Review Article Physical Examination of Knee Ligament Injuries

Abstract Robert D. Bronstein, MD The knee is one of the most commonly injured joints in the body. Joseph C. Schaffer, MD A thorough history and physical examination of the knee facilitates accurate diagnosis of ligament injury. Several examination techniques for the knee ligaments that were developed before advanced imaging remain as accurate or more accurate than these newer imaging modalities. Proper use of these examination techniques requires an understanding of the anatomy and pathophysiology of knee ligament injuries. Advanced imaging can be used to augment a history and examination when necessary, but should not replace a thorough history and physical examination.

he knee joint is one of the most injuries because the current injury may Tcommonly injured joints in the be the sequela of a previous injury. body. Knee ligament injury and sub- Here, we present specific tech- sequent instability can cause consid- niques for the ligamentous exami- erable disability. Diagnosis of knee nation, including identifying injuries ligament injuries requires a thorough of the anterior cruciate ligament understanding of the anatomy and (ACL), the medial collateral liga- the biomechanics of the joint. Many ment (MCL), the lateral collateral specific examination techniques were ligament (LCL), the posterolateral cor- developed before advanced imaging, ner (PLC), and the posterior cruciate and several techniques remain as ligament (PCL), and describe the asso- accurate or more accurate than the ciated anatomy and biomechanics and From the Division of Sports Medicine, new imaging modalities. Advanced the methods that allow for increased Department of Orthopaedics, University of Rochester School of Medicine and imaging (eg, MRI) is appropriate to diagnostic sensitivity and accuracy. Dentistry, Rochester, NY. use as necessary but should not Neither of the following authors nor replace the history and physical any immediate family member has examination. A survey of patients Anterior Cruciate Ligament received anything of value from or has who obtained a second opinion stock or stock options held in a regarding a knee injury reported that The ACL serves as the primary commercial company or institution related directly or indirectly to the 11% of the previously seen ortho- restraint against anterior tibial trans- subject of this article: Dr. Bronstein paedic surgeons did not palpate the lation in the knee. It also provides and Dr. Schaffer. injured knee and only 37% palpated rotational stability, especially in 1 The video that accompanies this the contralateral knee. extension. The ACL originates on the article is online at http://links.lww.com/ The orthopaedic surgeon should femur at the posteromedial aspect of JAAOS/A30. obtain a thorough history before per- the lateral femoral condyle (postero- J Am Acad Orthop Surg 2017;25: forming a physical examination of the lateral femoral notch) and runs anteri- 280-287 knee. A description of the mechanism orly to its wide tibial insertion at the DOI: 10.5435/JAAOS-D-15-00463 of injury allows the surgeon to assess lateral aspect of the anterior tibial the structures that may have been spine. The ACL has two fiber bundles, Copyright 2017 by the American Academy of Orthopaedic Surgeons. stressed or compressed. The patient the anteromedial and posterolateral should be queried about previous bundles, which provide varying tension

280 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Robert D. Bronstein, MD, and Joseph C. Schaffer, MD from flexion through extension. Injury Figure 1 to the knee ligaments is typically the result of a noncontact change in direc- tion or twisting or landing from a jump. The patient often describes a “pop” that is felt or heard at injury, with the appearance of swelling (ie, hemar- throsis) within a few hours.

Anterior Drawer Test Clinical instability of the knee asso- ciated with ACL injury was described as early as 1845.2 Historically, the anterior drawer test has been widely used for the diagnosis of ACL rup- tures, but the origin of the test is somewhat obscure. The test has been Arthroscopic images of the medial compartment obtained via a posterolateral traced back to an 1875 thesis by portal placed in an anterior cruciate ligament–deficient cadaver knee during the anterior drawer test. A, The compartment with no application of anterior tibial George Noulis, who was credited translatory force. B, The compartment with application of anterior tibial trans- with describing not only the anterior latory force. The posterior horn of the medial meniscus (white arrow) acts as a drawer test but also a form of what is doorstop, buttressing against the posterior aspect of the medial femoral condyle now known as the Lachman test.3 (black arrow) and preventing anterior translation of the tibia. The anterior drawer test is per- formed with the patient supine, the hip Figure 2 flexed at 45°, and the knee flexed at 90°. The foot is fixed to the table (often by sitting on it), and the clini- cian applies an anterior force to the proximal tibia, palpating the joint line for anterior translation. Increased anterior translation indicates ACL insufficiency. The sensitivity of the anterior drawer test, however, has been reported to be only 50% when performed with the patient under anesthesia because the posterior horn of the medial meniscus may act as Clinical photographs demonstrating hand positioning for the left knee (A) and the a so-called doorstop that prevents right knee (B) during the Lachman test. During the test, one hand stabilizes the anterior translation, even in the femur laterally while the other hand, which is placed medially, translates the tibia. presence of a torn ACL4 (Figure 1).

