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Orthopedics & Traumatology

PCL Tear, Chronic/Old, Right Knee

ICD-10 Code
M23.821

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

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents for follow-up of chronic right knee instability. Reports remote history of injury with persistent posterior knee pain, subjective "giving way," and difficulty with deceleration or descending stairs. Denies acute trauma, locking, or mechanical symptoms. Symptoms are stable but limiting high-impact activities.

Clinical Examination Findings

Right knee: No acute effusion. Posterior sag sign present (gravity-assisted). Posterior drawer test positive (Grade 1-2 laxity) with a soft endpoint. Lachman and pivot shift tests negative. Varus/valgus stress tests stable at 0 and 30 degrees. Range of motion: 0-135 degrees, painless. Neurovascular status intact distally.

Treatment Protocol

Conservative management continued. Referral to physical therapy for quadriceps strengthening and proprioceptive training. Recommendation for activity modification, avoiding high-impact sports. Use of a hinged knee brace during strenuous activity as needed. Follow-up in 3 months or sooner if symptoms worsen.

Detailed clinical guide coming soon.