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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 43-45

Clinical examination vs MRI evaluation for diagnosis of knee injuries


1 Assistant Professor, Radiology, IGIMS, India
2 Additional Professor, Orthopaedics, IGIMS, India
3 Assistant Professor, Orthopaedics, IGIMS, India
4 Professor and Head, Radiology, IGIMS, India

Date of Submission16-Aug-2019
Date of Acceptance16-Feb-2020
Date of Web Publication16-Nov-2020

Correspondence Address:
Ritesh Runu
Additional Professor, Orthopaedics, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Introduction: Knee is a weight bearing joint which has ligaments and menisci. Its injury is very common which may lead to pain, instability and loss of function. Its diagnosis is usually done clinically which may need confirmation with Magnetic resonance imaging (MRI). We compared the sensitivity and specificity of clinical examination compared to MRI
Material and Methods: 50 patients were enrolled in the study. They were clinically examined and then MRI was done.
Results: Comparing the clinical test with MRI we found that Clinical tests were moderately sensitive for ACL tear and poorly sensitive for meniscal injury. It was not sensitive for PCL injury. The clinical tests were highly specific for ACL, PCL and medial meniscus but moderately specific for lateral meniscus. Positive predictive value of clinical tests was high for ACL, moderate for medial meniscus but low for lateral meniscus. Negative predictive value was highest for PCL while moderate for ACL, medial meniscus and lateral meniscus.
Conclusion: We conclude that clinical tests are less sensitive compared to MRI but moderate to highly specific tool for knee injury diagnosis. It needs MRI confirmation for proper management of injury.

Keywords: Clinical test, Magnetic Resonance Imaging, Anterior Cruciate Ligament, Medial Meniscus, Sensitivity.


How to cite this article:
Pushpa, Runu R, Subhash A, Kumar V, Suman S K. Clinical examination vs MRI evaluation for diagnosis of knee injuries. J Indira Gandhi Inst Med Sci 2020;6:43-5

How to cite this URL:
Pushpa, Runu R, Subhash A, Kumar V, Suman S K. Clinical examination vs MRI evaluation for diagnosis of knee injuries. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2020 Nov 24];6:43-5. Available from: http://www.jigims.co.in/text.asp?2020/6/1/43/300738




  Introduction: Top


Knee joint is a common site of injury due to trauma and sports activity. Among all structures Anterior Cruciate Ligament (ACL) is most common ligament torn in the knee joint which leads to instability, pain and dysfunction of knee.[1]

The diagnosis of ligament injury depends on good history and thorough clinical examination. Due to pain in initial phase clinical examination is not possible and diagnosis is difficult.[2] In such condition Magnetic Resonance Imaging (MRI) and Arthroscopy has definite role.[3],[4],[5],[6],[7].

Being non-invasive, radiation free, better soft tissue contrast, multiplanar slice capability and real time imaging MRI is modality of choice. Extraarticular imaging accessibility of MRI scores over arthroscopy.[3]

Due to long queue in MRI appointments and being costly, we decided to compare and correlate clinical findings with MRI. There by we can conclude whether clinical examination alone is sufficient or MRI is needed.


  Material and Methods: Top


This was a retrospective study, done in an institutional setup in a tertiary level centre of our region. The patients reporting with knee pain, instability, locking, wasting of quadriceps muscle and history of trauma were evaluated clinically in Orthopaedics O.P.D. Complete history was taken including mode of injury. Complete clinical examination was done. Inspection done for any swelling and wasting of muscle, palpation done to find out site of tenderness and movement done for any locking and unlocking. Tests for ACL, Posterior cruciate ligament (PCL)(Drawer Test, Lachman Test), meniscus (McMurray test, Apley test), collateral ligament (stress test) were done. Based on clinical findings, patients were sent for X-ray and MRI of respective knee in Department of Radio diagnosis.


  Inclusion Criteria: Top


Patients with history of knee injury with clinical examination who underwent MRI of knee were included in this study.


  Exclusion Criteria: Top


◾Patients with additional knee injury before MRI examination.

◾ History of old significant trauma to the currently injured knee.

◾ Contraindication to MRI like pacemaker, metallic implant, claustrophobia.

◾ Patients with knee tumours, knee joint infection.

◾ Patients with age less than 10years.

Sample size: Total of 50 cases were included in this study from December2018.

MRI Technique: MRI of all patients was carried out in GE primitive of 1.5T. Written consent of all was taken. Patients were positioned supine with knee first in MRI scanner. The knee to be imaged in 15 to 20 degree externally rotated in order to facilitate visualization of ACL completely in sagittal plane. Study was performed with dedicated knee coil in the knee of interest. Knee to be examined was centered within 16cm FOV including both supra-patellar bursa and insertion of patellar ligament on tibial tubercle.