(3) the articulation of the relatively knee positioned between full extension Lachman Test acute convexity of the posterior medial and 15° flexion.5 Currently, the test is The Lachman test, which was initially femoral condyle and the posterior typically done with the knee flexed 20° described by Torg et al,5 is essentially horn of the medial meniscus that to 30°. The examiner places one hand an anterior drawer performed with the buttresses and prevents anterior laterally on the patient’s thigh to sta- knee at 20° to 30° of flexion. It was translation of the tibia. These limita- bilize the femur, while the other hand designed to overcome three identified tions can lead to false-negative find- grasps the proximal and more sub- limitations of the anterior drawer test: ings (See Video, Supplemental Digital cutaneous medial tibia and applies (1) acute effusion that often precludes Content 1, The Anterior Drawer Test, anterior stress (Figure 2). The test is flexion to 90°, (2) protective spasm of http://links.lww.com/JAAOS/A30). In positive in the presence of anterior the hamstring muscles that can prevent contrast, the Lachman test, as origi- translation and a soft or mushy end anterior translation of the tibia, and nally described, was done with the point. When the ACL is intact, the end

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Figure 3 Figure 4

Clinical photograph demonstrating the authors’ preferred positioning for Clinical photographs demonstrating a positive Lachman examination before (A) a right knee pivot shift test. and after (B) application of anterior translation. point is hard (Figure 3). With the knee tibia) as the knee approaches full hand against the left forearm, which in slight flexion (20° to 30°), the extension, and spontaneous reduction provides slight internal rotation to the hamstring loses mechanical advantage as the knee flexes to 30° to 40°.The leg.Thelefthandisplacedoverthe by simple geometry, and the relatively reduction is achieved by the pull of proximal fibula and valgus force is flat weight-bearing portion of the the iliotibial band as it passes poste- applied to the knee (Figure 4). This medial femoral condyle more easily rior to the axis of the knee.7 technique provides a stable base and glides over the posterior horn of the In the original description of the allows the examiner to slowly flex the medial meniscus. A positive Lachman pivot shift test, the patient is supine knee with great control. test is used to grade an injury as 1 (ie, with the knee extended. It is essential Because the pivot shift test involves anterior translation .1to5mm that the patient is relaxed for this applying a valgus stress to the knee, it compared with the uninjured knee), 2 test.6,8 The examiner grasps the heel is important that testing be limited in (ie, anterior translation 6 to 10 mm with one hand, pointing the foot the setting of a medial injury. The compared with the uninjured knee), or upward or with internal rotation, and change in the mechanics of the knee 3 (ie, anterior translation .10 mm with the other hand placed over the with the loss of the medial hinge may compared with the uninjured knee). fibular head, the examiner applies a affect the reliability of the test, These grades are based on objective valgus force through the knee, which although this phenomenon has not KT-1000 (arthrometer) measurements impinges the subluxated tibial plateau, been studied. The examiner must but can also be clinically estimated. preventing too easy a reduction. While distinguish between a true pivot shift Any difference between the injured the clinician maintains this valgus and a reverse pivot shift, which is seen and uninjured side should raise sus- force and slight internal rotation, the with posterolateral instability in picion for an ACL injury. Further knee is slowly flexed. As it passes 30° which the tibia reduces in extension classification includes a letter grade of to 40° of flexion, the reduction will and subluxates in flexion. A for a firm or hard end point and a occur and is often identified by the grade of B for a soft end point. patient as the instability symptom.6,8 Novel Tests Many modifications to the pivot shift Likely because of the strength of the test have been proposed, including clinical diagnostic ability of the Lach- Pivot Shift Test incorporation of different positions, man test, few novel tests have been In 1972, Galway et al6 first described modifying rotation, reversing the described since its introduction. One the pivot shift as both a clinical phe- maneuver, or adding grading systems, limitation of the Lachman test, how- nomenon resulting in the symptom of but all modifications hinge on the same ever, is the difficulty carrying out the test instability and as a physical sign that principle.2,8 In our preferred technique when the examiner’s hands are rela- can be elicited on examination of the for the right knee, the patient is posi- tively small compared with the girth of ACL-deficient knee. The pivot shift is tioned supine, and the examiner grasps the patient’s thigh. Therefore, minor characterized by anterior subluxation the right foot and ankle under the modifications to address this problem of the lateral tibial plateau (and examiner’s axilla, crossing the right were suggested in the late 1980s.9,10 concomitant internal rotation of the forearm under the leg and bracing the Although the Lachman test is used

