Knee Orthopaedic Test: Anterior Drawer Test of the Knee

The Anterior Drawer Test of the Knee assesses anterior tibial translation with the knee flexed to approximately 90 degrees. A positive finding may increase suspicion of ACL involvement when anterior translation, altered end-feel or apprehension is greater than the opposite side. The test has variable diagnostic accuracy and should be interpreted with history, Lachman, pivot shift, swelling, mechanism and functional findings.

Introduction

A client may report a twisting knee injury, a pop, rapid swelling, giving way or difficulty returning to pivoting tasks. The Anterior Drawer Test of the Knee can help assess anterior tibial translation and possible ACL involvement.

Recent diagnostic accuracy reviews indicate that ACL physical examination tests have varying accuracy depending on acute versus post-acute presentation, partial versus complete tear, anaesthesia status and reference standard.  

Quick Summary

Test name: Anterior Drawer Test of the Knee
Purpose: Assess anterior tibial translation and possible ACL involvement
Body region: Knee
Commonly associated presentation: ACL injury, anterior knee instability, giving way after pivoting injury
Positive finding: Increased anterior tibial translation, soft end-feel, apprehension or familiar instability compared with the opposite side
Negative finding: No meaningful side-to-side difference and firm end-feel
Best used with: Lachman Test, Pivot Shift Test, Lever Sign Test, swelling assessment, mechanism of injury and functional testing
Key limitation: May be less useful acutely due to pain, swelling, guarding and hamstring spasm

What Is the Anterior Drawer Test of the Knee?

The Anterior Drawer Test of the Knee is an orthopaedic test used to assess anterior movement of the tibia relative to the femur with the knee flexed to approximately 90 degrees.

It is commonly associated with ACL assessment. It provides information about translation, end-feel and side-to-side difference, but it does not confirm ACL rupture by itself.

Why It Is Used

The test is used when ACL injury or anterior knee instability is suspected. It can help support clinical reasoning when the history includes pivoting injury, giving way, swelling or instability.

What It Assesses

The test assesses anterior tibial translation and end-feel.

It does not directly visualise the ACL, grade tear severity, assess all rotational instability or rule out associated meniscal, collateral or chondral injury.

Who It Is Useful For

This test may be useful for clients with suspected ACL injury, giving-way episodes, pivoting injury history, knee instability or post-injury anterior laxity concerns.

It may not be suitable when acute pain, swelling, guarding or limited knee flexion prevents reliable testing.

When to Use This Test

Use the test when ACL involvement is suspected and the client can tolerate 90 degrees of knee flexion.

When Not to Use or When to Be Cautious

Use caution with suspected fracture, severe pain, locked knee, high swelling, inability to flex the knee, acute haemarthrosis or significant guarding.

Equipment Required

Treatment table
Pain scale
Measurz for recording
Optional comparison side notes
Optional video or referral notes

Step-by-Step Protocol / Practice

Setup

Position the client supine.

Client position

Flex the hip to approximately 45 degrees and the knee to approximately 90 degrees. The foot remains flat and relaxed.

Examiner position

Sit on or stabilise the client’s foot to prevent movement.

Hand placement

Place both hands around the proximal tibia, with thumbs near the tibial plateau.

Stabilisation

Ensure the hamstrings are relaxed. Compare with the opposite side.

Movement or force direction

Apply an anterior translation force to the tibia relative to the femur.

Instructions

Ask the client to relax and report pain, apprehension or familiar instability.

Positive finding

A positive finding may include increased anterior tibial translation, soft or absent end-feel, apprehension or familiar instability compared with the other side.

Negative finding

A negative finding is no meaningful side-to-side increase in anterior translation and a firm end-feel.

Stopping criteria

Stop if pain escalates, guarding prevents assessment or the test cannot be performed safely.

Safety notes

Avoid jerky force. Ensure hamstring guarding is minimised.

Positive and Negative Test Interpretation

A positive Anterior Drawer Test may increase suspicion of ACL involvement when it matches the mechanism, swelling pattern and other ACL test findings.

A negative test does not fully exclude ACL injury, especially in acute presentations where swelling, pain or hamstring guarding may limit translation.

Interpretation is stronger when combined with Lachman, pivot shift, lever sign, swelling history, mechanism of injury and functional instability.

Sensitivity, Specificity and Diagnostic Accuracy

A 2022 systematic review and meta-analysis of acute ACL tests found diagnostic accuracy evidence for ACL tests remains limited, with Lachman, anterior drawer, pivot shift and lever sign all affected by study quality and clinical context.  

A separate 2022 systematic review and meta-analysis reported that anterior drawer, Lachman, lever sign and pivot shift values were broadly comparable in some analyses, but highlighted that diagnostic accuracy differs by presentation and that previous estimates may be overestimated.  

Because values vary by acute versus chronic presentation and whether the exam is under anaesthesia, apply exact sensitivity and specificity values only when the source population matches the client context.

Reliability and Validity

Reliability depends on knee position, hamstring relaxation, examiner force, side comparison and end-feel interpretation.

Validity is strongest when the test is part of a cluster and interpreted with other ACL findings rather than used alone.

Common Errors and Limitations

Common errors include testing with active hamstring guarding, not stabilising the foot, failing to compare sides, pulling too distally, using sudden force and interpreting pain alone as ACL laxity.

Limitations include acute swelling, guarding, partial tears, concomitant injuries and reduced rotational information compared with pivot shift assessment.

Practical Applications

Use the Anterior Drawer Test to support ACL assessment, document anterior translation and guide further testing or referral decisions.

It is most useful when paired with Lachman, pivot shift, lever sign, effusion assessment and functional progression testing.

How to Record This in Measurz

Record test name, side tested, result as positive, negative, unclear or unable to test, pain score, symptom location, amount of translation, end-feel, apprehension, swelling, knee angle, comparison side, confidence in result and reason for stopping.

Related Tests / Internal Links

Lachman Test
Lever Sign Test
Pivot Shift Test
Slocum Test
Anterior Drawer Test of the Ankle
Sweep Test
Single-Leg Hop Tests

FAQs

What does a positive Anterior Drawer Test of the Knee mean?

It may suggest increased anterior tibial translation and possible ACL involvement when consistent with the broader assessment.

Does it diagnose an ACL tear?

No. It supports clinical reasoning but does not confirm ACL rupture on its own.

Why can the test be difficult after acute injury?

Pain, swelling and hamstring guarding can reduce test accuracy.

Should it be used with Lachman Test?

Yes. ACL assessment is stronger when multiple findings are considered together.

What should be recorded?

Record translation, end-feel, pain, apprehension, knee angle and side comparison.

Key Takeaways

The Anterior Drawer Test assesses anterior tibial translation.
A positive result may increase suspicion of ACL involvement.
A negative test does not fully exclude ACL injury.
Accuracy varies by timing, guarding and injury type.
Record translation, end-feel and symptoms in Measurz.

References

Tanaka, S., Inoue, Y., et al. (2022). Diagnostic accuracy of physical examination tests for suspected acute anterior cruciate ligament injury: A systematic review and meta-analysis. International Journal of Sports Physical Therapy, 17(5), 742–752.

Huang, W., et al. (2022). The diagnostic accuracy of clinical tests for anterior cruciate ligament injury: A systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 30, 3285–3295.

Benjaminse, A., Gokeler, A., & van der Schans, C. P. (2006). Clinical diagnosis of an anterior cruciate ligament rupture: A meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 36(5), 267–288.