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Current concepts review. The definitions of terms for motion and position of the
knee and injuries of the ligaments

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Current concepts review. The definitions of terms for motion and

position of the knee and injuries of the ligaments
FR Noyes, ES Grood and PA Torzilli
J. Bone Joint Surg. Am. 71:465-472, 1989.

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 Copyright 1989 by The Journal of Bone and Joint Surgery. Incorporated

Current Concepts Review

The Definitions of Terms for Motion and Position of the Knee

and Injuries of the Ligaments*
BY FRANK R. NOYES, M.D.t, EDWARD S. GROOD, PH.D.t, CINCINNATI, OHIO, AND
PETER A. TORZILLI, PH.D.t, NEW YORK, N.Y.

From the Noyes-Giannestras Biomechanics Laboratories, University of Cincinnati College of Engineering, Cincinnati;
the Cincinnati Sportsmedicine and Orthopaedic Center, Deaconess Hospital, Cincinnati;
and the Department ofBiomechanics, The Hospitalfor Special Surgery, Affiliated with Cornell University Medical College,
The New York Hospital, New York City

A review of the literature on the knee reveals consid- ond, we compared the terms that were used in all of the
erable discrepancies in the implied meanings of many terms. articles, to determine if a unique set of definitions had
These differences cause confusion when attempting to corn- evolved through common usage. Third, we reviewed and
municate the results of studies. Additionally, they have im- compiled the definitions that had been published in medical
plications for the development of systems of classification, and engineering textbooks2’6. Last, we noted how the terms
as precise terminology is an essential element of an effective were defined in both general and technical diction-
system. aries’9’45-49’25’. We considered the dictionaries as primary
Various systems of classification have been proposed. definition sources; textbooks, as secondary sources; and
The differences between them can be categorized into three published articles, as tertiary sources.
areas: ( 1 ) the terminology used to describe motion and po- When a term was used in several different ways, thus
sition ofthejoint, (2) how specific abnormalities are grouped resulting in ambiguity in meaning, we selected the least
to form the individual classifications, and (3) varying opin- ambiguous meaning on the basis of simplicity and clarity.
ions concerning which ligamentous injuries produce the Whenever possible, we chose definitions that were con-
classified abnormalities. sistent with primary or secondary sources. For example, we
Improved communication and the development of an defined laxity as looseness or slackness, a definition that
effective system of classification necessitate agreement on agrees with Webster’s ThirdNew InternationalDictionary”.
both the meaning and the appropriate use of terms to de- For terms that were not defined in primary or secondary
scribe the kinematic abnormalities of the knee clearly. The sources, we chose definitions that were consistent with the
purpose of this article is to present the meanings of medical most common usage in the orthopaedic literature and were
and engineering terms that are commonly used to describe as specific as possible.
motion and position of the knee during a clinical exami-
Terms to Describe Positions of the Knee
nation for injury to ligaments of the knee. To convey the
appropriate meaning of terms that have controversial mean- Position

ings, we propose adopting the least ambiguous usage. position [fr. L. ponere to put, to place]52
Four steps composed the systematic format that we 1. Of the human body: bodily posture or the arrangement of parts of
the body (body segments) as used for a particular examination or surgical
used to address problems in terminology. First, to categorize
procedure. 2. Of a point: the location of a point with respect to a reference
the terminology, we analyzed the major articles on injury
system. 3. Of a rigid body: the position of a point or particle in the body
of the ligaments that have been published in the English and the orientation of the body.
I .4,6-8. 10. 12-22.24-44.46-48.50.5 1 .53.54,56,58 We determined
whether the terms were defined in the body of the article The location of a point on the tibia, such as the tip of
and whether they were used consistently throughout. Sec- the medial aspect of the spine, can be described by three
translational coordinates - anterior-posterior, medial-hat-
* Supported in part by Grant AR 21 172 from the National Institute eral, and proximal-distal - that indicate where the point is
of Arthritis, Diabetes, Digestive, and Kidney Diseases, and the Cincinnati
Sportsmedicine and Orthopaedic Research and Educational Foundation.
located with respect to a refereIe coordinate system on the
t Cincinnati Sportsmedicine and Orthopaedic Center, Deaconess Hos- femur.
pital, 31 1 Straight Street, Cincinnati, Ohio 45219.
The orientation of a body refers to how it is rotated
1: Department of Biomechanics, The Hospital for Special Surgery.
535 East 70th Street, New York, N.Y. 10021. relative to other body segments . The orientation of the tibia

