Predicted probability of meniscus tears: comparing history and physical examination with MRI
BACKGROUND: The indication for surgical treatment of a meniscal lesion should not only rely on magnetic resonance imaging (MRI) findings, but also on a detailed history and a thorough clinical examination. However, various intra-articular lesions may often produce similar symptoms. So, what kinds of symptoms are more associated with a meniscal tear? Is MRI worth doing?
OBJECTIVE: The aims of this study were to identify sensitive and specific clinical tests and elements of patients’ history with a high predictive value, and to assess the combined diagnostic accuracy of sensitive and specific clinical tests and elements of patients’ history with MRI.
METHODS: Data from 281 consecutive knee arthroscopies to investigate and treat suspected internal knee pathologies were retrospectively collected between March 2009 and April 2010. The study group consisted of 262 knees. Statistically significant factors in the clinical diagnosis of meniscal tears were screened by a chi-square test. Logistic regression analysis was used to determine which factors associated with meniscal tears found during arthroscopy. The diagnostic values of MRI and the sensitive and specific clinical tests and elements of patients’ history with high predictive value for meniscal tears were calculated.
RESULTS: The overall diagnostic value of MRI for meniscal tears was: accuracy, 88.8%; sensitivity, 95.7%; specificity, 75.8%; positive predictive value (PPV), 88.2%; and negative predictive value (NPV), 90.4%. Giving way, locking and McMurray’s test were independent diagnostic factors with a predicted correct percentage of 80.0% (p<0.05) for the diagnosis of meniscal tears found during arthroscopy. Locking, McMurray’s test and MRI increased the predicted correct percentage of meniscal tears found during arthroscopy to 91.6% (p<0.05). For the diagnosis of meniscal tears found during arthroscopy, giving way, locking and McMurray’s test had the following values for accuracy (49.2, 60.9, 76), sensitivity (43.5, 55.2, 75.8), specificity (84, 96, 76.9), PPV (94.4, 98.8, 95.1) and NPV (19.4, 25.8, 35.1). Combining MRI, the diagnostic values of giving way, locking, and McMurray’s test were: accuracy, 88.3,89.9,89.4; sensitivity, 95.7,97.4,97.4; specificity, 74.2,75.8,74.2; PPV, 87.5,88.4,87.7; and NPV, 90.2,94,93.9.
CONCLUSIONS: Giving way, locking and McMurray’s test are independent clinical diagnostic factors for the diagnosis of meniscal tears. MRI has higher accuracy, sensitivity and NPV for the diagnosis of meniscal tears than giving way, locking and McMurray’s test. The combination of giving way, locking, McMurray’s test and MRI for confirmation is typical for a meniscal lesion diagnosis. Based on these findings, MRI should be used in a standard manner to detect meniscal tears found during arthroscopy.
- Terry GC, Tagert BE, Young MJ. Reliability of the clinical assessment in predicting the cause of internal derangements of the knee. Arthroscopy. 1995;11(5):568–76.
- Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108–15.
- Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359(11):1097–107.
- Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears.Int Orthop. 2007;31(1):57–60.
- Wagemakers HP, Heintjes EM, Boks SS, Berger MY, Verhaar JA, Koes BW, et al. Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice. Clin J Sport Med. 2008;18(1):24–30.
- Nickinson R, Darrah C, Donell S. Accuracy of clinical diagnosis in patients undergoing knee arthroscopy. Int Orthop. 2010;34(1):39–44.
- Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull. 2007;84(1):5–23.
- Crues JV 3rd, Mink J, Levy TL, Lotysch M, Stoller DW. Meniscal tears of the knee: accuracy of MR imaging. Radiology. 1987;164(2):445–8.
- Rubin DA, Paletta GA Jr. Current concepts and controversies in meniscal imaging. Magn Reson Imaging Clin N Am. 2000;8(2):243–70.
- Esmaili Jah AA, Keyhani S, Zarei R, Moghaddam AK. Accuracy of MRI in comparison with clinical and arthroscopic findings in ligamentous and meniscal tears of the knee.Acta Orthop Belg. 2005;71(2):189–96.
- Jeffrey LJ, Patrick GO, Kurt K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med. 2003;139(7):575–88.
- Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal tear.Clin Rehabil. 2008;22(2):143–61.
