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Tx for positive pivot shift test
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Tx for positive pivot shift test - June 14, 2004 7:30:00 PM
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Flexxion
Posts: 16
Joined: March 16, 2004
From: Miami, FL USA
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Hi everyone. I came across an interesting pt today. I manually stretched hamstrings to almost 90 supine, no problem and felt a give in the knee. Upon further examination found anterolateral rotary instability with a positive pivot shift test. ACL was fine, as was the LCL, so i think its should be the posterolateral capsule. What would you guys do for this pt?
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-Gil
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Re: Tx for positive pivot shift test - June 15, 2004 1:04:00 AM
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Alex Brenner PT MPT OCS
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Joined: February 29, 2004
From: Kentucky
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Hi Gil.
I learned that a positive pivot shift is highly indicative of an ACL tear. On an acute ACL tear you usually only get one try on that test because it is very painful for the patient to endure. On subsequent pivot shift testing the patient will then guard against it. I can not remember the exact sensitivites and specificities of that test but I know that they are both very high, especially with specificity. Are you sure the ACL is intact? How are you sure?
Also, what kind of complaints does this patient have? What are you treating him/her for?
ArmyPT
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Alex Brenner, PT, MPT, OCS
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Re: Tx for positive pivot shift test - June 15, 2004 8:26:00 AM
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Flexxion
Posts: 16
Joined: March 16, 2004
From: Miami, FL USA
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well the acl was intact, i did a lachmans and anterior drawer test, and she had a little bit of play, but it was equal bilaterally. I thought some people simply are born with flexible ligaments.
What i didnt understand was her complain of increased pain while sitting down for long periods of time... in the knee.
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-Gil
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Re: Tx for positive pivot shift test - June 15, 2004 9:53:00 AM
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Dr.Wagner
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From: Indianapolis
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Obviously the pivot shift test is subject to inter-rater reliability issues.
The GOLD STANDARD of diagnosis of knee instibility is arthroscopy. If the patient needs another set of hands then have another set of hands test the patient. If ligamentous instability is once again found, referral to an orthopedic surgeon is warranted. Visualization of the ligament is more specific than any exam...that means looking at it, not just MRI.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Tx for positive pivot shift test - June 15, 2004 11:34:00 AM
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OAK
Posts: 184
Joined: September 1, 2003
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"Also, what kind of complaints does this patient have? What are you treating him/her for?"
This is the more important question here.
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Re: Tx for positive pivot shift test - June 15, 2004 12:41:00 PM
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Geert Jeuring
Posts: 92
Joined: June 26, 2002
From: Möhnesee, Germany
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Hello Forum, as far as I know the general opinion on this side of the ocean is that the Lachmantest is indicated in acute situations (on the playing field or shortly afterwards) and that the normal anterior drawing test (90°, Therapist sitting on the patients foot) can be sensitised by internal rotation, which under normal conditions causes the ACL to twirl (?) around the posterior LC and makes the anterior drawer "stiffer". A non existent/ruptured ACL wouldn´t cause this sensation.
Greeting
Geert Jeuring
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Re: Tx for positive pivot shift test - June 15, 2004 5:47:00 PM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Lachmann's and anterior drawer are not always positive with an isolated ACL tear. I once had a patient with a definitive tear, as per arthroscopy (complete rupture) with intact secondary restraints. Both tests felt normal to my hands, and the KT-1000 test also was equal. As Army PT indicates, there is something else going on. HOWEVER, that does not necessarily mean something bad. There are lots of people who are ACL deficient functioning at high levels, so if you weren't treating them for the knee, it may not be a major issue. But, since they did easily pivot-shift, they may buckle during a strenuous routine and damage menisci or secondary restraints.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Tx for positive pivot shift test - June 15, 2004 6:32:00 PM
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rodgere
Posts: 49
Joined: June 2, 2004
From: Linden
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OAK, you are the man or the woman. nice comment!
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Re: Tx for positive pivot shift test - June 15, 2004 8:00:00 PM
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coloradojulie
Posts: 413
Joined: November 10, 2002
From: colorado usa
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Might want to consider the PCL which at times can create a false positive for ACL pathology. Also with knee pain after prolonged sitting, may be more PFS in nature and you may have felt a patellar subluxation.
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PRC
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Re: Tx for positive pivot shift test - June 15, 2004 11:08:00 PM
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Flexxion
Posts: 16
Joined: March 16, 2004
From: Miami, FL USA
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Well i wish i could tell you more about this patient, but it really wasnt my patient. I went to a friend's clinic, looking for a position as PT as i just passed my boards, and now have my license. We did look over this patient of his though... sorry i couldnt provide more info.
I appreciate everyone's input.. and will look further into it. thank you to all!
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-Gil
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