Posterior Cruciate Ligament (PCL) Injury

The Posterior Cruciate Ligament (PCL) is the is the strongest ligament in the knee joint and is located at the back of the knee, connecting the thigh bone (femur) to the shin bone (tibia). It plays a vital role in stabilizing the knee, helps the knee to move smoothly and preventing the tibia from moving too far backward. A PCL tear occurs when this ligament is overstretched or torn due to trauma or hyperextension.

PCL injuries are significantly rarer than anterior cruciate ligament (ACL) tears, accounting for less than 20% of all knee ligament injuries often occurring alongside other ligament injuries.

Treatment for PCL in Cuba depends on several factors, including the severity of the injury and the presence of any additional ligament or structural damage within the knee. For the most part however, treatment is with non-surgical such as physical therapy and pain medication, or surgical intervention to restore knee stability and function.

If a posterior cruciate ligament (PCL) tear is left untreated, it can lead to several complications over time such as:

• Knee unstable making it prone to further injuries
• Increased stress on other parts of the knee
• Potential damage to the meniscus or other ligaments
• Chronic pain, swelling, and difficulty performing daily activities or participating in sports.
• Development of osteoarthritis

Types of PCL Injuries

PCL injuries are referred to as sprains and are classified by grade ranging from one (the least severe) to four (the most severe):

• Grade I sprain: This is a partial tear with the ligament stretched, but the knee remains relatively stable.
• Grade II sprain This is a more significant partial tear in which the ligament is stretched and looser, causing noticeable knee instability.
• Grade III sprain: This type of tear involves a complete tear or rupture of the PCL causing high instability in the knee with significant difficulty in maintaining normal knee function.
• Grade IV Tear: This is the most severe tear and involves a complete tear of the PCL along with damage to other knee ligaments, such as the ACL, MCL). The knee is extremely unstable, with multiple structural issues requiring comprehensive treatment.

Causes of PCL Injuries

Any trauma to the knee, whether minor or severe, can cause a knee ligament injury, however, they rarely happen by a simple misstep. There are several ways that PCL injury can happen, with the main cause is a severe trauma to the knee joint.

• Direct Impact: Injury to the PCL occurs as a result of a sudden, forceful impact to the front of the knee while it is bent, such as in car accidents or contact sports like football and soccer.
• Hyperextension: Damage to the PCL is due to overstretching or overextending the knee joint beyond its normal range of motion, often seen in athletes during high-impact activities.
• Twisting Injuries: PCL injury happens because of sudden changes in direction or twisting movements that place excessive stress on the knee ligaments.

Symptoms of PCL Injuries

Symptoms of a PCL injury can be mild or severe, depending on the extent of the injury. In cases of mild ligament sprained the condition may be asymptomatic. For a partial tear or complete tear of the ligament, common symptoms include:

• Tenderness in the knee, specifically the back of the knee.
• Instability in the knee joint.
• Pain in the knee joint that worsens over time.
• Swelling and inflammation in the knee.
• Bruising around the knee, particularly on the back of the knee
• Stiffness in the joint.
• Reduced range of motion.
• Difficulty walking.
• Trouble going down the stairs.

Diagnosis of PCL Injuries

Diagnosing an PCL injury begins with medical history and physical examination whereby a review of symptoms, history of injury, range of motion, as well as examination of the knee for structures integrity and comparing the injured knee to the non-injured knee. Other tests which may help confirm diagnosis include:

• X-Ray: X-ray images do not detect injuries to the posterior cruciate ligament, they can however reveal if the ligament tore off a piece of bone during the injury. X-rays also help assess the extent to which the shin bone can move backward.
• Magnetic Resonance Imaging (MRI): MRI is typically used for diagnosing PCL injuries since these images provide detailed images of soft tissues. MRI can confirm the presence and extent of the tear.
• Computed tomography scan (CT): CT may be used if there are concerns about small bone fractures.

Treatment Options for PCL Injuries

Treatment for PCL injury typically begins with non-surgical approaches, including rest, ice application, compression, and elevation (R.I.C.E) to reduce pain and swelling. For minor injuries, bracing or physical therapy may be recommended with the goal of strengthening the quadriceps and hamstrings, enhancing range of motion, and improving knee stability through targeted exercises. For more severe injuries or when conservative treatments fail, surgical intervention, such as PCL reconstruction may be necessary.

Non-Surgical Options

• Bracing: This is an important non-surgical treatment option aimed at providing stability, support to the knee joint and preventing the tibia from moving excessively backward, to protect the healing ligament. By stabilizing the knee, bracing can enhance the effectiveness of rehabilitation exercises and facilitate a quicker return to daily activities.
• Physical Therapy: Physical therapy is essential for treating PCL injuries, crucial in both non-surgical and post-surgical recovery. Its primary goals are to restore function, increase strength, enhance flexibility, and prevent future injuries through a structured and progressive rehabilitation program. This includes:
  • Manual therapy.
  • Muscle strengthening.
  • Functional training.
  • Range of motion (ROM) exercises.
  • Quadriceps activation.
  • Weight-bearing activities.
  • Proprioception training exercises.
  • Patellar mobility.
  • Dynamic stability exercises.
  • Neuromuscular training.
  • Functional training.
  • Agility training.

Surgical Options

Consideration for surgical treatment is dependent on a number of factors, including:

• Severity of injury
• Presence of associated injuries or combined injuries
• Functional instability
• Response to non-surgical treatment
• Timing of injury
• Patient’s age and activity level
• Patient’s overall health

Surgical options include:

• PCL reconstruction: This is an arthroscopic procedure (minimally invasive) that is performed when the ligament is completely ruptured or has not responded to conservative treatments. The procedure typically involves using either an autograft (the patient’s own tissue) or an allograft (donor tissue) to replace the damaged ligament. During the surgery, tunnels are drilled in the femur and tibia to anchor the new ligament, which is secured with screws or other fixation devices.
• PCL Repair: In certain cases where the ligament has torn away from the bone, it can be reattached using sutures or anchors. This procedure is less common and is usually performed when the tear is recent, and the tissue quality is good.
• Combined Ligament Reconstruction: This procedure is often necessary when there is damage to multiple ligaments, such as the ACL, MCL, or LCL, in addition to the PCL, leading to significant knee instability The surgery typically employs a combination of autografts (the patient’s own tissue) and allografts (donor tissue) to reconstruct the damaged ligaments, providing comprehensive stabilization of the knee joint.
• Meniscal or Cartilage Repair: This procedure is carried out when there is damage to the knee’s meniscus or cartilage along with PCL tear. This procedure, typically performed arthroscopically, involves repairing or trimming the damaged meniscal tissue and smoothing or repairing the cartilage to restore the knee’s function and alleviate pain.
• Arthroscopic Debridement: This a minimally invasive surgery performed to clean out the knee joint to remove any loose fragments of tissue, damaged cartilage and any other debris when there is minimal instability but there is persistent discomfort or mechanical issues.

Post-surgical rehabilitation is crucial after any type of PCL surgery to ensure proper healing and to avoid further injury. This includes a gradual progression of exercises to restore range of motion, strength, and functional stability.