Question 1

I tore my PCL in a car accident 6 weeks ago when my knee hit the dashboard. My orthopedic surgeon says it's a Grade II isolated PCL tear and recommends physiotherapy rather than surgery. I'm confused because my friend tore his ACL and had surgery immediately. Why am I not having surgery?

Accepted Answer

PCL injuries are managed very differently from ACL injuries, and here's why: ACL VS PCL FUNCTIONAL DIFFERENCES: ACL (anterior cruciate ligament) prevents tibia sliding forward. When torn, creates dramatic instability with pivoting/cutting—knee gives way unpredictably during sports. Surgery needed for active individuals. PCL (posterior cruciate ligament) prevents tibia sliding backward. When torn (especially isolated tear without other ligament damage), quadriceps muscle compensates surprisingly well by pulling tibia forward during walking, running, stairs. This natural compensation is why isolated PCL tears can often be managed without surgery. NATURAL HISTORY STUDIES: Isolated PCL tears treated conservatively: 70-80% achieve satisfactory function and return to activities including recreational sports (not necessarily high-level cutting sports). Residual posterior laxity (looseness) common but doesn't cause functional problems if quadriceps strong. Isolated PCL tears treated surgically: 75-85% good outcomes, but results NOT dramatically better than conservative management, residual mild laxity still common even after surgery. Given similar outcomes, most surgeons prefer avoiding surgery (and its risks) for isolated PCL unless conservative fails. WHY YOUR CASE IS DIFFERENT: Your injury is: Grade II (moderate)—5-10mm posterior translation. Not severe enough to absolutely require surgery. Isolated—no posterolateral corner (PLC), ACL, or meniscus tears. This is critical. If you had combined PCL+PLC injury, surgery would be mandatory (conservative management fails badly for combined injuries). Dashboard injury—typical mechanism for isolated PCL tear. With strong quadriceps rehabilitation, you have 70-80% chance of good functional outcome without surgery. WHEN PCL SURGERY IS INDICATED: Grade III isolated tears (more than 10mm translation)—severe laxity harder to compensate. Combined injuries (PCL + PLC, PCL + ACL, multi-ligament)—require surgical reconstruction. Failed conservative management—if after 4-6 months of physiotherapy you have persistent instability, stairs difficulty, can't return to desired activities, then surgery considered. PCL avulsion fracture—if large bone fragment torn off with PCL, may need surgical fixation. High-level athletes—may opt for surgery to maximize return-to-sport potential. YOUR TREATMENT PLAN: Conservative management for 4-6 months: quadriceps-focused physiotherapy (quad sets, leg press, straight leg raises), avoid hamstring exercises initially (pull tibia backward stressing PCL), gradual return to activities as strength improves. If this fails (persistent instability, can't do stairs comfortably, can't return to work/sport), then discuss surgery. BOTTOM LINE: Your surgeon's recommendation is evidence-based and appropriate for isolated Grade II PCL tear. Give conservative management a genuine trial with committed physiotherapy. If you're not happy with results at 6 months, surgery remains an option. But most people in your situation do well without surgery.

Question 2

I had a motorcycle accident 2 weeks ago and tore my PCL, ACL, and lateral ligaments (my surgeon called it a 'multi-ligament knee injury'). I'm scheduled for surgery next week to reconstruct all the ligaments. This sounds like a massive operation—what should I realistically expect for recovery and will I ever walk normally again?

Accepted Answer

Multi-ligament knee injuries (MLKI) are among the most severe knee injuries, and you're right that this is a major operation with demanding recovery. However, outcomes have improved significantly with modern surgical techniques. Here's realistic expectations: INJURY SEVERITY: You have PCL + ACL + lateral-sided injury (PLC—posterolateral corner). This is classified as KD-III (knee dislocation grade III) or multi-ligament injury requiring reconstruction of 3+ structures. These injuries typically result from high-energy trauma (motorcycle accidents, falls from height, severe sports injuries). Your knee was likely dislocated at time of injury (even if it reduced spontaneously before you got to hospital). SURGERY: Multi-ligament reconstruction is complex 4-6 hour surgery: PCL reconstruction (Achilles allograft usually), ACL reconstruction (hamstring or patellar tendon graft), PLC reconstruction (anatomic repair/reconstruction of lateral collateral ligament, popliteus, popliteofibular ligament). All done arthroscopically and open. May need vascular surgery consultation if popliteal artery injured (5-10% of knee dislocations have artery injury—limb-threatening). May need nerve grafting if peroneal nerve injured (20-30% of MLKI have nerve injury causing foot drop). Hospital stay 3-5 days post-op. RECOVERY TIMELINE: Weeks 0-8: brace locked in extension, non-weight-bearing on crutches. Most challenging phase—completely dependent for mobility. Risk of blood clots (need blood thinners). Weeks 8-12: gradual weight-bearing, unlock brace to allow gentle motion (0-90 degrees). Physiotherapy 3-4 times weekly. Months 3-6: progressive weight-bearing, regain full ROM (120+ degrees flexion goal), intensive strengthening. Still using cane or single crutch. Months 6-12: walking without aids, progressive functional activities. Strength training continues. Month 12-18: return to physical work, recreational activities. May attempt return to sport if goals. REALISTIC OUTCOMES: Good news: 70-80% regain ability to walk normally and perform daily activities after multi-ligament reconstruction if surgery done acutely (within 2-3 weeks of injury—which you are). Challenges: Residual instability common (10-15% have some degree of persistent looseness despite surgery). Stiffness (15-20% don't regain full knee bending—average 5-10 degrees loss). Chronic pain (30-40% have ongoing pain affecting function). Arthritis highly likely long-term (50-60% have radiographic arthritis by 10 years, though not always symptomatic). Nerve injury: if you have peroneal nerve injury causing foot drop, 50-60% recover partially but many have permanent weakness requiring ankle brace. Return to sport: only 40-50% return to pre-injury sport level. Most can do recreational activities but not competitive cutting sports. COMPLICATIONS TO WATCH: Infection (3-5%—higher than single-ligament surgery). Arthrofibrosis (excessive scar tissue causing severe stiffness—10-15%, may need manipulation under anaesthetic). Graft failure (10-15%—one or more ligament reconstructions fails). Deep vein thrombosis/pulmonary embolism (blood clots—5%, need anticoagulation prophylaxis). Chronic regional pain syndrome (rare but serious—2-3%). WILL YOU WALK NORMALLY: Most likely yes, but: expect 12-18 months before walking comfortably without aids, may have slight limp or asymmetry, stairs and hills may always be more challenging than flat ground, unlikely to run or play sports at pre-injury level. PSYCHOLOGICAL IMPACT: MLKI recovery is as much mental as physical. Expect: frustration with slow progress (months of limited mobility), fear of reinjury (common in recovery), possible depression (20-30% develop this during recovery—seek help if needed). BOTTOM LINE: This is a severe, life-changing injury with long recovery, but modern surgery gives you good chance (70-80%) of regaining functional, pain-tolerable walking and daily activities. However, you'll likely have some permanent limitations compared to pre-injury. Commit to the long rehabilitation (12-18+ months), set realistic expectations, and use available support (physiotherapy, occupational therapy, psychological support if needed).

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Posterior Cruciate Ligament (PCL) Tear

📖What is Posterior Cruciate Ligament (PCL) Tear?

🔬What Causes It?

⚠️Risk Factors

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🛡️Prevention