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A Comparison Of Accuracy Between Clinical History, Physical Examination And Magnetic Resonance Imaging And Arthroscopy In The Diagnosis Of Meniscal And Anterior Cruciate Ligament Tears

Wee Lim Loo*,Yun-En Bernie Liu* ,Yee Han Dave Lee** ,Yee Hoong Michael Soon***

* Resident
* Resident
*** Consultant
Department of Orthopaedic Surgery, Alexandra Hospital, Singapore.

Address for Correspondence:  

Wee Lim Loo
Blk 2 St George’s Rd
#12-51 Singapore 320002
Tel: (65) 62925591


Background and aim: Magnetic resonance imaging of the knee is frequently used in the diagnosis of anterior cruciate ligament (ACL) and meniscal injuries. Arthroscopy has remained as the gold standard in the diagnosis of  internal pathologies of the knee, against which other modalities are compared. The aim of this retrospective study was to determine the reliability and value of clinical history, physical examination and MRI in our management of ACL and meniscal tears in the local context.
Methods: A total of 86 patients with a preoperative MRI done underwent arthroscopy over a 10 month period in a tertiary institution. Clinical history, physical examination and  MRI findings were compared with arthroscopic findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were then calculated.
Results: The sensitivity of clinical examination and MRI is 80.3% and 84.3% and specificity 94.2% and 91.4% for ACL tears respectively. Clinical examination for ACL tears has a PPV and NPV of 95.3% and 76.7% respectively while the PPV and NPV of MRI is 93.4% and 80% respectively. MRI is superior than clinical methods in diagnosing meniscus lesions. For the medial meniscus, It has a sensitivity of 91.4% and specificity of 66.6%. For the lateral meniscus, it has a sensitivity and specificity of 76% and 86.6% respectively.
Conclusion: Based on these findings, our current practice of requesting scans to routinely confirm the diagnosis should be altered. Unnecessary MRI scanning increases the financial burden and delays patient treatment. Equivocal clinical findings in patients with acute knee injury should lead to use of MRI in an appropriate clinical setting, and may lead to a reduction in unjustified knee arthroscopy.

J.Orthopaedics 2008;5(3)e8


Magnetic Resonance Imaging (MRI) has gained in popularity as a diagnostic tool of the musculoskeletal system since its introduction in the 1980s1. It is non-invasive and requires no exposure to ionizing radiation. Diagnostic arthroscopy of the knee has also been increasingly performed as it is highly accurate and can be therapeutic at the same setting. However, it may be complicated by infection, haemoarthrosis, adhesions and reflex sympathetic dystrophy, as well as complications related to anaesthesia2. In a medical environment with ever-increasing health costs and litigation, the judicious use expensive MRI or invasive arthroscopy in the diagnosis of internal derangements of the knee has not been clearly defined.  

Clinical diagnosis of knee pathology depends on the experience and expertise of the clinician. The high incidence of  abnormal MRI findings in asymptomatic subjects underscore the danger of relying on a diagnostic test without careful correlation with clinical history or examination3. Few would argue that there is little role for MRI when patients have definite clinical signs. However, when clinical symptoms and signs are subtle, MRI should be done as it may spare patients from unnecessary and expensive surgery4.  

Some authors5 suggest physical examination and well taken history are more cost-effective means of diagnosing anterior cruciate ligament and meniscal injury than MRI. If the clinical findings are sufficiently predictive, then an additional imaging study may be unnecessary before proceeding with a therapeutic arthroscopy. The patient can be saved time and expense. 

On the other hand, multiple nonrandomized studies in the literature have shown that MRI is cost-effective before the performance of knee arthroscopy6,7,8  and can decrease the frequency and subsequent need for arthroscopic surgery9. Rangger10 and Spiers11 have shown that in their studies that MRI examination of suspected meniscus injuries before the scheduled operation could reduce the total number of arthroscopies by 30%. Crotty12 proposed MRI as a screening tool before arthroscopy due to its high sensitivity for arthroscopically remediable lesions in cases of internal derangement of the knee. However, Bridgman et al13 reported that that MRI did not reduce arthroscopy rates or improve outcomes for his series of 252 patients waiting for knee surgery.  

