Raiyyan Tahsan

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TC(996).(05).Orthopedics Case No 74.Posterior Cruciate Ligament tear — PCL tear

Posterior Cruciate Ligament tear — PCL tear

1) Definition — সংজ্ঞা

PCL tear হলো হাঁটুর ভিতরের posterior cruciate ligament আংশিক বা সম্পূর্ণ ছিঁড়ে যাওয়া। PCL femur ও tibia-কে যুক্ত করে এবং tibia যেন femur-এর নিচে পিছনের দিকে সরে না যায়—এটা প্রতিরোধ করে। তাই PCL ছিঁড়লে হাঁটুতে pain, swelling, stiffness এবং posterior instability হতে পারে। AAOS অনুযায়ী PCL injury অনেক সময় subtle হয় এবং cartilage, bone বা অন্য ligament injury-এর সাথে থাকতে পারে।

2) Causes — কারণগুলো

  1. Dashboard injury — সবচেয়ে classical cause
    গাড়ি দুর্ঘটনায় হাঁটু বাঁকা অবস্থায় dashboard-এ আঘাত করলে tibia posterior দিকে push হয়, ফলে PCL tear হতে পারে।
  2. Fall on flexed knee
    হাঁটু ভাঁজ করা অবস্থায় সামনে পড়ে গেলে anterior tibia-তে direct blow লাগে—PCL tear হতে পারে।
  3. Sports injury
    Football, soccer, skiing, baseball ইত্যাদিতে contact injury, twisting injury, hyperextension injury থেকে PCL tear হতে পারে।
  4. Hyperextension / severe twisting injury
    হাঁটু অতিরিক্ত সোজা হয়ে পেছনের দিকে বাঁকলে বা শক্তভাবে ঘুরে গেলে PCL stretch/tear হতে পারে।
  5. Multiligament knee injury / knee dislocation
    Severe trauma-তে PCL-এর সাথে ACL, MCL, LCL, posterolateral corner, meniscus, cartilage injury থাকতে পারে। এই ধরনের injury বেশি dangerous, কারণ neurovascular injury-এর risk থাকে।

3) Symptoms — লক্ষণগুলো

  1. Pain
    হাঁটুর ভিতরে বা পেছনে ব্যথা; walking, stairs বা slope/downhill walking-এ বেশি হতে পারে।
  2. Swelling / effusion
    Injury-এর পর ধীরে ধীরে বা দ্রুত হাঁটু ফুলে যেতে পারে। AAOS pain with swelling, stiffness এবং limp-কে typical symptom হিসেবে উল্লেখ করেছে।
  3. Stiffness
    হাঁটু পুরোপুরি ভাঁজ বা সোজা করতে কষ্ট হয়।
  4. Difficulty walking / limp
    হাঁটতে গেলে ব্যথা, ভার নিতে কষ্ট, limp হতে পারে।
  5. Instability / “give way” feeling
    রোগী বলে হাঁটু “ঢিলা লাগে”, “পিছনে সরে যাচ্ছে”, বা “ভেঙে পড়বে মনে হয়”।
  6. Chronic PCL tear-এর symptom
    দীর্ঘদিনের PCL deficiency-তে anterior knee pain, medial compartment pain, stairs/downhill walking pain এবং early osteoarthritis হতে পারে।

4) Clinical diagnosis — bedside diagnosis

History নিতে হবে

  • Mechanism: dashboard injury, fall on flexed knee, sports contact, hyperextension।
  • Immediate swelling ছিল কিনা।
  • হাঁটু dislocation হয়েছিল কিনা।
  • Walking, stairs, downhill, running-এ instability আছে কিনা।
  • Neurovascular symptom: পা ঠান্ডা, numbness, pulse কম, severe calf pain।

