13-OA12-146s_OA1 9/17/20 4:20 PM Page 94 Malaysian Orthopaedic Journal 2020 Vol 14 No 2 Shekarchi B, et al doi: https://doi.org/10.5704/MOJ.2007.018 Comparison of Thessaly Test with Joint Line Tenderness and McMurray Test in the Diagnosis of Meniscal Tears Shekarchi B 1, MD, Panahi A 2, MD, Raeissadat SA 3, MD, Maleki N 4, MD, Nayebabbas S 4, MD, Farhadi P 5, MD 1Department of Radiology, AJA University of Medical Sciences, Tehran, Iran 2Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Tehran, Iran 3Department of Physical Medicine and Rehabilitation, Shaheed Beheshti University of Medical Sciences, Tehran, Iran 4Department of Physical Medicine and Rehabilitation, AJA University of Medical Sciences, Tehran, Iran 5Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Date of submission: 07th June 2019 Date of acceptance: 19th April 2020 ABSTRACT Keywords: Thessaly, joint line tenderness, McMurray, meniscal tears Introduction: Meniscus injuries are the most frequent problem of the knee. The aim of this study was to investigate the accuracy of the Thessaly test and comparing it with those of McMurray and Joint-line tenderness tests for diagnosing INTRODUCTION meniscal tears. Knee pain comprises approximately one third of all Materials and methods: This study was designed as a outpatient physical therapy visits 1 of which 9% are prospective observational one done in an outpatient clinic at associated with meniscal lesions 2. A combination of a university hospital. 106 patients with knee pain and 82 age- subjective symptoms increases the predictive value of matched control were included during study period (from recognising meniscal lesion to 70-80%, but patient history is February 2014 to January 2015). Each patient was clinically not enough for accurate diagnosis 3. examined with McMurray, Thessaly, and joint line tenderness tests. Then, the findings were matched by MRI Various physical tests have been described in the literature: and arthroscopic findings. The sensitivity, specificity, the McMurray’s, the Apley compression and distraction, and positive predictive value, negative predictive value and the joint line tenderness test with their adaptations are known accuracy were calculated as main outcomes. examples 4-14 . The diagnostic accuracy of the clinical tests Results: Based on MRI, Thessaly was the most sensitive for may improve with compressive forces applied to the knee medial meniscus tears (56.2%), while McMurray and joint- joint with weight-bearing axial compression 15,16 . Medial joint line tenderness were more specific (89.1% and 88.0%, line tenderness, knee locking, daily pain and work absence respectively). For lateral meniscus tears, McMurray was the have been reported to predict 61% of meniscal tear most sensitive (56.2%) and all were specific (McMurray confirmed by arthroscopy 3. 89.6%, Thessaly 88.4%, joint-line tenderness 90.2%). With arthroscopy, Thessaly was the most sensitive for medial More recently, the Thessaly test was suggested to be safely meniscus (76.6%), while McMurray and joint-line used as a first line screening test for identifying the tenderness were more specific (81.0%, and 81.0%). candidates of arthroscopic meniscal surgery. The test also Agreement with arthroscopy was the highest with McMurray was reported to have a lower false positive and false negative (for medial meniscus kappa=0.40, p<0.001, and for lateral compared to other clinical tests 16 . On the other hand, MRI is meniscus kappa=0.38, p=0.002). considered as the diagnostic method of choice because of Conclusion: The Thessaly can be used to screen for medial providing a reliable non-invasive tool in identifying common meniscus tears. McMurray and joint-line tenderness should knee pathology 4,17 . Arthroscopy is also the gold standard for be used for suspected medial meniscus tears. For lateral the diagnosis of meniscal lesions, with 90-95% accuracy 18 . In meniscus, McMurray is appropriate for screening and all the addition, arthroscopy provides simultaneous therapeutic tests are useful in clinic. possibilities. Corresponding Author: Pouya Farhadi, Department of Radiology, Shiraz University of Medical Sciences, Fars Province, Shiraz, Zand, Iran Email: [email protected] 94 13-OA12-146s_OA1 9/17/20 4:20 PM Page 95 Clinical Tests for Meniscal Tears Low specificity, sensitivity, and diagnostic accuracy of the matched participants as the group control from which 82 clinical tests may leave meniscal lesions undetected. The completed the study. The control group was randomly methodological quality of the studies on the clinical tests has selected from patients who