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What is the appropriate diagnostic evaluation of fibroids?
Although transvaginal sonography (TVS) has inconsistent sensitivity (0.21–1.00) and specificity (0.53–1.00), its cost-efficiency and noninvasiveness make it the best initial test for ruling in fibroid disease (strength of recommendation [SOR]:B, based on expert opinion, a systematic review, and prospective studies).
Sonohysterography (SHG) and hysteroscopy have superior sensitivity, specificity, and more discriminating positive and negative likelihood ratios for diagnosing fibroids than does TVS (SOR:B, systematic review). SHG is less painful, less invasive, and more cost-effective than hysteroscopy (SOR:B; single, prospective comparative study and cost comparison).
Magnetic resonance imaging (MRI) had comparable precision to TVS in a single study, but it is too expensive to be a good initial test for fibroids (SOR:C, expert opinion and an uncontrolled prospective study). One study reported a strong correlation between ultrasound and bimanual examination (SOR:C, retrospective case review).
Evidence summary
Uterine myomas are usually diagnosed by incidental visualization during pelvic sonography or bimanual palpation of an enlarged, mobile uterus with irregular contours.1 In a retrospective chart review of obese and nonobese patients with known uterine fibroids, clinical estimate of uterine size by bimanual examination correlated with both ultrasound fibroid sizing and posthysterectomy pathology analysis.2 Additional diagnostic testing is indicated for patients with suspected fibroids and abnormal uterine bleeding, increased pelvic girth, pelvic pressure contributing to urinary frequency or constipation, or pelvic pain with intercourse or other physical activity.3
TVS has high sensitivity for detecting myomas in a uterus of <10-week size. The use of high-frequency probes improves the sensitivity for diagnosing small myomas, although their precise location with respect to the uterine cavity often remains uncertain. Localization of fibroids in a larger uterus or when there are many tumors is limited.4 Also, TVS may fail to detect small fibroids and subserosal myomas. A systematic review of 9 heterogeneous studies evaluating TVS found wide ranges for sensitivity and specificity (TABLE).5 The cost of TVS is less than half of sonohysterography or diagnostic hysteroscopy, based on Medicare allowable pricing data.6
SHG uses an intrauterine saline contrast medium with transvaginal ultrasonography. This office-based procedure is more invasive than TVS but requires no anesthesia. SHG is more sensitive and specific than TVS in detecting submucous myomas and focal endometrial lesions.7 In a prospective study of 81 symptomatic patients, using a gold standard of surgical pathology, SHG demonstrated more discriminating positive and negative likelihood ratios (LR+, LR–) for detecting myomata than did TVS or hysteroscopy.8 A prospective study of 56 symptomatic patients with a gold standard of hysteroscopic or surgical pathology similarly found SHG to be superior to TVS.7 In a systematic review of 7 studies, SHG demonstrated a clinically significant LR+ of 29.7. There was too much heterogeneity in the data to calculate an LR– (TABLE).5
Hysteroscopy is as accurate but more invasive than SHG in evaluating uterine myomata. In a systematic review of 4 studies, hysteroscopy had a pooled LR+ of 29.4 for diagnosing fibroids. Due to study heterogeneity, a pooled LR– could not be calculated.5 A prospective, blinded comparative study of SHG and hysteroscopy for diagnosing fibroids in 117 women found SHG to have a higher failure rate (22% vs 6%) but a statistically significant lower median pain score: 1.6 (interquartile range 0.48–3.03) vs 3.2 (1.58–5.18) (P<.001)—than hysteroscopy.9 Failure of SHG was most commonly due to cervical stenosis.
