The Envelope of Laxity of the Pivot Shift Test

  • Breck Lord
  • Andrew A. AmisEmail author


The pivot shift is a dynamic test of knee laxity which correlates with subjective sensations of knee instability. As the knee flexes from full extension, the tibia subluxes, both in anterior translation and internal rotation, so that the lateral femoral condyle moves ‘downhill’ to the posterior edge of the tibial plateau under the influence of the compressive joint load. With further knee flexion, the tension in the iliotibial tract eventually overcomes the load which has maintained the subluxation and then the tibia is suddenly reduced to its anatomical articulation. Thus, the envelope of laxity of the pivot shift shows a pattern of simultaneous gradual pathological anterior translation and internal rotation, occurring over approximately 35° of knee flexion, followed by a relatively sudden reduction, which is a falling back posteriorly and externally to the anatomical position. It is desirable to measure both tibial translations and rotations to understand each injured knee, because differing patterns of injury may explain the wide range of tibiofemoral movements, such as the relative amount of tibial translation versus rotation, that have been reported during the pivot shift.


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Anterior Cruciate Ligament Injury Lateral Compartment Pivot Shift 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Kujala UM, Nelimarkka O, Koskinen SK (1992) Relationship between the pivot shift and the configuration of the lateral tibial plateau. Arch Orthop Trauma Surg 111(4):228–229CrossRefPubMedGoogle Scholar
  2. 2.
    Kaplan N, Wickiewicz TL, Warren RF (1990) Primary surgical treatment of anterior cruciate ligament ruptures. A long-term follow-up study. Am J Sports Med 18:354–358CrossRefPubMedGoogle Scholar
  3. 3.
    Noyes FR, Mooar PA, Matthews DS et al (1983) The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am 65A:154–162Google Scholar
  4. 4.
    Butler DL, Noyes F, Grood E (1980) Ligamentous restraints to anterior-posterior drawer in the human knee. J Bone Joint Surg Am 62(2):259–270PubMedGoogle Scholar
  5. 5.
    Galway R, Beaupre A, MacIntosh D (1972) Pivot shift: a clinical sign of symptomatic anterior cruciate insufficiency. J Bone Joint Surg [Br] 54:763–764Google Scholar
  6. 6.
    Galway H, MacIntosh D (1980) The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 147:45–50PubMedGoogle Scholar
  7. 7.
    Hey Groves EW (1920) The crucial ligaments of the knee joint: their function, rupture and the operative treatment of the same. Br J Surg 7:505–515CrossRefGoogle Scholar
  8. 8.
    Noyes FR et al (1991) An analysis of the pivot shift phenomenon the knee motions and subluxations induced by different examiners. Am J Sports Med 19(2):148–155CrossRefPubMedGoogle Scholar
  9. 9.
    Bull AMJ, Earnshaw PH, Smith A, Katchburian MV, Hassan ANA, Amis AA (2002) Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament. J Bone Jt Surg Br 84:1075–1081CrossRefGoogle Scholar
  10. 10.
    Bull AMJ, Amis AA (1998) The pivot shift phenomenon: a clinical and biomechanical perspective. Knee 5:141–158CrossRefGoogle Scholar
  11. 11.
    Bull AMJ, Amis AA (1998) Knee joint motion – description and measurement. Proc IMech E part H: Eng in Med 212:357–372CrossRefGoogle Scholar
  12. 12.
    Fukubayashi T, Torzilli PA, Sherman MF et al (1982) An in vitro biomechanical evaluation of anterior-posterior motion of the knee. Tibial displacement, rotation, and torque. J Bone Joint Surg Am 64A:258–264Google Scholar
  13. 13.
    Nordt WE, Lotfi P, Plotkin E et al (1999) The in vivo assessment of tibial motion in the transverse plane in anterior cruciate ligament reconstructed knees. Am J Sports Med 27:611–616PubMedGoogle Scholar
  14. 14.
    Amis AA, Scammell BE (1993) Biomechanics of intraarticular and extraarticular reconstructions of the anterior cruciate ligament. J Bone Jt Surg Br 75B:812–817Google Scholar
  15. 15.
    Amis AA et al (2003) Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 11(5):271–281CrossRefPubMedGoogle Scholar
  16. 16.
    Zarins B et al (1983) Rotational motion of the knee. Am J Sports Med 11(3):152–156CrossRefPubMedGoogle Scholar
  17. 17.
