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Non-operative Treatment of PCL Injury

Original Editor - Mariam Hashem

Top Contributors - Jess Bell, Mariam Hashem, Kim Jackson, Tony Lowe and Tarina van der Stockt

Introduction

The posterior cruciate ligament (PCL) is the largest intra-articular ligament of the knee. It originates at the anterolateral surface of the medial femoral condyle and inserts onto the posterior aspect of the tibial plateau,[1] crossing the ACL to form an 'X' shape. It consists of two functional bundles — the anterolateral and the posteromedial — which act co-dominantly to resist posterior tibial translation throughout flexion.[2][3] The PCL also resists tibial external rotation, as well as valgus and varus stress.[4] For more information on PCL anatomy, see Posterior Cruciate Ligament Injury.

Isolated PCL injuries are uncommon.[5] The majority of PCL injuries occur in conjunction with other ligamentous, meniscal or chondral damage.[6][7][8] The most common mechanism of injury is a direct posterior force applied to the proximal tibia with the knee in flexion, such as a dashboard injury or a fall onto the flexed knee.[6][9][10]

Assessment

The posterior drawer test and posterior sag sign are important clinical tests for diagnosing PCL injuries and determining the management plan.[4] These tests are shown in the following videos. To read more about these tests and others, see: Posterior Cruciate Ligament Injury: Assessment and Diagnosis.

[11]
[12]

PCL injuries can be graded according to the degree of posterior tibial translation. In a Grade I injury, the tibia translates 0–5 mm, and the tibial plateau remains anterior to the femoral condyles. In a Grade II injury, there is 5–10 mm of translation, and the tibial plateau sits flush with the femoral condyles. In a Grade III injury, the tibia translates more than 10 mm, and the tibial plateau moves posterior to the femoral condyles.[13][14][15]

Conservative vs Surgical Management

The decision between conservative and surgical management depends on the degree of laxity, the presence of associated injuries, and patient preference.[16]

Conservative management may be appropriate for isolated PCL injuries of any grade when the side-to-side difference in posterior tibial translation is less than 8 mm on stress radiography, there is less than 5° of abnormal rotatory laxity at 30° of knee flexion, and there is no significant collateral injury causing varus or valgus instability.[16]

For more information on surgical indications, see: Posterior Cruciate Ligament Injury: Management.

Conservative Management Outcomes

Non-operative PCL management is associated with good functional outcomes. One study found that patients managed conservatively with isolated Grade II or III PCL injuries returned to sport at 16 weeks on average. Of those who returned to sport, 91% were playing at the same level or higher at 2 years, though this declined to around 70% at the five-year follow-up.[17]

However, a significant proportion of patients with PCL-deficient knees go on to develop degenerative changes in their medial femoral condyle (77%) or their trochlea (47%) at five years.[18][19] These risks should be discussed with patients as part of shared decision-making

Rehabilitation

Conservative rehabilitation typically involves bracing, physiotherapy, quadriceps strengthening, and proprioceptive exercises.[9]

Clinical Precautions and Restrictions

Minimise posterior tibial sag. Patients should initially avoid positions where the tibia sags posteriorly, such as wall slides or unsupported sitting with the knee flexed. Placing a pillow underneath the proximal tibia when sleeping helps maintain a more neutral tibial position and reduces posterior translation.[4]

Dynamic PCL bracing. Dynamic PCL braces have a spring-loaded calf cuff that applies a constant anterior force to the tibia, reducing posterior sag and allowing the ligament to heal in a shortened position.[20][21] These braces are worn all day, apart from during showering.[4] If a dynamic brace is not available, a knee immobiliser may be used during the acute phase. The patient can then progress to a hinged athletic brace with a PCL strap. This brace should be worn for at least 12 months.[4]

Evidence for Dynamic PCL Bracing: A study of 21 patients using a dynamic PCL brace for one year found that the mean posterior tibial sag was reduced from 7.1 mm to 2.3 mm at 12 months.[22] However, it should be noted that the evidence base for dynamic bracing remains limited. A 2025 scoping review found significant variation across bracing protocols in type, duration, knee flexion restrictions, weight-bearing status, and activity limitations, with no studies directly comparing different dynamic bracing protocols or evaluating their efficacy against other approaches.[20]

Prone range of motion. Range of motion exercises should initially be performed in prone to limit the effect of gravity on posterior tibial translation.[4]

Weight-bearing. It is recommended to limit weight bearing initially to help restore joint homeostasis.[4]

Hamstring precautions. Isolated hamstring contractions should be avoided for at least 16 weeks in flexed knee positions. Hamstring activation in this range has been shown to significantly increase the mean forces applied to the PCL, beyond approximately 30 degrees.[4][23]

The following guidelines represent one approach to PCL rehabilitation. As noted, standardised protocols have yet to be established, and progression should be guided by individual patient response rather than timeframes alone.

