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Usefulness of McMurray Testing with Meniscus Tears A Case Study of Athlete with Lateral Meniscus Tear Mike Williamson, ATC, PT ,DPT Sports MedicineHattiesburg Clinic
Usefulness of McMurray Testing with Meniscus Tears
A Case Study of Athlete with Lateral Meniscus Tear
Mike Williamson, ATC, PT ,DPT Sports Medicine-‐Hattiesburg Clinic
* Using the PICO format McMurray Testing was reviewed in a case study to determine its validity in diagnosing lateral meniscus tears. * Clinical Question: Is McMurray testing alone a valid tool to use in diagnosing lateral meniscus tears?
McMurray Testing
* P-‐Patient 17 year old football player with suspected lateral meniscus tear * I-‐ McMurray Testing was the examination intervention * C-‐ Comparison was looking at statistical data for the test when compared to gold standard of either arthroscopic surgery and /or MRI * O-‐Outcomes were statistical values for McMurray in the review, the test in the case study and subsequent MRI and arthroscopic surgery result.
McMurray Testing
* PubMed (Search Engine maintained by US National Library of Medicine at the National Institutes of Health) and PEDro (Physiotherapy Evidence Database) databases were utilized to search for literature regarding meniscus injuries and testing for meniscus tears.
McMurray Testing
* 17 year old football player with suspected lateral meniscus tear found during physical screenings * Swenson et al high school knee injuries occur at a rate 2.98 per 10,000 exposures with meniscus injuries being 23 % of knee injuries.1
McMurray Testing
* The mechanism of meniscal injury may be due to a sudden change in direction while running, forceful squatting or due to rotational, valgus, varus, or hyperextension forces to the knee.2 The menisci become susceptible to injury with greater flexion angles of the knee due to increased compressive forces.2
* This athlete was injured while performing a weight lifting squat.
McMurray Testing
* During the examination by the athletic trainer, McMurray testing was positive. * Under the Nagi Disablement Model system of
classification, McMurray test is considered a test for impairment of an anatomical structure.3
* The McMurray test is described as placing the patient supine, bringing the knee into full flexion, medially rotating the tibia, then extending the knee for testing of the lateral meniscus with a positive test being when a snap or click and/or pain is produced.4
McMurray Testing
McMurray Testing
McMurray Testing
McMurray Testing
* Hing et al systematic literature review included 11 studies comparing to gold standards of arthroscopic surgery or MRI.5 * This review found a wide range of statistical values when a
positive result was determined with a click. * Sensitivity 16%-‐88%, Specificity 20%-‐98% * Sensitivity is the proportion of patients with a condition
that have a positive test (true positives). Highly sensitive test is useful in ruling out a condition when it is negative. * Specificity is the proportion of patients without a condition
who test negative (true negatives) Highly specific tests are useful in ruling in a condition when positive. * One study by Akseski et al where the inclusion of joint line
pain was considered a positive test found a Sensitivity of 63% and Specificity of 83%.6
McMurray Testing
* Positive Likelihood Ratios (LR+) in the Hing et al review ranged from 0.82 to 8.86. * Negative Likelihood Rations in the Hing et al review ranged from 0.24 to 1.45. * LR + is the probability that a person who tested positive for a condition has the condition (LR + = sensitivity/1-‐specificity). * LR-‐ is the probability of a person who tested negative for a condition does not have the condition (LR-‐ = 1-‐sensitivity/specificity) * The Akseki et al study showed an LR+ of 3.71 and LR – of 0.45.
McMurray Testing
LR+ LR− Interpretation
>10 <0.1 Generate large and often conclusive shifts in probability
5–10 0.1–0.2 Generate moderate shifts in probability
2–5 0.2–0.5 Generate small but sometimes important shifts in probability
1–2 0.5–1 Alter probability to a small and rarely important degree
McMurray Testing
Hing et al
* This review shows that using McMurray testing where a click is produced has a wide range of statistical values and therefore should not be used alone in diagnosing meniscus tears. * As stated ,when joint line pain is included as a positive test McMurray was found to have a higher Specificity and lower Sensitivity. This would indicate that McMurray testing including joint line pain to be more useful in ruling in a meniscus tear when it is positive.
McMurray Testing
* Ege’s test is a weight bearing meniscus test and when testing for lateral meniscus tears the athlete stands with both tibias internally rotated, squats and then stands up.7,8 The test is positive if pain and/or click is felt by the patient in the lateral joint line. * Akseki et al stated that this test had a Sensitivity of 64% and Specificity of 90%.6 As with McMurray testing, Ege’s test would be more useful in ruling in a meniscus tear when it is positive due to higher Specificity and lower Sensitivity.
Ege’s Test
Ege’s Test
* Thessaly’s Test-‐ Patient stands on involved leg. Test at 5 ̊ and 20 ̊ of flexion. Rotates body and leg medially an laterally.9 Had 96% specificity and 66% sensitivity. * The LR + would be 16.5 and LR – 0.35.
Thessaly’s Test
Thessaly’s Test
* From these studies one may conclude that McMurray testing should be used in only in conjunction with other tests such as the Ege’s test or Thessaly’s test or with MRI testing. Also, meniscus tests should include joint line pain as a positive test.
McMurray Testing
* As stated MRI and arthroscopy are considered gold standards when diagnosing meniscus tears.5
* This athlete had an MRI which was found to be positive for a lateral meniscus tear and then arthroscopic surgery that confirmed the tear.
McMurray Testing
* 1 Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. (2013). Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-‐2010/2011. Medicine and Science in Sports and Exercise. Mar;45(3):462-‐9.
* 2 Senter C, Hame SL. (2006). Biomechanical analysis of tibial torque and knee flexion angle: implications for understanding knee injury. Sports Medicine.36(8):635-‐641.
* 3 Guccione AA. (1991). Physical therapy diagnosis and the relationship between impairments and functions. Physical Therapy. 71(7):499-‐503.
* 4 Magee DJ. (2008). Orthopaedic Physical Examination. 5th ed. St. Louis, MO: Saunders Elselvier.
* 5 Hing W, White S, Reid D, Marshall R. (2009). Validity of the McMurray's test and modified versions of the test: a systematic literature review. Journal of Manual Manipulative Therapy. 17(1):22-‐35.
* 6 Akseki D, Ozcan O, Boya H, Pinar H. (2004). A new weight-‐bearing meniscal test and a comparison with McMurray's test and joint line tenderness. Arthroscopy.20:951–958.
* 7 Magee DJ. (2014). Orthopaedic Physical Examination. 6h ed. St. Louis, MO: Saunders Elselvier.
* 8 Messerve BB, Cleland JA, Boucher TR. (2008). A meta-‐analysis examining clinical test utilities for assessing meniscal tears. Clinical Rehabilitation. February; 22(2):143-‐161.
* 9 Karachalios T, Hantes M. Zibis, A, Zachos,V ,Karantanas A , Malizos K. (2005). Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. Journal of Bone Joint Surgery. 87 (5): 955 -‐962
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