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Knee Ligaments and Menisci: Jeffrey Katz, MD, MSc, and Jonathan Schaffer, MD, MBA, discuss the clinical examination for diagnosing injuries to knee ligaments and menisci.
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Knee Ligaments and Menisci: Jeffrey Katz, MD, MSc, and Jonathan Schaffer, MD, MBA, discuss the clinical examination for diagnosing injuries to knee ligaments and menisci.
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>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives Section. Today, I have the pleasure of speaking with Dr. Jeffrey Katz and Dr. Jonathan Schaffer about injuries to knee ligaments and menisci, a topic discussed in a chapter of the Rational Clinical Examination, co-authored by Drs. Katz, Schaffer, and other contributors. Dr. Katz, Dr. Schaffer, why don't you introduce yourselves to our listeners? >> I'm Dr. Jeffrey Katz from the Brigham and Women's Hospital and Harvard Medical School in Boston.
>> I'm Jonathan Schaffer. I'm an orthopedic surgeon in the Adult Reconstruction Section at the Center for Joint Replacement here at the Cleveland Clinic. >> Dr. Schaffer, can you briefly describe for our listeners the anatomy of the knee and the various injury patterns? >> Certainly. As I'm sure we all know, the knee joint is the largest articulation in the body, and the fact that it is somewhat subcutaneous, especially anteriorly, puts it at risks with certain activities.
The anatomic structures at risk would be the anterior cruciate ligament, the posterior cruciate ligament, the medial and lateral collateral ligaments, and the menisci. When we go through normal daily activities, these structures are often articulating in a very well-coordinated fashion. But certain movements, especially as we get older, such as pivoting and varus/valgus and varus stresses or stresses from the sides, can create injury patterns that become clinically very apparent. >> Dr. Katz, what do we know about the prevalence of ligamentous or meniscal tears?
And are there important demographic characteristics? >> We have reasonably good information about the frequency of surgery for these injuries and somewhat less precise information about the incidence of the injuries themselves. For anterior cruciate ligament tears, for example, we know that there are about 175,000 surgeries done per year in the United States to reconstruct these ligaments.
There are some patients who are treated non-operatively, especially older patients, so this would underestimate the incidence of the injuries, per se. There are some interesting demographic patterns in ACL or anterior cruciate ligament injuries. They are more common in females, and that's particularly true in female versus male athletes. Prior to 1972 when Title IX was passed, very few women actually participated in sports, and so this mini epidemic was not observed, but it's become more apparent recently that females and males playing the same sorts of sports, females are at much higher risk for an ACL tear.
And there's a lot of speculation as to -- and some emerging evidence as to why that may be. There are a variety of potential explanations including differences in anatomy and the hormonal milieu and the neuromuscular function. Turning to meniscal injuries, we know that about 1/3 of people greater than 50 years old in the population have meniscal tears on MRI, but most of these persons are asymptomatic. Most of these medical tears are clinically silent.
We know that people who have radiographic osteoarthritis are very likely to have evidence of meniscal tear on their MRI. As many as 3/4 of patients with osteoarthritis have meniscal tear. These are usually degenerative. And again, they usually are silent in the sense that the tear, per se, is not contributing to symptoms in the majority of these patients. >> Dr. Schaffer, what physical examination maneuvers are used to evaluate ligamentous tears or meniscal injuries? >> Well, for ligamentous tears, let's first start with the medial and lateral collateral ligament.
In order to assess the medial and lateral collateral ligament, the examiner should place the knee first an extension and then successfully place it in 30 and 60 degrees of flexion as they place a varus and a valgus stress across the knee. That varus and valgus stress places the medial and then the lateral collateral ligament under stress, and one can get a sense of any tenderness with those maneuvers, and tenderness would indicate a Grade 1 tear. And then, one could also assess if there's any ligamentous laxity or ligamentous discontinuity if there's a bit more movement as you go with the varus and valgus stress into a bit more pressure.
