Systematic Review of the Validity of Mcmurrays Test
J Man Manip Ther. 2009; 17(ane): 22–35.
Validity of the McMurray'south Test and Modified Versions of the Test: A Systematic Literature Review
Wayne Hing
aAssociate Professor, health & Rehabilitation Enquiry Heart, Schoolhouse of Rehabilitation and Occupation Studies, AUT Academy, Auckland, New Zealand
Steve White
bSenior Lecturer, School of Rehabilitation and Occupation Studies, Auckland University of Technology, Auckland, New Zealand
Duncan Reid
cHead of School of Rehabilitation and Occupation Studies, Auckland University of Engineering, Auckland, New Zealand
Rob Marshall
dSchool of Physiotherapy, Auckland University of Technology, Auckland, New Zealand
Abstract
Clinical assessment of meniscal pathology in the knee has proven difficult due to the wide number of tests bachelor and variations in their interpretation and application. The purpose of this paper was to appraise the literature investigating the validity and diagnostic accurateness of the McMurray's examination (and modifications) for determining meniscal pathology of the articulatio genus and then that conclusions could exist fatigued regarding its clinical usefulness as a test. Electronic databases (Medline, CINhAL, AMED, SPORTSDiscus, and SCOPUS) were searched from March 1980 to May 2008. In improver, cited references of relevant articles were examined. Studies were included for assay if they compared the McMurray'southward examination with a gold standard of knee arthroscopy or magnetic resonance imaging (MRI). Eleven studies met the inclusion criteria. Collectively, these studies indicate that there is little consensus in the reported measures of validity of the McMurray'south exam and that this is mostly due to limitations in the methodological quality of the studies that were assessed. Methodological scores on the STARD (Standards for Reporting of Diagnostic Accuracy) yielded scores from ten/25 to 20/25. More often than not, the McMurray's test has relatively loftier specificity and low sensitivity. The studies that compared the diagnostic accuracy of the McMurray's test with that of modified versions of the examination showed enhanced diagnostic accuracy for the modified tests. This review identified that the McMurray's exam is of limited clinical value due to relatively low sensitivity, with modified tests (associated with the traditional McMurray's examination) having higher diagnostic accurateness and thus these may be more than useful clinically.
KEYWORDS: Knee, McMurray's, Meniscal, Reliability, Sensitivity, Specificity, Testing, Validity
A broad multifariousness of clinical tests are used to diagnose meniscal pathology within the articulatio genus. Palpation for joint line tenderness, the Apley's Grind test, and the McMurray's exam are commonly used in concrete therapy practice1. The authentic diagnosis of meniscal pathology on the footing of the findings of such tests is often hard. A recent evidence-based guideline for the management of astute soft tissue injuries to the knee has recommended that joint line tenderness is the simply reliable clinical indicator of meniscal pathologytwo. The possibility of there being associated intra-articular pathology (such equally 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.
The McMurray's examination, as described in Corea et al4, was designed to detect tears in the posterior segment of the meniscus. It is performed by placing the genu across 90° of flexion and and so rotating the tibia on the femur into full internal rotation to examination the lateral meniscus, or total external rotation to test the medial meniscus. The same maneuvers are performed in gradually increasing degrees of knee flexion to progressively load more posterior segments of the menisci. No valgus or varus stress is applied. During the maneuver, the joint line is palpated both medially and laterally. A positive test is considered to be a thud or click that can sometimes be heard but tin can always be felt 4 (Figure i).
A) AND B): The McMurray'south test: Figure 1a) the tibia rotated on the femur into total internal rotation and Figure 1b) the tibia rotated on the femur into full external rotation.
The findings of studies testing the validity of the McMurray'south test have varied widely, mostly due to variations in the size and type of the study population as well as differences in description and application of the test3. More contempo research has shown that modifications to the original McMurray's test may have meliorate validity and diagnostic accuracy than the original McMurray's test3 , 5 – 8. The objective of this paper was to critically review the literature with respect to the validity and diagnostic accuracy of the traditional McMurray'due south test and any modifications of this test.
Method
Search Strategy
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. One of the search terms used was McMurray$ test$. This generic search strategy was then combined with a subject-specific strategy (Table ane). In addition to the database searches, personal files were hand-searched by the authors for publications and relevant material. The reference lists in review articles were cross-checked and any possibility of proper name/term variations was queried using MEDLINE and PUBMED.
Tabular array one
Medline and CINAHL search strategy via OVID.
| No. | Search history | Results |
|---|---|---|
| 1 | knee | 76439 |
| two | Menisc$ | 8911 |
| 3 | Mcmurray$ | 140 |
| 4 | Gold standard | 16986 |
| 5 | 1 and 2 | 6241 |
| 6 | 3 and 4 | 5 |
| 7 | 3 and v | 44 |
Search Selection
All abstracts for 44 manufactures from Medline, 19 articles from CINAhL, five manufactures from AMED, 18 manufactures from SPORTSDiscus, 548 articles from SCOPUS, and 6 articles from the paw search were reviewed past the authors (Figure 2). Agreement regarding which articles to read in full was determined past consensus. Studies were eligible for inclusion if they assessed measures of accuracy or validity of the McMurray's test or any modification of this exam against a gold standard of either arthroscopy or magnetic resonance imaging (MRI) and were written in English. In total, 11 studies have been included in this critical review.
