Senior Project Sample
A Senior Project
Entitled
Posterior cruciate ligament Injuries: A literature Review
Submitted as partial fulfillment of the requirement for
The Bachelor of Science Degree in Exercise Science
Date: July 17, 2013
Table of Contents
Abstract ………………………………………………………….…………...p4
Key Words ...……………………………………………………….…p4
Introduction …………..……………………………………….……………...p5-6
Anatomy of PCL…………………………..………………………..…………p6-10
Femoral attachment of PCL ………………………………….……….p6-8
Tibial attachment of the PCL……………………………………….....p8-9
Causes of PCL Injuries…………………..…...……………….………..……...p10-12
Athletics...………………………………….… ……………………….p10-111 Hyperflexion…………....……………………………….…….p10 Hyperextension…………..….………….………….…...…..…p11
Motor vehicle …show more content…
accidents……………………….………………………p11 Pretibial Trauma……………………………..………………...p12
Degree of PCL Injuries ……....………………………………………………p12-13 Grade 1………………………………………….………………….p13 Grade 2…………………………………………………..……………p13 Grade3………………………………………………………………..p13
Diagnosis of PCL …………………………………………………………….p14-15 History………………………………………………………....p 14 Physical examination…………………………………………..p14-15 Posterior drawer test………………………………......p14 Muller test……………………………………………..p15 Godfrey’s test………………………………………….p15 Imaging………………………………………………………….p15
Treatment………………………………………………………………………p15-19
Nonsurgical treatment………………………………………………..p16 Physical therapy………………………………………………p16 Surgical treatment……………………………………………………..p16 Reparation of PCL……………………………………………p17 Reconstruction…………………………………………………p18-19 Prevention……………………………………………………………………..p19
Conclusion …………………………………………………………………….p19-20
Citations ………………………………………………………………………p21-23
Abstract Knee injuries are very common in sports.
The knee can be subjected to multiple injuries such as the disruption of the anterior cruciate ligament (ACL), disruption of the medial collateral ligament (MCL), and a wide range of other injuries. This paper will describe the anatomy of the Posterior cruciate ligament and focus on injuries associated with it. It will also describe the causes of PCL injuries and what kind of examination and treatment of the PCL, as well as ways to avoid this kind of injury. It will also describe the degree of
injury.
Key words: fiber/ fibre, supine, PCL
Posterior Cruciate Ligament Injuries Litterature Review
Knee injuries are the most common in athletics. The most common knee injury is anterior cruciate ligament (ACL) injury, but posterior cruciate ligament (PCL) injuries are also common in sports, especially in soccer. According to Carrol (2013) during the 2012-2013 seasons, there were multiple incidents causing posterior cruciate ligament injuries in the English Premier League (EPL). Knee injuries are something that can happen to anyone and it’s very common, especially for those who play sports and exercise regularly. In the United States, a lot of people are involved in competitive sports. According to Hilgers (2006) “there are an estimated 41 million American children playing competitive youth sports” (para. 3). The number of people involved in sports is only increasing because nowadays teachers, parents, doctors etc. encourage their students, patients or children to practice a sport to remain healthy. As the number of athletes increase, the rate of possible knee injuries also increases. In fact, twenty-five percent or more of sports- related injuries are knee injuries. PCL injuries are not as common as ACL injuries, and often times they go unrecognized. PCL is known to be stronger and broader than ACL. A lot of times the posterior cruciate ligament usually gets injured when a force is applied to the proximal tibia when the knee is at a 180 degree angle.
The majority of time PCL injuries happen to athletes such as soccer players, runners, football players, skiers, dancers, basketball players, and tennis players. This injury, however, is not only seen in athletics, for the knee is constantly under stress, even if an individual performs daily activities such as walking the dog or climbing the stairs. The knees get hit, twisted awkwardly, or even bent unintentionally. With the help of doctors, however, we can get back to our daily activities in no time.
In order to understand the injuries associated with PCL, it’s important to understand the anatomy of the PCL. The posterior cruciate ligament is located in the back of the knee. A large number of ligaments connect the femur to the tibia, and the PCL happens to be one of those ligaments. The posterior cruciate ligament prevents the tibia from moving too far backwards. An injury to the posterior cruciate ligament requires a huge amount of force. Therefore, in order to prevent such injuries, it’s important to understand how the PCL is attached to the femur and the tibia.
Femoral attachment of the PCL
A. Amis, et al. (2006) did a good job describing the femoral attachment of the PCL stating that”it extends more than 20 mm in an anterior–posterior (AP) direction across the roof and medial side of the femoral intercondylar notch. The PCL attachment is bounded distally by the margin of the articular cartilage of the medial femoral condyle and in general conforms to a ‘half-moon’ shape. The extent of the attachment is variable, and is influenced by the presence or absence of the meniscofemoral ligaments (MFL). In the specimen illustrated in Figure 2, the PCL attachment extends as far posteriorly as it can against the margin of the articular cartilage. In some knees, the attachment is more compact than this and does not extend so far posteriorly. Also, the PCL does not attach solely to the medial side of the femoral intercondylar notch, but also to the roof of the notch. A straight posterior–anterior view reveals that the anterior fibres of the PCL, which are the most lateral part of it, pass in a sagittal plane to the roof of the notch. In contrast, the posterior fibres take an oblique path as they pass up to the wall of the femoral condyle medially and down to the tibia laterally. When viewed from the anterior aspect of the flexed knee, the distal aspect of the PCL femoral attachment is revealed in the so-called ‘notch view’ as shown in Figure. 3. It can be seen that the fibres extend in the left knee from approximately 12 to 1 o’clock, at the top of the notch, back round from approximately the 7:30 to 8 o’clock position, which is adjacent to the tibial plateau. Thus, the entire medial aspect of the femoral intercondylar notch has the PCL attached to it in this view. The anterior meniscofemoral ligament (aMFL) of Humphrey slants across the PCL and also attaches adjacent to the femoral condylar articular cartilage” (p.257-263).
