They rated the sensitivity at 25% and could not report any specificity percentage. How to appraise a diagnostic test. 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. More recent research has shown that modifications to the original McMurray's test may have better validity and diagnostic accuracy than the original McMurray's test3,58. followers. The possibility of there being associated intra-articular pathology (such as anterior cruciate ligament rupture) confounds results, and the unknown validity, sensitivity, and specificity of the tests make it difficult for the clinician to be confident in making a definitive diagnosis3. This is a key test to perform when assessing for posterolateral instability of the knee. It is important to take this into consideration when analyzing test results of studies that have used more than one examiner. Studies investigating the validity of diagnostic tests such as the McMurray's compare the findings of that test with a reference (gold) standard that has demonstrated validity11. Kurosaka et al6 stated that diagnostic accuracy is lessened in patients with multiple pathologies, whereas Akseki et al3 found that there was no reduction in diagnostic accuracy with an associated tear of the ACL. Both imaging modalities are recommended to diagnose both acute and chronic FCL injuries. Background: Functional hallux limitus (FHL) refers to dorsiflexion hallux mobility limitation when the first metatarsal head is under loading conditions but not in the unloaded state. Kane PW, Cinque ME, Moatshe G, Chahla J, DePhillipo NN, Provencher MT, LaPrade RF. The low sensitivity figures would indicate that in general, a negative test result is not reliable in ruling out meniscal pathology and a torn meniscus would likely be missed if the McMurray's test was the sole determinant of pathology. NCI CPTC Antibody Characterization Program. The studies that compared the diagnostic accuracy of the McMurray's test with that of modified versions of the test showed enhanced diagnostic accuracy for the modified tests. the contents by NLM or the National Institutes of Health. Douglas I, McDermott Meniscal tears. Interactive Content (Direct Video Demonstration, PubMed articles), Statistical Values for all Special Tests from the latest research, Currently on Version 6.0 Free lifetime updates. Clinical Rehabilitation, 22(2), 143-61. Some of the studies did not separate the data for medial from that of lateral meniscal testing5,6,22,25. 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. In chronic injuries, this test has a sensitivity of 92% and a specificity of 91%, but not in acute injuries. Clinial oriented anatomy. The Valgus Stress Test for LCL injuries has hardly been evaluated regarding its diagnostic accuracy. Clinically, we do not know whether a patient has the condition before the diagnostic test (arthroscopy or MRI) is performed. Epub 2018 Jul 27. When confidence intervals are not present, the CIs were incalculable due to absence of raw data. Sensitivity is the probability of a positive test result in someone with the pathology, whereas specificity is the probability of a negative test result in someone without the pathology.6Traditionally, tests which have high sensitivity values are able to correctly identify individuals with the pathology; thus, if the examiner obtains a negative MeSH I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Although blinding was not mentioned in respect to the other studies, the majority required the clinical examination to be performed prior to the diagnostic arthroscopy, suggesting that the examiner would indeed be blinded to the results of the diagnostic test. The Valgus Test of the knee is performed with the patient lies in the supine position. [1] The therapist applies a valgus stress at the knee while the ankle is stabilized in slight lateral rotation either with the hand or with the leg held between the examiner's arm and trunk. An assessment for one-plane lateral instability (i.e. Modified McMurray's to include valgus/varus stress. ODFlNzFkZTQ2MDZmOTVkM2Q1MjEzNzY5YTlmZTU2MTRmYWFkYzY2ZmRmNzlj 1173185. Given the results of the multivariate regression in Question 1, write the regression equation associated with this study. how likely a negative test result is in people who have the disease or dysfunction as compared to how likely it is in those who do not have the disease or dysfunction. The