varus stress test sensitivity and specificity

Common terms. Validity of the McMurray's Test and Modified Versions of the Test: A For the varus stress test, the patient is in supine position and asked to relax. Studies looking at diagnostic accuracy, sensitivity and specificity have demonstrated varied values. A) AND B): The McMurray's test: Figure 1a) the tibia rotated on the femur into full internal rotation and Figure 1b) the tibia rotated on the femur into full external rotation. Sae-Jung et al24 considered pain or a clicking sound to be a positive test. Edinburgh: Elsevier, 2006. Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared with MRI, with an overall sensitivity of 70% compared with 66%, respectively. Noble J, Erat K. In defence of the meniscus: A prospective study of 200 menisectomy patients. 2018 Nov 1;27(6):596-600. doi: 10.1123/jsr.2016-0188. The reliability of this test in extension is 68% and in 30 flexion only 56%. A recent literature review on composite testing of the diagnostic tests for the meniscus reported reasonable sensitivity and specificity when the findings of a number of tests are combined31. Anderson and Lipscomb5 compared the McMurray's test to a test termed the Medial-Lateral Grind test that included a varus/valgus component not included in the original McMurray's test. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Studies by Boeree and Ackroyd19, Akseki et al3, and Karachalios et al21 demonstrated small but sometimes important shifts in probability. Valgus and Varus test of the knee can be graded by the following 1: Grade I: The joint space opening is within 2 mm of the contralateral side. Based on chronicity of the injuries, MRI was more accurate for detecting acute FCL injuries than chronic injuries (P = .002), and varus stress radiographs were more accurate for detecting chronic FCL injuries than acute injuries (P = .041). Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared with MRI, with an overall sensitivity of 70% compared with 66%, respectively. Methodological scores on the STARD (Standards for Reporting of Diagnostic Accuracy) yielded scores from 10/25 to 20/25. Accuracy of 3 Diagnostic Tests for Anterior Cruciate Ligament Tears ZDg0M2Q2NDY1ZmIyNjFkZjBiOWE0MzQ3ZjJhZTY1NmRmYTUwYTBiMTNkNTIz Orthopedic Physical Assessment: 5 th Edition. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Canada. M2MwN2QyM2QzMGFjZjQ3MDgzMGRiYzAyMmRlZDc3MTAxODc4MDdhNzcyZWMz Similarly, Corea et al4 included consecutive patients who were clinically diagnosed as having torn menisci based on a number of signs and symptoms including locking, a positive McMurray's test, painful clicks, and giving way. Sensitivity & Specificity Sensitivity: 66 % Specificity: 60 % A study on 21 patients referred with chronic medial collateral ligament injuries, the Valgus stress test at 30, 60, 70, or 90 degrees of elbow flexion was performed (The Reference Standard was Surgical visualization ). In: DeLee & Drez's Orthopaedic Sports Medicine. Studies were eligible for inclusion if they assessed measures of accuracy or validity of the McMurray's test or any modification of this test against a gold standard of either arthroscopy or magnetic resonance imaging (MRI) and were written in English. Were the raters blinded to the results of the other test? [12] If the varus stress test is positive at 20, but negative at 0, only the LCL is torn. Talar Tilt Test 2023 | OrthoFixar Boeree NR, Ackroyd CE. The predictive value of Thve clinical signs in the evaluation of meniscal pathology. The sensitivity and specificity of the clinical tests and magnetic resonance (MR) imaging are reviewed because these parameters vary, and an understanding of the diagnostic utility of both the clinical and imaging tests is important in accurately formulating a definitive diagnosis. There are also discrepancies in the studies as to what constitutes a positive McMurray's test. Anderson AF, Lipscomb AB. Varus Stress Test Purpose: To assess the integrity of the LCL. Saunders. A recent meta-analysis illustrates the difference in test characteristics when performed on patients under anesthesia. If the CI is wide and contains values that are not clinically important, the usefulness of the measure may be questionable11. 