Concept 1: The Final Diagnosis of Knee Ligament Injuries Is Based on the Specific Anatomic Defect Derived from the Abnormal Motion Limit and Joint Subluxation

The term instability has been used to describe an abnormal motion or motion limit that exists to the joint due to a ligament injury. This term has also been used to indicate symptomatic giving-way of the knee joint that occurs during activity. Giving-way may be caused by many factors including a ligament rupture, poor muscular control of the knee joint, altered neurologic function and control mechanisms, or mechanical problems such as a torn meniscus or loose body. In many cases, giving-way occurs because of multiple factors and the term instability does not precisely indicate the exact cause of the episode. Rather than a diagnosis of anterior instability, it is more appropriate to reduce the abnormality to a precise anatomic diagnosis such as ACL rupture. In addition, other ligament deficiencies, if present, should be identified.

The term laxity simply indicates looseness and may be applied to increases in joint motion or increases in ligament elongation. Therefore, the term laxity does not provide a diagnosis of a specific abnormality. The knee has a normal amount of laxity (play or motion) required for function. An abnormal amount of laxity may occur as a result of a ligament disruption. Laxity may also indicate a ligament injury in which the ligament has an increase in length or elongation during loading. The finding of abnormal laxity represents a clinical sign that does not provide a precise diagnosis. Instead, the specific anatomic defect of the ruptured ACL and associated injured ligaments or capsular structures should be recorded as the diagnosis. The goal of a comprehensive knee examination is to detect an increase in the amount of motion (translation or rotation) or an abnormal position (subluxation) to determine the specific anatomic defects that are present.

Concept 2: Ligaments Have Distinct Mechanical Functions to Provide Limits to Tibiofemoral Motions and the Types of Motions That Occur between Opposing Cartilage Surfaces

Ligaments have distinct mechanical functions to provide limits to the amount of tibiofemoral motion that determines the types of motions that occur between opposing cartilage surfaces. The limits of motion are the main focus because loss of this function and the consequent subluxation are the underlying deficits in ligament-injured knees. In addition, the change in limits of motion is the primary basis of diagnosis.

The ability of ligaments to limit tibiofemoral motion provides the geometric parameters within which the neuromuscular system is able to control the position of the knee during activity. Although focus is placed on the mechanical function of the ligaments and capsular structures, the reader should be cognizant of the potentially important role of ligaments in providing sensory feedback to the neuromuscular system.^24,53 Ligaments have three properties that affect their ability to limit joint motion: location of their attachment on the bones, just-taut length, and stiffness.

Tibiofemoral motions are limited along the line that connects the ligament’s tibial and femoral attachments in the direction that loads the ligament. Ligaments are not able to limit motions perpendicular to their orientation or motions that cause them to become slack. Just-taut length is a determinant of joint laxity because it controls the amount of motion before the ligament begins to provide a resisting force. Because the two cruciate ligaments are required to limit anteroposterior (AP) translation, total AP translation is determined by the just-taut length of both ligaments.

Ligament stiffness controls how much additional joint movement is required after the ligament has become taut to create a force large enough for the ligament to resist the applied load. Decreased ligament stiffness produces an increase in the motion limit because a greater motion is required before the ligament can develop a sufficient restraining force.

The kinematic and biomechanical concepts required to interpret clinical tests are shown in Figure 3-1. First, the appropriate clinical test must be selected to diagnose a specific ligament structural abnormality. Diagnostic information is obtained based on understanding the primary and secondary ligament restraint system. The results of the tests must be understood and communicated in terms of the six-DOF system that determines the abnormal motion limits. The medial and lateral tibiofemoral compartments are examined separately to determine the different types of subluxation. The final diagnosis of the ligament defect must be made in precise anatomic and functional terms and according to the severity of ligament failure (partial or complete).

FIGURE 3-1 The results of clinical tests require specific biomechanical and kinematic principles for correct diagnosis of ligament defects. Ligament defects are defined by anatomic, functional, and severity categories.

(Reprinted from Noyes, F. R.; Grood, E. S: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, pp. 185–200, 1987.)

Concept 3: Although There Are Six DOF, the Manual Stress Examinations Are Designed to Test Just One or Two Limits at a Time

Although there are six DOF, the knee ligament examination is specifically designed to test just one or two motion limits at a time. Combinations of these motions (coupled motions) are particularly important to the diagnosis of knee ligament injury because they occur during many of the manual stress examinations.

