}ustin King, NSAT Stuuent, Webei State 0niveisity

6Su2 SensitivitySpecificity Special Tests Pioject

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The Anteiioi Biawei (AB) test anu Pivot Shift (PS) test aie two tests useu in the
uiagnosis of anteiioi instability of the anteiioi ciuciate ligament (ACL).
1
The ACL is the
piimaiy ligament that pioviues suppoit foi anteiioi movement of the tibia against the
femui oi visa veisa.
2
0thei majoi stiuctuies involveu with this tiansition aie the meuial
anu lateial femoial conuyles anu the meuial anu lateial tibial plateaus, especially in the PS
test.
1
Seconuaiy stiuctuies that coulu leau clinicians to false-negatives uuiing uiagnosis
incluue the hamstiings, which can contiact in an ACL ueficient knee causing uecieaseu
anteiioi tianslation of the tibia.
2

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Although ACL teais aie occui uuiing contact anu noncontact moments uuiing a
spoiting event, they aie moie common uuiing a nonvolatile even. They aie founu to occui
when an athlete is pivoting on theii knee, hypeiextenuing the knee, ueceleiating with the
knee taking the biunt of the foice, oi a combination of those actions. When an ACL iuptuie
occuis thiough contact, it usually occuis when a knee ieceive a blow fiom the lateial siue.
1

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The technique foi the Anteiioi Biawei Test consists of the patient lying supine on
theii back anu having them flexeu the injuieu knee at 9u uegiees. The clinician then places
theii thumbs ovei the anteiioi aspects of the meuial anu lateial plateaus with the 2
nu
- S
th

fingeis wiapping aiounu to the posteiioi poition of the knee. Befoie anteiioi tiansition of
the tibia is attempteu it is impoitant foi the patient to ielax theii hamstiings so no
impeuance occuis anu foi the tibia to be at its noimal position, so gieatei posteiioi laxity,
uue to a PCL ueficiency, is not mistaken foi abnoimal anteiioi tianslation. Buiing the
anteiioi pull, gieatei anteiioi tianslation shoulu be felt as well as a soft enu-feel.
1

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To begin the pivot shift test, have the patient lay supine, with theii knee in full
extension. The clinician iotates the knee inteinally with the opposite hanu applying a
valgus foice to the lateial pait of the knee. The clinician the lifts the leg anu biings the knee
into Su to 4u uegiees flexion, all the while applying the valgus foice. In an ACL ueficient
knee, the lateial plateau of the tibia will subluxate as the knee goes into flexion. Aiounu Su
uegiees of flexion the subluxateu poition of the lateial plateau will ieuuce anu the clinician
anu patient will feel a clunk in the joint as it moves back into place.
1


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While this Biagnostic Test analysis uoes not covei it, the uolu Stanuaiu foi ACL
ueficient knees is the Lachman Test. In a ieview 28 uiffeient stuuies, the Lachman test was
founu to be accuiate in the uiagnosis of both acute anu chionic ACL injuiies. The meta-
analysis concluueu with 9S% confiuence that the Lachman test was accuiate with a 86%
sensitivity anu a 91% specificity.
2
Although not the golu stanuaiu test foi ACL injuiies, the
AB test anu Pv test shoulu be useu in assisting to confiim the ACL uiagnosis, anu how that
shoulu be uone will be uiscusseu the following paiagiaphs.
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Biaunstein, wo
anesthesia
S

91% 1uu% SS.S u.1 2S9
Bonaluson, with
anesthesia
4

9u % X X X X
Bonaluson, wo
anesthesia
4

7u% X X X X
}ain, with
anesthesia
S

92% X X X X
}ain, wo
anesthesia
S

89.S% X X X X
Katz, with
anesthesia
6

41 % 9S% 8.6 u.6 14
Liu, wo
anesthesia
7

61 % X X X X
Rubinstein, wo
anesthesia
8

76 % 87% S.6 u.S 2u

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S

Compaiison of aithiogiaphy anu anteiioi uiawei test to see which was moie
ieliable
29 suigically pioven cases
o 1u tiue-positives, no false-positives, 18 tiue negatives, one false negative.
o The false negative was pioven suigically
Same piactitionei uoing the tests.
The high sensitivity anu high specificity means that accoiuing to this stuuy, the
anteiioi uiawei test is goou at iuling in a test if it is positive anu iuling out the
absence of the injuiy if it is negative.