2018 Aug;46(10):2355-2365. doi: 10.1177/0363546518784301. Miller GK. and transmitted securely. The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears Arthroscopy. Three studies in this review compared the McMurray's test to modified versions that incorporated the added components of varus/valgus stress and axial compression. During the maneuver, the joint line is palpated both medially and laterally. National Center for Biotechnology Information A prospective study comparing the accuracy of the clinical diagnosis of meniscal tears with magnetic resonance imaging and its effect on clinical outcome. Am J Roentgenol. The description of a test within a study should be sufficient to enable replication of the test by practitioners and subsequent researchers. Y2RkNzAxODk3NTIxMTE2ZTkyYzE2ZjgxNmFmNWUxZGMwNmY4Mjg1ZDQ3MTkw Epub 2017 Aug 16. The proportion of people who have the disease or dysfunction who test positive. HHS Vulnerability Disclosure, Help Grade III: The joint space opens 5 . IR of the tibia + Varus stress = lateral meniscus, ER of the tibia + Valgus stress = medial meniscus. The statistical measures of sensitivity, specificity, and likelihood ratios were calculated from the information provided in the studies. Clinical Orthopedic Examination Findings in the Lower Extremity Evans PJ, Bell GD, Frank CY. Three independent reviewers assessed each of the papers included in the review, and an overall STARD score of methodological quality was determined for each paper. MeSH The best statistics for summarizing usefulness of a diagnostic test appear to be likelihood ratios (LR)17. Medicina | Free Full-Text | Valgus Arthritic Knee Responds Better to Some studies have attempted to compare the diagnostic value of the McMurray's test to that of modified tests. OGNkMmFkZGY0YjIxNzkxN2RkOTg3YzgzMTdiYjY1OGMxMzA2NThmZjIxNGNi PMC When pooled together using the bivariate random effects model (BREM), the sensitivity value of the 8 studies was 0.2 and the specificity value was 0.88. Other signs that have been used to denote a positive test include the production of pain, a clunk, or a pop. What are sensitivity and specificity? | Evidence-Based Nursing The clinician hold the patient's ankle with one hand, while the other hand is on the lateral condyle of the femur. Sensitivity: the ability of a test to correctly identify patients with a disease. Schnke M, Schulte E, Schumacher U. Prometheus deel 1: Algemene anatomie en bewegingsapparaat. 133k If the varus stress test is positive at 20, but negative at 0, only the LCL is torn. As a stand-alone test, it had a sensitivity of 78% and specificity of 67% the pain was used as the outcome measure and a sensitivity of 91% and specificity of 49% when laxity was the outcome measure. Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD initiative. A 95% CI is the most commonly used and indicates a range of values within which the population value would lie with 95% certainty. The sensitivity of a test reflects the proportion of people with the disease in question who are tested positive, whereas the specificity is the proportion of those without the disease who are tested negative. MDUwOTJiNWVjMDExNzg5OTRkYzIwNjRlYzdhZmM2MzUyYjUwY2IxYTkzMTRk The fibular or lateral collateral ligament (LCL) is a cord-like band and acts as the primary varus stabilizer of the knee. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Clinical assessment of meniscal pathology in the knee has proven difficult due to the wide number of tests available and variations in their interpretation and application. [2] Harilainen A. Only one study by Harilainen et al. Changing the threshold to increase sensitivity decreases specificity and vice versa. PDF ssslideshare.com To eliminate this, the knee is held in 30 degrees of flexion. Valgus Stress Test. They also fail to take into account pre-test probability. The sensitivity and specificity of the McMurray's test reported in the studies identified in this review vary widely (Table (Table5).5). It is performed by placing the knee beyond 90 of flexion and then rotating the tibia on the femur into full internal rotation to test the lateral meniscus, or full external rotation to test the medial meniscus. How to Perform Varus Stress Test Position of Patient: The patient should be relaxed in the supine position. [9] When LCL is injured or torn, this cordlike band is not as noticeable as on the unaffected side. AP and lateral radiographic images of a SE-4 fracture - ResearchGate Varus Test | Special Tests Epub 2018 Jul 17. The technical storage or access that is used exclusively for statistical purposes. Check for excessive gapping and if