Translation of a rigid body (such as the tibia) is described by the motion of an arbitrarily selected point on the body. Typically, the AP translation is described by the motion of a point located midway between the medial and the lateral margins of the tibia. If only translation motions occur, the amount of motion does not depend upon which point is chosen, that is, whether the point is at the center of the knee or at the medial or lateral joint margin. This is because all points will move along parallel paths. However, when rotation and translation motions are combined, the amount of translation does depend upon which point is used. This can be seen by considering the four cases illustrated in Figure 3-2.

FIGURE 3-2 Combined anterior translation and tibial rotation. A, The tibial plateau is shown along with the contact area on the femur, indicated by the shaded regions. The tibia is in a reduced position. B, Anterior tibial translation of 10 mm. The amount of translation, shown by the vertical bars, is the same at the medial and lateral joint margins as it is at the center of the joint. C, 15° internal rotation about the joint center. Tibial contact is anterior on the lateral plateau and posterior on the medial plateau. The bars show the amount and direction of its translation at the medial-lateral joint lines. The amount of translation is approximately 10 mm in an average knee 80 mm wide. There is no translation at the center of the joint where the rotation axis is located. D, Combined tibial translation and rotation. A 10-mm anterior translation is combined with a 15° internal rotation at the medial aspect of the tibia. The center of the tibia translates anteriorly 10 mm, and the lateral joint margin translates 20 mm anteriorly.

(A–D, Redrawn from Grood, E. S.; Noyes, F. R.: Diagnosis of knee ligament injuries: biomechanical precepts. In Feagin, J. [ed.]: The Crucial Ligaments. New York: Churchill Livingstone, 1988, pp. 245–260.)

Figure 3-2B shows an anterior translation of 10 mm without associated tibial rotation. All points move anteriorly by the same amount. Figure 3-2C shows an internal rotation of 15° about an axis located midway between the spines of the intercondylar eminence. The point on the rotation axis is stationary while the lateral joint margin (edge) moves anteriorly and the medial margin posteriorly (see Fig. 3-2D). The amount of anterior and posterior motion of the points at the joint margin depends upon the amount of rotation and how far away the points are from the rotation axis (center of rotation). This illustrates that when translation is measured in the presence of a concurrent rotation, it is important to know at what point the translation was measured.

Concept 4: Ultimately, the Clinical Examination Must Be Analyzed by a Six-DOF System to Detect Abnormalities

The clinician who understands all of the possible motions in the knee joint that are normally limited by the knee ligaments will be able to perform manual stress tests and correctly determine the specific abnormality that is present. However, a diagnosis cannot be based solely on the abnormal motions detected. The diagnosis also requires knowledge of the biomechanical data regarding which ligaments limit each of the possible motions in the knee joint.

The field of science that describes the motions between objects is known as kinematics. A fundamental aspect of this field is the recognition that six possible motions may occur in three dimensions. Each of the six motions is discrete and separate from the other five motions. The six motions are referred to as degrees of freedom (DOF). The three rotational DOF in the knee joint are shown in Figure 3-3. Each rotation occurs about one axis: flexion-extension, internal-external, and abduction-adduction.

FIGURE 3-3 The three joint rotations in the knee joint. Flexion-extension occurs about the medially and laterally oriented axis in the femur. Internal and external tibial rotation occurs about an axis parallel to the shaft of the tibia. Abduction occurs about a third axis parallel to the femoral sagittal plane and also through the tibial transverse plane.

(Redrawn from Noyes, F. R.; Grood, E. S.: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, 1987; pp. 185–200.)

The flexion-extension axis is located in the femur and oriented in a pure medial-lateral direction perpendicular to the femoral sagittal plane. Rotation of the tibia about this axis does not have associated internal-external rotation or abduction-adduction motions.¹⁷ Because these motions occur during flexion, the flexion-extension axis shown in Figure 3-3 does not correspond to the functional flexion axis. The functional flexion axis is skewed in the knee and changes its orientation as the knee is flexed. This skewed orientation accounts for the combined motions of flexion, abduction, and tibial rotation.

The internal-external tibial rotation axis is located in the tibia, parallel to the tibial shaft and perpendicular to the tibial transverse plane. Rotations about this axis are pure internal and external tibial rotation motions without any associated abduction-adduction or flexion-extension.

The abduction-adduction rotation axis is more difficult to visualize because it is not located in either bone and its orientation can change relative to both. This axis is always parallel to the femoral sagittal plane. When the knee is flexed, the orientation of the abduction axis changes relative to the femur as it rotates in the sagittal plane. The abduction axis is perpendicular to the tibial rotation axis and parallel to the tibial transverse plane.

