Clinicians › Knee

Posterior cruciate ligament injury

86 citationsUpdated Sep 2026

Overview

Truly isolated posterior cruciate ligament (PCL) injuries are rare, as most occur with osseous and some degree of associated ligamentous injury [10]. Current knowledge and treatment of PCL injuries continue to lag behind that of anterior cruciate ligament injuries due to the relative infrequency of injuries and lack of consensus regarding natural history, surgical indications, technique, and rehabilitation [3]. Controversy remains regarding indications for surgical versus nonsurgical management and optimal surgical techniques [39]. There is no scientifically proven superior method for PCL reconstruction due to a lack of well-designed randomized clinical trials [60], and the superiority of single-bundle or double-bundle reconstruction remains uncertain [19].

Nonsurgical management is advocated for isolated grade I or II PCL injuries or for grade III injuries in patients with mild symptoms or low activity demands [14]. Surgical management is reserved for high-demand athletes or patients in whom nonsurgical management has been unsuccessful [14]. Posterolateral corner injuries are commonly associated with cruciate injuries, and early recognition is important to achieve successful outcomes [9]. Failure to treat posterolateral corner injuries potentially causes cruciate ligament reconstruction failure [12].

Posterior cruciate ligament reconstruction improves subjective patient outcomes and return to sport, although stability and knee kinematics may not return to normal [2]. Good functional results have been shown after reconstruction for isolated rupture of the PCL [13], and PCL replacement produced reasonable subjective, functional, and objective results in a group of complex, chronic knee injuries [1]. Isolated PCL and multi-ligament PCL reconstructions showed significant improvements in subjective outcomes but did not reach those observed in anterior cruciate ligament reconstructions [25]. Within the first 2 years after surgery, patients who undergo isolated PCL reconstruction can be expected to have similar failure rates to patients who undergo combined ligament reconstructions [157]. Functional outcomes for combined anterior or posterior cruciate ligament and posterolateral corner injuries were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears [4]. The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse events over arthroscopic anterior cruciate ligament reconstruction [18]. Patients who underwent a staged cruciate reconstruction had higher subjective outcome scores than those who had cruciate injuries left untreated [7]. All patients in a series of anatomic PCL reconstruction after multiligament knee injuries had a stable PCL at most recent clinical follow-up, and 77% had no laxity at all [5].

Anatomy & Pathophysiology

Bony Anatomy & Ligament Structure

The posterior cruciate ligament (PCL) is an intrasynovial but extraarticular structure that is stronger than the anterior cruciate ligament (ACL) and possesses a broader femoral attachment [84, 85]. Its cross-sectional area is approximately 50% larger than the ACL at the femur and 20% larger at the tibia [85]. The PCL originates on the posteromedial aspect of the intercondylar notch and inserts into the posterior sulcus of the tibia between the medial and lateral joint surfaces [98]. Proximally, it attaches to the lateral surface of the medial condyle [85]. The femoral insertion extends more than 20 mm from anterior to posterior [84]. Distally, the tibial attachment is narrower than the femoral insertion and located in a depression 1.0 to 1.5 cm behind and below the intraarticular portion of the tibia [84, 85]. The PCL footprint extends anteriorly and proximally from the medial meniscus root and the edge of the lateral plateau articular cartilage to a point 1 to 1.5 cm below the joint line [84]. The most posterior distal fibers consist of the thicker posteromedial bundle, which blends with the periosteum and posterior capsule [84].

The PCL comprises two functional components: the anterolateral bundle and the posteromedial bundle [84]. The anterolateral bundle forms the bulk of the ligament, is more vertical, and inserts on the anterior roof of the intercondylar notch [84, 85]. The posteromedial bundle is smaller, runs obliquely to the back of the tibia, and inserts posteriorly on the lateral wall of the medial femoral condyle [84, 85]. The anterior margin of the PCL is 2 mm from the articular cartilage, and the bundle centers are an average of 12 mm apart on the femur and 9 mm apart on the tibia [84]. Specific anatomical landmarks define the bundle centers: the anterolateral bundle center is 7.4 mm from the trochlear point, 11.0 mm from the medial arch point, and 7.9 mm from the distal articular cartilage [85]. The tibial attachment center is 6.1 mm from the shiny white fibers of the posterior medial meniscus root, 4.9 mm from the bundle ridge, and 10.7 mm from the “champagne glass” drop-off [85]. The posteromedial bundle attachment center is 11.1 mm from the medial arch point and 10.8 mm from the posterior point of the articular cartilage margin [85]. The functional center of the posteromedial bundle is 3.1 mm lateral from the medial groove of the medial tibial plateau articular surface and 4.4 mm anterior to the champagne glass drop-off [85]. The PCL is associated with the meniscofemoral ligaments of Humphrey (anterior) and Wrisberg (posterior), which averaged approximately 22% of the entire cross-sectional area of the PCL [84, 85].

Biomechanics & Function

The primary function of the PCL is to resist posterior displacement of the tibia relative to the femur in all knee flexion angles [84, 158]. It also acts as a secondary varus, valgus, and rotational stabilizer [84, 110]. The PCL facilitates internal rotation of the tibia at higher flexion angles [84]. Biomechanically, the anterolateral fibers are taut in flexion, while the posteromedial fibers are taut in extension [84, 98]. In knee extension, the PCL is concave antero-inferiorly and relatively distant from the posterior intercondylar eminence [158]. As the knee flexes, the PCL gradually straightens and moves closer to the posterior intercondylar eminence [158]. The maximal length of the PCL in the living knee occurs at 90–100° of knee flexion, where it is closest to the apex of the posterior intercondylar eminence [158]. A higher posterior intercondylar eminence may cause a tight PCL to collide with bone and rupture if a sudden posteriorly directed force is applied to the proximal tibia at knee flexion [158]. Differences in the shape of the knee are associated with the presence of a PCL rupture after injury [89].

Injury Mechanisms & Epidemiology

The most common cause of PCL injury is a direct blow to the proximal aspect of the tibia [15]. In athletes, the mechanism is usually a fall onto the flexed knee with the foot plantarflexed, which places a posterior force on the tibia [15]. The “dashboard” injury involves a posteriorly directed force from the dashboard with the knee in 90 degrees of flexion [26]. Sports injuries to the PCL result from an outside force or blow, in contrast to the typical deceleration twisting mechanism of ACL injuries [26]. The most common mechanism for isolated PCL injury in the athlete is a partial tear associated with hyperflexion of the knee [26]. Significant multiligamentous knee injuries with PCL tears can occur after varus or valgus stress is applied to the hyperextended knee [26]. In high-energy trauma such as motor vehicle accidents, the PCL is often injured with other capsuloligamentous structures [15]. Progressive damage to translational and rotational knee soft-tissue restraints occurs with increasing knee hyperextension [92].

PCL tears account for one fifth or more of all knee ligament injuries [28]. Reported incidence ranges from 1% to 44% of all acute knee injuries [28], with 5% to 20% of all ligamentous injuries to the knee involving the PCL [15]. PCL tears have historically been underdiagnosed because they are often asymptomatic [28]. Many PCL injuries are believed to go undiagnosed in the acutely injured knee [15]. An isolated PCL injury may be less obvious because instability is often subtle or even asymptomatic [15]. Injuries to the PCL may be isolated or combined with other capsuloligamentous injuries in the knee [15]. Injury to the posterolateral structures has been reported to occur in up to 60% of PCL injuries [26]. The most common injury pattern in high-grade multiligament knee injuries is an ACL/PCL/posterolateral corner combination [145]. Injury to at least one structure within the posteromedial corner was observed in 81% of patients with high-grade multiligament knee injuries [145].

