The arthroscopical and radiological corelation of lever sign test for the diagnosis of anterior cruciate ligament rupture
© Deveci et al. 2015
Received: 1 October 2015
Accepted: 17 December 2015
Published: 30 December 2015
The aim of the current study was to evaluate the sensitivity of the lever sign test and the widely used basic tests of the Lachman, anterior drawer and pivot shift tests, both under anaesthesia and without anaesthesia, according to the gold standard diagnostic arthroscopic results in patients undergoing anterior cruciate ligament reconstruction. The study included 117 patients, diagnosed with ACL tear which was definitively determined during an arthroscopic surgical procedure applied. Before anaesthesia and while under anaesthesia, the Lachman, anterior drawer, pivot shift and lever sign tests were applied to all patients. Evaluation was made of MR images for each patient and documented. The patients comprised 96 males and 21 females, witha mean age of 25.8 ± 5.9 years (range, 17–45 years). Total tear was determined in 82 cases, anteromedial (AM) bundle in 14, posterolateral (PL) bundle in 13 and elongation in 8. Pre-anaesthesia positivity was found in lever sign at 94.2 %, Lachman at 80.5 %, pivot shift at 62.3 % and anterior drawer at 60.1 %. These rates were determined after anaesthesia as lever sign 98.4 %, Lachman 88.7 %, pivot shift 88.3 % and anterior drawer 84.2 %. The lever sign test can be easily applied clinically and it seems to have higher sensitivity than the Lachman test which is the basis of classic information, it should be included in routine clinical practice. In the light of the results of this study, further studies are required to review the accepted view that the Lachmann test is the most reliable test.
Anterior cruciate ligament (ACL) injuries are the most frequently seen ligament injuries of the knee joint (Benjaminse et al. 2006; Prodromos et al. 2007). Diagnosis is based on history, physical examination and MRI findings and a definitive diagnosis is confirmed with arthroscopic imaging (Crawford et al. 2007; Oei et al. 2003; Finsterbush et al. 1989; Farquharson-Roberts and Osborne 1983; McDaniel 1976; Noyes et al. 1989; Lintner et al. 1995; DeFranco and Bach 2009). Although arthroscopic evaluation is the gold standard, the tear cannot be determined even with this method in cases where there is incorrect evaluation of the femoral attachment site and when there is continued integrity in the ACL fibres (DeFranco and Bach 2009).
In the clinical evaluation, the first and most important step of the patient history is the physical examination. Three basic tests are used in the physical examination from which different results may be obtained according to the sensitivity and specificity of each test. These are the Lachman, the anterior drawer and the pivot shift test (DeFranco and Bach 2009; Johannsen and Fruensgaard 1988; van Eck et al. 2013). Generally there are two problems related to physical examination methods. In partial tears in particular, in contrast to the complaint of instability, the findings of the physical examination made with the three tests in question may be normal (Lintner et al. 1995; DeFranco and Bach 2009; Zantop et al. 2007). The other problem is that the patient may have developed pain-resistance (Benjaminse et al. 2006; van Eck et al. 2013). In these situations, MRI evaluation is presented as a choice for making a diagnosis. Although MRI has reliability of 94–98 %, it is not practical, is expensive and should not be valued as a stand-alone test (Yao et al. 1995; Umans et al. 1995; Hong et al. 2003; Friedman and Jackson 1996; Kelly et al. 1991). Therefore, it should be combined in an approach with an efficient physical examination (Meuffels et al. 2012; Liu et al. 1995; Gelb et al. 1996; Kocabey et al. 2004). Despite the negative aspects, the Lachman, the anterior drawer and the pivot shift test are the most significant stage of the diagnostic approach as they can be applied easily, are cheap and non-invasive. Several evaluation tests have been developed to overcome the drawbacks. One of these, developed in recent years by A. Lelli is the ‘lever sign’ test (Lelli et al. 2014). It has been claimed that this test is more valuable than the other 3 tests in both partial and total lesions. In particular, it has been suggested that it could be applied effectively, regardless of the interval from trauma to examination. In literature, there is only the study by Alessandro Lelli related to the lever sign test, in which the sensitivity of the lever sign test and the sensitivity of the three basic tests was evaluated according to the MRI results without using the gold standard arthroscopic evaluation criteria.
The aim of the current study was to evaluate the sensitivity of the lever sign test and the widely used basic tests of the Lachman, anterior drawer and pivot shift tests, both under anaesthesia and without anaesthesia, according to the gold standard diagnostic arthroscopic results with reference to the results of diagnostic arthroscopy in patients undergoing anterior cruciate ligament reconstruction. The hypothesis of the study was that the lever sign test had higher sensitivity than the other three tests and was less affected by patient-related factors in patients under anaesthesia and without anaesthesia.