- Malanga G, Andrus S, Nadler S, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil. 2003;84(4):592–603.
- Rose R. The accuracy of joint line tenderness in the diagnosis of meniscal tears. West Indian Med J. 2006;55(5):323–6.
- Scholten RJ, Devillé WL, Opstelten W, Bijl D, van der Plas CG, Bouter LM. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract. 2001;50(11):938–44.
- Miller GK. A prospective study comparing the accuracy of the clinical diagnosis of meniscus tear with magnetic resonance imaging and its effect on clinical outcome. Arthroscopy. 1996;12(4):406–13.
- Canale ST, Beatty JH, editors. Phillips BB. Arthroscopy of the lower extremity. 11th ed. Philadelphia: Mosby Elsevier; 2007.
- Gillquist J, Hagberg G. A new modification of the technique of arthroscopy of the knee joint. Acta Chir Scand. 1976;142(2):123–30.
- Hamberg P. Treatment of meniscus lesions of the knee: a selective approach. Linkoping University Medical Dissertations;156. Linkoping, Sweden; 1983.
- Englund M, Niu J, Guermazi A, Roemer FW, Hunter DJ, Lynch JA, et al. Effect of meniscal damage on the development of frequent knee pain, aching, or stiffness. Arthritis Rheum. 2007;56(12):4048–54.
- Kornaat PR, Bloem JL, Ceulemans RY, Riyazi N, Rosendaal FR, Nelissen RG, et al. Osteoarthritis of the knee: association between clinical features and MR imaging findings. Radiology. 2006;239(3):811–7.
- Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am. 2003;85-A(1):4–9.
- Link TM, Steinbach LS, Ghosh S, Ries M, Lu Y, Lane N, et al. Osteoarthritis: MR imaging findings in different stages of disease and correlation with clinical findings. Radiology. 2003;226(2):373–81.
- Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2005;37(9):541–50.
- Rose NE, Gold SM. A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy. 1996;12(4):398–405.
- Ben-Galim P, Steinberg EL, Amir H, Ash N, Dekel S, Arbel R. Accuracy of magnetic resonance imaging of the knee and unjustified surgery. Clin Orthop Relat Res. 2006;447:100-4.
- Jerosch J, Riemer S. How good are clinical investigative procedures for diagnosing meniscus lesions? Sportverletz Sportschaden. 2004;18(2):59–67.
- Madhusudhan TR, Kumar TM, Bastawrous SS, Sinha A. Clinical examination, MRI and arthroscopy in meniscal and ligamentous knee Tears – a prospective study. J Orthop Surg Res. 2008;3:19–25.
- Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res. 2007;455:123–33.
- Muellner T, Weinstabl R, Schabus R, Vécsei V, Kainberger F. The diagnosis of meniscal tears in athletes. A comparison of clinical and magnetic resonance imaging investigations. Am J Sports Med. 1997;25(1):7–12.
- Laundre BJ, Collins MS, Bond JR, Dahm DL, Stuart MJ, Mandrekar JN. MRI accuracy for tears of the posterior horn of the lateral meniscus in patients with acute anterior cruciate ligament tear and the clinical relevance of missed tears. Am J Roentgenol. 2009;193(2):515–23.
- Kocabey Y, Tetik O, Isbell W, Atay O, Johnson D. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004;20(7):696–700.
- Dervin GF, Stiell IG, Wells GA, Rody K, Grabowski J. Physicians’ accuracy and interrator reliability for the diagnosis of unstable meniscal tears in patients having osteoarthritis of the knee. Can J Surg.2001;44(4):267–74.
- Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA. 2001;286(13):1610–20.
- Abdon P, Lindstrand A, Thorngren KG. Statistical evaluation of the diagnostic criteria for meniscal tears. Int Orthop. 1990;14(4):341–5.
- Ruth C, Gayle W, Stephen B, Nicola M. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull. 2007;84(1):5–23.
- Rayan F,Bhonsle S,Shukla DD. Clinical, MRI, and arthroscopic correlation in meniscal and anterior cruciate ligament tears. Int Orthop. 2009;33(1):129–32.
- Muellner T, Nikolic A, Vécsei V. Recommendations for the diagnosis of traumatic meniscal tears in athletes. Sports Med. 1999;27(5):337–45.