Non-Operative Treatment Works Best for PCL Tears

Over-treatment of isolated posterior cruciate ligament (PCL) tears with surgery is becoming increasingly common, due to lack of understanding of the natural history of this rare injury and the belief that surgery prevents joint degeneration. A two-part natural history study by researchers at Shelbourne Knee Center found that:

• The PCL heals with non-operative treatment
• Some laxity does not reduce activity, strength, or range of motion
• The incidence of moderate to severe osteoarthritis was the same for non-operative treatment and PCL reconstruction.^(1,2)

“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.

Physical Therapy Heals PCL Injuries

Researchers followed patients treated non-operatively for isolated PCL injuries at Shelbourne Knee Center for an average of at least 5.4 years after injury in the first study and up to 21 years after injury in the second study. Non-operative treatment consisted of physical therapy to reduce swelling and then improve range of motion before strengthening.

The first study included subjective evaluation of 133 patients at a mean of 5.4 years after injury (range, 2.3 to 11.4 years) and objective evaluation of 68 patients. The second study included subjective evaluation of 68 patients at a mean of 14.3 years after injury (range, 10 to 21 years) and objective evaluation of 48 patients.

Subjective evaluation consisted of three annual questionnaires:

• Modified Cincinnati Knee Rating System (CKRS)
• International Knee Documentation Committee (IKDC) knee survey
• Activity level survey

Objective evaluation consisted of:

• Digital radiographs
• Physical exam
• Measurement of range of motion

No Justification for PCL Reconstruction

Justifying the expense and potential morbidity of PCL reconstruction would require it to be significantly better than non-operative treatment. “There is no evidence of this,” says Dr. Shelbourne.

Both studies were 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 in 1999.

Results For 5.4 Years of Follow-Up ⁽¹⁾

• No change in laxity from initial injury to follow-up.
• No correlation between radiographic joint space narrowing and laxity grade.
• More laxity did not result in worse subjective scores.
• 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.

Results For 10+ Years of Follow-Up ⁽²⁾

Mean quadriceps muscle strength

• 97% of the noninvolved leg

Normal knee range of motion

• 100% of patients

Radiograph grade

• Normal:
  • 26 patients (59%)

• Nearly normal:
  • 13 patients (30%)

• Abnormal:
  • 4 patients (9%)

• Severely abnormal:
  • 1 patient (2%)

Osteoarthritis on radiographs

• No differences based on PCL laxity grade
• Medial joint space narrowing greater than 2 mm:
  • 5 patients (11%)

Mean IKDC subjective scores

• 73.4 + 21.7

Mean modified CKRS subjective scores

• 81.3 + 17.4

References

1. 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.
2. 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.