Execution
- 1Position the patient supine with the knee fully extended on the table.
- 2Place a closed fist under the proximal third of the calf so the knee flexes slightly.
- 3Apply a moderate downward force to the distal third of the quadriceps or femur.
- 4Watch whether the heel rises off the table.
- 5Compare the response with the opposite knee.
Positive outcome
If the ACL is intact, the heel lifts from the table. The test is positive when the heel does not lift and the tibial plateau translates anteriorly relative to the femoral condyles. Magee cautions that the test should not be used in isolation for ACL diagnosis.
Studies
| Study | Reliability | Sn | Sp | LR+ | LR− |
|---|---|---|---|---|---|
| Lelli et al. (2016) | NA | 100 | 100 | infinity | 0 |
| Jarbo et al. (2017) | NA | 63 | 90 | 6.3 | 0.41 |
CommentThe original Lever Sign report found perfect sensitivity and specificity, but later studies show more variable performance. The early infinite LR+ is likely small-sample and spectrum optimism. It is a useful low-irritability adjunct, especially when Lachman is painful, but should be combined with standard ACL tests.
Moderate Clinical Value