Amis and colleagues (2006) also stated that when the femoral attachment area of the PCL is viewed in the PCL- deficient knee, it is seen that the bulk of the attachment area that corresponds to the anterolateral (AL) bundle is between the 9 o’clock and 12 o’clock position in the left knee. The attachment also extends further down towards the tibial plateau that is posteriorly on the femur, as the posteromedial (PM) fibre bundle area. The shape and size of the anteromedial bundle is consistent in most knees; however, the variability in the size and shape of the PCL is mostly reflected in variations in the Posteromedial bundle (PMB) size both in midsubstance and its attachment. In some knees, the posterior meniscofemoral ligament (pMFL) is a significant and relatively large structure. This may have some bearing on PCL reconstruction technique, in that one may be able to replace the anterolateral bundle (ALB) alone if the pMFL is substantial and intact. Currently, however, this is simply a point of conjecture.
Tibial attachment of the PCL
According to Bruks and colleagues (1990),The posterior approach to the human knee is often time viewed as difficult and hazardous. Therefore, it is avoided when possible. For orthopedics surgeons, the most common indication for a direct posterior approach is bony avulsion of the posterior cruciate ligament (PCL). When looking at the tibial plateau closely, it is seen that the PCL attachment is relatively compact as shown in Figure 3. The attachment is placed between the posterior horns of the two menisci. The PCL tibial attachment is extended over the posterior rim of the shelf when viewed posteriorly. When observing Figure 3a, it can be seen that the attachment of the posteromedialfibre bundle includes the most posterior area above the shelf, and also the area below the shelf. Amis and colleagues (2006) state that” the Anterolateral bundle (ALB) occupies a central area covering almost the entire flat intercondylar surface of the posterior tibial plateau (posterior intercondylar fossa) from the posterior edge of the root of the posterior horn of the medial meniscus to within 2 mm of the posterior rim of the plateau. Its shape of the trapezoidal bundle (PMB) occupies a central area of the posterior surface of the tibia from immediately above the plateau rim” (p 257). According to Marshall and colleague (2006), the fibre anatomy of PCL can be divided into two main fibre bundles: Anterolateral (AL) and Posteromedial (PM). Each is very important in providing knee stability. The division between the two bundles is based on their different tightening and slackening behavior during knee flexion and extension. Both Kennedy (1979) and Detenbeck (1974) stated that the anterolateral fibers are tight in flexion and lax in extension, while the posteromedial fibers are tight in extension and lax in flexion. The split observed in Fig.3a is created by dissection. By observing Figure 3 a, it can be seen that the anterolateral bundle is attached mostly on the upper part of the intercondylar notch, while the posteromedial is attached mostly the medial side wall of the notch on to the medial femoral condyle. Some overlapping of the bundles can also be noted on the front to the back. The PMB is attached slightly proximal to the ALB. It’s important to know that the ALB has a larger cross- sectional than the PM, according to Amis (1994) it is also much stronger. Although the mid-substance proportions of the AL and PMBs are considerably different, the tibial attachments have much more similar areas.
Causes of PCL Injuries PCL injuries are not as common as other injuries associated with the knee. According to Evian Georgia (2013), the PCL injury account was between 3%- 20% of all knee injuries. Even though this type of injury is not very common, injuries can happen many different ways. It does not happen only to athletes who play sports, but to anyone; even a simple misstep can cause injuries. Below are some factors that can cause PCL injuries.
Athletics Injury Usually posterior cruciate ligament injuries occur when a force exceeds the strength of the ligament. As previously discussed, this kind of injury can happen by a simple misstep where the person doesn’t have contact with the ground. The person would probably hear a pop sound at the time of the injury causing the inability to continue activity. PCL injury can also occur as a result from contact, for example a tackle during a soccer game causing hyper flexion or hyper extension Hyperflexion By definition hyperflexion is the flexion of a limb or part beyond the normal limit. Fowler (1987) stated that the most common injury in sport is a hyper flexion injury, in which someone falls on their knee while it’s bent. According to Kanus and colleagues (1991) the (PCL) is the primary restraint preventing backward displacement of the leg upon the thigh. As the knee flexes, the anterolateral band of the PCL tightens. When the knee is flexed beyond its normal range unexpectedly, the tension of the PCL become greater and beyond its elastic limits a tear will take place Hyperextension Hyperextension by definition is the movement at a joint to a position beyond the joint 's normal maximum extension. According to Lee (1937), “hyperextension however can result in tearing of the PCL and posterior capsule”, and can progress to dislocation and neurovascular compromise (para 17). Observing Figure 4 one can see that the hyperextension of a knee can occur when the knee is bent upward passing the 180 degree, this injury is often occurred as a result of a back tackle playing soccer or a kick while the knee is already fully extend. A hyper extended knee can damage ligaments, cartilage and other stabilizing structures in the knee. Hyper extension of the knee is severe enough to cause swelling and pain. The knee’s stability should be evaluated by a doctor immediately. Janousek (1999) suggest to see a specialist if this kind of injury happen because the injury might not need surgery but , physical therapy may be needed to help restore leg strength and stability.
Motor Vehicle Injury
Car accidents are one of the main factors that cause PCL injuries. In a car crash, your knee is most likely going to hit the dashboard of a car, thus causing the injury. The injury will occur because of the position of the passengers in the car, for their knees are flexed, and during a collision, hypertension, or bending too far upwards, will mostly happen.
Pretibial Trauma
The most common traumatic mechanism is the dashboard injury. The knee is in a flexed position and a posteriorly directed force is applied to the pretibial area. An intrasubstance tear at the level of the tibial plateau or a tibial avulsion occurs. According to Janousek and colleagues (1999), “significant trauma will result in damage to the meniscofemoral ligaments. If the force is anteromedial and a rotational component is present the Posterolateral corner can be torn. Pretibial trauma with the knee near extension initially tightens the posteromedial bundle. Thus, the PCL may sleeve off its origin. These patients often have greater instability than the hyperflexion group.” Figure. 5 is an example of such injury.
