Testing for Meniscus Tears

Expand Your Assessment for Accuracy

By Erik Dalton, PhD
[Myoskeletal Alignment Techniques]

Almost everyone has a friend or relative who has had a “knee clean-out” due to a torn meniscus. This injury may happen suddenly, when the knee is flexed and twisted, or gradually, as the result of age-related degeneration from prolonged repetitive stress. Symptoms of a torn meniscus include swelling, pain along the joint line, and inability to fully extend the affected knee. Of course, not everyone with this injury has symptoms. Many clients are unaware when it happens, and the symptoms, if any, might not appear for several weeks.
If the brain decides to alert the client to the threat of possible tissue damage, the client may experience painful knee clicking, popping, locking, and catching. In addition, there may be a feeling of instability, as if the knee might give out, especially during movements such as walking up and down stairs.
In this article, I’ll outline simple assessments you can use to determine if a client with such knee issues is a good candidate for conservative care.

Meniscus Anatomy

Before we begin, let’s review meniscus anatomy to better understand how this tough tissue gets injured. Composed of thick, rubbery cartilage, the meniscus includes medial and lateral compartments located between the tibia and femur bones. Together they are referred to as menisci. The menisci are wedge-shaped—thinner toward the center of the knee and thicker toward the outside (Image 1).
Functionally, these odd C-shaped structures are critically important for improving load transference. The knee is composed of a round femur sitting on a relatively flat tibia, so without the menisci, the area of contact force between these two bones would be somewhat small and unstable (Image 2). When healthy, the paired medial and lateral menisci provide a great deal of shock absorption, lubrication, and joint stability to the actively engaged knee.
Generally speaking, the meniscus has poor blood supply, but the outer third of the cartilage is vascularized. This means it may be possible to heal small degenerative longitudinal tears—good news for manual therapists attempting to mobilize or stabilize a knee with this type of injury.
As far as the specific kinds of damage that occur in this part of the body, the medial meniscus is injured more often than its lateral counterpart. During a traumatic skiing or football accident, the meniscus, anterior cruciate ligament, and medial collateral ligament may all suffer serious injury. In sports circles, this season-ending condition is known as the “terrible triad.”

Assessing a Troubled Knee

It’s important to note that many orthopedic tests taken alone have low inter-tester reliability. However, when the following three meniscus exams are combined, their sensitivity rating (ability to identify injured tissue) and specificity rating (ability to rule out suspected tissue) improve dramatically—especially with the addition of a thorough clinical background history.

Modified McMurray

The Modified McMurray is a pain provocation test that helps determine if either the lateral or medial meniscus is at risk. Notice in Image 3 how the hip and knee are flexed at 90–90 with my left thumb compressing the lateral meniscus and my index finger compressing the medial meniscus at the tibiofemoral joint line. As my hands slowly take the tibia from a position of abduction and external rotation to adduction and internal rotation (valgus knee position), if the client reports discomfort or clicking along the lateral meniscal border, I make note that the McMurray is positive on that side. Conversely, if the pain occurs as I bring the knee into abduction and external rotation (varus knee position) and the client reports discomfort or clicking laterally, the test is positive for possible medial meniscus damage.

Apley Compression Test

Shown in Image 4, the Apley Compression Test is performed with the client prone. A positive test result is the production of deep pain or joint line tenderness when the client’s tibia is internally and externally rotated under moderate compression. If the client complains of discomfort during internal tibial rotation, the test is positive for medial meniscus damage and vice versa.

Joint Line Pain Provocation Test

In the Joint Line Pain Provocation Test (Image 5), the prone client’s knee and hip are flexed to 90–90 with the client’s left ankle resting on my right shoulder. To test both menisci at the same time, my thumbs compress the tibiofemoral joint line bilaterally while the client’s knee is slowly flexed. If the client reports tenderness on the lateral side during knee flexion and thumb compression, the test is positive for that side and vice versa.
During your intake evaluation, take time to look above and below the affected knee and examine the client’s system as a whole. As physical therapist and orthopedic-certified specialist Gray Cook says, “Treat the pattern, not the pain.” Ultimately, a thorough assessment will help pinpoint the appropriate treatment protocol. I’ve found that manual therapy, along with a well-designed and executed corrective exercise program, can improve movement pattern dysfunctions and enhance the body’s natural healing processes.

Erik Dalton, PhD, is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, he has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com.