282 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Robert D. Bronstein, MD, and Joseph C. Schaffer, MD primarily, two novel tests have been Table 1 described recently. The loss of exten- Accuracy of Physical Examination Tests for Diagnosis of Acute Anterior sion test is used to measure a loss of Cruciate Ligament Tears13 maximal passive extension of the knee, which is presumed to be a result of Awake With Anesthesia anterior subluxation of the tibia and Test Sensitivity Specificity Sensitivity Specificity resultant posterior capsule tightness.11 Lachman 0.81 0.81 0.91 0.78 The lever sign test, or Lelli test, is Anterior drawer 0.38 0.81 0.63 0.91 performed by placing a fist under the Pivot shift 0.28 0.81 0.73 0.98 calf of the affected leg; this acts as a fulcrum, and a downward force is applied to the quadriceps. Failure of the heel to rise off the table indicates an noncontact valgus stress is applied to (dMCL), and at least one cruciate ACL rupture. In a study of the accu- the knee. However, the medial knee ligament.18,19 In an anatomic study racy of the lever sign test for diagnosis structures work together to provide published in 1965, Hallén and Lin- of ACL tears, the lever sign was shown valgus and rotational knee stability, dahl20 showed that any number of to be more sensitive than other tests with a close functional relationship ligaments could be cut without (eg, Lachman, anterior drawer, pivot between the MCL and the ACL. Thus, compromising valgus stability in full shift) for diagnosis of acute and partial the mechanism of injury is frequently a extension as long as the posterior ACL tears.12 combination of forces that may result capsule and femoral and tibial con- in injury to multiple structures.15 Fetto dyles were intact. At 20° of flexion, Diagnostic Accuracy and Marshall16 noted that, in grade III however, successive division of the A meta-analysis of 20 studies of physi- MCL injuries, the ACL was disrupted sMCL, dMCL, ACL, and PCL pro- cal examination tests performed in 78% of the time. duced increasing laxity. awake patients and those under anes- The MCL examination begins with Fetto and Marshall16 developed a thesia found that, compared with the palpation. Fairbank17 noted that MCL classification system for valgus laxity anterior drawer and pivot shift tests, sprains typically affect the femoral measured at 0° and 30°, with grade I the Lachman test had the highest attachment and are characterized by denoting tenderness with stability at sensitivity for detecting acute complete tenderness at this point. Other struc- both angles, grade II denoting laxity ACL tears in awake patients and in tures, however, may cause tenderness at 30°, and grade III denoting laxity patients under anesthesia (81% and in the region of the MCL, including at both 0° and 30°. One advantage 91%, respectively).13 All tests had the medial patellofemoral ligament at of this system is that it follows the similar specificity in awake patients. In the medial femoral epicondyle, the biomechanics of the medial knee: at patients under anesthesia, the pivot joint line at the mid MCL, and pes 30°, the sMCL is the primary shifttestwasthemostspecificat bursitis or fracture at the distal MCL. restraint to valgus stress, whereas at 98% (Table 1). These results are in 0° the posterior oblique ligament general agreement with an earlier Valgus Stress Test and posterior medial corner complex systematic review, which also found The competency of the MCL is best are the primary restraints.15 Cur- that the anterior drawer test had assessed with the valgus stress test. rently, no classification system has good sensitivity for diagnosis of Pain or laxity with valgus stress been validated or is consistently used chronic tears.14 applied through the knee indicates an for outcomes reporting. MCL injury. Additionally, medial We perform the valgus stress test Medial Collateral Ligament pain with valgus stress helps the cli- first with the knee fully extended and nician to differentiate an MCL injury then with the knee slightly flexed The MCL is a broad, flat band that from a medial meniscus tear, which is (approximately 20° to 30°), which consists of superficial and deep com- unloaded with valgus stress. Initially, relaxes the posterior capsule and ponents. The superficial MCL (sMCL) the valgus stress test was thought to helps to isolate the MCL. When originates at the medial femoral epi- be best carried out with the knee fully valgus stress is applied, laxity, the condyle and inserts onto the medial extended—this opinion was com- amount of medial joint opening, and condyle of the tibia deep to the pes mon into the 1960s17—however, in the quality of the end point, should be anserinus. The primary function of the the 1950s, articles began noting that assessed. A great deal of normal sMCL is to resist valgus stress and thus instability in full extension required variation in laxity exists, so it is can be injured when a contact or injury to the sMCL, the deep MCL essential to compare the laxity of the

