McMurray's Test and Joint Line Tenderness for Medial Meniscus Tear: Are They Accurate?

Medial joint line tenderness is an indicator for meniscal injuries in dogs

BACKGROUND

Medial meniscal injury is an important aspect of cranial cruciate ligament disease in dogs. This study examines whether caudomedial joint line palpation of the stifle is correlated with medial meniscal injury in canine stifles with concurrent cranial cruciate ligament disease.

METHODS

A total of 91 dogs (97 stifles) presenting with cranial cruciate ligament disease were assessed by palpation of the caudomedial joint line of the affected stifle by a single surgeon. Surgery was then performed to assess for injury to the medial meniscus. The odds of dogs with pain on palpation having a medial meniscal tear were then calculated, with the significance level set at p-value of 0.05.

RESULTS

Dogs showing pain on caudomedial joint palpation had 34.5 times (95% confidence interval 9.7‒125) greater odds of having a medial meniscal tear. Pain on caudomedial joint line palpation had a sensitivity of 0.86, specificity of 0.85, positive predictive value of 0.94, negative predictive value of 0.70 and accuracy of 0.86 for identifying dogs with a medial meniscal tear.

LIMITATIONS

The amount of pressure placed on the caudomedial joint line was not assessed and a control group was not included.

CONCLUSION

Medial joint line tenderness has a significant relationship with medial meniscal tear in dogs with cranial cruciate ligament disease.

Using a combination of three clinical tests for detecting meniscal tears increases the accuracy of the clinical examination

BACKGROUND

Recent studies indicate that using combination of two or more clinical tests for detecting meniscal tear gets a higher sensitivity and specificity than any clinical test performed individually.

METHODS

The study involved 84 participants who were divided into two groups: the "OP group" consisting of participants diagnosed with a meniscal tear and who consequently underwent arthroscopic meniscectomy, and the "CN group" comprising of healthy participants with no history of knee injury. Two independent observers (orthopedic surgeons) recorded the results of six clinical tests: Thessaly Test, joint line tenderness, McMurray Test, Ege Test, Steinmann I Test, and atrophy of the thigh muscles. The tests were grouped into two combinations of three tests each. The first combination included Thessaly Test, joint line tenderness and McMurray Test, while the second combination comprised of remaining three tests. Cochran's Q Test was used to calculate interobserver variability for both combinations of clinical tests and for each test performed individually.

RESULTS

First combination of three clinical tests when considering the combination positive if two tests are positive had high sensitivity of 95%, specificity of 90.9%, and an overall accuracy of 92.9%. Furthermore, when compared to clinical tests performed individually, the combination demonstrated superior results.

CONCLUSIONS

This study shows that using a combination of three clinical tests for detection of meniscal tear (Thessaly Test, joint line tenderness, McMurray Test), when considering the combination positive if two tests are positive, has greater accuracy than six clinical tests performed individually. There were no statistically significant differences between observers.

Clinical and radiologic outcomes in patients with meniscal root tears

BACKGROUND

Meniscal root tears can lead to early knee osteoarthritis and pain. This study aimed (1) to compare clinical and radiological outcomes between patients who underwent arthroscopic meniscal root repair after meniscal root tears and those who received non-surgical treatment, and (2) to identify whether baseline MRI findings could be potential predictors for future treatment strategies.

METHODS

Patients with meniscal root tears were identified from our picture archiving and communication system from 2016 to 2020. Two radiologists reviewed radiographs and MRI studies using Kellgren-Lawrence (KL) grading and a modified Whole Organ MRI Scoring (WORMS) at baseline and follow-up. The median (interquartile range [IQR]) of follow-up radiographs and MRI studies were 134 (44-443) days and 502 (260-1176) days, respectively. MR images were assessed for root tear-related findings. Pain scores using visual analogue scale (VAS) and management strategies (non-surgical vs. arthroscopic root repair) were also collected. Chi-squared tests and independent t-tests were used to assess differences regarding clinical and imaging variables between treatment groups. Logistic regression analyses were performed to evaluate the associations between baseline MRI findings and each future treatment.

RESULTS

Ninety patients were included. VAS pain scores were significantly (p < 0.01) lower after arthroscopic repair compared to conservative treatment (1.27±0.38vs.4±0.52) at the last follow-up visit with median (IQR) of 325 (180-1391) days. Increased meniscal extrusion (mm) was associated with higher odds of receiving non-surgical treatment (OR = 1.65, 95%CI 1.02-2.69, p = 0.04). The odds of having arthroscopic repair increased by 19% for every 1 mm increase in the distance of the tear from the root attachment (OR = 1.19, 95% CI: 1.05-1.36, p < 0.01). The odds of undergoing arthroscopic repair were reduced by 49% for every 1 mm increase in the extent of meniscal extrusion (OR = 0.51, 95% CI: 0.29-0.91, p = 0.02) as observed in the baseline MRI.