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4

1u1 patients weie testeu, S7 of which hau an ACL teai.
The same patients weie testeu, which can give an accuiate uepiction of how much
moie effective the test is in one situation oi anothei.
Sensitivity is veiy high foi both of these tests which mean if you get a negative test,
it is pietty suie that they uo not have the injuiy.
o Specificity was not available foi this test because they it uiu not mention if
theie weie any tiue negatives oi false positives in it's finuings.

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28 male patients with a clinical ACL injuiy weie examineu in an outpatient setting
anu with anesthesia.
o Finuings weie compaieu with aithioscopy
Both aie veiy high in sensitivity. That means both negative iesults fiom the test aie
significant, in that the inuiviuual uoes not have the injuiy.
o Theie weie no false positives oi tiue negatives.
! This makes it uifficult to accept the specificity since eveiyone stuuieu
hau an ACL injuiy, so it was not possible to finu a false positive oi tiue
negative anu theiefoie calculate tiue specificity.

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A 4 month ietiospective stuuy to see the accuiacy of Anteiioi Biawei test.
8S patients, examinations peifoimeu unuei anesthesia, piobably why the test
iesulteu in such high Sn anu Sp.
Low sensitivity, of the anteiioi uiawei test hau ieseaicheis concluue that it was a
pooi uiagnostic test
o This is ieflecteu in the .6 in the high chance that the uiagnosis fiom using the
anteiioi uiawei test alone coulu be wiong anu just because it is a negative
test, it uoes not iule out the injuiy
o Fiom this uata a negative iesult coulu mean theie is a 6u% chance they still
have the injuiy fiom LR-= .6
2($
7

This stuuy was a compaiison between uiagnostic special tests anu KT-1uuu
aithiometiy.
o S8 patients with complete aithioscopically-pioven ACL teais.
Tests weie uone without aithioscopy.
Low sensitivity pioves the unieliability of the test if it is a negative iesult to the
anteiioi uiawei test.
o Anteiioi Biawei pioveu the least ieliable of the S tests |lachman (sn=9S),
pivot-shift (sn=71), & anteiioi uiawei (sn=61)j anu KT-1uuu (sn=84-97)j

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8

S9 patients, blinueu, ianuomizeu, anu contiolleu stuuy
Patients hau injuieu knees, but it was not specific if it ACL, PCL, oi no ligament
uamage.
o 0f the S9 patients, 9 of the knees weie ACL ueficient, 9 noimal, 19 PCL
o The paiameteis (involving a PCL gioup) of the stuuy help to tiuly test
specificity anu sensitivity because theie aie vaiiable iesults.
! Nany stuuies look at injuiy assessment of gioups that aie alieauy ACL
ueficient
Laigei specificity anu lowei sensitivity shows anteiioi uiawei bettei at iuling in an
injuiy insteau of iuling it out.
o Accoiuing to this ieseaich if AB is positive it is likely the knee is ACL ueficient,
if the test is negative, it is not veiy likely that theie is no injuiy piesent.

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7$#', )2$(,
3:,2'4 )"*+$,$#$,- )0"1$($1$,- E!F E!G 5H!
Bonaluson, wo
anesthesia
4

SS% X

X X X
Bonaluson, with
anesthesia
4

98 % X X X X
}ain, with
anesthesia
S

1uu% X X X X
}ain, wo
anesthesia
S

7S% X X X X
Katz, with
anesthesia
6

82% 98% S1.S u.2 279
Liu, wo
anesthesia
7

71% X X X X
Rubinstein, wo 9S%` 89% 8.S .1 114
anesthesia
8


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4

Patients testeu with anu without anesthesia
o The laige uiffeience between the sensitivities, show how much a negative
iesult fiom the pivot shift test cannot be tiusteu with only SS% sensitivity, as
the inuiviuual might still have the injuiy.
o Accoiuing to this test, pivot shift shoulu not be useu without anesthesia
because the patient might still have the injuiy.

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This stuuy enueu up with a bettei sensitivity foi pivot shift than otheis.
o Bowevei as mentioneu eailiei, when inuiviuuals aie stuuieu who only have
the injuiy it is haiu not to get a goou sensitivity finuing
! As stateu in the AB section, these iesults may not be entiiely ieliable
uue to the methous of the stuuy.
! The stuuy was uone in the same outpatient setting, but not necessaiily
by the same clinician.

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6

The positive iesults fiom the pivot shift test, inuicate that it is veiy ieliable both LR+
anu LR-.
o If theie is a positive test the chances that the inuiviuual has the injuiy
incieases by S1.S times.
o If the test is negative theie is only a 2u% chance that the inuiviuual still has
the injuiy

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7

A sensitivity of 71% is not incieuibly high, howevei in compaiison to anteiioi
uiawei, it is moie ieliable, howevei it is less ieliable than the Lachman test.

