Rear cruciate ligament rehabilitation

The fast facts:

• Only 3% of all knee injuries are posterior cruciate ligament injuries.
• The best-known genesis is dashboard trauma.
• In sports such as rugby, american football, as well as skiing, the risk of a knee injury is highest. 
• An akb injury often accompanies injury to other structures in the knee such as the meniscus or cartilage.
• An akb injury can occur in all ages but is most common in middle-aged athletes.

Anatomy and function of the posterior cruciate ligament

A joint is a place in the body where two pieces of bone come together. In the knee, this is the femur (upper leg) and the tibia (lower leg). Between these bone parts is cartilage which has a very smooth surface so it can move smoothly. To properly control the knee joint, there are different types of ligaments in and around the knee. On the inside and outside are the collateral ligaments. Between the femur and tibia is the inner and outer meniscus which acts as a shock absorber between these two parts of the bone. In the knee there is the anterior and posterior cruciate ligament. The posterior cruciate ligament provides passive stability to the knee. Tires, bones, capsules and the position of joints provide passive stability you have no control over. Active stability is controlled by muscles and tendons. So you do have control over this. Active and passive stability together determine how strong and stable a joint is. The posterior cruciate ligament inhibits the movement of the lower leg backward relative to the upper leg.

Diagnosis of the posterior cruciate ligament

A complete tear of the posterior cruciate ligament is not common. Less experienced therapists or doctors will also often miss this diagnosis. Based on the person's story, physical tests and additional diagnostics through X-ray or MRI, the diagnosis can be made. 

Physical examination for a posterior cruciate ligament injury:
There are a number of tests described to understand possible damage to the posterior cruciate ligament: 

• Rear drawer test
  In the posterior drawer test, the knee is in a flexed position. The examiner pushes off the upper leg. The degree of translation(shift) of the lower leg backward gives an indication ernste of the injury to the posterior cruciate ligament.
  

• Gravity sign
  The person's hip and knee are bent 90 degrees and the person is lying on their back. When the lower leg clearly sags due to gravity, the test is positive. 
  

• Dial sign
  If the lower leg can be rotated further than 15 degrees outward compared to the other side, then posterolateral angle damage may also be present. In some cases, this posterolateral angle instability goes along with posterior cruciate ligament injury. 

Surgical intervention or conservative treatment

When the posterior cruciate ligament is not completely torn, conservative management is usually chosen. A brace can support the knee in the initial phase. 

A better understanding of the structure and function of the posterior cruciate ligament has ensured that treatment, both operative and nonoperative (conservative) continues to evolve. Not operating may also be a responsible choice in some cases. But in people who are highly active and like to play a sport where you have to jump, turn or cowl, surgery is the best solution in most cases. So if you can accept that you can no longer play certain sports, it is not necessary to have surgery. However, a lot of training must be done in order for the neuromuscular system to function optimally. To a certain degree, the body can also actively stabilize the knee by means of the surrounding muscles. The risk of further damage to the meniscus or cartilage, for example, is much higher in people with significant instability problems. When two or more ligaments are torn where the posterior cruciate ligament is one of them, surgery is the best choice. The repair of the posterior cruciate ligament is called posterior cruciate ligament reconstruction.

The different stages in the treatment of the posterior cruciate ligament

Successful rehabilitation consists of several stages and steps. Proper strength, stability and control of the knee is necessary to safely return to your sport. Both after a surgical procedure and with conservative management.

Acute phase:
In this phase, we focus primarily on symptom reduction. There is often swelling, pain and reduced mobility of the knee. After surgery, a brace is fitted and must be worn for 6 months. In the first phase of rehabilitation that lasts up to 6 weeks, the leg may be loaded minimally(10%). Therefore, you must also walk with crutches in the first 6 weeks. In addition, it is important to regain good control of your quadriceps(upper leg muscle). After injury to the posterior cruciate ligament or surgery on that knee, we often see a significant decrease in strength and mass of the quadriceps. So it is critical to quickly regain proper function of the quadriceps. In addition, it is important to return to a normal gait pattern.

Strength and stabilization phase:
This phase involves more of a build-up in strength. Stabilizing exercises are also included. General fitness may also be worked on in between. 

Sport-specific phase:
The final phase focuses particularly on maximum strength, jumping power and explosiveness. This is all necessary to quickly change direction within your sport. Competitive fitness is also worked toward so that you can continue to perform under fatigue. The quality of movement must remain good under these conditions. The chance of re-injuring your knee is many times greater under fatigue.

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