Menses diagram of literature screening process.
Methodological Assay
Analysis of the quality of studies that evaluate the validity and accuracy of tests, such equally the McMurray's examination, is difficult if key data regarding the pattern, conduct, and analysis of the study are non reported by the authors9. Therefore, articles were assessed using the STARD (Standards for Reporting of Diagnostic Accuracy) checklist of methodological quality9, which uses established criteria for quality cess of different inquiry formatsx. The STARD checklist contains 25 items that assistance to make a judgment about potential bias in the study and appraisal of the applicability of the findings. It has been used previously for the systematic assessment of the methodology of studies into diagnostic accurateness10. 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.
Equally previously documented in the literature10, the definition and calculation of statistical measures of concurrent criterion-validity are based on the absenteeism or agreement between the clinical exam and the gold standard test. The four possible outcomes include true positive, a simulated positive, a false negative, and a truthful negative (see Table two). The statistical measures of sensitivity, specificity, and likelihood ratios were calculated from the data provided in the studies.
Table 2
Operational definitions of diagnostic accuracy terms used in the studies investigating validity of McMurray's test for meniscal pathology (modified from Powell & huijbregts10).
| Statistical Measure out | Definition | Calculation |
|---|---|---|
| Sensitivity | The proportion of people who have the disease or dysfunction who test positive. | TP/(TP + FN) |
| Specificity | The proportion of people who practice not have the affliction or dysfunction who test negative. | TN/(FP + TN) |
| Positive Predictive Value | The proportion of people who test positive and who have the illness or dysfunction. | TP/(TP + FP) |
| Negative Predictive Value | The proportion of people who exam negative and who practise not take the disease or dysfunction. | TN/(FN + TN) |
| Positive Likelihood Ratio | How likely a positive examination result is in people who have the affliction or dysfunction as compared to how likely information technology is in those who do non have the affliction or dysfunction. | Sensitivity/(1 - Specificity) |
| Negative Likelihood Ratio | how likely a negative exam result is in people who have the disease or dysfunction every bit compared to how likely information technology is in those who do not accept the disease or dysfunction. | (1 - Sensitivity)/Specificity |
| Accuracy | The proportion of true results (both true positives and true negatives) in the population. An accuracy of 100% ways that the exam identifies all sick and well people correctly. | = (Number of TP + Number of TN)/(Numbers of TP + FP + FN) |
Results
Methodological Quality
The assessment results for methodological quality has been presented under the post-obit headings: the STARD analysis, reference standard, population differences, blinding, clarification and interpretation of test, inter-tester reliability, diagnostic accuracy and validity, sensitivity and specificity, likelihood ratios, and McMurray's test compared to modified versions of the test.
STARD Assay
Based on the STARD scoring of each paper, information technology is possible to make a qualitative cess nigh the methodological quality. A consensus method was used to discuss and resolve discrepancies betwixt the markings of each paper between the three reviewers. The agreed quality for each paper is included in Table 3.
Table iii
ST A RD score of the studies retrieved.
| Report | Noble 1980 | Anderson 1986 | Fowler 1989 | Boeree 1991 | Evans 1993 | Corea 1994 | Manzotti 1997 | Kurosaka 1999 | Akseki 2004 | Karachailios 2005 | Sae-Jung 2007 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Identifies article as a study of diagnostic accuracy | 1 | 1 | one | ane | 1 | 1 | 1 | 1 | 1 | ane | one |
| States research questions or aims | 0 | 1 | 1 | 0 | i | 0 | ane | 1 | 1 | 1 | i |
| Describes study population (inclusion criteria, exclusion criteria, settings, locations) | 0 | 1 | 1 | 1 | 1 | 1 | i | 1 | 1 | 1 | 1 |
| Describes participant recruitment | i | 1 | ane | 1 | one | i | 1 | 1 | i | 1 | one |
| Describes participant sampling | 1 | 1 | 1 | 1 | 1 | one | 1 | 1 | i | one | 1 |
| Describes data drove (prospective or respective) | 1 | 1 | one | i | one | 1 | 1 | 1 | one | 1 | 1 |
| Describes reference standard and rationale | 0 | ane | 1 | ane | i | 1 | 1 | 1 | 1 | 1 | 1 |
| Describes technical Specifications of material and methods involved | 0 | one | 1 | 0 | 1 | 0 | 1 | 1 | ane | one | 1 |
| Describes definition and rationale of units, cut-of points, or categories of results of tests | 0 | one | 1 | 0 | one | 0 | 1 | 1 | 1 | 1 | 1 |
| Describes number, training, and expertise of raters | 0 | 0 | 0 | 0 | i | 0 | 0 | 1 | 0 | i | 0 |
| Were the raters blinded to the results of the other examination? | |||||||||||
| Describes clinical information available to raters | 1 | 1 | 1 | 1 | one | 1 | 1 | 1 | 1 | 1 | 1 |
| Describes statistical methods for comparing diagnostic accuracy and expressing doubt | 0 | 0 | 0 | 1 | 1 | 1 | 1 | ane | 1 | 1 | 1 |
| Describes methods for calculating test reproducibility; if done | 0 | 0 | 0 | ane | 1 | i | 0 | 1 | 1 | 1 | i |
| Reports when study was done with beginning and finish dates for recruitment | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 0 | 0 | 0 | ane |
| Reports clinical and demographic characteristics of subjects | 1 | 1 | 1 | ane | 0 | 1 | 1 | 1 | ane | 1 | 1 |
| Reports how many subjects satisfying inclusion criteria did not undergo the tests; describes why these subjects were non tested | one | 1 | 0 | 0 | 0 | 1 | 0 | 0 | i | 0 | 0 |
