History, clinical findings, magnetic resonance imaging, and arthroscopic correlation in meniscal lesions
Ercin E, Kaya I, Sugnur I, Demirbas E, Ugras AA, & Cetinus EM. Knee Surgery, Sports Traumatology, Arthroscopy. 2011 Aug 11. [Epub ahead of print] doi: 10.1007/s00167-011-1636-4
Thorough clinical evaluation, including a detailed history and clinical examination, is critical to making accurate injury diagnoses. Magnetic resonance imaging (MRI) is often used as a follow up measure in confirming or ruling out a suspected diagnosis. However, an MRI may be unnecessary given the accuracy of the clinical examination. To reduce unnecessary imaging (e.g., radiographs, MRI) and healthcare costs clinical guidelines have been described for other areas of the body (e.g., Ottawa Ankle Rules). The purpose of this study was to investigate the accuracy of clinical evaluation and MRI versus the “gold standard” arthroscopy in diagnosing meniscal tears. 30 patients (all presented with joint line pain with weight-bearing and/or mechanical symptoms and no prior arthroscopy or evidence of degenerative changes) underwent clinical evaluation, MRI, and arthroscopy in respective order. The clinical evaluation was performed independently by an experienced knee surgeon, a specialist in general orthopaedics, as well as two residents and consisted of seven special tests: 1. joint line tenderness, 2. McMurray’s, 3. Appley’s, 4. Steinmann I, 5. Payr’s, 6. Childress’ sign (Squat test), and 7. Ege’s (see Table 1 in the article for explanation of all tests; images available also). Meniscal tear was diagnosed if 2 of these tests were positive. The results of clinical evaluation, MRI, and arthroscopy were compared. Interestingly, clinical evaluation by an experienced knee surgeon was more accurate than MRI for medial meniscal tears; and the surgeon and MRI were comparable for lateral meniscal tears. Furthermore, the specialist in general orthopaedics was as accurate as the MRI for detecting medial and lateral meniscal tears. The sensitivity of MRI, experienced knee surgeon, and specialist in general orthopaedics were 95% for medial meniscal tears but considerably lower with lateral meniscal tears.
As clinicians, this study demonstrates the value of the clinical evaluation. MRI may not always be necessary when diagnosing and making treatment decisions. With rising healthcare costs, the value of clinical predictors is tremendous. For evaluation guidelines like the Ottawa Ankle Rules the emphasis is often on having a high sensitivity (sensitivity: positively diagnose a patient who has pathology) even if it has a lot of false positives (better to be safe than sorry). The clinical exam by the experienced surgeon or specialist had a high sensitivity for medial meniscal tears. Of interesting note, the study included evaluators with varying levels of experience, with the experienced knee surgeon performing the best. It would be interesting to see this pursued with more clinicians at each level of experience. Regardless, we should keep in mind the potential importance of experience level. Clinically, we often notice anecdotal trends of clinical tests or findings that may be more sensitive than others for many pathologies. Has anyone noticed any possible clinical predictors or tell-tale signs leading you to suspect certain pathologies?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
I love to see studies that evaluate the efficacy of certain special tests. I feel like this is a relatively novel area in research and is growing quickly. The idea of clinical predictor rules and using specific combinations of special tests will allow clinicians to improve upon their diagnostic skills. As an athletic trainer injury prognosis through history, palpation, ROM, strength and special testing is one of my favorite parts. It requires me to take into account so many different parts of my education and clinical experience. Having any understanding of how certain structures respond to injury (type and quality of pain, sensations, amount of swelling, etc.) involves having a vast background on pathophysiology but an equally as important clinical experience. Athletic trainers are lucky enough to see how certain injuries respond immediately, shortly after, the next day, etc. This way we can formulate in our minds a few things we think it is initially, narrow it in a couple hours and if there is still some uncertainty have a final prognosis within the next couple days! In sports medicine quick decision making skills are of vital importance. I think the current research being done on special testing will allow sports medicine experts to do such. Thanks for the post, I would love to see more like this!
Greg-Thanks for your interest in the post and this type of an article. There seems to be more and more research coming out like this in efforts to cut the insanely high costs of the healthcare system. I completely agree with you and I truly enjoy this aspect of being an athletic trainer. Our hands are sometimes our best tools, and in some instances, we can be more accurate than imaging. Ia m not sure if our litigious society will ever get to the point were clinical prediction rules trump imaging…but more studies like this can certainly help in lowering the skyrocketing health care costs.