CONCLUSIONS

Patients who underwent arthroscopic repair had lower pain scores than patients with conservative treatment in the follow-up. Distance of the torn meniscus to the root attachment and the extent of meniscal extrusion were significant predictors for arthroscopic repair in the next three weeks (time from the baseline MRI to the surgery date).

Consensus Delphi study on guidelines for the assessment of anterior cruciate ligament injuries in children

Background: Knee examination guidelines in minors are intended to aid decision-making in the management of knee instability. Clinical question: A Delphi study was conducted with a formal consensus process using a validated methodology with sufficient scientific evidence. A group consensus meeting was held to develop recommendations and practical guidelines for use in the assessment of instability injuries in children. Key findings: there is a lack of evidence to analyse anterior cruciate ligament injuries in children and their subsequent surgical management if necessary. Diagnostic guidelines and clinical assessment of the patient based on a thorough examination of the knee are performed and a guide to anterior cruciate ligament exploration in children is developed. Clinical application: In the absence of a strong evidence base, these established guidelines are intended to assist in that decision-making process to help the clinician decide on the most optimal treatment with the aim of benefiting the patient as much as possible. Following this expert consensus, surgical treatment is advised when the patient has a subjective sensation of instability accompanied by a pivot shift test ++, and may include an anterior drawer test + and a Lachman test +. If these conditions are not present, the conservative approach should be chosen, as the anatomical and functional development of children, together with a physiotherapy programme, may improve the evolution of the injury.

Diagnostic value of clinical tests and Mri for meniscal injury in patients with anterior cruciate ligament injury: Case series study

Introduction and importance

Meniscal tear is one of the most common knee injuries and knee surgery procedures. It is frequently associated with an anterior cruciate ligament (ACL) injury. We conducted this study, on patients with ACL reconstruction surgeries, which were occasionally accompanied by meniscal tears, in order to determine the diagnostic value of clinical examinations for meniscal tear, both individually and in combination, in correlations to magnetic resonance imaging (MRI) scans, with the goal of improving clinical diagnosis for patients with meniscal injuries in particular, as well as meniscal injuries associated with cruciate ligament knee injuries.

Case presentation

50 patients were thoroughly clinically examined, using Joint line tenderness, Thessaly test, McMurray's test, Apley's test followed by MRI, before their scheduled ACL reconstruction arthroscopic surgeries. The meniscal tears were then identified during the procedure, and were treated, if necessary. The data before and after the surgery was taken into calculating, with arthroscopic findings serving as the gold standard. Results: the sensitivity, specificity and accuracy of each clinical tests and MRI scans respectively were: for medial meniscus, Joint line tenderness (70%; 53,3%; 60%); McMurray's test (80%; 73,3%: 76%); Apley's test (65%; 70%; 68%); Thessaly test(70%; 76,7%; 74%); MRI (90%; 83,3%; 86%); lateral meniscus: Joint line tenderness (73%; 66,7%; 70%); McMurray's test (69,2%; 75%: 72%); Apley's test (69,2%; 70,8%; 70%); Thessaly test (73,1%; 75%; 74%); MRI (88,5%; 87,5%; 88%). However, when combining at least two positive tests into a single composite test, the diagnostic value is considerably enhanced with sensitivity, specificity and accuracy of 85%, 73,3%, 78% for medial meniscus, 92,3%, 87,5%, 90% for lateral meniscus.

Clinical discussion

Clinical tests are essential for diagnosis of meniscal tears, although inconsistent. A composite test consisting of at least two positive tests can considerably enhance the diagnostic value, even comparable to MRI scans. However, after the clinical examination, MRI is still necessary for the diagnostic process of meniscal injuries in particular, as well as meniscal injuries associated with cruciate ligament knee injuries.

Conclusion

The combination of clinical tests and MRI images will give a precise diagnosis as well as surgical indication for meniscus injury in patients with anterior cruciate ligament tear.

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Meniscus tear is frequently associated with ACL injury

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Identifying, classifying and grading meniscus lesion is very important because it can assist surgeon in providing appropriate treatment plans (meniscectomy or repair) and having an accurate prognosis for patients.

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Determine the diagnostic value in term of clinical in correlation with preoperative MRI images is the purpose of this study

The Rising Moon sign is specific and sensitive in the diagnosis of bucket handle tears of the medial meniscus

PURPOSE

Bucket handle tears of the meniscus are common and can lead to locking, extension deficit and functional impairment. The diagnosis is determined by a combination of physical examination and imaging, but in some cases the diagnosis may be challenging since specific clinical tests are lacking. The aim of the present study was to assess the value of a new clinical test, the elective pain at the anterior aspect of the joint line (defined as the "Rising Moon sign") in the diagnosis of bucket handle tears of the medial meniscus.

