Written by manual therapists Thomas T. Ødegaard and Roar Syltebø

The pivot shift was first described by Galway, Beaupre and MacIntosh at an orthopaedic congress in 1972 (Galway et al., 1972). In 1980, the same authors published a description of the pivot shift in article form (Galway & MacIntosh, 1980). The first pictures and description of what is now called a pivot shift manoeuvre, in which the patient provokes a pivot shift phenomenon themselves, were published as early as 1919 by Hey Groves (Hey Groves, 1919). The pivot shift test is intended to detect anterolateral rotational instability of the knee. The anterior cruciate ligament (ACL) is mainly responsible for this stability, and the pivot shift test is therefore an ACL test. The test exists in several different versions.

Indication

The pivot shift test is indicated in all knee examinations after trauma, when an ACL injury (partial or complete tear) is suspected and the main symptom is that the knee gives way. ACL injuries are usually associated with a rotational trauma that causes severe pain and rapid swelling (Bahr & Mæhlum, 2002). The test has also been shown to be useful postoperatively, and it correlates well with functional instability after ACL reconstruction.

Procedure

The pivot shift test is performed with the patient supine and the knee in extension. The clinician grasps the distal part of the patient’s lower leg and internally rotates the tibia, while flexing the knee and applying a valgus stress to the proximal tibia with the other hand. The rotation and valgus stress are maintained as the clinician gradually flexes the knee. In a positive test, the lateral tibial plateau subluxes. This usually occurs at 20–40° of flexion (Galway & MacIntosh, 1980; Johnson, 1982; Slocum et al., 1976).

Reference is also often made to Losee and colleagues, who published their version of the pivot shift test in 1978 (Losee et al., 1978). The patient lies supine and the clinician flexes the knee to 45°. The clinician’s distal hand grasps the distal part of the lower leg, while the other hand applies firm pressure to the posterolateral corner of the proximal tibia. At the start of the test the tibia is externally rotated, but it is allowed to rotate internally as it subluxes. From approximately 45° of flexion, the clinician extends the knee, and at 10–20° of flexion the knee may sublux, and the patient recognises the sensation (Losee et al., 1978).

As a third modification, the pivot shift test can be performed with a “figure-of-four” grip. The patient lies supine, with the hip and knee flexed to approximately 90°, and the patient’s lower leg and ankle are held between the clinician’s distal upper arm and trunk. The clinician’s proximal arm grips the patient’s proximal lateral tibia and fibula, and the distal hand is placed behind the patient’s lower leg and grips the forearm of the clinician’s proximal hand. The clinician then slowly extends the knee while maintaining internal rotation of the tibia. As the knee approaches full extension, the tibial plateau will sublux. The test is positive if a “clunk” is seen and/or heard (Cook & Hegedus, 2012; Hughston et al., 1976; Maffulli et al., 2011).

Since the 1980s, various modifications and versions of the pivot shift test have continued to appear, but these three form the basis of the versions most commonly used. Four to six other authors are known to have modified the test somewhat (Lane et al., 2008).

Interpretation

In an ACL tear, the knee will usually sublux at approximately 20–40° of flexion. This is a positive pivot shift test and indicates an ACL injury and/or complete tear. In addition, pain and apprehension or guarding by the patient against the subluxation are described as a positive test (Hughston et al., 1976; Losee et al., 1978; Galway & MacIntosh, 1980; Maffulli et al., 2011).

Clinical studies

In 1985, Donaldson and colleagues published a study assessing the sensitivity of the anterior drawer test, the Lachman test and the pivot shift test (Donaldson et al., 1985). They included 101 patients, of whom 37 had an isolated ACL injury and the rest had an ACL injury combined with various other knee ligament injuries. Only 35% of the 101 patients had a positive pivot shift test, and 27% of the patients with an isolated ACL injury. The patients were also examined under anaesthesia, and the sensitivity was then as high as 98% for the whole group and 100% for the isolated ACL tears. The authors point out that the patient’s protective response (guarding) can have a large effect on the outcome of the test, and that this must be taken into account when interpreting the pivot shift test (Donaldson et al., 1985).

The article “Stability tests in knee ligament injuries” was published in 1986 by Sandberg and colleagues. A total of 182 knee ligament injuries were verified surgically, and all were examined with the pivot shift test, among other tests. Of these, 92 were isolated ACL injuries and 32 combined ACL and MCL injuries. The remaining 58 were either isolated MCL injuries or injuries involving the posterior cruciate ligament. Without anaesthesia, the pivot shift test had a sensitivity of 4% for isolated ACL injuries and 9% for combined ACL and MCL injuries, with an overall sensitivity of 6%. None of the patients with injuries other than ACL injuries had a positive pivot shift test, so the specificity was 100% (Sandberg et al., 1986).

In 1991, Noyes and colleagues carried out a cadaver study to evaluate how different techniques affected the amount of internal rotation and translation in the knee during the pivot shift test. Ten knee surgeons took part (Noyes et al., 1991). They found large differences in how the test was performed, and large differences in the amount of movement depending on the technique. Maximum anterior subluxation of the lateral tibial plateau ranged from 14 to 19.8 mm, while the medial tibial plateau subluxed anteriorly by 6 to 16.9 mm. This shows the importance of standardising the test procedure and of clinicians being aware of how they perform the test (Noyes et al., 1991).

