Physical Therapy Management Of The Posterior Cruciate Ligament

Summary of Posterior Cruciate Ligament (PCL) Injury

PCL injury can also be identified as a PCL tear, PCL sprain, PCL strain, or a PCL rupture. This is a common sporting injury and can also occur frequently with front seat passengers in a motor vehicle accident whose knees came in contact with the dash board upon collision.
The PCL is one of the most important stabilizing ligaments of the knee preventing excessive twisting, hyperextension, and/or posterior translation of the tibia on the femur. A PCL tear can result by placing excessive force on the ligament in any of these movements or combination of movements.

A PCL tear is graded indicating the following:

• Grade I: There is laxity in the ligament determined by the posterior translation of the tibia but the tibial plateau remains anterior to the condyle. Full function is typically allowed.
• Grade II: There is a partial tear of the ligament indicated by the anterior border of the tibial plateau but sits flush with the femoral condyle. Moderate loss of function and instability is typically present.
• Grade III: A complete tear of the PCL is likely when the anterior border of the tibial plateau rests posterior to the femoral condyle. A complete rupture results in knee instability and major loss of function. Surgery is typically indicated.

More information regarding injury to the PCL, anatomy, incidence and prevalence, etiology, diagnostic and orthopedic testing can be found at: http://morphopedics.wikidot.com/posterior-cruciate-ligament-strain

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Clinical presentation and problems associated with PCL injury ¹

Signs and symptoms can vary according to the extent of the injury but may include loss of knee range of motion (ROM), decreased quadriceps strength, pain and swelling immediately following injury, reoccurrences of pain and swelling during and post activity, and decreased feeling of stability.

Patients with PCL injury should manage their activity so it does not aggravate or worsen their instability leading to a complete PCL rupture.

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Guide to PT Practice – Practice Pattern and Suggested Management ²

• Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
• Management: Information regarding procedural interventions for this pattern provided by the APTA can be found at: http://guidetoptpractice.apta.org/content/1/SEC11.body
  • Interventions will vary within this pattern based on the PT diagnosis and may include therapeutic exercise, functional training in self-care and home management, functional training in work, community, and leisure, manual therapy techniques, prescription, application, and, as appropriate, fabrication of devices and equipment, electrotherapeutic modalities, and physical agents and mechanical modalities.

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Treatment Research and General Guidelines

Conservative rehabilitation and post-operative rehabilitation of the PCL have the same outcome goals and will vary mainly by increased length of tissue healing time with a post-operative approach. The therapist will consider the patients pain, range of motion of the knee joint, strength deficits, and inflammation and edema acutely, during and after activity, and post operative.

R.I.C.E. Regime ³

• Patients should use this regime within the first 72 hours following a PCL tear or when inflammatory signs are present (i.e. morning pain or pain with rest). Restraining from aggravating activities. Ambulating with crutches or a brace, regular icing, the use of a compression bandage and keeping the leg elevated are all indicated at during this inflammatory phase.
  • Cryotherapy ^4,5
    • Relieving Pain: Applying cold therapy for a 10-20 minute session can control pain for 1 or more hours. This is a result of blocking nerve conduction by deep pain transmitting A-delta fibers and by applying the gait theory of pain transmission by the cutaneous thermal receptors.
    • Decrease Swelling: Apply ice or cold whirlpool immediately after injury and during the acute inflammatory phase of healing to help control bleeding, edema, and pain and to facilitate tissue healing.
    • Application Guidelines: Cold application should be limited to 20 minutes and repeated at least an hour apart.
  • Compression and Elevation
    • Reduction of joint swelling and edema will occur by driving extravascular fluid out of the swollen area into the venous and lymphatic drainage systems.
    • Compression can be applied by an elastic wrap
    • Elevation should be above the level of the heart
• Nonsteroidal anti-inflammatory drugs (NSAIDs)^6,7
  • Relieving Pain
    • NSAIDs are used for analgesic purposes and can relieve pain from inflammatory and non-inflammatory sources.
    • Lower doses and blood levels are required to reduce pain than to reduce inflammation.
  • Decreasing Swelling
    • NSAIDS have been shown to reduce activity in C and A-delta fibers in acute and chronic models of joint inflammation. Evidence also indicates NSAIDs have a central nervous system analgesic effect at the level of the spinal cord and the thalamus.
  • Long term NSAID use is contraindicated
    • Side effects of long-term NSAID use include gastrointestinal irritation and bleeding.

