Correlation Between the Posterior Tibial Slope, Proximal Tibial Angle, Distal Femoral Angle, and Femoral Intercondylar Notch Morphology and Posterior Cruciate Ligament Injury

Correlation Between the Posterior Tibial Slope, Proximal Tibial Angle, Distal Femoral Angle, and Femoral Intercondylar Notch Morphology and Posterior Cruciate Ligament Injury | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Correlation Between the Posterior Tibial Slope, Proximal Tibial Angle, Distal Femoral Angle, and Femoral Intercondylar Notch Morphology and Posterior Cruciate Ligament Injury Donger Hai, Jing Song, Xiaoyu Zhang, Fei Tian, Xilong Ma, Zhaowei Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7478907/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 15 You are reading this latest preprint version Abstract Background : Posterior cruciate ligament (PCL) injury is one of the common sports-related injuries of the knee joint, often leading to instability, pain, and functional impairment of the knee. In recent years, studies have found that certain anatomical factors, such as the posterior tibial slope angle and the morphology of the femoral intercondylar notch, are correlated with the occurrence of PCL injury. However, systematic research on the correlation between these factors and PCL injury is still limited, and there is currently no definitive or unified conclusion. Moreover, the potential correlation between the proximal tibial angle and the distal femoral angle with PCL injury remains an unexplored area. Purpose ：The aim of this study was to investigate the exact correlation between the posterior tibial slope angle and femoral intercondylar notch morphology with PCL injury by quantifying relevant anatomical indices. Additionally, this study further explored the correlation between the proximal tibial angle and the distal femoral angle with PCL injury, in order to provide a theoretical basis for the clinical early identification of high-risk populations for PCL injury and the development of personalized treatment plans. Methods : This study employed a retrospective analysis method, including patients who visited our hospital due to knee injuries from 2021 to 2024 and were diagnosed with isolated PCL injury via MRI. All patients underwent reconstruction surgery under knee arthroscopy. Meanwhile, patients without PCL injury during the same period were selected as the control group. Through imaging, the posterior tibial slope angle, proximal tibial angle, distal femoral angle, and the width, height, and angle of the femoral intercondylar notch were measured and assessed in both the case and control groups. Subsequently, univariate and multivariate logistic regression analyses, as well as other correlation analysis methods, were used to statistically analyze the correlation between each anatomical index and PCL injury, in order to clarify their potential associations. Results : This study included a total of 169 participants, comprising 80 patients with isolated PCL injury (case group) accounting for 47.34%, and 89 controls without PCL injury accounting for 52.66%. There were no statistically significant differences between the two groups in terms of age, gender, BMI, or side affected (P > 0.05), indicating comparability between the groups. In terms of anatomical parameter measurements, the mean posterior tibial slope angle in the PCL injury group was 7.81 ± 3.59°, significantly lower than that in the control group was 11.06 ± 4.07° (t = 5.46, P < 0.001). Additionally, the femoral intercondylar angle was significantly smaller in the case group compared with the control group (Z = -2.40, P < 0.05). However, no statistically significant differences were observed between the two groups in bicondylar width, intercondylar notch width index (NWI), intercondylar notch depth, intercondylar notch width, proximal tibial angle, or distal femoral angle (P > 0.05).Further ROC curve analysis revealed that a posterior tibial slope angle of ≤6.5° had predictive value for PCL injury, with an AUC of 0.734 (95% CI: 0.659–0.809), sensitivity of 43.8%, and specificity of 92.1%. Moreover, a femoral intercondylar angle of ≤49.5° also had some predictive value for PCL injury, with an AUC of 0.607 (95% CI: 0.522–0.693), sensitivity of 50%, and specificity of 69.7%. Conclusion : Compared with the control group, the posterior tibial slope angle and femoral intercondylar angle were significantly decreased in the PCL injury group. The risk of PCL injury was significantly increased when the posterior tibial slope angle was ≤6.5° and the femoral intercondylar angle was ≤49.5°. Therefore, corresponding preventive and intervention plans should be developed for these factors to reduce the incidence of PCL injury. Posterior cruciate ligament (PCL) Posterior tibial slope angle Proximal tibial angle Distal femoral angle Intercondylar notch morphology Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 What is known about this subject Numerous studies both domestically and internationally have identified a decreased tibial plateau posterior slope and a narrowed femoral intercondylar notch as potential risk factors for cruciate ligament injuries in the knee joint. However, the majority of these investigations have predominantly focused on the anterior cruciate ligament (ACL) of the knee. In contrast, research specifically targeting the posterior cruciate ligament (PCL) remains relatively limited. This gap in the literature highlights the need for further exploration into the anatomical and biomechanical factors that may contribute to PCL injuries, as the unique structural and functional characteristics of the PCL warrant a more detailed and specialized analysis. What this study addsto existing knowledge Building on the foundation of prior research, the present study has expanded the scope of investigation by incorporating several novel parameters, namely the distal femoral lateral angle, the proximal tibial medial angle, and the intercondylar width of the femur. These additional metrics have been integrated into a comprehensive analysis of their correlation with posterior cruciate ligament (PCL) injury. By quantifying these parameters, we have endeavored to elucidate the relationship between these anatomical features and PCL injury with greater precision. This approach not only enhances the clarity of the correlation but also provides a more nuanced understanding of the underlying biomechanical factors associated with PCL pathology. Furthermore, the findings of this study are expected to offer valuable reference data for clinical practice, potentially aiding in the diagnosis, treatment planning, and prevention strategies for PCL injuries. 1 Introduction The knee joint, as the most complex weight-bearing joint in the human body, relies on the precise coordinated action of the ligament-bone complex for its biomechanical stability 1 . The posterior cruciate ligament (PCL) serves as the core structure for posterior stability of the knee joint. It is not only the primary mechanical restraint limiting posterior tibial translation (with a tensile strength exceeding 2000 N) 2 , but also a key regulator of rotational stability and dynamic load transfer within the knee joint. The unique double-bundle anatomical structure of the PCL (the anterolateral bundle and the posteromedial bundle) exhibits dynamic tension regulation during knee flexion and extension through the coordinated action of the fiber bundles 3 – 5 . This characteristic has garnered significant attention in the field of sports medicine 6 . However, the anatomical features of the PCL, which is deeply situated within the joint capsule and enveloped by the synovium 7 , 8 , result in clinically occult manifestations following injury. This leads to a high rate of misdiagnosis, reaching 30–40%, a phenomenon particularly prominent in complex knee injuries. From an epidemiological perspective, PCL injuries account for 3–20% of sports-related knee injuries 9 , and the proportion rises to 38–44% in cases of traumatic hemarthrosis of the knee 3 , ranking second only to anterior cruciate ligament (ACL) injuries 10 . It is noteworthy that isolated PCL injuries represent only 1–6% 11,12 , while over 60% of cases are associated with concomitant meniscal tears, collateral ligament injuries, or cartilage damage 13 . This high rate of combined injuries not only exacerbates the biomechanical instability of the knee joint but also significantly increases the risk of secondary osteoarthritis. Long-term follow-up studies have shown that the incidence of osteoarthritis in patients with untreated PCL injuries can reach 50–80% within 10–15 years, a rate much higher than that in the general population. These data underscore the importance of early accurate diagnosis and individualized intervention. However, the current limitations in understanding the mechanisms of PCL injuries in clinical practice have become a key bottleneck restricting the improvement of diagnostic and therapeutic standards. Traditional theories on injury mechanisms have focused on high-energy traumatic forces, including the “dashboard injury” in motor vehicle accidents (direct posterior impact on the tibia in a flexed knee position) and over-flexion-rotation complex forces in sports injuries 14 . However, in recent years, anatomical susceptibility factors have gradually become a research hotspot. Studies have shown that a decreased posterior tibial slope is believed to increase posterior tibial translation, thereby increasing the force on the PCL, which may elevate the risk of PCL injury 15 , 16 . Meanwhile, systematic research on distal femoral anatomical parameters (such as the distal femoral angle) and proximal tibial morphology (such as the proximal tibial angle) remains a gap in the literature. These parameters may influence the distribution of PCL tension by altering the geometry of the intercondylar notch. More importantly, the stability of the knee joint is essentially the result of the coordinated action of multiple structures. An abnormal increase in the distal femoral angle may alter the peak contact stress region between the femoral condyles and the tibial plateau, while variations in the proximal tibial angle directly affect the load transfer efficiency of the posterior tibial slope. Some scholars have proposed the “anatomical coupling risk model,” suggesting that the triangular biomechanical system composed of the posterior tibial slope, distal femoral angle, and proximal tibial angle may collectively determine the susceptibility to PCL injury. However, no studies have systematically quantified the interactions among these parameters, and there is a lack of clinically meaningful threshold data. This knowledge gap has led to the inability of current risk assessment models to achieve accurate prediction and to provide a theoretical basis for individualized bony structure correction in ligament reconstruction surgery. The study aimed to address three major scientific questions: 1) Is there a dose-response relationship between the morphological characteristics of the posterior tibial slope and the risk of PCL injury? 2) Do the combined variations in intercondylar notch morphology, distal femoral, and proximal tibial anatomical parameters constitute a composite risk factor? 