Degree of PCL injuries
As previously stated, PCL injury occurs when the ligament is stretched or torn. Most of the time the PCL is injured while performing sports activities. PCL injury is common in athletics activities such as playing football, basketball and especially playing soccer and rugby. The PCL can tear when the athletes fall forward and land hard on the knee while it’s bent. The spraining of the PCL most commonly occurs when a person is involved in a car accident when the knee hits the dashboard. Similar to other types of sprains, PCL injuries are arranged depending on the degree of severity of the injury. The types of sprains are Grade I, Grade II and Grade III. Grade I A Grade I injury is a minor injury. Grade I sprains is a very small tear of the ligament. You can only see the tear with the help of a microscope. The ligament can be stretch out of shape but it is still able to maintain the integrity of the knee joint. Thus do not significantly affect the knee’s ability to support the weight of the individual in question. Grade II
In a Grade II sprains the knee is not fully stable, meaning it gives out from time to times when you stand for example and when you jump etc. When talking about Grade II sprains, doctor usually refer as a partial tear of the ligament. In a Grade II injury, no surgery is needed but however physical therapy is recommended Grade III
Grade III sprains as Figure 4 reveals is a completely tear of the ligament that link the femur to the tibia causing the knee to be unstable. Although the PCL is about two times stronger than the ACL, a large amount of weigh will cause a rupture in the ligament. Usually someone with a Grade III PCL sprain also sprain other ligaments such as anterior cruciate ligament ACL, medial collateral ligament MCL. There is a good chance that posterior cruciate ligament tears can heal on their own but with this type of tear surgery is without doubt needed. The good news is after the patient is fully recuperated he/she can play without knee stability problems.
Diagnosis of PCL Injuries
PCL injuries are not as common as they used to be in recent years, possibly it’s because people are more aware of it and doctors have better ways to recognize it. However it can be very difficult to diagnose it. Over the years, lots of different test have been developed and described to examine knee injuries bellow are the Posterior drawer test, Muller test and Godfrey’s test for the diagnostic of PCL injuries.
History
When a patient enters in the office of a doctor to find out what’s going on in their knee, the doctor will ask some information to have a better idea. He might ask some question like
What were you doing when the injury occurred
What position was your knee? Bent, straight
How long ago were you injured?
How did you feel right after you got injured?
The doctor would proceed to a physical examination performing those tests below.
Posterior drawer test: This test was modified and described by Hughston and colleagues in 1976 and was later described in a modern literature by Clancy and comrades in 1983 (Feltham, 2001). To perform this test, the patient stay on a supine position with the knee is being examined is flexed in a 90° angle while the other leg is lay flat on the surface. The examiner would try to stabilize the flexed knee by sitting on the patient’s leg. The doctor or whoever was diagnosing the injury would need to firmly hold the proximal lower leg, by the joint line and attempt to push it posteriorly. If there was an excessive posterior translation then, the test was positive. (Feltham, 2001).
Muller test: This test is performed in the same position as the posterior drawer test. The first thing the examiner would do according to Feltham (2001) was “examine the anterior silhouette of the proximal tibia form the side, and compare this to the uninjured contralateral knee. The patient is then asked to raise his or her foot of the table. A positive test reveals posterior sag of the proximal tibia initially, and anterior translation of the proximal tibia prior to the food leaving the table with attempted elevation of the foot” (para 2.)
Godfrey’s test: To perform the Godfrey’s test, the patient would lay flat on his back or on the supine position with the knee extended and closely together. The examiner would stand in the lateral side of the patient and lifts both of the patient’s lower legs and flex the knee and the hip at 90 degree angle and hold it. The lower legs need to be parallel to the surface. The examiner would then compare the level of the tibial tuberosity for both legs. Positive test reveal increase sag of the tibial tuberosity. Imaging
The doctor might ask the patient to do an x-ray because it provides a lot of information such as, if the injury is a partial tear, a complete tear of PCL. Just like Magnetic resonance imaging (MRI) is important to find problems such as cancer, tumor etc, it can also be used to detect the exact location of a tear in PCL injuries and can also provide more information about an x-ray imaging.
Treatment of PCL Posterior cruciate ligament can be treated surgically or non-surgically depending on the degree of the injury. Some surgical treatment still remains controversial so surgery might be at the doctor discretion. It’s important to know when an injury needs surgery or not.
Nonsurgical treatment
If someone has a posterior cruciate ligament injury of Grade I or a Grade II, the doctor may recommend to not undergo surgery. When first injured, the person should apply the RICE method. After consulting a doctor, he may recommend to keep follow the same method because it can speed up recovery. RICE is by definition
Rest the knee. It is recommended to not put pressure on the knee, crutches may be recommended as well as a brace to stabilize and prevent the knee from moving
Ice the injured area to reduce swelling. Ice the area for like 20 minutes and then take the ice pack off for 20 minutes then continue the same process. If keeping too long the Tissue might get injured.
Compress the swelling with an elastic bandage.
Elevate the injured area above the level of the heart. Physical therapy: If the knee is well rested you might not need to see a physical therapist as the injury will heal on its own but sometimes it’s important to see a therapist. The physical therapist will work with the patient to regain motion and functional strength. The physical therapist will teach the patient some exercises that help the knee get stronger as well as improve range of motion (ROM). The physical therapist might recommend protective bracing as well as crutches to rehabilitate the knee. Surgical treatment
Operative treatment will be recommended by any doctor if the injury is a Grade III injury or a combined injury. Usually in a Grade III injury multiple ligaments such as ACL, PCL, and MCL are damage simultaneously or completely disrupted. According to Levy (2012), there are still controversies in regard about timing (amount of time after the injury has occurred (example 2-4 months).) To perform surgery and whether a specialist should repair or reconstruct the combined cruciate and lateral-sided injuries when the injury is severe and surgery is required. A Grade III injury takes much longer to recover than a Grade I or Grade II, since surgery is required for a Grade III injury. PCL injury can be either chronic or acute. An acute PCL injury is when there is a sudden injury while a chronic injury develops as time passes. Iwamoto (2004) stated “surgical reconstruction of the PCL is recommended in acute injuries with severe posterior tibia subluxation and instability” (p.41-44) Reparation of PCL A doctor chose to repair a PCL only if he can reattach the fibers to each other. Here are the steps a specialist would take to repair a torn PCL according to Professor Michael J. Lysaght (2004).
