Low-Profile Modifications of the Losee Pivot Shift Test for Assessment of an ACL-Deficient Knee in the Awake Patient

Abstract

Background: Pivot shift test results have demonstrated widely inconsistent sensitivities when used on awake clinic patients. We believe the painful valgus force applied during traditional pivot shift techniques is the primary culprit and can be circumvented with our novel examination technique. Indications: The reason for publishing this examination technique is to maximize the sensitivity and accuracy of the pivot shift examination in the awake patient. Technique Description: Four major modifications of Ronald Losee’s original valgus-based examination technique are introduced. These are the 4 general modifications: minimizing the sagittal plane arc of motion, avoiding applying valgus force to the knee, application of gentle anteriorly directed force to the lateral tibia, and performing the examination on the patient’s noninjured knee first. We also provide detailed description of the hand placement during the Albright-Losee pivot shift test. (1) Once the patient is relaxed, the examiner’s hands are placed as follows: (1) the ulnar side of the examiner’s thumb is applied to the posterior aspect of the fibular head. The fingers are placed above the patella on the distal femur as shown in the video. (2) With the examiner’s hands in the correct position, the knee is flexed to 20° to 30°. One-to-3 pounds of anterior translatory force is then applied by the side of the thumb to the fibular head while the knee is taken slowly toward extension. Pathological anterior tibial translation can be expected to begin in a 20° to 30° range short of the patient’s complete knee extension. The examiner must be conscious not to provide any valgus or additional internal or external rotation of the leg. Results: This examination is useful for reproducing the subluxation phenomenon in anterior cruciate ligament (ACL)-deficient knees. Our work has shown that these modifications yield an accuracy of 95.51% and a sensitivity of 94.7% in 353 knees examined by 71 clinicians. Discussion/Conclusion: The Albright-Losee pivot shift test is an easy to perform, highly sensitive, and highly specific test. In our recently submitted American Journal of Sports Medicine manuscript, the Albright-Losee pivot shift test suggested to be of greater value than Lachman test. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.