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The Rational Clinical Examination |

Does This Patient Have a Torn Meniscus or Ligament of the Knee?  Value of the Physical Examination

Daniel H. Solomon, MD, MPH; David L. Simel, MD, MHS; David W. Bates, MD, MSc; Jeffrey N. Katz, MD, MSc; Jonathan L. Schaffer, MD, MBA
JAMA. 2001;286(13):1610-1620. doi:10.1001/jama.286.13.1610.
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Context While most meniscal or ligamentous knee injuries heal with nonoperative treatments, a subset should be treated with arthroscopic or open surgery.

Objective To analyze the accuracy of the clinical examination for meniscal or ligamentous knee injuries.

Data Sources MEDLINE (1966-December 31, 2000) and HealthSTAR (1975-December 31, 2000) databases were searched for English-language articles describing the diagnostic accuracy of individual examination items for the knee and a combination of physical examination items (composite examination). Other data sources included reference lists from relevant articles.

Study Selection Studies selected for data extraction were those that compared the performance of the physical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or magnetic resonance imaging. Eighty-eight articles were identified, of which 23 (26%) met inclusion criteria.

Data Extraction A rheumatologist and an orthopedic surgeon independently reviewed each article using a standardized rating scale that scored the assembly of the study, the relevance of the patients enrolled, the appropriateness of the reference standard, and the blinding of the examiner.

Data Synthesis Summary likelihood ratios (LRs) were estimated from random effects models. The summary LRs for physical examination for tears of the anterior cruciate ligament, using the anterior drawer test, were 3.8 (95% confidence interval [CI], 0.7-22.0) for a positive examination and 0.30 (95% CI, 0.05-1.50) for a negative examination; the Lachman test, 25.0 (95% CI, 2.7-651.0) and 0.1 (95% CI, 0.0-0.4); and the composite assessment, 25.0 (95% CI, 2.1-306.0) and 0.04 (95% CI, 0.01-0.48), respectively. The LRs could not be generated for any specific examination maneuver for a posterior cruciate ligament tear, but the composite assessment had an LR of 21.0 (95% CI, 2.1-205.0) for a positive examination and 0.05 (95% CI, 0.01-0.50) for a negative examination. Determination of meniscal lesions, using McMurray test, had an LR of 1.3 (95% CI, 0.9-1.7) for a positive examination and 0.8 (95% CI, 0.6-1.1) for a negative examination; joint line tenderness, 0.9 (95% CI, 0.8-1.0) and 1.1 (95% CI, 1.0-1.3); and the composite assessment, 2.7 (95% CI, 1.4-5.1) and 0.4 (95% CI, 0.2-0.7), respectively.

Conclusion The composite examination for specific meniscal or ligamentous injuries of the knee performed much better than specific maneuvers, suggesting that synthesis of a group of examination maneuvers and historical items may be required for adequate diagnosis.

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Figure 1. Anatomy of the Knee
Graphic Jump Location
Right knee shown. LCL indicates lateral collateral ligament; ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; and MCL, medial collateral ligament.
Figure 2. Examination Maneuvers
Graphic Jump Location
Right knee shown. Examination maneuvers include the Lachman, anterior drawer, lateral pivot shift, Apley compression, and McMurray tests. Lachman test, performed to detect anterior cruciate ligament (ACL) injuries, is conducted with the patient supine and the knee flexed to 20° to 30°. The anterior drawer test detects ACL injuries and is performed with the patient supine and the knee in 90° of flexion. The lateral pivot shift test is performed with the patient supine, the hip flexed 45°, and the knee in full extension. Internal rotation is applied to the tibia while the knee is flexed to 40° under a valgus stress (pushing the outside of the knee medially). The Apley compression test, used to assess meniscal integrity, is performed with the patient prone and the examiner's knee over the patient's posterior thigh. The tibia is externally rotated while a downward compressive force is applied over the tibia. The McMurray test, used to assess meniscal integrity, is performed with the patient supine and the examiner standing on the side of the affected knee. See "Function" section of text for full explanation of all examinations.



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