Update for chapter 19: How Reliable is the Physical Examination in the
Diagnosis of Sports Related Knee Injuries?

Nicola A DeAngelis

This paper is as an update to the chapter of the same name published in Evidenced-based
Sports Medicine in May 2002. As before, the update is based on articles published in the
various journals that are familiar to the physician interested in sports medicine. These
journals include: Arthroscopy, the American Journal of Sports Medicine, the Journal of
Bone and Joint Surgery (American and British editions), the Journal of the American
Academy of Orthopedic Surgeons, the Journal of Orthopedic and Sports Physical
Therapy, the Journal of Orthopedic Trauma, Knee Surgery Sports Traumatology and
Arthroscopy, and the Annals of the Royal College of Surgeons. In addition, Medline
searches were conducted using PubMed and OVID with search dates set from November
2000 to present using the same terms as the original paper.

Validation of the Physical Examination

General Examination

Jagodzinski, et.al., evaluated the accuracy of clinical and radiographic knee flexion and
extension measurement techniques using 15 human cadavers. They determined that the
use of a precision goniometer that relies on bony landmarks of the tibia and femur is
superior to both a standard and long arm goniometer when measuring knee flexion and
extension angles clinically. In addition, radiographic measurement of knee flexion and
extension angles is more accurate using the long axes of the femur and tibia when
compared to measurements made from radiographs of just the knee.

Kocher et.al. compared the diagnostic performance of clinical exam to MRI in the
evaluation of intraarticular knee disorders in children, using arthroscopy as the gold
standard. 113 patients (118 knees) were included over a seven year period. All patients
were less than 16 years of age. They concluded that there is no significant difference
between MRI and clinical exam with respect to agreement with arthroscopic findings,
overall sensitivity, or overall specificity. When stratified by diagnosis, only sensitivity
for lateral discoid meniscus (exam 88.9%, MRI 38.9%) and specificity of medial
meniscal tears (exam 80.7%, MRI 92.0%) are statistically different. In addition, MRI is
significantly less sensitive and specific in children less than 12 years old when compared
to those 12 to 16 years old.

Patellofemoral Joint

Niskaken et.al. attempted to correlate clinical examination of the patella with patellar
cartilaginous changes found at arthroscopy. 85 patients were subjected to the tracking,
apprehension, patellar inhibition, and flexion tests and then underwent arthroscopy. They
concluded that with the exception of flexion test specificity (85%), none of the tests

shows a specificity or sensitivity greater than 70% and thus are poor predictors of patellar
chondral pathology.

Watson et.al., studied the reliability of the patellar lateral pull and tilt tests in 52 patients
(95 knees, 19 symptomatic, 76 asymptomatic). Each knee was examined by two or three
examiners twice over a period of three to five days. They concluded that these two tests
have fair intrarater and poor interrater reliability and should be used with caution.

Meniscal Lesions and Cruciate Injuries

Rao et.al., reviewed their experience with discoid menisci. Of the over 1600 people
undergoing knee arthroscopy at their institution over a six year period of time, 5.8% (95
patients) were noted to have discoid menisci. Of interest, the classic discoid meniscal
thud or clunk could be elicited in only 25 patients (28.7%).

Solomon et.al. attempted to determine the accuracy of physical examination in
determining ligamentous and meniscal injuries of the knee by reviewing the literature
from 1966 to 2000. 23 studies met their inclusion criteria. Using likelihood ratios (LR),
they reached several conclusions. First, examination of the ACL is relatively accurate
with an overall LR of 25.0 and a Lachman test LR of 42.0. Similarly, examination of the
PCL had an LR of 21.0. Examination of the menisci is less reliable, with an overall LR
of 2.7, and a McMurray Test LR of 0.9.

Conclusion

In conclusion, several papers have added to our information base regarding the physical
examination of the knee since the publication of Evidence-based Sports Medicine in May
2002. This update, combined with the original chapter, will hopefully provide the reader
with a reasonable overview of a valid physical examination of the knee.

References

Jagodzinski M, V Kleeman, P Angele, V Schonhaar, KW Iselborn, G Mall, M Nerlich. Experimental and
Clinical Assessment of the Accuracy of the Knee Extension Measurement Techniques. Knee Surgery,
Sports Traumatology, Arthroscopy: vol. 8(6), pp. 329-36, Dec. 2000.

Niskanen R, P Paavilainen, M Jaakkola, O Korkala. Poor Correlation of Clinical Signs with Patellar
Cartilaginous Changes. Arthroscopy: vol. 17 (3), pp. 307-10, Mar. 2001.

Rao P, M Sharath, M Rao, R Paul. Clinical, Radiographic, and Arthroscopic Assessment of Discoid
Lateral Meniscus. Arthroscopy: vol. 17 (3), pp. 275-77, Mar. 2001.

Kocher M, J DiCanzio, D Zurakowski, L Micheli. Diagnostic Performance of Clinical Examination and
Selective Magnetic Resonance Imaging in the Evaluation of Intraarticular Knee Disorders in Children and
Adolescents. American Journal of Sports Medicine: vol. 29(3), pp. 292-96, May/June 2001.

Watson C, H Leddy, T Dynjan, J Parham. Reliability of the Lateral Pull Test and Tilt Test to Assess
Patellar Alignment in Subjects with Symptomatic Knees: Student Raters. Journal of Orthopedic and Sports
Physical Therapy: vol. 31(7), pp. 368-74, July 2001.

Solomon D, D Simei, D Bates, J Katz, J Schaeffer. Does This Patient Have a Torn Meniscus of Ligament
of the Knee? Value of the Physical Examination. Journal of the American Medical Association: vol. 286,
pp. 1610-20, Oct 3 2001.

Updated Summary Statement

General Examination

- Use of a precision
goniometer is superior to
standard and long-arm
goniometers when measuring
knee flexion angles

Patellofemoral Joint

- The patellar tracking,
apprehension, inhibition and
flexion tests are poor
predictors of patellar chondral
pathology
- The patellar lateral pull and
tilt tests have fair intrarater and
poor interrater reliability

Meniscal Lesions

- In children, there are no
significant differences between
MRI and clinical exam when
assessing intraarticular knee
disorders
- Clinical examination of the
menisci is relatively unreliable,
with a likelihood ratio of 2.7
- The McMurray test has a
likelihood ratio of 0.9

Posterior Cruciate

Ligament

- Clinical examination of the
PCL is relatively accurate,
with a likelihood ratio of 21.0

Anterior Cruciate

Ligament

- Clinical examination of the
ACL is relatively accurate,
with a likelihood ratio of 25.0
- The Lachman test has a
likelihood ratio of 42.0