Melanie McNeal, PT, CSCS, CFT
for patients of
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.
- 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
- 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
- Hamstring stretch – hold 30 seconds
- Gastroc stretch with towel – hold 30 seconds
- 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
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
- 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
- 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
- Wall squats 0-30°
- Calf raises
- Cycle when 110° of flexion is reached
- Continue with HS and calf stretching
- Weight shifting – med/lat
- Single leg stance – even and uneven surface – focus on knee flexion
- Plyoball – toss
- Cone walking – forward
- Continue to wear brace – unlocked to 90° at week 4
- Continue to use ice following exercise
Goals for this phase are good quad tone and N gait; patient should be able to perform N ADLs without difficulty.
- Goal is 0-140°
- Post-op brace will be D/C at 6 weeks and pt will be fitted for functional brace.
- 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
- 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
- Cycle and EFX – increase intensity
- Continue to use ice after exercise
*Continue with HEP at least 3X/week
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.
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
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
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
Sports specific drills
Single leg hop test
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