Knee Orthopaedic Test: Lever Sign Test

The Lever Sign Test assesses whether the heel lifts when a downward force is applied to the distal quadriceps region with the fist under the proximal calf. A positive test may occur when the heel does not lift, suggesting possible ACL involvement. Recent evidence suggests the Lever Sign Test may be useful, but diagnostic performance varies and it should be interpreted with other ACL tests and the clinical presentation.

Introduction

A client may present after a pivoting knee injury with swelling, giving way or concern about ACL injury. The Lever Sign Test offers a simple alternative or addition to Lachman, anterior drawer and pivot shift testing.

The test was introduced more recently than traditional ACL tests, and current evidence remains mixed. A 2022 systematic review of acute ACL examination tests included lever sign alongside Lachman, anterior drawer and pivot shift, highlighting that all ACL tests have context-dependent accuracy.  

Quick Summary

Test name: Lever Sign Test
Also known as: Lelli Test
Purpose: Assess possible ACL involvement using a passive lever mechanism
Body region: Knee
Commonly associated presentation: Suspected ACL injury, anterior knee instability, pivoting injury
Positive finding: Heel fails to lift from the table when downward force is applied
Negative finding: Heel lifts from the table during the test
Best used with: Lachman Test, Anterior Drawer Test, Pivot Shift Test, swelling assessment and mechanism of injury
Key limitation: Diagnostic accuracy varies and the test should not be used alone

What Is the Lever Sign Test?

The Lever Sign Test is an ACL special test performed with the client lying supine. The examiner places a fist under the proximal calf and applies downward pressure over the distal quadriceps. In a negative test, the heel lifts from the table. In a positive test, the heel remains on the table.

The proposed mechanism is that ACL disruption alters the lever system of the knee, preventing the heel from lifting normally.

Why It Is Used

The Lever Sign Test is used when ACL injury is suspected. It can be useful when traditional tests are difficult due to client guarding, examiner hand size or early assessment limitations, although it still requires careful interpretation.

What It Assesses

The test assesses heel lift response during a passive knee lever manoeuvre.

It does not directly visualise the ACL, determine tear severity, rule out partial injury or assess rotational instability by itself.

Who It Is Useful For

This test may be useful for clients with suspected ACL injury, pivoting knee injury, giving-way episodes, knee effusion or anterior instability.

It may not be suitable if the client cannot lie supine, has severe pain, suspected fracture, marked swelling or cannot tolerate pressure over the thigh/calf.

When to Use This Test

Use the test when ACL involvement is suspected and a non-invasive passive test is appropriate.

When Not to Use or When to Be Cautious

Use caution with severe acute pain, suspected fracture, open injury, high irritability, significant swelling or complex multi-ligament trauma.

Equipment Required

Treatment table
Pain scale
Measurz for recording
Optional comparison side notes
Optional referral notes

Step-by-Step Protocol / Practice

Setup

Position the client supine with both legs relaxed.

Client position

The tested leg rests on the table with the knee extended or near extension.

Examiner position

Stand beside the tested limb.

Hand placement

Place a closed fist under the proximal calf. Place the other hand over the distal quadriceps region.

Stabilisation

Ensure the client remains relaxed and does not actively lift the heel.

Movement or force direction

Apply a downward force over the distal quadriceps while the fist acts as a fulcrum under the calf.

Instructions

Ask the client to relax fully.

Positive finding

A positive Lever Sign Test is failure of the heel to lift from the table.

Negative finding

A negative test is visible heel lift from the table.

Stopping criteria

Stop if pain escalates, the client cannot relax or the test position is not tolerated.

Safety notes

Use controlled pressure and avoid excessive force.

Positive and Negative Test Interpretation

A positive Lever Sign Test may increase suspicion of ACL involvement when the heel does not lift and the history supports ACL injury.

A negative Lever Sign Test may reduce suspicion, but it does not exclude ACL injury. The result should be interpreted with Lachman, anterior drawer, pivot shift, swelling history and mechanism of injury.

Sensitivity, Specificity and Diagnostic Accuracy

A 2022 systematic review and meta-analysis on acute ACL examination included the Lever Sign Test and noted that evidence for diagnostic accuracy remains limited, with performance varying across studies.  

A 2022 study assessing the Lever Sign Test in primary care for acute knee injuries investigated sensitivity for ACL tears, showing ongoing interest in its role outside specialist settings but also reinforcing that it should be used alongside other findings.  

Because reported values vary by setting, examiner and reference standard, exact sensitivity and specificity should only be used when the study context matches.

Reliability and Validity

Reliability depends on client relaxation, fist position, force application, limb size and interpretation of heel lift.

Validity is strongest when the test is used as part of an ACL test cluster, not as a replacement for history, Lachman, anterior drawer, pivot shift or imaging when required.

Common Errors and Limitations

Common errors include placing the fist too distally, applying force too close to the knee, allowing active heel lift, failing to compare sides, using excessive force and interpreting an unclear heel movement as definite.

Limitations include body size variation, pain, guarding, partial tears and inconsistent study results.

Practical Applications

Use the Lever Sign Test as an additional ACL screen, especially when documenting a broader ACL assessment. It can be helpful as part of a multi-test approach.

How to Record This in Measurz

Record test name, side tested, result as positive, negative, unclear or unable to test, heel response, pain score, symptom location, guarding, comparison side, confidence in result, reason for stopping and related ACL findings.

Related Tests / Internal Links

Lachman Test
Anterior Drawer Test of the Knee
Pivot Shift Test
Slocum Test
Sweep Test
Posterior Drawer Test
Single-Leg Hop Tests

FAQs

What does the Lever Sign Test assess?

It assesses heel lift response during a passive knee lever manoeuvre used in suspected ACL injury.

What is a positive Lever Sign Test?

A positive test occurs when the heel fails to lift from the table.

Does the Lever Sign Test diagnose an ACL tear?

No. It supports clinical reasoning but does not confirm ACL rupture alone.

Should it replace the Lachman Test?

No. It is best used alongside established ACL tests.

What should be recorded?

Record heel response, pain, guarding, comparison side and confidence in the result.

Key Takeaways

The Lever Sign Test is used in suspected ACL injury.
A positive result is failure of the heel to lift.
Diagnostic accuracy varies across studies.
It should be interpreted with other ACL tests.
Record heel response and related findings in Measurz.

References

Tanaka, S., Inoue, Y., et al. (2022). Diagnostic accuracy of physical examination tests for suspected acute anterior cruciate ligament injury: A systematic review and meta-analysis. International Journal of Sports Physical Therapy, 17(5), 742–752.

Temponi, E. F., et al. (2022). Validity of the lever sign test for the clinical diagnosis of anterior cruciate ligament tears in primary care. Journal of ISAKOS, 7(5), 276–281.

Huang, W., et al. (2022). The diagnostic accuracy of clinical tests for anterior cruciate ligament injury: A systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 30, 3285–3295.