Lateral Joint Line Tenderness Research Articles

Meniscotibial Ligament Tear and Meniscocapsular Detachment of Anterior Horn of the Lateral Meniscus

The meniscotibial ligament (MTL) tear, along with a meniscocapsular separation, is a very rarely diagnosed injury pattern often missed on magnetic resonance imaging (MRI). The meniscus becomes hypermobile and can cause anterior knee pain, instability, and frequent locking. A 29-year-old female patient presented to the outpatient department with a history of a noncontact injury 3 months ago. Her Tegner Lysholm Knee Score was 41/100. On examination, there was lateral joint line tenderness and a positive McMurray test with a clicking sensation. MRI was performed, which showed torn fascicles in the anterior horn of the lateral meniscus. Knee arthroscopy confirmed that MTL was completely torn along with meniscocapsular detachment. A Scorpion jaw (Arthrex, Naples, FL) loaded with 2-0 FiberWire was used to take three bites from the meniscus. These ends of sutures were loaded on a 2.9 mm PushLock anchor and inserted at the tibia border. An 18G needle was loaded with a monofilament nitinol loop suture and passed through the capsule into the joint. A suture retriever was used to pick suture ends and pass through the loop. The monofilament loop was then pulled to pass the FiberWire ends from the capsule. All six FiberWire ends were passed through the capsule and three knots were tied from outside to reattach the capsule. This kind of injury can lead to anterolateral instability of the knee. Diagnosis of this lesion is very challenging and crucial. Biomechanical instability has prompted us to pay specific attention to its investigation and management. The described repair technique gives good results due to rigid fixation and the postoperative rehabilitation is also fast.

Correlation between Clinical Examination, Magnetic Resonance Imaging, and Arthroscopy in Meniscal Injuries of the Knee: A Prospective Cohort Study

Abstract Purpose: In comparison to magnetic resonance imaging (MRI) imaging, this study compares the diagnostic efficacy of meniscal injury with clinical examination tests such the McMurray’s test, Thessaly test, and joint line tenderness. Methodology: Two hundred and fifteen patients having a history of knee injuries with symptoms such as pain, instability, and locking were studied from June 2020 to June 2022 at our institution, for a 2-year period. Results: The sensitivity and specificity of McMurray’s test for medial meniscus were 84% and 84.21%, respectively. The sensitivity and specificity for medial joint line tenderness were 88.15% and 55.55%, respectively. Thessaly’s test for the medial meniscus was 92.10% sensitive and 88.8% specific. The sensitivity and specificity of MRI for medial meniscal injury were 94.87% and 93.75%, respectively. McMurray’s test for lateral meniscus had a sensitivity of 84.44% and a specificity of 76.92%. Lateral joint line tenderness for lateral meniscus had a sensitivity of 86.95% and a specificity of 66.66%. The sensitivity and specificity of Thessaly’s test for lateral meniscus were 93.33% and 84.61%, respectively. MRI revealed a sensitivity of 93.75% and a specificity of 90% for lateral meniscus injuries. Conclusion: Even though MRI is a precise and noninvasive method for detecting meniscal injuries, a thorough clinical examination by a skilled physician has the same diagnostic power as MRI to rule out meniscal injuries. In contrast to previous tests, the Thessaly test can be used as a useful tool to detect meniscal injuries, as we discovered in our study.