Checking it in full extension, of course, has the posterior capsule working and intact, so that would be part of the evaluation. And then, at 30 degrees, the posterior capsule is relaxed, so you're getting a better assessment of the medial and lateral collateral ligaments. The next maneuver would be to look at the anterior and posterior cruciate ligaments, and the test to do for that would be the anterior drawer test for the anterior cruciate ligament and the posterior drawer test for the posterior cruciate ligament. Those tests are typically done in 90 degrees of flexion.
The examiner can place their leg against the foot of the patient, and with their thumbs on the tibial tubercle, one can move the knee forward and actually move the tibia forward and then successfully back to get a sense of whether or not the anterior or posterior cruciate ligaments are intact. Now, one would also perhaps look at the knee with the hip flexed 90 degrees, so the femur pointing straight up, and then be able to look at the tibia and its relationship to the rest of the knee.
And if it's sagging down, one would suspect a posterior cruciate ligament, and you could also check the stability there. Now, really, one of the best and most sensitive tests is to do the Lachman test, and that is with the knee at 20 to 30 degrees of flexion, repeat the same maneuver you would for the anterior cruciate ligament, anterior drawer test, and assess whether or not there's a significant amount of movement, which is generally considered more than 1/2 to 1 centimeter. Once you get to a centimeter, you can see if the knee is in fact lax. That would indicate an anterior cruciate disruption.
And it's most important, of course, to check the contralateral side to see if they're both equal or if there is a significant difference between the amount of movement of the tibia anteriorly with relationship to the knee. >> Dr. Schaffer, which history and other physical examination findings are helpful when detecting knee injuries? And which findings are not helpful? >> Well, being a knee surgeon, I have to say that I consider almost everything around the knee to be important and also looking at the hip and the ankle, but what you really want to know is, hat is the position of the knee joint at the time of the injury?
Now, not everybody has had an injury, but you can get a sense of what sort of activities the patient first noticed the pain in the knee. So, where is the knee pain? You know, and I will ask them to point to it with one finger. What is the duration of the pain? Prior to the pain starting, was there any change in activities? Did they change their home exercise program? Or did they take a new job and now they walk up and down stairs or walk down a hallway that's perhaps slippery or has a different surface?
Does the knee joint become swollen any time around the injury or perhaps at the end of the day? Is there any giving way or buckling of the knee? Is the knee locking or catching? And when it does, is it in extension or flexion? Or is it going into extension or flexion? And then, looking for the joint above and joint below, it's always important to ask questions about the back, the thigh, the hip area, the ankle, and the foot. >> Dr. Katz, what are the reference standard tests for ligamentous or meniscal tears?
>> That has, of course, evolved over the years. And presently for meniscal tear, the gold standard continues really to be arthroscopy to actually look inside the knee. With that as the gold standard, MRI has become the non-invasive diagnostic test of choice, and it has sensitivity and specificities in the neighborhood of 85 percent to 90 percent. So, it's not perfect, but it's an accurate test.
And for anterior cruciate ligament injuries and other collateral ligament injuries, the same is essentially true, that is that for the ACL and the PCL, the arthroscopic evaluation is probably the most definitive evidence. But in terms of non-invasive evaluation, MRI is highly sensitive in the order of 90-plus percent and reasonably specific, 80-plus percent, for ACL tears. And as Dr. Schaffer was saying, the physical exam is actually quite good for ACL tears.
The Lachman test has a specificity of 90 percent also in a lot of series. So, one can learn a lot without having to resort to the technology. >> Is there anything else that JAMAevidence users should know about diagnosing knee injuries? >> Well, I think it's very important that you take a good history and you perform an exam. And what I often recommend to our trainees, both in internal medicine and also in orthopedic surgery, is to develop an exam that follows in a very logical progression, evaluating by looking at the alignment.
