Special Tests: Knee - Meniscus Tears, Patellofemoral Pain, and Fracture

Special Tests Covered in this Lesson:

• Meniscus Tear Tests
  • McMurray's Test
  • Thessaly's Test
• Patellofemoral Pain Syndrome (PFPS) Test-item Cluster
  • Eccentric Step Down Test
    • Functional Activities (Squats, kneeling, stair-climbing)
  • Resisted Knee Extension
• Red Flags (Fracture)
  • Ottawa Knee Rules

Knee special tests for meniscus tears, patellofemoral pain syndrome (PFPS), and knee fracture have enough accuracy to offer some clinical utility. Meniscus tears are generally reported following an acute knee injury, may occur on one side (e.g. lateral meniscus or medial meniscus), and may be accompanied by knee joint effusion (swelling). Generally, PFPS is a complaint of knee pain in the proximity of the patella that accompanies quadriceps contraction during functional tasks. The pain often begins spontaneously, or gradually, without a specific incident or acute injury. And, knee joint fracture, although relatively rare, may occur following direct trauma to the knee, or landing on the knee(s) during a fall. Clinical movement professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of the special tests for these conditions to aid in the development of an accurate prognosis, monitor concordant signs, and identify red flags. Note, special tests for the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament, and lateral collateral ligament are included in the course Special Tests: Knee Ligament Tests .

Summary:

The combination of patient history, physical examination, special tests, and radiographs has been investigated for the diagnosis of meniscus tear; however, study results are mixed (1, 4 - 21). Generally, the accuracy of special tests and examinations for the diagnosis of a meniscus tear is questionable. A diagnosis of a meniscal lesion without the confirmation of arthroscopy should likely be viewed with healthy skepticism. Based on available research Thessaly's Test may have the highest sensitivity (and potentially accuracy) (23, 34, 35, 40, 41); however, McMurray's Test is also recommended due to the relatively high specificity reported in a larger body of studies.

Although tests for patellofemoral pain syndrome (PFPS) have relatively high specificity, PFPS is a relatively broad diagnosis (41-45). A cluster (Cook's Cluster) including the Knee Extension Test, pain with palpation, and pain during a functional task (e.g. Eccentric Step Down Test ) may increase the accuracy of diagnosing PFPS (44); however, the broad diagnosis of PFPS may not be helpful for directing treatment. These tests are likely best used in the cluster mentioned, and the test that replicates the patient's complaints or symptoms (concordant sign) may be repeated throughout treatment as a pre/post-intervention reassessment.

The Ottowa Knee Decision Rules have been added to this course as a screen for the potential "Red Flag Issue" of knee fracture. It is unlikely that outpatient orthopedic professionals will use this cluster often, but it is worth having access to a quick reference in case knee fracture is suspected. Note, the diagnosis of fracture is not necessarily the goal of this cluster. The cluster of signs is highly sensitive (not necessarily specific), indicating that fracture is a possibility, and that referral for imaging is needed prior to additional treatment (46, 47).

Brookbush Institute Recommendation:

The Brookbush Institute recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of these tests. The Thessaly's Test (with confirmation from McMurray's Test ) may be beneficial for diagnosing meniscal tears and developing a more accurate prognosis for treatment. The Cook's Cluster may provide some clinical utility for identifying a concordant sign that can be used throughout treatment as a pre/post-intervention reassessment. And, being aware of the Ottowa Knee Decision Rules are advised for use when a knee fracture is suspected.

For an Introduction to Special Tests

• For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:
• Special Tests: Introduction

Courses covering Special Tests for the Knee

• Special Tests: Knee Ligament Tests
• Special Tests: Knee - Meniscus Tears, Patellofemoral Pain and Fracture

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Text and Illustrations
• Audio Voice-over
• Technique Videos
• Practice Exam
• Pre-approved Final Exam

1. Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.
2. Dutton, M. (2012). Dutton's Orthopaedic examination, evaluation, and intervention. McGraw-Hill Medical.
3. Magee, D. J. (2013). Orthopedic physical assessment. Elsevier Health Sciences.
   • Routine Combined Tests of Meniscus Tear
4. Dervin, G. F., Stiell, I. G., Wells, G. A., Rody, K., & Grabowski, J. (2001). Physicians’ accuracy and interrator reliability for the diagnosis of unstable meniscal tears in patients having osteoarthritis of the knee. Canadian journal of surgery, 44(4), 267.
5. Rose, N. E., & Gold, S. M. (1996). A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 12(4), 398-405.
6. Kocabey, Y., Tetik, O., Isbell, W. M., Atay, Ö. A., & Johnson, D. L. (2004). The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 20(7), 696-700.
7. Kocher, M. S., DiCanzio, J., Zurakowski, D., & Micheli, L. J. (2001). Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents. The American journal of sports medicine, 29(3), 292-296.
8. O'Shea, K. J., Murphy, K. P., Heekin, R. D., & Herzwurm, P. J. (1996). The diagnostic accuracy of history, physical examination, and radiographs in the evaluation of traumatic knee disorders. The American journal of sports medicine, 24(2), 164-167.
9. Jackson, J. L., O'Malley, P. G., & Kroenke, K. (2003). Evaluation of acute knee pain in primary care. Annals of internal medicine, 139(7), 575-588.
10. Wagemakers, H. P., Heintjes, E. M., Boks, S. S., Berger, M. Y., Verhaar, J. A., Koes, B. W., & Bierma-Zeinstra, S. M. (2008). Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice. Clinical Journal of Sport Medicine, 18(1), 24-30.
11. Miao, Y., Yu, J. K., Ao, Y. F., Zheng, Z. Z., Gong, X., & Leung, K. K. M. (2011). Diagnostic values of 3 methods for evaluating meniscal healing status after meniscal repair: comparison among second-look arthroscopy, clinical assessment, and magnetic resonance imaging. The American journal of sports medicine, 39(4), 735-742.
12. Muellner, T., Weinstabl, R., Schabus, R., Vecsei, V., & Kainberger, F. (1997). The Diagnosis of Meniscal Tears in Ath letes: A Comparison of Clinical and Magnetic Resonance Imaging Investigations. The American journal of sports medicine, 25(1), 7-12.
13. Bonamo, J. J., & Shulman, G. (1988). Double contrast arthrography of the knee: a comparison to clinical diagnosis and arthroscopic findings. Orthopedics, 11(7), 1041-1046.
14. Lowery, D. J., Farley, T. D., Wing, D. W., Sterett, W. I., & Steadman, J. R. (2006). A clinical composite score accurately detects meniscal pathology. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 22(11), 1174-1179.
15. Rayan, F., Bhonsle, S., & Shukla, D. D. (2009). Clinical, MRI, and arthroscopic correlation in meniscal and anterior cruciate ligament injuries. International orthopaedics, 33(1), 129-132.
16. Butt, F., Farooq, M., Dhar, M., Gani, S., Hussain, N., Mumtaz, A., Imran. (2007). Clinical Evaluation Of The Knee For Medial Meniscal Lesion And Anterior Cruciate Ligament Tears: An Assessment Of Clinical Reliability. Journal of Orthopaedics.
17. Wee, L. L. (2008). A comparison of accuracy between clinical history, physical examination and magnetic resonance imaging and arthroscopy in the diagnosis of meniscal and anterior cruciate ligament tears. J Orthopaed, 5(3), e8.
18. Oberlander, M. A., Shalvoy, R. M., & Hughston, J. C. (1993). The accuracy of the clinical knee examination documented by arthroscopy: a prospective study. The American journal of sports medicine, 21(6), 773-778.
19. Yoon, Y. S., Rah, J. H., & Park, H. J. (1997). A prospective study of the accuracy of clinical examination evaluated by arthroscopy of the knee. International orthopaedics, 21(4), 223-227.
20. Ryan, P. J., Reddy, K., & Fleetcroft, J. (1998). A prospective comparison of clinical examination, MRI, bone SPECT, and arthroscopy to detect meniscal tears. Clinical nuclear medicine, 23(12), 803-806.
21. Jah, A. E., Keyhani, S., Zarei, R., & Moghaddam, A. K. (2005). Accuracy of MRI in comparison with clinical and arthroscopic findings in ligamentous and meniscal injuries of the knee. Acta Orthop Belg, 71(2), 189-96.
    • McMurray's Test (4, 11, 14)
22. Akseki, D., Özcan, Ö., Boya, H., & Pınar, H. (2004). A new weight-bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 20(9), 951-958.
23. Karachalios, T., Hantes, M., Zibis, A. H., Zachos, V., Karantanas, A. H., & Malizos, K. N. (2005). Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. JBJS, 87(5), 955-962.
24. Kurosaka, M., Yagi, M., Yoshiya, S., Muratsu, H., & Mizuno, K. (1999). Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear. International orthopaedics, 23(5), 271-274.
25. Corea, J. R., Moussa, M., & Al Othman, A. (1994). McMurray's test tested. Knee Surgery, Sports Traumatology, Arthroscopy, 2(2), 70-72.
