Figure-of-four pivot shift test--a technical note

The pivot shift test is a cornerstone in the clinical diagnosis of anterior cruciate ligament (ACL) deficiency. It can be difficult to perform in overweight patients or in those with long or bulky legs. We present an alternative method to perform the pivot shift test that recalls the judo technique of figure-of-four knee lock and eases the examination of the patient with anterior cruciate ligament deficiency. This modality of execution also makes the surgeon able to perform varus-valgus tests with small changes in hand positions. The surgeon, embracing with one arm the tibia of the affected limb, grasps with this hand the wrist of his free arm opposite to the affected limb. Then the surgeon hooks onto the posterior surface of the leg with his free hand. In this way, the surgeon can exert a moment on the limb of the patient, and can apply combined internal rotation, flexion, and valgus stress to perform the pivot shift test or simply varus or valgus force to perform the varus-valgus tests.