What happens when they stand and they walk into the exam room? Or have they walked in the exam room? Inspect the joint. Palpate literally every part of the knee joint. Is the swelling in the pes anserine bursa or is it actually in the knee joint itself? What about the chondral surfaces? One can differentiate between a meniscal tear and the pain typically associated with an arthritic surface by flexing the knee and palpating the medial femoral condyle in most cases as opposed to the pain that you would see along the medial joint line.
You also would want to look at the patellofemoral joint, the bony surfaces as well, the rest of the areas outside where the cartilage is. And then, what's the range of motion? What's the strength like? What about the tendons, the quadriceps, the infrapatellar tendon, the iliotibial band? And then, various other tests looking along the joint line, as we were talking about, for meniscal tears, the McMurray test. We talked about the collateral and cruciate ligaments. The neurologic exam, of course, is very important.
And then, specialized tests, such as the Apley test, looking in compression for any meniscal irritation that may be present or when you're in the prone position being able to distract the joint and looking for ligamentous tenderness. So, I think it's very important to have all that accomplished because one can typically make the diagnosis with a good history, with a good physical, and then being able to get imaging studies, such as standing radiographs or, as Dr. Katz talked about, an MRI to corroborate what your thoughts were prior to that after getting the history and the physical and then using the imaging studies to simply corroborate whatever information you need to develop.
So, collecting all this information on the history and physical exam will help you make a diagnosis so that when you do get imaging studies, it will help corroborate your tentative diagnosis into one that's definitive so you can develop a treatment plan that's most appropriate for that patient. >> Dr. Katz, did you have something you would like to add? >> I had two thoughts. One is just to emphasize the importance of making a correct diagnosis, both in terms of the short-term and the long-term consequences of these intra-articular problems.
In the short term, these are genuinely debilitating problems, and they really have to be managed correctly, and patients need to modify their activities correctly to try to minimize the length of disability, which can be extended depending on the severity of injury and also so that they can get proper care. Many of these patients will wish to consider surgery, for example. Over the longer term, both meniscal tears and cruciate ligament injuries are well-documented risk factors for progression or accelerated onset of osteoarthritis of the knee, which of course is a major problem as we head into mid-life and later in life.
So, it's really important to make an accurate diagnosis and to address it correctly. The other point that I was going to make that addresses more specifically the issue of diagnosis is that for non-surgeons such as myself, I couldn't recommend strongly enough actually going to the operating room if you ever have an opportunity with a knee surgeon and just having a look at the anatomy. For many physicians, it's been ages since they've seen the knee, and it really helps to understand the structures and their relationship with each other to actually visualize them.
And short of that, I suppose there are some web-based virtual tours of the knee that one can do, but I'm not sure it substitutes for the real thing, but that's a really wonderful investment of time for anyone who has an interest. >> Jeff, we might also point out that, as we get older, we know that the tissues tend to degenerate, and the medial meniscus in particular being much more tethered to the tibial surface than the lateral meniscus, that risk of injury is pretty significant, and it's not uncommon or I should say it is common to have somebody who's in the kitchen reaching for something on a shelf, planting that foot, twisting their knee with a planted foot, and feeling that pop or something, as they'll say, it's tearing in that medial joint line.
And some menisci don't require surgery. You know, after three or six weeks of non-operative modalities, which would include maybe some physical therapy, some anti-inflammatories, some icing, some rest, then at that point, it may be an option to consider an arthroscopic intervention to deal with the torn piece of meniscus. But that early tear can often have those symptoms recede over time with appropriate non-operative modalities. I think as we get older, we can see different injury patterns that occur because that arthritis can get in the way as well and try to figure out is it an arthritic injury where that chondral gliding surface is injured or is it a meniscal injury is often challenging, even to the most expert of examiners.
