1. Reviewing the Use of Physical Diagnostic Testing Methods and Detection of Meniscal Tears
Heather bartz Masters in Athletic Training Student
Faculty Mentor: Valerie Moody

2. Clinical Background
Meniscal injuries may be the most common knee injury
Surgical procedures of the meniscus are performed on an estimated 850,000 patients each year
The prevalence of acute meniscal tears is 61 cases per 100,000 persons.
PROBLEM: The clinical relevance of current physical diagnostic tests (special tests) is poor
QUESTION: How can we change our approach to physical diagnostic testing to achieve a more concrete diagnosis of meniscal injury?
Why is this topic important?

3. Knee anatomy Meniscus: Medial and lateral C-shaped Fibrous cartilage
Knee stabilizer
Shock absorber of the knee joint
Here we have basic anatomical landmarks of the knee joint. We are focusing on the meniscus, which lie between the femur and tibia as you can see in the large image. The other image is a birds-eye-view of the meniscus as they sit on top of the tibia (shin bone). As you can see there are two menisci, lateral and medial. They are c-shaped and formed of fibrous cartilage, which is tough and more resistant to wear and tear than other types of cartilage. The menisci function as stabilizers and shock absorbers in the knee joint.

4. Meniscal Anatomy & Types of Tears
The vascularity of this structure is important to consider when discussing treatment options for a patient with a meniscal tear. As you can see, there are three general zones of differing vascularity in the meniscus. The red-red zone is highly vascular, meaning there is good blood flow to the area. The white-white zone has poor vascularity, meaning very little blood flow is available to the area. If a tear happens in the area with good blood flow, healing will happen quicker than if the tear happens in the less vascular tissue. Tears in the avascular area are also most often treated surgically, because they won’t heal on their own, since blood flow is necessary to promote healing.
There are many different variations in meniscal tears, as you can see. All will present with similar symptoms and will be treated similarly, but these are varieties that are commonly seen in imaging such as MRI .

5. Physical examination HISTORY CLINICAL EXAM FINDINGS Patient:
Swelling (24-48 hours post-injury)
Pain or crepitus along joint line
Decreased or compensated AROM
Pain or locking
Pain in extreme ends of PROM
Apprehension at extremes
Clicking or locking in functional assessment
Limping or lateral thrust during gait analysis
Primary ligament testing
HISTORY
Patient:
Young – sports injury due to “plant and twist”
Older – degenerative due to wear and tear
Main complaints: pain, swelling, “locking”, “giving out”, catching, and loss of motion
Previous history of knee injuries
Lateral meniscus is most common for degeneration
Swelling of the knee joint will only present in 4 injuries: ACL, PCL, patella dislocation, and meniscus injury
If a patient walked in with this history and complaining of these symptoms, I would observe and inspect the knee for swelling and any physical abnormalities. Then I would palpate, or feel, specific areas of her knee. The main area I would focus on would be the joint line (space between femur and tibia that is filled by the meniscus). The next step in an injury evaluation is range of motion assessment. ROM may be compromised due to pain or an actual mechanical block from the tear. The functional assessment and gait analysis may be altered due to mechanical block, instability, or pain.
The primary ligaments are tested at this point to ensure that none of them are involved in this injury, as almost 1/3 of all meniscal tears are linked to ACL tears

6. Physical examination
At this stage of the injury evaluation, the examiner usually is beginning to form ideas of what could potentially be going on that is causing the patient pain. To continue narrowing down potential injuries, there are diagnostic tests that are used to reproduce symptoms specific to certain pathologies.
For meniscal tears, there are three commonly used special tests: McMurray’s, Thessaly, and Apley’s Compression.

7. Diagnosis: special tests
Study
# Participants
Specificity (+)
Sensitivity
(-)
(+) LR
(-) LR
Apley’s
Rinonapoli
102
0.71
0.84
2.89
0.23 20
Konan
109
L 0.95
M 0.67
L 0.59
M 0.32
L 11.8
M 0.96
L 0.43
M 1.01
Joint Line Tenderness
L 0.97
M 0.76
L 0.68
M 0.83
L 22.67
M 3.45
L 0.33
M 0.22
Muhammed
147
0.81
0.77
4.05
0.28
McMurray’s
L 0.94
M 0.77
L 0.21
M 0.50
L 3.5
M 2.17
L 0.84
M 0.64
0.79
0.80
3.81
0.25
JL+McMurray’s
L 0.99
M 0.91
L 0.75
L 75
M 10.1
L 0.24
M 0.09
JL+Thessaly
M 0.92
L 0.78
M 0.93
L 78
M 11.6
L 0.22
M 0.08
MRI
0.86
0.78
5.57
0.26
Diagnosis: special tests
LR = likelihood ratio
JL = joint line tenderness
L = lateral meniscus
M = medial meniscus
MRI = magnetic resonance imaging
Bottom line: JL + McMurray’s or JL + Thessaly are just as effective as MRI
Specificity = the percentage that a positive test is a true positive
Sensitivity = the percentage that a negative test is a true negative
+LR >1 = result is associated with disease/pathology
-LR <1 = result is associated with absence of disease/pathology

8. Diagnosis X-ray MRI Arthroscopy – GOLD STANDARD 90-95% accuracy
X-ray – does not give a great view of the meniscus without multiple views; but you can see joint space narrowing, which is cause for suspicion of meniscal injury…cannot confirm meniscal injury on their own
MRI – imaging technique that is effective in accurately confirming meniscal tears 86% of the time
- determines the type and location of lesion and evaluates any potential damage to cartilage or bone
- Pro: no radiation exposure, no joint manipulation, painless
- Con: claustrophobia, obesity, pacemakers, orthopedic hardware
Arthroscopy – GOLD STANDARD w/ 90-95% accuracy
- Pro: kills two birds with one stone, diagnosing the injury and solving the problem in one step
- Con: cost and invasiveness

9. Treatment Treatment: Conservative Surgical Partial meniscectomy
Meniscus repair
Trephination
Allograft
Collagen Meniscal Implant
Implant
Debride vs Repair
After diagnosis of meniscal tear, there are many treatment options to consider. Treatment depends on the patients age, symptoms, and desired activity level after surgery. Location and type of tear must also be considered, remember the vascularity zones?
Conservative treatment is non-surgical and aimed at relieving symptoms, increasing ROM, reducing effusion, normalizing gait patterns, and maintaining an active lifestyle.
Partial meniscectomy: (3-8 weeks) under 40, symptoms for <1 year, no joint degeneration, no associated ligament injury
- Con: accelerated degenerative changes in the knee
Repair: (~5 months) good for tears in the vascular area
Trephination: if there is a small tear right near the joint line this is a viable option; small needle is used to puncture the joint line, causing bleeding that creates a small blood clot in the area; the goal is to stimulate a healing response in the area that leads to scar tissue development and healing of the small tear
Allograft

10. Long term prognosis Osteoarthritis Quality of Life
Mechanical: gait mechanics and neuromuscular adaptation
Biological: inflammation
Structural: cartilage degradation
Quality of Life
Loss of meniscus = higher incidence of OA
One study found no difference in OA progression in repair vs. meniscectomy at 3 years, but at 8 years there was a significant difference in symptoms, radiograph imaging, and loss of sport activity level.

11. Clinical recommendations final thoughts
Need for Early and Proper Diagnosis:
Combine JL + Thessaly + McMurray’s
MRI to confirm diagnosis
Treatment:
Help patient make an educated decision that takes into consideration their age, activity level, symptoms, type and location of tear, and other associated injuries (like an ACL tear)

12. THANK YOU!
QUESTIONS?

13. References
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