Examination — specific clinical tests

  1. Posterior drawer test — most important test
    Patient supine, hip 45° flexed, knee 90° flexed; tibia posterior দিকে push করলে excessive posterior translation হলে PCL tear suggest করে। Literature review অনুযায়ী posterior drawer test PCL diagnosis-এর সবচেয়ে accurate clinical test হিসেবে বিবেচিত।
  2. Posterior sag sign / Godfrey test
    দুই knee 90° flexed করলে affected side-এর tibia posterior দিকে sag করে। AAOS বলছে injured knee bent অবস্থায় পিছনের দিকে sag/slide করতে পারে।
  3. Quadriceps active test
    Knee 90° flexed রেখে patient quadriceps contract করলে posteriorly sagged tibia anterior দিকে reduce হয়—complete PCL tear suggestive।
  4. Dial test at 30° and 90°
    Increased external rotation 30° ও 90°—combined PCL + posterolateral corner injury suggest করে।
  5. Varus/valgus stress test
    MCL/LCL বা combined ligament injury আছে কিনা assess করতে হবে।
  6. Neurovascular exam
    Dorsalis pedis/posterior tibial pulse, capillary refill, sensation, motor power check করতে হবে। Weak distal pulse বা ABI <0.8 হলে popliteal artery injury suspect করে urgent vascular imaging দরকার।

5) Investigations — specific

  1. X-ray knee AP/lateral + skyline/merchant view
    PCL নিজে X-ray-তে দেখা যায় না, কিন্তু avulsion fracture, tibial plateau fracture, patellar injury, dislocation বা arthritis দেখা যায়। AAOS stress views দিয়ে tibia কতটা পিছনে যায় তা assess করার কথা বলেছে।
  2. Stress radiograph / posterior stress view
    Posterior tibial translation quantify করতে useful, grading ও follow-up-এ কাজে লাগে।
  3. MRI knee — investigation of choice
    MRI soft tissue—PCL, meniscus, cartilage, MCL/LCL/PLC injury—দেখার জন্য best। StatPearls অনুযায়ী PCL evaluation-এ MRI gold standard এবং reported accuracy 96–100%।
  4. CT scan
    Avulsion fracture বা complex bony injury suspected হলে CT দরকার।
  5. Vascular study
    Knee dislocation, absent/weak pulse, ABI <0.8, expanding hematoma, cold limb, severe neurovascular symptom থাকলে CT angiography / Doppler urgent।

PCL tear grading

  • Grade I: 1–5 mm posterior translation; partial tear।
  • Grade II: 6–10 mm; complete isolated PCL tear।
  • Grade III: >10 mm; often combined capsuloligamentous injury।

6) Differential diagnosis

  • ACL tear
  • MCL/LCL injury
  • Meniscus tear
  • Posterolateral corner injury
  • Tibial plateau fracture
  • Patellar dislocation
  • Knee osteochondral injury
  • Quadriceps/patellar tendon injury
    StatPearls PCL injury differential হিসেবে ACL, collateral ligament injury এবং meniscal injury উল্লেখ করেছে।

7) Complications — রোগের জটিলতা

  1. Chronic posterior instability
    Tibia বারবার posterior sag করলে হাঁটুতে abnormal biomechanics তৈরি হয়।
  2. Patellofemoral ও medial compartment osteoarthritis
    Chronic PCL deficiency-তে load distribution বদলে যায়; ফলে patellofemoral ও medial tibiofemoral osteoarthritis progress করতে পারে।
  3. Persistent pain and weakness
    Quadriceps inhibition/weakness থাকলে হাঁটু unstable ও painful থাকে।
  4. Meniscus/cartilage damage
    Untreated instability থাকলে secondary meniscus ও cartilage injury হতে পারে।
  5. Post-surgical complications
    Neurovascular injury, fracture, residual instability, stiffness, osteonecrosis, graft failure, revision surgery লাগতে পারে।
  6. Popliteal artery injury — emergency complication
    Knee dislocation/multiligament injury-তে vascular injury miss করলে limb-threatening হতে পারে।

