Current standards for the objective assessment and management of posterior cruciate ligament tears: a narrative review

Introduction

Background

The posterior cruciate ligament (PCL) is the primary restraint to posterior tibial translation (PTT) and it assists in restricting internal and external rotation after 90° of knee flexion (1). PCL tears are typically caused by a traumatic injury, such as a motor vehicle accident with a classic “dashboard injury”, an external force to the anterior tibia with a flexed knee that causes PTT, or a fall onto the knee with the foot plantar-flexed (2,3). Recent literature has reported that individuals with a flattened tibial slope of <6° are at an increased risk for a PCL tear (4). When a posterior force is applied to the tibia, a decreased posterior tibial slope increases the force encountered by the PCL, leading to a higher rate of PCL tears (4).

The reported incidence of isolated PCL tears demonstrates variation as it has been reported to range between 7% and 47% of cases (5-7). It is often difficult for patients to discern isolated PCL tears as they typically do not hear a distinctive popping sound or develop immediate swelling compared to anterior cruciate ligament (ACL) injuries (1,2,5,8). In comparison, patients with a traumatic or multiligament knee injury are more likely to remember the instigating event (9). The reported rate of PCL tear with a concomitant injury to other ligamentous structures (combined PCL injury) varies between 53% and 58.5% or more based on the mechanism of injury (5,7,10,11).

It is imperative to recognize and diagnose PCL tears early to enhance outcomes as the PCL has an increased healing capacity since the middle genicular artery courses adjacent to the tibial insertion (12,13). It is important to begin conservative treatment (bracing, taping, physical therapy) rapidly because the PCL can heal in an elongated position which may limit function and lead to disabilities, pain, and the future development of osteoarthritis (12,14). Therefore, the diagnosis of PCL tears requires a thorough medical history, physical examination, and imaging to provide a comprehensive diagnosis (12,15-19).

Rationale and knowledge gap

As improvements are made in the diagnosis of PCL tears and treatment, a standardized approach to patient evaluation needs to be followed. Utilizing objective, validated tools for PCL tears is a growing area of interest as it may improve the inter- and intra-rater reliability amongst clinicians, creating a standardized approach when evaluating possible PCL tears. A standardized approach can decrease the number of misdiagnosed and undiagnosed PCL tears leading to improved patient outcomes.

Objective

The objective of this narrative review was to review the current literature relating to the current diagnostic modalities, objective assessment tools, and management strategies for PCL tears. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-52/rc).

Methods

A narrative review was performed on the current standards for objective assessment of PCL tears. The literature review was conducted using PubMed and Scopus-indexed literature (no date restrictions, English only, up to October 2025). Studies were chosen based on a review of the title and abstract to determine relevance to the topic. Studies concerning PCL tears, PCL reconstruction (PCLR), or PCL anatomy, biomechanics, and management were considered and case reports were excluded as they often have a small sample size and are difficult to generalize to a larger population. All studies were cross referenced to find supplementary sources. A summary of research strategies used for this article can be found in Table 1.

Anatomy

The PCL is comprised of two major bundles, the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB), making it the largest intra-articular ligament in the knee (1,20). The ALB femoral attachment is located on the roof of the intercondylar notch, while the femoral attachment of the PMB is located along the medial wall of the intercondylar notch (21). The PMB femoral footprint is located between the anterior meniscofemoral ligament (aMFL) and the posterior meniscofemoral ligament (pMFL) (21,22).

The PCL bundles at the tibial attachment are tightly compacted (1,21). The ALB tibial center attachment is anterior to a bony prominence, known as the bundle ridge, whereas the PMB tibial center attachment is posterior to the bundle ridge (21). The shiny white fibers of the posterior horn of the medial meniscus are anteromedial to the bundles, while the champagne glass drop-off is posterior to the bundles (Figure 1) (21,23). The PMB tibial attachment is more compact than the ALB, and the thickest, functional portion is located posteromedial to the ALB (21).