Acute Rehabilitation (Weeks 0–4)

The initial phase focuses on protecting the healing ligament while restoring range of motion, managing swelling, and reactivating muscle function.[4]

As mentioned, range of motion exercises begin in prone. The patient can progress to the stationary bike once they have sufficient knee flexion (approximately 115°). Swelling should be managed in line with acute soft tissue injury guidelines. The PEACE and LOVE framework is currently recommended for acute ligament injuries; this approach emphasises early protection, load management, and avoiding anti-inflammatories, which may interfere with tissue healing.[24] In the first week, patients should be advised to limit activities to essential tasks and avoid prolonged walking.[4] Quadriceps activation should be introduced from the outset. When the quadriceps contracts, it draws the tibia anteriorly, reducing posterior subluxation and improving joint stability. The focus should be on achieving an isolated quadriceps contraction — drawing the patella superiorly and terminally extending the knee — rather than a co-contraction pattern.[4] Patients can progress to weight-bearing strengthening exercises when they have achieved 130° of knee flexion, terminal knee extension, and can walk comfortably in a brace for 15–20 minutes.[4]

Later Rehabilitation

Muscular endurance (weeks 5–10). The initial focus is on developing muscular endurance, using low loads and higher repetitions (for example, 15 repetitions, 3–4 sets with 40 seconds rest between sets). Example exercises for this phase include monster walks, forward and backwards walking with a resistance band, bilateral squats, leg press, eccentric step-downs from a small box (approximately 2.5 cm), and double- or single-leg Romanian deadlifts. The rationale for including the Romanian deadlift at this stage is that the small knee flexion angle keeps hamstring forces vertically oriented rather than creating a posterior tibial force. Eccentric work is particularly valuable, as patients with PCL deficiency frequently report instability during activities such as descending stairs or walking downhill.[4]

Muscular strength (weeks 11–16). The same exercises can be progressed by increasing the load and reducing the repetitions (for example, 10–12 repetitions, 3 sets with 1–2 minutes rest between sets). Additional exercises may include elevated split squats and weighted squats using kettlebells or dumbbells. Lumbopelvic stability exercises should also be incorporated, as proximal strength and control improve limb positioning accuracy and can reduce episodes of functional instability.[4]

Power, agility and running (weeks 17–22). Once a sufficient strength base has been established, the programme progresses to include power development and a graded running programme, which are typically introduced simultaneously.[4]

Return to Sport

A structured strength programme should be completed before returning to sport. Clinicians should be aware that some patients may experience fear or apprehension about returning to activity with a PCL-deficient knee. Successfully completing a progressive rehabilitation programme can help address this.[4]

There is a lack of standardised return-to-sport criteria following PCL injury.[16][25] However, various protocols and guidelines draw on ACL return-to-sport frameworks. Before returning to sport, side-to-side symmetry on quadriceps strength testing, Y-Balance Test anterior reach distance, and power measures, such as single-leg hop tests, should be demonstrated.[4] A realistic timeframe for return to competitive sport following conservative management of an isolated PCL injury is approximately 16–22 weeks, depending on the individual's response to rehabilitation and the demands of their sport.[4]

[26]

[27]

