It is widely agreed that when PCL injury occurs in combination with other major knee ligament injuries or when it occurs via bony avulsion, outcomes with nonoperative treatment are much poorer than with surgical intervention. The management of isolated PCL injuries is more controversial, however, because the natural history of isolated PCL injuries continues to be debated. Most series that report the results of nonoperative treatment of PCL tears include patients with mixed injury patterns and severities.
While many authors believe that the PCL has some potential for intrinsic healing, this healing phenomena does not necessarily restore normal functional status.1,11,16 Regardless, in some studies, as many as 80% of patients with isolated PCL injuries managed nonoperatively with quadriceps and hamstring strengthening were satisfied with their outcome, and most returned to preinjury levels of activity.17 Furthermore, many high-caliber athletes may function well with PCL-deficient knees because as many as 2% of high-caliber college football players have been found to have a chronic PCL-deficient knee. The outcome of nonoperative treatment may depend on the patient's ability to maintain quadriceps strength, as patients with better functional results appear to be those with greater quadriceps strength in the affected extremity.17 Many of these individuals have residual translation on posterior drawer testing, but this laxity does not appear to increase over time.12
Conversely, other authors suggest that even after isolated PCL injuries, many patients have frequent pain and occasional instability and giving way.1 In one study, although 88% of com petitive rugby players with isolated PCL injuries were able to return to preinjury levels of play, some patients took as long as 7 months to recover and nearly all reported subjective sensations of impaired ability, most commonly manifesting in highspeed running (slower acceleration and delayed response) and while turning.18 Long-term follow-ups have found that as many as 90% of patients with isolated PCL injuries may have persistent pain while walking, 45% report episodic instability, 65% report limitations of activity, and more than 50% demonstrate evidence of degenerative changes.4,7 Increasing literature points to a significant incidence of knee pain, patellofemoral symptoms, and medial compartment degeneration in the PCL-deficient knee. This is likely due to altered knee kinematics, with increased quadriceps activity, altered articular contact pressures (especially patellofemoral) and abnormal tibial translation and rotation noted under complex muscle loads in the PCL-deficient knee.19
Overall, although there currently exists a lack of conclusive scientific and clinical information, nonoperative management of isolated PCL tears is probably not as benign as previously believed. Whereas the outcome of conservative treatment of isolated mild injuries is likely acceptable, conservative treatment of more severe isolated injuries or of combined injuries leads to a worse outcome.15 Whether the PCL-deficient knee is at great risk of the development of significant degenerative changes is not clear, although it appears that progressive changes may occur in some affected knees.
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