Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley’s, McMurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis

Abstract

BackgroundReliable non-invasive diagnosis of meniscal tears is difficult. Magnetic resonance imaging (MRI) is often used but is expensive and incidental findings are problematic. There are a number of physical examination tests for the diagnosis of meniscal tears that are simple, cheap and non-invasive.ObjectivesTo determine the diagnostic accuracy of the Thessaly test and to determine if the Thessaly test (alone or in combination with other physical tests) can obviate the need for further investigation by MRI or arthroscopy for patients with a suspected meniscal tear.DesignSingle-centre prospective diagnostic accuracy study.SettingAlthough the study was performed in a secondary care setting, it was designed to replicate the results that would have been achieved in a primary care setting.ParticipantsTwo cohorts of patients were recruited: patients with knee pathology (n = 292) and a control cohort with no knee pathology (n = 75).Main outcome measuresSensitivity, specificity and diagnostic accuracy of the Thessaly test in determining the presence of meniscal tears.MethodsParticipants were assessed by both a primary care clinician and a musculoskeletal clinician. Both clinicians performed the Thessaly test, McMurray’s test, Apley’s test, joint line tenderness test and took a standardised clinical history from the patient.ResultsThe Thessaly test had a sensitivity of 0.66, a specificity of 0.39 and a diagnostic accuracy of 54% when utilised by primary care clinicians. This compared with a sensitivity of 0.62, a specificity of 0.55 and diagnostic accuracy of 59% when used by musculoskeletal clinicians. The diagnostics accuracy of the other tests when used by primary care clinicians was 54% for McMurray’s test, 53% for Apley’s test, 54% for the joint line tenderness test and 55% for clinical history. For primary care clinicians, age and past history of osteoarthritis were both significant predictors of MRI diagnosis of meniscal tears. For musculoskeletal clinicians age and a positive diagnosis of meniscal tears on clinical history taking were significant predictors of MRI diagnosis. No physical tests were significant predictors of MRI diagnosis in our multivariate models. The specificity of MRI diagnosis was tested in subgroup of patients who went on to have a knee arthroscopy and was found to be low [0.53 (95% confidence interval 0.28 to 0.77)], although the sensitivity was 1.0.ConclusionsThe Thessaly test was no better at diagnosing meniscal tears than other established physical tests. The sensitivity, specificity and diagnostic accuracy of all physical tests was too low to be of routine clinical value as an alternative to MRI. Caution needs to be exercised in the indiscriminate use of MRI scanning in the identification of meniscal tears in the diagnosis of the painful knee, due to the low specificity seen in the presence of concomitant knee pathology. Further research is required to determine the true diagnostic accuracy and cost-effectiveness of MRI for the detection of meniscal tears.Trial registrationCurrent Controlled Trial ISRCTN43527822.FundingThe National Institute for Health Research Health Technology Assessment programme.

Imaging of Athletic Injuries of Knee Ligaments and Menisci: Sports Imaging Series

“…We will review the pertinent anatomy, biomechanical function of ligamentous structures, mechanisms of injury, and the imaging appearances of specific ligamentous and meniscal injuries in the preoperative setting. Data regarding clinical evaluation of meniscal and ligamentous injuries are highlighted in the Table (2)(3)(4)(5). The role of imaging in the treatment decision-making process will also be discussed where relevant.…”

Diagnostic Validity of Combining History Elements and Physical Examination Tests for Traumatic and Degenerative Symptomatic Meniscal Tears

“…The medial joint line tenderness test was the only physical test in our diagnostic cluster for traumatic SMT. Previous findings showed that this test was not diagnostically valid when individually performed [16,19,49]. Interestingly, the test, when combined into a diagnostic cluster with patient's history elements, yields adequate diagnostic accuracy but only for traumatic SMT.…”

“…Also, mechanical symptoms, when present, do not arise exclusively from meniscal tears and may be positive in other disorders such as ACL tear or osteoarthritis [3,6]. This adds to the growing evidence suggesting that these history elements and tests may have limited diagnostic value, as well as a possibly limited use as a surgical criterion [3,10,16,18‐20,22,23,49,52‐55].…”

“…A possible explanation for this overreliance on MRI is that the diagnostic validity of physical examination tests presents conflicting results [16]. Based on low‐grade evidence, most commonly studied clinical tests (ie, joint line tenderness test, McMurray test, Apley maneuver, and the Thessaly test) are not able to accurately diagnose or exclude SMT when used individually [16‐20]. Yet, it is often reported that medical specialists or physiotherapists with extensive training and expertise in musculoskeletal disorders can make an accurate clinical diagnosis of a SMT based on a complete physical examination combined with the patient's history.…”

Cartilage Delamination Flap Mimicking a Torn Medial Meniscus

“…The Thessaly test, Mcmurray's test, and Apley's test may be positive, and joint line tenderness may be present. However, these tests have limited diagnostic accuracy [1–3], and further investigations are often required, such as magnetic resonance imaging (MRI) studies.…”