The aim of this review is to determine the accuracy of clinical history, physical examination and MR Imaging in the diagnosis of knee injuries in our local population. This allows us to practice in a more cost effective approach, thus saving the patient unnecessary MRI or unjustified knee arthroscopy.

Material and Methods :

From our operative records between July 2007 and May 2008, we identified 86 patients who had a MRI knee investigation performed, and subsequently underwent knee arthroscopy as day case procedure under either regional or general anaesthesia. There were 8 female and 78 male patients age ranged from 18 to 53 years of age.

We retrospectively reviewed their medical records to review their clinical history and physical examination findings, MRI and arthroscopy findings of ACL and meniscus pathology.

A positive clinical history of a torn ACL includes symptoms of giving way or instability, and complaints of locking or decreased range of motion signify a positive history of meniscus pathology. A torn ACL is determined by clinical examination using the anterior drawer test or Lachman test while Mcmurray test is used to determine the presence of a meniscus tear.

Direct signs of ACL tear on MRI include nonvisualisation, discontinuity, wavy and irregular appearance and edematous mass in region of anterior cruciate ligament. Meniscal tears are depicted on MR images as areas of linear abnormally increased signal intensity within the meniscus, which extend to and communicate with an articular surface.

The MRI findings of anterior cruciate ligament (ACL), medial and lateral meniscal tears were recorded. This was compared against the intraoperative knee arthroscopy findings, which were regarded as the gold standard.

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were then calculated. The sensitivity measures the proportion of actual positives which are correctly identified while the specificity measures the proportion of negatives which are correctly identified as such. The positive predictive value is the proportion of patients with positive test results who are correctly diagnosed. The negative predictive value is the proportion of patients with negative test results who are correctly diagnosed. Accuracy is the proportion of true results (both true postive and true negatives) in the study cohort.

We then tabulated the sensitivity, specificity, PPV, NPV and accuracy of clinical history, physical examination and MRI against arthroscopy, which was used as a gold standard, in the diagnosis of ACL and meniscus tears. We then compared MRI against arthroscopy in determining medial and lateral meniscus tears.

Results :

ACL Tears

Figure 1 showed that clinical history has lower sensitivity, specificity, PPV and NPV than clinical examination and MRI. Clinical history of giving way or instability only has an accuracy of 75.7% (table 1).  Both clinical examination and MRI have higher accuracy of 86% and 87.2% respectively.

Clinical examination and MRI share similar sensitivity (80.3% v 84.3%) and specificity (94.2% v 91.4%) for ACL tears. Clinical examination for ACL tears has a PPV and NPV of 95.3% and 76.7% respectively while the PPV and NPV of MRI is 93.4% and 80% respectively. (refer to table 2 and 3)  

Meniscus tears

Clinical history of locking or decreased ROM has low sensitivity and specificity in diagnosing meniscus tears (table 1). Similary, the McMurray test exhibits only a sensitivity and specificity of 42% and 80.5% respectively (table 2). The overall accuracy of clinical history and examination is 50% and 58.1% respectively.

According to our results, MRI is superior to clinical methods in diagnosing meniscus tears (figure 2). Table 3 showed that for the medial meniscus, MRI has a sensitivity and specificity of 91.4% and 66.6% respectively. For the lateral meniscus, it has a sensitivity and specificity of 76% and 86.6% respectively.

MRI has a higher NPV of 91.8% (medial meniscus) and 89.8% (lateral meniscus), as compared to NPV of 80% for ACL tears.

Table 4 shows in the presence of a positive history and McMurray test, the PPV is 80%, which is higher than the PPV of MRI. However, it only has a low sensitivity of 16%.

Discussion :

The usefulness of MRI in evaluating the knee was first recognized in the early 1980s. It has also been shown to determine the extent of an injury and help in the planning of its management. Even when a particular diagnosis is clinically apparent, MRI can be used to delineate associated abnormalities and more fully demonstrate the extent of the injuries.

