Lever Sign Test (Lelli Test): a simple alternative for assessing the ACL

Not every knee test requires complicated positions or years of practice to get the right "feel." The Lever Sign Test, also known as the Lelli test (after the surgeon who described it), is a relatively simple and well-tolerated alternative for assessing the integrity of the anterior cruciate ligament (ACL), particularly useful when the patient has pain or apprehension that makes other tests difficult.

What does this test measure?

The Lever test indirectly assesses ACL integrity by observing whether the heel lifts off the table when downward pressure is applied to the thigh, with the examiner's fist placed under the leg at the proximal third of the tibia/calf. The logic is biomechanical: if the ACL is intact, it acts as a "lever" that transmits the force and lifts the heel; if it's torn, that transmission is lost and the heel doesn't lift (or lifts much less).

Equipment needed

• Treatment table
• No additional tools required (the examiner's own fist acts as the fulcrum)

Step-by-step protocol

1. The patient lies supine, with the leg completely relaxed and extended
2. Place your closed fist under the leg, at the proximal third of the calf/tibia (just below the knee), so it acts as a fulcrum
3. With the other hand, apply firm downward pressure on the distal third of the thigh (just above the patella), toward the table
4. Watch what happens to the heel: under normal conditions, it should lift slightly off the table due to the lever effect
5. Compare with the contralateral leg

Common mistakes

• Placing the fist in the wrong position (it should be at the proximal third of the leg, not the ankle or thigh)
• Not making sure the leg is fully relaxed and extended
• Not comparing with the healthy side to determine what heel lift is "normal" for that person

How to interpret the result

Result	Interpretation
The heel lifts off the table, same as on the healthy side	Negative — ACL likely intact
The heel doesn't lift, or lifts much less than on the healthy side	Positive — suggests an ACL tear

The Lever test has been proposed as a particularly useful option in patients with acute pain or apprehension that makes tests like the Lachman or Pivot Shift difficult, since it doesn't require direct manipulation of the knee. Even so, it should be interpreted alongside other tests and, if suspicion remains, confirmed with MRI.

Relationship with other tests

The Lever test can be used as a complement or alternative when other tests are hard to apply:

• Lachman Test — the reference test, especially if the patient tolerates manipulation well
• Pivot Shift Test — for assessing rotational instability once acute pain subsides

One more tool in your knee battery

The more tests you have recorded from the same assessment, the easier it is to spot inconsistencies or confirm a clear pattern. With Movalytics you can include the Lever test result alongside the rest of your knee stability tests in the athlete's record, all organized by assessment date.

Frequently asked questions

Does the Lever test replace the Lachman test? Not necessarily, but it can be a good complementary option, especially in the acute phase when the patient tolerates other more invasive maneuvers poorly. Is this a painful test? It's generally well tolerated, since it doesn't involve directly manipulating the knee joint, but rather applying pressure on the thigh with a fulcrum on the leg. What if the result is inconclusive? As with any screening test, if the result is inconclusive it's best to repeat it, combine it with other ACL tests, and, if clinical suspicion persists, refer for imaging.