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Guide for
Meniscus Diagnosis
By Daniel Bossen & Marcel Jurado
Index
Introduction ................................................................................ 3
Anatomy .................................................................................. 3
Vascular Anatomy ..................................................................... 4
Neuroanatomy .......................................................................... 5
Biomachanics .......................................................................... 5
Meniscal healing ....................................................................... 7
Mechanism of Meniscal and Ligamentous Knee Injuries.................. 7
Patient History............................................................................. 9
Instruction meniscus tests .......................................................... 11
Joint line tenderness (JLT)........................................................ 11
McMurray test......................................................................... 11
Apley (grind) test.................................................................... 12
The Thessaly Test at 5° and 20° of flexion ................................ 12
Ege’s Test ............................................................................. 14
Flowchart.................................................................................. 16
References................................................................................ 17
2
Introduction
The various diagnostic tests are important to assess a menisculesion. The
intake, however, is the most important tool of the assessment. A diagnosis
can be made accurately in 75% of the meniscal injuries on the basis of the
history alone.
This guide lists the necessary points to guarantee a complete meniscus
examination. It consists of essential background information about the
menisci, shows the most important questions regarding the patient history
and gives a description of the most common meniscus tests.
Instantaneous damage to both ligamentous and meniscal structures is more
common than isolated injury1 with the combination of meniscus and ACL as
the most frequent one.2 Therefore this guide not only focuses on the
meniscus, but also takes the significance of the knee ligaments into
consideration.
Why Is the Diagnosis Important?
Ten percent to 15% of adults in the community report knee symptoms with
over 3.3 million new visits made annually (USA).3,4 Overall, knee pain
accounts for 3% to 5% of all visits to physicians and a substantial proportion
result in referrals for diagnostic imaging and/or specialty care.5 A careful
history taking and physical examination can assist the examiner in
determining whether the knee pain is part of a systemic condition or whether
it represents a local musculoskeletal problem. If the knee pain is part of a
local regional musculoskeletal disorder, the clinician must decide whether the
pain represents a torn meniscal or ligamentous structure and then whether
nonoperative or operative intervention is indicated. Since torn meniscal or
ligamentous structures can cause significant pain and disability, injuries to
these structures may require expeditious repair. The physical examination
can aid the primary care clinician in assessing the likelihood of a torn
meniscal or ligamentous structure and whether a referral will be beneficial.
Background information
Anatomy
6
The menisci (Fig. 1) extend the superior tibial surface, improving its
congruency with the femoral condyles. Both menisci are fibro-cartilaginous
and wedge shaped in the coronal plane. The medial meniscus is more
crescent shaped, and the lateral meniscus is more circular. The superior
portions of the menisci are concave, enabling effective articulation with their
respective convex femoral condyles, whereas the inferior surfaces are flat to
conform to the tibial plateaus. Anterior and posterior meniscal horns attach
to the intercondylar eminence of the tibial plateau. The coronary ligaments
provide peripheral attachments between the tibial plateau and the perimeter
of both menisci. The medial meniscus is also attached to the medial collateral
ligament, which limits its mobility.
3
The lateral meniscus is connected to the femur via the anterior (ligament of
Humphrey) and posterior (ligament of Wrisberg) meniscofemoral ligaments,
which can tension its posterior horn anteriorly and medially with increasing
knee flexion. The transverse ligament provides a connection between the
anterior aspects of both menisci. The increased stability provided by the
ligamentous attachments prevents the menisci from being extruded out of
the joint during compression.
Figure 1
Vascular Anatomy
6
Vascular supply is crucial to meniscal healing. The medial, lateral, and middle
geniculate arteries, which branch off the popliteal artery, provide the major
vascularization to the inferior and superior aspects of each meniscus.The
middle geniculate artery is a small posterior branch that pierces the oblique
popliteal ligament at the posteromedial corner of the tibiofemoral joint. A
premeniscal capillary network arising from branches of these arteries
originates within the synovial and capsular tissues of the knee along the
periphery of the menisci. Only 10% to 30% of the peripheral medial
meniscus border and 10% to 25% of the lateral meniscus border receive
direct blood supply. Endoligamentous vessels from the anterior and posterior
horns travel a short distance into the substance of the menisci and form
terminal loops, providing another direct route for nourishment. The
remaining portion of each meniscus (65% to 75%) receives nourishment only
from the synovial fluid via diffusion.
