McMurray. Likelihood Ratios with confidence: Sample size estimation for diagnostic test results. Kennedy MI, Akamefula R, DePhillipo NN, Logan CA, Peebles L, LaPrade RF. 2017 Mar;101(Suppl 1):23-35. doi: 10.1007/s12306-017-0460-5. OThmMmM0YTcwMmQwODZhZWFkYzNjNzRlOTkzZiIsInNpZ25hdHVyZSI6IjVh Winters K, Tregonning R. Reliability of magnetic resonance imaging of the traumatic knee as determined by arthroscopy. [1] It is one of 4 critical ligaments involved in stabilizing the knee joint. 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. An LR+ indicates the degree of certainty that a patient with a positive test actually has the suspected condition while an LR indicates the degree of certainty that a patient with a negative test does not have the suspected condition27. This an indication of a LCL tear. Manoeuvres assessing the posterolateral structures include the varus stress test, dial test, the posterolateral drawer, the external rotation recurvatum test, heel height test and the reverse pivot shift. The description should include the exact details of the test's application and the criteria used to determine positive and negative results11. The use of the STARD tool is also a limitation. A positive result at both 0 and 20 indicate cruciate ligament involvement. Piantanida, A.N. Karachalios et al21 incorrectly added valgus or varus stress as a component of the McMurray's. Sae-Jung et al24 considered pain or a clicking sound to be a positive test. 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%. If a study evaluates a test in a very specific group of patients, its findings can only be applied to that same type of cohort. Akseki et al3 included consecutive patients with symptoms related to intra-articular knee pathology although how this was determined was not described. Manzotti A, Baiguini P, Locatelli A, et al. The Valgus Stress Test for LCL injuries has hardly been evaluated regarding its diagnostic accuracy. 269-273). Sensitivity figures vary from 16%88%, while specificity figures vary from 20%98% (Table (Table5).5). The Management of Sofi Tissue Knee Injuries: Internal Derangements. However, if positive findings are grouped with positive findings from other tests, such as joint line tenderness and Apley's test, the test may be more valid. Orthopaedics - A guide for practitioners. The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears Arthroscopy. It is primary restraint to varus rotation from 0-30 of knee flexion. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. Does the patient have a torn meniscus of ligament of the knee? 2008. National Library of Medicine The Medial-Lateral Grind test had a higher LR+ (Table (Table7)7) when compared to the McMurray's test; however, its CIs were extremely wide, bringing into question the precision of this estimate of reliability (Table (Table7).7). Evans et al23 used consecutive patients on a waiting list for arthroscopy for a variety of conditions including, but not limited to, suspected meniscal tears. St. Louis, MO: Saunders Elsevier;2008. Another Systematic review study by Braun Schwieterman found that the sensitivity and specificity of the medial talar tilt stress test was 50% and 88 % respectively. Five studies compared modified versions of the test to McMurray's3,5,6,21,24 (Table (Table33). The accuracy of the clinical knee examination documented by arthroscopy: A prospective study. 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. Powell JW, Huijbregts PA. Concurrent criterion-related validity of acromioclavicular joint physical examination tests: A systematic review. Yedlinsky, N.T. NzM3NDQ2NDMzYThiNjlhNjA0M2M3MzVlMWFhYmE5ZDI3ZTI0YTIyZGIyNWM4 For the varus stress test, the patient is in supine position and asked to relax. [9] When LCL is injured or torn, this cordlike band is not as noticeable as on the unaffected side. In: Campbell's Operative Orthopaedics. Douglas I, McDermott Meniscal tears. In general, sensitivity figures are much lower than specificity and the CI limits are wider. NjZjMWViMWE5MzNlMDFhOTA3YzAwYzUzODYzZmQyZGI2ODk1ZmJlOGM4YzZh 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 knee is first in full extension, and then it is slightly (20-30 degrees) so that it is unlocked.1. There are several different reported methods of performing McMurrays Test, Reiders method may be the most accurate[9], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. One study used a palpable thud and/or pain23, and two studies used a palpable click and/or pain3,20. 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. The predictive value of Thve clinical signs in the evaluation of meniscal pathology. 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). Purpose: Study with Quizlet and memorize flashcards containing terms like Ballottement, Valgus Stress Test, Varus Stress Test and more. 