objective of this paper was to critically review the literature with respect to the validity and diagnostic accuracy of the traditional McMurray's test and any modifications of this test. Bethesda, MD 20894, Web Policies Sae-Jung et al24 considered pain or a clicking sound to be a positive test. The proportion of people who have the disease or dysfunction who test positive. ODYyNmRjODBkYjVlYTFhN2Q3ZjEzNDRkNGI0OGNkZjQyNzhlZWM2MDE1MmQ1 2018 Aug;46(10):2355-2365. doi: 10.1177/0363546518784301. Would you like email updates of new search results? Moreover, the ACL stabilizes the knee's rotation under varus or valgus stress. Zappia M, Capasso R, Berritto D, Maggialetti N, Varelli C, D'Agosto G, Martino MT, Carbone M, Brunese L. Musculoskelet Surg. Sensitivity and specificity of diagnosing FCL injuries on MRI were determined based on review by a fellowship-trained musculoskeletal radiologist, blinded to the pathology associated with each patient (FCL injury vs control), and compared with the gold standard of examination under anesthesia, followed by surgical confirmation of an FCL tear at the time of FCL reconstruction. Evaluation of knee instability in acute ligamentous injuries. Churchill Livingstone, 2002. MGQ5MzQyZWI5MjJjMjUxYjFhM2E1ZjQ5NTgzMzdmNTY4NmYwZWM1ZWQ3YTU3 Four authors stated that they used the McMurray's test but did not describe the actual testing procedure3,5,19,25. and transmitted securely. Flow diagram of literature screening process. In: DeLee & Drez's Orthopaedic Sports Medicine. Valgus Stress Test. MRI has also shown to be highly reliable, but due to its expensive cost, they are less frequently used. M2NhODMyZGZjNTEwMzAzY2JkMWI0MTUwM2I3NjNjN2RjYmY4NmEyNWE1ZjZk LaPrade RF, DePhillipo NN, Cram TR, Cinque ME, Kennedy MI, Dornan GJ, O'Brien LT. Am J Sports Med. In one of these studies, the CIs are extremely wide5. YWU3NTg0YTg5NzcxMzE4M2I5NjZiYzgxNzlkYjQyNmRjYjE1OWNjZjJmNzVh Specificity is the proportion of patients without the condition who have a negative test result and indicates the ability to use a test to recognize when the condition is absent11. 1985;13(1):14. In addition, cited references of relevant articles were examined. 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 ). Purpose: The Varus Stress Test is used to assess the integrity of the LCL or lateral collateral ligament of the knee. These authors considered the overall accuracy of the axially loaded pivot shift test to be higher than that of the McMurray's test (Table (Table7).7). The IR of the tibia followed by extension, the examiner can test the entire posterior horn to the middle segment of the meniscus. An assessment for one-plane medial instability (gapping of the tibia away from the femur on the medial side). [3] McClure P,W et al. As previously documented in the literature10, the definition and calculation of statistical measures of concurrent criterion-validity are based on the absence or agreement between the clinical test and the gold standard test. 1987; 76: 269-273. Akseki et al3 included consecutive patients with symptoms related to intra-articular knee pathology although how this was determined was not described. 2006;20:8594. YzFjZGMyZmVmOTJjNWQ2NWYyNDVkNDE1OWM3Yzg5NjE2MWNhYTY1ZGZlNGYw ZDM4MDExNDhjN2VjY2ExMjE4ZTQxZWUwYTUzMGUzZDcwYWYzMDA5YTYwODZh ZDIwNGI3MGM0NDMzZmMxM2YxZDdmZWM0YmE5MDI5OWJiMmE4MmFhZTdkODE1 Apply slight lateral rotation and perform passive adduction at the knee joint and thus put stress on the LCL. Results: MDUwOTJiNWVjMDExNzg5OTRkYzIwNjRlYzdhZmM2MzUyYjUwY2IxYTkzMTRk 4th Edition. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. Arthrosc Tech. National Library of Medicine Level II, case-control study. 2017 Dec;33(12):2177-2181. doi: 10.1016/j.arthro.2017.06.028. Obviously, if the test is performed differently and/or the interpretation of a positive test is not the same, the demonstrated accuracy of the test cannot be compared. These comments are also supported by the findings of a recent meta-analysis carried out by Hegedus et al7 and Meserve et al8. OWFmOGE3YWY0OWM1ZWIzOTU5Mjg5Y2I4ODIwZmU1MmQyZWRhMmUxY2ZlMGU3 Although the support of a clinical study is needed in order to make a definite conclusion, the dial test is probably not reliable in the presence of medial instability, The external validity of a study is largely dependent on the study population. Useful tests should produce large shifts in probability once the result of the test