4
Neuroanatomy
6
The knee joint is innervated by the posterior articular branch of the posterior
tibial nerve and the terminal branches of the obturator and femoral nerves.
Nerve fibers penetrate the joint capsule, along with the vascular supply, and
service the substance of the menisci. Ruffini, Pacinian, and Golgi tendon
mechanoreceptors have been identified in the knee joint capsule and in the
peripheral menisci. Type I (Ruffini) mechanoreceptors are low threshold and
slowly adapting to changes in static joint position and pressure. Type II
(Pacinian) mechanoreceptors are low threshold and fast adapting to tension
changes, signaling joint acceleration. Type III (Golgi) mechanoreceptors
signal when the knee joint approaches the terminal range of motion (ROM)
and are associated with neuromuscular inhibition. Concentrations of meniscal
mechanoreceptors (especially Pacinian mechanoreceptors) are greatest in the
meniscal horns, leading researchers to study their contributions to
proprioception.
Biomachanics 7
The main function of the menisci is one of load transmission. The majority of
the collagen fibres are large and coarse and are arranged in a circumferential
manner. These fibres are stabilised with radially running fibres acting as ties.
This structure suggests the ability to bear load is by containment of the socalled ‘hoop stresses’ (Fig. 2).
Figure 2
A
compressive
force
(white
arrow) is converted by the shape
of the meniscus to a radially
directed force (black arrow),
which is taken up as tension force
(dashed
arrow)
within
the
meniscus.
It has been determined that approximately 50% of the body’s weight is
transmitted through the menisci in extension and up to 85% in 90° of
flexion. The menisci, however, are mobile structures that move anteriorly
and posteriorly to allow maintenance of congruency throughout the range of
flexion. The radius of curvature also changes to accommodate the reduced
radius of the femoral condyles as flexion and rollback occurs. The medial
meniscus is more restrained than the lateral meniscus, particularly in the
postero-medial corner, and this may explain why tears of this area are more
common.
5
It is now well accepted that loss of all or part of a meniscus increases point
loading and results in premature wear of the knee due to altered mechanical
forces. The rate at which arthrosis develops, however, depends on a number
of factors and these may be regarded as knee factors and patient factors.
The volume of meniscus lost has been considered.
Total menisectomy has been estimated to reduce the joint surface contact
area by 75%, increasing local peak contact pressure by 235%. Partial
menisectomy also reduces contact area by 10% and increases point
pressures by 65%. The nature of the tear is important. Radial tears
extending to the periphery may not result in much volume loss but may
completely defunction the meniscus through an inability to resist hoop
stresses. Associated injuries either at the time of meniscal tear or
subsequently, such as chondral damage and anterior cruciate ligament
rupture, will also have a significant effect on the knee’s long-term prognosis.
Patient factors include limb alignment, age at time of injury, activity level,
weight and inherent genetic constitution. The menisci also act as secondary
stability restraints in the knee. The effect in a stable knee remains
controversial but in an ACL deficient knee there is no doubt that loss of a
meniscus increases measurable joint laxity. In these situations, it is
suggested that the intact posterior horn of the medial meniscus acts as a
wedge or ‘stop’ to anterior translation of the tibia (Fig. 3).
Figure 3
With ACL deficiency an anterioly force
(white arrow) is partly resisted by an
intact medial meniscus (black arrow). If
the meniscus is also deficient then the
tibia can move further anteriorly.