>> Thank you, Dr. Katz and Dr. Schaffer, for this overview of ligamentous or meniscal evidence from review articles. For additional information, JAMAevidence subscribers can consult the online chapter on this topic in the Rational Clinical Examination. This has been Joan Stephenson of JAMA talking with Dr. Jeffrey Katz and Dr. Jonathan Schaffer for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives Section. Today, I have the pleasure of speaking with Dr. Jeffrey Katz and Dr. Jonathan Schaffer about injuries to knee ligaments and menisci, a topic discussed in a chapter of the Rational Clinical Examination, co-authored by Drs. Katz, Schaffer, and other contributors. Dr. Katz, Dr. Schaffer, why don't you introduce yourselves to our listeners? >> I'm Dr. Jeffrey Katz from the Brigham and Women's Hospital and Harvard Medical School in Boston.
>> I'm Jonathan Schaffer. I'm an orthopedic surgeon in the Adult Reconstruction Section at the Center for Joint Replacement here at the Cleveland Clinic. >> Dr. Schaffer, can you briefly describe for our listeners the anatomy of the knee and the various injury patterns? >> Certainly. As I'm sure we all know, the knee joint is the largest articulation in the body, and the fact that it is somewhat subcutaneous, especially anteriorly, puts it at risks with certain activities.
The anatomic structures at risk would be the anterior cruciate ligament, the posterior cruciate ligament, the medial and lateral collateral ligaments, and the menisci. When we go through normal daily activities, these structures are often articulating in a very well-coordinated fashion. But certain movements, especially as we get older, such as pivoting and varus/valgus and varus stresses or stresses from the sides, can create injury patterns that become clinically very apparent. >> Dr. Katz, what do we know about the prevalence of ligamentous or meniscal tears?
And are there important demographic characteristics? >> We have reasonably good information about the frequency of surgery for these injuries and somewhat less precise information about the incidence of the injuries themselves. For anterior cruciate ligament tears, for example, we know that there are about 175,000 surgeries done per year in the United States to reconstruct these ligaments.
There are some patients who are treated non-operatively, especially older patients, so this would underestimate the incidence of the injuries, per se. There are some interesting demographic patterns in ACL or anterior cruciate ligament injuries. They are more common in females, and that's particularly true in female versus male athletes. Prior to 1972 when Title IX was passed, very few women actually participated in sports, and so this mini epidemic was not observed, but it's become more apparent recently that females and males playing the same sorts of sports, females are at much higher risk for an ACL tear.
And there's a lot of speculation as to -- and some emerging evidence as to why that may be. There are a variety of potential explanations including differences in anatomy and the hormonal milieu and the neuromuscular function. Turning to meniscal injuries, we know that about 1/3 of people greater than 50 years old in the population have meniscal tears on MRI, but most of these persons are asymptomatic. Most of these medical tears are clinically silent.
We know that people who have radiographic osteoarthritis are very likely to have evidence of meniscal tear on their MRI. As many as 3/4 of patients with osteoarthritis have meniscal tear. These are usually degenerative. And again, they usually are silent in the sense that the tear, per se, is not contributing to symptoms in the majority of these patients. >> Dr. Schaffer, what physical examination maneuvers are used to evaluate ligamentous tears or meniscal injuries? >> Well, for ligamentous tears, let's first start with the medial and lateral collateral ligament.
In order to assess the medial and lateral collateral ligament, the examiner should place the knee first an extension and then successfully place it in 30 and 60 degrees of flexion as they place a varus and a valgus stress across the knee. That varus and valgus stress places the medial and then the lateral collateral ligament under stress, and one can get a sense of any tenderness with those maneuvers, and tenderness would indicate a Grade 1 tear. And then, one could also assess if there's any ligamentous laxity or ligamentous discontinuity if there's a bit more movement as you go with the varus and valgus stress into a bit more pressure.
