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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE April 2023 Lachman’s Effectiveness Previously Overestimated...improving Diagnostic Accuracy for ACL Tears by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 54 yr old male injured his L knee playing recreational softball with a deceleration change of direction non-contact MOI, hearing a “pop” and experiencing pain and then swelling within 30 minutes. Plain films are (-) for fracture. Gait is antalgic with 150 lack of extension and poor swing phase also. AROM is 12-1150 and he has a 100 SLR lag from resting 150. Clinical exam difficult due to guarding and large extremity size. Lachman’s is equivocal, anterior drawer 1+, posterior drawer (-), Apley’s (-), unable to perform McMurray’s due to pain/guarding, varus/valgus tests (-), ER/Dial tests (-) also. The patient works a remote job doing marketing research and his goals are walking and hiking with his wife, biking, recreational table tennis and possibly a return to softball at 1st base or outfield but is not concerned about hitting/running bases. Pt is inquiring if he has torn his ACL. He has a high deductible insurance and essentially self-pay at this time. He prefers to avoid an MRI if possible. You have determined his work and activity goals do not merit ACL reconstruction at this time and that he likely is a non-operative candidate. I would: 1. Order an MRI to confirm current partial ACL tear diagnosis and order Physical Therapy. 2. Prescribe NSAID’s and FU in 2 wks for re-exam to determine final diagnosis and plan of care. 3. Aspirate effusion and do diagnostic lidocaine injection to allow better clinical exam. 4. Perform Lever Test for ACL integrity to support diagnosis and plan for non-op care. Current Evidence: Sokal PA, Norris R et al. The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis. Knee Surg, Sports Traum, Arth. 30 ( ) , 3287-3303, 2022 https://link.springer.com/article/10.1007/s00167-022-06898-4 SUMMARY: ACL injury is common especially in athletics. Clinical diagnostic accuracy becomes paramount in determining both confident diagnoses and also resulting plans of care appropriate for each individual patient. The Lachman’s test, previously considered a “gold standard” of sorts regarding ACL examination, has supportive evidence based in numerous studies that allowed for concomitant knee ligament injury, calling into question if this diagnostic accuracy is as high in isolated ACL injury cases. Sokal et al in this systematic review and meta-analysis showed that the pivot shift and Lever (or Lelli) sign were the best tests for diagnositic accuracy of ruling in and ruling out ACL tear respectively. The Lever sign has also been proposed to indicate a functioning ligament in cases of a partial tear. This may contribute to decision making on non-operative care routes depending on the patient’s comorbidities/injury and goals. The Lever sign may also be useful for those with smaller hands/larger knee situations as well as for additional evidence when MRI pre-authorizations are required. The (-) Lever sign may provide evidence to support non-op care despite (+) Lachmans or Anterior Drawer testing in certain scenarios. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: There have been several common longstanding tests performed by physicians and other medical providers to confirm or rule out ACL tear, however, many supportive studies included subjects with additional knee ligament injury. The Lachman’s test has previously been shown to have high diagnostic value. The Lever (or Lelli) sign demonstrates good diagnostic accuracy but has not been compared using the same inclusion/exclusion criteria Purpose: To report the diagnostic accuracy of clinical tests for ACL injury, both partial and complete, without concomitant knee ligament injury. Methods: A systematic review with a meta-analysis reporting sensitivity and/or specificity of clinical tests for ACL injury with or without a present meniscal injury. Diagnostic accuracy values, using bivariate random-effects modelling where possible, were calculated for the Lachman, anterior drawer, Lever sign and pivot shift tests overall and in acute (< 3 wks) or subacute (> 3 wks) settings. Results/Findings: Using a bivariate model for overall sensitivity and specificity respectively, pooled estimates include anterior drawer test at 83% and 85%, Lachman test at 81% and 85%, pivot shift test at 55% and 94%, and Lever sign test at 83% and 91%. For complete tears, Lachman test was 68% and 79%; post-acute injuries 70% and 77%. Authors Conclusion: The diagnostic accuracy of the Lachman test especially for post-acute presentations and complete tears was lower than previously reported. The pivot shift and Lever sign were the best tests overall for ruling in and ruling out ACL tear, respectively. Further research is recommended for the Lachman test in acute presentations and partial tears. THE PEAK PERFORMANCE PERSPECTIVE ACL injury screening, although commonplace in the orthopedic setting, has a variety of clinical diagnostic tests utilized by clinicians, each with the varying levels of reported diagnostic accuracy, that remain under scrutiny from further review and research. While the Lachman’s has often been considered a “gold standard” of sorts regarding clinical tests for ACL injury, there are several situations where this test can be difficult to perform well such as operator with small hands in comparison to a much larger knee-thigh-leg as well as acutely with greater swelling and pain that make relaxation difficult. There are also cases where non-operative care may be most appropriate despite a suspicion of ACL tear and further test cluster findings may help avoid the expense of an MRI in some cases. In other instances the addition of another accurate test may assist in supportive evidence when an MRI may be called for but insurance pre-approval is necessary. Sokal et al in this systematic review and meta-analysis found the Lachman test was not as accurate with ruling in or ruling out solely ACL tears as previously thought. One associated factor was many past studies showing positive results utilizing the Lachmans included concomitant knee ligament injury. This study also utilized bivariate random-effects modelling where able, rather than the typical univariate modelling, adding to the strength of the findings. The Lever sign is also thought to indicate in the cases of partial tear whether the intact fibers leave the ACL “functioning” regarding normal knee biomechanics. While not suggesting complete integrity the (-) Lever sign may suggest adequate fiber