References

  1. ↑ Logterman SL, Wydra FB, Frank RM. Posterior cruciate ligament: anatomy and biomechanics. Curr Rev Musculoskelet Med. 2018 Sep;11(3):510-514.
  2. ↑ Chahla J, Williams BT, Ellman WB, Laprade RF. Posterior cruciate ligament. In: LaPrade RF, Chahla J. Editors. Evidence-based management of complex knee injuries. Elsevier, 2022. p90-102.
  3. ↑ Winkler PW, Zsidai B, Wagala NN, Hughes JD, Horvath A, Senorski EH, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. Knee Surg Sports Traumatol Arthrosc. 2021 Mar;29(3):672-681.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 O'Brien L. PCL Reconstruction Rehabilitation Course. Physiopedia Plus, 2019.
  5. ↑ Vaquero-Picado A, Rodríguez-Merchán EC. Isolated posterior cruciate ligament tears: an update of management. EFORT Open Rev. 2017 Apr 27;2(4):89-96.
  6. ↑ 6.0 6.1 Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe G, Ziegler C, LaPrade RF. Posterior cruciate ligament: current concepts review. Arch Bone Jt Surg. 2018 Jan;6(1):8-18.
  7. ↑ Geller JS, Perez JR, Harner CD, Baraga MG. PCL injuries: evaluation and management. In: Slullitel P, Rossi L, Camino-Willhuber G. Editors. Orthopaedics and Trauma. Springer, Cham, 2024.
  8. ↑ Zsidai B, Engler ID, Narup E, Lin RT, Nazzal EM, Winkler PW, et al. Delayed multiligament PCL reconstruction is associated with a higher prevalence of intraarticular injury and may influence treatment. BMC Musculoskelet Disord. 2023 Jun 19;24(1):502.
  9. ↑ 9.0 9.1 Tedeschi R, Giorgi F, Platano D, Berti L, Vita F, Donati D. Balancing stability and recovery: a scoping review on conservative vs. surgical management of acute posterior cruciate ligament injuries. Surgeries. 2025; 6(1):24.
  10. ↑ Fortier LM, Stylli JA, Civilette M, Duran NS, Hanukaai S, Wilder H, et al. An evidence-based approach to multi-ligamentous knee injuries. Orthop Rev (Pavia). 2022 May 31;14(4):35825.
  11. ↑ Physiopedia. Posterior Drawer Test (Knee). Available from: http://www.youtube.com/watch?v= YJKTCPJ37OI [last accessed 12/04/2026]
  12. ↑ Clinical Physio. PCL Sag Test (Sag Sign) of the Knee | Clinical Physio. Available from: http://www.youtube.com/watch?v= Z4B0did7TIQ [last accessed 12/04/2026]
  13. ↑ Wang D, Graziano J, Williams RJ 3rd, Jones KJ. Nonoperative treatment of PCL injuries: goals of rehabilitation and the natural history of conservative care. Curr Rev Musculoskelet Med. 2018 Jun;11(2):290-297.
  14. ↑ Wilebski BJ, Tollefson LV, Lee DR, Rasmussen MT, LaPrade RF. Current standards for the objective assessment and management of posterior cruciate ligament tears: a narrative review. Ann Jt. 2026 Jan 23;11:9.
  15. ↑ Kew ME, Cavanaugh JT, Elnemer WG, Marx RG. Return to play after posterior cruciate ligament injuries. Curr Rev Musculoskelet Med. 2022 Dec;15(6):606-615.
  16. ↑ 16.0 16.1 16.2 Gao S, Meng J, Zeng C, Monllau JC, LaPrade RF, Taft TN, et al. Management of posterior cruciate ligament injuries: an expert consensus from 17 countries. Int J Surg. 2025 Jun 1;111(6):4080-4085.
  17. ↑ Agolley D, Gabr A, Benjamin-Laing H, Haddad FS. Successful return to sports in athletes following non-operative management of acute isolated posterior cruciate ligament injuries: medium-term follow-up. Bone Joint J. 2017 Jun;99-B(6):774-778.
  18. ↑ Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003 Mar;19(3):262-8.
  19. ↑ Welch T, Keller T, Maldonado R, Metzger M, Mohr K, Kvitne R. The effect of a dynamic PCL brace on patellofemoral compartment pressures in PCL-and PCL/PLC-deficient knees. J Exp Orthop. 2017 Dec;4(1):10.
  20. ↑ 20.0 20.1 Sura WJ, Gill BS, Walker A. Exploring and comparing bracing protocols for acute isolated posterior cruciate ligament injuries: A scoping review of rationales and approaches. Musculoskelet Sci Pract. 2025 Nov;80:103412.
  21. ↑ Zappalà G, Delmedico M, Ciclamini D, Trapella N, Pasquali C, Crespi C, Ronga M. Effectiveness of dynamic brace in posterior tibial translation in acute PCL lesion: a pilot, single center exploratory study. Healthcare. 2026; 14(7):953.
  22. ↑ Jacobi M, Reischl N, Wahl P, Gautier E, Jakob RP. Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report. The Journal of bone and joint surgery. British volume. 2010 Oct;92(10):1381-4.
  23. ↑ Markolf KL, O'Neill G, Jackson SR, McAllister DR. Effects of applied quadriceps and hamstrings muscle loads on forces in the anterior and posterior cruciate ligaments. The American journal of sports medicine. 2004 Jul;32(5):1144-9.
  24. ↑ Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020 Jan;54(2):72-73.
  25. ↑ Tortoli E, Gerini A, Pellicciari L, Gokeler A. Redefining the paradigm: advancing evidence-based return-to-sport criteria following isolated posterior cruciate ligament reconstruction: A Scoping Review. Sports Med. 2026 Mar 11.
  26. ↑ Y Balance Test Explained . Available from:https://www.youtube.com/watch?v=1gfGkxWlx4o
  27. ↑ Physio REHAB. ACL + Knee Injury - Return to Sport Tests (Pt.1) | Tim Keeley | Physio REHAB. Available from: https://www.youtube.com/watch?v=Y0xp8-2nLhs [last accessed 25/06/2024]
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