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Physical Examination of Knee Ligament Injuries injured knee with that of the contra- reversing the previously described luxated in varus upon foot strike, may lateral knee. Valgus instability in full valgus stress test. Like the MCL, the be readily noted on examination, extension indicates tearing of the LCL is best isolated at 30° flexion, particularly in the setting of chronic dMCL, sMCL, and at least one cru- and the varus stress test should instability. However, the examiner ciate ligament.15 likewise be performed at both 0° and should be careful to consider that Radiography can be used as an 30° flexion. Laxity at 0° indicates some patients may have learned to adjunct to valgus stress testing, help- more severe injury, including injury compensate with a flexed knee gait ing the clinician to quantify the to not only the LCL, but also to the pattern or may have an underlying degree of medial joint line opening. In PLC and/or associated cruciate varus knee deformity with medial practice, this is rarely done; however, ligaments.21,22 compartment collapse rather than if laxity to valgus stress is seen in the Unlike tears of the MCL, isolated lateral opening, which can obscure the setting of open physes, stress radiog- LCL tears are relatively rare but often physical examination findings.29 raphy must be performed to distin- accompany injury to the posterolateral Several special tests, including the guish between an MCL injury and a structures. Aside from the LCL, the external rotation recurvatum, pos- nondisplaced physeal fracture. main structures of the PLC are the terolateral rotary drawer, and dial popliteus tendon and the pop- tests, are used to evaluate the PLC Anteromedial Drawer Test liteofibular ligament. In addition, the and assess rotatory instability, which lateral capsule and sometimes the can be subtle and requires careful The anteromedial drawer test is arcuate ligament and the fabello- attention. No single test is diagnostic another tool that can be used to assess fibular ligament provide static stabil- in itself, and accurate evaluation of abnormal medial compartment rota- ity, whereas the biceps femoris, the PLC requires a careful history as tion and anterior translation. The knee popliteus muscle, iliotibial tract, and well as a combination of tests. is flexed 90° with the foot internally the lateral head of the gastrocnemius rotated and fixed at 15°,whilean provide dynamic stability. The pri- anterior force is applied to the tibia. External Rotation mary function of these structures is to This test helps to isolate the posterior Recurvatum Test provide rotary stability. Isolated PLC oblique ligament and posteromedial The external rotation recurvatum test injuries are rare, accounting for ,2% capsule. Asymmetric increased trans- is the most basic special test for PLC of all knee ligament injuries,23 and lation indicates a significant injury to injury. The examiner supports the most PLC injuries occur in the setting these structures.15 relaxed lower extremity by the great of multiligamentous injuries, which toe and examines the position of the areashighas87%.24 Despite being knee. Relative hyperextension (which relatively rare, PLC injuries carry Lateral Collateral Ligament can be measured with a goniometer significant morbidity and, therefore, and Posterolateral Corner or heel-height comparison), tibial must be quickly recognized. Twenty- external rotation, and knee varus The LCL is a narrow cordlike band five percent of PLC injuries are asso- alignment compared with the con- that originates slightly proximal and ciated with peroneal nerve injuries,25 tralateral side may indicate PLC posterior to the lateral femoral epi- and failure to recognize and/or treat injury.30 The sensitivity of this test condyle and inserts on the medial the PLC injuries has been shown to ranges from 33% to 94%.31 fibular head, deep to the biceps fem- increase the failure rates of ACL and oris tendon. The primary function of PCL reconstructions.26-28 the LCL is to resist varus stress. It can Posterolateral Rotary Drawer easily be directly palpated by flexing Test the knee to 90° and resting the ankle Varus Thrust Gait The posterolateral rotary drawer test on the contralateral leg to form LaPrade and Wentorf29 described the and the dial test are the two most the figure-4 position. This position posterolateral injury as one of the commonly used special tests for PLC places varus stress on the knee and most debilitating injuries to the knee evaluation. First described by Hugh- opens the lateral joint line, allowing because, in the absence of the pos- ston and Norwood30 in 1980, the the examiner to palpate the intact terolateral static stabilizers, the convex posterolateral rotary drawer test is a taut ligament. Fairbank17 noted that opposing surfaces of the lateral tibial variation of the standard posterior LCL sprains typically affect the fib- plateau and femoral condyles can drawer test for PCL evaluation. With ular attachment, and tenderness cause lateral compartment opening the knee flexed to 90°, the hip flexed might localize there. Gross laxity even in normal gait. This varus thrust to 45°, and the foot fixed in slight under varus load can be assessed by gait, in which the knee joint is sub- external rotation (usually best at