Natural History & Pathology

The natural history of PCL injuries is not entirely clear, but evidence shows that certain PCL injuries, especially combined ones, will progress to instability, pain, and osteoarthritis of the knee [15]. Osteoarthritis following PCL injury especially affects the patellofemoral and medial tibiofemoral compartments [15]. PCL ruptures altered walking patterns in both the involved and uninvolved legs, which could affect alignment of the lower limb and loading on the knee, hip, and ankle joints [127]. Patients with multiple-ligament knee reconstruction display abnormalities in knee kinematics during gait at an average of 4.5 years after surgery [94]. When three or more ligamentous structures are injured, the injury should be viewed as a dislocated knee and the vascular status of the injured limb should be assessed [15].

Classification

PCL Injury Grading and Classification Systems

PCL injuries are classified based on physical examination and MRI findings [15]. The posterior drawer test is the primary dynamic test to diagnose a PCL injury, classified by the degree of increased posterior tibial translation compared with the uninvolved knee at 90° of flexion [15].

Grade I: Defined by 3 to 5 mm of increased posterior tibial translation on the posterior drawer test [15]. In this grade, the tibial plateau step-off at 90° of flexion is less than 1 cm, but the tibial plateau remains anterior to the femoral condyle [15].

Grade II: Defined by 6 to 10 mm of increased posterior tibial translation on the posterior drawer test [15]. In this grade, the tibial plateau is flush with the femoral condyle at 90° of flexion [15].

Grade III: Defined by more than 10 mm of increased posterior tibial translation on the posterior drawer test [15]. In this grade, the tibial plateau is posterior to the femoral condyle at 90° of flexion [15].

Partial PCL Injury: Characterized by posterior tibial translation of less than 10 mm on the posterior drawer test with the knee in neutral rotation and a present end point [15]. The degree of posterior tibial translation may decrease with internal tibial rotation in partial tears [15].

Complete Isolated PCL Injury: Characterized by posterior tibial translation of 8–10 mm on the posterior drawer test with the knee in neutral rotation, which is diminished with the knee in internal rotation [15].

Combined PCL and Capsuloligamentous Injury: Characterized by posterior tibial translation greater than 10 mm on the posterior drawer test with the knee in neutral rotation [15]. This injury is indicated by more than 15 mm of posterior translation with the knee at 90° and in neutral rotation, and more than 10 mm with the knee in internal rotation [15].

Quadriceps-Active Test: Positive when the tibia translates anteriorly at 90° of flexion with resisted knee extension [15].

MRI Classification: Preoperative MRI classification of PCL injury location includes Type P (proximal tear with distal remnant) and Type D (distal tear with proximal remnant) [137].

Clancy Classification: Used to grade posterior drawer laxity, with grades ranging from 0 to 3 [67].

Associated Injuries and Multi-Ligament Classifications

PCL injuries occur in isolation or in combination with other injuries [15]. Isolated PCL injuries are common, although the injury is most commonly associated with other ligament injuries [34].

Schenck Classification: An anatomically based system for classifying knee dislocations [53]. It was modified to include vascular injuries and specify medial versus lateral injuries [53]. The Schenck classification serves as a useful communication, planning, and prognostic tool for evaluating potential associated neurovascular injuries in knee dislocations [151]. However, it does not consistently guide clinical decision making [53].

Pathoanatomic MLKI Classification: Proposed by Poploski et al., this is a modification of the Schenck classification designed to encompass multiple ligament knee injuries separately from knee dislocations [138]. The Poploski et al. classification expanded MLKI to include collateral ligamentous injuries occurring alongside isolated cruciate ligamentous injuries [138]. It designates clinically incompetent ligaments as third-degree injuries for MLKI classification purposes [138].

KD Classification: The KD classification alone was not predictive of surgery timing, staging, or any type of intervention for any injured ligament [139].

Other Considerations: Separation of injury patterns into distinct classifications for knee dislocations and multiple ligament knee injuries allows researchers to stratify by newer modifications and shows potential for assisting in patient prognosis [46].

Clinical Presentation

Mechanism of Injury

In athletes, PCL injury typically results from a fall onto the flexed knee with the foot plantarflexed, applying a posterior force to the tibia [15]. The “dashboard” injury is a common mechanism where the anterior tibia sustains a posteriorly directed force from the dashboard with the knee in 90 degrees of flexion [26]. Sports injuries to the PCL result from an outside force or blow, contrasting with the typical deceleration twisting mechanism of an ACL injury [26]. Significant multiligamentous knee injuries with PCL tears can occur after varus or valgus stress is applied to the hyperextended knee [26]. Other mechanisms include hyperflexion and hyperextension, the latter associated with proximal tear location and anterior tibial plateau compression fractures [80]. Excessive varus, valgus, internal, or external torque of the tibia are also injury mechanisms and may relate to concomitant injuries of peripheral capsuloligamentous structures, menisci, and cartilage [80].

Symptoms and History

Patients commonly complain of knee pain, swelling, and stiffness [26]. It is rare for patients with PCL injuries to report hearing a “pop” or feelings of subjective instability [26]. Clinically, patients primarily report pain or discomfort after an acute PCL injury [80]. This pain commonly affects the patellofemoral, anteromedial, or posterior part of the knee and occurs during uphill or downhill walks [80]. Unlike in ACL deficiency, patients with isolated PCL tears rarely report symptoms of instability [80]. The perception of instability becomes more present in chronic and combined PCL injuries [80]. Patients with significant varus alignment or injury to the lateral structures of the knee will often complain of feelings of instability and giving way [26]. The presentation of a patient with a subacute or chronically injured PCL can range from asymptomatic to significant instability and pain [26]. Hemarthrosis in patients after acute knee injuries may be indicative of PCL tears [80].

Physical Examination

Inspection: Specific cues to PCL injury on initial inspection include abrasions or ecchymosis around the proximal anterior tibia and ecchymosis in the popliteal fossa [26].

Palpation and Stability Testing: The physical examination is specific for a PCL injury, typically classified based on the degree of injury [15]. At 90° of flexion, there is normally a 1-cm step-off between the tibial plateau and femoral condyle [15]. In a grade I injury, the step-off is < 1 cm but the tibial plateau remains anterior to the femoral condyle [15]. In a grade II injury, the tibial plateau is flush with the femoral condyle [15]. In a grade III injury, the tibial plateau is posterior to the femoral condyle [15]. In the normal knee, the medial tibial plateau is 10 mm anterior to the medial femoral condyle with the knee in 90° flexion [73]. In grade I injury, there is asymmetry side to side, but the medial tibial plateau remains anterior to the medial femoral condyle [73]. In grade II injury, the posterior drawer at 90° pushes the tibial plateau to the level of the medial femoral condyle [73]. In grade III injury, the medial tibial plateau can be pushed posterior to the medial femoral condyle [73].

The posterior drawer is the primary dynamic test to diagnose a PCL injury and is classified based on the degree of increased posterior tibial translation compared with the uninvolved knee at 90° of flexion [15]. It is the most accurate clinical test of PCL integrity [26]. * Grade I: 3 to 5 mm of increased posterior tibial translation [15]. * Grade II: 6 to 10 mm of increased posterior tibial translation [15]. * Grade III: >10 mm of increased posterior tibial translation [15].

