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Posterior Cruciate Ligament Injury

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Introduction

The posterior cruciate ligament (PCL) is the strongest and largest ligament in the knee.[1] Its primary role is to prevent posterior translation of the tibia relative to the femur.[2] It also contributes to rotatory stability.[3] Isolated PCL injuries are relatively uncommon.[4] The estimated annual incidence is approximately 2 per 100,000 people.[5][6] The majority (95%) of PCL injuries occur alongside other ligament, meniscus, or chondral injuries.[1][5][7]

This page provides an overview of PCL injury. For detailed rehabilitation guidance, see Non-operative Treatment of PCL Injury and PCL Reconstruction.

Clinically Relevant Anatomy

The PCL is one of the two cruciate ligaments of the knee. It originates at the anterolateral surface of the medial femoral condyle and inserts onto the posterior aspect of the tibial plateau, approximately 1 cm below the joint line.[8] It crosses the anterior cruciate ligament (ACL) to form an 'X' shape.

The PCL consists of two functional bundles: the anterolateral (AL) bundle and the posteromedial (PM) bundle.[1] The larger AL bundle is the main restraint to posterior tibial translation between 70–105° of knee flexion, while the PM bundle is the main restraint from 0–15°.[1] The two bundles act co-dominantly to protect the knee from posterior translation throughout the full range of flexion.[9]

Anterior view knee
Posterior view knee

Epidemiology and Mechanism of Injury

PCL injuries are more common in men with an average age at injury of 28–34 years.[9] The most common mechanism of PCL injury involves a posterior force applied to the proximal tibia with the knee flexed — the classic "dashboard injury". This high-impact trauma frequently results in a multi-ligament injury. Hyperflexion injuries (such as falling onto a flexed knee with the ankle plantarflexed) are more likely to result in isolated PCL tears. Non-contact hyperextension or hyperflexion injuries are less common.[1][10][11]

Clinical Presentation

PCL injuries present differently depending on the mechanism of injury, severity, and chronicity.[1]

High-energy injuries, such as motor vehicle accidents, often cause significant pain, swelling, difficulty with weight bearing, and reduced range of motion.[12] Haemarthrosis following acute knee trauma with a suspected posterior tibial translation mechanism should raise suspicion of a PCL tear.[9]

The signs and symptoms of acute isolated PCL injuries tend to be more subtle. Patients rarely describe hearing or feeling a "pop" and may be able to continue their activity.[12] Pain commonly occurs in the posterior knee, patellofemoral region, or anteromedial aspect of the knee.[9] In contrast to ACL injuries, patients with acute isolated PCL injuries are less likely to report instability, but they may experience stiffness and swelling.[1][9]

Patients with chronic PCL injuries typically present with anterior knee pain, difficulty descending stairs, squatting, and walking on inclines, and increasing feelings of instability — particularly when other ligamentous structures are also involved.[1][9][12] Medial compartment and patellofemoral arthrosis may develop over time.[12]

Assessment and Diagnosis

A complete knee examination is essential to identify a PCL injury and rule out associated pathology, such as anterior cruciate ligament injury and posterolateral corner (PLC) injury.[9][13] For more information, see Overview of Knee Assessment.

Key special tests for the PCL include the posterior drawer test, posterior sag sign and quadriceps active test.

Posterior Drawer Test: This is the most widely used clinical test for PCL injury, with a reported sensitivity of 90% and specificity of 99%.[14]

To perform this test, the patient is supine with their knee flexed to 90°. The examiner stabilises the patient’s foot and applies a posteriorly directed force to the proximal tibia. The test is positive if there is excessive posterior translation compared to the unaffected side. It is important to first check whether the tibia is already sitting posteriorly, as this can result in a false negative.[15] The following video shows how to perform this test.

[16]

PCL injuries can be graded by the degree of posterior tibial translation on posterior drawer testing:[12][17] [18]

  • Grade I (0–5 mm): The tibial plateau remains anterior to the femoral condyles.
  • Grade II (6–10 mm): The tibial plateau sits flush with the femoral condyles.
  • Grade III (>10 mm): The tibial plateau moves posterior to the femoral condyles. This degree of translation is frequently associated with injury to additional structures, such as the posterolateral corner and/or collateral ligaments.