There are three linear DOF in the knee joint referred to as translations. One simple approach to describing translations is to visualize relative sliding between the bones along each of the three rotational axes (Fig. 3-4). The sliding motion along the flexion-extension axis is the medial-lateral translation between the tibia and the femur. The sliding motion along the tibial rotation axis results in joint compression and distraction translation. Sliding motions along the abduction-adduction rotation axis produce AP translations. These are also commonly known as drawer motions.

FIGURE 3-4 The three translations of the knee joint are motions of a point on the tibia parallel to each of the three axes. The point of the tibia used is located midway between the spines of the tibial plateau and is indicated by the arrow originating from the center point of the femur. Medial-lateral translation is motion of the point parallel to the flexion-extension axis. Anteroposterior (AP) translation is motion of the tibial point parallel to the abduction axis, and compression-distraction translation is motion of the point along the internal and external rotation axis.

(Redrawn from Noyes, F. R.; Grood, E. S.: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, 1987; pp. 185–200.)

Therefore, six possible motions can occur in the knee, three rotations and three translations. Three axes are required to explain these six motions, one fixed in each bone, as shown in Figure 3-4. Each axis represents two DOF, one a rotation occurring about the axis and the other a translation.

The purpose of the examination is to determine the specific increase in motion (amount and direction) of each clinically relevant DOF. In many cases, coupled motions occur in the knee joint, such as anterior translation combined with internal tibial rotation during Lachman testing, which is further increased on pivot shift testing. First, the examiner must understand the effect that ligament defects have upon each of these motions, because one or both may be increased. Second, both the amount of increased motion and the resulting subluxation of the tibial plateaus depend on the position of the knee joint, which is defined in terms of six DOF. Third, after a ligament is ruptured, an abnormal position usually is present in the axis of internal-external tibial rotation. This may be detected on examination and is helpful in diagnosing the ligament defect.

In order to understand the results of the clinical examination, a distinction must be made between abnormalities in joint motion and abnormalities in joint position (subluxation) that occur at the limit of the test. An abnormality in one or more motion limits can cause a subluxation of the knee joint. The subluxation depends on the direction and magnitude of the loads applied. Clinical tests are used to detect the motion limit and the final abnormal joint position. The examination usually detects a subluxation and not a complete knee dislocation, in which contact of the articulating surfaces of both tibiofemoral compartments is lost.

Concept 5: Together, the Ligaments and Joint Geometry Provide Two Limits (Opposite Directions) for Each DOF

Together, the ligaments and joint geometry provide two limits (opposite directions) for each DOF. All together, there are 12 possible limits of motion of the knee (Table 3-1). Injury to the structures that limit each motion increases joint laxity. The position of the joint at the final limits of motions (reflecting the ligament attachment sites) provides the information required for diagnosis. From a diagnostic standpoint, it would be ideal if each of the 12 limits of motion were controlled by a single ligamentous structure. Differential diagnosis could then be performed by evaluating each of the 12 limits separately. Clearly, this ideal situation does not exist. The ligaments, capsular structures, and joint geometry all work together and each contributes to limiting more than one motion. Thus, the problem of diagnosing knee injuries reduces to determining how to apply individual or combination motions to lengthen primarily a single ligament or capsular structure so that structure can be evaluated independently.

TABLE 3-1 Twelve Limits of Knee Joint Motion

* Menisci, joint compressive effects after injury to primary restraint.

The ability to isolate each structure is the key to differential diagnosis of individual ligament injuries. The isolation of a structure is accomplished by placing the knee at the proper joint position (specifically, knee flexion angle and tibial rotation position) before the clinical stress test is performed. For example, the abduction (valgus) stress test is performed both in full extension and at 20° to 30° of flexion. In the flexed position, the posterior capsule becomes slack, which allows the examiner to primarily load the MCL and midmedial capsule. The evaluation of ACL function is performed at 20° of knee flexion⁵⁶ as opposed to the 90° position²⁹ commonly used many years ago because the 20° position more often results in increased anterior subluxation because secondary restraints are more slack and less able to block this motion. Diagnosis of an injury to a specific ligament is performed at a joint position at which other structures are the most lax and least able to block the abnormal subluxation from the ligament injury. The lax secondary restraints allow an increase in joint motion before they become taut and resist further joint motion. Thus, isolating a ligament so its integrity may be individually tested requires placing the knee in a position in which other supporting structures are slack.