3) Can the critical values of these parameters serve as clinical early warning indicators? The findings of this study will enhance the multidimensional understanding of PCL injury mechanisms, provide quantitative criteria for screening high-risk populations, and lay a theoretical foundation for optimizing anatomy-guided ligament reconstruction techniques, with significant clinical translational value. 2 Materials and Methods 2.1 General Information This study was a retrospective case-control study conducted at our institution. Approval for this study was obtained from our institutional ethics committee(approval number: 2025-LL-021), which also waived the requirement for informed consent. This study retrospectively analyzed patients who visited our hospital and underwent knee MRI examinations from January 2021 to December 2024. Patients who met the inclusion and exclusion criteria were divided into two groups: the case group (PCL injury group) and the control group (non-PCL injury group). 2.2 Inclusion Criteria Inclusion Criteria for the Case Group: MRI evidence of disruption of PCL continuity or abnormal signal intensity, with arthroscopic confirmation of partial or complete tear; No concurrent complete rupture of other major knee ligaments (Anterior cruciate ligament (ACL),Medial collateral ligament (MCL),Lateral collateral ligament (LCL)). Inclusion Criteria for the Control Group: MRI and arthroscopic confirmation of no PCL injury; Other knee injuries (e.g., meniscal tears, partial ACL injury) may be present. 2.3 Exclusion Criteria Tibial plateau fractures or distal femoral fractures; Previous history of knee surgery or joint replacement; Degenerative osteoarthritis (Kellgren-Lawrence grade ≥ II); Congenital knee deformities or developmental abnormalities; Incomplete or substandard quality of imaging data. 2.4 Statistical Indicators Measurement of Anatomical Parameters(Fig. 1): Posterior Tibial Slope Angle (PTSA): Measured on lateral knee radiographs as the angle between the tangent to the tibial plateau and the perpendicular line to the tibial anatomical axis. Proximal Tibial Angle (PTA): Measured on anteroposterior and lateral knee radiographs as the lateral angle between the plane of the tibial plateau and the longitudinal axis of the tibial shaft in the anteroposterior view. Distal Femoral Angle (DFA): Measured on anteroposterior and lateral knee radiographs as the lateral angle between the anatomical axis of the distal femur and the tangent to the femoral condylar joint surface in the anteroposterior view. Intercondylar Notch Morphology: Measured on knee CT scans to determine the intercondylar notch width, intercondylar notch angle (also referred to as the notch angle), intercondylar notch depth, and bicondylar width. The intercondylar notch width index (NWI) was then calculated as the ratio of the intercondylar notch width to the bicondylar width.Confounding Factors:Age; Gender; Body Mass Index (BMI); Mechanism of injury (high-energy/low-energy); Time to treatment: The time interval from injury to hospital admission. 2.5 Data Collection and Quality Control Radiological measurements were independently performed by one orthopedic surgeon and one senior radiologist using a double-blind method. The Neusoft system (version 5.5) was used with its digital measurement tools. Standardized training was conducted prior to the measurements to ensure consistency in the measurement methods. Each measurement was repeated twice, and the mean value was taken. 2.6 Statistical Analysis Data analysis was performed using SPSS version 27.0. Continuous variables are presented as mean ± standard deviation and were compared between groups using independent samples t-tests or Mann-Whitney U tests. Categorical variables are described as frequencies (percentages) and were compared using chi-square tests or Fisher's exact tests. Multivariate logistic regression analysis was used to identify risk factors for PCL injury, with odds ratios (OR) and 95% confidence intervals (CI) calculated. The diagnostic efficacy of anatomical parameters was assessed using receiver operating characteristic (ROC) curves, with the area under the curve (AUC) calculated. The significance level was set at α = 0.05 (two-sided tests). 3 Results 3.1 Analysis of Basic Information A total of 169 subjects were enrolled in this study. The case group, comprising patients with PCL injury, included 80 individuals (48 males and 32 females) and accounted for 47.34%. The control group included 89 individuals (59 males and 30 females) and accounted for 52.66%. There were no significant differences between the two groups in terms of age, gender, BMI, and side of involvement (p > 0.05), indicating comparability (Table 1). In the case group, 20% (16 cases) of the injuries were caused by motor vehicle accidents, 23.75% (19 cases) by sprains, and 56.25% (45 cases) by falls. In the control group, 5.62% (5 cases) of the injuries were caused by motor vehicle accidents, 74.16% (66 cases) by sprains, and 20.22% (18 cases) by falls. 3.2 Tibial Plateau Posterior Slope Angle (PTSA), Proximal Tibial Angle (PTA), and Distal Femoral Angle (DFA) The mean PTA in the case group was 94.04 ± 2.32, compared with 93.48 ± 2.26 in the control group (t = -1.57, p = 0.118), with no significant difference between the two groups. There was also no significant difference in DFA between the two groups (case group: 80.83 ± 1.97 vs. control group: 81.00 ± 2.10, p = 0.578). The mean PTSA in the PCL injury group was 7.81 ± 3.59, which was significantly lower than that in the control group (11.06 ± 4.07, t = 5.46, p < 0.001) (Table 2). 3.3 Morphological Characteristics of the Femoral Intercondylar Notch Three-dimensional CT reconstruction measurements showed that the interquartile range was significantly smaller in the case group than in the control group. There was a statistically significant difference in the intercondylar angle (°) between the two groups (Z = -2.40, P 0.05) (Table 3). 3.4 Univariate and Multivariate Logistic Regression Analysis of PCL Injury Univariate logistic regression analysis revealed that a PTSA of ≤6.5° (OR = 0.803, 95% CI: 0.733–0.880) and intercondylar angle (°) (OR = 1.050, 95% CI: 1.011–1.091) were independent risk factors for PCL injury (both p < 0.05) (Table4) (Figure 2). Multivariate logistic regression analysis revealed that the femoral angle, tibial plateau posterior slope angle, femoral intercondylar notch width, bicondylar width, intercondylar notch depth, and intercondylar notch angle collectively serve as risk factors for PCL injury (all p <0.05) (Table5) (Figure 3). ROC curve analysis demonstrated that a PTSA of ≤6.5° had predictive value for PCL injury (AUC = 0.734, 95% CI: 0.659–0.809), with a sensitivity of 43.8% and specificity of 92.1% (Figure 2). An intercondylar angle of ≤49.5° also had predictive value for PCL injury (AUC = 0.607, 95% CI: 0.522–0.693), with a sensitivity of 50% and specificity of 69.7% (Figure 4)(Figure 5). 3.5 Correlation Analysis of Radiological Features The intercondylar notch width was significantly positively correlated with body weight (r = 0.288, p < 0.001). The bicondylar width was also significantly positively correlated with body weight (r = 0.574, p < 0.001). Additionally, the intercondylar notch depth was significantly positively correlated with body weight (r = 0.538, p < 0.001). The femoral distal angle was significantly positively correlated with body weight (r = 0.276, p < 0.001) (Figure 6). 4 Discussion The key findings of this study indicate that a decreased PTSA and a reduced intercondylar angle are closely associated with an increased risk of PCL injury. However, no significant correlation was observed between PCL injury and factors such as the DFA, PTA, intercondylar notch width, bicondylar width, intercondylar notch depth, NWI, duration of pain, and BMI. The correlation between posterior tibial slope angle and PCL injury Currently, the relationship between the PTSA and ACL injury has been extensively studied and is well-established, with a large number of studies confirming that an increased posterior tibial slope angle is a risk factor for ACL injury 16 – 19 . However, the correlation between the size of the PTSA and PCL injury remains immature, and there is no unified conclusion. Significant controversy still exists. Bernhardson et al. measured the posterior tibial slope on lateral radiographs of the knee in 104 patients with PCL injuries and 104 age- and sex-matched normal individuals. They found that the mean posterior tibial slope values were (5.7 ± 2.1) ° in the PCL injury group and (8.6 ± 2.2) ° in the control group, with a statistically significant difference. They concluded that a decreased posterior tibial slope is associated with PCL injury and is a risk factor for PCL injury 15 . Our study also reached the same conclusion. We found that the mean posterior tibial slope values were (7.81 ± 3.59) ° in the PCL injury group and (11.06 ± 4.07)° in the control group, with a statistically significant difference. However, comparison revealed that there is still some variability in the data. Shelburne et al. used a computer model to demonstrate that for every 1° increase in posterior tibial slope, the force on the PCL decreases by 6 N. Additionally, during squatting, a decreased posterior tibial slope results in increased load on the PCL 20 . Giffin et al. conducted a biomechanical study investigating the effects of posterior tibial slope on PCL-deficient knees and found that increasing the posterior tibial slope helps to reduce posterior tibial translation and restore the stability of the PCL under posterior tibial load and axial compressive load 21 . Similarly, Singerman et al. reported that in total knee arthroplasty with PCL retention, the force on the PCL increases as the posterior tibial slope decreases from 10° to 5° 22 . Biomechanical studies have also shown that a decreased posterior tibial slope is detrimental to the PCL's ability to maintain posterior stability of the knee joint. In addition, a decreased posterior tibial slope may have an adverse effect on the outcomes of PCL reconstruction and could even be an important risk factor for graft failure 23 . Our study results indicate that a reduced posterior tibial slope is associated with an increased risk of PCL injury, which is similar to the findings of many previous studies. This conclusion is supported by prior research. Moreover, some studies have conducted correlation analyses based on knee MRI, further subdividing the PTSA into medial and lateral PTSA. Similar conclusions were reached, indicating that a decreased medial or lateral PTSA increases the risk of PCL injury. However, as of now, a unified conclusion has not yet been reached. Some studies have demonstrated that an increased LTS/MTS ratio and a decreased MTS are significantly associated with the risk of PCL injury, while LTS is not related to the risk of PCL injury 24 . They suggested that the tibia in patients with PCL injury exhibits net internal rotation 19 . Therefore, the increased LTS/MTS ratio, which leads to net internal rotation of the tibia, may increase the load on the PCL, thereby predisposing it to injury. However, other