What is a pivot shift test and how significant is it?

The pivot shift test is the most specific clinical test as it is able to accurately indicate an anterior cruciate ligament (ACL) rupture. The results can be divided into a low-grade tear, which indicates an ACL rupture in isolation, and a high-grade tear which indicates an ACL rupture with disruption of secondary stabilisers of lateral compartment, e.g. anterolateral ligament (see vumedi reference)/ lateral meniscus) ITB.

What is a pivot shift test?

A pivot shift can be used to assess the combined tibio-femoral internal rotation and anterior tibial translation when the ACL is deficient. There are two main components of the pivot shift test:

  • translation – anterior subluxation of the lateral tibial plateau
  • rotation – rotation of the tibia relative to the femur

The test is performed with the patient’s knee starting in full extension. While maintaining internal rotation of the tibia, a valgus force is applied and the knee is slowly flexed to 25-30 degrees. The examiner will feel for a subluxation of the lateral tibial plateau as it reduces to its normal position. You may find the following YouTube video a useful reference:

The examination is then carried out in each of three positions of rotation. A positive test may result in a gentle slide (Grade 1), or in a more severe jerk (Grade 2), or clunk (Grade 3). The grade of the pivot shift has been shown to correlate with patient-reported functional instability and clinical outcomes.

False negative tests may occur in the following cases:

  • medial collateral ligament (MCL) is deficient and it is not possible to apply valgus force
  • haemarthrosis is present
  • there is guarding by an apprehensive patient
  • symptomatic varus osteoarthritis
  • lateral compartment osteoarthritis.

The pivot shift as an outcome measure for ACL reconstruction[1],[2]

Confirming the importance of this test in assessment of patients’ ongoing functional instability after surgery, 85% of studies assessing clinical outcomes after ACL reconstruction use the pivot shift test.

Historically, clinicians have used the Lachman’s test (KT 1000) to determine the functional outcome. However, obliteration of anterior translation may not significantly correlate with subjective and objective function.

Recent studies correlate residual rotatory instability with decreased patient satisfaction, increased functional instability, chondromalacia and the development of osteoarthritis.


[1] Ayeni OR, et al. Knee Surg Sports Traumatol Arthrosc (2012) 20;767-777 Pivot shift as an outcome measure for ACL reconstruction: a systematic review

[2] Tanaka M, et al. Knee Surg Sports Traumatol Arthrosc (2012) 20;737-742 What does it take to have a high-grade pivot shift?

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