Clinical Presentation

For Medical Students

What It Tests

The clinical presentation of a meniscal tear is what the whole of this chapter is trying to detect, so it is worth stating before the tests.

There are two presentations and they behave differently. A traumatic tear in a younger knee, and a degenerate tear in an older one.

The traumatic tear follows a twisting injury on a loaded knee, produces pain on the affected joint line, swells over hours to days, and may catch or lock. 4.2.18 covers the mechanism.

The degenerate tear often has no injury at all, or a trivial one, and presents as activity-related joint line pain in a knee with other degenerative findings. 4.9.11 covers it.

How It Is Performed

Take the history before the examination, and take the mechanism, the swelling timing and the mechanical symptoms specifically. 4.2.3 covers swelling.

Then inspect for an effusion, wasting and the position of rest.

Palpate the joint lines with the knee flexed to about ninety degrees, which opens the line and makes it accessible. 4.9.2 covers the technique.

Assess range and look for a loss of extension, which is the finding that changes the urgency. 4.7.8 covers extension lag.

Then perform the provocative tests, which the rest of this chapter covers, and perform them last because they hurt.

What a Positive Means

Joint line tenderness on the symptomatic side, with a matching mechanism and mechanical symptoms, is the core presentation.

A loss of extension with a hard endpoint is a displaced tear and a mechanical block. 4.9.8 covers it.

An effusion supports an intra-articular problem and does not identify the meniscus. 4.8.2 covers significance.

Posterior joint line pain in deep flexion, with a history of a squatting injury, raises a posterior horn or root tear. 4.9.9 covers roots.

No joint line tenderness at all makes a meniscal tear less likely but does not exclude one, particularly a root tear.

MRCS Level

How It Is Performed

In a viva the meniscal examination is expected as a sequence that ends with the special tests rather than beginning with them.

Inspect, palpate both joint lines, assess range including a deliberate check for full extension, assess the effusion, then test.

Say which tests you are doing and what a positive would mean, and say that no single test is sufficient.

Finish by examining the ligaments, because a meniscal injury and a cruciate injury share a mechanism and the combination is common. 4.10.2 covers acute cruciate injury.

What a Positive Means

A positive finding on a meniscal test means the manoeuvre reproduced pain or a click at the joint line. It does not mean a tear is present.

The combination of findings is what carries weight: a matching history, joint line tenderness and at least one positive provocative test.

A single positive test in the absence of joint line tenderness is weak.

Joint line tenderness in the absence of any other finding is also weak, because it is common in degenerate knees without a symptomatic tear.

A mechanical block is the exception: it stands alone as a finding and it is the one that determines urgency. 4.9.8 covers it.

How Good It Is

The meniscal tests share a pattern and it is worth learning as a pattern rather than test by test.

They are more specific than sensitive. A positive result is informative and a negative result excludes very little, which is the opposite of what a screening test should do.

Joint line tenderness is the most sensitive single finding and the least specific. The provocative tests are the reverse.

The combination outperforms any single test, which is why the sequence exists.

No figures appear anywhere in this chapter, under decision 023, because the ranking is standard teaching and the percentages written from memory would not be.

FRCS Level

How Good It Is

At decision level the examination's job is not to diagnose a tear, since imaging does that better. It is to establish whether the tear is the problem.

That question matters because degenerate tears are common in asymptomatic knees, so a tear on a scan is not an indication. 4.1.6 covers the era of imaging.

The examination contributes three things imaging cannot: whether the joint line that is tender matches the tear, whether there is a mechanical block, and whether the patient's range and function are limited by it.

In a young knee after a defined injury the examination and the imaging usually agree and the question is repairability rather than attribution.

In an older knee they frequently disagree and the examination is the tie-breaker rather than the confirmation.

Where It Misleads

The commonest error is treating a positive provocative test as an indication, when the whole group is specific rather than sensitive and a positive in a degenerate knee is often incidental.

The second is treating a negative examination as excluding a tear, particularly a root tear, which examines poorly. 4.9.9 covers roots.

The third is examining a knee too acutely. A swollen guarding knee gives a meniscal examination of little value, and repeating it at two to six weeks is more useful than persisting. 4.1.5 covers the timing problem.

And attributing all joint line tenderness to the meniscus, when the collateral, the pes anserinus and the posteromedial corner are all nearby. 4.16.7 covers one.

Fellowship Level

Where It Misleads

In referred practice the presentation is usually a knee that has been resected and is no better, or a tear that was repaired and has failed.

The examination then has to distinguish a new or recurrent tear from the altered mechanics of a deficient meniscus, and the two feel similar to the patient. 4.9.10 covers deficiency.

Joint line tenderness after a resection is common, persistent and poorly specific, so it contributes little at this level.

A mechanical block after a repair is the finding that matters most and still stands alone. 4.20.2 covers meniscal repair assessment.

The honest limit is that the examination after meniscal surgery is substantially less useful than before it, and the history and the imaging carry proportionally more.

No figure here supports that claim, under decision 023.