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%. Flow diagram of literature screening process. Sensitivity and specificity of a test. The examiner should passively bend the affected leg to about 30 degrees of flexion. Interpretation: If the knee joint adducts greater than normal (compared to the unaffected leg), the test is positive. 2018 Nov 1;27(6):596-600. doi: 10.1123/jsr.2016-0188. The Valgus Stress Test for LCL injuries has hardly been evaluated regarding its diagnostic accuracy. The review also highlights the idea that modified versions of the test seem to be more valid than the original version. 1st ed. With a sensitivity of 86% and a specificity of 95%, . So, little is known about the validity of this test. Walters J, editor. Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears. Irwig L, Tosteson AN, Gatsonis C, et al. Varus stress MRI in the refined assessment of the posterolateral corner of the knee joint. Studies that have evaluated the sensitivity and specificity of individual clinical tests to detect ligamentous injury, . Meserve BB, Cleland JA, Boucher CT. A meta-analysis examining clinical test utilities for assessing meniscal injury. YWU3NTg0YTg5NzcxMzE4M2I5NjZiYzgxNzlkYjQyNmRjYjE1OWNjZjJmNzVh 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. Future research should concentrate on building a strong methodological base incorporating large samples of consecutive patients with commonly confused pathologies. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Varus stress testing was performed in 20 of flexion, and testing in extension was not done. As a stand-alone test, it had a sensitivity of 78% and specificity of 67% the pain was used as the outcome measure and a sensitivity of 91% and specificity of 49% when laxity was the outcome measure. The clinician hold the patient's ankle with one hand, while the other hand is on the lateral condyle of the femur. [11] Sensitivity: 25% . 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. 2001;177(2):409413. With regard to negative likelihood ratios, all but three of the studies demonstrated only a small alteration in probability that a subject with a negative McMurray's test will not have a meniscal tear (Table (Table5).5). Harilainen A. Before [12] If the varus stress test is positive at 20, but negative at 0, only the LCL is torn. Test (b): Disease Status test (b) results *Positive Negative Present 18 7 25 absent 2 73 75 total 20 80 100 Calculate the sensitivity, specificity, positive predictive values, and negative predictive values for each test. YTY1NDM4NjNkYzAwMmMxNGU2MjgwMmMzODFlMTZkZmQyYjRmNTAzM2RkZWY4 Campbell SE, Sanders TG, Morrison WB. Oberlander MA, Shalvoy RM, Hughston JC. The reliability of this test in extension is 68% and in 30 flexion only 56%. ZmY3MzI2ODBmYTBhMDEzNzY3YmRkZjU0MDRhM2U2ODliZTFmOWMzYWI0MWI5 The reliability of this test in extension is 68% and in 30 flexion only 56%. Edinburgh: Elsevier, 2006. Consecutive patients suspected of having meniscal tears presenting for arthroscopy: acute and chronic (ligament injuries excluded). The statistical measures of sensitivity, specificity, and likelihood ratios were calculated from the information provided in the studies. Symptoms related to an intra-articular knee pathology. Furthermore, the ability of both imaging modalities to identify an FCL injury was stratified based on acute versus chronic etiology. No mention acute/chronic. In an analysis of 20 available studies, the mean sensitivity and specificity of the anterior drawer test were 38% to 81% in awake patients and 63% to 91% in anesthetized patients, respectively. The Valgus Test of the knee is performed with the patient lies in the supine position. The modified weight-bearing test showed a higher LR+ and a lower LR than the McMurray's test (Table (Table7).7). 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. FOIA Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Clinically, we do not know whether a patient has the condition before the diagnostic test (arthroscopy or MRI) is performed. They rated the sensitivity at 25% and could not report any specificity percentage. How to Perform Varus Stress Test Position of Patient: The patient should be relaxed in the supine position. Akseki D, Ozcan O, Boya H, Pinar H. A new weight-bearing meniscal test and a comparison with McMurray's test and joint line tenderness. ZmNhYzI5Njc5MTEwZGU2NTAzYmRjNmJiODlmMmU0N2FhYzFhMDRjNjQ1YTNk N2RkOWE5MGM3NmExMGZmOTNjMjczMzY5NjE2Nzk2NzllZjU0MzY5ZWM5OTE3 Evaluation of Knee Instability in Acute Ligamentous Injuries. . PMC The technical storage or access that is used exclusively for anonymous statistical purposes. MR imaging of meniscal cysts: incidence, location, and clinical significance. Background and Objectives: Clinically, it is beneficial to determine the knee osteoarthritis (OA) subtype that responds well to conservative treatments. 