Physical Examination Tests for Assessing a Torn Meniscus in the Knee: A Systematic Review With Meta-analysis

Victor Hasselblad, Adam P. Goode, Douglas C. McCrory, Eric J. Hegedus, Chad E. Cook

DOI: 10.2519/jospt.2007.2560

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: To identify, analyze, and synthesize the literature to determine which physical examination tests, if any, accurately diagnose a torn tibial meniscus. BACKGROUND: Knee pain has a lifetime prevalence of up to 45% and as many as 31% of individuals with knee pain will consult a general practitioner. Roughly 5% of these individuals will undergo a tibial meniscectomy and many more will undergo partial meniscectomy or meniscus repair. Determining which of these individuals is appropriate for surgical consult depends on clinical examination findings. METHODS AND MEASURES: We searched MEDLINE, CINAHL, and SPORTDiscus from 1966 to August 2006 and extracted all English- and German-language studies that reported the diagnostic accuracy of individual physical examination tests for a torn meniscus. We retrieved data regarding true positives, false positives, true negatives, and false negatives to create 2x2 tables for each article and test. Like tests were then subjected to meta-analysis and subanalysis.  Cochran Q test and the I2 statistic were used to examine for the presence of heterogeneity and the extent of the effect of heterogeneity, respectively. A qualitative analysis was also performed using the QUADAS tool. RESULTS: Eighteen studies qualified for the final analyses. Three physical examination tests (McMurray's, Apley's, and joint line tenderness) were examined in more than 7 studies and had enough data to consider meta-analysis. However, study results were heterogeneous. Pooled sensitivity and specificity were 70% and 71% for McMurray's, 60% and 70% for Apley's, and 63% and 77% for joint line tenderness. Large between-study differences could not be explained by prevalence, study quality, or how well an index test was described. CONCLUSIONS: No single physical examination test appears to accurately diagnose a torn tibial meniscus and the value of history plus physical examination is unknown. Differences between studies in diagnostic performance remain unexplained, presumably due to local differences in the way the tests are defined, performed, and interpreted. We recommend a more standardized approach to performing and interpreting these tests and the development of a clinical prediction rule to aid clinicians in the diagnosis of a torn tibial meniscus.

J Orthop Sports Phys Ther. 2007;37(9):541-550, published online 30 May 2007. doi:10.2519/jospt.2007.2560

KEY WORDS: Apley's, diagnosis, joint line tenderness, McMurray's, primary care, tibiofemoral joint

No single physical examination test appears to accurately diagnose a torn tibial meniscus and the value of history plus physical examination is unknown. Differences between studies in diagnostic performance remain unexplained, presumably due to local differences in the way the tests are defined, performed, and interpreted. The authors recommend a more standardized approach to performing and interpreting these tests and the development of a clinical prediction rule to aid clinicians in the diagnosis of a torn tibial meniscus.

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