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

Special tests for the knee joint. 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, and Ottawa Knee Rules. The reliability, specificity, sensitivity, validity, safety, and screening for knee pain, knee pathology, knee sprains, ligament integrity, tibial meniscus tear, patellofemoral pain syndrome, and knee fracture.

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

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Patellofemoral Pain Syndrome (PFPS) Test-item Cluster

Functional Activities (Squats, kneeling, stair-climbing)

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 


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 

 may have the highest sensitivity (and potentially accuracy) (23, 34, 35, 40, 41); however, 

 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. 

) 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).

 recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of these tests. The 

) 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 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:

Courses covering Special Tests for the Knee

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

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

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

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

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

Introduction

Summary and Recommendations

McMurray&#39;s Test

McMurray's Test

Thessaly's Test

Tibial Meniscus Tear Tests

Image of the Patella

Eccentric Step Down Test (and Functional Tasks)

Dr. Brent Brookbush Palpating the Knee Joint

Knee Extension Test, Palpation and Cook's Cluster

Patellofemoral Pain Syndrome (PFPS)

A positive test is the presence of any of the following criteria, and indicates that the patient should be referred for an x-ray:

Inability to flex the knee to at least 90 degrees

Inability of the patient to bear weight both immediately and in the emergency department for four steps

Red Flags - Ottawa Knee Decision Rule

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

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. 

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

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. 

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. 

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. 

Jackson, J. L., O'Malley, P. G., & Kroenke, K. (2003). Evaluation of acute knee pain in primary care. 

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. 

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. 

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. 

Bonamo, J. J., & Shulman, G. (1988). Double contrast arthrography of the knee: a comparison to clinical diagnosis and arthroscopic findings. 

Lowery, D. J., Farley, T. D., Wing, D. W., Sterett, W. I., & Steadman, J. R. (2006). A clinical composite score accurately detects meniscal pathology. 

Rayan, F., Bhonsle, S., & Shukla, D. D. (2009). Clinical, MRI, and arthroscopic correlation in meniscal and anterior cruciate ligament injuries. 

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.

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. 

Oberlander, M. A., Shalvoy, R. M., & Hughston, J. C. (1993). The accuracy of the clinical knee examination documented by arthroscopy: a prospective study. 

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. 

Ryan, P. J., Reddy, K., & Fleetcroft, J. (1998). A prospective comparison of clinical examination, MRI, bone SPECT, and arthroscopy to detect meniscal tears. 

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. 

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. 

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. 

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. 

Corea, J. R., Moussa, M., & Al Othman, A. (1994). McMurray's test tested. 

Knee Surgery, Sports Traumatology, Arthroscopy

Evans, P. J., Bell, G. D., & Frank, C. Y. (1993). Prospective evaluation of the McMurray test. 

Pookarnjanamorakot, C., Korsantirat, T., & Woratanarat, P. (2004). Meniscal lesions in the anterior cruciate insufficient knee: the accuracy of clinical evaluation. 

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

Boeree, N. R., & Ackroyd, C. E. (1991). Assessment of the menisci and cruciate ligaments: an audit of clinical practice. 

Fowler, P. J., & Lubliner, J. A. (1989). The predictive value of five clinical signs in the evaluation of meniscal pathology. 

Anderson, A. F., & Lipscomb, A. B. (1986). Clinical diagnosis of meniscal tears: description of a new manipulative test. 

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

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. 

Konan, S., Rayan, F., & Haddad, F. S. (2009). Do physical diagnostic tests accurately detect meniscal tears?. 

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

Jain, D. K., Amaravati, R., & Sharma, G. (2009). Evaluation of the clinical signs of anterior cruciate ligament and meniscal injuries. 

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

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. 

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. 

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

Nijs, J., Van Geel, C., & Van de Velde, B. (2006). Diagnostic value of five clinical tests in patellofemoral pain syndrome. 

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. 

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. 

Näslund, J., Näslund, U. B., Odenbring, S., & Lundeberg, T. (2006). Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. 

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

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. 

Bibliography

Questions, comments, and criticisms are welcomed and encouraged

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

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