  MRI Protocol: Top


Localiser was taken after proper positioning of patient. Knee was examined in three standard plane - sagittal, coronal and axial plane with slice thickness of 3mm in T1w, T2W, PDFS, MERGE and STIR.

Reporting Performa of MRI:

ACL/PCL: Partial / complete tear with site –

Mucoid degeneration –

Anterior translation of femur –

LCL / MCL: tear with grading Menisci – lateral and medial.

Osteo-chondral changes

Changes in peri-articular soft tissue of knee joint –

Joint effusion - present/absent –

Other findings - Popliteal fossa cyst/ ganglion

Table 1: Clinical examination and MRI findings

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CE - clinical examination, MRI - magnetic resonance imaging, ACL - anterior cruciate ligament, PCL - posterior cruciate ligament, MM - medial meniscus, LM - lateral meniscus, + present , - absent
Table 2: Anterior cruciate ligament tear

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PPV - positive preditive value, NPV - Negative predictive value, NA - not available

Table 3: Medial meniscus tear

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Table 4: Lateral meniscus tear

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  Observation and Results: Top


In our study of 50 patients (male 46 and females 4) with average age of 30.12 yrs males were affected more due to high activity level compared to females. ACL tear was the most common injury seen. MRI proven ACL injury was seen in 39 patients, partial tear in 13 and complete tear in 26 patients. In our study anterior drawer test was positive in 19 patients. The sensitivity of clinical test for diagnosis of ACL injury was 43%.

Clinical diagnosis of PCL injury was difficult. None were diagnosed clinically while 3 on MRI.

MRI proven medial meniscus tear was seen in 26 patients. Complete tear seen in 17 and partial in 9 cases. On McMurray test only 9 were positive.

MRI proven lateral meniscus injury was seen in 17 patients. Only 5 cases had both positive McMurray test and MRI. In 12 patients clinical finding was not elicitable.

Comparing the clinical test with MRI we found that clinical tests for ACL were highly specific but low sensitive for ACL tears. Clinical tests were found moderately sensitive for ACL and poorly sensitive for meniscal injury. It was 0% for PCL. All the tests were highly specific for ACL, PCL and medial meniscus but moderately sensitive for lateral meniscus. Positive predictive value of clinical tests was high for ACL, moderate for medial meniscus but low for lateral meniscus. Negative predictive value was highest for PCL while moderate for ACL, medial meniscus and lateral meniscus.


  Discussion Top


Ligaments and meniscus are usually injured in knee trauma. Purpose of this study was to compare the accuracy of clinical examination in comparison to MRI in diagnosis of knee injuries. Studies have recommended that clinical examination is the most important tool to diagnose knee injuries.[2],[3],[4],[5],[6],[7] MRI and arthroscopy are complementary tools.5 ACL injury is better diagnosed clinically compared to meniscus.6 Specific history of pivoting traumatic event, a popping sensation and immediate effusion favours ACL tear.8 Clinical examination in acute setting has its own limitations. Due to pain, muscle spasm, swelling, knee joint effusion the results of anterior drawer test and Lachman test are not conclusive. Associated meniscal tear can produce false negative drawer test and lachman test. Hence MRI correlation of clinical findings is needed.[4],[9] Torg et al found three causes of false negative ACL tears. First was due to hemarthrosis and synovitis which precludes knee flexion of more than 90degree, second protective hamstring muscle spasm and third was entrapment of posterior horn of medial meniscus in between.[10]

Gupta et al.[2] suggested that MRI is more sensitive and specific in diagnosis of knee injuries. It can diagnose intraarticular, extra-articular, postero-lateral compartment lesion and bone lesions better than arthroscopy.[10] Displaced medial meniscus tear are better seen on MRI. It can diagnose intrasubstance tear of ACL which can not be seen on arthroscopy.[2] Nonvisualization of normal ACL on sagittal image has been reported to occur in 5- 10% of cases. It can be addressed by utilizing thin section and routine oblique sagittal image oriented to ACL axis (10- 20degree of internal rotation). Multiplanar section is essential for accurate diagnosis of wide range of injuries of ACL.[11] False positive findings of 6-11% were seen for medial meniscus.[12] False negative findings were seen for ACL and meniscus due to intact mucosum.[3] False positive results may be seen in intrabody mucosal or eosinophilic degeneration of ACL.[13]

Arthroscopy has been regarded as gold standard for diagnosis of knee injuries. It is real time and can physically confirm the lesion. Compared to arthroscopy MRI has been found less or equally sensitive and specific.[2],[3],[4],[5],[7], Arthroscopy is an invasive procedure that carries with it the risks of anaesthesia and risks of surgery such as infection, neurovascular injury and postoperative pain. It is preferably performed only for therapeutic purposes, provided that alternative non-invasive diagnostic imaging modalities such as MRI are not available.[12]

Limitation in present study was lack of arthroscopic correlation of MRI and clinical findings. Conclusion: We conclude that MRI is sensitive and specific tool for knee injury diagnosis. It can better define ACL and meniscal injury compared to clinical examination.