In a double-blinded comparative study of 106 consecutive premenopausal women undergoing hysterectomy for benign reasons, MRI and TVS detected myomas with equal precision (TABLE). MRI is preferred in cases for which exact myoma mapping is necessary and those with multiple myomas or large uteri who are scheduled for advanced surgical procedures.4 MRI costs up to twice as much as sonohysterography or diagnostic hysteroscopy, when comparing Medicare allowable pricing data.6
TABLE
Evaluations of diagnostic tools for fibroids
| DIAGNOSTIC TOOL | PASRIJA ET AL7 | BONNAMY ET AL8 | DUEHOLM ET AL4 | FARQUHAR ET AL5 | ROGERSON ET AL9 |
|---|---|---|---|---|---|
| Summary characteristics of trial | Prospective, 56 pts, symptomatic, gold standard hysteroscopy or hysterectomy pathology | Prospective, 81 symptomatic pts, gold standard of “clinical survey” or histopathology | Double-blind, 106 premenopausal pts undergoing hysterectomy for benign reasons | Systematic review including 19 studies with significant heterogeneity | 117 women; SHG compared with outpatient hysteroscopy (gold standard) |
| TVS | (9 studies) | ||||
| Sensitivity | 84.8 | 65 (43–84) | 99 (92–100) | 21–100 | |
| Specificity | 79 | 94 (79–99) | 91 (75–98) | 53–100 | |
| PPV | 82.4 | 96 (88–99) | |||
| NPV | 82 | 97 (82–100) | |||
| LR+ | 4.0 | 10 (2.6–4.1) | 11 (3.0–50) | 1.61–62.25 | |
| 0.19 | 0.4 (0.2–0.7) | 0.01 (0.11–0) | 0.03–0.80 | ||
| SHG | (7 studies) | ||||
| Sensitivity | 94.1 | 91 (72–99) | 57–100 | 85.2 | |
| Specificity | 88.5 | 94 (79–99) | 96–100 | 87.3 | |
| PPV | 91.4 | 74.3 | |||
| NPV | 92 | 93.2 | |||
| LR+ | 8.2 | 15 (3.8–56) | 29.7 (17.8–49.6) | 6.7 | |
| LR– | 0.067 | 0.1 (0.02–0.4) | 0.06–0.47 | 0.17 | |
| Hysteroscopy | (4 studies) | ||||
| Sensitivity | 88 (62–98) | 53–100 | |||
| Specificity | 94 (79–99) | 97–100 | |||
| LR+ | 14 (3.5–52) | 29.4 (13.4–65.3) | |||
| LR– | 0.1 (0.04–0.5) | 0.08–0.48 | |||
| MRI | |||||
| Sensitivity | 99 (92–100) | ||||
| Specificity | 86 (71–94) | ||||
| PPV | 92 (83–97) | ||||
| NPV | 97 (85–100) | ||||
| LR+ | 7.1 (03.2–16.7) | ||||
| LR– | 0.012 (0.11–0) | ||||
| Italicized values were not reported in the original studies, but calculated for this review. Numbers in parentheses represent 95% confidence levels. | |||||
| LR+ = positive likelihood ratio (a value greater than 10 is clinically significant and the higher the value, the more helpful the test at ruling in the diagnosis); LR– = negative likelihood ratio (a value less than 0.1 is clinically significant and the lower the value, the more helpful the test at ruling out the diagnosis). | |||||
| PPV, positive predictive value; NPV, negative predictive value; TVS, transvaginal sonography; SHG, sonohysterography; MRI, magnetic resonance imaging. | |||||
Recommendations from others
A 1994 American College of Obstetrics and Gynecology (ACOG) bulletin stated that uterine fibroids can be diagnosed with 95% certainty by examination alone.10 ACOG recommends augmenting physical examination with ultrasonography in cases involving obese women or when adnexal pathology cannot be excluded based on examination alone. This bulletin also points out that routine ultrasonography does not improve long-term clinical outcomes for fibroids. A more recent bulletin (2000) addressed management but not evaluation or diagnosis of leiomyomas.11
A 2003 guideline from the Society of Obstetrics and Gynecology of Canada recommends against routine ultrasonography, since it rarely affects the clinical management of uterine fibroids. However, it emphasizes the importance of ruling out underlying endometrial pathology in women with abnormal uterine bleeding.12
When evaluating potential fibroids, a reasonable first step is a sonogram
Lynda DeArmond, MD
Waco Family Practice Residency Program, Waco, Tex
In the asymptomatic patient with an enlarged, irregularly contoured uterus on routine exam, the differential includes fibroids, fibroids, and fibroids. My usual next step is to get a sonogram. The test is noninvasive, well-tolerated by patients, and significantly less expensive than the alternatives. It quickly and easily gives a great deal of useful information regarding the size, shape, consistency of the myometrium and the endometrium, from which we can reassure the patient regarding the benign natural history of this finding, especially in the perimenopausal woman. If the patient presents with symptoms of abnormal bleeding, pelvic pressure, or adnexal findings on exam, the review suggests that further workup may be indicated. However, the sonogram remains a very useful initial test even in this case.
1. Mayer DP, Shipilov V. Ultrasonography and magnetic resonance imaging of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667-725.
2. Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstet Gynecol 1998;92:109-112.
3. Becker E, Jr, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-247.
4. Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-415.
5. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493-504.
6. 2004 Interactive Physician Fee Schedule. Missouri Medicare Services. Available at: www.momedicare.com/provider/disclosure/fee2004.asp.
7. Pasrija S, Trivedi SS, Narula MK. Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal bleeding. J Obstet Gynaecol 2004;30:27-33.
8. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
9. Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002;109:800-804.
10. ACOG. ACOG Technical Bulletin no. 192. Uterine leiomyomata. Int J Gynaecol Obstet 1994;46:73-82.
11. ACOG. ACOG Practice Bulletin no. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000.
12. Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC Clinical Practice Guideline no. 128. The management of uterine leiomyomas. May 2003.
Although transvaginal sonography (TVS) has inconsistent sensitivity (0.21–1.00) and specificity (0.53–1.00), its cost-efficiency and noninvasiveness make it the best initial test for ruling in fibroid disease (strength of recommendation [SOR]:B, based on expert opinion, a systematic review, and prospective studies).