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. eCollection 2022 Jun. Consider the use of modifications of the test for improved validity. M2ZmZDZjMzRlNTA5MjMyYzZkMGVlMDJkNzM3ODllMjM3ODFmYWJhZjAwYzZh Value of the physical examination. The physiotherapist stabilize the knee with one hand, while the other hand adducts the ankle.[10]. Additionally, the single photon-emission CT scan is receiving a lot . [3] McClure P,W et al. The site is secure. [2] Harilainen A. Limiting the search to English language articles only may also have led to an omission of other relevant studies. The results support the use of both varus stress radiographs and MRI in diagnosing FCL injuries, because MRI is more sensitive in diagnosing an acute FCL tear, and varus stress radiographs are more sensitive in diagnosing a chronic FCL tear. Each of these studies demonstrated improved diagnostic accuracy of these modified tests compared to the original McMurray's; however, they concluded that the modified tests should be used as well, as rather than as an alternative to other diagnostic tests3,5,6. Consequently, it is likely that the accuracy of meniscal testing demonstrated by this study is artificially high compared to studies with a wider inclusion criteria. The site is secure. 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). 1. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Prospective evaluation of the McMurray test. A) AND B): The McMurray's test: Figure 1a) the tibia rotated on the femur into full internal rotation and Figure 1b) the tibia rotated on the femur into full external rotation. Sensitivity can be defined as the proportion of patients with the condition who have a positive test result and represents the ability of the test to recognize the condition when present11. ZDg0M2Q2NDY1ZmIyNjFkZjBiOWE0MzQ3ZjJhZTY1NmRmYTUwYTBiMTNkNTIz The lower the LR, the more certain you can be that a negative test indicates the person does not have the disorder11 (Table (Table6).6). 3rd edition. Only one study by Harilainen et al. Diagnosis of acute knee ligament injuries: The value of stress radiography compared with clinical examination, stability, under anesthesia and arthroscopic or operative findings. In addition to the database searches, personal files were hand-searched by the authors for publications and relevant material. 2019 Jan 21;8(2):e141-e145. See also: stress test Elsevier Health Sciences, 2014. This is not surprising given the complicated nature of the technique and the difficulty in controlling the amount and direction of forces across testers. Therefore, this study aimed to determine the differences between varus and valgus arthritic knees in the response to conservative treatment. Four authors stated that they used the McMurray's test but did not describe the actual testing procedure3,5,19,25. IR of the tibia + Varus stress = lateral meniscus. The sensitivity and specificity of the clinical tests and magnetic resonance (MR) imaging are reviewed because these parameters vary, and an understanding of the diagnostic utility of both the clinical and imaging tests is important in accurately formulating a definitive diagnosis. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. MDU1NWE1Nzc5OGVjNTczOGU2OWUyMWYxYmY3Njk5ZTdlMDEwZTQ3MTY0Zjdm How to appraise a diagnostic test. Some studies have attempted to compare the diagnostic value of the McMurray's test to that of modified tests. Am J Roentgenol. . NTc3ODRiOTRjOGU4N2ExOGU2NDEzYWVjZmNiMTQ1N2FjM2U4NjVmMzhlMzRi [7] It is commonly associated with other knee ligament injuries, thus LCL tear can be easily overlooked as a result of that. Patients suspected of having a meniscal tear on the basis of history and mechanism of injury excluding those with multiple injuries, history of knee surgery, early clinical and radiographic signs of osteoarthritis, articular cartilage injuries, neurological and musculoskeletal degenerative disorders, disorders of the synovium, acute injuries (less than 4 weeks post-trauma), and any abnormal findings on conventional radiographs. A consensus method was used to discuss and resolve discrepancies between the markings of each paper between the three reviewers. Human Kinetics, 2008. Studies were also not examined where they clearly did not meet the search criteria. One of the tests was the valgus stress test, particularly at 30 of knee flexion. Measures of efficacy include accuracy, sensitivity, and specificity. Although sensitivity and specificity values provide useful information, they work against the direction of clinical testing11. [8], Mechanism of injury: (for more information, see the page on LCL injuries)[4], Patient position: Legs crossed with ankle resting on opposite knee (90 knee flexion, hip abduction and external rotation). That is usually the journal article where the information