8) Treatment / Management

Acute first-aid — first 48–72 hours

  • RICE: Rest, Ice, Compression, Elevation।
  • Knee brace / PCL brace: tibia posterior sag কমাতে।
  • Crutches: painful weight bearing কমাতে।
  • Avoid: deep knee flexion, hamstring resisted exercise, twisting, running।
    AAOS isolated PCL injury-তে nonsurgical treatment হিসেবে RICE, immobilization/bracing, crutches এবং physiotherapy উল্লেখ করেছে।

Non-operative management — common for isolated Grade I–II

  • Indication: isolated acute Grade I–II PCL tear, mild symptoms, no major associated injury।
  • Main treatment: PCL brace + progressive rehab + quadriceps strengthening।
  • Early rehab principle: posterior tibial subluxation avoid করতে hamstring loading avoid, quadriceps strengthening emphasize।

Surgical management — when needed

Surgery consider হবে যদি:

  • Knee dislocation / multiligament injury
  • Bony avulsion fracture
  • Repairable meniscus tear with instability
  • Posterior tibial translation >12 mm acute injury
  • Chronic symptomatic instability or persistent pain despite rehab
    AAOS combined injury, knee dislocation, persistent instability/pain despite nonoperative treatment—এসব ক্ষেত্রে PCL reconstruction recommend হতে পারে বলে উল্লেখ করেছে।

9) Pharmacological management — Bangladesh practice-oriented list

Important: PCL ligament heal করার ওষুধ নেই। Drug দেওয়া হয় pain, swelling, inflammation, muscle spasm বা NSAID-induced gastric irritation control করার জন্য। NSAID একসাথে দুইটা দেওয়া উচিত নয়। Kidney disease, peptic ulcer, anticoagulant use, uncontrolled HTN, heart failure, asthma-sensitive NSAID, pregnancy third trimester থাকলে NSAID avoid/modify করতে হবে।

A) First-line analgesic

1. Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative / non-opioid analgesic
  • Purpose in PCL tear: Mild–moderate pain control; NSAID contraindicated হলে safest initial option।
  • Adult dose: 500 mg orally every 6–8 hours PRN; usual max 3 g/day; selected healthy adults under physician supervision up to 4 g/day।
  • Duration: 3–5 days PRN, then reassess।
  • Side effects: Nausea, rash; overdose বা liver disease/alcohol use-এ hepatotoxicity।
  • Interactions: Warfarin-এর সাথে prolonged high-dose use INR বাড়াতে পারে; chronic alcohol/liver enzyme inducer hepatotoxicity risk বাড়ায়।
  • Bangladesh available brand examples:
    • Napa 500 mg — Paracetamol — Beximco
    • Ace 500 mg — Paracetamol — Square
    • Ace Power 1000 mg — Paracetamol — Square
    • Napa One 1000 mg — Paracetamol — Beximco
    • Napa Extend 665 mg — Paracetamol ER
    • Ace XR 665 mg — Paracetamol ER
    • Tamen XR 665 mg — Paracetamol ER
      MedEx-এ Napa 500 mg ও Ace 500 mg paracetamol হিসেবে listed এবং pain/sprain/back pain/inflammatory pain indication উল্লেখ আছে।

