Review Article
Management of Posterior Cruciate
Asheesh Bedi, MD
Volker Musahl, MD
James B. Cowan, MD
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From the Department of Orthopaedic
Surgery, University of Michigan, Ann
Arbor, MI (Dr. Bedi and Dr. Cowan),
and the Department of Orthopaedic
Surgery, University of Pittsburgh
Medical Center, Pittsburgh, PA
(Dr. Musahl).
J Am Acad Orthop Surg 2016;24:
277-289
http://dx.doi.org/10.5435/
JAAOS-D-14-00326
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
May 2016, Vol 24, No 5
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ligament Injuries: An
Evidence-Based Review
Abstract
Isolated injuries of the posterior cruciate ligament are uncommon, are
often caused by a posteriorly directed force to the proximal tibia, and
result in abnormal knee kinematics and function. A thorough clinical
evaluation, including history, physical examination, and imaging, is
required to rule out a concomitant structural knee injury. No clear
prognostic factors predict outcomes, and ideal management remains
uncertain. Nonsurgical management is advocated for isolated grade I
or II posterior cruciate ligament injuries or for grade III injuries in
patients with mild symptoms or low activity demands. Surgical
management is reserved for high-demand athletes or patients in
whom nonsurgical management has been unsuccessful. Although
biomechanical studies have identified differences between single-
bundle, double-bundle, transtibial, and tibial inlay reconstruction
techniques, the optimal surgical technique has not been established.
No high-quality evidence is available regarding immobilization,
weight-bearing, bracing, or rehabilitation protocols for patients treated
either nonsurgically or surgically. Additional long-term clinical studies
with homogeneous patient populations are needed to identify the ideal
management of these injuries.
I solated injuries of the posterior
cruciate ligament (PCL) are
uncommon, and a thorough clinical
cross-sectional area of the PCL are 32
to 38 mm, 13 mm, and 31.2 mm2,
respectively.2,4 The PCL is an intra-
evaluation is required to rule out a synovial and extra-articular struc-
concomitant structural knee injury. ture. Synovial reflections from the
Although nonsurgical and surgical posterior capsule cover the anterior,
management options have been medial, and lateral aspects of the
described, the ideal management PCL.3
strategy remains to be determined. The PCL consists of the postero-
medial bundle (PMB) and the
anterolateral bundle (ALB), which is
Anatomy and the larger and stronger bundle (Fig-
Biomechanics ure 1). Anderson et al5 described the
ALB and PMB footprints and pro-
The PCL connects the lateral aspect vided qualitative landmarks and
of the medial femoral condyle adja- quantitative measurements to locate
cent to the articular cartilage with the the femoral anterolateral, femoral
PCL facet of the posterior tibia 1 to 1.5 posteromedial, and tibial tunnels for
cm below the articular surface of the arthroscopic reconstruction. They
posterior tibial plateau.1-3 The aver- reported a mean femoral attachment
age length, width, and midsubstance area of 192 mm2 and a mean tibial
277
Management of Posterior Cruciate Ligament Injuries: An Evidence-based Review

Figure 1

Anterior (A) and posterior (B) illustrations of a right knee depicting the anterolateral and posteromedial bundles of the
posterior cruciate ligament. ACL = anterior cruciate ligament, ALB = anterolateral bundle, aMFL = anterior meniscofemoral
ligament, PCL = posterior cruciate ligament, PMB = posteromedial bundle, pMFL = posterior meniscofemoral ligament
(Reproduced with permission from Anderson CJ, Ziegler CG, Wijdicks CA, Engebretsen L, LaPrade RF: Arthroscopically
pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament. J Bone Joint Surg Am
2012;94[21]:1936-1945.)

attachment area of 219 mm2.
However, other researchers have
reported different values.
The primary function of the PCL is
to limit posterior tibial translation
relative to the femur, with increasing
effect at greater degrees of knee
flexion.1 The ALB and PMB each
provide this restraint throughout
the full range of knee flexion.6 Most
PCL fibers lengthen with pro-
gressive knee flexion, although
some of the more posterior fibers,
constituting approximately 10% to
15% of the PCL, demonstrate iso-
metric or near isometric behavior.7
Although isometric reconstruction
was previously thought to provide
greater stability over a wide range of
knee flexion, anatomic reconstruc-
tion using the femoral and tibial
footprints has been found to more
closely reproduce normal knee
motion.8 The PCL also restrains
external, internal, and varus-valgus
rotation; however, its contribution
in these planes is much less than that
in other planes because of the
mechanical disadvantage resulting
from its central location in the knee.1,6

Dr. Bedi or an immediate family member serves as a paid consultant to Smith & Nephew; has stock or stock options held in A3 Surgical; and
serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine. Dr. Musahl or an
immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports
Medicine. Neither Dr. Cowan nor any immediate family member has received anything of value from or has stock or stock options held in a
commercial company or institution related directly or indirectly to the subject of this article.