you can reproduce the patients pain. Clinically, we do not know whether a patient has the condition before the diagnostic test (arthroscopy or MRI) is performed. Describes clinical information available to raters, Describes statistical methods for comparing diagnostic accuracy and expressing uncertainty, Describes methods for calculating test reproducibility; if done, Reports when study was done with start and end dates for recruitment, Reports clinical and demographic characteristics of subjects, Reports how many subjects satisfying inclusion criteria did not undergo the tests; describes why these subjects were not tested, Reports time interval between researched and reference test and any treatment provided in between tests, Reports disease severity in subjects with target condition and other diagnoses in subjects without target condition, Reports cross-tabulation of researched and reference test, Reports adverse effects from researched and reference test, Reports estimates of diagnostic accuracy and measures of statistical uncertainty, Reports how indeterminate test results, missing responses, and outliers of researched test were handled, Reports estimates of variability between raters, centers, or subject subgroups; if done, Reports estimates of test reproducibility; if done, Discusses clinical applicability of study findings. Although these authors mentioned that the examiners were blinded to the results of the MRI, they did not make it clear if the examiners knew that there were a similar number of normals and symptomatic subjects included in the study or if they knew which group each individual subject belonged to. 2017 Mar;101(Suppl 1):23-35. doi: 10.1007/s12306-017-0460-5. sharing sensitive information, make sure youre on a federal Harilainen A. Purpose: The varus stress test shows a lateral joint line gap. Whiting WC, Zernicke RF. Elsevier Health Sciences, 2014. Piantanida, A.N. Solomon DH, Simel DL, Bates DW, Katz JN, Schafter JL. any of these symptoms can indicate a compromised medial or lateral meniscus. That is usually the journal article where the information was first stated. Saunders Elsevier. Three of these studies had fairly broad inclusion criteria that better reflect the population seen in clinical practice with two including subjects with suspected meniscal or ligamentous pathology6,19; the study by Sae-jung et al24 included any patients identified as needing arthroscopy. Journal of Orthopaedic and Sports Physical Therapy, 37(9), 541-50. 2008. A prospective evaluation of a test for lateral meniscal tears. Reid MC, Lachs MS, Feinstein AR. Agreement regarding which articles to read in full was determined by consensus. Authors of 9 studies examined the Lachman test and reported sensitivity values ranging from 0.63-0.93 and specificity values ranging from 0.55-0.99. 4th Edition. Cinque ME, Geeslin AG, Chahla J, Moatshe G, Pogorzelski J, DePhillipo NN, LaPrade RF. Bossuyt PM, Reitsma JB, Bruns DE, et al. The test has therefore often been reported to be of limited value in current clinical practice. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); If you want to assess the integrity of the medial collateral ligament (MCL), check out the Valgus Stress Test of the Knee. Then he applies a strong valgus force, with a counterforce applied at the . Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and 2nd ed. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. Thus, to avoid selection bias, it is important that a study include consecutive patients with pathologies that could be commonly confused with a meniscal tear and should not include patients without symptoms. Manoeuvres assessing the posterolateral structures include the varus stress test, dial test, the posterolateral drawer, the external rotation recurvatum test, heel height test and the reverse pivot shift. ZDZkZjczMGZkNzQ1OWMxZTQyNDY2ZTAzYTM5OTk2ZmQ1YjkzNDFjMDhmNzMy In addition, cited references of relevant articles were examined. This is true in the case of the study by Akseki et al3 but not for the study by Evans et al23 (Tables (Tables44 and and55). In: Campbell's Operative Orthopaedics. [8]The test has therefore often been reported to be of limited value in current clinical practice. Flow diagram of literature screening process. National Library of Medicine followers. OTY4NzkyOGEwY2VjNzA3NjZiZWFkZmRlNjgyOGUwMGYxNDhkNjlhNDBhZmVi Symptoms related to an intra-articular knee pathology. The test is fairly