Approval for the study was granted by the Institutional Review Board. The study included 117 patients, diagnosed with ACL tear which was definitively determined during an arthroscopic surgical procedure applied between January–August 2015. The decision for surgical intervention was made by a combined evaluation of the physical examination, MRI and the patient’s complaints of instability. For patients found to have an intact ACL in the physical examination and MRI evaluation, the decision for an arthroscopic intervention was made according to complaints of instability such as the feeling of giving way, unreliability, pain and weakness. All examinations were performed on a 1.5 T whole body MRI system (Excite, General Electrics, Milwaukee, Wisconsin) with a 33 mT/m maximum gradient capacity.
Following the trauma, all patients were given cold pack therapy, anti-inflammatory medical treatment and weight-bearing was not permitted in the first week. Before the arthroscopic procedure, quadriceps and hamstring strengthening exercises were applied for at least 3 weeks. The mean period between trauma and surgery was 8.7 weeks (range, 4–25 weeks). All patients were admitted for surgery under spinal anaesthesia without the application of muscle relaxant. The cases for which ACL reconstruction procedures were applied after the 4th week were grouped as acute or chronic. Patients were excluded if there was medial meniscus posterior root tear, bilateral ACL tear, multiple ligament injuries or previous arthroscopic surgery.
Descriptive statistics were used to characterize the sample. Sensitivity was calculated by measuring the proportion of actual positives in the total sample and formulated as true positives/(true positive + false negative). All calculations were performed with SPSS 20.0 software (SPSS Inc.,Chicago, IL, USA.).
Demographic data of the patients
25.8 ± 5.9 (17–45)
The sensitivity values of stress tests at pre- anaesthesia and under anaesthesia
Pre-anaesthesia assesment (%)
Under anaesthesia assesment (%)
Lever sign test
Pivot shift test
Anterior drawer test
MRI sensitivity was determined as 92.3 %. In 9 patients determined with total ACL tear in the arthroscopic evaluation, it was reported as intact in the MRI evaluation.
According to these results, the lever sign test has much higher sensitivity than the other tests both before anaesthesia and under anaesthia. The sensitivity value under anaesthesia was even found to be higher than the MRI evaluation. In the pre-anaesthesia evaluation, the examination method with the lowest reliability was seen to be the anterior drawer test. The test with the lowest sensitivity under anaesthesia was determined to be the pivot shift test.
The most significant finding of this study was that the lever sign test is a new test with higher sensitivity than the Lachman test which can be applied easily both under anaesthesia and without anaesthesia.
Due to the stress of the trauma and patient resistance, it may be difficult to apply the standard physical examination methods effectively. Secondly, if the tear is partial or if the ruptured ACL is attached to another point, false negative results may be given (Lintner et al. 1995; DeFranco and Bach 2009; van Eck et al. 2013; Zantop et al. 2007; Katz and Fingeroth 1986). Different results may also be obtained depending on the person applying the examination and whether or not the examination method is applied under anaesthesia (van Eck et al. 2013). The lever sign test differs from other tests in that the basic area of manipulation is primarily not the tibia but the femur (Lelli et al. 2014). Furthermore, application of the test is very easy and practical. There is no difficult learning curve for the test.
As 85 % of ACL injuries are from the femoral attachment and there can be considered to be a possibility of attachment of the ruptured ligament to the PCL or structures within the femoral notch, it is more correct for manipulation to be made from the femur.
In the study by Lelli, it was determined that the lever sign test had high sensitivity regardless of the degree of the ACL tear or the time of injury (Lelli et al. 2014). In that study, the lever sign test results were consistent with the MRI examination. However, because of errors in application technique or evaluation of MRI, false negative results may be obtained (Liu et al. 1995; Gelb et al. 1996; Kocabey et al. 2004; Steckel et al. 2006). The decision for an arthroscopic approach was based on complaints of instability in the current cases and patients were included for whom ACL reconstruction was planned. As arthroscopic evaluation is the gold standard in the diagnosis of ACL tear, the test was truly evaluated. Thus it was thought that more accurate results were obtained from a point confirming the definite ACL injury.
