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Pivot shift test

Authoring team

Pivot Shift Test

  • pivot shift test:
    • assesses degree of incapacitating dysfunction in knee with anterior crucitate ligament (ACL) deficiency and secondary restraint deficiency
    • reproduces event that occurs when knee gives way becuase of loss of ACL
      • there is a forward subluxation of tibia during sudden change in direction
    • test may also be used to judge the success of ACL reconstruction

  • various methods of eliciting pivot-shift phenomenon have been described

  • during test, patient is supine and examiner holds patient's leg with both hands

  • is important to abduct the hip to relax the IT band allow the tibia to rotate

  • knee is held at approx 20 degrees of flexion and in neutral rotation

  • patient relaxes his or her muscles, which allows femur to drop backward (if the ACL is torn)

  • knee is then placed in full extension with aplication of valgus stress and internal rotation stress;
    • knee extension: posterior capsule holds reduction

  • slowly flex the knee while valgus and internal rotation is maintained;
    • knee flexion: at 40 degrees: iliotibial band provides reduction

  • load is then placed on knee joint by application of axial or valgus force (or both) while tibia is kept in a neutral rotation

  • if test is positive, a subluxation (lateral > medial) will occur at 20 to 40 deg of flexion, indicating ACL deficiency

  • rotation can be added to accentuate or diminish subluxation

  • isolated tear of the ACL will produce only small subluxation;
    • greater subluxation occurs when the lateral capsular complex or semimembranosus corner is also deficient

  • test can also be be performed from flexion to extension;
    • tibia is placed in external rotation and as the knee is extended ensure that the tibia can rotate - allowing subluxation to occur at between 10-20 degrees


  • this is a difficult test because meniscal involvement, such as with bucket handle tears of the medial meniscus, may limit range of motion and muscle guarding to produce a false-negative

Click here for video of Pivotal Shift Test


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The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

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