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Drawer test

The drawer test is a fundamental orthopedic physical examination maneuver used to assess the integrity of the cruciate ligaments in the , specifically evaluating anterior-posterior stability by measuring the displacement of the relative to the when the knee is flexed. It encompasses two primary variants: the anterior drawer test, which tests the (ACL) by applying forward force to the proximal , and the posterior drawer test, which evaluates the (PCL) by applying backward force. These tests are integral to the initial clinical of ligamentous injuries, often performed alongside like MRI for confirmation, and guide decisions on or surgical intervention. In the anterior drawer test, the patient lies with the hip flexed to 45 degrees and the to 90 degrees, after which the examiner stabilizes the patient's foot and pulls the anteriorly; a positive result is indicated by excessive translation exceeding 5-6 mm or a soft endpoint, suggesting compromise. Conversely, the posterior drawer test positions the similarly at 90 degrees of flexion, with the examiner pushing the posteriorly while palpating the line; abnormal posterior displacement greater than 5 mm, often graded from 1 (mild, 5 mm) to 3 (severe, >10 mm), signals PCL injury. Factors such as acute swelling, muscle guarding, or concomitant injuries can influence test accuracy, making it essential to compare with the contralateral and integrate with other assessments like the Lachman or pivot-shift tests. The reliability of the drawer test varies by and injury acuity; for evaluation, the anterior drawer test exhibits of 18-92% and specificity of 78-100%, performing better in cases but less so acutely due to protective spasms. For PCL assessment, the posterior drawer test demonstrates superior diagnostic performance, with of 90%, specificity of 99%, and overall accuracy of 96%, particularly for moderate to severe laxity (grades 2-3). These metrics underscore the test's value as a high-specificity tool for confirming ruptures when positive, though negative results warrant further investigation.

Overview

Definition and Purpose

The drawer test is a clinical physical examination maneuver designed to assess the stability of the by evaluating the degree of anterior-posterior translation of the relative to the . It specifically targets potential compromise of the () or (), which are key stabilizers against such translational forces. The primary purpose of the drawer test is to detect ligamentous instability resulting from or PCL injuries, thereby aiding in the early of and guiding subsequent , such as or surgical referral. By quantifying excessive tibial displacement, it helps differentiate isolated ligament tears from more complex multi-ligamentous damage, contributing to a comprehensive orthopedic evaluation. Originating as a standard orthopedic assessment in the early , the drawer test's foundational descriptions appeared in during , with Isadore Palmer introducing the "drawer sign" in 1938 as a pathognomonic indicator of rupture. It is generally indicated for patients presenting with acute or chronic knee trauma, , or symptoms of instability, including recurrent giving-way episodes during weight-bearing activities.

Types

The drawer test encompasses two primary variants designed to evaluate the integrity of specific ligaments: the anterior drawer test and the posterior drawer test. The anterior drawer test targets the () by assessing the degree of forward (anterior) displacement of the relative to the when anterior force is applied to the proximal . In contrast, the posterior drawer test focuses on the () by measuring backward (posterior) displacement of the through the application of posterior force to the proximal . Both tests are typically performed with the flexed to 90 degrees, but they differ fundamentally in the direction of force: pulling anteriorly for the assessment and pushing posteriorly for the evaluation. A less common variation, the lateral-anterior drawer test, has been proposed for assessing posterior cruciate ligament (PCL) integrity by evaluating lateral-anterior tibial translation, with a 2022 study demonstrating its clinical accuracy compared to magnetic resonance imaging for diagnosing PCL ruptures.

