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Rehabilitation after posterior cruciate ligament reconstruction: a review of the literature and theoretical support

  • Arthroscopy and Sports Medicine
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Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The purpose of this study was to conduct a literature review of studies that have addressed rehabilitation after posterior cruciate ligament (PCL) reconstruction. In particular, we intended to perform categorical analysis and discuss some critical points.

Materials and methods

A literature review of English language articles was performed using the PubMed databases. Our literature search was performed using the following text words: [posterior cruciate ligament OR PCL] AND [reconstruction] AND [rehabilitation]. A total of 34 articles met our criteria and were included in the final systematic review. Rehabilitation protocols were reviewed and tabulated according to main rehabilitation protocol categories [range of motion (ROM), weight bearing, bracing, and strengthening].

Results

Ranges of motion of 90° and 120° were allowed at 4–8 and 6–12 weeks postoperatively in 70 % of studies. Full weight bearing was delayed until 6 weeks postoperatively in 60 % of studies. Most studies (73 % of studies) used a brace for 6–8 weeks and active hamstring exercise was not allowed for 6–24 weeks postoperatively.

Conclusions

The review showed that flexion of 90° was allowed at around 6 weeks and prone passive flexion exercise or supine passive ROM exercise with posterior support was used to prevent a posteriorly directed force. Most authors used non-weight bearing or partial weight bearing in their rehabilitation programs, however it may be possible to perform active weight bearing in full extension or early flexion grades as soon as the soft tissue situation allows. Co-strengthening exercises could be recommended because these exercises produce co-contraction between the quadriceps and hamstring muscles with little posterior shear force.

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References

  1. Aalbersberg S, Kingma I, Ronsky JL, Frayne R, van Dieen JH (2005) Orientation of tendons in vivo with active and passive knee muscles. J Biomech 38:1780–1788

    Article  PubMed  Google Scholar 

  2. Ahn JH, Yang HS, Jeong WK, Koh KH (2006) Arthroscopic transtibial posterior cruciate ligament reconstruction with preservation of posterior cruciate ligament fibers: clinical results of minimum 2-year follow-up. Am J Sports Med 34:194–204

    Article  PubMed  Google Scholar 

  3. Bynum EB, Barrack RL, Alexander AH (1995) Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med 23:401–406

    Article  PubMed  CAS  Google Scholar 

  4. Chan YS, Yang SC, Chang CH, Chen AC, Yuan LJ, Hsu KY, Wang CJ (2006) Arthroscopic reconstruction of the posterior cruciate ligament with use of a quadruple hamstring tendon graft with 3- to 5-year follow-up. Arthroscopy 22:762–770

    Article  PubMed  Google Scholar 

  5. Chen CH, Chen WJ, Shih CH, Chou SW (2004) Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon autograft: minimal 3 years follow-up. Am J Sports Med 32:361–368

    Article  PubMed  Google Scholar 

  6. Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH (2006) Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up. Knee Surg Sports Traumatol Arthrosc 14:1045–1054

    Article  PubMed  CAS  Google Scholar 

  7. Chuang TY, Ho WP, Chen CH, Shieh MH, Liau JJ, Huang CH (2011) Non-hardware posterior cruciate ligament reconstruction using knot/press-fit technique with periosteum-enveloped hamstrings tendon autograft. Am J Sports Med 39:1081–1089

    Article  PubMed  Google Scholar 

  8. Cooper DE, Stewart D (2004) Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med 32:346–360

    Article  PubMed  Google Scholar 

  9. Daniel DM, Stone ML, Barnett P, Sachs R (1988) Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. J Bone Jt Surg Am 70:386–391

    CAS  Google Scholar 

  10. Deehan DJ, Salmon LJ, Russell VJ, Pinczewski LA (2003) Endoscopic single-bundle posterior cruciate ligament reconstruction: results at minimum 2-year follow-up. Arthroscopy 19:955–962

    Article  PubMed  Google Scholar 

  11. Edson CJ, Fanelli GC, Beck JD (2010) Postoperative rehabilitation of the posterior cruciate ligament. Sports Med Arthrosc 18:275–279