Figure 1 Depiction of the anterior (A) and posterior (B) views of the PCL anatomy. The ALB, the larger bundle, femoral attachment is located within the roof of the intercondylar notch, while the PMB femoral attachment is located on the medial wall of the intercondylar notch (A) The tibial attachments of the ALB and PMB are separated by the bundle ridge and the champagne glass drop-off is located just posterior to attachment (B). The aMFL and the pMFL are located anterior and posterior to the PMB. Permission is not needed from Kennedy et al. (23). ACL, anterior cruciate ligament; ALB, anterolateral bundle; aMFL, anterior meniscofemoral ligament (ligament of Humphrey); FCL, fibular collateral ligament; PCL, posterior cruciate ligament; PFL, popliteofibular ligament; PMB, posteromedial bundle; pMFL, posterior meniscofemoral ligament (ligament of Wrisberg); POL, posterior oblique ligament.

Biomechanics

The PCL functions as the primary restraint to PTT, with recent literature describing a synergistic and codominant relationship between the two bundles throughout the range of motion (ROM) of the knee (23,24). Harner et al. (25) and Kennedy et al. (23) both evaluated the effect of a complete PCL deficiency, and both reported similar amounts of increased PTT (11.4–11.7 mm) at 90° of flexion. Kennedy et al. explored further isolated sectioning of the ALB and PMB at 90° flexion with an increase of 2.6 mm and 0.9 mm respectively compared to intact testing (23).

Historically, it was believed that the PCL was exclusive to limiting PTT, but recent literature has suggested that the PCL also provides a significant role in rotational stability at higher knee flexion angles (23,26). It was reported that the ALB and PMB both play a significant role in limiting internal rotation at all ranges of flexion, with the PMB providing the primary restraint to internal rotation at 90° of flexion and greater (23).

The orientations of the ALB and PMB fibers differ at varying degrees of knee flexion and experience peak forces at different graft fixation angles (24). The ALB fibers appear horizontal with knee extension and vertical in flexion, while the PMB fibers are horizontal in flexion and vertical in extension (24). Throughout application of a posterior tibial load from 0° to 90°, it was reported that the ALB experienced peak forces at mid- flexion while the PMB encountered peak forces with full extension and deep flexion (23).

Clinical examination findings

PCL tears in the traumatic and athletic setting commonly occur due to an external impact to a flexed knee that generates a posteriorly directed force to the proximal tibia (5,27). In the acute setting, patients typically present with swelling, pain, and stiffness at the posterior aspect of the knee with occasional instability during quick movements (20,28). In contrast, patients that present during the subacute or chronic phase may experience anterior knee pain, and instability when decelerating while running or when descending inclines or stairs (20,28).

Physical examination techniques

Sensitivity and specificity for the following physical examination techniques for the evaluation of PCL tears are provided in Table 2 (16,29,30).

Posterior drawer test

The posterior drawer test is typically performed with the patient lying supine with 45° of hip flexion and 80°–90° of knee flexion (3). The examiner may sit on the patient’s foot to provide stabilization and evaluate the position of the distal femur and proximal tibia bilaterally (Figure 2). The medial femoral condyle and medial tibial plateau typically rest in a neutral position with varying amounts of natural step off in a native, uninjured knee. At the natural, neutral position a posterior translational force is applied to the proximal tibia with a thumb on the medial and lateral joint line (3,27). The clinician then evaluates for a noticeable side-to-side difference (SSD) in PTT (3,27).

Figure 2 Demonstration of a posterior drawer test on a right knee with the patient lying supine. The posterior drawer test is typically performed with the patient’s hip at 45° of flexion and 80°–90° of knee flexion. The examiner starts the test at neutral ensuring the medial femoral condyle and medial tibial plateau are at the native position as compared to the contralateral knee. The examiners thumbs are placed near the medial and lateral joint line and the examiner evaluates for posterior tibial translation as a posterior force is applied.

Test grading is based on the subjective amount of PTT translation (Table 3) (19). Past literature has reported that the posterior drawer is the most accurate test when evaluating the PCL, however a recent systematic review reported heterogenous sensitivity and specificity results could only be obtained from one case-control-type accuracy study (Table 2) (16).