Anatomy and Pathophysiology

Knee Ligaments Involved

The drawer test evaluates the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), the primary intra-articular ligaments responsible for anteroposterior stability of the knee joint. These cruciate ligaments cross within the intercondylar notch, forming an "X" configuration that counters translational forces between the tibia and femur during knee motion. The originates from the posteromedial aspect of the lateral femoral condyle and inserts onto the anterior tibial plateau, specifically the area anterior and lateral to the medial intercondylar . It consists of two functional bundles: the anteromedial bundle, which tightens in flexion, and the posterolateral bundle, which tightens in extension. The 's primary function is to resist anterior tibial translation relative to the , providing up to 85% of this restraint, while secondarily resisting hyperextension and internal tibial to maintain rotational . The PCL, the stronger of the two cruciates, originates from the anterolateral aspect of the medial femoral condyle within the intercondylar notch and inserts onto the posterior tibial plateau in the , approximately 1 cm below the articular surface. Composed of an anterolateral bundle (taut in flexion) and a posteromedial bundle (taut in extension), the PCL primarily prevents posterior tibial translation, contributing up to 95% of total posterior restraint at 90 degrees of flexion, and maintains overall throughout the flexion arc. It also resists hyperflexion and provides secondary resistance to varus, valgus, and external rotation forces. Secondary stabilizers, including the medial and lateral menisci and collateral ligaments, support the cruciates by enhancing congruence and load distribution. The menisci deepen the tibial articular surface to improve against shear forces, while the resists valgus stress and the lateral collateral ligament counters varus stress, collectively aiding tibiofemoral without directly influencing anteroposterior translation.

Injury Mechanisms

Anterior cruciate ligament (ACL) injuries most commonly occur through non-contact mechanisms involving pivoting or sudden changes in direction, such as cutting maneuvers in sports like soccer or , which impose a valgus force combined with internal rotation of the on the . Contact injuries, including direct blows to the as in dashboard impacts during accidents, account for a smaller proportion of cases. Epidemiologically, ACL tears are prevalent among athletes, with an incidence of approximately 0.68 per 1,000 athlete-exposures in high-risk sports. Posterior cruciate ligament (PCL) injuries typically result from direct posterior forces applied to the anterior with the flexed, such as falls onto the proximal or athletic collisions, or from hyperextension. These injuries frequently occur in combination with other ligamentous damage, with up to 95% of PCL tears involving multi-ligament disruptions, often from high-energy trauma. PCL injuries represent 3-5% of all ligament injuries, making them less common than tears. Rupture of the or PCL leads to increased anterior-posterior joint laxity, resulting in instability that predisposes patients to recurrent subluxations and long-term secondary due to altered and wear. In the acute phase, hemarthrosis and muscle guarding often mask clinical signs of laxity during drawer testing, reducing diagnostic sensitivity compared to presentations.

Procedure

Anterior Drawer Test

The anterior drawer test is a clinical maneuver used to evaluate the integrity of the () by assessing anterior tibial translation relative to the . To perform the test, position the patient on an examination table with the flexed to 45 degrees and the knee flexed to 90 degrees, ensuring the foot is stabilized—typically by the examiner sitting on the patient's foot or using an assistant to prevent movement. The examiner stabilizes the distal femur with one hand if needed while placing both hands on the proximal calf and heel of the affected leg, grasping firmly just below the tibial plateau or tibiofemoral joint line. An anteriorly directed force is then applied to the tibia in a controlled manner, translating it forward relative to the femur while maintaining neutral rotation; this force is applied steadily to assess the response. Force application begins gently and gradually increases, allowing evaluation of the end-point feel—where a firm endpoint suggests an intact , and a soft or empty feel may indicate deficiency—while avoiding excessive force that could cause discomfort. Key precautions include instructing the patient to relax the hamstrings and to prevent muscle guarding, which can lead to false-negative results by resisting translation; additionally, the test should be performed on the contralateral knee for comparative assessment of .