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466 F. R. NOYES, E. S. GROOD, AND P. A. TORZILLI

with respect to the femur is described by the three angles posterior position of a point on the medial and lateral tibial
of flexion-extension, abduction-adduction (or valgus-varus plateaus.
rotation), and internal-external rotation of the tibia.
Terms to Describe Motion of the Knee
Tibial position is important in the diagnosis of injuries
of the ligament in two ways. First, the position of the tibia Motion
before the clinical examination has been conducted is im-
motion [fr. L. movere to move]52
portant because it determines the tension in each of the The act or process of changing position.
ligaments and capsular structures and the starting or neutral
position of the test. Second, the position of the tibia when The motion of an object is described by specifying its
maximum subluxation is reached during the examination is velocity that is, the rate and direction
- with which it is
important because it indicates which ligaments are injured. changing position. This is equivalent to stating the direction
There is not yet uniform agreement on the abnormal posi- and speed of each point in the object.
tions that result from injury to all of the ligaments, alone The sequential positions of an object in motion com-
or in combination. Therefore, it is especially important to pose the path of the motion. The net effect of a motion can
describe clearly the abnormal positions that are observed be quantified two ways: (1) by describing the distance that
during the examination and the examiner’s interpretation of an object travels along its path, and (2) by describing the
these positions. displacement (see later definition) between the starting and
ending points of its path, without regard to the details of
Dislocation the intervening motion.
dislocation [fr. L. de away from; locare to place]52
Displacement
An abnormal position of the osseous structures forming a joint, such
that there is no longer contact between the normally opposed, articulating
displacement [fr. Old French des away; placer to place]”
surfaces.
The net effect of a motion. The change in position of a body or
particle between two points along its path without regard to the path
Generally, dislocation has been used in the literature
followed.
to indicate a complete non-contact position of both tibiofem-
oral compartments or of the patellofemoral joint. Theoret- The displacement of a rigid body is the change in its
ically, a dislocation of only the medial or lateral aspect of position without regard to the path that it follows. The
the tibiofemoral joint also could be defined as a dislocation displacement of a rigid body can be described by the dis-
of that particular compartment. Although dislocation has placement of any particle in the rigid body plus the change
been used at times as a synonym for displacement, we advise in orientation of the body. The change in position of the
authors to avoid using the term in this context. particle is called the translation of the rigid body, and the
In the literature, dislocations of the knee joint tradi- change in orientation of the body is called the rotation of
tionally are classified by the final tibial position - anterior, the rigid body. The standard international unit of translation
posterior, medial, lateral, or rotatory27. Luxation, a syn- is the meter, and rotation is measured in radians or degrees.
onym for dislocation, sometimes appears in the medical Any general displacement can be described as a combination
literature. Either term describes the loss of contact between of three translations and three rotations, each of which cor-
the normally opposed articulating surfaces. responds to a degree of freedom (for a total of six degrees
of freedom).
Subluxation
Translation
subluxation [fr. L. sub under, beneath; luxare to put out of joint]52
A partial dislocation in which there is an abnormal position of the translation [fr. L. trans across; ferre to carry]52
osseous structures forming the joint; however, a portion of the opposing A type of motion or displacement of a rigid body in which all lines
articulating surfaces are still in contact. attached to it remain parallel to their original orientation.

Generally, subluxation has been defined as incomplete An equivalent definition is a type of motion by which
or partial dislocation. In the literature, subluxation has been all points in the body move along paths that are parallel to
used synonymously with abnormal motion. However, it is each other. A body that follows a curved path undergoes
incorrect to equate abnormal motion of the knee with sub- translation if its orientation does not change during the mo-
luxation, because subluxation represents a position of the tion. At each instant during a translation, all points move
joint, not its motion. It is correct to say that an abnormal with the same speed and in the same direction. If the di-
motion produces a subluxated position. rection of motion is constant, the body moves in a straight
Difficulty arises in identifying and quantifying a sub- path. If the direction changes with time, the body follows
luxation. The term does not have units; therefore, the author a curved path. The motions of points should not be referred
must describe a subluxation by the position of the tibia to as translations; points are said to displace, not translate.
relative to the femur. Rotatory subluxations are described The concept of translation should describe only the motion
by the rotation of the tibia and the position of any point on of a rigid body (the tibia).
the tibia. An alternate approach is to specify the anterior- In the orthopaedic literature, the term translation of the

