The Pivot Shift Test assesses anterolateral rotational instability of the knee, most commonly in relation to anterior cruciate ligament deficiency. A positive result may increase suspicion of ACL-related rotational instability, especially when it matches the client’s history, but it does not confirm an ACL injury on its own.
ACL-related knee instability can affect confidence during:
pivoting
cutting
deceleration
landing
change of direction
sport-specific movement
The Pivot Shift Test is an orthopaedic knee test used to assess anterolateral rotational instability. It attempts to reproduce the combined rotational and translational movement that may occur in an ACL-deficient knee.
It is commonly used alongside:
Lachman Test
Anterior Drawer Test
Lever Sign Test
knee swelling assessment
range of motion testing
functional hop or landing assessment
history of giving way or pivoting injury
imaging where clinically appropriate
The Pivot Shift Test can be clinically useful, but it is technically challenging and may be difficult to perform in painful, swollen or guarded knees. Recent diagnostic accuracy reviews suggest the Pivot Shift Test generally has high specificity but lower sensitivity, meaning a positive result may be more useful for increasing suspicion than a negative result is for decreasing suspicion.
Test name: Pivot Shift Test
Body region: Knee
Purpose: Assess anterolateral rotational knee instability
Commonly associated presentation: ACL injury or ACL-deficient knee
Positive finding: Sudden reduction, clunk, glide or shift of the tibia during knee flexion
Negative finding: No rotational shift, clunk or instability response
Best used with: Lachman Test, Anterior Drawer Test, Lever Sign Test, swelling assessment and history
Key limitation: Low sensitivity and examiner-dependence; a negative test does not exclude ACL injury
The Pivot Shift Test is a clinical special test used to assess rotational instability of the knee.
It is most commonly associated with ACL deficiency.
The test applies a combination of:
hip flexion
hip internal rotation
knee valgus force
axial load
controlled knee flexion
This combination may create an anterior subluxation of the lateral tibial plateau in an ACL-deficient knee, followed by a reduction as the knee flexes.
A positive test is often described as a:
shift
glide
clunk
sudden reduction
giving-way sensation
The test is not simply a pain provocation test. The main finding is abnormal rotational movement or instability response.
The Pivot Shift Test may help assess rotational knee instability when ACL injury or ACL deficiency is suspected.
It may help professionals:
assess anterolateral rotational instability
compare the symptomatic and non-symptomatic knee
identify a giving-way response
support ACL assessment reasoning
document baseline instability response
guide further assessment or referral decisions
monitor change after rehabilitation or surgery where appropriate
The test should not be used alone to diagnose or exclude ACL injury.
The Pivot Shift Test assesses dynamic rotational instability of the knee.
It may provide information about:
ACL-related instability
anterolateral rotational laxity
lateral tibial plateau subluxation and reduction
side-to-side difference
client apprehension or guarding
functional instability relevance
It does not directly measure:
ACL fibre continuity
partial versus complete ACL tear
meniscal injury
cartilage injury
bone bruising
exact ligament structure involved
readiness to return to sport
This test may be useful for:
experienced rehabilitation professionals
sports medicine teams
strength and conditioning professionals working with allied health support
movement assessment professionals
students learning knee special tests
professionals using Measurz or MAT for structured assessment recording
It may be relevant for clients who report:
pivoting injury mechanism
non-contact cutting injury
rapid swelling after injury
giving-way episodes
instability during sport
reduced confidence during direction change
previous ACL injury or reconstruction
Use the Pivot Shift Test when the history suggests possible ACL-related instability and the client can tolerate controlled testing.
It may be useful when the client reports:
a pivoting injury
a “pop” at the time of injury
giving way
instability during cutting or landing
recurrent episodes of knee shift
reduced confidence with sport-specific movement
symptoms consistent with rotational instability
The test is more meaningful when it produces a clear mechanical shift rather than pain alone.
Use caution with:
acute painful knee injury
large effusion or suspected haemarthrosis
suspected fracture
suspected multi-ligament injury
recent surgery
severe pain
high irritability
strong guarding
poor client relaxation
limited knee range of motion
Stop testing if:
pain escalates
guarding prevents smooth movement
the client becomes highly apprehensive
symptoms feel unsafe
the client asks to stop
there is concern about acute structural injury requiring medical review
Treatment table or plinth
Pain scale
Symptom and confidence recording
Measurz recording workflow
Optional comparison-side notes
Optional referral or further assessment notes where appropriate
Position the client in supine lying.
Explain the test before starting.
The client should understand that the test assesses knee stability during controlled movement, and that testing will stop if symptoms become uncomfortable or unsafe.
Client lies on their back
Tested leg is relaxed
Hip begins in slight flexion
Knee begins near extension
Foot and lower limb remain relaxed
Quadriceps and hamstrings should be as relaxed as possible
Stand beside the tested leg
Hold the lower leg and foot securely
Use the other hand near the proximal tibia or lateral knee to control valgus and rotation
Maintain a slow, controlled movement
Common hand placement includes:
one hand holding the foot or ankle to control tibial rotation
the other hand applying valgus force at the proximal tibia or lateral knee
The exact grip may vary by training background, but the movement should remain controlled and repeatable.