Sonohysterography (SHG) and hysteroscopy have superior sensitivity, specificity, and more discriminating positive and negative likelihood ratios for diagnosing fibroids than does TVS (SOR:B, systematic review). SHG is less painful, less invasive, and more cost-effective than hysteroscopy (SOR:B; single, prospective comparative study and cost comparison).
Magnetic resonance imaging (MRI) had comparable precision to TVS in a single study, but it is too expensive to be a good initial test for fibroids (SOR:C, expert opinion and an uncontrolled prospective study). One study reported a strong correlation between ultrasound and bimanual examination (SOR:C, retrospective case review).
Evidence summary
Uterine myomas are usually diagnosed by incidental visualization during pelvic sonography or bimanual palpation of an enlarged, mobile uterus with irregular contours.1 In a retrospective chart review of obese and nonobese patients with known uterine fibroids, clinical estimate of uterine size by bimanual examination correlated with both ultrasound fibroid sizing and posthysterectomy pathology analysis.2 Additional diagnostic testing is indicated for patients with suspected fibroids and abnormal uterine bleeding, increased pelvic girth, pelvic pressure contributing to urinary frequency or constipation, or pelvic pain with intercourse or other physical activity.3
TVS has high sensitivity for detecting myomas in a uterus of <10-week size. The use of high-frequency probes improves the sensitivity for diagnosing small myomas, although their precise location with respect to the uterine cavity often remains uncertain. Localization of fibroids in a larger uterus or when there are many tumors is limited.4 Also, TVS may fail to detect small fibroids and subserosal myomas. A systematic review of 9 heterogeneous studies evaluating TVS found wide ranges for sensitivity and specificity (TABLE).5 The cost of TVS is less than half of sonohysterography or diagnostic hysteroscopy, based on Medicare allowable pricing data.6
SHG uses an intrauterine saline contrast medium with transvaginal ultrasonography. This office-based procedure is more invasive than TVS but requires no anesthesia. SHG is more sensitive and specific than TVS in detecting submucous myomas and focal endometrial lesions.7 In a prospective study of 81 symptomatic patients, using a gold standard of surgical pathology, SHG demonstrated more discriminating positive and negative likelihood ratios (LR+, LR–) for detecting myomata than did TVS or hysteroscopy.8 A prospective study of 56 symptomatic patients with a gold standard of hysteroscopic or surgical pathology similarly found SHG to be superior to TVS.7 In a systematic review of 7 studies, SHG demonstrated a clinically significant LR+ of 29.7. There was too much heterogeneity in the data to calculate an LR– (TABLE).5
Hysteroscopy is as accurate but more invasive than SHG in evaluating uterine myomata. In a systematic review of 4 studies, hysteroscopy had a pooled LR+ of 29.4 for diagnosing fibroids. Due to study heterogeneity, a pooled LR– could not be calculated.5 A prospective, blinded comparative study of SHG and hysteroscopy for diagnosing fibroids in 117 women found SHG to have a higher failure rate (22% vs 6%) but a statistically significant lower median pain score: 1.6 (interquartile range 0.48–3.03) vs 3.2 (1.58–5.18) (P<.001)—than hysteroscopy.9 Failure of SHG was most commonly due to cervical stenosis.
In a double-blinded comparative study of 106 consecutive premenopausal women undergoing hysterectomy for benign reasons, MRI and TVS detected myomas with equal precision (TABLE). MRI is preferred in cases for which exact myoma mapping is necessary and those with multiple myomas or large uteri who are scheduled for advanced surgical procedures.4 MRI costs up to twice as much as sonohysterography or diagnostic hysteroscopy, when comparing Medicare allowable pricing data.6
TABLE
Evaluations of diagnostic tools for fibroids
| DIAGNOSTIC TOOL | PASRIJA ET AL7 | BONNAMY ET AL8 | DUEHOLM ET AL4 | FARQUHAR ET AL5 | ROGERSON ET AL9 |
|---|---|---|---|---|---|
| Summary characteristics of trial | Prospective, 56 pts, symptomatic, gold standard hysteroscopy or hysterectomy pathology | Prospective, 81 symptomatic pts, gold standard of “clinical survey” or histopathology | Double-blind, 106 premenopausal pts undergoing hysterectomy for benign reasons | Systematic review including 19 studies with significant heterogeneity | 117 women; SHG compared with outpatient hysteroscopy (gold standard) |