An Unusual Cause Of Knee Pain Impacting An ICU Nurse’s Ability To Run For Codes

History: A 49 yo active female ICU nurse who enjoys hiking presented with right achy knee pain that hadstarted 6 months prior, but worsened 3 months ago when she twisted her knee playing with her nephewin the pool. The pain was worse with prolonged time on her feet preventing her from exercising andimpacting her ability to work, particularly running to code blues. She also noted pain in her distal thighand intermittent swelling with increase in venous distension. PHYSICAL EXAMINATION:Right Knee examAppearance: No skin abnormalities. Mild varum deformity. Small effusion. Gait: Antalgic Palpation: Lateral joint line tenderness to palpation Range of motion: Normal range of motion, pain with flexion. Meniscal testing: Positive McMurray’s, Thessaly, and bounce test. Ligament testing: Negative Lachman’s, anterior drawer, posterior drawer. Pain but no laxity with varusstress at 30 degrees. Patellar testing: Positive inhibition Strength/Function: 5-/5 quadriceps strength DIFFERENTIAL DIAGNOSIS:1. Meniscal tear 2. Venous thromboembolism 3. Malignancy 4. Osteoarthritis Tests/Results:XR 3V Right Knee:There are small spurs along the lateral and patellofemoral compartment. The joint spaces are normal.There is a small right effusion. There is a 2.4 cm focus of ill-defined sclerosis in the distal femoral shaft.This was not evident on the comparison study. MRI Right Knee without Contrast:There is a distal femoral metaphyseal lesion with chondroid matrix measuring 28 mm. There is a 2 mmextraosseous component anteriorly at the prefemoral fat pad.There is a T2 hyperintense focus in the proximal fibula which may represent a intraosseous ganglionversus an additional small cartilaginous lesion. FINAL DIAGNOSIS:Chondrosarcoma of the femur TREATMENT/OUTCOMES:The patient was referred to Orthopedic Oncology. Follow-up CT scan of the femur and chest showed nometastasis. The patient’s case was reviewed with the medical tumor board and she was scheduled fordistal femur replacement.

An adult case of spontaneous healing of concurrent osteochondritis dissecans of the lateral femoral condyle after saucerization with meniscal repair for discoid lateral meniscus: A case report.

BackgroundThe treatment strategy for osteochondritis dissecans (OCD) with discoid lateral meniscus (DLM) in adults remains unclear.Case presentationA 22-year-old man presented with left knee pain after spraining his knee. Physical examination revealed lateral joint line tenderness and a positive McMurray test. Radiographic imaging showed OCD of the lateral femoral condyle classified as stage 3 on Brückl's classification. Magnetic resonance imaging showed complete DLM with anterocentral shift based on Ahn's classification and an OCD of 11 mm × 8 mm, grade 2 based on Nelson's classification. On computed tomography (CT), a demarcated fragment was observed in the lesion. Based on these findings, saucerization with meniscal repair was performed for unstable DLM. The OCD lesion presented with softening without any fissure and was diagnosed as grade 1. No surgical procedure was added. One year after surgery, the union of the fragment was confirmed on radiograph and CT. At the final follow-up five years after surgery, the Lysholm score had improved from 58 to 100 points.ConclusionsWe experienced an adult case of stable OCD with concurrent DLM that achieved spontaneous healing after undergoing reshaping surgery for DLM, mimicking normal meniscal morphology, without additional treatment for the stable OCD lesion.

Repair of a Complete Radial Tear of the Lateral Meniscus

Background: Recognizing and repairing a lateral meniscus complete radial tear is critical, as this tear pattern makes the meniscus nonfunctional for load sharing of axial forces, and the convex shape of the lateral tibial plateau increases contact pressure. Indications: The diagnosis of a lateral meniscus complete radial tear was supported by joint effusion, lateral joint line tenderness, positive McMurray test, and magnetic resonance imaging findings. Arthroscopy confirmed the complete radial tear. Technique Description: During the procedure, a self-capturing suture passer was used to pass a size 0 high-strength suture through the meniscus. To start the repair, the free ends of the suture were passed from top to bottom on both sides of the tear. These free ends were then crossed on the bottom of the meniscus to create an X configuration and passed from the bottom to top slightly further back from the first suture passes. A spinal needle and a chia were used from outside-in to create a side-to-side suture across the tear to reinforce the repair, and a knot was then tied on the outer capsule. The chia was used once again to shuttle the size 0 sutures to the exterior portion of the knee and the knots were tied on top of the capsule. Results: Postoperatively, patients are 25% weightbearing with a 0° to 90° range of motion restriction for 6 weeks, with no deep squatting for 3 months. With an isolated radial tear repair, the patient can expect to return to sport by 5 months. Radial tear repair outcomes demonstrate reduced lateral meniscus extrusion, complete meniscus healing in 86.4% of patients, and significantly improved International Knee Documentation Committee, Lysholm, and Tegner scores. Discussion/Conclusion: Repairing a complete radial tear of the lateral meniscus restores the function of the meniscus. This surgical technique provides a high rate of complete meniscus healing and excellent patient satisfaction.

