Lelli test (Lever test): Clinical test for the diagnosis of Anterior cruciate ligament (ACL) rupture

Lever test is carried out with patient in supine position, knee in full extension and heel touching the bed.

  • A clenched fist is placed beneath the proximal calf just distal to tibial tuberosity.
  • Gentle downwards pressure is applied over quadriceps tendon and the examiner looks to see if the heel ‘lifts off’ the bed.

Lelli on the Lever test 2014 NEGATIVE test
a: Negative Lever Sign test. With the fist acting as a fulcrum under the calf and a second hand pushing down on the quadriceps (large arrow), the ACL is able to counteract the downward force on the foot due to gravity (small arrow). Lelli 2014
  • The test is POSITIVE if there is no heel lift-off and indicates likely ACL disruption
  • With a partially or completely ruptured ACL, the ability to offset the force of gravity on the lower leg is compromised and then tibial plateau slides anteriorly with respect to the femoral condyles. In this case, the gravity pulls the heel down to the examination table
Lelli on the Lever test 2014 POSITIVE
b: Positive Lever Sign test. With the fist acting as a fulcrum under the calf and a second hand pushing down on the quadriceps (large arrow), the ruptured ACL is not able to counteract the downward force on the foot and the foot remains on the examination table (small arrow) Lelli 2014
Demonstration of positive and negative Lelli/Lever test

2005 – Developed by Alessandro Lelli to better assess the functional aspects of ACL disruption

2014Lelli et al reviewed 400 patients divided into four groups (A-D) each with 100 patients. A single clinician, blinded to MRI results, and examined every patient with the same series of physical tests: the Lachman test, Anterior Drawer test, Pivot Shift test, and Lever Sign test.

Lelli 2014 400 cases 4 groups 4 tests
Percentage of patients successfully diagnosed with the three most common physical examinations and the proposed Lever Sign test. Lelli 2014

They concluded that in general, chronic, complete tears were most successfully diagnosed and that acute, partial tears were least successfully diagnosed. The Lever Sign test was more sensitive to correctly diagnose both acute and partial tears of the ACL, regardless of the elapsed time from injury, compared with other common manual tests.

2015Deveci et al evaluated the sensitivity values of stress tests at pre-anaesthesia and under anaesthesia.

Deveci et al 2014 knee tests ACL
Sensitivity values of stress tests at pre- anaesthesia and under anaesthesia Deveci 2015

Lever sign test found to have higher sensitivity compared to other tests. Under anaesthesia, an increase was seen in the sensitivity of the lever sign test and of the other tests. Although this change was significant, it was not at a very high rate in the lever sign test. Possibly the Lever test is affected less than the other tests by patient-related factors.

2015 – Thapa et al reviewed 80 patients (aged 20-45) attending sports clinic at Department of orthopedics, Tribhuvan University. 35/80 had ACL tear, isolated (37.1%) or with associated meniscus tear (62.8%). Comparison of the arthroscopic findings of ACL tear and clinical tests Anterior Drawer test, Lachman test, Pivot shift test and Lelli test.

Thapa lelli test 2015

2019McQuivey et al found that, compared with other clinical tests of anterior cruciate ligament (ACL) disruption, the Lelli/Lever sign is more accurate and sensitive in an ED setting. In a single-center implementation study in which emergency physicians were trained in performing the lever test. 45 patients between the ages of 12 and 55 who presented to the ED with acute knee injuries were enrolled. Patients were diagnosed as having ACL rupture or not with the lever sign test during the first 4.5 months of the study and either the anterior drawer or the Lachman test for the second 4.5 months of the study. Follow-up MRI imaging was used as the gold standard.

Lelli test or Lever test in ACL disruption 2019
Fig 1. How to perform the Lever sign. McQuivey et al 2019
  • The lever sign test was found to be 95% accurate, 100% sensitive, 94% specific for ACL rupture.
  • Anterior drawer/Lachman testing was 88% accurate, 40% sensitive, 100% specific.
  • Diagnostic confidence was slightly higher for the lever test and there did not appear to be any difference in accuracy based on training level of the provider.
Evaluation of screening tests 2019
Figure 3. Evaluation of screening tests McQuivey et al 2019

Lelli explains the clinical examination test
Lelli test: Alessandro Lelli (2005)

Associated Persons

Alternative names
  • Lever Test


Original articles

Review articles

Dr Ronan McKenna LITFL author 601

Dr Ronan McKenna, MB BCh BAO at National University of Ireland Galway. Living in Australia with  plans for a future in Emergency Medicine. A keen interest in Medical History, Wilderness Medicine and Sport.

Dr Iona Dollery LITFL author

Irish doctor MB BCH BAO, NUI Gallway. Currently Emergency Medicine RMO in Perth, Western Australia. Interests in emergency medicine, GAA and exploring WA

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