| TVS | (9 studies) | ||||
| Sensitivity | 84.8 | 65 (43–84) | 99 (92–100) | 21–100 | |
| Specificity | 79 | 94 (79–99) | 91 (75–98) | 53–100 | |
| PPV | 82.4 | 96 (88–99) | |||
| NPV | 82 | 97 (82–100) | |||
| LR+ | 4.0 | 10 (2.6–4.1) | 11 (3.0–50) | 1.61–62.25 | |
| 0.19 | 0.4 (0.2–0.7) | 0.01 (0.11–0) | 0.03–0.80 | ||
| SHG | (7 studies) | ||||
| Sensitivity | 94.1 | 91 (72–99) | 57–100 | 85.2 | |
| Specificity | 88.5 | 94 (79–99) | 96–100 | 87.3 | |
| PPV | 91.4 | 74.3 | |||
| NPV | 92 | 93.2 | |||
| LR+ | 8.2 | 15 (3.8–56) | 29.7 (17.8–49.6) | 6.7 | |
| LR– | 0.067 | 0.1 (0.02–0.4) | 0.06–0.47 | 0.17 | |
| Hysteroscopy | (4 studies) | ||||
| Sensitivity | 88 (62–98) | 53–100 | |||
| Specificity | 94 (79–99) | 97–100 | |||
| LR+ | 14 (3.5–52) | 29.4 (13.4–65.3) | |||
| LR– | 0.1 (0.04–0.5) | 0.08–0.48 | |||
| MRI | |||||
| Sensitivity | 99 (92–100) | ||||
| Specificity | 86 (71–94) | ||||
| PPV | 92 (83–97) | ||||
| NPV | 97 (85–100) | ||||
| LR+ | 7.1 (03.2–16.7) | ||||
| LR– | 0.012 (0.11–0) | ||||
| Italicized values were not reported in the original studies, but calculated for this review. Numbers in parentheses represent 95% confidence levels. | |||||
| LR+ = positive likelihood ratio (a value greater than 10 is clinically significant and the higher the value, the more helpful the test at ruling in the diagnosis); LR– = negative likelihood ratio (a value less than 0.1 is clinically significant and the lower the value, the more helpful the test at ruling out the diagnosis). | |||||
| PPV, positive predictive value; NPV, negative predictive value; TVS, transvaginal sonography; SHG, sonohysterography; MRI, magnetic resonance imaging. | |||||
Recommendations from others
A 1994 American College of Obstetrics and Gynecology (ACOG) bulletin stated that uterine fibroids can be diagnosed with 95% certainty by examination alone.10 ACOG recommends augmenting physical examination with ultrasonography in cases involving obese women or when adnexal pathology cannot be excluded based on examination alone. This bulletin also points out that routine ultrasonography does not improve long-term clinical outcomes for fibroids. A more recent bulletin (2000) addressed management but not evaluation or diagnosis of leiomyomas.11
A 2003 guideline from the Society of Obstetrics and Gynecology of Canada recommends against routine ultrasonography, since it rarely affects the clinical management of uterine fibroids. However, it emphasizes the importance of ruling out underlying endometrial pathology in women with abnormal uterine bleeding.12
When evaluating potential fibroids, a reasonable first step is a sonogram
Lynda DeArmond, MD
Waco Family Practice Residency Program, Waco, Tex
In the asymptomatic patient with an enlarged, irregularly contoured uterus on routine exam, the differential includes fibroids, fibroids, and fibroids. My usual next step is to get a sonogram. The test is noninvasive, well-tolerated by patients, and significantly less expensive than the alternatives. It quickly and easily gives a great deal of useful information regarding the size, shape, consistency of the myometrium and the endometrium, from which we can reassure the patient regarding the benign natural history of this finding, especially in the perimenopausal woman. If the patient presents with symptoms of abnormal bleeding, pelvic pressure, or adnexal findings on exam, the review suggests that further workup may be indicated. However, the sonogram remains a very useful initial test even in this case.
Although transvaginal sonography (TVS) has inconsistent sensitivity (0.21–1.00) and specificity (0.53–1.00), its cost-efficiency and noninvasiveness make it the best initial test for ruling in fibroid disease (strength of recommendation [SOR]:B, based on expert opinion, a systematic review, and prospective studies).
Sonohysterography (SHG) and hysteroscopy have superior sensitivity, specificity, and more discriminating positive and negative likelihood ratios for diagnosing fibroids than does TVS (SOR:B, systematic review). SHG is less painful, less invasive, and more cost-effective than hysteroscopy (SOR:B; single, prospective comparative study and cost comparison).
Magnetic resonance imaging (MRI) had comparable precision to TVS in a single study, but it is too expensive to be a good initial test for fibroids (SOR:C, expert opinion and an uncontrolled prospective study). One study reported a strong correlation between ultrasound and bimanual examination (SOR:C, retrospective case review).
