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Orthopedics & Traumatology

PCL Tear, Chronic/Old, Left Knee

ICD-10 Code
M23.822

Clinical diagnosis and template for PCL Tear, Chronic/Old, Left Knee.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents for follow-up of a chronic left knee injury. History is consistent with a remote posterior cruciate ligament (PCL) injury. Patient reports persistent posterior knee discomfort, occasional sense of instability during deceleration or stair descent, and chronic dull aching. Denies acute trauma, locking, or mechanical symptoms. Symptoms are stable but limiting to high-impact activities.

Clinical Examination Findings

Left knee examination: No acute swelling or effusion. Posterior sag sign is positive (Grade I/II). Posterior drawer test is positive with a soft endpoint. Lachman and anterior drawer tests are negative. Varus/valgus stress tests are stable. Range of motion is full but associated with mild discomfort at terminal flexion. Neurovascular status is intact distally.

Treatment Protocol

Conservative management plan: Continue physical therapy focusing on quadriceps strengthening and hamstring stabilization. Activity modification to avoid high-impact pivoting or contact sports. Consider hinged knee bracing for symptomatic instability. NSAIDs as needed for pain management. Follow up in 3-6 months or sooner if symptoms worsen.

Detailed clinical guide coming soon.