B) NSAID — pain + inflammation + swelling

2. Generic name: Ibuprofen

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-steroidal anti-inflammatory drug — NSAID
  • Purpose in PCL tear: Acute inflammatory pain ও swelling কমাতে।
  • Adult dose: 400 mg orally every 8 hours after food PRN; mild painে 200–400 mg 6-hour interval; avoid exceeding 1200 mg/day without physician supervision।
  • Duration: 3–5 days; severe inflammation হলে shortest effective course।
  • Side effects: Gastritis, dyspepsia, GI ulcer/bleeding, renal impairment, BP rise, edema, asthma exacerbation, dizziness।
  • Interactions: Warfarin/DOAC/aspirin/clopidogrel/SSRI/steroid → bleeding risk; ACEi/ARB + diuretic → AKI risk; lithium/methotrexate toxicity risk।
  • Bangladesh available brand examples:
    • Profen 400 mg — Ibuprofen — ACME
    • Flamex 400 mg — Ibuprofen — ACI
    • Advel 400 mg — Ibuprofen — Opsonin
    • Intaflam 400 mg — Ibuprofen — Incepta
    • Reumafen 400 mg — Ibuprofen — Beximco
    • G-Ibuprofen 400 mg — Ibuprofen — Gonoshasthaya
      MedEx ibuprofen-কে NSAID therapeutic class হিসেবে list করেছে এবং mild–moderate pain, inflammation-associated pain, fever, muscular pain-এর indication ও adult 200–400 mg dose interval উল্লেখ করেছে।

3. Generic name: Naproxen sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID
  • Purpose in PCL tear: Longer acting NSAID; painful swelling/inflammation হলে useful।
  • Adult dose: 500 mg initially, then 250 mg every 6–8 hours PRN, অথবা 250–500 mg twice daily after food; max 1000 mg/day।
  • Duration: 3–7 days, shortest effective duration।
  • Side effects: Heartburn, abdominal pain, nausea, diarrhea, headache, vertigo, drowsiness, edema, renal impairment, GI bleeding।
  • Interactions: ACE inhibitor effect কমাতে পারে; diuretics effect কমাতে পারে; aspirin/warfarin/SSRI → GI bleeding risk; methotrexate toxicity বাড়াতে পারে।
  • Bangladesh available brand examples:
    • Naproxen 500 mg — Naproxen sodium
    • NAN 500 mg — Naproxen sodium — Reliance
    • Naproxen Plus 500 mg + 20 mg — Naproxen sodium + Esomeprazole
    • PainCare 500 mg + 20 mg — Naproxen sodium + Esomeprazole — Labaid
    • Inflect 500 mg + 20 mg — Naproxen sodium + Esomeprazole — Kemiko
      MedEx naproxen sodium-কে NSAID class হিসেবে list করেছে; musculoskeletal pain/inflammation-related indications ও dose 500 mg initial then 250 mg 6–8 hourly উল্লেখ আছে।

4. Generic name: Diclofenac sodium / Diclofenac potassium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID
  • Purpose in PCL tear: Acute post-traumatic pain, inflammation, swelling কমাতে short-term use।
  • Adult dose: Diclofenac sodium 50 mg orally 2–3 times daily after food; max 150 mg/day. Diclofenac potassium 50 mg 2–3 times daily short-term।
  • Duration: 2–5 days usually; CV/GI/renal risk থাকলে avoid।
  • Side effects: Gastritis, peptic ulcer/GI bleed, renal impairment, edema, BP rise, liver enzyme rise, rash, bronchospasm।
  • Interactions: Anticoagulant/antiplatelet/SSRI/steroid → bleeding risk; ACEi/ARB + diuretic → AKI risk; lithium/methotrexate toxicity risk।
  • Bangladesh available brand examples:
    • A-Fenac 50 mg — Diclofenac sodium — ACME
    • A-Fenac SR 100 mg — Diclofenac sodium — ACME
    • Diclofen 50 mg — Diclofenac sodium — Opsonin
    • Diclo 50 mg — Diclofenac sodium
    • Diloren 50 mg — Diclofenac sodium
    • Diclofen K 50 mg — Diclofenac potassium — Opsonin
    • A-Fenac K 50 mg — Diclofenac potassium — ACME
      MedEx diclofenac sodium brand listে A-Fenac 50 mg, Diclofen 50 mg, SR/TR preparations, gel/injection forms listed; diclofenac potassium post-traumatic pain, inflammation and swelling indication-এ listed।