solid. An assessment for one-plane lateral instability (i.e. The inclusion of patients with multiple pathologies is likely to lessen the diagnostic accuracy of a test; however, this would reflect actual clinical practice6,18. eCollection 2022 Jun. Reliability Study of Diagnostic Tests for Functional Hallux Limitus These authors also observed that the studies on these new tests have only been subjected to scientific scrutiny on one occasion and further research is required on these tests. Likelihood Ratio +/-. (1987) evaluated the varus stress test and found rather poor diagnostic accuracy. Described a modified version (Medial-Lateral Grind test) but no description of McMurray's. The accuracy of joint line tenderness by physical examination in the No mention acute/chronic. The review suggests that modifications of the interpretation of a positive test to include reproduction of pain either as well as or on its own may enhance the validity of the test. Evaluation of Knee Instability in Acute Ligamentous Injuries. Differences in the type of tear have been suggested as influencing the result of clinical tests; however, no detailed investigation of this issue exists in the current literature3. However, this provisional diagnosis was also based on other symptoms that one might consider could be associated with pathologies other than meniscal tears, e.g., pain, recurrent effusion, muscle wasting, and instability. The incidence of LCL injuries are relatively low (6%) when compared to other knee injuries. [7] It is commonly associated with other knee ligament injuries, thus LCL tear can be easily overlooked as a result of that. MR imaging of meniscal cysts: incidence, location, and clinical significance. Of the four studies that demonstrated the highest shifts in probability, only Corea et al4 and Akseki et al3 contained calculable CIs, which were relatively narrow (Table (Table55). Physical examination of the knee: A review of the original test description and scientific validity of common orthopedic tests. An assessment for one-plane medial instability (gapping of the tibia away from the femur on the medial side). So, little is known about the validity of this test. Studies of specificity and sensitivity have demonstrated varied values as a result of poor methodological quality A recent meta-analysis reports sensitivity and specificity to be 70% and 71%. LaPrade RF, DePhillipo NN, Cram TR, Cinque ME, Kennedy MI, Dornan GJ, O'Brien LT. Am J Sports Med. NTc3ODRiOTRjOGU4N2ExOGU2NDEzYWVjZmNiMTQ1N2FjM2U4NjVmMzhlMzRi Arthroscopy has demonstrated an accuracy between 93% and 96%12. Level of evidence: . However, they only included patients who had had symptoms for at least one year, making extrapolation of their findings to the acute population challenging. 2017 Dec;33(12):2177-2181. doi: 10.1016/j.arthro.2017.06.028. Performing the Test: The patient's leg should be relaxed for this test. True negative: the person does not have the disease and the test is negative. Evans et al23 compared a senior examiner with over 10 years experience to a medical student who had recently been taught the technique whereas Karachalios et al21 compared two experienced orthopaedic surgeons with two inexperienced residents. The differences in study populations are likely to have contributed to the wide variability of results across studies. While it is difficult to compare results across studies due to the differences in the tests being used, the results of this review appear to show that the modified tests have higher diagnostic value than the McMurray's test. The reported incidence of ACL sprains and tears in the knee injuries. Comparable sensitivity and specificity were shown in regards to the Thessaly test, 85.4% and 54%, respectively. These authors excluded subjects with clinical or radiographic evidence of arthritis or fracture that would increase the accuracy of testing but decrease the generalizability of the findings. The same maneuvers are performed in gradually increasing degrees of knee flexion to progressively load more posterior segments of the menisci. Valgus Stress Test ZmNhYzI5Njc5MTEwZGU2NTAzYmRjNmJiODlmMmU0N2FhYzFhMDRjNjQ1YTNk Biomechanics and physical examination of the - ScienceDirect New York: Appleton-Century-Crofts, 1976. The wide range of positive likelihood ratios (0.828.86) make it difficult to draw any conclusions about the actual magnitude of this ratio. McMurray. Apply slight lateral rotation