Posterior Drawer Test

The posterior drawer test evaluates the (PCL), the primary stabilizer against posterior tibial translation relative to the . The patient is positioned on the examination table with the hip flexed to 45 degrees and the flexed to 90 degrees, ensuring the muscle is fully relaxed to prevent anterior of the . The examiner stabilizes the patient's foot, often by sitting on it, to maintain neutral rotation and prevent compensatory movement. The examiner places one hand on the distal aspect of the for stabilization and the other hand on the proximal anterior , with thumbs positioned along the medial and lateral lines for . A posteriorly directed force is applied to the proximal , beginning gently and increasing gradually while observing for posterior sag or excessive translation, and comparing findings to the contralateral . In acute injuries, if knee flexion to 90 degrees elicits significant pain or muscle guarding, the test may be modified by performing it at 30 degrees of flexion to improve tolerance and reliability.

Interpretation

Grading System

The drawer test results are graded based on the degree of tibial displacement relative to the , assessed at 90 degrees of flexion, with grades reflecting the severity of and integrity of restraining structures. For both anterior and posterior variants, the system typically classifies laxity into three grades: Grade 1 indicates mild displacement of 0-5 mm, suggesting minimal with intact primary and secondary restraints, resulting in a firm upon . Grade 2 denotes moderate displacement of 5-10 mm, consistent with a partial tear and compromised but present secondary restraints, yielding a soft or mushy that allows increased before . Grade 3 represents severe displacement exceeding 10 mm, indicative of a complete tear with absent primary restraint and potential multi-ligament involvement, characterized by no firm and excessive . Displacement is approximated clinically using the thumb-and-index finger pinch method to gauge the anterior or posterior tibial shift relative to the femoral condyles, or occasionally a for angular correlation, though bilateral comparison to the uninjured remains essential for establishing baseline laxity and accounting for individual variations. The anterior drawer test grading specifically evaluates integrity, while the posterior variant assesses PCL stability, with translations measured in the . For anterior testing, secondary stabilizers include the medial and lateral collateral ligaments and menisci; for posterior testing, the posteromedial and posterolateral structures. Recent studies from 2022 have explored combined grading approaches for lateral variants, such as the lateral-anterior drawer test, integrating rotational components to quantify multi-planar laxity in posterolateral corner injuries alongside or PCL deficits.

Clinical Implications

A positive anterior drawer test strongly suggests an (ACL) tear, warranting confirmation via (MRI) to assess the extent of injury and associated damage, such as meniscal or chondral lesions. In cases of grade 2 or 3 instability indicated by the test, management typically involves referral for ACL , particularly for active individuals or athletes to restore knee stability and prevent further damage. A positive posterior drawer test indicates a (PCL) injury, often managed with bracing to limit posterior tibial translation and support healing, especially in isolated cases. For grade 1 or 2 PCL tears, conservative treatment is standard, incorporating and bracing for 12 weeks to promote recovery without surgery, while grade 3 injuries may require surgical intervention if instability persists. Grade 3 findings on drawer tests correlate with a substantially elevated risk of post-traumatic , with approximately 50% of injuries progressing to within 10-20 years and higher rates (up to 90%) if concomitant meniscal or chondral damage is present; PCL injuries carry a lower but increased risk, around 10-50% depending on severity and . These severe instabilities also impact return-to-sport timelines, typically requiring 6-12 months post-repair for safe clearance, emphasizing phased rehabilitation to rebuild strength and . Drawer test results should be integrated with patient history, such as pivoting trauma mechanisms common in injuries, to form a comprehensive and tailor management, avoiding reliance on the test in isolation.