Unfortunately, it is not uncommon to witness an ACL deficient knee in an
active individual sequentially undergoing medial and lateral menisectomies
with a rapid progression to premature arthrosis. Further biomechanical
functions of the menisci have been postulated. These include shock
absorption, lubrication, joint nutrition and proprioception. The menisci exhibit
viscoelastic properties, which may serve to attenuate impacts sustained
through the knee on loading. The improved congruity that they provide has
been suggested to aid joint lubrication and cartilage nutrition by promoting
fluid shifts in and out of the cartilage surface layers. Recent studies have
shown the presence of mechano-receptors and free nerve endings in the
peripheral, two thirds of the meniscus body and the horns, particularly the
posterior horns. This suggests an important role of the menisci in
proprioceptive feedback, the initiation of protective reflexes and joint pain.
This may also explain why meniscal tears without a significant mechanical
component can still be a source of painful symptoms.
6
Meniscal healing
7
The capacity of meniscus to heal is limited, particularly the central portions,
which are largely avascular, aneural and alymphatic. However, in 1936, King
showed that meniscal healing in dogs could occur providing there was
communication with the peripheral blood supply.
As with other soft and bony tissues, there is a need for a balance between
blood supply, and hence associated cellular and tissue repair factors, and
component stability to permit healing.
The process would appear to be along the same lines as healing in other soft
tissues and, in the vascular portion of the meniscus, it would appear that
healing is largely complete by 10 weeks, although maturation of the scar
may continue for many months. As indications for meniscal repair are
extended, attempts to promote an environment more conducive to healing
have been introduced. The vascular anatomy of the human meniscus has
been well described by Arnoczky and Warren. The blood supply is by way of
the superior and inferior medial and lateral geniculate arteries. The outer rim
of the meniscus is vascularized up to 30% of its width on the medial side and
25% on the lateral side. In addition, there is a synovial fringe that extends
some 3 mm over the surface of each meniscus adding further to the
peripheral vascularity.
The concept of ‘red-on-red’, red-on-white’ and ‘white-on-white’ tears,
describing the vascular status of each tear location, is a useful classification.
‘Red-on-red’ tears are perhaps a misnomer as all tears must be ‘redonwhite’, as the central portion, by its nature, must have had its vascular
supply disrupted. Nevertheless, it is a reflexion of the peripheral location and
is a good indicator that healing should occur. ‘White-on-white’ tears are
located within the avascular zone and hence have the least potential to heal.
The majority of reports on meniscal repair address primarily longitudinal
tears, which are indeed the commonest tear to be repaired. Current practice
suggests that certain tears are incapable of healing although anecdotally this
has not been our experience. As with any scarred tissue, it is likely, however,
that even fully healed menisci will not regain normal biomechanical strength.
Indeed, there is some evidence at 12 weeks after meniscal suture, meniscal
strength may be significantly reduced at only 26% of the normal side.
Mechanism of Meniscal and Ligamentous Knee Injuries
The position of the joint at the time of the traumatic force dictates which
anatomic structures are at risk for injury; hence, an important aspect of
obtaining the patient history for acute injuries is to allow him/her to describe
the position of the knee and direction of forces at the time it was injured. In
full knee extension, the ACL and PCL limit the antero-posterior motion of the
tibia on the femur. The ACL is often injured during traumatic twisting injuries
in which the tibia moves forward with respect to the femur, often
accompanied by valgus stress. No direct blow to the knee or leg is required,
but the foot is usually planted and the patient may remember a "popping"
sensation at the time of the injury.
7
Similar to the ACL, PCL injuries often occur during twisting with a planted
foot in which the force of the injury is directed posteriorly against the tibia
with the knee flexed. The most common collateral ligament injury results
from an abduction and external rotation force applied on a knee in an
extended or slightly flexed position. An intact MCL helps the ACL prevent
posterior motion of the femur. An injury to the MCL may allow for anterior
subluxation of the tibial plateau during flexion, especially in an ACL-deficient
patient.
Meniscal injuries typically occur through application of specific forces while
the knee joint is in certain positions. During flexion, if the tibia is rotated
internally, the posterior horn of the medial meniscus is pulled toward the
center of the joint.
