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The pivot shift test, in contrast to the Lachman or anterior drawer, is a manually subjective clinical test that simulates the injury mechanism. It is the most sensitive test to determine ACL insufficiency. This paper reviews the history, development, research, and treatment associated with the pivot shift phenomenon which is associated with tearing and loss of function of the knee anterior cruciate ligament. The pivot shift test most closely recapitulates what the symptomatic anterior cruciate ligament deficient patient feels is happening which is an abnormal translation and rotation of the injured joint during flexion or extension. The test is best conducted in the relaxed patient by applying knee flexion, tibial external rotation, and valgus stress. The pivot shift biomechanics and treatment measures are reviewed.

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BACKGROUND: Several studies have shown persistent postural control deficits and rotatory instability in patients after isolated Anterior Cruciate Ligament (ACL) reconstruction. There is evidence to support that the Anterolateral Ligament (ALL) plays an important role in the remaining anterolateral rotatory laxity of the knee. There are no further evidences in order to understand how patients with a combined ACL + ALL reconstruction surgery indication behave regarding postural control. The aim of this cross-sectional study was to assess if patients with a clinical indication for the combined ACL + ALL surgery showed a deficient postural control in single leg stance compared to subjects with a regular ACL reconstruction indication and to a control group. METHODS: An assessment of static postural control on single leg stance was performed on a force plate, with eyes open and closed, and the center of pressure (COP) displacement variables were analyzed: maximum and mean amplitude in anteroposterior (AP) and in mediolateral (ML) direction; mean velocity of displacement and area of displacement. Eighty-nine male individuals participated and were divided into 3 groups: ACL Group, ACL + ALL Group and Control Group. RESULTS: The ACL+ ALL Group showed significantly greater COP displacement in most variables in the injured leg for the eyes closed test, compared to the ACL Group, as detailed: Total ML displacement (9.8 ± 6.77 vs. 13.98 ± 6.64, p < 0.001); Mean ML displacement (2.58 ± 2.02 vs. 3.72 ± 1.99, p < 0.001); Total AP displacement (9.5 ± 3.97 vs. 11.7 ± 3.66, p = 0.001); Mean AP displacement (1.77 ± 0.87 vs. 2.27 ± 0.86, p = 0.001); Area of displacement (111.44 ± 127.3 vs. 183.69 ± 131.48, p < 0.001). CONCLUSION: Subjects with a clinical indication for ACL + ALL combined reconstruction surgery showed increased COP displacement compared to patients with indication for an ACL isolated reconstruction surgery.

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INTRODUCTION: Anterior cruciate ligament (ACL) tear and knee osteoarthritis (KOA) are the most prevalent musculoskeletal disorders of the knee. Rehabilitation with progressive resistance training is recommended for both disorders. Rating of perceived exertion (RPE) is widely used to prescribe, monitor, and control exercise load. However, the lack of detailed methodological description and variability in the use of RPE may hinder its validity. This scoping review summarises methodological aspects of the use of RPE in resistance exercises during ACL reconstruction and KOA rehabilitation. We also aim to identify possible methodological issues related to the use of RPE and provide recommendations for future studies. METHODS AND ANALYSIS: This scoping review protocol was developed following the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement extension for Scoping Reviews. The search will be conducted in Medline/PubMed, Embase, CINAHL, PEDro, Central and SPORTDiscus databases. The terms "anterior cruciate ligament rehabilitation", "knee osteoarthritis" and "resistance exercise" and their synonymous will be used isolated and combined (boolean operators AND/OR/NOT). Two reviewers will independently conduct title and abstract screening and evaluate full texts of potentially eligible articles. Data related to study design, sample, intervention characteristics and RPE outcomes will be extracted, summarised and qualitatively analysed. ETHICS AND DISSEMINATION: The proposed scoping review does not require ethical approval since it will synthesise information from publicly available studies. Regarding dissemination activities, results will be submitted for publication in a scientific journal and presented at conferences in the field.

