MS III ALGORITHM PROJECTMENISCAL TEARKatie Martin, Sara Karcher,Kate Wiens, Sarah Lickteig

http://orthoinfo.aaos.org/topic.cfm?topic=a00358

ANATOMY Each knee contains a medial (c-shaped) and lateral

(o-shaped) meniscus Made of fibrocartilage Held in place by coronary ligaments externally and

anchored by anterior and posterior “horns” internally Transverse ligament connects the two menisci on the

anterior tibia Menisci sit on the articular surface of the tibia in

order to seat the femoral condyles Lateral meniscus moves freely, but the medial

meniscus is more limited in motion, causing medial meniscus to be torn more often

Blood supply to the external border of the menisci is greater than to the innermost structure

ANATOMY

http://images.yourdictionary.com/images/main/A4menisc.jpghttp://www.kneeandshouldersurgery.com/knee-disorders/meniscal-surgery.html

BIOMECHANICS Primary purposes of the menisci are to:

Protect tibiofemoral joint from compressive forces Stabilize & guide joint movement Lubricate the joint Provide proprioception during flexion and

extension and internal and external rotation of the tibiofemoral joint

The menisci follow the direction of the tibia during arthrokinematic movements: Flexion tibia and menisci move posterior & into

IR Extension tibia and menisci move anterior &

into ER relative to the femur

MECHANISM OF INJURY “Forceful, axial rotation

of the femoral condyles over a partially flexed and weight-bearing knee” (Neumann 2010)

Medial meniscus may be injured when there is axial rotation coupled with a valgus force to the knee

There are many kinds of meniscal tears.

http://www.orthoassociates.com/SP11B39/

WHAT ELSE CAUSES KNEE PAIN? MCL Tear LCL Tear ACL Tear PCL Tear Osteoarthritis Patellofemoral

Bursitis Patellofemoral

Syndrome/Pain

OCD Pes Anserine ITBS Plica Syndrome RA Bone Cancer L3-S2 Irritation

WHO IS AT RISK? Most common in young athletes, especially if

participating in sports that involve twisting and pivoting of the knee, like tennis, soccer, or basketball as well as contact sports like football Peak age is 20-30 y/o (Loudon 2008)

Can also occur in older population (>40 y/o) due to degeneration of the cartilage

Overweight and obese people Knee is misaligned or has history of ligamentous

instability especially in the ACL Conflicting evidence on males vs. females, but

most resources said males have a greater risk than females with the ratio of 2.5 men to 1 female

SIGNS AND SYMPTOMS A “pop” may be felt upon injury with gradual stiffness over

the next 2-3 days Joint line tenderness and possible effusion Decreased knee ROM Pt reports: “My knee hurts when I straighten it out” Worsened symptoms by flexing and loading the joint

ex: squatting Pain with turning, pivoting, twisting, going down stairs,

getting up from a chair C/o clicking, locking, catching, or giving way Feelings of an unstable knee Sharp pain with movement/dull ache at end of day Gait abnormalities 50% of acute injuries of ACL are associated with a

concurrent injury to meniscus

SPECIAL TESTSRULE IN: Meniscal Instability (medial or lateral) McMurray’s Test: + test when clunk is felt/heard or

reproductions of symptoms. Apley’s Compression and Distraction Test: + test

when clunk is felt/heard or reproduces symptoms (compression) and lessening of symptoms (distraction)

Grinds Test: + test when click or reproduction of symptoms

Thessaly: + test when sense of locking, catching and reproduction of symptoms

Ege’s Test: + test when reproduction of pain and or click is felt

SPECIAL TESTSRULE OUT:Tibiofemoral Instability Anterior Drawer Test: assesses integrity of ACL. + test when abnormal

or excessive anterior translation of tibia as compared to other extremity

Lachman’s Test: assesses integrity of ACL. + test when abnormal or excessive anterior translation of tibia as compared to other extremity

Posterior Drawer Test: assesses integrity of PCL. + test when abnormal or excessive posterior translation of tibia as compared to other extremity

