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Knee Surg Sports Traumatol Arthrosc. 2016 Sep;24(9):2794-7. doi: 10.1007/s00167-014-3490-7. Epub 2014 Dec 25.

The "Lever Sign": a new clinical test for the diagnosis of anterior cruciate ligament rupture.

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Villa Laura Multi-Specialty Clinic, Emilia Levante Street #137, 40124, Bologna, Italy.
DePuy Synthes Mitek Sports Medicine, 325 Paramount Drive, Raynham, MA, 02767, USA.
Unit of Pediatric Surgery, University of Bologna, Massarenti Street, 40138, Bologna, Italy.



A new clinical test for the diagnosis of ACL rupture is described: the so-called "Lever Sign". This prospective study on four groups of patients divided subjects on the basis of MRI findings (complete or partial ACL lesion) and the clinical phase of the injury (acute or chronic). The hypothesis was that this manual test would be diagnostic for both partial and complete tears of the ACL regardless of the elapsed time from injury.


A total of 400 patients were evaluated and divided into four, equal-sized groups based on time elapsed from injury and MRI findings: Group A (acute phase with positive MRI for complete ACL rupture), Group B (chronic phase with positive MRI for complete ACL rupture), Group C (acute phase with positive MRI for partial ACL rupture), and Group D (chronic phase with positive MRI for partial ACL rupture). Clinical assessment was performed with the Lachman test, the Anterior Drawer test, the Pivot Shift test, and the Lever Sign test. The Lever Sign test involves placing a fulcrum under the supine patient's calf and applying a downward force to the quadriceps. Depending on whether the ACL is intact or not, the patient's heel will either rise off of the examination table or remain down. Additionally, the Lever Sign test was performed on the un-injured leg of all 400 patients as a control.


All tests were nearly 100 % sensitive for patients with chronic, complete tears of the ACL. However, for patients with acute, partial tears, the sensitivity was much lower for the Lachman test (0.42), Anterior Drawer test (0.29), and Pivot Shift test (0.11), but not the Lever Sign test (1.00).


In general, chronic, complete tears were most successfully diagnosed but acute, partial tears were least successfully diagnosed. The Lever Sign test is more sensitive to correctly diagnosing both acute and partial tears of the ACL compared with other common manual tests. The clinical relevance is that some ACL ruptures may be more accurately diagnosed.


ACL rupture; Anterior Drawer test; Lachman test; Lever Sign test; Pivot Shift test

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