Archives of Orthopaedic and Trauma Surgery

, Volume 135, Issue 11, pp 1567–1570 | Cite as

Gender differences in the accuracy of joint line tenderness for arthroscopically confirmed meniscal tears

  • Barak Haviv
  • Shlomo Bronak
  • Yona Kosashvili
  • Rafael Thein
Arthroscopy and Sports Medicine

Abstract

Introduction

The reliability of joint line tenderness was previously investigated among other clinical tests for the diagnosis of meniscal pathology with variable results. The aim of this study was to evaluate and compare the accuracy of joint line tenderness as a clinical diagnosing test for arthroscopically confirmed meniscal tears between males and females.

Materials and methods

For the purpose of preoperative joint line tenderness accuracy calculations, this study included male and female groups of patients who have had knee arthroscopy following preoperative diagnosis of meniscal tear. Overall, 195 patients were included in the study, 134 males and 61 females. The mean age was 43.4 (13–76) years.

Results

In the male group, the diagnosis of meniscal tear by joint line tenderness was correct in 84 (62.7 %) of 134 knees for the medial side and in 115 (85.8 %) for the lateral side. In the female group, the diagnosis was correct in 35 (57.4 %) of 61 knees for the medial side and in 57 (93.4 %) for the lateral side. In order to refine the accuracy of medial joint line tenderness, the data were recalculated for patients with medial meniscal tears and no chondral lesion or cruciate ligament tears; however, the accuracy remained low.

Conclusions

The physical finding of joint line tenderness of the knee as a test for lateral meniscal tear was found reliable in both males and females. For medial meniscal tears, the test had low reliability and thus less useful if used alone, in both genders.

Keywords

Joint line tenderness Knee Meniscus Accuracy 

Introduction

The joint line tenderness (JLT) test is commonly used to screen for meniscal injuries [1, 2]. The test is easily performed and considered positive if pain is localized to either the medial or lateral aspect of the joint. Previous studies have investigated the reliability of JLT among other clinical tests for the diagnosis of meniscal pathology [3]. Fowler et al. [4] reported on high sensitivity and low specificity of JLT for meniscal tears from 161 knees. In two different prospective controlled trials by Akseki et al. [5] and Karachalios et al. [6], JLT was compared to other diagnostic tests and gave an accuracy of 71 and 82 %, respectively. Most studies also compared the reliability of JLT between medial and lateral meniscal tears; however, none had analyzed the differences between genders. Eren [7] evaluated 104 male recruits with suspected meniscal lesions who underwent arthroscopy and found the JLT to be an accurate test for lateral but not for medial meniscal tears. The author mentioned that his study was designed for young men and the findings for women and other age groups could be different. He also concluded that further studies in other populations are needed to contribute to the understanding of the value of this clinical test. Although in clinical practice JLT is performed in conjunction with other meniscal maneuvers, it is suggestive of intra-compartmental pathology and thus gender differences may influence decision making. The aim of this study was to evaluate and compare the accuracy of JLT as a clinical diagnosing test for arthroscopically confirmed meniscal tears between males and females. The hypothesis was that JLT accuracy is similar for both sexes.

Materials and methods

Patients

From January 2012 to December 2013, 841 patients have had knee arthroscopic procedures in our department which serves as a regional referral center for arthroscopic surgery. For the purpose of joint line tenderness (JLT) accuracy calculations this study included male and female groups of patients who had arthroscopy for a preoperative diagnosis of meniscal tear. Patients who had concurrent osteotomy, patellar realignment, surgery for synovial disease (e.g., rheumatoid arthritis, pigmented villonodular synovitis) or ipsilateral previous knee surgery, were excluded. In addition, we excluded patients with acute pain (<8 weeks) and patients with related workers’ compensation claim. Male and female populations were compared in terms of demographic data, general health, activity level and preceding injury. Consequently, 195 patients who fulfilled the above criteria with complete preoperative records were included in the study, 134 males and 61 females. The mean age was 43.4 (13–76) years at surgery. Prior to this study a local institution review board approval was obtained.

Preoperative evaluation and surgical technique

All preoperative evaluations and operations were undertaken and recorded by 3 senior orthopedic surgeons who were very experienced in knee arthroscopy and who work together at a regional referral center for knee arthroscopic surgery. Preoperative data obtained included demographic details, clinical evaluation by history and physical examination, plain radiographs and magnetic resonance imaging. In the case of diagnosed meniscal tear the indication for knee arthroscopy was an active patient with unresolved knee pain and activity limitation for at least 8 weeks, who had no radiographic evidence for knee osteoarthritis on AP and lateral radiographs (i.e., Kellgren–Lawrence classification Grade 0). As part of the preoperative knee exam on the day of surgery, surgeons have documented the specific tender regions around the knee (i.e., joint line, femoral and tibial condyles, patellofemoral) either medial or lateral with the patient lying on the table with the knee in midflexion [2].

Surgery was done under general anesthesia with the patient in the supine position. A leg holder and tourniquet were placed around the thigh of the affected leg. Standard anterolateral and anteromedial knee portals were used. Diagnostic arthroscopy was performed to evaluate abnormal findings such as meniscal tears, cruciate ligament tears and chondral lesions before debridement or reconstruction. At surgery, cartilage lesions were probed, measured and then graded according to the international cartilage repair society (ICRS) classification [8].