The posterior sag or Godfrey test involves flexing the knee and hip and noting the posterior pull of gravity creating posterior “sag” of the tibia on the femur [26]. An adjunct to this test involves watching for a reduction of this subluxation with active quadriceps contraction [26]. The reverse pivot shift is performed by placing a valgus stress on the knee with the foot externally rotated and extending from 90 degrees of flexion, noting a palpable reduction of the posterolateral tibial plateau between 20 and 30 degrees of flexion [26]. The Lachman test for ACL injury, varus and valgus laxity testing, and determining differences in external and internal tibial rotation are critical in differentiating between isolated and combined injuries [15]. Evaluation of ACL laxity in the presence of an acute PCL injury is challenging due to the lack of a stable reference point to perform a Lachman or anterior drawer test [26]. The 'false Lachman' test corresponds to the reduction of the posterior drawer in cases of PCL injury and may be a source of confusion in cases of multiplanar laxity associated with swelling [44].

Imaging

Plain radiographs are important initially to rule out fractures and avulsions [15]. Plain radiographs of the knee are essential to evaluate for bony injuries, dislocation, or evidence of other associated injuries [26]. When the knee (intact ACL and PCL) is centered in the sagittal plane, the tibia is anterior to the femoral condyles [15]. Subtle posterior subluxation on the lateral radiograph may also indicate PCL injury [26]. Stress posterior drawer radiographs and contralateral comparisons may also increase the sensitivity for detecting PCL injuries with plain radiographs [26]. In the chronic setting of PCL injury, radiographs are useful to assess for patellofemoral and medial compartment degenerative changes that can occur over time [26]. Stress radiographs support accurate diagnosis of complex knee injuries and provide an objective measure of knee stability following ligament reconstruction [29].

MRI has been shown to have a very high sensitivity and specificity in diagnosing a PCL injury [15]. MRI has been reported to be 96–100% sensitive at diagnosing PCL tears [26]. MRI complements the history and physical examination and helps to determine the site and degree of injury by assessing the continuity of the PCL [15]. MRI is extremely valuable in its ability to detect associated injuries [26]. MRI may also indicate the presence of other meniscal, chondral, or ligamentous injuries, which may influence treatment strategies [15]. MRI is particularly important in diagnosing posterolateral corner injuries because these can often be missed on the initial clinical examination [26]. In multiligamentous knee injuries, MRI can also be of use in assessing the ACL as clinical examination of the ACL is challenging in the setting of a complete PCL tear [26].

Classification

The grades of PCL injuries are based on the physical examination and MRI findings [15]. * Partial PCL injury: Characterized by posterior tibial translation <10 mm on posterior drawer test with the knee in neutral rotation and an end point is present [15]. * Complete isolated PCL injury: Characterized by posterior tibial translation of 8–10 mm on posterior drawer test with the knee in neutral rotation and is diminished with the knee in internal rotation [15]. * Combined PCL and capsuloligamentous injury: Characterized by posterior tibial translation >10 mm on posterior drawer test with the knee in neutral rotation, where the PCL is injured in conjunction with other structures such as the ACL, posterolateral corner, or medial side [15].

Associated Injuries and Complications

When three or more ligamentous structures are injured, the physician should view the injury as a dislocated knee and should assess the vascular status of the injured limb [15]. Evidence shows that certain PCL injuries (especially combined) will progress to instability, pain, and osteoarthritis of the knee—especially of the patellofemoral and medial tibiofemoral compartments [15]. PLC injuries are commonly associated with cruciate injuries, and early recognition is important to achieve successful outcomes [9]. Concomitant damage to the anterior or posterior cruciate ligaments is a common indication for surgical management of high-grade medial collateral ligament injuries [17]. Multiple ligament injured knees are often part of a multisystem injury complex where additional injuries affect surgical timing and treatment results [90].

Investigations

History and Clinical Presentation

Patients with posterior cruciate ligament (PCL) injuries typically present with knee pain, swelling, and stiffness [26]. It is rare for these patients to report hearing a "pop" or feelings of subjective instability [26]. However, patients with significant varus alignment or injury to the lateral structures of the knee often complain of feelings of instability and giving way [26]. The history of the injury helps differentiate between high- and low-energy traumas [15]. Concurrent injuries such as knee dislocation, neurovascular injury, and additional ligamentous or skeletal injuries assist in the evaluation [15].

Physical Examination

The posterior drawer test is the primary dynamic test to diagnose a PCL injury [15]. At 90° of flexion, there is normally a 1-cm step-off between the tibial plateau and femoral condyle [15]. In the intact state, the medial tibial plateau is approximately 1 cm anterior to the medial femoral condyle [119]. The posterior drawer test is classified based on the degree of increased posterior tibial translation compared with the uninvolved knee at 90° of flexion: grade I injury is 3 to 5 mm, grade II injury is 6 to 10 mm, and grade III injury is >10 mm [15]. In a grade I injury, there is 0.5 cm of posterior tibial translation [119]. In a grade II injury, the tibia is flush with the femoral condyles [119]. In a grade III injury, the tibia translates posterior to the femoral condyles [119]. The accuracy, sensitivity, and specificity of the clinical examination findings for PCL injury are greater than 90% [119]. Specific cues to PCL injury on initial inspection include abrasions or ecchymosis around the proximal anterior tibia and ecchymosis in the popliteal fossa [26].

Imaging

Plain radiography: Subtle posterior subluxation on the lateral radiograph may indicate PCL injury [26]. Stress posterior drawer radiographs and contralateral comparisons may increase the sensitivity for detecting PCL injuries with plain radiographs [26]. In the chronic setting of PCL injury, radiographs are useful to assess for patellofemoral and medial compartment degenerative changes [26]. Stress radiography is superior to both the arthrometer and clinical posterior drawer testing for determining posterior cruciate ligament status [148]. Posterior stress radiography with TELOS and kneeling stress radiography are the most reliable methods to evaluate posterior cruciate ligament laxity [164]. Intra-articular fractures of the distal femoral epiphysis can mimic ligamentous injuries, particularly posterior cruciate ligament insufficiency, and require stress radiographs for diagnosis [55]. If grade III posterior tibial laxity is present and radiographs show more than 10 mm of posterior subluxation, a combined PCL and posterolateral corner injury should be suspected [119].

MRI: MRI may indicate the presence of other meniscal, chondral, or ligamentous injuries, which may influence treatment strategies [15]. MRI is extremely valuable in its ability to detect associated injuries, particularly posterolateral corner injuries which can often be missed on initial clinical examination [26]. In multiligamentous knee injuries, MRI can be of use in assessing the ACL as clinical examination of the ACL is challenging in the setting of a complete PCL tear [26]. MRI is a sensitive measure of cruciate and collateral ligament injury in acute knee dislocation [50]. However, MRI does not reliably diagnose injury to the posterolateral corner or meniscus in acute knee dislocation [50]. A higher index of suspicion is required during arthroscopy to prevent misdiagnosis of posterolateral corner or meniscal injury which could affect long-term clinical outcome [50]. MRI evaluation of the PCL fibers had poor sensitivity for chronic PCL tears and PCL reconstruction graft tears [140].

Other Considerations: The modified Lachmeter technique holds promise as an alternative to stress radiography for patients with isolated PCL injuries [165]. Most PCL and posterolateral corner injuries occur in combination with other ligament injuries [167]. A graft that restores knee kinematics for an isolated posterior cruciate ligament deficiency is rendered ineffective and may be overloaded if the posterolateral structures are deficient [31].

