PCL Tear Injury Treatment
Posterior Cruciate Ligament (PCL) Injuries
What Is The PCL
The PCL (Posterior Cruciate Ligament) is a ligament that prevents the tibia from sliding too far backwards. Along with the ACL which keeps the tibia from sliding too far forward, the PCL helps maintain the tibia in position below the femur.
PCL tears make up less than 20% of injuries to the knee ligaments. Injuries that tear the PCL often damage some of the other ligaments or cartilage in the knee as well. In some cases, the ligament can also break loose a piece of underlying bone.
How do you injure your PCL
Common causes of PCL injuries are due to a blow to the knee while it's bent, for example falling on a bent knee, or a car accident. It is also common to injure your PCL during sports activities such as football, soccer, baseball or skiing. The injury is commonly associated with injuries to other structures in the rear compartment of the knee joint such as lateral meniscus tears. In addition the articular cartilage may also be damaged.
- Grade 1 - the PCL is sprained
- Grade 2 - the ligament is partially torn
- Grade 3 - the ligament is almost completely torn
- Grade 4 - the ligament is completely ruptured and may also have injuries to other ligaments in the knee
Men are more likely than women to injure their PCL. Participation in sports such as football and soccer also may increase the risk of injury. In many cases, other structures within the knee - including other ligaments or cartilage - are also damaged when you experience a PCL injury. Depending on how many of these structures were damaged, you may also experience some long term knee pain and instability. You may also be at a higher risk of developing arthritis in your affected knee.
Most people don't feel or hear a 'popping' sensation in the knee after a PCL injury. This is more common with an injury to the ACL. After a PCL injury, people often think they only have a minor knee problem. Most usually try to go on with their usual activities, however, some of the symptoms may start to appear.
- Knee pain
- Wobbly sensation in the knee
- Trouble walking or bearing weight on the knee
Over time a PCL tear can lead to osteoarthritis in the knee.
Conservative treatment is everything that does not include surgery. This is indicated in most PCL injuries and may consist of ice and heat treatment, ultrasound and manual therapy exercises. Advice on a specific rehabilitative exercise program which may include quadriceps and hamstring strengthening, gait re-education and balance training using wobble boards. A knee support or brace can be used in the early to mid-stages. Hinged knee braces will provide the most support for knee ligament injuries.
It is possible for the PCL to heal on its own, without the help of surgery. Surgery is usually only required for complete tears of the ligament. Surgery usually takes place after a few weeks, in order to allow swelling to decrease and regular motion to return to the knee. A procedure called ligament reconstruction is used to replace the torn PCL with a new ligament, which is usually a graft taken from a hamstring or Achilles tendon from a cadaver. An arthroscope allows a complete evaluation of the entire knee joint, including the knee cap (patella), the cartilage surfaces, the meniscus, the ligaments (ACL and PCL) and the joint lining. Then, the new ligament is attached to the bone of the thigh and lower leg with screws to hold it in place.
Physical therapy once the injury has started healing will greatly reduce the recovery time. During the healing process it's important to make sure that the muscles, ligaments and tendons surrounding the injury site stay mobile to prevent any tightening. That would put additional strain on the PCL, and slow down recovery time.
Taping an injury like a PCL strain or tear can help provide your damaged tissue with support and protection. It can also help relieve swelling throughout the day and is even thought to improve movement during physical activity.
It's best to try several different taping applications for your PCL injury before settling on one. This will help you figure out which one works best for you. There are many examples online, including instructional videos. Here's a PCL taping application we found effective:
1. Take a full length piece of tape (about 10 inches long) and cut it in half, rounding the corners, so you have two pieces that are each about 5 inches long.
2. Bend your knee to 90° and take one of the 5 inch strips, tearing the backing in the middle and peeling it away so you're holding onto the two anchor ends.
3. Apply the tape horizontally just below your kneecap, using 80% stretch in the middle and no stretch at the ends.
4. Take the other 5 inch strip and tear the backing in the middle, peeling it away so you're holding onto the two anchor ends.
5. Apply the tape horizontally just below your kneecap, directly over top of the first piece you applied, using 80% stretch in the middle and no stretch at the ends.
6. Take a full length piece of tape and measure it from the right side of your kneecap up to your thigh.
7. Tear the backing off the end at your thigh and anchor it onto your quad muscle, using no stretch.
8. Using 25% stretch, pull the tape down along the outside of your kneecap.
9. Once the tape is even with your knee, use 50% stretch and let the tape follow the bottom of your kneecap, around to the opposite side of your knee.
10. Lay down the end of the tape with no stretch, then rub the tape in to ensure it sticks.
11. Use the technique described in Steps 6-10 for the left side of your knee.
Mechanism Of Injury
Physicians often are familiar with the clinical presentation and management of collateral ligament and anterior cruciate ligament (ACL) strains or ruptures because these injuries occur somewhat frequently in active persons. They may be less familiar with injuries of the posterior cruciate ligament (PCL) which is an important stabilizer of the knee. The PCL is injured far less frequently, but when it is disrupted in isolation the injury may have a subtle presentation that can elude even the experienced examiner. In addition, patients who sustain isolated PCL injuries may continue to function at a competitive level, because the symptoms may develop until long after the original event, and the natural history of the isolated PCL deficient knee remains unclear.
With or without surgery, recovery times can vary, but most people are back on their feet between six to ten months. The five phases of the recovery period are outlined below. Whether or not surgery was had, the below guidelines will help achieve the same goal.
