Sports Medicine Research: In the Lab & In the Field: Clinical Prediction Rule for Meniscal Tears? (Sports Med Res)
Wednesday, July 10, 2013

Clinical Prediction Rule for Meniscal Tears?

Joint Line Tenderness and McMurray's Tests for the Detection of Meniscal Lesions: What is Their Real Diagnostic Value?

Galli M, Ciriello V, Menghi A, Aulisa AG, Rabini A & Marzetti E. Archives of Physical Medicine and Rehabilitation.  2013, 94:1126-31.  doi: 10.1016/j.apmr.2012.11.008

Take Home Message:  Joint line tenderness and McMurray's tests used together do not necessarily improve meniscal lesion diagnosis. 

Clinical prediction rules, such as the Ottawa Ankle Rules, improve clinical care and reduce healthcare costs from unnecessary diagnostic imaging.  Knee meniscal clinical tests may be coupled together to yield similar results; however, the accuracy of combining meniscal special tests remains unclear. Therefore, the authors investigated the accuracy of joint line tenderness (JLT) and the McMurray's tests in diagnosing meniscal tears. Three physicians with varying years of experience independently evaluated 60 patients (~29 years of age) needing knee arthroscopy.  Separately, the two tests did not have great sensitivity (JLT: 40-80%, McMurray’s 14-45%) or specificity (JLT: 20-60%, McMurray’s: 70-80%). In other words, JLT lacked value in diagnosing meniscal lesions, and McMurray’s was only relatively efficient at determining when a patient did not have a meniscal lesion (Click here for definitions of Sensitivity & Specificity).  Interestingly, years of experience improved the accuracy of the McMurray’s test. Furthermore, combining the two clinical tests did not improve the accuracy of meniscal tear diagnosis beyond what the McMurray’s test alone could offer.

A set of clinical prediction rules has yet to be established for the knee; however, the results of this study are still interesting.  Meniscal tear diagnosis is relatively accurate when using the McMurray’s test and combining the use of JLT did not help improve the diagnosis of a meniscal tear.  However, years of experience affected the overall McMurray’s diagnostic accuracy.  This demonstrates the importance of practicing and clinical experience.  It would be interesting to see if the combination of JLT and McMurray’s helped improve diagnosis in a novice or less experienced clinician.  Also, the authors used arthroscopy as the gold standard for meniscal lesion diagnosis.  It would be interesting to see how these tests and others in combination compare to magnetic resonance imaging (MRI) results as well.  In some cases, clinical examination may be as good as an MRI.  While combining these two tests does not seem to improve accuracy and prediction of pathology, there may still be a battery of tests that would. 

Questions for Discussion: Do you think that there are other tests that may help (in isolation or combination) diagnose meniscal tears as part of a clinical prediction rule?  Do you think that MRIs are over used?  Do you think insurances or clinicians would ever consider surgical recommendations based on clinical examination alone, without obtaining an MRI?
 
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:
Galli M, Ciriello V, Menghi A, Aulisa AG, Rabini A, & Marzetti E (2013). Joint Line Tenderness and McMurray Tests for the Detection of Meniscal Lesions: What Is Their Real Diagnostic Value? Archives of Physical Medicine and Rehabilitation, 94 (6), 1126-31 PMID: 23154135

11 comments:

Erika Spudie said...

Your questions are definitely important in light of rising healthcare costs. How nice it would be if we could decide to do surgery based solely on clinical findings! Unfortunately, I don't think that will ever happen- insurance companies are all about concrete evidence, and I think there is too much room for human error.

As a newly certified athletic trainer, I was mostly taught in undergrad that McMurray's should be the go-to test. However, I did learn other tests such as medial-lateral grind (which I think is very similar to McMurray's) and bounce home. It would be interesting to look at the validity of these tests as well. I would think the grind test would be similar; however, I've found that bounce home is pretty painful and springy with most knee pathologies. Sort of like Clarke's sign for the patella- it just plain hurts!

Nicole Cattano said...

Erika-thanks for your comment. Some tests (like Clarkes) do just result in a lot of false positive results by hurting nearly everyone. Which can be deceptive since theses types of tests will likely have high sensitivity (meaning if you get a negative result when you perform the test, it is likely that the participant doesn't have the and it is a true negative rather than a false negative). This is why or is important to look at both sensitivity and specificity, as well as trying to improve overall accuracy looking at a combination of tests.

I agree it would be interesting to look at sins of theses other tests too. Regarding surgery, I do think you're right to that insurance companies really need concrete evidence. While I don't think that this would happen any time soon, I am optimistic to think that if we continue to do research and find a battery of tests that have great accuracy... it MIGHT be possible.

Eddy Voeten said...

Several specialized tests with
different accuracies have been described for evaluating meniscal pathology. The Thessaly test has been described and reported to have a very high diagnostic accuracy rate of 94% for medial meniscus tears and 96% for lateral meniscus tears.

