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Higher sensitivity with the lever sign test for diagnosis of anterior cruciate ligament rupture in the emergency department

  • Arthroscopy and Sports Medicine
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript



The objective of this study was to assess the diagnostic value of the “lever sign test” to diagnose ACL rupture and to compare this test to the two most commonly used, the Lachman and anterior drawer test.


This prospective study was performed in the ED of the Cliniques Universitaires Saint-Luc (Brussels, Belgium) from March 2017 to May 2019. 52 patients were included undergoing knee trauma, within 8 days, with an initial radiograph excluding a fracture (except Segond fracture or tibial spine fracture). On clinical investigation, patients showed a positive lever sign test and/or a positive Lachman test and/or a positive anterior drawer test. Exclusion criteria were a complete rupture of the knee extensor mechanism and patellar dislocation. All the physicians involved in this study were residents in training. An MRI was performed within 3 weeks for all included patients after the clinical examination. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were investigated for all three tests with MRI used as our reference standard.


Forty out of 52 patients suffered an ACL rupture (77%) and 12 did not (23%). The sensitivity, specificity, PPV and NPV of the lever sign test were respectively 92.5%, 25% 82% and 50%. Those of the Lachman test were 54%, 54.5%, 81% and 25%, and those of the anterior drawer test were 56%, 82%, 90.5% and 37.5%. Twelve out of 40 ACL ruptures (30%) were diagnosed exclusively with a positive lever sign test.


When investigating acute ACL ruptures (< 8 days) in the ED, the lever sign test offers a sensitivity of 92.5%, far superior to that of other well-known clinical tests. The lever sign test is relatively pain-free, easy to perform and its visual interpretation requires less experience. Positive lever sign test at the ED should lead to an MRI to combine high clinical sensitivity with high MRI specificity.

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This study received no specific funding or grant.

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Authors and Affiliations



Prospective study performed in close collaboration between 3 departments of a teaching Hospital (Emergency Department, Radiology Department, Orthopedics and Traumatology Department).

All authors fulfill the criteria according to the ICMJE Guidelines.

All authors contributed to the study design. The lever sign test teaching for all involved residents was conducted by Kevin Guiraud, Christophe Bastin, Guillaume Silvestre and Philippe Meert.

Christophe Bastin and Philippe Meert oversaw the unfolding of the study in the emergency department. MRI appointment were scheduled by Frederic Lecouvet. MRI studies were analyzed by Frederic Lecouvet and Dimitar Boyadzhiev. Data collection was performed by Kevin Guiraud. Statistical analysis and tables were performed by Adrian Benitez. Litterature review was performed by Kevin Guiraud and Guillaume Silvestre. The first draft of the manuscript was written by Kevin Guiraud and all authors commented to polish its content. Emmanuel Thienpont supervised the study and critically reviewed each draft. All authors red and approved the final manuscript.

Corresponding author

Correspondence to Kevin Guiraud.

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Conflict of interest

The authors declare no conflicts directly related to this work.

Their individual conflicts are submitted under ICJME form with AOTS.

Ethical statement

Kevin Guiraud declares educational support: Resident Learning Course 2016 (Strasbourg, France)—Stryker. Educational support: Resident Learning Course 2016 (Lyon, France)—Zimmer Biomet. Educational support: Resident Learning Course 2017 (Lyon, France)—Zimmer Biomet. Educational Support: Course inscription 2020 (Brugges, Belgium)—TRB Chemedica AG.

Emmanuel Thienpont discloses (Institutional Support, Royalties, Board Societies, Speakers Bureau).

Speaker bureau—Convatec, KCI, Lima, Medacta, Zimmer Biomet. Royalties—Zimmer Biomet. Board Societies—EKS Board. Institutional Support—Zimmer Biomet.

Ethical approval

The Ethical Commitee of the Cliniques Universitaires Saint-Luc approved this protocol study (2016/06DEC/528—No. B403201630470).

Informed consent

Informed consent was obtained from all individual participants included in this study.

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Guiraud, K., Silvestre, G., Bastin, C. et al. Higher sensitivity with the lever sign test for diagnosis of anterior cruciate ligament rupture in the emergency department. Arch Orthop Trauma Surg 142, 1979–1983 (2022).

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