1) “The surgeon enters the knee arthroscopically.
2) A suture punch is then used to pass sutures into the remaining PCL.
3) The sutures are then guided through a tunnel that is bored from the insertion site of the PCL through the femoral condyle, exiting on the medial border of the femur.
4) The sutures are then tied in a fisherman 's slip knot down to the bone, and then to each other.
5) After this, any associated capsular tearing is then repaired.” Reconstruction of PCL
If the specialist performing the surgery realize there isn’t enough good tissue to be save the PCL he would perform a reconstruction in which he will have to open the knee. Reconstruction of PCL will take longer than reparation of PCL. Below are the steps to reconstruct the ligament according to Professor Michael J. Lysaght (2004) at Brown University.
1) “The surgeon inspects the knee and removes the remains of the old PCL using an arthroscopic shave.
2) The graft which is used for reconstruction is harvested arthroscopically and prepared for the replacement. Usually the patellar tendon or the semitendinosis and gracilis tendon autografts are used in athletes.
3) After harvesting the tissue, a hole is drilled from the front of the tibia diagonally into the knee and ends up where the ACL attaches to the top of the shin. Next, the surgeon drills a hole in the femur between the two heads running diagonally and up from the middle to the outside. The PCL surgery differs from the ACL in that the bones are drilled from opposite sides. If both were to be performed at ones, the drills would form an X in the knee. This to simulate the actual way the ACL and PCL run in the knee.
4) The harvested replacement is attached to two long sutures, attached to the drill bit, and pulled into place through the holes which were just drilled.
5) The new ligament is then held into place by two bioabsorbable screws or metallic screws.
6) The knee is checked for stability and the surgeon carries out any other repairs.”
On average a patient take 6-9 months to recover fully after a PCL reconstruction it but sometimes it depends on the age and the health condition of the patient.
Prevention of PCL Injury PCL injury can happen to anyone; however it can be prevented if you follow some guidelines. To prevent PCL injuries and others associated knee injury in sports, one should
Warm up: usually run for about 5 minutes and sprint for short distance for 3 minutes
Stretch: It’s very important to stretch before practice or a game because it helps with mobility and flexibility of the soft tissues that surround joints. Do exercises that help strengthen the muscles that surround the knee such as: squat with Swiss ball, Resistance band knee extension in sitting, Resistance band hamstring curl,
Hydrate : it helps minimize cramps and at the same time maintain health
Don’t work out too hard or increase intensity all of the sudden
Wear protective equipment such as shin guards for example when playing soccer
Conclusion
Posterior cruciate ligament injuries can be very devastating. Most of the time this kind of injury happen in sports and in automobile accidents. PCL Injury is not as common as ACL injuries for this reason there isn’t much research about it and if often goes unrecognized. According to Rosenthal (2012) If PCL injury is not well treated in will eventually result in functional limitations and will progress in osteoarthritis. It’s very important to warm up and stretch before a game to prevent injuries as well as performing exercises that strengthen the muscles around the knee.
References
American Association Orthopaedic Society. 2009"Posterior Cruciate Ligament Injuries”-OrthoInfo - AAOS.
Amis AA.( 1999), Anatomy and biomechanics of the posterior cruciate ligament. Sports Med Arthrosc Rev, 7:225–234
Amis, A , Gupte M. & Edwards A. (2006), Anatomy of the posterior cruciate ligament and
Bruks, RT., Schaffer, MD. (1990), A simpled approach to the tibial attachment of the posterior cruciate ligament. Clinical orthopaedics an related research.; (254):216-9
Carrol,W.(2013, January 13) Wayne Rooney, Demba Ba: Knees Key in Premier League." Bleacher Report. http://bleacherreport.com/articles/1489813-wayne-rooney-demba-ba-knees-key-in-premier-league Detenbeck LC. (1974) Function of the cruciate ligaments in knee stability. Sports Med.; 2:217-221. Feltham, GT, Albright JP (2011) the Diagnosis of PCL Injury: Literature Review and Introduction of Two Novel Tests. Iowa Orthop J.; 21: 36–42.
Fowler PJ, Messieh SS. (1987) Isolated posterior cruciate ligament injuries in athletes Am J Sports Med;15:553-7
Girgis FG, Marshall JL, et al. (1975) the cruciate ligaments of the knee joint. anatomical, functional and experimental analysis. Clin Orthop 106:216–231
Hilgers, Laura.(2006,July 5).Youth Sports Drawing More than Ever. CNN. Cable News Network, 05 Retrieved from http://www.cnn.com/2006/US/07/03/rise.kids.sports/.
Iwamoto, J., Takeda, T., Suda, Y., Otami, T., & Matsumoto, H. (2004). Conservative treatment of isolated posterior cruciate ligament injury in professional baseball players: a report of two cases. The Knee, 11, 41-44.
Janousek AT, Jones et al (1999) . Posterior cruciate ligament injuries of the knee joint. J sports Med;28(60):429-41
Kanus P, Bergfeld J et al. (1991) Injuries to the posterior cruciate ligament of the knee. Sports Med; 12:110-31 Kennedy JC, Roth JH, Walker DM. ( 1979) Posterior cruciate ligament injuries. Orthop Digest.; 7:19-32
Laskowdki R. Hyperextended knee: Cause of serious Injury? Mayo clinic . 2012
Lee HG (1937). Avulsion fracture of the tibial attachments of the crucial ligaments. J Bone Joint Surg Am 19:460-8 Lysaght Michael J (2004). Posterior Cruciate Ligament Repair and Reconstruction Surgery. Retrieved from : http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group06/Group6project/Therapy/SurgeryPCL.htm
Race A, Amis AA.(1994) The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech, 27:13–24
Rosenthal, MD., & Rainey (2012) Evaluation and management of posterior cruciate ligament injuries. Physical therapy in sports, 13(4), 196-2012 themeniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 14: 257–263
Timothy R., Evan Georgia. The posterior cruciate ligament: Retrieved from http://www.hughston.com/hha/a.pcl.htm Accessed June 27, 2013
.
