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 McMurray 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.
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.
Methods
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 colleagues8 and the Cochrane Methods Group on Systematic Review of Screening and Diagnostic Tests9 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 Table w1, Table w1a 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
Statistical analysis was performed according to a strategy adapted from Midgette and colleagues. Figure W1 10** For each study, the sensitivity and specificity of each index test were calculated. The c2 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.