Do clinical tests correlate with arthroscopic findings in patients with traumatic anterior cruciate ligament injury? A prospective study

Background: Anterior cruciate ligament (ACL) tears are common, comprising roughly half of knee ligament injuries in active adults. Clinical examination (e.g., Lachman, anterior drawer, and pivot shift; McMurray/Apley for menisci) remains the first-line option for assessment of ligamentous injury assessment. Diagnostic arthroscopy is the intraoperative reference standard, while magnetic resonance imaging (MRI) has high sensitivity for ACL pathology but may miss associated meniscal lesions. In resource-limited settings, a reliable clinical–arthroscopic correlation is needed. Materials and Methods: Thirty consecutive patients (age: 15–60, mean: 27.8 ± 6.1 years) undergoing arthroscopic ACL reconstruction at a tertiary care hospital in Bhopal, India, were studied prospectively. A standardized exam battery (Lachman, anterior drawer, pivot shift; posterior drawer; varus/valgus stress; McMurray, Apley, joint-line palpation; dial test) was performed preoperatively and then repeated under anesthesia. Findings were compared to those of intraoperative arthroscopy (reference standard). Sensitivity, specificity, and Cohen’s κ (95% confidence interval) were calculated using Statistical Package for the Social Sciences version 25. Results: The Lachman test showed the highest sensitivity (~90%–97%) among ACL tests. Under anesthesia, pivot-shift sensitivity increased markedly (≈67% awake to ~90% anesthetized), while the anterior drawer remained moderate (~70%–83%). Meniscal tests had lower accuracy: McMurray’s test achieved substantial agreement with arthroscopy ( κ ≈ 0.7–0.8; pooled sens: ~70%), whereas Apley’s compression and joint-line palpation were only moderately sensitive (~60%–63%). All dynamic tests (e.g., pivot shift and McMurray) showed higher sensitivity under anesthesia. Most injuries were isolated ACL tears, but concomitant medial/lateral meniscal tears were common. Conclusion: In traumatic ACL injuries, structured clinical examination correlates well with arthroscopic findings. Pivot-shift testing under anesthesia significantly improves the detection of rotational instability. Meniscal tear tests are less reliable. Given MRI limitations, use of a comprehensive exam battery (Lachman + pivot shift; targeted meniscal maneuvers) can effectively triage patients. Arthroscopy remains definitive, but a focused exam (including under anesthesia) can enhance preoperative diagnostic accuracy.