    Article  PubMed  Google Scholar 

  12. Edson CJ, Fanelli GC, Beck JD (2011) Rehabilitation after multiple-ligament reconstruction of the knee. Sports Med Arthrosc 19:162–166

    Article  PubMed  Google Scholar 

  13. Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE, Andrews JR (1998) Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc 30:556–569

    Article  PubMed  CAS  Google Scholar 

  14. Fanelli GC (2008) Posterior cruciate ligament rehabilitation: how slow should we go? Arthroscopy 24:234–235

    Article  PubMed  Google Scholar 

  15. Fanelli GC, Edson CJ (2002) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy 18:703–714

    Article  PubMed  Google Scholar 

  16. Fanelli GC, Larson RV (2002) Practical management of posterolateral instability of the knee. Arthroscopy 18:1–8

    PubMed  Google Scholar 

  17. Freeman RT, Duri ZA, Dowd GS (2002) Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. Knee 9:309–312

    Article  PubMed  CAS  Google Scholar 

  18. Garofalo R, Jolles BM, Moretti B, Siegrist O (2006) Double-bundle transtibial posterior cruciate ligament reconstruction with a tendon-patellar bone-semitendinosus tendon autograft: clinical results with a minimum of 2 years’ follow-up. Arthroscopy 22:1331–1338 (e1331)

    Article  PubMed  Google Scholar 

  19. Goudie EB, Will EM, Keating JF (2010) Functional outcome following PCL and complex knee ligament reconstruction. Knee 17:230–234

    Article  PubMed  CAS  Google Scholar 

  20. Hankemeier S, Hufner T, Wang G, Kendoff D, Zeichen J, Zheng G, Krettek C (2006) Navigated open-wedge high tibial osteotomy: advantages and disadvantages compared to the conventional technique in a cadaver study. Knee Surg Sports Traumatol Arthrosc 14:917–921

    Article  PubMed  CAS  Google Scholar 

  21. Hermans S, Corten K, Bellemans J (2009) Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med 37:1499–1507

    Article  PubMed  Google Scholar 

  22. Higgins H (1896) Geniculate articular surfaces of the femur and tibia. J Anat Physiol 30:292–295

    PubMed  CAS  Google Scholar 

  23. Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M (2004) Primary repair of posterior cruciate ligament avulsion fracture: the effect of occult injury in the midsubstance on postoperative instability. Am J Sports Med 32:1230–1237

    Article  PubMed  Google Scholar 

  24. Irrgang JJ, Fitzgerald GK (2000) Rehabilitation of the multiple-ligament-injured knee. Clin Sports Med 19:545–571

    Article  PubMed  CAS  Google Scholar 

  25. Iwamoto J, Takeda T, Suda Y, Otani T, Matsumoto H (2004) Conservative treatment of isolated posterior cruciate ligament injury in professional baseball players: a report of two cases. Knee 11:41–44

    Article  PubMed  CAS  Google Scholar 

  26. Jackson WF, van der Tempel WM, Salmon LJ, Williams HA, Pinczewski LA (2008) Endoscopically-assisted single-bundle posterior cruciate ligament reconstruction: results at minimum ten-year follow-up. J Bone Jt Surg Br 90:1328–1333

    CAS  Google Scholar 

  27. Jung TM, Lubowicki A, Wienand A, Wagner M, Weiler A (2011) Knee stability after posterior cruciate ligament reconstruction in female versus male patients: a prospective matched-group analysis. Arthroscopy 27:399–403

    Article  PubMed  Google Scholar 

  28. Jung YB, Jung HJ, Kim SJ, Park SJ, Song KS, Lee YS, Lee SH (2008) Posterolateral corner reconstruction for posterolateral rotatory instability combined with posterior cruciate ligament injuries: comparison between fibular tunnel and tibial tunnel techniques. Knee Surg Sports Traumatol Arthrosc 16:239–248

    Article  PubMed  Google Scholar 

  29. Jung YB, Jung HJ, Tae SK, Lee YS, Lee KH (2005) Reconstruction of the posterior cruciate ligament with a mid-third patellar tendon graft with use of a modified tibial inlay method. J Bone Jt Surg Am 87(suppl 1):247–263