Limitations and Considerations

Diagnostic Accuracy

The anterior for () integrity exhibits variable diagnostic accuracy, with reported ranging from 18% to 92% (pooled estimate 62%) and specificity from 78% to 97% across multiple studies. Its is notably lower in acute injuries (as low as 22%) due to protective spasm and , which limit tibial translation and contribute to false negatives. In chronic tears, however, improves to around 41-92%, as muscle guarding diminishes over time. In contrast, the posterior drawer test for (PCL) isolation shows high reliability, with sensitivity of 90% and specificity of 99% in detecting PCL tears. A 2013 of tests affirmed its superiority for PCL diagnosis, reporting positive likelihood ratios up to 50 in high-quality studies, though overall pooled values varied due to differences in injury grading and examiner experience. guarding can still reduce sensitivity for both tests in acute phases, potentially leading to false negative results depending on spasm severity and timing post-injury. Comparatively, the anterior drawer test is inferior to the for ACL assessment, with the latter demonstrating a pooled of 86% versus the drawer's 62%. Recent evidence from 2022 prospective studies incorporating the KT-1000 arthrometer indicates that drawer test results, when combined with clinical history (e.g., mechanism of ), yield positive predictive values of 87-97% for tears, enhancing overall diagnostic utility in non-acute settings.

Contraindications

The drawer test, encompassing both anterior and posterior variants, should be approached with caution or avoided in acute injuries characterized by significant , swelling, and muscle guarding, as these factors can reduce diagnostic accuracy and cause discomfort during manipulation. In such cases, the test's is notably low for (ACL) assessment within the first two weeks post-injury, potentially leading to misleading results without risking further structural damage. Absolute contraindications include gross deformity suggestive of following , open wounds over the , or signs of vascular compromise, such as diminished distal pulses, to prevent exacerbation of injury during tibial mobilization. Severe represents another key exclusion, as it may amplify intra-articular pressure and discomfort under applied force. Patient-specific factors further limit applicability; the test is contraindicated in uncooperative individuals or those with neuromuscular conditions hindering quadriceps relaxation, as inadequate control invalidates the endpoint assessment. When contraindications preclude the drawer test, alternatives such as (MRI) for definitive ligament evaluation or the , which is less dependent on full relaxation and more reliable in acute settings, should be prioritized. In scenarios involving recent reduction, drawer testing should follow only after neurovascular stability is confirmed to avoid complications.

