The function of the posterior cruciate ligament (PCL) is to prevent the femur from sliding off the anterior edge of the tibia and to prevent the tibia from displacing posterior to the femur. Common causes of PCL injuries are direct blows to the flexed knee, such as the knee hitting the dashboard in a car accident or falling hard on the knee, both instances displacing the tibia posterior to the femur. Surgery to repair the posterior cruciate ligament is controversial due to its placement and technical difficulty. The posterior drawer test is one of the tests used by doctors and physiotherapists to detect injury to the PCL. An additional test of posterior cruciate ligament injury is the posterior sag test, where, in contrast to the drawer test, no active force is applied. Rather, the person lies supine with the leg held by another person so that the hip is flexed to 90 degrees and the knee 90 degrees. The main parameter in this test is step-off, which is the shortest distance from the femur to a hypothetical line that tangents the surface of the tibia from the tibial tuberosity and upwards. Normally, the step-off is approximately 1 cm, but is decreased (Grade I) or even absent (Grade II) or inverse (Grade III) in injuries to the posterior cruciate ligament. Patients who are suspected to have a posterior cruciate ligament injury should always be evaluated for other knee injuries that often occur in combination with an PCL injuries. These include cartilage/meniscus injuries, bone bruises, ACL tears, fractures, posterolateral injuries and collateral ligament injuries.
Cause
Related anatomy
The PCL is located within the knee joint where it stabilizes the articulating bones, particularly the femur and the tibia, during movement. It originates from the lateral edge of the medial femoral condyle and the roof of the intercondyle notch then stretches, at a posterior and lateral angle, toward the posterior of the tibia just below its articular surface.
Related physiological features Although each PCL is a unified unit, they are described as separate anterolateral and posteromedial sections based on each section's attachment site and function. During knee joint movement, the PCL rotates such that the anterolateral section stretches in knee flexion but not in knee extension and the posteromedial bundle stretches in extension rather than flexion.
The types of mechanisms that lead to PCL injury In this position, the PCL functions to prevent movement of the tibia in the posterior direction and to prevent the tilting or shifting of the patella. However, the respective laxity of the two sections makes the PCL susceptible to injury during hyperflexion, hyperextension, and in a mechanism known as a dashboard injury. Because ligaments are viscoelastic (p. 50 ) they can handle higher amounts of stress only when the load is increased slowly (p. 30 ). When hyperflexion and hyperextension occur suddenly in combination with this viscoelastic behavior, the PCL deforms or tears. In the third and most common mechanism, the dashboard injury mechanism, the knee experiences impact in a posterior direction during knee flexion toward the space above the tibia. These mechanisms occur in excessive external tibial rotation and during falls that induce a combination of extension and adduction of the tibia, which is referred to as varus-extension stress, or that occur while the knee is flexed.
Prevention
Knee injury Knee injuries are very common among athletes as well as regular active people and can always be prevented. Ligament tears account for more than forty percent of knee injuries and the posterior cruciate ligament is considered one of the less common injuries. Although it is less common, there are still important measures that can be taken in order to prevent this type of knee injury. Maintaining proper exercise and sport technique is crucial for injury prevention, which include not exceeding the body or not going over the proper range of motion of the knee, properly warming up and cooling down
Quadriceps-to-Hamstring Strength Ratio Another important aspect of maintaining injury-free knees is having a sufficient hamstrings-to-quadriceps strength ratio because they help stabilize the knees. The ratio is a measure of the relative strength of the hamstrings compared to the quadriceps. This means having a 50% H/Q ratio equates to your hamstrings being half as strong as your quadriceps, while a 100% ratio means that your hamstrings and quadriceps are equally as strong. Generally the higher one's H/Q ratio, the better the hamstrings can help the ACL resist dangerous forces during sudden movements and in sports, while a low H/Q ratio is associated with a higher degree of knee injury. According to Sports Performance Bulletin, a 50% ratio is enough for "daily living activities", but the ratio needs to be higher near 80% for athletic activity, while for ACL injury prevention, the ratio should ideally be closer to a balanced 1.0 (100%). Exercises that primarily activates the quadriceps can increase "shearing-type" forces on the knee joint. This is why strong hamstrings are necessary to support the ACL by preventing the shin bone shifting forward as the knee straightens. When the H/Q ratio is low, meaning the hamstrings are relatively weak, certain exercises can help improve the ratio. These include Romanian deadlift, Nordic hamstring curls, Swiss ball hamstring curls, leg curls, leg lifts, prone knee flexion with resistance band, knee extensions, side stepping with an elastic band around the knees, and side and forward hop exercises. Some stretches to help prevent injury to the posterior cruciate ligament include stretching of the hamstring muscles by extending the legs, toes pointing up, leaning forward until the stretch is felt and holding for a few seconds.
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