL is innervated by the posterior articular nerve which is
a branch from the tibial nerve. The afferent feedback to the central
nervous system provided by the intact PCL is believed to assist in
proprioceptive feedback and assist in stabilizing the knee. While PCL
injury is known to adversely impact joint kinesthesia and proprio-
ception, proprioception has been found to return to at least near
normal levels following reconstruction (Safran, Harner, Giraldo,
Lephart, Borsa, & Fu, 1999). Multiple factors are believed to
contribute to restoration of joint proprioception and no single factor
has been identified as having a greater influence than the others.
Contributing factors include enhanced neuromuscular control (from
rehabilitation), improved joint mechanoreceptor sensitivity, and
proprioceptive input provided by the reconstructed PCL. The blood
supply to the PCL is the middle genicular artery which is a branch off
the popliteal artery (Arnoczky,1985; Scapinelli, 1997). While the PCL
has greater vascularity surrounding it, than the ACL, the intrinsic
blood supply is not different (Scapinelli, 1997). The inferior medial
and lateral genicular arteries also vascularize the PCL by way of the
patellar fat pad (Arnoczky, 1985).
197
Biomechanically the double bundle arrangement results in
tension changes throughout the arc of motion in the ALB and PMB.
While the ALB is somewhat loose in the fully extended knee, the
PMB is taut in full terminal extension. The PMB immediately begins
to slacken once flexion is initiated and remains less taut until
terminal flexion when they become taut again. This occurs at the
end range of flexion because the femoral attachment moves ante-
riorly and also superiorly away from the tibia attachment. The ALB
becomes taut once flexion is initiated and remains taut throughout
knee flexion. In cross sectional studies, the ALB has demonstrated
to have a thicker mid-section compared to the PMB at almost twice
the size, and also has a corresponding increased resistance to
failure compared to the PMB fibers of the PCL.
The posterior cruciate ligament is the primary restraint to
posterior tibial translation. In a literature review on biomechanics
of the PCL, Grassmyer et al. reported all in vitro studies demon-
strated that isolated PCL deficient knees allowed increased poste-
rior tibial translation of 3.8e14.1 mm at 90 of flexion (Grassmayr,
Parker, Coolican, & Vanwanseele, 2008). However, what has not
been agreed upon is the PCL’s role with regards to posterior
translation in other ranges of knee motion. Kugamai et al. stated
that in vitro studies with PCL deficient knees showed no posterior
tibial translation from 0 (full extension) to 25 of flexion
(Kumagiai, Mizuno, Mattessich, Elias, Cosgarea, & Chao, 2002).
Other cadaveric studies with PCL deficient knees demonstrated
posterior tibial translation only from 60 or greater of flexion, while
other showed translation occurring between 0 and 120 of flexion
(Gollehon, Torzilli, & Warren, 1987; Hagemeister, Duval, Yahia,
et al., 2002; Harner, 1998; Li, Most, Defrate, et al., 2004; Pearsall
& Hollis, 2004).
In vivo studies have also confirmed posterior tibial translation in
the PCL deficient knee. Castle et al. measured tibia translation while
squatting and found a mean of 7.4 mm posterior translation through
the 70e90 range and only a 2 mm average between 32 and 50 of
flexion (Castle, Noyes, & Grood, 1992). It has also been demonstrated
in squatting with an applied posterior drawer maneuver and
measured under MRI that there was significant medial compart-
ment translation throughout the range of a squat in the PCL deficient
knee with the most significant motion occurred at 90 of flexion
with a mean 10.1 mm (Castle et al., 1992) Logan et al. showed that an
isolated PCL rupture leads to an increase in passive sagittal laxity of
the medial compartment of the knee (Logan, Williams, Levelle, et al.,
2004), ultimately changing knee kinematics and increasing the
incidence of articular cartilage degeneration. In vitro studies have
shown that posterior subluxation of the tibia reduces the weight
bearing load on the menisci which increased pressure across the
articular surface of the knee (Ahmed & Burke, 1983). To date, there
has been no conclusive literature that demonstrates increased varus
or valgus translation with the isolated PCL deficient knee
(Grassmayr et al., 2008), however, there have been varying studies
indicating effects of external rotation on the PCL deficient knee.
In vitro studies have measured external rotation translation that
demonstrated up to 4 of ER translation with the isolated PCL
deficient knee (Gupte et al., 2003; Harner, 1998; Li et al., 2004;
Nielsen, Ovesen, & Rasmussen, 1985), while other studies
concluded there was no significant rotational translation (Gollehon
et al., 1987; Hoer, Harner, Vogrin, et al., 1998; Kaneda, Moriya,
Takahashi, et al., 1997; Logan et al., 2004; Nielsen & Helmig, 1986).
One study demonstrated increased internal rotational translation at
90 of flexion in the PCL deficient knee with an in vitro study, but no
other research has supported this finding (Ogate, 1988).
Although not anatomically associated with PCL, the posterior
lateral corner (PLC) of the knee joint is important to consider when
discussing the PCL kinematics, as the PLC is often involved with
traumatic injury involving the PCL. Most notably, the lateral
198 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
collateral ligament and popliteal complex, comprised of the pop-
liteus muscle-tendon unit, popliteal fibular ligament, and the
posterior lateral capsular tissue (Harner & Roher, 1998). Nielson
et al. demonstrated a significant amount of increased varus insta-
bility, noting 0.9  1.0 of varus laxity with an isolated PCL lesion
versus up to 27.5  6.4 with both PCL and PLC deficient knees at
70 of knee flexion (Nielsen et al., 1985). Hagemeister et al. reported
between 30.9 and 41.7 of increased internal and external tibial
rotational translation with a combined PCL and PLC deficient knee
(Hagemeister et al., 2002).
Posterior cruciate ligament deficiency results in significant
pressure increases in the medial tibiofemoral compartment (Logan
et al., 2004). This is caused by persistent posterior subluxation of
the medial tibia throughout the 0e90 ROM while lateral
compartment kinetics are not altered. A recent study by Van de
Velde et al. reported the significant shift in tibiofemoral contact
increases in an anterior and medial direction beyond 75 of knee
flexion (Van de Velde, Bingham, Gill, & Li, 2009). MacDonald et al.
reported appreciable load increases at both 60 and 90 of flexion
with PCL deficient knees, whereas Skyhar et al. reported a mean
elevation of pressure at 52% in the medial compartment regardless
of the knee flexion angle (MacDonald, Miniaci, Fowler, et al., 1996;
Skyhar, Warren, Ortiz, et al., 1993). Their in vitro study also
demonstrated a significant increase in patellofemoral joint (PFJ)
pressure change in the PCL deficient knee. The PFJ pressure was
further increased by excising the posterior lateral structures
(Skyhar et al., 1993).
3. Mechanism of injury
The mechanism of injury (MOI) for PCL injury is often foretelling
of the involvement of concomitant structures. The hyperextension
MOI often demonstrates contusions to the anterior aspect the
articular surfaces of the tibia and femoral condyles (Sonin,
Fitzgerald, Hoff, Friedman, & Bresler, 1995). Additionally, ACL
rupture is often encountered with the hyperextension MOI.