Another example of the importance of selecting the joint position for clinical tests is the diagnosis of PCL injury. Figure 3-5 shows the amount of increased posterior tibial translation that occurs when the PCL is removed.^10,16,17 The increase in posterior translation is two to three times greater at 90° of flexion than at 20° of flexion. This phenomenon is easily understood using a bumper model analogy in which the amount of joint motion after a ligament is injured depends on the role and function of the remaining ligaments that must ultimately limit the joint motion (Fig. 3-6). Thus, the increase in joint motion that occurs when a ligament is injured reflects the amount of additional joint motion required before the remaining intact ligaments become stretched and are able to limit further motion.

FIGURE 3-5 A, The increase in posterior translation is shown in 22 cadaveric knees under 100 N posterior force applied to the proximal tibia. The posterior force did not constrain the other degrees of freedom. The increase in posterior translation was 5.7 ± 0.4 mm at 30° flexion (B) and 12.1 ± 0.46 at 90° flexion (C). The data show that the majority of knees (15 of 22) that had the posterior cruciate ligament (PCL) sectioned alone had greater than 10 mm of increased posterior translation. This demonstrates the variability in knees in the physiologic tightness or slackness of the secondary restraints in resisting posterior tibial translation after PCL disruption.

(A–C, From J. T. Shearn and F. R. Noyes, unpublished data.)

FIGURE 3-6 Effect of knee flexion on posterior bumpers. After loss of the PCL and as the knee is flexed, the posterior capsular structures become slack, allowing increased tibial displacement before they limit posterior translation. This is shown in the model by the more posterior position of the posteromedial and posterolateral bumpers at 90° compared with 30° of knee flexion. ACL, anterior cruciate ligament; AL, anterolateral restraints; CAP, capsule; MCL, medial collateral ligament; PL, posterolateral restraints; PM, posteromedial restraints.

(Redrawn from Grood, E. S.; Noyes, F. R.: Diagnosis of knee ligament injuries: biomechanical precepts. In Feagin, J. [ed.]: The Crucial Ligaments. New York: Churchill Livingstone, 1988; pp. 245–260.)

Figure 3-7 illustrates the limits to internal tibial rotation in the knee joint.¹⁶ At 30° flexion (see Fig. 3-7A), the limits to internal rotation are provided by posteromedial structures, lateral structures, and the ACL all working together. Sectioning either the ACL or the lateral structures produces a small increase in internal rotation. When both of these structures are cut together, a larger increase in internal rotation occurs. The further limit to internal rotation is the FCL, based upon its anatomy.

FIGURE 3-7 Limits to internal rotation. A, At 30° of flexion, internal rotation is limited by the ACL centrally and the lateral restraints. These structures limit anterior translation. In addition, the posterior translation of the medial plateau is limited by the posteromedial (PM) restraints. B, At 10° of flexion, the posterior bumpers move in closer toward the PCL owing to a reduction in the slackness present in the posterior capsule. In addition, the ACL bumper moves posteriorly as a result of tightening the ACL/PCL complex. Because of this, internal rotation of the tibia is now limited by the ACL centrally and the PM restraints alone. The tibia can no longer rotate far enough to engage the lateral restraints. C, At 80° flexion, the posterior bumpers move further posterior, reflecting the increased slackness in the posterior capsule. In addition, the distance between the ACL and the PCL bumpers has increased slightly to reflect the increased laxity of these structures. The medial and lateral structures are now moved posteriorly owing to tightening of the extra-articular restraints with knee flexion. Internal rotation is now limited by the lateral and PM restraints without direct involvement with the ACL.

(A–C, Redrawn from Grood, E. S.; Noyes, F. R.: Diagnosis of knee ligament injuries: biomechanical precepts. In Feagin, J. [ed.]: The Crucial Ligaments. New York: Churchill Livingstone, 1988; pp. 245–260.)

The ACL dominates at flexion angles less than 30°, whereas the lateral structures dominate at flexion angles greater than 30°. This can be explained by considering the changes that occur in ligament slackness with flexion and extension. As the knee is extended past 20°, the amount of AP translation decreases owing to reduction in the combined slackness of both cruciate ligaments. This brings these bumpers closer together. The posteromedial capsule (PMC) also tightens, moving its bumper anteriorly. This combination (see Fig. 3-7B) results in a decreased role of the anterolateral structures because the tibia can no longer rotate to the point where they become taut.

