When do you need surgery for a PCL tear, and when can you avoid knee surgery and try rehab and physical therapy? In this Ask Dr. Geier column, I address PCL reconstruction and rehab.

Jacqueline Barnoski in Fairmont, NC asks:

I am interested in knowing your view on PCL injuries. Repair vs rehab.

What is a PCL injury?

Great question. For those of you who aren’t familiar with PCL injuries, the PCL is the posterior cruciate ligament. It sits behind the ACL in the center of the knee. It provides stability to the knee where a force directs the tibia backwards. So it is usually torn in motor vehicle accidents where a person’s knee hits the dashboard and is driven posteriorly (backwards) against the femur. Athletes suffer PCL injuries by either landing on the knee and the ground drives the tibia back. Or an opponent hits the player on the tibia and creates this posterior-directed force. Fortunately it is much less common than ACL injuries. In fact, here in Charleston, I perform well over 100 ACL surgeries per year but only occasional PCL reconstructions or repairs.

Do you need surgery for a PCL tear?
This image of the knee seen on MRI shows a tear of the posterior cruciate ligament (yellow arrow).

Rehab for an isolated PCL tear

Jacqueline, here are my thoughts about surgery or rehabilitation. There have been a number of studies that have shown that isolated PCL injuries (meaning no other ligament damage in that same injury) often do well without surgery. The key to a good outcome with nonoperative treatment seems to be whether or not the athlete gets his or her quad strength back. In my experience with patients with isolated PCL injuries, aggressive physical therapy has almost always gotten people back what they want to do with little limitations.

Surgery for a PCL tear

Now there are two situations where I am more aggressive and consider surgery for a PCL tear early. The first is the multi-ligament injury, such as an ACL-PCL injury or PCL-posterolateral corner injury. In those situations, I either plan surgical repair or reconstructions in either one long surgery or staged procedures. Those decisions depend on the nature of what ligaments and other structures are torn. The other scenario where I consider surgery is the less common injury where the athlete pulls the PCL and a large piece of bone off the femur or tibia rather than tearing the ligament in its midsubstance. In those situations, I have had good success fixing the bone fragment back to the rest of the femur or tibia and hold it with one or two screws. Athletes seem to recover much faster when surgeons can do this type of primary repair as opposed to a PCL reconstruction where surgeons make a new ligament with tendons or ligaments from the patient’s knee or a donor graft.

Those are just my thoughts. There are very different opinions when it comes to whether or not you need surgery for a PCL tear, and if they are reconstructed surgically, which of a number of different techniques is best.

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