Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review

Abstract

Background: Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. Methods: Study Design: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots. Results: A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy. Conclusion: Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research. Clinical relevance: Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.

Does the Lever Sign Test Have Added Value for Diagnosing Anterior Cruciate Ligament Ruptures?

“…The diagnostic accuracy of the other ACL tests is well established in multiple meta-analyses and systematic reviews. 1,9,16,18,19,21 In accordance with the current study, the Lachman test appears to have the highest diagnostic accuracy overall, while the pivot-shift test has the highest specificity but low sensitivity. However, the low diagnostic accuracy of the anterior drawer test is in contrast with the high specificity in the current study.…”

“…9 The included articles in the meta-analyses and systematic reviews were of low-level evidence because of different observational designs with diverse patient populations, resulting in a large interstudy heterogeneity. 16,19 A difference between the current study when compared with other studies is the recruitment of patients. The majority of studies in the literature only reported physical examination findings of patients with known ACL injuries based on MRI or an arthroscopic examination.…”

Diagnostic Value of Oblique Coronal and Oblique Sagittal Magnetic Resonance Imaging (MRI) in Diagnosis of Anterior Cruciate Ligament (ACL) Tears

“…[ 8 ] On the other hand, arthroscopy is another diagnostic method which allows direct visualization of all intra-articular structures. [ 9 ] But this method is relatively expensive and invasive [ 10 ], therefore, finding a new method or new procedure with high diagnostic value in evaluating ACL injury is needed. Tackling this issue, Kosaka et al demonstrated that a new method was not needed, as MRI accuracy can be increased by using a different view of knee lesions such as ACL injury.…”

Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study

“…Lateral compartment translation and the tibial acceleration Please see "Appendix" section for the Pivot Study Group members. physical examination, instrumented testing, diagnostic imaging, and arthroscopic findings [5,27,47,52].…”

“…The clinical identification of an ACL lesion is based on several physical examination tests [2,15,17,25,48,52], each one with its own specificity and sensitivity [5,21,52]. The most commonly used tests are designed to evaluate the knee laxity in the sagittal plane and include the Lachman and anterior drawer [15,17,19,35,50].…”