Improving Clinical Detection of Meniscal Tears: Choosing the best test to expedite proper treatment or referral to orthopedic specialist (Mar 2018)

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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2018   Improving Clinical Detection of Meniscal Tears: Choosing the best test to expedite proper treatment or referral to orthopedic specialist   CURRENT EVIDENCE Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Jt Surg Am. 2005;87:955–62.  by Andrew Neumeister, PT, DPT, FAFS Background Clinical assessments rely on using diagnostic techniques to determine meniscal pathology; however, reliability on commonly used tests was not statistically significant for many of them. Recent research shows that the Thessaly test is much more reliable during routine clinical assessments of knee pain and injury for meniscus tears than McMurray’s test and Apley’s Grinding Test.    Method 213 patients presenting with knee injury and 197 asymptomatic volunteers were examined and recorded through 5 clinical tests: medial and lateral joint line tenderness test, the McMurray test, the Apley compression and distraction test, and the Thessaly test at both 20 deg. and 5 deg. of flexion. Afterwards, all participants underwent MRI imaging for reference standard and the symptomatic group received therapeutic arthroscopic surgery for further confirmation.  Results The Thessaly test performed at 20-deg. knee flexion was statistically significant for diagnosing medial and lateral meniscus tears. For medial and lateral tears, respectively, sensitivity was .89 and .92 while specificity was .97 and .96. Accuracy in the test was 94% for MM tear diagnosing and 96% for LM tear diagnosing. All other tests performed were less than 90% accurate with the Thessaly at 5 deg. performing next most clinically relevant. THE PEAK PERFORMANCE PERSPECTIVE The aforementioned was a level 1 study, helping clinicians decide best practice when evaluating knee pain and suspecting there might be a meniscal tear that may require referral to an orthopedic specialist.  Performing the Thessaly Test at 20 deg. knee flexion is simple and takes less than 60 seconds when done efficiently. The patient stands on the affected leg alone, knee flexed to 20 deg. and internally/externally rotates the hip and knee. A positive test is depicted as reproduction of symptoms and/or a locking/catching sensation. Early detection is crucial in getting the appropriate practitioners involved to treat the tear, both conservatively with physical therapy or with more aggressive measures when warranted. Although the article helps us to rule out meniscus injury, it would be nice to know the false positive rates for r/o other ligamentous/joint pathology, which may be symptomatic with weight-bearing rotational stress to the knee (i.e. OA, MCL, LCL, ACL, ITB syndrome). Once a meniscal tear is diagnosed, the best evidence currently suggests those patients with a degenerative tear may be equally or preferably appropriate for non-operative conservative management through Physical Therapy. Utilizing careful frontal and transverse plane pre-positioning and/or movements during WB exercises can be a key to success during exercises otherwise often causing pain or defined as “unable due to symptoms” with traditional approaches. While there are no singular and fixed compensations that “everybody” “always” demonstrates, we do find very good results, even with otherwise deemed “failed PT” cases, when adequate ROM and function are restored to adjacent joints.  For example, inadequate internal rotation ROM of the hip and the ability to control it can result in increased transverse plane motion of the tibio-femoral joint, predominately in knee-flexed positions, which creates further rotational demands at the knee. From a bottom-up perspective, the foot hitting the ground can mitigate stress towards or away from the knee depending on availability and ability to decelerate pronation at the rear and midfoot complex. Over-pronation could lead to a genu valgus type presentation with increased lateral compressive forces and likewise genu varus with a tight ITB and supinated (or lacking pronation) foot types, which contributes potentially to medial joint loading   THE PEAK PERFORMANCE EXPERIENCE John stated after his rehabilitation: “PT helped me move from tightness, fear, and limited mobility in my right knee to confidence and near-normal range of motion. It has been a very satisfying experience with the crew at Peak Performance.” HX: The patient is a 64-year-old male with a right knee MM tear per MRI and decreased mobility secondary to pain and limited ROM and strength. He had a cortisone injection 10 days prior to initial eval without any relief.  Right Knee Subjective: Max Sx 8/10. Self-reported function at 20% with difficulty sitting greater than 10 min, symptoms with stair navigation, and reduced ambulatory ability. IKDC outcome questionnaire rated 60% (performed on reevaluation) Objective Data: Modified Thessaly with standing rotational balance at 5 degree angle (+) for pain reproduction and limited performance vs uninvolved knee. See table below.    MEASURE *=pain  INITIAL EVALUATION DISCHARGE AROM Knee Flexion deg. 0-132* 0-147 Isometric Quad kg 39.7/30.1* (76%) 39.7/42.0 (106%) Single leg squat (2-finger assist) 107/95* (89%)   107/110 (103%) Stepdown Ant. Quad testing 6” no load – 26x/10x (38%)  4” with 12 lbs - 14x/11x (79%) Anterior hop 1x N/T 52 cm/65cm (125%) Treatment: Manual Therapy Joint mobilizations for increasing symptom-free flexion Joint mobilizations to address eversion loss to reduce lateral stress at the knee Exercise Flexion PROM, Quad stretching Progressive WB strengthening Utilizing medial joint protection with pre-positioning and reaches especially for quad activation Stair training with step up/down for distinguishing hip and knee functional muscle recruitment Hips and foot-ankle emphasized for dynamic control at adjacent joints Proprioceptive training SLB rotatory drills for controlling foot pronation and resupination ability at the ankle patient had a varus position of both the forefoot and rear foot reducing frontal and transverse plane control with weight baring and impact drills Right Knee Discharge Testing: Reported fxn at 75%, max Sx 4/10 and less frequent at 2-3/wk. Patient able to navigate stairs without Sx, increased elliptical speed and hiking ability while avoiding deep squats as still symptomatic. IKDC on discharge 57%; however, performed only 2 visits after initial record.   You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs.   Andrew Neumeister, PT, DPT, FAFS Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester.   We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients.  No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering.    No surprises. No hassles. Confident your patient is in the right place.   COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com