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Interobserver reliability of the pivot shift test: A modified classification improves agreement.

Juan P Martinez-Cano1,2, Sebastian Mejia-Barreto3, Jacobo Triviño-Arias4

  • 1Departamento de Ortopedia Fundación Valle del Lili Cali Colombia.

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|August 6, 2025
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Summary

A modified pivot shift test significantly enhances interobserver reliability for assessing knee instability in anterior cruciate ligament (ACL) injuries. This improved grading system offers better clinical decision-making for patients with high-grade pivot shifts.

Keywords:
anterior cruciate ligamentdiagnostic testjoint instabilitykneeknee injuryphysical examination

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Area of Science:

  • Orthopedic surgery
  • Sports medicine
  • Knee biomechanics

Background:

  • Anterior cruciate ligament (ACL) injuries often result in anterolateral rotational instability.
  • The pivot shift test is a key clinical maneuver to assess this instability.
  • Variability in the classic pivot shift test grading can impact diagnostic accuracy and treatment decisions.

Purpose of the Study:

  • To evaluate the interobserver reliability of the classic pivot shift test.
  • To assess the reliability of a modified pivot shift classification system.
  • To determine if a modified grading improves diagnostic consistency for knee instability.

Main Methods:

  • An interobserver reliability study involving 4 orthopedic surgeons assessing 17 patients with suspected ACL injuries.
  • Observers were blinded to diagnostic imaging and independently evaluated pivot shift grading.
  • Kappa-Fleiss statistics were used to compare agreement for classic (grades I-III) and modified (low-grade, high-grade) classifications.

Main Results:

  • The modified pivot shift classification demonstrated superior interobserver reliability (0.73) compared to the classic method (0.39).
  • Agreement for the classic test was poor for grade II (0.06) and grade III (0.34) pivot shifts.
  • The modified approach achieved substantial agreement for high-grade pivot shifts (0.73) versus poor/fair agreement in the classic system.

Conclusions:

  • A modified pivot shift test grading system significantly improves interobserver reliability.
  • Consolidating high-grade pivot shifts (II and III) into a single category enhances diagnostic agreement.
  • The modified classification is recommended for clinical practice and research to improve consistency in evaluating knee instability.