Posterior directed force to the proximal tibia in a flexed knee
position (less than approximately 100 ) may also produce posterior
capsular injury. When the posteriorly directed force occurs with the
knee in a hyperflexed position, the soft tissue approximation of the
posterior thigh and leg muscles limits posterior translation and
therefore less likely posterior capsular involvement. Varus and
valgus stress injuries typically occur in conjunction with rotational
stresses and involve multiple ligaments (collateral and cruciate).
This MOI often involves meniscal tears and chondral injuries at the
site of tibiofemoral impaction. Grade IIeIV cartilage lesions most
commonly occur at either the medial femoral condoyle (50%) or
patella (33%) and the lesions are more common in combined PCL
injuries (76%) than in isolated PCL injured knees (57%) (Strobel,
Weiler, Schulz, Russe, & Eichhorn, 2003).
4. Clinical examination
A comprehensive history and physical examination is necessary
to accurately diagnose a PCL injury. Patients suffering a PCL injury
rarely report an audible “pop” or “tear” that is commonly reported
with ACL and MCL injuries. Patients with PCL injuries more
commonly report vague, non-specific symptoms, such as discom-
fort that is difficult to isolate. With the exception of concomitant
ACL or multi-ligament injured knees, patients with PCL injuries
infrequently report episodes of gross knee instability.
Patients who present in the acute phase of injury may complain
of various symptoms such as knee effusion, stiffness, or mild to
moderate pain in the posterior aspect of the knee. Pain with deep
knee flexion, such as squatting and kneeling activities, has also
been reported. Patients who present in the chronic phase of injury
may complain of vague anterior knee pain, difficulty with
ascending and/or descending stairs, or pain with sprinting or
deceleration (Margheritini, Rihn, Musahl, Mariani, & Harner, 2002;
Petrigliano & McAllister, 2006).
The physical examination is essential in diagnosing PCL insuf-
ficiency, as well as determining the severity of injury and evalua-
tion of potential injury to neighboring structures such as the PLC.
First, the patient’s gait and weight bearing posture should be
assessed. Static and dynamic alignment can give an indication of
a suspected PCL deficiency. Patients may present with tibial
external rotation, genu recurvatum, or a bent-knee gait to avoid
terminal knee extension (Margheritini et al., 2002; Petrigliano &
McAllister, 2006).
Range-of-motion (ROM) should be assessed and compared to
the uninvolved side. Patients may have a 10e20 lack of knee
flexion compared to the uninvolved side, as well as mild effusion
upon manual palpation. The lack of knee flexion can be attributed
to altered biomechanics of the tibia moving on the femur in flexion.
With the loss of normal restraint to posterior tibial displacement,
the tibia shifts posteriorly earlier during knee flexion and thereby
reaches an “end point” earlier in the ROM. This premature posterior
tibial displacement is responsible for the reported 10e20 lack of
knee flexion. Additional contributions to limitation of motion
include knee effusion and pain.
Numerous special tests have been described in the literature to
diagnosis a PCL injury. The commonly performed clinical exami-
nation for assessing the status of the PCL is the Posterior Drawer
test (Cho et al., 2001). The Posterior Drawer test is performed with
the patient supine with the hip flexed 45 and the knee flexed 90
(Fig. 1). The tibia is held in a neutral position with the foot flat on
the examining table. The neutral position of the tibia decreases the
likelihood of a false negative test for PCL injury or false positive for
ACL injury by minimizing the tension through the posterior lateral
comer (PLC) and allowing for maximal posterior tibial subluxation.
The examiner should stabilize the patient’s foot and palpate for the
anterior joint line between the femoral condyles and tibial plateau.
Thumbs are placed along the anterior tibial plateau with the fingers
wrapping around the tibia assessing for hamstring muscle activa-
tion. A posteriorly directed force is applied to the tibia, while
assessing the medial tibial plateau position in reference to the
medial femoral condoyle. The Posterior Drawer test is based on the
relationship between the medial femoral condyle and the medial
tibial plateau (Margheritini et al., 2002). Quantity of posterior tibia
displacement and quality of end feel are assessed during the
Posterior Drawer test.
Fig. 1. Posterior drawer test.
 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208 199

Posterior Drawer measurements are graded 0, I, II, or III based

upon the amount of posterior translation or step off at the medial
joint line according to the International Knee Documentation
Committee (IKDC) (Higgins et al., 2007; Irrgang, Ho, Harner, & Fu,
1998). When a posteriorly directed force is applied to a normal
resting knee, the tibia lies approximately 0e2 mm anterior to the
femoral condyles and is labeled a Grade 0. A grade I injury is
3e5 mm of posterior tibial translation; grade II is 6e10 mm of
posterior tibial translation (anterior border of the tibial plateau and
femoral condyles are flush); and grade III is greater than 10 mm
(anterior border of the tibial plateau is posterior to the femoral
condyles) (Hefti, Muller, Jakob, & Staubli, 1993; Margheritini et al.,
2002; Sekiya, Whiddon, Zehrns, & Miller, 2008). A recent cadav-
eric study by Sekiya et al. found that the presence of a grade III
posterior drawer and >10 mm of posterior tibial translation noted
on stress radiography is suggestive of additional injury to the
posterolateral comer (Sekiya et al., 2008). The Posterior Drawer test
Fig. 3. Godfrey test.
has been reported in the literature to be the most sensitive (90%)
and specific (99%) test for identifying PCL injuries with an þLR of 90
and LR of 0.10 (Cleland, 2007). When stratified by grade, the
prominent. The posterior sag test has been reported to have
sensitivity was lower for grade I (70%) versus grade II and III (97%)
a sensitivity of 79% and specific of 100% with a þLR of 79 and LR of
injuries (Petrigliano & McAllister, 2006).
0.21 (Cleland, 2007; Petrigliano & McAllister, 2006).
