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