The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. (Original Research).
* There is little evidence that the diagnosis of meniscal lesions of the knee can be improved by applying the assessment of joint effusion, the McMurray test, joint line tenderness, or the Apley compression test.
* Physicians should be aware of the limited value of those tests.
* The need for applying advanced diagnostic methods or referral for surgical treatment can be based only on the severity of the patient's complaints.
* OBJECTIVE Our systematic review summarizes the evidence about the accuracy of physical diagnostic tests for assessing meniscal lesions of the knee.
* SEARCH STRATEGY We performed a literature search of MEDLINE (1966-1999) and EMBASE (1988-1999) with additional reference tracking.
* SELECTION CRITERIA Articles written in English, French, German, or Dutch that addressed the accuracy of at least one physical diagnostic test for meniscus injury with arthrotomy, arthroscopy, or magnetic resonance imaging as the gold standard were included.
* DATA COLLECTION AND ANALYSIS Two reviewers independently selected studies, assessed the methodologic quality, and abstracted data using a standardized protocol.
* MAIN RESULTS Thirteen studies (of 402) met the inclusion criteria. The results of the index and reference tests were assessed independently (blindly) of each other in only 2 studies, and in all studies verification bias seemed to be present. The study results were highly heterogeneous. The summary receiver operating characteristic curves of the assessment of joint effusion, the McMurray test, and joint line tenderness indicated little discriminative power for these tests. Only the predictive value of a positive McMurmy test was favorable.
* CONCLUSIONS The methodologic quality of studies addressing the diagnostic accuracy of meniscal tests was poor, and the results were highly heterogeneous. The poor characteristics indicate that these tests are of little value for clinical practice.
* KEY WORDS Meta-analysis; diagnosis; physical examination; predictive value of tests; sensitivity and specificity; knee joint; knee injuries; menisci, tibial. (J Fam Pract 2001; 50:938-944)
Various physical diagnostic tests are available to assess meniscal lesions, such as assessment of joint effusion and joint line tenderness (JLT), the McMurray test, and the Apley compression test. (1-4) Many meniscal tests, however, are not easy to perform and seem to be prone to errors. (1,2,4) Also, the diagnostic accuracy of the various meniscal tests has been questioned, (3-5) and conflicting results regarding that accuracy have been reported. (6) Therefore, we systematically reviewed the medical literature to summarize the available evidence about the diagnostic accuracy of physical diagnostic tests for assessing meniscal lesions of the knee and to combine the results of individual studies when possible. We focused on the most common meniscal tests: the assessment of joint effusion, the McMurray test, JLT, and the Apley compression test.
Selection of Studies
We conducted a literature search of MEDLINE (1966-1999) and EMBASE (1988-1999) to identify articles written in English, French, German, or Dutch. The Medical Subject Headings (MESH) terms "knee injuries," "knee joint," "knee," and "menisci tibial," and the text words "knee" and "effusion" were used. The results of this strategy were combined with a validated search strategy for the identification of diagnostic studies using the MeSH terms "sensitivity and specificity" (exploded), "physical examination" and "not (animal not (human and animal))" and the text words "sensitivity," "specificity," "false positive," "false negative," "accuracy," and "screening," (7) supplemented with the text words "physical examination" and "clinical examination." Also, the cited references of relevant publications were examined.
Studies were eligible for inclusion if they addressed the accuracy of at least one physical diagnostic test for the assessment of meniscal lesions of the knee and used arthrotomy, arthroscopy, or magnetic resonance imaging (MRI) as the gold standard. Studies were excluded if no reference group (nondiseased group or subjects with lesions other than the lesion of study) had been included, if only test-positives had been included, if the study pertained to cadavers only, or if only physical examination under anesthesia was considered.
The studies were selected by 2 reviewers independently. A preliminary selection of each study was made by checking the title, the abstract, or both. A definite selection was made by reading the complete article. During a consensus meeting disagreements regarding the selection of studies were discussed, and a definite selection was made. If disagreement persisted, a third reviewer made the final decision.
Assessment of Methodologic Quality and Data Abstraction
The methodologic quality of the selected studies was assessed, and data were abstracted by 2 reviewers independently. A checklist adapted from Irwig and colleagues (8) and the Cochrane Methods Group on Systematic Review of Screening and Diagnostic Tests (9) was used for quality assessment. This checklist consisted of 6 criteria for study validity, 5 criteria relevant to the clinical applicability of the results, and 5 items pertaining to the index test. * In a subsequent consensus meeting, both assessors discussed each criterion on which they initially disagreed. If disagreement persisted, a third reviewer made the final decision.
