The pivot shift: a global user guide



The use of several different maneuvers for the pivot shift test has resulted in inconsistent quantitative measurements. The purpose of this study was to describe, analyze, and group several surgeon-specific techniques for the pivot shift test and to propose a standardized pivot shift test.


Twelve expert surgeons examined a whole lower cadaveric extremity with their preferred technique and assigned a clinical grade, I–III. Anterior tibial translation and acceleration were measured using an electromagnetic system. The test was repeated after watching an instructional video focused on a standardized pivot shift technique. Measurements were repeated and compared with the preferred technique.


The expert surgeons utilized valgus stress unanimously in addition to fixed internal rotation (n = 5), fixed external rotation (n = 1), a motion-allowing technique (n = 3), a dislocation-type maneuver (n = 2), and a fixed anterior drawer type of maneuver in extension (n = 1). Anterior tibial translation measured was on average 15.9 ± 3.7 mm. Average tibial acceleration was 3.3 ± 2.1 mm/s2. Average clinical grading was 2.3 ± 0.5. There were no differences in average clinical grading when using high stress (2.5 ± 0.6) versus low stress (2.3 ± 0.5, n.s.), or using fixed rotation (2.2 ± 0.5) versus a motion-allowing technique (2.3 ± 0.6; n.s.).


Clinical grading, tibial translation, and acceleration vary between examiners performing the pivot shift test. High forces and extremes of rotation are not necessary to produce a clinical detectable pivot shift. In the future, a standardized pivot shift test—which can be performed universally and utilizes only gentle forces allowing motion to occur—may be beneficial when assessing differences in outcome following ACL reconstruction.

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  1. 1.

    Bedi A, Musahl V, Lane C, Citak M, Warren RF, Pearle AD (2010) Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis. Knee Surg Sports Traumatol Arthrosc 18(9):1269–1276

  2. 2.

    Benjaminse A, Gokeler A, van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36(5):267–288

  3. 3.

    Bull AM, Earnshaw PH, Smith A, Katchburian MV, Hassan AN, Amis AA (2002) Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 84(7):1075–1081

  4. 4.

    Dejour H, Walch G, Chambat P, Ranger P (1988) Active subluxation in extension: a new concept of study of the ACL deficient knee. Am J Knee Surg 1:204–211

  5. 5.

    Galway R, Beaupre A, MacIntosh D (1972) Pivot shift: a clinical sign of symptomatic anterior cruciate insufficiency. J Bone Joint Surg Br 54:763–764

  6. 6.

    Hoshino Y, Kuroda R, Nagamune K, Nishimoto K, Yagi M, Mizuno K, Yoshiya S, Kurosaka M (2007) The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics. Knee Surg Sports Traumatol Arthrosc 15(5):508–514

  7. 7.

    Hoshino Y, Kuroda R, Nagamune K, Yagi M, Mizuno K, Yamaguchi M, Muratsu H, Yoshiya S, Kurosaka M (2007) In vivo measurement of the pivot-shift test in the anterior cruciate ligament-deficient knee using an electromagnetic device. Am J Sports Med 35(7):1098–1104

  8. 8.

    Irrgang JJ, Ho H, Harner CD, Fu FH (1998) Use of the international knee documentation committee guidelines to assess outcome following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 6(2):107–114

  9. 9.

    Katz JW, Fingeroth RJ (1986) 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 14(1):88–91

  10. 10.

    Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ (2004) Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 32(3):629–634

  11. 11.

    Kuroda R, Hoshino Y, Kubo S, Araki D, Oka S, Nagamune K, Kurosaka M (2011) Similarities and differences of diagnostic manual tests for anterior cruciate ligament insufficiency: a global survey and kinematics assessment. Am J Sports Med. doi:10.1177/0363546511423634

  12. 12.

    Lane CG, Warren RF, Stanford FC, Kendoff D, Pearle AD (2008) In vivo analysis of the pivot shift phenomenon during computer navigated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 16(5):487–492

  13. 13.

    Leitze Z, Losee RE, Jokl P, Johnson TR, Feagin JA (2005) Implications of the pivot shift in the ACL-deficient knee. Clin Orthop Relat Res 436:229–236

  14. 14.

    Liu SH, Osti L, Henry M, Bocchi L (1995) The diagnosis of acute complete tears of the anterior cruciate ligament. Comparison of MRI, arthrometry and clinical examination. J Bone Joint Surg Br 77(4):586–588

  15. 15.

    Lopomo N, Zaffagnini S, Signorelli C, Bignozzi S, Giordano G, Marcheggiani Muccioli GM, Visani A (2011) An original clinical methodology for non-invasive assessment of pivot-shift test. Comput Methods Biomech Biomed Eng. doi:10.1080/10255842.2011.591788

  16. 16.

    Losee RE (1983) Concepts of the pivot shift. Clin Orthop Relat Res 172:45–51

  17. 17.

    Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG (2009) Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 91(10):2321–2328

  18. 18.

    Markolf KL, Park S, Jackson SR, McAllister DR (2008) Simulated pivot-shift testing with single and double-bundle anterior cruciate ligament reconstructions. J Bone Joint Surg Am 90(8):1681–1689

  19. 19.

    Musahl V, Bedi A, Citak M, O’Loughlin P, Choi D, Pearle AD (2011) Effect of single-bundle and double-bundle anterior cruciate ligament reconstructions on pivot-shift kinematics in anterior cruciate ligament- and meniscus-deficient knees. Am J Sports Med 39(2):289–295

  20. 20.

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

  21. 21.

    Musahl V, Voos J, O’Loughlin PF, Stueber V, Kendoff D, Pearle AD (2009) Mechanized pivot shift test achieves greater accuracy than manual pivot shift test. Knee Surg Sports Traumatol Arthrosc 18(9):1208–1213

  22. 22.

    Noyes FR, Grood ES, Cummings JF, Wroble RR (1991) An analysis of the pivot shift phenomenon. The knee motions and subluxations induced by different examiners. Am J Sports Med 19(2):148–155

  23. 23.

    Oh YK, Kreinbrink JL, Ashton-Miller JA, Wojtys EM (2011) Effect of ACL transection on internal tibial rotation in an in vitro simulated pivot landing. J Bone Joint Surg Am 93(4):372–380

  24. 24.

    Petermann J, Trus P, Kunneke M, Gotzen L (1996) The pivot-shift test in relation to hip position and lower leg rotation. A clinical analysis. Unfallchirurg 99(3):191–195

  25. 25.

    Tashman S, Collon D, Anderson K, Kolowich P, Anderst W (2004) Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med 32(4):975–983

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The authors would like to sincerely thank the expert surgeons for their participation and inspiring comments during the study (Drs. Roland Becker, Shiyi Chen, Moises Cohen, Andreas Imhoff, Timo Jarvela, Masahiro Kurosaka, Benjamin Ma, Willem van der Merwe, Philippe Neyret, Robert Smigielski).

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Correspondence to Volker Musahl.

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Musahl, V., Hoshino, Y., Ahlden, M. et al. The pivot shift: a global user guide. Knee Surg Sports Traumatol Arthrosc 20, 724–731 (2012) doi:10.1007/s00167-011-1859-4

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  • Pivot shift
  • Standard technique
  • Acceleration
  • ACL