Monitor for:
muscle guarding
hamstring contraction
quadriceps tension
hip rotation
trunk movement
facial expression
apprehension
The test is difficult to interpret if the client cannot relax.
The common Pivot Shift Test movement includes:
slight hip flexion
tibial internal rotation
valgus force at the knee
axial load through the lower limb
slow knee flexion from near extension
In an ACL-deficient knee, the lateral tibial plateau may sublux anteriorly near extension and reduce as the knee flexes.
Ask the client to:
stay as relaxed as possible
report pain, apprehension or instability
say if the feeling is familiar
identify symptom location if symptoms occur
tell you immediately if they want the test stopped
Example instruction:
“I’m going to gently move your knee through a controlled position that may show whether it has a shifting or giving-way response. Please stay relaxed and tell me if you feel pain, instability or apprehension.”
A positive Pivot Shift Test may include:
sudden shift
glide
clunk
reduction of the tibia during knee flexion
familiar giving-way sensation
clear side-to-side difference
apprehension linked to instability rather than pain alone
The most meaningful finding is a mechanical shift or reduction, not simply discomfort.
A negative finding involves:
no shift
no clunk
no abnormal rotational movement
no familiar giving-way response
no meaningful side-to-side difference
Stop if:
pain increases sharply
guarding prevents movement
the client feels unsafe
there is strong apprehension
the knee cannot be moved smoothly
the client asks to stop
Use controlled movement only
Do not force the knee
Avoid aggressive valgus or rotation
Do not repeat excessively in irritable knees
Interpret cautiously if there is swelling, pain or guarding
A positive Pivot Shift Test may increase suspicion of ACL-related rotational instability when a clear tibial shift, glide or clunk is felt.
A positive result is more meaningful when it matches:
pivoting injury mechanism
rapid swelling after injury
giving-way episodes
instability during cutting or landing
positive Lachman Test
positive Anterior Drawer Test
functional instability
relevant imaging findings where available
A positive result does not confirm an ACL injury on its own.
Other factors may influence the result, including:
examiner technique
client guarding
pain
swelling
meniscal injury
anterolateral complex involvement
generalised laxity
previous ACL reconstruction
partial versus complete injury pattern
A negative Pivot Shift Test does not exclude ACL injury.
A negative result may occur when:
the knee is too painful
swelling limits movement
the client guards
the examiner cannot create the correct movement
the injury is partial
the test is performed too early after injury
the client is unable to relax
Interpretation is stronger when the Pivot Shift Test is combined with history, Lachman Test, Anterior Drawer Test, swelling findings, functional assessment and imaging where clinically appropriate.
The Pivot Shift Test is generally considered more specific than sensitive for ACL injury.
This means:
a positive result may be useful for increasing suspicion of ACL-related instability
a negative result does not reliably decrease suspicion or exclude ACL injury
A 2022 diagnostic accuracy review of clinical tests for ACL injury highlighted that previous estimates may be affected by study design, associated ligament injuries and methods that do not fully account for the relationship between sensitivity and specificity.
A 2022 systematic review and meta-analysis of acute ACL clinical tests reported that evidence for the Lachman, Anterior Drawer, Pivot Shift and Lever Sign tests remains limited in acute settings, and clinical tests should be interpreted with caution rather than used alone.
Across commonly cited summaries, the Pivot Shift Test is often reported as having:
lower sensitivity
high specificity
greater usefulness when positive than when negative
Some clinical summaries report sensitivity ranges around 0.18–0.48 and specificity around 0.97–0.99 for ACL tear assessment, but values vary by source, population, chronicity, examiner experience and reference standard.
Practical interpretation:
Higher specificity means a clear positive Pivot Shift Test may increase suspicion of ACL-related instability.
Lower sensitivity means a negative Pivot Shift Test does not exclude ACL injury.
Likelihood ratios and pre-test probability are usually more useful than sensitivity and specificity alone.
The test is most useful when combined with history, swelling, Lachman Test, Anterior Drawer Test and imaging where clinically appropriate.
The Pivot Shift Test can be difficult to perform consistently.
Reliability may be influenced by:
examiner experience
hand placement
amount of valgus force
amount of tibial rotation
knee flexion angle
axial load
client relaxation
pain
swelling
guarding
whether grading is binary or graded
A recent interobserver reliability study noted that the Pivot Shift Test evaluates anterolateral rotational instability in ACL injury and that office-based testing remains common, although objective quantitative methods are not yet widely available in routine clinical practice.
The Pivot Shift Test has clinical validity because it reflects a functional rotational instability pattern that many clients describe as giving way. However, validity is stronger when the finding matches:
injury history
instability symptoms
positive ACL laxity tests
functional instability tasks
imaging findings where relevant
A review of pivot shift methodology and clinical utility highlighted that quantitative pivot shift assessment is an active research area, particularly because the traditional clinical test is examiner-dependent and difficult to quantify.