Evidence summary
Uterine myomas are usually diagnosed by incidental visualization during pelvic sonography or bimanual palpation of an enlarged, mobile uterus with irregular contours.1 In a retrospective chart review of obese and nonobese patients with known uterine fibroids, clinical estimate of uterine size by bimanual examination correlated with both ultrasound fibroid sizing and posthysterectomy pathology analysis.2 Additional diagnostic testing is indicated for patients with suspected fibroids and abnormal uterine bleeding, increased pelvic girth, pelvic pressure contributing to urinary frequency or constipation, or pelvic pain with intercourse or other physical activity.3
TVS has high sensitivity for detecting myomas in a uterus of <10-week size. The use of high-frequency probes improves the sensitivity for diagnosing small myomas, although their precise location with respect to the uterine cavity often remains uncertain. Localization of fibroids in a larger uterus or when there are many tumors is limited.4 Also, TVS may fail to detect small fibroids and subserosal myomas. A systematic review of 9 heterogeneous studies evaluating TVS found wide ranges for sensitivity and specificity (TABLE).5 The cost of TVS is less than half of sonohysterography or diagnostic hysteroscopy, based on Medicare allowable pricing data.6
SHG uses an intrauterine saline contrast medium with transvaginal ultrasonography. This office-based procedure is more invasive than TVS but requires no anesthesia. SHG is more sensitive and specific than TVS in detecting submucous myomas and focal endometrial lesions.7 In a prospective study of 81 symptomatic patients, using a gold standard of surgical pathology, SHG demonstrated more discriminating positive and negative likelihood ratios (LR+, LR–) for detecting myomata than did TVS or hysteroscopy.8 A prospective study of 56 symptomatic patients with a gold standard of hysteroscopic or surgical pathology similarly found SHG to be superior to TVS.7 In a systematic review of 7 studies, SHG demonstrated a clinically significant LR+ of 29.7. There was too much heterogeneity in the data to calculate an LR– (TABLE).5
Hysteroscopy is as accurate but more invasive than SHG in evaluating uterine myomata. In a systematic review of 4 studies, hysteroscopy had a pooled LR+ of 29.4 for diagnosing fibroids. Due to study heterogeneity, a pooled LR– could not be calculated.5 A prospective, blinded comparative study of SHG and hysteroscopy for diagnosing fibroids in 117 women found SHG to have a higher failure rate (22% vs 6%) but a statistically significant lower median pain score: 1.6 (interquartile range 0.48–3.03) vs 3.2 (1.58–5.18) (P<.001)—than hysteroscopy.9 Failure of SHG was most commonly due to cervical stenosis.
In a double-blinded comparative study of 106 consecutive premenopausal women undergoing hysterectomy for benign reasons, MRI and TVS detected myomas with equal precision (TABLE). MRI is preferred in cases for which exact myoma mapping is necessary and those with multiple myomas or large uteri who are scheduled for advanced surgical procedures.4 MRI costs up to twice as much as sonohysterography or diagnostic hysteroscopy, when comparing Medicare allowable pricing data.6
TABLE
Evaluations of diagnostic tools for fibroids
| DIAGNOSTIC TOOL | PASRIJA ET AL7 | BONNAMY ET AL8 | DUEHOLM ET AL4 | FARQUHAR ET AL5 | ROGERSON ET AL9 |
|---|---|---|---|---|---|
| Summary characteristics of trial | Prospective, 56 pts, symptomatic, gold standard hysteroscopy or hysterectomy pathology | Prospective, 81 symptomatic pts, gold standard of “clinical survey” or histopathology | Double-blind, 106 premenopausal pts undergoing hysterectomy for benign reasons | Systematic review including 19 studies with significant heterogeneity | 117 women; SHG compared with outpatient hysteroscopy (gold standard) |
| TVS | (9 studies) | ||||
| Sensitivity | 84.8 | 65 (43–84) | 99 (92–100) | 21–100 | |
| Specificity | 79 | 94 (79–99) | 91 (75–98) | 53–100 | |
| PPV | 82.4 | 96 (88–99) | |||
| NPV | 82 | 97 (82–100) | |||
| LR+ | 4.0 | 10 (2.6–4.1) | 11 (3.0–50) | 1.61–62.25 | |
| 0.19 | 0.4 (0.2–0.7) | 0.01 (0.11–0) | 0.03–0.80 | ||
| SHG | (7 studies) | ||||
| Sensitivity | 94.1 | 91 (72–99) | 57–100 | 85.2 | |
| Specificity | 88.5 | 94 (79–99) | 96–100 | 87.3 | |
| PPV | 91.4 | 74.3 | |||
| NPV | 92 | 93.2 | |||
| LR+ | 8.2 | 15 (3.8–56) | 29.7 (17.8–49.6) | 6.7 | |
| LR– | 0.067 | 0.1 (0.02–0.4) | 0.06–0.47 | 0.17 | |
| Hysteroscopy | (4 studies) | ||||
| Sensitivity | 88 (62–98) | 53–100 | |||
| Specificity | 94 (79–99) | 97–100 | |||
| LR+ | 14 (3.5–52) | 29.4 (13.4–65.3) | |||
| LR– | 0.1 (0.04–0.5) | 0.08–0.48 | |||
| MRI | |||||
| Sensitivity | 99 (92–100) | ||||
| Specificity | 86 (71–94) | ||||
| PPV | 92 (83–97) | ||||
| NPV | 97 (85–100) | ||||
| LR+ | 7.1 (03.2–16.7) | ||||
| LR– | 0.012 (0.11–0) | ||||
| Italicized values were not reported in the original studies, but calculated for this review. Numbers in parentheses represent 95% confidence levels. | |||||
| LR+ = positive likelihood ratio (a value greater than 10 is clinically significant and the higher the value, the more helpful the test at ruling in the diagnosis); LR– = negative likelihood ratio (a value less than 0.1 is clinically significant and the lower the value, the more helpful the test at ruling out the diagnosis). | |||||