and perform passive adduction at the knee joint and thus put stress on the LCL. Sensitivity and specificity values infer the probability of a correct test, given the result of the reference standard11. Physical examination tests for assessing a torn meniscus in the knee: A systematic review with meta-analysis. Acute knee injuries: use of decision rules for selective radiograph ordering. Test Position: Supine. YmRhYTcyZWFhNTQ5OTM0YWYwODRjZDU1OWU3ZjBjNmMyMjA4NTcxZTRmMDYw Slocum Drawer Test: Inconclusive Crossover Test: Inconclusive Pivot Shift Test: Sensitivity: 60% Specificity: 96% Other studies3,5,19 commented that greater clinical experience may affect the results of the test but they did not provide any statistical evidence to support this assertion. the tibia moves away from the femur an excessive amount on the lateral aspect of the leg). Fibular collateral ligament and the posterolateral corner. TP=true positive, FP=false positive, FN=false negative, TN=true negative. Knee Examination: Overview, Periprocedural Care, Technique - Medscape Patients diagnosed with meniscal lesions (based on symptoms including pain, recurrent edema, giving way, joint clicks, or block to movement) having arthroscopic surgery. The Valgus Stress Test for LCL injuries has hardly been evaluated regarding its diagnostic accuracy. 1st ed. Studies that have evaluated the sensitivity and specificity of individual clinical tests to detect ligamentous injury, . . The LCL acts as a secondary stabilizer to anterior and posterior tibial translation when the cruciate ligaments are torn. Increased Accuracy of Varus Stress Radiographs Versus Magnetic - PubMed I concluded that joint line tenderness as a test for lateral meniscal tears is accurate (96%), sensitive (89%), and specific (97%). 24 General examination included carrying angle (normal, valgus,. 4th ed. The preliminary nature of this tool also means that a more narrative review of the validity and accuracy of the tests has been presented. Be aware of the validity issues surrounding this test. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Results also indicate that testing for medial meniscal pathology is more sensitive than testing for lateral; however, tests for lateral meniscal pathology are more specific than tests for medial pathology3,4,19. Painful conditions of the knee, inPain Management Vol 1.,2007. Corea JR, Moussa M, Al Othman A. McMurray's test tested. Patients identified as needing arthroscopy excluding those with intra-articular fracture, neurological or degenerative disorders. Methodology and description of the 11 studies investigating validity and clinical accuracy of McMurray's test for meniscal pathology. 8600 Rockville Pike ZTU5MGVlOWM4MDcwMGE2YmJiZjNjZTBiMjQ2N2E5OTFmNTliZDgyYzc4ZjQ0 ZmFjMDhjZmYyOWRiNWU2YjhhMWNhYjFiNTU5YTI5ODM3MTY1ODYwYzc2NmFi In contrast, the paper by Sae-Jung et al24 found sensitivity for medial and lateral menisci of 70% and 68%, respectively, and specificity values for medial and lateral menisci of 60.7% and 47.8%, respectively. Accuracy is the percentage of subjects who are correctly identified as either having or not having a meniscal tear. Likelihood ratios overcome some of the problems involved with sensitivity and specificity values by summarizing the information contained in these values in a manner that can be used to quantify shifts in probability once the meniscal test results are known28. 2nd ed. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. Consecutive patients clinically diagnosed as having torn menisci (based on symptoms of pain, locking, painful clicks, recurrent effusions, giving way or signs of extension block, wasting, or instability) Patients with evidence of fracture or arthritis, a previous history of surgery, or with an acute locked knee or haemarthrosis were excluded. In this position the iliotibial band relaxes and makes the LCL easier to isolate. These authors also demonstrated that the Medial-Lateral Grind test had smaller (better) LR compared to the McMurray's test although the change in probability was still only small and should be considered rarely important (Table (Table77). Published by Elsevier Inc. All rights reserved. NjZjMWViMWE5MzNlMDFhOTA3YzAwYzUzODYzZmQyZGI2ODk1ZmJlOGM4YzZh Rose NE, Gold SM. One of the search terms used was McMurray$ test$. The acute tears frequently result from sports injuries where there is a twisting motion on the partially flexed, weight-bearing knee.[3].