5. Generic name: Aceclofenac

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID
  • Purpose in PCL tear: Pain + inflammation control; Bangladesh practice-এ musculoskeletal painে commonly used।
  • Adult dose: 100 mg orally twice daily after food।
  • Duration: 3–5 days; reassess।
  • Side effects: Dyspepsia, abdominal pain, nausea, diarrhea, dizziness, edema, renal impairment, GI bleeding।
  • Interactions: Same as NSAIDs—anticoagulant, antiplatelet, steroid, SSRI, ACEi/ARB+diuretic, lithium, methotrexate।
  • Bangladesh available brand examples:
    • Flexi 100 mg — Aceclofenac — Square
    • Flexi SR 200 mg — Aceclofenac — Square
    • Ceclofen 100 mg — Aceclofenac — Renata
    • Paino 100 mg — Aceclofenac — Eskayef
    • Acelock 100 mg — Aceclofenac — Bristol
    • Acenac 100 mg — Aceclofenac — Medicon
    • Acelon 100 mg — Aceclofenac — Central
      MedEx aceclofenac page pain/inflammation in trauma and musculoskeletal pain-related indications list করেছে, এবং brand listে Flexi, Ceclofen, Paino, Acelock/Acenac/Acelon examples আছে।

C) Topical NSAID — local pain/swelling

6. Generic name: Diclofenac sodium topical gel ± methyl salicylate/menthol

  • Therapeutic category: Topical analgesic, anti-inflammatory
  • Pharmacological class: Topical NSAID / counterirritant combination
  • Purpose in PCL tear: Local pain/swelling কমাতে; oral NSAID avoid করতে হলে useful adjunct।
  • Dose: Thin layer / approximately 1-inch gel affected area-এ দিনে 3–4 বার apply; broken skin-এ নয়।
  • Duration: 5–7 days; persistent swelling/pain হলে reassess।
  • Side effects: Local burning, rash, itching, photosensitivity; excessive use করলে systemic NSAID effect rare but possible।
  • Interactions: Oral NSAID-এর সাথে excessive topical NSAID use করলে total NSAID exposure বাড়ে।
  • Bangladesh available brand examples:
    • Voligel 1% w/w — Diclofenac sodium gel
    • VOLINAC 1% w/w — Diclofenac sodium + methyl salicylate + linseed oil + menthol — Square
    • VOLINAC Max 2% w/w — same combination
    • Diclofen 1% w/w gel — Diclofenac sodium — Opsonin
    • Volicool 1% w/w — Diclofenac sodium — Ibn Sina
      MedEx Voligel/VOLINAC musculoskeletal sprain, strain, soft-tissue injury, pain, swelling, inflammation indication-এ listed।

D) Severe acute pain — short course only

7. Generic name: Ketorolac tromethamine

  • Therapeutic category: Strong analgesic
  • Pharmacological class: NSAID
  • Purpose in PCL tear: Severe acute painে very short-term rescue analgesic; routine বা long-term নয়।
  • Adult dose: 10 mg orally every 6 hours PRN; max 40 mg/day; total duration usually ≤5 days।
  • Duration: 1–3 days preferable; maximum 5 days।
  • Side effects: High GI bleeding risk, renal impairment, dizziness, edema, BP rise, bronchospasm।
  • Interactions: Other NSAID, aspirin, anticoagulant/antiplatelet, steroid, SSRI → bleeding risk; ACEi/ARB+diuretic → renal risk।
  • Bangladesh available brand examples:
    • Rolac 10 mg — Ketorolac tromethamine
    • Painfree 10 mg — Ketorolac tromethamine
    • Painlok 10 mg — Ketorolac tromethamine
    • Painrel 10 mg — Ketorolac tromethamine
    • Pair 10 mg — Ketorolac tromethamine
    • Inket 10 mg — Ketorolac tromethamine
      MedEx ketorolac pages short-term moderate–severe acute/post-operative pain indication list করেছে, এবং ketorolac 10 mg brands Rolac/Inket/Painfree/Painlok/Painrel/Pair পাওয়া যায়।

