Skip to main content
SpringerLink
Log in

The “sleeper’s sign” is valid and suggestive of a medial sub-meniscal flap tear

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To describe, evaluate and validate the diagnostic performance of a new clinical sign, the sleeper’s sign, for the diagnosis of a medial submeniscal flap tear (MSMFT).

Methods

This retrospective single-center series included patients aged 18–55 years old who underwent arthroscopic treatment in 2013–2015 for a medial meniscal tear. This study was performed according to STARD (standards for reporting of diagnostic accuracy) guidelines, and the reference test was a peroperative diagnosis of a MSMFT. The preoperative consultation reports were all analyzed to search for the sleeper’s sign, defined as night time medial tibiofemoral pain when the patient is in the fetal position with both knees in contact and no pain during daytime activities.

Results

Three-hundred and ten patients responded to the study criteria, mean age 41.7 ± 9.7 years old. The sleeper’s sign was identified in 39 (12.6%) patients and a MSMFT was confirmed during arthroscopy in 47 (15.2%) cases, with significant agreement between this sign, arthroscopy (kappa = 0.78, p = 10–4) and MR-imaging (kappa = 0.72, p < 0.0001). The performance parameters of the sleeper’s sign were: sensitivity 74.5 ± 12.5%, specificity 98.5 ± 1.6%, Youden index 0.73 and accuracy 96.9%. MR imaging was found to be more sensitive (91.5 ± 8%). Multivariate analysis identified the sleeper’s sign as a risk factor of MSMFT during arthroscopy: OR 131.9 CI 95% [26.9–646.2], p < 0.0001 and a bone edema next to the flap tear on MR-imaging: OR 13, CI 95% [1.9–7.1], p = 0.008.

Conclusion

The “sleeper’s sign” is a new, valid, highly specific clinical sign for the diagnosis of a medial submeniscal flap tear. MRI was found to be more sensitive than the sleeper’s sign.

Level of evidence

II.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Anderson AF, Lipscomb AB (1986) Clinical diagnosis of meniscal tears: description of a new manipulative test. Am J Sports Med 14:291–293

    Article  CAS  Google Scholar 

  2. Anderson AF, Irrgang JJ, Dunn W et al (2011) Interobserver reliability of the International Society of Arthroscopic, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears. Am J Sports Med 39:926–932

    Article  Google Scholar 

  3. Apley G (1947) The diagnosis of meniscus injuries. J Bone Joint Surg Am 29:78–84

    CAS  PubMed  Google Scholar 

  4. Aydingoz U, Firat AK, Atay OA, Doral MN (2003) MR imaging of meniscal buckethandle tears: a review of signs and their relation to arthroscopic classification. Eur Radiol 13:618–625

    Article  Google Scholar 

  5. Bossuyt PM, Cohen JF, Gatsonis CA, Korevaar DA, STARD group (2016) STARD 2015: updated reporting guidelines for all diagnostic accuracy studies. Ann Transl Med 4:85

    PubMed  PubMed Central  Google Scholar 

  6. Dandy DJ (1990) The arthroscopic anatomy of symptomatic meniscal lesions. J Bone Joint Surg Br 72:628–633

    Article  CAS  Google Scholar 

  7. De Smet AA, Tuite MJ, Norris MA, Swan JS (1994) MR diagnosis of meniscal tears: analysis of causes of errors. AJR Am J Roentgenol 163:1419–1423

    Article  Google Scholar 

  8. Dorsay TA, Helms CA (2003) Bucket-handle meniscal tears of the knee: sensitivity and specificity of MRI signs. Skeletal Radiol 32:266–272

    Article  Google Scholar 

  9. Haramati N, Staron RB, Rubin S, Shreck EH, Feldman F, Kiernan H (1993) The flipped meniscus sign. Skeletal Radiol 22:273–277

    Article  CAS  Google Scholar 

  10. Harrison BK, Abell BE, Gibson TW (2009) The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med 19:9–12

    Article  Google Scholar 

  11. Helms CA, Laorr A, Cannon WD Jr (1998) The absent bow tie sign in bucket-handle tears of the menisci in the knee. AJR Am J Roentgenol 170:57–61

    Article  CAS  Google Scholar 

  12. Herman LJ, Beltran J (1988) Pitfalls in MR imaging of the knee. Radiology 167:775–781

    Article  CAS  Google Scholar 

  13. Herschmiller TA, Anderson JA, Garrett WE, Taylor DC (2015) The trapped medial meniscus tear: an examination maneuver helps predict arthroscopic findings. Orthop J Sports Med 3:2325967115583954

