November 2017 - Lenny Macrina

Meniscal tears are commonly observed in an outpatient physical therapy setting. The ability of a PT to evaluate a patient’s knee and diagnose a meniscus tear can help guide the treatment plan for that patient. Having specific tests that can accurately and quickly pick up a meniscal tear are valuable.

Lots of test options but stick with the subjective

There are many theories, tests, and exam techniques that are reported in the literature. I definitely don’t know all of them but have been exposed to a bunch of common ones that I have found to be helpful.

Before I get bogged down with these tests and try to sound intelligent, I’d be remiss to not state the obvious… the subjective portion of the exam is by far the most important aspect and needs to be thoroughly utilized. In many cases, ok maybe most cases, the client will tell you what’s going on…as long as you ask the questions correctly and listen to their responses.

This will most likely be a blog post at some point in the near future but as a collective profession known as medicine, we suck at listening and utilizing the information correctly. But I digress…

What Tests are out there?

There are many tests reported in the literature, commonly including:

McMurray’s
Apley’s compression
Joint line tenderness
Thessaly’s
End range flexion/extension overpressure

Unfortunately, the literature does not support using these tests to diagnose and may add to the fear avoidance a patient may exhibit after such a diagnosis. This systematic review and meta-analysis in the British Medical Journal stated:

“The results of this systematic review indicate that the accuracy of McMurray’s, Apley’s, JLT and Thessaly to diagnose meniscal tears remains poor. This conclusion must be taken with caution since frequent methodological design flaws exist within the included studies, most studies suffered from various biases, and between-study heterogeneity makes pooled data unreliable.”

To tell you the truth, I don’t even do the Apley’s compression test. I probably haven’t done the test since PT school sometime in 2001. Never saw a value, kinda like the Thessaly Test. Nice in theory but just not good enough when tried in a clinical setting. Unfortunately, most research and the associated methods are lacking so the results are pretty poor when trying to diagnose a meniscus tear.

Oh boy, now what do we do? Do we even need to diagnose the tear in the 1st place and add more fear to the patient’s hurting knee?

Even need to Diagnose Meniscus Tears?

I say yes… but with a caveat!

We must accurately diagnose and explain to the patient that many people have meniscal tears in their knee. The recent literature builds a strong case for a very good recovery without surgery. That’s right, surgery is often not needed for many people diagnosed with a meniscus tear.

This landmark paper in the New England Journal of Medicine (neighbors of Champion PT and Performance in Waltham, MA) really created waves when it was released in 2013. They stated that “outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.” Now, these people did have a diagnosis of knee arthritis as well, but so do many of the people we see on a daily basis.

Hopefully, many clinicians have changed their treatment algorithms and have opted for conservative treatment first.

Don’t get me wrong, surgery may be needed, especially for the people sustaining an acute meniscus tear. But that may only be a small portion of the people presenting to us in the clinic. In these people, I still say give it a bout of conservative treatment to calm the knee down, restore ROM and strength and see how they do. Maybe a 6 week PT course is all they need, you never know. I have definitely seen it work, no doubt!

What meniscus tests do I do?

With all of that being said, I still believe your clinical examination is ultra-important to help guide the treatment plan.

As usual, keep it simple and don’t over-search. It needs to be pretty straightforward and it often is. The exam NEEDS to match the clinical history…let me say that again….the exam NEEDS to match the clinical history.

The client is going to tell me their issue and I just need to make sure my tests and measures solidify my working theory. I promise you that if you ask the right questions the right way, then you will have that much more information to at your disposal.

So, my go-to tests are:

Joint line palpation
End range flexion/extension pain/locking
McMurray’s (but often not very valuable)

…in that order. I’d say joint line palpation and end range of motion are my 2 most valuable tests. I still do the McMurray’s test to see if it can add to the story. It often gives me very little information so I don’t rely on it too much.

Many of you are going to ask why I didn’t even mention the Thessaly test. I see it talked about a lot on social media. I just don’t understand why we’d want to put our client in a weight-bearing position, slightly bend their knee, and have them twist on a painful knee.

Never mind the research telling us that the test is not very valid which goes completely against early research that said it was a valid test.

