The games have only just begun......
The film opens with the autopsy of the now deceased Jigsaw killer, John Kramer, who was killed in the ending climax of Saw III. During the operation, a wax-coated mini cassetet is found in Jigsaw's stomach, which realizes that in a flashback of showing Jigsaw pouring wax on the tape, grabs it and puts it in his mouth and swallows it. Detective Hoffman is called to the scene, where he plays the tape which states that, although Jigsaw is dead, "the games have just begun."
The scene changes to two men awakening in a mausoleum, finding themselves in one of Jigsaw's arranged games. One man has been rendered blind (his eyes sewn shut), while the other is mute (his lips sewn together). They are both connected by a chain around their neck to a machine. They pull the chain in opposite directions, one after the other. This results in a key being turned, triggering the machine, which starts pulling them in slowly. In a desperate attempt to escape, the mute man kills the panicking blind man, takes a key from the blind man's neck, and frees himself. He then begins screaming in terror which causes the stitches to tear free and blood pours from his mouth.
The police, meanwhile, have discovered the remains of Detective Kerry who was killed in the Angel trap, set up by Amanda Young in Saw III. Lieutenant Rigg, distraught at the find, leaves the scene as FBI Agents Perez and Strahm arrive and begin investigating. They quickly deduce that Amanda needed help in placing Kerry in the trap, and that Jigsaw has another apprentice who is still alive.
That night, Rigg is attacked in his home by a person wearing a pig mask, and left unconscious, awakening to a series of interconnected tests that have been arranged. In the first test, which takes place in his own home, Rigg struggles to free a woman named Brenda from a device, though his tape suggests that he leave her alone. After saving Brenda's life, she responds by attempting to kill Rigg, who is forced to subdue her. He later learns that she had a test of her own, which was to kill him with a knife that was taped under the TV should he save her, or else she would be jailed for prostitution.
Finding clues to the next phase of the game, Rigg travels to a hotel and uses a key supplied by Jigsaw to gain access to a room that contains his next instruction. Rigg opens a chest on the bed and finds a pig mask and a photo of a man inside. Rigg's objective is to capture Ivan - the clerk of the hotel. Rigg captures Ivan and moves him to another room containing a vice within which Rigg is instructed to place Ivan's head. Rigg also makes Ivan strap his arms and legs onto the bed. Rigg plays Ivan's tape and Ivan must either push two buttons that would gouge his eyes out or have the device rip off his arms and legs. Surrounded by photos and video evidence of Ivan's sordid past as a rapist, an enraged Rigg decides to follow Jigsaw's advice and forces Ivan in the trap, who fails to complete it and has his arms and legs severed.
We are then shown a flashback of Rigg's past before he became a member of SWAT, dealing with the apparent beating of a child by her father. Unable to secure a confession from the father, Rigg, is forced to let him go; but not before Rigg assaults the man. Rigg escaped prosecution thanks to his underhanded lawyer, Art Blanc.
In present time, the FBI raid Rigg's home, believing that he may be connected to Jigsaw. There they find that Brenda has died from her injuries. The evidence there leads them to suspect Rigg and also helps them to discover Jill, Jigsaw's ex-wife, as a possible source of information about the recent traps.
Meanwhile, Rigg enters the now derelict school where the dreaded event took place, finding the deceased abusive father and his wife, chained together, with a single spike piercing their body, the woman still alive. A flashback shows the woman being instructed to escape her abusive relationship by removing the spikes from her body while simultaneously killing her husband. However, she is unable to remove the final spike due to the wounds inflicted by previous spikes. Instructed by Jigsaw that Rigg must stand aside and allow her to complete her own test, Rigg hands her a key which will unlock her from her shackles - but tells her that she must remove the final spike herself as he follows his next clue. On the way out, he pulls the fire alarm to alert the authorities.
