Author Affiliations: Division of Rheumatology, Immunology, and Allergy, Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center (Drs Solomon and Katz), Division of Pharmacoepidemiology and Pharmacoeconomics (Dr Solomon), Division of General Medicine, Departments of Medicine (Dr Bates), and Orthopedic Surgery (Dr Schaffer), Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC (Dr Simel). Dr Schaffer is now with The Cleveland Clinic.
The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and
Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor, JAMA.
Context While most meniscal or ligamentous knee injuries heal with nonoperative
treatments, a subset should be treated with arthroscopic or open surgery.
Objective To analyze the accuracy of the clinical examination for meniscal or
ligamentous knee injuries.
Data Sources MEDLINE (1966-December 31, 2000) and HealthSTAR (1975-December 31, 2000)
databases were searched for English-language articles describing the diagnostic
accuracy of individual examination items for the knee and a combination of
physical examination items (composite examination). Other data sources included
reference lists from relevant articles.
Study Selection Studies selected for data extraction were those that compared the performance
of the physical examination of the knee with a reference standard, such as
arthroscopy, arthrotomy, or magnetic resonance imaging. Eighty-eight articles
were identified, of which 23 (26%) met inclusion criteria.
Data Extraction A rheumatologist and an orthopedic surgeon independently reviewed each
article using a standardized rating scale that scored the assembly of the
study, the relevance of the patients enrolled, the appropriateness of the
reference standard, and the blinding of the examiner.
Data Synthesis Summary likelihood ratios (LRs) were estimated from random effects models.
The summary LRs for physical examination for tears of the anterior cruciate
ligament, using the anterior drawer test, were 3.8 (95% confidence interval
[CI], 0.7-22.0) for a positive examination and 0.30 (95% CI, 0.05-1.50) for
a negative examination; the Lachman test, 25.0 (95% CI, 2.7-651.0) and 0.1
(95% CI, 0.0-0.4); and the composite assessment, 25.0 (95% CI, 2.1-306.0)
and 0.04 (95% CI, 0.01-0.48), respectively. The LRs could not be generated
for any specific examination maneuver for a posterior cruciate ligament tear,
but the composite assessment had an LR of 21.0 (95% CI, 2.1-205.0) for a positive
examination and 0.05 (95% CI, 0.01-0.50) for a negative examination. Determination
of meniscal lesions, using McMurray test, had an LR of 1.3 (95% CI, 0.9-1.7)
for a positive examination and 0.8 (95% CI, 0.6-1.1) for a negative examination;
joint line tenderness, 0.9 (95% CI, 0.8-1.0) and 1.1 (95% CI, 1.0-1.3); and
the composite assessment, 2.7 (95% CI, 1.4-5.1) and 0.4 (95% CI, 0.2-0.7),
Conclusion The composite examination for specific meniscal or ligamentous injuries
of the knee performed much better than specific maneuvers, suggesting that
synthesis of a group of examination maneuvers and historical items may be
required for adequate diagnosis.
Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. Does This Patient Have a Torn Meniscus or Ligament of the Knee?Value of the Physical Examination. JAMA. 2001;286(13):1610-1620. doi:10.1001/jama.286.13.1610