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Re: MCL vs. medial meniscus ?
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Re: MCL vs. medial meniscus ? - May 6, 2005 6:29:00 PM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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Sarah:
Forgive me for the "Scott" thing...it was late Friday afternoon....finally someone agrees that an MCL sprain could occur without a traumatic event...actually J. Silvernail did mention that earlier...thanks again everyone...I'm going to check the article from Zack..
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Re: MCL vs. medial meniscus ? - May 6, 2005 6:34:00 PM
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srcase
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From: Michigan
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Can you post the full article please? ;)
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Re: MCL vs. medial meniscus ? - May 6, 2005 6:38:00 PM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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I tried to get it...wouldn't work, so I emialed Zack..we will see what happens ??
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Re: MCL vs. medial meniscus ? - May 7, 2005 3:56:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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The initial evaluation was quite thorough, but I noticed something (as did some others) that I have always stressed to my students....don't get too hung up on figuring out what "tissue" is specifically involved (especially at the knee). You will miss the whole point of the person being in PT to begin with.
Even if by some divine intervention, you find out that there is a small but healable tear in the menisco-femoral ligament, is that really going to change anything you do?
With patients such as this, where there could be one or multiple interrelated issues, I do rule out lumbar involvement and even distal neural entrapment, and then focus on the basics: Restore motion, restore strength, restore normal mechanics, reduce inflammation, and 99% of the time, the patient WILL get better....without ever knowing exactly and definitively what was wrong. Some PT's can accept this, but for some reason, others cannot.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: MCL vs. medial meniscus ? - May 7, 2005 5:12:00 AM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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John:
Thank you for your insight..I know sometimes I do tend to do this and your right, it won't change my way of treatment (in the example you mentioned above "menisco-femoral ligament")..however, this is what makes this site so awesome, is that we can pose these questions and get some different points-of-view, as well as strike up some enlightening conversation. Moreover, I enjoy tossing the biomechanical concepts around and the findings from the exam (to get feedback regarding my approach)...This particular pt is somewhat overweight and her alignment and stress at both knees and lumbo-pelvic region could well have contributed to her current condition, as well as past hx (hx of contralateral meniscal tear...this was the first day exam and honestly, I did not have enough time to perform a thorough lumbo-pelvic exam, after the knee, hip and ankle...this will be addressed at her next visit.
Thanks again John !!
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Re: MCL vs. medial meniscus ? - May 7, 2005 1:49:00 PM
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steve
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From: Canada
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Just a little side on Alex's comment on sensitivity and having high false positives. Spin and Snnout rules are posted here but I do not believe that high sensitivity automatically leads to an increase in false positives:
http://www.cebm.net/sppins_snnouts.asp
I would love to see the article on Thessaly's test and see how the test is performed.
Steve
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Re: MCL vs. medial meniscus ? - May 7, 2005 9:30:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Steve,
Whoops. I meant to report that the McMurray test has a low sensitivity although different studies have shown sensitivity levels varying from .26-.58
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: MCL vs. medial meniscus ? - May 8, 2005 4:52:00 AM
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jma
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From: NY
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Hello,
The following was taken from the article.
"The Thessaly test is a dynamic reproduction of load transmission in the knee joint and is performed at 5° and 20° of flexion (Figs. 1-A, 1-B, 1-C, 1-D, 1-E). It was named in honor of the county, or prefecture, in our country, where our hospital serves as an academic medical referral center and which has a continuous, uninterrupted ten-thousand-year history. The examiner supports the patient by holding his or her outstretched hands while the patient stands flatfooted on the floor. The patient then rotates his or her knee and body, internally and externally, three times, keeping the knee in slight flexion (5°). Then the same procedure is carried out with the knee flexed at 20°. Patients with suspected meniscal tears experience medial or lateral joint-line discomfort and may have a sense of locking or catching. The theory behind the test is that, with this maneuver, the knee with a meniscal tear is subjected to excessive loading conditions and almost certainly will have the same symptoms that the patient reported. The test is always performed first on the normal knee so that the patient may be trained, especially with regard to how to keep the knee in 5° and then in 20° of flexion and how to recognize, by comparison, a possible positive result in the symptomatic knee."
JMA
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Re: MCL vs. medial meniscus ? - May 8, 2005 10:51:00 AM
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KAK
Posts: 200
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Thanks JMA!
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Re: MCL vs. medial meniscus ? - May 8, 2005 12:47:00 PM
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SJBird55
Posts: 2438
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From: Michigan
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LOL I never knew that was an actual test. I dink around with patients doing that same thing, almost - I don't hold onto their hands.
Steve - thanks for the specificity and sensitivity stuff. I can never keep the Ins and Outs straight in my head. That little page simplifies it so I'll probably have better luck remembering. Robert Duvall did a crappy job in his differential diagnosis continuing ed and without looking through his information, I think he was missing the capital P and the capital N in those explanations. NOW I understand and can probably remember without looking up the meanings.
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Re: MCL vs. medial meniscus ? - May 8, 2005 1:13:00 PM
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jma
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From: NY
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It appears that this new test shows promise but it still has to go through the paces before it is widely accepted. Otherwise, its just an unproven test.