In literature, the Lachman test has been reported as the test with the highest sensitivity and the pivot shift as that with the highest specificity (Benjaminse et al. 2006; DeFranco and Bach 2009; van Eck et al. 2013; Steckel et al. 2006). Lelli et al. evaluated the lever sign, Lachman, anterior drawer and pivot shift tests. Sensitivity rates were found to be 1.00, 0.62, 0.72 and 0.47 respectively. Sensitivity of the Lachman test was seen to be lower than rates in literature and in the current study (Lelli et al. 2014). Pre-anaesthesia sensitivity in the current study was determined as lever sign 0.94, Lachman 0.80, anterior drawer 0.60 and pivot shift test 0.62. Under anaesthesia, these values were determined as lever sign 0.98, Lachman 0.94, anterior drawer 0.84 and pivot shift test 0.78. The sensitivity of the lever sign test was extremely high when applied both before and under anaesthesia and the results were seen to be consistent with those of the study by Lelli.
The high sensitivity value of the Lachman test in the current study may be due to low patient resistance as there was no acute trauma group. The lever sign test was seen to have much higher sensitivity compared to the other tests in both the evaluation pre-anaesthesia and under anaesthesia. Under anaesthesia, an increase was seen in the sensitivity of the lever sign test and of the other tests. Although this change was significant, it was not at a very high rate in the lever sign test. This shows that the test was affected less than the other tests by patient-related factors.
In a meta-analysis by Carola F. Van Eck et al., the sensitivity of the Lachman, anterior drawer and pivot shift tests applied without anaesthetic was found to be 0.81, 0.38 and 0.28 respectively (van Eck et al. 2013). In the current study, the pre-anaesthesia sensitivity values were determined as Lachman 0.80, anterior drawer 0.60, pivot shift 0.62 and lever sign test 0.94. In contrast to the similarity found in the sensitivity of the Lachman test, the sensitivity of the pivot shift test and anterior drawer test in the current study was found to be higher than that of the study by Carola F. Van Eck. This may be due to low patient resistance as there was no acute trauma group in the current study. In the meta-analysis by Carola F. Van Eck et al., the sensitivity values of the Lachman, anterior drawer and pivot shift tests applied under anaesthetic were found to be 0.91, 0.63 and 0.73 respectively. A significant increase was seen in the sensitivity of all 3 tests under anaesthesia, showing that all 3 tests were affected by patient-related factors.
In the Lelli study, the sensitivity of the examination method was evaluated according to the MRI diagnosis of the ACL tear (Lelli et al. 2014). The sensitivity of MRI in the evaluation of ACL tear has been reported as 92–96 % (Steckel et al. 2006; Lefevre et al. 2014). Although arthroscopic evaluation is an invasive method, it is the gold standard for definitive diagnosis (Crawford et al. 2007; Oei et al. 2003). A superior aspect of the current study is that the diagnosis of ACL tear and type were clearly established. Thus, by referring back to a definite diagnosis, the accuracy of the examination method was better checked. The high values obtained in the the lever sign test both before anaesthesia and under anaesthesia showed that even if there were external effects such as pain and patient resistance, the accuracy rate in the current study cases, including partial tears, was much higher.
A limitation of the current study was the small sample size as the evaluation was only of arthroscopic surgery cases. For the same reason, no acute cases were evaluated and therefore the study only included chronic cases. As the number of cases with partial tear was extremely low, test reliability could not be evaluated in respect of partial and full tear cases. Evaluation was not made according to different types of anaesthesia. As the number of females in the sample was low, differences in terms of gender were not evaluated. Finally, when evaluating the sensitivity of the tests, no examination was made of specificity.
Diagnosis of ACL tear is made by a combined evaluation of the patient history, physical examination and MRI. Accurate diagnosis is made by interpretation of these 3 steps together. The physical examination methods are indispensable as practical, cheap, non-invasive methods.
The lever sign test can be easily applied clinically and it seems to have higher sensitivity than the Lachman test which is the basis of classic information, it should be included in routine clinical practice. In the light of the results of this study, further studies are required to review the accepted view that the Lachmann test is the most reliable test.
