Reliability and validity of the Lever Sign Test in suspected ligament and/or meniscus injury of the knee : a comparison between orthopedic surgeon and physical therapist
Creators: name: Cavelti, David
name: Grehn, Holger
name: Luomajoki, Hannu
Publisher: name: ZHAW Zürcher Hochschule für Angewandte Wissenschaften
Year: 2024
Subjects: 615.82: Physiotherapie
617.5: Orthopädische Chirurgie

description: Introduction: Background. Anterior cruciate ligament rupture is the most common ligament injury to the knee. According to SUVA accident statistics (as of 2019), over 37,000 occupational and non-occupational accidents involving knee injuries occur in Switzerland every year. According to a report by the Swiss Medical Board from 2009, around 10,000 -12,000 people suffer an injury to the anterior cruciate ligament (ACL) every year. In 2016, the inventor of the Lever Sign Test, Allessandro Lelli, published an article in which he presented the Lever Sign Test for the examination of an ACL lesion. The results of his study were excellent. The advantages of the Lever Sign test over the established standard tests described in the literature could help to improve the diagnosis of an ACL rupture, spare patients unnecessary examinations and reduce healthcare costs. The purpose of this study was to investigate the intertester reliability and validity of the Lever Sign Test. Intertester reliability has received little attention in previous studies. In order to make comparisons with other studies, the intertester reliability and validity of the Lachman and Anterior Drawer Tests were also calculated.
Methods: Location and period. The cross-sectional study was conducted from March 2021 to December 2021 in the orthopaedic consultation department of the Cantonal Hospital of Graubünden (Chur/Switzerland). Tests and testers. The intertester reliability and criterion validity of the Lever Sign, Lachman and Anterior Drawer Tests were examined. The tests were administered in a randomized and blinded manner by an experienced senior orthopaedic physician with 17 years of professional experience and by a physiotherapist with 12 years of professional experience. Inclusion criteria. Patients between the ages of 18 and 50 with suspected ligament and/or meniscus injuries were included. Exclusion criteria were suspected malignant, systemic or central neurological diseases, acute cartilage injuries, suspected fracture or knowledge of the knee findings. Assessment. The Lever Sign Test was examined in a standardized manner (Fig. 1a-c). The Lachman Test and Anterior Drawer Test were tested as described in the literature.
Results: Drop outsand subgrouping. There were two drop-outs, one due to a suspected fracture and the second due to exceeding the age limit for the inclusion criteria. Due to the small sample size and in order toreflect the reality of orthopaedicconsultations, no further subgrouping was made, for example into chronic or acute injuries. Test evaluation. The three tests were assessed as either positive or negative. If the tests were not meaningful or could not be performed, the result (NA) was removed from the analysis. The reasons for this were pain, fear of performing the test, restricted movement or severe protective spasm.
Discussionand Conclusion: Overview.The hypothesis that the intertester reliability of the Lever Sign Test would be moderate to good was confirmed in the study. As described in the literature, the Lachman test remains the most valid. Intertester reliability. The range of Cohen's kappa in the reliability studies published to date on the Lever Sign Test varies greatly between κ= 0.3 -0.82. Due to the low number of studies about reliability of the Lever Sign test and the heterogeneity of the study designs, it is difficult to make comparisons. Sensitivity and specificity. The range of sensitivity in the previous studies extends from 0.37 -1.00. A possible reason for low SN values could be the inclusion criteria, the experience or the profession of the investigators. The specificity in the present study is 0.89 and 0.79, similar to most previous studies. It appears that the Lever Sign Test is well suited for the inclusion of an ACL injury. 
Why the test device?
• A soft surface can have a negative influence on the test result.
• The hand width and the place where the hand is placed have an influence on the result. 
Weaknesses of the study
• The results of this study are only consistent with the population in outpatient consultations.
• Information bias because of knowledge of the patient's medical history.
• The inclusion of meniscus and/or other ligament injuries can be regarded as a confounder.
• The functional mechanism of the test remains unclear.