Posterior Sag: assesses integrity of PCL. + test when abnormal or excessive posterior translation of tibia as compared to other extremity

Valgus Stress Test (20-30 degrees): structures involved include MCL, PCL and posterior oblique ligament. + test when abnormal or excessive gapping compared to the other extremity

Varus Stress Test (20-30 degrees): structures involved include LCL, posteriolateral capsule, arcuate-popliteus complex, IT band, biceps femoris tendon. + test when abnormal or excessive gapping compared to the other extremity

Summary of Ranges for Sensitivity and Specificity of the Tests

TestSensitivity

RangeSpecificity

RangeMcMurray’s 16–70% 59–98%Joint Line Tenderness

55–95% 15–97%

Bounce Home (forced hyperextension)

36–47% 67–86%

Apley’s 13–41% 80–93%Thessaly 65–92% 80–97%Ege’s 64–67% 81–90%KKU (compression rotation) (1 study)

86% 88%

Axial Loaded Pivot Shift

71% 83%

Composite Score

11–100% 77–99%

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2796951/

EGE’S TEST

Internal Rotation

External Rotation

TAKE HOME MESSAGEHow this algorithm will assist you in the clinic: Follows exam sequence we learned

Includes Subjective and Objective Information Clear and easy to follow Literature supports the use of McMurray’s test,

symptoms of giving-way and locking as best independent diagnostic tests of meniscal tear with 80% accuracy (Yan et al, 2011).

McMurray’s is best for diagnosing flap tear or radial tears in posterior lateral meniscus (Kim et al, 2012).

Special tests used to rule in have high specificity and tests used to rule out have high sensitivity Added rule out tests to prevent biased results*Important to note that MRI is the gold standard for diagnostic imaging.

REFERENCES D Akseki, O Ozcan, H Boya, and H Pinar. A new weight-bearing meniscal test and a comparison with

McMurray's test and joint line tenderness. Arthroscopy, The Journal of Arthroscopic & Related Surgery; Nov 2004; 20(9): 951-958

Chivers, M. D., & Howitt, S. D. (2009). Anatomy and physical examination of the knee menisci: a narrative review of the orthopedic literature. The Journal of the Canadian Chiropractic Association, 53(4), 319-33. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2796951&tool=pmcentrez&rendertype=abstract

Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new

clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005;87(5):955-962

Kim, S., Hwang, B., Choi, D., & Mei, Y. (2012). The Paradoxial McMurray Test for the Detection of Meniscal Tears. The Journal of Bone and Joint Surgery. (94) e118.

Loudon, J., Swift, M., & Bell, S. (2008). The clinical orthopedic assessment guide. (2nd ed., pp. 307-308)  Milroy, D. (2012, February 13). The Human Knee, PTRS745. KUMC Mohan, B. R., & Gosal, H. S. (2007). Reliability of clinical diagnosis in meniscal tears. International

orthopaedics, 31(1), 57-60. doi:10.1007/s00264-006-0131-x Neumann, D. A. (2010). Kinesiology of the Musculoskeletal System. (2nd ed.). St. Louis, MO: Mosby

Elsevier. Overweight patients face higher meniscal tear risk | Orthopedics. (n.d.). Retrieved April 22, 2013, from

http://www.healio.com/orthopedics/knee/news/online/%7B9d61da87-2d5b-461b-850e-8ae95e5a6463%7D/overweight-patients-face-higher-meniscal-tear-risk

Urgery, S., Ncorporated, I., & Arthroscopic, A. (2012). The Paradoxical McMurray Test for the Detection of Meniscal Tears. Bone, 118(1), 1-7.

Yan, R., Wang, H., Yang, Z., Ji, Z. H., & Guo, Y. M. (2011). Predicted probability of meniscus tears: comparing history and physical examination with MRI. Swiss medical weekly, 141(December), w13314. doi:10.4414/smw.2011.1331 Retrieved from http://ptrs745.wikispaces.com/Knee on 4/22/13