The examiner grasps and immobilizes the lateral femoral condyle with one hand and palpates the proximal tibia or fibula with the thumb.
With the other hand, the examiner holds the patient’s lower leg in internal rotation and abduction (valgus stress).
From this starting position the knee is then moved from extension into flexion.
What does a positive Pivot Shift Test mean?
In the presence of a torn anterior cruciate ligament, the valgus stress will cause the tibia to subluxate anteriorly while the knee is still in extension. The blockade of the knee in anterior subluxation depends on the degree of valgus stress applied.
The knee is then flexed while the same internal rotation and abduction of the lower leg is maintained; this then causes the subluxated tibial head to reduce posteriorly at 20 to 40° of flexion.
The patient usually confirms the diagnosis by reporting that the typical sensation of the knee giving way felt in sports activities can be reproduced in this test.
Sensitivity & Specificity
In a meta-analysis 2 that looked at 28 studies to assess the accuracy of clinical tests for diagnosing ACL ruptures, Benjaminse et al. found the pivot shift test to be very specific both in acute as well as in chronic conditions, and recommended that both the Lachman and pivot shift tests be performed in all cases of suspected ACL injury:
Sensitivity: 24 %
Specificity: 98 %
A positive test result is always dependent on an intact iliotibial tract because the iliotibial tract (which with increasing flexion glides from a position anterior to the lateral epicondyle in extension to a position posterior to the axis of flexion) draws the tibial head posteriorly again.
The sign can be elicited more easily when the examiner immobilizes the patient’s leg between his or her own forearm and waist while applying slight axial compression.
In an anterior cruciate tear, both the medial and lateral portions of the tibia migrate anteriorly under the stress of the anterior drawer.
In an isolated tear of the anterior cruciate ligament, the anterior motion of the lateral portion of the tibia will be more pronounced than that of the medial portion.
The anterior motion of the medial portion of the tibial plateau increases relative to that of the lateral portion as the number of injured medial structures increases. Increasing anterior motion of the medial tibial plateau in turn increases the severity of the subluxation and subsequent reduction phenomenon observed by the examiner. This reduction will also be observed to occur at an increasingly high degree of flexion.
According to Jakob, a genuine pivot shift phenomenon can partially disappear, despite anterior cruciate ligament insufficiency, under the following conditions:
When a complete tear of the medial collateral ligament is present, the valgus opening prevents force concentration in the lateral compartment. Subluxation cannot occur under these circumstances.
When the iliotibial tract is traumatically divided, only the subluxation will be observed, not the abrupt reduction.
A bucket-handle tear of the medial or lateral meniscus can prevent anterior translation or reduction of the tibia.
Increasing osteoarthritis in the lateral compartment with osteophytes can create a concave contour along the once convex lateral tibial plateau.
Jakob Graded Pivot Shift Test
Gradation of the pivot shift test allowing for translation and rotation of the tibia.
The procedure is identical to the pivot shift test except that here instability of the knee is assessed with the lower leg not only in internal rotation but also in neutral and external rotation.
Pivot shift grade I:
The pivot shift test is positive only in maximum internal rotation; it is negative in neutral and external rotation.
The subluxation as the knee approaches extension is more palpable than visible to the examiner (slight translation m ay be apparent).
Pivot shift grade II:
The pivot shift test is positive in internal and neutral rotation; however, it is negative in external rotation.
There is visible and palpable translation on the lateral aspect of the joint.
Pivot shift grade III:
The pivot shift test is clearly positive in neutral rotation and particularly conspicuous in external rotation.
The sign is less distinct in internal rotation.
Pivot shift grade III can only be demonstrated in acute knee injuries where the posteromedial and lateral structures are damaged in addition to the anterior cruciate.
In chronic instability, a grade III pivot shift will be detectable in cases where the secondary stabilizers have loosened over time.
Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res. 1980 Mar-Apr;(147):45-50. PMID: 7371314.
Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006 May;36(5):267-88. doi: 10.2519/jospt.2006.2011. PMID: 16715828.
Clinical Tests for the Musculoskeletal System 3rd Edition.
Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.