Epidemiology Meniscus lesion

Epidemiology Meniscus lesion

Meniscus laesion Meniscus Injuries: total tear or rupture in the medial or lateral meniscus, depending on the type of tear refers to a vertical crack length (bucket handle tear or flap), (vertical) or horizontal radial tear (fishmouth) meniscus tear. This last type is located in the plane of the meniscus and may be a manifestation of degeneration.1
Incidence The incidence of meniscal lesion in the CMR is 2 per 1,000 males and 1 in 1,000 women with a peak incidence between 25 and 65 years.2
Function The major meniscal functions are to distribute stress across the knee during weight bearing,12,13 provide shock absorption,12,14,15 serve as secondary joint stabilizers,16-19 provide articular cartilage nutrition and lubrication, facilitate joint gliding, prevent hyperextension, and protect the joint margins.17,18 Circumferential meniscal stress measurements have shown that 45% to 70% of the weight-bearing load is transmitted through the menisci when the peripheral margins are intact.8-11,14
Sex Male > Female 2:12
Age 25 en 65 jaar2
Pain location Knee joint
Pain sensation / Symptoms A meniscus injury can in the acute phase and some time after trauma, be accompanied by hydrops and pain and locking complaints when bending or straightening the knee.3,4,5,6,7
History of injury Meniscus injury is most likely to happen after a trauma In a closing level of the knee. A meniscus injury often occurs after a (forced) rotation of the lower leg during simultaneous flexion or extension, but can also occur without apparent prior trauma. In this last case, it may go to degenerative meniscus injury. There is evidence that symptoms of meniscal injury within three months to one year significantly reduce and some meniscal lesions spontaneously recover.3,4,5,6,7
Literature
  1. http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden/NHGStandaard/M66_std.htm
  2. Van de Lisdonk EH, Van den Bosch WJHM, Lagro-Janssen ALM. Ziekten in de huisartspraktijk. 5de ed. Maarssen: Elsevier Gezondheidszorg, 2008.
  3. Baker P, Coggon D, Reading I, Barrett D, McLaren M, Cooper C. Sports injury, occupational physical activity, joint laxity, and meniscal damage. J Rheumatol 2002;29:557-63.
  4. Bansal P, Deehan DJ, Gregory RJH. Diagnosing the acutely locked knee. Injury 2002;33:495-8.
  5. Verhaar JAN, Van Mourik JBA. Orthopedie. Houten: Bohn Stafleu Van Loghum, 2008.
  6. Kuijer PPFM, Frings-Dresen MHW. Meniscusletsel als beroepsziekte? TBV;14:330.
  7. Sarimo J, Rantanen J, Heikkila J, Orava S. Acute traumatic extension deficit of the knee. Scand J Med Sci Sports 2003;13:155-8.
  8. Seedholm B. Transmission of the load in the knee with special reference to the role of the meniscus: part I. Eng Med. 1979;8:207–221.
  9. Seedholm B, Hargeaves D. Transmission of the load in the knee with special reference to the role of the meniscus: part II. Eng Med. 1979;8:221–228.
  10. Shrive NB, O’Connor JJ, Goodfellow JW. Load-bearing in the knee joint. Clin Orthop. 1978;131:279–287.
  11. Mow V, Fithian D, Kelly M. Fundamentals of articular cartilage and meniscus biomechanics. In: Ewing JW, editor. Articular Cartilage and Knee Joint Function: Basic Science and Arthroscopy. New York, NY: Raven Press; 1989. pp. 1–18.
  12. Arnoczky S, Adams M, Mow V. The meniscus. In: Buckwalter J, Woo S, editors. The Injury and Repair of Musculoskeletal Soft Tissue. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1988. pp. 487–537.
  13. The effect of medial meniscectomy on anterior-posterior motion of the knee. Levy IM, Torzilli PA, Warren RF J Bone Joint Surg Am. 1982 Jul; 64(6):883-8.
  14. Review Material properties and structure-function relationships in the menisci. Fithian DC, Kelly MA, Mow VC Clin Orthop Relat Res. 1990 Mar; (252):19-31.
  15. Shock absorption of meniscectomized and painful knees: a comparative in vivo study. Voloshin AS, Wosk JJ Biomed Eng. 1983 Apr; 5(2):157-61.
  16. The effect of lateral meniscectomy on motion of the knee. Levy IM, Torzilli PA, Gould JD, Warren RF J Bone Joint Surg Am. 1989 Mar; 71(3):401-6.
  17. Radin EL, de Lamotte F, Maquet P. Role of menisci in distribution of stress in the knee. Clin Orthop. 1984;185:290–294.
  18. Fukubayashi T, Torzilli PA, Sherman MF, Warren RF. An in vitro biomechanical evaluation of anterior-posterior motion of the knee: tibial displacement, rotation, and torque. J Bone Joint Surg Am. 1982;64:258–264.
  19. Mechanical changes in the knee after meniscectomy. Krause WR, Pope MH, Johnson RJ, Wilder DG J Bone Joint Surg Am. 1976 Jul; 58(5):599-604.