The Clancy sign may be identified while a posterior drawer test is performed. As the examiner places their fingers on the anteromedial and lateral prominences of the tibia with knee at 90° of flexion, a positive Clancy sign is identified when there is loss of the anteromedial and lateral prominences of the tibial plateau below the femoral condyles indicating a possible PCL tear (31).

Posterior sag test

The posterior sag test, also known as Godfrey’s test, is carried out by flexing both knees to 90° with the hips flexed to 45°, and both feet resting on the table. The examiner then evaluates for asymmetrical knee PTT due to gravitational pull (Figure 3) (22,32). If a PCL tear is present, the proximal tibial will present with an abnormal contour or sag (32). An alternative method is performed by placing the hip in 90° of knee flexion while a hand supports the leg underneath the heel. As the leg is suspended in the air with the tibia parallel to the ground, the examiner visualizes the tibial plateau looking for posterior translation due to the gravitational pull (22,33). The systematic review performed by Kopkow et al. discovered the posterior sag test as the most sensitive exam in the review (Table 2) (16), although this is likely due to a positive test being evident in the worst of PCL injuries. Within the systematic review, only one study could be used to calculate specificity (Table 2) (16).

Figure 3 Demonstration of a posterior sag sign in a patient lying supine. The injured knee (R) demonstrates a positive posterior sag sign as the tibia is translated posteriorly due to gravitational forces. Conversely, the uninjured knee (L) does not exhibit posterior translation. Permission is not needed from LaPrade et al. (22).

Quadriceps active test

The quadriceps active test is performed with the patient lying supine with the hip flexed at 45° and 90° of knee flexion (Figure 4) (33). The patient then voluntarily contracts the quadriceps muscle while the examiner applies counter pressure against the ankle (33). If the patient has a PCL tear, a contraction will cause the tibia to move anteriorly into the native position, while the tibia will remain stable with an intact PCL (33,34). This test may be useful when there is a partial PCL tear present. Kopkow et al. reported the mean sensitivity of the quadriceps active test as 75.0% and the mean specificity as 98.0% (Table 2) (16).

Figure 4 Demonstration of a quadriceps activation test on a right knee with the patient lying supine. With the patient lying supine with the hip flexed to 45° and the knee flexed to 90°, the patient contracts the quadriceps muscle as the examiner applies counter pressure against the ankle. A positive test will display the tibia moving anterior into the normal position.

Internal rotation test

The current literature has established that the PCL has a role in the prevention of tibial internal rotation at higher knee flexion angles (1,23,29,35); however, there are few physical exam tests that evaluate this component. The internal rotation test is performed with the patient lying supine, and the test is completed at the following flexion angles: 60°, 75°, 90°, 105°, and 120° (29). The examiner first evaluates the position of the tibial tubercle at neutral. Then with the knee flexed, the examiner applies an internal rotation torque (approximately 5 Nm) to the patient’s foot and measures the rotation of the tibial tubercle to quantify the amount of excursion (Table 4) (29). Moulton et al. assessed the diagnostic accuracy of the supine IR test and reported that knees with a PCL tear had a significant increase in the SDS of internal rotation and the test was highly sensitive (95.5%) and specific (97.1%) for diagnosing grade III PCL tears (Table 2) (29).

Dial test

The dial test has been commonly thought to be pathognomonic for posterolateral corner (PLC) injuries; however, the literature also notes it can be positive for PCL, ACL, and medial collateral ligament (MCL) injuries (30,36). The test is performed at both 30° and 90° and can be performed prone or supine. When performed supine (Figure 5), the knee is flexed to 30° or 90°, and then an external rotation force is applied through the foot and ankle. According to the literature, 10°–15° of increased SSD of posterolateral rotation at 30° of knee flexion is present with an isolated PLC injury. Comparatively, at 90° an isolated PLC injury will elicit a decreased amount posterolateral rotation (30,37). Norris et al. reported contrary results with 80% of patients with isolated PLC injuries presented with positive dial tests at 30° and 90° (30). Positive tests at both 30° and 90° of knee flexion are representative of a combined PLC-PCL, PLC-ACL, or an isolated MCL injury (30,31,36).