With flexion beyond 30°, the lateral structures become progressively tighter and the posteromedial structures become progressively slack. This combination causes internal rotation to be limited first by the extra-articular restraints. This is consistent with laboratory results that showed that sectioning the ACL alone does not increase internal rotation when the knee is flexed between 40° and 80°.

Figure 3-8 illustrates the limits to external rotation. At 30° flexion, external rotation is limited only by the extra-articular restraints. On the lateral side, this includes all of the posterolateral structures, which act as a unit. Large increases in rotation do not occur until all structures are cut. At 90° flexion, the posterior capsule is slack and the PCL blocks significant increases in external rotation when the posterolateral structures are sectioned. In laboratory studies, external rotation increases an average of only 5.3° ± 2.6° when all of the posterolateral structures are sectioned and the PCL is intact. When the PCL is also sectioned, a large additional increase in external rotation occurs, ranging from 15° to 20°.

FIGURE 3-8 Limits to external rotation. A, At 30° flexion, the external rotation of the tibia is limited by the bumpers, which stop anterior translation of the medial plateau and posterior translation of the lateral plateau. Owing to the position of the structures, there is no direct involvement of either the ACL or the PCL in limiting external rotation. B, At 90° flexion, the posterior bumpers are moved posterior, reflecting the increased slack in the posterior capsule. Because of this, the PCL is nearly taut at the limit of external rotation. After removing the PL restraints, only a small increase in external rotation occurs at this flexion angle.

(A and B, Redrawn from Grood, E. S.; Noyes, F. R.: Diagnosis of knee ligament injuries: biomechanical precepts. In Feagin, J. [ed.]: The Crucial Ligaments. New York: Churchill Livingstone, 1988; pp. 245–260.)

An example of the changes in motion limits in ACL ruptures is shown in Figure 3-9. In cadaver knees, cutting the ACL causes an abnormal increase in both anterior tibial translation and internal tibial rotation.⁸ The increase in anterior tibial translation is the primary abnormality, because it increases 100% while there is a small increase in internal rotation (approximately 15%). Cutting the ACL alone produced a small but significant increase in internal rotation, greatest at 0° and 15° (Fig. 3-10). Subsequently, sectioning the ITB and lateral capsule produced statistically significant increases at 30° and greater.

FIGURE 3-9 Anterior translation versus tibial rotation is shown during the Lachman-type anterior loading test at 15° of knee flexion. The amount of anterior tibial translation is shown vertically and the position of tibial rotation is shown horizontally.

(From Noyes, F. R.; Grood, E. S.: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, 1987; pp. 185–200.)

FIGURE 3-10 Limits of internal rotation with 5 Nm moment for intact specimens and with the ACL, ACL/ALS, ACL/ALS/FCL, and ALL structures (ACL/ALS/FCL/PLS) cut. Increases in internal rotation with the ACL cut are all statistically significant, but these increases are of such small magnitude that they are clinically unimportant. With ACL/ALS sectioning, increases in internal rotation are statistically significant at 30° of flexion and above. Statistically significant increases are found at 15° of flexion and above in the ACL/ALS/FCL cut state, and at all flexion angles of the ALL cut state. The effect of the PLS on restraining internal rotation in the extended knee can be seen by comparing the ACL/ALS/FCL curve and the ALL cut curve. The difference between these curves reflects sectioning the PLS. The largest differences are found at 15° and 30° of flexion. ALS, the iliotibial band and midlateral capsule; FCL, fibular collateral ligament; PLS, popliteus tendon and posterolateral capsule.

(Modified from Wroble, R. R.; Grood, E. S.; Cummings, J. S.; et al.: The role of the lateral extra-articular restraints in the anterior cruciate ligament–deficient knee. Am J Sports Med 21:257–262; discussion 263, 1993.)

Coupled motions (anterior tibial translation, internal tibial rotation) occur in cadaver knees after sectioning the ACL and lateral extra-articular structures. Coupled motions can be caused by factors intrinsic to the knee or by the manner in which the clinical test is performed. For instance, the amount of internal tibial rotation elicited depends on the amount of rotation the clinician applies during the examination. This is why it is difficult to obtain reproducible results with the Lachman and other clinical tests. The KT-2000 provides an objective measurement of the amount of tibial translation measured at the center of the tibia. However, the millimeters produced by this device do not include the added millimeters of translation at the lateral tibiofemoral joint with added internal tibial rotation, such as that produced during the pivot shift test.

