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

Materials and Methods

Patient Demographics

This prospective study was done on 100 patients with chronic, complete ACL tear at Zagazig University Hospitals between January 2017 and March 2018. The patients were diagnosed using MRI to confirm complete ligament tears. The patients were clinically examined using four physical tests including the lever sign test to assess ACL injury. This study was approved from our university's institutional review board ethical committee, and informed consents were obtained from the patients. The exclusion criteria of this study were partial ACL tears, acute ACL injuries (less than 4 wk), associated meniscal or chondral lesions, multi-ligamentous injuries, and bilateral ACL tears. Associated knee injuries were excluded to eliminate the variables that may give false negative results for this test. The demographic data of the studied group are summarized in (Table 1).

Technique of Lever Sign Test

The patients were clinically examined in the operating room before arthroscopic reconstruction and after induction of the anesthesia. Anterior drawer, Lachman, pivot-shift, and lever sign tests were performed by two different examiners on the injured and the normal knees for comparison. The lever sign test was done as described by Lelli et al.,[11] with the patient supine on the examination table with the knee completely extended. With the examiner standing on the injured side of the patient, his closed fist is placed under the proximal part of the patient's calf at the level of the tibial tuberosity. This results in slight knee flexion; the closed fist acts as a fulcrum and the patient's leg as a lever (Figure 1). With the other hand of the examiner, a downward force is exerted on the distal part of the patient's thigh. If the ACL is intact, the heel of the patient will lift off the examination table and the test is considered negative. When the ligament is torn, the downward force exerted on the distal third of the quadriceps cannot overcome the gravity force of the patient's leg. This will make the tibia shift forward on the femur and the heel will not rise up, which is considered positive.

Figure 1.

The examiner's closed fist under proximal third of the calf in a patient with a re-rupture of a previously reconstructed anterior cruciate ligament.

Statistical Analysis

Statistical analysis was done using SPSS Microsoft program version 25 (Microsoft, Chicago, USA). The numerical data were presented as mean±standard deviation. The sensitivity was recorded for all clinical tests with the interobserver reliability measured for the lever sign test. Chi-square test was used to compare the sensitivity of lever sign test with other tests. A P-value<0.05 was considered statistically significant.