PCL PROTOCOL

Melanie McNeal, PT, CSCS, CFT

DAVID LINTNER, MD

The PCL is the strongest ligament in the knee (2X as strong as ACL) and provides a significant amount of knee stability. PCL deficient knees are susceptible to degeneration at the medial femoral compartment and the patello-femoral joint due to the increased translation at these joint surfaces. The PCL is approximately 38mm in length and 13mm wide. It runs from the medial femoral condyle to the posterior tibia. It is composed of two distinct bands (anterolateral and posteromedial) and is closely connected to the menisco-femoral ligament. The bands are named with respect to their anatomic location with the femoral insertion specified first followed by the tibial insertion. The anterolateral band is twice as large as the posteromedial band and 1.5 times stronger. It becomes taut with knee flexion whereas the posteromedial band tightens with knee extension.

The PCL provides 95% restraint to posterior tibial translation and acts as a secondary restraint to tibial external rotation, varus, and hyperextension. With PCL rupture, there is an increased posterior translation when a posterior load is applied to the tibia and this translation increases as knee flexes with maximum translation from 70-90°, where the ACL is on full slack. Isolated PCL tears are uncommon due to the strength of the PCL.

There is much debate as to whether one should reconstruct a ruptured PCL or opt for conservative treatment. Many studies have shown that isolated PCL tears do well with conservative treatment. Conservative treatment of the PCL should focus on quadriceps rehab and protective weight bearing. Hamstring activity should be restricted due to the posterior pull the hamstrings elicit on the tibia. Quad activity helps counteract this posterior pull and should be addressed aggressively. Open kinetic chain activities are advised from 60-0° and closed chain activities from 0-60°. The therapist must watch for patellar pain due to the increased tibial drop back present with a ruptured PCL. The therapist must also be aware that the lateral structures of the knee act as secondary stabilizers to posterior translation and need to be guarded initially.

This protocol is for patients who have undergone PCL reconstruction. When reconstruction is the treatment of choice, the anterolateral component of the PCL is the focus due to its superior structural properties over the posteromedial band. An allograft or autograft can be used usually from the hamstring tendon, Achilles tendon, bone patellar tendon bone, or quad tendon. Following surgery, active knee flexion and hamstring muscle firing will place significant stress on the new graft and thus, should be avoided during the first six weeks post-op. Six weeks is chosen because this is the amount of time it takes soft tissue reconstruction to undergo biological healing.

PCL PROTOCOL

PHASE ONE

Weeks 1-2

*The patient will be in a post-op IROM brace that is locked at 0 degrees. The brace is to be worn at all times. The brace will be moved slowly to 30° depending on how stiff the patient may be getting.

*Pt needs to be educated that activities such as walking down a ramp/hill/incline, sudden deceleration, and squatting activate the Hamstrings and should be avoided.

Keys during phase one:

*Protect the new graft – no active knee flexion (HS activity).

*Any weight-bearing exercises should be performed in brace.

*Gain full knee extension so patient can ambulate with N gait.

*Neuro-muscular quad control – use biofeedback on VMO

EXERCISES

ROM

Passive only 0-30°

Manual patella mobs – especially superior/inferior

Seated heel slides using towel

Supine heel slides at wall if needed

Prone hangs if needed to gain full extension

STRENGTH AND NM CONTROL

Quad sets (10 X 10sec)– the more the better – at least 100/day

SLR – 3 way (avoid extension)

SAQ per ROM limitations

STRETCHING

Hamstring stretch – hold 30 seconds

Gastroc stretch with towel – hold 30 seconds

MODALITIES

EMS may be needed to facilitate quad if contraction cannot be voluntarily evoked

EGS may be needed to help control swelling and increase circulation

Ice should be used following exercise and initially every hour for 20 minutes

*Perform HEP 3X/Day

PHASE TWO

Weeks 2-6

By end of this phase, the patient should ambulate with N gait I, have good quad control, controlled swelling, and be able to ascend/descend stairs.