Performing the Posterior Drawer test with the tibia in internal or
The Quadriceps Active test is performed with the patient supine
external rotation may suggest further ligamentous injury (i.e.,
and the knee flexed to 90 in the drawer test position. The examiner
combined injury rather than isolated injury to the PCL) (Aichroth &
stabilizes the foot and asks the patient to extend the knee by sliding
Cannon, 1992). Excessive posterior tibial translation in internal
the foot down the examining table. (Fig. 4) In a PCL deficient knee,
rotation is suggestive of a concomitant MCL or posteromedial
voluntary quadriceps contraction anteriorly reduces the posteriorly
corner (PMC) injury, while increased translation with external
subluxated tibia. A positive test for PCL disruption occurs when
rotation may indicate the presence of a LCL or PLC injury (Aichroth
there is a tibial reduction greater than 2 mm. The quadriceps active
& Cannon, 1992).
test has a reported sensitivity range of 54e98% and specificity of
Posterior Sag test, also known as the “step off sign,” or Godfrey
97e100% with a þLR of 18 and LR of 0.47 (Daniel, Stone, Barnett, &
test are tests that can be used to evaluate the integrity of the PCL in
Sachs, 1988; Petrigliano & McAllister, 2006; Rubinstein,
reference to gravity. The Posterior Sag test is performed with the
Shelbourne, McCarroll, Van Meter, & Rettig, 1994).
patient supine and the hip flexed to 45 and the knee flexed to 90
Whipple and Ellis (1991) described a test to evaluate PCL
(Fig. 2). In this position the patient is encouraged to relax the
integrity while avoiding quadriceps contraction, which can dilute
muscles of the lower extremity while the clinician maintains
the quality and accuracy of the test. The Whipple test is performed
sagittal plane alignment of the legs. The examiner observes for
with the patient prone and the knee is flexed to approximately 70 .
posterior sag of the tibia on the femur in the presence of a PCL
The examiner grasps the distal tibia with one hand for support and
injury. The Godfrey test involves the patient actively raising the
applies a posteriorly directed force by pushing on the tibial tubercle
knees to a position of 90 hip flexion and 90 knee flexion (Fig. 3).
with the other hand. (Fig. 5) Few sensitivity or specificity values
The clinician supports the legs in this position, the patient is asked
have been reported in the literature (Margheritini et al., 2002;
to completely relax the lower extremity musculature, and the
Whipple & Ellis, 1991).
position of the tibia of both extremities is evaluated from a lateral
view. In the PCL deficient knee, gravity causes the tibia to rest in
a posterior subluxed position, causing the tibial tubercle to be less

Fig. 2. Posterior sag test. Fig. 4. Quadriceps active test.

200 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
Fig. 5. Whipple test.
Posterior cruciate ligament injuries commonly involve the PLC
and can be evaluated with the Dial test, External Rotation Recur-
vatum test, and the Reverse Pivot Shift test. The Dial test is used to
differentiate between isolated PLC injuries and combined PCL and
PLC injuries. The test is performed with the patient prone with the
knees flexed to 30 (Fig. 6A). An external rotation force is applied to
the patient’s heels by placing the fingers and thumb alongside the
Fig. 6. Dial test at 30 and 90 .
talor-calcaneal contours (Manske & Prohaska, 2008). The test is
then performed with the knees flexed to 90 (Fig. 6B). External
rotation can be assessed by comparing the medial aspect of the foot
with the shaft of the femur. A difference of greater than 10 at 90 of
knee flexion compared to the contralateral side is considered
indicative of PCL involvement (Manske & Prohaska, 2008). An
increase in external rotation of 10 or more at 30 knee flexion, but
not at 90 knee flexion, suggests an isolated PLC injury. An increase
in external rotation at both 30 and 90 knee flexion suggests
a combined PCL and PLC injury (Petrigliano & McAllister, 2006). The
PCL is taut at 90 knee flexion and acts as a secondary stabilizer to
further prevent tibial external rotation. Sensitivity and specificity
values have not been reported for the Dial test (Lunden, Bzdusek,
Monson, Malcomson, & LaPrade, 2010).
The External Rotation Recurvatum test is performed with the
patient in supine. The examiner grasps the great toe of each foot
and raises it along with the leg while stabilizing the distal thigh.
The patient’s knees are allowed to fall into full passive extension
and amount of genu recurvatum is observed (Lunden et al., 2010;
Manske & Prohaska, 2008). (Fig. 7) A positive test occurs when
the involved knee assumes a posture of hyperextension, varus
angulation, and external rotation of the tibia compared to the
uninvolved side (Hughston & Norwood, 1980; LaPrade, Resig,
Wentorf, & Lewis, 1999; Lunden et al., 2010; Manske & Prohaska,
2008). Caution should be used in interpreting the External Rota-
tion Recurvatum test, it has been shown to have a high incidence of
false negative results for ACL-PLC injuries (LaPrade, Ly, & Griffith,
2008; Lunden et al., 2010) and it is rarely positive in patients
with PCL-PLC or isolated PLC injuries (Lunden et al., 2010; Staubli &
Jakob, 1990). Specifically, the sensitivity of the external rotation
recurvatum test for ACL-PLC injuries has been reported as 30%,
while the specificity was 100% (LaPrade et al., 2008; Lunden et al.,
2010).
The Reverse Pivot Shift test is performed with the patient in
supine and the knee flexed to 90 . The examiner grasps the
patient’s distal tibia with one hand and the proximal tibial with the
other hand. A valgus stress and external rotation is applied, while
passively extending the patient’s knee (Fig. 8). If positive, a “shift”
or “clunk” will occur at approximately 20e30 knee flexion. This is
the result of the posteriorly subluxated lateral tibial plateau relo-
cating anteriorly from the action of the iliotibial band. The Reverse
Pivot Shift has a reported sensitivity of 26% and specificity of 59%
with a (þ) LR of 0.63 and () LR of 1.25 (Cleland, 2007), thus
Fig. 7. External Rotation Recurvatum test.
 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
Fig. 8. Reverse Pivot Shift test.
rendering this test incapable of shifting the probability on the
presence of a PCL injury.
The KT-1000 and KT-2000Ô arthrometers were developed to
provide objective measurement of the sagittal plane motion of the
tibia relative to the femur. They have been used to test ACL and PCL
integrity and employed for research purposes for quantifying
outcomes of ACL and PCL reconstruction respectively. Huber et al.
found that KT-1000 use in the PCL deficient knee may be influenced
by several factors, including the position of the foot, relaxation of
the hamstrings and quadriceps muscles during the examination,
and the quadriceps neutral angle (the knee angle at which the
quadriceps contraction produces no anterior or posterior tibial
translation), which may be difficult to assess (Huber, Irrgang,
Harner, & Lephart, 1997; Margheritini, Mancini, Mauro, & Mariani,
2003). It was concluded that the KT-1000 is a moderately reliable
tool for detecting PCL insufficiency and that it must be used
cautiously when diagnosing injury and documenting changes in
posterior laxity over time (Margheritini et al., 2003). The KT-2000
has been reported to underestimate the degree of posterior laxity
in PCL deficient knees (Margheritini et al., 2003) and the grade of
posterior laxity has not been found to correlate with patient
outcomes (Petrigliano & McAllister, 2006).
5. Imaging
Radiographic imaging in the patient with suspected or known
PCL injury will most commonly include plain radiographs (X-rays)
and magnetic resonance imaging (MRI). Standard radiographic
images include antero-posterior image, tunnel view, sunrise view
and a lateral view (Colvin & Meislin, 2009). Plain radiographs
during the early post-injury stage can be helpful in diagnosing PCL
avulsion injuries which often do well with early operative repair
(Harner & Roher, 1998). Also reported following high energy
trauma to the knee in association with a PCL injury is an avulsion
injury of the deep medial collateral ligament at the tibial attach-
ment (Escobedo, Mills, & Hunter, 2002). This injury, termed
a reverse Segond fracture, indicates a valgus mechanism of injury
and has been noted occur with concomitant injuries of medial
meniscus tear and lateral tibial plateau fractures.
