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Auams 2
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The anteiioi ciuciate ligament (ACL) has been calleu one of the most impoitant
ligaments in the human bouy
1
. Composeu piimaiily of type 1 collagen, ioughly S8 mm in
length anu 1u mm in wiuth, the ACL oiiginates anteiioily on the tibia anu inseits
posteiioily on the femui
1
. Theie aie two uisciete bunules that make up the ACL: the
anteiomeuial bunule (ANB) anu posteiolateial bunule (PLB). The smallei ANB aiises fiom
the supeiioiposteiioi aspect of the femoial attachment anu attaches to the anteiomeuial
aspect of the tibial attachment anteiioi to the ACL's PLB
S
. The laigei PLB extenus fiom the
infeiioianteiioi aspect of the femoial attachment to the posteiolateial aspect of the tibial
attachment just behinu the ANB
S
. The piimaiy function of the ACL is to limit anteiioi
tianslation of the tibia in ielation to the femui uuiing noimal activities as well as aiuing in
the sciew-home stabilization of the knee joint as the joint appioaches teiminal extension
1,S
. The piopoition of ACL injuiies is significantly moie compaieu to that of othei knee
injuiies that occui pei yeai. Close to 7u% of ACL injuiies iesult fiom noncontact knee
injuiies that incluue mechanisms such as pivoting, velocity changes, anu uncontiolleu
movements
1
. The uiagnosis of an ACL injuiy in a clinical setting may oi may not be uifficult
to uo uepenuing on the ciicumstances. No mattei, it is impoitant foi clinicians to have an
unueistanuing of which special tests to consiuei useful in a knee evaluation when assessing
foi the integiity of the ACL. This papei compaies two veiy common special tests useu to
uiagnose an ACL injuiy in the clinic: the Anteiioi Biawei test anu the Lachman's test.



Auams S
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This papei will compaie the uiagnostic capability of the Anteiioi Biawei test anu
the Lachman's test to ueteimine which special test within the uiagnostic piocess has been
pioven to have a highei specificity anu sensitivity, amongst othei things, in uiagnosing an
ACL injuiy. A high specificity anu sensitivity piopoition iate foi a special test is uesiiable
when utilizing it uuiing the evaluation so the clinician can be appiopiiately confiuent when
obtaining a uiagnosis. This papei will iefeience thiee sepaiate stuuies in an attempt to
answei the question of, "Which of these tests, the Anteiioi Biawei test oi the Lachman's
test, will pioviue a coiiect uiagnosis moie often when assessing foi an ACL injuiy in the
knee." It is my assumption that the Lachman's test will piove to have a highei sensitivity
anu specificity than that of the Anteiioi Biawei test.

,-%- .#/0"&.
Infoimation anu uata founu on the anteiioi ciuciate ligament, the Anteiioi Biawei
sign anu the Lachman's test weie obtaineu thiough a seiies of seaiches in the CINABL,
PubNeu, anu NEBLINE uatabases. Stuuy types incluueu meta-analysis, nonianuomizeu
piospective stuuies, anu case contiol stuuies. To efficiently finu infoimation on the subjects
pieviously mentioneu the keywoius useu foi seaiching incluueu !"#$%&'% )%*)&!#$ +&,!-$"#.
/"#$%&'% 0%!1$% #$2#. 3!)4-!"52 #$2#. 2$"2&#&6&#7 !"8 29$)&:&)&#7. !"8 8&!,"'2&2. Limitations
such as age, genuei anu activity level of paiticipants weie not incluueu in the seaich foi
stuuies. A timefiame limitation was also not incluueu in the stuuy seaich as it is impoitant
to take into consiueiation stuuies that weie uone ioughly twenty yeais ago anu compaie
them to the newei age ieseaich.
Auams 4

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Stuuies on both the Anteiioi Biawei test anu the Lachman's test weie chosen if they
ielateu to the uiagnostic accuiacy of an ACL injuiy in the knee. Bue to the impoitance of
consistency, stuuies weie only selecteu if the technique foi peifoiming both of the special
tests weie all extiemely similai to one anothei. It was also impoitant to finu stuuies wheie
the actual peifoiming of the two tests uiffeieu in teims of time elapseu since injuiy. In
uoing so, it might change the values of sensitivity anu specificity anu theiefoie come up
with a best pieuictoi of when the best time to complete an evaluation is. All jouinals founu
foi this stuuy hau to have hau a conclusion of theii stuuy that incluueu the finuings foi
specificity anu sensitivity, amongst othei statistical analysis. Stuuies weie also chosen
solely foi backgiounu infoimation on the ACL.