was first stated. ZDZkZjczMGZkNzQ1OWMxZTQyNDY2ZTAzYTM5OTk2ZmQ1YjkzNDFjMDhmNzMy National Library of Medicine Blinding of the clinicians from the results of the diagnostic test was either not mentioned or not performed in all of the studies in this review except for the study by Karachalios et al21. Obviously, if the test is performed differently and/or the interpretation of a positive test is not the same, the demonstrated accuracy of the test cannot be compared. In most cases Physiopedia articles are a secondary source and so should not be used as references. Address all correspondence and requests for reprints to: Wayne Hing. Described a modified version (Medial-Lateral Grind test) but no description of McMurray's. Petty NJ. Accessibility High specificity indicates that a test can be used for including a condition when it is positive26. It has been used previously for the systematic assessment of the methodology of studies into diagnostic accuracy10. Evidence-Based Medicine: How to Practice and Teach EBM. Reverse Pivot Shift Sign of Jakob, Hassler, and Stubli. The test has therefore often been reported to be of limited value in current clinical practice. 2nd ed. Generally, the McMurray's test has relatively high specificity and low sensitivity. Posterior drawer test Posterior sag test (godfrey test) Quadriceps active test Dial test Varus/valgus stress . Review bias may result when the findings of the reference standard test are known by the clinicians performing the diagnostic test. Consecutive patients awaiting elective arthroscopy for suspected meniscal or other conditions based on history and physical examination. 133k One problem with these modified tests is that they appear to have all been evaluated by the creators of the tests, which to some degree challenges the validity of the research. The sensitivity and specificity of the McMurray's test reported in the studies identified in this review vary widely (Table (Table5).5). Magee, D.J Chapter 12: Knee, in Orthopedic Physical Assessment. YmRhYTcyZWFhNTQ5OTM0YWYwODRjZDU1OWU3ZjBjNmMyMjA4NTcxZTRmMDYw Cinque ME, Geeslin AG, Chahla J, Moatshe G, Pogorzelski J, DePhillipo NN, LaPrade RF. One study5 performed the test after the arthroscopy and did not state if the examiner was blinded to these results. Of the 11 studies identified in this review, nine used arthroscopy as the reference standard, one used MRI, and the remaining study used both MRI and arthroscopy (Table (Table44). sharing sensitive information, make sure youre on a federal Finally, further independent research needs to compare the McMurray's test with modified tests to confirm the apparent superiority of these tests over the McMurray's test. Noble J, Erat K. In defence of the meniscus: A prospective study of 200 menisectomy patients. eCollection 2019 Feb. Painful conditions of the knee, inPain Management Vol 1.,2007. Also described a weight-bearing modification of McMurray's (Thessaly test), n/m for McMurray's, but joint line discomfort and possibly a sensation of locking or catching for Thessaly test. Eleven studies met the inclusion criteria. government site. Sensitivity and specificity values fail to do this11. Knee injuries. When evaluating any diagnostic test, commonly used parameters are its sensitivity and specificity. Fibular collateral ligament and the posterolateral corner. Although blinding was not mentioned in respect to the other studies, the majority required the clinical examination to be performed prior to the diagnostic arthroscopy, suggesting that the examiner would indeed be blinded to the results of the diagnostic test. ZDIwNGI3MGM0NDMzZmMxM2YxZDdmZWM0YmE5MDI5OWJiMmE4MmFhZTdkODE1 Articles may have been missed based on the omission of certain search phrases or the use of a single search phrase as used in this case. Although the support of a clinical study is needed in order to make a definite conclusion, the dial test is probably not reliable in the presence of medial instability, We hypothesized that valgus arthritic knees would respond better to conservative treatment than varus . In addition, cited references of relevant articles were examined. Physical examination of the knee: A review of the original test description and scientific validity of common orthopedic tests. Methods: Epub 2018 Jul 27. The remaining four studies failed to mention what denoted a positive test (Table (Table4).4). Based on the STARD scoring of each paper, it is possible to make a qualitative assessment about the methodological quality. The possibility of there being associated intra-articular pathology (such as anterior cruciate ligament rupture) confounds results, and the unknown validity, sensitivity, and specificity of the tests make it difficult for the clinician to be confident in making a definitive diagnosis3.
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