PIVOT SHIFT

TEST

​• Test positioning

The client lies supine with the test knee in full extension.

The therapist stands with the proximal hand on the client's anterolateral tibiofemoral joint, with the thumb on or posterior to the fibular head.

The distal hand grasps the client's midfoot and heel.

​• Alternate test positioning

Place the client's foot between the therapist's distal arm and body with the same hand on the tibia.

The proximal hand is placed on the posterolateral leg, just distal to the knee, with the thumb on or posterior to the fibular head.

​• Action

Internally rotate the tibia with the distal hand, apply a valgus force with the proximal hand, and slowly flex the knee.

The same procedure applies for the alternate test positioning, except a slight axial load is first applied to the extended knee.

​• Positive finding

A palpable "clunk" or shift at -20 to 30 degrees of flexion is indicative of anterolateral rotary instability secondary to tearing of the ACL and posterolateral capsule.

​• Special considerations & comments

It is important to provide the axial load before flexing the knee, as this helps to accentuate the "clunk" or shift that will facilitate detection of a trace pivot shift.

It should be noted that this test often reproduces the mechanism of injury, which may create client anxiety and apprehension, thus increasing the potential for false-negative findings. 

This may be the most sensitive and accurate test for assessing anterior tibiofemoral instability.

However, it is difficult to perform and client anxiety reduces the opportunity for the therapist to gain experience as compared to administering other special tests.

The Pivot Shift Test is attributed to Dr. Freddie Fu for his work on rotational instability and ACL injuries, with contributions from Dr. James Cyriax’s orthopedic manual therapy techniques to refine its clinical application.