MAGNETIC RESONANCE IMAGING OF LATERAL MENISCAL POSTERIOR ROOT TEARS IN THE ADOLESCENT KNEE: IS THE DIAGNOSIS MISSED, MENTIONED, OR MADE?

Background:The meniscal roots play a vital role in maintaining proper knee kinematics. Neglected meniscal root tears place excess stress on the articular cartilage and increase the risk of premature osteoarthritis. As opposed to medial meniscal root tears, lateral meniscal posterior root tears (LMPRTs) are more likely to be associated with anterior cruciate ligament (ACL) pathology. Failure to identify and address meniscal root tears may place undue loads on ACL grafts and lead to inferior post-surgical outcomes.Purpose:To examine preoperative knee magnetic resonance imaging (MRI) radiologist interpretations for the identification of lateral meniscal root pathology in children and adolescents.Methods:We performed a retrospective review of children and adolescents that underwnent knee arthroscopy between 3/1/2010 and 4/1/2020 and had an arthroscopically confirmed LMPRT. Arthroscopic findings were compared to the reading radiologist’s preoperative MRI interpretations. LMPRTs were graded using the LaPrade classification. ANOVA was performed to assess if body mass index (BMI), open physes, time from injury to MRI, time from MRI to surgery, MRI magnet field strength, musculoskeletal radiologist designation, insurance type and tear grade were associated with the preoperative MRI identification of a LMPRT.Results:During the study period, 1285 knee arthroscopies were performed. 607 of which were ACL reconstructions. 54 children were found to have a LMPRT arthroscopically and all were associated with an ACL tear 54/607 (9%). One patient had 2 preoperative MRIs for a total of 55 MRIs in 54 pateints. Average age was 16 years (range 14-21). Preoperative MRI diagnosis of a LMPRT was made in only 14/55 (25%) and missed in 22/55 (40%). In 19/55 (35%), pathology of the lateral meniscus nonspecific to the root was mentioned. Lateral joint line tenderness was present in 23/54 (46%). There was no statistical significance found in regards to patient BMI, skeletal maturity, time from injury to MRI, time from MRI to surgery, MRI magnet strength, if the radiologist was musculoskeletal fellowship-trained, or insurance type, with a reliable diagnosis. (Table)Conclusion:The final interpretation of preoperative MRIs did not provide a clear definitive diagnosis of a LMPRT in 75 % in patients. As the intraoperative management of LMPRTs can be involved and diverge from standard meniscal work, preoperative diagnosis would be advantageous. All LMPRTs in this study were associated with a concomitant ACL tear. Surgeons caring for ACL tears in children and adolescents should be prepared to treat a LMPRT regardless of a inconclusive MRI interpretation for meniscal root pathology.

Arthroscopic side-to-side repair for complete radial posterior lateral meniscus root tears

BackgroundThe aim of this study was to determine the radiographic, second-look, and functional outcomes after arthroscopic side-to-side repair for complete radial posterior lateral meniscus root tears (PLMRTs).MethodsPatients who underwent arthroscopic side-to-side repair for complete radial PLMRTs were identified. Clinical assessment consisted of symptoms (locking, catching, giving way and effusion), examinations of joint-line tenderness and McMurray test, and subjective scores of International Knee Documentation Committee (IKDC), Lysholm, and Tegner. In addition, postoperative MRI scan and second-look arthroscopy were performed to assess the healing status of the repaired meniscus.ResultsTwenty-nine patients met the inclusion criteria. The mean age was 25.41 years. The mean follow-up period was 26.68 months. During the follow-up, none of the patients had symptoms of meniscal retear, lateral joint-line tenderness or a positive McMurray test. The postoperative subjective scores of IKDC, Lysholm, and Tegner improved significantly compared to the preoperative values (P = 0.01). Postoperative MRI scan showed that 28/29 (96.6%) patients achieved meniscus healing. Twenty-two patients underwent second-look arthroscopy, among whom 19 (86.4%) patients showed complete meniscus healing and 3 (13.6%) patients showed partial healing.ConclusionArthroscopic side-to-side repair was a valuable surgical repair technique for complete radial PLMRTs, which leaded to significant improvements in both objective and subjective functional outcomes with a high rate of meniscus healing.Level of evidenceLevel IV, case series.

