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Clinical Evaluation Of The Knee For Medial Meniscal Lesion And Anterior Cruciate Ligament Tears: An Assessment Of Clinical Reliability

 Mohammad Farooq Butt *,Munir Farooq **,Shabir A Dhar* ,Naseemul Gani*** ,Anwar Hussain *,Imran Mumtaz #

*    Senior Registrar
**  Associate Professor
***Specialist Resident
#   PG ScholarGovt. Hospital for Bone & Joint Surgery, Srinagar. Kashmir.India.190005.

Address for Correspondence:

Mohammad Farooq Butt
Govt. Hospital for Bone & Joint Surgery, Srinagar. Kashmir.India.190005.
TELEPHONE: 91 94 19004007

J.Orthopaedics 2007;4(4)e7


The knee is one of most frequently injured joint because of its anatomical structure, its exposure to external forces and the functional demands placed on it.1 With increase in vehicular trauma, competitive and recreational athletic activities acute traumatic lesions of the knee are becoming increasingly common.

            Accurate diagnosis of these traumatic lesions is of paramount importance to facilitate appropriate management, prevention of long term disability and improve clinical outcome.1 Clinical suspicion provokes the clinician to request other diagnostic modalities to rule out any fallacy in the clinical judgment. A no of non invasive and invasive diagnostic aids are currently available to confirm the intraarticular pathologies. Despite this rapid progress in diagnostic imaging, clinical evaluation still remains the basic step in management of these injuries. Accurate clinical diagnosis can decrease the incidence of unnecessary costly investigation.

            The purpose of this study was to compare the findings on clinical evaluation, with those on arthroscopy to determine the accuracy of clinical methods for specific type of knee lessons.

Material and Methods :

This was a retrospective study of one hundred and forty cases with knee pain in whom a clinical evaluation was followed by arthroscopic examination by the senior author (M.F).There were ninety eight male and forty two female patients. The patient age ranged from sixteen to fifty seven years (mean forty two years) Right knee was involved in eighty nine and left in fifty one cases. Duration of symptoms avenged six months (range four month to thirteen months). Patients wee referred to senior author from out patient department, general practitioners and orthopedics surgeon with the clinical suspicions of a knee lesion. Patients were evaluated by the senior author and the co-authors.

            Examination involved detailed clinical examination of the involved joint apart from an entire general examination. Specific tests were performed to diagnose the cause of pain.2. These included. -McMurry’s test for meniscal tears, Appley’s grinding test, Squat test 1, Anterior and posterior drawer test for cruciate ligament integrity, valgus and varus tests for collateral ligament stability

 A clinical diagnosis was made and recorded in the patients’ record sheet.  Patients were required to get their affected knee radiographed, followed by magnetic resonance imaging [MRI].Patients were provisionally dated for an arthroscopic examination of the knee.

 Arthroscopic examination in all cases was done by the senior author [MF].  A Storz arthroscope was used for examination. Procedure was performed under spinal, epidural or general anesthesia. Tourniquet was applied before the procedure was begun.

            An inflow cannula was inserted in the suprapetellar pouch and joint distended with normal saline. An anterolateral portal was chosen, located approximately one cm above the lateral joint line and approximately, one cm lateral to the margin of the patellar tendon. If required an anteromedial portal one cm above the medial joint line and one cm inferior to the tip of the patella and one cm medial to the edge of the patellar tendon was used. A 30-degree oblique fore lense arthroscope was used for most diagnostic procedures. The examination of the joint was routinely done in the following compartments, supra patellar pouch, patelo- femoral joint,, medial and lateral gutter, medial and lateral compartment, intra condylar notch and posteromedial and posterolateral compartment.

            The findings of knee examination were recorded in the case sheet. Specific procedure was carried out in the same or addressed subsequently.

            The data was analyzed to calculate the sensitivity and specificity and the predictive value of the clinical examination, with arthroscopy as the gold standard for comparison.

Results :

The results of clinical examination were compared with those of arthroscopy. Clinical examination of medial meniscal tear yielded seventy four true positive, thirty two true negatives nineteen false positives and fifteen false- negative results. The sensitivity was 83.14% and the specificity 62.74%. the positive predictive value i.e. percentage of patients who were diagnosed as having a medial meniscal tear on clinical examination were subsequently found to have tear on arthroscopy, was 79.56%. The negative predictive value i.e. the percentage of patients who were diagnosed as having no tear on clinical examination and were subsequently found to have no tear on arthroscopy was 68.08%

            Clinical examination of anterior cruciate ligament tear yielded twelve true positive, seven false negatives, eight false positives and one hundred thirteen true negative results. The sensitivity in this case was 63.15% and specificity of 93.38%. The positive prediction value of clinical examination            was 60% and negative predictive value of 94.16%

                        Common condition which was mostly misdiagnosed as medial meniscal tear included medial compartment osteoarthritis.


Knee pain is present in up to 20% of the adult general population 3, 4 and is associated with clinically significant disability 3, 4, 5.   Meniscal and ligament injuries are amongst the common cause of this ailment. Approximately two thirds of all derangements of the knee joint are due to lesions or degenerative changes of the menisci 2, 6.