Statistical analysis was performed according to a strategy adapted from Midgette and colleagues. (10) ** For each study, the sensitivity and specificity of each index test were calculated. The [chi square] test was used to assess the homogeneity of the sensitivity and the specificity among studies. If homogeneity of both sensitivity and specificity was not rejected (P >.10), summary estimates of sensitivity and specificity were calculated. (10) Heterogeneity of sensitivity and specificity might be caused by differences between studies in how clinicians define a positive test result. (8) In that case, the pairs of sensitivity and specificity will be negatively correlated, as indicated by a negative Spearman rank correlation coefficient (Rs). When the pairs of sensitivity and specificity are negatively correlated, these pairs can be considered to be originating from a common receiver operating characteristic (ROC) curve, and a summary ROC (SROC) curve was estimated by meta-regression. (8,10,11) The better the diagnostic accuracy of the test, the larger the area under the curve.
Differences between study characteristics are another potential source of heterogeneity of sensitivity and specificity. (8) Those other sources of heterogeneity were assessed by adding the following characteristics to the meta-regression model: study validity items (most valid category of each item vs other categories), setting (primary care vs other), the spectram of the diseased and the nondiseased (broad spectrum vs small spectrum), the prevalence of meniscal lesions, and the year of publication. When a significant subgroup was identified (P <.05), separate analyses were performed for each subgroup.
The summary estimates of sensitivity and specificity were used to calculate the predictive value of a positive (PV+) and negative (PV-) test result for circumstances with varying prevalences of meniscal lesions. When the sensitivities or specificities were heterogeneous between studies, however, the summary estimate of sensitivity was used for calculating predictive values with the accompanying specificity, estimated from the SROC curve.
Selection of Studies
The literature search revealed a total of 402 potentially eligible studies, of which 10 were selected for inclusion. (12-21) Three other studies were found by reference tracking. (22-24) Thus, 13 studies met the selection criteria. The reply to a letter to the editor to one of the studies contained additional information and was also considered for analysis. (17,25,26)
Methodologic Quality and Study Characteristics
The index test and reference standard had been measured independently (blindly) of each other in only 2 studies. (16,21) Verification bias seemed to be present in all studies (patients with an abnormal physical test result were more likely to undergo the gold standard test, inflating the sensitivity and decreasing the specificity). Nine studies applied arthroscopy as the gold standard, (12-14,16,17,19-21,24) and 1 study used MRI. (15) No study was performed in a primary care setting. In 7 studies a broad spectrum of knee lesions was reported, (12-15,17,20,21) and in 4 studies the spectrum was not specified (Table 1). (18,19,22,23) A broad spectrum of conditions in the reference group (nondiseased) was present in 8 studies, (12-15,17,20,22,23) while in 4 studies the spectrum was not specified. (18,19,21,24) Details regarding the index tests were poorly reported, except in 2 studies. (17,21) In all studies that addressed the McMurray test, the experience of a "thud" or "click" was used for designating a test as positive. (12,13,15-19,22) Only 2 studies mentioned assessment of the index test independent of knowledge of other clinical information (including the results of other meniscal tests). (17,21) * The age and sex distribution of the patients and the duration of complaints are presented in Table 1.
Accuracy of Meniscal Tests
The accuracy of the assessment of joint effusion was determined in 4 studies, the McMurray test in 11, JLT in 10, the Apley compression test in 3, and 5 studies addressed various other tests. No data were presented in or could be derived from 1 study pertaining to joint effusion, 3 studies regarding the McMurray test, (14,23,24) and 1 study on JLT, (24) while from 1 study pertaining to both the McMurray test and JLT only the point estimates of the various test characteristics were reported without the original number of patients in the various categories. (15) Of the study of Evans and coworkers, (17,26) who presented data of an inexperienced and experienced researcher, only the latter results were used. Of the study of Abdon and colleagues, (14) who made a distinction between tenderness of the medial and posterior part of the joint line, only the data of the medial part were considered. It should be noted that 2 studies incorporated a very small number of nondiseased subjects. (23,24) Also, one of those studies presented results from individual knees instead of subjects. (24) Part of their results pertained to both knees of the same subject, which violates the assumption of (statistical) independence of the observations. Therefore, this study was excluded from further analysis. Finally, some studies did not make a distinction between medial and lateral meniscal lesions, (13,17,19,22,23) while others presented the results for medial and lateral meniscal lesions separately. (12,14,15,18,20) Of the latter studies, only the results of medial meniscal tests were used for statistical analysis.