Treatment

Non-Operative

Nonsurgical management is advocated for isolated grade I or II posterior cruciate ligament (PCL) injuries [14]. It is also indicated for grade III PCL injuries in patients with mild symptoms or low activity demands [14]. Conservative management focuses on quadriceps strengthening to prevent posterior tibial sag [132]. Return to sports is usually achieved in 2 to 4 weeks for grade I-II injuries treated conservatively [132]. For grade III injuries, conservative treatment includes relative immobilization in extension for 4 weeks [132]. Special braces have been designed to prevent posterior sag [132]. A 7-year follow-up study reported that 92% of patients with grade I or II injuries had a good to excellent result after nonsurgical management [134]. Two natural history studies of nonsurgically treated isolated grade I or II injuries found good subjective and objective outcomes with no functional deterioration [134]. These studies also found 97% quadriceps and 93% hamstring strength [134]. With adequate quadriceps exercises, the prognosis of a ruptured PCL can be greatly improved, with 80% of ruptures achieving a good or excellent result with effective management [36]. Acute PCL injuries treated non-surgically display a high degree of PCL continuity on MR images 11 years after injury [70]. The PCL-deficient knee in children may be treated nonoperatively with satisfactory subjective results in the short term [38]. However, the long-term consequences of chronic PCL deficiency in children are not known [38]. An optimal set of guidelines for the nonoperative management of PCL injuries has not yet been defined or agreed upon [95].

Active non-operative treatment of acute isolated PCL injury using cylinder cast immobilization and brace may be one of the recommendable treatment methods [105]. In this protocol, a cylinder cast immobilization with tibial supporter with full extension of the knee is applied for 6 weeks [105]. A PCL brace with tibial supporter and posterior elastic rubber band is then applied for another 6 weeks to prevent posterior sagging of the proximal tibia [105].

Operative

Indications: Surgical treatment is indicated in patients with symptomatic isolated PCL tears [132]. It is also indicated in the setting of a multiligament injured knee [132]. Surgical treatment is recommended for a chronic grade III PCL lesion if the patient is symptomatic [134]. The treatment of isolated grade III PCL injuries is controversial [134]. Operative stabilization is recommended for definite isolated PCL insufficiency, particularly in younger patients with high performance requirements [143]. Early operative treatment of the multiligament-injured knee yields improved functional and clinical outcomes compared with nonoperative management or delayed surgery [156]. Patients who underwent a staged cruciate reconstruction(s) had higher subjective outcome scores than those who had cruciate injuries left untreated [7]. Early surgical repair of acute PCL injuries with concomitant ligamentous lesions and vascular injuries can lead to superior long-term results compared to conservative treatment [66].

Surgical Approach / Technique: Primary repair or open reduction and internal fixation is performed for PCL avulsion injuries [132]. Reconstruction is performed for PCL injuries other than avulsion injuries [132]. Options for PCL reconstruction include tibial inlay versus transtibial, single-bundle versus double-bundle, and autograft versus allograft [132]. The tibial inlay technique theoretically reduces the “killer turn” between the posterior border of the tibial plateau and the graft, which may decrease failure rates [132]. The double-bundle technique is theoretically stronger and may be beneficial in the revision setting or with multiple ligament reconstruction [132]. There has been no evidence to suggest one PCL reconstruction technique is superior over another [132]. An osteotomy should be considered in the setting of malalignment for PCL injuries [132]. A high tibial osteotomy can treat both varus malalignment as well as increase tibial slope to help reduce posterior tibial sag [132].

Avulsion of the PCL usually occurs at the femoral attachment and can be repaired using suture anchors or femoral bone tunnels [134]. Large osseous avulsion fragments from the tibial attachment can be repaired with open reduction and screw-and-washer fixation [134]. The tibial inlay technique is usually performed through an open posterior approach [134]. In the tibial inlay technique, the bone block is recessed and fixed with an interference screw at the posterior tibia, ensuring to avoid graft protrusion [134]. Advantages of the tibial inlay technique include osseous graft healing, avoidance of so-called killer turn stresses, decreased graft wear, and improved graft biomechanics [134]. An arthroscopic inlay technique using suture button fixation over the tibial-side bone block has been described as combining the advantages of arthroscopic and inlay techniques [134].

In the transtibial technique, the tibial tunnel is reamed from anterior to posterior through the tibia under direct arthroscopic and fluoroscopic visualization [134]. The tibial footprint for the transtibial technique is approximately 7 mm anterior to the posterior tibial cortex as seen on a perfect lateral image [134]. Cadaver biomechanical data revealed no difference between transtibial and tibial inlay techniques when grafts were appropriately pretensioned before insertion [134]. Multiple studies report no difference in functional, radiographic, or clinical outcomes between transtibial and tibial inlay techniques or between arthroscopic and open techniques [134].

Biomechanical comparison studies of double-bundle and single-bundle PCL reconstruction techniques concluded that double-bundle reconstruction is preferable for decreasing posterior tibial translation and improving rotational restraint [134]. However, biomechanical advantages of double-bundle PCL reconstruction were not correlated with superior clinical outcomes [134]. Isolated single-bundle PCL reconstruction yields good long-term results without functional differences in comparison with double-bundle reconstruction [134]. Recent studies on double-bundle reconstruction suggest better restoration of knee kinematics, though no significant clinical differences have been established between various surgical techniques [41]. There is no scientifically proven superior method for PCL reconstruction due to a lack of well-designed randomized clinical trials [60].

The two-tunnel technique has been shown in clinical studies to have increased stability and to better fill the large PCL footprint [133]. The single-tunnel technique is used mostly for reconstruction of multiple knee ligaments in knee dislocations [133]. The two-tunnel technique is used primarily in isolated PCL reconstruction [133]. An Achilles tendon allograft is a preferred graft source for PCL reconstruction [133]. Comparable results have been reported with allografts and autografts for PCL reconstruction [133]. An all-arthroscopic inlay procedure using a retrocutting reamer and a closed-ended tibial tunnel with suture fixation anteriorly produces a shorter, stiffer graft construct and removes the “killer curve” that sometimes occurs in the transtibial technique [133]. A killer curve still remains on the femoral side in all-arthroscopic inlay PCL reconstruction [133]. Comparative studies show that anatomic single-tunnel and inlay procedures produce equal function and stability [133]. Double-bundle PCL techniques have been shown to be slightly better (2.5 mm of posterior displacement compared with 3.2 mm), with better IKDC scores, in most studies [133]. The most important factors for long-term success in PCL reconstruction are correction of associated instabilities and meniscal preservation [133].

Other Considerations: The current attitude favors acute-phase treatment and reconstruction rather than repair for combined cruciate ligament and posterolateral corner tears [116]. Treatment of posterolateral corner injuries depends on severity: nonoperative for grade-I and most grade-II injuries, early repair or reconstruction for acute grade-III injuries, and reconstruction for chronic injuries [12]. A combined posterior cruciate ligament and posterolateral corner reconstruction can restore intact knee kinematics at time zero [11]. The posterior oblique ligament is the predominant structure in the posteromedial corner of the knee joint, and surgical reconstruction should be considered the gold standard treatment in case of injury [37]. Both fibular-based and tibiofibular-based constructs for posterolateral corner reconstruction had comparable clinical outcomes and were equally effective in restoring varus and rotational stability [125]. Significant improvement in objective knee stability scores and clinical outcomes with anatomical reconstruction showed that this technique can be used to treat patients with chronic PLC injured knees [112]. A systematic approach to chronic posterolateral instability of the knee combining bony axial correction, collateral and central ligament reconstruction can result in significant amelioration of function and positive outcomes for ADL and low level athletic activities [128]. The repaired lateral side and untreated posterior cruciate ligament heal with continuity, allowing patients to return to high levels of activity [20].

