Further, subjects who are positive on the reference standard should reflect a continuum of severity, whereas those who are negative should have conditions commonly confused with meniscal tears17. = (Number of TP + Number of TN)/(Numbers of TP + FP + FN), Identifies article as a study of diagnostic accuracy, Describes study population (inclusion criteria, exclusion criteria, settings, locations), Describes data collection (prospective or respective), Describes reference standard and rationale, Describes technical Specifications of material and methods involved, Describes definition and rationale of units, cut-of points, or categories of results of tests, Describes number, training, and expertise of raters. In contrast, the paper by Sae-Jung et al24 found sensitivity for medial and lateral menisci of 70% and 68%, respectively, and specificity values for medial and lateral menisci of 60.7% and 47.8%, respectively. The test is fairly solid. The description should include the exact details of the test's application and the criteria used to determine positive and negative results11. Three of these studies had fairly broad inclusion criteria that better reflect the population seen in clinical practice with two including subjects with suspected meniscal or ligamentous pathology6,19; the study by Sae-jung et al24 included any patients identified as needing arthroscopy. The knee is first in full extension, and then it is slightly (20-30 degrees) so that it is unlocked.1. The .gov means its official. Varus Stress Test of the Knee: Genu Varum (aka bow-leggedness, bandiness, bandy-leg, and tibia vara), is a physical deformity marked by (outward) bowing of the lower leg in relation to the thigh, giving the appearance of an archer's bow. Bhandari M, Guyatt GH. Some of the studies did not separate the data for medial from that of lateral meniscal testing5,6,22,25. A recent evidence-based guideline for the management of acute soft tissue injuries to the knee has recommended that joint line tenderness is the only reliable clinical indicator of meniscal pathology2. Methodological scores on the STARD (Standards for Reporting of Diagnostic Accuracy) yielded scores from 10/25 to 20/25. ODA3OTUwYWUyMzM0ODhjYWM2MzMzZDc4YTcxNWI4Njc5NDlmMTE2NjIxOTc0 The therapist applies a varus stress at the knee while the ankle is stabilized. N2IwYjAxYmE3NzM4ZmE2MTE5MTMyY2Q0M2I3NTQ5YjlkMzU3ODI3ODIyNzg0 YzA0Nzk1ZjQxYjY5Mzg4MWUwNDRlODM0NDRiNzZiM2I4OWVhNTQ1YmVlMDNj A total of 232 patients were included: 98 patients in the FCL tear group (mean age: 33.6 12.2 years) and 134 patients in the control group (mean age: 44.0 17.2 years). When pooled together using the bivariate random effects model (BREM), the sensitivity value of the 8 studies was 0.2 and the specificity value was 0.88. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Consecutive patients clinically diagnosed as having torn menisci (based on symptoms of pain, locking, painful clicks, recurrent effusions, giving way or signs of extension block, wasting, or instability) Patients with evidence of fracture or arthritis, a previous history of surgery, or with an acute locked knee or haemarthrosis were excluded. Sae-Jung S, Jirarattanaphochai K, Benjasil T. KKU knee compression-rotation test for detection of meniscal tears: A comparative study of its diagnostic accuracy with the McMurray test. Clipboard, Search History, and several other advanced features are temporarily unavailable. $ is the truncation character. Slocum Drawer Test: Inconclusive Crossover Test: Inconclusive Pivot Shift Test: Sensitivity: 60% Specificity: 96% Were the raters blinded to the results of the other test? 4th Edition. So, little is known about the validity of this test. An official website of the United States government. document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); We use cookies to optimize our website and our service. Of the four studies that demonstrated the highest shifts in probability, only Corea et al4 and Akseki et al3 contained calculable CIs, which were relatively narrow (Table (Table55). Orthopedic Physical Assessment: 5 th Edition. Canada. M2YxNmU0NGVlMWUwYjVjMDY4MzIwZjY3OTJmYTc0YzFhMDIyMDAwNTVhNGJm Anderson AF, Lipscomb AB. In: DeLee & Drez's Orthopaedic Sports Medicine. The incidence of LCL injuries are relatively low (6%) when compared to other knee injuries. The Valgus Stress Test for LCL injuries has hardly been evaluated regarding its diagnostic accuracy. Differences in the type of tear have been suggested as influencing