E) Opioid analgesic — avoid routine; only selected severe pain

8. Generic name: Tramadol hydrochloride

  • Therapeutic category: Analgesic
  • Pharmacological class: Opioid analgesic / centrally acting synthetic analgesic
  • Purpose in PCL tear: Severe pain when paracetamol/NSAID insufficient or NSAID contraindicated; short-term only।
  • Adult dose: 50 mg orally every 6–8 hours PRN; severe acute painে 50–100 mg 4–6 hourly may be used; max 400 mg/day.
  • Duration: 1–3 days; dependence/sedation risk থাকায় prolonged use avoid।
  • Side effects: Dizziness, nausea, vomiting, constipation, somnolence, sweating, pruritus, dry mouth; rare respiratory depression, seizure, serotonin syndrome।
  • Interactions: Alcohol, benzodiazepine, sedatives, opioids → respiratory depression; SSRI/SNRI/MAOI/linezolid → serotonin syndrome/seizure risk; carbamazepine effect কমাতে পারে।
  • Bangladesh available brand examples:
    • Tramadol 50 mg capsule — Tramadol HCl — Amico
    • Tamadol 50 mg — Tramadol HCl — Mystic
    • Doloran 50 mg / 100 mg — Tramadol HCl — Sandoz
    • Trado 50 mg — Tramadol HCl — Pacific
    • NapaDol 325 mg + 37.5 mg — Paracetamol + Tramadol HCl — Beximco
    • Tamenol 325 mg + 37.5 mg — Paracetamol + Tramadol HCl — Eskayef
      MedEx tramadol-কে opioid analgesic class হিসেবে list করেছে; moderate–severe painful conditions indication, 50–100 mg 4–6 hourly dosing, max 400 mg/day, side effects ও CNS depressant/MAOI interaction উল্লেখ আছে।

F) Gastroprotection with NSAID

9. Generic name: Pantoprazole sodium

  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor — PPI
  • Purpose in PCL tear: NSAID-induced gastritis/ulcer risk কমাতে, especially gastritis history, age >60, high-dose NSAID, steroid/anticoagulant use।
  • Adult dose: 20–40 mg orally once daily 30 minutes before breakfast।
  • Duration: NSAID যতদিন + high-risk হলে 1–2 weeks; chronic unnecessary use avoid।
  • Side effects: Headache, diarrhea/constipation, abdominal discomfort; long-term useে hypomagnesemia, B12 deficiency, C. difficile risk।
  • Interactions: Clopidogrel interaction omeprazole-এর চেয়ে কম; warfarin/digoxin/methotrexate monitoring; gastric pH-dependent drug absorption affect করতে পারে।
  • Bangladesh available brand examples:
    • Pantonix 20/40 mg — Pantoprazole sodium — Incepta
    • Pantobex 20/40 mg — Pantoprazole sodium — Beximco
    • Pantolok 20/40 mg — Pantoprazole sodium — Ibn Sina
    • Pansec 20/40 mg — Pantoprazole sodium — Drug International
    • Neopanta 20/40 mg — Pantoprazole sodium
    • Pantex 20/40 mg — Pantoprazole sodium — ACI
      MedEx pantoprazole-কে proton pump inhibitor হিসেবে NSAID-induced ulcer/GERD/peptic ulcer indication-এ list করেছে, এবং multiple Bangladesh brands listed আছে।