This movement can produce a traction injury of the medial meniscus, tearing
it from its peripheral attachment and producing a longitudinal tear of the
substance of the meniscus. With aging, the meniscal tissue degenerates and
can delaminate, thus making it more susceptible to splitting from shear
stress, resulting in horizontal cleavage tears. Without the menisci, the loads
on the articular surfaces are increased significantly leading to a greater
potential for degenerative arthritis. Since the menisci are without pain fibers,
it is the tearing and bleeding into the peripheral attachments as well as
traction on the capsule that most likely produce a patient's symptoms of
pain. In fact, 16% of asymptomatic patients have meniscal tears
demonstrated on magnetic resonance imaging (MRI) with the incidence
increasing to 36% for patients older than 45 years.8 With posterior horn
tears, the meniscus can return to its anatomic position with extension. If the
tear extends anteriorly beyond the MCL creating a bucket-handle tear, then
the unstable meniscus fragment cannot always move back into an anatomic
position.
Such a meniscal tear can result in locking of the knee in a flexed position.
The lateral meniscus, being more mobile, is less likely to be associated with
locking when torn. The patient may also note a "clicking" sensation while
walking due to traction against a torn medial or lateral meniscus. Locking of
the knee is more common in younger patients with meniscal tears. Older
patients are more likely to have degenerative meniscal tears with less
mechanical symptoms and an insidious onset.
8
Patient History 9
These questions are important during the intake. The questions are specific
for detecting meniscus laesies. The questions are indispensable during the
patient’s history.
1.
How did the injury occur or what was the mechanism of injury?
The primary mechanisms of in the knee are valgus force (with or without
rotation), hyperextension, flexion with posterior translation, and varus force.
The first often results in injury to the medial collateral ligament,
frequentlyaccompanied by injury to the posteromedial capsule, medial
meniscus, and anterior cruciate (‘terrible triad’).
2. Did the injury occur during acceleration, during deceleration, or
when the patient was moving at a constant speed?
Acceleration and twisting injuries may involve the meniscus. Deceleration
injuries often involve the cruciate ligaments. Constant speed with cutting
may involve the anterior cruciate ligament.
3. Does the knee ‘give way’?
This finding usually indicates instability in the knee, meniscus pathology,
patellar subluxation (if present when rotation or stoping is involved),
undisplaced osteochondritis dissecans, patellofemoral syndrome, plica or
loose body. ‘Giving way’ when walking uphill or downhill is more likely the
result of a retropatellar lesion.
4. Has the knee ever locked?
True locking of the knee is rare. Loose bodies may cause recurrent locking.
Locking must be differentiated from catching, which is the momentary
locking or giving way as a result of reflex inhibition or pain. Locking in the
knee usually means that the knee cannot fully extend with flexion often being
normal, and is related to meniscus pathology.
5. Is the joint swollen?
Does the swelling occur with activity or several hours after activity, or does
the joint feel tight at rest? Swelling with activity may be caused by
instability, and tightness at rest may be caused by arthritic changes or
patellofemoral dysfunction. Is the swelling recurrent? If so, what activitiy
causes it? Swelling with pivoting or twisting may be a result of meniscus
problems or instability at the tibiofemoral joint.
9
Figure 4
Mechanisms of the knee and Possible Structures Injured
9
Varus or valgus contact without rotation
1.
2.
3.
Collateral ligament
Epiphyseal fracture
Patellar dislocation or subluxation
Varus or valgus contact with rotation
1.
2.
Collateral or cruciate ligaments
Collateral ligaments and patellar
dislocation or subluxation
Meniscus tear
3.
Blow to patellofemoral joint, or fall on flexed
knee, foot dorsiflexed
1.
Patellar articular injury or
osteochondral fracture
Blow to tibial tubercle, or fall on flexed knee,
foot plantar flexed
1.
Posterior cruciate ligament
Anterior blow to tibia, resulting in knee
hyperextension
1.
2.
Anterior cruciate ligament
Anterior and posterior cruciate
ligament
1.
2.
Anterior cruciate ligament
Posterior capsule
1.
Anterior cruciate ligament
1.