Additional plain radiographs that may be incorporated into the
evaluation are stress views for assessment of posterior subluxation.
Potential stress views include imaging while kneeling, during
active hamstring contraction at 90 knee flexion, or with an
201
instrumented stress device (Telos) (Jackman, LaPrade, Pontinen, &
Lender, 2008; Margheritini et al., 2002). Plain radiographs have
been useful in identifying bony avulsion injuries (Coooper, 1999).
Stress radiography has been shown to be superior to instrumented
arthrometry (laxity) testing (KT-1000 or KT-2000) in assessing
magnitude of posterior tibial translation in the PCL injured knee
(Hewett, Noyes, & Lee, 1997; Margheritini & Huber, 1997). The
accuracy of stress radiography can be adversely affected by muscle
guarding, effusion, and tibial rotation (Schulz, Russe, Lampakis, &
Strobel, 2005).
In the patient with a chronic PCL injury plain radiographs may
be helpful in the assessment of joint space narrowing. Preferred
images include weight bearing AP and sunrise views (Colvin &
Meislin, 2009). The onset or progression of degenerative changes
following PCL injuries appears high in both PCL (acute and chronic)
reconstructed groups (Buess, Imhoff, & Rodier, 1996).
Magnetic resonance imaging can be helpful in identifying
whether the PCL tear is complete or incomplete and also show
other concomitant injuries (Colvin & Meislin, 2009; Gross, Grover,
Bassett, Seeger, & Finerman, 1992; Patten, Richardson, Zink-Brody,
& Rolfe, 1994; Shelbourne et al., 1999). A retrospective review by
Sonin et al. reported 38% of patients had complete PCL tears, 55%
had partial tears (most being mid-substance), and 7% having an
avulsion injury of the tibial insertion with an intact PCL (Sonin et al.,
1995). Posterior cruciate ligament injury patterns recognized by
MRI include meniscal tears (medial 35%, lateral 28%), osteochondral
injury (25%) involving the anterior tibia plateau and anterior-lateral
femoral condoyle, and ligamentous injury (ACL 43%, MCL 27%, LCL
14%). Only 24% of the patients in Sonin et al. review had an isolated
PCL injury. The double PCL sign, a low-signal intensity band located
parallel and anteroinferior to the intact PCL, has been noted to
adversely impact diagnostic accuracy. This finding is most often
produced by a bucket handle tear of the medial meniscus, is most
consistently present with an intact ACL and has not been associated
with PCL injuries (Camacho, 2004).
The sensitivity and specificity of MRI in the assessment of acute
PCL injury is high (Vas, de Camargo, de Santana, & Valezi, 2005;
Winters & Tregonning, 2005). Two reports have provided classifi-
cation levels for categorization of acute PCL tears which may factor
into management decisions and be useful in monitoring PCL heal-
ing (Bellelli, Mancini, Polito, David, & Mariani, 2006; Gross et al.,
1992). Diagnostic accuracy of MRI in the evaluation of the chronic
PCL insufficient knee (>5 months) has been reported at 40e80%
(Servant, Ramos, & Thomas, 2004) and multiple reports indicate
a high potential for anatomical healing and restoration of conti-
nuity, of the injured PCL (Jung et al., 2008; Shelbourne et al., 1999;
Tewes, Fritts, Fields, Quick, & Buss, 1997). The presence of restored
PCL continuity has been reported as normal or abnormal appear-
ance with continued abnormal laxity (Shelbourne et al., 1999;
Tewes et al., 1997). Altered appearance of the chronically injured
PCL included elongation, angulation (hyper-buckled), lobulation,
and thinning (Shelbourne et al., 1999). Healing of the chronically
injured PCL appears more favorable in low to mid-grade injuries
and appears to be independent of the location of the tear (proximal,
middle or distal) (Shelbourne et al., 1999). Other knee ligament
injuries in conjunction with PCL tears appear to have a negative
influence of restoration of PCL continuity (Jung et al., 2008).
Bone scans may be a useful tool in the evaluation of patients
with chronic PCL injury who are experiencing pain and instability
(Harner & Roher, 1998). Areas of increased radiotracer uptake can
provide an indication of localized degenerative changes which are
most commonly encountered in the medial and patellofemoral
compartments.
Cho et al. reported on the possible use of ultrasound in the
evaluation of suspected PCL injuries a means to provide a more cost
202 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
effective imaging alternative to MRI (Cho et al., 2001). Numerous
limitations were noted in the study and further research is neces-
sary to validate frequent use of this imaging modality in the
management of PCL injuries.
6. Injury management
Non-operative management is often recommended when the
PCL is injured in isolation. Grade I, II, and III tears can be managed
without surgical intervention (Harner & Roher, 1998; Matava, Ellis,
& Gruber, 2009; Peccin, Almeida, Amaro, Cohen, Soares, & Atallah,
2009). Surgical considerations come into play when the non-
operative other ligamentous structures are involved and increase
the rotational instability of the knee. Increased rotational laxity and
subsequent instability occurs with most combined ligamentous
injuries and often requires early surgical intervention (Harner &
Roher, 1998; Petrie & Harner, 1999). Surgical intervention is
considered when the non-operative management has failed or the
PCL deficient knee begins to show increased osteoarthritic changes.
Long term studies of PCL deficient knees show that some patients
may develop medial and patellofemoral compartment articular
cartilage degeneration (Harner & Roher, 1998; Petrigliano &
McAllister, 2006; Wind, Bergfeld, & Parker, 2004).
6.1. Non-operative management
For patients suffering acute isolated grade I or grade II PCL
injuries, non-operative management yields satisfactory subjective
outcomes for the majority of patients, with most patients returning
to sport (Petrigliano & McAllister, 2006). Surgical reconstruction of
the PCL is recommended in acute injuries with severe posterior
tibia subluxation and instability (Iwamoto, Takeda, Suda, Otami, &
Matsumoto, 2004; Margheritini et al., 2002). Management of the
acute PCL injured knee may include protective weight bearing for
Grade IIeIII tears (Wind et al., 2004). During acute management,
the focus is on reducing knee joint effusion, restoring knee range of
motion, and regaining strength especially of the quadriceps muscle
group (Matava et al., 2009; Petrie & Harner, 1999).
