Posterior Cruciate Ligament: Current Concepts Review



Steadman Philippon Research Institute, The Steadman Clinic, Vail, Colorado, USA


The posterior cruciate ligament (PCL) is the largest and strongest ligament in the human knee, and the primary posterior
stabilizer. Recent anatomy and biomechanical studies have provided an improved understanding of PCL function. PCL
injuries are typically combined with other ligamentous, meniscal and chondral injuries. Stress radiography has become
an important and validated objective measure in surgical decision making and post-operative assessment. Isolated
grade I or II PCL injuries can usually be treated non-operatively. However, when acute grade III PCL ruptures occur
together with other ligamentous injury and/or repairable meniscal body/root tears, surgery is indicated. Anatomic singlebundle
PCL reconstruction (SB-PCLR) typically restores the larger anterolateral bundle (ALB) and represents the most
commonly performed procedure. Unfortunately, residual posterior and rotational tibial instability after SB-PCLR has
led to the development of an anatomic double-bundle (DB) PCLR to restore the native PCL footprint and co-dominant
behavior of the anterolateral and posteromedial bundles and re-establish normal knee kinematics. The purpose of this
article is to review the pertinent details regarding PCL anatomy, biomechanics, injury diagnosis and treatment options,
with a focus on arthroscopically assisted DB-PCLR.


Main Subjects

1. Fanelli GC, Edson CJ. Posterior cruciate ligament
injuries in trauma patients: Part II. Arthroscopy.
1995; 11(5):526–9.
2. Logan M, Williams A, Lavelle J, Gedroyc W, Freeman
M. The effect of posterior cruciate ligament
deficiency on knee kinematics. Am J Sports Med.
2004; 32(8):1915–22.
3. MacDonald P, Miniaci A, Fowler P, Marks P, Finlay B. A
biomechanical analysis of joint contact forces in the
posterior cruciate deficient knee. Knee Surg Sports
Traumatol Arthrosc. 1996; 3(4):252–5.
4. Kennedy NI, LaPrade RF, Goldsmith MT, Faucett SC,
Rasmussen MT, Coatney GA, et al. Posterior cruciate
ligament graft fixation angles, part 1: biomechanical
evaluation for anatomic single-bundle reconstruction.
Am J Sports Med. 2014; 42(10):2338–45.
5. Anderson CJ, Ziegler CG, Wijdicks CA, Engebretsen L,
LaPrade RF. Arthroscopically pertinent anatomy of
the anterolateral and posteromedial bundles of the
posterior cruciate ligament. J Bone Joint Surg Am.
2012; 94(21):1936–45.
6. Ahmad CS, Cohen ZA, Levine WN, Gardner TR,
Ateshian GA, Mow VC. Codominance of the individual
posterior cruciate ligament bundles. An analysis of
bundle lengths and orientation. Am J Sports Med.
2003; 31(2):221–5.
7. Kennedy NI, Wijdicks CA, Goldsmith MT, Michalski
MP, Devitt BM, Å􀇒 røen A, et al. Kinematic analysis of
the posterior cruciate ligament, part 1: the individual
and collective function of the anterolateral and
posteromedial bundles. Am J Sports Med. 2013;
8. Boutefnouchet T, Bentayeb M, Qadri Q, Ali S.
Long-term outcomes following single-bundle
transtibial arthroscopic posterior cruciate ligament
reconstruction. Int Orthop. 2013; 37(2):337–43.
9. Dennis MG, Fox JA, Alford JW, Hayden JK, Bach BR Jr.
Posterior cruciate ligament reconstruction: current
trends. J Knee Surg. 2004; 17(3):133–9.
10. Harner CD, Xerogeanes JW, Livesay GA, Carlin GJ,
Smith BA, Kusayama T, et al. The human posterior
cruciate ligament complex: an interdisciplinary study.
Ligament morphology and biomechanical evaluation.