Anterior cruciate ligament
Noncontact, quickly turning one way with
tibia rotated in opposite direction
1.
Patellar dislocation or subluxation
Noncontact, rotation with varus or valgus
loading
1.
Meniscus injury
1.
2.
Meniscus injury
Osteochondral fracture
Hyperflexion
1.
2.
Meniscus (posterior horn)
Anterior cruciate ligament
Forced medial rotation
1.
Meniscus injury (lateral meniscus)
Forced lateral rotation
1.
2.
3.
Meniscus injury (medial meniscus)
Medial collateral ligament and possibly
anterior cruciate ligament
Patellar dislocation
Flexion-varus-medial rotation
1.
Anterolateral instability
Flexion-varus-lateral rotation
1.
Anteromedial instability
Dashboard injury
1.
2.
Isolated posterior cruciate ligament
Posterior cruciate ligament and
posterior capsule
Posterolateral instability
Posteromedial instability
Patellar fracture
Tibial fracture (proximal)
Tibial plateau fracture
Acetabular and pelvic fracture
Noncontact hyperextension
Noncontact deceleration
Noncontact deceleration, with tibial medial
rotation or femoral lateral rotation on fixed
tibia
Noncontact, compressive rotation
3.
4.
5.
6.
7.
8.
10
Instruction meniscus tests
Tests for Meniscal Injuries
10
Meniscal tears occur commonly, however, their clinical diagnosis is often
difficult, even for an experienced clinician. Because the menisci are avascular
and have no nerve supply on their inner two thirds, an injury to the meniscus
can result in little or no pain or swelling, which makes accurate diagnosis
even more challenging. In 1803, Hey described “internal derangement of the
knee,” and since then a significant literature on the clinical diagnosis of
meniscal tears has evolved.11
Joint line tenderness (JLT)
10
Joint line palpation is among the most basic maneuvers, yet it often provides
more useful information than the provocative maneuvers designed to detect
meniscal tears. Flexion of the knee enhances palpation of the anterior half of
each meniscus. The medial edge of the medial meniscus becomes more
prominent with internal rotation of the tibia, allowing for easier palpation.
Alternatively, external rotation allows improved palpation of the lateral
meniscus.
McMurray test
10
The McMurray test is among the primary clinical tests to evaluate for a
meniscal tear. McMurray12 first described the test in 194013 The original
description of the test, as described by McMurray, was: In carrying out the
manipulation with patient lying flat, the knee is first fully flexed until the heel
approaches the buttock; the foot is then held by grasping the heel and using
the forearm as a lever. The knee being now steadied by the surgeon’s other
hand, the leg is rotated on the thigh with the knee still in full flexion. During
this movement the posterior section of the cartilage is rotated with the head
of the tibia, and if the whole cartilage, or any fragment of the posterior
section, is loose, this movement produces an appreciable snap in the joint.
By external rotation of the leg the internal cartilage is tested, and by internal
rotation any abnormality of the posterior part of the external cartilage can be
appreciated. By altering the position of flexion of the joint the whole of the
posterior segment of the cartilages can be examined from the middle to their
posterior attachment… Probably the simplest routine is to bring the leg from
its position of acute flexion to a right angle, whilst the foot is retained first in
full internal, and then in full external rotation… When the click occurs with a
normal but lax cartilage, the patient experiences no pain or discomfort, but
when produced by a broken cartilage, which has already given trouble, the
patient is able to state that the sensation is the same as he experienced
when the knee gave way previously.10
11
Apley (grind) test
10
The Apley (grind) test was described by Apley in 1947.14,15 The original
description of the test follows: For this examination the patient lies on his
face. He should be on a couch not more than 2 feet high, or the tests become
difficult, and he must be well over to the edge of the couch nearest the
surgeon. To start the examination, the surgeon grasps one foot in each hand,
externally rotates as far as possible, and then flexes both knees together to
their limit. When this limit has been reached, he changes his grasp, rotates
the feet inward, and extends the knees together again. . . . The surgeon then
applies his left knee to the back of the patient’s thigh. It is important to
observe that in this position his weight fixes 1 of the levers absolutely. The
foot is grasped in both hands, the knee is bent to a right angle, and the
powerful external rotation is applied. This test determines whether simple
rotation produces pain. Next, without changing the position of the hands, the
patient’s leg is strongly pulled upward, while the surgeon’s weight prevents
the femur from rising off the couch. In this position of distraction, the
powerful external rotation is repeated. Two things can be determined: (1)
whether or not the maneuver produces pain and (2), still more important,
whether the pain is greater than in rotation alone without the distraction. If
the pain is greater, the distraction test is positive, and a rotation sprain may
be diagnosed. Then the surgeon leans well over the patient and, with his
whole body weight, compresses the tibia downward onto the couch. Again he
rotates powerfully, and if addition of compression had produced an increase
of pain, this grinding test is positive, and meniscal damage is diagnosed.