Giant Cell Tumor Masquerading as Lateral Meniscus Injury: A Case Report

Giant cell tumor (GCT) is a benign bone tumor with aggressive characteristics and capacity to metastasize. They are more common in the third decade of life and demonstrate a preference for being located in the epiphyseal region of long bones. They have a high local recurrence rate, which depends on the type of treatment and initial tumor presentation. Early detection of GCT is possible with proper clinical assessment and radiograph. However, due to its rarity, physicians may have neglected the possibility of bone tumor as one of the differential diagnosis for cases referred as “soft tissue injury”.We report a case of a 22-year-old lady who presented with seven-month-history of right knee pain, lateral joint line tenderness and positive McMurray test and initially treated as right lateral meniscus injury. However, the knee pain worsened over time and became persistent despite starting on physiotherapy and home-based-exercises. Upon subsequent visit two months later, she presented with tender bony swelling over the lateral tibial plateau and radiological examination revealed a lytic lesion over her proximal right tibia. Magnetic resonance imaging and histopathology testing confirmed the diagnosis of Giant cell tumor. This case report aims to increase the awareness of possible bone tumors in soft tissue injury cases and highlight the importance of detailed reassessment and reviewing diagnosis during each follow up.International Journal of Human and Health Sciences Vol. 04 No. 02 April’20 Page : 148-151

Knee Pain - Swimming in Dangerous Waters

Title: Knee Pain - Swimming in Dangerous Waters Authors: Lauren Nadkarni, MD and Kate Quinn, DO (sponsored by Heather Gillespie, MD, MPH, FACSM) HISTORY: A 17-year-old male with a non-contributory past medical history developed acute pain in his left knee while swimming 3 days prior to presentation. He experienced a popping sensation with hyperextension of his knee while treading water and throwing a rope swing to his friends on the bank of a river. He had immediate swelling and felt pressure on the lateral and posterior parts of his knee, associated with sharp and stabbing pain when straightening his knee. His pain was worse with flexion beyond 90 degrees, straightening his leg, or walking, but was improved with rest and ice. He did not have any give-way or locking episodes. PHYSICAL EXAM: Office examination of his left knee was limited by guarding but demonstrated a very subtle posterior sag sign and a positive effusion. There were no overlying skin changes. His range of motion was 5 degrees of hyperextension to 110 degrees flexion actively his flexion increased to 120 degrees passively. He also had mild posterior lateral joint line tenderness, negative patellar testing, and positive posterior drawer and lateral flexion pinch testing. His anterior drawer testing was negative, although he did exhibit guarding. His contralateral knee, ipsilateral hip/ankle, and neurovascular exams were unremarkable. DIFFERENTIAL DIAGNOSIS: • PCL injury • ACL injury • Lateral meniscus injury • Posterior lateral corner injury • Patellar subluxation • Lateral tibial plateau contusion or fracture • Lateral femur contusion or fracture TESTS AND RESULTS: Left knee x-ray: • Normal anatomy with small effusion • No acute fracture Left knee MRI: • Isolated PCL rupture FINAL/WORKING DIAGNOSIS: • Isolated PCL rupture TREATMENT AND OUTCOMES: • Knee immobilizer for 3-4 weeks • Physical therapy with initial avoidance of hamstring activation for the first 4 weeks • Over the counter analgesics as needed • Return to sport progression

Do Clinical Correlates of Knee Osteoarthritis Predict Outcome of Intraarticular Steroid Injections?