Am J Sports Med. 1995; 23(6):736–45.
11. Strickland JP, Fester EW, Noyes FR. Lateral, posterior,
and cruciate knee anatomy. Noyes’ knee Disord
surgery, Rehabil Clin outcomes. Philadelphia:
Saunders; 2009. P. 20-43.
12. Girgis FG, Marshall JL, Monajem A. The cruciate
ligaments of the knee joint. Anatomical, functional
and experimental analysis. Clin Orthop Relat Res.
1975; 106:216–31.
13. Markolf KL, Feeley BT, Tejwani SG, Martin DE,
McAllister DR. Changes in knee laxity and ligament
force after sectioning the posteromedial bundle of
the posterior cruciate ligament. Arthroscopy. 2006;22(10):1100–6.
14. Tsai AG, Wijdicks CA, Walsh MP, Laprade RF.
Comparative kinematic evaluation of all-inside singlebundle
and double-bundle anterior cruciate ligament
reconstruction: a biomechanical study. Am J Sports
Med. 2010; 38(2):263–72.
15. Moulton SG, Cram TR, James EW, Dornan GJ, Kennedy
NI, LaPrade RF. The Supine internal rotation test: a
pilot study evaluating tibial internal rotation in grade
III posterior cruciate ligament tears. Orthop J Sport
Med. 2015; 3(2):2325967115572135.
16. Kopkow C, Freiberg A, Kirschner S, Seidler A, Schmitt J.
Physical examination tests for the diagnosis of posterior
cruciate ligament rupture: a systematic review. J Orthop
Sports Phys Ther. 2013; 43(11):804–13.
17. Hewett TE, Noyes FR, Lee MD. Diagnosis of complete
and partial posterior cruciate ligament ruptures. Stress
radiography compared with KT-1000 arthrometer
and posterior drawer testing. Am J Sports Med. 1997;
18. Jung TM, Reinhardt C, Scheffler SU, Weiler A.
Stress radiography to measure posterior cruciate
ligament insufficiency: a comparison of five different
techniques. Knee Surg Sports Traumatol Arthrosc.
2006; 14(11):1116–21.
19. Margheritini F, Mariani PP. Diagnostic evaluation of
posterior cruciate ligament injuries. Knee Surg Sports
Traumatol Arthrosc. 2003; 11(5):282–8.
20. Spiridonov SI, Slinkard NJ, LaPrade RF. Isolated and
combined grade-III posterior cruciate ligament tears
treated with double-bundle reconstruction with use
of endoscopically placed femoral tunnels and grafts:
operative technique and clinical outcomes. J Bone
Joint Surg Am. 2011; 93(19):1773–80.
21. Stäubli HU, Jakob RP. Posterior instability of the knee
near extension. A clinical and stress radiographic
analysis of acute injuries of the posterior cruciate
ligament. J Bone Joint Surg Br. 1990; 72(2):225–30.
22. Jackman T, LaPrade RF, Pontinen T, Lender PA.
Intraobserver and interobserver reliability of the
kneeling technique of stress radiography for the
evaluation of posterior knee laxity. Am J Sports Med.
2008; 36(8):1571–6.
23. Bedi A, Musahl V, Cowan JB. Management of posterior
cruciate ligament injuries: an evidence-based review.
J Am Acad Orthop Surg. 2016; 24(5):277–89.
24. Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman
GA. Magnetic resonance imaging of the posterior
cruciate ligament. Clinical use to improve diagnostic
accuracy. Am J Sports Med. 1992; 20(6):732–7.
25. Heron CW, Calvert PT. Three-dimensional gradientecho
MR imaging of the knee: comparison with
arthroscopy in 100 patients. Radiology. 1992;
26. Wilson KJ, Surowiec RK, Ho CP, Devitt BM, Fripp J,
Smith WS, et al. Quantifiable imaging biomarkers for 
evaluation of the posterior cruciate ligament using
3-T magnetic resonance imaging: a feasibility study.