278 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

The PCL complex includes the
anterior meniscofemoral ligament
(MFL) and the posterior MFL, which
originate from the posterior horn of
the lateral meniscus and insert on the
femur anteriorly and posteriorly to
the PMB, respectively.1,5 These liga-
ments are often referred to as the
anterior MFL of Humphry, named
after the British anatomist George
Murray Humphry, and the posterior
MFL of Wrisberg, named after the
German anatomist Heinrich August
Wrisberg. Studies have found at least
one MFL in up to 95% of cadavers
and both MFLs in up to 60% of
cadaver specimens; however, the
MFLs may coexist more frequently
in younger patients.1,5,9 Although
the precise function of the MFLs has
been debated, biomechanical evi-
dence suggests that they act as sec-
ondary restraints to posterior tibial
translation.1,9
Epidemiology, Natural
History, and Mechanism of
Injury
The reported incidence of acute PCL
injuries ranges from 1% to 44% of
acute knee injuries.10 Isolated PCL
injuries are less common than those
with concomitant posterolateral
corner (PLC) or other ligamentous
injuries.11,12 The sport-specific inci-
dence of PCL injuries ranges from
1% to 4%.4,11 Parolie and Bergfeld13
found a 2% to 3% incidence of
chronic, asymptomatic PCL insuffi-
ciency in elite college football players.
Deficiency of the PCL results in
abnormal kinematics and contact
pressures in the medial and patello-
femoral compartments of the knee
and may increase strain on the
posterolateral knee structures, placing
them at risk of subsequent injury.14-16
Goyal et al17 found abnormal
tibiofemoral knee kinematics during
functional activities, such as stair
ascent and running, in patients with
May 2016, Vol 24, No 5
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
asymptomatic, isolated grade II PCL
injuries. Van de Velde et al18 found a
statistically significant increase in
magnitude and a more anterior and
medial position of peak cartilage
deformation in the medial knee
compartment of patients with PCL
deficiency compared with that of
persons with an intact PCL. These
tibiofemoral kinematic alterations
suggest that, in patients with PCL
deficiency, reduced weight-bearing
load may be transmitted through
the menisci and the areas of thickest
articular cartilage. Long-term studies
have found that degenerative changes
after PCL injury occur primarily in
the medial and patellofemoral com-
partments.19-23 In a systematic review
of the literature, Kim et al24 were
unable to determine the overall inci-
dence, location, or predictors of
osteoarthritis in patients with isolated
PCL injuries because of variable
study design and methodology.
In patients with isolated PCL
injuries, common mechanisms of
injury include a posteriorly directed
force to the proximal tibia with the
knee flexed, a fall onto a flexed knee, or
sudden knee hyperflexion or hyperex-
tension.12 In the case of PCL injury
resulting from a fall onto a flexed
knee, the foot position at the time of
impact affects the pattern of injury.
When the foot is dorsiflexed, force is
transmitted through the patella and
extensor mechanism. When the foot is
plantarflexed, a posteriorly directed
force is imparted to the proximal tibia.
When these mechanisms are combined
with rotational forces or forces in the
coronal plane, the medial and lateral
knee structures are at increased risk.
Clinical Evaluation
History and Physical
Examination
A thorough history and physical
examination are crucial to establish
the correct diagnosis. Whereas
Asheesh Bedi, MD, et al
patients with anterior cruciate liga-
ment (ACL) injuries typically report a
palpable or audible “pop” followed
by substantial pain, knee effusion,
and an inability to bear weight,
patients with PCL injuries more
commonly report subtle signs and
symptoms, and the mechanism of
injury may be unknown.4,11,12,25 A
patient with an isolated PCL injury
may report vague knee pain, stiff-
ness, swelling, or discomfort with
activities requiring higher levels of
knee flexion, such as squatting,
kneeling, or walking on stairs.
Higher-energy mechanisms of injury
and more severe pain, instability, or
disability suggest a combined liga-
mentous injury.
A thorough physical examination
has been found to have high accu-
racy, sensitivity, and specificity in the
diagnosis of PCL tears, with better
results for grade II and III injuries
than for grade I injuries.26 Physical
examination should include com-
parison of the injured and contra-
lateral extremities. The examiner
should evaluate gait (when possible),
weight-bearing limb alignment,
range of motion, and neurovascular
status; palpate for an effusion or
areas of point tenderness; and per-
form stress testing of the cruciate and
collateral ligaments.
Numerous maneuvers to evaluate
PCL integrity have been described. The
posterior drawer test is the most sensi-
tive and specific clinical test for PCL
insufficiency.26 On an uninjured knee,
the medial tibial plateau lies approxi-
mately 1 cm anterior to the medial
femoral condyle; therefore, the poste-
rior drawer tests must be performed
starting from that resting position.4,25
If the examination starts with the tibia
in a posteriorly subluxated position,
the results of the Lachman test may be
