With precisely dosed rotation for dynamic therapy

Treatment options for the posterior cruciate ligament

medi has expanded its range of orthoses:
the new M.4s PCL dynamic is the youngest member of medi's tried and tested M.4s orthosis family.

The M.4s PCL dynamic holds the tibia securely in the desired position by actively exerting a force via the PCL protection pad. The integrated tensioning dial enables the support pad to be adjusted exactly to suit the individual patient. The aim of dynamic therapy is to mobilise patients as early as possible. This effectively supports the healing process for the posterior cruciate ligament.

Patients with a (partial) rupture of the posterior cruciate ligament can be treated with the orthosis conservatively or after surgery.

M.4s PCL dynamic from medi

Detailed description of the product

  1. Protection pad

    - The pad presses actively on the tibia (shinbone) and holds it in the desired position.
    - Thanks to its scallop shape, the pad moulds itself perfectly to the calf.

  2. Individually adjustable

    - The integrated tensioning dial enables the support pad to be adjusted exactly to suit the individual patient.
    - The tensioning dial is easy to lock and release.

  3. physioglide hinge

    - The patented physioglide hinge mimics the natural roll / glide movement of the knee joint as closely as possible, thus ensuring that the orthosis fits securely on the leg.
    - The flat construction of the hinge enables the orthosis to be worn under clothing.

  4. Tool-free wedge change

    - physioglide TF: new joint construction with tweezers in each hinge cover provides for tool-free wedge changes

  5. Pre-formed tibia pad

    - The pre-formed pad moulds itself perfectly to the anatomical shape of the shin bone.
    - The pad distributes the pressure comfortably and effectively.

Physiotherapy exercises as an add-on for treatment after injuries of the posterior cruciate ligament

Step by step instructions

In order to provide patients with active support during their rehabilitation phase, medi offers these six selected exercises that activate and strengthen the leg muscles, also as step by step instructions and as a download.

Click here for the full patient instructions
Associate Professor René El Attal MD

Interview with Professor René El Attal MD

Professor René El Attal MD studied medicine in Innsbruck. He completed his training as a doctor in general practice and specialist for accident surgery. Today he is senior consultant and has also been head of the Knee Team at Innsbruck University Department for Accident Surgery since 2013. His clinical and scientific work concentrates on the complex anatomy and biomechanical aspects of the human knee joint.

Professor Attal, how many posterior cruciate ligaments (PCL) do you treat every year?

I treat between 30 and 50 PCLs.  Around 15 of these are treated surgically, the rest conservatively.

Are there any particularly important points to observe when diagnosing a PCL injury?

The diagnosis is easy for an experienced clinician. However, you must not just do the Lachman's test and assume "that's only an anterior cruciate ligament rupture". It can be confusing in such cases when you pull the knee out of the posterior drawer and then think that Lachman's test is positive. There are some cases like this, but we have given our colleagues intensive training to ensure that they treat our patients properly right from the outset. The wrong brace would only necessitate a change of treatment and switch to a different brace. You always have to assume a PCL injury and examine the patient accordingly.

You have conducted a biomechanical study with medi's M.4s PCL dynamic knee brace. What conclusions have you drawn?

It is the first biomechanical study that has ever been conducted on this subject. We chose a study design that is comparable to the actual clinical situation when treating patients. This enabled us to investigate how this orthosis acts on posterior tibial translation. We saw that we could significantly reduce this drawer with conservative therapy. And we also saw that after an operation, this brace, together with the reconstruction, can completely restore the state of the cruciate ligament to how it was before the injury. That is a very good outcome indeed.

How have the results of this study affected your treatment?

We make sure that the patients start wearing this dynamic brace as soon as possible. But we also have patients with dislocated knees or those with severe injuries, for example, after road traffic accidents, who have tremendous swelling or bruising, so we can't fit them with it straight away. In these cases, we work first with the PTS brace until the swelling has subsided. Then we switch to the dynamic brace as soon as possible, i.e. after about two weeks. This way we enable the joint to move and prevent problems with arthrofibrosis later on.

What feature must an orthosis have for successful PCL treatment?

It must always prevent posterior drawer. This is essential for both conservative and postoperative care, because gravity works against us. When you lift the lower leg off any surface and bend the knee to 90°, the entire gravitational pull acts on the lower leg and pulls on either the ruptured cruciate ligament or on the reconstruction. The brace must prevent this.

Which product feature of medi's M.4s PCL dynamic do you find particularly positive?

Two things, one is that it is comfortable to wear, the other is the fact that it is also pleasant to wear in the summer when it's warmer. All my patients who have worn the PCL so far are very satisfied with it. 

Professor Attal, many thanks for the interview.

Interview with Professor Philip Bastian Schöttle MD

Professor Philip Bastian Schöttle MD has been Director of the Department for Orthopaedics and Accident Surgery at ISAR Munich University Medical Centre since January 2013. Before that, he spent two and a half years as a partner at Zurich Joint Centre and was a consultant in the Department and Outpatient Department for Sports Orthopaedics and leader of the knee surgery team at Rechts der Isar University Medical Centre in Munich from 2007 to 2010.

