Implementing the Lever Sign in the Emergency Department: Does it Assist in Acute Anterior Cruciate Ligament Rupture Diagnosis? A Pilot Study

J Emerg Med. 2019 Dec;57(6):805-811. doi: 10.1016/j.jemermed.2019.09.003. Epub 2019 Nov 7.


Background: Within the emergency department (ED) setting, anterior cruciate ligament (ACL) rupture is commonly misdiagnosed, leading to improper treatment and potential meniscal injury and total joint replacement. Utilizing traditional clinical tests to diagnosis ACL rupture leads to the correct diagnosis in about 30% of cases. The lever sign is a new and effective clinical test used to diagnose ACL rupture with 100% sensitivity.

Objective: We aim to study if the lever sign used in the ED setting is more sensitive to diagnose ACL rupture than traditional tests.

Methods: Patients between 12 and 55 years of age were examined utilizing either traditional methods or the lever sign. Diagnostic findings in the ED were compared with those of a sports medicine specialist using magnetic resonance imaging as the diagnostic standard. A survey was given to ED providers to collect data on diagnosis and physician confidence in diagnosis.

Results: The sensitivity of the lever sign was 100% (94.7% accuracy, 93.75% specificity), whereas the sensitivity of the anterior drawer/Lachman test was 40% (87.5% accuracy, 100% specificity). Physician confidence in diagnosis was higher utilizing the lever sign vs. the anterior drawer/Lachman test at 8.45 (±1.82) compared with 7.72 (±1.82) out of 10, respectively. There was no statistically significant association between diagnostic accuracy with either test and level of training of the ED provider.

Conclusion: Implementation of the lever sign in the ED setting resulted in a higher sensitivity, higher physician confidence in screening test diagnosis, and a decrease in the number of undiagnosed ACL ruptures.

Keywords: ACL; anterior cruciate ligament; lever sign; lever test.

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament / abnormalities
  • Anterior Cruciate Ligament / physiopathology
  • Anterior Cruciate Ligament Injuries / diagnosis*
  • Anterior Cruciate Ligament Injuries / physiopathology
  • Child
  • Emergency Service, Hospital / organization & administration
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Humans
  • Location Directories and Signs / standards*
  • Location Directories and Signs / statistics & numerical data
  • Male
  • Middle Aged
  • Physical Examination / methods
  • Pilot Projects
  • Sensitivity and Specificity