Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests

Abstract

ObjectiveTo assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.DesignProspective diagnostic study.SettingsOrthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.ParticipantsConsecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).InterventionsNot applicable.Main outcome measuresHistory elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated.ResultsForty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24).ConclusionDiagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

Towards Improving the Identification of Anterior Cruciate Ligament Tears in Primary Point-of-Care Settings

“…Similar to previous investigators, (33)(34)(35)43) we have demonstrated that a combination of clinical history and examination variables is diagnostically superior to individual elements, (24,35,39) and that immediate swelling (24,35,39) and the Lachman test result (33,35) are important diagnostic criteria for an ACL tear. Further, we have confirmed the importance of trauma (in particular sport-related) for the diagnosis of an ACL tear previously reported by Decary et al, (35) and that when considered individually, a Lachman test may be useful (LR+ between 5-10) for diagnosing, and almost conclusive (LR-between <0.1) for excluding an ACL tear when performed by clinicians with advanced orthopaedic training. (44) In contrast to past studies, (45,46) we have identified that increasing age and a family history of an ACL tear, may be important diagnostic criteria for an ACL tear.…”

“…sensation at the time of injury, giving away and anterior drawer or pivot shift test result (24,35,39,43) did not factor into our findings. Reasons for this may include: previous studies smaller sample sizes; (24,34,39) differences in sample characteristics (participant age, acuteness and diversity of knee conditions); number of practitioners; practitioner characteristics (profession, experience, degree of confidence in performing and interpreting clinical tests) and; inability to assess specific variables (age, family history, 'popping' sensation or pivoting mechanism of injury) due to insufficient or lack of data availability.…”

“…Although the clinometric properties of individual diagnostic tests for full-thickness ACL tears, (33,34) and the diagnostic value of common clinical signs and symptoms (17) have been examined, previous investigations suffer from methodological limitations (i.e., small sample sizes), risk of selection bias (20,23,24,28,(35)(36)(37)(38)(39) and have not acknowledged differences in the approach to ACL tear diagnosis between primary point-of-care practitioners and those with advanced orthopaedic training.…”

Sensitivity and Specificity of Anterior Cruciate Clinical Examination in Acute Setting Before and After Hemarthrosis Aspiration

“…C Co on nc cl lu us si io on n: : Hemarthrosis aspiration improved the sensitivity of all three tests both for orthopedic consultants and emergency physicians but did not affect specificity. 1,2,12,13,14 Meta-analysis of previous studies showed that these tests have variable sensitivity and specificity especially in acute injuries. 3,4 Unreliable and inaccurate clinical examination makes clinician uncertain of the diagnosis and compel to make unnecessary, expensive MRI imaging or misdiagnose an ACL tear.…”

Clinical Value of an Acute Popping Sensation in Throwing Athletes With Medial Elbow Pain for Ulnar Collateral Ligament Injury

“…A pop at the time of injury has been shown to be one of the factors that can be used to screen for anterior cruciate ligament lesions of the knee, with high diagnostic validity for partial or complete tears. 6,17 The purpose of this study was to assess the diagnostic value of the subjective experience of a popping sensation for significant UCL injury among throwing athletes who sustained an injury causing medial elbow pain. In addition, we examined the association of a popping sensation with UCL tear severity and explored whether a pop is associated with tears at either the proximal or distal attachment site of the anterior bundle of the UCL.…”