Meniscal Lesions: Diagnosis and Treatment

Robert S. P. Fan, MD, Richard K. N. Ryu, MD

Disclosures
In This Article

Diagnosis

The clinical diagnosis of a meniscal lesion depends on the insight and experience of the physician. The patient with meniscal pathology typically presents with symptoms referable to the joint line, either medially or laterally. In traumatic cases, an injury is brought on with the knee in flexion, weight bearing, followed by rotation. A pop may or may not be felt. Symptoms are frequently worsened by flexing and loading the knee, and activities such as squatting and kneeling are poorly tolerated. Patients will frequently complain of a "pop" or "clunk" sensation as the knee is brought through the range of motion.

An effusion may be present to a varying extent. Patients most frequently will have specific joint line point tenderness. Often, the examiner may appreciate a small focus of swelling or bogginess in the area of the point tenderness, particularly if the knee is in flexion. A number of tests have been described in order to appreciate meniscal pathology. Apley's test is performed with the patient prone, and with the examiner hyperflexing the knee and rotating the tibial plateau on the condyles (Figure 3). Steinman's test is performed on a supine patient by bringing the knee into flexion and rotating (Figure 4). Reproduction of specific joint line pain with either of these 2 maneuvers is considered a positive test. McMurray's test is positive if a pop or a snap at the joint line occurs while flexing and rotating the patient's knee (Figure 5). Asking patients to squat and/or duck-walk will frequently reproduce symptoms. No test is specifically pathognomonic and, therefore, a combination of provocative maneuvers should be performed. In general, clinical diagnosis is more sensitive for pathology on the medial than the lateral side.[18,19,20]

Figure 3.

The Apley test is performed with patient in prone position by rotating the tibia on the femur and applying axial compression to reproduce joint line pain. (Reprinted with permission.)

Insall JN. Examination of the knee. In: Insall JN, ed. Surgery of the Knee. New York, NY: Churchill Livingstone; 1984:62, Figure 4.5.

 

Figure 4.

The Steinman test produces joint line pain when the tibia is rotated internally and externally while the knee is flexed over the examination table. (Reprinted with permission.)

Insall JN. Examination of the knee. In: Insall JN, ed. Surgery of the Knee. New York, NY: Churchill Livingstone; 1984:63, Figure 4.7.

 

Figure 5.

The McMurray test Is performed by flexing the patient's hip and knee and palpating for a pop or click along the joint line as the tibia is internally and externally rotated. (Reprinted with permission.)

Insall JN. Examination of the knee. In: Insall JN, ed. Surgery of the Knee. New York, NY: Churchill Livingstone; 1984:62, Figure 4.6.

 

The differential diagnosis for meniscal pathology includes patellofemoral syndromes, osteoarthritis, inflammatory arthritides, osteochondritis dessicans, medial patella plica syndrome, and osteonecrosis. In addition, collateral ligament injury, stress fracture, and localized bursitis or tendinitis can mimic meniscal pathology. Finally, referred pain from a slipped capital femoral epiphysis, degenerative hip disease, lumbar radiculopathy, or other peripheral neuropathy should also be excluded.

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