studies have shown no differences in MTS among different groups 5 , 25 . With the development of society and the increasing awareness of health, more and more people are engaging in sports. Meanwhile, the knee joint, being the largest load-bearing joint in the human body, is prone to various injuries. Identifying more risk factors for PCL injury can help patients prevent such injuries early. Compared with MRI, X-ray is less costly and more suitable for screening. The correlation between femoral intercondylar notch morphology and PCL injury So far, numerous studies have conducted correlation analyses between the width of the intercondylar notch, bicondylar width, depth of the intercondylar notch, intercondylar angle, and NWI with ACL injury. It has been concluded that a narrow intercondylar notch is a risk factor for ACL injury 26 – 29 . However, the correlation between these factors and PCL injury has been relatively less studied. Currently, there is a lack of robust research to confirm the relationship, and thus this viewpoint remains worth exploring. Our study found that the width of the intercondylar notch, bicondylar width, depth of the intercondylar notch, and intercondylar notch width index were not significantly correlated with PCL injury. In contrast, the intercondylar angle of the femur was significantly associated with PCL injury, and a decreased intercondylar angle increased the risk of PCL injury. Some studies have investigated the relationship between the femoral intercondylar notch space and ACL injury. They found that a decreased intercondylar notch width and a decreased intercondylar angle lead to a reduced volume of the intercondylar notch, causing friction and impingement between the ACL and bony structures, thereby resulting in ACL injury 30 – 33 . From an anatomical perspective, we propose that a decreased femoral intercondylar angle implies a reduction in the angle between the medial and lateral femoral condyles, thereby narrowing the space of the intercondylar notch. During knee joint movement, the PCL needs to slide and adjust its position within the intercondylar notch. When the intercondylar angle is reduced, the movement space for the PCL within the notch may be restricted, increasing the likelihood of friction and collision with surrounding bony structures or other soft tissues. Chronic friction and impact can lead to wear and degeneration of the PCL, reducing its tensile strength and thereby increasing the risk of injury. From a biomechanical standpoint, changes in the femoral intercondylar angle can affect the load distribution within the knee joint. Under normal conditions, the load borne by the knee joint is evenly distributed across the articular surfaces between the femoral condyles and the tibial plateau. When the femoral intercondylar angle is decreased, this normal load distribution pattern may be disrupted, potentially leading to increased load on the PCL. Prolonged excessive load can cause fatigue damage or even rupture of the PCL. In the future, further extensive research is needed to elucidate the relationship between the morphology of the femoral intercondylar notch, particularly the intercondylar width and angle, and PCL injuries. This will provide clinicians with more evidence to develop comprehensive prevention and treatment strategies. The correlation between Proximal Tibial Angle (PTA), and Femoral Distal Angle (FDA) with PCL injury So far, although many studies have investigated the relationship between knee joint anatomy and ligament injuries, there are still relatively few studies on the correlation between the DFA and the PTA with PCL injury. To our knowledge, this study is the first to conduct a systematic analysis in this area. Our findings revealed that there was no significant correlation between theDFA and the PTA and PCL injury (P > 0.05). However, further correlation analysis showed that body weight was positively correlated with the bicondylar width, intercondylar notch width, intercondylar notch depth, and DFA (P < 0.05). This result suggests that body weight may indirectly increase the risk of knee ligament injury by affecting the anatomical structure of the knee joint. From an anatomical perspective, the DFA, PTA, bicondylar width, intercondylar notch width, intercondylar notch depth, and tibial plateau together constitute the complex anatomical basis of the knee joint. The morphology and position of these structures have an important impact on the stability of the knee joint, its range of motion, and the distribution of mechanical forces. From a biomechanical standpoint, the alignment, pressure distribution, and ligament tension within the knee joint are all closely related to the aforementioned anatomical structures. For example, abnormal alignment of the knee joint can lead to uneven load distribution, increasing stress in specific areas and potentially causing ligament injury. Moreover, body weight, as an important biomechanical factor, may increase the load on the knee joint, alter the pressure distribution within the joint, and thereby affect the tension and stability of the ligaments. Therefore, future studies need to expand the sample size and combine more biomechanical models and clinical data to further explore the complex relationship between the anatomical structure of the knee joint and ligament injury. This will help to better understand the pathogenesis of PCL injury and provide a stronger basis for clinical prevention and treatment. There were inevitably some limitations in the implementation of this study. First, as a retrospective study, its inherent limitations have had a certain impact on the interpretation and generalizability of the research results. Second, the relatively small sample size of this study may have limited the statistical power and universality of the findings. Therefore, future research should conduct larger-scale, multicenter prospective studies to further validate the findings of this study and provide a more comprehensive and reliable basis for research in this field. 5 Conclusion A decreased PTSA and a narrowed femoral intercondylar notch angle are associated with an increased risk of primary PCL rupture. Individuals with a PTSA of less than 6.5° and a femoral intercondylar notch angle of less than 49.5° are particularly susceptible to PCL rupture. Preventive and intervention plans for PCL rupture should be specifically targeted at these individuals. It should be noted that future studies need to focus on different injury mechanisms and conduct multicenter research to provide better references for prevention and intervention plans. Abbreviations Posterior cruciate ligament (PCL) Anterior cruciate ligament (ACL) Medial collateral ligament (MCL) Lateral collateral ligament (LCL) Posterior Tibial Slope Angle (PTSA) Proximal Tibial Angle (PTA) Distal Femoral Angle (DFA) Intercondylar notch width index (NWI) Body Mass Index (BMI) Declarations Ethics approval and consent to participate The study was carried out in accordance with the guidelines of the Declaration of Helsinki and Good Clinical Practice. The study protocol was approved by the Medical Ethics Committee of People's Hospital of Ningxia Hui Autonomous Region (approval number: 2025-LL-021). Written informed consent was taken from all participants. Consent for publication Not applicable. Availability of data and material The data and materials are available. Competing interests The authors declare no competing interests. Funding The Internet Plus Health Care Project (Grant No. 2023CJE09036). This study was supported by the Sports Prescription Project (Grant No. 2023BEG02061). Authors' contributions Jun Ma and Donger Hai designed the study. Donger Hai, Jing Song,Xiaoyu Zhang,Fei Tian and Xilong Ma conducted the investigation. Donger Hai wrote the manuscript. Donger Hai and Jing Song conducted the analysis. Jun Ma revised the manuscript. All authors contributed to the article and approved the submitted version. Acknowledgements We would like to thank all the participants, our school, and the hospital. Clinical trial number : not applicable. References Hassebrock JD, Gulbrandsen MT, Asprey WL, Makovicka JL, Chhabra A. Knee Ligament Anatomy and Biomechanics. Sports Med Arthrosc Rev . 2020;28(3):80-86. DePhillipo NN, Cinque ME, Godin JA, Moatshe G, Chahla J, LaPrade RF. Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears. Am J Sports Med . 2018;46(2):341-347. Chahla J, Williams BT, LaPrade RF. Posterior Cruciate Ligament. Arthrosc J Arthrosc Relat Surg . 2020;36(2):333-335. Ahmad CS, Cohen ZA, Levine WN, Gardner TR, Ateshian GA, Mow VC. Codominance of the Individual Posterior Cruciate Ligament Bundles: An Analysis of Bundle Lengths and Orientation. Am J Sports Med . 2003;31(2):221-225. Kennedy NI, Wijdicks CA, Goldsmith MT, et al. Kinematic Analysis of the Posterior Cruciate Ligament, Part 1: The Individual and Collective Function of the Anterolateral and Posteromedial Bundles. Am J Sports Med . 2013;41(12):2828-2838. Dasari SP, Warrier AA, Condon JJ, et al. A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques. Am J Sports Med . 2023;51(13):3567-3582. Kato T, Śmigielski R, Ge Y, Zdanowicz U, Ciszek B, Ochi M. Posterior cruciate ligament is twisted and flat structure: new prospective on anatomical morphology. Knee Surg Sports Traumatol Arthrosc . 2018;26(1):31-39. Osti M, Tschann P, Künzel KH, Benedetto KP. Anatomic Characteristics and Radiographic References of the Anterolateral and Posteromedial Bundles of the Posterior Cruciate Ligament. Am J Sports Med . 2012;40(7):1558-1563. Van Kuijk KSR, Reijman M, Bierma-Zeinstra SMA, Waarsing JH, Meuffels DE. Posterior cruciate ligament injury is influenced by intercondylar shape and size of tibial eminence. Bone Jt J . 2019;101-B(9):1058-1062. Chung KS. An increasing trend of posterior cruciate ligament reconstruction in South Korea: epidemiologic analysis using Korean National Health Insurance System Database. Knee Surg Relat Res . 2021;33(1):44. Winkler PW, Zsidai B, Wagala NN, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. Knee Surg Sports Traumatol Arthrosc . 2021;29(3):672-681. Lind M, Nielsen TG, Behrndtz K. Both isolated and multi-ligament posterior cruciate ligament reconstruction results in improved subjective outcome: results from the Danish Knee Ligament Reconstruction Registry. Knee Surg Sports Traumatol Arthrosc . Published online May 25, 2017. Schlumberger M, Schuster P, Eichinger M, et al. Posterior cruciate ligament lesions are mainly present as combined lesions even in sports injuries. Knee Surg Sports Traumatol Arthrosc . 2020;28(7):2091-2098. Schüttler KF, Ziring E, Ruchholtz S, Efe T. Verletzungen des hinteren Kreuzbands. Unfallchirurg . 2017;120(1):55-68. Bernhardson AS, DePhillipo NN, Daney BT, Kennedy MI, Aman ZS, LaPrade RF. Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury. Am J Sports Med . 2019;47(2):312-317. Grassi A, Macchiarola L, Urrizola Barrientos F, et al. Steep Posterior Tibial Slope, Anterior Tibial Subluxation, Deep Posterior Lateral Femoral Condyle, and Meniscal Deficiency Are Common Findings in Multiple Anterior Cruciate Ligament Failures: An MRI Case-Control Study. Am J Sports Med . 