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BACKGROUND: Anterior drawer test, Lachman test including evaluation of the endpoint, and pivot shift test have been commonly applied clinically in diagnosing anterior cruciate ligament (ACL) injury but how they function in the appraisal of partial ACL tears is less known. The aims of this study were to examine the diagnostic values of the commonly used knee function tests on patients in detecting ACL injury including partial injury patterns, to assess each of the test's predictive values on the specific ACL injury pattern, and to assess if using multiple tests collectively for the diagnosis of the injury could improve diagnostic accuracy. METHODS: We evaluated 36 consecutive patients who underwent ACL single bundle augmentation surgery. Those patients were matched by gender and age to 36 patients with a complete rupture of the ACL. Data was obtained from the patients' records. The rupture pattern was confirmed by arthroscopy. An examination under anesthesia was routinely performed by two surgeons who were blinded to the rupture pattern prior to surgery. RESULTS: Collectively using both Lachman test and pivot shift test increases ability to distinguish between partial tears and complete ruptures. When comparing partial PL tears and complete ruptures the pivot shift test is more important than the Lachman test. In diagnosing a complete rupture, the evaluation of the endpoint during the Lachman test is more sensitive than the evaluation of the anterior tibial translation during the Lachman test. CONCLUSION: Based on the findings of this study, a diagnostic algorithm has been implemented and is presented in this manuscript.

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BACKGROUND: Anterior cruciate ligament (ACL) repair is increasing in frequency in younger children. Recognition of the normal development of the intercondylar notch is important for successful ACL graft placement, allowing surgeons to better understand the anatomy and risk factors related to ACL tears and its reconstruction. The purpose of this study was to compile normative data on the intercondylar notch in the pediatric population with magnetic resonance imaging (MRI), emphasizing the differences between males and females. METHODS: In this retrospective study, musculoskeletal radiologists evaluated intercondylar notch width, bicondylar distance and notch width index (NWI). A total of 253 MRI examinations (130 males and 123 females between six and 18 years of age) were included. The association between measurements, sex and age was considered. Linear and fractional polynomial regression models were used to evaluate the relationships between measurements. RESULTS: Intercondylar notch width increased up to 10 years of age in females and 11 years of age in males, with relative stabilization up to 13 years in girls and 14 years in boys and a slight reduction in values at subsequent ages. Bicondylar distance showed significant progressive growth with age in both sexes. NWI showed a discrete and homogenous reduction with age in both sexes. CONCLUSION: Intercondylar notch width interrupts its growth around 10-11 years of age, with relative stabilization up to 13-14 years and a slight reduction in dimensions in subsequent ages. This growth pattern resembles the development of the ACL area observed in recent studies.

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Purpose: To verify the quality of questionnaires/scales regarding knee instability caused by anterior cruciate ligament (ACL) insufficiency and their translated versions.Materials and methods: Searches were conducted on Web of Science, Pubmed, Medline, Cinahl, and SportDiscuss. The COnsensus-based Standards for the selection of Health Measurement INstruments (COSMIN) scale was used to assess the article's quality; and the measurement properties of each questionnaire/scale were also analysed.Results: Searches identified 7703 studies and 29 were included in this review. Nine were articles reporting the original development of a questionnaire/scale and 20 were translations. The original questionnaires/scales were written in English or French and were translated into Brazilian Portuguese, Portuguese, Dutch, Turkish, German, Korean, Italian, Arabic, Polish, French, and Chinese. The questionnaires/scales with best overall quality were the Cincinatti Knee Rating System, the International Knee Documentation Committee - Subjective Knee Form and the PPLP. The International Knee Documentation Committee had positive results for internal consistency (Cronbach's alpha 0.89-0.92); for reliability and agreement (intraclass correlation coefficient (ICC) ranging from 0.88 to 0.99); and for construct validity (Pearson's r ranged from 0.1 to 0.85).Conclusions: The International Knee Documentation Committee had the largest number of translated versions and it was considered the best instrument assessed. Furthermore, The International Knee Documentation Committee was considered to be easy to apply, short and accessible, thus it is the choice of several clinicians and researchers.Implications for rehabilitationKnee instability is one of the most important factors to be evaluated during rehabilitation of people with anterior cruciate ligament injury in both surgical and non-surgical approach.The use of questionnaires may provide a better overall functionality assessment of people with knee instability from ACL injury.To choose the most appropriate questionnaire, clinicians should consider their needs and should consider validated questionnaires linked with adequate psychometric properties which guarantee the original characteristics of a questionnaire and also guarantee reliable results.