Figure 5 Demonstration of the dial test performed prone and supine with the knee flexed to 30°. When performed supine, the knee is flexed to 30° or 90°, and the examiner applies an external rotation force from the foot and ankle through the knee (A). The prone test is performed similarly; however, both sides are tested simultaneously to compare the difference in rotation (B). A positive test (increase of 10°–15° in posterolateral motion) at both 30° and 90° is indicative of a possible PLC and posterior cruciate ligament, PLC and anterior cruciate ligament, or an isolated medial compartment injury. A positive test at 30° and negative test at 90° is indicative of an isolated PLC injury. PLC, posterolateral corner.

Therefore, it is vital to utilize a comprehensive physical examination, stress radiographs, and magnetic resonance imaging (MRI) to determine the correct diagnosis (31,36).

Reverse pivot shift test

The reverse pivot shift test is performed with the patient lying supine as the examiner flexes the patient’s knee and applies a valgus and axial force (38,39). As the knee flexes to 80°–90°, the tibia moves freely into external rotation, and posterolateral subluxation of the tibia may be palpated (Figure 6) (39,40). As the knee is brought back into extension, the reduction of the knee may result in an audible “clunk” (40,41). Kopkow et al. reported the mean sensitivity and specificity as 22.5% and 95.0% (Table 2) (16). Petrigliano et al. performed a cadaveric study that evaluated whether isolated or combined sectioning of the PCL and PLC would correlate with a significantly increased reverse pivot shift and they concluded that a combined PCL and PLC injury should be suspected with a positive reverse pivot shift (41). However, Cooper evaluated the reverse pivot shift in 100 subjects under anesthesia for an unrelated operation and reported that 35% of subjects presented with a positive test (40). This article provides another example of the importance of performing a thorough physical exam comparing the degree of rotation compared to the normal contralateral knee (40).

Figure 6 Demonstration of a reverse pivot shift test on a right knee with the patient in the supine position. The examiner flexes the knee and applies an axial and valgus force, and as the knee reaches 80°–90° the tibia may subluxate posterolaterally. The knee is then carried back into extension and reduction of the tibia may result in an audible “clunk”, producing a positive test. It is important to perform this test bilaterally and evaluate for asymmetry as up to 35% of normal knees may demonstrate a positive reverse pivot shift test (40).

Imaging

PCL stress radiograph views

Stress radiography is frequently utilized to provide an objective assessment of knee ligament stability (42,43). Ligament stability can be evaluated when the SSD is compared between the injured knee and the non-injured knee. Stress radiography provides an objective, quantifiable assessment of the knee ligaments as discrepancies in the inter-rater reliability and reproducibility of the PCL physical examination have been noted in the literature (1,44,45).

There are varying techniques to apply stress to the knee to assess for PCL tears. They include: kneeling, Telos device (Metax, Nhungen-Obbornhofen, Germany), X-stress device (SAMO, Bologna, Italy), PCL-Press (University Hospital of Geneva, Geneva, Switzerland), sagging view, and manual (17,46). Kneeling PCL stress radiography in particular is a widely used, reproducible, and reliable technique that requires the patient to kneel with the knee flexed to 90° as the tibial tubercle rests on an apparatus allowing the proximal tibial plateau to displace posteriorly compared to the non-injured knee if a PCL tear is present (Figure 7) (1,17,45). Partial, isolated complete, and complete PCL + combined ligament tears can be determined utilizing PCL stress radiography (Table 3). The grade of PCL injury and the PTT displacement both assist with determining the treatment strategy as patients with <8 mm of PTT usually undergo non-operative treatment with rehabilitation, while those experiencing ≥8 mm of PTT are more likely to undergo PCL reconstruction (22,47). Additionally, PTT >12 mm should encourage a clinician to evaluate other posterolateral structures as Sekiya et al. demonstrated that sequential sectioning of the PCL and PLC resulted in 12.7±1.0 and 22.3±1.6 mm of PTT, respectively, on stress radiography highlighting the synergistic role of the PCL and PLC in PTT and importance of a comprehensive examination (48).

