Meniscus

Diagnosis

Tear of a healthy meniscus

Injury to a healthy meniscus occurs with a rotational force on a loaded knee. The meniscus follows the tibia with flexion and also follows the femur with rotation.

Medial meniscal tears are more common than lateral meniscal tears (Baker et al- 81% to 19% with sex ratio being 3:1 male:female) Lateral meniscal tears can more commonly occur with acute ACL ruptures as there is anterolateral rotatory translation of the tibia on the femur. Medial meniscal tears are as common with chronic ACL deficiency.

There is sports specific difference in type and location of tears. Medial meniscus posterior horn tears and longitudinal tears are more common with football, skiing and basketball. Lateral meniscal tears are as commoner in wrestling, gymnastics and volleyball. Most tears of the medial meniscus involve the posterior third whilst middle zone tears of the lateral meniscus are more common..

Tear of a degenerate meniscus

A degenerate meniscus can tear with no specific injury. There is a reduction in mucopolysacharides with fibrocartilage degeneration and it is more likely that the tear is due to degeneration rather than the tear causing degeneration (Noble 1975) Degenerate meniscal tears are often associated with arthritic knees. Calcific menisci have a two-fold higher association with degenerate meniscal tear. Degenerate meniscal tears are usually flap tears, horizontal cleavage or of complex pattern.

History

Mechanism of injury

Sporting history

Occupation

Presence of clicking or locking or giving way

Pain on squatting or deep flexion

Tenderness

Tenderness along the joint line is more specific for lateral meniscal tears than medial meniscal tears. In the presence of an acute ligament injury, tenderness is not a useful sign. Careful evaluation by an experienced examiner identifies patients with surgically treatable meniscus lesions with equal or better reliability than MRI (Ryzewicz CORR 2007- Systematic Review). Numerous authors have reported that there is no significant difference in the accuracy of clinical examination and MRI in the diagnosis of meniscal or ACL tears. ( Rose Arthroscopy 1996, Kocabey Arthroscopy 2004, Thomas Knee Surg Sports Traumatol Arthrosc. 2007).

 Diagnostic Composite

 (1) a history of "catching" or "locking" as reported by the patient,
 (2) pain with forced hyperextension,
 (3) pain with maximum flexion,
 (4) pain or an audible click with McMurray's test, and
 (5) joint line tenderness to palpation.


Five positive findings on composite examination yielded a positive predictive value of 92.3% (Lowery,Steadman et al). Positive predictive values remained greater than 75% with composite scores of at least 3 in the absence of ACL and DJD pathologies. The presence of an ACL injury decreased the positive predictive value of 5 composite findings to 67%, whereas the presence of DJD increased predictability to 100%.

Special tests

  • McMurrays
  • Deep flexion
  • Steinman test
  • Apley's grinding test
  • Thesally test

    MRI Scan

    The negative predictive value (NPV) of clinical examination is no greater than 67%; therefore, about one third of meniscal tears are missed with clinical screening alone (Fowler, 1989; Spiers, 1993). In situations of multiple knee lesions, the accuracy of clinical examination in diagnosing meniscal tears decreases (Alseki 2003, Eren 2003, Shelbourne 1995, Oberlander, 1993). The negative predictive value of MRI scans is high and hence are useful to avoid unnecessary arthroscopy. The sensitivity of MRI scans to diagnose multiple injuries reaches almost 100% whilst for meniscal tears For MRI Scans to be more useful, there needs to be an integration of clinical findings with the Orthopaedic Surgeon's review of the scans. (Luhmann JBJS-A 2005) Musculoskeletal radiologists have to be given enough clinical information when requests are made for MRI scans.

    • MRI

    Peripheral Tear Posterior Horn Tear
    Root Avulsion Bucket Handle Tear


    Arthroscopy

    normal meniscus flap tear
    radial tear horizontal cleavage tear
    bucket-handle tear note

    References

    Ryzewicz M, Peterson B, Siparsky PN, Bartz RL The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res. 2007 Feb;455:123-33

    Fowler PJ, Lubliner JA. The predictive value of five clinical signs in the evaluation of meniscal pathology. Arthroscopy. 1989;5(3):184-186.

    Christoforakis J, Pradhan R, Sanchez-Ballester J, Hunt N, Strachan RK. Is there an association between articular cartilage changes and degenerative meniscus tears? Arthroscopy. 2005 Nov;21(11):1366-9.

    Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination.JAMA. 2001 Oct 3;286(13):1610-20. Review

    Eren OT.The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears.Arthroscopy. 2003 Oct;19(8):850-4.

    Rose NE, Gold SM.A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy. 1996 Aug;12(4):398-405.

    Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL.The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004 Sep;20(7):696-700.

    Thomas S, Pullagura M, Robinson E, Cohen A, Banaszkiewicz P.The value of magnetic resonance imaging in our current management of ACL and meniscal injuries. Knee Surg Sports Traumatol Arthrosc. 2007 May;15(5):533-6.

    Shelbourne KD, Martini DJ, McCarroll JR, VanMeter CD.Correlation of joint line tenderness and meniscal lesions in patients with acute anterior cruciate ligament tears. Am J Sports Med. 1995 Mar-Apr;23(2):166-9.

    Lowery DJ, Farley TD, Wing DW, Sterett WI, Steadman JR A clinical composite score accurately detects meniscal pathology. Arthroscopy 2006 Nov;22(11):1174-9

    Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005 May;87(5):955-62.

    Fahmy NR, Williams EA, Noble J. Meniscal pathology and osteoarthritis of the knee. J Bone Joint Surg Br. 1983 Jan;65(1):24-8.

    Yoon YC, Kim SS, Chung HW, Choe BK, Ahn JH.Diagnostic efficacy in knee MRI comparing conventional technique and multiplanar reconstruction with one-millimeter FSE PDW images.Acta Radiol. 2007 Oct;48(8):869-74.

      No single test is diagnostic of a meniscal tear. A combination of clinical history with mechanism of injury, joint line tenderness and special tests help in the diagnosis.

    If the clinical diagnosis is doubtful, MRI scans are 90-98% sensitive in making the diagnosis. There is limited role for diagnostic arthroscopy of the knee. Clinical tests for meniscal tears are less accurate in the presence of acute ligament injuries. preservation and even restoration 

          
    © Knee Joint Surgery 2010


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