The primary goal of chiropractic physicians is to DIAGNOSE. And some of the most notable diagnoses in the knee involve the anterior cruciate ligament (ACL). Ruling out an ACL tear (acute or chronic) is essential before initiating treatment and rehab. Fortunately, there is a simple and reliable new test to help us identify ACL ruptures.
“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)
Watch this quick tutorial and review 3 steps for sharpening your knee “best practices”.
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. (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. (Click on the links below for a refresher)
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. (2) A subsequent evaluation of diagnostic utility for the Lever Sign demonstrated high, but not perfect accuracy with 63% sensitivity and 90% specificity. (1)
3. How Do You Incorporate the Lever Sign in Practice?
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* ChiroUp would like to extend a special thank you to fellow subscriber Mike Krasnov for introducing us to this valuable information. Mike is a rock-star clinician who makes our profession stronger. Be sure to follow the ChiroUp Facebook page this week for Mike’s video of tips for managing FAI.
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- 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.
- 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.
About the Author
Dr. Brandon Steele
DC, DACODr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.