Figure 7 Comparison of PCL stress radiographs. To optimize the radiograph, the top of Blumensaat’s line should be visualized, the femoral condyles should overlap perfectly, and the tibia must be non-rotated. Once optimized, a line is drawn along the posterior cortex of the tibia through the femur. A perpendicular line is drawn either up or down to Blumensaat’s point, and the measurements are then compared. The injured knee (L) demonstrates 8.0 mm of increased posterior tibial translation compared to the normal contralateral knee (R). PCL, posterior cruciate ligament.

The sensitivity and specificity of PCL stress radiography was identified as 93.5% and 84.2%, respectively, in a systematic review by James et al. (17). Additionally, the intraobserver and interobserver reliability was reported to be good-to-excellent (Table 3) in a systematic review by Guth et al. (49). Disadvantages to kneeling stress radiography may include patient pain and associated injuries (49), along with the practicality of performing the radiographs on a daily basis, with a busy practice. Holliday et al. reported that patients preferred weighted gravity stress testing compared to kneeling stress radiography as patients exhibited significantly greater visual analog scale pain in the latter (50).

Overall, the literature has not proposed that one technique of PCL stress radiography is optimal; however, it has been demonstrated to be a reliable test to quantify PTT and guide clinical decision-making (17,49). LaPrade et al. have recommended that PCL stress radiographs are performed pre-operatively and post-operatively to compare the magnitude of injury and evaluate post-operative outcomes (1).

MRI

MRI is a common modality used to aid in the diagnosis of PCL injuries and has been considered the gold standard in diagnosing acute PCL injury (9,22,51-53). An intact PCL can be best visualized on a sagittal T2-weighted fat suppressed MRI sequence and is demonstrated by a robust uniform low signal-intensity (black) band running from the posterior tibia to the anteromedial femoral notch, often in a slightly curved nature. Indications of a PCL tear include high signal intensity (white) along the normal PCL and can include avulsions, intra-substance tears, or femoral peel-off lesions (Figure 8). The sagittal view of the PCL can also be used to evaluate for posterior translation of the tibia in relation to the femur, although it can also be visualized to a lesser extent on both axial and coronal views (34). The sensitivity of MRI for acute PCL tears has been reported as 100%, with the specificity disclosed as 97-100% in the acute phase, however recent literature has revealed that MRI may not be as sensitive or specific for chronic PCL injuries (1,8,22,54,55). As PCL tears begin to heal, the signal and shape of the PCL may become re-established regardless of the concurrent laxity that is present, creating a difficult state for conventional MRI to diagnosis a chronic PCL tear (55). DePhillipo et al. evaluated the accuracy of MRI in diagnosing chronic PCL tears and determined that it was 62.5% sensitive; although, the sensitivity was improved to 80.0% if evaluation of the medial compartment PTT (≥2.0 mm) was utilized (54).

Figure 8 Sagittal MRI of normal and injured PCL. (A) A sagittal T1 MRI image that demonstrates an intact PCL (white arrow) with a dark band that courses from the femur to the bundle ridge superior to the champagne-glass drop-off of the tibia. (B) The acute PCL tear demonstrates hyperintensity and disorganized fibers with laxity (white arrows). (C) The chronic PCL tear appears intact and reestablished, but is non-functional with laxity (white arrows). MRI, magnetic resonance imaging; PCL, posterior cruciate ligament.

Newer techniques such as quantitative MRI or PTT measurements on standard MRI may be useful to help diagnose chronic PCL injuries and graft tears (54,56). DePhillipo et al. compared medial compartment knee PTT measurements on MRI to a radiologist’s MRI interpretation and found PTT measurements improved diagnostic sensitivity of chronic PCL tears (80.0%) or PCL graft tears (92.0%) (54). Quantitative 3T MRI also demonstrated potential utility evaluating acute and chronic continuous appearing, functionally torn PCLs. Mean T2 values were reported to be higher in the functionally torn PCLs, indicating an increase in water content and alteration of the collagen orientation (56).