Orthop J Sport Med. 2016; 4(4):2325967116639044.
27. LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade
RF. Emerging updates on the posterior cruciate
ligament: a review of the current literature. Am J
Sports Med. 2015; 43(12):3077–92.
28. LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB. The
reproducibility and repeatability of varus stress
radiographs in the assessment of isolated fibular
collateral ligament and grade-III posterolateral knee
injuries. An in vitro biomechanical study. J Bone Joint
Surg Am. 2008; 90(10):2069–76.
29. Laprade RF, Bernhardson AS, Griffith CJ, Macalena
JA, Wijdicks CA. Correlation of valgus stress
radiographs with medial knee ligament injuries: an
in vitro biomechanical study. Am J Sports Med. 2010;
30. Cross MJ, Powell JF. Long-term followup of posterior
cruciate ligament rupture: a study of 116 cases. Am J
Sports Med. 1984; 12(4):292–7.
31. Fowler PJ, Messieh SS. Isolated posterior cruciate
ligament injuries in athletes. Am J Sports Med. 1987;
32. Parolie JM, Bergfeld JA. Long-term results of
nonoperative treatment of isolated posterior cruciate
ligament injuries in the athlete. Am J Sports Med.
1986; 14(1):35–8.
33. 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. 1999; 27(3):276–83.
34. Shelbourne KD, Muthukaruppan Y. Subjective results
of nonoperatively treated, acute, isolated posterior
cruciate ligament injuries. Arthroscopy. 2005;
35. Shino K, Horibe S, Nakata K, Maeda A, Hamada M,
Nakamura N. Conservative treatment of isolated
injuries to the posterior cruciate ligament in athletes.
J Bone Joint Surg Br. 1995; 77(6):895–900.
36. Tibone JE, Antich TJ, Perry J, Moynes D. Functional
analysis of untreated and reconstructed posterior
cruciate ligament injuries. Am J Sports Med. 1988;
37. Torg JS, Barton TM, Pavlov H, Stine R. Natural history
of the posterior cruciate ligament-deficient knee. Clin
Orthop Relat Res. 1989; 246:208–16.
38. Chen CH, Chen WJ, Shih CH. Arthroscopic doublebundled
posterior cruciate ligament reconstruction
with quadriceps tendon-patellar bone autograft.
Arthroscopy. 2000; 16(7):780–2.
39. Dandy DJ, Pusey RJ. The long-term results of
unrepaired tears of the posterior cruciate ligament. J
Bone Joint Surg Br. 1982; 64(1):92–4.
40. Dejour H, Walch G, Peyrot J, Eberhard P. [The natural
history of rupture of the posterior cruciate ligament].
Rev Chir Orthop Reparatrice Appar Mot. 1988;
41. Keller PM, Shelbourne KD, McCarroll JR, Rettig AC.
Nonoperatively treated isolated posterior cruciate
ligament injuries. Am J Sports Med. 1993; 21(1):132–6.
42. Boynton MD, Tietjens BR. Long-term followup of
the untreated isolated posterior cruciate ligamentdeficient
knee. Am J Sports Med. 1996; 24(3):306–10.
43. Geissler WB, Whipple TL. Intraarticular abnormalities
in association with posterior cruciate ligament
injuries. Am J Sports Med. 1993; 21(6):846–9.
44. Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S, Zarins
B, et al. The effect of posterior cruciate ligament
reconstruction on patellofemoral contact pressures
in the knee joint under simulated muscle loads. Am J
Sports Med. 2004; 32(1):109–15.
45. Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ.
Arthroscopic evaluation of articular cartilage lesions
in posterior-cruciate-ligament-deficient knees.
Arthroscopy. 2003; 19(3):262–8.
46. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically
assisted combined posterior cruciate ligament/
posterior lateral complex reconstruction. Arthroscopy.
1996; 12(5):521–30.