Our results suggest that in diagnosing ACL tears, clinical examination is comparable to MRI. The anterior drawer or Lachman test in diagnosing ACL tear has also been validated in other studies14, although the sensitivity varies depending on the experience of the surgeon. Madhu15 and Gelb16 reported 100% sensitivity while Nikolaou17 reported only 68% sensitivity of clinical examination. In our study, sensitivity of clinical examination is 80.3% and specificity is 94.2%, compared to sensitivity of MRI 84.3 and 91.4% respectively. Jackson18 reported a MRI sensitivity of 100% while Glashow19 reported only 61% in his cohort. In a multi-centre analysis of 1014 patients20, the accuracy of the diagnosis of ACL tear by MRI was 93%, compared to 87.2% in our centre. These results suggest that MRI is centre and radiologist dependent. The high PPV of clinical examination of 95.3% is comparable to other studies. This means that MRI may not cost effective in diagnosing ACL tears21, as compared to clinical methods.

In the diagnosis of meniscus lesions, the McMurray test, Apley test, Steinman sign and Childress test are examples of the numerous tests described in the literature. Joint line tenderness of the knee joint is non specific. Graham Apley wise words of “there is no pathgnomoic sign of meniscus” still ring true today, as our results show.

Clinical history of locking or decreased range of motion is not accurate (50%) and McMurray test has low accuracy of 58.1% in our study. Madhu15 reported only 38.75% sensitivity for meniscus tear by clinical examination and 59% sensitivity by MRI. His finding that clinical examination has low sensitivity is rather similar to our results of 42%, although we found that MRI has a sensitivity of 90% of identifying meniscus tears. In contrast, Rayan22 reported that clinical examination was overall superior to MRI in terms of sensitivity, specificity, PPV, NPV and accuracy in diagnosing meniscus tears.

Our study showed a sensitivity of 91.4% and 76% of MRI in diagnosing medial meniscus and lateral meniscus tears respectively. In our cohort, MRI has a specificity of 66.6% for medial meniscus tears and 86.8% for lateral meniscus tears and our results are similar to other published reports. Rangger10 reported sensitivity of MRI compared to arthroscopic findings was 93% for medial meniscus and 78% for lateral meniscus; specificity was 74% for medial meniscus and 89% for lateral meniscus. Raunest23 and Oei 24 also showed that MRI has a higher sensitivity for detection of tears of medial meniscus than for tears of lateral meniscus. Specificity is higher for tears of the lateral meniscus than for tear of medial meniscus.

Nevertheless, MRI has its limitations in diagnosing meniscus tears25, hyaline articular cartilage wear and in differentiating of complete and partial anterior cruciate ligament tears26. False positive MRI diagnoses of meniscal tears may lead to unjustified knee arthroscopy27. However, some authors sugest that at these meniscal abnormalities seen at MRI represent closed intrasubstance tears, which may not be detected at arthroscopy unless carefully probed. 

We recognise the limitations of this study in terms of the small numbers but believe that the groups studied are representative of the population normally attending the orthopaedic clinics. 


Our results emphasize the importance of history and clinical examination in the diagnosis of ligament and meniscus injuries of the knee. The anterior drawer or Lachman test is highly accurate compared to the MRI in diagnosing ACL tears. Our study also showed that a positive history and clinical finding of a meniscus tear has a higher positive predictive value than MRI. Therefore, MRI in these clinical scenarios may be unnecessary.

However, MRI has a role in excluding meniscus tears due to its high negative predicitive value, and may save the patient unjustified surgery. This study enables us to counsel our patients appropriately on the value of doing such an investigation as well as the subsequent management of MRI findings.

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This is a peer reviewed paper 

Please cite as : Wee Lim Loo: A Comparison Of Accuracy Between Clinical History, Physical Examination And Magnetic Resonance Imaging And Arthroscopy In The Diagnosis Of Meniscal And Anterior Cruciate Ligament Tears

J.Orthopaedics 2008;5(3)e8





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