the result of clinical tests; however, no detailed investigation of this issue exists in the current literature3. Elsevier Health Sciences, 2014. MGY4MmExODg4MDUwZTk2NzUzNjQ0OTMxYjkxN2QwYjQ5MmMxODdmMWU4MDdi Results also indicate that testing for medial meniscal pathology is more sensitive than testing for lateral; however, tests for lateral meniscal pathology are more specific than tests for medial pathology3,4,19. Based on the STARD scoring of each paper, it is possible to make a qualitative assessment about the methodological quality. A positive result at both 0 and 20 indicate cruciate ligament involvement. These authors demonstrated significantly larger (better) positive likelihood ratios and significantly smaller (better) negative likelihood ratios than the McMurray's. Orthopaedics - A guide for practitioners. YzM5MWNkYzMyMjQ0ZmU4MDdjZjg2NzYxZjhlMGI2N2RmMGI3ODExOWFmMDdl ZTU5MGVlOWM4MDcwMGE2YmJiZjNjZTBiMjQ2N2E5OTFmNTliZDgyYzc4ZjQ0 St. Louis, MO: Saunders Elsevier;2008. Studies were included for analysis if they compared the McMurray's test with a gold standard of knee arthroscopy or magnetic resonance imaging (MRI). 8600 Rockville Pike Fowler PJ, Lubliner JA. When evaluating any diagnostic test, commonly used parameters are its sensitivity and specificity. Before A consensus method was used to discuss and resolve discrepancies between the markings of each paper between the three reviewers. The review also highlights the idea that modified versions of the test seem to be more valid than the original version. That is usually the journal article where the information was first stated. These authors considered the overall accuracy of the axially loaded pivot shift test to be higher than that of the McMurray's test (Table (Table7).7). Anterior cruciate ligament reconstruction: MR imaging findings. Valgus and Varus Stress Test [1] Magee DJ. This study evaluated not only the McMurray's test but also a new test (Ege's test) for meniscal pathology that is performed in a weight-bearing position. Patients who underwent arthroscopy to assess suspected meniscal or meniscal together with ACL injuries. This lack of consensus in the literature highlights the risk that the criteria indicating a positive test can influence the test outcome, irrespective of whether the test was performed in the same manner on the same patient. Pg 791. Positive likelihood ratios presented in the studies reviewed generally indicated small to moderate shifts in probability (0.828.86) in that a positive test will indicate true meniscal pathology although the studies with the highest methodological quality demonstrated likelihood ratios considered to indicate moderate improvements in the probability that this will be the case3,4. Rose NE, Gold SM. [1] It is one of 4 critical ligaments involved in stabilizing the knee joint. Neuromusculoskeletal examination assessment: A handbook for therapists. A prospective study comparing the accuracy of the clinical diagnosis of meniscal tears with magnetic resonance imaging and its effect on clinical outcome. Evidence-Based Medicine: How to Practice and Teach EBM. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Selection bias may occur when study subjects are not representative of the population on whom the test is typically applied in practice and can affect the results of a study11. . Consider the findings of this test in conjunction with those of other tests to enhance the likelihood of a correct diagnosis such as joint line tenderness. 1. The majority of studies did not report intertester or intratester reliability of the McMurray's test. Whenever suspecting a posterolateral complex injury, one has to carefully perform a valgus stress test in 0 degrees and 30 degrees. To some degree, this is achieved by sensitivity and specificity, which provide useful information for interpreting the results of diagnostic tests. Evans et al23 compared a senior examiner with over 10 years experience to a medical student who had recently been taught the technique whereas Karachalios et al21 compared two experienced orthopaedic surgeons with two inexperienced residents. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. Only one study by Harilainen et al. Harilainen A. Results: The site is secure. The low sensitivity figures would indicate that in general, a negative test result is not reliable in ruling out meniscal pathology and a torn meniscus would likely be missed if the McMurray's test was the sole determinant of pathology. Y2RkNzAxODk3NTIxMTE2ZTkyYzE2ZjgxNmFmNWUxZGMwNmY4Mjg1ZDQ3MTkw Operational definitions of diagnostic accuracy terms used in the studies investigating validity of McMurray's test for meniscal pathology (modified from Powell & huijbregts10). 