is known. Schulzer M. Diagnostic tests: A statistical review. Waldman,S.D. Varus stress MRI in the refined assessment of the posterolateral corner of the knee joint. Studies of specificity and sensitivity have demonstrated varied values as a result of poor methodological quality[7] A recent meta-analysis reports sensitivity and specificity to be 70% and 71%. Published by Elsevier Inc. All rights reserved. Bearing these findings in mind, the following recommendations can be made for the clinician: This review has demonstrated that the intertester reliability and sensitivity of the McMurray's test is relatively low; however, it has also highlighted that it can be a relatively specific test, especially with respect to the lateral meniscus. As is true of all statistics, sensitivity and specificity values are taken from a sample and represent an estimate of the true value that could be found in the population. Campbell SE, Sanders TG, Morrison WB. Methods: No mention acute/chronic. 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. doi: 10.1016/j.eats.2018.10.007. Fibular collateral ligament and the posterolateral corner. Bethesda, MD 20894, Web Policies Bookshelf IR of the tibia + Varus stress = lateral meniscus, ER of the tibia + Valgus stress = medial meniscus. TP=true positive, FP=false positive, FN=false negative, TN=true negative. 2001;177(2):409413. Another Systematic review study by Braun Schwieterman found that the sensitivity and specificity of the medial talar tilt stress test was 50% and 88 % respectively. Partial Controlled Early Postoperative Weightbearing Versus Nonweightbearing After Reconstruction of the Fibular (Lateral) Collateral Ligament: A Randomized Controlled Trial and Equivalence Analysis. Epub 2017 Aug 16. That is usually the journal article where the information was first stated. How to Perform Varus Stress Test Position of Patient: The patient should be relaxed in the supine position. With one hand fixate the femur. 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. Am J Sports Med. The incidence of LCL injuries are relatively low (6%) when compared to other knee injuries. Sensitivity figures vary from 16%88%, while specificity figures vary from 20%98% (Table (Table5).5). Malanga GA, Andrus S, Nadler SF, McLean J. Merriman L, Turner W. Assessment of the Lower Limb. The fibular or lateral collateral ligament (LCL) is a cord-like band and acts as the primary varus stabilizer of the knee. All abstracts for 44 articles from Medline, 19 articles from CINAhL, 5 articles from AMED, 18 articles from SPORTSDiscus, 548 articles from SCOPUS, and 6 articles from the hand search were reviewed by the authors (Figure (Figure2).2). 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. Philadelphia: Elsevier, 2016; 2121-2297. Irwig L, Tosteson AN, Gatsonis C, et al. HHS Vulnerability Disclosure, Help Described a modified version (Medial-Lateral Grind test) but no description of McMurray's. OThmMmM0YTcwMmQwODZhZWFkYzNjNzRlOTkzZiIsInNpZ25hdHVyZSI6IjVh 2008. Arthroscopy has demonstrated an accuracy between 93% and 96%12. 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. Simmel DL, Samsa GP, Matchar DB. Whenever suspecting a posterolateral complex injury, one has to carefully perform a valgus stress test in 0 degrees and 30 degrees. The studies by Akseki et al3, Corea et al4, and Manzotti et al20 revealed negative likelihood ratios that are slightly lower than the other studies. Evans et al23 concluded that examiner experience had little effect on the accuracy of the diagnosis; however, they noted that the student examiner demonstrated a significant association (p = 0.002) between the diagnosis of a medial meniscus tear and reproduction of a medial thud, while the experienced examiner demonstrated a significant association between this diagnosis and the reproduction of pain (p = 0.008) or a medial sensation (p = 0.001). 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. Bossuyt PM, Reitsma JB, Bruns DE, et al. 24 General examination included carrying angle (normal, valgus,. The statistical measures of sensitivity, specificity, and likelihood ratios were calculated from the information provided in the studies. In order to make the retrieval of articles as comprehensive as possible, a generic search strategy was employed using Medline, CINAhL, and AMED databases through OVID, SPORTDiscus database through EBSCO, and SCOPUS, from 1980 to May 2008. Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears. any of these symptoms can indicate a compromised medial or lateral meniscus. At the proximal level this ligament is closely related to the joint capsule, without having direct contact, as it is separated by fat pad, The insertion is augmented by the iliotibial band. The https:// ensures that you are connecting to the . This lack of consensus in the literature highlights the risk that the criteria indicating a positive test can influence the test outcome, irrespective of whether the test was performed in the same manner on the same patient. All patients who underwent an isolated FCL or combined anterior cruciate ligament (ACL)/FCL reconstruction by a single surgeon between 2010 and 2017 with preoperative varus stress radiographs and magnetic resonance imaging (MRI) were included in this study. Evaluation of Knee Instability in Acute Ligamentous Injuries. The review also highlights the idea that modified versions of the test seem to be more valid than the original version. There is conflicting evidence in the literature over the accuracy of MRI. Further, the description of the test itself should be well explained, and improving intertester reliability in the future would increase the validity of the studies. The Medial-Lateral Grind test had a higher LR+ (Table (Table7)7) when compared to the McMurray's test; however, its CIs were extremely wide, bringing into question the precision of this estimate of reliability (Table (Table7).7). 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. Limiting the search to English language articles only may also have led to an omission of other relevant studies. 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. Original description. Medline and CINAHL search strategy via OVID. Prospective evaluation of the McMurray test. Consecutive patients suspected of having meniscal tears presenting for arthroscopy: acute and chronic (ligament injuries excluded). One study used a palpable thud and/or pain23, and two studies used a palpable click and/or pain3,20. Fibular Collateral Ligament: Varus Stress Radiographic Analysis Using 3 Different Clinical Techniques. How to use diagnostic test articles in the intensive care unit: Diagnosing weanability using f/Vt. Varus stress testing was performed in 20 of flexion, and testing in extension was not done. The preliminary nature of this tool also means that a more narrative review of the validity and accuracy of the tests has been presented. Miller RH, Azar FM. M2MwN2QyM2QzMGFjZjQ3MDgzMGRiYzAyMmRlZDc3MTAxODc4MDdhNzcyZWMz Agreement regarding which articles to read in full was determined by consensus. Only one study by Harilainen et al. The proportion of people who test positive and who have the disease or dysfunction. NTcwOGRhYWNmMWQyOTg0NjE1M2QwNTU5MTk0Nzk2OTQzMGU3YmUxODlhZjM0 Although six studies used multiple testers, these did not provide statistics for reliability6,1923. Akseki D, Ozcan O, Boya H, Pinar H. A new weight-bearing meniscal test and a comparison with McMurray's test and joint line tenderness. Malanga GA, Andrus S, Nadler SF, McLean J. 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. However, of those that have made this distinction, there is some consensus that the McMurray's test has higher sensitivity with respect to medial meniscal tears and higher specificity with lateral meniscal tears3,4,19,20,24. YzZhYjViODEyOTFlYzkyIn0= If a study evaluates a test in a very specific group of patients, its findings can only be applied to that same type of cohort. Sackett D, Richardson S, Rosenberg W, Haynes RB. In: Campbell's Operative Orthopaedics. Yedlinsky, N.T. Sensitivity, specificity, and likelihood ratios (LR) of the McMurray's test with confidence intervals (CI). MR imaging of meniscal cysts: incidence, location, and clinical significance. The test is performed at 0 and 20-30, so the knee joint is in the closed packed position. Studies were included for analysis if they compared the McMurray's test with a gold standard of knee arthroscopy or magnetic resonance imaging (MRI). YzA0Nzk1ZjQxYjY5Mzg4MWUwNDRlODM0NDRiNzZiM2I4OWVhNTQ1YmVlMDNj The description should include the exact details of the test's application and the criteria used to determine positive and negative results11. 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).
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