 

Physical examination

McMurray’s Test 
  1. patient supinewith theleginexternal rotation.
    2. Slowly extend from maximal flexion + simultaneous palpation of the medial side of the joint.
    3. test is positive when a “pop” felt while palpating, this indicates a lesion of the medial meniscus (testing the lateral meniscus in the same way, but with the leg in internal rotation and palpating the lateral side.)

Apley’s test 
The patient is in the prone position, the knee ± 90 ° flexion. The therapist stands at the affected side to investigate. The other hand of the therapist is placed on the calcaneus, in which the ankle joint is held in maximum dorsiflexion. The lower arm is located in the extension of the lower leg of the patient. The thigh is fixed against the bank. The therapist performs ‘while holding’ compression, alternately maximum exo- and endo rotation movements. This compression is applied to the alternating lateral and medial meniscus.
For differentiation of ligamentous lesions, the following test is performed in traction: The therapist holds both hands at the distal part of the lower leg. The thigh is fixated by the knee of the therapist on the treatment table. The therapist performs while holding traction, alternating maximum exo- and endo rotation movements. If this test is positive, then there probably is a lateral ligament injury and not of meniscal injury.

Thessaly’s Test at 5 and 20 graden
The Thessaly test is a reproduction of dynamic weight transfer to the knee, performed at 5 ° and 20 ° flexion of the knee. The therapist supports the patient through holding his outstretched hands, while the patient stands on one leg. The patient endororates – and exororates his or her knee and body three times, while the knee in 5 ° flexion remains. The same procedure is performed with the knee in 20 ° flexion. Patients with suspected meniscal injury experience a medial or lateral sensitivity in the joint space. This sensitivity may be associated with a painful click or popping sound in the knee.1

Ege’s Test
  1. Place feet 8-10 inches appart with feet pointed outward (medial meniscus) or inward (lateral meniscus.
  2. Patiënt squats down with feet flat of the floor. Pain or a click when the knee approaches 90 indicates meniscal tear.

Axiale pivot-shift test
Initial posture: patient supine. The leg is supported by the treatment table.
Therapist: includes only pt. with the homolateral hand and holds axial pressure.
The lateral hand presses the fibula head to anteromedial.
Execution: Now with the homolateral hand the knee is put into flexion and internal rotation. (while holding axial pressure).
Test Result: positive if the knee shoots back between 30 ° and 50 ° from the subluxation position (latral tibia plateau to ventral by starting posture of the test)
Steinmann I Sign
The patient supine, with the knee in 0° position. The therapist stands at the side next to knee joint that has to be examined. In the 0 ° position, the medial meniscus can be palpated between the quadriceps tendon and the medial collateral ligament. The consistency of the meniscus edge can be reviewed. By gradually flexing the knee the pain will disappear and the pain point and will be palpable more posteriorly. This pain point displacement dorsally indicates a meniscal lesion.
When a pain point is at the height of the medial collateral ligament and at the height of the joint space, this test is less reliable, because both the medial meniscus and the band during flexion of the knee to move posteriorly.

