Isolated posterior cruciate ligament (PCL) injuries are rare, with about 1 PCL tear for every 20 anterior cruciate ligament tears. Lack of knowledge of the natural history of isolated PCL tears has led to controversy about the most effective treatment, and a tendency to over-treat with PCL reconstruction, especially if posterior laxity exceeds 10 mm.
“Our research shows that there’s no reason for orthopedic surgeons to operate on PCL tears,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.
Dr. Shelbourne and his colleagues followed patients treated non-operatively for isolated PCL injuries at Shelbourne Knee Center for an average of at least 5.4 years and up to 21 years after injury.
The non-operative treatment consisted of Shelbourne Knee Center’s physical therapy protocol, which focuses on reducing swelling, and then improving range of motion before strengthening.
The PCL Heals Without Surgery
Key results from two studies show that:
- Isolated PCL tears heal without surgery
- Some laxity does not reduce activity, strength or range of motion
- The incidence of moderate to severe osteoarthritis is the same for non-operative treatment and PCL reconstruction.
The original study and the follow-up study were both published in the American Journal of Sports Medicine 1,2. The American Orthopedic Society for Sports Medicine awarded Dr. Shelbourne and his co-authors on the original study a Hughston Award for the most outstanding paper published in the American Journal of Sports Medicine.
Results for 5.4 Years of Follow-Up
The original study1 involved 133 patients with isolated PCL tears, all of whom completed a subjective questionnaire each year for an average of 5.4 years (range, 2.3 to 11.4 years) after injury. Sixty-eight of the patients returned to Shelbourne Knee Center for long-term objective follow-up evaluation.
Physical examination showed no change in laxity from initial injury to follow-up. There was no correlation between radiographic joint space narrowing and the grade of laxity.
Patients with more laxity did not have worse subjective scores. There was no correlation between subjective knee scores and time from injury.
Regardless of the amount of laxity:
- Half of the patients returned to the same sport at the same or a higher level
- One-third returned to the same sport at a lower level
- One-sixth did not return to the same sport.
For many orthopedic surgeons, laxity exceeding 10 mm is an indication for PCL reconstruction. “We found out that in isolated PCL injuries, more laxity isn’t bad,” says Dr. Shelbourne. “It doesn’t matter if the PCL heals with a little looseness or a lot of looseness.”
Results for 10+ Years of Follow-Up
The follow-up study2 involved 68 patients with isolated PCL tears, 44 of whom completed both objective and subjective evaluations at a mean of 14.3 years (range, 10 to 21 years) after injury. All 68 patients completed subjective follow-up at a mean of 17.6 years after injury.
Patients achieved overall good results:
- Maintenance of full knee range of motion
- Maintenance of good quadriceps muscle strength
- Low prevalence of moderate OA
- Ability to maintain an active lifestyle, even with some residual PCL laxity.
The prevalence of moderate to severe osteoarthritis was 11%, which is comparable with the reported prevalence after PCL reconstruction.
Conclusion
“Five out of six patients were happy with the outcome of non-operative treatment for their PCL tears,” says Dr. Shelbourne. To justify the expense and potential morbidity of PCL reconstruction, it would have to result in outcomes that are significantly better than non-operative treatment. There is no evidence of this.
For more information about non-operative treatment for isolated PCL tears at Shelbourne Knee Center, call 888-FIX-KNEE.
References
- Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. May-Jun 1999;27(3):276-83.
- Shelbourne KD, Clark M, Gray T. Minimum 10-Year Follow-up of Patients After an Acute, Isolated Posterior Cruciate Ligament Injury Treated Nonoperatively. Am J Sports Med. 2013;41(7):1526-1533.