The diagnostic accuracy of assessment of joint effusion and the various meniscal tests is shown in Table 2. There was significant heterogeneity of sensitivity and specificity of all tests, except for specificity of the Apley compression test (P=.89).
Sensitivity and specificity were negatively correlated for joint effusion (Rs = -1.0), the McMurray test (Rs = -0.43), and JLT (Rs = -0.62). This means that as one increased, the other decreased, which is to be expected. The SROC curves (Figure 1) indicate lime discriminative power of those meniscal tests. No significant subgroups were detected for both tests. The power of meta-regression analysis, however, was low because of the small number of available studies.
[FIGURE 1 OMITTED]
Sensitivity and specificity of the Apley compression test were not correlated (RS = 0.0) and no SROC curve was estimated. Sources of heterogeneity could not be identified. Only 3 studies, however, addressed this test.
Figure 2 shows the positive predictive value (PV+) and negative predictive value (PV-) for the assessment of joint effusion, the McMurray test, and JLT, according to varying prevalences of meniscal lesions. The summary estimate of sensitivity and accompanying specificity (derived from the SROC curve) were used for joint effusion (0.43 and 0.70), the McMurray test (0.48 and 0.86), and JLT (0.77 and 0.41). Only the McMurray test had a favorable estimated PV+. The PV+ of joint effusion and JLT exceeded the presumed prevalences only slightly, indicating poor additional diagnostic value. The PV-of all tests was poor.
[FIGURE 2 OMITTED]
Our goal was to summarize the available evidence on the accuracy of various physical diagnostic tests for assessing meniscal lesions of the knee. The accuracy of those tests seems to be poor, and only a positive McMurray test result seems to be of some diagnostic significance.
However, because of the small number and poor quality of the studies found, we have significant concerns about the application of these results. Because of the methodologic flaws, the estimates of the various parameters of test accuracy probably will be biased, and the results of this meta-analysis should be interpreted with care. In view of the presence of review bias and verification bias in the various studies, the sensitivity of the various meniscal tests will be overestimated. The effect of those biases on specificity estimates, however, is less clear: Those specificities could be either overestimated or underestimated. Therefore, a rigorous conclusion regarding the diagnostic accuracy of the various meniscal tests cannot be made. Also, analysis of the influence of other potential sources of bias (like the type of gold standard, setting, and spectrum) was impeded by the low number of studies or the lack of information from studies.
The various physical diagnostic meniscal tests do not seem to be very helpful in guiding clinical decision making, and physicians should be aware of the very limited value of those tests. In the clinical determination of a meniscal lesion, however, meniscal tests are, of course, not applied in isolation. Combining the results of the various tests might improve accurate diagnosis of a meniscal lesion, and including other characteristics as well (eg, elements of history-taking) will further improve diagnosis setting. Those characteristics may even have more diagnostic power than the meniscal tests. Abdon and coworkers (14) performed a discriminant analysis and addressed the McMurray test, JLT, and various other signs and symptoms jointly. Of the meniscal tests only, JLT resulted in some additional discriminative power (apart from various elements of history-taking). The results of their analysis, however, are not readily understandable, and the contribution of the individual items to improve the ability to diagnose meniscal lesions correctly remains obscure. Reanalysis of their results by multiple logistic regression might give results that are more directly applicable in clinical practice.
Because no study has been performed in primary care, and test characteristics are influenced by referral filters, (27) one can only speculate what the effect will be of extrapolating the observed results to a primary care setting. If family physicians, who will be less experienced in performing those meniscal tests, apply as low a threshold for interpreting a test result as positive, the sensitivity of those tests will be higher, but the specificity will be lower. The predictive value of a negative test result will be affected only slightly, but the predictive value of a positive test result will decrease. On the other hand, when family physicians would apply a high threshold for test positivity, sensitivity decreases and specificity increases, resulting in an increased predictive value of a positive test result. Because of the case mix of patients with traumatic knee problems in primary care (ranging from vague minor knee disorders to clear-cut meniscal lesions), the prior probability (or prevalence) of having a meniscal lesion will be low in primary care, which means that the diagnostic gain will be low also (Figure 2).
RECOMMENDATIONS FOR FUTURE RESEARCH
Methodologically sound research on the diagnostic accuracy of the various physical diagnostic tests (determined both for each test separately and for all tests jointly) in combination with patient characteristics (eg, age, physical fitness, and functional demands) and elements of the medical history (eg, the type of trauma and the nature of the complaints) is needed. Such research will be more relevant to clinical practice and patient care if the effect of a correct early diagnosis on the functional outcome of the patient is assessed as well.
