Pivot Shift Test

The pivot shift test is a dynamic and passive clinical test used to detect anterolateral rotational instability of the knee. A positive test almost always indicates an anterior cruciate ligament (ACL) injury, often in combination with injury to the anterolateral ligament (ALL)¹.

The test is particularly useful in chronic conditions, where it helps grade instability and guide surgical or conservative treatment planning. Although its sensitivity is low, its specificity is very high, making it the gold standard for confirming ACL rupture².

Clinical Anatomy

The knee joint (articulatio genus) is the most complex synovial joint in the body. It is formed by the femur, tibia, and patella, and stabilized by four major ligaments – including the anterior and posterior cruciate ligaments – as well as menisci and capsular structures³.

The ACL originates from the anterior intercondylar area of the tibia and runs obliquely upward, backward, and laterally to attach to the medial surface of the lateral femoral condyle⁴. Its main function is to prevent anterior translation of the tibia relative to the femur and to control rotational movements under load. When the ACL is ruptured, the knee loses its ability to restrain tibial shift during rotation, producing the characteristic “shift” in the pivot shift test⁴.

Test Procedure

Starting position:

• The patient lies supine with relaxed musculature.

• The examiner holds the patient’s heel with one hand and places the other hand over the proximal fibula to stabilize the tibia.

Technique:

• The tibia is internally rotated with the knee in full extension.

• A valgus stress and axial compression are applied to the tibia.

• The knee is gradually flexed to around 30–40°.

• In a positive test, the lateral tibial plateau subluxes in extension and suddenly reduces when the knee is flexed, producing the classic “clunk”⁵.

Positive finding:

• Palpable or visible subluxation and reduction of the tibia.

• Patients may also recognize the sensation of instability, often experienced during sports or trauma.

IKDC Grading

Pivot shift results can be graded according to the degree of tibial translation and reduction:

• Grade 0: Normal

• Grade 1 (Glide): Mild shift, no obvious clunk

• Grade 2 (Clunk): Distinct subluxation and reduction

• Grade 3 (Locked subluxation): Tibia remains shifted anteriorly until flexion⁶

Diagnostic Value

Parameter	Value
Sensitivity	0.18–0.48
Specificity	0.97–0.99
Mean sensitivity	0.32
Mean specificity	0.98
More accurate under anesthesia	Yes
More reliable in chronic ACL lesions	Yes
Quantifiable via navigation	Possible

The test has low sensitivity, especially in acute injuries, but very high specificity. It is regarded as the most functional and specific clinical test for ACL rupture⁸. Objective measurement with surgical navigation has further improved quantification in recent research⁹.

Anatomical Explanation

• Intact ACL: Prevents anterior tibial translation and rotational shift → no subluxation.

• Ruptured ACL: Lateral tibial plateau translates anteriorly in extension → reduces in flexion.

• Subluxation occurs due to loss of rotational control and anterior stability, especially anterolaterally¹⁰.

Rotational Variations

It is recommended to perform the pivot shift test in different tibial rotations:

• Medial rotation: Detects residual rotational laxity (Grade I).

• Neutral: Most sensitive for ACL rupture (Grade II).

• Lateral rotation: Reveals combined injuries involving posterolateral corner (Grade III).

This systematic variation increases reproducibility but still depends heavily on examiner skill and patient muscle relaxation¹¹.

Clinical Significance

A positive pivot shift indicates functional instability, not just mechanical laxity. The test simulates the uncontrolled sliding seen in rapid sports maneuvers, making it more representative of “real instability” than the Lachman or anterior drawer test¹².

Prognostic value:

• Grade 2–3 correlates with higher risk of meniscal injury and early osteoarthritis.

• Grade 3 often indicates combined injury (ACL + anterolateral/posterolateral structures).

Summary

The pivot shift test is the most specific clinical tool for diagnosing ACL rupture. It identifies functional anterolateral rotational instability and provides essential information for injury grading and surgical decision-making. While difficult to quantify manually, variations in tibial rotation and modern navigation systems enhance its diagnostic accuracy. The test is most reliable in chronic ACL injuries and under anesthesia.

Sources:

1. Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral menisectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2010;38(8):1591–1597.

2. Jakob RP, Staubli HU, Deland JT. Grading the pivot shift, objective tests with implications for treatment. J Bone Joint Surg Br. 1987;69(2):294–299.

3. Prentice WE. Principles of Athletic Training – A Competency Based Approach. 13th ed. New York: McGraw-Hill Higher Education; 2009. p.654–669.

4. Moore KL, Dalley AF. Clinically Oriented Anatomy. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p.690.

5. The Knee Resource. Pivot Shift Test. Tilgjengelig fra: https://www.youtube.com/watch?v=inPx9dwQuYE

6. AMBOSS: Medical Knowledge Distilled. Pivot Shift Test – Clinical Examination. Tilgjengelig fra: https://www.youtube.com/watch?v=JyT-7-fqW2w

7. Vaudreuil NJ, Rothrauff BB, de SA D, Musahl V. The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury. Curr Rev Musculoskelet Med. 2019;12(1):41–49.

8. Lane CG, Warren R, Pearle AD. The Pivot Shift. J Am Acad Orthop Surg. 2008;16(12):679–688.

9. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The Reliability, Validity, and Responsiveness of the Lysholm Score and Tegner Activity Scale for Anterior Cruciate Ligament Injuries of the Knee: 25 Years Later. Am J Sports Med. 2009;37:890–897.

10. Prins M. The Lachman test is the most sensitive and the pivot shift the most specific test for the diagnosis of ACL rupture. Aust J Physiother. 2006;52(1):66.

11. Ostrowski JA. Accuracy of 3 Diagnostic Tests for Anterior Cruciate Ligament Tears. J Athl Train. 2006;41(1):120–121.

12. Lopomo N, Zaffagnini N, Bignozzi S, Visani A, Marcacci M. Pivot Shift Test: Analysis and Quantification of Knee Laxity Parameters using a Navigation System. J Orthop Res. 2010;28(2):164–169.

13. Katz JW, Fingeroth RJ. The Diagnostic Accuracy of Ruptures of the Anterior Cruciate Ligament Comparing the Lachman Test, the Anterior Drawer Sign, and the Pivot Shift Test in Acute and Chronic Knee Injuries. Am J Sports Med. 1986;14(1):88–91.

14. Heijboer MP. Indicatie, fysische diagnostiek van de knie. Chronische knieklachten. Universiteit van Utrecht; 2004. p.5,7. Tilgjengelig fra: http://www.scopie.info/files/Website-elementen/kniecursus2004.pdf