Phase 1 the first two weeks
- control of inflammation by using cold compression
- range of motion - full extensions and 90 degree bending
- control and strengthening of quadriceps
- crutches are important for the first seven to ten days until comfortable walking
- prevention of patellar tendon from shortening - this will cause loss of motion
Phase 2 two to six weeks
- strengthening - light weights and sports cords
- full range of motion should be achieved
- improvement of endurance and proprioception - by use of treadmill, step machine and elliptical trainer
Phase 3 six weeks to four months
- improvement of confidence in the knee
- continued progression in strength, power and proprioception - preparing for return to normal activities
- jogging can be achieved at this point
Phase 4 four months to six months
- possible to return to sports
- pain free and full range of motion should be present
- sufficient strength and proprioception should be achieved
- advanced lifting exercises can be started at this point
- this stage is typically customized more towards the individuals activity level and participation in sports
Phase 5 six months
- no soft tissue or range of motion complaints
- education about possible limitations
- maintenance of strength, endurance, and proprioception
Yoga poses that will help strengthen everything from your calves to your core.
Bridge - Strengthens leg muscles, gluteus and knee joints
Lie on your back. Bend both knees and walk your ankles directly beneath your knees keeping your feet straight. Extend your arms along your body, palms face down. Press evenly into the soles of your feet, lift your pelvis off the ground, walk your shoulder blades towards one another and underneath your back. Puff your chest towards your chin. Roll your thighs inward and down. Keep your knees directly above your ankles throughout the duration of the exercise. Hold for 20 seconds. Add 10 seconds every other day until your reach one minute. Then, build to two minutes.
Bridge with Leg Lift - Strengthens all leg muscles, keeps the knee joint mobile, helps stabilize the knee joint
Assume bridge position as described previously. Elevate one leg directly above your hip so that your foot points towards the ceiling. Hold for 20 seconds. Add 10 seconds every other day until you reach one minute.
Moving Warrior - Strengthens all leg muscles, keeps the knee joint mobile, helps stabilize knee joint
Stand with your legs one legs distance apart, feet parallel. Pivot your right foot out to 90 degrees. Line your right heel up with your left arch. Engage your core by lifting your navel towards your chin. Keeping your chest and hips open, elevate your arms to shoulder height. Bend your right knee so that it is directly over your ankle. Hold for 10 breaths. Then straighten your leg making sure not to lock your knees and bend it again to come back to warrior. Repeat 10 times per side. Complete two sets.
Reclined Leg Raises - Strengthen the quadriceps
Lie down on your back, supporting yourself on your forearms. Bend your left leg and place the sole of your foot on the floor. Keeping it straight, elevate your right leg to the same height as the knee of the left making sure isometrically hug your quads (upper thigh muscles) into your thighbone. Lower the leg to an inch above the ground and then repeat the lift. Do 25 of these and hold the last one for 10 seconds. Add 10 reps every other day until you reach 50 leg lifts with a hold of 1 minute at the end of each set.
Tree - Stretches MCL of the bent knee, stabilizes the knee joint and strengthens the muscles surrounding the knee of the standing leg.
Stand with your feet together, toes all facing forward, hands on hips. Elevate your rightknee to hip height. Turn out your right hip and place the entire sole of your foot onto your left calf or inner thigh (grab your ankle to hike the foot up to the thigh). With an MCL tear, you might not be able to turn your hip/leg out a lot at first. Ease into this external rotation over time. It can take months to get a full turnout. Keep your gaze steady on a single focal point. Hold for 5 breaths. Build to 10 breaths and ultimately one minute. Repeat with the left leg.
Leg Slides - Helps reduce swelling, keeps the knee joint mobile and helps improve knee flexion
Lie down with your legs up the wall. Cross your ankle and bend your knees. Slide your heels up and down the wall working between flexion and extension. Do 20 reps. Complete 3 days. Switch the crossing of your ankles and repeat.
Seated Staff Isometric Quad Engagement - Helps quadriceps begin to fire again after the injury and assists in stabilizing the knee joint
Sit with your legs straight in front of you. Keep your shoulders aligned over your waist and keep your spine tall. Gently press your legs against the ground and hug your quadriceps (thigh muscles) into your thighbone. Release your muscles to neutral. Do 20 reps. Complete three rounds.
Child's Pose - Stretches the MCL and helps regain flexion limitations due to ACL injuries
Very slowly test sitting back towards your heel and bringing your forehead to the floor. Hold yourself up with your hands to control how far you go. Stop when you feel any sign of slight discomfort. Over time, gradually increase your range lowering your buttocks closer to your heels. It can take many months to assume the full child's pose position.
Moving High Lunge - Strengthen all leg muscles and the knee joint, stabilizes the knee
Stand with your feet together. Place your hands on your hips. Step your left foot back as you bend your right knee over your ankle. Straighten and bend your right knee very slowly, making sure not to lock the knee when you extend the leg. Repeat 10 times. Switch sides. Do three sets.
The posterior cruciate ligament is described as the primary stabilizer of the knee. To understand what the PCL does, some background on its partner the ACL will need to be discovered first. The ACL is one of the two cruciate ligaments inside the knee that cross the other ligament to form an 'X'. The ACL is attached to the front of the femur and crosses over the back of the knee and connects to the tibia. The PCL does the same as the ACL, attaches from the tibia and crosses to the femur, but crosses towards the back of the knee, hence posterior.
PCL injuries are far less common than ACL injuries, and often go unrecognized. Because the PCL is thicker and stronger than the ACL, most often a PCL injury is accompanied by another ligament or meniscus injury.
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