Lever Sign Test for ACL Tears

Key Takeaways

The lever sign test is a clinical examination maneuver used to assess anterior cruciate ligament (ACL) integrity in the knee, also known as Lelli’s test.

The test shows high sensitivity (80-90%) for ACL tears and requires no imaging equipment, making it practical for emergency and physiotherapy settings.

A positive lever sign (heel does not rise when downward pressure is applied to the distal thigh) suggests ACL disruption and warrants further investigation.

Practice management software like Pabau enables standardized documentation of lever sign test findings through structured assessment templates, with easy integration into patient records.

Download your free lever sign test assessment template

Healthcare professionals performing musculoskeletal assessments need a reliable, low-cost screening tool for anterior cruciate ligament (ACL) injuries. The lever sign test (also called Lelli’s test) offers exactly that. It is a simple, equipment-free maneuver for any clinical setting, from sports medicine to physiotherapy to emergency departments.

This guide walks through the test procedure, interprets findings, and reviews diagnostic accuracy data. It also provides a downloadable template to standardize documentation in your practice.

What is the lever sign test? Clinical definition and purpose

The lever sign test is a physical examination technique used to assess the integrity of the anterior cruciate ligament (ACL). In fact, the ACL is the primary stabilizer of the knee joint. First described by Lelli et al. in 2016, the test is also known as Lelli’s test or the lever test.

It relies on a simple biomechanical principle. When the ACL is intact, the knee maintains a stable lever arm under a specific directional force. Conversely, when the ACL is torn or ruptured, that lever arm collapses, producing a specific clinical sign.

The lever sign test is distinct from other ACL screening tests like the Lachman, anterior drawer, and pivot shift tests. Notably, it requires no special equipment and no specialized positioning. The standard supine position is used, and it needs no prior training beyond understanding the procedure.

Indeed, it can be performed in seconds. It stays sensitive even in acute injury settings where patient guarding makes other tests hard to interpret. Like the Finkelstein test for wrist tendon pain, the lever sign is a quick bedside special test. Typically, clinicians use these tests before ordering imaging.

• Indication: Suspected ACL tear or rupture
• Patient population: Any patient presenting with acute or chronic knee pain, instability, or mechanism of injury consistent with ACL injury
• Equipment required: None-the clinician’s fist and applied force are the only tools needed
• Clinical setting: Suitable for physiotherapy and sports medicine practices, emergency departments, and primary care

How to perform the lever sign test: Step-by-step procedure

The lever sign test procedure is straightforward and takes seconds to perform. Following a consistent sequence ensures reliable, reproducible findings. It also enables accurate comparison across repeat examinations of the same patient or across your practice’s patient population.

1. Patient positioning: Place the patient supine (lying on their back) on an examination table or bed. The patient’s legs should be relaxed and extended.
2. Examiner hand placement: Position your fist under the patient’s proximal tibia (the upper shin, just below the knee joint). Thus, your closed fist acts as a fulcrum or lever point.
3. Apply downward pressure: Place your other hand on the distal femur, just above the knee. Apply firm, steady downward pressure-gentle enough to avoid discomfort but firm enough to load the knee.
4. Observe the heel: Watch the patient’s heel carefully. In an intact ACL, the heel lifts off the table as you apply pressure. As a result, the tibia “levers” up under the load. In a torn ACL, the heel remains flat on the table (does not rise).
5. Record the finding: Document whether a heel lift occurred. A heel lift means a negative test (ACL likely intact); no heel lift means a positive test (ACL likely disrupted).

Additionally, the test can be repeated 2-3 times on the same leg to confirm consistency. It should also be performed bilaterally, on both legs, to allow comparison. A positive finding on one leg compared to the unaffected side increases clinical confidence in the result.

Interpreting results: Positive vs negative lever sign test

Understanding what each test result means is critical for deciding whether further investigation (imaging or specialist referral) is warranted. Importantly, a single physical examination test never rules an ACL tear in or out on its own. Instead, all findings must be integrated with the patient’s history, mechanism of injury, and other clinical signs.

• Negative lever sign (heel lifts): The tibia levers upward when downward pressure is applied to the distal femur. This is a normal, expected response and therefore suggests the ACL is functionally intact. In other words, the patient likely does not have an acute ACL tear.
• Positive lever sign (heel does not lift / remains flat): The heel stays flat on the table. It does not rise despite downward pressure on the thigh. This indicates loss of the normal lever mechanism. Therefore, it suggests the ACL has been disrupted-either a complete tear, partial tear, or severe sprain.
• Equivocal result: The heel may partially lift, or the result may be unclear. Often, patient guarding, pain, or anatomical variation can cause this. Repeating the test or performing additional ACL tests (Lachman, anterior drawer) helps clarify the finding.

Diagnostic accuracy: Sensitivity and specificity of the lever sign test

The clinical value of the lever sign test lies in its diagnostic accuracy. This measures how reliably it identifies patients who have ACL tears versus those who do not. Two metrics dominate this discussion. Sensitivity is the test’s ability to detect ACL tears when they are present. Specificity is, by contrast, its ability to rule out ACL tears when they are absent.

