TDNet Discover

Background: The ACL is the most torn ligament in the knee and serves to stabilize the knee joint. The gold standard for diagnosing an ACL tear is an MRI or arthroscopy;however, these can be expensive and unnecessary if the diagnosis could be ruled out using clinical tests. The current guidelines suggest the use of Lachman, anterior drawer, and pivot shift tests to clinically diagnose an ACL tear, with Lachman being the gold standard. Current literature fails to incorporate factors like provider hand size and patient leg circumference that can make performing these tests more difficult, possibly skewing sensitivities and specificities of each test. Newer specialty tests, including MADT and lever sign test, have been established with these concerns in mind. Purpose: This research examines which of the newer ACL diagnostic tests - MADT and lever sign - yields the highest sensitivity and specificity and how this compares to older ACL diagnostic tests such as Lachman, anterior drawer, and the pivot shift test. Methods: An EBCR literature review was performed. Researchers initially screened articles by title and relevant articles underwent a full-text review. Remaining articles were further narrowed using a Quality Assessment Tool and Risk of Bias Tool. Finally, a data extraction tool was implemented to aid in the qualitative synthesis of the included studies. Results: The top 3 articles were used in the final review. The sensitivity of the lever sign test ranged from 0.37-1.00, with a pooled sensitivity of 77%. The specificity ranged from 0.50-1.00 with a pooled specificity of 90%. The sensitivity and specificity of the MADT were 89% and 94%, respectively. Anterior drawer yielded a sensitivity of 72.5% and specificity of 92.7%. The sensitivity of the pivot shift was 49%, and the specificity was 97.5%. The Lachman test yielded a sensitivity and specificity of 87.1% and 97%, respectively. Conclusion: In a suspected ACL injury, the MADT has the highest sensitivity and a very high specificity compared to other special tests. The sensitivity of the lever sign test is much more comparable to the Lachman than the anterior drawer and pivot shift tests are, making both the MADT and lever sign test great options for providers who are having a difficult time performing the Lachman test. Conversely, the pivot shift test had the greatest specificity. Finally, the current “gold standard”, the Lachman test, yielded a sensitivity slightly lower than the MADT and a slightly lower specificity than the pivot shift test, but remained the best overall diagnostic choice for ACL injury.