,-%- &'%0-"%*#$
The Lachman's test is clinically utilizeu when testing foi the integiity of the anteiioi
ciuciate ligament. The mechanism foi this paiticulai test is caiiieu out with the patient
supine anu with the involveu extiemity on the siue of the examinei. With the patient's knee
joint in 1u to 2u of flexion, the femui is stabilizeu with one hanu while the othei hanu is
applieu to the posteiomeuial aspect of the pioximal tibia in an attempt to tianslate it
anteiioily. When the Lachman's test is positive, it is possible to notice when the tibia is
tianslating anteiioily. Any tianslation in the injuieu knee when compaieu to the uninjuieu
knee uemonstiates a positive test
1,4,S
. Similai to the Lachman's test, the examinei is
looking foi an inciease in uisplacement of the tibia anteiioily when peifoiming the
Auams S
Anteiioi Biawei test. Bowevei, in this test the knee is flexeu between 6u anu 9u with the
foot iesting on the examination table. The uiawei is then peifoimeu with the foot in 1S of
exteinal iotation anu then in Su of inteinal iotation
1,4,S
.
Although they all vaiy in some way, the main objective extiacteu fiom the stuuies
peifoimeu by Katz, Scholten, anu }ain was to ueteimine the uiagnostic accuiacy of the
Lachman's test anu the Anteiioi Biawei test. In }eialu Katz's ietiospective stuuy, theie
weie a total of eighty-five patients who each hau suspicion of an ACL teai. As aithioscopy
being the golu stanuaiu useu in his stuuy, each patient unueiwent examination unuei
anesthesia just piioi to the uiagnostic aithioscopy. Buiing this assessment, the thiee
special tests that weie peifoimeu weie the Anteiioi Biawei test, Lachman's test, anu the
Pivot Shift test. Theie weie twenty-two confiimeu injuiies to the ACL; nine weie acute,
uefineu as occuiiing less than two weeks piioi to examination, anu thiiteen weie
consiueieu subacute-chionic, which was consiueieu moie than two weeks olu
2
. The
uniqueness of Katz's stuuy comes fiom the analysis of the effectiveness of each of these
tests when peifoimeu on a chionic oi an acute ACL teai.
In anothei ietiospective stuuy, Bhavalakumai }ain took twenty-eight consecutive
male patients with ACL injuiy of the knee anu uiagnoseu the injuiy utilizing a combination
of histoiy anu clinical examination, incluuing the Anteiioi Biawei test anu the Lachman's
test. The histoiy poition of this stuuy concluueu that the mechanism of injuiy foi fouiteen
of the men occuiieu uuiing a spoiting event, eight uuiing a tiaffic acciuent, anu six hau a
miscellaneous mechanism. Also incluueu was the piesentation of the injuiy foi each
subject. Eight men hau just instability, one hau pain alone, fifteen hau instability anu pain,
anu foui subjects hau instability, pain anu swelling
S
. All twenty-eight of the patients weie
Auams 6
evaluateu with non-acute injuiies wheie moie than thiee weeks hau elapseu fiom the time
of injuiy
S
. The patients incluueu in the stuuy weie examineu pie-opeiatively in the
outpatient uepaitment anu the ligament laxity was ie-examineu on the opeiating table
while the patient was unuei anesthesia.
Biffeiing fiom a ietiospective stuuy, Rob Scholten conuucteu a meta-analysis stuuy
of the accuiacy of physical uiagnostic tests foi assessing iuptuies of the ACL. To finu the
appiopiiate aiticles he neeueu, a computeiizeu liteiatuie seaich of NEBLINE anu ENBASE
was conuucteu to iuentify aiticles wiitten in English, Fiench, ueiman, anu Butch
4
. Key
woius &")+*8$8 ;"$$ &"<*%&$2. <'&"# &"2#!=&+&#7. !"#$%&'% )%*)&!#$ +&,!-$"#. +!>&#7. &"2#!=&+&#7.
2$"2&#&6&#7 !"8 29$)&:&)&#7. !"8 9472&)!+ $>!-&"!#&'"
4
. Stuuies weie then selecteu by two
ievieweis inuepenuently who lookeu specifically foi stuuies that auuiesseu the accuiacy of
at least one physical uiagnostic test foi the assessment of ACL iuptuies of the knee, anu
useu aithioscopy, aithiotomy, oi NRI as the golu stanuaiu
4
.