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15°31), a posteriorly directed force is true. Veltri and Warren32 showed aspect of the medial femoral condyle. applied through the tibial tuberos- that a 10° increase in external rota- The PCL runs posterolaterally ity.22 The PCL is relaxed in this tion at 30° knee flexion (compared toward the central posterior aspect of position, allowing rotary and trans- with the contralateral side) was the tibia, inserting on its own fovea latory laxity. Furthermore, this abnormal and indicated a PLC approximately 1 cm distal to the joint position places the PCL in a more injury. A dial test that is positive (ie, line, just posterior to the posterior direct anterior-to-posterior orientation, 10° increased external rotation) at horn of the medial meniscus. The focusing its function on translatory 30° but not at 90° indicates isolated PCL is made up of the anterolateral stability. The key point is to quantify PLC injury. If the test is positive at and the posteromedial fiber the ratio of translation to rotation and 90°, there is a concomitant injury to bundles.37 to compare this ratio to the ratio ob- the PCL or to the PCL and the medial As previously noted, injuries to the tainedfromthesametestdonewiththe structures.33 A recent clinical study PLC tend to be high energy, and as knee in neutral rotation. With an iso- investigated the reliability of the dial many as 87% of injuries are multi- lated PLC injury, there will be more test using a handheld inclinometer ligamentous.24 Furthermore, 95% of rotatory instability seen with slight with the patient in the supine posi- PCL injuries diagnosed in emergency external rotation than with neutral tion.34 The authors found that, for departments are associated with rotation because the PCL provides side-to-side comparison, a difference multiligamentous injuries.38 A com- more translational stability with neu- of .15° was required for clinical monly described mechanism of tral rotation. With an isolated PCL significance.34 Notably, Jung et al35 injury is striking the tibia on the injury, more translatory instability showed that, in knees with combined dashboard during a motor vehicle than rotary instability will be present.21 PCL-PLC injuries and resting poste- collision. Isolated PCL injuries also rior subluxation, application of an are seen in athletic competition when anteriorly directed force to reduce the athlete falls directly onto the knee Dial Test the subluxation resulted in approxi- with the foot plantar flexed, allow- The examiner can use the dial test to mately 6° increased external rotation ing the tibial tuberosity to strike determine the amount of external at both 30° and 90° knee flexion. the ground. However, the injury rotation of the tibia on the femur, can be caused by both hyperflexion which helps the examiner to differ- Standing Apprehension Test and hyperextension.39 Isolated PCL entiate an isolated PLC injury from a injuries are often undiagnosed Ferrari at al36 described the use of the combined PLC and PCL injury. The because the classic popping sound at standing apprehension test to detect test must be done with the patient in injury is not as distinctive and the posterolateral instability of the knee. the prone position, which allows swelling is not as severe as that The patient stands with the knee simultaneous bilateral testing and associated with ACL injuries, and slightly bent and internally rotates provides a good opportunity to visu- recurrent instability is rare.40 the torso away from the leg, pro- ally examine the posterior knee for The posterior drawer test and the ducing an internal rotation of the complications, such as ecchymosis quadriceps active test are used for femur on the tibia. If the patient and swelling. To perform the test, diagnosis of PCL tears. Each test is experiences apprehension or insta- both knees are flexed first to 30° performed with the hip flexed to 45° bility, the test is considered positive. (which best isolates the PLC), then to and the knee flexed to 90°.Inthis The authors considered the test to be 90°, with external rotation applied position, there is a loss of the nor- 100% sensitive, but this estimation to the tibias at each position. The mal anterior tibial step-off with a was based on a small patient cohort, examiner compares the injured side PCL injury.31 Typically, when the and all of the patients had positive with the uninjured side. The feet, knee is flexed to 90°,theante- dial tests at 90° knee flexion, indi- with the ankles fully dorsiflexed romedial tibial plateau extends 1 cm cating injury to the PCL and PLC. to minimize laxity, are used as a anteriorly beyond the medial femo- marker for tibial rotation. The use of ral condyle.3 the thigh-foot angle runs the risk of Posterior Cruciate overestimation of the true tibial Ligament angle, but, because the aim of the Posterior Sag Sign dial test is only to provide a side-to- The PCL is the primary restraint to The posterior sag sign can be used to side comparison, if the examiner posterior tibial translation. Its femo- assess for loss of anterior tibial step- assumes similar laxity in the bilateral ral insertion is a broad, vertically off, without any manipulation of the ankles, the difference should remain oriented footprint at the anterolateral joint.3 A randomized, controlled,