Outcomes: All patients had a stable posterior cruciate ligament at most recent clinical follow-up after anatomic reconstruction following multiligament knee injuries, and 77% had no laxity at all [5]. This study shows good functional results after reconstruction for isolated rupture of the posterior cruciate ligament [13]. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears for combined anterior or posterior cruciate ligament and posterolateral corner injuries [4]. Isolated PCL and multi-ligament PCL reconstructions showed significant improvements in subjective outcomes but did not reach those observed in ACL reconstructions [25]. Despite good clinical outcome, complete restoration of ligament stability was achieved in only 52% of the knees with arthroscopic single bundle reconstruction for complete posterior cruciate ligament tear [64]. One-third of the knees showed mild and 9.7% showed moderate ligament laxity after arthroscopic single bundle reconstruction for complete posterior cruciate ligament tear [64]. The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse events over arthroscopic ACL reconstruction [18]. The generally low methodological quality of studies on PCL injury management shows that caution is required when interpreting results, and firm recommendations on treatment choice cannot be given at this time [153]. Controversy remains regarding indications for surgical versus nonsurgical management and optimal surgical techniques for PCL injuries [39].

Postoperative Rehabilitation: Complications of PCL surgery include injury to the saphenous nerve and popliteus vessels [132]. Postoperative rehabilitation for PCL surgery consists of early immobilization in extension and protection against gravity [132]. Early range of motion should be performed in the prone position for PCL surgery rehabilitation [132]. The focus of postoperative rehabilitation for PCL surgery is on quadriceps strengthening [132]. Resisted hamstring strengthening should be avoided early in rehabilitation because the posterior pull increases stress on the graft [132].

Patients with KDIIIM reconstruction are kept nonweightbearing for a total of 6 weeks to allow all soft tissues to heal after a major orthopaedic operation [106]. Patients with KDIIIM reconstruction are initially protected in a postoperative brace locked in extension for the first 2 weeks [106]. Range of motion from full extension up to 70° of flexion is allowed from Weeks 2 through 6 for KDIIIM reconstruction [106]. Full active and passive range of motion is allowed after Week 6 for KDIIIM reconstruction [106]. Jogging is not allowed for a minimum of 3 months postoperatively for KDIIIM reconstruction [106]. Complex reconstructions for KDIIIM injuries more often take 9 to 12 months of recovery [106].

Postoperative care for combined cruciate ligament and posterolateral corner tears included 6 weeks’ complete non-weight-bearing in 73.5% of cases and 3 weeks’ in 26.5% [116]. Rehabilitation sessions in 0–90° flexion were allowed immediately in 86.8% of cases for combined cruciate ligament and posterolateral corner tears [116]. For combined cruciate ligament and posterolateral corner tears, rehabilitation was initiated only after 3 weeks’ immobilization in cases where immediate motion was not allowed [116]. Rehabilitation for combined cruciate ligament and posterolateral corner tears continued with the patient using an articulated brace, worn for a mean 16 weeks (range, 12–24 weeks) [116].

Complications

Surgical Adverse Events: The surgical management of multi-ligament knee injuries confers a significant increased risk of 30-day post-operative minor or severe adverse events compared to arthroscopic ACL reconstruction [18].

Infection: Septic arthritis after arthroscopic posterior cruciate ligament and multi-ligament reconstructions is rare and can be successfully treated with arthroscopic irrigation and debridement [35].

Graft and Hardware Complications: Patellar tendon ruptures are rare after ACL graft harvest and typically occur in a proximal-medial/distal-lateral or entirely distal pattern [57]. Patients with complications after anterior cruciate ligament reconstruction with a patellar tendon autograft may have less difficulty obtaining full knee motion when the graft is harvested from the contralateral knee [65].

Instability and Functional Outcomes: Posterior laxity increases over time after PCL reconstruction [21]. Tibial slope strongly influences knee stability after posterior cruciate ligament reconstruction [21]. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears in combined anterior or posterior cruciate ligament and posterolateral corner injuries [4]. An isolated rupture of the posterior cruciate ligament results in reduced preoperative knee function in comparison with an anterior cruciate ligament injury [24].

Other Considerations: Delaying reconstruction in active children increases the risk of meniscal and cartilage damage, leading to poor long-term outcomes [147]. Patients with a previous history of knee ligament surgery had a significantly worse quality of life relative to those with no history of knee ligament surgery [54].

Recovery

Operative Outcomes: Posterior cruciate ligament (PCL) replacement using a two-strand quadriceps tendon-patellar bone autograft and tibial inlay technique produces reasonable subjective, functional, and objective results in complex, chronic knee injuries [1]. In multiligament knee injuries treated with anatomic PCL reconstruction using a combination of tibial-inlay and two-femoral-tunnel techniques, all patients demonstrated a stable PCL at most recent clinical follow-up [5]. Within this same series, 77% of patients exhibited no laxity at all at most recent clinical follow-up [5]. Functional outcomes following surgical reconstruction of combined anterior or posterior cruciate ligament and posterolateral corner injuries are satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears [4]. Patients who underwent staged cruciate reconstruction for combined posterolateral corner avulsion injuries achieved higher subjective outcome scores than those who had cruciate injuries left untreated [7]. Clinical studies demonstrate good functional results after reconstruction for isolated rupture of the PCL [13]. After follow-up for more than 60 months, patients achieved satisfactory function after PCL reconstruction using a quadriceps tendon–patellar bone autograft [58]. In a study of arthroscopic single-bundle reconstruction for complete PCL tear, complete restoration of ligament stability was achieved in only 52% of the knees [64]. In the same study, one-third of the knees showed mild ligament laxity and 9.7% showed moderate ligament laxity [64]. Proprioceptive function, defined as time to detect passive motion, is maintained after single-bundle PCL reconstruction with remnant preservation for chronic injuries [141]. Postoperative clinical scores and posterior laxity significantly improve after single-bundle PCL reconstruction with remnant preservation [141].

Non-Operative Outcomes: Long-term results after an isolated PCL injury treated nonoperatively show that patients remain active, have good strength and full knee range of motion, and report good subjective scores [62]. In a case of isolated PCL rupture following postero-lateral dislocation of the knee, examination at 3 months revealed residual laxity of the PCL, stable collateral ligaments and anterior cruciate ligament, and the patient reported no functional difficulties [23]. The PCL-deficient knee in children may be treated nonoperatively with satisfactory subjective results in the short term, but the long-term consequences of chronic PCL deficiency in children are not known [38]. In a case of knee dislocation with lateral side injury, the repaired lateral side and untreated PCL healed with continuity, allowing patients to return to high levels of activity [20].