Treatment strategies

Nonoperative management

Nonoperative management is a viable option for isolated, grade I PCL tears, diagnosed through objective measures including: <8 mm SDS in PTT on PCL stress radiography, <5° abnormal internal or external rotation at 30° of flexion, and an absence of an associated collateral ligament injury (14,22,57). The middle genicular artery runs adjacent to the PCL which potentially increases its native healing ability in the acute setting; however, conservatively treated chronic tears are likely to heal in an elongated or lax position due to gravity and the posterior pull generated by the hamstrings (22,58,59). When non-operative management is indicated and initialized early for acute, partial PCL tears, success can be optimized as the PCL has an intrinsic ability to heal (12). Rehabilitation should focus on quadriceps extensor strengthening (14), and Jacobi et al. reported that the use of a dynamic PCL brace in acute isolated PCL tears can reduce the posteriorly translated tibia to the physiologic positioning, creating healing with less attenuation (59). PCL stress radiographs provide an objective measurement that may be used through follow-up visits to critically evaluate the success of non-operative treatment (49,50).

A dynamic PCL brace is frequently used to potentially limit the amount of posterior displacement of the tibia (59,60). The literature has reported that the PCL has varying tension throughout knee ROM (23), therefore a dynamic PCL brace that can apply different forces at varying knee flexion angles should be utilized (61). Dynamic PCL braces attempt to recreate the native PCL forces, providing greater applied forces at 45° of knee flexion and at increased flexion angles (60).

Surgical intervention

The treatment decision for complete, isolated PCL tears (≥8 mm of PTT) has varied in the literature (58,59,62,63). Recent non-operative studies discovered patients with isolated PCL tears demonstrated adequate subjective functional scores and improvements on MRI at short-term follow up; however, objective outcomes were not seen (55,58). A study by Jacobi et al. utilized lateral PCL stress radiographs as a method to evaluate the use of a dynamic PCL brace in the management of an acute isolated PCL tear (59). They discovered pre-treatment PTT (8.1 mm) significantly decreased following treatment with the dynamic PCL brace at 12 months (3.1 mm of PTT) and 24 months (3.4 mm of PTT), along with improved PCL continuity on MRI (95%) (59). Comparatively, other authors have reported radiographic progression of osteoarthritis and a higher residual laxity in isolated PCL tears managed nonoperatively compared with those treated by surgical reconstruction (1,22,64).

Surgical intervention is typically recommended in patients with a combined PCL-PLC tears or posteromedial knee ligament tears (>12 mm of PTT), as it can re-establish joint stability and improve functional outcomes (62,65,66). Previous literature suggested a single-bundle (SB) technique was optimal as the ALB was the primary ligament that prevented PTT, leading surgeons to focus on reconstructing the ALB (67-69) (Figure 9). However, biomechanical studies have determined that a SB PCLR does not restore the native knee kinematics (66,68,70). Kennedy et al. verified the relationship between the two bundles and determined the bundles are codominant and function biomechanically at varying flexion angles, therefore both bundles should be reconstructed (23). A systematic review performed by Chahla et al. evaluated the functional and objective outcomes between SB and DB PCLR (Figure 10) (66). The results determined SB and DB PCLR led to similar, improved post-operative patient-reported outcomes; however, DB PCLR significantly improved objective PTT stability when compared to SB PCLR with a Telos device at 90° (mean SSD =−0.52 mm, 95% confidence interval: −1.06, −0.01; P=0.019) (66). Additionally, LaPrade et al. demonstrated that isolated double-bundle (DB) PCLR improved functional and objective outcomes and the subjective and functional outcomes were comparable to isolated ACL reconstruction (62).