    Google Scholar 

  30. Jung YB, Jung HJ, Tae SK, Lee YS, Yang DL (2006) Tensioning of remnant posterior cruciate ligament and reconstruction of anterolateral bundle in chronic posterior cruciate ligament injury. Arthroscopy 22:329–338

    Article  PubMed  Google Scholar 

  31. Katonis P, Papoutsidakis A, Aligizakis A, Tzanakakis G, Kontakis GM, Papagelopoulos PJ (2008) Mechanoreceptors of the posterior cruciate ligament. J Int Med Res 36:387–393

    Article  PubMed  CAS  Google Scholar 

  32. Kim SJ, Jung M, Moon HK, Kim SG, Chun YM (2011) Anterolateral transtibial posterior cruciate ligament reconstruction combined with anatomical reconstruction of posterolateral corner insufficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction over a 2- to 6-year follow-up. Am J Sports Med 39:481–489

    Article  PubMed  Google Scholar 

  33. Lee KH, Jung YB, Jung HJ, Jang EC, Song KS, Kim JY, Lee SH (2011) Combined posterolateral corner reconstruction with remnant tensioning and augmentation in chronic posterior cruciate ligament injuries: minimum 2-year follow-up. Arthroscopy 27:507–515

    Article  PubMed  Google Scholar 

  34. Lee YS, Kim NK (2011) Rehabilitation after posterior cruciate ligament reconstruction. Minerva Orthop Traumatol 62:291–295

    Google Scholar 

  35. Lee YS, Lim BO, Kim JG, Lee KK, Park HO, An KO, Ryew CC, Kim JH (2011) Serial assessment of knee joint moments in posterior cruciate ligament and posterolateral corner reconstructed patients during a turn running task. Arch Orthop Trauma Surg 131:335–341

    Article  PubMed  Google Scholar 

  36. Li B, Wen Y, Wu H, Qian Q, Wu Y, Lin X (2009) Arthroscopic single-bundle posterior cruciate ligament reconstruction: retrospective review of hamstring tendon graft versus LARS artificial ligament. Int Orthop 33:991–996

    Article  PubMed  CAS  Google Scholar 

  37. Lutz GE, Palmitier RA, An KN, Chao EY (1993) Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises. J Bone Jt Surg Am 75:732–739

    CAS  Google Scholar 

  38. MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF (2006) Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy 22:320–328

    Article  PubMed  Google Scholar 

  39. McGuire DA, Hendricks SD (2010) Comparison of anatomic versus nonanatomic placement of femoral tunnels in Achilles double-bundle posterior cruciate ligament reconstruction. Arthroscopy 26:658–666

    Article  PubMed  Google Scholar 

  40. Mesfar W, Shirazi-Adl A (2008) Knee joint biomechanics in open-kinetic-chain flexion exercises. Clin Biomech (Bristol, Avon) 23:477–482

    Article  CAS  Google Scholar 

  41. Miller MD, Cooper DE, Fanelli GC, Harner CD, LaPrade RF (2002) Posterior cruciate ligament: current concepts. Instr Course Lect 51:347–351

    PubMed  Google Scholar 

  42. Min BH, Lee YS, Jin CZ, Son KH (2011) Evaluation of transtibial double-bundle posterior cruciate ligament reconstruction using a single-sling method with a tibialis anterior allograft. Am J Sports Med 39:374–379

    Article  PubMed  Google Scholar 

  43. Nagi SZ, Marsh J (1980) Disability, health status, and utilization of health services. Int J Health Serv 10:657–676

    Article  PubMed  CAS  Google Scholar 

  44. Ninos JC, Irrgang JJ, Burdett R, Weiss JR (1997) Electromyographic analysis of the squat performed in self-selected lower extremity neutral rotation and 30 degrees of lower extremity turn-out from the self-selected neutral position. J Orthop Sports Phys Ther 25:307–315

    Article  PubMed  CAS  Google Scholar 

  45. Noyes FR, Barber-Westin SD (2005) Posterior cruciate ligament revision reconstruction, part 2: results of revision using a 2-strand quadriceps tendon-patellar bone autograft. Am J Sports Med 33:655–665