10. Generic name: Omeprazole

  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor — PPI
  • Purpose in PCL tear: NSAID-associated gastric/duodenal ulcer prophylaxis or dyspepsia control।
  • Adult dose: 20 mg orally once daily before breakfast।
  • Duration: NSAID course + short extension if dyspepsia।
  • Side effects: Headache, nausea, diarrhea/constipation; long-term risks same PPI group।
  • Interactions: Clopidogrel activation কমাতে পারে; warfarin/diazepam/phenytoin interaction possible; gastric pH-dependent absorption affect।
  • Bangladesh available brand examples:
    • Seclo 20 mg — Omeprazole — Square
    • Omep 20/40 mg — Omeprazole — Aristopharma
    • Omenix 20 mg — Omeprazole — Incepta
    • Omegut 20/40 mg — Omeprazole — Popular
    • Omecap 20 mg — Omeprazole — Chemist
    • Prazover 20/40 mg — Omeprazole — Veritas
      MedEx omeprazole NSAID-associated gastric/duodenal ulcer and prophylaxis indications list করেছে; Seclo/Omep/Omenix/Omegut/Prazover brands listed আছে।

G) Muscle spasm — not routine for PCL, only if painful spasm/guarding

11. Generic name: Tolperisone hydrochloride

  • Therapeutic category: Muscle relaxant
  • Pharmacological class: Centrally acting skeletal muscle relaxant
  • Purpose in PCL tear: Painful muscle spasm/guarding থাকলে short course; ligament healing করে না।
  • Adult dose: 50 mg orally 2–3 times daily after food; dose depends on clinician judgment।
  • Duration: 3–5 days।
  • Side effects: Dizziness, weakness, nausea, GI upset, hypersensitivity/rash।
  • Interactions: Sedatives/alcohol dizziness বাড়াতে পারে; other muscle relaxant একসাথে avoid।
  • Bangladesh available brand examples:
    • Myolax 50/100 mg — Tolperisone HCl — Incepta
    • Mydocalm 50 mg — Tolperisone HCl
    • Tolson 50/100 mg — Tolperisone HCl — Opsonin
    • Tolmus 50 mg — Tolperisone HCl — Beximco
    • A-Calm 50 mg — Tolperisone HCl — ACME
      MedEx tolperisone centrally acting muscle relaxant হিসেবে list করেছে এবং Myolax/Mydocalm/Tolson/Tolmus/A-Calm brands listed আছে।

10) Bangladesh doctors’ common prescription pattern — practical list

For an adult PCL tear patient, contraindication না থাকলে Bangladesh orthopedic/GP practice-এ সাধারণত নিচের ধরনের drug pattern দেখা যায়:

  1. Paracetamol 500 mg PRN
    Mild–moderate pain control; safer baseline analgesic।
  2. One NSAID only — Ibuprofen / Naproxen / Aceclofenac / Diclofenac
    Swelling ও inflammatory pain কমাতে। একসাথে দুই NSAID নয়।
  3. PPI — Pantoprazole or Omeprazole
    NSAID দিলে gastritis/ulcer risk কমাতে, বিশেষ করে high-risk patient।
  4. Topical diclofenac gel
    Local pain/swelling control; oral NSAID কমাতে adjunct।
  5. Tramadol short course
    Severe painে rescue; sedation/dependence risk থাকায় routine নয়।
  6. Tolperisone / Eperisone short course
    Painful muscle spasm থাকলে; routine PCL management নয়।

Avoid: unnecessary antibiotic, steroid injection into acute traumatic knee without clear indication, prolonged opioid, prolonged NSAID without renal/GI/CV assessment।

11) Prevention — কীভাবে PCL tear prevent করবেন

  1. Vehicle safety
    Seatbelt ব্যবহার, dashboard impact কমানো, motorcycle protective gear।
  2. Sports technique training
    Landing technique, cutting/pivoting control, safe tackling, fall technique।
  3. Strength training
    Quadriceps, gluteus, core strengthening; hamstring–quadriceps balance।
  4. Neuromuscular training
    Balance board, proprioception, agility drill, plyometric training।
  5. Warm-up and flexibility
    Sports-এর আগে dynamic warm-up; cold muscle দিয়ে high-intensity sport নয়।
  6. Avoid risky early return
    Pain/swelling/instability থাকলে running, football, jumping, deep squat avoid।
  7. Proper rehab after injury
    Incomplete rehab করলে chronic instability ও osteoarthritis risk বাড়ে।