Figure 9 Diagram demonstrating the posterior (A) and anterior (B) views of the SB PCLR. The SB PCLR recreates the ALB of the PCL as the literature previously reported that the ALB was the primary restraint to PTT. Permission is not needed from Wijdicks et al. (68). ACL, anterior cruciate ligament; ALB, anterolateral bundle; aMFL, anterior meniscofemoral ligament (ligament of Humphrey); FCL, fibular collateral ligament; PCL, posterior cruciate ligament; PCLR, posterior cruciate ligament reconstruction; PFL, popliteofibular ligament; pMFL, posterior meniscofemoral ligament (ligament of Wrisberg); POL, posterior oblique ligament; PTT, posterior tibial translation; SB, single-bundle.

Figure 10 Diagram demonstrating the posterior (A) and anterior (B) views of a DB PCLR. The DB PCLR recreates the codominant and synergistic relationship between the ALB and PMB, creating an anatomic reconstruction of the PCL. This technique utilizes the anatomic femoral (B) and tibial (A) attachments of the ALB and PMB. Permission is not needed from Wijdicks et al. (68). ACL, anterior cruciate ligament; ALB, anterolateral bundle; aMFL, anterior meniscofemoral ligament (ligament of Humphrey); DB, double-bundle; FCL, fibular collateral ligament; PCL, posterior cruciate ligament; PCLR, posterior cruciate ligament reconstruction; PFL, popliteofibular ligament; PMB, posteromedial bundle; pMFL, posterior meniscofemoral ligament (ligament of Wrisberg); POL, posterior oblique ligament.

Limitations

Limitations of this narrative review include the utilization of two databases (PubMed, Scopus), which could lead to selection bias. The selection of topic and content for this narrative review was performed individually by the authors, rather than using an algorithm and performing a systematic review. Study heterogeneity was present in the systematic reviews that evaluated physical examination testing and imaging. There is also limited research comparing the quality and accuracy of PCL physical examination tests that can account for bias. Furthermore, the biomechanical studies evaluating the utility of the physical exam testing often relied on cadaveric testing. Other knee physical examination techniques may be used for the evaluation of PCL tears, however, only the most common ones reported in the literature were listed and described for the review. Long term outcomes comparing DB PCLR compared to SB PCLR are limited as indications, timing, and functional outcome analysis are highly heterogenous. Future direction of this topic includes the standardization of PCL stress radiology protocols and the addition of machine learning to recognize patterns of PCL tears, Additionally, the development of combined exam-imaging algorithms would provide practitioners with an evidence-based decision-making pathway to follow when faced with a PCL tear as there is variability in the current methodology.

Conclusions

Isolated and combined PCL tears may be difficult to diagnose from other ligamentous knee injuries due to overlapping symptoms and similar physical examination findings. This can lead to long-term functional disabilities and future osteoarthritis if the PCL tears go unrecognized. The diagnosis and determination of proper management for PCL tears cannot be determined by one test alone, rather a comprehensive history, a multitude of physical examination tests, and imaging (PCL stress radiographs and MRI) increases diagnostic accuracy. Grade I (<8 mm of PTT) PCL tears are typically managed non-operatively initially as they have a high likelihood of healing, whereas complete or combined PCL tears (≥8 mm of PTT) typically require surgical intervention. In surgically indicated PCL tears, SB and DB PCLR have both demonstrated improved functional outcomes compared to nonoperative management, and DB PCLR achieved improved objective outcomes when compared to SB PCLR.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-52/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-52/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-52/coif). R.F.L. serves as an unpaid editorial board member of Annals of Joint from September 2024 to December 2026. R.F.L. is a consultant for Ossur, Smith & Nephew, and Responsive Arthroscopy; collects royalties from Ossur, Smith & Nephew, Elsevier, and Arthrex; has research grants from Ossur, Smith & Nephew, AANA, AOSSM; is on the committees for ISAKOS, AOSSM, AANA; and is on the editorial boards for AJSM, JEO, KSSTA, JKS, JISPT, OTSM. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was not provided as the photographs are completely unidentified and there are no details on persons mentioned within the text.

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