Diagnostic Accuracy of Physical Examination Tests for Suspected Acute Anterior Cruciate Ligament Injury: A Systematic Review and Meta-Analysis.

Background: Many tests are used to examine the knee when anterior cruciate ligament (ACL) injury is suspected. However, evidence of diagnostic accuracy in the Lachman, anterior drawer, pivot shift, and lever sign tests is limited. Purpose: The purpose of this study was to perform a systematic review and meta-analysis of original research studies that assessed the diagnostic accuracy of four physical examination tests for ACL injury acutely after an injury. Study design: Systematic review and meta-analysis. Methods: A literature search was conducted in the PubMed, MEDLINE, CINAHL, Web of Science, and Ichushi databases. Original articles with prospective cohort and cross-sectional studies in English and Japanese were included. The searched words were "anterior cruciate ligament", "injury"," rupture"," tear", "lachman test", "pivot shift test", "anterior drawer test", "lever sign test". The methodological quality of the diagnostic studies was evaluated using QUADAS-2. Summary sensitivity, specificity, likelihood ratio (LR)+, and LR- with 95% confidence intervals were calculated. Results: Eight studies were included in this review. The methodological quality of the included studies was mostly favorable. For the domain of flow and timing in the QUADAS-2, three studies did not assess the timing between the reference and index tests. The pooled sensitivities were 0.79, 0.78, 0.55, and 0.82 in the Lachman, anterior drawer, pivot shift, and lever sign tests, respectively, and the pooled specificities were 0.91, 0.91, 0.96, and 0.88, respectively. The lever sign test had the lowest LR- (0.21) and the pivot shift test had the highest LR+ (11.60). The area under the curve for the four physical examinations was > 0.70. Conclusion: The lever sign and pivot shift tests are useful for diagnosing ACL injuries in an acute setting. Level of Evidence: Level 2.