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Special Tests: Knee Ligament Tests Audio

Special tests for the ligaments of the knee. Anterior Cruciate Ligament Test, Medial and Lateral Collateral Ligaments Tests, Valgus and Varus Stress Tests, Posterior Cruciate Ligament (PCL) Tests, Posterior Drawer Test, and Quadriceps Active Test. The reliability, specificity, sensitivity, validity, safety, and screening for knee pain, knee injury, and knee ligament tears (ACL, PCL, MCL, LCL).

Special Tests: Knee Ligament Tests

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Lachman's Test (and Anterior Drawer Test)

Medial and Lateral Collateral Ligaments (MCL, LCL): 

Valgus Stress Test and Varus Stress Tests

Posterior Drawer Test and Quadriceps Active Test

Knee special tests for ligament injuries are relatively accurate, and research demonstrates that their inclusion in a routine combination of exams (patient history, movement assessment, radiography, special tests) results in diagnostic accuracy equivalent to MRI. Generally, the occurrence of knee ligament injury is correlated with acute trauma. Anterior cruciate ligament injuries (ACL) injuries are the most commonly reported, especially during sports; however, most traumatic ACL injuries occur in conjunction with some damage to the other large ligament of the knee (e.g. most commonly the collateral ligaments). When compared to the other major ligaments of the knee, posterior cruciate ligament (PCL) injuries are relatively rare, and most often occur in conjunction with damage to other major ligaments. Clinical movement professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of the special tests for ligament injuries, as assessment of a ligament injury should result in referral for further testing and potentially a surgical consultation.



The routine combination of patient history, physical examination, and radiographs, is as accurate as MRI for diagnosing anterior cruciate ligament (ACL) injury (1, 4-15). This combination of exams is also accurate for posterior cruciate ligament (PCL) injuries (1, 9, 15 - 17), and is specific, but may lack sensitivity, for collateral ligament injuries (1, 16, 17). Unfortunately, the studies themselves lack the details necessary to identify an optimal set of subjective exam questions, special tests, movement assessments, and/or radiographs. At this point, no studies could be located regarding a "test-item cluster" for knee ligament injury; however, based on the reported findings of these studies more consideration should be given to the potential for a knee evaluation cluster.

The tests in the course were chosen to ensure that the major stabilizing ligaments of the knee were assessed, this includes "best tests" for the anterior cruciate ligament (ACL), collateral ligaments, and posterior cruciate ligament (PCL).

For testing the ACL, current research suggests that 

 (4 - 15, 18 - 37). This is due in large part to the relatively low sensitivity of the 

 has been included in this course due to its common use in practice.

Collateral ligament tests have been generally understudied. The available research suggests that the 

Varus Stress Test and Valgus Stress Tests

 are the best available tests for the lateral collateral ligament (LCL) and medial collateral ligament (MCL); however, they appear to be more sensitive than specific (16, 17, 37 - 42). This implies a negative result may rule out collateral ligament injury, but a positive test should lead to further testing.

Two tests were chosen for assessing PCL tears in an attempt to improve accuracy. The 

 exhibits good sensitivity and may be an effective screen. A negative test result likely rules out PCL injury; however, a positive test result should lead to further testing (43 - 45, 47). Although more research investigating the 

 is recommended, the test demonstrated excellent specificity in several studies, suggesting a positive result is a strong indicator of PCL rupture (47 - 49). This implies the 

 could be used to confirm the findings of a positive test result on the Posterior Drawer test. Note, to date no research exists investigating the accuracy of these tests combined.



 recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of these tests. The 

Varus Stress Test, and Valgus Stress Test

 are accurate tests for assessing ACL, LCL, and MCL injuries, and PCL injuries can be assessed with the 

 used as a screen, and positive findings confirmed by the 

. Assessment of a ligament injury should result in referral for further testing and potentially a surgical consultation.

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:

Courses covering Special Tests for the Knee

Special Tests: Knee - Meniscus Tears, Patellofemoral Pain and Fracture

Course Description: Special Tests: Knee Ligament Tests

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

Knee Pain

Introduction

Note: Based on current research, Lachman's is the more accurate special test. The Brookbush Institute recommends that Lachman's be the preferred exam in clinical practice. The Anterior Drawer Test is only included for the purposes of student awareness, as this is the more commonly performed exam in practice.

The patient is supine and the affected knee is flexed to 15°

The examine uses the hand closer to the patient's head to stabilize the femur, by firmly wrapping a hand around the distal end of the thigh (just proximal to the patella).

The examiner places the other hand under the tibia, wrapping the hand firmly around the proximal portion of the 

The examiner then applies a posterior-to-anterior force on the tibia, while preventing the femur from moving.

A positive test for an ACL tear is a more anterior motion of the tibia on the affected side when compared to the unaffected side.

The patient is supine and the affected knee is flexed to 90°, hip flexed to 45°, and the patient's foot is in a neutral position and flat on the table.

The examiner then sits on the patient's foot (facing the patient) to stabilize the tibia.

The examiner firmly wraps the fingers of both hands firmly around the proximal 

The thumbs should be allowed to extend upward toward the knee, so that the joint line on either side of the patellar tendon may be palpated.

A posterior to anterior force is applied to the tibia (the tibia is pulled toward the examiner).

Anterior Cruciate Ligament Tear

The patient is asked to lay supine with the affected leg close to the edge of the table.

The examiner uses the hand closest to the patient's foot to lift the leg from under the calf and brace the ankle and foot between the examiner's arm and torso (like a "head-lock" for the foot).

The examiner's other hand is placed on the lateral aspect of the distal femur, just above the knee, wrapping the hand around the side of the thigh.