Grade I and II tears usually have a rapid recovery. The goal is to
get patients back to sports within two to four weeks of injury (Pepe
& Harner, 2001; Petrie & Harner, 1999). The focus of rehabilitation is
working on the lower extremity kinematics rather than a specific
muscle group in isolation. Maclean, Taunton, Clement, and Regan
(1999) looked at the ratio between the hamstring and quadriceps
in PCL deficient knees, as well as, the eccentric/concentric ratio of
these muscles. The involved limb was weaker eccentrically in both
muscle groups and had a lower ratio. They concluded that eccentric
strengthening should be included in PCL rehabilitation for the
quadriceps and hamstring muscles. Closed chain exercises should
also be performed with this population. Closed chain exercises
allow for increased neuromuscular re-education which helps with
balance, proprioception, and coordination (Maclean & Taunton,
2001). These exercises help to create a co-activation of the antag-
onist muscles which in part decreases the tibofemoral shear forces
during active knee flexion and extension. Once strength, endur-
ance, and neuromuscular control have been achieved, the patient
can return to an agility based program. The presence of joint pain or
effusion during the rehabilitation process indicates a need to
reduce exercise volume and/or intensity. Shelbourne et al. (1999)
found that out of 133 patients with Grade I or II tears 67 were
able to return back to the same sport at the same or higher level, 42
patients returned to sports at a lower level. Only 22 patients,
roughly one-sixth, did not return to the same sport after injury.
There was no correlation between PCL laxity and return to sport in
this study.
Grade III tears recover much slower than I and II. The patients
are usually immobilized for the initial two to four weeks in full
extension. Immobilization of the knee eliminates the posterior
subluxation caused by the hamstrings and allows for potential
healing of concomitantly injured soft tissue structures about the
knee (e.g., PLC, PMC, etc.) with less shear forces or stress on the area
(Iwamoto et al., 2004; Petrie & Harner, 1999; Wind et al., 2004).
Initially the patient is partial weight bearing in a knee immobilizer.
Physical therapy starts with basic quadriceps setting and straight
leg raises as an exercise program. At two to four weeks, active
assistive motion can begin along with advancing to weight bearing
as tolerated. Quadriceps based exercises are the main focus for
these patients in attempt to promote dynamic stabilization by the
quadriceps counteracting posterior tibial subluxation. Flexion past
70 , as well as isolated hamstring strengthening exercises are
initially avoided (Edson, Fanelli, & Beck, 2010). Along with closed
chain exercises, eccentric open kinetic chain quadriceps exercises
are added to the program. As the patient progresses, functional
exercises such as biking, leg press, elliptical, and stair climbing are
added. Patients are usually able to return to sports at the three
month mark depending on the sport (Harner & Roher, 1998; Wind
et al., 2004). Patients that continue to have pain and do not progress
to prior level of function may need surgical intervention. While
some reports indicate surgical intervention may be necessary to
mitigate the development of medial or patellofemoral compart-
ment chondrosis, there are no prospective studies demonstrating
a lower incidence of osteoarthritic changes following surgical
management (Harner & Roher, 1998). Some long term studies have
reported a substantial frequency of osteoarthritic change about the
patellofemoral and medial tibiofemoral compartments (Boynton &
Tietjens, 1996; Petrie & Harner, 1999; Wind et al., 2004).
There’s a scarcity of information on functional bracing following
PCL injury (Edson et al., 2010; Peitre & Harner, 1999). Bracing of the
PCL injured knee is directed toward improvements in dynamic knee
stability and prevention of posterior tibial translation during
activity. Jacobi, Reischi, Wahl, Gautier, and Jakob (2010) looked at
the use of functional braces for acute PCL tears. Twenty-one
patients were given the braces to wear for the initial four months
after injury. Follow up at one and two years demonstrated
decreased posterior sag as compared to initial measurement. There
are limitations of this study as it failed to include a control group;
therefore, it cannot be determined if the reduction in posterior sag
was the result of brace wear.
6.2. Surgical management
Surgical reconstruction of the PCL is recommended in acute
injuries with severe posterior tibia subluxation and instability
(Iwamoto et al., 2004; Margheritini et al., 2002). Surgery is most
commonly recommended if the PCL has greater than 10 mm of
posterior translation or if there are multiple ligamentous injuries.
In patients presenting with multiple ligamentous injuries, surgery
is often performed within two weeks of the injury. This allows for
best anatomical ligament repair of the PCL and decreased capsular
scarring (Wind et al., 2004). Multiple ligamentous injuries to the
knee often result in pain and chronic instability without effective
surgical intervention and rehabilitation (DeFrate, Gill, & Guoan,
2004; Shelborne, Thorp, &Patel, 1999). When there are multiple
ligamentous injuries, the PCL reconstruction may not be the first
surgery performed. It is secondary to the repair or reconstruction of
other structures such as the PLC or PMC. The PCL does not form as
much scar tissue and for this reason PCL reconstruction can be done
later with little negative long term side effects. Conversely, the PLC
structures scar quickly and make anatomical repair difficult if
 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
delayed for more than three weeks following injury (Petrie &
Harner, 1999).
The primary objective of PCL reconstructive surgery is to restore
normal knee mechanics and dynamic knee stability. There are
various recommendations on the optimal surgical approach.
Similar to other knee ligament reconstruction procedures, debate
exists to the best graft type or source, placement of tibia and
femoral tunnels, number of graft bundles, and the amount of graft
tension. Graft sources include numerous allograft and autologous
tissues. The main allograft tissue used is the Achilles tendon. In
terms of autologous tissues, bone-patellar tendon-bone, quadru-
pled hamstring (gracilis and semitendonosis), and quadriceps
tendon have been used (Petrie & Harner, 1999). The most common
of these grafts is the bone-patellar tendon-bone, due to the bone
plugs that allow for sufficient fixation of the tissue. The disadvan-
tages to this graft are the harvest site morbidity and the incomplete
filling of the tunnels with collagen due to the rectangular nature of
the graft (Harner & Roher, 1998). Use of the hamstring graft
decreased the morbidity factor, but results in an inferior fixation
method. Quadriceps tendon grafts have less morbidity than the
patellar tendon graft and also have adequate biomechanical prop-
erties (Wind et al., 2004). Allograft reconstruction provides addi-
tional benefits of decreased surgical time and absence of iatrogenic
trauma to the harvest site (Harner & Roher, 1998; Wind et al., 2004).
The use of Achilles tendon allograft allows for a large amount of
collagen which ensures that the tunnels are completely filled in.
The soft tissue can easily be pulled through the bone tunnels and
allows for good fixation at the femur with a soft tissue screw and at
the tibial side of the graft with a cancellous screw or washer.
Recent literature has increasingly focused on the single versus
the double bundle approach for PCL reconstruction using either
a tibial inlay or tunnel method (Apsingi, Nguyen, Bull, Unwin,
Deehan, & Amis, 2008; Harner & Roher, 1998; Petriagliano &
McAllister, 2006; Stannard & McKean, 2009; Wind et al., 2004).
The double bundle allows for reconstruction of both the antero-
lateral and posteromedial bundles of the PCL, while the single
bundle only corrects the larger and stronger anterolateral bundle.
Biomechanical studies in human subjects have shown that the
double bundle is able to restore normal knee kinematics across the
full range of motion as compared to the single bundle which
primarily restores the 0e60 knee flexion arc (Petriagliano &
McAllister, 2006, Stannard & McKean, 2009). There is no litera-
ture to date that showing superior functional outcomes of one
surgical approach (single or double bundle) over the other (Apsingi
et al., 2008; Colvin & Meislin, 2009; Matava et al., 2009; Van Tongle
& MacDonald, 2010).