The amount of anterior tibial translation induced during anterior drawer testing is dependent upon the amount of internal or external tibial rotation applied at the beginning of the test (Fig. 3-11). The instrumented knee joint is shown for measuring rotations and translation motions during the clinical examination in Figure 3-12. This is because rotation tightens the extra-articular secondary restraints. The greatest amount of anterior or posterior tibial translation will be produced when the tibial is not forcibly rotated internally or externally, tightening extra-articular structures, during the clinical test. If the tibia is internally or externally rotated prior to the start of testing, the amount of tibial translation elicited will be smaller. Thus, the clinician controls the amount of translation both by the initial rotational position of the tibia and by the amount of rotation imposed during the test. There is considerable variation in examination techniques of clinicians that makes all of the clinical tests highly subjective and qualitative, as is discussed.

FIGURE 3-11 The amount of AP translation depends on the rotational position of the tibia at the beginning of the anterior drawer test.

(From Noyes, F. R.; Grood, E. S.: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, 1987; pp. 185–200.)

FIGURE 3-12 The six-degrees-of-freedom electrogoniometer provides the clinician with immediate feedback on the motions induced during the manual drawer tests.

(From Noyes, F. R.; Grood, E. S: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago, American Academy of Orthopaedic Surgeons, 1987; pp. 185–200.)

The pivot shift¹² and flexion-rotation⁴⁴ drawer (Fig. 3-13) tests involve a complex set of tibial rotations and AP translations. At the beginning of the flexion-rotation drawer test, the lower extremity is simply supported against gravity (Fig. 3-14, position A). After ligament sectioning, both anterior tibial translation and internal rotation increase as the femur drops back and externally rotates into a subluxated position.⁴² This position is accentuated as the tibia is lifted anteriorly (see Fig. 3-14, position B). At approximately 30° of flexion, the tibia is pushed posteriorly, reducing the tibia into a normal relationship with the femur (see Fig. 3-14, position C). This is the limit of posterior tibial translation resisted primarily by the PCL. From position C to position A, the knee is extended to produce the subluxated position again.

FIGURE 3-13 A, Flexion-rotation drawer test, subluxated position. With the leg held in neutral rotation, the weight of the thigh causes the femur to drop back posteriorly and rotate externally, producing anterior subluxation of the lateral tibial plateau. B, Flexion-rotation drawer test, reduced position. Gentle flexion and a downward push on the leg reduces the subluxation. This test allows the coupled motion of anterior translation–internal rotation to produce anterior subluxation of the lateral tibial condyle.

(A and B, Redrawn from Noyes, F. R.; Bassett, R. W.; Grood, E. S.; et al.: Arthroscopy in acute traumatic hemarthrosis of the knee. J Bone Joint Surg Am 62:687–695, 1980.)

FIGURE 3-14 The knee motions during the flexion-rotation drawer and pivot shift tests are shown for tibial translation and rotation during knee flexion. The clinical test is shown for the normal knee (open circle) and after ligament sectioning (dotted circle). The ligaments sectioned were the ACL, iliotibial band (ITB), and lateral capsule. Position A equals the starting position of the test, B is the maximum subluxated position, and C indicates the reduced position. The pivot shift test involves the examiner applying a larger anterior translation load that increases the motion limits during the test.

(Redrawn from Noyes, F. R.; Grood, E. S.; Suntay, W. J.: Three-dimensional motion analysis of clinical stress tests for anterior knee subluxations. Acta Orthop Scand 60:308–318, 1989.)

The rotational component of the test can be purposely accentuated by the examiner inducing a rolling motion of the femur. One advantage of the flexion-rotation drawer test is that it is not necessary to produce joint compression or add a lateral abduction force required in the pivot shift test. The rolling motion avoids the sometimes painful “thud/clunk” phenomenon induced in the pivot shift test. A finger may also be placed along the anterior aspect of the lateral and medial plateau and the tibiofemoral step-off palpated to provide a qualitative estimate of the millimeters of anterior tibial subluxation. The examiner can easily visualize the translation and rotation motions. Translation is observed by watching the forward motion of the tibial plateaus. Rotation is observed by watching the patella rotate externally with the femur in the subluxated position and internally in the reduced position.

The pivot shift and flexion-rotation drawer tests are graded only in qualitative terms because it is not possible to determine accurately the actual amount of internal tibial rotation or anterior translation elicited. A fully positive pivot shift test (grade III) indicates a gross subluxation of the lateral tibiofemoral articulation along with an increased anterior displacement of the medial tibial plateau (Table 3-2). The amount of anterior subluxation elicited is indicative of rupture to the ACL and laxity to the secondary extra-articular restraints. The lateral tibial plateau demonstrates the greater subluxation in a positive pivot shift test, indicating that the lateral restraints (ITB, lateral capsule) are not functionally tight. This does not mean that these restraints are injured because a physiologic slackness of the ITB tibiofemoral attachments is normal at the knee flexion position used in this test. These attachments are tightest at knee flexion angles of 45° and higher. Therefore, the majority of knees with an isolated ACL tear will have a positive pivot shift phenomenon.