Overview / Summary

PCL tear হলো হাঁটুর posterior stabilizer ligament ছিঁড়ে যাওয়া, সাধারণত dashboard injury, flexed knee fall, sports trauma, twisting/hyperextension বা multiligament injury থেকে হয়। Diagnosis mainly history + posterior drawer/sag/quadriceps active/dial test; MRI is investigation of choice. Isolated Grade I–II বেশিরভাগ ক্ষেত্রে brace + physiotherapy + quadriceps strengthening দিয়ে ভালো হয়; combined injury, avulsion, severe posterior translation বা persistent instability হলে surgery দরকার হতে পারে। Drug treatment symptomatic—paracetamol/NSAID/PPI/topical analgesic ± short rescue tramadol/muscle relaxant।

Actionable Plan / Steps

  1. Acute injury হলে: RICE + knee immobilizer/PCL brace + crutches।
  2. Assess red flags: deformity, locked knee, absent pulse, numb/cold foot, severe swelling, suspected dislocation → urgent referral।
  3. Confirm diagnosis: X-ray AP/lateral ± stress view; MRI knee for PCL grade and associated injuries।
  4. Medicine: paracetamol first; one NSAID only if no contraindication; PPI if NSAID risk; topical diclofenac adjunct।
  5. Rehab: early swelling control → ROM → quadriceps strengthening; early resisted hamstring exercise avoid।
  6. Refer orthopedics: Grade III, multiligament injury, avulsion fracture, meniscus injury, persistent instability/pain।

Reference List

Textbook references

  1. DeLee, Drez & Miller’s Orthopaedic Sports Medicine, latest ed., Knee Ligament Injuries / PCL chapter.
  2. Campbell’s Operative Orthopaedics, latest ed., Sports Medicine / Knee ligament reconstruction chapter.
  3. Rockwood and Green’s Fractures in Adults, latest ed., Knee dislocation and multiligament injury sections.
  4. Netter’s Orthopaedic Clinical Examination, knee ligament examination sections.

Guideline / clinical sources

  1. American Academy of Orthopaedic Surgeons. Posterior Cruciate Ligament Injuries — symptoms, imaging, nonsurgical and surgical treatment.
  2. StatPearls / NCBI Bookshelf. Posterior Cruciate Ligament Knee Injuries — mechanism, grading, MRI accuracy, management, complications.
  3. MedEx Bangladesh drug database — Bangladesh brand names, therapeutic classes, doses, interactions and adverse effects for listed medicines.

Peer-reviewed journal references with DOI

  1. Bedi A, Musahl V, Cowan JB. Management of Posterior Cruciate Ligament Injuries: An Evidence-Based Review. J Am Acad Orthop Surg. 2016;24(5):277–289. DOI: 10.5435/JAAOS-D-14-00326.
  2. Wang D, Graziano J, Williams RJ, Jones KJ. Nonoperative Treatment of PCL Injuries: Goals of Rehabilitation and the Natural History of Conservative Care. Curr Rev Musculoskelet Med. 2018;11(2):290–297. DOI: 10.1007/s12178-018-9487-y.
  3. Kew ME, Cavanaugh JT, Elnemer WG, Marx RG. Return to Play after Posterior Cruciate Ligament Injuries. Curr Rev Musculoskelet Med. 2022;15(6):606–615. DOI: 10.1007/s12178-022-09794-z.
  4. Kopkow C, Freiberg A, Kirschner S, et al. Physical Examination Tests for the Diagnosis of Posterior Cruciate Ligament Rupture: A Systematic Review. J Orthop Sports Phys Ther. 2013. DOI: 10.2519/jospt.2013.4906.

Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday,Time:-03-25-12 Pm

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