| Reports time interval between researched and reference test and whatsoever treatment provided in between tests | 0 | 0 | i | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Reports disease severity in subjects with target condition and other diagnoses in subjects without target condition | 1 | 1 | ane | ane | 1 | ane | 0 | i | i | one | 0 |
| Reports cross-tabulation of researched and reference test | 1 | ane | i | 1 | ane | 1 | one | i | 1 | 1 | i |
| Reports adverse furnishings from researched and reference test | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| Reports estimates of diagnostic accuracy and measures of statistical dubiety | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | one | 1 | one |
| Reports how indeterminate test results, missing responses, and outliers of researched exam were handled | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Reports estimates of variability betwixt raters, centers, or subject area subgroups; if washed | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | i | 0 |
| Reports estimates of test reproducibility; if done | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Discusses clinical applicability of written report findings | 1 | i | 1 | ane | 1 | 1 | 1 | 1 | 1 | one | ane |
| Total Score | ten | 16 | sixteen | 15 | xviii | 16 | xvi | 18 | eighteen | xx | 17 |
Reference Standard
Studies investigating the validity of diagnostic tests such as the McMurray's compare the findings of that test with a reference (golden) standard that has demonstrated validityxi. Both arthroscopy and MRI have been used equally a gold standard measure for detection of meniscal injuries in knees. Arthroscopy has demonstrated an accuracy betwixt 93% and 96%12. In that location is conflicting evidence in the literature over the accurateness of MRI. A recent study by Winters and Tregonningthirteen showed a diagnostic accuracy for MRI to exist 90% for the medial meniscus and 82% for the lateral meniscus. The sensitivity was 87% for the medial meniscus merely just 46% for the lateral meniscusxiii. Even so, other studies take shown MRI to be no more accurate than clinical test for the diagnosis of meniscal tearsfourteen , 15. Of the 11 studies identified in this review, nine used arthroscopy as the reference standard, one used MRI, and the remaining written report used both MRI and arthroscopy (Table iv).
TABLE iv
Methodology and description of the 11 studies investigating validity and clinical accuracy of McMurray'due south test for meniscal pathology.
| Study | No. of Subjects | Patient Population | Clarification of McMurray's Examination | Objective signs of McMurray's Test | No. of Testers | Blinding Test/Arthroscopy | Reference Standard |
|---|---|---|---|---|---|---|---|
| Akseki et aliii | 150 | Consecutive patients. Symptoms related to an intra-articular knee pathology. Astute patients (< six weeks) excluded. | Described a modified version (Ege'due south examination) but no description of McMurray'due south. | Pain and/or click | n/g | north/yard | Arthroscopy |
| Anderson & Lipscomb5 | 100 | Sequent patients suspected of having meniscal tears presenting for arthroscopy: acute and chronic (ligament injuries excluded). | Described a modified version (Medial-Lateral Grind test) simply no description of McMurray'southward. | northward/m | 1 | n/one thousand | Arthroscopy |
| Boeree & Ackroyd19 | 203 | Referred from GP/A&East with suspected cruciate ligament or meniscal pathology. | n/m | n/thousand | 2 (multiple not articulate) | n/grand | MRI |
| Corea et aliv | 93 | Sequent patients clinically diagnosed equally having torn menisci (based on symptoms of pain, locking, painful clicks, recurrent effusions, giving fashion 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 human knee or haemarthrosis were excluded. | Original clarification | Thud or click | 1 | n/m | Arthroscopy/Arthrotomy |
| Evans et al23 | 104 | Consecutive patients awaiting elective arthroscopy for suspected meniscal or other conditions based on history and physical examination. No mention acute/chronic. | Original description | Thud/awareness and/or hurting | 2 | n/grand | Arthroscopy |
| Fowler & Lubliner22 | 161 | Sequent patients with knee pain of at least one year's elapsing that warranted arthroscopic investigation. | Original description | Click/thud | 2 | n/m | Arthroscopy |
| Karachalios et al21 | 213 | Patients suspected of having a meniscal tear on the ground of history and mechanism of injury excluding those with multiple injuries, history of knee surgery, early on clinical and radiographic signs of osteoarthritis, articular cartilage injuries, neurological and musculoskeletal degenerative disorders, disorders of the synovium, acute injuries (less than 4 weeks post-trauma), and whatever abnormal findings on conventional radiographs. | Modified McMurray's to include valgus/varus stress. Also described a weight-bearing modification of McMurray's (Thessaly examination) | n/grand for McMurray's, but articulation line discomfort and possibly a sensation of locking or catching for Thessaly test | 4 | Yes | MRI and arthroscopy |
| Kurosaka et al6 | 156 | Patients who underwent arthroscopy to assess suspected meniscal or meniscal together with ACL injuries. All had persistent symptoms at least 8 weeks mail-injury. Acute injuries excluded. | Original description | Click/thud | 2 | No blinding | Arthroscopy |
| Manzotti et al20 | 130 | Patients diagnosed with meniscal lesions (based on symptoms including pain, recurrent edema, giving way, joint clicks, or block to motility) having arthroscopic surgery. Excluding any with past history of trauma and any with associated fractures, serious arthrosis, previous history of knee joint surgery or discoid meniscus identified arthroscopically | Original clarification | Painful (oftentimes) click felt past examiner | four | n/thou | Arthroscopy |
| Noble & Erat25 | 200 | Consecutive patients scheduled for menisectomy; acute and chronic. | n/m | n/one thousand | 1 | n/m | Arthroscopy |