In knees with a grade III pivot shift test, the amount of anterior tibial subluxation is so great that the posterior margin of the lateral tibial plateau impinges against the lateral femoral condyle and blocks further knee flexion during the test. The examiner must add both a maximal anterior force and an internal tibial rotation force to determine whether the maximum subluxation position can be reached. In revision ACL reconstructions, a combined intra-articular graft and extra-articular ITB surgical approach is often considered, as is discussed.³⁴

In a small percentage of knees with ACL ruptures, the classic “thud” or “clunk” will not be elicited during the pivot shift test. An experienced examiner will detect an increased slipping sensation in the knee (grade I), which indicates that the extra-articular secondary restraints are physiologically “tight,” limiting the amount of anterior tibial subluxation or that a partial ACL tear exists.

Concept 6: Rotatory Subluxations Are Characterized by the Separate Compartment Translations That Occur to the Medial and Lateral Tibial Plateaus during the Clinical Test

A simple concept may assist in explaining the abnormal motions that occur after ACL rupture: rotatory subluxations can be classified according to the amount of anterior and posterior translation of each tibiofemoral compartment. Figure 3-15A shows a Lachman test performed on a knee in which the combined motions of anterior tibial translation and internal tibial rotation occur about a medially located rotation axis. In this example, only planar motion occurs; the ACL rupture doubles the amount of anterior tibial translation and slightly increases internal tibial rotation. The rotation axis shifts medially. The ratio of tibial translation to degrees of internal tibial rotation determines how far medially the axis of rotation shifts.

FIGURE 3-15 A, A simplification of the abnormal knee motions after ACL sectioning. An understanding of rotatory subluxations requires specifying changes in (1) position of the vertical axis of rotation and (2) displacement of the medial and lateral tibiofemoral compartments. The normal or subluxated position of the joint is determined by the degrees of rotation and the amount of translation. In the figure, an anterior pull is applied to the knee, which has an intact ACL. There is a normal anterior translation (d₁) and internal tibial rotation (a₁) about the center of rotation (CR). After ACL sectioning, there is a 100% increase in tibial translation (d₂) along with only a slight (15%) increase in internal tibial rotation (a₂). This shifts the axis of rotation medially and produces the subluxation of the lateral compartment and medial compartment, as demonstrated. Loss of the medial extra-articular restraints would result in a further medial shift in the axis of rotation. This would increase the anterior subluxation of the medial tibial plateau and lateral tibial plateau. B, The amount of anterior tibial translation is shown for the medial and lateral tibiofemoral compartments during the flexion-rotation drawer test in a cadaveric knee preparation using the instrumented spatial linkage and digitization of the tibia and femoral joint geometry.

(A, Redrawn from Noyes, F. R.; Grood, E. S.: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, 1987; pp. 185–200; B, redrawn from Noyes, F. R.; Grood, E. S.; Suntay, W. J.: Three-dimensional motion analysis of clinical stress tests for anterior knee subluxations. Acta Orthop Scand 60:308–318, 1989.)

The abnormalities in tibial rotation and translation are easily expressed in terms of the different amounts of anterior translation that occur to the medial and lateral compartments (see Fig. 3-15B) in biomechanical tests. During the clinical tests, the clinician may qualitatively palpate and observe the anterior or posterior translation of each tibial plateau. The AP translation of each plateau is characterized instead of defining the individual components of translation, rotation, and rotation axis location that all lead to the anterior subluxation. The combined effect of the rotation and translation determines the translation of the medial and lateral tibiofemoral compartments.

The type of rotatory subluxations that occur depends on both the ligament injury and the knee flexion position. The subluxations of the medial and lateral compartment are usually recorded at two knee flexion positions, such as 20° and 90°. To be described later is the dial test for posterolateral injuries, in which the examiner determines whether increases in external tibial rotation reflect anteromedial or posterolateral tibial subluxations. It should be noted that rotatory subluxations are historically based on increases in tibial internal or external rotation and in only a few studies have the actual medial and lateral tibial subluxations in an AP direction been determined.^16,45 There are complex rotatory subluxations involving increases in translation, but in opposite directions of both the medial and the lateral compartments with combined medial and lateral ligament injuries.

