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Three Part Question

in [adults with a suspected meniscal injury] is [one clinical test better than another] at [diagnosing meniscal injury]

Clinical Scenario

A 28 year old male presents to the AED knee review clinic two weeks after a twisting injury whilst playing football. The history and his symptoms make you suspicious of a meniscal injury, but you are unsure of the best test to confirm this. You wonder if there is any evidence to help you choose.

Search Strategy

MEDLINE 1966-09/07, CINAHL 1982 –05/07, AMED 1985-09/07, SPORTDiscus 1830-09/07, EMBASE 1996-09/07, via the OVID interface. In addition the Cochrane database and PEDro database were also searched
(exp knee joint) AND (exp physical examination) AND (internal derangement.mp) AND (exp menisci, tibial). LIMIT to human studies AND English language.

Search Outcome

101 papers were retrieved. There were 4 systematic reviews, 2 with meta-analysis, which included all the other relevant papers pertinent to the 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Scholten et al 2001 Holland	13 studies (n= 402) on accuracy of physical diagnostic tests for meniscal lesions	1a Systematic review	1. McMurray's test	1. Mean % Sensitivity 48% Specificity 86%	Small number of poor quality studies Sensitivity & specificity estimates affected by verification bias
			2. Joint line tenderness	2. Mean % Sensitivity 77% Specificity 41%
Solomon et al 2001 USA	9 studies (n = 1018) on diagnostic accuracy of examination for meniscal injury	1a Systematic review	1. Composite examination (9 studies)	1.Mean % (SD) Sensitivity 77%(7%) Specificity 91% (3%).	9 studies all used arthroscopy as gold standard (verification bias)
			2. Joint line tenderness (4 studies)	2. Mean % (SD) Sensitivity 79%(4%) Specificity 15% (22%) SummaryLR (95% CI) Positive LR 0.9 (0.8-1) Negative LR1.1(1-1.3)
			3. McMurray's test (4 studies)	3. Mean%(SD) Sensitivity 53% (15%) Specificity 59% (36%) Summary LR (95% CI) Positive LR 1.3(0.9-1.7) Negative LR 0.8(0.6-1.1)
			4. Apley's test (1 study)	4. Sensitivity 16% Specificity NA
			5. med/lat grind test (1 study)	5. Sensitivity 69% Specificity 86%. Summary LR (95% CI) Positive LR 4.8 (0.8-30) Negative LR 0.4(0.2-.6)
Hegedus et al 2007 USA	18 studies (n = 2670) on physical tests for torn meniscus	1a Systematic review & meta-analysis	1.McMurray's test	1. Pooled % (95% CI) Sensitivity 71% (67,73) Specificity 71% (69,73) Odds ratio (95%CI) 4.5(3.7,5.4)	Meta analysis limited by qualities of the studies analysed. Heterogeneous data in patient populations, ages gender ratio, chronicity of injury.
			2. Joint line tenderness	2. Pooled % (95% CI) Sensitivity 63% (61,66) Specificity 77% (76,79) Odds ratio(95%CI) 4.5(3.8,5.4)
			3. Apley's test	3.Pooled % (95%CI) Sensitivity 61% (55,66) Specificity 70% (68,72) Odds ratio (95%CI) 0.69(0.65,0.73)
Ryzewicz et al 2007 USA	6 studies (n= 825) on performance of clinical meniscal tests	1a Systematic review	1. Joint line tenderness	1. No summary statistic given	No summary statistics of multiple studies 6 studies reviewed had variable quality Use of arthroscopy as gold standard in most studies means verification bias
			2. McMurray's test (5 studies)	2. No summary statistic given
			3. Apley's test (2 studies)	3. No summary statistic given
			4. Ege's test (1 study)	4. med/lat meniscus sensitivity 67%/64% specificity 81%/90% PPV 86%/58% NPV 57%/90%
			5. Thessaly test (1 study) @ 20deg knee flexion	5. med/lat meniscus sensitivity 89%/92% specificity 97%/96% False Pos 2.2%/3.7% False Neg 3.6%/0.73% Accuracy 94%/96%
			5. Thessaly test (1 study) @ 5deg knee flexion	6. (med/lat meniscus) sensitivity 66%/81% specificity 96%/91% False Pos 2.9%/8% False Neg 11%/1.7% Accuracy 86%/90%

Comment(s)

The systematic reviews concur that a composite examination (good history and several clinical tests) may provide greater diagnostic accuracy than a specific physical test. These recommendations don't seem to apply to acutely injured knees, or those with degenerative menisci. All clinical tests tended to decrease reliability with concomitant ligament injury.

Clinical Bottom Line

There is no single, pathognomonic clinical test to adequately diagnose a meniscal tear.

References

1. Scholten RJPM, Deville WLJM, Opstelten W, Bijl D, van der Plas CG, Bolter LM The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee. The Journal of Family Practice 2001;50(11): 938-944
2. Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer LJ. Does this patient have a torn meniscus or ligament of the knee? JAMA 2001;Oct 3; 286(13): 1610-1620
3. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus of the knee: a systematic review with meta-analysis Journal of Orthopaedic & Sports Physical Therapy 2007; 37(9): 541-550
4. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscal tears. The role of MRI and clinical examination Clinical Orthopaedics and Related Research 2007; 445; 123-133