These figures come from the original Lelli study and subsequent peer-reviewed validation research. The lever sign test compares favorably to older ACL tests. Moreover, it has a particularly high negative predictive value. A negative result is therefore highly reassuring that the ACL is intact.

Lever sign test vs other ACL tests: Lachman, anterior drawer, and pivot shift

Clinicians have several physical examination options for ACL screening. However, each has advantages and limitations. The table below compares the lever sign test to the most commonly used alternatives.

The lever sign test’s key advantage is ease of use in acute settings. Specifically, it requires no patient repositioning and minimal technical skill. It is particularly valuable in emergency departments, primary care, and sports injury settings where rapid ACL assessment informs referral decisions. Use the lever sign test alongside other clinical findings, such as patient history, mechanism, and pain pattern. Do not rely on any single test.

Clinical applications: When and how to use the lever sign test in practice

The lever sign test fits into a practical clinical workflow at specific decision points. Knowing when to apply it-and when to combine it with other tests or imaging-supports better patient outcomes. It also makes efficient use of your practice’s time and resources.

• Acute knee injury (within 2 weeks): The lever sign test is highly sensitive in acute settings. Soon after injury, the knee has not yet developed the protective muscle guarding that can mask a positive finding. Use it as a first-line screening test in emergency departments and urgent care clinics. A confirmed tear often proceeds to diagnostic knee arthroscopy, billed under CPT code 01382.
• Chronic knee instability: Patients with long-standing instability may develop compensatory muscle strength. Consequently, this can produce false-negative results on some tests. Use the lever sign test alongside the Lachman test and patient history for confirmation.
• Sports medicine clearance: Athletes returning to sport after knee injury need ACL status confirmed. A negative test with low clinical suspicion can help clear return-to-play decisions. Logging the result in sports medicine software keeps it alongside imaging and rehab notes. In contrast, a positive test warrants imaging and specialist referral.
• Primary care screening: In general practice, the lever sign test offers a quick, accessible way to triage knee pain. It helps decide whether a patient needs orthopedic referral or can be managed conservatively.
• Physiotherapy reassessment: Track changes in lever sign test results across a course of rehabilitation, combined with manual muscle testing. Ultimately, this helps monitor ACL healing. It also flags when conservative treatment is not progressing and specialist input is needed.

A structured assessment template-like the downloadable form above-ensures consistent documentation across your team. It supports quality improvement by tracking which findings led to which clinical decisions and outcomes.

How to document lever sign test findings in your practice management system

Recording test findings in a standardized way lets your team track outcomes and audit accuracy. It also helps demonstrate that care meets professional standards. Digital documentation systems that integrate with patient records keep findings accessible to everyone involved in the patient’s care. They also retain findings as part of the permanent clinical record.

When documenting your lever sign test findings, capture:

1. Test date and time – Essential for tracking longitudinal changes if the test is repeated.
2. Test result (positive/negative/equivocal) – Use clear language. Avoid ambiguity: “Positive lever sign: heel did not rise on downward thigh pressure” is clearer than “possible positive.”
3. Limb tested (left/right/bilateral) – Specify which knee(s) were examined and, if bilateral, note any asymmetry.
4. Patient response (pain, guarding, cooperation) – Record any pain or muscle guarding during testing. Importantly, these factors affect test reliability. Note if the patient was unable to cooperate fully.
5. Examiner notes and clinical context – Note how the result fits with other ACL tests, patient history, and clinical impression. Example: “Positive lever sign in context of acute mechanism and positive Lachman → recommend orthopedic referral for MRI.”
6. Next steps and referral status – If a positive result led to specialist referral or imaging, document that decision. If the test was negative and no further action taken, note that rationale.

Many practices use digital intake forms built into physical therapy EMR systems to create custom fields for physical examination findings. Overall, this structure ensures no detail is missed. It also creates a searchable database of test results that supports quality improvement and research.

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Conclusion

The lever sign test offers a quick, sensitive, equipment-free way to screen for ACL injuries at the point of care. It suits physiotherapists, sports medicine clinicians, and emergency practitioners alike. Its combination of ease, reliability, and high negative predictive value makes it an ideal first-line tool for knee injury assessment.

Documenting findings consistently with a structured template-like the downloadable form above-helps your team maintain high-quality clinical records. Above all, these records support patient safety and enable outcome tracking. Combined with patient history, mechanism of injury, and other clinical tests, it becomes a powerful part of your diagnostic toolkit.

Continue your research

Curious about other quick bedside orthopedic tests? Our foot stress fracture test guide covers a similarly fast lower-limb screening technique clinicians use before ordering imaging.

Need to screen for hip pain too? The resisted external derotation test uses a similar hands-on approach to assess gluteal tendon pathology.

Want to audit your clinical decision-making over time? Insights Plus, an upcoming add-on for deeper reporting, is designed to track examination findings and outcomes to support quality improvement initiatives.

Frequently asked questions about the lever sign test