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 DEFINITIONS OF TERMS FOR MOTION AND POSITION OF THE KNEE 467

knee is used consistently to describe the motion of the tibia is to describe the amount of rotation that can occur. How-
with respect to the femur. The translation of the tibia is ever, there is also a range of motion for each of the trans-
composed of three independent components (also referred lational and rotational degrees of freedom. For motions other
to as translational degrees of freedom): medial-lateral trans- than flexion-extension, the range of motion generally de-
lation , anterior-posterior translation , and proximal-distal pends on the angle of flexion of the knee. The range of
translation. Tibial translations are commonly reported in anterior-posterior translation depends both on the angle of
millimeters. (See also the discussion of translation that is flexion and on the position of tibial rotation in which the
included under rotation.) knee is placed before the measurement is made39. The range
of motion also depends on the loads that are applied to the
Rotation
knee, because the two limits that define the range depend
rotation [fr. L. rotare to turn]52 on the load that is applied.
A type of motion or displacement in which all points on a body move
about an axis as a center, or a motion in which one point is fixed. The Limits of Motion
axis is commonly termed the axis of rotation.
limit [fr. L. limes boundary]52

During a rotation, the points on a body have different The extreme positions of movement that are possible in each of the
six degrees of freedom.
directions of motion and different speeds. At each instant,
they appear to be going in circles about the axis of rotation. Two limits, in opposite directions, are necessary to
This differs from a translation, in which all points move in define the range of motion. Specifying the limits of motion
the same direction at the same speed. provides additional useful information that is not provided
Rotations, like translations, are composed of three in- by the range of motion. An example is a knee in which the
dependent degrees of freedom. In the knee, each rotational range of motion is restricted by 15 degrees. Without know-
degree of freedom occurs about one of three axes: flexion- ing what the position of the knee was at the two limits, it
extension rotation, internal-external rotation, and abduction- is impossible to know whether the restriction is a limitation
adduction rotation. The flexion-extension axis is located in of extension or flexion, or of both. The limits of motion
the femur, and its orientation, relative to the femur, does during examination of the ligaments of the knee are the
not change. The internal-external rotational axis is located positions of the tibia at the two extremes of movement that
similarly in the tibia, and its orientation, relative to the tibia, are induced by the applied loads. Injury to the ligamentous
does not change. The abduction-adduction axis is perpen- and osseous structures about the knee alters the limits of
dicular to both the flexion and tibial rotational axes, and its motion, thus inducing an increase in the range of motion.
orientation can change relative to both bones. There is a total of twelve limits of motion in the knee,
Motion and displacement of the knee can be described two for each of the six independent degrees of freedom.
as a combination of the change in orientation of the tibia A convention that is commonly used in Europe is to
and the motion or displacement of some reference or base describe the range and limits of flexion-extension with three
point on the tibia. The change in orientation is quantified numbers that denote maximum hyperextension, the zero or
by the rotation of the tibia about the three independent axes neutral point, and maximum flexion. For example, 5-0-145
and the motion or displacement of the reference point on describes a knee that goes from 5 degrees of hyperextension
the tibia. The motion of this point is often referred to as the to 145 degrees of flexion. A knee that lacks 15 degrees of
translation of the tibia. Because translation, in its purest full extension would be described by 0-15-145. This system
usage, refers to the motion of a rigid body (and not of a describes the range of motion by the limits.
point), the use of translation in this latter context (referring
to a point) has evolved from general usage. The location of Coupled Displacement and Motion
the reference point for translation can be chosen arbitrarily.
coupled [fr. L. copula bond]52
However, the amount of translation will depend on which A displacement or motion in one or more degrees of freedom that is
point is selected; any associated rotation could cause the caused by a load (force or moment) applied in another degree of freedom.
reference points to move differently. Typically, the refer-
ence point that is used to describe translation of the knee is The concept of a coupled motion is best illustrated by
located midway between the medial and lateral margins of the internal rotation that results when an anteriorly directed
the joint, although the precise location of the point often is force is applied to the tibia’#{176}.However, the amount of cou-
not specified. Some investigators have used a point on the pled motion depends on where the force is applied to the
tibial condyle that is midway between the spines of the tibia and on whether the center of rotation is constrained or
intercondylar eminence. allowed to move freely. Coupled motions often occur during
the clinical examination. Examples include the coupled mo-
Range of Motion tions of external rotation when a posteriorly directed force
range lfr. Old French ranc row]” is applied to the tibia and of internal rotation when an an-
The displacement that occurs between the two limits of movement teriorly directed force is applied to the tibia. The type and
for each degree of freedom.
amount of coupled motion that occurs during the clinical
The most common use of range of motion in the knee examination depend on the mechanical properties of the

