title: The Supine Internal Rotation Test: A Pilot Study Evaluating Tibial Internal Rotation in Grade III Posterior Cruciate Ligament Tears.
abstract: BACKGROUND
  Biomechanical studies have reported that the posterior cruciate ligament (PCL) functions as a restraint against excessive tibial internal rotation at higher degrees of knee flexion.
  
  
  OBJECTIVE
  To investigate the use of a supine internal rotation (IR) test for the diagnosis of grade III PCL injuries. The hypothesis was that internal rotation would be greater in patients with grade III PCL injuries compared with other knee injuries and that the supine IR test would demonstrate excellent diagnostic accuracy.
  
  
  METHODS
  Cohort study (diagnosis); Level of evidence, 2.
  
  
  METHODS
  A consecutive series of 309 patients underwent arthroscopic and/or open knee ligament reconstruction surgery. Seven patients were excluded based on the inability to perform a side-to-side comparison of internal rotation. Tibial internal rotation was assessed bilaterally on 302 patients during examination under anesthesia by a single orthopaedic surgeon measuring tibial tubercle excursion (mm) while applying internal rotation torque. Internal rotation was graded from 0 to 4 at 60°, 75°, 90°, 105°, and 120° of knee flexion. Data were collected and stored prospectively. The optimal threshold for the supine IR test was chosen based on maximization of the Youden index. Diagnostic accuracy parameters were calculated. Multiple logistic regression models were constructed to assess the influence of other knee pathologies on diagnostic accuracy.
  
  
  RESULTS
  Examination of the 22 PCL-deficient knees demonstrated an increase in tibial internal rotation at 60°, 75°, 90°, 105°, and 120° of knee flexion. The supine IR test had a sensitivity of 95.5%, a specificity of 97.1%, a positive predictive value of 72.4%, and a negative predictive value of 99.6% for the diagnosis of grade III PCL injuries. Posterolateral corner injury had a significant interaction with the supine IR test, increasing its sensitivity and decreasing its specificity.
  
  
  CONCLUSIONS
  PCL-deficient knees demonstrated an increase in the side-to-side difference in tibial internal rotation compared with other knee pathologies. The supine IR test offers high sensitivity and specificity for grade III PCL injuries and may represent a useful adjunct for diagnosing PCL injuries.
authors.affiliation: Steadman Philippon Research Institute, Vail, Colorado, USA.
authors.forename: Samuel G
authors.initials: SG
authors.lastname: Moulton
authors.affiliation: The Steadman Clinic, Vail, Colorado, USA.
authors.forename: Tyler R
authors.initials: TR
authors.lastname: Cram
authors.affiliation: Steadman Philippon Research Institute, Vail, Colorado, USA.
authors.forename: Evan W
authors.initials: EW
authors.lastname: James
authors.affiliation: Steadman Philippon Research Institute, Vail, Colorado, USA.
authors.forename: Grant J
authors.initials: GJ
authors.lastname: Dornan
authors.affiliation: Steadman Philippon Research Institute, Vail, Colorado, USA.
authors.forename: Nicholas I
authors.initials: NI
authors.lastname: Kennedy
authors.affiliation: Steadman Philippon Research Institute, Vail, Colorado, USA. ; The Steadman Clinic, Vail, Colorado, USA.
authors.forename: Robert F
authors.initials: RF
authors.lastname: LaPrade
keywords: diagnostic accuracy; internal rotation; posterior cruciate ligament; supine internal rotation test