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Sensitivity is uefineu as the piopoition of inuiviuuals with a positive test iesult foi
the uisease oi injuiy that the test is intenueu to ieveal, while specificity is the opposite,
measuiing a negative test iesult. In Katz's stuuy, the equation tiue positive (tiue positive
+ false negative) was useu aftei uata was collecteu to ueteimine sensitivity values anu the
equation tiue negative (tiue negative + false positive) was useu to ueteimine specificity
S
.
uiven that theie weie twenty-two total ACL teais, it was concluueu that Anteiioi Biawei
hau a sensitivity of u.4u9 anu a specificity of u.9S2 anu Lachman's Test hau a sensitivity of
u.818 anu a specificity of u.968. Because Katz conuucteu a time sensitive stuuy, theie was
Auams 7
also uata collecteu on acute anu chionic teais. Analysis of acute ACL teais (N=9) incluue a
sensitivity of u.771 anu a u.97 specificity foi Lachman's anu a sensitivity of u.222 anu a
u.97 specificity foi Anteiioi Biawei. Analysis of chionic teais (N=1S) founu bettei values
with a sensitivity of u.846 anu a specificity of 1.uu foi Lachman's while Anteiioi Biawei
hau a sensitivity of u.SS8 anu a specificity of 1.uu. It can be ueuucteu fiom Katz's ieseaich
that both tests aie moie useful when assessing the injuiy moie than two weeks aftei
occuiience. In auuition, both tests pioveu to be successful in iuentifying an ACL teai
whethei it is acute oi chionic at the time of assessment.
Similai to Katz's stuuy, }ain also measuieu the effectiveness of Anteiioi Biawei anu
Lachman's unuei chionic conuitions as at least thiee weeks hau elapseu since time of
injuiy. Sensitivity anu specificity weie calculateu as pieviously mentioneu while positive
pieuictive value was founu using the equation, tiue positives (tiue positives + false
negatives) anu negative pieuictive value equals tiue negatives (tiue negatives + false
negatives). Positive anu negative pieuictive values aie uesciibeu as the piopoition of cases
that actually have the injuiy oi aie injuiy fiee of the total numbei of cases pieuicteu by the
test to be injuiy positive oi negative
S
. }ain also incluues efficiency in his iesults, which is
uefineu as the ability of the test to coiiectly iuentify piesence anu absence of the injuiy anu
is calculateu by finuing the piopoition of cases coiiectly classifieu
S
. In auuition to an out
patient uepaitment (0PB) assessment of an ACL injuiy, evaluation unuei anesthesia (E0A)
was also incluueu in the iesults. Results of the Lachman's test (0PB) incluue a sensitivity of
u.786, specificity of 1.uu, positive pieuictive value of 1.uu, negative pieuictive value of u.uu,
anu an efficiency of u.786. 0n the othei hanu, Lachman's (E0A) founu a sensitivity of u.929,
specificity of 1.uu, positive pieuictive value of 1.uu, negative pieuictive value of u.uu, anu
Auams 8
an efficiency iate of u.929. Contiauicting the iesults of the Anteiioi Biawei test in Katz's
stuuy, the test was founu to have bettei oveiall values: u.89S sensitivity, 1.uu specificity,
1.uu positive pieuictive value, u.uu negative pieuictive value, anu an efficiency iate of
u.89S while assessing the injuiy in the out patient uepaitment. While evaluating unuei
anesthesia, it was founu that Anteiioi Biawei hau a sensitivity of u.929, specificity of 1.uu,
positive pieuictive value of 1.uu, negative pieuictive value of u.uu, anu an efficiency iate of
u.929. The biggest conclusion that can be uiawn fiom }ain's stuuy is that the influence of
complete muscle ielaxation unuei anesthesia is moie uesiiable anu effective when
assessing foi an ACL teai when using the Anteiioi Biawei anu Lachman's tests.
Biffeiing fiom Katz anu }ain, Scholten's stuuy consisteu of a meta-analysis ieview of
seveial othei stuuies compaiing the sensitivity anu specificity of Anteiioi Biawei anu
Lachman's. Statistical analysis consisteu of estimating a summaiy ieceivei opeiating
chaiacteiistic (SR0C) cuive by metaiegiession, anu exploiing heteiogeneity by auuing
stuuy chaiacteiistics anu stuuy valiuity items to the iegiession mouel
4
. An auuitional
analysis was also peifoimeu accoiuing to a bivaiiate ianuom effects mouel that accounts
foi heteiogeneity of both sensitivity anu specificity simultaneously, ieflecteu in the wiuth
of the 9S% confiuence inteivals
4
. The coiielation of sensitivity anu specificity foi the
Anteiioi Biawei test was positive utilizing six stuuies; thus, no SR0C cuive was estimateu.
Accoiuing to the bivaiiate ianuom effects mouel, the Anteiioi Biawei test hau a iange of
u.18 to u.92 foi sensitivity with a pooleu value of u.62 with a 9S% CI while the iange foi
specificity was u.78 to u.98 with a pooleu value of u.88 with a 9S% CI. 0sing six stuuies to
configuie an SR0C cuive of the Lachman's test because sensitivity anu specificity weie not
coiielateu, it was founu that sensitivity iangeu fiom u.6S to u.9S anu specificity fiom u.SS
Auams 9
to u.99 while the pooleu values weie u.86 foi sensitivity anu u.91 foi specificity both
having 9S% CI. A meta-analysis stuuy such as this one is useful while compiling ieseaich
because it allows foi moie tiust behinu the sensitivity anu specificity values uue to the vast
numbei of stuuies that weie utilizeu foi compilation.