falsely positive, resulting in an incor-
rect diagnosis of ACL injury when in
fact the examiner is only returning the
tibia to its reduced position. For the
posterior drawer test, the patient is
279
Management of Posterior Cruciate Ligament Injuries: An Evidence-based Review
Table 1
Posterior Drawer Test
Injury Posterior Translation of the
Grade Tibial Plateau (mm)
I 0 to 5
II 6 to 10
III .10
positioned supine, with the hip flexed
to 45° and the knee flexed to 90°. The
examiner places his or her thumbs on
the anterior joint line and applies a
posteriorly directed force to the prox-
imal tibia (Video, Supplemental Digital
Content 1, Posterior Drawer Test,
http://links.lww.com/JAAOS/A0). The
test grade is based on either the
position of the tibial plateau rela-
tive to the medial femoral condyle
or the posterior translation of the
tibial plateau relative to its position
in the contralateral, uninjured knee
(Table 1).
The quadriceps active test is used to
evaluate the integrity of the PCL
without the application of passive or
external force. The patient lies supine
with the hip flexed to 45° and the
knee flexed to 90° and is instructed
to slide his or her foot down the table
(Video, Supplemental Digital Con-
tent 2, Quadriceps Active Test,
http://links.lww.com/JAAOS/A1). A
positive test (ie, indicating PCL defi-
ciency) occurs when contraction of
the quadriceps shifts the tibia ante-
riorly from its posteriorly subluxated
position.
For the posterior sag (ie, Godfrey)
test, the patient is placed in a supine
position, and the examiner holds
the patient’s lower extremity with the
hip and knee each flexed to 90°. The
examiner looks for posterior sagging
of the tibia or loss of prominence of
the tibial tubercle.11 From this posi-
tion, the leg is passively extended for
the dynamic posterior shift test. In a
positive test, the examiner detects a
280
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Position of the Tibial Plateau
Relative to the Medial Femoral
Condyle
Anterior
Even
Posterior
palpable clunk from reduction of the
tibiofemoral joint.
Physical examination is crucial to
exclude a concomitant PLC injury.
Numerous maneuvers, including the
reverse pivot shift test and the external
rotation recurvatum test, have been
described to evaluate PLC integrity.
The tibial external rotation (ie, dial)
test is particularly useful for identify-
ing combined PCL and PLC injuries.
With the patient lying prone, the
examiner grasps the patient’s feet and
applies an external rotation stress on
the bilateral lower extremities. The
examiner assesses the angle between
the medial border of the foot and the
axis of the femur at 30° and 90° of
knee flexion. A difference of .10°
between the affected and unaffected
limbs represents a positive result. A
positive result occurring only at 30° of
knee flexion indicates a PLC injury,
whereas a positive result at both 30°
and 90° of knee flexion indicates
combined PCL and PLC injuries. In a
biomechanical study of 20 cadaver
knees, Sekiya et al27 concluded that a
grade III posterior drawer test and
.10 mm of posterior tibial trans-
lation on stress radiography corre-
lated with the presence of PLC injury
and complete disruption of the PCL.
Imaging
Initial evaluation should include a
series of knee radiographs, including
AP, lateral, axial, and 45° knee flexion
weight-bearing views. Lateral view
stress radiography can be used to
quantify posterior tibial translation.
Journal of the American Academy of Orthopaedic Surgeons
Stress radiography techniques include
the use of a kneeling position, gravity,
hamstring contraction, an axial view,
or a commercially available stressing
device.28 The use of a kneeling position
and the use of a stress-test device are
the most sensitive techniques for stress
radiography and have high intra-
observer and interobserver reliability.
However, these techniques are also the
most painful for the patient.28,29 Stress
radiographs also are useful for identi-
fying a concomitant PLC injury.
LaPrade et al30 noted that an unrec-
ognized or undertreated PLC injury
can put substantial stress on cruciate
ligament reconstruction. On radio-
graphs with clinician-applied varus
stress, the authors found increased
lateral compartment gapping of
2.7 mm, 4.0 mm, and 7.8 mm in
patients with isolated fibular collateral
injuries, grade III PLC injuries, and
combined ACL, PCL, and PLC
injuries, respectively. When a chronic
PCL injury is suspected, long-leg
standing radiographs are useful for
assessing coronal alignment.
The sensitivity, specificity, and
accuracy of MRI have been found to
approach 100% in the detection of
acute PCL injuries. MRI is less useful in
the evaluation of chronic PCL injuries
than in the evaluation of acute PCL
injuries. In one study, patients with
acute, isolated, complete PCL tears
identified on MRI were found to have
continuous but abnormally shaped
PCLs on follow-up MRI as soon as 5
months after the initial injury.31
Because functional instability can exist
even in the presence of structurally
intact tissue, the clinician should not
rely solely on MRI findings in the
evaluation of patients with suspected
chronic PCL injuries.
Management
Nonsurgical
Despite evidence of abnormal tibio-
femoral kinematics in patients with
 Asheesh Bedi, MD, et al

