The pivot shift: a global user guide

Purpose 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. Methods 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. Results 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/s(2). 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.). Conclusions 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.