PCL Injury of The Knee Joint

Knee joint is one of the most vulnerable joints to sustain a ligamentous injury. There are four major ligaments which keep the knee stable.

Being the most common, we frequently hear and read about ACL (Anterior Cruciate Ligament) injury of the knee joint, but the rest of the ligaments are equally important for the joint stability.

PCL (Posterior Cruciate Ligament) is present on the back side of the knee joint and prevents the

shinbone (tibia) from displacing backwards. Injury to PCL can significantly affect the joint stability, function and hence the quality of life, if not diagnosed and managed at the right time.

Lets have a look at some key details.

Where exactly is PCL located?

Knee joint is stabilised by four major ligaments, viz:

Anterior cruciate ligament (ACL): gives stability from the front

Posterior cruciate ligament (PCL): keeps the knee stable from back side

Medial collateral ligament (MCL): stabilises the inner knee.

Lateral collateral ligament (LCL): stabilises the outer knee.

PCL is the thickest and strongest ligament out of these, located deep inside the joint. It connects the back of the tibia (shin bone) to the inside of the femur (thigh bone) and is crucial for activities like walking, running, and climbing stairs.

How does PCL get injured?

PCL injury usually occurs due to a high-energy trauma with a direct impact to the front of the shin bone. Common causes include:

1. Sports injuries: Falling on a bent knee in football, soccer, or basketball.

2. Road Traffic Accidents: Most common

   scenario is the ‘dashboard injury’ where the shin strikes the dashboard during a car crash, gets pushed backward.

3. Hyperextension injury: Rarely, excessive straightening of the knee can injure the PCL

How severe can the injury be?

PCL injury is graded based on the severity:

• Grade I (Sprain): ligament is stretched & swollen but intact.

• Grade II (Partial tear): some fibres are torn but the rest remain functional.

• Grade III (Complete tear): leading to significant instability.

  
  

How to suspect a PCL injury?

Symptoms are usually subtle compared to ACL, which is why PCL injuries often go undiagnosed in the initial stages. Common complaints include:

• Pain, swelling over knee: immediately after injury.

• Instability: A feeling that the knee is ‘giving way’ especially when walking downhill or climbing down the stairs.

• Difficulty in running or pivoting during sports

• Pain on the front side of the knee - in chronic cases

How is it diagnosed?

Accurate diagnosis requires a combination of clinical evaluation and imaging.

1. Physical examination: Posterior sag of tibia, loss of tibial step-off, Posterior Drawer Test are the key clinical tests

2. X-rays: performed to see associated fractures or avulsion injuries.

3. MRI Scan: gold standard to confirm PCL tear, assess severity, and detect associated soft tissue injuries.

What are the treatment options?

Treatment depends on the grade of injury, patient’s activity level, and associated injuries.

1. Non-Surgical

Most isolated grade I and II PCL injuries can be managed without surgery.

Treatment includes:

• Rest, Ice, Compression, Elevation (RICE): initially after injury

• Medications: non-steroidal anti-inflammatory drugs for a short course

• Knee brace: special PCL braces prevent backward subluxation of tibia

• Physiotherapy: strengthening hip muscles, quadriceps, hamstrings balance followed by proprioception, gait training and sport specific rehab

  
  

Non-surgical treatment can restore stability in many cases, especially in non-athletes or low-demand individuals.

2. Surgical Management:

Surgery is considered for:

• Grade III tears (complete tears)

• Multi-ligament injuries

• Persistent instability despite supervised physiotherapy

• High-demand athletes or active individuals.

Arthroscopic Reconstruction

In this key-hole procedure, the torn ligament is replaced using a graft harvested from patient’s own body. Most commonly used tendons for reconstruction are hamstring and peroneus longus.

Being a minimally invasive procedure, recovery is much faster with minimum post-operative pain.

What is the timeline for rehabilitation after PCL injury?

Recovery is a gradual process and requires a structured physiotherapy program:

• Phase I (0–6 weeks): focus is on reducing pain, brace support, limited weight-bearing, and gentle range-of-motion exercises

• Phase II (6–12 weeks): progressive strengthening of muscles, stationary cycling, and proprioceptive training

• Phase III (3–6 months): advanced strengthening, running drills, agility exercises

• Phase IV (6–9 months): sports-specific training and gradual return to competition

Most patients return to daily activities within 3–4 months, but return to competitive sports takes 9–12 months.

What if PCL injuries are ignored?

If left untreated, especially in complete tears, long-term consequences may include:

•  Chronic knee instability

• Meniscus tears and cartilage damage

• Early osteoarthritis of the knee, particularly in the patello-femoral compartment

• Persistent pain, reduced activity levels and compromised quality of life

How to prevent PCL injuries?

While not all injuries can be prevented, certain strategies reduce the risk:

>  Safe driving practices: reduce risk of road traffic accidents

>  Strength training: strong quadriceps provide better knee stability

>  Balance and proprioception exercises: improve joint control

>  Sports technique training: learning safe landing and deceleration techniques

>  Protective gear: use of knee braces in high-risk sports

To conclude..

PCL injury may not be as widely discussed as ACL tears, but it is equally significant and debilitating.

Early diagnosis, appropriate treatment and structured rehabilitation are essential to prevent chronic instability and arthritis.

With advancements in arthroscopic surgery and physiotherapy, most patients with PCL injuries can return to an active, pain-free lifestyle and even competitive sports.