Reverse Pivot Shift Test

The Reverse pivot shift test is a dynamic test used to demonstrate abnormal posterolateral laxity of the knee joint by inducing a posterolateral subluxation followed by a sudden reduction.

See Also: Pivot Shift Test

How do perform the Reverse Pivot Shift Test?

• The patient is placed in supine position, while the examiner stands on the side of the injured leg.
• With one hand, the examiner grasps the patient’s foot while the other hand supports the lateral aspect of the lower leg at the level of the knee.
• The thumb of this hand palpates the fibular head and applies valgus pressure.
• The examiner now flexes the patient’s knee 70 to 80°.
• Externally rotating the foot in this position causes posterior subluxation of the lateral tibial plateau.
• The examiner then slowly extends the knee while maintaining slight valgus stress.

The differences from pivot shift test is the following (Reverse Pivot Shift Test VS Pivot Shift Test):

Pivot Shift Test	Reverse Pivot Shift Test
Assess the anterior rotatory instability (ACL injury)	Assess the posterolateral instability (PCL & PLC injuries)
The starting position is from extension to flexion	The starting position is from flexion to extension
With Internal rotation	With External rotation
The tibia subluxates anteriorly	posterior subluxation of the lateral tibial plateau

What does a positive Reverse Pivot Shift Test mean?

In the presence of a posterolateral injury with the knee flexed, the tibia follows gravity and drops into posterolateral subluxation (positive Reverse Pivot Shift Test). Externally rotating the tibia increases this subluxation.

As the knee is then extended and passes through 30 to 20° of flexion, the iliotibial tract begins to act as an extensor and reduces the joint.

The posterolateral capsule, the posterior soft tissue envelope of the knee, and the quadriceps also contribute to the reduction.

Notes

• This test is the functional counterpart of the dynamic anterior subluxation test. However, it can be positive in patients with increased generalized laxity of the ligaments.
• Reverse Pivot Shift Test is only clinically significant when a positive result can be elicited unilaterally and faithfully reproduces the painful subluxation symptoms described by the patient.
• A positive Reverse Pivot Shift Test primarily suggests a posterolateral capsular ligament injury. Injury to the posterior cruciate ligament is likely in patients with a history of trauma and simultaneous posterolateral instability in the form of a positive posterior drawer when the lower leg is in external rotation.

Dynamic Posterior Shift Test

Dynamic Posterior Shift Test is similar in mechanism to Reverse Pivot Shift Test.

The patient is supine. The examiner passively flexes both the hip and the knee of the affected leg to 90°, holding the knee in neutral rotation. One of the examiner’s hands rests on the thigh and acts as a buttress while the examiner slowly extends the knee with the other hand.

Once the knee reaches about 20° of flexion, the examiner will be able to observe and palpate an abrupt movement of the tibial plateau out of posterior subluxation into reduction and external rotation.

References

• Jakob RP, Hassler H, Staeubli HU. 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. 1981;191:1-32. doi: 10.3109/ort.1981.52.suppl-191.01. PMID: 6945790.
• Petrigliano FA, Lane CG, Suero EM, Allen AA, Pearle AD. Posterior cruciate ligament and posterolateral corner deficiency results in a reverse pivot shift. Clin Orthop Relat Res. 2012 Mar;470(3):815-23. doi: 10.1007/s11999-011-2045-1. PMID: 21874389; PMCID: PMC3270184.
• Shelbourne KD, Benedict F, McCarroll JR, Rettig AC. Dynamic posterior shift test. An adjuvant in evaluation of posterior tibial subluxation. Am J Sports Med. 1989 Mar-Apr;17(2):275-7. doi: 10.1177/036354658901700221. PMID: 2757132.
• Clinical Tests for the Musculoskeletal System 3rd Edition.