Table 2
Selected Clinical Outcomes of Nonsurgical Management of Posterior Cruciate Ligament Injuries
Study (Level of Mean Follow-up
Evidence) Injury Type (no. of pts) (mo) Outcomesa

Boynton and
Tietjens19 (IV)
Cross and Powell36 (IV)
Dandy and Pusey33 (IV)
Jacobi et al35 (I)
Keller et al34 (IV)
Parolie and
Bergfeld13 (IV)
Shelbourne et al10 (I)
a
Numerical outcome measures are mean values.
NA = not available, PCL = posterior cruciate ligament
Isolated PCL injury (38)
Multiligamentous injury
(86)
Isolated PCL injury (20)
Isolated PCL injury (17)
Isolated PCL injury (40)
Isolated PCL injury (25)
Isolated PCL injury (68)
161 Cincinnati Sports Medicine and Orthopaedic
Center anterior cruciate ligament laxity
questionnaire: 73.6 on 100-point scale,
functional score 38.8 on 50-point scale
Posterior drawer test (neutral rotation): grade
I, 5 of 30 pts (17%); grade II, 15 of 30 pts
(50%); grade III, 10 of 30 pts (33%)
NA Posterior drawer test (neutral rotation): grade
0, 2 of 89 pts (2%); grade I, 17 of 89 pts
(19%); grade II, 47 of 89 pts (53%); grade III,
23 of 89 pts (26%)
86 Objective: 40% fair, 60% poor
Subjective: 40% good, 50% fair, 10% poor
Functional: 25% good, 55% fair, 20% poor
24 Lysholm score, 94; Tegner score, 7.2;
International Knee Documentation
Committee score, 95; posterior tibial laxity,
3.2 mm (Rolimeter)
72 Noyes score 76.4, posterior drawer test
(neutral rotation): grade I, 24 of 40 pts (60%);
grade II, 13 of 40 pts (33%); grade III, 3 of 40
pts (8%)
74 80% satisfaction rate, 68% of pts returned to
previous athletic function without disability,
48% of pts were pain free, 44% had
mechanical symptoms
Posterior drawer test (neutral rotation): grade
II, 9 of 25 pts (36%); grade III, 14 of 25 pts
(56%); grade IV, 2 of 25 pts (8%), posterior
tibial laxity 7.12 mm (KT-1000)
65 Lysholm score, 83.4; Noyes score, 84.2 (133
pts); Tegner score, 5.7; posterior drawer test
(neutral rotation): grade 1, 26 of 68 pts (38%);
grade 1.5, 20 of 68 pts (29%); grade 2, 22 of
68 pts (32%), posterior tibial laxity, 5.3 mm
(KT-1000)

PCL deficiency, no clear prognostic
factors have been found to predict
which patients will experience dis-
ability, pain, or osteoarthritis as a
result of chronic insufficiency of the
PCL. Furthermore, discrepancies
between subjective and objective
outcome measures are common in
patients with PCL injury.19,32,33
Parolie and Bergfeld13 found high
levels of satisfaction, return to sport,
and performance in 25 elite athletes
who underwent nonsurgical treat-
ment of isolated PCL injuries. Satis-
faction and return to activity were
not related to the amount of knee
instability measured instrumentally
but were related to quadriceps
function on Cybex testing. In a long-
term study of 133 patients who
underwent nonsurgical treatment of
acute, isolated grade I or II PCL
injuries, Shelbourne et al10 found no
correlation between knee laxity and
subjective knee scores or radio-
graphic changes. All patients except
two returned to athletic participa-
tion, although only 67 patients re-
turned to their preinjury sport and
performance level. However, Keller
et al34 found that patients with
greater ligamentous laxity had a
larger number of subjective com-
plaints, had lower knee scores, and
were less likely to return to their
preinjury activity level. In a study of
21 patients with grade I or II isolated
PCL injuries managed with the use of
a dynamic anterior drawer brace,

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Management of Posterior Cruciate Ligament Injuries: An Evidence-based Review

Table 3
Selected Clinical Outcomes of Surgical Management of Posterior Cruciate Ligament Injuries
Mean
Study (Level of Follow-up
Evidence) Injury Type (no. of pts) Techniques (mo) Outcomesa

Houe and Isolated PCL injury (16) SB or DB transtibial repair, 35 Lysholm score, 97.5; Tegner
Jørgensen40 BPTB autograft, or score, 6; posterior tibial
(II) hamstring autograft laxity, 3.0 mm at 30° and 70°
(DonJoy KLT)
Jackson Isolated PCL injury (23) SB transtibial repair, .120 Lysholm score, 90; IKDC
et al21 (II) Combined PCL and medial hamstring autograft score, 87; posterior drawer
collateral ligament test (neutral rotation): grade
injury (3) 0, 8 of 22 pts (36%); grade I,
12 of 22 pts (55%); grade II, 2
of 22 pts (9%); posterior tibial
laxity, 1.1 mm (KT-1000)
Li et al41 (II) Isolated PCL injury (46) SB transtibial or DB 30 Lysholm score, 88.9; Tegner
transtibial repair, tibialis score, 6.5; IKDC, 68.7
anterior allograft (subjective), 87 (objective);
posterior tibial laxity, 3.1 mm
(KT-1000)
Li et al42 (III) Isolated PCL injury (37) SB transtibial repair, 28 Lysholm score, 84.5; Tegner
hamstring autograft, or score, 6; IKDC, 76; posterior
tibialis anterior allograft drawer test (neutral rotation):
grade 0, 11 of 37 pts (30%);
grade I, 20 of 37 pts (54%);
grade II, 6 of 37 pts (16%);
posterior tibial laxity, 3.7 mm
(arthrometer)
McGuire and Isolated PCL or DB transtibial anatomic or 27 Lysholm score, 83.6; posterior
Hendricks43 multiligamentous injury DB transtibial nonanatomic drawer test (neutral rotation):
(III) (17) repair, Achilles tendon grade 0, 9 of 17 pts (53%);
allograft grade I, 6 of 17 pts (35%);
grade II, 2 of 17 pts (12%)