RECOMMENDATIONS FOR CLINICAL PRACTICE
For the time being, there is little evidence that the diagnosis of meniscal lesions of the knee can be improved by applying the assessment of joint effusion, the McMurray test, JLT, or the Apley compression test. The need for applying more advanced diagnostic methods (eg, MRI) or referral for surgical treatment can be based only on the severity of the patient's complaints.
TABLE 1 CHARACTERISTICS OF 13 STUDIES REGARDING THE ACCURACY OF PHYSICAL EXAMINATION FOR THE DIAGNOSIS OF MENISCAL LESIONS OF THE KNEE Spectrum of Lesion in: Study Diseased Nondiseased Noble, 1980 (22) Not specified CM, various other knee lesions Barry, 1983 (23) Not specified CM, various other knee lesions Anderson, 1986 (24) M+LM Not specified Steinbruck, MM, LM, various CM, ACL, various 1988 (12) other knee lesions other knee lesions Fowler, 1989 (13) M+LM, ACL ACL, CM, contralateral meniscus Abdon, 1990 (14) MM, LM, various Healthy subjects, various other knee lessions 0ther knee lesions Boeree, 1991 (15) MM, LM, ACL, PCL, contralateral ACL, PCL meniscus Saengnipanthkul, MM Plica medialis 1991 (16) M+LM, various Various other knee lesions Evans, 1993 (17,25) other knee lesions Corea, 1994 (18) Not specified Not specified Grifka, 1994 (19) Not specified Not specified Shelbourne, M+LM, ACL ACL, contralateral 1995 (20) meniscus Mariani, 1996 (21) LM, ACL Not specified Total No, of Age (Years) Patients Studied Mean (Range) Study Noble, 1980 (22) 200 (10-60+) Barry, 1983 (23) 37 men 7 women Not specified Anderson, 1986 (24) 76 men 24 women 31 (11-78) Steinbruck, 205 men 95 women 31 1988 (12) Fowler, 1989 (13) 106 men 55 women 33 (13-67) Abdon, 1990 (14) 110 men 35 women (16-66) Boeree, 1991 (15) 154 men 49 women 32.7 (6-71) Saengnipanthkul, 148 men, 42 women 26 (14-59) 1991 (16) Evans, 1993 (17,25) 104 Not specified Corea, 1994 (18) 93 men 25.3 (18-40) Grifka, 1994 (19) 61 men, 52 women 47 (15-78) Shelbourne, 118 men, 55 women 22.4 1995 (20) Mariani, 1996 (21) 243 men, 162 women 34 (14-77) Duration of Complaints Study Noble, 1980 (22) <1 month to > 1 year Barry, 1983 (23) Not specified, Anderson, 1986 (24) <2 weeks: 17; 2 weeks- 3 months: 31; >3 months: 52 Steinbruck, Not specified 1988 (12) Fowler, 1989 (13) >1 year Abdon, 1990 (14) Not specified Boeree, 1991 (15) Not specified Saengnipanthkul, Not specified 1991 (16) Evans, 1993 (17,25) Not specified Corea, 1994 (18) Not specified Grifka, 1994 (19) Not specified Shelbourne, 8 days (0-30 days) 1995 (20) Mariani, 1996 (21) Not specified CM denotes chondromalacia patelle; M+LM, medial + lateral meniscus (not separately presented); MM, medial meniscus; LM, lateral meniscus; ACL, anterior cruciate ligament; PCL, posterior cruciate ligament. TABLE 2 DIAGNOSTIC ACCURACY OF THE TESTS BASED ON THE DATA OF THE INDIVIDUAL STUDIES Study Affected Number of Meniscus Subjects Prevalence Joint Effusion Noble (22) * Medial+lateral ([dagger]) 200 0.73 Barry (23) * Medial+lateral ([dagger]) 44 0.84 Steinbruck (12) * Medial ([dagger]) 300 0.33 Lateral 300 0.13 McMurray Test Noble (22) * Medial+lateral ([dagger]) 200 0.73 Fowler (13) Medial+lateral ([dagger]) 161 0.50 Evans (17,25) Medial+lateral ([dagger]) 104 0.44 Grifka (19) medial+lateral ([dagger]) 113 0.65 Steinbruck (12) * Medial ([dagger]) 300 0.33 Lateral 300 0.13 Boeree (15) Medial 203 not estimable Lateral 203 not