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468 F. R. NOYES, E. S. GROOD, AND P. A. TORZILLI

knee and on the magnitude and direction of loads that the erties and on its point of application. Thus, if an anteriorly
examiner applies. directed force is applied to the tibia, the resulting motion
of the tibia will depend on where the force is applied and
Constrained and Unconstrained Motion
how large it is. The direction of the force is the combination
of its orientation (along the anterior-posterior axis, in this
constrain [fr. L. constringere, fr. con together + stringere to draw
tight]52
instance) and its sense (which was specified as anterior).
To restrict the motion of a (mechanical) body in a particular mode.
Moment
During the clinical examination to detect a ligamentous
moment [ft. L. momentum movement]’
injury, the tibia moves into a final position that depends The influence on a body that causes an angular (rotational) acceleration
both on the applied loads and on the integrity of the liga- of the body.
mentous and osseous structures. The motion of the knee
joint may be allowed to occur freely in an unconstrained A moment also has three properties: (1) an orientation,
manner or it may be constrained (restricted). If the motion or line of action; (2) a sense, clockwise or counterclockwise,
is unconstrained, the tibia displaces into its maximum po- about its line of action; and (3) a magnitude, which is mea-
sition. Constrained tests limit the amount of motion that sured in newton-meters.
occurs. The magnitude of the moment is directly proportional
An example of an unconstrained clinical test is the to the magnitude of the force that produces it and to the
external rotation test that is performed to evaluate the pos- perpendicular distance to the line of action of the force
terolateral ligamentous structures. Typically, motions of ex- (moment arm). When indicating the moment at the knee, it
terna] rotation of the tibia, posterior translation of the tibia, is essential to state the axis about which the moment is
and sometimes, abduction rotation, occur”. The examiner determined, as the magnitude of the moment will depend
does not limit or constrain the motions but rather permits on where the axis is located and on the orientation of the
thejoint to displace to its position ofmaximum subluxation. axis.
Most clinical tests that are performed on the knee joint
Laxity
are constrained. In the abduction and adduction tests, the
coupled external or internal tibial rotations are often pur- laxity [fr. L. laxare to relax, slacken]’2

posely blocked to assess medial and lateral opening of the ( 1) Slackness or lack of tension (a characteristic of a ligament) and
(2) looseness, referring to a normal or abnormal range of motion of a joint.
joint that is caused only by the abduction-adduction motion.
The examiner should realize that complete elimination of In the orthopaedic literature, the term laxity has two
external or internal rotation of the tibia is not possible. One general meanings, and problems arise with each of the
advantage of a constrained test is that the specific motions usages. When applied to a ligament, the term laxity indicates
are known and can be reproduced in the laboratory, per- a slackness in the ligament or a lack of tension that is, -

mitting the primary and secondary higamentous restraints a lax ligament. In the intact knee, many ligaments can be
for the motion to be experimentally determined’3-’4. made slack by positioning the tibia to shorten the distance
When performing the Lachman test or the anterior between the femoral and tibial attachments. Laxity can be
drawer test, the examiner might choose to constrain the normal or abnormal, so the adjective abnormal should al-
amount of coupled internal rotation of the tibia. Accord- ways be used to indicate when laxity is pathological. Ab-
ingly, the specific ligaments and the importance of each normal laxity of a ligament may be congenital or it may
ligament in limiting the final position will depend on how result from a stretching injury.
the test is performed38. Diagnostic information is available Laxity is also used in the orthopaedic literature to de-
for both constrained and unconstrained tests on the knee scribe the looseness ofajoint. Commonly, the term indicates
joint as long as the forces, motions, and displacements are some amount of motion that results from the application of
known38. This is described in detail later. forces and moments. The International Dictionary of Med-
icine and Biology defines laxity, in part, as ‘either normal ‘

