Execution
- 1Position the patient supine with the hip flexed and the knee extended.
- 2Hold the heel or foot and internally rotates the tibia.
- 3Apply valgus stress to the knee while maintaining axial compression.
- 4Slowly flex the knee from extension.
- 5Observe and feel for anterior subluxation of the lateral tibial plateau reducing near 30 degrees flexion.
Positive outcome
A sudden shift, clunk, or reduction of the lateral tibial plateau as the knee flexes is positive. The test reflects anterolateral rotatory instability, usually ACL deficiency with secondary restraint involvement. In awake patients, guarding may produce apprehension rather than a clear clunk.
Studies
| Study | Reliability | Sn | Sp | LR+ | LR− |
|---|---|---|---|---|---|
| Benjaminse et al. (2006) | meta-analysis | 24 | 98 | 11.6 | 0.8 |
| van Eck et al. (2013) | systematic review/meta-analysis | 55 | 96 | 13.7 | 0.47 |
CommentPivot shift is highly specific but insensitive in the awake patient because pain and guarding suppress the reduction event. It is more useful under anesthesia and for grading functional rotatory instability than as an early screening test. Positive findings are clinically important, but negative findings do not exclude ACL injury.
High Clinical Value