ABSTRACT
BACKGROUND: An accurate physical examination of knee pain can aid in determining the need for further diagnostic testing, specialist referral, and surgical intervention.
POPULATION STUDIED: The authors of this systematic review conducted searches of MEDLINE, Health STAR, and bibliographies of retrieved articles. They identified 88 articles of which 23 compared physical examination techniques to a reference standard (arthroscopy, arthrotomy, or magnetic resonance imaging).
STUDY DESIGN AND VALIDITY: Two of the authors graded the methodologic quality of the included studies using a standardized scoring system. The authors abstracted data from individual studies to calculate the sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for specific examination techniques.
OUTCOMES MEASURED: The sensitivity, specificity, LR+, and LR- were calculated for examination of anterior cruciate ligament (ACL) injuries (“composite” examination and Lachman, anterior drawer, and lateral pivot shift maneuvers), posterior cruciate ligament (PCL) injuries (“general” examination and posterior drawer and abduction stress test maneuvers), and for meniscus injuries (joint line tenderness, presence of joint effusion, and the McMurray and medial-lateral grind tests). No articles were found that examined the diagnostic accuracy of physical examination techniques for medial collateral ligament (MCL) or lateral collateral ligament (LCL) injuries. The review includes detailed descriptions of the examination techniques.
RESULTS: The results for all of the diagnostic tests are in the form of LRs. An LR greater than 10 provides strong evidence that the disorder is present; an LR less than 0.1 provides strong evidence that the disorder is not present. Scores between 0.5 and 2.0 are neutral. Summary LRs with 95% confidence intervals (95% CI) for examinations of ACL injuries were as follows: composite examination (specific maneuvers not delineated): LR+ = 25.0 (95% CI, 2.1-306.2), LR- = 0.04 (95% CI, 0.01-0.48); the Lachman test: LR+ = 25.0 (95% CI, 2.7 -651), LR - = 0.1 (95% CI, 0.0 - 0.4); anterior drawer test: LR+ = 3.8 (95% CI, 0.7 - 22.0), LR- = 0.3 (95% CI, 0.05 -1.50); and pivot shift stress test: LR+ = 42 (95% CI, 2.7-651.0) and LR- = 0.1 (95% CI, 0.0-0.4).
The anterior drawer, pivot shift, and Lachman maneuvers are useful for evaluating ACL injuries. The abduction stress test may be useful for evaluating PCL injuries but the posterior drawer test has not been evaluated. A “composite” examination has good test properties for ruling in or out either ACL or PCL tears; however, the specific maneuvers that constitute the “composite” are not defined. As also shown in a recent meta-analysis,1 no test including examining for joint line tenderness or for joint effusion, the medial-lateral grind test, or McMurray test is of value for determining meniscal tears. No data exist for the examination of MCL or LCL lesions.