Force free motion or greater than normal motion, as of a joint’ ‘23#{149}

force [fr. L. fortis brave, strong]” Often the specific type of motion is not stated or, if stated,
The influence on a body, such as a push or pull, that accelerates is ambiguous. For example, does anterior laxity of the knee
(changes either the speed or direction of motion) or deforms (changes
refer to the motions of both anterior translation and rotation
either the size or shape) the body.
of the tibia, or just to the amount of anterior translation of
A force has three properties: (1) an orientation or line the tibia? If anterior laxity is used to describe only the
of action, (2) a sense, forward or backward, along its line anterior translation, it is preferable to use the term anterior
of action; and (3) a magnitude, which is expressed in new- translation. The author thus avoids ambiguity and can spec-
tons. One newton is the force required to accelerate one ify the amount, in millimeters, of anterior translation that
kilogram at the rate of one meter per second per second. occurred under the applied load. If the amount of motion
One newton is equivalent to 0.2248 pound. that is reported is the difference between the involved and
The effect of a force depends on all three of its prop- non-involved knees, this should always be clearly indicated;

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 DEFINITIONS OF TERMS FOR MOTION AND POSITION OF THE KNEE 469

we recommend the use of the term difference in anterior acterized by increased orexcessive displacement ofthe tibia.
translation. In this context, the use of the term is similar to its use in
A useful synonym for laxity, as applied tojoint motion, the literature on spinal injuries, in which excessive mobility
is play. One of the many meanings of play is free or un- ofthe cervical vertebrae is referred to as cervical instability.
impeded motion, as in a part of a machine. An example is Although the practice is common, it is incorrect to use the
the play that is present in a bearing or that develops with word instability to describe an anatomical structure, as in
wear of the bearing. Whether laxity or play is used, it is the phrase instability of the anterior cruciate ligament.
still necessary to indicate whether the looseness is normal Rather, it is preferable to specify the precise defect of the
or abnormal. ligament (one or more anatomical structures) and to specify
Problems arise when articles in the English language separately the abnormal displacement of the tibia, including
that use the word laxity are translated into German. The the pertinent loading conditions that led to the diagnosis.
closest equivalent German term is ungespant, meaning not We recommend that the term instability be used only in a
tense (as in a loosely tensioned rope). Translating the word general sense, to indicate abnormal displacement ofthe tibia
laxity into French is also difficult because there are many as a result of traumatic injury to tissue. The increased range
word choices, and the relative ambiguity ofthe English word of motion due to hyperelastic ligaments, which occurs in
makes it difficult to select an exact word or phrase in French. some diseases ofconnective tissue, should not be considered
Lache, an adjective meaning lax or loose, conveys the mean- instability.
ing of an abnormally loose joint, as after an injury. A phys-
iological laxity of the knee (no injury) is described by the Terms to Describe an Injury of a Ligament
verb d#{233}tendre (to loosen or to slacken). And if one is re- Sprain of a Ligament
ferring to the state of a single ligament, the term flaccidite
sprain [possibly fr. Old French espreindre to squeeze, fr. Latin ex-
is used. Thus, difficulties exist in both French and German
primere to squeeze or press out]52
when translating the word laxity. Because laxity also has An injury to joint ligaments that stretches or tears ligament fibers but
many different general meanings in English, its use should does not completely disrupt the ligament (its continuity remains intact).
be avoided, and more specific terms should be used to de-
scribe abnormalities in motion or position of the joint. All of the reference dictionaries define a sprain of a
We recommend that, due to its ambiguity, the term ligament as an injury in which there is tearing of portions
laxity not be used to describe a motion or displacement. It of the ligament but not a complete disruption. For example,
should be used only in a general sense, to indicate slackness in Dorland’s Illustrated Medical Dictionary, the injury is
or lack of tension in a ligament. When referring to motion defined as a tear in ‘some of the fibers’ ‘ ‘ but the ‘conti- ‘

of the knee, it is preferable to describe the specific motion. nuity. remains

. intact’ In the International ‘. Dictionary of
The use of laxity as a synonym for motion of the joint is un- Medicine and Biology, a sprain is defined as overstretched
necessary and vague. or torn fibers, but it is specified that the injury ‘leaves the ‘