Checking it in full extension, of course, has the posterior capsule working and intact, so that would be part of the evaluation. And then, at 30 degrees, the posterior capsule is relaxed, so you're getting a better assessment of the medial and lateral collateral ligaments. The next maneuver would be to look at the anterior and posterior cruciate ligaments, and the test to do for that would be the anterior drawer test for the anterior cruciate ligament and the posterior drawer test for the posterior cruciate ligament. Those tests are typically done in 90 degrees of flexion.
The examiner can place their leg against the foot of the patient, and with their thumbs on the tibial tubercle, one can move the knee forward and actually move the tibia forward and then successfully back to get a sense of whether or not the anterior or posterior cruciate ligaments are intact. Now, one would also perhaps look at the knee with the hip flexed 90 degrees, so the femur pointing straight up, and then be able to look at the tibia and its relationship to the rest of the knee.
And if it's sagging down, one would suspect a posterior cruciate ligament, and you could also check the stability there. Now, really, one of the best and most sensitive tests is to do the Lachman test, and that is with the knee at 20 to 30 degrees of flexion, repeat the same maneuver you would for the anterior cruciate ligament, anterior drawer test, and assess whether or not there's a significant amount of movement, which is generally considered more than 1/2 to 1 centimeter. Once you get to a centimeter, you can see if the knee is in fact lax. That would indicate an anterior cruciate disruption.
And it's most important, of course, to check the contralateral side to see if they're both equal or if there is a significant difference between the amount of movement of the tibia anteriorly with relationship to the knee. >> Dr. Schaffer, which history and other physical examination findings are helpful when detecting knee injuries? And which findings are not helpful? >> Well, being a knee surgeon, I have to say that I consider almost everything around the knee to be important and also looking at the hip and the ankle, but what you really want to know is, hat is the position of the knee joint at the time of the injury?
Now, not everybody has had an injury, but you can get a sense of what sort of activities the patient first noticed the pain in the knee. So, where is the knee pain? You know, and I will ask them to point to it with one finger. What is the duration of the pain? Prior to the pain starting, was there any change in activities? Did they change their home exercise program? Or did they take a new job and now they walk up and down stairs or walk down a hallway that's perhaps slippery or has a different surface?
Does the knee joint become swollen any time around the injury or perhaps at the end of the day? Is there any giving way or buckling of the knee? Is the knee locking or catching? And when it does, is it in extension or flexion? Or is it going into extension or flexion? And then, looking for the joint above and joint below, it's always important to ask questions about the back, the thigh, the hip area, the ankle, and the foot. >> Dr. Katz, what are the reference standard tests for ligamentous or meniscal tears?
>> That has, of course, evolved over the years. And presently for meniscal tear, the gold standard continues really to be arthroscopy to actually look inside the knee. With that as the gold standard, MRI has become the non-invasive diagnostic test of choice, and it has sensitivity and specificities in the neighborhood of 85 percent to 90 percent. So, it's not perfect, but it's an accurate test.
And for anterior cruciate ligament injuries and other collateral ligament injuries, the same is essentially true, that is that for the ACL and the PCL, the arthroscopic evaluation is probably the most definitive evidence. But in terms of non-invasive evaluation, MRI is highly sensitive in the order of 90-plus percent and reasonably specific, 80-plus percent, for ACL tears. And as Dr. Schaffer was saying, the physical exam is actually quite good for ACL tears.
The Lachman test has a specificity of 90 percent also in a lot of series. So, one can learn a lot without having to resort to the technology. >> Is there anything else that JAMAevidence users should know about diagnosing knee injuries? >> Well, I think it's very important that you take a good history and you perform an exam. And what I often recommend to our trainees, both in internal medicine and also in orthopedic surgery, is to develop an exam that follows in a very logical progression, evaluating by looking at the alignment.
What happens when they stand and they walk into the exam room? Or have they walked in the exam room? Inspect the joint. Palpate literally every part of the knee joint. Is the swelling in the pes anserine bursa or is it actually in the knee joint itself? What about the chondral surfaces? One can differentiate between a meniscal tear and the pain typically associated with an arthritic surface by flexing the knee and palpating the medial femoral condyle in most cases as opposed to the pain that you would see along the medial joint line.
