Pivot Shift Test – Orthopedic Examination of the Knee

The Pivot Shift Test is commonly used in orthopedic examinations to test for anterior cruciate ligament (ACL) and posterior capsule integrity. It is one of the most well-known and accurate tests when testing the stability of the knee. To better understand the mechanics of this test and why it is effective, you may want to review basic knee anatomy.

Ruptured Anterior Cruciate Ligament (ACL)
Torn ACL
The Joint Clinic, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons

Involved Structures

  • primarily the anterior cruciate ligament (ACL) but also the lateral cruciate ligament (LCL) and posterior capsule

Starting Position

The test is performed with the patient in a relaxed, supine position. The knee to be tested should be fully extended and the hip flexed to approximately 30 degrees. One of the examiners hands holds heel of the foot of the leg to be tested. The examiner’s other hand is on the lateral aspect of the proximal tibia, with the fifth metacarpal near the head of the fibula.

Test Movement

From the starting position, the examiner holds the lower leg in internal rotation and slowly flexes the knee while putting a moderate valgus and internal rotation force on the proximal tibia.

Positive Pivot Shift Test

This test is considered positive if the proximal tibia subluxes anteriorly on the distal femur at about 30 degrees of flexion. In a positive test, the proximal tibia will clunk back into place while returning the knee to extension. Flexion past approximately 40 degrees will also reduce the tibia due to the iliotibial band.

Accuracy of Test

The Pivot Shift Test is very accurate when performed correctly. However, it can be difficult for the person being examined to relax as much as is necessary during this test since the movement reproduces their instability. The Pivot Shift Test is the most specific test for the diagnosis of ACL rupture.

Video Demonstration

video source: Russ Hoff

>> Return to the list of Common Tests in Orthopedic Examination of the Knee

Other tests for ACL integrity include:

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