Management Options

Non-operative Management


Natural history





- PFJ OA secondary to increased forces across this joint

- medial compartment OA as medial femoral condyle subluxes posteriorly


Wang et al. PLoS One 2018

- retrospective database review of 4,000 patients with PCL tear

- increased risk of meniscal tear, osteoarthritis, and TKA


Sanders et al. KSSTA 2017

- 48 isolated PCL tears followed for mean 12 years

- 6 x risk of symptomatic osteoarthritis compared to matched patients

- 3 x risk of TKA


Shelbourne et al. Am J Sports Med 2013

- 44 patients with isolated PCL injury

- mean follow up 14 years

- moderate to severe medial OA in 11%

- no difference based upon degree of PCL laxity


Non operative protocol acute isolated injury


PCL brace concept


Dynamic anterior drawer brace

- holds tibia reduced / stops tibia subluxing posteriorly with flexion

- PCL can heal as is extra-synovial

- don't want it to heal in a stretched position




Jacobi et al. JBJS Br 2010

- bracing of 21 patients with acute PCL injury

- decreased mean sag from 7mm to 3 mm at 2 years


Agolley et al. Bone Joint J 2017

- 46 patients with acute PCL and grade II / III instability

- all semi-professional or professional athletes

- 91% return to sport at same level 2 years post injury

- mean return 4 months


Shelbourne et al. Am J Sports Med 1999

- 133 patients with isolated PCL injuries followed for mean of 5 years

- 1/2 returned to sport at same level of play

- 1/3 returned to sport at lower level of play




JACK PCL brace protocol (Agolley et al. BJJ 2017)

- 2 - 3 weeks: locked in full extension in brace, partial weight bear

- 2 - 6 weeks: full weight bear in brace, passive ROM in brace, closed chain quads strengthening, no hamstring

- 6 - 12 weeks: open chain quads

- 12 - 16: begin hamstring strengthening

- > 16 weeks: remove brace, begin running program



Ossur Rebound PCL braceJack PCL brace

Ossur Rebound PCL brace                              Jack PCL brace


Operative Management




1.  Combined ligamentous injuries

- only 1/4 PCL injuries is an isolated injury


2.  Displaced bony avulsion fracture


3.  Symptomatic grade III PCL injury

- pain and swelling

- development of PFJ pain / medial pain

- instability

- inability to return to sport


4.  Acute grade III injury in athlete

- MRI evidence of tibial / femoral peel off

- consider acute repair


PCL Peel off MRI

Acute femoral peel off of PCL


Acute Surgical Options


1.  Repair bony avulsion

2.  Acute suture repair of femoral peel off +/- augmentation


Repair Bony Avulsion




Open posterior approach

- posterior approach

- Burks modified posterior approach






Hooper et al. Am J Sports Med 2018

- systematic review of PCL tibial-sided bony avulsions comparing open and arthroscopic repairs

- 28 articles with 637 patients

- better functional outcomes with arthroscopic repair

- higher risk of stiffness in the arthroscopic group




All arthroscopic bony avulsion surgical technique PDF


AO foundation open posterior approach


Vumedi video open fixation PCL bony avulsion


Acute repair of femoral peel off with suture tape augmentation


Acute PCL femoral Peel offPCL femoral peel off




Femoral avulsion of the PCL

Acute injury




Repair to PCL to femoral insertion with sutures

Pass suture tape through tibial insertion to femoral insertion PCL to augment


Arthroscopic PCL repair surgical technique PDF


PCL Reconstruction




Outcomes of PCL Reconstruction


Kim et al. Am J Sports Med 2010

- systematic review of single bundle transtibial reconstruction

- review of 10 studies

- improves stability by 1 grade

- 75% patients resumed normal / near normal activity

- does not prevent OA


Devitt et al. Orthop J Sports Med 2018

- systematic review of 14 studies on isolated PCL reconstruction

- minimum 2 year follow up

- mean time injury to surgery 10 months

- 82% achieved IKDC A/B

- KT-1000 side to side difference mean 3.8 mm

- 44% return to sport


Single v Double Bundle


Chahla et al. Arthroscopy 2017

- systematic review of single v double bundle PCL reconstructions

- 441 patients

- no difference in functional outcomes

- improved surgeon measured and Telos measured stability with double bundle


Transtibial PCL reconstruction v Tibial Inlay technique


Shin et al. CORR 2017

- systematic review of 7 studies and 350 patients

- no difference in clinical outcome scores or recurrent laxity

- 25% of patients had significant residual laxity


Autograft v Allograft


Ansari et al. Arthroscopy 2019

- systematic review of 25 studies and 900 patients

- 600 autograft, 300 allograft

- no difference in functional outcome

- 2 comparative studies found reduced posterior laxity with autograft

- 2 comparative studies found no difference in posterior laxity between graft choices


Synthetic Ligaments


McDonald et al. Knee 2021

- systematic review of LARS for PCL reconstruction

- 7 studies for isolated PCL injuries with total 180 patients

- 3 retrospective cohort studies comparing LARS to hamstring autograft

- no difference in clinical outcomes or laxity

- synovitis rate 1%

- graft rupture rate 3%


Surgical techniques



1.  Trans-tibial

2.  Tibial inlay

3.  Double bundle


Trans-tibial Method


PCL transtibial



- tunnels in tibia and femur

- can be difficult to pass graft around back of tibia / killer turn

- concern that the killer turn of graft around the tibia can injure graft over time


Boneschool PCL reconstruction technique


Tibial Inlay Method




Open / arthroscopic placement of graft into tibial trough

- avoids 'killer turn' of graft in tunnel method

- soft tissue or bony graft into tibia


Tibial inlay 1Tibial inlay 2Tibial inlay 3Arthrex tibial inlay


Double bundle PCL 1Double bundle PCL 2

Arthrex tibial inlay technique using flip cutter to create bony socket arthroscopically


Open tibial inlay surgical technique PDF


Arthrex arthroscopic tibial inlay surgical technique PDF


Double bundle


PCL double bundle 1PCL double bundle 2Double bundle PCL graft


Double bundle PCL 1Double bundle PCL 2



- single tibial tunnel

- 2 femoral tunnels

- use of a Y shaped graft

- divide tendon into two for the two femoral bundles

- AL bundle tensioned at 90o, PM bundle tensioned at 30o


Surgical technique double bundle PCL PDF


Arthrex double bundle PCL surgical technique