2018 Aug;46(10):2355-2365. doi: 10.1177/0363546518784301. [4] The popliteus tendon is deep to the LCL, seperating it from the lateral meniscus. Additionally, the single photon-emission CT scan is receiving a lot . Each test is repeated with the knee in full extension. Review bias may result when the findings of the reference standard test are known by the clinicians performing the diagnostic test. St. Louis, MO: Saunders Elsevier;2008. Moreover, the ACL stabilizes the knee's rotation under varus or valgus stress. MDU1NWE1Nzc5OGVjNTczOGU2OWUyMWYxYmY3Njk5ZTdlMDEwZTQ3MTY0Zjdm See also: stress test Limitations of this review relate to the search strategy used. (1987) evaluated the varus stress test and found rather poor diagnostic accuracy. Your access to this site was blocked by Wordfence, a security provider, who protects sites from malicious activity. Some studies have attempted to compare the diagnostic value of the McMurray's test to that of modified tests. However, these authors stated that they determined these findings in a study of 20 subjects prior to the main study and they did not provide any details of how this pilot study was performed or analyzed. Kurosaka M, Yagi M, Yoshiya S, Muratsu H, Mizuno K. Effcacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear. Specificity is the proportion of patients without the condition who have a negative test result and indicates the ability to use a test to recognize when the condition is absent11. Waldman,S.D. During the maneuver, the joint line is palpated both medially and laterally. This means that tests rarely have both high sensitivity and specificity. Unauthorized use of these marks is strictly prohibited. This review identified that the McMurray's test is of limited clinical value due to relatively low sensitivity, with modified tests (associated with the traditional McMurray's test) having higher diagnostic accuracy and thus these may be more useful clinically. Take the leg and bring it in 30 Flexion (MLPP) and use a cushion or edge of the bed so the patient can relax. The .gov means its official. Studies of specificity and sensitivity have demonstrated varied values as a result of poor methodological quality[7] A recent meta-analysis reports sensitivity and specificity to be 70% and 71%. The test is performed at 0 and 20-30, so the knee joint is in the closed packed position. Accessibility 2022 Jun 6;10(6):23259671221100216. doi: 10.1177/23259671221100216. [1]. There is conflicting evidence in the literature over the accuracy of MRI. Future research should concentrate on building a strong methodological base incorporating large samples of consecutive patients with commonly confused pathologies. These authors also observed that the studies on these new tests have only been subjected to scientific scrutiny on one occasion and further research is required on these tests. Malanga GA, Andrus S, Nadler SF, McLean J. Merriman L, Turner W. Assessment of the Lower Limb. OWFmOGE3YWY0OWM1ZWIzOTU5Mjg5Y2I4ODIwZmU1MmQyZWRhMmUxY2ZlMGU3 Assessment of the menisci and cruciate ligaments: An audit of clinical practice. Based on chronicity of the injuries, MRI was more accurate for detecting acute FCL injuries than chronic injuries (P = .002), and varus stress radiographs were more accurate for detecting chronic FCL injuries than acute injuries (P = .041). YzZhYjViODEyOTFlYzkyIn0= FOIA Eleven studies met the inclusion criteria. aAssociate Professor, health & Rehabilitation Research Centre, School of Rehabilitation and Occupation Studies, AUT University, Auckland, New Zealand, bSenior Lecturer, School of Rehabilitation and Occupation Studies, Auckland University of Technology, Auckland, New Zealand, cHead of School of Rehabilitation and Occupation Studies, Auckland University of Technology, Auckland, New Zealand, dSchool of Physiotherapy, Auckland University of Technology, Auckland, New Zealand. Kurosaka et al6 stated that diagnostic accuracy is lessened in patients with multiple pathologies, whereas Akseki et al3 found that there was no reduction in diagnostic accuracy with an associated tear of the ACL. 2018 May 2;6(5):2325967118770170. doi: 10.1177/2325967118770170. Background and Objectives: Clinically, it is beneficial to determine the knee osteoarthritis (OA) subtype that responds well to conservative