| Sae-Jung et al24 | 68 | Patients identified as needing arthroscopy excluding those with intra-articular fracture, neurological or degenerative disorders. | Original description. Also described a modified version (the KKU pinch-rotation test) | Pain or a clicking sound | due north/m | n/m | Arthroscopy |
Population Differences
The external validity of a study is largely dependent on the study population. 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. In testing the accuracy of a clinical test like the McMurray'south exam, ideally the study participants should consist of individuals who would be likely to undergo the test in clinical do and who accept a reasonable chance of having the condition16. Further, subjects who are positive on the reference standard should reflect a continuum of severity, whereas those who are negative should have atmospheric condition commonly confused with meniscal tears17. Selection bias may occur when study subjects are not representative of the population on whom the test is typically applied in practice and tin affect the results of a study11. Thus, to avoid choice bias, it is important that a report include consecutive patients with pathologies that could be commonly confused with a meniscal tear and should not include patients without symptoms. The inclusion of patients with multiple pathologies is probable to lessen the diagnostic accurateness of a test; however, this would reflect bodily clinical practise6 , 18.
Six of the studies within this review included consecutive patients (Table 4). Anderson and Lipscomb5 used consecutive patients who were suspected of having a meniscal tear; however, these authors excluded subjects who had associated ligamentous injuries (equally demonstrated by arthroscopy) from the statistical analysis. Consequently, information technology is likely that the accurateness of meniscal testing demonstrated by this study is artificially high compared to studies with a wider inclusion criteria.
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'southward test, painful clicks, and giving fashion. However, this provisional diagnosis was as well based on other symptoms that one might consider could be associated with pathologies other than meniscal tears, eastward.grand., hurting, recurrent effusion, musculus wasting, and instability. These authors excluded subjects with clinical or radiographic evidence of arthritis or fracture that would increase the accurateness of testing only subtract the generalizability of the findings.
Evans et al23 used consecutive patients on a waiting listing for arthroscopy for a diversity of conditions including, merely not limited to, suspected meniscal tears. This was a purposeful strategy designed to enhance their ability to determine the truthful sensitivity and specificity of the McMurray's test in a population that reflects the symptomatic knee cohort that presents clinically. Fowler and Lubliner22 had a similarly broad population in that they included consecutive patients who warranted arthroscopic exam for any reason. However, they only included patients who had had symptoms for at to the lowest degree one year, making extrapolation of their findings to the acute population challenging.
Akseki et althree included consecutive patients with symptoms related to intra-articular knee pathology although how this was determined was non described. This study evaluated non only the McMurray's test merely also a new test (Ege's test) for meniscal pathology that is performed in a weight-begetting position. Because they were investigating this weight-begetting test likewise, the authors excluded any patients who presented within half-dozen weeks of trauma and those unable to bear weight or unable to squat. Once again, this affects the generalizability of the findings.
The remaining studies practise non clearly state if their subjects were consecutive. Iii of these studies had adequately broad inclusion criteria that better reverberate the population seen in clinical practise with two including subjects with suspected meniscal or ligamentous pathologysix , 19; the written report by Sae-jung et al24 included any patients identified as needing arthroscopy. The final ii studiesxx , 21 limited their study population to patients suspected of meniscal injury.
Blinding
Review bias may event when the findings of the reference standard test are known by the clinicians performing the diagnostic test. Cognition of the diagnosis could influence the interpretation of the findings of the diagnostic test leading to an overstated diagnostic accuracy3. Blinding of the clinicians from the results of the diagnostic examination was either non mentioned or non performed in all of the studies in this review except for the report past Karachalios et al21. Although these authors mentioned that the examiners were blinded to the results of the MRI, they did not make information technology articulate 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 private subject belonged to. Although blinding was not mentioned in respect to the other studies, the bulk 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. However, only Kurosaka et al6 and Evans et al23 made it clear that the examiners were not given whatsoever details virtually the subject's history so that they would not be influenced by this information. One report5 performed the test afterwards the arthroscopy and did not country if the examiner was blinded to these results.
Description/Interpretation of Exam
The clarification of a test inside a study should be sufficient to enable replication of the test by practitioners and subsequent researchers. The description should include the exact details of the test's application and the criteria used to determine positive and negative results11. Failure to practice this makes it difficult to determine if the findings of the written report can be compared to other studies that take evaluated the aforementioned examination. Apparently, 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.