As the FBI and police investigate the crime scene, an accident with the now-completed trap occurs, spearing the forensic photographer through the head and killing her. Frustrated and disgusted, Perez and Strahm search the school further, finding Jigsaw's puppet, Billy, and a tape addressed to themselves. Perez is told that Strahm is "about to kill an innocent man" and that "her next step is crucial". As Perez peers more closely to investigate a ticking sound, the puppet's face explodes, sending shrapnel into her face and revealing a camera hidden in the puppet's skull.
Desperate, Strahm attempts to elicit information from Jill. Flashbacks reveal that Jill lost her and John's baby due to the inadvertent actions of a drug addict named Cecil. John was sitting outside the clinic where Jill worked, waiting to pick her up, when he was solicited for sex by Addison. Noticing Cecil running from a scene where he had accidentally slammed a door into Jill, John investigated, finding Jill wounded, and carried her to the hospital. However, the baby is lost and John is visibly distraught. John became obsessed with the idea that only the victims can change themselves and began developing traps to test subjects. Jill, having healed from her assault, came to John's workshop with Art, discussing a project that they were partners in. John showed no interest, still consumed with his loss and told them both to leave. He tracked and abducted Cecil, then placed him in the first trap he constructed. There, John explained to Cecil that the purpose of the trap was to make Cecil "as ugly on the outside as he was on the inside". Cecil must push his face into a knife trap that is placed around his face. During the test, the trap collapsed, freeing Cecil, though his face and wrists were already severely injured. John, unwaveringly stood as Cecil berated him; Cecil lunged at John, who side-stepped the attempt, causing Cecil to throw himself into a pile of razor wire. John then left Cecil to die.
Moving back to current time, Rigg has followed his clue to the Gideon factory owned by John, with Agent Strahm close behind using information obtained from Jill. As Rigg and Strahm move through the facility, we see Jeff, the protagonist of Saw III, working his way through the building. Strahm follows the noise that Jeff is making, leading him away from Rigg, while Rigg finds a door that leads him to his final test.
Inside the room are Detective Matthews, Detective Hoffman, and Art Blanc, each involved in his own test. Flashbacks reveal that Matthews has been a prisoner of Jigsaw for six months. Art has been instructed that once the time for the test is up, he can activate a switch which will free them all. Part of the test requires him to give Matthews a revolver with a single bullet. Each subject discovers however, that if someone enters the main door they will trigger another trap which will instantly kill Detective Matthews. An exhausted Rigg lunges at the door, smashing through it as Matthews shoots him in a vain attempt to stop him. Unfortunately, the trap is still activated and Detective Matthews is killed, his head crushed in between two ice blocks (each about the size of the block he stands on) angled upwards as they swing down on both sides. Rigg shoots Art, believing him to be Jigsaw's accomplice, fatally wounding him. As a final tape is played, Rigg is told that he has failed his test; his obsession to save others has inadvertently led to their deaths. Rigg had been warned by superiors on at least two occasions not to open unsecured doors, which he did once more, causing Matthews' death. Had he simply allowed time to run out and not saved them, they would have been safe from harm and released from their traps.
Meanwhile, Strahm still following Jeff, approaches a fridge like door. Before he can enter it the door closes shut with him on the outside. He opens the door and steps into the room. He finds Jeff and the bodies of Lynn, Amanda, and Jigsaw. As Jeff waves his weapon in a threatening manner, demanding to know the location of his daughter, Strahm kills him in defense.
Rigg lies wounded on the floor, Hoffman releases himself from his trap, revealing that he is involved in the game, a new Jigsaw apprentice. He leaves Rigg to die, stating "Game Over,". Hoffman then approaches the door Strahm had entered and closes it sealing him inside.
It is then revealed that the events of Saw IV have run concurrently to those of Saw III, with Strahm intercepting Jeff just after the deaths of Jigsaw, Amanda and Doctor Lynn. The autopsy scene that occurred at the beginning of the film is shown again, revealing it to have occurred after the events of the film and not before. As the tape found in Jigsaw's stomach is played again, Detective Hoffman is told that Jigsaw's games have only just begun, and he will not walk away untested.
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