 
  References Top

1.
Seena CR, Prashanth Moorthy, Nataranjan, Kulasekaran. MRI and Arthroscopic correlation in Anterior Cruciate Ligament injuries in knee. Journal of Medical Science and Clinical Research. 2017, 5(5): 22013-25.  Back to cited text no. 1
    
2.
Gupta K, Guleria M, Parambir S, Ritu G. Correlation of Clinical, MRI and Arthroscopic findings in diagnosing meniscus ligaments injuries at knee joints- a prospectìve study. Journal of Orthopaedics and Allied Science. 2013; 1(1):2-6.  Back to cited text no. 2
    
3.
Patel I, Chandru V, Nekkantì S, Renukarya R, Reddy VV, Gopalakrishana SV. Clinical, Magnetìc Resonance Imaging and Arthroscopic correlation in Anterior Cruciate Ligament and Meniscal injuries of the Knee. J Orthop Trauma Rehab 2018, 24. https://doi.org/10.1016/j.jotr.2017.05.005.  Back to cited text no. 3
    
4.
Rayan F, Bhonsle S, Shukla DD. Clinical, MRI and Arthroscopic correlation in meniscal and anterior cruciate ligament injuries. Int Orthop 2009, 33(1):129-132.  Back to cited text no. 4
    
5.
Niltron Orlando Jr, Marcos George de Souza Leao, Nelson Henrique Carvalho de Oliveira. Diagnosis of knee injuries: comparison of the physical examinatìon and magnetic resonance imaging with the findings from arthroscopy. Rev Bras Orthop 2015; 50(6):717-919.  Back to cited text no. 5
    
6.
Ajaykumar SP, KMK Verma, S Arya, D Manni, Ranjith AC and GS Kumar. Correlatìon of Clinical, radiological and arthroscopic findings of meniscal and anterior cruciate ligament injuries of knee. Intern J Orthop Sci. 2017; 3 (3): 92 -95.  Back to cited text no. 6
    
7.
S R Puri, SK Biswas, A Salgia, S Sanghi, T Agrawal, P Patel. Study of correlatìon between clinical, magnetìc resonance imaging and arthroscopic findings in meniscal and anterior cruciate ligaments injuries. Med J DY Patìl Univ 2013; 6:263- 266.  Back to cited text no. 7
    
8.
S Decary, M Fallaha, S Belzile, J Martel - Pelletìer, J Piere Pelletìer, D Feldman, Marie - Pierre Sylvestre, et al. Clinical diagnosis of partìal or complete anterior cruciate ligament tears using patìents’ history elements and physical examinatìon tests. PLoS ONE 2018; 13(6): e 0198797.  Back to cited text no. 8
    
9.
Amir Mohammad Nawali MD, Mohammadreza Bafari MD, Ali Tabrizi MD. Arthroscopic evaluatìon of the accuracy of clinical examinatìon versus MRI in diagnosing meniscus tears and cruciate ligament ruptures. Archives of Iranian Medicine 2013, 16(4):229 - 232.  Back to cited text no. 9
    
10.
Torg JS, Conrad W, Kalen. Clinical diagnosis of anterior cruciate ligament instability in the athelete. Am J Sports Med 1976, 4(2): 8493.  Back to cited text no. 10
    
11.
Eric M Remer, Steven W Fitzgerald, Harold Friedman, Lee F Roger, Ronald W Hendrix, Michael F shafer. ACL injury: MRI diagnosis and pattern of injury. Radiographics 1992; 12: 901-915.  Back to cited text no. 11
    
12.
Hamid Rahamtullah Bin Abd Razak, Andrew Arjun Sayampanathan, Thean-Home Bryan Koh, Hwee-chyne Andrew Tan. Diagnosis of ligamentous and meniscal pathologies in patìents with anterior cruciate ligament injuries: comparison of magnetìc resonance imaging and arthroscopic findings. Ann Transl Med 2015, 3 (17) :243.  Back to cited text no. 12
    
13.
Choubey R, Jain A. Mucoid degeneration of the anterior cruciate ligament: a case report and review of literature. J orthop Case Reports 2015, 5(3): 87-89.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  In this article
Abstract
Introduction:
Material and Met...
Inclusion Criteria:
Exclusion Criteria:
MRI Protocol:
Observation and ...
Discussion
References
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