| PPV, positive predictive value; NPV, negative predictive value; TVS, transvaginal sonography; SHG, sonohysterography; MRI, magnetic resonance imaging. | |||||
Recommendations from others
A 1994 American College of Obstetrics and Gynecology (ACOG) bulletin stated that uterine fibroids can be diagnosed with 95% certainty by examination alone.10 ACOG recommends augmenting physical examination with ultrasonography in cases involving obese women or when adnexal pathology cannot be excluded based on examination alone. This bulletin also points out that routine ultrasonography does not improve long-term clinical outcomes for fibroids. A more recent bulletin (2000) addressed management but not evaluation or diagnosis of leiomyomas.11
A 2003 guideline from the Society of Obstetrics and Gynecology of Canada recommends against routine ultrasonography, since it rarely affects the clinical management of uterine fibroids. However, it emphasizes the importance of ruling out underlying endometrial pathology in women with abnormal uterine bleeding.12
When evaluating potential fibroids, a reasonable first step is a sonogram
Lynda DeArmond, MD
Waco Family Practice Residency Program, Waco, Tex
In the asymptomatic patient with an enlarged, irregularly contoured uterus on routine exam, the differential includes fibroids, fibroids, and fibroids. My usual next step is to get a sonogram. The test is noninvasive, well-tolerated by patients, and significantly less expensive than the alternatives. It quickly and easily gives a great deal of useful information regarding the size, shape, consistency of the myometrium and the endometrium, from which we can reassure the patient regarding the benign natural history of this finding, especially in the perimenopausal woman. If the patient presents with symptoms of abnormal bleeding, pelvic pressure, or adnexal findings on exam, the review suggests that further workup may be indicated. However, the sonogram remains a very useful initial test even in this case.
1. Mayer DP, Shipilov V. Ultrasonography and magnetic resonance imaging of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667-725.
2. Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstet Gynecol 1998;92:109-112.
3. Becker E, Jr, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-247.
4. Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-415.
5. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493-504.
6. 2004 Interactive Physician Fee Schedule. Missouri Medicare Services. Available at: www.momedicare.com/provider/disclosure/fee2004.asp.
7. Pasrija S, Trivedi SS, Narula MK. Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal bleeding. J Obstet Gynaecol 2004;30:27-33.
8. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
9. Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002;109:800-804.
10. ACOG. ACOG Technical Bulletin no. 192. Uterine leiomyomata. Int J Gynaecol Obstet 1994;46:73-82.
11. ACOG. ACOG Practice Bulletin no. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000.
12. Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC Clinical Practice Guideline no. 128. The management of uterine leiomyomas. May 2003.
1. Mayer DP, Shipilov V. Ultrasonography and magnetic resonance imaging of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667-725.
2. Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstet Gynecol 1998;92:109-112.
3. Becker E, Jr, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-247.
4. Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-415.
5. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493-504.
6. 2004 Interactive Physician Fee Schedule. Missouri Medicare Services. Available at: www.momedicare.com/provider/disclosure/fee2004.asp.
7. Pasrija S, Trivedi SS, Narula MK. Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal bleeding. J Obstet Gynaecol 2004;30:27-33.
8. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
9. Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002;109:800-804.
10. ACOG. ACOG Technical Bulletin no. 192. Uterine leiomyomata. Int J Gynaecol Obstet 1994;46:73-82.
11. ACOG. ACOG Practice Bulletin no. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000.
12. Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC Clinical Practice Guideline no. 128. The management of uterine leiomyomas. May 2003.
Evidence-based answers from the Family Physicians Inquiries Network
For knee pain, how predictive is physical examination for meniscal injury?
No single clinical examination element, or combination of such elements, reliably detects meniscal injury. The McMurray test is best for ruling in meniscal pathology. Assuming a 9% prevalence of meniscal tears among all knee injuries (a rate reflecting national primary care data), the posttest probability that a patient with McMurray’s sign has a meniscal injury ranges from <30% to 63% (strength of recommendation [SOR]: B). In contrast, the absence of any positive physical examination findings effectively rules out meniscal pathology, yielding a posttest probability of 0.8% for lateral meniscus injury, 1.0% for medial meniscus injury, and 3.8% for any meniscal injury among primary care populations (SOR: B).
