Sports Medicine Research: In the Lab & In the Field: Thessaly Test is not Necessarily Value Added for Meniscal Diagnosis Accuracy (Sports Med Res)


Wednesday, January 7, 2015

Thessaly Test is not Necessarily Value Added for Meniscal Diagnosis Accuracy

Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study

Goossens P, Keijesers E, van Geenen RJ, Zijta A, van den Broek M, Verhagen AP, & Scholten-Peeters GG. J Orthop Sports Phys Ther.: 1-26. E pub ahead of print November 24, 2014

Take Home Message: The Thessaly test is comparable in accuracy to a modified McMurray test in a group of patients with a high prevalence of meniscal tears. 

The Thessaly test is a newer test that was designed to assist in the diagnosis of meniscal tears during clinical examination.  The Thessaly test is performed by asking a patient to stand with about 20 degrees of knee flexion and having them internally and externally rotate their body. Since the introduction of the test in 2005, a couple of studies have investigated it, but the accuracy of this test has yet to be established.  The authors of this study aimed to evaluate the diagnostic accuracy of the Thessaly test in comparison to arthroscopy (the gold standard) in 593 patients (average age = 49 years).  The Thessaly test was performed first, followed by the more traditional McMurray test, and then the findings were compared to what a surgeon discovered during arthroscopic surgery.  The Thessaly test had a 64% sensitivity and a 53% specificity where the McMurray test has a 70% sensitivity and a 45% specificity (see definitions below).  The authors reported that when combining the two tests, both tests being positive did not improve the diagnostic accuracy, but that both tests being negative increased the sensitivity to 82%.      

The overall accuracy of the Thessaly test is comparable with the McMurray test.  However, clinically there still seems to be a lack of a relatively accurate test to help rule out or in meniscal pathology.  This study was done in a population that had a high prevalence of meniscal injuries, and it would be interesting to see what the results would be like in a different population.  For example, the Thessaly test was compared with arthroscopy because it is the gold standard for diagnosing meniscal tears but this means only surgical candidates were included even though we often evaluate patients who don’t require an arthroscopy. In the current study examined, the clinical evaluation was performed by 1 of a 7 experienced physiotherapists following the same protocol.  The authors indicated that they did not assess inter-rater reliability, but it would have been valuable to have multiple physiotherapists perform the same tests, or to have a more limited range of possible physiotherapists perform the evaluation.  The authors noted that a higher amount of false positives for the McMurray test may be due to the fact that they used a modified version of the McMurray test where a positive result was pain and or clicking.  If the authors of this study could have looked back at what positive results (pain or clicking) they had, they may have been able to determine which interpretation of the results helped to produce better accuracy outcomes. There is still a lot of questions about using the Thessaly test to diagnose a meniscal tear but the results so far seem to indicate that we should not rely on it as our only test. Ultimately, the best approach for a clinician may still be to use a battery of tests in combination with patient history to most accurately assess during their clinical examination.    

Questions for Discussion:  What combination of clinical tests do you utilize to help to rule out or in a meniscal tear?  Have you used or do you see value in integrating the Thessaly test in your clinical evaluations?     

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Helpful Information:

Goossens, P., Keijsers, E., van Geenen, R., Zijta, A., van den Broek, M., Verhagen, A., & Scholten-Peeters, G. (2014). Validity of the Thessaly Test in Evaluating Meniscal Tears Compared With Arthroscopy: A Diagnostic Accuracy Study Journal of Orthopaedic & Sports Physical Therapy, 1-26 DOI: 10.2519/jospt.2015.5215


Rachel Koldenhoven said...

Special tests are a great tool for health care professionals to confirm their suspected diagnosis. It is key to have a thorough history prior to using special tests. Personally, I like to use the Thessaly test, but in combination with McMurray and Apley's compression/distraction. As someone with a smaller build, I cannot always provoke the patients symptoms with the McMurray test. This is why it is helpful to have those additional tests. Sometimes when using the Thessaly test I get a better provocation of pain than when performing McMurray's. I've personally had the athlete use varying positions of knee flexion and do the test repeatedly (not only testing at 20ยบ). Relying only on a special test is not going to give you an accurate diagnosis the majority of the time. It is also important to take into account the level of clinician experience with this injury. Someone with more experience taking a thorough history and asking good questions in addition to properly performing the special tests will probably have better accuracy than a new clinician with little experience.

Nicole Cattano said...

Thanks for your comment Rachel. I absolutely agree that a thorough examination (including all aspects and the history) is key. A thorough history can help to build your differential diagnoses to inform the remainder of your evaluation process.

Performing the Thessaly test at varying degrees may have some implications regarding where the meniscal tear is.

But clinician experience is always a confounding factor. Thanks for your comments!

Rahul Katbamna said...

Rahul Katbamna:
Incorporating a certain group of tests for a certain injury can improve and target what would deem positive or negative when the test is conducted. Personally, I have never used Thessaly's Test for evaluating possible meniscus tears because although the test can provide results, I personally believe that it could have potential to cause more damage/pain to the knee area. Also, I feel the athlete would be apprehensive to even do the rotational motion. I usually stick with apley's compression and McMurrays Test because I do feel as clincians we can control the amount of torque to place and we do our best to recreate the mechanism that caused the athlete pain.

Jeffrey Driban said...

Rahul: Why do you think the Thessaly's test will cause more damage/pain that the Apley's Compression or McMurray's Test? Just to play devil's advocate - With the Thessaly's test the patient has the ability to stop the test themselves once they are uncomfortable while with the other tests the clinician is the one really deciding to stop. I think you make a great point that a patient's apprehension towards the Thessaly's test may happen. It could even be a possible positive result...that should probably be tested.

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