PCL Injury
Lower LimbOverview
PCL injuries represent a significant knee ligament injury that occurs when the posterior cruciate ligament is stretched or torn, typically from direct anterior force to the proximal tibia or hyperextension mechanisms. These injuries are less common than ACL injuries but frequently occur in conjunction with other ligamentous injuries, potentially compromising knee stability and function. Early assessment and appropriate management are essential to prevent chronic instability and secondary degenerative changes.
Pathophysiology
The posterior cruciate ligament, originating from the medial femoral condyle and inserting on the posterior tibia, is the primary restraint to posterior tibial translation. When subjected to excessive force—particularly direct blow to the anterior proximal tibia, forced hyperextension, or combined rotational mechanisms—the ligament fibers undergo partial or complete disruption. This disruption impairs proprioceptive feedback and neuromuscular control, leading to altered knee biomechanics, increased tibiofemoral shear forces, and potential secondary damage to menisci, collateral ligaments, and articular cartilage. Grade I (partial tear) involves incomplete fiber disruption; Grade II represents significant partial tear with functional instability; Grade III indicates complete rupture with marked instability.
Patient Education
PCL injuries require early diagnosis and conservative management with graduated strengthening to restore dynamic stability; most isolated PCL injuries heal well without surgery if rehabilitation is consistent and activity is appropriately modified.
Typical Presentation
Site
Posterior and medial knee joint, with pain typically diffuse throughout the knee; posterolateral knee pain if posterolateral corner involved
Quality
Dull aching pain, sense of instability or 'giving way,' sensation of knee sliding backward
Intensity
Mild to moderate in isolated injuries (4-6/10); severe in acute complete tears or combined injuries (7-9/10); often less painful than ACL injuries acutely
Aggravating
Descending stairs, walking downhill, activities requiring deceleration, deep knee flexion, pivoting movements, sitting with knee flexed (posterior wall compression), prolonged standing or walking
Relieving
Rest and elevation, knee extension, ice application, anti-inflammatory medication, activity modification, knee bracing or taping
Associated
Posterior knee swelling (less obvious than ACL), sense of instability with cutting/pivoting, difficulty with running and jumping, pain with posterior tibial sag test, difficulty squatting, mild effusion, positive posterior drawer test, positive quadriceps active test
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Posterior Drawer Test
Procedure
Patient supine, hip bent to 45° and knee to 90°, foot flat. Sit gently on the foot, check the starting position of the tibia (look for a sag first), then push the upper tibia backwards and compare with the other knee.
Positive Finding
More backwards movement than on the other side, with a soft end-point.
Sensitivity / Specificity
Reference: Rubinstein RA et al., Am J Sports Med 1994; PMID 7943523
Interpretation
A positive test supports a posterior cruciate ligament injury. Check the starting position first: a tibia that already sags backwards can make the test look like an anterior drawer.
Quadriceps Active Drawer Test
Procedure
Patient supine, knee bent to 90°, foot held on the plinth. Ask the patient to gently try to slide the foot forwards (contract the quadriceps) while you watch the tibial tuberosity from the side.
Positive Finding
The tibia moves forwards as the quadriceps contract, out of its sagged position.
Interpretation
Shows that the tibia was sagging backwards at rest and supports a posterior cruciate ligament injury. Useful when the patient cannot relax enough for a passive drawer. Daniel (1988) found anterior translation in 41/42 PCL-deficient knees with no false positives (a small descriptive series); a formal sensitivity/specificity pair was not reported.
Posterior Sag Test (Gravity Drawer)
Procedure
Patient supine with both hips bent to 45° and knees to 90°, feet flat. Look at both knees from the side and compare the position of the tibial tuberosities.
Positive Finding
The tibia on the injured side sits further back (sags) than on the other side.
Interpretation
A visible sag supports a posterior cruciate ligament injury. Compare sides carefully; a small sag is easy to miss. The previously cited Lelli (2014) paper describes the "lever sign" for ACL, not the PCL posterior sag; no isolated sensitivity/specificity for the sag sign is established.
Dial Test
Procedure
Patient prone. Bend both knees to 30°, hold the feet and rotate both tibias outwards equally, and compare the angle between the foot and thigh on each side. Repeat at 90° of knee flexion.
Positive Finding
More external rotation on the injured side, usually by a clear margin.
Interpretation
More rotation at 30° only suggests a posterolateral corner injury; more rotation at both 30° and 90° suggests a combined posterolateral corner and posterior cruciate ligament injury. The external rotation recurvatum test is a separate test. The dial test assesses posterolateral corner rotational laxity rather than isolated PCL injury; the figure previously shown was not supported by the cited source.
Sources
- Educational sitePhysiopedia. Dial Test.
Reverse Pivot Shift Test (Jakob Test)
Procedure
Patient supine and relaxed. Start with the knee bent to about 70–90°, the foot turned out and a valgus force applied. Slowly straighten the knee while keeping these forces.
Positive Finding
A clunk as the lateral tibial plateau moves forwards back into place, usually at about 20–30° of flexion.
Interpretation
Suggests posterolateral rotatory instability, often with a posterior cruciate ligament injury. Some people with lax knees have a positive test on both sides, so compare sides.