    Amis AA (1989) Anterior cruciate ligament replacement knee stability and the effects of implants. J Bone Jt Surg Br 71B:819–824Google Scholar
  18. 18.
    Daniel DM, Malcom LL, Losse G et al (1985) Instrumented measurement of anterior laxity of the knee. J Bone Jt Surg Am 67A:720–726Google Scholar
  19. 19.
    Slocum DB, Larson RL (1968) Rotatory instability of the knee – its pathogenesis and a clinical test to demonstrate its presence. J Bone Jt Surg Am 50A:211–225Google Scholar
  20. 20.
    Slocum DB et al (1976) Clinical test for anterolateral rotary instability of the knee. Clin Orthop Relat Res 118:63–69PubMedGoogle Scholar
  21. 21.
    Markolf KL, Mensch JS, Amstutz HC (1976) Stiffness and laxity of the knee – the contributions of the supporting structures. A quantitative in vitro study. J Bone Jt Surg Am 58A:583–594Google Scholar
  22. 22.
    Seering WP, Piziali RL, Nagel DA et al (1980) The function of the primary ligaments of the knee in varus-valgus and axial rotation. J Biomech 13(9):785–794CrossRefPubMedGoogle Scholar
  23. 23.
    Norwood LA, Andrews JR, Meisterling RC et al (1979) Acute anterolateral rotatory instability of the knee. J Bone Jt Surg Am 61A:704–709Google Scholar
  24. 24.
    Lipke JM (1981) Role of incompetence of the anterior cruciate and lateral collateral ligaments in anterolateral and anteromedial instability. A biomechanical study of cadaver knees. J Bone Jt Surg Am 63A:954–960Google Scholar
  25. 25.
    Andersen HN, Dyhre-Poulsen P (1997) The anterior cruciate ligament does play a role in controlling axial rotation of the knee. Knee Surg Sports Traumatol Arthrosc 5:145–149CrossRefPubMedGoogle Scholar
  26. 26.
    Lane JG, Daniel D (1994) The anterior cruciate ligament in controlling axial rotation. Am J Sports Med 22:289–293CrossRefPubMedGoogle Scholar
  27. 27.
    Wroble RR, Grood ES, Cummings JS et al (1993) The role of the lateral extraarticular restraints in the anterior cruciate ligament-deficient knee. Am J Sports Med 21:257–263CrossRefPubMedGoogle Scholar
  28. 28.
    Wang CJ, Walker PS (1974) Rotatory laxity of the human knee joint. J Bone Jt Surg Am 56A:161–170Google Scholar
  29. 29.
    Kaneda Y, Moriya H, Takahashi K et al (1997) Experimental study on external tibial rotation of the knee. Am J Sports Med 25:796–800CrossRefPubMedGoogle Scholar
  30. 30.
    Mannel H, Claes L, Durselen L (2004) Anterior cruciate ligament rupture translates the axes of motion within the knee. Clin Biomech 19:130–135CrossRefGoogle Scholar
  31. 31.
    Terry GC et al (1993) How iliotibial tract injuries of the knee combine with acute anterior cruciate ligament tears to influence abnormal anterior tibial displacement. Am J Sports Med 21(1):55–60CrossRefPubMedGoogle Scholar
  32. 32.
    Hughston JC, Andrews JR, Cross MJ et al (1976) Classification of knee ligament instabilities. Part II. The lateral compartment. J Bone Joint Surg Am 58A:173–179Google Scholar
  33. 33.
    Matsumoto H (1990) Mechanism of the pivot shift. J Bone Jt Surg Br 72B:816–821Google Scholar
  34. 34.
    Losee RE, Johnson TR, Southwick WO (1978) Anterior subluxation of the lateral tibial plateau. A diagnostic test and operative repair. J Bone Joint Surg Am 60(8):1015–1030PubMedGoogle Scholar
  35. 35.
    Jakob RP, Hassler H, Staeubli HU (1981) Observations on rotatory instability of the lateral compartment of the knee. Experimental studies on the functional anatomy and the pathomechanism of the true and the reversed pivot shift sign. Acta Orthop Scand Suppl 191:1–32CrossRefPubMedGoogle Scholar
  36. 36.
    Bach BR, Warren RF, Wickiewicz TL (1988) The pivot shift phenomenon: results and description of a modified clinical test for anterior cruciate ligament insufficiency. Am J Sports Med 16:571–576CrossRefPubMedGoogle Scholar
  37. 37.