(continued )
a
Numerical outcome measures are mean values except as noted. When reported as a percentage, IKDC results refer to the percentage of patients
with normal or nearly normal scores.
BPTB = bone–patellar tendon–bone, DB = double-bundle, IKDC = International Knee Documentation Committee, PCL = posterior cruciate ligament,
SB = single-bundle

Jacobi et al35 found substantial
reduction in posterior tibial sag and
good to excellent functional results
in all patients at 1- to 2-year follow-
up. The outcomes of clinical studies
of nonsurgical management of PCL
injuries are summarized in Table 2.
In general, nonsurgical manage-
ment has been advocated for patients
with isolated grade I or II PCL
injuries or for those with grade III
injuries but mild symptoms or low
activity demands.3,13,25,32,33 In
studies of nonsurgical management,
favorable outcomes may be the
result of inclusion of patients with
low-grade PCL injuries, the com-
pensatory function of intact struc-
tures that serve as secondary
restraints on posterior tibial trans-
lation, and increased tibial slope in
included patients.25 Athletic patients
who sustain an in-season grade I or II
PCL injury should complete a pro-
gressive rehabilitation protocol that
includes specific criteria for return to
play, such as the criteria outlined by
Pierce et al.37 Patients must be
informed that nonsurgical manage-
ment is not curative and that pain,
instability, and activity limitations
may persist or even worsen despite
compliance with the nonsurgical
rehabilitation protocol.
Surgical
In 1917, Hey Groves38 published an
early technique for surgical recon-
struction of the PCL. The goals of
PCL reconstruction are to reproduce
the normal anterior tibial step-off,
restrain posterior tibial displace-
ment, and allow stable and pain-free
knee function.39 Surgical manage-
ment of isolated PCL injuries is
typically reserved for patients with
acute or chronic symptomatic grade