Posterior Sag Sign: This test has a sensitivity of 57–91% and a specificity of 85–100%.[14]

To perform this test, the patient lies supine with their hips and knees flexed to 90°. The examiner supports the patient’s ankles. They observe the anterior profile of the proximal tibia, looking for posterior displacement compared to the opposite side. The test can also be performed with the patient’s feet resting on the bed, with their hips at 45°, knees at 90°.

Quadriceps Active Test: This test is useful for identifying complete PCL tears. It has a sensitivity of 29–76% and a specificity of 96–100%.[14]

The patient lies supine with their knee flexed to 90° and their foot resting on the bed. If the PCL is torn, the proximal tibia may be posteriorly subluxed in this position. The examiner stabilises the patient’s foot and asks the patient to try to extend their knee or slide their foot down the bed against resistance. The test is positive if the proximal tibia visibly translates anteriorly as the quadriceps contracts.

This video shows how to perform this test:

[19]

The reverse Lachman test can also be used to assess the PCL. As PCL injuries commonly co-occur with posterolateral corner injury,[2] tests such as the varus stress test, dial test, reverse pivot shift test, and external rotation recurvatum test should be considered.

The following videos provide additional information on posterolateral corner knee injuries and relevant tests.

[20]
[21]

Imaging

Radiographs can be used to identify fractures or dislocation. Stress radiography can quantify posterior laxity and may help identify posterolateral corner injuries. CT can be used to evaluate PCL injuries when fractures or avulsions are present. MRI is recommended for diagnosing PCL injuries and any associated injuries (e.g., ligament, meniscus, tendon, and cartilage).[22]

Management

Management decisions are guided by the severity of the PCL injury, the presence of associated injuries, and the patient's activity demands and goals.[22] Conservative management may be appropriate when:[22]

  • 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
  • there is no significant collateral injury causing varus/valgus instability

Surgical reconstruction is generally recommended when:[22]

  • the patient has a symptomatic complete (Grade III) tear
  • the side-to-side difference in posterior tibial translation exceeds 8 mm on stress radiography
  • there are other intra-articular or capsuloligamentous injuries
  • there is high-grade knee laxity

It is also important to consider patient preference, particularly in athletic populations. Delayed reconstruction may be indicated for patients aged under 60 years who have persistent pain or instability.[22]

Conservative Management

Conservative management can achieve good outcomes in appropriately selected patients. Agolley et al.[23] reported that in 46 athletes with Grade II or III isolated PCL injuries managed conservatively, the average return to competitive sport was 16 weeks. At follow-up, 91% of athletes were playing at their pre-injury level or higher at two years and 70% at five years.[23] More recently, Rasmussen et al.[24] reported significant improvements in patient-reported outcomes at five years following a physiotherapy-led exercise and bracing programme, with only 14% requiring conversion to surgery.[24] However, patients should be counselled that PCL-deficient knees are at increased risk of developing medial and patellofemoral compartment osteoarthritis over the longer term.[25][26]

The general principles of conservative management include avoiding posterior tibial translation in the early phase to optimise ligament healing, and progressive rehabilitation emphasising range of motion and quadriceps-dominant strengthening.[22] For detailed guidance, see Non-operative Treatment of PCL Injury.

Post-Operative Management

Rehabilitation following PCL reconstruction typically spans 9–12 months.[22][27] The overarching priority is protecting the graft from posterior tibial translation. Bracing is used to prevent posterior tibial displacement.[22] Quadriceps strengthening is prioritised throughout, while isolated hamstring exercises are avoided in the early stages. After the early protective phases of rehabilitation, patients should be progressed through structured phases of endurance training, strengthening, power development and sport-specific training. Patients can transition to higher-level activities once quadriceps strength reaches 90% of the uninvolved side.[22] For detailed guidance, see PCL Reconstruction.