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Re: MCL vs. medial meniscus ? - May 9, 2005 7:56:00 AM
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karmzack
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From: Hawaii
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Here is the table with sensitivity and specificity of the meniscus tests they used in the Thessaly article. None of the older tests were very sensitive in picking up a meniscal tear. I'll start using the 20 degree Thessaly test and see how it goes:
TEST DIAGNOSIS
McMurray test MMT LMT Men + ACL
Sensitivity 48% 65% 45%
Specificity 94% 86% 76%
False positive 4.20% 12.40% 23%
False negative 17.60% 3.20% 2.70%
Accuracy 78% 84% 74%
Apley test
Sensitivity 41% 41% 20%
Specificity 93% 86% 84%
False positive 4.60% 13% 38%
False negative 20% 5.40% 4%
Accuracy 75% 82% 59%
Joint-line tenderness
Sensitivity 71% 78% 65%
Specificity 87% 90% 80%
False positive 8.80% 9.30% 19%
False negative 10% 2% 1.70%
Accuracy 81% 89% 80%
Thessaly test at 5° of flexion
Sensitivity 66% 81% 65%
Specificity 96% 91% 83%
False positive 2.90% 8% 17.60%
False negative 11.40% 1.70% 1.70%
Accuracy 86% 90% 82%
Thessaly test at 20° of flexion
Sensitivity 89% 92% 80%
Specificity 97% 96% 91%
False positive 2.20% 3.70% 9%
False negative 3.60% 0.73% 1%
Accuracy 94% 96% 90%
_____________________________
Zack Solomon MPT, OCS, CSCS
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Re: MCL vs. medial meniscus ? - May 9, 2005 9:26:00 AM
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karmzack
Posts: 181
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From: Hawaii
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I have to criticize my last post. I wrote:
"None of the older tests were very sensitive in picking up a meniscal tear."
What I should have said was that none of the older tests were very sensitive in ruling out a meniscal tear.
Am I right with my Spin and Snnouts now?
_____________________________
Zack Solomon MPT, OCS, CSCS
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Re: MCL vs. medial meniscus ? - May 9, 2005 11:20:00 AM
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SJBird55
Posts: 2438
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From: Michigan
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The McMurray and the Apley have a decently high specificity for medial meniscus tear. So... if a positive test result occurred, then the diagnosis would be ruled in. (I think. LOL)
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Re: MCL vs. medial meniscus ? - May 9, 2005 2:40:00 PM
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jma
Posts: 2414
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From: NY
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The sensitivity and specificity of the Thessaly test at 20 degrees of flexion looks very promising. Wonder if someone has done a meta-analysis of all kinds of tests pertaining to the knee.
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Re: MCL vs. medial meniscus ? - May 9, 2005 2:55:00 PM
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karmzack
Posts: 181
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From: Hawaii
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Here is a meta-analysis done in 2001 in the Journal of Family Practice. All I have is the abstract. I'm trying to get an online full text copy. This analysis has a pretty strong conclusion.
The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis.
Scholten RJ, Deville WL, Opstelten W, Bijl D, van der Plas CG, Bouter LM.
OBJECTIVE: Our systematic review summarizes the evidence about the accuracy of those tests. SEARCH STRATEGY: We performed a literature search of MEDLINE (1966-1999) and EMBASE (1988-1999) with additional reference tracking. SELECTION CRITERIA: Articles written in English, ******, German, or Dutch, that addressed the accuracy of at least one physical diagnostic test for meniscus injury with arthrotomy, arthroscopy, or magnetic resonance imaging as the gold standard were included. We excluded studies if no reference group or only test-positives had been included, if the study pertained to cadavers only, or if only physical examination under anesthesia was considered. DATA COLLECTION/ANALYSIS: Two reviewers independently selected studies, assessed the methodologic quality, and abstracted data using a standardized protocol. We calculated sensitivity, specificity, and likelihood ratios for each test, and summary estimates when appropriate and possible. MAIN RESULTS: Of 402 identified studies, 13 met the inclusion criteria. The results of the index and reference tests were assessed independently (blindly) of each other in only 2 studies, and in all studies verification bias seemed to be present. The study results were highly heterogeneous The summary receiver operating characteristic curves of the assessment of joint effusion, the McMurray test and joint line tenderness indicated little discriminative power for these tests. Only the predictive value of a positive McMurray test was favorable. CONCLUSIONS: The methodologic quality of studies addressing the diagnostic accuracy of meniscal tests was poor, and the results were highly heterogeneous. The poor characteristics indicate that these tests are of little value for clinical practice.
_____________________________
Zack Solomon MPT, OCS, CSCS
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Re: MCL vs. medial meniscus ? - May 9, 2005 3:09:00 PM
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jma
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From: NY
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Interesting. I wonder what this new test will change that once it is added to the mix and then reviewed as well.
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Re: MCL vs. medial meniscus ? - May 14, 2005 10:33:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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I have read the research article about the Thassely test and have started using it in my clinic. Interestingly, last week I had a patient who I suspected had a lateral meniscal tear referred from our primary care department with diagnosis of lateral collateral sprain and had a pending knee MRI. He had a positive Thassely at 5 degrees and 20 degrees with lateral knee pain. His MRI came back on Friday confirming a fairly large lateral meniscal lesion. So far 1 for 1 on this test. Just thought I would pass that on.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: MCL vs. medial meniscus ? - May 15, 2005 3:21:00 AM
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jma
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From: NY
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Lets all try it and see if we get the same results as Alex did.
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Re: MCL vs. medial meniscus ? - May 16, 2005 4:48:00 AM
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USAPT
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I tried the test last week on an individual I suspected to have a MMT. She c/o of the same pain at both 5 and 20. Maybe there is something to this.
So, like Alex, I too am 1 for 1:)
_____________________________
Jason, PT
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