To determine whether clinical correlates of knee osteoarthritis (OA) affect the outcome of intraarticular steroid injections (IASI) in symptomatic knee OA. Men and women aged ≥ 40 years with painful knee OA who participated in an open-label trial of IASI completed questionnaires and clinical examination. The Outcome Measures in Rheumatology (OMERACT)-Osteoarthritis Research Society International (OARSI) criteria were used to assess response to therapy in the short term (within 2 weeks). Among those who initially responded, those whose pain had not returned to within 20% of the baseline Knee Injury and Osteoarthritis Outcome Score pain score at 6 months were characterized as longer-term responders. Log-binomial regression was used to examine factors associated with outcome. One hundred ninety-nine participants were included, of whom 146 (73.4%) were short-term and 40 (20.1%) longer-term responders. Compared to short-term nonresponders, participants with these characteristics were more likely to be short-term responders: medial joint line tenderness [relative risk (RR) 1.42, 95% CI 1.10-1.82], medial and lateral joint line tenderness (RR 1.38, 95% CI 1.03-1.84), patellofemoral tenderness (RR 1.27, 95% CI 1.04-1.55), anserine tenderness (RR 1.27, 95% CI 1.06-1.52), and a belief that treatment would be effective [RR/unit increase (range 0-10) = 1.05 (1.01-1.09)]. Aspiration of joint fluid (RR 0.79, 95% CI 0.66-0.95) and previous ligament/meniscus injury (RR 0.63, 95% CI 0.44-0.91) were associated with a reduced risk of being a short-term responder. Compared to initial nonresponders and those whose pain recurred within 6 months, participants with a higher number of pain sites [RR/unit increase (range 0-10) = 0.83, 95% CI 0.72-0.97], chronic widespread pain (RR 0.32, 95% CI 0.10-0.98), perceived chronicity of disease [RR/unit increase (range 0-10) = 0.86, 95% CI 0.78-0.94], and a higher depression score [RR/unit increase (range 0-21) = 0.89, 95% CI 0.81-0.99] were less likely to be longer-term responders. Among patients with symptomatic knee OA, tenderness around the knee was associated with better short-term outcome of IASI. However, clinical-related factors did not predict longer-term response, while those with chronic widespread pain and depressive symptoms were less likely to obtain longer-term benefits.

The Role of Clinical Examination in Predicting Relevant MRI Findings in Acute Knee Injuries: A Retrospective Study.

The objective of this study was to delineate the usefulness of clinical examination and magnetic resonance imaging (MRI) in acute knee injuries. We aim to establish whether the time period post acute knee injury is related to the diagnostic accuracy of clinical examination and to investigate the strength of specific clinical examination findings in predicting a clinically relevant MRI abnormality. Seventy patients were referred to fracture clinic with an acute knee injury who subsequently went on to be investigated with MRI over 12 months. These patients were retrospectively analyzed looking at the time period they were reviewed, the components that were assessed at physical examination, and the results of their eventual MRI scan looking for any correlation. A greater proportion of patients who were examined at 2 weeks had relevant positive findings on MRI scan, p = 0.03. Range of movement and lateral joint line tenderness were not associated with a positive MRI scan at any period after injury. The presence of a moderate to large effusion was not associated with an MRI abnormality if the examination was within 2 weeks of injury but was if present 2 weeks after injury, p = 0.0001. Range of movement should not form part of the decision making on whether an injury should be investigated with MRI. Joint effusion in isolation within 2 weeks after injury should not be an indication for MRI but a repeat clinical examination in 2 weeks, where if still present, should be investigated with MRI.

Relationship between Clinical, MRI, and Arthroscopic Findings: A Guide to Correct Diagnosis of Meniscal Tears.