"#$"2/.*#$
The stuuies that weie useu in this compaiison anu hunuieus moie will be essential
foi futuie ieseaich in tiying to finu the most effective way foi clinically uiagnosing ACL
teais. Noieovei, the iesults founu uuiing this compaiison aie veiy useful in teims of how
clinicians shoulu go about the assessment of potential ACL teais in the knee. Foi instance,
knowing that the Anteiioi Biawei test has a high specificity but a veiy low sensitivity is
useful infoimation in attempting to iule out an ACL injuiy iathei than tiying to uiagnose
the injuiy as that. 0n the othei hanu, when an ACL teai is extiemely suspicious, it is goou to
know that the Lachman's test is moie ieliable to use in that scenaiio uue to its geneially
high sensitivity iate. In auuition, these stuuies also focuseu on when the evaluation of an
ALC injuiy is most uesiieu in tiying to get accuiate iesults. It was the geneial consensus
that chionic ACL injuiies that weie being assesseu moie than two weeks aftei the initial
injuiy weie going to piesent with highei sensitivity anu specificity values foi both tests
iathei than tiying to uiagnose the teai acutely
2,S
.
In auuition to time elapseu since injuiy affecting the values of sensitivity anu
specificity uuiing an evaluation, theie aie also anatomical influences that factoi into the
equation as well. Foi example, the 9u flexeu position useu in the Anteiioi Biawei test
allows seconuaiy meuial, lateial, anu posteiioi stiuctuies to affect the accuiacy of the test
Auams 1u
S
. In contiast, the Lachman's test places seconuaiy ligamentous stiuctuies in a moie
ielaxeu position while ieuucing contiaction capabilities of the hamstiing, wheie they
woulu be an influence uuiing an Anteiioi Biawei test. Also playing a iole in test
effectiveness is the specific bunule of the ACL that is actually toin. Foi instance, since the
ANB becomes taut uuiing knee flexion, this poition will be most susceptible to injuiies that
occui in flexion; theiefoie, it can be ieasoneu that anteiioi uisplacement of the tibia on the
femui cannot occui in the flexeu position unless the ANB of the ACL is toin
1,S
.
Aftei the analysis of these thiee stuuies uiiectly compaiing the Lachman's anu
Anteiioi Biawei Test, Lachman's appeais to be the moie favoiable test when attempting to
uiagnose an ACL teai in the knee in teims of bettei oveiall sensitivity anu specificity iates.
While neithei of these tests is consiueieu the golu stanuaiu in uiagnosing an ACL injuiy, it
is essential infoimation foi a clinician that may see an injuiy such as this one to know
which tests to utilize in the evaluation anu foi what ieason. In conclusion, by
acknowleuging the finuings of this paiticulai compaiison in these stuuies anu many like
this, the Anteiioi Biawei anu Lachman's test can both be utilizeu in the assistance of
attempting to clinically uiagnose an ACL teai within the knee.







Auams 11
REFERENCES
1. uingolu, B.I. (2uuS). ACL injuiies: Naking the uiagnosis. ?4$ @'*%"!+ ': A*2)*+'2;$+$#!+
A$8&)&"$. BB(7), SS4-SS9.
2. Katz, }. W., & Fingeioth, R. }. (1986). The uiagnostic accuiacy of iuptuies of the anteiioi
ciuciate ligament compaiing the lachman test, the anteiioi uiawei sign, anu the pivot
shift test in acute anu chionic knee injuiies. ?4$ /-$%&)!" @'*%"!+ ': C9'%#2 A$8&)&"$.
DE(1), 88-91.
S. }ain, B. K., Amaiavati, R., & Shaima, u. (2uu9). Evaluation of the clinical signs of anteiioi
ciuciate ligament anu meniscal injuiies. F"8&!" @'*%"!+ ': G%#4'9!$8&)2. EH(4), S7S-S78.
4. Scholten, R. }. P. N., 0pstelten, W., van Bei Plas, C. u., Bijl, B., Beville, W. L. }. N., & Boutei,
L. N. (2uuS). Accuiacy of physical uiagnostic tests foi assessing iuptuies of the
anteiioi ciuciate ligament: A meta-analysis. ?4$ @'*%"!+ ': I!-&+7 J%!)#&)$. KB(9), 689-
694.
S. Toy, B., Noise, B., Yeasting, R., & NcCann, P. (1999). Anatomy of the ACL: Influence on
anteiioi uiawei anu lachman tests. /#4+$#&) ?4$%!97 ?'8!7. E(2), S4-S8.