Anterior Drawer Test: What Physical Therapists Should Know About ACL Screening

The anterior drawer test is a commonly used orthopedic assessment tool to evaluate the integrity of the anterior cruciate ligament (ACL) in the knee. Understanding how and when to use this test can assist physical therapists in forming accurate clinical impressions, guiding appropriate interventions, and determining referrals when needed.

What Is the Anterior Drawer Test?

The anterior drawer test assesses the knee's stability by measuring the tibia's anterior translation relative to the femur. A positive test may indicate a sprain or tear of the ACL, particularly in the middle or posterior bundle fibers. It is most useful in subacute or chronic injury presentations, as acute swelling and guarding can limit reliability during early-stage evaluation.

Clinical Purpose

Physical therapists use the anterior drawer test as part of a broader knee assessment. The test provides insight into potential ACL compromise, often in patients presenting with instability, a history of trauma, or giving-way episodes. While it should not be used in isolation, it remains a fundamental component of orthopedic screening when ACL injury is suspected.

Testing Procedure

To perform the anterior drawer test:

1. Position the patient in a supine position with the knee flexed to 90 degrees and the hip flexed to approximately 45 degrees.

2. Stabilize the foot by sitting on it or placing it against the table.

3. Grasp the proximal tibia with both hands just below the joint line.

4. Apply an anterior force to the tibia while observing for anterior translation and assessing the quality of the end feel.

A soft or absent endpoint, along with increased anterior displacement compared to the uninvolved limb, suggests a positive test.

Reliability and Limitations

Its accuracy tends to be higher in chronic settings compared to acute evaluations, where hamstring guarding can limit anterior tibial translation¹.

It is most reliable when used in conjunction with other ACL-specific tests such as the Lachman and pivot shift tests. While the anterior drawer test is more accessible and easier to perform, especially in outpatient settings, the Lachman test may offer higher diagnostic value due to improved sensitivity².

Interpreting Results in Context

A positive anterior drawer test alone should not dictate diagnosis or intervention. Therapists should consider patient history, mechanism of injury, and concurrent findings such as swelling, joint line tenderness, or meniscal signs. When ACL rupture is suspected, referral for imaging or orthopedic consultation may be appropriate.

The anterior drawer test remains a standard orthopedic tool in the assessment of ACL integrity. Its value lies in its simplicity and ability to provide useful clinical information when combined with other examination techniques. For physical therapists working with athletes or patients with knee trauma, understanding this test’s role within a full orthopedic screening process is an important skill in clinical reasoning and care planning.

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References

1. Van Eck, C. F., Schkrohowsky, J. G., Working, Z. M., Irrgang, J. J., & Fu, F. H. (2013). Prospective analysis of the diagnostic value of physical examination after ACL injury. The American Journal of Sports Medicine, 41(9), 2047–2052. https://journals.sagepub.com/doi/10.1177/0363546513490652 ↩

2. Mulligan, E. P., Harwell, J. L., & Robertson, W. J. (2011). Reliability and diagnostic accuracy of the Lachman test performed in a prone position. The Journal of Athletic Training, 46(4), 386–392. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418131/ ↩