2019;47(2):285-295. Edwards TC, Naqvi AZ, Dela Cruz N, Gupte CM. Predictors of Pediatric Anterior Cruciate Ligament Injury: The Influence of Steep Lateral Posterior Tibial Slope and Its Relationship to the Lateral Meniscus. Arthrosc J Arthrosc Relat Surg . 2021;37(5):1599-1609. Elmansori A, Lording T, Dumas R, Elmajri K, Neyret P, Lustig S. Proximal tibial bony and meniscal slopes are higher in ACL injured subjects than controls: a comparative MRI study. Knee Surg Sports Traumatol Arthrosc . 2017;25(5):1598-1605. Simon RA, Everhart JS, Nagaraja HN, Chaudhari AM. A case-control study of anterior cruciate ligament volume, tibial plateau slopes and intercondylar notch dimensions in ACL-injured knees. J Biomech . 2010;43(9):1702-1707. Shelburne KB, Kim H, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res . 2011;29(2):223-231. Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SLY, Harner CD. Importance of Tibial Slope for Stability of the Posterior Cruciate Ligament—Deficient Knee. Am J Sports Med . 2007;35(9):1443-1449. Singerman R, Dean JC, Pagan HD, Goldberg VM. Decreased posterior tibial slope increases strain in the posterior cruciate ligament following total knee arthroplasty. J Arthroplasty . 1996;11(1):99-103. Petrigliano FA, Suero EM, Voos JE, Pearle AD, Allen AA. The Effect of Proximal Tibial Slope on Dynamic Stability Testing of the Posterior Cruciate Ligament– and Posterolateral Corner–Deficient Knee. Am J Sports Med . 2012;40(6):1322-1328. Li L, Li J, Zhou P, et al. Decreased medial posterior tibial slope is associated with an increased risk of posterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc . 2023;31(7):2966-2973. DePhillipo NN, Cinque ME, Godin JA, Moatshe G, Chahla J, LaPrade RF. Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears. Am J Sports Med . 2018;46(2):341-347. Barnum MS, Boyd ED, Vacek P, Slauterbeck JR, Beynnon BD. Association of Geometric Characteristics of Knee Anatomy (Alpha Angle and Intercondylar Notch Type) With Noncontact ACL Injury. Am J Sports Med . 2021;49(10):2624-2630. Fernández-Jaén T, López-Alcorocho JM, Rodriguez-Iñigo E, Castellán F, Hernández JC, Guillén-García P. The Importance of the Intercondylar Notch in Anterior Cruciate Ligament Tears. Orthop J Sports Med . 2015;3(8):2325967115597882. Wordeman SC, Quatman CE, Kaeding CC, Hewett TE. In Vivo Evidence for Tibial Plateau Slope as a Risk Factor for Anterior Cruciate Ligament Injury: A Systematic Review and Meta-analysis. Am J Sports Med . 2012;40(7):1673-1681. Zeng C, Cheng L, Wei J, et al. The influence of the tibial plateau slopes on injury of the anterior cruciate ligament: a meta-analysis. Knee Surg Sports Traumatol Arthrosc . 2014;22(1):53-65. Zeng C, Gao S guang, Wei J, et al. The influence of the intercondylar notch dimensions on injury of the anterior cruciate ligament: a meta-analysis. Knee Surg Sports Traumatol Arthrosc . 2013;21(4):804-815. Van Diek FM, Wolf MR, Murawski CD, Van Eck CF, Fu FH. Knee morphology and risk factors for developing an anterior cruciate ligament rupture: an MRI comparison between ACL-ruptured and non-injured knees. Knee Surg Sports Traumatol Arthrosc . Published online July 6, 2013. Hoteya K, Kato Y, Motojima S, et al. Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes. Arch Orthop Trauma Surg . 2011;131(3):371-376. Cha JH, Lee SH, Shin MJ, Choi BK, Bin SI. Relationship between mucoid hypertrophy of the anterior cruciate ligament (ACL) and morphologic change of the intercondylar notch: MRI and arthroscopy correlation. Skeletal Radiol . 2008;37(9):821-826. Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files PCL.xlsx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 08 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 17 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviews received at journal 08 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviews received at journal 05 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviewers invited by journal 03 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Editor invited by journal 01 Sep, 2025 Submission checks completed at journal 29 Aug, 2025 First submitted to journal 29 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7478907","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511714995,"identity":"9a4827ec-e678-437d-b08f-d35d09c48441","order_by":0,"name":"Donger Hai","email":"","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Donger","middleName":"","lastName":"Hai","suffix":""},{"id":511714996,"identity":"96301b91-08c7-4f0f-824a-71f360cd68d4","order_by":1,"name":"Jing Song","email":"","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Song","suffix":""},{"id":511714997,"identity":"6c6aa8ce-fdbb-4bdc-93a1-3d3568076916","order_by":2,"name":"Xiaoyu Zhang","email":"","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyu","middleName":"","lastName":"Zhang","suffix":""},{"id":511714998,"identity":"b5303703-e670-4d70-8bb1-7c531aac2fdb","order_by":3,"name":"Fei Tian","email":"","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Tian","suffix":""},{"id":511714999,"identity":"8c517ab8-120d-4b39-a1f6-7098233bc601","order_by":4,"name":"Xilong Ma","email":"","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xilong","middleName":"","lastName":"Ma","suffix":""},{"id":511715000,"identity":"8a47b547-a692-4aec-8672-318b1688b5fe","order_by":5,"name":"Zhaowei Wang","email":"","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhaowei","middleName":"","lastName":"Wang","suffix":""},{"id":511715001,"identity":"07f55c02-1bac-4a64-9b69-589239724ba5","order_by":6,"name":"Jun Ma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACNvbmg49/GNjY8cs/bHyQUFFDWAsfz7FkY4aKtGTJhuTDBg/OHCOsRU4ix0ya4cwhxg0H0tIkH7YwE+EwnjNm0oVtB5glG86YVSQ2sDHwt3cnEPBLW7H1zLY7fPyMPWY3EnfIMEicObuBgC2HN97gbXvGLNnMA9Ryho3BQCKXgBaJBAMJ3rbDjBuO8ZgVJLYxE6MlxUia5wxQyxm2NAbitAAD2XAGKJBnMB+WSDhzjIegX+Tbmw8++ACKSgnGxo8/Kmrk+Nt78WvBADykKR8Fo2AUjIJRgBUAAKXjTViK/GAqAAAAAElFTkSuQmCC","orcid":"","institution":"People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jun","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2025-08-28 09:53:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7478907/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7478907/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-025-09480-4","type":"published","date":"2026-01-08T15:59:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91076644,"identity":"c66ced8f-cc69-45ac-88ae-6bff6baec326","added_by":"auto","created_at":"2025-09-11 11:11:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":748400,"visible":true,"origin":"","legend":"\u003cp\u003ea): Distal Femoral Angle (DFA): The lateral angle between the anatomical axis of the distal femur and the tangent to the femoral condylar joint surface in the anteroposterior view of the knee joint; b): Proximal Tibial Angle (PTA): The lateral angle between the tibial plateau plane and the longitudinal axis of the tibia in the anteroposterior view of the knee joint; c): Posterior Tibial Slope Angle (PTSA): The angle measured on the lateral view of the knee joint X-ray between the tangent to the tibial plateau and the vertical line of the tibial anatomical axis, which is calculated as 90° - ∠C; d): Notch Angle: The angle between the medial and lateral walls of the femoral intercondylar notch; e): Notch Depth: The vertical distance from the bottom of the femoral intercondylar notch to the tangent of the distal surfaces of the medial and lateral femoral condyles;Notch Width: The distance between the medial and lateral femoral condyles at the level of half the notch depth, measured perpendicularly to the femoral distal end; f): Bicondylar Width: The horizontal distance between the most lateral points of the medial and lateral femoral condyles at the level of half the notch depth.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/ec9d6fd5870ef4bca4c19dd5.png"},{"id":91072849,"identity":"f872da64-5d2b-46c6-9c6e-8357e7ee860d","added_by":"auto","created_at":"2025-09-11 10:55:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":419524,"visible":true,"origin":"","legend":"\u003cp\u003eUnivariate Logistic Regression Analysis of Risk Factors for PCL Injury\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/f879cbe7cef56b59624668a6.png"},{"id":91072850,"identity":"47ad649d-7363-498c-850b-c71f1c645aef","added_by":"auto","created_at":"2025-09-11 10:55:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":445664,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariate Logistic Regression Analysis of Risk Factors for PCL Injury\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/e7ab87af4dee7b86fe085d6e.png"},{"id":91072855,"identity":"8570422b-6ce4-4c5e-a27c-2c113e2395e0","added_by":"auto","created_at":"2025-09-11 10:55:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":199498,"visible":true,"origin":"","legend":"\u003cp\u003ea: Receiver Operating Characteristic (ROC) curve of the tibial plateau posterior slope angle between the PCL injury group and the control group; b: Receiver Operating Characteristic (ROC) curve of the intercondylar notch angle between the PCL injury group and the control group.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/cc60ba0f64c634cc58e76bfa.png"},{"id":91072860,"identity":"118e0984-254d-4642-9d18-d4ef554d0b5f","added_by":"auto","created_at":"2025-09-11 10:55:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":467165,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot showing the distribution of measured variables between the PCL injury group and the control group. The posterior tibial slope angle was significantly lower in the case group than in the control group (p \u0026lt; 0.001), and the intercondylar angle was significantly higher in the case group than in the control group (p = 0.012). However, there was no significant difference in the intercondylar notch width index between the two groups (p \u0026gt; 0.05).\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/bb225659f327d3490fda907c.png"},{"id":91074633,"identity":"74253024-969b-422d-b755-237cc4bf39a6","added_by":"auto","created_at":"2025-09-11 11:03:52","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":440401,"visible":true,"origin":"","legend":"\u003cp\u003ea, b, c, and d depict the correlation analysis between variables in the PCL injury group and the control group.\u003c/p\u003e","description":"","filename":"figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/d3fcb668a06664e655c2f19f.png"},{"id":100070496,"identity":"0c06ed51-43e1-44b8-b43b-8425f78070cc","added_by":"auto","created_at":"2026-01-12 16:17:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3996737,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/014f2488-5ee6-408e-96b4-69913878c848.pdf"},{"id":91078317,"identity":"b432bc30-0574-4370-9a85-5a0b2c0486b1","added_by":"auto","created_at":"2025-09-11 11:19:52","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":78220,"visible":true,"origin":"","legend":"","description":"","filename":"PCL.