Purpose The aim of this prospective study was to compare and correlate clinical, MRI, and arthroscopic findings in cases of suspected meniscal tears. Using arthroscopic findings as the gold standard, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of clinical investigation and MRI were evaluated to determine if is possible, after a careful examination, to bypass MRI and perform directly arthroscopy in suspected cases. Methods A total of 80 patients with a history of knee trauma, preoperative RX, and MRI underwent arthroscopy over an 8-month period at our department. All patients had a clinical examination performed by an experienced knee surgeon. These examiners evaluated and recorded the results of three tests: medial and lateral joint line tenderness test, McMurray's test, and Apley's test. The injury was classified as a meniscal tear if there were at least two positive tests. Finally, using the arthroscopic findings as the gold standard, sensibility, specificity, accuracy, positive and negative predictive values of clinical examination, and MRI were evaluated and compared. Results Clinical examination performed by an experienced knee surgeon reported better sensitivity (91 vs. 85%), specificity (87 vs. 75%), accuracy (90 vs. 82%), positive predictive value (94 vs. 88%), and negative predictive value (81 vs. 71%) than MRI for medial meniscal tears. These parameters showed minimal differences for lateral meniscal tears. Conclusion Clinical examination performed by an experienced knee surgeon provided equal or better results to diagnose meniscal injuries in comparison to MRI. MRI is not necessary to confirm these lesions and should not be used as the primary diagnostic tool. Level of Evidence Level II, prospective study.

Utility of Dynamic Sonographic Evaluation of Left Knee Pain & Locking in a Softball Catcher

HISTORY: An 18 year-old softball catcher presenting with a 3 year history of left progressive postero-lateral knee discomfort with associated knee locking when squatting or deep knee flexion. Onset was 3 years ago when she was in a squat position during a softball game. She had been avoiding aggravating activities and initially sought medical care 3 months ago, presenting to an orthopedic specialist’s clinic. Following a negative MRI, she was referred to our clinic for diagnostic ultrasound of the knee. She reported no reliable way to reproduce locking, but, when locking does occur, she must manually unlock herself. Previous treatment included 8 weeks of physical therapy without benefit. PHYSICAL EXAMINATION: No discoloration or swelling of the left knee. Non-antalgic gait. Valgus alignment with dynamic valgus on single leg squat. Posterior lateral joint line tenderness. No other focal tenderness. Full and symmetric bilateral knee active range of motion without pain, except in terminal flexion. Negative McMurray’s, cruciate and collateral ligament testing and dial test. 9/9 Beighton criteria. DIFFERENTIAL DIAGNOSIS: 1. Meniscocapsular separation 2. Lateral meniscus injury 3. Proximal tibiofibular ligament injury 4. Popliteus muscle/tendon injury 5. Anteriolateral complex sprain 6. PFL injury TEST AND RESULTS: MRI: Subtle irregularity of posterior superior meniscocapsular fascicle deemed secondary to volume-averaging artifact. Otherwise, no discrete pathology was noted. Ultrasound: No discrete lesion of entirety of lateral meniscus on static exam. Development of a separation (3.1mm) between posterior knee capsular tissue and posterior outermost fiber of left lateral meniscus when knee is in near full flexion. FINAL WORKING DIAGNOSIS: left postero-lateral meniscocapsular separation TREATMENT AND OUTCOMES: Management options (expectant management, injection options to mitigate pain, and a surgery) were discussed. Patient elected surgical fixation of lateral meniscus. Arthroscopic fixation of lateral meniscus with 2 vertical mattress sutures using a FasTFix device was performed. After 4 weeks of bracing to allow proper surgical healing, she was able to start using an elliptical at 6 weeks and jogging at 9 weeks. She remains void of pre-surgical pain and locking at 16 weeks post-operatively.

Diagnostic value of the clinical investigation in acute meniscal tears combined with anterior cruciate ligament injury using arthroscopic findings as golden standard.

The main purpose of our study was to evaluate the accuracy of clinical investigation for meniscal tears associated with ACL injuries. We hypothesized that combined ACL injury can decrease the accuracy of clinical examination in acute onset. One hundred and thirty-seven patients with a mean age of 28.5 years (from 12 to 55) were prospectively examined for acute combined ACL and meniscal injuries, between March and November 2012 at our department. For meniscal tears, clinical examination was performed using McMurray test, Apley test and medial and lateral joint line tenderness. The diagnoses of ACL tear were made using Lachman test, jerk test and pivot-shift test, anterior drawer test and KT-2000 side-to-side difference. Each patient was examined using X-ray and MRI. All the patients underwent arthroscopic surgery performed by the same surgeon within 6 weeks after the injury. Finally, using the arthroscopic findings as gold standard, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of clinical investigation and MRI were evaluated. The specificity of clinical investigation was 63.5 and 46.0 % and the sensitivity was 74.4 and 77.3 % for the medial meniscus and the lateral meniscus, respectively. Overall, the accuracy of the clinical investigation was 70.3 % for the MM and 65.5 % for the lateral meniscus. The accuracy of MRI investigation was 76.4 and 69.5 % for medial and lateral meniscus, respectively. In combined acute ACL injury and meniscal tears, we have found a decreased accuracy of the clinical investigation. The remnants of the torn ACL and the synovitis increased the rate of false positives, and it could simulate meniscal tears. However, clinical investigation can provide sufficient information for the treatment decision and MRI can be avoided as a routine diagnostic tool. Level II, prospective study.

