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The lever sign test demonstrates limited clinical utility for diagnosing full-thickness anterior cruciate ligament tears after a traumatic knee injury

Norris R, Price A, Byrne J, Pulford S, van Melick N, Maddox TW, Boswell W, Kerin C, Oldershaw RA

Orthopaedic Journal of Sports Medicine 2025 May 14;13(5)

primary study

BACKGROUND: Current systematic reviews with meta-analyses have identified the lever sign test as the best clinical examination for ruling out an anterior cruciate ligament (ACL) tear, but the included studies have methodological limitations that could bias the test outcome, potentially overestimating its clinical utility. PURPOSE(S): To investigate the interrater reliability and concurrent validity of the lever sign test after a traumatic knee injury and to investigate the association between test variables (surface used, fist position, effusion grade, force applied, pain reported) and test outcomes. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHOD(S): The lever sign test was performed on hard and soft surfaces in 101 participants after a traumatic knee injury. Magnetic resonance imaging was used as the reference standard, with index testing performed after magnetic resonance imaging was conducted (>3 weeks after injury). Agreement between observers based on the surface used and fist position was evaluated with the Cohen kappa coefficient (kappa). Concurrent validity was assessed through sensitivity, specificity, and likelihood ratios. Logistic regression was used to determine whether effusion grade, force applied, and pain reported were significantly associated with test outcomes. RESULT(S): Interrater reliability was superior on the soft surface but demonstrated only moderate agreement (kappa = 0.529 [95% CI, 0.368 to 0.691]). Sensitivity was higher on the soft surface, and specificity was higher on the hard surface, for both assessors. At best, positive and negative likelihood ratios were 3.02 (95% CI, 1.60 to 5.69) and 0.45 (95% CI, 0.28 to 0.73), respectively. Test outcomes were affected by the surface used and fist position, but effusion grade, force applied, and pain reported were not significantly associated with correct/incorrect test results. CONCLUSION(S): In participants assessed from 3 weeks after a traumatic knee injury, the lever sign test demonstrated limited clinical utility for diagnosing full-thickness ACL tears. Test outcomes were affected by the surface used and fist position of the assessor. Registration: NCT05416632 (ClinicalTrials.gov).

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