The clinical examination for laxity of the knee joint structural integrity of the ligaments intact’ ‘23, The definition
involves determining the abnormal displacements of the tib- of sprain in Stedman’s Medical Dictionary recognizes that,
ia and the positions that can be induced by the application as a result of a sprain, thejoint may have ‘a range of motion ‘

of forces and moments. These clinical signs are then used greater than normal”49, implying that there is some loss of
to infer the extent of injury to the ligaments and capsular function of the ligament.
structures (abnormal laxity). In the American Medical Association’s Standard No-
menclature ofAthletic Injuries3, published in 1966, sprains
Instability
of a ligament are classified into three categories. A first-
instability lfr. L. in not; stabilitas firmness. steadiness]’2
degree sprain has ‘ ‘minimum tearing of ligament fibers’ ; a ‘
A condition of a joint characterized by an abnormal increased range
of motion (mobility) due to injury to the ligaments, capsule, menisci, second-degree sprain is a ‘partial ‘ tear of the ligament”,
cartilage. or bone. with ‘slight
‘ to moderate abnormal motion”; and a third-
degree sprain is a ‘complete
‘ tear of a ligament’ ‘ , with ‘loss ‘

In the literature, the term instability is used in two of function’ ‘ and ‘marked ‘ abnormal motion. ‘ ‘ In the lit-
ways: (1 ) to describe an episode of giving-way (symptom), erature, however, a complete tear of a ligament is most
and (2) to describe a condition of increased mobility of the commonly referred to as rupture of a ligament, not as a
joint (a physical sign). In the former context, functional third-degree sprain.
instability may result in partial collapse or a subjective sen- In Athletic
Training and Sports Medicine, The Amer-
sation. Unless the extent of the symptom is specifically ican Academy of Orthopaedic Surgeons similarly defined
stated, a reader cannot know which meaning is intended. the severity of injuries of the ligament according to the three
To avoid ambiguity, we recommend that instability not be categories of first, second, and third-degree sprain. The
used to indicate an episode of giving-way. Describing the definition by The American Academy of Orthopaedic Sur-
actual event is always preferable. geons correctly indicates that a second-degree partial tear
In the literature, the term instability is used more corn- of a ligament may be associated with slight or moderate
monly to indicate a condition (physical sign) that is char- abnormal motion.

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470 F. R. NOYES, E. S. GROOD, AND P. A. TORZILLI

