History

Fact Explanation
Knee pain In isolated Posterior Cruciate Ligament Injuries,knee pain is often subtle and more difficult to evaluate than other ligament injuries.It usually occurs along with injuries to other structures in the knee such as cartilage, other ligaments, and bone. The pain is felt predominantly in the retropatellar area and medial compartment. This is most prevalent with long distance walking and descending stairs. Patient usually has a history of a direct blow to the front of the knee,bent knee hitting a dashboard in a car crash, or a fall onto a bent knee in sports,twisting or hyperextension.Patients usually reports hearing a “pop” at time of injury. However "pop'' sound is less distinctive in posterior cruciate ligament injuries than anterior cruciate ligament injuries. [1,2]
Knee swelling occurs steadily and quickly after the injury due to joint effusion. [1,2]
Difficulty in walking Swelling that makes the knee stiff and may cause a limp.The knee feels unstable, like it may "give out". [1,2]
Restriction in knee movements Patient usually complains of difficulty in knee flexion.This is due to joint effusion initially, followed by pain. [1,2]
References
  1. COLVIN,A.C, R.J. MEISLIN, Posterior cruciate ligament injuries in the athlete: diagnosis and treatment [online],Bull NYU Hosp Jt Dis. 2009,67(1),45-51. [viewed 26 April 2014]. Available from: http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=dff59f6f-92ea-496b-9c1c-685b79819c60
  2. LEE,B.K. et al. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles [online],Knee Surg Relat Res 2011,23(3),135-141. [viewed 26 April 2014]. Available from: http://dx.doi.org/10.5792/ksrr.2011.23.3.135

Examination

Fact Explanation
Vascular examination of the lower limb This is important because Posterion cruciate ligament injury may be accompanied by a popliteal artery injury.So distal arterial pulses should be checked.If pulse is weak or ankle-brachial index is low, further evaluation should be done immediately. [1]
Joint swelling Rapidly develops due to joint effusion.[1]
Restricted range of movements of the knee Initial restriction of movements (flexion) occurs due to effusion and further restriction occurs due to the pain. [1,2]
Posterior drawer test The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner sits on the patient's feet and grasps the patient's tibia and pulls it backward. If the tibia pulls backward more than normal, the test is considered positive.In poterior cruciate ligament injury this test becomes positive as the function of posterior cruciate Ligament Injury is to hold tibia in place so that it doesn't slip over femur. (sensitivity 79%, specificity 100%).However, these tests can be unreliable with severe swelling of the joint. The grade is determined by the extent of laxity measured during examination. [1,2,3]
Quadriceps active test Involved limb is kept in a position of 45 degrees hip flexion and 90 degrees of knee flexion. Look for the tibia to "sag" compared to the position of the femur. The examiner should then sit on the foot of the affected limb to stabilize. Next, patient is asked to actively contract their quadriceps muscle. A positive test occurs if the patient's tibia shifts forward. However, these tests can be unreliable with severe swelling of the joint. [2,3]
References
  1. LEE,B.K. et al. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles [online],Knee Surg Relat Res 2011,23(3),135-141. [viewed 26 April 2014]. Available from: http://dx.doi.org/10.5792/ksrr.2011.23.3.135
  2. COLVIN,A.C, R.J. MEISLIN, Posterior cruciate ligament injuries in the athlete: diagnosis and treatment [online],Bull NYU Hosp Jt Dis. 2009,67(1),45-51. [viewed 26 April 2014]. Available from: http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=dff59f6f-92ea-496b-9c1c-685b79819c60
  3. SCONEY,B. Sports knee injuries - assessment and management[online],Aust Fam Physician. 2010 Jan-Feb,39(1-2),30-4 [viewed 26 April 2014]. Available from: http://www.racgp.org.au/afp/201001/35839

Differential Diagnoses

Fact Explanation
Anterior Cruciate Ligament Injury Injury Presents with knee pain and swelling. Occurs after a blow to the back of the tibia with our without rotation. Feeling of giving away of the knee. On examination there is reduced range of movement of the knee. While Lachman's Test and anterior drawer test will be positive.[1]
Lateral Collateral Knee Ligament Commonly has a history of varus force applied to the knee.Knee pain and swelling followed by locking or catching of the knee with movement. [1]
Meniscus Injuries Sharp, stabbing pain that is more prominent during tortional or weight bearing movements of the knee. Followed by a dull aching pain that lasts several hours. Meniscal injuries can cause a synovitis that stretches the knee joint capsule causing pain. Abnormal motion at the knee due to an unstable meniscus fragment may also contribute. [2]
Medial Collateral Knee Ligament Injury Knee pain is worsened by standing or stressing. Patient complains of a tearing or ripping sensation along the inner joint line of the knee. There is swelling and instability at the knee joint. On examination there is tenderness at the insertion of the MCL into the upper medial tibia. While a valgus stress test will reveal laxity and/or pain.[1]
References
  1. GREGORY A, MD SCHMALE. Adolescent Knee Pain Management, Pediatric Annals, 2013 March, 42,3,122-127. [viewed 8 March 2014]. Available from: DOI 10.3928/00904481-20130222-12.
  2. SHIRAEV T. et al. Meniscal tear - presentation, diagnosis and management. Australian Family Physician. 2012 Apr,41(4),182-7. [viewed 8 March 2014]. Available from: http://www.racgp.org.au/afp/201204/46219

