elevant? Menisci lesions - Knee Course€¦ · elevant? eau, Doha, Qatar. Meniscus Injuries • om athletic activities and e a eason eferral for orthopedic evaluation. • Annual

Menis

ci le

sio

ns:

Are

the c

linic

al s

igns re

leva

nt?

Ph. L

and

reau

Asp

eta

r, Do

ha, Q

ata

r

Menis

cus In

jurie

s

•M

enis

cus in

jurie

s, b

oth

from

ath

letic

activitie

s a

nd

activitie

s o

f daily livin

g, a

re a

co

mm

on re

aso

n o

f refe

rral

for o

rtho

ped

ic e

valu

atio

n.

•A

nnual in

cid

ence: 6

0 p

er 1

00

,00

0 in

divid

uals

in th

e

genera

l po

pula

tion.

•M

enis

cus te

ars

are

one o

f the m

ost c

om

mo

n in

jurie

s to

the k

nee a

nd

sho

uld

ofte

n b

e in

clu

ded

at th

e to

p o

f the

diffe

rentia

l dia

gno

sis

for p

atie

nts

pre

sentin

g w

ith k

nee

pain

Menis

cus d

iag

no

sis

and

diffe

rentia

l dia

gno

sis

•sho

uld

be e

sta

blis

hed

clin

ically b

y:

•his

tory ta

kin

g,

•p

hys

ical e

xam

inatio

n, a

nd

•p

lain

rad

iog

rap

hs to

pro

vide th

e b

asis

for in

form

ed

co

nsent d

iscussio

ns w

ith

patie

nts

and

to d

ete

rmin

e if s

pecia

l

stu

die

s, s

uch a

s

•M

RI o

r arth

ro C

T, are

req

uire

d fo

r

furth

er e

valu

atio

n.

Sir W

illiam

Osle

r:

“Lis

ten to

your

patie

nt, h

e is

tellin

g

you th

e d

iagnosis

”

Care

ful H

isto

ry Takin

g: S

cenario

•S

ud

den o

nset o

f pain

in th

e s

ettin

g o

f a tw

istin

g in

jury to

the k

nee —

> m

ore

likely to

req

uire

furth

er d

iag

no

stic

testin

g a

nd

, perh

ap

s, s

urg

ical in

terve

ntio

n.

•P

atie

nts

with

an in

sid

ious o

nset o

f pain

with

out p

reced

ing

inju

ry may h

ave

und

erlyin

g a

rticula

r cartila

ge

deg

enera

tion a

nd

join

t wear th

at w

ill mo

re th

an lik

ely

dic

tate

the tre

atm

ent s

trate

gy.

His

tory ta

kin

g

•P

ain

localize

d to

the jo

int-lin

e

•P

rovo

cate

d b

y: Hyp

erfle

xio

n, d

irectio

nal c

hange d

urin

g w

alk

ing, w

hen

cro

ssin

g th

e le

gs, w

hen c

atc

hin

g o

ne’s

foot o

n a

n irre

gula

r surfa

ce

•M

echanic

al s

ymp

tom

s s

uch a

s “c

lickin

g” o

r “catc

hin

g,”

•R

ecurre

nt e

ffusio

ns

•C

om

pla

int o

f “lockin

g” w

ith a

mechanic

al b

lock to

exte

nsio

n

•A

traum

atic

pain

ful k

nee in

a yo

ung p

atie

nt s

hould

be d

istin

guis

hed

from

non-tra

um

atic

chro

nic

knee p

ain

in a

patie

nt o

ver 4

0 ye

ars

of

age

Phys

ical e

xam

inatio

n

•G

ait

•A

lignem

ent

•M

ob

ility

•Laxity

•P

ate

llo-fe

mo

ral

•E

ffusio

n…

•…

and

menis

cus

Jo

int lin

e p

alp

atio

n

•P

ain

or d

isco

mfo

rt is re

pro

duced

by p

alp

atio

n o

f the jo

int

line.

JD

Kelly

McM

urra

y Test

•P

atie

nt s

up

ine.

•The k

nee is

exte

nd

ed

from

a fu

lly flexed

positio

n

while

inte

rnally ro

tatin

g

the tib

ia. T

he te

st is

rep

eate

d w

hile

exte

rnally

rota

ting th

e tib

ia.

•P

op

pin

g a

nd

tend

ern

ess

alo

ng th

e jo

int lin

e

ind

icate

a p

ositive

sig

n

McM

urra

y Test

Ap

ley Te

st

•P

atie

nt in

pro

ne p

ositio

n w

ith

the k

nee fle

xed

to 9

0°.

•T

he tib

ia is

co

mp

ressed

into

the d

ista

l fem

ur a

nd

rota

ted

exte

rnally to

assess th

e m

ed

ial

menis

cus a

nd

inte

rnally to

assess th

e la

tera

l menis

cus.

•T

he te

st is

co

nsid

ere

d p

ositive

if it pro

duces p

ain

, whic

h is

less s

eve

re o

r relie

ved

when

the m

aneuve

r is re

peate

d w

ith

dis

tractio

n o

f the tib

ia.

Ap

ley Te

st

Oth

er te

sts

: Thessaly Te

st

(Eg

e’s

test)

Thessaly Te

st

Rele

vance?

•S

tud

ies: m

eth

od

olo

gic

al q

uality va

ried

from

po

or to

fair

am

ong

stu

die

s, a

ffectin

g te

st p

erfo

rmance.

•G

old

sta

nd

ard

: MR

I, arth

rosco

py.

•N

um

ber o

f ind

ividuals

is va

riab

le

Rele

vance?