In 1991, Boeree and Ackroyd published a study in which 203 patients with knee injuries were examined for cruciate ligament and meniscal injuries. The Lachman test, the anterior drawer test and the pivot shift test were used to assess the ACL, and the injuries were verified with MRI. MRI showed 29 isolated ACL tears and 30 combined meniscal and cruciate ligament injuries. The article does not state whether the combined injuries involved the anterior or posterior cruciate ligament. The pivot shift test had a sensitivity of 30.5% and a specificity of 96.5%. The sensitivity was clearly lower than for the two other tests (Lachman test 62.7%, anterior drawer test 55.9%). The authors conclude that little is gained by combining several ACL tests, and that the pivot shift test was the least sensitive of the three (Boeree & Ackroyd, 1991).

In 1994, Rubinstein and colleagues published a study of the clinical examination of posterior cruciate ligament injuries, in which nine patients with an ACL injury were included. For the pivot shift test, a sensitivity of 93% and a specificity of 89% are reported (Rubinstein et al., 1994). These figures should be interpreted with caution. The study was designed to examine the posterior cruciate ligament and not the pivot shift test, the figures are based on very few patients with an ACL injury.

In 1995, Liu and colleagues studied the sensitivity of the Lachman test, the anterior drawer test and the pivot shift test in 38 patients with an arthroscopically confirmed ACL tear. The pivot shift test was negative in 11 and positive in 27 of the patients, giving a sensitivity of 71% (Liu et al., 1995).

Décary et al. (2018) studied 279 patients with knee complaints from orthopaedic outpatient clinics and general practice. The pivot shift test had a positive likelihood ratio of 37.5 and a negative likelihood ratio of 0.24. If the patient reported neither a pivoting injury nor a “popping” sensation, and both the Lachman test and the pivot shift test were negative, the negative likelihood ratio was 0.08 (Décary et al., 2018).

Systematic reviews

In a systematic review, Solomon and colleagues (Solomon et al., 2001) analysed the accuracy of clinical tests compared with arthroscopy, MRI and arthrotomy. They reviewed the English-language literature in Medline and HealthSTAR from 1966 to 2000. Of 88 articles identified, 23 (26%) were included, of which only five studied the pivot shift test. The study by Donaldson and colleagues described above was one of these (Donaldson et al., 1985). A rheumatologist and an orthopaedic surgeon independently rated the studies using a standardised rating scale. The sensitivity of the pivot shift test ranged from 27% to 95%, with a mean of 38%. None of the five studies of the pivot shift test assessed its specificity (Solomon et al., 2001).

In 2003, Malanga and colleagues published a large review in which they systematically searched Medline from 1970 to 2000 (Malanga et al., 2003). The aim was to trace the original descriptions of clinical knee tests and then assess their scientific validity and accuracy. Only three articles studying the pivot shift test were included, one of which was the study by Donaldson and colleagues described above (Donaldson et al., 1985). They found that the pivot shift test performed under anaesthesia had a sensitivity of 84–98.4%. Testing under anaesthesia is rarely available and is not possible in ordinary clinical practice. Without anaesthesia, the sensitivity of the test is considerably lower, down to 35%. The specificity was 98.4% when the test was performed under anaesthesia. Malanga and colleagues did not find any studies of the specificity of the pivot shift test without anaesthesia (Malanga et al., 2003).

In a meta-analysis from 2006, Benjaminse and colleagues reviewed articles in three large databases (Medline, Embase and CINAHL) from 1966 to 2005, limited to English, German and Dutch. The aim was to determine the accuracy of clinical tests for detecting an ACL injury. After screening, 15 studies assessing the sensitivity and eight assessing the specificity of the pivot shift test without anaesthesia were included. The pivot shift test had the following properties:

		95% confidence interval
Sensitivity	24%	21–27%
Specificity	98%	96–99%
Negative likelihood ratio	0.9	0.8–1.0
Positive likelihood ratio	8.5	4.7–15.5
Diagnostic odds ratio	12	5–31

The meta-analysis concludes that the pivot shift test is a very specific test in both acute and chronic ACL-deficient knees, and that it should be part of the clinical assessment of acute knee injuries (Benjaminse et al., 2006).

In a meta-analysis of acute, complete ACL tears, van Eck et al. (2013) found that, in the clinic without anaesthesia, the pivot shift test had a sensitivity of 28% and a specificity of 81%. Under anaesthesia, the sensitivity increased to 73% and the specificity to 98%. Under anaesthesia, the pivot shift test had the highest specificity of the three tests studied (van Eck et al., 2013).

In a more recent meta-analysis using bivariate analysis, Sokal et al. (2022) found a sensitivity of 55% (95% CI 47–62%) and a specificity of 94% (95% CI 88–97%) for the pivot shift test, corresponding to a positive likelihood ratio of 10.7 and a negative likelihood ratio of 0.48. The pivot shift test was the best test for confirming an ACL tear (Sokal et al., 2022). In patients with a suspected acute ACL injury, Tanaka et al. (2022) found a sensitivity of 55% and a specificity of 96%, with the highest positive likelihood ratio (11.6) of the tests studied (Tanaka et al., 2022).