Investigations - for Diagnosis

Fact Explanation
X-ray Usually anteroposterior, lateral, and Merchant views of the knee are taken.Though it does not show ligament tears,associated avulsion fractures and posterior subluxations are well demonstrated by radiography. It may also show presence of varus malalignment,specially on a standing X-ray. tibial plateau fracture can indicate a more severe injury. [1,2]
Magnetic resonance imaging (MRI) Diagnostic of posterior cruciate Ligament Injurise. (sensitivity - 97%) A MRI will confirm posterior cruciate Ligament Injury and exclude associated injuries such as bony avulsion, meniscal tears and chondral damages. [1,2,3]
Arthroscopy Useful in acute cases.posterior cruciate ligament ruptures can be visualized with arthroscopy or evidenced by hemorrhage.[2]
References
  1. COLVIN,A.C, R.J. MEISLIN, Posterior cruciate ligament injuries in the athlete: diagnosis and treatment [online],Bull NYU Hosp Jt Dis. 2009,67(1),45-51. [viewed 26 April 2014]. Available from: http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=dff59f6f-92ea-496b-9c1c-685b79819c60
  2. LEE,B.K. et al. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles [online],Knee Surg Relat Res 2011,23(3),135-141. [viewed 26 April 2014]. Available from: http://dx.doi.org/10.5792/ksrr.2011.23.3.135
  3. SCONEY,B. Sports knee injuries - assessment and management[online],Aust Fam Physician. 2010 Jan-Feb,39(1-2),30-4 [viewed 26 April 2014]. Available from: http://www.racgp.org.au/afp/201001/35839

Investigations - Screening/Staging

Fact Explanation
X-ray Stress radiographs have been advocated to help differentiate between complete and partial PCL tears. [1,2]
Magnetic resonance imaging (MRI) Grading of posterior cruciate Ligament Injury is best done with MRI along with physical examination. Grade 1 is a mild ligament damage.The ligament is mildly damaged and slightly stretched, but is still able to help keep the knee joint stable. Grade 2 is a partial tearing of the ligament.The ligament is stretched to the point where it becomes loose. Grade 3 is a complete tearing of the ligament.It has split into two pieces, and the knee joint is unstable. [1,2]
References
  1. COLVIN,A.C, R.J. MEISLIN, Posterior cruciate ligament injuries in the athlete: diagnosis and treatment [online],Bull NYU Hosp Jt Dis. 2009,67(1),45-51. [viewed 26 April 2014]. Available from: http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=dff59f6f-92ea-496b-9c1c-685b79819c60
  2. LEE,B.K. et al. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles [online],Knee Surg Relat Res 2011,23(3),135-141. [viewed 26 April 2014]. Available from: http://dx.doi.org/10.5792/ksrr.2011.23.3.135

Management - General Measures

Fact Explanation
Rest Appropriate as initial management; however complete inactivity or immobilization should be avoided to prevent the possibility of disuse atrophy, which will affect rehabilitation. Activities that cause pain should be limited. This includes running, jumping, and weight lifting using the legs. [2,3]
Application of ice Provides local vasoconstrictive and analgesic effects. [2,3]
Knee brace Stabilize the knee and reduces movements.Compression can help prevent more swelling. [1,2]
Crutches keep extra weight off the knee. [3]
Physical therapy Once the symptoms have settled, physical therapy is beneficial to improve knee motion and strength.Optimal recovery will be achieved through a guided rehabilitation program over 6–10 weeks. Exercises for quadriceps and hip strengthening should be done. These non surgical conservative methods are mostly used in grade 1 and 2 injuries. [2,3]
Non steroidal anti-inflammatory drugs. (NSAIDs) NSAIDs provide pain relief. Topical application can be supplemented by oral NSAIDs if needed. [1]
References
  1. LEE,B.K. et al. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles [online],Knee Surg Relat Res 2011,23(3),135-141. [viewed 26 April 2014]. Available from: http://dx.doi.org/10.5792/ksrr.2011.23.3.135
  2. COLVIN,A.C, R.J. MEISLIN, Posterior cruciate ligament injuries in the athlete: diagnosis and treatment [online],Bull NYU Hosp Jt Dis. 2009,67(1),45-51. [viewed 26 April 2014]. Available from: http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=dff59f6f-92ea-496b-9c1c-685b79819c60
  3. SCONEY,B. Sports knee injuries - assessment and management[online],Aust Fam Physician. 2010 Jan-Feb,39(1-2),30-4 [viewed 26 April 2014]. Available from: http://www.racgp.org.au/afp/201001/35839

Management - Specific Treatments

Fact Explanation
Ligament reconstruction Surgical procedures are used in treatment for grade 3 injuries.During ligament reconstruction,torn ligament is replaced with a tissue graft. This graft is taken from another part of the patients body (Autograft), or from another human donor (Allograft). It can take several months for the graft to heal into the bone. This procedure is done with an arthroscopically using small incisions. So,it is less invasive,less painful postoperatively and has a quicker recovery time. [1,2,3]
Post operative rehabilitation Postoperatively, there is a tendency to posterior translation in flexion of the knee, especially in active flexion.The tendon graft becomes weak after several weeks. So it is essential to start Quadriceps femoris muscle strengthening exercise and straight leg raising exercise immediately after surgery for synergy effect. [1,2]
References
  1. CHEN,C.H. ,Surgical Treatment of Posterior Cruciate Ligament Injury [online],Chang Gung Med J. 2007, 30, 6. [viewed 26 April 2014]. Available from: http://core.kmi.open.ac.uk/download/pdf/916672.pdf
  2. LEE,B.K. et al. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles [online],Knee Surg Relat Res 2011,23(3),135-141. [viewed 26 April 2014]. Available from: http://dx.doi.org/10.5792/ksrr.2011.23.3.135
  3. COLVIN,A.C, R.J. MEISLIN, Posterior cruciate ligament injuries in the athlete: diagnosis and treatment [online],Bull NYU Hosp Jt Dis. 2009,67(1),45-51. [viewed 26 April 2014]. Available from: http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=dff59f6f-92ea-496b-9c1c-685b79819c60