*Brace will gradually be unlocked to 90° around week 4-6

*HS active motion is initiated in this phase but ONLY prone to eliminate post sag

EXERCISES

ROM

Passive ROM 0-90° week 4-6 (depends on stiffness of pt)

0-110° week 6-8

Perform scar massage aggressively at portals

Prone hangs (do not add weight to ankle) w/BF

Heel slides – seated and/or supine

STRENGTH

Quad sets are continued until swelling is gone and quad tone is good

SLR (3 way) add ankle weights when ready

LAQ from 70-0°

Active knee flexion – PRONE – 0-30/40°

Shuttle/Total gym – 0-60° - bilateral and unilateral; focus on weight distribution more on heel than toes to avoid overload on Patella tendon

Multi-hip – increase intensity as able

Closed chain terminal knee extension (TKE)

Leg Press

Step-ups – forward

Step-overs

Wall squats 0-30°

Calf raises

CARDIO

Cycle when 110° of flexion is reached

STRETCHING

Continue with HS and calf stretching

BALANCE

Weight shifting – med/lat

Single leg stance – even and uneven surface – focus on knee flexion

Plyoball – toss

GAIT

Cone walking – forward

Continue to wear brace – unlocked to 90° at week 4

MODALITIES

Continue to use ice following exercise

PHASE THREE

Weeks 6-12

Goals for this phase are good quad tone and N gait; patient should be able to perform N ADLs without difficulty.

ROM

Goal is 0-140°

Post-op brace will be D/C at 6 weeks and pt will be fitted for functional brace.

STRENGTH

Continue with above exercises, increasing intensity as able

Active knee flexion – prone – 0-90°

Knee extensions – 0-90°

Step-ups – forward and lateral; add dumbbells to increase I; focus on slow, controlled movement during the ascent and descent

Squats – Smith press or standing (wk 8)

Lunges – forward and reverse; add dumbbells or med ball

T-band hip flexion

Single leg squats

Single leg wall squats

Cycle – increase intensity; single leg cycle maintaining 80 RPM

BALANCE

Plyoball – toss – even and uneven surface

Squats on balance board/foam roll/airex

Steamboats – 4 way; even and uneven surface

Strength activities such as step-ups and lunges on airex

CARDIO

Cycle and EFX – increase intensity

MODALITIES

Continue to use ice after exercise

*Continue with HEP at least 3X/week

PHASE FOUR

Weeks 12-36

Exercises for strengthening should continue with focus on high intensity and low repetitions (6-10) for increased strength.

Hamstring and calf stretches should also continue.

Quad stretch should be implemented.

Light resisted Hamstring work can be initiated at week 12.

Initiate lateral movements and sports cord: lunges, forward, backward, or side-step with sports cord, lat step-ups with sports cord, step over hurdles.

Jogging/Plyos:

When cleared by the physician, the patient can begin light plyos and jogging at a slow to normal pace focusing on achieving normal stride length and frequency. Initiate jogging for 2 minutes, walking for 1 until this is comfortable for the patient and then progress the time as able. Jogging should first be performed on a treadmill or track (only straight-aways) and then progressed to harder surfaces such as grass and then asphalt or concrete. It is normal for the patient to have increased swelling as well as some soreness but this should not persist beyond one day or the patient did too much.

Jump rope and line jumps can be initiated when the patient is cleared to jog.

This can be done for time or repetitions and should be done bilaterally and progressed to unilateral.

Jogging and plyos should be performed with brace on.

Advanced Plyos can include squat jumps, tuck jumps, box jumps, depth jumps, 180 jumps, cone jumps, broad jumps, scissor hops

Leg circuit: squats, lunges, scissor jumps on step, squat jumps

Power skipping

Bounding in place and for distance

Quick feet on step – forward and side-to-side – use sports cord

Progress lateral movements – shuffles with sports cord; slide board

Ladder drills

Swimming – all styles

Focus should be on quality, NOT quantity

Landing from jumps is critical – knees should flex to 30° and should be aligned over second toe. Controlling valgus will initially be a challenge and unilateral hops should not be performed until this is achieved.

Initiate sprints and cutting drills.

Progression: Straight line, figure 8, circles, 45° turns, 90° cuts

Carioca

Sports specific drills

Biodex test

Single leg hop test

Biodex goals:

Peak Torque/BW Males Pk T/BS females

60°/s (%) 110-115 80-95

180°/s (%) 60-75 50-65

300°/s (%) 30-40 30-45

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