The Thessaly Test at 5° and 20° of flexion
16
The Thessaly test is a dynamic reproduction of load transmission in the knee
joint and is performed at 5° and 20° of flexion. It was named in honor of the
county, or prefecture, in our country, where our hospital serves as an
academic medical referral center and which has a continuous, uninterrupted
ten-thousand-year history. The examiner supports the patient by holding his
or her outstretched hands while the patient stands flatfooted on the floor.
The patient then rotates his or her knee and body, internally and externally,
three times, keeping the knee in slight flexion (5°). Then the same procedure
is carried out with the knee flexed at 20° (Fig. 5).
12
Figure 5
Thessaly Test at 20° of flexion
16
Lateral view of Thessaly at 20°
Frontal view in neutral position
Frontal view in external rotation
Frontal view in internal rotation
Patients with suspected meniscal tears experience medial or lateral joint-line
discomfort and may have a sense of locking or catching. The theory behind
the test is that, with this maneuver, the knee with a meniscal tear is
subjected to excessive loading conditions and almost certainly will have the
same symptoms that the patient reported. The test is always performed first
on the normal knee so that the patient may be trained, especially with regard
to how to keep the knee in 5° and then in 20° of flexion and how to
recognize, by comparison, a possible positive result in the symptomatic knee.
13
Ege’s Test
17
The test is performed with the patient in a standing position. The knees are
in extension and the feet are held 30 to 40 cm away from each other at the
beginning of the test. To detect a medial meniscal tear, the patient squats
with both lower legs in maximum external rotation and then stands up slowly
(Fig. 6A and B). The distance between the knees increases and each knee
becomes externally rotated as the squatting proceeds (Fig. 6B).
Figure 6
For lateral meniscal tears, both lower extremities are held in maximum
internal rotation while the patient squats and stands up (Fig. 6C and D). A
full squat in internal rotation is almost impossible even in healthy individuals.
So a slightly less than full squat is required in internal rotation, and the
patient is allowed to use an object nearby as a support. In contrast to the
medial meniscal test, the distance between the knees decreases and each
knee becomes internally rotated as the squatting proceeds (Fig. 6D). The
test is positive when pain and/or a click is felt by the patient (sometimes
audible to the physician) at the related site of the joint line.11 Further
squatting is stopped as soon as the pain and/or click is felt; hereby a full
squat is not needed in all of the patients. Sometimes pain and/or click may
not be felt until maximum squat, but may be felt as the patient comes out of
the squat. This finding is also accepted as a positive sign of the test. Pain
and/or click are felt at around 90° of knee flexion.
14
Anteriorly located tears produce the symptoms in earlier knee flexion,
whereas tears located on posterior horn of the menisci produce the
symptoms in more knee flexion, as in other meniscal tests. Flexion-extension
and internal-external rotation components of the test are similar to that of
McMurray’s test. However, the most important difference is the weightbearing position of the patient. The test may also be called the weightbearing McMurray’s test. Varus and valgus stresses are also produced during
internal and external rotation positions, respectively.
15
Flowchart
16
References
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KN. J Bone Joint Surg Am 2005; 87:955-962
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17