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PURPOSE: Understanding the pathomechanics of a bicruciate injury (BI) is critical for its correct diagnosis and treatment. The purpose of this biomechanical study aims to quantify the effects of sequential sectioning of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) bundles on knee laxity. METHODS: Twelve cadaveric knees (six matched pairs) were used. Knee laxity measurements consisted of neutral tibial position, anterior-posterior translation, internal-external rotation, and varus-valgus angulation in different conditions: intact, ACL cut, incomplete BI (divided into two groups: anterolateral (AL) bundle intact or posteromedial (PM) bundle intact) and complete bicruciate tear. Data were collected using a Microscribe system at 0°, 30°, 60°, and 90° of knee flexion. RESULTS: In comparison to the intact knees, incomplete BI and complete BI showed a significant increase of total antero-posterior tibial translation. The largest significant increase was observed at 90° of flexion after a complete bicruciate resection (p < 0.001). A threshold difference greater than 15 mm from the intact could be used to identify a complete BI from an incomplete BI evaluating the total antero-posterior translation at 90°. All sectioned states had significant increases compared with the intact condition in internal-external rotation and varus-valgus stability at all tested flexion angles. CONCLUSION: Both incomplete and complete BI led to an important AP translation instability at all angles; however, full extension was the most stable position at all injured models. Total antero-posterior translation at 90° of knee flexion over 15 mm, in comparison to the intact condition, was indicative of a complete BI. Since the appropriate assessment of a combined ACL and PCL lesion remains a challenge, this study intends to assist its diagnosis. As BI's main antero-posterior instability occurred at 90°, a total antero-posterior drawer test is proposed to evaluate BI in the clinical setting. Total antero-posterior translation at 90° > 15 mm, in comparison to the intact condition or the contra-lateral non-injured knee, can be used to identify a complete from an incomplete BI.

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Introducción: La lesión del ligamento cruzado anterior es la lesión ligamentaria más frecuente en la rodilla. En gran número de pacientes, en especial en lesiones parciales del LCA o en casos agudos, no hay una correlación clara entre las pruebas clínicas habituales y las imágenes de resonancia magnética. La prueba de palanca fue descrita y publicada inicialmente por Alessandro Lelli. El objetivo de este estudio es demostrar la eficacia de la prueba de palanca en relación con las pruebas clínicas tradicionales. Material y Métodos: En este estudio se seleccionaron 120 pacientes,remitidos con trauma en rodilla y sospecha de lesión del LCA. Todos los pacientes fueron examinados en 3 escenarios: consulta preoperatoria,en quirófano con el paciente anestesiado y en el posoperatorio inmediato. Resultados: Fueron evaluados los resultados clínicos en los 120 pacientes objeto del estudio. En todos los casos se comparó la prueba de palanca con las de cajón anterior, Lachman y desplazamiento del pivote, encontrándose mayor sensibilidad de la prueba de palanca, tanto en pacientes con y sin anestesia. Se realizó un análisis estadístico en los diferentes momentos del examen. Conclusión: Se comprobó la eficacia de la prueba de palanca para el diagnóstico de rupturas del LCA, por lo que se considera una prueba sensible y sencilla de realizar en el diagnóstico de rupturas del LCA y se propone su utilización junto con las otras pruebas clásicas, para tener un parámetro clínico adicional en la elección de candidatos a reconstrucción de LCA. Tipo de Estudio: Serie de Casos. Nivel de Evidencia: IV

Introduction: The injury of the anterior cruciate ligament is the most common ligament injury in the knee. In large numbers of patients, especially partial lesions of the ACL or in acute cases, there is no clear correlation between usual clinical tests and magnetic resonance imaging. The lever test was originally described and published by Alessandro Lelli. of this study is to demonstrate the effectiveness of the lever test in relation to traditional clinical tests. Material and methods: In this study, 120 patients were selected, referred with knee trauma and suspected ACL injury. All the patients were examined in 3 scenarios: preoperative consultation, in the operating room with the anesthetized patient and in the immediate postoperative period. Results: The clinical results were evaluated in the 120 patients studied. In all cases the lever test was compared with those of the anterior drawer, Lachman and pivot displacement, with greater sensitivity of the lever test, both in patients with and without anesthesia. A statistical analysis was performed at the different moments of the examination. Conclusion: The effectiveness of the lever test for the diagnosis of ACL ruptures was proven, so it is considered a sensitive and simple test to perform in the diagnosis of ACL ruptures and its use is proposed along with the other classic tests, to have an additional clinical parameter in the election of candidates for ACL reconstruction. Type of Study: Case Series. Level of Evidence: IV

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