Anterior Drawer Test

The Anterior Drawer Test is a clinical orthopedic test used to evaluate the integrity of the anterior cruciate ligament (ACL) and detect possible ruptures or overstretching [1].

A positive test indicates:

• Laxity in the knee due to ACL injury.

• Excessive anterior translation of the tibia relative to the femur (>6 mm).

• Lack of a firm end-feel.

Test Procedure

Patient position

• Supine lying position.

• Hip flexed to 45°, knee flexed to 90°.

• Feet resting flat on the table.

Examiner position

• Sits on the patient’s foot to stabilize the leg.

• Hands placed around the proximal tibia, just below the joint line.

Execution

• Tibia is pulled forward relative to the femur, parallel to the joint line.

• The examiner evaluates the amount of anterior translation and end-feel.

• Comparison is always made with the contralateral side.

Positive test

• 6 mm anterior translation compared to the unaffected side.

• Absence of a firm end-point.

• Possible audible or palpable “jumping sign” (Finochietto sign), which may also indicate meniscal damage [4].

Clinical Considerations

• False positives may occur in patients with posterior cruciate ligament (PCL) injury (posterior sag).

• False negatives may occur in acute settings due to swelling or guarding.

Other recommended ACL tests:

• Lachman Test – more sensitive for acute ACL injuries.

• Pivot Shift Test – useful for assessing functional instability.

Diagnostic Accuracy

• Sensitivity: 0.18 – 0.92

• Specificity: 0.78 – 1.00 [5]

• Higher accuracy in chronic ACL injuries (sensitivity 92%, specificity 91%) [6].

• Lower sensitivity in acute ACL injuries (22.2% within 2 weeks) [1].

Clinical Relevance

• Best applied in subacute and chronic ACL injuries.

• Should be combined with other ACL tests (Lachman, Pivot Shift) to improve diagnostic accuracy [8].

• Remains a cornerstone in orthopedic knee assessment despite limitations in acute settings.

Conclusion

The Anterior Drawer Test is a valuable but not always reliable test for ACL ruptures, especially in acute injuries. It is most accurate in chronic cases and should be used in combination with Lachman and Pivot Shift Tests for optimal diagnostic value.

Sources:

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. The American Journal of Sports Medicine 1986;14:88-91.fckLRhttp://ajs.sagepub.com/content/14/1/88.short (accessed 18 July 2013).

2.  Flynn TW, Cleland JA, Whitman JM. Users' guide to the musculoskeletal examination: fundamentals for the evidence-based clinician. United States: Evidence in Motion; 2008.

3. Katie Yost. Physical Exam of the Knee . Available from: http://www.youtube.com/watch?v=8CZ-219Dtlc [last accessed 26/09/14]

4. Strobel M, Stedtfeld HW. Diagnostic evaluation of the knee. Springer Science & Business Media; 2012 Dec 6.

5.  Scholten RJ, Opstelten W, Van Der Plas CG, Bijl D, Devillé WL, Bouter LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. Journal of family practice. 2003;52(9):689-94.

6. Benjaminse A, Gokeler A van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36(5):267-88.

7.  Butler DL, Noyes FR, Grood ES. Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. JBJS. 1980 Mar 1;62(2):259-70.

8. Ostrowski JA. Accuracy of 3 diagnostic tests for anterior cruciate ligament tears. Journal of athletic training. 2006;41(1):120.