, Volume 472, Issue 9, pp 2644-2657
Date: 07 Feb 2014

Stress Radiography for the Diagnosis of Knee Ligament Injuries: A Systematic Review

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Stress radiography is a widely used diagnostic tool to assess injury to the anterior and posterior cruciate ligaments and the medial and lateral structures of the knee. However, to date, numerous techniques have been reported in the literature with no clear consensus as to which methodology is best for assessing ligament stability.


The purpose of this review was to identify which stress radiographic techniques have support in the literature for the diagnosis of acute or chronic knee ligament injuries, to define which technique is most accurate and reliable for diagnosing knee ligament injuries, and to compare the use of stress radiography with other diagnostic tests.


Two independent reviewers performed a systematic review of PubMed (MEDLINE), the EMBASE library, and the Cochrane Controlled Trials Register for English language studies published from January 1970 to August 2013 on the diagnosis of knee ligament injuries using stress radiography. Information describing the ligament(s) investigated, stress radiographic technique, magnitude of force, measures of accuracy and reliability, and comparative diagnostic tests were extracted. Risk of bias was assessed using the QUADAS-2 tool.


A total of 16 stress techniques were described for stress radiography of the knee. The diagnostic accuracy of stress radiography including the sensitivity, specificity, and positive and negative predictive values varied considerably depending on the technique and choice of displacement or gapping threshold. Excellent reliability was reported for the diagnosis of anterior cruciate ligament, posterior cruciate ligament, varus, and valgus knee injuries. Inconsistencies were found across studies regarding the efficacy of stress radiography compared with other diagnostic modalities.


Based on the multitude of stress techniques reported, varying levels of diagnostic accuracy, and inconsistencies regarding comparative efficacy of stress radiography to other diagnostic modalities, we are not able to make specific recommendations with regard to the best stress radiography technique for the diagnosis of knee ligament injuries. Additional comparative studies using consistent methodology and appropriate blinding are necessary to further define differences in accuracy and reliability both among stress radiography techniques and between stress radiography and other diagnostic tests.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

One of the authors (RFL) is a paid consultant for Arthrex (Naples, FL, USA). One of the authors certifies that he (EWJ, BTW, RFL) or a member of his or her immediate family, has or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from Smith & Nephew Endoscopy (London, UK), less than USD 10,000 from Arthrex, Inc, less than USD 10,000 from Siemens Medical Solutions USA (Malvern, PA, USA), less than USD 10,000 from Sonoma Orthopedics, Inc (Santa Rosa, CA, USA), less than USD 10,000 from ConMed Linvatec (Largo, FL, USA), less than USD 10,000 from Össur Americas (Foothill Ranch, CA, USA), less than USD 10,000 from Small Bone Innovations, Inc (Morrisville, PA, USA), less than USD 10,000 from Opedix (Scottsdale, AZ, USA), and less than USD 10,000 from Evidence Based Apparel (Alignmed, Santa Ana, CA, USA).
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.
This work was performed at the Steadman Philippon Research Institute, Vail, CO, USA.