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Figure 5 is increased when combined with rately and efficiently diagnose a a complete knee examination. If variety of knee pathologies, including increased posterior translation rela- ligamentous injuries. Radiographs tive to the uninjured knee is observed should be obtained in any case of and the tibia remains anterior to the knee injury. MRI, which may be femoral condyles, the posterior helpful in certain cases, is not always drawer result is rated 11. When the necessary and should not be obtained tibia is even with the femoral con- in place of a thorough history and dyles, the posterior drawer result is physical examination. rated 21, and when the tibia drops behind the femoral condyles, the test is graded 31. References Clinical photograph demonstrating a positive posterior drawer test in the Evidence-based Medicine: Levels of left knee. Note the increased Quadriceps Active Test evidence are described in the table of posterior translation compared with The quadriceps active test was contents. In this article, references 35 that of the contralateral side. described by Daniel et al.43 The and 41 are level I studies. References patient position for this test is the 4, 5, 10, 11, 13, 14, 24, and 43 are same as that for the posterior drawer level II studies. References 12, 16, blinded study of chronic tears re- test, but the patient is asked to and 34 are level III studies. Refer- ported that the sensitivity and spec- slightly contract the quadriceps ences 3, 6, 8, 9, 22, 23, 25, 36, 38, ificity of this test was 79% and rather than having the examiner 39, and 42 are level IV studies. 41 100%, respectively. apply force. In a PCL-deficient knee References 1, 2, 7, 15, 17, 18, 21, 26- placed in the resting 90° flexion 33, and 40 are level V expert Posterior Drawer Test position, the tibia is subluxated opinion. posteriorly, but activation of the The posterior drawer test essentially References printed in bold type are quadriceps causes the patellar ten- adds a posteriorly directed force to those published within the past 5 don to reduce the tibia. This the posterior sag sign. The foot is years. observable reduction constitutes a positioned in neutral rotation (versus positive test result. Daniel et al43 1. Shelbourne KD: The art of the knee the slight external rotation in the examination: Where has it gone? J Bone reported a 98% sensitivity and posterolateral rotary drawer test). Joint Surg Am 2010;92(9):e9. 100% specificity for the quadriceps The examiner then immobilizes the 2. Lane CG, Warren R, Pearle AD: The pivot active test, but their study was foot (often by sitting on it), places the shift. J Am Acad Orthop Surg 2008;16(12): unblinded and nonrandomized. In a 679-688. thumbs on the tibial plateau, and randomized controlled blinded pushes posteriorly on the tibia to 3. Malanga GA, Andrus S, Nadler SF, study, Rubinstein et al41 reported McLean J: Physical examination of the assess for increased translation com- knee: A review of the original test that the test had a sensitivity and pared with the contralateral side description and scientific validity of specificity of 54% and 97%, common orthopedic tests. Arch Phys Med (Figure 5). Some studies have found respectively. These differences are Rehabil 2003;84(4):592-603. the posterior drawer test sensitivity attributable both to methodology 4. DeHaven KE: Diagnosis of acute knee to be as low as 51%42 or 55%30 in and patient population; however, injuries with hemarthrosis. Am J Sports the setting of acute PCL tears, but Med 1980;8(1):9-14. compared with the other previously other studies report a sensitivity of mentioned tests, the quadriceps 5. Torg JS, Conrad W, Kalen V: Clinical 90% and a specificity of 99% in the diagnosis of anterior cruciate ligament active test may be less sensitive. instability in the athlete. Am J Sports Med setting of chronic tears.41 Malanga Because the quadriceps active test 1976;4(2):84-93. et al3 found that, although many begins with a positive posterior 6. Galway RD, Beauprey A, MacIntosh DL: studies have reported on the accu- drawer result, we have found it to be Pivot shift: A clinical sign of anterior racy of the posterior drawer test, cruciate insufficiency. J Bone Joint Surg Br redundant. those studies had flaws in sample size 1972;54B:763. or methodology, and the authors 7. Slocum DB, James SL, Larson RL, Singer KM: Clinical test for anterolateral rotary concluded that the posterior drawer Summary instability of the knee. Clin Orthop Relat test is highly sensitive and specific Res 1976;118:63-69.