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8

Bigh sensitivity is veiy goou at iuling out the existence of injuiy.
o If theie is a negative iesult foi pivot shift theie is only a 1u peicent chance
that the injuiy actually is piesent.
This high specificity of pivot shift coupleu with a high specificity of anteiioi uiawei
will help to inciease the powei of the test of iuling an injuiy as piesent if both tests
aie positive.

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As mentioneu pieviously, the Lachman test is the golu stanuaiu test in assessing a
knee foi an ACL injuiy. Bowevei, the Anteiioi Biawei anu Pivot-Shift test shoulu be useu
in uiffeient ciicumstances in suppoit of ueteimining a uiagnosis. The anteiioi uiawei test
hau both high anu low numbeis when it came to sensitivity. When without anesthesia,
numbeis became lowei. When uata fiom fuithei othei ieseaich is contiibuteu to the
uiscussion, sensitivity without anesthesia, while tiying to assess an acute injuiy is between
4S%-SS%.
2
These numbeis aie too low to tiust a negative iesult while tiying to iule out an
ACL injuiy. Specificity of the AB test is highei in the ieseaich we ievieweu as well as when
computing the same pieviously mentioneu uata aiounu 92%
2
This means a positive iesult
will be much moie ieliable than a negative iesult when applying the AB test. The PS test
hau a highei specificity than AB test in both ievieweu ieseaich anu othei mentioneu
ieseaich at 98%.
2
This means if a PS test is positive the chances of a tiue-positive aie veiy
high. The same uata is also ieflecteu in the high likelihoou iatio. Although the sensitivity
was high in the ievieweu liteiatuie, most uata ieflects extiemely low sensitivity in a iange
of 2S% to S8% in acute ACL injuiies.
2
In conclusion, neithei the anteiioi uiawei oi pivot
shift test aie goou at iuling out an injuiy, leaving the chances of a false-negative with those
tests veiy high. Bowevei if the tests aie positive, especially PS, theie is a high chance that
the inuiviuual uoes have an ACL ueficient knee. Remembei, this is only in suppoit of an
initial assessment aftei a Lachman test.

Woiks Citeu
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Examination foi Instability of the Knee. !4 5 16'%#- 7$8. 2uu8;S6(S):S77-S94.
2. Benjaminse A, uokelei A, van uei Schans CP. Clinical uiagnosis of an anteiioi ciuciate
ligament iuptuie: a meta-analysis. ,2$ 5'9%"*: '3 '%#2'6*$8&; *"8 -6'%#- 62<-&;*: #2$%*6<.
2uu6;S6(S):267.
S. Biaunstein EN. Anteiioi ciuciate ligament injuiies: a compaiison of aithiogiaphic anu
physical uiagnosis. !5=. 1982;1S8(S):42S-42S.
4. Bonaluson WF, Waiien RF, Wickiewicz T. A compaiison of acute anteiioi ciuciate
ligament examinations Initial veisus examination unuei anesthesia. !4 5 16'%#- 7$8.
198S;1S(1):S-1u.
S. }ain BK, Amaiavati R, Shaima u. Evaluation of the clinical signs of anteiioi ciuciate
ligament anu meniscal injuiies. >"8&*" 5 ?%#2'6. 2uu9;4S(4):S7S-S78.
6. Katz }W, Fingeioth R}. The uiagnostic accuiacy of iuptuies of the anteiioi ciuciate
ligament compaiing the Lachman test, the anteiioi uiawei sign, anu the pivot shift test in
acute anu chionic knee injuiies. ,2$ !4$%&;*" @'9%"*: '3 -6'%#- 4$8&;&"$. 1986;14(1):88-
91.
7. Liu SB, 0sti L, Beniy N, Bocchi L. The uiagnosis of acute complete teais of the anteiioi
ciuciate ligament. Compaiison of NRI, aithiometiy anu clinical examination. 5'9%"*: '3
A'"$ B 5'&"# 19%C$%<D A%&#&-2 E':94$. 199S;77(4):S86-S88.
8. Rubinstein RA, Shelbouine KB, NcCaiioll }R, vanNetei CB, Rettig AC. The accuiacy of the
clinical examination in the setting of posteiioi ciuciate ligament injuiies. ,2$ !4$%&;*"
@'9%"*: '3 -6'%#- 4$8&;&"$. 1994;22(4):SSu-SS7.