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Physical Therapy Interventions

• Improving Range of Motion ⁸
  • ROM exercises should begin immediately following the acute inflammatory phase to avoid the loss of range. Active and active-assisted ROM exercises are appropriate. The main consideration is to protect against posterior tibial sag. This can be accomplished with the use of a protective brace or positioning of the patient. This should not an issue with post-operative treatment.
  • Hydrotherapy: a hot whirlpool can be used to increase tissue extensibility and is also recommended for pain.
• Increasing Strength ¹
  • A very important component of PCL rehabilitation is pain-free strengthening of the quadriceps, hamstring, gluteal and calf muscles to improve the stability of the knee joint with weight-bearing activities.
  • Strengthening exercises include but are not limited to straight leg raises, 4 way hip strengthening, and quadriceps sets. Progress to calf raises, hamstring raises, wall sits, stairmaster, water walking, treadmill training, agility training and return to full function will subsequently follow.
    • Note: stairmaster with the patient facing the reverse direction puts an emphasis on quadriceps and can be used in conjunction with cardiovascular training.

• Rehab Guidelines
  • • Conservative: http://morphopedics.wikidot.com/posterior-cruciate-ligament-strain
    • Sugical: When to move forward with PCL reconstruction visit the graph posted at http://morphopedics.wikidot.com/posterior-cruciate-ligament-strain.
  • Post-Operative Rehab Protocols
    • Robert F. LaPrade, M.D., Assistant Professor, University of Minnesota http://www.sportsdoc.umn.edu/Clinical_Folder/Rehab_Protocols/postop%20pcl%20recon.html
    • University of Delaware Physical Therapy Clinic - NMES included in rehab protocol. http://www.udel.edu/PT/PT%20Clinical%20Services/RehabGuidelines/PCL.pdf

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Special Considerations ⁹

For conservative treatment place pillow under proximal tibia at rest to prevent posterior tibial sag for the first 6 weeks post injury.

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Bibliography

1. PCL tear - posterior cruciate ligament - PCL injury - PhysioAdvisor http://www.physioadvisor.com.au/10200450/pcl-tear-posterior-cruciate-ligament-pcl-injur.htm.

2. Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction — APTA guide to phys. therapist prac. http://guidetoptpractice.apta.org/content/1/SEC11.body.

3. R.I.C.E. - rest ice compression elevation - injury treatment - PhysioAdvisor http://www.physioadvisor.com.au/7672729/rice-rest-ice-compression-elevation-injury.htm.

4. Ohkoshi Y, Ohkoshi M, Nagasaki S, Ono A, Hashimoto T, Yamane S. The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction Am J Sports Med. 1999;27(3):357-362.

5. Oshikoya CA, Shultz SJ, Mistry D, Perrin DH, Arnold BL, Gansneder BM. Effect of coupling medium temperature on rate of intramuscular temperature rise using continuous ultrasound J Athl Train. 2000;35(4):417-421.

6. Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery Anesth Analg. 1991;73(6):696-704.

7. Jurna I, Spohrer B, Bock R. Intrathecal injection of acetylsalicylic acid, salicylic acid and indomethacin depresses C fibre-evoked activity in the rat thalamus and spinal cord Pain. 1992;49(2):249-256.

8. Wade J. Sports splash. Rehab Mgmt. 1997;10(4):64-70.

9. PCL reconstruction rehabilitation protocol http://www.sportsdoc.umn.edu/Clinical_Folder/Rehab_Protocols/postop pcl recon.html.

Image references

http://sportsmedicine.about.com/cs/rehab/a/rice.htm
http://www.fotosearch.com/photos-images/medicine-bottle.html
http://www.fotosearch.com/CSP478/k4786964/
http://www.webmd.com/osteoarthritis/joint-injections-9/slideshow-knee-exercises