282 Journal of the American Academy of Orthopaedic Surgeons

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Table 3 (continued )
Selected Clinical Outcomes of Surgical Management of Posterior Cruciate Ligament Injuries
Study (Level of
Evidence) Injury Type (no. of pts)
Song et al22 (III) Isolated PCL injury (66)
Wang et al44 (I) Isolated PCL injury (55)
Wang et al45 (II) Isolated PCL injury (35)
Wong et al46 (I) Isolated PCL injury (55)
Yoon et al47 (II) Isolated PCL injury (53)
a
Numerical outcome measures are mean values except as noted. When reported as a percentage, IKDC results refer to the percentage of patients
with normal or nearly normal scores.
BPTB = bone–patellar tendon–bone, DB = double-bundle, IKDC = International Knee Documentation Committee, PCL = posterior cruciate ligament,
SB = single-bundle
III PCL injuries in whom nonsurgical
management was unsuccessful.
Outcomes of studies of surgical
management of PCL injuries are
summarized in Table 3.
Although reconstruction of the PCL
may reduce posterior tibial trans-
lation, results have been inconsistent
regarding the efficacy of the procedure
in restoring normal function and
kinematics. Few studies have reported
long-term results of reconstruction
of isolated PCL injuries. Jackson
et al21 reported 88% participation in
moderate to strenuous activity and
increased International Knee Docu-
mentation Committee (IKDC) and
May 2016, Vol 24, No 5
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Follow-up
Techniques
SB transtibial or SB open
inlay repair, hamstring
autograft, or BPTB
autograft
SB transtibial repair,
quadriceps tendon-patellar
bone autograft, Achilles
tendon allograft, hamstring
autograft, or tibialis anterior
allograft
SB or DB transtibial repair,
hamstring autograft
SB transtibial repair,
hamstring autograft
SB transtibial or DB
transtibial repair, Achilles
tendon allograft
Lysholm scores 10 years after PCL
reconstruction. However, 8 of 22
patients in the study had radiographic
evidence of grade II or III degenera-
tive changes. Hermans et al20 found
considerably improved IKDC and
Lysholm scores after reconstruction
despite persistently increased poste-
rior tibial translation. The authors
noted substantially worse functional
outcome scores among patients
treated surgically .1 year after injury
and patients who had cartilage dam-
age at the time of the procedure. In
another study, researchers found that
at a mean 7-year follow-up, 13 of 25
patients had no difference between
Asheesh Bedi, MD, et al
Mean
(mo) Outcomesa
141 Lysholm score, 90.9; Tegner
score, 5.9; posterior drawer
test (neutral rotation): grade
0 or I, 56 of 66 pts (85%);
grade II, 10 of 66 pts (15%);
posterior tibial laxity, 4.1 mm
(Telos)
34 Lysholm score, 89.7; Tegner
score, 4.7; IKDC, 67;
posterior drawer test (neutral
rotation): 0.8 mm, posterior
tibial laxity, 3.0 mm
(KT-1000)
41 Lysholm score, 88; Tegner
score, 4.8; IKDC, 69;
posterior drawer test (neutral
rotation): 1.1 mm; posterior
tibial laxity, 2.7 mm
(KT-1000)
47 Lysholm score, 89; Tegner
score, 4.7; IKDC, 74;
posterior drawer test (neutral
rotation): 0.9 mm; posterior
tibial laxity, 3.0 mm (KT-
1000)
32 Lysholm score, 90; Tegner
score, 6; IKDC, 81;
posterior tibial laxity, 3.8 mm
(Telos)
preoperative and postoperative pos-
terior tibial translation and 15 of 25
patients had radiographic evidence of
degenerative changes in the medial
and patellofemoral compartments.48
Single-bundle Versus
Double-bundle Reconstruction
Although the goal of single-bundle
reconstruction is to re-create the
tight flexion of the ALB, some
authors recommend a double-
bundle technique, in which both the
ALB and the PMB are reconstructed
in an effort to restore the function
and biomechanics of the native PCL.
In a cadaver study, Bergfeld et al49
283
Management of Posterior Cruciate Ligament Injuries: An Evidence-based Review
found no statistically significant
differences in instrumentally mea-
sured posterior tibial translation
between intact PCLs, single-bundle
reconstructions, and double-bundle
reconstructions. In other studies,
double-bundle reconstruction of the
PCL has been found to more closely
approximate native knee kinematics
and restraint of posterior tibial
translation compared with single-
bundle reconstruction.50,51
In a clinical study comparing single-
bundle reconstruction with bone–
patellar tendon–bone autograft and
double-bundle reconstruction with
hamstring autograft, Houe and
Jørgensen40 found no marked dif-
ferences in instrumentally measured
posterior tibial translation, activity
level, Tegner and Lysholm knee
scores, or patient satisfaction
between the two groups. In a ran-
domized study, Wang et al45 found
no differences between single- and
double-bundle reconstructions (all of
which used hamstring autograft)
with respect to functional assess-
ment, posterior tibial translation,
knee scores, or radiographic
changes. In both studies, the single-
and double-bundle reconstruction
groups demonstrated marked
improvement in Lysholm and Tegner
knee scores and satisfaction com-
pared with preoperative assessment.
Yoon et al47 found no difference in
range of motion or outcome scores
between single- and double-bundle
reconstruction groups but a consid-
erable decrease in posterior tibial
translation of 1.4 mm in the double-
bundle reconstruction group. The
authors of the study noted that the
clinical or functional relevance of
this difference was uncertain. Li
et al52 randomized patients to either
single- or double-bundle recon-
struction with tibialis anterior allo-
graft and found no substantial
difference in Lysholm and Tegner
scores between the two groups.
Compared with the single-bundle
284
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
group, however, the double-bundle
group had considerably better
objective IKDC grade distribution,
subjective IKDC score, and post-
operative side-to-side posterior tibial
translation measured with a KT-1000
arthrometer.
In a systematic review of bio-
mechanical and clinical studies com-
paring single- and double-bundle PCL
reconstruction, Kohen and Sekiya53
noted that comparison of these studies
is complicated by heterogeneity of
injuries and differences in study tech-
niques and design. They concluded
that further well-designed bio-
mechanical studies and prospective,
randomized clinical studies are needed
to determine the superiority of single-
or double-bundle PCL reconstruction.
Transtibial Tunnel Versus Tibial
Inlay Techniques
Advocates of the tibial inlay tech-
nique cite potential benefits includ-
ing bony healing, avoidance of graft
abrasion at the so-called killer tibial
turn, and use of large graft sizes.
Bergfeld et al54 compared trans-
tibial and tibial inlay PCL recon-
struction techniques in paired
cadaver knees and found sub-
stantially less instrumentally mea-
sured posterior tibial translation in
the inlay group. The authors also
noted graft thinning and fraying at
the so-called killer turn in the
transtibial group but no apprecia-
ble graft degradation in the inlay
group. In a subsequent cadaver
study, the inlay technique was
found to be superior to the trans-
tibial technique with respect to
graft failure, thinning, and perma-
nent elongation.55 Other cadaveric
studies revealed no substantial dif-
ferences between transtibial and
open tibial inlay techniques with
respect to knee laxity or posterior
tibial translation. 56,57
Clinical studies comparing the
transtibial and tibial inlay techniques
Journal of the American Academy of Orthopaedic Surgeons
have been published. Seon and Song58
found no considerable differences in
knee scores, activity levels, or
instrumentally measured posterior
tibial translation in 43 patients who
underwent either transtibial or open
tibial inlay reconstruction. A follow-
up study including 66 patients
again revealed no substantial clinical
differences between these recon-
struction techniques.22 MacGillivray
et al39 compared transtibial and tibial
inlay reconstructions and found no
considerable differences in posterior
drawer test results, instrumentally
measured knee laxity, functional test
results, or knee score outcome mea-
sures. However, both of these studies
used a variety of graft types, includ-
ing bone–patellar tendon–bone
autograft and allograft, hamstring
autograft, and Achilles tendon allo-
graft. Kim et al59 compared single-
bundle transtibial, single-bundle
arthroscopic inlay, and double-
bundle arthroscopic inlay recon-
struction techniques. They found a
significant difference in the mean
side-to-side difference in posterior
tibial translation between the trans-
tibial group (5.6 6 2.00 mm) and the
double-bundle arthroscopic inlay
group (3.6 6 1.43 mm), but no other
differences were found in posterior
tibial translation, knee range of
motion, or Lysholm knee scores.
Panchal and Sekiya60 reviewed
biomechanical and clinical studies
comparing arthroscopic transtibial
and open tibial inlay reconstruc-
tion techniques. They concluded
that the superiority of either tech-
nique remains uncertain because of
conflicting biomechanical studies
and the paucity of comparable
clinical studies.
Open Versus Arthroscopic Tibial
Inlay Techniques
The arthroscopic tibial inlay tech-
nique has been advocated to avert the
potential morbidity of an open

