Anterior Drawer Test of the Knee

 Anterior Drawer Test of the Knee

What is Anterior Drawer Test of the Knee?

Anterior Drawer Test of the Knee is used to determine the integrity of the Anterior Cruciate Ligament (ACL), full or partial ACL tear.

See Also:  Anterior Cruciate Ligament Injury

How it’s Performed?

What does a positive Anterior Drawer Test of the Knee mean?

This test is positive for an ACL tear when an abnormal anterior movement of the tibia occurs compared with the other extremity.

It is graded by severity:

  1. Grade 1: 5 mm
  2. Grade II: 5-10 mm
  3. Grade III: > 10 mm.

Sensitivity & Specificity

There is wide variation in the reported sensitivities of the anterior drawer test. The anterior drawer test in 80 degrees of flexion without rotation has been found to have 1:

Anterior drawer test variations:

There are a number of variations to the anterior drawer test, all of which involve positioning the patient supine 2:

Anterior drawer test and maximal external rotation:

Anterior drawer test and maximal internal rotation:

As a rule, the anterior drawer is best assessed in neutral rotation. This allows one to demonstrate the greatest degree of displacement.

Rotation forces the tibia into a position where the twisting of the peripheral ligaments and capsular structures increases tension in the joint, impairing the mobility of the drawer.

Assessment of rotational stability together with assessment of lateral stability in flexion and extension provides information about the complexity of the ligament injury and the stability of the secondary stabilizers.

Jakob Maximum Drawer Test:

Notes

False-negatives may occur with this test for the same reasons as those in the Lachman test:

  1. Significant hemarthrosis,
  2. Protective hamstring spasm,
  3. Tear of the posterior horn of the medial meniscus.

The anterior drawer test in 90° of flexion is often negative in acute injuries because pain often prevents the patient from achieving this degree of flexion and causes reflexive muscle contraction.

The situation is different in chronic ligament injuries, where the primary symptom is the sensation of instability.
In these cases, the test can usually be performed painlessly in 90° of flexion and still provide useful diagnostic information.

Given the low sensitivity of this test, the clinician should not rule out an acute ACL injury solely on the basis of a negative anterior drawer.

An anterior drawer should not automatically be interpreted as an anterior cruciate ligament tear. On the other hand, a negative drawer test does not necessarily confirm that the anterior cruciate is intact. The proximal portion of the tibia is pulled anteriorly or pushed posteriorly. It can be difficult to determine the exact starting position (the neutral position) from which an anteriorly directed force will produce an anterior drawer.

For example, where the examiner exerts an anterior drawer stress in the presence of a posterior cruciate ligament injury in which the tibial head is posteriorly depressed (a spontaneous posterior drawer), it will seem as if an isolated anterior drawer is present. What has actually happened in this case is that the tibia has merely been draw n anteriorly out of its posterior displacement (due to the posterior cruciate tear) and into a neutral position. The anterior cruciate then tenses and limits further anterior displacement of the tibia.

Reference

  1. Katz JW, Fingeroth RJ. The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries. Am J Sports Med. 1986 Jan-Feb;14(1):88-91. doi: 10.1177/036354658601400115. PMID: 3752353.
  2. Winkel D, Matthijs O, Phelps V: Examination of the Knee. Gaithersburg, MD: Aspen, 1997..
  3. Clinical Tests for the Musculoskeletal System, Third Edition book.
  4. Mark Dutton, Pt . Dutton’s Orthopaedic Examination, Evaluation, And Intervention, 3rd Edition Book.

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