Entitled
Posterior cruciate ligament Injuries: A literature Review
Submitted as partial fulfillment of the requirement for
The Bachelor of Science Degree in Exercise Science
Date: July 17, 2013
Table of Contents
Abstract ………………………………………………………….…………...p4
Key Words ...……………………………………………………….…p4
Introduction …………..……………………………………….……………...p5-6
Anatomy of PCL…………………………..………………………..…………p6-10
Femoral attachment of PCL ………………………………….……….p6-8
Tibial attachment of the PCL……………………………………….....p8-9
Causes of PCL Injuries…………………..…...……………….………..……...p10-12
Athletics...………………………………….… ……………………….p10-111 Hyperflexion…………....……………………………….…….p10 Hyperextension…………..….………….………….…...…..…p11
Motor vehicle …show more content…
accidents……………………….………………………p11 Pretibial Trauma……………………………..………………...p12
Degree of PCL Injuries ……....………………………………………………p12-13 Grade 1………………………………………….………………….p13 Grade 2…………………………………………………..……………p13 Grade3………………………………………………………………..p13
Diagnosis of PCL …………………………………………………………….p14-15 History………………………………………………………....p 14 Physical examination…………………………………………..p14-15 Posterior drawer test………………………………......p14 Muller test……………………………………………..p15 Godfrey’s test………………………………………….p15 Imaging………………………………………………………….p15
Treatment………………………………………………………………………p15-19
Nonsurgical treatment………………………………………………..p16 Physical therapy………………………………………………p16 Surgical treatment……………………………………………………..p16 Reparation of PCL……………………………………………p17 Reconstruction…………………………………………………p18-19 Prevention……………………………………………………………………..p19
Conclusion …………………………………………………………………….p19-20
Citations ………………………………………………………………………p21-23
Abstract Knee injuries are very common in sports.
The knee can be subjected to multiple injuries such as the disruption of the anterior cruciate ligament (ACL), disruption of the medial collateral ligament (MCL), and a wide range of other injuries. This paper will describe the anatomy of the Posterior cruciate ligament and focus on injuries associated with it. It will also describe the causes of PCL injuries and what kind of examination and treatment of the PCL, as well as ways to avoid this kind of injury. It will also describe the degree of
injury.
Key words: fiber/ fibre, supine, PCL
Posterior Cruciate Ligament Injuries Litterature Review
Knee injuries are the most common in athletics. The most common knee injury is anterior cruciate ligament (ACL) injury, but posterior cruciate ligament (PCL) injuries are also common in sports, especially in soccer. According to Carrol (2013) during the 2012-2013 seasons, there were multiple incidents causing posterior cruciate ligament injuries in the English Premier League (EPL). Knee injuries are something that can happen to anyone and it’s very common, especially for those who play sports and exercise regularly. In the United States, a lot of people are involved in competitive sports. According to Hilgers (2006) “there are an estimated 41 million American children playing competitive youth sports” (para. 3). The number of people involved in sports is only increasing because nowadays teachers, parents, doctors etc. encourage their students, patients or children to practice a sport to remain healthy. As the number of athletes increase, the rate of possible knee injuries also increases. In fact, twenty-five percent or more of sports- related injuries are knee injuries. PCL injuries are not as common as ACL injuries, and often times they go unrecognized. PCL is known to be stronger and broader than ACL. A lot of times the posterior cruciate ligament usually gets injured when a force is applied to the proximal tibia when the knee is at a 180 degree angle.
The majority of time PCL injuries happen to athletes such as soccer players, runners, football players, skiers, dancers, basketball players, and tennis players. This injury, however, is not only seen in athletics, for the knee is constantly under stress, even if an individual performs daily activities such as walking the dog or climbing the stairs. The knees get hit, twisted awkwardly, or even bent unintentionally. With the help of doctors, however, we can get back to our daily activities in no time.
In order to understand the injuries associated with PCL, it’s important to understand the anatomy of the PCL. The posterior cruciate ligament is located in the back of the knee. A large number of ligaments connect the femur to the tibia, and the PCL happens to be one of those ligaments. The posterior cruciate ligament prevents the tibia from moving too far backwards. An injury to the posterior cruciate ligament requires a huge amount of force. Therefore, in order to prevent such injuries, it’s important to understand how the PCL is attached to the femur and the tibia.
Femoral attachment of the PCL
A. Amis, et al. (2006) did a good job describing the femoral attachment of the PCL stating that”it extends more than 20 mm in an anterior–posterior (AP) direction across the roof and medial side of the femoral intercondylar notch. The PCL attachment is bounded distally by the margin of the articular cartilage of the medial femoral condyle and in general conforms to a ‘half-moon’ shape. The extent of the attachment is variable, and is influenced by the presence or absence of the meniscofemoral ligaments (MFL). In the specimen illustrated in Figure 2, the PCL attachment extends as far posteriorly as it can against the margin of the articular cartilage. In some knees, the attachment is more compact than this and does not extend so far posteriorly. Also, the PCL does not attach solely to the medial side of the femoral intercondylar notch, but also to the roof of the notch. A straight posterior–anterior view reveals that the anterior fibres of the PCL, which are the most lateral part of it, pass in a sagittal plane to the roof of the notch. In contrast, the posterior fibres take an oblique path as they pass up to the wall of the femoral condyle medially and down to the tibia laterally. When viewed from the anterior aspect of the flexed knee, the distal aspect of the PCL femoral attachment is revealed in the so-called ‘notch view’ as shown in Figure. 3. It can be seen that the fibres extend in the left knee from approximately 12 to 1 o’clock, at the top of the notch, back round from approximately the 7:30 to 8 o’clock position, which is adjacent to the tibial plateau. Thus, the entire medial aspect of the femoral intercondylar notch has the PCL attached to it in this view. The anterior meniscofemoral ligament (aMFL) of Humphrey slants across the PCL and also attaches adjacent to the femoral condylar articular cartilage” (p.257-263).