            The diagnosis of internal derangement of the knee caused by meniscal tear can be difficult even for experienced orthopaedic surgeon. History and clinical examination supplemented by standard radiographs, imaging techniques and arthroscopy minimizes the errors in diagnosing meniscal tears to less than 5% 1. On the other hand with a careful history and examination, an acute injury to a knee ligament usually can be localized, classified and graded according to its severity. Though the advances in technology in medicine have resulted in a de-emphasis on the rudimentary history and clinical examination 2 the significance of a meticulous clinical evaluation in diagnosing a knee problem cannot be under estimated.


                        An early study demonstrated that physical examination had a clinical accuracy of 75 percent in patients who had symptoms suggestive of internal derangement of the knee; the clinical findings were compared with the arthroscopy 7. Jackson et al 8 while evaluating the knee pain in the primary care reported that physical examination was reasonably sensitive in detecting  meniscal injuries, anterior cruciate ligament, and posterior cruciate ligament tears (74% to 81%) but less sensitive for  detecting other cartilaginous lesions. For all lesions, except medial meniscal lesions, specificity was high (92% to 96%) suggesting that physical examination is usually normal in patients without damage to these structures. Our findings are in agreement with the above observation in that specificity of clinical examination in diagnosing medial meniscal lesions was only 62.24% whereas the same for anterior cruciate ligament was 93.38%.


Another study 9 on correlation of arthroscopic and clinical examination with magnetic resonance imaging findings of injury knees in children and adolescents reported a highly positive correlation (78.5%) between clinical and arthroscopic finding for meniscal, anterior cruciate ligament and articular surface injuries. In this series, accuracy, positive prediction value, negative predictive value, sensitivity, and specificity data were much more favorable for clinical examination than from magnetic resonance imaging.  

The findings of the present study show that clinical examination had a high specificity (P<0.05) for diagnosing anterior cruciate ligament injuries, the sensitivity though was less. On the contrary specificity for diagnosing a tear of medial meniscal was statistically insignificant (P>0.05) Most common conditions that were erroneously diagnosed as medial meniscal tear were medial compartment osteoarthritis loose bodies and chondromlacia patellae.           

Gilles 10 in 1979 which comparing clinical evaluation, arthrography and arthroscopy reported that a clinical evaluation was the most accurate diagnostic procedure in diagnosing meniscal lesions. The rapid progress in arthroscopic surgery during the past decade may prove this statement wrong, but the fact is that the importance of a clinical examination can never be overlooked. Supported by the current findings and reports in literature, we reiterate the importance of a robust clinical diagnosis, sparing patients from expensive & unnecessary diagnosis tests.


Knee pain is a common presentation in orthopaedics and traumatology, and clinicians choose several imaging modalities to come to a diagnosis. A careful physical examination is especially importance in initial evaluation with remarkably good diagnostic accuracy in the hands of a trained examiner. This would avoid unnecessarily non invasive requisitions, and referral for invasive diagnostic modalities apart from the potential cost saving benefits.

Reference :

Miller RH. In Campbell’s operative orthopaedics. S. Terry Cannale (Ed) St. Louis Mosby. 1998. 

2.         Shahriaree, Heshmat (Editor) O’Connor’s Textbook of arthroscopic surgery, Philadelphia,   J B Lippincot. 1984. 

3.         Lohnert. J. Raunest J: Die artheroskopie des kniegelenkes; Eine analyse aus 3500 artheroskopien. Orhthop. Praxis, 23; 8-11, 1986. 

4.         McAlindon TE, Cooper C, Kirwan JR, Dippe PA, Knee pain and disability in the community, Br. J. Rheumatol 1992:31;189-92. 

5.         Gucclone AA, Felson DT, Anderson J.J. Defining arthritis and measuring functional status in  elders: methodological issues in the study of disease and physical disability. Am J. Public Health 1990:80; 945-9.

6.         Raunest, J. Lohnert J. Intra und postoperative komplikationen bei 7000 arthenoskopischen Operationnen am knie.  Arthroskopie, 2 47-52, 1989. 

7.         McAlindon TE, Snow S, Cooper C, Dippe PA. Radiographic patterns of osteoarthritis of the knee joint in the community: the importance of the patelofemoral joint. Ann Rheum Dis; 1992:51; 844-9. 

8.         Jackson JL. O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med 2003:139:575-588. 

9         Stanitiski CL. Correlation of arthroscopic and clinical examination with magnetic resonance imagining finding of injured knees in children & adolescents The Am J sports Med. 1998:26; 2 - 6 

10        Gilles H, Seligson D. Precision in the diagnosis of meniscal lesion: A comparison of         clinical evaluation arthrography, and arthroscopy. J Bone Joint Surg. 1979, 61-A, 343-6. 


This is a peer reviewed paper 

Please cite as : Mohammad Farooq Butt : Clinical Evaluation Of The Knee For Medial Meniscal Lesion And Anterior Cruciate Ligament Tears: An Assessment Of Clinical Reliability

J.Orthopaedics 2007;4(4)e7





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