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/6e612144f7eca062c03629a4.xlsx"},{"id":91072848,"identity":"ca399f02-d854-4b41-8cf6-be1ec14647ec","added_by":"auto","created_at":"2025-09-11 10:55:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":36032,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7478907/v1/6348d9629c97124d3ee1e1a6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlation Between the Posterior Tibial Slope, Proximal Tibial Angle, Distal Femoral Angle, and Femoral Intercondylar Notch Morphology and Posterior Cruciate Ligament Injury","fulltext":[{"header":"What is known about this subject","content":"\u003cp\u003eNumerous studies both domestically and internationally have identified a decreased tibial plateau posterior slope and a narrowed femoral intercondylar notch as potential risk factors for cruciate ligament injuries in the knee joint. However, the majority of these investigations have predominantly focused on the anterior cruciate ligament (ACL) of the knee. In contrast, research specifically targeting the posterior cruciate ligament (PCL) remains relatively limited. This gap in the literature highlights the need for further exploration into the anatomical and biomechanical factors that may contribute to PCL injuries, as the unique structural and functional characteristics of the PCL warrant a more detailed and specialized analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat\u0026nbsp;this\u0026nbsp;study\u0026nbsp;addsto\u0026nbsp;existing\u0026nbsp;knowledge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBuilding on the foundation of prior research, the present study has expanded the scope of investigation by incorporating several novel parameters, namely the distal femoral lateral angle, the proximal tibial medial angle, and the intercondylar width of the femur. These additional metrics have been integrated into a comprehensive analysis of their correlation with posterior cruciate ligament (PCL) injury. By quantifying these parameters, we have endeavored to elucidate the relationship between these anatomical features and PCL injury with greater precision. This approach not only enhances the clarity of the correlation but also provides a more nuanced understanding of the underlying biomechanical factors associated with PCL pathology. Furthermore, the findings of this study are expected to offer valuable reference data for clinical practice, potentially aiding in the diagnosis, treatment planning, and prevention strategies for PCL injuries.\u003c/p\u003e"},{"header":"1 Introduction","content":"\u003cp\u003eThe knee joint, as the most complex weight-bearing joint in the human body, relies on the precise coordinated action of the ligament-bone complex for its biomechanical stability\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The posterior cruciate ligament (PCL) serves as the core structure for posterior stability of the knee joint. It is not only the primary mechanical restraint limiting posterior tibial translation (with a tensile strength exceeding 2000 N)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, but also a key regulator of rotational stability and dynamic load transfer within the knee joint. The unique double-bundle anatomical structure of the PCL (the anterolateral bundle and the posteromedial bundle) exhibits dynamic tension regulation during knee flexion and extension through the coordinated action of the fiber bundles\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. This characteristic has garnered significant attention in the field of sports medicine\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, the anatomical features of the PCL, which is deeply situated within the joint capsule and enveloped by the synovium\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, result in clinically occult manifestations following injury. This leads to a high rate of misdiagnosis, reaching 30\u0026ndash;40%, a phenomenon particularly prominent in complex knee injuries.\u003c/p\u003e\u003cp\u003eFrom an epidemiological perspective, PCL injuries account for 3\u0026ndash;20% of sports-related knee injuries\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, and the proportion rises to 38\u0026ndash;44% in cases of traumatic hemarthrosis of the knee\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, ranking second only to anterior cruciate ligament (ACL) injuries\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. It is noteworthy that isolated PCL injuries represent only 1\u0026ndash;6%\u003csup\u003e11,12\u003c/sup\u003e, while over 60% of cases are associated with concomitant meniscal tears, collateral ligament injuries, or cartilage damage\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. This high rate of combined injuries not only exacerbates the biomechanical instability of the knee joint but also significantly increases the risk of secondary osteoarthritis. Long-term follow-up studies have shown that the incidence of osteoarthritis in patients with untreated PCL injuries can reach 50\u0026ndash;80% within 10\u0026ndash;15 years, a rate much higher than that in the general population. These data underscore the importance of early accurate diagnosis and individualized intervention. However, the current limitations in understanding the mechanisms of PCL injuries in clinical practice have become a key bottleneck restricting the improvement of diagnostic and therapeutic standards.\u003c/p\u003e\u003cp\u003eTraditional theories on injury mechanisms have focused on high-energy traumatic forces, including the \u0026ldquo;dashboard injury\u0026rdquo; in motor vehicle accidents (direct posterior impact on the tibia in a flexed knee position) and over-flexion-rotation complex forces in sports injuries\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. However, in recent years, anatomical susceptibility factors have gradually become a research hotspot. Studies have shown that a decreased posterior tibial slope is believed to increase posterior tibial translation, thereby increasing the force on the PCL, which may elevate the risk of PCL injury\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Meanwhile, systematic research on distal femoral anatomical parameters (such as the distal femoral angle) and proximal tibial morphology (such as the proximal tibial angle) remains a gap in the literature. These parameters may influence the distribution of PCL tension by altering the geometry of the intercondylar notch.\u003c/p\u003e\u003cp\u003eMore importantly, the stability of the knee joint is essentially the result of the coordinated action of multiple structures. An abnormal increase in the distal femoral angle may alter the peak contact stress region between the femoral condyles and the tibial plateau, while variations in the proximal tibial angle directly affect the load transfer efficiency of the posterior tibial slope. Some scholars have proposed the \u0026ldquo;anatomical coupling risk model,\u0026rdquo; suggesting that the triangular biomechanical system composed of the posterior tibial slope, distal femoral angle, and proximal tibial angle may collectively determine the susceptibility to PCL injury. However, no studies have systematically quantified the interactions among these parameters, and there is a lack of clinically meaningful threshold data. This knowledge gap has led to the inability of current risk assessment models to achieve accurate prediction and to provide a theoretical basis for individualized bony structure correction in ligament reconstruction surgery.\u003c/p\u003e\u003cp\u003eThe study aimed to address three major scientific questions: 1) Is there a dose-response relationship between the morphological characteristics of the posterior tibial slope and the risk of PCL injury? 2) Do the combined variations in intercondylar notch morphology, distal femoral, and proximal tibial anatomical parameters constitute a composite risk factor? 3) Can the critical values of these parameters serve as clinical early warning indicators? The findings of this study will enhance the multidimensional understanding of PCL injury mechanisms, provide quantitative criteria for screening high-risk populations, and lay a theoretical foundation for optimizing anatomy-guided ligament reconstruction techniques, with significant clinical translational value.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 General Information\u003c/h2\u003e\n \u003cp\u003eThis study was a retrospective case-control study conducted at our institution. Approval for this study was obtained from our institutional ethics committee(approval number: 2025-LL-021), which also waived the requirement for informed consent.\u003c/p\u003e\n \u003cp\u003eThis study retrospectively analyzed patients who visited our hospital and underwent knee MRI examinations from January 2021 to December 2024. Patients who met the inclusion and exclusion criteria were divided into two groups: the case group (PCL injury group) and the control group (non-PCL injury group).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Inclusion Criteria\u003c/h2\u003e\n \u003cp\u003eInclusion Criteria for the Case Group: MRI evidence of disruption of PCL continuity or abnormal signal intensity, with arthroscopic confirmation of partial or complete tear; No concurrent complete rupture of other major knee ligaments (Anterior cruciate ligament (ACL),Medial collateral ligament (MCL),Lateral collateral ligament (LCL)).\u003c/p\u003e\n \u003cp\u003eInclusion Criteria for the Control Group: MRI and arthroscopic confirmation of no PCL injury; Other knee injuries (e.g., meniscal tears, partial ACL injury) may be present.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Exclusion Criteria\u003c/h2\u003e\n \u003cp\u003eTibial plateau fractures or distal femoral fractures; Previous history of knee surgery or joint replacement; Degenerative osteoarthritis (Kellgren-Lawrence grade\u0026thinsp;\u0026ge;\u0026thinsp;II); Congenital knee deformities or developmental abnormalities; Incomplete or substandard quality of imaging data.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Statistical Indicators\u003c/h2\u003e\n \u003cp\u003eMeasurement of Anatomical Parameters(Fig. 1): Posterior Tibial Slope Angle (PTSA): Measured on lateral knee radiographs as the angle between the tangent to the tibial plateau and the perpendicular line to the tibial anatomical axis. Proximal Tibial Angle (PTA): Measured on anteroposterior and lateral knee radiographs as the lateral angle between the plane of the tibial plateau and the longitudinal axis of the tibial shaft in the anteroposterior view. Distal Femoral Angle (DFA): Measured on anteroposterior and lateral knee radiographs as the lateral angle between the anatomical axis of the distal femur and the tangent to the femoral condylar joint surface in the anteroposterior view. Intercondylar Notch Morphology: Measured on knee CT scans to determine the intercondylar notch width, intercondylar notch angle (also referred to as the notch angle), intercondylar notch depth, and bicondylar width. The intercondylar notch width index (NWI) was then calculated as the ratio of the intercondylar notch width to the bicondylar width.Confounding Factors:Age; Gender; Body Mass Index (BMI); Mechanism of injury (high-energy/low-energy); Time to treatment: The time interval from injury to hospital admission.