METHODS

Forty patients treated for a bucket handle of the medial meniscus were enrolled as the study group and were compared to a matched group of 40 patients with a posterior horn tear of the medial meniscus and 50 healthy subjects. The following aspects were investigated in the groups: body mass index, extension deficit, pain at the posterior aspect of the joint line (PPJL), at the middle joint line (PMJL), at the anterior join line (PAJL) and at combined hyperflexion of the knee and external rotation of the foot (PHE). Pain at the anterior joint line (PAJL) was defined as the Rising Moon sign.

RESULTS

In the bucket handle group the average flexion contracture was 12° (0-30°). The average PPJL was one (0-2), the average PMJL was 1.6 (0-3), PAJL was 2.5 (1-3) and PHE was 1.6 (1-2). In the posterior horn tear group the average flexion contracture was 0.9° (- 10 to 5°). The average PPJL was 2.2 (1-3), the average PMJL was 1.4 (0-3), PAJL was 0.6 (0-2) and PHE was 2.5 (1-3). The rising moon showed 95% sensitivity and 98% specificity in the diagnosis of bucket handle tears. In addition it showed a positive predictive value of 97.4% and negative predictive value of 96%. Finally it also demonstrated high inter-observer reliability (0.905).

CONCLUSIONS

The "Rising Moon" sign has shown to be highly predictive for bucket handle tears of the medial meniscus with very high specificity and sensitivity. In addition it is easy to perform with very high inter-observer reliability.

LEVEL OF EVIDENCE

Level IV.

Comparison of Thessaly Test with Joint Line Tenderness and McMurray Test in the Diagnosis of Meniscal Tears

Introduction:

Meniscus injuries are the most frequent problem of the knee. The aim of this study was to investigate the accuracy of the Thessaly test and comparing it with those of McMurray and Joint-line tenderness tests for diagnosing meniscal tears.

Materials and methods: This study was designed as a prospective observational one done in an outpatient clinic at a university hospital. 106 patients with knee pain and 82 age-matched control were included during study period (from February 2014 to January 2015). Each patient was clinically examined with McMurray, Thessaly, and joint line tenderness tests. Then, the findings were matched by MRI and arthroscopic findings. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated as main outcomes.

Results:

Based on MRI, Thessaly was the most sensitive for medial meniscus tears (56.2%), while McMurray and joint-line tenderness were more specific (89.1% and 88.0%, respectively). For lateral meniscus tears, McMurray was the most sensitive (56.2%) and all were specific (McMurray 89.6%, Thessaly 88.4%, joint-line tenderness 90.2%). With arthroscopy, Thessaly was the most sensitive for medial meniscus (76.6%), while McMurray and joint-line tenderness were more specific (81.0%, and 81.0%). Agreement with arthroscopy was the highest with McMurray (for medial meniscus kappa=0.40, p<0.001, and for lateral meniscus kappa=0.38, p=0.002).

Conclusion:

The Thessaly can be used to screen for medial meniscus tears. McMurray and joint-line tenderness should be used for suspected medial meniscus tears. For lateral meniscus, McMurray is appropriate for screening and all the tests are useful in clinic.

Risk factors, diagnosis and non-surgical treatment for meniscal tears: evidence and recommendations: a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement aimed at summarising and appraising the available evidence for risk factors, diagnostic tools and non-surgical treatments for patients with meniscal tears. We systematically searched electronic databases using a pragmatic search strategy approach. Included studies were synthesised quantitatively or qualitatively, as appropriate. Strength of evidence was determined according to the Grading of Recommendations Assessment Development and Evaluation framework. Low-quality evidence suggested that overweight (degenerative tears, k=3), male sex (k=4), contact and pivoting sports (k=2), and frequent occupational kneeling/squatting (k=3) were risk factors for meniscal tears. There was low to moderate quality evidence for low to high positive and negative predictive values, depending on the underlying prevalence of meniscal tears for four common diagnostic tests (k=15, n=2474). Seven trials investigated exercise versus surgery (k=2) or the effect of surgery in addition to exercise (k=5) for degenerative meniscal tears. There was moderate level of evidence for exercise improving self-reported pain (Effect Size (ES)-0.51, 95% CI -1.16 to 0.13) and function (ES -0.06, 95% CI -0.23 to 0.11) to the same extent as surgery, and improving muscle strength to a greater extent than surgery (ES -0.45, 95% CI -0.62 to -0.29). High-quality evidence showed no clinically relevant effect of surgery in addition to exercise on pain (ES 0.18, 95% 0.05 to 0.32) and function (ES, 0.13 95% CI -0.03 to 0.28) for patients with degenerative meniscal tears. No randomised trials comparing non-surgical treatments with surgery in patients younger than 40 years of age or patients with traumatic meniscal tears were identified. Diagnosis of meniscal tears is challenging as all clinical diagnostic tests have high risk of misclassification. Exercise therapy should be recommended as the treatment of choice for middle-aged and older patients with degenerative meniscal lesions. Evidence on the best treatment for young patients and patients with traumatic meniscal tears is lacking.