treatments. [5] The LCL further splits the biceps femoris into two parts. However, this provisional diagnosis was also based on other symptoms that one might consider could be associated with pathologies other than meniscal tears, e.g., pain, recurrent effusion, muscle wasting, and instability. ZmFjMDhjZmYyOWRiNWU2YjhhMWNhYjFiNTU5YTI5ODM3MTY1ODYwYzc2NmFi ODU2Y2M1MDM5YjZiZGYwM2E5ZDEyYjk5Nzc0MTA0ZWQxYmE5MmJiMjRlYWQ2 Fowler and Lubliner22 attributed their low sensitivity results (compared to previous studies)5,25 to population differences between the studies (Table (Table5).5). A recent literature review on composite testing of the diagnostic tests for the meniscus reported reasonable sensitivity and specificity when the findings of a number of tests are combined31. [7] It is commonly associated with other knee ligament injuries, thus LCL tear can be easily overlooked as a result of that. Houten: Bohn Stafleu Van Loghum, 2005. To evaluate the diagnostic accuracy of magnetic resonance imaging and varus stress radiographs for fibular collateral ligament (FCL) tears, and compare these modalities to intraoperative findings. YjRkMzE0ZTk0MWM3ZmIzYWU4Mjc2ZTg2NzY5MWVlZTQwNTFlM2VjN2JkOTYy Simmel DL, Samsa GP, Matchar DB. The final two studies20,21 limited their study population to patients suspected of meniscal injury. IR of the tibia + Varus stress = lateral meniscus. Studies of specificity and sensitivity have demonstrated varied values as a result of poor methodological quality A recent meta-analysis reports sensitivity and specificity to be 70% and 71%. The therapist applies a valgus stress at the knee while the ankle is stabilized in slight lateral rotation either with the hand or with the leg held between the examiners arm and trunk. Modified McMurray's to include valgus/varus stress. Test Position: Supine. M2NhODMyZGZjNTEwMzAzY2JkMWI0MTUwM2I3NjNjN2RjYmY4NmEyNWE1ZjZk Cinque ME, Geeslin AG, Chahla J, Moatshe G, Pogorzelski J, DePhillipo NN, LaPrade RF. However, in general, the CI limits are relatively narrow over all. As is true of all statistics, sensitivity and specificity values are taken from a sample and represent an estimate of the true value that could be found in the population. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. No valgus or varus stress is applied. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. The https:// ensures that you are connecting to the Ciba M, Winkelmeyer EM, Schock J, Westfechtel S, Nolte T, Knobe M, Prescher A, Kuhl C, Truhn D, Nebelung S. Sci Rep. 2022 Jul 13;12(1):11858. doi: 10.1038/s41598-022-15787-2. Miller RH, Azar FM. Purpose: The varus stress test shows a lateral joint line gap. Comparison of likelihood ratio's for McMurray's test with modified tests. These authors excluded subjects with clinical or radiographic evidence of arthritis or fracture that would increase the accuracy of testing but decrease the generalizability of the findings. M2ZmZDZjMzRlNTA5MjMyYzZkMGVlMDJkNzM3ODllMjM3ODFmYWJhZjAwYzZh The findings of studies testing the validity of the McMurray's test have varied widely, mostly due to variations in the size and type of the study population as well as differences in description and application of the test3. (2008) A meta-analysis examining clinical test utilities for assessing meniscal injury. Therefore, this study aimed to determine the differences between varus and valgus arthritic knees in the response to conservative treatment. Journal of Orthopaedic and Sports Physical Therapy, 37(9), 541-50. Evaluation of Knee Instability in Acute Ligamentous Injuries. These authors also demonstrated that the Medial-Lateral Grind test had smaller (better) LR compared to the McMurray's test although the change in probability was still only small and should be considered rarely important (Table (Table77). More recent research has shown that modifications to the original McMurray's test may have better validity and diagnostic accuracy than the original McMurray's test3,58. [11] Sensitivity: 25% . Studies by Boeree and Ackroyd19, Akseki et al3, and Karachalios et al21 demonstrated small but sometimes important shifts in probability. Bookshelf Address all correspondence and requests for reprints to: Wayne Hing. MjUwZDBiZTEwYzA5YjkxZGRiYzI0YTE2MzY2ODI3ZDhjODQyYjNiZjU1YTU5 Corea JR, Moussa M, Al Othman A. McMurray's test tested. [9] When LCL is injured or torn, this cordlike band is not as noticeable as on the unaffected side. The inclusion of patients with multiple pathologies is likely to lessen the diagnostic accuracy of a test; however, this would reflect actual clinical practice6,18. ZmZjN2MzNzdhZDFlZWY2OGI0YWExNTViZjA5ZDc3OTA3MTJmYTYyOGFmMGEw LaPrade RF, DePhillipo NN, Cram TR, Cinque ME, Kennedy MI, Dornan GJ, O'Brien LT. Am J Sports Med. The anterior portion of the meniscus is not easily tested because the pressure to that part of the meniscus is not as great. Disclaimer. 