Diz manyetik rezonans görüntüleme bulguları ve fizik muayene bulgularının artroskopik bulgular ile karşılaştırılması

Comparison of magnetic resonance imaging and pysical examination of knee with arthroscopic findings Objective: To determine the effects of physical examination findings with the results of manyetik rezonans imaging (MRI) on the decision for arthroscopic surgery. Methods: Preoperative physical examination findings and MRI results of the patients undergoing knee arthroscopy in our clinic were evaluated statistically by reference of arthroscopy retrospectively. Results: The mean age of patients in the study is 47.2 (22.73), respectively. 25 of the patients were female, 20 of them were male. Arthroscopic surgery was performed for 27 left knee and 18 right knee. Mc Murray test sensitivity in patients with medial meniscus tear is 69.8%. The medial joint line tenderness sensitivity is 97.7% in the patients with medial meniscus tear. Sensitivity of MRI is determined as 93% in the group with medial meniscus tear. Mc Murray test sensitivity in patients with lateral meniscal tear is 71.4%. The lateral joint line tenderness sensitivity is 100% in the patients with lateral meniscus tear. Sensitivity of MRI is determined as 85.7% in the group with lateral meniscus tear. Mc Murray test sensitivity is 68.9%, joint line tenderness sensitivity is 97.8% and sensitivity of MRI is determined as 93.3% without discrimination on the medial and lateral meniscal tear. Conclusion: A careful physical examination is the most effective diagnostic method to determine meniscal pathologies. We think that careful physical examination could reduce the rates of

Ganglion cyst or meniscal cyst—a dilemma!

An otherwise healthy 49-year-old gentleman presented to our out-patient clinic with knee swelling since 2 years with associated pain on squatting and walking long distances. He gave no history of locking or instability. On examination, he had a globular swelling on the lateral aspect of the knee, over the lateral joint line about 3×4 cm in size. The swelling was firm in consistency, not mobile, and became more prominent on knee flexion. He had lateral joint line tenderness. There was slight limitation of flexion with the range of movement being 0–120°. The tests for stability and the Mc Murray’s test were negative.

History, clinical findings, magnetic resonance imaging, and arthroscopic correlation in meniscal lesions

The aim of this prospective study was to compare the accuracy of clinical examination and magnetic resonance imaging (MRI) versus arthroscopic findings and to determine the value of an experienced examiner in clinical decision making. A total of 30 patients with a preoperative MRI underwent arthroscopy over a 5-month period. All patients had a clinical examination performed by an experienced knee surgeon, a specialist in general orthopedics, a senior resident, and a fourth-year resident. These examiners recorded and evaluated the results of seven tests: the medial and lateral joint line tenderness test, the McMurray test, the Apley test, the Stienmann I test, the Payr's test, Childress' sign, and the Ege's test. The injury was classified as a meniscal tear if there were two positive tests. Clinical history, physical examination, and MRI findings were compared with the arthroscopic findings. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these methods of evaluation were then calculated. Clinical examination performed by an experienced knee surgeon had better specificity (90% vs. 60%), positive predictive value (95% vs. 83%), negative predictive value (90% vs. 86%), and diagnostic accuracy (93% vs. 83%) than MRI for medial meniscal tears. These parameters showed only a marginal difference in lateral meniscal tears. The experienced knee surgeon had better sensitivity, specificity, predictive values, and diagnostic accuracy parameters for medial meniscus tears in comparison with the other three examiners. These results indicate that clinical examination by an experienced examiner using multiple meniscus tests is sufficient for a diagnosis of a meniscal tear. II.