Statistics

Unpaired t tests and Chi-square tests were applied to compare data between the male and female groups. A p value <0.05 was considered statistically significant. Arthroscopy is considered the gold standard for the accurate diagnosis of pathologic changes in the knee joint. Therefore, the accuracy, sensitivity, specificity, and positive and negative-predictive values of joint line tenderness (JLT) were based on arthroscopic findings. A true-positive result was when a preoperative JLT (medial for medial meniscal tear and lateral for lateral meniscal tear) predicted a meniscal tear that was confirmed at arthroscopy. The sensitivity was calculated as the number of true-positive results divided by the number of true-positive results plus the number of false-negative results. Specificity was calculated as the number of true-negative results divided by the number of true-negative plus false-positive results. The negative-predictive value (NPV) was determined by the number of true-negative results divided by the number of true-negative plus false-negative results. The positive-predictive value (PPV) was determined by the number of true-positive results divided by the number of true-positive plus false-positive results. The overall accuracy was calculated as the number of true-positive plus true-negative results divided by the total number of examinations.

Results

In this study, male patients were younger, healthier and more active than female patients, with higher percentage of preceding knee injury (Table 1). Overall, from 195 knee arthroscopies there were 160 meniscal tears found at surgery. From 134 procedures in the male group, there were 89 tears of the medial meniscus, 17 of the lateral meniscus and 11 of both menisci. From 61 procedures in the female group, there were 36 tears of the medial meniscus, 5 of the lateral meniscus and 2 of both menisci.
Table 1

Comparison of demographic details between genders

 

Male

Female

p value

Number of patients

134

61

 

Age (years)

39 (13–72)

51.8 (16–76)

<0.001

Body mass index (kg/m2)

27.1 (16.7–39.7)

28.2 (20.2–42.5)

0.09

Side (R:L)

102:32

27:34

<0.001

Number of patients with comorbidities

18 (13.4 %)

21 (34.4 %)

<0.001

Physical workers

65 (48.5 %)

24 (39.3 %)

0.23

Recreational sports participants

93 (69.4 %)

28 (45.9 %)

0.001

Number of patients with preceding injury

69 (51.5 %)

19 (31.1 %)

0.008

In the male group, the diagnosis of meniscal tear by JLT was correct in 84 (62.7 %) of 134 knees for the medial side and in 115 (85.8 %) for the lateral side. In the female group, the diagnosis of meniscal tear by JLT was correct in 35 (57.4 %) of 61 knees for the medial side and in 57 (93.4 %) for the lateral side (Table 2).
Table 2

Comparison of joint line tenderness reliability in the diagnosis of medial meniscal (MMT) tears and lateral meniscal tears (LMT) between genders

 

Male

Female

MMT (%)

LMT (%)

MMT (%)

LMT (%)

Sensitivity

58.4

50

48.6

40

Specificity

73.5

100

70.8

98.2

Accuracy

62.7

85.8

57.4

93.4

Positive-predictive value

86.8

100

72

66.7

Negative-predictive value

37.3

92.2

47.2

94.8

Specifically in the male group for the diagnosis of medial meniscal tears by medial JLT there were 59 true-positive, 25 true-negative, 9 false-positive and 42 false-negative results. For the diagnosis of lateral meniscal tears by lateral JLT there were 9 true-positive, 106 true-negative, 0 false-positive and 9 false-negative results. In the female group, for the diagnosis of medial meniscal tears by medial JLT there were 18 true-positive, 17 true-negative, 7 false-positive and 19 false-negative results. For the diagnosis of lateral meniscal tears by lateral JLT, there were 2 true-positive, 55 true-negative, 1 false-positive and 3 false-negative results.

The detection of lateral meniscal tears by JLT was found accurate in both males and females, while the detection of medial meniscal tears was found inaccurate (Table 2).

Additional intra-articular pathologies at surgery are given in Table 3.
Table 3

Comparison of additional chondral lesions and anterior cruciate ligament tears (ACLT) at arthroscopy between genders

 

Male

Female

Complete ACLT

32

8

 

Male

Female

 

Medial compartment

Lateral compartment

Patellar

Medial compartment

Lateral compartment

Patellar

Chondral lesion grade 2

17

4

3

9

2

10

Chondral lesion grade 3

7

3

3

20

2

5

Chondral lesion grade 4

9

0

1

8

2

2

In order to refine the accuracy of medial JLT the data were recalculated for patients with medial meniscal tears and no chondral lesion or cruciate ligament tears; however, the accuracy remained low (Table 4).
Table 4

Comparison of joint line tenderness reliability in the diagnosis of medial meniscal tears between genders in knees without chondral lesions or cruciate ligament tears

 

Male (%)

Female (%)

Sensitivity

62.9

55

Specificity

65.2

75

Accuracy

63.4

62.5

Positive-predictive value

84.6

78.6

Negative-predictive value

36.6

50

Discussion

The key finding in this study was that the detection of lateral meniscal tears at arthroscopy by preoperative joint line tenderness (JLT) was found accurate in both males and females while the detection of medial meniscal tears was found inaccurate regardless of additional cruciate ligament tears or chondral lesions.