Of the studies evaluated in this review, half-dozen used the original description of the McMurray's examination4 , 6 , 20 , 22 – 24. Four authors stated that they used the McMurray'due south test but did non draw the bodily testing procedurethree , five , xix , 25. Karachalios et al21 incorrectly added valgus or varus stress as a component of the McMurray'due south. Five studies compared modified versions of the test to McMurray'sthree , 5 , half-dozen , 21 , 24 (Tabular array 3).
There are too discrepancies in the studies as to what constitutes a positive McMurray'southward test. Under the original description of the test, a thud or a click felt by the examiner (and sometimes heard) while performing the test was considered positive (McMurray as cited in Corea et al4). Other signs that have been used to denote a positive exam include the product of pain, a clunk, or a popular.
3 of the studies in this review considered a positive test to be the reproduction of a palpable thud or click 4 , half dozen , 22 (Table 4). One study used a palpable thud and/or hurting 23, and two studies used a palpable click and/or pain 3 , 20. Sae-Jung et al24 considered pain or a clicking sound to be a positive test. The remaining four studies failed to mention what denoted a positive test (Table 4). This lack of consensus in the literature highlights the risk that the criteria indicating a positive test can influence the test result, irrespective of whether the test was performed in the same way on the same patient.
Intertester Reliability
The majority of studies did non report intertester or intratester reliability of the McMurray'due south exam. Although six studies used multiple testers, these did not provide statistics for reliability6 , 19 – 23. Three studies used only ane tester4 , five , 25, and ii studies did not mention how many examiners were used3 , 24. Evans et al23 compared a senior examiner with over 10 years experience to a medical educatee who had recently been taught the technique whereas Karachalios et al21 compared two experienced orthopaedic surgeons with two inexperienced residents. Evans et al23 demonstrated a low level of agreement betwixt the two examiners with intertester agreements ranging from poor for reproduction of a medial sensation (Kappa = −0.x) to fair (1000 = +0.38) for lateral hurting. They commented that the lack of intertester understanding may have been due to differences in the amount of forcefulness produced.
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 clan (p = 0.002) between the diagnosis of a medial meniscus tear and reproduction of a medial thud, while the experienced examiner demonstrated a significant clan between this diagnosis and the reproduction of pain (p = 0.008) or a medial "sensation" (p = 0.001). Other studiesiii , 5 , nineteen commented that greater clinical feel may impact the results of the test but they did not provide whatever statistical testify to back up this assertion.
These findings are contrasted by those of Karachalios et al21, who reported a 95% agreement for both intra- and intertester reliability for all of the clinical tests they employed. However, these authors stated that they determined these findings in a study of twenty subjects prior to the master study and they did not provide whatever details of how this airplane pilot study was performed or analyzed.
Diagnostic Accuracy and Validity
Measures of efficacy include accuracy, sensitivity, and specificity. Accuracy is the percentage of subjects who are correctly identified every bit either having or not having a meniscal tear. The accuracy measure has express usefulness in that information technology does non distinguish betwixt the diagnostic value of positive and negative results11. To some degree, this is accomplished by sensitivity and specificity, which provide useful information for interpreting the results of diagnostic tests.
Sensitivity and Specificity
Sensitivity can be defined as the proportion of patients with the condition who have a positive exam result and represents the ability of the test to recognize the status when nowadays11. Specificity is the proportion of patients without the condition who take a negative exam upshot and indicates the power to utilise a test to recognize when the condition is absent11. High sensitivity indicates that a test can be used for excluding a status when information technology is negative, but it does not address the value of a positive test. Loftier specificity indicates that a test tin be used for including a condition when it is positive26. Sensitivity and specificity rely on a unmarried threshold for classifying a test outcome every bit positive or negative. Changing the threshold to increment sensitivity decreases specificity and vice versa. This merchandise-off between sensitivity and specificity makes information technology of import that they exist considered jointly27. This means that tests rarely have both high sensitivity and specificity.
As is true of all statistics, sensitivity and specificity values are taken from a sample and represent an gauge of the truthful value that could be institute in the population. The confidence interval (CI) attests to the precision of this estimate11. A 95% CI is the most ordinarily used and indicates a range of values within which the population value would lie with 95% certainty. If the CI is wide and contains values that are not clinically important, the usefulness of the measure out may be questionable11.
The sensitivity and specificity of the McMurray'south test reported in the studies identified in this review vary widely (Table 5). Sensitivity figures vary from 16%–88%, while specificity figures vary from 20%–98% (Table 5). In general, sensitivity figures are much lower than specificity and the CI limits are wider. Sensitivity figures were higher than specificity for three studiesv , xx , 25 (Table five). The low sensitivity figures would indicate that in general, a negative exam upshot is non reliable in ruling out meniscal pathology and a torn meniscus would likely exist missed if the McMurray'due south test was the sole determinant of pathology. Higher specificity figures announce that in general when the McMurray'southward test is positive, it is fairly reliable for ruling in meniscal pathology.