estimable Saengnipanthkul Medial ([dagger]) 73 0.26 (16) Corea (18) Medial ([dagger]) 93 0.37 Lateral 93 0.33 Joint Line Tenderness Noble (22) * Medial+lateral ([dagger]) 200 0.73 Barry (23) * Medial+lateral ([dagger]) 44 0.84 Fowler (13) Medial+lateral ([dagger]) 161 0.50 Grifka (19) Medial+lateral ([dagger]) 113 0.65 Steinbruck (12) * Medial ([dagger]) 300 0.33 Lateral 300 0.13 Abdon (14) Medial (dagger) 122 0.53 Lateral 80 0.29 Boeree (15) Medial 203 Not estimable Lateral 203 Not estimable Saengnipanthkul Medial ([dagger]) 73 0.26 (16) Shelbourne (20) Medial ([dagger]) 173 0.40 Lateral 173 0.53 Apley Compression Fowler (13) Medial+lateral ([dagger]) 157 0.49 Grifka (19) Medial+lateral ([dagger]) 113 0.65 Steinbruck (12) * Medial ([dagger]) 300 0.33 Lateral 300 0.13 Study Positive Negative Sensiti- Specifi- Likelihood Likelihood vity city Ratio (LR+) Ratio (LR-) Joint Effusion Noble (22) * 0.53 0.54 1.1 0.9 Barry (23) * 0.30 1.00 Infinity 0.7 Steinbruck (12) * 0.33 0.79 1.5 0.9 0.20 0.74 0.8 1.1 McMurray Test Noble (22) * 0.63 0.57 1.5 0.6 Fowler (13) 0.29 0.96 7.8 0.7 Evans (17,25) 0.20 0.91 2.3 0.9 Grifka (19) 0.66 0.63 1.8 0.5 Steinbruck (12) * 0.34 0.86 2.3 0.8 0.10 0.98 6.5 0.9 Boeree (15) 0.29 0.87 2.3 0.8 0.25 0.90 2.5 0.8 Saengnipanthkul 0.47 0.94 8.5 0.6 (16) Corea (18) 0.65 0.93 9.5 0.4 0.52 0.94 8.0 0.5 Joint Line Tenderness Noble (22) * 0.73 0.13 0.8 2.1 Barry (23) * 0.86 0.43 1.5 0.3 Fowler (13) 0.85 0.30 1.2 0.5 Grifka (19) 0.95 0.05 1.0 1.1 Steinbruck (12) * 0.73 0.62 1.9 0.4 0.53 0.91 5.9 0.5 Abdon (14) 0.78 0.56 1.8 0.4 0.78 0.95 14.9 0.2 Boeree (15) 0.64 0.69 2.1 0.5 0.28 0.87 2.1 0.8 Saengnipanthkul 0.58 0.74 2.2 0.6 (16) Shelbourne (20) 0.58 0.53 1.2 0.8 0.38 0.71 1.3 0.9 Apley Compression Fowler (13) 0.16 0.80 0.8 1.1 Grifka (19) 0.58 0.80 2.9 0.5 Steinbruck (12) * 0.47 0.82 2.6 0.6 0.23 0.99 19.5 0.8 * 2 x 2 tables reconstructed. ([dagger]) Study results used for meta-analysis.
* The checklist is available as Table WI on the JFP Web site, www.jfpopline.com.
** A schematic presentation of the strategy is available as Figure W1 on the JFP Web site.
* A detailed description of the methodologic quality of the 13 included studies is available as Table W2 on the JFP Web site, www.jfponline.com.
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ROB J.P.M. SCHOLTEN, MD, PHD WALTER L.J.M. DEVILLE, MD, PHD, WIM OPSTELTEN, MD; DICK BIJL, MD; CEES G. VAN DER PLAS, MD; AND LEX M. BOUTER, PHD Amsterdam, Utrecht, and Monnickendam, the Netherlands
* Submitted, revised, June 8, 2001.
From the Institute for Research in Extramural Medicine, Vrije Universiteit Medical Center, Amsterdam, (R.J.S., W.L.D., D.B., L.M.B.); the Julius Center for General Practice and Patient Oriented Research, University Medical Center, Utrecht (W.O.); and private practice, Monnickendam (C.G.v.d.P.). Reprint requests should be addressed to Rob J.P.M. Scholten, MD, PhD, Dutch Cochrane Centre, J2-229, Academic Medical Center, P.O. Box 22700, 1100 DE Amsterdam, the Netherlands. E-mail: R.J.Scholten@AMC.UVA.NL
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|Author:||Scholten, Rob J.P.M.; Deville, Walter L.J.M.; Opstelten, Wim; Bijl, Dick; Van Der Plas, Cees G.; Bou|
|Publication:||Journal of Family Practice|
|Article Type:||Statistical Data Included|
|Date:||Nov 1, 2001|
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