came to the clinic for complaints a significant effect on reported sensitivities and specificities other than knee problems (e.g., pain in their shoulders). as well 2,19 . At the beginning of the study, research staff was briefed. Our High cost and false positives are the disadvantages of MRI clinical assessors were two specialists of physical medicine for the diagnosis of meniscal lesions 4,20 . A false positive of and rehabilitation. The study was carried out under the 65% for identifying medial meniscal tears and 43% for supervision of two board-certified physical medicine and lateral meniscus tears have been estimated for MRI when rehabilitation specialists, and an associate professor of compared with surgical findings 21 . Even, some researchers radiology. believe that MRI is not superior to physical examination in the diagnosis of meniscal tears 20 . Invasiveness and high cost Patients were interviewed to obtain their past medical are the major drawbacks for common use of arthroscopy histories. The presence of the symptoms and signs of too 4. meniscal lesions and other knee problems were questioned. In addition, the recruitment questionnaire asked about Therefore, we need less expensive, non-invasive, and more consultation with a physician and active or previous accurate methods of identifying meniscal lesions. The treatment and surgery. Then our clinical assessors performed optimal clinical tests and measures should be selected with physical examinations and conducted further investigations high sensitivity and specificity. The aim of conducting the for the diagnosis of meniscal lesions. We recorded any pain present study was to investigate the accuracy of the Thessaly or discomfort, clicking sensation or locking on movement, test in screening for meniscal tears. We examined whether and swelling and injury of the knee. the Thessaly test alone or in combination with other clinical tests could provide a non-invasive means of identifying For the Thessaly test, participants were instructed to stand lesions. while supported by holding their hands. Thereafter, they were guided to perform internal and external rotation of the knee and body in three occasions during which the knee was MATERIALS AND METHODS flexed at almost 20°. We considered the test as positive when The present study was designed as a prospective the patients had medial or lateral joint-line discomfort or observational one which was conducted from February 2014 experienced locking in the knee 4. For all the participants, we to January 2015 in an outpatient clinic of physical medicine performed McMurray and joint line tenderness at the lateral and rehabilitation at the university hospital; Imam Reza, a and medial sides. Further investigations including MRI were large referral practice and research centre in Tehran. The ordered and lesions were graded 22 . Then, the patients with study protocol was approved by the institutional review suspected meniscal lesions were referred to arthroscopy for board (IRB) of AJA University of Medical Sciences and we definitive diagnosis and appropriate treatment. obtained ethics approval from the local ethics committee before the study was commenced. All the participants read We used a block design to randomise the patients to the and signed an informed consent form prior to study observers. The investigators who performed physical involvement. examinations were blinded to patients’ medical history. Moreover, the assigned radiologists also were unaware of the Consecutive patients aged more than 15 years who had a study question and patients’ medical history. current knee pain or discomfort, history of swelling or effusion, knee locking, or clicking sensation on movement of All statistical analyses were performed with the Statistical the knee were enrolled in the study. Exclusion criteria Package for Social Sciences version 16.0 [SPSS Inc, included individuals with a previous history of knee surgery Chicago, IL, USA]. The distribution of variables was or arthroscopy, and the radiologic evidence or clinical analysed with Kolmogorov-Smirnov test. Continuous data manifestations of osteoarthritis and rheumatologic diseases. are presented as mean and standard deviation, and In addition, we excluded patients if they could not attend the categorical data, as numbers and proportions. We used Chi- clinical examinations and did not take MRI or refused squared and t-test to assess differences in demographic arthroscopy. characteristics between the two groups. Sensitivity, specificity, positive and negative predictive values, positive At the first visit and according to