In terms of the tibial inlay versus the tunnel method, orthopedic
surgeons have focused on which approach is going to recreate the
optimal biomechanical restraint of the PCL. The tunnel method is
an arthroscopic approach to the placement of the graft. In this
procedure, the graft is placed in an acute angular turn which has
been termed the ‘killer turn’. The tibial inlay is an open procedure in
which the graft is placed near the trough at the tibia insertion of the
PCL. This placement allows for the PCL to avoid the killer turn which
can elongate and thin the graft over time (Colvin & Meislin, 2009;
Gastel, Bergfeld, Calabrese, & Gray, 1999; Wind et al., 2004). More
research is needed to determine if either procedure is superior and
to collect conclusive evidence on the long term outcomes (Matava
et al., 2009; Petriagliano & McAllister, 2006).
Complications associated with PCL reconstruction include frac-
ture, neurovascular injury to the popliteal artery, deep vein
thrombosis, residual laxity and loss of range of motion. While
correction of posterior tibial laxity is the primary goal of the
surgery, residual laxity is the most commonly noted problem
following surgery (Colvin & Meislin, 2009; Zawodny & Miller, 2010).
203
Residual laxity can be due to undiagnosed concomitant soft tissue
injuries such as a posterolateral corner injury. In such cases the
rotatory laxity leads to the posterior tibal insertion of the PCL
shifting medially and anteriorly causing a functional laxity of the
PCL (Zawodny & Miller, 2010). Range of motion complications
following PCL reconstruction are most commonly due to limitations
in knee flexion. Physical therapy can help to regain normal kine-
matics of the joint while clinically significant loss of mobility may
be addressed with a manipulation under anesthesia (Gastel et al.,
1999). Range of motion limitations can also be due to improper
placement of the graft or excessive tension placed on the graft.
6.3. Post-surgical rehabilitation
Rehabilitation after PCL reconstruction plays an important role
in optimizing patient functional outcomes. The goal of rehabilita-
tion is to achieve 90% of normal quadriceps and hamstring strength
leading up to return to pre-injury activity levels (Margheritini et al.,
2002) and typically spans 6e9 months. Post-operative rehabilita-
tion starts by focusing on protecting the PCL graft to allow for
adequate healing. The patient is placed in a hinged ROM knee brace
locked at 0 extension to minimize forces to the PCL and prevent
the development of a flexion contracture. Patients should sleep and
ambulate with the knee brace locked at extension, unlocking it only
during periods of sitting and performing range of motion and
strengthening exercises. Weight bearing recommendations vary
among orthopedic surgeons, typically ranging from partial weight
bearing (<50% bodyweight) to weight bearing as tolerable (WBAT)
with crutches. Weight bearing has been found to stimulate tunnel
healing and graft adherence and is therefore recommended barring
any contraindications (Wilk, Andrews, Clancy, Crockett, & O’Mara,
1999).
In the immediate post-operative phase (weeks 0e2), passive
knee flexion and active knee extension ROM are encouraged from
0 to 90 . Performing passive knee flexion in prone with clinician
support (Fig. 9A), using the uninvolved leg, or a stretch strap
(Fig. 9B) are the safest ways to promote increasing mobility without
posterior tibia shear. The 0e90 range can also be pursued by
performing open kinetic chain (OKC) knee extension as the
eccentric control by the quadriceps muscles in lowering the leg
prevent posterior tibial sag. Open kinetic chain, non-weight
bearing, knee flexion is not recommended during this early phase
in order to prevent posterior shear forces on the PCL graft produced
by hamstring muscle activation. Markolf et al. have demonstrated
that activation of the hamstrings significantly increased mean
forces applied to the PCL when the knee was in excess of 30 of
flexion (Markolf, Slauterbeck, Armstrong, et al., 1997). Isometric
quadriceps strengthening exercises and straight leg raises (SLR) are
performed, along with hamstring stretching. Exercises are typically
performed three to four times per day for 10e25 repetitions.
Straight leg raises are initially performed in the knee immoblizer.
Independent performance of SLRs may be enhanced by performing
the exercises in supine with hip flexion between 45 and 90
degrees or in standing to reduce the influence of gravity. Once the
SLR can be performed without a knee extension lag these exercises
may be conducted without the knee immobilizer.
Resisted knee flexion exercises should not be allowed until week
8 as research indicates increased posterior tibial shear with OKC
knee flexion of greater than 10 (Pandy & Shelburne, 1997). Patella
mobilizations in all directions are performed to facilitate restora-
tion of knee ROM and prevention of arthrofibrosis in the early
phases of rehabilitation. Knee effusion is a significant contributor to
muscle atrophy and inhibition and therefore should be aggressively
addressed and monitored. The primary modality for effusion
management is the application of ice for 10e20 min every 2e4 h,
204 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208

Table 1
PCL reconstruction rehabilitation practice guidelines.

Time frame Clinical milestones Activities

Weeks 0e2 Passive ROM knee Patella/tibiofemoral
flexion (0e90 ) mobilizations
Active ROM knee PROM/AROM
extension (90e0 )
Quadriceps control Quad exercises
Full knee extensiona SLRs
NMES & Ice
Scar massage
Gait Training
Weeks 2e6 Full weight bearing OKC quad exercises 0e70
Walking without crutches CKC exercises 0e45
ROM 0e120 Pool therapy (no kicking)
Quad strength 4/5a Stationary bike
Passive extension
Weeks 6e12 Normal gait pattern Stair training/Stair machine
Full AROM Unilateral exercises
Quad strength 4þ/5 (>90%)a Balance/proprioception
Use of stairs without difficulty CKC exercises 0e60
Treadmill with no pain/edema OKC HS at week 8 (0e30 )
Pool agility drills
Weeks 12e16 5/5 quad and gluteal strength Begin jogging progression
Hop tests >80% Continue strength exercises
Able to jog 10 min Begin light agility drills
OKC quad exercises (90e0 )
OKC HS exercises (0e45 )
CKC exercises (0e75 )
Swimming (any stroke)
Weeks 16e24 Performance tests >90% Sport specific exercises
4þ/5 HS strength Agility drills
Low level plyometrics
Continue strength exercises
OKC HS (0e60 )
CKC exercises (0e90 )
Fig. 9. Prone passive knee flexion, (A) partner or clinician assisted, (B) utilizing stretch
strap. >24 Weeks Return to sports Sport specific exercises
Plyometrics
Agility drills
Olympic lifts
along with compression and elevation. While this is standard
clinical management the evidence basis for utilization on patients NMES ¼ neuromuscular electrical stimulation, OKC ¼ open kinetic chain,
CKC ¼ closed kinetic chain, quad ¼ quadriceps femoris, HS ¼ hamstring.
following PCL reconstruction has not been established. Addition- a
Compared with uninvolved side.
ally, the long term effects of cryotherapy and the effect on the tissue
repair are not known (Hubbard & Denagar, 2004).
