Development and preliminary validation of a meniscal symptom index.
Niu NN, Losina E, Martin SD, Wright J, Solomon DH, Katz JN. Arthritis Care Res (Hoboken). 2011 Feb;63(2):208-15.
Many of us were trained to ask patients with knee symptoms if they experience “popping”, “giving way”, or “catching”; potential signs of a meniscal tear. Surprisingly, there is little research exploring the diagnostic value of these questions. The authors of this study describe the development of expanded descriptions/questions of meniscal symptoms. A checklist of key terms and expanded descriptions/questions were field tested among 300 adult patients (average age 52 years) being seen in an outpatient orthopaedic clinic (121 had a symptomatic meniscal tear). The reliability and indicators of validity were higher for expanded descriptions of the symptoms than simple checklists of symptoms. After a reliability and validity test the authors developed a Meniscal Symptom Index (score 0 to 4) that included four of the expanded description/question items:
- “Do you feel a clicking sensation or hear a clicking noise when you move your knee?”
- “Do you feel that sometimes something is caught in your knee that momentarily prevents movement?”
- “Do you sometimes feel that your knee will give out and not support your weight?”
- “Is your knee pain centered to 1 spot on the knee that you can point to with your finger?”
7 other questions were endorsed but not included in the Index.
The probability of having a meniscal tear increases with the Meniscal Symptom Index: a score of 0 = 16% chance of a meniscal tear and a score of 4 = 76% chance of a meniscal tear. The authors note that the Meniscal Symptom Index requires more research to validate it. Over half of the patients with meniscal tears also had knee osteoarthritis or patellofemoral syndrome. It would be interesting to see this Index tested in younger patients (for example, college and high school athletes).
This study makes a compelling argument that rather than rattling off a list of signs and symptoms (for example, has your knee ever experienced popping, clicking, catching, or episodes of giving way?) we should consider using expanded descriptions. I think the last sentence of the paper has the best take home lesson: “On a more general level, our study demonstrates that the way physicians ask questions is important and that time-honored features of the clinical history methods deserve critical scrutiny.” I think this extends to every health care professional that performs an examination. I remember times when a physician and I would get two different sets of answers to similar questions. We just worded them slightly different or asked a different follow-up question and in return received different information (sometimes contradictory information). We base a lot of initial decisions on our clinical history examination but yet we know very little about the diagnostic value of this key part of our evaluations. We need more research like this study and as clinicians we need to take more time talking to our patients about their clinical history to ensure we are getting all of the facts.
Written by: Jeffrey Driban
Reviewed by: Stephen Thomas
Jeff/Steve
Great review and comments. Knowing the importance of the medical hx related to the problem, and how it guides the initial layer of care, this article has serious significance.
Great wake up call for clinicians (like myself) in busy environments, to realize it is not what you say but how you say it.
Ultimately saving time by getting a better intial clinical picture to initiate care.
Keep up the great work
Tom