1987; 76: 269-273. ODA1ZGIwMjcwNDYzZDc3OTkwMWYwNWVkMWRlYzk1ZWExOTVhNjBiNWQ2MzUw Saunders. HHS Vulnerability Disclosure, Help official website and that any information you provide is encrypted Similarly, Corea et al4 included consecutive patients who were clinically diagnosed as having torn menisci based on a number of signs and symptoms including locking, a positive McMurray's test, painful clicks, and giving way. Douglas I, McDermott Meniscal tears. Under the original description of the test, a thud or a click felt by the examiner (and sometimes heard) while performing the test was considered positive (McMurray as cited in Corea et al4). A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Please enable it to take advantage of the complete set of features! Acute knee injuries: use of decision rules for selective radiograph ordering. The reliability of this test in extension is 68% and in 30 flexion only 56%. In this position the iliotibial band relaxes and makes the LCL easier to isolate. The best statistics for summarizing usefulness of a diagnostic test appear to be likelihood ratios (LR)17. On the basis of the results of the studies in this review, it seems that intertester reliability using the McMurray's test is low. The MCL and LCL are tested with a valgus and varus stress, respectively, with the knee held at 30 of flexion to isolate the collateral ligaments. Collectively, these studies indicate that there is little consensus in the reported measures of validity of the McMurray's test and that this is mostly due to limitations in the methodological quality of the studies that were assessed. HHS Vulnerability Disclosure, Help followers. N2RkOWE5MGM3NmExMGZmOTNjMjczMzY5NjE2Nzk2NzllZjU0MzY5ZWM5OTE3 The goal of the study was to evaluate 3 common manual tests (Buell, Dananberg, and Jack tests) for assessing first metatarsophalangeal joint (MPJ) mobility and determining the normal values needed to detect FHL . Referred from GP/A&E with suspected cruciate ligament or meniscal pathology. Careers, Unable to load your collection due to an error. Fibular collateral ligament and the posterolateral corner. Karachalios et al21 incorrectly added valgus or varus stress as a component of the McMurray's. Although six studies used multiple testers, these did not provide statistics for reliability6,1923. Patient in supine. Kane PW, Cinque ME, Moatshe G, Chahla J, DePhillipo NN, Provencher MT, LaPrade RF. How to Perform Varus Stress Test Position of Patient: The patient should be relaxed in the supine position. 2nd ed. and transmitted securely. The same maneuvers are performed in gradually increasing degrees of knee flexion to progressively load more posterior segments of the menisci. Likelihood Ratio +/-. Saunders Elsevier. MDYzNWEzNGQxNDFiMmU0MDBmMmJkZTU4YzNiNzE1MWYxNWM3ZGU1NzFkM2Zm The accuracy of the clinical knee examination documented by arthroscopy: A prospective study. Common terms. The review suggests that modifications of the interpretation of a positive test to include reproduction of pain either as well as or on its own may enhance the validity of the test. The accurate diagnosis of meniscal pathology on the basis of the findings of such tests is often difficult. Studies looking at diagnostic accuracy, sensitivity and specificity have demonstrated varied values. Meserve BB, Cleland JA, Boucher CT. A meta-analysis examining clinical test utilities for assessing meniscal injury. Patients identified as needing arthroscopy excluding those with intra-articular fracture, neurological or degenerative disorders. National Library of Medicine Currently, a triple phase technium-99 bone scan (scintigraphy) is the most accurate method of diagnosing stress fractures with a sensitivity of 100% and specificity of 76%. [4, 6] Thessaly Test. eCollection 2018 May. doi: 10.1016/j.eats.2018.10.007. 13th ed. Jaeschke RZ, Meade MO, Guyatt GH, Keenan SP, Cook DJ. It is important to take this into consideration when analyzing test results of studies that have used more than one examiner. Of the studies evaluated in this review, six used the original description of the McMurray's test4,6,20,2224.