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Physical Exam: Anterior Drawer Test

    Purpose
    • To assess the integrity of the anterior cruciate ligament (ACL) in the knee.
    Anatomy
    • The ACL attaches to the anterior intercondylar area of the tibia then passes posteriorly, laterally, and upward to attach to the femur on the medial side of its lateral condyle.
    • The ligament prevents forward sliding of the tibia on the femur and prevents hyperextension of the knee.


    Physical Exam Technique
    1. The patient should be lying supine on the exam table
    2. Have the patient flex the hip and knees to 90°, feet should be flat on the table (the examiner may sit on the patients foot to ensure it stays flat)
    3. Cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstring
    4. Apply an posterior-to-anterior directed force through the superior tibia to draw the tibia forward toward you
    5. Observe if the tibia slides forward (like a drawer) from under the femur
    6. Repeat the test on the other leg, comparing the degree of forward movement
    Results

    • Positive Test:
      • The tibia jerks forward showing the contours of the upper tibia and includes the lack of an end-feel or excessive translation
      • An ACL tear is 11.5 times more likely
    • Negative Test:
      • Little movement is noted
      • A few degrees of forward movement are normal if equally present on both sides
    Diagnostic Accuracy
    • Summary: The anterior drawer test appears to be a specific test when ruling in a torn ACL when the test is positive and the sensitivity and specificity appear to be better for chronic conditions.
    • Acute:
      • Sensitivity = 49%
      • Specificity = 58%
    • Chronic:
      • Based on a meta-analysis of 28 studies (Benjaminse et al), the anterior drawer test shows sensitivity and specificity, however there was heterogeneity in the studies included:
        • Sensitivity = 92% (95% CI, 88 - 95%)
        • Specificity = 91% (95% CI, 87 - 94%)
    • Likelihood ratios:
      • Positive exam: LR = 3.8 (95% confidence interval [CI], 0.7 - 22.0)
      • Negative exam: LR = 0.30 (95% CI, 0.05 - 1.50)
    Pearls

    • Performing the test with the foot internally rotated further isolates the ACL
    • Synthesis of a group of examination maneuvers and historical items may be required for adequate diagnosis (the composite examination for specific ligamentous injuries of the knee performed much better than specific maneuvers)
    References
    1. Benjaminse A et al. "Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis." J Ortho Sports Phys Ther 2006;36(5):267-288.  PubMed
    2. Solomon DH et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA. 2001;286(13):1610-20.  PubMed
    3. Bickley LS et al. Bates' Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2013;658.
    4. Marieb EN, Hoehn K. Anatomy & Physiology. 3rd ed. San Fransisco, CA: Pearson Benjamin Cummings. 2008;237.
    5. McGee S. Examination of the musculoskeletal system - the shoulder. Ch 53. In Evidence-Based Physical Diagnosis, 2nd ed. St. Louis: Saunders, 2007.
    6. Orient, JM. Sapira's Art and Science of Bedside Diagnosis. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2010;512-3.
    Editors & Reviewers

    Editors:

    • Anthony J. Busti, MD, PharmD, FNLA, FAHA

    Last Reviewed:  July 2015