Amis and colleagues (2006) also stated that when the femoral attachment area of the PCL is viewed in the PCL- deficient knee, it is seen that the bulk of the attachment area that corresponds to the anterolateral (AL) bundle is between the 9 o’clock and 12 o’clock position in the left knee. The attachment also extends further down towards the tibial plateau that is posteriorly on the femur, as the posteromedial (PM) fibre bundle area. The shape and size of the anteromedial bundle is consistent in most knees; however, the variability in the size and shape of the PCL is mostly reflected in variations in the Posteromedial bundle (PMB) size both in midsubstance and its attachment. In some knees, the posterior meniscofemoral ligament (pMFL) is a significant and relatively large structure. This may have some bearing on PCL reconstruction technique, in that one may be able to replace the anterolateral bundle (ALB) alone if the pMFL is substantial and intact. Currently, however, this is simply a point of conjecture.
Tibial attachment of the PCL
According to Bruks and colleagues (1990),The posterior approach to the human knee is often time viewed as difficult and hazardous. Therefore, it is avoided when possible. For orthopedics surgeons, the most common indication for a direct posterior approach is bony avulsion of the posterior cruciate ligament (PCL). When looking at the tibial plateau closely, it is seen that the PCL attachment is relatively compact as shown in Figure 3. The attachment is placed between the posterior horns of the two menisci. The PCL tibial attachment is extended over the posterior rim of the shelf when viewed posteriorly. When observing Figure 3a, it can be seen that the attachment of the posteromedialfibre bundle includes the most posterior area above the shelf, and also the area below the shelf. Amis and colleagues (2006) state that” the Anterolateral bundle (ALB) occupies a central area covering almost the entire flat intercondylar surface of the posterior tibial plateau (posterior intercondylar fossa) from the posterior edge of the root of the posterior horn of the medial meniscus to within 2 mm of the posterior rim of the plateau. Its shape of the trapezoidal bundle (PMB) occupies a central area of the posterior surface of the tibia from immediately above the plateau rim” (p 257). According to Marshall and colleague (2006), the fibre anatomy of PCL can be divided into two main fibre bundles: Anterolateral (AL) and Posteromedial (PM). Each is very important in providing knee stability. The division between the two bundles is based on their different tightening and slackening behavior during knee flexion and extension. Both Kennedy (1979) and Detenbeck (1974) stated that the anterolateral fibers are tight in flexion and lax in extension, while the posteromedial fibers are tight in extension and lax in flexion. The split observed in Fig.3a is created by dissection. By observing Figure 3 a, it can be seen that the anterolateral bundle is attached mostly on the upper part of the intercondylar notch, while the posteromedial is attached mostly the medial side wall of the notch on to the medial femoral condyle. Some overlapping of the bundles can also be noted on the front to the back. The PMB is attached slightly proximal to the ALB. It’s important to know that the ALB has a larger cross- sectional than the PM, according to Amis (1994) it is also much stronger. Although the mid-substance proportions of the AL and PMBs are considerably different, the tibial attachments have much more similar areas.
Causes of PCL Injuries PCL injuries are not as common as other injuries associated with the knee. According to Evian Georgia (2013), the PCL injury account was between 3%- 20% of all knee injuries. Even though this type of injury is not very common, injuries can happen many different ways. It does not happen only to athletes who play sports, but to anyone; even a simple misstep can cause injuries. Below are some factors that can cause PCL injuries.
Athletics Injury Usually posterior cruciate ligament injuries occur when a force exceeds the strength of the ligament. As previously discussed, this kind of injury can happen by a simple misstep where the person doesn’t have contact with the ground. The person would probably hear a pop sound at the time of the injury causing the inability to continue activity. PCL injury can also occur as a result from contact, for example a tackle during a soccer game causing hyper flexion or hyper extension Hyperflexion By definition hyperflexion is the flexion of a limb or part beyond the normal limit. Fowler (1987) stated that the most common injury in sport is a hyper flexion injury, in which someone falls on their knee while it’s bent. According to Kanus and colleagues (1991) the (PCL) is the primary restraint preventing backward displacement of the leg upon the thigh. As the knee flexes, the anterolateral band of the PCL tightens. When the knee is flexed beyond its normal range unexpectedly, the tension of the PCL become greater and beyond its elastic limits a tear will take place Hyperextension Hyperextension by definition is the movement at a joint to a position beyond the joint 's normal maximum extension. According to Lee (1937), “hyperextension however can result in tearing of the PCL and posterior capsule”, and can progress to dislocation and neurovascular compromise (para 17). Observing Figure 4 one can see that the hyperextension of a knee can occur when the knee is bent upward passing the 180 degree, this injury is often occurred as a result of a back tackle playing soccer or a kick while the knee is already fully extend. A hyper extended knee can damage ligaments, cartilage and other stabilizing structures in the knee. Hyper extension of the knee is severe enough to cause swelling and pain. The knee’s stability should be evaluated by a doctor immediately. Janousek (1999) suggest to see a specialist if this kind of injury happen because the injury might not need surgery but , physical therapy may be needed to help restore leg strength and stability.
Motor Vehicle Injury
Car accidents are one of the main factors that cause PCL injuries. In a car crash, your knee is most likely going to hit the dashboard of a car, thus causing the injury. The injury will occur because of the position of the passengers in the car, for their knees are flexed, and during a collision, hypertension, or bending too far upwards, will mostly happen.
Pretibial Trauma
The most common traumatic mechanism is the dashboard injury. The knee is in a flexed position and a posteriorly directed force is applied to the pretibial area. An intrasubstance tear at the level of the tibial plateau or a tibial avulsion occurs. According to Janousek and colleagues (1999), “significant trauma will result in damage to the meniscofemoral ligaments. If the force is anteromedial and a rotational component is present the Posterolateral corner can be torn. Pretibial trauma with the knee near extension initially tightens the posteromedial bundle. Thus, the PCL may sleeve off its origin. These patients often have greater instability than the hyperflexion group.” Figure. 5 is an example of such injury.