Locking Knee in a Football Player

HISTORY: 16 y.o. high school sophomore football player sustained a knee injury while running in a game. During the second quarter of a midseason football game, he suddenly experienced locking and pain of his left knee. No clear mechanism of injury known. After being escorted off the field he was examined by the team orthopaedic surgeon. His left knee was manipulated by fully flexing the knee and applying varus stress while extending the knee. There was an audible "clunk". The player successfully performed sideline drills pain free and he returned to the game. Repeat exam following the game revealed only lateral joint line tenderness. MRI of the knee was performed with normal findings. He was placed in a long hinged knee brace for play. Subsequently, during a regular practice session, he again experienced pain and locking of the same knee while running. He was re-examined by the orthopaedic surgeon, the left knee reduced with an audible "clunk", and returned to play. PHYSICAL EXAM: Exam on the sidelines revealed no swelling, effusion, or bruising. The left knee lacked 20 degrees of full extension. There was pain with forced extension. He had tenderness along the lateral joint line. Lachman negative. Anterior and Posterior Drawer were negative. Varus and Valgus stress at 0 and 30 degress were negative. Mcmurray negative. Neurovascularly he was intact. After manipulation of the knee by fully flexing the knee and then extending while applying varus stress to the knee, there was an audible "clunk" and the patient's pain resolved. Re-examination was within normal limits. Differential Includes: Meniscal Tear Hypermobile Meniscus Discoid Meniscus TEST AND RESULTS: MRI of the knee revealed intact medial and lateral meniscus, intact cruciate and collateral ligaments, and normal bony anatomy. Otherwise normal MRI of the knee. FINAL WORKING DIAGNOSIS: Hypermobile lateral meniscus Treatment: Conservative care including a hinged knee brace restricting motion between 0 and 90 degrees. He has continued to play in a hinged brace restricting his motion without further reoccurrence. Definitive treatment involves arthroscopic examination and manipulation to further define the problem and potentially secure the lateral meniscus.

An 11-Year-Old Girl Presenting with Chronic Knee Pain: A Case Report with Diagnostic Dilemma

Discoid meniscus is the commonest anatomical aberration of the knee joint, among rare cases such as bilateral separated lateral meniscus, accessory lateral meniscus, partial deficiency of the lateral meniscus and double-layered lateral meniscus. An 11-year-old girl presented with history of chronic pain in her right knee for the last 6 months. The problem disturbed her involvement in the sport activities at school. Clinical examination revealed a clicking sensation on knee extension with lateral joint line tenderness. Magnetic resonance imaging (MRI) of her right knee showed torn posterior horn of lateral meniscus. Arthroscopy examination revealed a discoid meniscus with absence posterior horn. Posterior horn deficient discoid meniscus is a rare form of a congenital meniscus anomaly. We as clinicians believe that the abnormal shaped meniscus may pose a diagnostic challenge clinically and radiologically. Presentation of this case may be beneficial for orthopaedicians in their daily clinical practice.

Correlation of Joint Line Tenderness and Meniscus Pathology in Patients with Subacute and Chronic Anterior Cruciate Ligament Injuries

We evaluated joint line tenderness (JLT) as a test for meniscus pathology in 3531 patients who underwent anterior cruciate ligament (ACL) reconstruction >30 days postinjury. If the patient had no additional giving-way episode after the index ACL injury, the injury was considered subacute; otherwise, it was considered chronic. Immediately before surgery, the presence or absence of medial or lateral JLT was evaluated. During ACL reconstruction, the presence or absence of meniscal tears was documented. In the subacute population, JLT was 41% sensitive, 56% specific, and 50% accurate for detecting medial meniscal tears and 57% sensitive, 44% specific, and 49% accurate for detecting lateral meniscal tears. In the chronic population, JLT was 55% sensitive, 50% specific, and 52% accurate for detecting medial meniscal tears and 46% sensitive, 52% specific, and 50% accurate for detecting lateral meniscal tears. The presence of JLT alone should not be used in the clinical decision making process to guide treatment.