Clinical Examination for Meniscus

Today’s post is a review of a recent meta-analysis looking at the accuracy of clinical tests for meniscal lesions from our friend Dan Lorenz, MS, PT, ATC/L, CSCS.

RESEARCH UPDATE: Clinical Tests for Meniscal Lesions

Dan Lorenz, MS, PT, ATC/L, CSCS

It has been estimated that approximately 27% of all outpatient physical therapy visits are for knee pain.1 Of the many possible lesions causing pain, one common source is from a meniscal lesion. Recently, Meserve et al2 did a meta-analysis summarizing the accuracy of clinical tests for assessing meniscal lesions of the knee. Previous researchers have performed meta-analyses on clinical tests for meniscus tear, but failed to account for the variability and in test sensitivity and specificity due to differences in methodological quality among the studies.3-5 Because of that, diagnostic accuracy could be skewed. Clinicians should select tests with the highest sensitivity or negative likelihood ratio to rule out meniscal injury, or conversely, rule in meniscal injury with tests having high specificity or positive likelihood ratios.1 The purpose of this update is to provide a synopsis of what was found in their review.

Eleven studies satisfied the authors criteria of sixty-four total considered for potential review. Joint line tenderness, Apley’s, and McMurray’s were reviewed based on them being the most common tests utilized. Ege’s and Thessaly tests were also evaluated, but the quality of the studies was not good based on small sample sizes. Of note, diagnostic tests findings were interpreted without considering whether the lateral or medial meniscus was torn.

The researchers ultimately found that:

  • Joint line tenderness was found to be the superior test in terms of sensitivity, followed by the McMurray’s and then Apley’s.
  • Specificity values were larger with Apley’s compared to joint line tenderness and McMurray’s.
  • Ege’s Test and the Thessaly Test,6-7 tests that have either compression with weight bearing or clinician-applied axial rotation, were found to have the strongest diagnostic accuracy, but with smaller samples in the studies.

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Based on this review, like any other special test used clinically, a combination of a thorough history along with a physical exam will help the clinician differentially diagnose conditions that are presented to them. As with many other tests used for other pathologies, it appears that using several tests to detect meniscal lesions is supported by the literature.

 

EDITOR’S NOTE: The results are interesting and clinically applicable. Anecdotally, I have always observed that joint line pain and pain with deep knee flexion, either with weightbearing or passively, where the most indicative of meniscal pathology in my hands. Conversely, passively extending the knee into hyperextension seems to be uncomfortable in patients with anterior horn tears. One test that just doesn’t seem to work well for me is the Apley’s test. Sounds like the test may still useful as the specificity is high. What has your experience been? What other tests you feel are helpful in detecting a meniscal lesion? Thanks for the review Dan.

References

  1. Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997; 77: 145-54.
  2. Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clinical Rehabilitation. 2008; 22: 143-161.
  3. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003; 139: 575-88.
  4. Scholten RJ, Deville WL, Opstelten W, et al. Accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract. 2001; 50: 938-44.
  5. Solomon DH, Simel DL, Bates DW, et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA. 2001; 286: 1610-20.
  6. Akseki D, Ozcan O, Boya H, et al. A new weight bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. Arthroscopy. 2004; 20: 951-58.
  7. Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005; 87: 955-62.

 

Meserve BB, Cleland JA, & Boucher TR (2008). A meta-analysis examining clinical test utilities for assessing meniscal injury. Clinical rehabilitation, 22 (2), 143-61 PMID: 18212035

5 replies
  1. Harrison Vaughan, PT, DPT
    Harrison Vaughan, PT, DPT says:

    Nice Post Dan!
    I agree with Chad that I do like the Thessaly test, which has good numbers; but considering case control design, its not the most accurate study. It does have high specificity, so good to rule – in the condition if you want to save it for last in the exam.

    Rose & Gold showed that a composite exam (hx, exam…basically the big picture), showed a sensitivity of 92, LR+: 2.3.

    Not huge numbers but can show we can rule out meniscal tear better than ruling-in with that study.

    Harrison

  2. amy castillo
    amy castillo says:

    History paired with joint line tenderness seems to be the most useful. Curious to see if further test on Thessaly test will show as good results. OBriens test looked gold at first glance too.

  3. Chad Ballard, PT
    Chad Ballard, PT says:

    Nice review. I'm personally a big fan of the Thessaly and weight it fairly heavy in my cluster of tests for patients that tend to be very guarded (they at least feel like they have a little control with the Thessaly).

  4. Anonymous
    Anonymous says:

    nice post…apleys usually works for me, though deep knee flexion is good too…treatment is hard, as Chrsite suggested, I try to manaeg the symtoms usings mods for swelling etc, advice, and cont ex prog avoiding rotn/twsiting…

  5. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    This is always an area of interest of mine.

    What, specifically were the ranges of sen/spec?

    Also, what is the rate of meniscal tears amongst the general population without knee pain?

    What I'm waiting for are some type of clinical prediction rules as to who will respond well to conservative treatment and who will require surgery. At best, the Cochrane guidelines (I think) state that those with tears greater than 7mm usually require surgery.

    A further point, what treatment, if any, is proposed for those who will respond to PT? I always get a little miffed when I get an order for someone that says "strengthening" when the person is already exceptionally strong (ie, my black belt karate person)….This is another area where I use repeated motion testing…

    Good post

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