    Kittl C et al (2016) The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. Am J Sports Med 44(2):345–354CrossRefPubMedGoogle Scholar
  38. 38.
    Lopomo N, Zaffagnini S, Amis AA (2013) Quantifying the pivot shift test: a systematic review. Knee Surg Sports Traumatol Arthrosc 21(4):767–783CrossRefPubMedGoogle Scholar
  39. 39.
    Lane CG et al (2008) In vivo analysis of the pivot shift phenomenon during computer navigated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 16(5):487–492CrossRefPubMedGoogle Scholar
  40. 40.
    Zaffagnini S et al (2012) Can the pivot-shift be eliminated by anatomic double-bundle anterior cruciate ligament reconstruction? Knee Surg Sports Traumatol Arthrosc 20(4):743–751CrossRefPubMedGoogle Scholar
  41. 41.
    Hoshino Y et al (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):1098–1104CrossRefPubMedGoogle Scholar
  42. 42.
    Araki D et al (2011) A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Int Orthop 35(3):439–446CrossRefPubMedGoogle Scholar
  43. 43.
    Lopomo N et al (2012) Quantitative assessment of pivot-shift using inertial sensors. Knee Surg Sports Traumatol Arthrosc 20(4):713–717CrossRefPubMedGoogle Scholar
  44. 44.
    Ishibashi Y, Tsuda E, Yamamoto Y, Tsukada H, Toh S (2009) Navigation evaluation of the pivot-shift phenomenon during double-bundle anterior cruciate ligament reconstruction: is the posterolateral bundle more important? Arthroscopy 25(5):488–495CrossRefPubMedGoogle Scholar
  45. 45.
    Colombet P, Robinson J, Christel P, Franceschi J-P, Djian P (2007) Using navigation to measure rotation kinematics during ACL reconstruction. Clin Orthop Relat Res 454:59–65CrossRefPubMedGoogle Scholar
  46. 46.
    Bignozzi S, Zaffagnini S, Lopomo N, Fu FH, Irrgang JJ, Marcacci M (2010) Clinical relevance of static and dynamic tests after anatomical double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18(1):37–42CrossRefPubMedGoogle Scholar
  47. 47.
    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):1269–1276CrossRefPubMedGoogle Scholar
  48. 48.
    Lopomo N, Zaffagnini S, Bignozzi S, Visani A, Marcacci M (2010) Pivot-shift test: analysis and quantification of knee laxity parameters using a navigation system. J Orthop Res 28(2):164–169PubMedGoogle Scholar
  49. 49.
    Kocher MS et al (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):629–634CrossRefPubMedGoogle Scholar
  50. 50.
    Yasuda K et al (2004) Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 20(10):1015–1025CrossRefPubMedGoogle Scholar
  51. 51.
    Meredick RB et al (2008) Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 36(7):1414–1421CrossRefPubMedGoogle Scholar
  52. 52.
    Suomalainen P et al (2012) Double-bundle versus single-bundle anterior cruciate ligament reconstruction a prospective randomized study with 5-year results. Am J Sports Med 40(7):1511–1518CrossRefPubMedGoogle Scholar
  53. 53.
    Ferretti A, Monaco E, Labianca L, De Carli A, Maestri B, Conteduca F (2009) Double-bundle anterior cruciate ligament reconstruction: a comprehensive kinematic study using navigation. Am J Sports Med 37:1548–1553CrossRefPubMedGoogle Scholar
  54. 54.
    Aglietti P et al (1995) A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 3(1):2–8CrossRefPubMedGoogle Scholar
  55. 55.
    Lie DT, Bull AM, Amis AA (2007) Persistence of the mini pivot shift after anatomically placed anterior cruciate ligament reconstruction. Clin Orthop Relat Res 457:203–209PubMedGoogle Scholar
  56. 56.
    Lemaire M, Combelles F (1980) Technique actuelle de plastie ligamentaire pour rupture ancienne du ligament croisé antérieur. Rev Chir Orthop 66:523–525PubMedGoogle Scholar
  57. 57.
    MacIntosh D, Darby T (1976) Lateral substitution reconstruction. Proc Can Orthopaedic Asso J Bone Joint Surg Br 58:142Google Scholar
  58. 58.
    Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med 18:169–176CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Mechanical Engineering DepartmentBiomechanics Group, Imperial College LondonLondonUK
  2. 2.Department of Surgery and CancerMusculoskeletal Surgery Group, Imperial College London School of MedicineLondonUK

Personalised recommendations