Tabular array 5
Sensitivity, specificity, and likelihood ratios (LR) of the McMurray's test with conviction intervals (CI).
| Report | Sensitivity (%) CI (%) | Specificity (%) CI (%) | LR+ (CI 95%) | LR− (CI 95%) | ||||
|---|---|---|---|---|---|---|---|---|
| Medial & Lateral combined = meniscal tear | Medial meniscus | Lateral meniscus | Medial & Lateral combined = meniscal tear | Medial meniscus | Lateral meniscus | |||
| Akseki et al3 | 63 (55–71) | 67 (59–75) | 53 (45–61) | 83 (77–89) | 69 (62–76) | 88 (83–93) | three.71 (three.xix–iv.13) | 0.45 (0.39–0.52) |
| Anderson & Lipscomb5 | 58* (48–68) | 29* (20–38) | 0.82 (0.v–one.3)** | 1.45 (0.4–iv.ix)** | ||||
| Boeree & Ackroyd19 | 27* (21–33) | 29.3 (23–36) | 25 (19–31) | 89* (85–93) | 87.3 (83–92) | 89.8 (86–94) | two.31* | 0.81* |
| Corea et al4 | 58.five (48–69) | 65 (55–74) | 52 (41–62) | 93.4 (88–98) | 93 (88–98) | 94 (88–99) | 8.86 (vii.17–x.91) | 0.44 (0.36–0.54) |
| Evans et al23 | 33* (24–42) | 16 (ix–23) | 50 (40–60) | 96* (92–100) | 98 (95–100) | 94 (89–99) | eight.33* | 0.70* |
| Fowler & Lubliner22 | 29* (22–36) | 96* (93–99) | vii.25* | 0.74* | ||||
| Karachalios et al21 | 48 | 65 | 94 | 86 | eight.00 | 0.553 | ||
| 4.64 | 0.40 | |||||||
| Kurosaka et alvi | 37 (30–44) | 77 (70–84) | 1.61*0.82* | |||||
| Manzotti et al20 | 88 | 79 | fifty | 20 | 1.76 | 0.24 | ||
| 0.98 | 1.05 | |||||||
| Noble & Erat25 | 63 (56–70) | 57 (50–64) | 1.50 (1.1–2.1)** | 0.60 (0.5–0.9)** | ||||
| Sae-Jung et al24 | seventy.half dozen (55–82) | 70 | 68.ii | 82.49 (55–95) | 60.7 | 47.viii | four.00 (one.four–11.three) | 0.358 (0.22–0.56) |
Fowler and Lubliner22 attributed their low sensitivity results (compared to previous studies)five , 25 to population differences between the studies (Tabular array 5). This was also discussed by Evans et al23, who attributed their low sensitivity rates to broad patient entry criteria including differing pathologies (Table 4).
A recent study by Akseki et aliii reported loftier combined sensitivity and specificity figures (63% and 83%, respectively) and relatively narrow confidence intervals (Table 5). These authors suggested that this increase in sensitivity and specificity compared to previous studies was due to their broader definition of a positive test, i.e., reproduction of a click or hurting3; however, this does not explicate the similar findings of Corea et aliv in which just a click was indicative of a positive exam.
Some of the studies did non split the data for medial from that of lateral meniscal testing5 , 6 , 22 , 25. Nevertheless, of those that have made this distinction, in that location is some consensus that the McMurray'due south test has college sensitivity with respect to medial meniscal tears and higher specificity with lateral meniscal tearsiii , 4 , 19 , xx , 24.
Likelihood Ratios
Although sensitivity and specificity values provide useful information, they work against the management of clinical testing11. Clinically, we do not know whether a patient has the status before the diagnostic examination (arthroscopy or MRI) is performed. Sensitivity and specificity values infer the probability of a correct test, given the consequence of the reference standard11. They also neglect to take into account pre-examination probability. Useful tests should produce large shifts in probability once the result of the examination is known. Sensitivity and specificity values fail to exercise this11. The best statistics for summarizing usefulness of a diagnostic exam appear to be likelihood ratios (LR)17. Likelihood ratios overcome some of the problems involved with sensitivity and specificity values by summarizing the information independent in these values in a manner that can be used to quantify shifts in probability once the meniscal examination results are known28.
An LR+ indicates the caste of certainty that a patient with a positive test actually has the suspected status while an LR– indicates the caste of certainty that a patient with a negative test does non have the suspected status27. An LR of i indicates that the test consequence does nothing to change the likelihood that the patient either does or does not take the condition, whereas the college the LR+, the more than certain you can be that a positive test indicates the person has the disorder. The lower the LR–, the more than certain you can exist that a negative test indicates the person does not have the disorderxi (Table vi). An case of this would be equally follows: If the McMurray'south test had a LR+ of nine.2 for a particular study, a positive McMurray's test is 9.2 times more likely to occur in patients with a meniscal tear than in those without one29.
Table 6
A guide to the estimation of likelihood ratio (LR) values.
| LR+ | LR− | Interpretation |
|---|---|---|
| >10 | <0.ane | Generate large and often conclusive shifts in probability |
| 5–10 | 0.1–0.2 | Generate moderate shifts in probability |
| 2–5 | 0.2–0.5 | Generate small-scale simply sometimes important shifts in probability |
| ane–2 | 0.5–1 | Alter probability to a small-scale and rarely important caste |
Table five shows the LR+ and LR− for the 11 studies included within this review with 95% CIs. The wide range of positive likelihood ratios (0.82–8.86) make it difficult to draw whatsoever conclusions almost the actual magnitude of this ratio. Four studies demonstrated that a positive examination alters the probability to just a small, rarely important degree5 , 6 , 25, suggesting uncertainty that a positive test will indicate meniscal pathology (Table five). Studies by Boeree and Ackroyd19, Akseki et althree, and Karachalios et al21 demonstrated small but sometimes of import shifts in probability. Unfortunately, information technology is not possible to accurately determine the precision of reliability of the Boeree and Ackroydnineteen written report as CIs could non be calculated. Of the four studies that demonstrated the highest shifts in probability, simply Corea et al4 and Akseki et al3 contained calculable CIs, which were relatively narrow (Tabular array 5).