posterior incision, avoid the inconve-
nience of prone or lateral positioning,
and decrease the surgical time com-
pared with that of an open procedure.
Zehms et al61 found comparable
knee stability between double-bundle
arthroscopic inlay and open inlay
groups in a biomechanical cadaver
study. Long-term clinical studies
comparing these techniques are in
progress, but the superiority of either
an arthroscopic or open approach
has not been reported to date.
Repair of Posterior Cruciate
Ligament Avulsion Injuries
Avulsion injuries of the PCL occur at
the tibial or femoral attachments and
may be bony avulsions or so-called
peel-off injuries consisting of avul-
sion of the PCL without bony
involvement. Bony avulsions are
often visible on plain radiographs,
particularly on the lateral view (Fig-
ure 2). The use of CT can help to
further characterize the fracture.
Nonsurgical management of dis-
placed PCL avulsions is unlikely to
be successful because it does not
allow for adequate manipulation,
reduction, or stabilization of the bony
fragment. Good results have been re-
ported with several open and arthro-
scopic repair techniques, including
open reduction and internal fixation,
cannulated screw or Kirschner wire
fixation, transosseous suture repair,
and repair using suture anchors and
knotless anchors. To our knowledge,
no prospective randomized trials have
compared fixation techniques. There-
fore, the choice of fixation should be
based on the characteristics of the
injury and the surgeon’s experience.
Authors’ Preferred Technique
Several surgical techniques have re-
sulted in satisfactory clinical and
biomechanical outcomes. Here we
describe our preferred technique for
single-bundle transtibial reconstruc-
tion. For double-bundle reconstruc-
May 2016, Vol 24, No 5
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Asheesh Bedi, MD, et al
tion, we recommend the technique Figure 2
described by Forsythe et al.62
After induction of anesthesia and
administration of intravenous anti-
biotics, the affected extremity is
examined thoroughly and compared
with the contralateral extremity.
Tests should include the posterior
drawer test, the posterior sag test to
assess for loss of tibiofemoral offset,
and dynamic stress tests to assess for
insufficiency of the collateral liga-
ments, the PLC, and the poster-
omedial corner. The affected
extremity is prepped and draped. A
sterile tourniquet is placed high on
the thigh. Arthroscopy is initiated
with a 30° arthroscope in the stan-
dard anterolateral portal. The ante-
romedial portal is established with a
spinal needle under direct visualiza-
tion close to the patellar tendon and
relatively superior in order to
Lateral radiograph of the left knee
improve access and exposure to the
demonstrating a moderately
posterior aspect of the tibia. A
displaced posterior cruciate ligament
thorough diagnostic arthroscopy is avulsion-type injury (arrow) of the
performed, including meticulous tibial attachment in a 10-year-old girl
who sustained a posteriorly directed
inspection of all chondral surfaces,
force to the proximal anterior tibia of
the menisci, the patellofemoral
her flexed knee.
articulation, the suprapatellar
pouch, and the medial and lateral
recesses. The medial and lateral (Figure 4). The trajectory must allow
menisci are probed to evaluate for unencumbered access to the tibial
full-thickness or partial-thickness footprint. Dissection continues lat-
tears throughout the superior and erally behind the ACL and 10 to
inferior surfaces of the posterior 12 mm below the joint line until the
horn, body, and anterior horn. Par- cephalad border of the popliteus
ticular care should be taken to muscle fibers is identified. The tibial
identify and preserve posterior horn guide is placed on the inferior aspect
attachments (Figure 3). of the PCL facet (Figure 5), with care
The PCL is examined, and remnant taken to center the footprint at least
fibers are débrided. Care must be 10 mm distal to the joint line and just
taken to preserve the margins of the lateral to the posterior root of the
ligament footprints for subsequent medial meniscus. The working edge
tunnel placement. Intact residual of the tunnel will be anterior after
fibers and the meniscofemoral liga- tensioning. Therefore, it is critical
ments are preserved if they do not that the tunnel be located sufficiently
compromise visualization or expo- below the joint line and contained
sure. A posteromedial portal is es- within the PCL footprint. A nearly
tablished with a spinal needle under vertical trajectory for guide pin
direct visualization to ensure an placement minimizes the acuity of
appropriate trajectory for prepara- the turn of the graft at the posterior
tion of the PCL tibial footprint tibia. Fluoroscopy may be used in
285
Management of Posterior Cruciate Ligament Injuries: An Evidence-based Review
Figure 3
Intraoperative arthroscopic view of
the right knee obtained with a 30°
arthroscope through the anterolateral
portal demonstrating an intact medial
meniscus root.
Figure 4
Intraoperative arthroscopic view of
the right knee obtained with a 30°
arthroscope through the anterolateral
portal demonstrating a cannula
inserted through the posteromedial
portal. The posteromedial portal is
best created with the knee in flexion
and with needle guidance to ensure
an appropriate trajectory for
dissection of the tibial footprint of
the posterior cruciate ligament.
combination with direct arthro-
scopic visualization to confirm a
favorable trajectory and safe passage
of pins and reamers. The guide pin is
protected and advanced under direct
visualization with a 70° arthroscope.
Appropriate pin placement may be
confirmed with AP and lateral
286
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 5
Intraoperative arthroscopic view of
the right knee obtained with a 70°
arthroscope through the anterolateral
portal demonstrating the tibial
footprint of the posterior cruciate
ligament (PCL) and the position of the
tibial guide relative to the joint line.
The guide was placed via the
anteromedial portal. The footprint of
the PCL is centered at least 10 mm
distal to the joint line and just lateral to
the posterior root of the medial
meniscus.
Figure 6
Intraoperative arthroscopic view of
the right knee obtained with a 70°
arthroscope through the anterolateral
portal demonstrating drilling of the
tibial tunnel for the posterior cruciate
ligament. The reamer is visualized
completely during breaching of the
posterior cortex, and the pin is
protected from advancement during
reaming.
fluoroscopy. The pin is overreamed
in antegrade fashion until the pos-
Journal of the American Academy of Orthopaedic Surgeons
Figure 7
Intraoperative arthroscopic view of
the right knee obtained with a 30°
arthroscope through the anterolateral
portal demonstrating the femoral
footprint of the posterior cruciate
ligament. A single-bundle approach is
used in this procedure, which involves
reconstruction of multiple ligaments.
The tunnel is centered primarily within
the footprint of the anterolateral
bundle and shifts in a cephalad and
anterior direction when the patient’s
knee is flexed.
terior cortex is contacted. Because of
the close proximity to the posterior
neurovascular structures of the knee,
reaming is completed by hand under
direct visualization until the cortex is
breached (Figure 6). The margins of
the tunnel are rasped and freshened,
particularly anteriorly, to remove all
debris and minimize graft abrasion.
Attention now turns to the femoral
tunnel. We prefer to use an outside-in
preparation method with a retro-
grade cutting device or a standard
two-incision approach to minimize
the acuity of the graft turn and to
avoid the creation of a second killer
turn that would result from the use of
an inside-out drilling trajectory. If a
formal two-incision approach is
used, a small incision is centered just
proximal to the medial epicondyle.
The fascia of the vastus medialis
oblique is incised, and the muscle is
elevated to expose the distal femoral
metaphysis. A small periosteal win-
dow is created, and the outside-in