The most common definiton of the word sprain is an the conditions under which the test is conducted (position
acute injury of a ligament with a partial tear but without of the patient and of the lower limb, and the applied loads)
complete rupture or loss of function of the ligament. To and the outcomes of the test that is, motions
- of the knee
avoid ambiguity, if a sprain is classified as a third-degree that occur, maximum displacements that are induced, and
sprain (according to the classification of the American Med- the final tibiofemoral position. Specifying how the test is
ical Association), it is preferable to include the term third conducted is important because the results and diagnosis
degree, to indicate a complete tear of the ligamentous fibers. depend on the conditions of the test. A change in any con-
dition could change the diagnostic interpretation of the
Rupture ofa Ligament test394. For example, during a constrained abduction test,
rupture [ft. L. rumpere to break]52 the leg is positioned over the side of the table, and an
A tear or tearing apart.
abduction moment is applied to the tibia while the external
The use of the term rupture usually implies complete rotation of the tibia is purposely constrained. The results of
tearing of the ligament with loss of function. A common the test are reported in millimeters of medial opening of the
synonym for rupture is tear. It is acceptable to use the joint rather than in degrees of tibiofemoral rotation. The
adjective partial to indicate an incomplete rupture or tear of abduction test of the knee also can be performed by en-
the ligament in which some function remains. Because a hancing external rotation of the tibia instead of constraining
ligament may undergo a complete tear but still retain con- it. In this instance, the displacements of the knee and the
tinuity between disrupted fibers, it is the loss of function restraining ligaments differ from the first situation. Instead
(resistance to displacement) that defines a tear, not the prop- of performing the test with the leg placed over the side of
erty of continuity. In the absence of the designation partial, the table, it can be performed with the leg elevated, where
the word rupture is usually used to indicate a complete gravity acts posteriorly on the femur, producing a relative
disruption. anterior translation of the tibia. If the anterior cruciate hg-
ament is ruptured, the tibia will subluxate anteriorly, and
Deficiency of a Ligament the response of the knee to the applied abduction moment
and how the test is interpreted might differ8.
deficiency [fr. L. deficere to fail]52
The state or condition of lacking a substance, quality, or characteristic
In our review of the literature, we found that most
essential for completeness. articles lacked a rigorous specification of test conditions,
resulting in confusion as to how the clinical tests were per-
This general term is used to indicate that a defect exists, formed and how the diagnostic information was interpreted.
without specifying the exact extent of the defect. It is there- Also, the term one-plane or straight is often used as a de-
fore incumbent on the author to define the defect. For ex- scriptor for types of instability of the knee that are found
ample, in the pediatric literature, congenital deficiencies of during the examination, as well as in some systems of clas-
the limbs are classified into different types on the basis of sification. It is less ambiguous to use the terminology that
the specific anatomical part that is absent29. we presented here.
In the literature on injuries of the ligaments, the term The same logic applies to the rotational subluxations
deficiency is used in two ways: (1) to describe a knee in of the knee. In describing the motions and positions that
which the ligament is absent, such as a knee with a defi- occur in a knee with a rotatory instability, the terms an-
ciency of the anterior cruciate ligament, and (2) to indicate terolateral, posterolateral , anteromedial , and posteromedial
when a loss of function has occurred, such as when the have been commonly used. There is a great deal of confusion
ligament still exists but is stretched and non-functional. In and lack of uniformity in the literature as to what these
this context, the deficiency is based on the abnormal motions terms mean and how they are applied. Although some au-
or positions which occur. For example, the presence of a thors use them to describe abnormal motions, other authors
pivot-shift phenomenon or abnormal anterior displacement use them to describe an abnormal position of a joint. For
defines the deficiency of the ligament. example, the descriptive term anterolateral instability leaves
A commonly used medical synonym is insufficiency. the following matters unclear: (1) What specific abnormal
Insufficiency is usually used to refer to an inadequate level motions are being described: anterior translation of the tibia,
of function. It is defined in the International Dictionary of internal rotation of the tibia, or both? (2) Is there associated
Medicine and Biology as ‘a failure of an organ, ‘part, or opening of the lateral aspect of the joint, or is the term used
system to perform at a normal or adequate level of function; to describe only the abnormal anterior position (subluxation)
relative ineffectuality of function’ ‘23#{149} of the lateral tibial condyle? (3) Is there associated anterior
subluxation of the medial tibial condyle? (4) Where is the
Application of the Terms to the Clinical Examination axis for internal-external rotation of the tibia, and what
The examination of the knee joint involves determining determines its position? (5) Are there different types of the
the motions, limits of motion, and initial and final positions instability when combined with other ligamentous defects?
of the joint that result from specified loading conditions. Given this confusion, it is not surprising that there has been
Whether the test is performed in a qualitative clinical manner no agreement on what defects ofthe ligaments cause rotatory
or by a quantitative method, the examiner should specify subluxations’3-39.

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 DEFINITIONS OF TERMS FOR MOTION AND POSITION OF THE KNEE 471

The descriptions of the motions of the knee that occur of words and phrases that are used to describe abnormalities
during the test should be separate from the descriptions for of the ligaments of the knee and to suggest a common set
the displacements and subluxations of the joint that are used ofterms and descriptions. We recommend that authors avoid
to quantify the test. Rather than using the term anterolateral terms that are highly ambiguous or undefined, and suggest
instability, the specific motions of anterior translation and the use of our proposed definitions in future classifications
internal rotation of the tibia should be noted, and the de- of injuries ofthe ligaments ofthe knee. The use of consistent
scription of the position of the joint should be noted as an terminology to describe the changes in motion and position
anterior subluxation of the lateral aspect of the tibial con- of the knee and the resultant subluxations will permit a more
dyle. It is also necessary to describe an anterior subluxation precise diagnosis of which structures are damaged, as well
of the medial aspect of the tibial condyle, if it is present. as a less ambiguous interpretation ofthe results of treatment.
This applies to the description of other rotatory subluxations
NoTE: The authors thank Kimberly Walz and Cecilia Franz for their assistance in preparing
of the knee , as well . the manuscript. Cheryl Grood for her assistance with Latin roots. and the International Knee
. . . Documentation Committee of the American Orthopaedic Society for Sports Medicine and the
Our purpose has been to identify problems in the use European Society of Knee Arthroscopy for the review our definitions.

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