title: Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review.
abstract: BACKGROUND
  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.
  
  
  METHODS
  
  
  
  METHODS
  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.
  
  
  RESULTS
  A 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.
  
  
  CONCLUSIONS
  Despite 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.
  
  
  CONCLUSIONS
  Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, 2109, Australia.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Swain
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Institute of Public Health, University of Heidelberg, Heidelberg, 69120, Germany.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Henschke
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Epidemiology and Biostatistics, EMGO + Institute, VU University Medical Center, Amsterdam, 1081BT, Netherlands.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Kamper
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, 2109, Australia.
authors.forename: Aron S
authors.initials: AS
authors.lastname: Downie
authors.affiliation: Department of General Practice, Erasmus MC, University Medical Centre, Rotterdam, 50 3015 GE, Netherlands.
authors.forename: Bart W
authors.initials: BW
authors.lastname: Koes
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia.
authors.forename: Chris G
authors.initials: CG
authors.lastname: Maher
keywords: Anterior cruciate ligament; Diagnosis; Diagnostic test accuracy; Medical history taking; Physical examination