Degree of PCL injuries
As previously stated, PCL injury occurs when the ligament is stretched or torn. Most of the time the PCL is injured while performing sports activities. PCL injury is common in athletics activities such as playing football, basketball and especially playing soccer and rugby. The PCL can tear when the athletes fall forward and land hard on the knee while it’s bent. The spraining of the PCL most commonly occurs when a person is involved in a car accident when the knee hits the dashboard. Similar to other types of sprains, PCL injuries are arranged depending on the degree of severity of the injury. The types of sprains are Grade I, Grade II and Grade III. Grade I A Grade I injury is a minor injury. Grade I sprains is a very small tear of the ligament. You can only see the tear with the help of a microscope. The ligament can be stretch out of shape but it is still able to maintain the integrity of the knee joint. Thus do not significantly affect the knee’s ability to support the weight of the individual in question. Grade II
In a Grade II sprains the knee is not fully stable, meaning it gives out from time to times when you stand for example and when you jump etc. When talking about Grade II sprains, doctor usually refer as a partial tear of the ligament. In a Grade II injury, no surgery is needed but however physical therapy is recommended Grade III
Grade III sprains as Figure 4 reveals is a completely tear of the ligament that link the femur to the tibia causing the knee to be unstable. Although the PCL is about two times stronger than the ACL, a large amount of weigh will cause a rupture in the ligament. Usually someone with a Grade III PCL sprain also sprain other ligaments such as anterior cruciate ligament ACL, medial collateral ligament MCL. There is a good chance that posterior cruciate ligament tears can heal on their own but with this type of tear surgery is without doubt needed. The good news is after the patient is fully recuperated he/she can play without knee stability problems.
Diagnosis of PCL Injuries
PCL injuries are not as common as they used to be in recent years, possibly it’s because people are more aware of it and doctors have better ways to recognize it. However it can be very difficult to diagnose it. Over the years, lots of different test have been developed and described to examine knee injuries bellow are the Posterior drawer test, Muller test and Godfrey’s test for the diagnostic of PCL injuries.
History
When a patient enters in the office of a doctor to find out what’s going on in their knee, the doctor will ask some information to have a better idea. He might ask some question like
What were you doing when the injury occurred
What position was your knee? Bent, straight
How long ago were you injured?
How did you feel right after you got injured?
The doctor would proceed to a physical examination performing those tests below.
Posterior drawer test: This test was modified and described by Hughston and colleagues in 1976 and was later described in a modern literature by Clancy and comrades in 1983 (Feltham, 2001). To perform this test, the patient stay on a supine position with the knee is being examined is flexed in a 90° angle while the other leg is lay flat on the surface. The examiner would try to stabilize the flexed knee by sitting on the patient’s leg. The doctor or whoever was diagnosing the injury would need to firmly hold the proximal lower leg, by the joint line and attempt to push it posteriorly. If there was an excessive posterior translation then, the test was positive. (Feltham, 2001).
Muller test: This test is performed in the same position as the posterior drawer test. The first thing the examiner would do according to Feltham (2001) was “examine the anterior silhouette of the proximal tibia form the side, and compare this to the uninjured contralateral knee. The patient is then asked to raise his or her foot of the table. A positive test reveals posterior sag of the proximal tibia initially, and anterior translation of the proximal tibia prior to the food leaving the table with attempted elevation of the foot” (para 2.)
Godfrey’s test: To perform the Godfrey’s test, the patient would lay flat on his back or on the supine position with the knee extended and closely together. The examiner would stand in the lateral side of the patient and lifts both of the patient’s lower legs and flex the knee and the hip at 90 degree angle and hold it. The lower legs need to be parallel to the surface. The examiner would then compare the level of the tibial tuberosity for both legs. Positive test reveal increase sag of the tibial tuberosity. Imaging
The doctor might ask the patient to do an x-ray because it provides a lot of information such as, if the injury is a partial tear, a complete tear of PCL. Just like Magnetic resonance imaging (MRI) is important to find problems such as cancer, tumor etc, it can also be used to detect the exact location of a tear in PCL injuries and can also provide more information about an x-ray imaging.
Treatment of PCL Posterior cruciate ligament can be treated surgically or non-surgically depending on the degree of the injury. Some surgical treatment still remains controversial so surgery might be at the doctor discretion. It’s important to know when an injury needs surgery or not.
Nonsurgical treatment
If someone has a posterior cruciate ligament injury of Grade I or a Grade II, the doctor may recommend to not undergo surgery. When first injured, the person should apply the RICE method. After consulting a doctor, he may recommend to keep follow the same method because it can speed up recovery. RICE is by definition
Rest the knee. It is recommended to not put pressure on the knee, crutches may be recommended as well as a brace to stabilize and prevent the knee from moving
Ice the injured area to reduce swelling. Ice the area for like 20 minutes and then take the ice pack off for 20 minutes then continue the same process. If keeping too long the Tissue might get injured.
Compress the swelling with an elastic bandage.
Elevate the injured area above the level of the heart. Physical therapy: If the knee is well rested you might not need to see a physical therapist as the injury will heal on its own but sometimes it’s important to see a therapist. The physical therapist will work with the patient to regain motion and functional strength. The physical therapist will teach the patient some exercises that help the knee get stronger as well as improve range of motion (ROM). The physical therapist might recommend protective bracing as well as crutches to rehabilitate the knee. Surgical treatment
Operative treatment will be recommended by any doctor if the injury is a Grade III injury or a combined injury. Usually in a Grade III injury multiple ligaments such as ACL, PCL, and MCL are damage simultaneously or completely disrupted. According to Levy (2012), there are still controversies in regard about timing (amount of time after the injury has occurred (example 2-4 months).) To perform surgery and whether a specialist should repair or reconstruct the combined cruciate and lateral-sided injuries when the injury is severe and surgery is required. A Grade III injury takes much longer to recover than a Grade I or Grade II, since surgery is required for a Grade III injury. PCL injury can be either chronic or acute. An acute PCL injury is when there is a sudden injury while a chronic injury develops as time passes. Iwamoto (2004) stated “surgical reconstruction of the PCL is recommended in acute injuries with severe posterior tibia subluxation and instability” (p.41-44) Reparation of PCL A doctor chose to repair a PCL only if he can reattach the fibers to each other. Here are the steps a specialist would take to repair a torn PCL according to Professor Michael J. Lysaght (2004).