Literature
  1. Karachalios, T., Hantes, M.H., Zibis, A.H., Zachos, V., Karantanas, A.H., Malizos, K.N.; Diagnosis Accuracy of a New Clinical Test (the Thessaly Test) for Early Detection of Meniscal Tears. In: The Journal of Bone & Joint Surgery, The Journal of Bone and Yoint Surgery, 2005, pp. 955?962.

 

Evidence Based Practice

McMurray’s Test Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Karachalios et al.7
Medial 48 94 9
Lateral 65 86 9
Akseki et al.2
Medial 67 69 11
Lateral 53 88 11
Kurosaka et al.10
Medial + Lateral 37 77 10
Pookarnjanamorakot et al.12
Medial + Lateral 28 92 11
Fowler & Lubliner5
Medial + Lateral 29 96 10
Anderson & Lipscomb6
Medial + Lateral 58 29 9

 

Apley’s test  Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Karachalios et al.7
Medial + Lateral 41 93 9
Kurosaka et al.10
Medial + Lateral 13 90 10
Pookarnjanamorakot et al.12
Medial + Lateral 16 80 11
Fowler & Lubliner5
Medial + Lateral 16 100 10

 

Thessaly’s Test at 20 degrees / Disco Test Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Karachalios et al.7
Medial 89 97 9
Lateral 92 96 9

 

Thessaly’s Test at 5 degrees Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Karachalios et al.7
Medial 66 96 9
Lateral 81 91 9
Pookarnjanamorakot et al.12
Medial + Lateral 27 96 11

 

Ege’s Test* Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
 Akseki et al.2
Medial 67 81 11
Lateral 64 90 11

* Ege’s test improves the posttest probability of detecting a torn meniscus by a small to moderate amount. Further research needs to be performed to corroborate the statistics reported in this study

 

Axial pivot shift test* Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Kurosaka et al.10
Medial + Lateral 71 83 10

* The axial pivot-shift test improves the posttest probability of detecting a torn meniscus by a small amount in patients who have symptoms for longer than 8 weeks. More research is needed to confirm this conclusion

 

Steinmann I Sign* Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Dervin et al.4 NT NT NA
Pookarnjanamorakot et al.12 27 96 11

* The one study to examine the diagnostic accuracy of the Steinmann I Sign indicates a perfectly specific test that would rule in a meniscus tear if positive. However, the lack of interobserver agreement of this test and the fact that only one study has examined this test make any conclusions about diagnostic accuracy tentative

 

Literature
  1. Akseki D, Ozcan O, Boya H, Pinar H. A new weight-bearing meniscal test and a comparison with McMurray’s test and join line tenderness. Arthroscopy. 2004;20:951-958.
  2. Anderson AF, Lipscomb AB. Clinical diagnosis of meniscal tears: description of a new manipulative test: Am J Sports Med. 1986;14:291-293
  3. Dervin GF, Stiell IG, Wells GA, Rody K, Grabowski J. Physicians’ accuracy and interrater reliability for the diagnosis of unstable meniscal tears in patients having osteoarthritis of the knee. Can J Surg. 2001;44:267-274
  4. Fowler PJ, Lubliner JA. The predictive value of five clinical signs in the evaluation of meniscal pathology. Arthroscopy. 1989;5:184-186
  5. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;139:575-588
  6. Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005;87:955-962
  7. Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004;20;696;700
  8. Kocher MS, DiCanzio J, Zurakowski D, Micheli LJ. Diagnostic performance of clinical examination and selevetive magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents. Am J Sports Med. 2001;29:292-296
  9. Kurosaka M, Yagi M, Yoshiya S, Muratsu H, Mizuno K. Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear. Int Orthop. 1999;23:271-274
  10. O’shea KJ, Murphy KP, Heekin RD, Herzwurm PJ. The Diagnostic accuracy of history, physical examination, and radiographs in the evaluation of traumatic knee disorders. Am J Sports Med. 1996;24:164-167
  11. Pookarnjanamorakot C, Korsantirat T, Woratanarat P. Meniscal lesions in the anterior cruciate insufficient knee: the accuracy of clinical evaluation. J Med Assoc Thai. 2004;87:618-623
  12. Rose NE, Gold SM. A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy. 1996;12:398-405

 

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