integrity to more confidently move forward with non-operative care in specific patient situations. With the positive findings for high sensitivity and specificity of the Lever sign, medical providers examining patients in acute settings, whether physicians and athletic trainers on the field or any provider assessing an injured knee within the first weeks when pain and swelling have settled in, may be able to obtain a more accurate diagnosis of an insufficient ACL and/or be able to have evidence that despite likely partial tearing that the integrity is adequate to entertain non-op care whereas Lachman’s tests alone sometimes are equivocal and then tend to merit more expensive MRI testing. While Sokal et al contribute to the evidence by looking at knees without other ligament injury also, this is mutually a weakness of the study. As they indicate, more than half of all ACL tears are accompanied by a medial or lateral ligament injury. Therefore, this improved diagnostic accuracy of the Lever sign may not apply in such cases. The test is simple to perform and very easy to measure the results. Below is a link explaining and demonstrating the Lever sign. https://www.youtube.com/watch?v=29JTT0uLubs While not replacing the Lachmans or other ACL tests this Lever sign may be a beneficial addition as well for the small operator hands/large knee scenario as well. Non-operative ACL injuries may still allow for patients to have a good quality of life, based on age and activity level of course. When PTs typically see a patient with an ACL injury, it usually is after decisions have already been formed, whether prehab is the focus, or this individual has chosen a non-operative route to get function and ROM back. Many patients don’t realize that despite their “knee” being injured that optimal recovery will involve addressing especially hip and foot-ankle function as these joints directly influence knee function and mechanics. The typical mechanism limitations are still present, whether it was a valgus deceleration non-contact trauma, or a hyperextension force from contact, there still exists some mobility loss and muscle atrophy occurring. The most common limitations we as PTs see in either post-op ACL reconstructive surgery or non-operative ACL trauma is some level of quad weakness, but also excessive femoral IR that leads to dynamic valgus mechanics. For some this is related to anteversion influences, for others it may be a lack of hip ER mobility or simply a weakness of the Abd’s-Er’s of the hip. A patient with overpronation, because of kinetic chain relationships, especially of the talus with the tibia-fibula, can also experience dynamic valgus-rotational tendencies that often mimic the MOI originally seen. While somewhat less critical for a short term pre-op care bout, those patients doing non-op PT care will have significant limitations in ADL/athletics if proximal and distal factors are not addressed adequately. Oftentimes traditional care will emphasize simple NWB and WB quads and hamstring strengthening and balance work, however care must be taken to identify each patient’s unique biomechanical issues It’s very common to see a patient gain better quad control without pain and increase their WB tolerance once these limitations throughout the entire kinetic chain are assessed and addressed. Whether it’s through manual joint mobilizations to the hip and rearfoot or myofascial work to one’s psoas, followed by dynamic hip transverse plane drills, and supination driven ankle stepping, each individual is unique and at a varying level of activity requiring frequent testing and re-testing of functional movements. Reducing dynamic valgus-rotational MOI-like tendencies can also significantly improve “dynamic stability” so that more intensive strengthening and neuromuscular drills can be implemented...leading to speed and impact training in preparation for return to recreational/athletic endeavors. The case below represents an example of a patient suffering an ACL re-injury following prior reconstruction who opted for non-op care due after only partial tear was confirmed. THE PEAK PERFORMANCE EXPERIENCE Kelle said: “I can play golf without any issue! Biking and walking on the beach is fine now!” History: 57 year old female with history of prior L ACL reconstruction and recent re-injury from downhill skiing requiring surgery for medial and lateral menisectomy and confirmed 30% ACL intact without reconstruction. Subjective: 5/10 pain random walking. Difficulty with descending stairs at times in morning and unable to run with new onset heel pain and history of intermittent L SI jt pain and L sided back pain. Objective: Initial Evaluation Re-eval Knee flexion 1430 1480 Knee extension -40 20 hyper Prone hip ER 250 250 Prone hip IR 500 550 Isometric Quad NT @ 900 89% Isometric Hams NT @ 450 105% SLB rotational NT ↑ pronation/IR w/o orthotic Gait L leg loading Flex’d knee mid stance Ext’d knee mid stance Key Findings: At initial evaluation, pt unable to ambulate without flexed knee during stance phase, minimal quad control with active SLR, unable to perform any step down depth, discomfort with end range knee extension anterior joint line with effusion. Positive special tests for decreased hip extension, decreased hip adduction and decreased foot/ankle control with pronation collapse in SLB. Treatment: Knee mobility focus first: Prone knee hang for TKE ROM, SLR long sitting for extension endurance for WB Manual therapy focus of hip: Anterior hip jt mobilizations for extension, passive hip joint ER stretching in standing hip flexor stretch, frontal plane hip abductor stretching for WS in gait Mobility/active stretching: gastroc and hip flexor stretching, hip ER stretching, functional abductor stretching with hip adduction drills in WB Strength: Anterior slide drills for terminal stance extension control at hip/ankle, TR plane supination assisted balance drills, SL calf raises for push off, Step down drill with L quad load in pelvic L rot for valgus prevention, L lateral hip loading with tubing with stepping drill for pelvic stability at abductors. Anterior step downs loading quad with DBs with pelvic L rotation assisted femoral ER/valgus prevention. Addition of Superfeet OTC arch supports with neutral sneaker. Outcome: Pt very happy with her knee sx’s for most ADLs. Recent re-eval demonstrates some diminished quad strength vs contralat knee, but able to go up/down stairs, walk on uneven ground without brace short durations, and bike and use elliptical > 20 min each, and walk at least 1 mile without sx’s onset. Further dynamic control at ankle and hip required for more advanced activity level.