Key Evidence

• [L4] Posterior cruciate ligament replacement produced reasonable subjective, functional, and objective results in this group of complex, chronic knee injuries. [1] (10.2106/jbjs.d.02272)
• [L4] Posterior cruciate ligament reconstruction improves subjective patient outcomes and return to sport, although stability and knee kinematics may not return to normal. [2] (10.1177/0363546511416316)
• [L5] Current knowledge and treatment of posterior cruciate ligament injuries continue to lag behind that of anterior cruciate ligament injuries due to the relative infrequency of injuries and lack of consensus regarding natural history, surgical indications, technique, and rehabilitation. [3] (10.1177/0363546504270481)
• [L3] Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. [4] (10.1016/j.otsr.2014.09.010)
• [L4] All patients had a stable posterior cruciate ligament at most recent clinical follow-up, and 77% had no laxity at all. [5] (10.1177/03635465030310020701)
• [L4] Patients who underwent a staged cruciate reconstruction(s) had higher subjective outcome scores than those who had cruciate injuries left untreated. [7] (10.1177/23259671221131817)
• [L5] PLC injuries are commonly associated with cruciate injuries, and early recognition is important to achieve successful outcomes. [9] (10.5435/jaaos-d-23-00278)
• [L3] Truly isolated posterior cruciate ligament injuries are rare, as most occur with osseous and some degree of associated ligamentous injury. [10] (10.1177/0363546504266481)
• [L5] A combined posterior cruciate ligament and posterolateral corner reconstruction can restore intact knee kinematics at time zero. [11] (10.1177/0363546504268039)
• [L5] Treatment depends on severity: nonoperative for grade-I and most grade-II injuries, early repair or reconstruction for acute grade-III injuries, and reconstruction for chronic injuries, with failure to treat posterolateral corner injuries potentially causing cruciate ligament reconstruction failure. [12] (10.2106/00004623-200101000-00015)
• [L4] This study shows good functional results after reconstruction for isolated rupture of the posterior cruciate ligament. [13] (10.1007/s00167-010-1176-3)
• [L4] 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, while surgical management is reserved for high-demand athletes or patients in whom nonsurgical management has been unsuccessful. [14] (10.5435/jaaos-d-14-00326)
• [L5] Most isolated medial collateral ligament injuries are treated nonsurgically, while concomitant damage to the anterior or posterior cruciate ligaments is a common indication for surgical management of high-grade injuries. [17] (10.5435/00124635-200903000-00004)
• [L4] The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse events over arthroscopic ACL reconstruction. [18] (10.1007/s00167-020-06252-6)
• [L1] The superiority of single-bundle or double-bundle posterior cruciate ligament reconstruction remains uncertain. [19] (10.1016/j.arthro.2008.11.006)
• [L4] The repaired lateral side and untreated posterior cruciate ligament heal with continuity, allowing patients to return to high levels of activity. [20] (10.1177/0363546507299444)
• [L5] At last clinical review 3 months after the injury examination revealed residual laxity of the PCL, stable collateral ligaments and ACL and the patient reported no functional difficulties. [23] (10.1016/s0020-1383(03)00077-9)
• [L1] [24] (10.1007/s00167-012-2132-1)
• [L3] Isolated PCL and multi-ligament PCL reconstructions showed significant improvements in subjective outcomes but did not reach those observed in ACL reconstructions. [25] (10.1007/s00167-017-4577-8)
• [L5] [28] (10.5435/00124635-200109000-00003)
• [L5] Stress radiographs support accurate diagnosis of complex knee injuries and provide an objective measure of knee stability following ligament reconstruction. [29] (10.1016/j.arthro.2020.11.001)
• [L5] A graft that restores knee kinematics for an isolated posterior cruciate ligament deficiency is rendered ineffective and may be overloaded if the posterolateral structures are deficient. [31] (10.1177/03635465000280011801)
• [L2] Isolated PCL injuries are common, although the injury is most commonly associated with other ligament injuries. [34] (10.1007/s00167-015-3786-2)
• [L4] With adequate quadriceps exercises, the prognosis of a ruptured posterior cruciate ligament can be greatly improved, with 80% of ruptures achieving a good or excellent result with effective management. [36] (10.1177/036354658401200409)
• [L5] The posterior oblique ligament (POL) is the predominant structure in the posteromedial corner of the knee joint, and surgical reconstruction should be considered the gold standard treatment in case of injury. [37] (10.1302/2058-5241.6.200127)
• [L4] The PCL-deficient knee in children may be treated nonoperatively with satisfactory subjective results in the short term, but the long-term consequences of chronic PCL deficiency in children are not known. [38] (10.1177/03635465030310010701)
• [L4] The purpose of this review was to evaluate the current state of the literature on PCL injuries and variables associated with injury decision making based on reported outcomes, noting that controversy remains regarding indications for surgical versus nonsurgical management and optimal surgical techniques. [39] (10.5435/jaaos-d-25-00500)
• [L5] Recent studies on double-bundle reconstruction suggest better restoration of knee kinematics, though no significant clinical differences have been established between various surgical techniques. [41] (10.1302/2058-5241.2.160009)
• [L5] [44] (10.1002/ksa.70082)
• [L5] Separation of injury patterns into distinct classifications for knee dislocations and multiple ligament knee injuries allows researchers to stratify by newer modifications and shows potential for assisting in patient prognosis. [46] (10.1016/j.arthro.2025.05.011)
• [L2] MRI is a sensitive measure of cruciate and collateral ligament injury in acute knee dislocation; however, it does not reliably diagnose injury to the posterolateral corner or meniscus, and therefore, a higher index of suspicion is required during arthroscopy to prevent misdiagnosis which could affect long-term clinical outcome. [50] (10.1007/s00167-015-3857-4)
• [Paper] [53] (10.1016/j.csm.2018.11.006)
• [L4] Patients with a previous history of knee ligament surgery had a significantly worse quality of life relative to those with no history of knee ligament surgery. [54] (10.1177/2325967115s00073)
• [Case_report] Intra-articular fractures of the distal femoral epiphysis can mimic ligamentous injuries, particularly posterior cruciate ligament insufficiency, and require stress radiographs for diagnosis. [55] (10.2106/00004623-198870030-00024)
• [L4] Patellar tendon ruptures are rare after ACL graft harvest and typically occur in a proximal-medial/distal-lateral or entirely distal pattern. [57] (10.1177/0363546512449815)
• [L4] After follow-up for more than 60 months, patients achieved satisfactory function after PCL reconstruction by using a quadriceps tendon–patellar bone autograft. [58] (10.1016/j.arthro.2006.12.011)
• [L5] There is no scientifically proven superior method for ACL or PCL reconstruction due to a lack of well-designed randomized clinical trials, and the field continues to rely on unproven assumptions and varying opinions. [60] (10.1007/s00167-001-0251-1)
• [L4] Long-term results after an isolated PCL injury show that patients remain active, have good strength and full knee range of motion, and report good subjective scores. [62] (10.1177/0363546513486771)
• [L4] Despite good clinical outcome, complete restoration of ligament stability was achieved in only 52% of the knees with 1/3 of the knees showing mild and 9.7% moderate ligament laxity. [64] (10.1016/s0020-1383(02)00197-3)
• [L3] Patients with complications after anterior cruciate ligament reconstruction with a patellar tendon autograft may have less difficulty obtaining full knee motion when the graft is harvested from the contralateral knee. [65] (10.1177/0363546510388163)
• [Case_report] The case demonstrates that early surgical repair of acute PCL injuries with concomitant ligamentous lesions and vascular injuries can lead to superior long-term results compared to conservative treatment, with the patient showing intact perfusion, physiological gait, and intact cruciate ligaments at 1-year follow-up. [66] (10.1007/s00167-005-0677-y)
• [L4] [67] (10.1016/j.otsr.2010.02.007)
• [L3] Acute PCL injuries treated non-surgically display a high degree of PCL continuity on MR images 11 years after injury. [70] (10.1186/s12891-023-06480-0)
• [L4] [73] (10.1007/s001670050169)
• [L5] [80] (10.1007/s00167-020-06357-y)
• [L3] This study shows that differences in the shape of the knee are associated with the presence of a PCL rupture after injury. [89] (10.1302/0301-620x.101b9.bjj-2018-1567.r1)
• [L5] Multiple ligament injured knees are often part of a multisystem injury complex where additional injuries affect surgical timing and treatment results. [90] (10.1016/j.csm.2018.11.004)
• [L5] The study suggests progressive damage to translational and rotational knee soft-tissue restraints with increasing knee hyperextension. [92] (10.1177/0363546507308189)
• [L3] Patients with MLKR display abnormalities in knee kinematics during gait at an average of 4.5 years after surgery. [94] (10.1007/s00167-016-4104-3)
• [L4] An optimal set of guidelines for the nonoperative or postoperative management of PCL injuries has not yet been defined or agreed upon. [95] (10.1007/s00167-012-1970-1)
• [L4] [105] (10.1007/s00167-008-0531-0)
• [L4] [106] (10.1007/s11999-014-3557-2)
• [L3] Significant improvement in objective knee stability scores and clinical outcomes with anatomical reconstruction showed that this technique can be used to treat patients with chronic PLC injured knees. [112] (10.1007/s00402-015-2291-x)
• [L4] [116] (10.1016/j.otsr.2014.10.003)
• [L4] Both constructs had comparable clinical outcomes and were equally effective in restoring varus and rotational stability for PLC knee injuries. [125] (10.1177/03635465221138548)
• [L3] PCL ruptures altered walking patterns in both the involved and uninvolved legs, which could affect alignment of the lower limb and loading on the knee, hip, and ankle joints. [127] (10.1177/2325967119891164)
• [L4] A systematic approach to chronic posterolateral instability of the knee combining bony axial correction, collateral and central ligament reconstruction can result in significant amelioration of function and positive outcomes for ADL and low level athletic activities. [128] (10.1016/j.arthro.2013.07.136)
• [L4] [137] (10.1016/j.otsr.2014.06.018)
• [L4] [138] (10.1177/23259671251320981)
• [L3] The KD classification alone was not predictive of surgery timing, staging, or any type of intervention for any injured ligament. [139] (10.1055/s-0039-1695739)
• [L2] MRI evaluation of the PCL fibers had poor sensitivity for chronic PCL tears and PCL reconstruction graft tears. [140] (10.1177/0363546517734201)
• [L4] The proprioceptive function, defined as TTDPM, is maintained after single-bundle PCL reconstruction with remnant preservation, and the postoperative clinical scores and posterior laxity significantly improve. [141] (10.1016/j.otsr.2013.12.020)
• [L4] The authors recommend operative stabilization for definite isolated PCL insufficiency, particularly in younger patients with high performance requirements. [143] (10.1007/s00402-011-1403-5)
• [L4] [145] (10.1007/s00167-009-1011-x)
• [L5] Delaying reconstruction in active children increases the risk of meniscal and cartilage damage, leading to poor long-term outcomes. [147] (10.1016/j.csm.2011.07.002)
• [L4] Stress radiography is superior to both the arthrometer and clinical posterior drawer testing for determining posterior cruciate ligament status. [148] (10.1177/036354659702500510)
• [Paper] Despite limitations in validation, the Schenck classification serves as a useful communication, planning, and prognostic tool for evaluating potential associated neurovascular injuries in knee dislocations. [151] (10.1097/corr.0000000000001186)
• [L2] The generally low methodological quality of studies on PCL injury management shows that caution is required when interpreting results, and firm recommendations on treatment choice cannot be given at this time. [153] (10.1007/s00167-008-0632-9)
• [L2] Our review suggests that early operative treatment of the multiligament-injured knee yields improved functional and clinical outcomes compared with nonoperative management or delayed surgery. [156] (10.1016/j.arthro.2009.01.008)
• [L3] Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions. [157] (10.1177/03635465241238461)
• [L3] [158] (10.1186/s12891-022-05189-w)
• [L2] The results of this systematic review indicate that posterior stress radiography with TELOS and kneeling stress radiography are the most reliable methods to evaluate posterior cruciate ligament laxity. [164] (10.1016/j.asmr.2022.05.013)
• [L2] Consequently, the modified Lachmeter technique holds promise as an alternative to stress radiography for patients with isolated PCL injuries. [165] (10.1177/23259671251391352)
• [L2] Most PCL and posterolateral corner injuries occur in combination with other ligament injuries. [167] (10.1016/j.arthro.2007.07.024)