•N

ob

le J

, Era

t K. In

defe

nse o

f the m

enis

cus: a

pro

sp

ective

stu

dy o

f 20

0 m

enis

cecto

my p

atie

nts

. J B

one

Jo

int S

urg

Br 1

98

0; 6

2: 7

–1

1:

•C

ontin

uin

g p

ain

gre

ate

r than o

ne m

onth

, effu

sio

n,

lockin

g a

nd

insta

bility to

be s

tatis

tically h

igher in

ind

ividuals

with

menis

cal te

ars

.

Rele

vance?

•A

bd

on P

, Lin

dstra

nd

A, T

ho

rng

ren K

G. S

tatis

tical e

valu

atio

n o

f

the d

iag

no

stic

crite

ria fo

r menis

cal te

ars

. Int O

rtho

p 1

99

0; 1

4:

34

1–4

5:

•A

co

mb

inatio

n o

f patie

nt-re

po

rted

sym

pto

ms in

cre

ased

the

pre

dic

tive va

lue o

f identifyin

g m

enis

cal le

sio

n to

70

–8

0%

.

•In

that s

tud

y, the p

resence o

f med

ial jo

int lin

e te

nd

ern

ess,

knee ‘lo

ckin

g’, d

aily p

ain

and

if the p

atie

nt w

as o

n ‘s

ick

leave

’ from

wo

rk a

ccura

tely p

red

icte

d 6

1%

of th

ose

patie

nts

exhib

iting

a m

enis

cal te

ar c

onfirm

ed

by

arth

rosco

py.

His

tory re

leva

nce

•Fro

m h

isto

ry-takin

g, th

e d

ete

rmin

ants

‘‘ag

e o

ver 4

0

years

,’’ ‘‘co

ntin

uatio

n o

f activity im

po

ssib

le,’’ a

nd

“weig

ht-

bearin

g d

urin

g tra

um

a’’ in

dic

ate

d a

n a

sso

cia

tion w

ith a

menis

cal te

ar a

fter m

ultiva

riate

log

istic

reg

ressio

n

analys

is.

Tests

rele

vance

Tests

rele

vance

•M

eserve

BB

, Cle

land

JA

, Boucher T

R. A

meta

-analys

is e

xam

inin

g c

linic

al

test u

tilities fo

r assessin

g m

enis

cal in

jury. C

linic

al R

ehab

ilitatio

n 2

008 ; 2

2:

143-1

61.

•R

yzew

icz M

, Pete

rson B

, Sip

ars

ky P

N, B

artz R

L. T

he d

iagnosis

of

menis

cus te

ars

: the ro

le o

f MR

I and

clin

ical e

xam

inatio

n. C

lin O

rthop

Rela

t

Res 2

007; 4

55: 1

23–133.

•S

cholte

n R

J, D

eville

WL, O

pste

lten W

, Bijl D

, van d

er P

las C

G, B

oute

r LM

.

The a

ccura

cy o

f phys

ical d

iagnostic

tests

for a

ssessin

g m

enis

cal le

sio

ns o

f

the k

nee: a

meta

-analys

is. J

Fam

Pra

ct 2

001; 5

0: 9

38–944.

•S

olo

mon D

H, S

imel D

L, B

ate

s D

W, K

atz J

N, S

chaffe

r JL. D

oes th

is p

atie

nt

have

a to

rn m

enis

cus o

r ligam

ent o

f the k

nee? V

alu

e o

f the p

hys

ical

exam

inatio

n. J

AM

A 2

001; 2

86: 1

610–1620.

Tests

rele

vance?

•M

eserve

BB

, Cle

land

JA

, Bo

ucher T

R. A

meta

-analys

is

exam

inin

g c

linic

al te

st u

tilities fo

r assessin

g m

enis

cal

inju

ry. Clin

ical R

ehab

ilitatio

n 2

00

8 ; 2

2: 1

43

-16

1:

•Jo

int lin

e te

nd

ern

ess is

the b

est ‘c

om

mo

n’ te

st, fo

llow

ed

by M

cM

urra

y’s a

nd

Ap

ley’s

.

•T

hessaly’s

test re

po

rted

the s

trong

est, b

ut s

am

ple

s w

ere

sm

alle

r (n.4

10

), than th

ose fo

r join

t line te

nd

ern

ess (n

.

13

54

), McM

urra

y’s (n

.12

32

) and

Ap

ley’s

(n.4

79

)

Whic

h te

st?

•A

sin

gle

clin

ical te

st is

no

t suffic

ient to

esta

blis

h a

co

rrect

dia

gno

sis

. Dia

gno

stic

accura

cy is

imp

rove

d if th

e re

sults

of m

ore

than o

ne te

st a

re c

om

bin

ed

.

•G

enera

lly, all c

linic

al te

sts

tend

to b

e le

ss re

liab

le in

the

pre

sence o

f co

nco

mita

nt lig

am

ento

us in

jury (A

CL).

•Furth

erm

ore

, phys

ical e

xam

inatio

n is

less a

ccura

te in

patie

nts

with

deg

enera

tive te

ars

than in

young

patie

nts

with

acute

inju

ries.

Menis

ci le

sio

ns:

Are

the c

linic

al s

igns re

leva

nt?

•D

ifficult to

answ

er

•C

om

bin

atio

n o

f his

tory a

nd

diffe

rent te

sts

•Join

t line te

nd

ern

ess, M

cM

urra

y test, A

ple

y test

•Thessaly te

st?

•Futu

re s

tud

ies s

hould

, where

possib

le, u

tilize la

rger

sam

ple

s o

f ind

ividuals

with

out m

enis

cal le

sio

ns to

bette

r

estim

ate

test s

pecific

ity and

thus m

ore

accura

tely id

entify

op

timal c

linic

al te

sts

.

Thank Y

ou