In vivo static and dynamic lengthening measurements of the posterior cruciate ligament at high knee flexion angles

Rehabilitation is an important aspect of both non-operative and operative treatments of knee ligament tear. Posterior cruciate ligament (PCL) non-operative treatment consists of a step-by-step rehabilitation protocol and is well described. It goes from rest (phase I) to strengthening exercises (phase IV). More specific and high-intensity exercises such as cutting, sidestepping or jumps are, however, not described in detail, as no in vivo data exist to tell how these exercises constrain the ligaments and whether they have the same effect on all of them, in particular regarding lengthening. The goal of this study was to measure the ligament lengthening in static knee flexion based on 3D reconstructions from magnetic resonance imaging (MRI) and from motion capture and ligament simulation during dynamic exercises.

The knee of nine volunteers was first imaged in a closed-bore MRI scanner at various static knee flexion angles (up to 110°), and the corresponding lengthening of the PCL and the other major knee ligaments was measured. Then, the volunteers underwent motion capture of the knee where dynamic exercises (sitting, jumping, sidestepping, etc.) were recorded. For each exercise, knee ligament elongation was simulated and evaluated.

According to the MRI scans, maximal lengthening occurred at 110° of flexion in the anterior cruciate ligament and 90° of flexion in the PCL. Daily living movements such as sitting were predicted to elongate the cruciate ligaments, whereas they shortened the collateral ligaments. More active movements such as jumping put the most constrain to cruciate ligaments.

This study provides interesting insights into a tailored postoperative regimen. In particular, knowing the knee ligament lengthening during dynamic exercises can help better define the last stages of the rehabilitation protocol, and hence provide a safe return to play.