Abstract
BackgroundNumerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury.MethodsStudy Design: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069).Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots.ResultsA total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman’s test, prone Lachman’s test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy.ConclusionDespite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research.Clinical relevanceClinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.
Highlights
Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear
Clinical relevance: Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury
Many cases are initially missed [7] in primary care and these undiagnosed ACL injuries are of concern because of the risk of cartilage tear and premature knee osteoarthritis [8]
Summary
Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. The prevalence of ACL injury in adults presenting to primary care with acute knee pain is estimated to be 4% [6]. Clinical diagnosis of ACL injury is based upon history and physical examination findings with suspected cases confirmed by MRI or arthroscopy [9]. Numerous clinical tests and findings have been proposed to aid the diagnosis of ACL injury. There are over 25 specific physical tests and numerous features from the clinical history that have been proposed for detection of ACL injury [10]. At present the diagnostic accuracy of these tests is unclear
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