You also would want to look at the patellofemoral joint, the bony surfaces as well, the rest of the areas outside where the cartilage is. And then, what's the range of motion? What's the strength like? What about the tendons, the quadriceps, the infrapatellar tendon, the iliotibial band? And then, various other tests looking along the joint line, as we were talking about, for meniscal tears, the McMurray test. We talked about the collateral and cruciate ligaments. The neurologic exam, of course, is very important.
And then, specialized tests, such as the Apley test, looking in compression for any meniscal irritation that may be present or when you're in the prone position being able to distract the joint and looking for ligamentous tenderness. So, I think it's very important to have all that accomplished because one can typically make the diagnosis with a good history, with a good physical, and then being able to get imaging studies, such as standing radiographs or, as Dr. Katz talked about, an MRI to corroborate what your thoughts were prior to that after getting the history and the physical and then using the imaging studies to simply corroborate whatever information you need to develop.
So, collecting all this information on the history and physical exam will help you make a diagnosis so that when you do get imaging studies, it will help corroborate your tentative diagnosis into one that's definitive so you can develop a treatment plan that's most appropriate for that patient. >> Dr. Katz, did you have something you would like to add? >> I had two thoughts. One is just to emphasize the importance of making a correct diagnosis, both in terms of the short-term and the long-term consequences of these intra-articular problems.
In the short term, these are genuinely debilitating problems, and they really have to be managed correctly, and patients need to modify their activities correctly to try to minimize the length of disability, which can be extended depending on the severity of injury and also so that they can get proper care. Many of these patients will wish to consider surgery, for example. Over the longer term, both meniscal tears and cruciate ligament injuries are well-documented risk factors for progression or accelerated onset of osteoarthritis of the knee, which of course is a major problem as we head into mid-life and later in life.
So, it's really important to make an accurate diagnosis and to address it correctly. The other point that I was going to make that addresses more specifically the issue of diagnosis is that for non-surgeons such as myself, I couldn't recommend strongly enough actually going to the operating room if you ever have an opportunity with a knee surgeon and just having a look at the anatomy. For many physicians, it's been ages since they've seen the knee, and it really helps to understand the structures and their relationship with each other to actually visualize them.
And short of that, I suppose there are some web-based virtual tours of the knee that one can do, but I'm not sure it substitutes for the real thing, but that's a really wonderful investment of time for anyone who has an interest. >> Jeff, we might also point out that, as we get older, we know that the tissues tend to degenerate, and the medial meniscus in particular being much more tethered to the tibial surface than the lateral meniscus, that risk of injury is pretty significant, and it's not uncommon or I should say it is common to have somebody who's in the kitchen reaching for something on a shelf, planting that foot, twisting their knee with a planted foot, and feeling that pop or something, as they'll say, it's tearing in that medial joint line.
And some menisci don't require surgery. You know, after three or six weeks of non-operative modalities, which would include maybe some physical therapy, some anti-inflammatories, some icing, some rest, then at that point, it may be an option to consider an arthroscopic intervention to deal with the torn piece of meniscus. But that early tear can often have those symptoms recede over time with appropriate non-operative modalities. I think as we get older, we can see different injury patterns that occur because that arthritis can get in the way as well and try to figure out is it an arthritic injury where that chondral gliding surface is injured or is it a meniscal injury is often challenging, even to the most expert of examiners.
>> Thank you, Dr. Katz and Dr. Schaffer, for this overview of ligamentous or meniscal evidence from review articles. For additional information, JAMAevidence subscribers can consult the online chapter on this topic in the Rational Clinical Examination. This has been Joan Stephenson of JAMA talking with Dr. Jeffrey Katz and Dr. Jonathan Schaffer for JAMAevidence.
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