1) “The surgeon enters the knee arthroscopically.
2) A suture punch is then used to pass sutures into the remaining PCL.
3) The sutures are then guided through a tunnel that is bored from the insertion site of the PCL through the femoral condyle, exiting on the medial border of the femur.
4) The sutures are then tied in a fisherman 's slip knot down to the bone, and then to each other.
5) After this, any associated capsular tearing is then repaired.” Reconstruction of PCL
If the specialist performing the surgery realize there isn’t enough good tissue to be save the PCL he would perform a reconstruction in which he will have to open the knee. Reconstruction of PCL will take longer than reparation of PCL. Below are the steps to reconstruct the ligament according to Professor Michael J. Lysaght (2004) at Brown University.
1) “The surgeon inspects the knee and removes the remains of the old PCL using an arthroscopic shave.
2) The graft which is used for reconstruction is harvested arthroscopically and prepared for the replacement. Usually the patellar tendon or the semitendinosis and gracilis tendon autografts are used in athletes.
3) After harvesting the tissue, a hole is drilled from the front of the tibia diagonally into the knee and ends up where the ACL attaches to the top of the shin. Next, the surgeon drills a hole in the femur between the two heads running diagonally and up from the middle to the outside. The PCL surgery differs from the ACL in that the bones are drilled from opposite sides. If both were to be performed at ones, the drills would form an X in the knee. This to simulate the actual way the ACL and PCL run in the knee.
4) The harvested replacement is attached to two long sutures, attached to the drill bit, and pulled into place through the holes which were just drilled.
5) The new ligament is then held into place by two bioabsorbable screws or metallic screws.
6) The knee is checked for stability and the surgeon carries out any other repairs.”
On average a patient take 6-9 months to recover fully after a PCL reconstruction it but sometimes it depends on the age and the health condition of the patient.
Prevention of PCL Injury PCL injury can happen to anyone; however it can be prevented if you follow some guidelines. To prevent PCL injuries and others associated knee injury in sports, one should
Warm up: usually run for about 5 minutes and sprint for short distance for 3 minutes
Stretch: It’s very important to stretch before practice or a game because it helps with mobility and flexibility of the soft tissues that surround joints. Do exercises that help strengthen the muscles that surround the knee such as: squat with Swiss ball, Resistance band knee extension in sitting, Resistance band hamstring curl,
Hydrate : it helps minimize cramps and at the same time maintain health
Don’t work out too hard or increase intensity all of the sudden
Wear protective equipment such as shin guards for example when playing soccer
Conclusion
Posterior cruciate ligament injuries can be very devastating. Most of the time this kind of injury happen in sports and in automobile accidents. PCL Injury is not as common as ACL injuries for this reason there isn’t much research about it and if often goes unrecognized. According to Rosenthal (2012) If PCL injury is not well treated in will eventually result in functional limitations and will progress in osteoarthritis. It’s very important to warm up and stretch before a game to prevent injuries as well as performing exercises that strengthen the muscles around the knee.
References
American Association Orthopaedic Society. 2009"Posterior Cruciate Ligament Injuries”-OrthoInfo - AAOS.
Amis AA.( 1999), Anatomy and biomechanics of the posterior cruciate ligament. Sports Med Arthrosc Rev, 7:225–234
Amis, A , Gupte M. & Edwards A. (2006), Anatomy of the posterior cruciate ligament and
Bruks, RT., Schaffer, MD. (1990), A simpled approach to the tibial attachment of the posterior cruciate ligament. Clinical orthopaedics an related research.; (254):216-9
Carrol,W.(2013, January 13) Wayne Rooney, Demba Ba: Knees Key in Premier League." Bleacher Report. http://bleacherreport.com/articles/1489813-wayne-rooney-demba-ba-knees-key-in-premier-league Detenbeck LC. (1974) Function of the cruciate ligaments in knee stability. Sports Med.; 2:217-221. Feltham, GT, Albright JP (2011) the Diagnosis of PCL Injury: Literature Review and Introduction of Two Novel Tests. Iowa Orthop J.; 21: 36–42.
Fowler PJ, Messieh SS. (1987) Isolated posterior cruciate ligament injuries in athletes Am J Sports Med;15:553-7
Girgis FG, Marshall JL, et al. (1975) the cruciate ligaments of the knee joint. anatomical, functional and experimental analysis. Clin Orthop 106:216–231
Hilgers, Laura.(2006,July 5).Youth Sports Drawing More than Ever. CNN. Cable News Network, 05 Retrieved from http://www.cnn.com/2006/US/07/03/rise.kids.sports/.
Iwamoto, J., Takeda, T., Suda, Y., Otami, T., & Matsumoto, H. (2004). Conservative treatment of isolated posterior cruciate ligament injury in professional baseball players: a report of two cases. The Knee, 11, 41-44.
Janousek AT, Jones et al (1999) . Posterior cruciate ligament injuries of the knee joint. J sports Med;28(60):429-41
Kanus P, Bergfeld J et al. (1991) Injuries to the posterior cruciate ligament of the knee. Sports Med; 12:110-31 Kennedy JC, Roth JH, Walker DM. ( 1979) Posterior cruciate ligament injuries. Orthop Digest.; 7:19-32
Laskowdki R. Hyperextended knee: Cause of serious Injury? Mayo clinic . 2012
Lee HG (1937). Avulsion fracture of the tibial attachments of the crucial ligaments. J Bone Joint Surg Am 19:460-8 Lysaght Michael J (2004). Posterior Cruciate Ligament Repair and Reconstruction Surgery. Retrieved from : http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group06/Group6project/Therapy/SurgeryPCL.htm
Race A, Amis AA.(1994) The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech, 27:13–24
Rosenthal, MD., & Rainey (2012) Evaluation and management of posterior cruciate ligament injuries. Physical therapy in sports, 13(4), 196-2012 themeniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 14: 257–263
Timothy R., Evan Georgia. The posterior cruciate ligament: Retrieved from http://www.hughston.com/hha/a.pcl.htm Accessed June 27, 2013
.