Lever Sign Test: Is it Sensitive for the Diagnosis of Anterior Cruciate Ligament Disruption?

Fahmy Samir Fahmy, MD; Hossam Fathi, MD


Curr Orthop Pract. 2019;30(4):343-346. 

In This Article

Abstract and Introduction


Background: Anterior cruciate ligament (ACL) tear is a common knee injury with various manual tests used for clinical diagnosis. The aim of this prospective study was to evaluate the lever sign test sensitivity as a new clinical test for diagnosis of ACL disruptions compared to other manual diagnostic tests.

Methods: One hundred patients with chronic ACL tears were included in this study between January 2017 and March 2018. The mean age was 29.1±8.2 yr. Four clinical tests (anterior drawer, Lachman test, pivot shift, and lever sign) were obtained in all patients by two different clinicians. The contralateral uninjured knees were used as controls for comparison. The sensitivity of these tests was estimated with recording of the interobserver reliability for lever sign test. Statistically significant differences between the lever test and other clinical tests were assessed using chi-square analysis.

Results: The recorded sensitivities of anterior drawer, pivot-shift, and Lachman tests were 82%, 88%, and 91%, respectively. The sensitivity of the lever sign test was much lower (34%) with 100% interrater reliability. There was a statistically significant difference between the lever sign test and other physical tests (P-value<0.05).

Conclusions: The lever sign test has much lower sensitivity than other clinical diagnostic tests in patients with chronic ACL lesions. More biomechanical studies should be carried out to prove the validity of this test for the diagnosis of ACL injuries.

Level of evidence: Level III.


Anterior cruciate ligament (ACL) disruption is a common knee injury in clinical practice. The reported incidence is 35 in 100,000 population, with approximately 100,000 reconstructions being performed per year.[1–3] The most common mechanism of injury is a twisting, noncontact trauma of the limb fixed to the ground during sports activities.[4]

The most accurate method for diagnosis of an ACL tear is direct visualization through diagnostic arthroscopy. MRI is widely accepted as a gold standard tool for diagnosis of knee injuries because it is noninvasive with excellent sensitivity and specificity (94% to 98%).[5–7]

Clinical examination of the injured knee is important and integral to imaging because it gives a clue to the diagnosis and detects other knee injuries. The most common diagnostic tests of (ACL) tears are the Lachman, anterior drawer, and pivot shift tests. These tests have wide variations in sensitivity and specificity. Acute injury, partial tears, and muscle guarding are the main factors that may negatively affect the accuracy of these clinical tests.[8–10]

In 2005, a new clinical test for ACL diagnosis called the lever sign was described.[11] The preliminary results of this test were 100% sensitivity in acute, chronic, complete, and partial tears. The authors stated that it was much superior to the classic diagnostic tests.[11] The goal of this study was to record the sensitivity of the lever sign test in patients with chronic ACL disruptions and compare the results with the other clinical tests.

Our hypothesis was that the lever sign test has a poor sensitivity for the diagnosis of ACL injuries compared with other manual diagnostic tests.