47. Jacobi M, Reischl N, Wahl P, Gautier E, Jakob RP. Acute
isolated injury of the posterior cruciate ligament
treated by a dynamic anterior drawer brace: a
preliminary report. J Bone Joint Surg Br. 2010;
48. Tewes DP, Fritts HM, Fields RD, Quick DC, Buss DD.
Chronically injured posterior cruciate ligament:
magnetic resonance imaging. Clin Orthop Relat Res.
1997; 335:224–32.
49. Patel DV, Allen AA, Warren RF, Wickiewicz TL,
Simonian PT. The nonoperative treatment of acute,
isolated (partial or complete) posterior cruciate
ligament-deficient knees: an intermediate-term
follow-up study. HSS J. 2007; 3(2):137–46.
50. 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):1526–33.
51. Jansson KS, Costello KE, O’Brien L, Wijdicks CA,
Laprade RF. A historical perspective of PCL bracing.
Knee Surg Sports Traumatol Arthrosc. 2013;
52. LaPrade RF, Smith SD, Wilson KJ, Wijdicks CA.
Quantification of functional brace forces for posterior
cruciate ligament injuries on the knee joint: an in vivo
investigation. Knee Surg Sports Traumatol Arthrosc.
2015; 23(10):3070–6.
53. Berg EE. Posterior cruciate ligament tibial inlay
reconstruction. Arthroscopy. 1995; 11(1):69–76.
54. Hermans S, Corten K, Bellemans J. Long-term results
of isolated anterolateral bundle reconstructions
of the posterior cruciate ligament: a 6- to 12-
year follow-up study. Am J Sports Med. 2009;
55. MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz
TL, Warren RF. Comparison of tibial inlay versus
transtibial techniques for isolated posterior cruciate
ligament reconstruction: minimum 2-year follow-up.
Arthroscopy. 2006; 22(3):320–8.
56. Panchal HB, Sekiya JK. Open tibial inlay versus
arthroscopic transtibial posterior cruciate ligament
reconstructions. Arthroscopy. 2011; 27(9):1289–95.
57. Wijdicks CA, Kennedy NI, Goldsmith MT, Devitt BM,
Michalski MP, Å􀇒 røen A, et al. Kinematic analysis of the
posterior cruciate ligament, part 2: a comparison of
anatomic single- versus double-bundle reconstruction.
Am J Sports Med. 2013; 41(12):2839–48.
58. Bergfeld JA, McAllister DR, Parker RD, Valdevit AD,
Kambic HE. A biomechanical comparison of posterior
cruciate ligament reconstruction techniques. Am J
Sports Med. 2001; 29(2):129–36.
59. Kim SJ, Jung M, Moon HK, Kim SG, Chun YM.
Anterolateral transtibial posterior cruciate
ligament reconstruction combined with anatomical
reconstruction of posterolateral corner insufficiency:
comparison of single-bundle versus double-bundle
posterior cruciate ligament reconstruction over a 2-
to 6. Am J Sports Med. 2011; 39(3):481–9.
60. Markolf KL, Feeley BT, Jackson SR, McAllister DR.
Where should the femoral tunnel of a posterior
cruciate ligament reconstruction be placed to best
restore anteroposterior laxity and ligament forces?
Am J Sports Med. 2006; 34(4):604–11.
61. Papannagari R, DeFrate LE, Nha KW, Moses JM,
Moussa M, Gill TJ, et al. Function of posterior cruciate
ligament bundles during in vivo knee flexion. Am J
Sports Med. 2007; 35(9):1507–12.
62. LaPrade CM, Smith SD, Rasmussen MT, Hamming MG,
Wijdicks CA, Engebretsen L, et al. Consequences of
tibial tunnel reaming on the meniscal roots during
cruciate ligament reconstruction in a cadaveric
model, Part 2: the posterior cruciate ligament. Am J
Sports Med. 2015; 43(1):207–12.