26. Kurosaka, M., Yagi, M., Yoshiya, S., Muratsu, H., & Mizuno, K. (1999). Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear. International orthopaedics, 23(5), 271-274.
27. Evans, P. J., Bell, G. D., & Frank, C. Y. (1993). Prospective evaluation of the McMurray test. The American journal of sports medicine, 21(4), 604-608.
28. Pookarnjanamorakot, C., Korsantirat, T., & Woratanarat, P. (2004). Meniscal lesions in the anterior cruciate insufficient knee: the accuracy of clinical evaluation. JOURNAL-MEDICAL ASSOCIATION OF THAILAND, 87(6), 618-623.
29. Saengnipanthkul, S. U. K. I. T., Sirichativapee, W. I. N. A. I., Kowsuwon, W. E. E. R. A. C. H. A. I., & Rojviroj, S. O. M. B. A. T. (1992). The effects of medial patellar plica on clinical diagnosis of medial meniscal lesion. Journal of the Medical Association of Thailand= Chotmaihet thangphaet, 75(12), 704-708.
30. Boeree, N. R., & Ackroyd, C. E. (1991). Assessment of the menisci and cruciate ligaments: an audit of clinical practice. Injury, 22(4), 291-294.
31. Fowler, P. J., & Lubliner, J. A. (1989). The predictive value of five clinical signs in the evaluation of meniscal pathology. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 5(3), 184-186.
32. Anderson, A. F., & Lipscomb, A. B. (1986). Clinical diagnosis of meniscal tears: description of a new manipulative test. The American journal of sports medicine, 14(4), 291-293.
33. Noble, J., & Erat, K. (1980). In defence of the meniscus. A prospective study of 200 meniscectomy patients. The Journal of bone and joint surgery. British volume, 62(1), 7-11.
34. Mirzatolooei, F., Yekta, Z., Bayazidchi, M., Ershadi, S., & Afshar, A. (2010). Validation of the Thessaly test for detecting meniscal tears in anterior cruciate deficient knees. The Knee, 17(3), 221-223.
35. Konan, S., Rayan, F., & Haddad, F. S. (2009). Do physical diagnostic tests accurately detect meniscal tears?. Knee Surgery, Sports Traumatology, Arthroscopy, 17(7), 806-811.
36. Jaddue, D. A., Tawfiq, F. H., & Sayed-Noor, A. S. (2010). The utility of clinical examination in the diagnosis of medial meniscus injury in comparison with arthroscopic findings. European Journal of Orthopaedic Surgery & Traumatology, 20(5), 389-392.
37. Jain, D. K., Amaravati, R., & Sharma, G. (2009). Evaluation of the clinical signs of anterior cruciate ligament and meniscal injuries. Indian journal of orthopaedics, 43(4), 375.
38. Manzotti, A., Baiguini, P., Locatelli, A., Zucca, P., Solomon, V., Andreoletti, G., … & Tecchio, G. (1997). Statistical evaluation of McMurray's test in the clinical diagnosis of meniscus injuries. JOURNAL OF SPORTS TRAUMATOLOGY AND RELATED RESEARCH, 19(2), 83-89.
39. Sae-Jung, S., Jirarattanaphochai, K., & Benjasil, T. (2007). KKU knee compression-rotation test for detection of meniscal tears: a comparative study of its diagnostic accuracy with McMurray test. JOURNAL-MEDICAL ASSOCIATION OF THAILAND, 90(4), 718.
    • Thesaly's Test (23, 28, 34, 35)
40. Harrison, B. K., Abell, B. E., & Gibson, T. W. (2009). The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clinical Journal of Sport Medicine, 19(1), 9-12.
41. Goossens, P., Keijsers, E., Van Geenen, R. J., Zijta, A., Van den Broek, M., Verhagen, A. P., & Scholten-Peeters, G. G. (2015). Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. journal of orthopaedic & sports physical therapy, 45(1), 18-24.
    • Patellofemoral Pain Syndrome
42. Nijs, J., Van Geel, C., & Van de Velde, B. (2006). Diagnostic value of five clinical tests in patellofemoral pain syndrome. Manual therapy, 11(1), 69-77.
43. Loudon, J. K., Wiesner, D., Goist-Foley, H. L., Asjes, C., & Loudon, K. L. (2002). Intrarater reliability of functional performance tests for subjects with patellofemoral pain syndrome. Journal of athletic training, 37(3), 256.
44. Cook, C., Hegedus, E., Hawkins, R., Scovell, F., & Wyland, D. (2010). Diagnostic accuracy and association to disability of clinical test findings associated with patellofemoral pain syndrome. Physiotherapy Canada, 62(1), 17-24.
45. Näslund, J., Näslund, U. B., Odenbring, S., & Lundeberg, T. (2006). Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. Physiotherapy theory and practice, 22(3), 105-118.
46. Elton, K., McDonough, K., Savinar, E., & Jensen, G. (1985). A preliminary investigation: history, physical, and isokinetic exam results versus arthroscopic diagnosis of chondromalacia patella. Journal of Orthopaedic & Sports Physical Therapy, 7(3), 115-123.
    • Ottowa Knee Decision Rule
47. Jackson, J. L., O'Malley, P. G., & Kroenke, K. (2003). Evaluation of acute knee pain in primary care. Annals of internal medicine, 139(7), 575-588.
48. Richman, P. B., McCuskey, C. F., Nashed, A., Fuchs, S., Petrik, R., Imperato, M., & Hollander, J. E. (1997). Performance of two clinical decision rules for knee radiography. Journal of Emergency Medicine, 15(4), 459-463.