References

  1. [1]
    Anterior Cruciate Ligament (ACL) Injuries | Cedars-Sinai
    ### Summary of Anterior Drawer Test for ACL Injuries
  2. [2]
    Anterior Drawer Test: What Physical Therapists Should Know About ...
    The anterior drawer test is a commonly used orthopedic assessment tool to evaluate the integrity of the anterior cruciate ligament (ACL) in the knee.Missing: definition | Show results with:definition
  3. [3]
    Physical Exam: Posterior Drawer Test - EBM Consult
    The posterior drawer test is a physical exam technique that is done to assess the integrity of the posterior cruciate ligament (PCL).
  4. [4]
    Anterior Drawer Test - Purpose, Results, Normal Range, and more
    The Anterior Drawer Test is a clinical examination technique used to evaluate the integrity of ligaments in the knee or ankle.Missing: definition | Show results with:definition
  5. [5]
    Accuracy of Lachman and Anterior Drawer Tests for Anterior ... - NIH
    The aim of this study is to evaluate the accuracy of Lachman and anterior drawer tests in ACL injury in compare with arthroscopy.
  6. [6]
    Anterior Cruciate Ligament Knee Injury - StatPearls - NCBI Bookshelf
    The anterior drawer test is performed with the patient lying supine with their affected knee flexed to 90 degrees and the foot planted (Sometimes, it is easier ...
  7. [7]
    Posterior Cruciate Ligament Knee Injuries - StatPearls - NCBI - NIH
    Aug 8, 2023 · The posterior drawer test: This is the most accurate test for assessing PCL integrity. It is performed with the patient in a supine position ...
  8. [8]
    ACL Tear - Knee & Sports - Orthobullets
    May 8, 2025 · ACL tears are common athletic injuries leading to anterior and lateral rotatory instability of the knee. Diagnosis can be suspected clinically ...Missing: definition | Show results with:definition
  9. [9]
    MCL Knee Injuries - Knee & Sports - Orthobullets
    No readable text found in the HTML.<|control11|><|separator|>
  10. [10]
    The Diagnosis of PCL Injury: Literature Review and Introduction of ...
    In a recent investigation, the posterior drawer test was found to be the most accurate clinical test in the diagnosis of PCL laxity.
  11. [11]
    Consensus Delphi study on guidelines for the assessment of ...
    In 1938, Palmer first discussed the "drawer sign" indicating that the positivity of this sign is a pathognomonic sign of ACL rupture. In 1960, Ritchei described ...
  12. [12]
    Evaluation of Patients Presenting with Knee Pain: Part I. History ...
    Sep 1, 2003 · Anterior Cruciate Ligament. For the anterior drawer test, the patient assumes a supine position with the injured knee flexed to 90 degrees.
  13. [13]
    Anterior Drawer Test of the Knee - Physiopedia
    The knee anterior draw test, although widely used, is a poor diagnostic indicator of ACL ruptures, especially in the acute setting.
  14. [14]
    Posterior Drawer Test (Knee) - Physiopedia
    The posterior drawer is the best test to determine PCL integrity, but conclude that grading is the most important as this will determine the course of ...
  15. [15]
    How Knee Ligament Tests Identify ACL, MCL, and Other Injuries
    Purpose: The posterior drawer test evaluates the stability of the posterior cruciate ligament (PCL). This ligament prevents your shin bone from slipping ...Anterior Drawer Test · Posterior Drawer Test · Valgus Stress Test<|control11|><|separator|>
  16. [16]
    Clinical Accuracy of the Lateral-Anterior Drawer Test for Diagnosing ...
    Aug 19, 2022 · The Lateral-Anterior Drawer test (LAD-test) is a suggested alternative that previously demonstrated concurrent validity in situ.
  17. [17]
    Anatomy, Bony Pelvis and Lower Limb, Knee Anterior Cruciate ...
    Jul 24, 2023 · The anterior cruciate ligament (ACL) is one of the two cruciate ligaments which stabilizes the knee joint by preventing excessive forward ...
  18. [18]
    Biomechanics of the anterior cruciate ligament and implications for ...
    With both internal and external rotation, the ACL tightens so that it may operate as a major restraint against rotational moments acting about the knee joint [7] ...
  19. [19]
    PCL Injury - Knee & Sports - Orthobullets
    May 31, 2023 · Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for ...
  20. [20]
    Anatomy, Bony Pelvis and Lower Limb: Knee Posterior Cruciate ...
    The PCL is the largest and strongest ligament in the knee and consists of two bundles: the anterolateral bundle and the posteromedial bundle.
  21. [21]
  22. [22]
    Anatomy, Bony Pelvis and Lower Limb, Knee - StatPearls - NCBI - NIH
    Nov 5, 2023 · Anterior cruciate ligament (ACL): emerges from the anterior tibial intercondylar area posterior to the medial meniscal attachment and inserts ...
  23. [23]
    Non-contact ACL Injuries: Mechanisms and Risk Factors - PMC
    Most ACL injuries involve minimal to no contact. Female athletes sustain a two- to eightfold greater rate of injury than do their male counterparts.