PCL Stress Radiograph (Posterior Drawer Stress View)
Procedure
Arranged by the specialist: a lateral X-ray of the knee at 90° of flexion while a standard backwards force is applied to the upper tibia, compared with the other knee.
Positive Finding
More backwards movement of the tibia on the injured side than on the other side.
Interpretation
Measures the amount of posterior laxity, which helps grade the injury and plan treatment. Interpreted by the specialist.
⚠ Red Flags
- •Acute severe trauma with inability to bear weight and significant swelling within 2 hours (suggests grade III tear or multi-ligament injury)
- •Vascular compromise signs: absent pedal pulses, pale or cyanotic foot, severe swelling with compartment pain
- •Signs of posterolateral corner injury with severe rotational instability
- •Associated fractures of tibial plateau, femoral condyle, or fibular head
- •Neurovascular deficit with peroneal nerve injury (foot drop, inability to dorsiflex)
- •Signs of complex knee dislocation with multiple ligament injuries
- •Uncontrolled swelling not responding to ice and compression within 48 hours
⚡ Yellow Flags
- •Catastrophic thinking about knee function and return to sport
- •Fear-avoidance beliefs regarding movement and activity, leading to deconditioning
- •Delayed presentation (>2 weeks) with ongoing instability and functional loss
- •High-level athlete with significant psychological distress regarding career implications
- •Poor compliance with rehabilitation expectations or denial of injury severity
- •Litigation or compensation issues related to injury circumstances
- •History of previous knee injuries with incomplete rehabilitation
- •Unrealistic expectations for rapid return to sport without appropriate progression
Osteopathic Techniques
Isolated grade I–II PCL injuries, and grade III in people with mild symptoms or low demands, are usually managed without surgery, as the PCL can heal. Early care is rest, ice, compression and elevation.
- Reference bookRaj et al. · StatPearls 2023
Region
Vastus medialis obliquus and quadriceps
Technique
Rationale
Hands-on work to the quadriceps and the tissues around the knee to ease tension and pain.
How it's done & evidence
How it's done
Hands-on kneading, stroking and sustained pressure to the quadriceps, the patellar and quadriceps tendons, the iliotibial band near the knee and the tissues around the joint. Transverse friction massage across a tendon is one form. In trials it was given alongside exercise.
Evidence in PCL Injury
Searched 24 Oct 2026: no trials of quadriceps soft tissue technique in PCL injury.
Sources
- Journal articleFurlan et al. · Cochrane 2015
- Journal articleRagone et al. · Healthcare (Basel) 2024
Region
Hip flexors and tensor fasciae latae
Technique
Rationale
Low-force, patient-powered stretch for tight hip and thigh muscles.
How it's done, cautions & evidence
How it's done
The muscle (for example the hamstrings, adductors or rectus femoris) is taken to its barrier. The patient pushes gently, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.
Cautions
Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.
Evidence in PCL Injury
Searched 24 Oct 2026: no trials of hip muscle energy technique in PCL injury.
Sources
- Reference bookWaxenbaum & Sina · StatPearls 2026
Rehabilitation Exercises
Supine Knee Flexion and Extension
Prone Knee Flexion Slides
Supine Figure-Four Hamstring and Piriformis Stretch
Gastrocnemius and Soleus Wall Calf Stretch
Supine Quadriceps Setting with Towel Roll
Straight Leg Raise (Supine)
Seated Knee Extension with Resistance Band
Standing Hip Flexor Strengthening (Marching)
Standing Hip Abduction with Resistance Band
Prone Hamstring Curls with Resistance Band
Bilateral Stance Stability with Upper Body Movement
Single-Leg Stance with Hand Support
Double-Leg Stance on Foam Pad
Wall Squats (Partial to Full Depth Progression)
Step-Ups on 4-6 Inch Step (Bilateral)
Sit-to-Stand from Chair
Lateral Band Walk (Double Leg)
Clamshells (Hip External Rotation)
Quadruped Alternating Limb Extension
Single-Leg Stance on Unstable Surface
Single-Leg Squats (Assisted Progression)
Stationary Cycling (Upright, Moderate Resistance)
Referral Criteria
- •Multi-ligament knee injuries requiring surgical consultation (especially posterolateral corner injuries with rotational instability)
- •Acute grade III (complete) PCL tear in young athletic population considering surgical reconstruction
- •Associated fractures (tibial plateau, femoral condyle, fibular head) requiring orthopedic specialist evaluation
- •Vascular or neurological compromise requiring emergency vascular surgery consultation
- •Unresolved swelling and effusion persisting beyond 4 weeks despite conservative management
- •Persistent severe instability not improving with 6-8 weeks of appropriate rehabilitation
- •Significant secondary meniscal or cartilage damage identified on imaging
- •Failure to progress in rehabilitation or developing chronic pain syndrome features
- •Athlete seeking clearance for high-impact sport return requiring sports medicine evaluation
- •Suspected complex knee dislocation or posterolateral corner involvement requiring specialized imaging and assessment
- •Development of persistent swelling with compartment syndrome concern
- •Patient preference for surgical intervention after failure of conservative management trial