Professor Schöttle studied human medicine in Munich. From 1999 onwards, he trained at Munich Technical University's Rechts der Isar University Medical Centre and at Hôpital Ambroise-Paré of the University of Paris V, at the Orthopaedic Department of the Balgrist University Hospital in Zurich and at the Centre for Musculoskeletal Surgery, Charité University Medical Centre in Berlin to become an orthopaedic specialist.

Professor Schöttle, how many posterior cruciate ligaments (PCL) do you treat every year?

I treat about 20 PCLs.

What is the ratio of conservative to surgical treatment?

I treat most of my patients conservatively due to the secondary injuries that have to heal first. If conservative treatment of the injury is correctly carried out, no operation is needed afterwards.

How do you organise your treatment? Do you make any distinction between operative and conservative management, for example, in treatment with the M.4s PCL dynamic?

No, none whatsoever. Treatment is identical with both methods. The posterior cruciate ligament first needs to be immobilised, irrespective of whether it has been reconstructed or recently ruptured. Depending on what secondary injuries may also be present, that means between one and two weeks in extension or in 20 degrees flexion, but always with anterior translation. Then I start patients on mobilisation to 60 and 90 degrees flexion for six weeks. I decide how to treat the patient with the brace over the next six weeks depending on the clinical findings.

You have also already treated a number of professional athletes, for example the footballer Patrick Herrmann. Do you draw any distinctions between treating professional athletes and "normally sporty" people or patients?

Not by definition no, but of course you have to judge the indications differently. Professional athletes are generally fitter and are more aware of their own bodies than amateur sportsmen. I don't spend six hours a day on the playing field or in the gym, I might only play sports for two or three hours a week. This means that muscle activity and demands on the body are different and thus the intensity of physiotherapy differs as well. The treatment is the same – but it's only natural that professional athletes want to regain their mobility more quickly than normal patients. 

How important is communication between the doctor and the physiotherapist during PCL treatment?

This communication is tremendously important, particularly with posterior cruciate damage, because it is a rare injury. 

In your opinion, which product features of medi's M.4s PCL dynamic are particularly valuable for therapy?

It is particularly helpful that I can exert force on the tibia from behind with the brace as it is a simple mechanism. The patient also understands the mode of action straight away. This means that this function also helps the patient understand why he is wearing the brace. It is light to wear and it is moveable. I can use it in a fixed position in the primary phase and then dynamically later on. And I can customise it to suit the patient: no matter how much force has to act on the tibia, I can set the orthosis individually. There's a difference between treating a prop forward and a ballerina. 

Are there any cases in which an immobilisation brace like medi PTS would make sense?

Yes, there most certainly are – for example in cases of multiple trauma with fractures that have to be treated first. It is also very important to immobilise the leg if there is pronounced soft-tissue swelling. Furthermore, the brace must leave enough room for the soft tissue swelling to go down. This is when you need an immobilising brace. Such a brace is clearly the right choice for femoral fractures too, in which the posterior cruciate ligament can also be involved.

Professor Schöttle, many thanks for the interview.

Associate Professor Philip Bastian Schöttle MD
Interview with Dr Adrian Wilson about PCL injuries

Interview with Prof Dr Adrian Wilson

Prof Dr Adrian Wilson has worked since 2005 as a consultant at the North Hampshire Hospital in the UK and is the clinical head of the Knee Surgery division. He studied biochemistry at the University of Manchester and Medicine at St. Bartholomew's Medical School. In 1999, he joined the North West Thames Orthopaedic training programme. During his six-year specialist training, he worked in a number of leading teaching hospitals, including the Chelsea and Westminster Hospital and the Royal National Orthopaedic Hospital. Prod Dr Wilson completed his training in Australia with a twelve-month fellowship in knee surgery at the Brisbane Orthopaedic Sports Medicine Centre.

Prof Dr Wilson, how many posterior cruciate ligaments (PCL) do you treat each year?

I do around twelve PCL treatments a year.

What is the ratio between conservative and operative care?

Here in the UK, patients with this type of injury generally do not go to the doctor in the acute stage. This applies even to severe PCL injuries. It is therefore almost always a chronic condition and has to be treated operatively. If patients do come to us in the acute phase, we treat PCL injuries conservatively if possible. 

How do you treat PCL injuries?

I am a supporter of the conservative method. That is to say: Firstly, the patient must not put any weight on his knee for six weeks, and this is followed by gradual application of weight and then full weight application after twelve weeks. However, if an operation is necessary, our patients are given the medi PTS immobilising brace for two weeks and are not allowed to move their knee during this time. After this, they are given a dynamic leg brace. We then increase the extent of movement over four periods, i.e. from 0 to 30 degrees, to 0 to 60 degrees, then to 0 to 90 degrees. After six weeks, movement is unlimited. Patients wear the leg brace as often as possible over a period of three months.

What property must a knee brace have to make it particularly suitable for PCL treatment?