  24. [24]
    Compliance With Neuromuscular Training and Anterior Cruciate ...
    They reported an incidence of ACL injury of 0.68 per 1000 hours of AE in the intervention group and 0.12 per 1000 hours of AE in the control group.
  25. [25]
    Posterior Cruciate Ligament - Physiopedia
    The posterior cruciate ligament (PCL) is the strongest and largest intra-articular ligament in human knee and the primary posterior stabilizer of the knee.
  26. [26]
    Posterior cruciate ligament injury - UpToDate
    May 29, 2025 · Common mechanisms for posterior cruciate ligament (PCL) injury · Posterior drawer test · Quadriceps active test to diagnose PCL tear. Pictures.
  27. [27]
    Anterior Cruciate Ligament Injury Clinical Presentation
    Jun 9, 2025 · The anterior drawer test, as shown in the image below, may be influenced by hamstring spasm in the acutely injured knee; thus, this test is ...
  28. [28]
    Anterior Drawer Test: What It Is & Test Details - Cleveland Clinic
    The anterior drawer test is a set of knee and lower leg movements healthcare providers use to diagnose ACL tears. You'll lie on your back and your provider will ...
  29. [29]
    Anterior Drawer Test - Robert LaPrade, MD
    The anterior drawer test is more of a historical test rather than an actual useful clinical test. It was originally felt that it was positive when there was an ...
  30. [30]
    Anterior Drawer Test: Determine ACL state - GENOUROB
    The Anterior Drawer test is a clinical examination test destined to diagnose injuries associated to the anterior cruciate ligament (ACL).
  31. [31]
    Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment ...
    The posterior drawer test is the most accurate test for PCL injuries. At 90° of knee flexion, posterior sagging of the tibia is observed on the affected side.
  32. [32]
    Posterior Drawer Test - Robert LaPrade, MD
    The posterior drawer test is performed with the knee flexed to approximately 80°-90°. For this test, it is essential for the knee to be relaxed in order to ...
  33. [33]
    Clinical Examination in the Diagnosis of Anterior Cruciate Ligament ...
    Feb 8, 2023 · It indicates that the Lachman test and anterior drawer are both specific for ACL tear with a notable difference as compared with the Lever test.Missing: implications | Show results with:implications
  34. [34]
    [PDF] PCL – Non-Operative - Sanford Health
    It is designed for rehabilitation following a PCL injury/tear, typically grade I and II. ... PCL brace is to be worn for 12 weeks. •. Since PCL loading ...
  35. [35]
    PCL Rehab
    Dec 22, 2024 · For an isolated grade 1 or 2 tear of the PCL, nonoperative treatment is recommended. An isolated grade 3 injury can also be treated ...
  36. [36]
    Post-traumatic osteoarthritis following ACL injury
    Mar 24, 2020 · As reported, 50–90% of ACL injuries progress to PTOA [6]. After ACL injury, grade III or IV radiologic changes in the Kellgren–Lawrence ...
  37. [37]
    Rehab Timeline Expectations ACL Rehabilitation Program at Emory ...
    ... after surgery for psychological confidence. Phase V - return to sport, usually at six months. Patient must meet all the criteria for return to sports; No soft ...
  38. [38]
    Return to Play after Posterior Cruciate Ligament Injuries - PMC - NIH
    Return to sport-specific exercises can begin at 2–3 months after conservative management and 6–7 months after surgical treatment. Patient outcomes after ...
  39. [39]
    a new clinical sign for the anterior cruciate ligament insufficient knee
    Apr 5, 2013 · Up until the first half of the 1970s, a clinical diagnosis of an anterior cruciate ligament (ACL) tear was only assigned based on the results of ...
  40. [40]
    The diagnostic accuracy of ruptures of the anterior cruciate ligament ...
    For all ACL injuries, irrespective of age, the Lachman test was 81.8% sensitive and 96.8% specific; the anterior drawer sign was 40.9% sensitive and 95.2% ...
  41. [41]
    Physical Examination Tests for the Diagnosis of Posterior Cruciate ...
    Oct 31, 2013 · The posterior drawer test was the most frequently studied test, with sensitivity data reported in 8 studies, ...
  42. [42]
    The Lachman test is the most sensitive and the pivot shift the most ...
    Aug 8, 2025 · Sensitivity of the anterior drawer test was 76.3% in obese patients compared to 88.2% in the nonobese control group. Sensitivity of the ...<|control11|><|separator|>
  43. [43]
    Diagnostic values of history taking, physical examination and KT ...
    Jul 26, 2022 · The aim of this study was to determine the diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect ACL injuries in ...
  44. [44]
    Apley Grind Test - StatPearls - NCBI Bookshelf
    Apr 29, 2023 · As stated in the contraindications section, this test should not be performed on a patient with gross deformity of the knee after major trauma.