Figure 8
Intraoperative arthroscopic view
of the right knee obtained with a
30° arthroscope through the
anterolateral portal demonstrating
the posterior cruciate ligament
(arrow) reconstruction.
guide is centered within the femoral
footprint of the PCL. If a single-
tunnel approach is used, the guide is
centered primarily within the ALB
fibers, with the anterior tunnel mar-
gin located approximately 2 mm off
the chondral junction at the roof of
the notch (Figure 7). The femoral
tunnel is overreamed and prepared.
A shuttling stitch is used to pass the
graft through the tibial and femoral
tunnels. The graft is seated into
position and fixed with a cortical
fixation device and/or interference
fixation. With the graft under
maximum tension and the patient’s
knee in 90° of flexion, the graft is
fixed on the tibial side with an
interference screw and additional
suspensory fixation as needed, de-
pending on screw purchase and
bone quality. The trajectory and
obliqueness of the graft are con-
firmed (Figure 8). The graft is
trimmed. Incisions are irrigated and
closed in standard layered fashion.
Postoperative radiographs of the
knee following PCL reconstruction
are shown in Figure 9.
May 2016, Vol 24, No 5
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Asheesh Bedi, MD, et al
Figure 9
Postoperative AP (A) and lateral (B) radiographs demonstrating the right knee of
an 18-year-old man who underwent isolated, arthroscopically assisted
reconstruction of the posterior cruciate ligament with autogenous hamstring
autograft and semitendinosus allograft augmentation.
literature on rehabilitation of PCL
Rehabilitation injuries and proposed protocols for
nonsurgical and postoperative reha-
To achieve a successful outcome of
bilitation. Further evidence-based
either nonsurgical or surgical man-
research is needed to determine
agement, recovery of quadriceps
optimal rehabilitation protocols after
strength and knee range of motion is
nonsurgical and surgical manage-
crucial.13 Controlled activity should
ment of PCL injuries.
be balanced with the need to avoid
excessive stress on an incompletely
healed repair construct. Because of Summary
the lack of sufficient high-quality
evidence, no clear protocols have Isolated PCL injuries are uncommon
been developed to guide immobi- and require thorough clinical evalu-
lization, weight bearing, bracing,63 ation to ensure the absence of a
range of motion, strengthening, concomitant structural knee injury.
agility exercise programs, or post- The available literature consists pri-
operative rehabilitation.37 Although marily of level III or IV studies, and
some surgeons think that early or the ideal management of PCL
overly aggressive rehabilitation may injuries remains uncertain and con-
compromise postoperative knee troversial. Although biomechanical
stability, others argue that rehabil- studies have identified differences
itation should depend on the between surgical techniques, addi-
reconstruction technique. Pierce tional well-designed, long-term
et al37 reviewed the peer-reviewed clinical studies on a homogeneous
287
Management of Posterior Cruciate Ligament Injuries: An Evidence-based Review
population of patients with equiva-
lent injuries are needed to define the
optimal management algorithm and
reconstruction techniques.
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