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Data Collection and Quality Control\u003c/h2\u003e\n \u003cp\u003eRadiological measurements were independently performed by one orthopedic surgeon and one senior radiologist using a double-blind method. The Neusoft system (version 5.5) was used with its digital measurement tools. Standardized training was conducted prior to the measurements to ensure consistency in the measurement methods. Each measurement was repeated twice, and the mean value was taken.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e\n \u003cp\u003eData analysis was performed using SPSS version 27.0. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and were compared between groups using independent samples t-tests or Mann-Whitney U tests. Categorical variables are described as frequencies (percentages) and were compared using chi-square tests or Fisher\u0026apos;s exact tests. Multivariate logistic regression analysis was used to identify risk factors for PCL injury, with odds ratios (OR) and 95% confidence intervals (CI) calculated. The diagnostic efficacy of anatomical parameters was assessed using receiver operating characteristic (ROC) curves, with the area under the curve (AUC) calculated. The significance level was set at \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05 (two-sided tests).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Analysis of Basic Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 169 subjects were enrolled in this study. The case group, comprising patients with PCL injury, included 80 individuals (48 males and 32 females) and accounted for 47.34%. The control group included 89 individuals (59 males and 30 females) and accounted for 52.66%. There were no significant differences between the two groups in terms of age, gender, BMI, and side of involvement (p \u0026gt; 0.05), indicating comparability (Table 1). In the case group, 20% (16 cases) of the injuries were caused by motor vehicle accidents, 23.75% (19 cases) by sprains, and 56.25% (45 cases) by falls. In the control group, 5.62% (5 cases) of the injuries were caused by motor vehicle accidents, 74.16% (66 cases) by sprains, and 20.22% (18 cases) by falls.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Tibial Plateau Posterior Slope Angle (PTSA), Proximal Tibial Angle (PTA), and Distal Femoral Angle (DFA)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean PTA in the case group was 94.04 \u0026plusmn; 2.32, compared with 93.48 \u0026plusmn; 2.26 in the control group (t = -1.57, p = 0.118), with no significant difference between the two groups. There was also no significant difference in DFA between the two groups (case group: 80.83 \u0026plusmn; 1.97 vs. control group: 81.00 \u0026plusmn; 2.10, p = 0.578). The mean PTSA in the PCL injury group was 7.81 \u0026plusmn; 3.59, which was significantly lower than that in the control group (11.06 \u0026plusmn; 4.07, t = 5.46, p \u0026lt; 0.001) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Morphological Characteristics of the Femoral Intercondylar Notch\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree-dimensional CT reconstruction measurements showed that the interquartile range was significantly smaller in the case group than in the control group. There was a statistically significant difference in the intercondylar angle (\u0026deg;) between the two groups (Z = -2.40, P \u0026lt; 0.05). However, no statistically significant differences were found in the bicondylar width, NWI, intercondylar notch depth, or intercondylar notch width (P \u0026gt; 0.05) (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Univariate and Multivariate Logistic Regression Analysis of PCL Injury\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnivariate logistic regression analysis revealed that a PTSA of \u0026le;6.5\u0026deg; (OR = 0.803, 95% CI: 0.733\u0026ndash;0.880) and intercondylar angle (\u0026deg;) (OR = 1.050, 95% CI: 1.011\u0026ndash;1.091) were independent risk factors for PCL injury (both p \u0026lt; 0.05) (Table4) (Figure 2). Multivariate logistic regression analysis revealed that the femoral angle, tibial plateau posterior slope angle, femoral intercondylar notch width, bicondylar width, intercondylar notch depth, and intercondylar notch angle collectively serve as risk factors for PCL injury (all p \u0026lt;0.05) (Table5) (Figure 3). ROC curve analysis demonstrated that a PTSA of \u0026le;6.5\u0026deg; had predictive value for PCL injury (AUC = 0.734, 95% CI: 0.659\u0026ndash;0.809), with a sensitivity of 43.8% and specificity of 92.1% (Figure 2). An intercondylar angle of \u0026le;49.5\u0026deg; also had predictive value for PCL injury (AUC = 0.607, 95% CI: 0.522\u0026ndash;0.693), with a sensitivity of 50% and specificity of 69.7% (Figure 4)(Figure 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Correlation Analysis of Radiological Features\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intercondylar notch width was significantly positively correlated with body weight (r = 0.288, p \u0026lt; 0.001). The bicondylar width was also significantly positively correlated with body weight (r = 0.574, p \u0026lt; 0.001). Additionally, the intercondylar notch depth was significantly positively correlated with body weight (r = 0.538, p \u0026lt; 0.001). The femoral distal angle was significantly positively correlated with body weight (r = 0.276, p \u0026lt; 0.001) (Figure 6).\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe key findings of this study indicate that a decreased PTSA and a reduced intercondylar angle are closely associated with an increased risk of PCL injury. However, no significant correlation was observed between PCL injury and factors such as the DFA, PTA, intercondylar notch width, bicondylar width, intercondylar notch depth, NWI, duration of pain, and BMI.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe correlation between posterior tibial slope angle and PCL injury\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCurrently, the relationship between the PTSA and ACL injury has been extensively studied and is well-established, with a large number of studies confirming that an increased posterior tibial slope angle is a risk factor for ACL injury\u003csup\u003e\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. However, the correlation between the size of the PTSA and PCL injury remains immature, and there is no unified conclusion. Significant controversy still exists. Bernhardson et al. measured the posterior tibial slope on lateral radiographs of the knee in 104 patients with PCL injuries and 104 age- and sex-matched normal individuals. They found that the mean posterior tibial slope values were (5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1) \u0026deg; in the PCL injury group and (8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2) \u0026deg; in the control group, with a statistically significant difference. They concluded that a decreased posterior tibial slope is associated with PCL injury and is a risk factor for PCL injury\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Our study also reached the same conclusion. We found that the mean posterior tibial slope values were (7.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59) \u0026deg; in the PCL injury group and (11.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.07)\u0026deg; in the control group, with a statistically significant difference. However, comparison revealed that there is still some variability in the data. Shelburne et al. used a computer model to demonstrate that for every 1\u0026deg; increase in posterior tibial slope, the force on the PCL decreases by 6 N. Additionally, during squatting, a decreased posterior tibial slope results in increased load on the PCL\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Giffin et al. conducted a biomechanical study investigating the effects of posterior tibial slope on PCL-deficient knees and found that increasing the posterior tibial slope helps to reduce posterior tibial translation and restore the stability of the PCL under posterior tibial load and axial compressive load\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Similarly, Singerman et al. reported that in total knee arthroplasty with PCL retention, the force on the PCL increases as the posterior tibial slope decreases from 10\u0026deg; to 5\u0026deg;\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Biomechanical studies have also shown that a decreased posterior tibial slope is detrimental to the PCL's ability to maintain posterior stability of the knee joint. In addition, a decreased posterior tibial slope may have an adverse effect on the outcomes of PCL reconstruction and could even be an important risk factor for graft failure\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Our study results indicate that a reduced posterior tibial slope is associated with an increased risk of PCL injury, which is similar to the findings of many previous studies. This conclusion is supported by prior research. Moreover, some studies have conducted correlation analyses based on knee MRI, further subdividing the PTSA into medial and lateral PTSA. Similar conclusions were reached, indicating that a decreased medial or lateral PTSA increases the risk of PCL injury. However, as of now, a unified conclusion has not yet been reached. Some studies have demonstrated that an increased LTS/MTS ratio and a decreased MTS are significantly associated with the risk of PCL injury, while LTS is not related to the risk of PCL injury\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. They suggested that the tibia in patients with PCL injury exhibits net internal rotation\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Therefore, the increased LTS/MTS ratio, which leads to net internal rotation of the tibia, may increase the load on the PCL, thereby predisposing it to injury. However, other studies have shown no differences in MTS among different groups\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. With the development of society and the increasing awareness of health, more and more people are engaging in sports. Meanwhile, the knee joint, being the largest load-bearing joint in the human body, is prone to various injuries. Identifying more risk factors for PCL injury can help patients prevent such injuries early. Compared with MRI, X-ray is less costly and more suitable for screening.