Background/Purpose: Clinicians often rely on mechanical symptoms (e.g. clicking, catching, popping, giving way) and tests such as the McMurray sign in the diagnosis of symptomatic meniscal tear (MT). While the diagnostic value of these findings has been validated in younger patients with traumatic MT, there is limited data on the utility of the history and physical exam in the diagnosis of symptomatic MT in middle-age and older persons.

Methods: We enrolled patients > 45 years old presenting with unilateral knee pain to 2 academic orthopedists. A research associate completed a standardized medical history and musculoskeletal physical exam. The history included mechanical symptoms and other items such as symptom duration and diffuse vs. localized location. The exam included identification of tender areas, motion, provocative tests and performance tests. The orthopedist, blind to this standardized assessment, rated his confidence that patients’ symptoms were attributable to MT from 0 (certain the symptoms are NOT from MT) to 100 (certain that symptoms ARE from MT). We defined the primary outcome (“expert diagnosis of MT”) as confidence > 70. History and physical exam findings associated with this outcome (p < 0.05 or OR > 1.5 or < 0.75) in bivariate analyses were advanced to multivariate models. Findings associated in the model (p < 0.05) with expert diagnosis of MT were included in an additive index, with weights proportional to adjusted OR’s.  We calculated the proportion of subjects with particular index scores that had expert diagnosis of MT.

Results:  The sample consisted of 80 persons who provided history and physical exam data. Median age was 62 years (range 47, 90) and 66% were female. 28% had expert diagnosis of MT. In bivariate analyses, none of the traditional mechanical symptoms (locking, clicking, catching, popping, giving way) were associated with expert’s diagnosis of MT, nor was the McMurray test. History findings associated with expert diagnosis of MT included having localized pain (that the subject could point to with 1 finger) and pain present for < 1 year. Physical exam findings associated with expert diagnosis of MT were joint line tenderness, absence of anserine bursa tenderness and knee pain with the step down test. These history and exam findings were aggregated into an additive index with 1 point for each positive feature and 1 subtracted for anserine bursal pain.  6% (1/17; 95% CI 0-17%) of subjects with -1 or 0 points had expert diagnosis of MT, while 21% (9/43; 95% CI 9-33%) of those with 1-2 points and 60% (12/20; 95% CI 38-82%) of those with 3-4 points had expert diagnosis of MT.

Conclusion:   In this sample of middle-age and older subjects with knee pain, select history and physical findings identified subjects with low (~6%) risk of expert diagnosis of MT and a group with moderate risk of ~60%. These findings suggest that the history and physical exam may be useful in the diagnosis of MT, but that emphasis on the “mechanical symptoms” traditionally thought to be associated with meniscal tear may not be useful in determining whether those symptoms are attributable to MT in older patients with knee pain.   

---

« Back to 2013 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-value-of-history-and-physical-examination-findings-in-the-diagnosis-of-symptomatic-meniscal-tear-among-middle-age-subjects-with-knee-pain/