Common errors include:
forcing the knee aggressively
moving too quickly
using inconsistent valgus force
using inconsistent tibial rotation
not comparing both sides
interpreting pain alone as positive
testing when the client is guarding heavily
failing to record the grade or quality of shift
using the test as a stand-alone ACL diagnosis
not combining with Lachman or Anterior Drawer findings
Limitations include:
low sensitivity
technical difficulty
examiner-dependence
reduced usefulness in acute painful knees
reduced usefulness when swelling is high
subjective grading
variable inter-rater reliability
difficulty distinguishing ACL-only instability from combined injury patterns
The Pivot Shift Test may help professionals:
assess rotational knee instability
support ACL assessment reasoning
document giving-way response
compare involved and uninvolved sides
guide further testing or referral discussion
support communication with allied health or sports medicine teams
monitor instability response over time where appropriate
For athletes, it may support broader decision-making when combined with:
strength testing
hop testing
landing assessment
change-of-direction testing
confidence measures
training load review
sport-specific movement assessment
For general population clients, it may help explain why pivoting, twisting or sudden direction changes feel unstable.
For Measurz users, the main value is consistent recording of side, result, symptom quality, instability response and related findings.
Record:
test name: Pivot Shift Test
side tested: left, right or both
result: positive, negative, unclear or unable to test
grade if used: none, glide, clunk or gross shift
client position
knee range used
force direction: valgus, internal rotation and axial load
whether a shift or clunk was felt
whether symptoms were familiar
pain score from 0–10
symptom location
symptom quality
apprehension or guarding
comparison side
irritability level
reason for stopping if stopped early
related findings, such as Lachman, Anterior Drawer, swelling or functional instability
interpretation notes
planned retest date if monitoring change
Record whether the main response was:
mechanical shift
glide
clunk
familiar giving way
pain only
guarding
unclear response
unable to test safely
This improves:
repeatability
communication
client education
assessment reasoning
team consistency
progress monitoring
reporting quality
Lachman Test
Anterior Drawer Test
Lever Sign Test
Posterior Drawer Test
Slocum Test
Sweep Test
Single-Leg Squat Test
Hop Testing
It assesses anterolateral rotational instability of the knee, most commonly in relation to ACL deficiency.
A positive result may include a sudden shift, glide, clunk or reduction of the tibia during controlled knee flexion.
No. A positive result may increase suspicion of ACL-related instability, but it does not confirm an ACL injury on its own.
No. The test has relatively low sensitivity, so a negative result does not reliably exclude ACL injury.
It requires coordinated valgus force, tibial rotation, axial load and knee flexion while the client remains relaxed.
It may be easier to perform in less irritable or chronic presentations. Acute pain, swelling and guarding can make the test harder to interpret.
It is best used with history, swelling assessment, Lachman Test, Anterior Drawer Test, functional testing and imaging where appropriate.
The Pivot Shift Test assesses rotational knee instability.
It is most commonly associated with ACL deficiency.
A positive result may include a shift, glide or clunk during knee flexion.
A positive test may increase suspicion of ACL-related instability.
A negative test does not exclude ACL injury.
The test is technically demanding and examiner-dependent.
Interpretation is stronger when combined with history, swelling, Lachman Test, Anterior Drawer Test, functional assessment and imaging where relevant.
Measurz should record side, result, grade, symptom response, pain, guarding, comparison side and related findings.
American Academy of Orthopaedic Surgeons. (2022). Management of anterior cruciate ligament injuries: Evidence-based clinical practice guideline. https://www.aaos.org/aclcpg
Tanaka, M. J., et al. (2022). Diagnostic accuracy of physical examination tests for suspected acute anterior cruciate ligament injury: A systematic review and meta-analysis. International Journal of Sports Physical Therapy, 17(4), 606–615. https://ijspt.scholasticahq.com/article/36434-diagnostic-accuracy-of-physical-examination-tests-for-suspected-acute-anterior-cruciate-ligament-injury-a-systematic-review-and-meta-analysis
van Eck, C. F., van den Bekerom, M. P. J., Fu, F. H., Poolman, R. W., & Kerkhoffs, G. M. M. J. (2022). The diagnostic accuracy of clinical tests for anterior cruciate ligament injury. Knee Surgery, Sports Traumatology, Arthroscopy, 30, 3283–3292. https://doi.org/10.1007/s00167-022-06898-4
Vaudreuil, N. J., Rothrauff, B. B., de SA, D., & Musahl, V. (2019). The pivot shift: Current experimental methodology and clinical utility for anterior cruciate ligament rupture and associated injury. Current Reviews in Musculoskeletal Medicine, 12, 41–49. https://doi.org/10.1007/s12178-019-09529-7
Vázquez, A. H., et al. (2025). Interobserver reliability of the pivot shift test: A modified classification. Journal of Experimental Orthopaedics. https://pmc.ncbi.nlm.nih.gov/articles/PMC12322695/