    Article  PubMed  Google Scholar 

  46. Nyland J, Hester P, Caborn DN (2002) Double-bundle posterior cruciate ligament reconstruction with allograft tissue: 2-year postoperative outcomes. Knee Surg Sports Traumatol Arthrosc 10:274–279

    Article  PubMed  Google Scholar 

  47. Ohkoshi Y, Yasuda K, Kaneda K, Wada T, Yamanaka M (1991) Biomechanical analysis of rehabilitation in the standing position. Am J Sports Med 19:605–611

    Article  PubMed  CAS  Google Scholar 

  48. Seon JK, Song EK (2006) Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison of the transtibial and tibial inlay techniques. Arthroscopy 22:27–32

    Article  PubMed  Google Scholar 

  49. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo MS (1995) Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program. Am J Sports Med 23:575–579

    Article  PubMed  CAS  Google Scholar 

  50. Shelbourne KD, Nitz P (1990) Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 18:292–299

    Article  PubMed  CAS  Google Scholar 

  51. Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman KR (1993) Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 21:438–444

    Article  PubMed  CAS  Google Scholar 

  52. Van Dommelen BA, Fowler PJ (1989) Anatomy of the posterior cruciate ligament. A review. Am J Sports Med 17:24–29

    Article  PubMed  Google Scholar 

  53. Wang CJ, Chen HS, Huang TW, Yuan LJ (2002) Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury 33:815–821

    Article  PubMed  Google Scholar 

  54. Wilk KE (1994) Rehabilitation of isolated and combined posterior cruciate ligament injuries. Clin Sports Med 13:649–677

    PubMed  CAS  Google Scholar 

  55. Wong T, Wang CJ, Weng LH, Hsu SL, Chou WY, Chen JM, Chan YS (2009) Functional outcomes of arthroscopic posterior cruciate ligament reconstruction: comparison of anteromedial and anterolateral trans-tibia approach. Arch Orthop Trauma Surg 129:315–321

    Article  PubMed  Google Scholar 

  56. Wu CH, Chen AC, Yuan LJ, Chang CH, Chan YS, Hsu KY, Wang CJ, Chen WJ (2007) Arthroscopic reconstruction of the posterior cruciate ligament by using a quadriceps tendon autograft: a minimum 5-year follow-up. Arthroscopy 23:420–427

    Article  PubMed  Google Scholar 

  57. Yoon KH, Bae DK, Song SJ, Cho HJ, Lee JH (2011) A prospective randomized study comparing arthroscopic single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers. Am J Sports Med 39:474–480

    Article  PubMed  Google Scholar 

  58. Zayni R, Hager JP, Archbold P, Fournier Y, Quelard B, Chambat P, Sonnery-Cottet B (2011) Activity level recovery after arthroscopic PCL reconstruction: a series of 21 patients with a mean follow-up of 29 months. Knee 18:392–395

    Article  PubMed  Google Scholar 

  59. Zhang H, Hong L, Wang XS, Zhang J, Geng XS, Liu X, Feng H (2010) Single-bundle posterior cruciate ligament reconstruction and mini-open popliteofibular ligament reconstruction in knees with severe posterior and posterolateral rotation instability: clinical results of minimum 2-year follow-up. Arthroscopy 26:508–514

    Article  PubMed  Google Scholar 

  60. Zhao J, Huangfu X (2007) Arthroscopic single-bundle posterior cruciate ligament reconstruction: retrospective review of 4- versus 7-strand hamstring tendon graft. Knee 14:301–305

    Article  PubMed  Google Scholar 

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Acknowledgments

This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (2012000971).

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, Seoul, Korea

    Jin Goo Kim, Byung Se Yang, Soo Jin Oh & Sang Jin Yang

  2. Department of Orthopedic Surgery, Gil Hospital, Gil Medical Center, Gachon University School of Medicine, Gachon University, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Korea

    Yong Seuk Lee

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  1. Jin Goo Kim
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Correspondence to Yong Seuk Lee.

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Kim, J.G., Lee, Y.S., Yang, B.S. et al. Rehabilitation after posterior cruciate ligament reconstruction: a review of the literature and theoretical support. Arch Orthop Trauma Surg 133, 1687–1695 (2013). https://doi.org/10.1007/s00402-013-1854-y

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