Assessing ACL Injuries with the Lever Sign

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A July 2021 study from Acta Ortopédica Brasileira concluded that the Lever Sign is a near-perfect test for detecting ACL injuries:

“The Lever Sign test shows to be a maneuver of easy execution, with 100% specificity and 100% PPV [positive predictive value]" (1)

A 2017 study from The Orthopaedic Journal of Sports Medicine produced similar encouraging findings:

“The Lever sign (aka Lelli test) is a new orthopedic examination tool to diagnose anterior cruciate ligament (ACL) tears. Preliminary results suggest almost 100% sensitivity and specificity to diagnose acute and chronic complete ACL tears and clinically significant partial tears as compared with magnetic resonance imaging (MRI).” (1)

Check out this 60-second ChiroUp Smarter by the Minute tutorial video to see the test in action.

1. How Do You Perform the Lever Sign?

With the patient in a supine position, the injured knee in full extension, and the heel resting on the examination table, the clinician places a closed fist under the proximal third of the calf at the level of the tibial tubercle to act as a fulcrum.  With the other hand, the clinician pushes in an anterior-to-posterior direction on the distal third of the quadriceps muscle. If the ACL is intact, it will counteract the downward gravitational force on the foot, and the heel will rise off the examination table. If the ACL is not intact, it cannot counteract the gravitational force, and the heel will stay on the examination table as the tibia slides anteriorly on the femur. (3)

2. How Does the Diagnostic Accuracy Compare to Other Assessments?

Historically, the three most common tests to investigate ACL integrity are the Anterior Drawer, Lachman, and Pivot-Shift Test.

Lelli et al. (2016) compared the Lever Sign to actual MRI results for a suspected ACL injury. The Lever Sign had a sensitivity and specificity of nearly 100% in patients with acute or partial tears.  The Lachman, Anterior Drawer, and Pivot-Shift Tests had sensitivities of 42%, 29%, and 11%, respectively. (3)

3. How Do You Incorporate the Lever Sign in Practice?

To deliver the best care, you must have easy access to the best information. Rest assured that your ChiroUp team will continue to find new ways to make your job easier.

The Lever Sign has been recorded and is available for subscribers to review in the ChiroUp Clinical Evaluations section of the Clinical Skills tab. It is also listed on the updated ChiroUp knee exam form.

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* ChiroUp would like to extend a special thank you to fellow subscriber Mike Krasnov for initially introducing us to this valuable test. Mike is a rock-star clinician who strengthens our profession.

• References

  1. Sobrado MF, Bonadio MB, Ribeiro GF, Giglio PN, Helito CP, Demange MK. Lever sign test for chronic acl injury: a comparison with lachman and anterior drawer tests. Acta Ortopédica Brasileira. 2021 Jul 2;29:132-6. Link

  2. Jarbo KA, Hartigan DE, Scott KL, Patel KA and Chhabra A. Accuracy of the Lever Sign Test in the Diagnosis of Anterior Cruciate Ligament Injuries. The Orthopaedic Journal of Sports Medicine, 5(10), 2017.

  3. Lelli A, Di Turi RP, Spenciner DB, Domini M. The “lever sign”: a new clinical test for the diagnosis of anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2794-2797.