Electrical stimulation may also be utilized to minimize quadri- Leardini, Catani, & O’Connor, 2000). . Castle et al. assessed static
ceps inhibition and facilitate recruitment. Gentle scar massage may squatting with PCL deficiency and showed a mean increase in
commence in the early rehab phase once the incisions are healed. posterior translation of 7.4 mm for high angle squats (70e90
Goals at the end of week 2 and criteria for progression into Phase II flexion) compared to 2.1 mm for low flexion squats (32e50
include: (1) achieving 0e90 or greater ROM; (2) no quadriceps flexion) (Castle et al., 1992). Promotion of early CKC exercises may
extension lag during performance of a SLR; and (3) decreased joint include bilateral leg press and progressing to unilateral leg press in
effusion. supine or quadruped (Fig. 10A and B). Quadruped leg press creates
For the maximum protection phase (weeks 2e6), range-of- an extension movement pattern more similar to functional
motion and weight bearing are progressed gradually. ROM should demands on the knee than the supine leg press. Although there are
be progressed from 0 to 120 (Table 1) (Wilk et al., 1999). Weight no biomechanical studies comparing the two exercises, the starting
bearing status is also progressed from WBAT with crutches during position of the quadruped leg press seems less likely to induce
weeks 0e2 to full weight bearing without crutches by week 4e6. A posterior strain on the PCL graft as well.
weight scale can be used for biofeedback to monitor weight bearing From weeks 4e6, the stationary bike can be performed once
status to the surgical extremity. Progression of gait training may knee flexion is greater than 100 . Pool therapy can also begin at
include weaning from 2 crutches to 1 crutch. Crutches may be week 4; however, kicking should not be allowed so as to limit
discontinued as early as week 3e4. Criteria for discontinuation of posterior tibial displacement caused by strenuous hamstring acti-
crutches include good quadriceps control, no extension lag with vation. Incorporation of additional strengthening exercises such as
a SLR, full extension ROM, ability to do single leg stance without SLRs using resistance up to 10% of the patient’s bodyweight and leg
pain or unsteadiness, and a non-antalgic gait. Normalization of gait presses and mini squats at 0e45 knee flexion. Leg presses and mini
is critical during this phase with quadriceps activation during the squats can be progressed from double-limb support to single-limb
loading and stance phases of gait of utmost importance. The support based upon patient’s comfort level while performing the
quadriceps role in gait is to provide functional knee stability during exercises. Active resisted knee extension may be performed in the
the loading phase. From week 2e6, OKC knee extension exercises in 0e90 . Isometric holds at various ROM points can be performed if
a range of 70e0 should be performed, along with closed kinetic the patient lacks muscular control with dynamic movements. Ice
chain (weight bearing) exercises (CKC) at 0e45 , a safe range for and electrical stimulation should be continued as needed for pain
limiting posterior tibial sheer (Wilk et al., 1999; Toutoungi, Lu, relief, effusion management, and muscle recruitment. Goals at the
 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
Fig. 10. Prone leg press (donkey kick).
end of week 6 and criteria for progression into Phase III include: (1)
minimal effusion; (2) full and pain free weight bearing; (3) 0e120
ROM; (4) quadriceps strength of 4/5 determined by manual muscle
test (MMT) as described by Kendall, and (5) ability to perform
a 2e4” step up and step down with a good movement pattern
(Kendall & McCreary, 1982). Progression between phases is
performance-based. The timelines provided in association with
each phase of rehab are approximate timelines to provide time
based goals that apply to most patients.
Phase III, the controlled ambulation phase (weeks 6e12),
involves progression of CKC exercises from bilateral to unilateral
within an increasing knee flexion range of 45e60 . Research
examining posterior tibial shear have demonstrated an increase in
stress with wall squatting, single leg squats, and lunges necessi-
tating a gradual increase in ROM and transition from static to
dynamic movements (i.e., static lunge versus forward step and
return lunge) (Escamilla, 2009, 2010a, 2010b). Lunging exercises
can be further progressed by adding resistance (e.g. hand held
weights) or performing upper extremity diagonal movements with
a medicine ball towards and away from the lead leg. The knee brace
should be discontinued and a normalized gait pattern should be
achieved by week 8. Treadmill walking and pool jogging are initi-
ated. Progression may include duration of activity, speed, and angle
of incline. Exercises including balance and proprioceptive drills,
forward and lateral step ups, and stair climbing should be per-
formed throughout this phase. Resisted knee flexion exercises
should not be performed until week 8e12 due to the large shear
force that the PCL is subjected to as the tibia is pulled posteriorly by
the hamstrings (Toutoungi et al., 2000; Wilk et al., 1999). Goals at
205
the end of week 12 and criteria for progression into Phase IV
include: (1) a normal gait pattern; (2) symmetry of single leg stance
stability; (3) lower extremity strength (quadriceps, hip abduction,
and hip extension) of 4þ to 5/5 determined by MMT, and ability to
step up and down from a 6e8" step with a normal movement
pattern. Hip abduction strength is important for both dynamic knee
stability and decreasing reinjury risk (Myer, Paterno, Ford,
Quatman, & Hewett, 2006).
Phase IV, the light activity phase (weeks 12e16), involves
a walk to run progression program and light agility drills, such as
line hops, bounding, and ladder drills, which are initiated and
progressed over 4e12 weeks. Criteria for beginning a walk to jog
progression program are normal gait, knee ROM 0e120 , absence
of joint effusion, pain free single leg hopping, and walking toler-
ance of 25 min. All agility drills in the light activity phase
involve movements primarily in the sagittal plane with limited
frontal or transverse plane movements, such as pivoting and
change of direction drills. Criteria for progression are no increased
pain or effusion during or after the activity and maintaining
optimal joint alignment/stability throughout activity. Exercise
progression should involve increasing ranges of motion, increase
in speed of motion, increase in resistance, and/or increase in
volume or duration of exercise performance. Agility drills in the
pool including lateral stepping and forward running should begin
and are continued throughout this phase. While continuing knee
and hip strengthening exercises, swimming can also begin, using
any stroke desirable. Open kinetic chain quadriceps exercises may
now be performed in the range of 90e0 , OKC hamstring exer-
cises from 0 to 45 , and CKC squatting/lunging from 0 to 75 .
Research by Escamilla and Toutoungi indicate that peak PCL
stresses during CKC exercise occur at 80 (Escamilla, 2009;
Toutoungi et al., 2000).