In a review article by Malanga et al. [2], the reported sensitivity for joint line tenderness (JLT) in the literature was 55–85 %, with a specificity range of 29–67 %. Thus, JLT is likely to be present in those with meniscal tears. However, JLT alone is common to other diagnoses and is not pathognomonic for meniscal injury. In the current study, the preoperative examination at the day of surgery for JLT had low sensitivity for meniscal tears diagnosis in both genders. This could be due to the heterogeneity of the current study population, inclusion of both traumatic and non-traumatic tears, variable earlier treatments and considerable differences in symptomatic phases (months to years) before surgery. In a level I randomized controlled trial performed on a younger and somewhat more homogenous cohort of patients [6], the accuracy of JLT in diagnosing medial meniscal tears was higher than in the current study and similar for lateral meniscal tears.

The reliability of clinical meniscus tests has been found to be negatively affected by accompanied lesions of cartilage, while tears of the cruciate ligaments [4, 5, 6, 9] had variable influences in different reports. The exclusion of knees with cruciate tears or chondral lesions improved the specificity for medial meniscus tear diagnosis in females to a limited extent probably due to a relatively high percentage of moderate-to-severe chondral lesions in the female group.

In concordance with previous reports the specificity of JLT was high for lateral and low for medial meniscal tears [5, 6, 7]. Previous reports have failed to explain the higher reliability of JLT in the diagnosis of lateral compared to medial meniscal tears. In the current study, the specificity and accuracy for JLT in the diagnosis of lateral meniscal tears remained high in both the male and female groups although both groups varied in terms of age, health, activity level and preceding injury. This may be due to the fact that in comparison to medial meniscal tears, almost all lateral meniscal tears at surgery were not accompanied by significant chondral lesions while lateral compartment chondral lesions were generally scarce.

Although JLT is a very common examination of the knee and has been investigated before, to our knowledge there are no studies that compare the accuracy of JLT between genders. This study has several limitations. The reproducibility of JLT was not evaluated; the exam was performed by one of three examiners prior to and at the day of surgery which may have biased the results although the three surgeons work together at the same department and share similar clinical approach. Because data were retrieved retrospectively, we were unable to control the heterogeneity of factors such as earlier non-surgical treatments and the length of symptomatic phases before surgery which also may influence the results.

Conclusions

The physical finding of joint line tenderness of the knee as a test for lateral meniscal tear was found reliable in both males and females. For medial meniscal tears the test had low reliability and thus less useful if used alone, in both genders.

Notes

Compliance with ethical standards

Conflict of interest

All authors declare no financial relationships.

References

  1. 1.
    Galli M, Ciriello V, Menghi A, Aulisa AG, Rabini A, Marzetti E (2013) Joint line tenderness and McMurray tests for the detection of meniscal lesions: what is their real diagnostic value? Arch Phys Med Rehabil 94(6):1126–1131CrossRefPubMedGoogle Scholar
  2. 2.
    Malanga GA, Andrus S, Nadler SF, McLean J (2003) Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil 84(4):592–603CrossRefPubMedGoogle Scholar
  3. 3.
    Scholten RJ, Deville WL, Opstelten W, Bijl D, van der Plas CG, Bouter LM (2001) The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J FamPract 50:938–944Google Scholar
  4. 4.
    Fowler PJ, Lubliner JA (1989) The predictive value of five clinical signs in the evaluation of meniscal pathology. Arthroscopy 5:184–186CrossRefPubMedGoogle Scholar
  5. 5.
    Akseki D, Ozcan O, Boya H, Pinar H (2004) A new weight-bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. Arthroscopy 20(9):951–958CrossRefPubMedGoogle Scholar
  6. 6.
    Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN (2005) Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am 87(5):955–962CrossRefPubMedGoogle Scholar
  7. 7.
    Eren OT (2003) The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears. Arthroscopy 19:850–854CrossRefPubMedGoogle Scholar
  8. 8.
    Brittberg M, Winalski CS (2003) Evaluation of cartilage injuries and repair. J Bone Joint Surg Am 85(Suppl 2):58–69PubMedGoogle Scholar
  9. 9.
    Oberlander MA, Shalvoy RM, Hughston JC (1993) The accuracy of the clinical knee examination documented by arthroscopy. A prospective study. Am J Sports Med 21:773–778CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Barak Haviv
    • 1
    • 2
  • Shlomo Bronak
    • 1
  • Yona Kosashvili
    • 2
    • 3
  • Rafael Thein
    • 1
    • 2
  1. 1.Arthroscopy and Sports Injuries UnitHasharon Hospital, Rabin Medical CenterPetach-TikvaIsrael
  2. 2.Orthopedic Department, Sackler Faculty of MedicineTel-Aviv UniversityTel-AvivIsrael
  3. 3.Orthopedic DepartmentBeilinson Hospital, Rabin Medical CenterPetach-TikvaIsrael

Personalised recommendations