(more so in chronic than in acute With a thorough history and physical 8. Galway HR, MacIntosh DL: The lateral tears) and that the utility of the test examination, a clinician can accu- pivot shift: A symptom and sign of anterior

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cruciate ligament insufficiency. Clin corner of the knee. Sports Med Arthrosc 32. Veltri DM, Warren RF: Anatomy, Orthop Relat Res 1980;147:45-50. 2015;23(1):10-16. biomechanics, and physical findings in posterolateral knee instability. Clin Sports 9. Wroble RR, Lindenfeld TN: The stabilized 22. Hughston JC, Andrews JR, Cross MJ, Med 1994;13(3):599-614. Lachman test. Clin Orthop Relat Res 1988; Moschi A: Classification of knee ligament 237:209-212. instabilities: Part II. The lateral 33. Veltri DM, Deng XH, Torzilli PA, Warren compartment. J Bone Joint Surg Am 1976; RF, Maynard MJ: The role of the cruciate 10. Adler GG, Hoekman RA, Beach DM: Drop 58(2):173-179. and posterolateral ligaments in stability of leg Lachman test: A new test of anterior the knee: A biomechanical study. Am J knee laxity. Am J Sports Med 1995;23(3): 23. DeLee JC, Riley MB, Rockwood CA Jr: Sports Med 1995;23(4):436-443. 320-323. Acute posterolateral rotatory instability of the knee. 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