Evidence summary
The accuracy of physical examination findings for meniscal injury varies widely among meta-analyses. In a meta-analysis of 13 studies, no physical examination test—including assessment for joint effusion, McMurray test, joint line tenderness, or the Apley compression test—yielded clinically significant positive or negative likelihood ratios for a meniscal tear ( Table ). The McMurray test performed best, but at 9% to 11% pretest probability of JFP_1104_CI.final 10/18/04 11:06 AM Page 918 meniscal lesions, based on prevalence estimates among primary care/specialist populations,2 the posttest probability of a positive exam is still <30%.
A meta-analysis of 4 studies by Jackson compared the utility of the McMurray test and joint line tenderness.3 For detecting meniscal tears, the McMurray test had a clinically and statistically significant positive likelihood ratio of 17.33, corresponding to a posttest probability of nearly 61%. Negative likelihood ratios for the McMurray test and joint line tenderness (0.5 and 0.8) were not clinically significant, indicating that absence of the McMurray sign or joint line tenderness alone is of little benefit in ruling out meniscal injury.
In another meta-analysis including 9 studies of meniscal injury diagnosis,4 individual tests for joint line tenderness, joint effusion, the medial-lateral grind test, and the McMurray test failed to yield statistically significant likelihood ratios for the presence or absence of meniscal tears ( Table footnotes). Positive and negative likelihood ratios for aggregate physical examination were 2.7 (95% confidence interval [CI], 1.4–5.1) and 0.4 (95% CI, 0.2–0.7), which are statistically, but not clinically, significant values for ruling meniscal lesions in or out.
Jackson’s meta-analysis also calculated the posttest probability of injury for a composite meniscal examination. Based on the positive likelihood ratio of 3.1 (95% CI, 0.54–5.7) and negative likelihood ratio of 0.19 (95% CI, 0.11–0.77), the posttest probability of a medial meniscal tear was 17% in the setting of composite physical exam findings and 1% in the absence of physical exam findings. For a lateral meniscal tear, based on the positive likelihood ratio of 11 (95% CI, 1.8–20.2), and negative likelihood ratio of 0.13 (95% CI, 0.0–0.25), the posttest probability of injury with a positive exam was 41% and with a negative exam 0.8%.
Authors of all meta-analyses noted the lack of standardization in physical examination maneuvers (especially the McMurray test)5 and, in some cases, no specification of how physical examination tests were performed. Authors analyzed the utility of the aggregate and composite knee examinations without specifying what constituted such an exam. No study included in the meta-analyses used control subjects without meniscal pathology, and few studies were blinded. Lack of blinding may have introduced verification bias; use of specialty patients in all studies made referral bias likely. Studies were heterogeneous and results were associated with wide confidence intervals, introducing an element of random error into the processes of combining and interpreting data.
TABLE
Physical exams for meniscal tear
| Summary characteristics | Solomon et al 4 | Scholten et al 1 | Jackson et al 3 |
| 9 studies 1018 patients Specialist population Specialist examiners | 13 studies 2231 patients Specialist population Specialist examiners | 4 studies 424 patients Specialist population Specialist examiners | |
| McMurray | Positive likelihood ratio (95% CI) | ||
| 1.3 (0.9–1.7) | 1.5–9.5 | 17.3 (2.7–68) | |
| Joint line tenderness | 0.9 (0.8–1.0) | 0.8–14.9 | 1.1 (0.7–1.6) |
| Aggregate exam | 2.7 (1.4–5.1) | — | — |
| Aggregate exam, medial meniscus tears | — | — | 3.1 (0.54–5.7) |
| Aggregate exam, lateral meniscus tears | — | — | 11 (1.8–20.2) |
| McMurray | Negative likelihood ratio (95% CI) | ||
| 0.8 (0.6–1.1) | 0.4–0.9 | 0.5 (0.3–0.8) | |
| Joint line tenderness | 1.1 (1.0–1.3) | 0.2–2.1 | 0.8 (0.3–3.5) |
| Aggregate exam | 0.4 (0.2–0.7) | — | — |
| Aggregate exam, medial meniscus tears | — | — | 0.19 (0.11–0.77) |
| Aggregate exam, lateral meniscus tears | — | — | 0.13 (0–0.25) |
| Note: The results are presented as likelihood ratios, which represent the change in the odds of a diagnosis, based on the outcome of the test. For example, given a positive likelihood ratio of 2, if a test result is positive, the odds of the disease being present is doubled. A positive likelihood ratio >10 provides strong evidence that the disorder is present. A negative likelihood ratio <0.1 provides strong evidence that the disorder is not present. Scores between 0.5 and 2.0 are neutral. In Scholten’s meta-analysis, likelihood ratios are given in ranges (no composite value given). | |||
Recommendations from others
The American Academy of Orthopaedic Surgeons’ clinical guideline on the evaluation and treatment of knee injuries lists the following findings as associated with a meniscal tear: delayed swelling of the knee, twisting injury, painful popping and catching, effusion, joint line tenderness, positive McMurray’s test, and negative radiography.6 The guideline fails to list the strength and type of supporting evidence for these associations.