63. Chahla J, Nitri M, Civitarese D, Dean CS, Moulton
SG, LaPrade RF. Anatomic double-bundle posterior
cruciate ligament reconstruction. Arthrosc Tech.
2016; 5(1):e149-56.
64. Moatshe G, Brady AW, Slette EL, Chahla J, Turnbull TL,
Engebretsen L, et al. Multiple ligament reconstruction
femoral tunnels: intertunnel relationships and
guidelines to avoid convergence. Am J Sports Med.
2017; 45(3):563–9.
65. Moatshe G, Slette EL, Engebretsen L, LaPrade
RF. Intertunnel relationships in the tibia during
reconstruction of multiple knee ligaments: how to
avoid tunnel convergence. Am J Sports Med. 2016;
66. Fanelli GC. Posterior cruciate ligament rehabilitation:
how slow should we go? Arthroscopy. 2008;
67. Pierce CM, O’Brien L, Griffin LW, Laprade RF. Posterior
cruciate ligament tears: functional and postoperative
rehabilitation. Knee Surg Sports Traumatol Arthrosc.
2013; 21(5):1071–84.
68. Harner CD, Höher J. Evaluation and treatment of
posterior cruciate ligament injuries. Am J Sports Med.
1998; 26(3):471–82.
69. Bellelli A, Adriani E, Margheritini F, Camillieri G, Della
Rocca C, Mariani PP. [Synovial healing in reconstructed
cruciate ligaments. Our personal experience
compared in single interventions and combined
reconstructions]. Radiol Med. 1999; 98(6):454–61.
70. Nyland J, Hester P, Caborn DN. Double-bundle
posterior cruciate ligament reconstruction with
allograft tissue: 2-year postoperative outcomes. Knee
Surg Sports Traumatol Arthrosc. 2002; 10(5):274–9.
71. Shin YS, Kim HJ, Lee DH. No clinically important
difference in knee scores or instability between
transtibial and inlay techniques for pcl reconstruction:
a systematic reviewsystematic review. Clin Orthop
Relat Res. 2017; 475(4):1239–48.
72. Seon JK, Song EK. Reconstruction of isolated posterior
cruciate ligament injuries: a clinical comparison of the
transtibial and tibial inlay techniques. Arthroscopy.
2006; 22(1):27–32.
73. Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the
clinical results of three posterior cruciate ligament
reconstruction techniques. J Bone Joint Surg Am.
2009; 91(11):2543–9.
74. Kim YM, Lee CA, Matava MJ. Clinical results of
arthroscopic single-bundle transtibial posterior
cruciate ligament reconstruction: a systematic review.
Am J Sports Med. 2011; 39(2):425–34.
75. Chahla J, Moatshe G, Cinque ME, Dornan GJ, Mitchell
JJ, Ridley TJ, et al. Single bundle and double bundle
posterior cruciate ligament reconstructions: a
systematic review and meta-analysis of 441 patients
at a minimum 2 years follow up. Arthrosc. 2017;
76. Qi YS, Wang HJ, Wang SJ, Zhang ZZ, Huang AB, Yu JK.
A systematic review of double-bundle versus singlebundle
posterior cruciate ligament reconstruction.
BMC Musculoskelet Disord. 2016; 17:45-54.
77. Li Y, Li J, Wang J, Gao S, Zhang Y. Comparison of
single-bundle and double-bundle isolated posterior
cruciate ligament reconstruction with allograft: a
prospective, randomized study. Arthroscopy. 2014;
78. Noyes FR, Barber-Westin S. Posterior cruciate ligament
replacement with a two-strand quadriceps tendonpatellar
bone autograft and a tibial inlay technique.
J Bone Joint Surg Am. 2005; 87(6):1241–52.
79. Lee SH, Jung YB, Lee HJ, Jung HJ, Kim SH. Revision
posterior cruciate ligament reconstruction using
a modified tibial-inlay double-bundle technique. J
Bone Joint Surg Am. 2012; 94(6):516–22.