Education and repetition improve success rate and quantitative measures of the pivot shift test

  • Jan-Hendrik NaendrupEmail author
  • Neel K. Patel
  • Jason P. Zlotnicki
  • Conor I. Murphy
  • Richard E. Debski
  • Volker Musahl



Clinicians have different techniques and varying levels of experience with the pivot shift test, introducing variability into its performance. The purpose of this study was to evaluate the influence of teaching and repetition on the success rate and anterior translation of the lateral knee compartment during the pivot shift test in a cadaveric ACL injury model.


Twenty-five participants (five each of medical students, orthopaedic surgery residents, physical therapists, athletic trainers, sports medicine fellows) were recruited and a senior orthopaedic surgeon served as gold standard examiner. Each participant performed 20 pivot shift tests on lower extremity cadaveric specimens with ACL deficiency and lateral meniscectomy: 5 prior to education (baseline), 10 after watching an instructional video (passive teaching), and 5 after an interactive education session (active teaching). The anterior translation of the lateral knee compartment was recorded during each pivot shift test using electromagnetic tracking system.


For medical students and orthopaedic surgery residents, significant improvement in success rate was found when compared to baseline (12% and 24%, respectively) after both passive (36% and 60%, respectively) and active teaching (52% and 72%, respectively) (p < 0.5). Medical students and residents were the only participants that independently achieved significant increases in anterior translation of the lateral knee compartment, each tripling the respective baseline value (p < 0.5). In the entire study population, significant increases in anterior translation of the lateral knee compartment and success rate of the pivot shift test were seen with continuous repetition (p < 0.5). However, the standard deviation of anterior translation of the lateral knee compartment was more than twice the gold standard examiner’s standard deviation, indicating a high degree of variability.


Teaching of the pivot shift test plays a major role in the development of a proper technique. However, variability persisted despite teaching and repetition. New methods may be needed to improve the teaching of the pivot shift test.


Knee Anterior cruciate ligament Pivot shift test Education Repetition Knee biomechanics 



Anterior cruciate ligament


Analysis of variance


Author contributions

JHN performed acquisition, interpretation, and analysis of data, and drafted the original manuscript. NKP, JPZ, and CIM performed acquisition, interpretation, and analysis of data. RED and VM edited the original manuscript, assisted with the interpretation and analysis of data, and conceived and designed the original project.


There was no external source of funding for this study.

Compliance with ethical standards

Conflict of interest

The authors of this study confirm that they have no conflicts of interest related to this study.

Ethical approval

Prior to the start of this study, approval was obtained from the Institutional Review Board of the University of Pittsburgh and the Committee for Oversight in Research Involving Decedents (CORID) in accordance with the ethical standards of the Declaration of Helsinki (1964) and its later amendments (PRO15060142).


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical CenterWitten/Herdecke UniversityCologneGermany
  2. 2.Orthopaedic Robotics Laboratory, Department of Bioengineering and Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA

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