See Also

• Posterolateral corner injury
• High tibial osteotomy
• ACL reconstruction
• Anterior cruciate ligament injury

References

[1] Posterior Cruciate Ligament Replacement with a Two-Strand Quadriceps Tendon-Patellar Bone Autograft and a Tibial Inlay Technique. The Journal of Bone and Joint Surgery (American). 2005. DOI: 10.2106/jbjs.d.02272

[2] Posterior Cruciate Ligament. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511416316

[3] Evaluation and Treatment of Posterior Cruciate Ligament Injuries. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546504270481

[4] Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: A systematic review. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2014.09.010

[5] Anatomic Reconstruction of the Posterior Cruciate Ligament after Multiligament Knee Injuries: A Combination of the Tibial-Inlay and Two-Femoral-Tunnel Techniques. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310020701

[7] Repair of Acute Grade 3 Combined Posterolateral Corner Avulsion Injuries Using an Enhanced Fixation Technique. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221131817

[9] Posterolateral Corner of the Knee: An Update on Current Evaluation and Management Strategies. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00278

[10] Incidence and Location of bone Bruises after Acute Posterior Cruciate Ligament Injury. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546504266481

[11] Biomechanical Analysis of a Combined Double-Bundle Posterior Cruciate Ligament and Posterolateral Corner Reconstruction. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504268039

[12] Injuries of the Posterolateral Corner of the Knee. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200101000-00015

[13] Clinical outcome after reconstruction for isolated posterior cruciate ligament injury. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1176-3

[14] Management of Posterior Cruciate Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-14-00326

[15] Aaos Comprehensive Orthopaedic Review 3. Ligamentous Injuries of the Knee > II. Posterior Cruciate Ligament Injuries.

[17] Treatment of Medial Collateral Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200903000-00004

[18] Multi‐ligament reconstructions as a risk factor for adverse outcomes in arthroscopic surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06252-6

[19] Single‐Bundle Versus Double‐Bundle Posterior Cruciate Ligament Reconstruction. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2008.11.006

[20] Knee Dislocation with Lateral Side Injury. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507299444

[21] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH BONE-PATELLAR TENDON-BONE GRAFT > POSTERIOR CRUCIATE LIGAMENT.

[23] Isolated posterior cruciate ligament rupture following postero-lateral dislocation of the knee. Injury. 2003. DOI: 10.1016/s0020-1383(03)00077-9

[24] An isolated rupture of the posterior cruciate ligament results in reduced preoperative knee function in comparison with an anterior cruciate ligament injury. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2132-1

[25] Both isolated and multi-ligament posterior cruciate ligament reconstruction results in improved subjective outcome: results from the Danish Knee Ligament Reconstruction Registry. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4577-8

[26] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > 4. Posterior Cruciate Ligament Injuries.

[28] Posterior Cruciate Ligament Injuries: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200109000-00003

[29] Stress Radiographs for Ligamentous Knee Injuries. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2020.11.001

[31] Biomechanical Analysis of a Posterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280011801

[34] Epidemiology of surgically treated posterior cruciate ligament injuries in Scandinavia. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3786-2

[35] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE AND ANTROLATERAL LIGAMENT RECONSTRUCTION (BOX 51.8) > POSTERIOR CRUCIATE LIGAMENT.