With regard to negative likelihood ratios, all but iii of the studies demonstrated merely a small alteration in probability that a subject with a negative McMurray's test will not have a meniscal tear (Table five). In one of these studies, the CIs are extremely wide5. However, in general, the CI limits are relatively narrow over all. The studies by Akseki et aliii, Corea et aliv, and Manzotti et al20 revealed negative likelihood ratios that are slightly lower than the other studies. These represent small but sometimes important shifts in probability and the stronger methodology of these studies is reflected by the relatively narrow CIs (Table 5).
McMurray's Test Compared to Modified Versions
Some studies have attempted to compare the diagnostic value of the McMurray's test to that of modified tests. These studies have hypothesized that by incorporating aspects of varus/valgus stress and/or axial loading into the original McMurray's test, in that location is an increase in diagnostic valuethree , 5 , 6.
Anderson and Lipscomb5 compared the McMurray'south examination to a test termed the Medial-Lateral Grind exam that included a varus/valgus component not included in the original McMurray's test. The Medial-Lateral Grind exam had a higher LR+ (Table 7) when compared to the McMurray's test; nonetheless, its CIs were extremely wide, bringing into question the precision of this estimate of reliability (Tabular array seven). These authors as well demonstrated that the Medial-Lateral Grind test had smaller (better) LR– compared to the McMurray's examination although the change in probability was still but small and should be considered rarely important (Table 7).
Table 7
Comparing of likelihood ratio's for McMurray'due south test with modified tests.
| Study | LR | McMurray's | Modified | ||||
|---|---|---|---|---|---|---|---|
| | |||||||
| Full general | Medial meniscus | Lateral meniscus | General | Medial meniscus | Lateral meniscus | ||
| Akseki et althree | LR+ LR− | 3.71 (3.19–4.xiii) 0.45 (0.39–0.52) | 5.15 (4.48–5.93) 0.38 (0.33–0.44) | ||||
| Anderson & Lipscomb5 | LR+ | 0.82 (0.5–one.3)** | 4.8 (0.8–30.0) | ||||
| LR− | ane.45 (0.4–4.nine)** | 0.4 (0.two–0.half dozen) | |||||
| Karachalios et al21 | LR+ | 8.0 | 4.64 | 26.8 (xiv–51) | 23.0 (13–37) | ||
| LR− | 0.55 | 0.40 | 0.xi (0.06–0.eighteen) | 0.08 (0.02–0.2) | |||
| Kurosaka et alhalf dozen | LR+ | 1.61* | four.18 | ||||
| LR− | 0.82* | 0.35 | |||||
| Sae-Jung et al24 | LR+ | 1.63 | 1.64 | 1.77 | 1.95 | ||
| LR− | 0.69 | 0 | 0.33 | 0 | |||
Kurosaka et al6 took the modification of the Medial-Lateral Grind test further by comparing the McMurray'southward test to a pin shift test that not only had a component of varus/valgus stress but also included a component of centric loading. These authors considered the overall accuracy of the axially loaded pivot shift test to be higher than that of the McMurray'due south test (Table 7). Conviction intervals could not be calculated32 from the information provided past these authors making it difficult to assess the accuracy of results.
Akseki et althree compared the McMurray'due south test with a weight-bearing version of the McMurray'southward test that incorporated axial compression and varus/valgus stress, with the patient squatting downwards in internal and then external rotation (Ege'southward test). The modified weight-bearing examination showed a higher LR+ and a lower LR− than the McMurray's examination (Table seven). These results have been supported past Karachalios et al21, who compared another weight-bearing modification (the Thessaly examination) of the McMurray'due south with the original test. These authors demonstrated significantly larger (better) positive likelihood ratios and significantly smaller (improve) negative likelihood ratios than the McMurray's.
The final written report past Sae-Jung et al24 compared a modified version to McMurray'south added axial compression, similar to that applied past Kurosaka et alsix but without added valgus or varus stress. These authors demonstrated marginally better LR+ but almost interestingly, reported that their modified examination (the KKU test) was 100% sensitive for lateral meniscal tears indicating that the test tin can be used for excluding a status when information technology is negative.
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 testify that the modified tests accept higher diagnostic value than the McMurray's test.
Discussion
On the basis of the results of the studies in this review, it seems that intertester reliability using the McMurray'south exam is low. This is non surprising given the complicated nature of the technique and the difficulty in decision-making the amount and direction of forces across testers. It is important to take this into consideration when analyzing test results of studies that have used more than one examiner. While some studies accept stated that greater clinical experience aids correct diagnosisiii , v , 19, the only current statistical evidence in this regard shows no deviation betwixt an experienced and inexperienced tester 23.