The knee is flexed to 30° and the examiner gently applies pressure on the thigh from lateral to medial with the intent of creating a "valgus" force that would gap the medial knee.

A positive test is an excessive opening of the medial joint space of the knee, lateral bending of the tibia on the femur, and/or the concordant sign/pain. The test should be compared to the unaffected side. Keep in mind, that this test is uncomfortable, and hyper-mobility may have an effect on observer reliability.

Note: The test should be performed at 30° and 0°. If the test is positive at 0° damage to the posterior cruciate ligament (PCL) and capsule may be implicated.

The examiner approaches the patient's foot, uses the outside hand to lift the leg by the ankle, and step between the leg and the table facing the medial side of the patient's lower leg. The examiner may sit on the table and use their thigh to aid in supporting some of the weight of the patient's leg.

Similar to the Valgus Stress Test, the examiner is going to control the lower leg by wrapping the hand closest to the patient's foot around the 

 and bracing the ankle and foot between the examiner's arm and torso (like a "head-lock" for the foot).

The examiner's other hand is going to be placed on the medial aspect of the distal femur, just above the knee, wrapping the hand around the medial side of the thigh.

The knee is flexed to 30° and the examiner gently applies a medial to lateral pressure, with the intent of creating a "varus" force that would gap the lateral knee.

A positive test is excessive opening of the lateral joint space of the knee, lateral bending of the tibia on the femur, and/or the concordant sign/pain. The test should be compared to the unaffected side. Keep in mind, that this test is uncomfortable, and hyper-mobility may have an effect on observer reliability.

Note: The test should be performed at 30° and 0°, if the test is positive at 0° damage to the posterior cruciate ligament (PCL) and capsule may be implicated.

Lateral View of the Knee (LCL and Lateral Meniscus)

Valgus Stress Test and Varus Stress Test

The examiner firmly wraps the fingers of both hands around the proximal 

An anterior to posterior force is applied to the tibia (the tibia is pushed away from the examiner).

A positive test for PCL tear is dependent on the amount of posterior motion of the tibia, Grade 1+ (0-5mm), Grade 2+ (6 - 10mm), Grade 3+ (11mm+)

The examiner stands at the "foot" end of the table, eyes level with the patient's knee, one hand palpating the 

 to ensure it is "relaxed", and the other hand firmly bracing the anterior ankle.

The patient is asked to slide their foot down the table toward the examiner (activating their 

A positive test is anterior tibial displacement resulting from the 

Note: In this test, it assumed that if the PCL is ruptured that the tibia would "sink" or glide posteriorly on the femur when the 

 are relaxed. In this test, it is assumed that anterior displacement would be a return to normal from excessive posterior displacement.

Posterior Drawer Test and Quadriceps Active Test (PCL Injury)

Questions, comments, and criticisms are welcomed and encouraged

Copyright

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Dutton's Orthopaedic examination, evaluation, and intervention

Routine Orthopedic Evaluation for Anterior Cruciate Ligament

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Routine Orthopedic Evaluation of Collateral Ligaments

Kastelein, M., Wagemakers, H. P., Luijsterburg, P. A., Verhaar, J. A., Koes, B. W., & Bierma-Zeinstra, S. M. (2008). Assessing medial collateral ligament knee lesions in general practice. 

Routine Orthopedic Evaluation of Posterior Cruciate Ligament (9, 15 - 17)

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Anterior Drawer Test (12, 18 - 19, 23 - 25, 27)

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Clinical orthopaedics and related research

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Clinical Orthopaedics and Related Research®

Harilainen, A. (1987). Evaluation of knee instability in acute ligamentous injuries. In 

Harilainen, A., Myllynen, P., Rauste, J., & Silvennoinen, E. (1986). Diagnosis of acute knee ligament injuries: the value of stress radiography compared with clinical examination, stability under anaesthesia and arthroscopic or operative findings. In 

McClure, P. W., Rothstein, J. M., & Riddle, D. L. (1989). Intertester reliability of clinical judgments of medial knee ligament integrity. 

Hughston, J. C., Andrews, J. R., Cross, M. J., & Moschi, A. (1976). Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. 

Loos, W. C., Fox, J. M., Blazina, M. E., Del Pizzo, W., & Friedman, M. J. (1981). Acute posterior cruciate ligament injuries. 

Clendenin, M. B., DeLee, J. C., & Heckman, J. D. (1980). Interstitial tears of the posterior cruciate ligament of the knee. 

Fowler, P. J., & Messieh, S. S. (1987). Isolated posterior cruciate ligament injuries in athletes. 

Moore, H. A., & Larson, R. L. (1980). Posterior cruciate ligament injuries: results of early surgical repair. 

Rubinstein JR, R. A., Shelbourne, K. D., McCarroll, J. R., VanMeter, C. D., & Rettig, A. C. (1994). The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. 

Kowalczuk, M., Leblanc, M. C., Rothrauff, B. B., Debski, R. E., Musahl, V., Simunovic, N., & Ayeni, O. R. (2015). Posterior tibial translation resulting from the posterior drawer manoeuver in cadaveric knee specimens: a systematic review. 

Knee Surgery, Sports Traumatology, Arthroscopy

Daniel, D. M., Stone, M. L., Barnett, P., & Sachs, R. (1988). Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. 

The Journal of bone and joint surgery. American volume

Staubli, H. U., & Jakob, R. P. (1990). Posterior instability of the knee near extension. A clinical and stress radiographic analysis of acute injuries of the posterior cruciate ligament. 

Special Tests: Knee Ligament Tests

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