PCL Injury – A ruckman’s curse
By Ryan Hobbs
Injuries are an inevitable part of football given the high speed, change of direction and contact aspects of the game. Some players are luckier than others and injuries are few and far between, whilst others are frustratingly plagued by injury. Unfortunately, I sustained a PCL injury to my right knee 6 weeks ago which has put an end to my season. However, it gives me a good chance to reflect and share my experiences to date.
In a ruck contest in the 3rd quarter I ran to jump with my leading knee up high to protect my body from impact from the opposition ruckman. My opponent’s knee hit just on the right spot on the proximal tibia (upper lower leg bone) just below my knee and forced my tibia posteriorly (backwards). I felt the tearing sensation and immediate pain.
In the AFL there is now a 10 metre outer centre circle which limits the run up distance available to the ruckman. This rule change in 2004 was bought in as a result of many AFL ruckman sustaining PCL injuries by extremely high impact forces as ruckman clashed knees from a long run up. Since this rule chance the incidence of PCL injuries in ruck contests has significantly dropped.
Testing for PCL injury is a relatively simple test for the skilled examiner as a posterior sag of the tibia in relation to the femur is obvious in the resting position and furthermore when pushed into further posterior sag. I had sustained a grade II PCL, which is essentially a high grade partial tear.
The PCL, unlike the anterior cruciate ligament (ACL) has the intrinsic ability to heal and regain continuity after an injury. Insufficient healing after PCL rupture can lead to significant pathologies such as knee osteoarthritis and chronic knee pain. To sum this up, whilst it is every sports person’s desire to return to their sport as quickly as possible, it must also be a safe return with minimal risk of re-injury and consideration of any longer term consequences such as early onset of osteoarthritis.
I am currently wearing a PCL specific brace made by orthopaedics equipment company Össur, called the Rebound PCL brace. It is the world’s first dynamic PCL brace which essentially contains a wire tensioning system that tightens up as the knee bends to maintain an anterior force on the calf area to prevent posterior sag of the tibia. Hence, reducing the strain on the PCL and potentially allowing it to heal without excessive laxity. The brace is typically used for the first 6-8 weeks post injury.
The main focus of PCL rehabilitation is centred around working hard on quadriceps strengthening which again allows the PCL to heal in a more normal position by pulling the tibia anteriorly. Upon return to sport, strong quadriceps will keep the knee joint stable and limit any episodes of instability. Also as part of rehabilitation it is important to consider the kinetic chain as the trunk, hip, and ankle joints can all affect forces through the knee joint. A comprehensive rehab program will encompass strengthening exercises that target any deficiencies in the kinetic chain.
The fundamentals underpinning any form of rehabilitation is a gradual re-loading of injured tissue. This is done in an accelerated but controlled way thus giving the best chance of both a quick recovery but also a safe recovery. If rehab is accelerated too aggressively then problems such as swelling or re-injury of affected structures will delay recovery or even lead to further damage and long term disability.
Currently, my rehab is going well and I’m looking forward to commencing running and returning to sport, this process is usually the 3-6 month mark of recovery. Return to sport criteria is used to direct progress throughout this phase. Examples include; adequate ligament healing timeframes, no swelling, quads strength >90% of contralateral side and good performance on functional tests such as hopping for distance etc.
Physiotherapists aren’t immune from injuries themselves and whilst we have great knowledge of the injuries our bodies are still essentially built the same and our ligaments are no stronger than others. As a therapist, if there is one thing that I have taken away from this particular injury it is the benefit of having a professional guide you through the rehab process. Personally, this has helped me to combat the ‘clinician’ vs ‘competitive athlete’ voices through a shared decision making process. The moral to the story is that therapists are just as prone to injury as anyone else, and even we need a little direction and care when rehabilitating from an injury.