Similarly, sensitivity figures ranged from 27% to 70% beyond the reviewed papers, generally indicating that a torn meniscus is likely to exist missed in many patients; all the same, specificity figures (29–96%) indicating that imitation positive tests are relatively low and that a positive test makes it likely that the patient actually does accept a torn meniscus. Results too indicate that testing for medial meniscal pathology is more sensitive than testing for lateral; notwithstanding, tests for lateral meniscal pathology are more than specific than tests for medial pathologyiii , 4 , nineteen. In dissimilarity, the paper by Sae-Jung et al24 found sensitivity for medial and lateral menisci of lxx% and 68%, respectively, and specificity values for medial and lateral menisci of lx.7% and 47.eight%, respectively. Unlike the medial meniscus, which is attached to the medial ligament, the lateral meniscus is non fastened to the lateral ligament. Mariani et al30 accept suggested that the differences in anatomical attachments of the two menisci contribute to these variations in sensitivity and specificity of diagnostic tests30.
Positive likelihood ratios presented in the studies reviewed generally indicated small to moderate shifts in probability (0.82–viii.86) in that a positive test will indicate true meniscal pathology although the studies with the highest methodological quality demonstrated likelihood ratios considered to bespeak moderate improvements in the probability that this volition be the case3 , four. Relatively narrow conviction intervals also attest to the reliability of these two studies3 , 4 (Table 5).
The differences in written report populations are likely to accept contributed to the broad variability of results across studies. Those that do not include consecutive patients and those that exclude dissimilar pathologies may accept biased results. At that place is alien show with respect to the result of the presence of an associated anterior cruciate ligament (ACL) deficiency. Kurosaka et al6 stated that diagnostic accurateness is lessened in patients with multiple pathologies, whereas Akseki et al3 constitute that there was no reduction in diagnostic accuracy with an associated tear of the ACL. The inclusion of patients with different pathologies would brand the results of studies more generalizable to the clinical setting.
The varying definitions of a positive McMurray'due south test are besides likely to have contributed to the variability of the results demonstrated past the studies reviewed. It seems logical that those studies that include both pain and a click should accept higher diagnostic value as compared to studies that just use one sign or the other. This is true in the case of the study by Akseki et al3 but not for the study by Evans et al23 (Tables 4 and v).
Differences in the type of tear take been suggested as influencing the outcome of clinical tests; however, no detailed investigation of this issue exists in the current literature3. McMurray clearly indicated that the test that bears his proper noun is only relevant for tears in the posterior portion of the cartilage (McMurray, 1942, cited in Corea et al4).
A recent literature review on blended testing of the diagnostic tests for the meniscus reported reasonable sensitivity and specificity when the findings of a number of tests are combined31. This, along with the conclusions discussed to a higher place, suggests that the McMurray's test should exist used every bit ane of a combination of tests in the clinical settingthree , 22 , 23.
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. Each of these studies demonstrated improved diagnostic accuracy of these modified tests compared to the original McMurray'south; even so, they concluded that the modified tests should be used also, as rather than as an culling to other diagnostic tests3 , 5 , 6. I trouble with these modified tests is that they appear to have all been evaluated by the creators of the tests, which to some degree challenges the validity of the research. These comments are also supported by the findings of a recent meta-analysis carried out by Hegedus et al7 and Meserve et al8. These authors also observed that the studies on these new tests take only been subjected to scientific scrutiny on 1 occasion and further research is required on these tests.
Limitations
Limitations of this review chronicle to the search strategy used. Manufactures may have been missed based on the omission of certain search phrases or the use of a single search phrase equally used in this instance. Limiting the search to English linguistic communication articles but may also accept led to an omission of other relevant studies. Studies were also not examined where they clearly did not see the search criteria.
The use of the STARD tool is also a limitation. This is a relatively new tool and has non been subjected to an analysis of its reliability at this time; nevertheless, the tool does provide a consistent framework on which to base the analysis of diagnostic studies. The preliminary nature of this tool also means that a more than narrative review of the validity and accuracy of the tests has been presented.
Inquiry and Clinical Implications
Future research should concentrate on building a stiff methodological base of operations incorporating large samples of sequent patients with commonly confused pathologies. 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. Finally, farther contained enquiry needs to compare the McMurray's examination with modified tests to confirm the credible superiority of these tests over the McMurray's test.
Begetting these findings in listen, the following recommendations can be made for the clinician:
-
Exist enlightened of the validity issues surrounding this test.
-
Consider reproduction of pain during the test as a positive test, non just the reproduction of a click or thud.
-
Consider the findings of this test in conjunction with those of other tests to heighten the likelihood of a correct diagnosis such as articulation line tenderness.
-
Consider the use of modifications of the exam for improved validity.
Determination
This review has demonstrated that the intertester reliability and sensitivity of the McMurray's test is relatively low; still, it has also highlighted that it can be a relatively specific test, peculiarly with respect to the lateral meniscus. The review suggests that modifications of the interpretation of a positive test to include reproduction of pain either also as or on its own may enhance the validity of the test. The review also highlights the idea that modified versions of the examination seem to exist more valid than the original version.
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Articles from The Journal of Transmission & Manipulative Therapy are provided here courtesy of Taylor & Francis
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704345/
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