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

Miranda C Lichtenberg; Christiaan H Koster; Lennart P J Teunissen; Frits G J Oosterveld; Annelieke M K Harmsen; Daniel Haverkamp; Daniel Hoornenborg; Robert P Berg; Frank W Bloemers; Irene R Faber

doi:10.1177/2325967118759631

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

Orthop J Sports Med. 2018 Mar 16;6(3):2325967118759631. doi: 10.1177/2325967118759631. eCollection 2018 Mar.

Affiliations

¹ Physical Therapy Practice Versgras, Winterswijk, the Netherlands.
² Department of Trauma Surgery, VU University Medical Center Amsterdam, Amsterdam, the Netherlands.
³ Faculty of Physical Activity and Health, Saxion University of Applied Sciences, Enschede, the Netherlands.
⁴ Department of Orthopaedic Surgery, Medical Centre Slotervaart, Amsterdam, the Netherlands.
⁵ Department of Orthopaedic and Trauma Surgery, Regional Hospital Koningin Beatrix, Winterswijk, the Netherlands.

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.

Keywords: ACL; anterior cruciate ligament; diagnosis; lever sign; physical test.