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Lever test yielded high sensitivity, specificity in diagnosis of ACL injury
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Results of this level 2 study showed the lever test resulted in high sensitivity, specificity and overall accuracy in the detection of ACL tears.
"The lever test had a similar accuracy to more established ACL instability tests, is well-tolerated by injured patients, and is easy to learn,” Patrick C. McCulloch, MD, told Healio.com/Orthopedics. “As a dichotomous test that does not require grading (either the heel lifts off or it does not), it may be especially useful for those who do not perform ACL examinations routinely.”
Examiners blinded to the presence or absence of ACL injury performed the Lachman, anterior drawer, pivot shift and lever tests on 91 patients aged 16 years to 60 years who presented after a knee injury with subjective swelling or an objective effusion. All patients had an uninjured normal contralateral knee for comparison.
Results showed 78% of patients had MRI-confirmed complete ACL tears. McCulloch and colleagues found the lever test had a sensitivity of 83%, had a specificity of 80% and had an accuracy of 82%, which was not statistically significantly different from that of the Lachman, anterior drawer and pivot shift tests.
According to results, the timing of injury and additional ligament tears did not affect the accuracy of the lever test. However, researchers noted the presence of a meniscus tear led to a statistically significant difference in the accuracy of the lever test. The presence of a meniscus tear also led to decreased accuracy in the Lachman and anterior drawer tests, but led to no difference in the accuracy of the pivot shift test. – by Casey Tingle
Disclosures: McCulloch reports that he receives support from NIA Magellan, Genzyme, Slack, DePuy, Arthrex and Zimmer. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Theodore B. Shybut, MD
The study by Massey and colleagues suggests orthopedic surgeons can confidently add the lever test to their physical exam for diagnosing complete ACL tears. In the investigators’ hands, the lever test achieved similar accuracy to Lachman, pivot shift and anterior drawer tests, with no significant differences in sensitivity or specificity.
The methodology is thoughtful, grounded in prior literature with appropriate exclusion criteria and has good awareness of the importance of power in this study. Likewise, the section on limitations is well written. Key limitations (which the authors did recognize) were that MRI, rather than arthroscopy was used as the reference standard for ACL status, and their subanalyses were underpowered.
It remains to be seen how well the lever test will generalize to non-orthopedic sports surgeons (eg, primary care doctors, athletic trainers, etc.) examining injured knees. In addition, this study does not address partial- or single-bundle ACL tears, evaluation of previously ACL-reconstructed knees or ACL tears that were not detected on MRI.
Consistent with prior studies, the Lachman was most sensitive and the pivot shift test was most specific in this investigation. Thus, surgeons do not necessarily need to perform the lever test in addition to these maneuvers. However, I intend to do so — this study reminds us that even experienced orthopedic surgeons can learn new tricks of the trade.
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