The pivot shift: a global user guide

Knee Surg Sports Traumatol Arthrosc. 2012 Apr;20(4):724-31. doi: 10.1007/s00167-011-1859-4. Epub 2012 Jan 1.


Purpose: The use of several different maneuvers for the pivot shift test has resulted in inconsistent quantitative measurements. The purpose of this study was to describe, analyze, and group several surgeon-specific techniques for the pivot shift test and to propose a standardized pivot shift test.

Methods: Twelve expert surgeons examined a whole lower cadaveric extremity with their preferred technique and assigned a clinical grade, I-III. Anterior tibial translation and acceleration were measured using an electromagnetic system. The test was repeated after watching an instructional video focused on a standardized pivot shift technique. Measurements were repeated and compared with the preferred technique.

Results: The expert surgeons utilized valgus stress unanimously in addition to fixed internal rotation (n = 5), fixed external rotation (n = 1), a motion-allowing technique (n = 3), a dislocation-type maneuver (n = 2), and a fixed anterior drawer type of maneuver in extension (n = 1). Anterior tibial translation measured was on average 15.9 ± 3.7 mm. Average tibial acceleration was 3.3 ± 2.1 mm/s(2). Average clinical grading was 2.3 ± 0.5. There were no differences in average clinical grading when using high stress (2.5 ± 0.6) versus low stress (2.3 ± 0.5, n.s.), or using fixed rotation (2.2 ± 0.5) versus a motion-allowing technique (2.3 ± 0.6; n.s.).

Conclusions: Clinical grading, tibial translation, and acceleration vary between examiners performing the pivot shift test. High forces and extremes of rotation are not necessary to produce a clinical detectable pivot shift. In the future, a standardized pivot shift test-which can be performed universally and utilizes only gentle forces allowing motion to occur-may be beneficial when assessing differences in outcome following ACL reconstruction.

Publication types

  • Comparative Study

MeSH terms

  • Arthrometry, Articular / standards*
  • Biomechanical Phenomena
  • Cadaver
  • Female
  • Guidelines as Topic*
  • Humans
  • Joint Instability / diagnosis*
  • Knee Joint / physiopathology*
  • Male
  • Physical Examination / methods
  • Range of Motion, Articular / physiology*
  • Reproducibility of Results
  • Rotation
  • Stress, Mechanical
  • Video Recording