Injury and Treatment Complications

Neurovascular injuries can occur with multi-ligament injuries. Conservative management may be associated with ongoing laxity, stiffness, pain, and degenerative joint disease. Surgical complications can include ongoing laxity, stiffness, anterior knee pain, painful hardware, heterotopic ossification and infection.[22]

Summary

PCL injuries frequently occur alongside other injuries. They most commonly result from high-energy trauma or sporting hyperflexion injuries. Treatment decisions are guided by injury severity, associated injuries, and patient preference. Both conservative and surgical management can achieve good outcomes in appropriately selected patients, though PCL-deficient knees carry an increased long-term risk of osteoarthritis. Rehabilitation, whether conservative or post-operative, prioritises graft/ligament protection, quadriceps strengthening, and criterion-based progression to full activity.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 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.
  2. ↑ 2.0 2.1 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. ↑ Lynch TB, Chahla J, Nuelle CW. Anatomy and biomechanics of the posterior cruciate ligament. J Knee Surg. 2021 Apr;34(5):499-508.
  4. ↑ 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.
  5. ↑ 5.0 5.1 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.
  6. ↑ Knapik DM, Gopinatth V, Jackson GR, Chahla J, Smith MV, Matava MJ, Brophy RH. Global variation in isolated posterior cruciate ligament reconstruction. Journal of experimental orthopaedics. 2022 Dec;9(1):1-2.
  7. ↑ 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.
  8. ↑ Logterman SL, Wydra FB, Frank RM. Posterior cruciate ligament: anatomy and biomechanics. Curr Rev Musculoskelet Med. 2018 Sep;11(3):510-514.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 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.
  13. ↑ Kondo E, Nishida Y, Joutoku Z, Kawamura D, Iwasaki K, Matsuoka M, et al. Double-bundle posterior cruciate ligament reconstruction procedure leads to better restoration of posterior knee laxity in isolated and multiple ligament knee injuries than single-bundle procedure. J Exp Orthop. 2025 Jun 5;12(2):e70295.
  14. ↑ 14.0 14.1 14.2 Logerstedt DS, Scalzitti D, Risberg MA, Engebretsen L, Webster KE, Feller J, et al. Knee stability and movement coordination impairments: knee ligament sprain revision 2017. J Orthop Sports Phys Ther. 2017 Nov;47(11):A1-A47.
  15. ↑ O'Brien L. PCL Reconstruction Rehabilitation Course. Physiopedia Plus, 2019.
  16. ↑ Physiopedia. Posterior Drawer Test (Knee). Available from: http://www.youtube.com/watch?v= YJKTCPJ37OI [last accessed 12/04/2026]
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ Physiopedia. Quadriceps Active Test – PCL Assessment. Available from: http://www.youtube.com/watch?v=lWl7LDDPYos [last accessed 11/04/2026]
  20. ↑ Clinical Physio. Posterolateral Corner Knee Injuries | Expert Physio Guide. Available from: http://www.youtube.com/watch?v=lxCp4yJElQg [last accessed 11/-4/2026]
  21. ↑ British Journal of Sports Medicine (BJSM). Knee Exam (16 of 27): Posterolateral corner. Available from: http://www.youtube.com/watch?v=bnXaTdvZZ6o [last accessed 11/04/2026]
  22. ↑ 22.00 22.01 22.02 22.03 22.04 22.05 22.06 22.07 22.08 22.09 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.
  23. ↑ 23.0 23.1 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.
  24. ↑ 24.0 24.1 Rasmussen RG, Blaabjerg B, Nielsen TG, Lind M. Long-term follow-up of patients with acute posterior cruciate ligament injury treated non-operatively with a physiotherapy-led exercise and support brace intervention. Int J Sports Phys Ther. 2025 May 2;20(5):648-656.
  25. ↑ Shelbourne KD, Clark M, Gray T. Minimum 10-year follow-up of patients after an acute, isolated posterior cruciate ligament injury treated nonoperatively. Am J Sports Med. 2013 Jul;41(7):1526-33.
  26. ↑ 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.
  27. ↑ Senese M, Greenberg E, Todd Lawrence J, Ganley T. Rehabilitation following isolated posterior cruciate ligament reconstruction: a literature review of published protocols. Int J Sports Phys Ther. 2018 Aug;13(4):737-751.





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