Earlier knee braces for the PCL were not particularly comfortable to wear, as they were bulky and large. This meant that compliance was poor. The leg braces still looked very new after a three-month wearing period, since they were so uncomfortable that people didn't wear them. In contrast, people cope very well with the M.4s PCL dynamic brace. You only need to lift it up: It is very light. The brace is easy to put on and adjust individually. And patients can also wash themselves. In the six months in which I have been using it, I have found that compliance is extraordinarily good for this brace.

What property of the M.4s PCL dynamic do you like most?

In my view, the quick, easy adjustment of the support pad with the integrated rotating knob is a great advantage. This means that the effect of the brace can really come into play both in conservative treatment and after an operative reconstruction. For me, this is the best property.

When do you feel that an immobilising leg brace like the medi PTS is necessary?

Clearly, in the acute stage, when the patient comes to the doctor in the first days after his injury with swelling and pain. This brace is ideal for immobilising the knee, as it is very comfortable. Once the swelling has gone down and the pains have eased, a dynamic brace can be applied after two weeks. 

Prof Dr Wilson, thank you very much for the interview. 

Interview with Dr Ramón Cugat Bertomeu

Dr Ramón Cugat Bertomeu is Head of the Department of Orthopaedic Surgery and Traumatology in the Hospital Quiron Barcelona and President of the Medical Association of the Catalan Mutual Insurance of Football of The Royal Spanish Football Association. In addition, he is part of the international team of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). Dr Cugat studied medicine at the University of Barcelona and is regarded as a pioneer in arthroscopic surgery in Spain. At the 1992 Olympic Games in Barcelona, he was a member of the orthopaedic surgery team. He has worked in hospitals in Spain, England and the United States of America.

Dr Cugat, how many posterior cruciate ligaments (PCL) do you treat each year?

I carry out around 30 to 40 PCL treatments a year for members of the Royal Spanish Football Association.

What is the ratio between conservative and operative care?

Over half of PCL injuries are treated conservatively, because football players wish to avoid an operation as far as possible.

How do you treat PCL injuries?

If it is a partial rupture and the posterior drawer is seven to eight millimetres, I treat it conservatively. An operation is only carried out if there is a complete rupture and in combination with injuries to the posterolateral joint structures. In this case, the players need to be careful, since they generally have a varus deformity. This leads to a further load on the posterolateral joint structures. In addition, there is an overloading of the medial meniscus, the medial side of the patella and the femorotibial joint.

Do you make a distinction between the treatment of professional athletes and that of "normally athletic" people or patients?

Yes, slightly, because with people who are not professional athletes, the knee can also be immobilised for two or three weeks. The situation is different for professional sports people: They want to be able to play again instantly. For them, it is important to be able to be up and about and fit again quickly. So they tend to start with rehab measures. Also, these are more intensive for them.

As part of the care plan, you also use medi M.4s PCL dynamic knee brace. What properties are you most impressed with?

For me, one element that is particularly important for football players with a partial rupture is: In acute cases, we can move the tibia forward with the PCL knee brace, achieve a good alignment and maintain the position. In this way, we correct the posterior sag and good healing is possible. In addition, growth factors can be injected into the tissue of the posterior cruciate ligament.

How good is patient compliance if a knee brace such as the M.4s PCL dynamic is used?

Compliance is very high. Professional football players want to play again as quickly as possible and not wear a plaster cast or a splint. They are very happy with the medi knee brace, because they may be able to walk again even on the first or second day. They get used to the brace very quickly and get on with it famously.

Dr Cugat, thank you very much for talking to us.

Interview with Dr Ramón Cugat Bertomeu

Do you need support?

You are very welcome to contact a medi Customer Service representative for advice on products, best practices or questions:

E-mail: export@medi.de

Additional treatment options for doctors

The following medical devices can be used for injuries of the cruciate and collateral ligaments:

Patient information: the posterior cruciate ligament

The posterior cruciate ligament (PCL) connects the thigh bone (femur) to the shinbone (tibia). It is the thickest and also one of the most important ligaments in the knee joint.

Together with other ligaments, the posterior cruciate ligament stabilises the knee joint and stops the calf slipping backwards relative to the thigh.

The PCL also acts together with other ligaments to limit rotation in the knee joint.

Click here to learn more about the tendons and ligaments in the knee joint
The posterior cruciate ligament

Causes of injury

Compared to the anterior cruciate ligament, injuries of the posterior cruciate ligament are relatively uncommon. However, they are often overseen, which leads to inadequate and unsuitable treatment or even no treatment at all. Injuries of the posterior cruciate ligament very often occur as a result of high forces acting on the knee.

For example, in a car crash, the dashboard can force the driver's lower leg backwards, resulting in a rupture of the posterior cruciate ligament.

Around 50% of all cruciate ligament ruptures happen during sports. Football is one of the most common causes here. A fall onto the bent knee, or a direct trauma caused by colliding with the opponent are typical reasons for this type of injury.

Further information about cruciate ligament ruptures

Marco Naumann
Orthopaedics Product Manager

Marco Naumann

“The M.4s PCL dynamic was developed to provide safe, reliable and targeted treatment for injuries of the posterior cruciate ligament. We paid particular attention to early, dynamic and functional treatment of the injury. The orthosis is marked by its high comfort in wear, which, in turn, contributes to patient compliance and thus to successful therapy”.