But....fore example

Meniscal injuries are frequently associated with anterior cruciate ligament (ACL) tears. Clinical tests that are useful for detecting meniscal tears may not be valid in this setting. The Thessaly test had a sensitivity of 79%, specificity of 40%, positive predictive value of 56%, negative predictive value of 66%, positive likelihood ratio of 1.33, negative likelihood ratio of 0.51%, and overall accuracy of 60%. So the Thesally test has a low
specificity in patients with combined ACL and meniscal injuries and can not be recommended as a diagnostic test combined with ACL Tears.

Caitlyn Richbourg said...

To be able to refer to, and practice clinically according to a set of knee injury diagnostic guidelines, such as we do for the ankle with the Ottawa Ankle Rules, I believe is the ultimate goal when researching knee special tests and their validity and reliability. Ideally, clinical diagnostic tests would be accurate 100% of the time, but unfortunately, this is a very far fetched concept. I believe this study is a definitely good step towards furthering the amount of research necessary in the future to provide more feedback on the accuracy of the combination of clinical tests used to diagnose meniscal injuries.

I would also be really interested to see if the combination of JLT and McMurray's Test, when done by a newly certified, or novice athletic trainer, yielded more accurate diagnosis of a meniscal tear.

Erin said...

I don't believe that surgery will ever be preformed off of just clinical assessment with special tests. While this would be ideal and cut down on costs to the patient, I don't think it is feasible. However, if ATs can prefect their skills, maybe we can cut down on the unnecessary imaging. All of this comes with experience. I agree with Caitlyn in that it would be interesting so see if the combination of JLT and McMurry's Test yielded more accurate diagnosis. One of the most important tests we have though is collecting an accurate history. We must be patient when collecting a history and not rush through it. Also listening when the patient tells you a test produces pain, but also watching their expressions. Special tests are there to help us rule out and narrow our list of possible injuries. By perfecting them, we help ourselves and the patient. We will never be correct 100% percent of the time; however, imaging techniques miss things too.

Nicole Cattano said...

There were some previous studies that investigated the accuracy of JLT and McMurray's in physicians based on various years of experience (as well as this one), but to my knowledge, I have not seen any on varying levels of experience in ATs. To re-emphasize Erin's point, interestingly in one study, the experienced orthopedic was more accurate than an MRI. Although MRI's are getting better and better, and this study was from a few years ago.

I agree with the comments that maybe like the Ottawa Ankle Rules, we can at least help minimize unnecessary imaging. Although insurance companies aren't the only ones who always want one...sometimes it is the athlete/patient or parents.

Great conversation!

Comment via LinkedIn: said...

I have found that in addition to JLT and McMurrays pain at end ROM in flexion and extension aid in diagnosis. In deep flexion posterior knee pain seems to be a good indicator and anterior pain with full extension when doing a bounce home test.
By Jake Ritter MEd, ATC

Nicole Cattano said...

Thanks Jake! Have you found that there are any differences based on the location of the tear?

Zach Johnson said...

I believe that MRI and other imaging techniques are overused in general. I do not know how often they are overused for meniscal imaging specifically. The Ottawa ankle rules are a great tool, but it is hard to compare rules for a different joint that are to rule out a fracture.
I agree with Erin that the history is a very important component with evaluation, and I also like how Jake points out that pain with ROM can help indicate possible diagnosis. For now we must continue to perform a complete exam to rule in or out every type of pathology associated with injuries.
I like the direction this research is going in what tests or signs can help us best indicate certain pathologies and it definitely can help us as clinicians to better understand the different special tests we perform. There are many special tests that have very little evidence or research on them and it would be very helpful in the future to see research on all of them to help us see how clinically applicable they all are.

Comment via LinkedIn said...

Pain in deep flexion I would I would lean towards the posterior aspect of the meniscus while anterior with a positive bounce home. McMurray's iis the only teat that I know to try and isolate b/w medial and lateral. But at the end of the day an MRI is the gold standard.
By Jake Ritter MEd, ATC

Nicole Cattano said...

Zach- great point about overusing MRIs. I think it's difficult to determine since the Ottawa ankle rules were originally designed to try to minimize emergency room visits/xrays. Obviously there's not nearly as much MRI use in an ER setting.

I like where the research is headed as well... and I think Jake's thoughts about the bounce home and knee flexion are great. While I agree that MRIs are common practice and a current good standard. They cost money, aren't always accurate, there still human error in reading them, and there is still radiation emitted when receiving one.

I think a battery of clinical tests to help reduce the number of MRIs done would be great. But Zach raises a great point... Anecdotally I personally feel like MRIs are overused (at least in my clinical setting), but does anyone know of any studies with numbers? Also, is anyone else seeing high MRI use clinically?

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