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Pivot-Shift Test: Knee Examination for ACL Rupture

The pivot-shift test is a clinical examination method used to diagnose anterior cruciate ligament rupture in the knee joint. It assesses rotational instability of the knee.

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The pivot-shift test is a clinical examination method used to diagnose anterior cruciate ligament rupture in the knee joint. It assesses rotational instability of the knee.

What is the Pivot-Shift Test?

The pivot-shift test is a specialized clinical examination technique used in orthopaedics and sports medicine. It is performed to detect a rupture (tear) of the anterior cruciate ligament (ACL) in the knee joint. In particular, it evaluates the so-called rotational instability of the knee – the tendency of the tibia (shinbone) to subluxate (slip forward) beneath the femur (thighbone) when the knee is loaded and simultaneously rotated.

The test was first described in the 1970s by orthopaedic surgeons MacIntosh and Galway and is now a standard component of clinical knee examination worldwide.

How is the Pivot-Shift Test Performed?

The examination is typically performed by a physician with the patient lying down. The procedure is as follows:

The patient's leg is held in full extension.
The examiner applies a gentle internal rotation to the lower leg while slowly flexing the knee from extension into flexion.
Simultaneously, a valgus stress (inward lateral pressure) is applied to the knee.
In the presence of an ACL tear, at approximately 20–30 degrees of flexion, a noticeable and often visible jerk or glide of the tibial head occurs – the so-called “shift.” This phenomenon occurs because the iliotibial band (a connective tissue band along the outer thigh) suddenly pulls the subluxated tibia back into its correct position at this degree of flexion.

Clinical Significance

The pivot-shift test is considered one of the most specific tests for anterior cruciate ligament instability. It provides important information about whether functional knee stability remains despite an ACL tear, or whether surgical intervention may be necessary.

The intensity of the pivot-shift phenomenon is commonly graded as follows:

Grade 0: No shift (negative finding)
Grade I: Slight glide
Grade II: Pronounced clunk
Grade III: Gross subluxation

Sensitivity and Specificity

The diagnostic accuracy of the pivot-shift test depends greatly on the experience of the examiner and the muscle tone of the patient. In a relaxed patient or under anaesthesia, sensitivity is significantly higher. Studies report a sensitivity of approximately 24–48% in awake patients and up to 98% under general anaesthesia, with a specificity exceeding 95%.

Combination with Other Tests

The pivot-shift test is frequently combined with other knee examination techniques to confirm the diagnosis:

Lachman test: Assesses anterior tibial translation at 20–30 degrees of flexion.
Anterior drawer test: An older test evaluating anterior stability at 90 degrees of flexion.
MRI (magnetic resonance imaging): Imaging confirmation when clinical suspicion is present.

When is the Pivot-Shift Test Used?

The test is typically indicated in the following situations:

Suspected acute or chronic anterior cruciate ligament tear following a sports injury or accident
Preoperative planning for ACL reconstruction surgery
Postoperative follow-up to assess the success of reconstruction
Sports orthopaedic evaluations in competitive athletes

References

Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clinical Orthopaedics and Related Research, 1980; 147: 45–50.
van Eck CF, van den Bekerom MP, Fu FH et al. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surgery, Sports Traumatology, Arthroscopy, 2013; 21(8): 1895–1903.
Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. Journal of Orthopaedic and Sports Physical Therapy, 2006; 36(5): 267–288.

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