AD carried out the study; DC and SY supervised the work; AD and GO, wrote the manuscript, and EA and MB prepared the data for analysis and conducted the analyses. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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- Benjaminse A, Gokeler A, van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36(5):267–288View ArticleGoogle Scholar
- Crawford R, Walley G, Bridgman S, Maffulli N (2007) Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 84:5–23View ArticleGoogle Scholar
- DeFranco MJ, Bach BR (2009) A comprehensive review of partial anterior cruciate ligament tears. J Bone Joint Surg Am 91(1):198–208View ArticleGoogle Scholar
- Farquharson-Roberts MA, Osborne AH (1983) Partial rupture of the anterior cruciate ligament of the knee. J Bone Joint Surg Br 65(1):32–34Google Scholar
- Finsterbush A, Frankl U, Mann G (1989) Fat pad adhesion to partially torn anterior cruciate ligament: a cause of knee locking. Am J Sports Med 17(1):92–95View ArticleGoogle Scholar
- Friedman RL, Jackson DW (1996) Magnetic resonance imaging of the anterior cruciate ligament: current concepts. Orthopedics 19(6):525–532Google Scholar
- Gelb HJ, Glasgow SG, Sapega AA, Torg JS (1996) Magnetic resonance imaging of knee disorders. Clinical value and cost-effectiveness in a sports medicine practice. Am J Sports Med 24(1):99–103View ArticleGoogle Scholar
- Hong SH, Choi JY, Lee GK, Choi JA, Chung HW, Kang HS (2003) Grading of anterior cruciate ligament injury. Diagnostic efficacy of oblique coronal magnetic resonance imaging of the knee. J Comput Assist Tomogr 27:814–819View ArticleGoogle Scholar
- Johannsen HV, Fruensgaard S (1988) Arthroscopy in the diagnosis of acute injuries to the knee joint. Int Orthop 12(4):283–286View ArticleGoogle Scholar
- Katz JW, Fingeroth RJ (1986) The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries. Am J Sports Med 14(1):88–91View ArticleGoogle Scholar
- Kelly MA, Flock TJ, Kimmel JA (1991) MR imaging of the knee: clarification of its role. Arthroscopy 7(1):78–85View ArticleGoogle Scholar
- Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL (2004) The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy 20(7):696–700View ArticleGoogle Scholar
- Lefevre N, Naouri JF, Bohu Y, Klouche S, Herman S (2014) Sensitivity and specificity of bell-hammer tear as an indirect sign of partial anterior cruciate ligament rupture on magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 22(5):1112–1118View ArticleGoogle Scholar
- Lelli A1, Di Turi RP, Spenciner DB, Dòmini M (2014) The “Lever Sign”: a new clinical test for the diagnosis of anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. Dec 25Google Scholar
- Lintner DM, Kamaric E, Moseley JB, Noble PC (1995) Partial tears of the anterior cruciate ligament. Are they clinically detectable? Am J Sports Med 23(1):111–118View ArticleGoogle Scholar
- Liu SH, Osti L, Henry M, Bocchi L (1995) The diagnosis of acute complete tears of the anterior cruciate ligament. Comparison of MRI, arthrometry and clinical examination. J Bone Joint Surg Br 77(4):586–588Google Scholar
- McDaniel WJ (1976) Isolated partial tear of the anterior cruciate ligament. Clin Orthop Relat Res 115:209–212 (Mar-Apr) Google Scholar
- Meuffels DE, Poldervaart MT, Diercks RL, Fievez AW, Patt TW, Hart CP, Hammacher ER, Fv Meer, Goedhart EA, Lenssen AF, Muller-Ploeger SB, Pols MA, Saris DB (2012) Guideline on anterior cruciate ligament injury. Acta Orthop 83(4):379–386View ArticleGoogle Scholar
- Noyes FR, Mooar LA, Moorman CT III, McGinniss GH (1989) Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency. J Bone Joint Surg Br 71(5):825–833Google Scholar
- Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Myriam Hunink MG (2003) MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology 226(3):837–848View ArticleGoogle Scholar
- Portney LG, Watkins MP (2000) Foundations of Clinical research: Applications to Practice, 2nd edn. Prentice Hall Health, Saddle RiverGoogle Scholar
- Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K (2007) A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 15(12):851–856Google Scholar
- Steckel H, Vadala G, Davis D, Fu FH (2006) 2D and 3D 3-tesla magnetic resonance imaging of the double bundle structure in anterior cruciate ligament anatomy. Knee Surg Sports Traumatol Arthrosc 14(11):1151–1158View ArticleGoogle Scholar
- Umans H, Wimpfheimer O, Haramati N, Applbaum YH, Adler M, Bosco J (1995) Diagnosis of partial tears of the anterior cruciate ligament of the knee: value of MR imaging. AJR Am J Roentgenol 165(4):893–897View ArticleGoogle Scholar
- van Eck CF, van den Bekerom MP, Fu FH, Poolman RW, Kerkhoffs GM (2013) Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc 21(8):1895–1903View ArticleGoogle Scholar
- Yao L, Gentili A, Petrus L, Lee JK (1995) Partial ACL rupture: an MR diagnosis? Skeletal Radiol 24(4):247–251View ArticleGoogle Scholar
- Zantop T, Brucker PU, Vidal A, Zelle BA, Fu FH (2007) Intraarticular rupture pattern of the ACL. Clin Orthop Relat Res 454:48–53View ArticleGoogle Scholar