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe correlation between femoral intercondylar notch morphology and PCL injury\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSo far, numerous studies have conducted correlation analyses between the width of the intercondylar notch, bicondylar width, depth of the intercondylar notch, intercondylar angle, and NWI with ACL injury. It has been concluded that a narrow intercondylar notch is a risk factor for ACL injury\u003csup\u003e\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. However, the correlation between these factors and PCL injury has been relatively less studied. Currently, there is a lack of robust research to confirm the relationship, and thus this viewpoint remains worth exploring. Our study found that the width of the intercondylar notch, bicondylar width, depth of the intercondylar notch, and intercondylar notch width index were not significantly correlated with PCL injury. In contrast, the intercondylar angle of the femur was significantly associated with PCL injury, and a decreased intercondylar angle increased the risk of PCL injury. Some studies have investigated the relationship between the femoral intercondylar notch space and ACL injury. They found that a decreased intercondylar notch width and a decreased intercondylar angle lead to a reduced volume of the intercondylar notch, causing friction and impingement between the ACL and bony structures, thereby resulting in ACL injury \u003csup\u003e\u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. From an anatomical perspective, we propose that a decreased femoral intercondylar angle implies a reduction in the angle between the medial and lateral femoral condyles, thereby narrowing the space of the intercondylar notch. During knee joint movement, the PCL needs to slide and adjust its position within the intercondylar notch. When the intercondylar angle is reduced, the movement space for the PCL within the notch may be restricted, increasing the likelihood of friction and collision with surrounding bony structures or other soft tissues. Chronic friction and impact can lead to wear and degeneration of the PCL, reducing its tensile strength and thereby increasing the risk of injury. From a biomechanical standpoint, changes in the femoral intercondylar angle can affect the load distribution within the knee joint. Under normal conditions, the load borne by the knee joint is evenly distributed across the articular surfaces between the femoral condyles and the tibial plateau. When the femoral intercondylar angle is decreased, this normal load distribution pattern may be disrupted, potentially leading to increased load on the PCL. Prolonged excessive load can cause fatigue damage or even rupture of the PCL. In the future, further extensive research is needed to elucidate the relationship between the morphology of the femoral intercondylar notch, particularly the intercondylar width and angle, and PCL injuries. This will provide clinicians with more evidence to develop comprehensive prevention and treatment strategies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe correlation between Proximal Tibial Angle (PTA), and Femoral Distal Angle (FDA) with PCL injury\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSo far, although many studies have investigated the relationship between knee joint anatomy and ligament injuries, there are still relatively few studies on the correlation between the DFA and the PTA with PCL injury. To our knowledge, this study is the first to conduct a systematic analysis in this area. Our findings revealed that there was no significant correlation between theDFA and the PTA and PCL injury (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, further correlation analysis showed that body weight was positively correlated with the bicondylar width, intercondylar notch width, intercondylar notch depth, and DFA (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This result suggests that body weight may indirectly increase the risk of knee ligament injury by affecting the anatomical structure of the knee joint. From an anatomical perspective, the DFA, PTA, bicondylar width, intercondylar notch width, intercondylar notch depth, and tibial plateau together constitute the complex anatomical basis of the knee joint. The morphology and position of these structures have an important impact on the stability of the knee joint, its range of motion, and the distribution of mechanical forces. From a biomechanical standpoint, the alignment, pressure distribution, and ligament tension within the knee joint are all closely related to the aforementioned anatomical structures. For example, abnormal alignment of the knee joint can lead to uneven load distribution, increasing stress in specific areas and potentially causing ligament injury. Moreover, body weight, as an important biomechanical factor, may increase the load on the knee joint, alter the pressure distribution within the joint, and thereby affect the tension and stability of the ligaments. Therefore, future studies need to expand the sample size and combine more biomechanical models and clinical data to further explore the complex relationship between the anatomical structure of the knee joint and ligament injury. This will help to better understand the pathogenesis of PCL injury and provide a stronger basis for clinical prevention and treatment.\u003c/p\u003e\u003cp\u003eThere were inevitably some limitations in the implementation of this study. First, as a retrospective study, its inherent limitations have had a certain impact on the interpretation and generalizability of the research results. Second, the relatively small sample size of this study may have limited the statistical power and universality of the findings. Therefore, future research should conduct larger-scale, multicenter prospective studies to further validate the findings of this study and provide a more comprehensive and reliable basis for research in this field.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eA decreased PTSA and a narrowed femoral intercondylar notch angle are associated with an increased risk of primary PCL rupture. Individuals with a PTSA of less than 6.5\u0026deg; and a femoral intercondylar notch angle of less than 49.5\u0026deg; are particularly susceptible to PCL rupture. Preventive and intervention plans for PCL rupture should be specifically targeted at these individuals. It should be noted that future studies need to focus on different injury mechanisms and conduct multicenter research to provide better references for prevention and intervention plans.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePosterior cruciate ligament (PCL)\u003c/p\u003e\n\u003cp\u003eAnterior cruciate ligament (ACL)\u003c/p\u003e\n\u003cp\u003eMedial collateral ligament (MCL)\u003c/p\u003e\n\u003cp\u003eLateral collateral ligament (LCL)\u003c/p\u003e\n\u003cp\u003ePosterior Tibial Slope Angle (PTSA)\u003c/p\u003e\n\u003cp\u003eProximal Tibial Angle (PTA)\u003c/p\u003e\n\u003cp\u003eDistal Femoral Angle (DFA)\u003c/p\u003e\n\u003cp\u003eIntercondylar notch width index (NWI)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBody Mass Index (BMI)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was carried out in accordance with the guidelines of the Declaration of Helsinki and Good Clinical Practice. The study protocol was approved by the Medical Ethics Committee of People\u0026apos;s Hospital of Ningxia Hui Autonomous Region (approval number: 2025-LL-021). Written informed consent was taken from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data and materials are available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Internet Plus Health Care Project (Grant No. 2023CJE09036).\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Sports Prescription Project (Grant No. 2023BEG02061).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJun Ma and Donger Hai designed the study. Donger Hai, Jing Song,Xiaoyu Zhang,Fei Tian and Xilong Ma conducted the investigation. Donger Hai wrote the manuscript. Donger Hai and Jing Song conducted the analysis. Jun Ma revised the manuscript. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants, our school, and the hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHassebrock JD, Gulbrandsen MT, Asprey WL, Makovicka JL, Chhabra A. Knee Ligament Anatomy and Biomechanics. \u003cem\u003eSports Med Arthrosc Rev\u003c/em\u003e. 2020;28(3):80-86. \u003c/li\u003e\n\u003cli\u003eDePhillipo NN, Cinque ME, Godin JA, Moatshe G, Chahla J, LaPrade RF. Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2018;46(2):341-347. \u003c/li\u003e\n\u003cli\u003eChahla J, Williams BT, LaPrade RF. Posterior Cruciate Ligament. \u003cem\u003eArthrosc J Arthrosc Relat Surg\u003c/em\u003e. 2020;36(2):333-335. \u003c/li\u003e\n\u003cli\u003eAhmad CS, Cohen ZA, Levine WN, Gardner TR, Ateshian GA, Mow VC. Codominance of the Individual Posterior Cruciate Ligament Bundles: An Analysis of Bundle Lengths and Orientation. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2003;31(2):221-225.\u003c/li\u003e\n\u003cli\u003eKennedy NI, Wijdicks CA, Goldsmith MT, et al. Kinematic Analysis of the Posterior Cruciate Ligament, Part 1: The Individual and Collective Function of the Anterolateral and Posteromedial Bundles. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2013;41(12):2828-2838. \u003c/li\u003e\n\u003cli\u003eDasari SP, Warrier AA, Condon JJ, et al. A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2023;51(13):3567-3582. \u003c/li\u003e\n\u003cli\u003eKato T, Śmigielski R, Ge Y, Zdanowicz U, Ciszek B, Ochi M. Posterior cruciate ligament is twisted and flat structure: new prospective on anatomical morphology. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2018;26(1):31-39. \u003c/li\u003e\n\u003cli\u003eOsti M, Tschann P, K\u0026uuml;nzel KH, Benedetto KP. Anatomic Characteristics and Radiographic References of the Anterolateral and Posteromedial Bundles of the Posterior Cruciate Ligament. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2012;40(7):1558-1563. \u003c/li\u003e\n\u003cli\u003eVan Kuijk KSR, Reijman M, Bierma-Zeinstra SMA, Waarsing JH, Meuffels DE. Posterior cruciate ligament injury is influenced by intercondylar shape and size of tibial eminence. \u003cem\u003eBone Jt J\u003c/em\u003e. 2019;101-B(9):1058-1062. \u003c/li\u003e\n\u003cli\u003eChung KS. An increasing trend of posterior cruciate ligament reconstruction in South Korea: epidemiologic analysis using Korean National Health Insurance System Database. \u003cem\u003eKnee Surg Relat Res\u003c/em\u003e. 2021;33(1):44. \u003c/li\u003e\n\u003cli\u003eWinkler PW, Zsidai B, Wagala NN, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2021;29(3):672-681. \u003c/li\u003e\n\u003cli\u003eLind M, Nielsen TG, Behrndtz K. Both isolated and multi-ligament posterior cruciate ligament reconstruction results in improved subjective outcome: results from the Danish Knee Ligament Reconstruction Registry. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. Published online May 25, 2017.\u003c/li\u003e\n\u003cli\u003eSchlumberger M, Schuster P, Eichinger M, et al. Posterior cruciate ligament lesions are mainly present as combined lesions even in sports injuries. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2020;28(7):2091-2098.\u003c/li\u003e\n\u003cli\u003eSch\u0026uuml;ttler KF, Ziring E, Ruchholtz S, Efe T. Verletzungen des hinteren Kreuzbands. \u003cem\u003eUnfallchirurg\u003c/em\u003e. 2017;120(1):55-68. \u003c/li\u003e\n\u003cli\u003eBernhardson AS, DePhillipo NN, Daney BT, Kennedy MI, Aman ZS, LaPrade RF. Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2019;47(2):312-317. \u003c/li\u003e\n\u003cli\u003eGrassi A, Macchiarola L, Urrizola Barrientos F, et al. Steep Posterior Tibial Slope, Anterior Tibial Subluxation, Deep Posterior Lateral Femoral Condyle, and Meniscal Deficiency Are Common Findings in Multiple Anterior Cruciate Ligament Failures: An MRI Case-Control Study. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2019;47(2):285-295. \u003c/li\u003e\n\u003cli\u003eEdwards TC, Naqvi AZ, Dela Cruz N, Gupte CM. Predictors of Pediatric Anterior Cruciate Ligament Injury: The Influence of Steep Lateral Posterior Tibial Slope and Its Relationship to the Lateral Meniscus. \u003cem\u003eArthrosc J Arthrosc Relat Surg\u003c/em\u003e. 2021;37(5):1599-1609. \u003c/li\u003e\n\u003cli\u003eElmansori A, Lording T, Dumas R, Elmajri K, Neyret P, Lustig S. Proximal tibial bony and meniscal slopes are higher in ACL injured subjects than controls: a comparative MRI study. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2017;25(5):1598-1605. \u003c/li\u003e\n\u003cli\u003eSimon RA, Everhart JS, Nagaraja HN, Chaudhari AM. A case-control study of anterior cruciate ligament volume, tibial plateau slopes and intercondylar notch dimensions in ACL-injured knees. \u003cem\u003eJ Biomech\u003c/em\u003e. 2010;43(9):1702-1707. \u003c/li\u003e\n\u003cli\u003eShelburne KB, Kim H, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. \u003cem\u003eJ Orthop Res\u003c/em\u003e. 2011;29(2):223-231. \u003c/li\u003e\n\u003cli\u003eGiffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SLY, Harner CD. Importance of Tibial Slope for Stability of the Posterior Cruciate Ligament\u0026mdash;Deficient Knee. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2007;35(9):1443-1449. \u003c/li\u003e\n\u003cli\u003eSingerman R, Dean JC, Pagan HD, Goldberg VM. Decreased posterior tibial slope increases strain in the posterior cruciate ligament following total knee arthroplasty. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 1996;11(1):99-103. \u003c/li\u003e\n\u003cli\u003ePetrigliano FA, Suero EM, Voos JE, Pearle AD, Allen AA. The Effect of Proximal Tibial Slope on Dynamic Stability Testing of the Posterior Cruciate Ligament\u0026ndash; and Posterolateral Corner\u0026ndash;Deficient Knee. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2012;40(6):1322-1328. \u003c/li\u003e\n\u003cli\u003eLi L, Li J, Zhou P, et al. Decreased medial posterior tibial slope is associated with an increased risk of posterior cruciate ligament rupture. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2023;31(7):2966-2973. \u003c/li\u003e\n\u003cli\u003eDePhillipo NN, Cinque ME, Godin JA, Moatshe G, Chahla J, LaPrade RF. Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2018;46(2):341-347. \u003c/li\u003e\n\u003cli\u003eBarnum MS, Boyd ED, Vacek P, Slauterbeck JR, Beynnon BD. Association of Geometric Characteristics of Knee Anatomy (Alpha Angle and Intercondylar Notch Type) With Noncontact ACL Injury. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2021;49(10):2624-2630. \u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez-Ja\u0026eacute;n T, L\u0026oacute;pez-Alcorocho JM, Rodriguez-I\u0026ntilde;igo E, Castell\u0026aacute;n F, Hern\u0026aacute;ndez JC, Guill\u0026eacute;n-Garc\u0026iacute;a P. The Importance of the Intercondylar Notch in Anterior Cruciate Ligament Tears. \u003cem\u003eOrthop J Sports Med\u003c/em\u003e. 2015;3(8):2325967115597882. \u003c/li\u003e\n\u003cli\u003eWordeman SC, Quatman CE, Kaeding CC, Hewett TE. In Vivo Evidence for Tibial Plateau Slope as a Risk Factor for Anterior Cruciate Ligament Injury: A Systematic Review and Meta-analysis. \u003cem\u003eAm J Sports Med\u003c/em\u003e. 2012;40(7):1673-1681. \u003c/li\u003e\n\u003cli\u003eZeng C, Cheng L, Wei J, et al. The influence of the tibial plateau slopes on injury of the anterior cruciate ligament: a meta-analysis. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2014;22(1):53-65. \u003c/li\u003e\n\u003cli\u003eZeng C, Gao S guang, Wei J, et al. The influence of the intercondylar notch dimensions on injury of the anterior cruciate ligament: a meta-analysis. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. 2013;21(4):804-815. \u003c/li\u003e\n\u003cli\u003eVan Diek FM, Wolf MR, Murawski CD, Van Eck CF, Fu FH. Knee morphology and risk factors for developing an anterior cruciate ligament rupture: an MRI comparison between ACL-ruptured and non-injured knees. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc\u003c/em\u003e. Published online July 6, 2013. \u003c/li\u003e\n\u003cli\u003eHoteya K, Kato Y, Motojima S, et al. Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes. \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e. 2011;131(3):371-376. \u003c/li\u003e\n\u003cli\u003eCha JH, Lee SH, Shin MJ, Choi BK, Bin SI. Relationship between mucoid hypertrophy of the anterior cruciate ligament (ACL) and morphologic change of the intercondylar notch: MRI and arthroscopy correlation. \u003cem\u003eSkeletal Radiol\u003c/em\u003e. 2008;37(9):821-826. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Posterior cruciate ligament (PCL), Posterior tibial slope angle, Proximal tibial angle, Distal femoral angle, Intercondylar notch morphology","lastPublishedDoi":"10.21203/rs.3.rs-7478907/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7478907/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Posterior cruciate ligament (PCL) injury is one of the common sports-related injuries of the knee joint, often leading to instability, pain, and functional impairment of the knee. In recent years, studies have found that certain anatomical factors, such as the posterior tibial slope angle and the morphology of the femoral intercondylar notch, are correlated with the occurrence of PCL injury. However, systematic research on the correlation between these factors and PCL injury is still limited, and there is currently no definitive or unified conclusion. Moreover, the potential correlation between the proximal tibial angle and the distal femoral angle with PCL injury remains an unexplored area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e：The aim of this study was to investigate the exact correlation between the posterior tibial slope angle and femoral intercondylar notch morphology with PCL injury by quantifying relevant anatomical indices. Additionally, this study further explored the correlation between the proximal tibial angle and the distal femoral angle with PCL injury, in order to provide a theoretical basis for the clinical early identification of high-risk populations for PCL injury and the development of personalized treatment plans.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This study employed a retrospective analysis method, including patients who visited our hospital due to knee injuries from 2021 to 2024 and were diagnosed with isolated PCL injury via MRI. All patients underwent reconstruction surgery under knee arthroscopy. Meanwhile, patients without PCL injury during the same period were selected as the control group. Through imaging, the posterior tibial slope angle, proximal tibial angle, distal femoral angle, and the width, height, and angle of the femoral intercondylar notch were measured and assessed in both the case and control groups. Subsequently, univariate and multivariate logistic regression analyses, as well as other correlation analysis methods, were used to statistically analyze the correlation between each anatomical index and PCL injury, in order to clarify their potential associations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: This study included a total of 169 participants, comprising 80 patients with isolated PCL injury (case group) accounting for 47.34%, and 89 controls without PCL injury accounting for 52.66%. There were no statistically significant differences between the two groups in terms of age, gender, BMI, or side affected (P \u0026gt; 0.05), indicating comparability between the groups. In terms of anatomical parameter measurements, the mean posterior tibial slope angle in the PCL injury group was 7.81 ± 3.59°, significantly lower than that in the control group was 11.06 ± 4.07° (t = 5.46, P \u0026lt; 0.001). Additionally, the femoral intercondylar angle was significantly smaller in the case group compared with the control group (Z = -2.40, P \u0026lt; 0.05). However, no statistically significant differences were observed between the two groups in bicondylar width, intercondylar notch width index (NWI), intercondylar notch depth, intercondylar notch width, proximal tibial angle, or distal femoral angle (P \u0026gt; 0.05).Further ROC curve analysis revealed that a posterior tibial slope angle of ≤6.5° had predictive value for PCL injury, with an AUC of 0.734 (95% CI: 0.659–0.809), sensitivity of 43.8%, and specificity of 92.1%. Moreover, a femoral intercondylar angle of ≤49.5° also had some predictive value for PCL injury, with an AUC of 0.607 (95% CI: 0.522–0.693), sensitivity of 50%, and specificity of 69.7%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Compared with the control group, the posterior tibial slope angle and femoral intercondylar angle were significantly decreased in the PCL injury group. The risk of PCL injury was significantly increased when the posterior tibial slope angle was ≤6.5° and the femoral intercondylar angle was ≤49.5°. Therefore, corresponding preventive and intervention plans should be developed for these factors to reduce the incidence of PCL injury.\u003c/p\u003e","manuscriptTitle":"Correlation Between the Posterior Tibial Slope, Proximal Tibial Angle, Distal Femoral Angle, and Femoral Intercondylar Notch Morphology and Posterior Cruciate Ligament Injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 10:55:47","doi":"10.21203/rs.3.rs-7478907/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-17T04:28:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T13:17:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T07:39:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49135605879495245629947331241378304492","date":"2025-09-06T13:38:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107581553185284154571947781741852915737","date":"2025-09-06T07:02:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158762960908573108051395672840600296338","date":"2025-09-05T10:34:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-05T08:28:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188931466454755915531996867961094913238","date":"2025-09-04T02:18:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276362542626323317175164402069085137033","date":"2025-09-04T01:40:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37184188933944572570471403572070664926","date":"2025-09-03T21:12:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-03T20:43:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T20:41:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-01T05:10:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-29T12:42:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-08-29T12:38:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9fec8c47-02fa-4acd-ad41-8a08baea0975","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:14:04+00:00","versionOfRecord":{"articleIdentity":"rs-7478907","link":"https://doi.org/10.1186/s12891-025-09480-4","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-01-08 15:59:30","publishedOnDateReadable":"January 8th, 2026"},"versionCreatedAt":"2025-09-11 10:55:47","video":"","vorDoi":"10.1186/s12891-025-09480-4","vorDoiUrl":"https://doi.org/10.1186/s12891-025-09480-4","workflowStages":[]},"version":"v1","identity":"rs-7478907","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7478907","identity":"rs-7478907","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}