[36] Long-term followup of posterior cruciate ligament rupture: A study of 116 cases. The American Journal of Sports Medicine. 2004. DOI: 10.1177/036354658401200409

[37] Posterior oblique ligament of the knee: state of the art. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200127

[38] Posterior Cruciate Ligament Injury and Posterolateral Instability in a 6-Year-Old Child. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310010701

[39] Management of Posterior Cruciate Ligament Injury: A Concise Overview of Current Indications, Techniques, and Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00500

[41] Isolated posterior cruciate ligament tears: an update of management. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160009

[44] Multiligamentous injuries of the knee: Fast (and not furious) or later. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70082

[46] Editorial Commentary : Precise Categorization of Ligament Injuries in Knee Dislocations and Multiple Ligament Knee Injury Shows Potential for Improved Awareness of Neurovascular Injury and Patient Prognosis. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.05.011

[50] How sensitive and specific is 1.5 Tesla MRI for diagnosing injuries in patients with knee dislocation?. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3857-4

[53] Multiple Ligament Knee Injuries. Clinics in Sports Medicine. 2019. DOI: 10.1016/j.csm.2018.11.006

[54] Quality of Life and Functional Outcomes after Multi-Ligament Knee Reconstruction. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00073

[55] Intra-articular fracture of the femur mimicking insufficiency of the posterior cruciate ligament. A case report.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870030-00024

[57] Tear Patterns, Surgical Repair, and Clinical Outcomes of Patellar Tendon Ruptures After Anterior Cruciate Ligament Reconstruction With a Bone–Patellar Tendon–Bone Autograft. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512449815

[58] Arthroscopic Reconstruction of the Posterior Cruciate Ligament by Using a Quadriceps Tendon Autograft: A Minimum 5‐Year Follow‐up. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.12.011

[60] Treatment of ACL and PCL. Knee Surgery, Sports Traumatology, Arthroscopy. 2001. DOI: 10.1007/s00167-001-0251-1

[62] Minimum 10-Year Follow-up of Patients After an Acute, Isolated Posterior Cruciate Ligament Injury Treated Nonoperatively. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513486771

[64] Outcome of arthroscopic single bundle reconstruction for complete posterior cruciate ligament tear. Injury. 2003. DOI: 10.1016/s0020-1383(02)00197-3

[65] Infections and Patellar Tendon Ruptures After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510388163

[66] Femoral avulsion fracture of the posterior cruciate ligament in association with a rupture of the popliteal artery in a 9‐year‐old boy: a case report. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-005-0677-y

[67] Does combined posterior cruciate ligament and posterolateral corner reconstruction for chronic posterior and posterolateral instability restore normal knee function?. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.02.007

[70] Clinical, patient-reported, radiographic and magnetic resonance imaging findings 11 years after acute posterior cruciate ligament injury treated non-surgically. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06480-0

[73] Proprioception in the posterior cruciate ligament deficient knee. Knee Surgery, Sports Traumatology, Arthroscopy. 1999. DOI: 10.1007/s001670050169

[80] Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06357-y

[84] Orthopaedic Knowledge Update Sports Medicine 6. Cruciate Ligament Injuries > Posterior Cruciate Ligament Injury > Anatomy and Biomechanics.

[85] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH BONE-PATELLAR TENDON-BONE GRAFT > POSTERIOR CRUCIATE LIGAMENT ANATOMY.

[89] Posterior cruciate ligament injury is influenced by intercondylar shape and size of tibial eminence. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b9.bjj-2018-1567.r1

[90] Multiple Ligament Injured Knee. Clinics in Sports Medicine. 2019. DOI: 10.1016/j.csm.2018.11.004

[92] Biomechanical and Anatomical Assessment after Knee Hyperextension Injury. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507308189

[94] Gait adaptations following multiple-ligament knee reconstruction occur with altered knee kinematics during level walking. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4104-3

[95] Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1970-1

[98] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Plate 35.2 Scapulocostal Stabilization for Scapular Winging (Ketenjian Technique) > Pediatric Posterior Cruciate Ligament Injuries.

[105] Active non‐operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0531-0

[106] A Novel Posteromedial Approach for Tibial Inlay PCL Reconstruction in KDIIIM Injuries: Avoiding Prone Patient Positioning. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-014-3557-2

[110] Campbell S Operative Orthopaedics 4 Volume Set. POSTERIOR CRUCIATE–RETAINING TOTAL KNEE ARTHROPLASTY OF A VARUS KNEE.

[112] Outcome of the treatment of chronic isolated and combined posterolateral corner knee injuries with 2- to 6-year follow-up. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2291-x

[116] Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: For what functional results?. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2014.10.003

[119] Orthopaedic Knowledge Update Sports Medicine 6. Cruciate Ligament Injuries > Posterior Cruciate Ligament Injury > Diagnosis.

[125] Fibular- Versus Tibiofibular-Based Reconstruction of the Posterolateral Corner of the Knee: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221138548

[127] Lower Limb Biomechanics During Level Walking After an Isolated Posterior Cruciate Ligament Rupture. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119891164

[128] Paper #131: Secondary Reconstruction After Traumatic Knee Dislocation: Results of an Algorithm‐Based Approach. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.07.136

[132] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Soft-­Tissue Injuries About the Knee > Posterior Cruciate Ligament > Treatment.

[133] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE AND ANTROLATERAL LIGAMENT RECONSTRUCTION (BOX 51.8) > POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION.

[134] Orthopaedic Knowledge Update Sports Medicine 6. Cruciate Ligament Injuries > Posterior Cruciate Ligament Injury > Treatment and Outcomes.

[137] Serial magnetic resonance imaging study of posterior cruciate ligament reconstruction or augmentation using hamstring tendons. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2014.06.018

[138] Uniplanar Coronal Tibiofemoral Subluxation in Patients After Multiligament Knee Injuries: A Multicenter Retrospective Case Series. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251320981

[139] Multiple Ligament Knee Injuries: Does the Knee Dislocation Classification Predict the Type of Surgical Management?. The Journal of Knee Surgery. 2020. DOI: 10.1055/s-0039-1695739

[140] Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517734201

[141] Proprioceptive function after isolated single-bundle posterior cruciate ligament reconstruction with remnant preservation for chronic posterior cruciate ligament injuries. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.12.020

[143] Isolated AL bundle reconstruction of the PCL. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1403-5

[145] Injury patterns to the posteromedial corner of the knee in high‐grade multiligament knee injuries: a MRI study. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-1011-x

[147] Anterior Cruciate Ligament Reconstruction Timing in Children with Open Growth Plates: New Surgical Techniques Including All-Epiphyseal. Clinics in Sports Medicine. 2011. DOI: 10.1016/j.csm.2011.07.002

[148] Diagnosis of Complete and Partial Posterior Cruciate Ligament Ruptures. The American Journal of Sports Medicine. 1997. DOI: 10.1177/036354659702500510

[151] Classifications in Brief: The Schenck Classification of Knee Dislocations. Clinical Orthopaedics & Related Research. 2020. DOI: 10.1097/corr.0000000000001186

[153] Clinical studies on posterior cruciate ligament tears have weak design. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0632-9

[156] Decision Making in the Multiligament‐Injured Knee: An Evidence‐Based Systematic Review. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.01.008

[157] Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465241238461

[158] Patients with isolated posterior cruciate ligament rupture had a higher posterior intercondylar eminence. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05189-w

[164] Stress Radiography Is a Reliable Method to Quantify Posterior Cruciate Ligament Insufficiency: A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2022.05.013

[165] Comparison Between the Modified Lachmeter Technique and Stress Radiographic Measurement in an Isolated Posterior Cruciate Ligament Injury. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251391352

[167] A Prospective Magnetic Resonance Imaging Study of the Incidence of Posterolateral and Multiple Ligament Injuries in Acute Knee Injuries Presenting With a Hemarthrosis. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.07.024