Concept 7: The Damage to Each Ligament and Capsular Structure Is Diagnosed Using Tests in Which the Primary and Secondary Ligament Restraints Have Been Experimentally Determined

Tears to the ACL and injury to the extra-articular ligamentous and capsular structures may be diagnosed using the Lachman, pivot shift, and flexion-rotation drawer tests. These tests provide the basic signs that allow the clinician to determine which structures are injured based on abnormal motion limits and resultant joint subluxations. The tests are performed in knee flexion positions in which the secondary restraints are unable to resist abnormal motions so that maximum displacement (subluxation) of the joint is produced. Table 3-3 provides a general summary of the primary and secondary restraints for the major tests used in the clinical examination. Later in this chapter, the specific restraining function of the ligaments is discussed in detail.

The qualitative grading of the pivot shift phenomenon is illustrated in Figure 3-16 to explain how ligament structures resist combined tibiofemoral motions. The cruciate ligaments are represented by a set of central bumpers that limit the amount of AP translation. There are also medial and lateral sets of bumpers that resist medial and lateral tibiofemoral compartment translations. For the medial and lateral bumpers, different ligament structures commonly work together as systems to provide the resistance. The bumpers represent not the anatomic position of the ligament structures, but rather a visual schematic to show the final restraints to tibial motion, summarizing the effect of the ligaments, menisci, and capsular structures. The tension-retraining effect of the ligaments is replaced by an opposite mechanism, a compressive bumper.

FIGURE 3-16 A, Grade I pivot shift. There is anterior translation of the lateral compartment that is resisted by the ACL. There will be a slight increase in anterior translation with a partial ACL tear. Many knees with physiologic ACL laxity have a normal grade I pivot shift. Rarely, a knee will have excessively tight lateral structures that also limit anterior translation and, even with an ACL tear, there is only a grade I pivot shift phenomena. The lower line represents the posterior limit of tibial displacement. The upper line represents the anterior limit of tibial excursion resisted by the appropriate ligament bumpers. The millimeters of increased translation to the lateral-central-medial compartments is shown, reflecting the coupled motions of anterior translation and internal rotation. B, Grade II pivot shift. This is the usual finding after ACL disruption. The lateral extra-articular structures are physiologically lax between 0° and 45° of knee flexion, allowing for increased anterior translation of the lateral tibiofemoral compartment. The lesion may also involve injury to the lateral structures (ITB, lateral capsule). C, Grade III pivot shift. There is associated laxity of the lateral extra-articular restraints. There may also be associated laxity of the medial ligament structures. This allows for a gross subluxation of both the medial and the lateral tibial plateaus easily palpable during the pivot shift test, as well as the flexion-rotation drawer and Lachman tests.

(A–C, Redrawn from Noyes, F. R.; Grood, E. S.: Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. In Griffin, P. [ed.]: AAOS Instructional Course Lectures, Vol. XXXVI. Chicago: American Academy of Orthopaedic Surgeons, 1987; pp. 185–200.)

In diagnosing abnormal knee motion limits, the Lachman test involves primarily tibial translation without significant tibial rotation, testing the central bumper represented by the ACL. A bumper model representation of a partial ACL tear or an ACL-deficient knee with tight medial and lateral extra-articular restraints that limit the amount of anterior tibial translation is shown in Figure 3-16A. The amount of central and lateral tibial translation is only slightly increased. The bumper model illustrates how the anterior restraints limit motion during the flexion-rotation drawer test, which allows the maximal anterior excursion of the medial and lateral tibiofemoral compartments. In this knee, the pivot shift test is qualitatively listed as a grade I.

The most common type of anterior subluxation that occurs after an ACL rupture is shown in Figure 3-16B. The center of rotation shifts medially outside the knee joint, with a resultant increase in translation to both the medial and the lateral compartments, with the anterior subluxation of the lateral compartment being the greatest. The anatomic structures include the ACL and the lateral extra-articular restraints. In this knee, the pivot shift test is qualitatively listed as a grade II.

A knee with gross anterior subluxation is represented in Figure 3-16C. There is increased translation and subluxation to both the medial and the lateral compartments and the rotation axis shifts even further medially outside the knee joint. The pivot shift test is listed as a grade III, indicative of gross subluxation with impingement of the posterior aspect of the tibia against the femoral condyle. Partial damage to the medial ligamentous structures may be present.