Patients who have undergone ACL surgery have also been followed up with the pivot shift test. Kaplan and colleagues (Kaplan et al., 1990) found a significant correlation between the grade of a positive or negative pivot shift test and the patient’s ability to return to physical activity and sport. In patients examined on average seven years after surgery, a negative pivot shift test was associated with a higher activity level. Some years later, Kocher and colleagues (Kocher et al., 2004) confirmed the same findings. In 202 patients after ACL reconstruction, Kocher also found a strong correlation between a positive pivot shift test, symptoms of giving way and patient satisfaction. They therefore conclude that the pivot shift test is a better measure of “functional instability” after ACL reconstruction than other tests such as the KT-1000 and the Lachman test (Kocher et al., 2004).

In their 2008 review and summary of the pivot shift, Lane and colleagues (Lane et al., 2008) write that it is a good test, but that several factors prevent it from achieving the same clinical accuracy as the Lachman test. A major source of error in studies of the pivot shift test is that many different versions are used. Hip angle, the degree of rotation and similar clinical and technical factors can affect the outcome of the test. Another factor is the clinician’s individual skill in examination technique, how much force is applied, how the test is interpreted and therefore the ability to reproduce the same test. The pivot shift test has defined outcomes, but it is easily influenced by subjectivity. A third important point is that many patients have naturally increased laxity and may have a positive pivot shift test even without injury. The fourth and final point raised by Lane and colleagues is that some patients find the test uncomfortable and will therefore guard, and that pain and associated soft-tissue injuries can make the pivot shift test more difficult to perform (Lane et al., 2008).

In an interesting article, Kuroda and colleagues (Kuroda et al., 2012) compared the clinical performance of the pivot shift test by experienced orthopaedic surgeons with electromagnetic measurement of knee kinematics. At an orthopaedic conference in Japan, five orthopaedic surgeons from five different continents, with an average of 28 years of experience, were selected at random. Each performed the pivot shift test three times on a patient with an ACL tear in the operating theatre under anaesthesia, while electromagnetic measurements were made. All five performed the test from an extended to a flexed knee, but each used their own modified technique with regard to grip, rotation and so on. Three chose internal rotation and two external rotation of the tibia. The electromagnetic measurements also clearly documented large individual differences in the force applied, the acceleration and the amount of valgus applied to the knee. The subluxation occurred at approximately 40° of flexion, and all five recorded a positive pivot shift test, one grading it +++ and the others ++. A limitation of the study is that only five orthopaedic surgeons tested one patient, but the study nevertheless documents how many sources of error can arise during the clinical pivot shift test. The patient was under general anaesthesia, as the study focused on comparing manual testing with electromagnetic kinematics, which is not the case in ordinary clinical practice. All participants also knew that the patient had an ACL injury before the test was performed.

In the same study, orthopaedic surgeons from all over the world attending the congress were surveyed. Sixty per cent performed the pivot shift test from flexion to extension. All applied a valgus stress to the knee, while 58% used internal rotation of the tibia and the rest external rotation. The study concludes that the pivot shift can be measured as tibial translation and/or acceleration, and that the pivot shift as a clinical test has a number of limitations (Kuroda et al., 2012).

In their book, Cook and Hegedus (2012) give the pivot shift test a utility score of 2, meaning that the evidence moderately supports its use in clinical practice to test for instability and ACL injuries of the knee (on a scale from 1, strong support, to 3, minimal or no support). This assessment reflects the literature up to 2012. The more recent meta-analyses described above call this score into question, but in the opposite direction from most other tests: they found a higher sensitivity than earlier reviews and identified the pivot shift test as the best clinical test for confirming an ACL tear. The test may therefore be of greater value than the score suggests, particularly for confirming an ACL tear (Sokal et al., 2022; Tanaka et al., 2022).

Body Examination suggests the following interpretation of the pivot shift test:

• Anterior subluxation, and possibly relocation, of the tibia during the test is regarded as a positive pivot shift test.
• The pivot shift test has low sensitivity and should not be used as the only ACL test, but a positive pivot shift test points with relatively high certainty towards an ACL tear. Newer meta-analyses confirm that it is the best clinical test for confirming an ACL tear.
• Clinicians differ, and the evidence on how the test should be performed is unclear. The pivot shift test is also technically demanding. It is therefore important that clinicians take the time to standardise their own procedure and learn the test thoroughly.
• Body Examination’s experience is consistent with the literature. The pivot shift test is a very good test that says a great deal about the functional stability of the knee. It can be used after injury and also postoperatively.
• Body Examination recommends interpreting the test as positive if the patient is apprehensive and does not allow the joint to sublux.
• Remember that patients with increased laxity may have a positive pivot shift test without a knee injury. Always test both knees.

Literature search, updating and translation were carried out with the assistance of AI (Claude, Anthropic). The professional content has been reviewed and quality-assured by the editor-in-chief, Roar Syltebø.

References

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