The more (tests) the Merrier

Maybe we need to combine this test with others to help improve our accuracy as this paper showed in 2009.

Either way, there seems to be a case to cluster tests to help us draw better conclusions, as was stated in this paper in 2006. “Five positive findings on composite examination yielded a positive predictive value of 92.3%. Positive predictive values remained greater than 75% with composite scores of at least 3 in the absence of ACL and DJD pathologies.”

This paper nearly matches my thought process. Obtain a good history, assess the joint line for tenderness, then put the joint at end range flexion/extension. If the symptoms match, then we will OFTEN have a meniscus tear.

Keep in mind that the particular side of the meniscus tear may influence the ability to detect a pathology. Lateral meniscal tears may be easier to distinguish than medial meniscal tears if we’re talking about joint line tenderness alone and was even the case in this 2009 article too.

Final Word on Diagnosing Meniscus Tears

Meniscus tears are pretty prevalent in the outpatient setting. Rehab specialists, including PT’s and athletic trainers need to understand what tests are best to deploy. I’m sticking with my in-depth history, joint line tenderness, and painful end-range as my go-to cluster of tests.

I’m pretty sure it has done me well over the years…and the research seems to match my thoughts too.

Online Knee Seminar Course

We discuss this and much much more in my online knee course that I have with Mike Reinold. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint.

As a physical therapist, athletic trainer or any other rehabilitation specialist, we are always looking to improve our client’s outcomes. Without question, that is the single most important thing we can do to help others.

How do we do improve outcomes?

I can honestly say that you don’t always need to take every continuing education course under the sun and build all of your manual therapy skills in order to achieve better outcomes.

That’s not to say that it can’t help…but I’d say the one thing that helped improve my outcomes with my clients was a philosophical change I made with them and myself.

Too much of a softy

You see, I was too easy on them. I spent hours upon hours working with them in the clinic. I used all of my knowledge acquired from going to CEU courses, teaching me how to improve my manual therapy skills or how to assess their movement even better than I thought I was already doing.

All of this is great, I suppose, but only a very small fraction of what is truly needed to succeed as a PT (or any other clinician).

Empower the Client

To me, the greatest change that I made was to empower my clients (translation: hold them accountable!)

When I first started practicing PT in 2003, I would assign homework, so to speak, in the form of a home exercise program, like most of us do. The problem was, I didn’t always follow through in making sure the client was accountable.

I remember people telling me that they just didn’t have the time to do the work or forgot to do it. I tried to blame them and wasn’t pro-active enough. In retrospect, I was always reacting to each situation instead of setting the tone for the treatment plan.

Philosophical Change

I had to change my philosophy, my delivery, my rapport and my interactions. It was me, not them. It’s this mindset that many need to utilize when they’re dealing with others, in general. If something doesn’t go as expected, one needs to look at their own actions and emotions and figure out how to make the situation better in the future.

It’s easy to blame others when things don’t go right.

In the PT-client relationship, you are dictating the situation therefore the outcomes will rely on your ability to take the lead. The client has no idea what to expect or what to do. Often times, they’ve never been to PT before or have never had to deal with an injury or surgery.

Understand the WHY

The PT needs to step up and ensure that the client fully understands the home program and WHY the program will help them in their recovery. It’s easy to slip a pre-made sheet of exercises at someone and tell them to do it daily (which I very rarely tell people to do anyway) or to do them every other day (yeah, that’s more my style!)

The key is for the client to feel excited by their new home program because it will be the key to their success, the key to their recovery and the key to returning to whatever they’re looking to do. I somehow missed that point when I was first practicing as a PT.

My key, now, is to connect with the client as quickly as possible so they have the utmost trust in all I say and do. They trust that I’m not going to waste their time and efforts. They fully understand the exercise, why it will help them and a potential mechanism of why it is the best for them right now.

I’m not afraid to tell them “I don’t know” but I will tell them that a particular movement or exercise has helped others in the past and believe the same is true for them too. Take each experience and interaction and file it away…you’ll need it for the future.

Take it to the house

So, if you’re looking to improve your outcomes, make sure the client is held accountable and they fully buy in to your plan. That edge will be the game changer in your practice, trust me!

Diagnosing meniscus tears: What’s the literature telling us now?