    PubMed  PubMed Central  Google Scholar 

  14. Konan S, Rayan F, Haddad FS (2009) Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc 17:806–811

    Article  Google Scholar 

  15. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

    Article  CAS  Google Scholar 

  16. Le Hir P, Charousset C, Duranthon LD et al (2007) Magnetic resonance imaging of medial meniscus tears with displaced fragment in the meniscal recesses. Rev Chir Orthop Reparatrice Appar Mot 93:357–363

    Article  Google Scholar 

  17. Lecas LK, Helms CA, Kosarek FJ, Garret WE (2000) Inferiorly displaced flap tears of the medial meniscus: MR appearance and clinical significance. AJR Am J Roentgenol 174:161–164

    Article  CAS  Google Scholar 

  18. Lefevre N, Naouri JF, Herman S, Gerometta A, Klouche S, Bohu Y (2016) A current review of the meniscus imaging: proposition of a useful tool for its radiologic analysis. Radiol Res Pract 2016:8329296

    PubMed  PubMed Central  Google Scholar 

  19. Mackenzie R, Dixon AK, Keene GS, Hollingworth W, Lomas DJ, Villar RN (1996) Magnetic imaging of the knee: assessment of effectiveness. Clin Radiol 51:245–250

    Article  CAS  Google Scholar 

  20. McMurray TP (1942) The semilunar cartilages. Br J Surg 29:407–414

    Article  Google Scholar 

  21. Miller GK (1996) A prospective study comparing the accuracy of the clinical diagnosis of meniscal tear with magnetic resonance imaging and its effect on clinical outcome. Arthroscopy 12:406–413

    Article  CAS  Google Scholar 

  22. Newman AP, Daniels AU, Burks RT (1993) Principles and decision making in meniscal surgery. Arthroscopy 9:33–51

    Article  CAS  Google Scholar 

  23. Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Hunink MGM (2003) MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology 226:837–848

    Article  Google Scholar 

  24. Rubin DA, Paletta GA Jr (2000) Current concepts and controversies in meniscal imaging. Magn Reson Imaging Clin N Am 8:243–270

    CAS  PubMed  Google Scholar 

  25. Van de Berg BC, Malghem J, Poilvache P, Maldague B, Lecouvet FE (2005) Meniscal tears with fragments displaced in notch and recesses of knee: MR imaging with arthroscopic comparison. Radiology 234:842–850

    Article  Google Scholar 

  26. Watanabe AT, Carter BC, Teitelbaum GP, Seeger LL, Bradley WG Jr (1989) Normal variations in MR imaging of the knee: appearance and frequency. AJR Am J Roentgenol 153:341–344

    Article  CAS  Google Scholar 

Download references

Acknowledgements

Study investigators: Olivier Grimaud: Clinique du Sport Paris, 75005 Paris, France, Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France; Serge Herman: Clinique du Sport Paris, 75005 Paris, France, Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France; Alain Meyer: Clinique du Sport Paris, 75005 Paris, France, Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France.

Funding

Fonds de Dotation pour la Recherche Clinique en Orthopédie et Pathologie du Sport, Paris, France (Grant No. 2019).

Author information

Authors and Affiliations

  1. Clinique du Sport Paris, 36 Boulevard Saint Marcel, 75005, Paris, France

    Nicolas Lefevre, Shahnaz Klouche, Hasan Basri Sezer, Antoine Gerometta, Yoann Bohu, Edouard Lefevre, Olivier Grimaud, Serge Herman & Alain Meyer

  2. Institut de L’Appareil Locomoteur Nollet, 75017, Paris, France

    Nicolas Lefevre, Shahnaz Klouche, Hasan Basri Sezer, Antoine Gerometta, Yoann Bohu, Olivier Grimaud, Serge Herman & Alain Meyer

Authors
  1. Nicolas Lefevre
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shahnaz Klouche
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hasan Basri Sezer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Antoine Gerometta
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yoann Bohu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Edouard Lefevre
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

Study investigators

  • Olivier Grimaud
  • , Serge Herman
  •  & Alain Meyer

Corresponding author

Correspondence to Shahnaz Klouche.

Ethics declarations

Conflict of interest

The authors have no conflict of interest to declare.

Ethical approval

Ethics approval for this study was received from the Comité de Protection des Personnes Ile-de-France IV (CPP IDF IV), Hôpital Saint-Louis.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Study investigators authors are listed in the Acknowledgements section.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (mp4 132515 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lefevre, N., Klouche, S., Sezer, H.B. et al. The “sleeper’s sign” is valid and suggestive of a medial sub-meniscal flap tear. Knee Surg Sports Traumatol Arthrosc 29, 51–58 (2021). https://doi.org/10.1007/s00167-019-05655-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-019-05655-4

Keywords

Search

Navigation