Lever Sign or Lelli’s Test | Anterior Cruciate Ligament Rupture Assessment

The Lever Sign, also known as Lelli’s Test is a new orthopedic test to assess the integrity of the anterior cruciate ligament (ACL).
A study comprised of 400 patients with either acute or chronic complete and incomplete tears evaluated the lever sign with a sensitivity and specificity of an outstanding 100%, which would make it a perfect test statistically speaking.  There might be a high risk of bias as the author is the founder of the test.

More studies have been conducted in the years after, amongst others from Jarbo et al. (2017), showing that this test is decent, but not perfect with a sensitivity of 63% and a specificity of 90%. Considering all study results, this test has a moderate clinical value to confirm ACL tears.

To conduct the test, have your patient in supine lying position with the leg fully extended. Place one fist under the proximal third of the patient’s calf and then apply moderate downward force to the distal third of the patient’s quadriceps.

With an intact ACL, the downward force applied to the quadriceps will result in knee extension and you will see the heel rise off the table indicating a negative test.

In a partially or completely ruptured ACL, the lever created by the ligament to offset gravity is impaired, which would result in anterior translation of the tibial plateau in relation to the femoral condyles. In this case, the heel will remain on the table indicating a positive test.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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Other common tests to assess for an ACL tear are:

• Anterior Drawer Test
• Lachman Test
• Lateral Pivot-Shift Test

Jarbo KA, Hartigan DE, Scott KL, Patel KA, Chhabra A. Accuracy of the lever sign test in the diagnosis of anterior cruciate ligament injuries. Orthopaedic journal of sports medicine. 2017 Oct 9;5(10):2325967117729809.

Lelli A, Di Turi RP, Spenciner DB, Dòmini M. The “Lever Sign”: a new clinical test for the diagnosis of anterior cruciate ligament rupture. Knee Surgery, Sports Traumatology, Arthroscopy. 2016 Sep;24(9):2794-7.

Mulligan, E. P., Anderson, A., Watson, S., & Dimeff, R. J. (2017). The diagnostic accuracy of the lever sign for detecting anterior cruciate ligament injury. International journal of sports physical therapy, 12(7), 1057.

Gürpınar, T., Polat, B., Polat, A. E., Çarkçı, E., & Öztürkmen, Y. (2019). Diagnostic accuracy of lever sign test in acute, chronic, and postreconstructive ACL injuries. BioMed Research International, 2019.

Massey, P. A., Harris, J. D., Winston, L. A., Lintner, D. M., Delgado, D. A., & McCulloch, P. C. (2017). Critical analysis of the lever test for diagnosis of anterior cruciate ligament insufficiency. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(8), 1560-1566.