Hop tests (Barber et al., 1990; Daniel, Stone, Riehl, & Moore,
1982; Noyes, Barber, & Mangine, 1991) should be performed
with a goal of 80% compared to contralateral limb before return
to sport activities (sport specific/agility drills) are performed. Hop
testing described by Noyes et al. is a combination of 4 different
hop tests that is used as a performance-based outcome measure
for lower extremity post-surgical patients. The series of hop tests
include a single hop for distance, a 6-m timed hop, a triple hop for
distance, and crossover hops for distance and involve an array of
movements that mimic sporting activity demands and challenge
dynamic knee stability (Reid, Birmingham, Stafford, Alcock, &
Giffin, 2007). The goal at the end of week 16 and criteria for
progression into Phase V include: (1) achieving 30 min of
continuous aerobic activity 3e4 days per week; (2) hop tests
80% of the uninvolved side, (3) 5/5 gross manual muscle test of
the quadriceps and hip musculature, (4) if isokinetic testing is
available, quadriceps performance should be within 80%
symmetry of the uninvolved limb, and (4) an IKDC Subjective
Knee Form score of 70 or greater. The IKDC Subjective Knee Form
is a reliable and valid tool for determining the patient’s rating of
knee symptoms, function, and ability to participate in sport
following knee injury (Irrgang, Anderson, Boland, et al., 2001).
Patients with an IKDC rating of 70 or less may need additional
recovery time and improvement in functional status before
beginning sport specific training.
Phase V, the return to sport phase (weeks 16e24), focuses on
progression of strengthening exercises and increasing neuromus-
cular control demands. Examples include multi-directional lunges,
single leg stance with perturbation, Fig. 8 running, change of
direction drills, and bench or box jumps. Sport specific activities
during Phase V differ from light agility drills in Phase IV, as they
incorporate movements in the sagittal, frontal, and transverse
planes. These activities are performed in order to prepare the
206 M.D. Rosenthal et al. / Physical Therapy in Sport 13 (2012) 196e208
patient for the tri-planar physical demands sporting activities will
have on the lower extremity and the reconstructed PCL. Criteria for
progression are symmetry of movement with single leg testing (i.e.
star excursion), normal jogging gait, and avoidance of dynamic
knee varus or valgus during squatting, lunging or jumping. During
the later stages of rehabilitation, advancement of exercises is based
upon patient specificity and demonstrable improvements in
dynamic neuromuscular control and performance. Closed kinetic
chain exercises may advance into the range of 0e90 and OKC
hamstring exercises performed in the range of 0e60 . High impact
activities may be performed 2e4 times per week and include
(60e85% maximum heart rate) cardiovascular endurance activities.
Athletes are typically able to return to non-contact sports at 6
months post-surgery and return to contact sports at 6e9 months
(Wilk et al., 1999). Hop testing (Barber et al., 1990; Daniel et al.,
1982; Noyes et al., 1991) is the preferred functional testing for
return to sport determination following lower extremity surgery
with an ultimate goal of 90% compared to the unaffected limb.
Patient’s jumping and landing mechanics should be observed
during functional testing to avoid hyperextension and varus or
valgus angulation during landing.
Patients should be instructed on how important compliance
with their home exercise program (HEP) is after their formal
physical therapy sessions are over. Those receiving clearance to
return to sport activities and competition should continue their
HEP designed by their physical therapist. Lastly, a functional knee
brace may be worn during sport activities to increase propriocep-
tive input and facilitate normal knee mechanics during running,
cutting and pivoting activities (Lunden et al., 2010).
7. Outcomes
While many studies report successful outcomes following
conservative management and reconstruction of the PCL, there
have been minimal randomized prospective studies to assess
outcomes. A recent review of outcomes following PCL reconstruc-
tion by Hammond et al. identified 21 studies involving patients
with isolated PCL reconstructions, one which involved prospective
methodology, and 10 studies which involved PCL reconstruction in
conjunction with other procedure(s), all which were prospective in
nature (Hamrnoud, Reinhardt, & Marx, 2010). This review article
noted a failure rate of approximately 12% for each group and
a greater return to pre-injury activities in the isolated PCL group
(50e 82% versus 19e68% in the combined PCL group). Additionally,
“outcome measures” most commonly utilized in these studies were
the Lysholm scale, Tegner activity scale, and IKDC (% normal and %
nearly normal) (Hammond, Reinhardt, & Marx, 2010). Although not
yet reported in the literature for use in the evaluation and
management of PCL injuries, the lower extremity functional scale
(LEFS) a regional body part outcome scale may also be incorporated
as a patient report measure.
A systematic review of conservative management by Grassmayr
et al. found 17 studies on conservative management and concluded
that comparison between the studies is difficult due to subject and
medical management heterogeneity (Grassmayr et al., 2008). Two
of the larger prospective conservative management studies found
50% to 76% return to same level of sport with an additional 32% in
the study by Shelbourne and Muthukaruppan that returned at
a lower level of function. (Shelbourne & Muthukaruppan, 2005;
Cross & Powell, 1984).
Outcome measurements for the patient with a PCL injury should
incorporate quality of life measures, patient reported functional
outcomes, along with objective (clinical and functional) measure-
ments. Ideally these measurement tools will be incorporated soon
after the initial injury or in the case of PCL reconstruction, prior to
surgery. These tools will provide necessary insight into the various
areas that will impact patient satisfaction and long term outcome.
There are numerous quality of life (QOL) measurements which
have been utilized in the orthopedic literature. Most commonly
utilized are the Short Form (SF) 12, SF36, and the World Health
Quality of Life scale. In addition to these scales there is growing
support for the assessment of fear avoidance or kinesiophobia
behaviors following knee injury and surgery. For the PCL injured or
posterior cruciate ligament reconstructed (PCLR) patient we
recommend utilization of the Fear Avoidance Beliefs
Questionnaire-knee or the Tampa Kinesiophobia scale. Each of
these scales can provide valuable information specific to a patient’s
concerns regarding safety or risk of re-injury upon returning to the
pre-injury level of activities.
Objective outcome measures may include isolated strength
assessment along with performance and functional testing. Iso-
lated strength and muscular performance testing may include
isokinetic strength and power testing beginning at 4e6 months
post-surgery or 3 months post-injury in the non-operative pop-
ulation. Parolie and Bergfield found that good quadriceps
strength was a better indicator of return to function than poste-
rior tibial translation laxity (Parolie & Bergfield, 1986). Functional
testing may include the hop tests (single leg hop for distance, 6 m
timed single leg hop, triple hop for distance, and crossover triple
hop for distance), most commonly associated with outcomes
assessment following anterior cruciate ligament reconstruction,
or sport specific drills (i.e. T-test for tennis, pro-agility for foot-
ball). Additional sport specific drills should be implemented
based upon the movement demands required of the athlete in
their chosen sport.
8. Conclusion
Posterior cruciate ligament injuries can be a devastating injury
resulting in long term functional limitations along with develop-
ment and progression of osteoarthritis. Limited research reports
good outcomes with both conservative and surgical management
in the case of isolated PCL injuries. Posterior cruciate ligament
injuries combined with concomitant soft tissue (ligamentous,
meniscal, or osteochondral) injury portend a longer and more likely
limited recovery. Further research is warranted to develop
a stronger evidence based foundation for management of PCL and
combined PCL injuries.
Conflict of Interest
No conflict of interest for any of the contributing authors.
Ethical Approval
Ethical approval of this study is not applicable.
Disclaimer
The views expressed in this article are those of the authors and
do not necessarily reflect the official policy or position of the
Department of the Navy, Department of Defense, or the United
States Government.
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