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

Abstract

Background:Diagnosing an anterior cruciate ligament (ACL) rupture based on a physical examination remains a challenge for both surgeons and physical therapists. The lever sign test was developed to overcome the practical limitations of other tests and to optimize diagnosis. An evaluation of the measurement properties of the lever sign test is needed to make adequate interpretations in practice.Purpose:To evaluate the reliability and diagnostic value of the lever sign test.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 94 patients were recruited between November 2014 and July 2016. Patients were included if they were at least 16 years old, suffered from knee trauma, and had indications for knee arthroscopic surgery. Lever sign, anterior drawer, Lachman, and pivot-shift test outcomes were examined by an orthopaedic/trauma surgeon and a physical therapist. A test-retest design was used to investigate interrater reliability. Moreover, the lever sign test outcomes, alone and in combination with the other diagnostic tests, were compared with arthroscopic results, which served as the gold standard for the test’s diagnostic value.Results:The lever sign test and pivot-shift test had kappa values exceeding 0.80 for interrater reliability. The kappa values for the anterior drawer test and Lachman test were 0.80 and 0.77, respectively. The lever sign test showed the highest specificity (100%) and the lowest sensitivity (39%) when compared with the other 3 tests. Moreover, its positive and negative predictive values were 100% and 65%, respectively, while an accuracy of 71% was calculated. Clustering the lever sign test parallel with the other 3 tests resulted in the highest accuracy of 91%.Conclusion:The lever sign test appears to have high interrater reliability and is the most specific test, showing a maximal positive predictive value. A positive lever sign test result indicates an ACL rupture. These results support the added value of the lever sign test for diagnosing ACL ruptures.

Comparing the Diagnostic Accuracy of Two Selective Tissue Tests for Anterior Cruciate Ligament Injuries: A Critically Appraised Topic

“…3,11 Lichtenburg et al found the sensitivity and specificity for the lever sign test to be 39% and 100%, respectively. 12 They found the values for the Lachman test to be 87% and 91%, respectively. While Lichtenburg et al also found that the sensitivity of the lever sign test was significantly lower than the Lachman test, it contradicts the other two studies by showing the specificity of the lever sign to be better than the Lachman test.…”

“…11 Lichtenburg et al compared tests to arthroscopic visualization. 12 Mulligan et al found the sensitivity and specificity values for the lever sign to be 33% and 50%, respectively. In comparison, the Lachman test had values of 65% and 100%, respectively.…”

“…3,11,12 The included studies compared the sensitivity and specificity values for the lever sign test and the Lachman test. 3,11,12 One study 11 included cohorts of patients under anesthesia when the tests were administered, and the others had cohorts of awake patients. 3,12 Jarbo et al compared results of the tests to the reference standard of MRI.…”

“…3,11,12 One study 11 included cohorts of patients under anesthesia when the tests were administered, and the others had cohorts of awake patients. 3,12 Jarbo et al compared results of the tests to the reference standard of MRI. 3 Mulligan et al compared tests to either MRI or the gold standard, arthroscopic visualization.…”

“…While Lichtenburg et al also found that the sensitivity of the lever sign test was significantly lower than the Lachman test, it contradicts the other two studies by showing the specificity of the lever sign to be better than the Lachman test. 3,11,12 Results of Evidence Quality Assessment…”