The American College of Radiology’s Appropriateness Criteria for Acute Trauma to the Knee states that decision rules for meniscal tears and other soft tissue injuries to the knee are being investigated, but it fails to mention specific evaluation strategies for meniscal tears.7
Meniscus injury likely with suggestive history, joint line tenderness, and an inability to squat because of pain
Roy Henderson, MD
Director, Sports Medicine Fellowship, MacNeal Family Practice Residency Program, Chicago, Ill
I often suspect meniscal injuries as a cause of knee pain but am rarely certain based on physical examination alone. I look for a history of joint line pain, locking, or popping with movement. If the patient lacks joint line tenderness, a meniscal injury is unlikely. The McMurray test is usually negative. In the absence of another explanation for the patient’s symptoms, a meniscus injury is high on my list in the presence of a suggestive history, joint line tenderness, and an inability to squat because of pain. When my suspicion is high I usually resort to an MRI.
1. Scholten RJ, Deville WL, Opstelten W, Bijl D, van der Plas CG, Bouter LM. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract 2001;50:938-944.
2. National Ambulatory Medical Care Survey 1996. Available at: ftp://ftp.cdc.gov/pub/Health-Statistics/NCHS/Datasets/NAMCS/. Accessed on August 18, 2004.
3. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med 2003;139:575-588.
4. Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee?. JAMA 2001;286:1610-1620.
5. Stratford PW, Binkley J. A review of the McMurray test: definition, interpretation, and clinical usefulness. J Orthop Sports Phys Ther 1995;22:116-120.
6. American Academy of Orthopaedic Surgeons. AAOS Clinical Guideline on Knee Injury: Support Document. Last updated February 26, 2002. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2001. Available at: http://www.guidelines.gov. Accessed on September 30, 2004.
7. American College of Radiology (ACR) Expert. Panel on Musculoskeletal Imaging ACR Appropriateness Criteria for Acute Trauma to the Knee. Updated October 1, 2002. Reston, Va: American College of Radiology; 2001. Available at: http://www.acr.org/cgi-bin/fr?tmpl:appcrit,pdf:0365374_acute_trauma_to_knee.ac.p df. Accessed on September 30, 2004.
No single clinical examination element, or combination of such elements, reliably detects meniscal injury. The McMurray test is best for ruling in meniscal pathology. Assuming a 9% prevalence of meniscal tears among all knee injuries (a rate reflecting national primary care data), the posttest probability that a patient with McMurray’s sign has a meniscal injury ranges from <30% to 63% (strength of recommendation [SOR]: B). In contrast, the absence of any positive physical examination findings effectively rules out meniscal pathology, yielding a posttest probability of 0.8% for lateral meniscus injury, 1.0% for medial meniscus injury, and 3.8% for any meniscal injury among primary care populations (SOR: B).
Evidence summary
The accuracy of physical examination findings for meniscal injury varies widely among meta-analyses. In a meta-analysis of 13 studies, no physical examination test—including assessment for joint effusion, McMurray test, joint line tenderness, or the Apley compression test—yielded clinically significant positive or negative likelihood ratios for a meniscal tear ( Table ). The McMurray test performed best, but at 9% to 11% pretest probability of JFP_1104_CI.final 10/18/04 11:06 AM Page 918 meniscal lesions, based on prevalence estimates among primary care/specialist populations,2 the posttest probability of a positive exam is still <30%.
A meta-analysis of 4 studies by Jackson compared the utility of the McMurray test and joint line tenderness.3 For detecting meniscal tears, the McMurray test had a clinically and statistically significant positive likelihood ratio of 17.33, corresponding to a posttest probability of nearly 61%. Negative likelihood ratios for the McMurray test and joint line tenderness (0.5 and 0.8) were not clinically significant, indicating that absence of the McMurray sign or joint line tenderness alone is of little benefit in ruling out meniscal injury.
In another meta-analysis including 9 studies of meniscal injury diagnosis,4 individual tests for joint line tenderness, joint effusion, the medial-lateral grind test, and the McMurray test failed to yield statistically significant likelihood ratios for the presence or absence of meniscal tears ( Table footnotes). Positive and negative likelihood ratios for aggregate physical examination were 2.7 (95% confidence interval [CI], 1.4–5.1) and 0.4 (95% CI, 0.2–0.7), which are statistically, but not clinically, significant values for ruling meniscal lesions in or out.
Jackson’s meta-analysis also calculated the posttest probability of injury for a composite meniscal examination. Based on the positive likelihood ratio of 3.1 (95% CI, 0.54–5.7) and negative likelihood ratio of 0.19 (95% CI, 0.11–0.77), the posttest probability of a medial meniscal tear was 17% in the setting of composite physical exam findings and 1% in the absence of physical exam findings. For a lateral meniscal tear, based on the positive likelihood ratio of 11 (95% CI, 1.8–20.2), and negative likelihood ratio of 0.13 (95% CI, 0.0–0.25), the posttest probability of injury with a positive exam was 41% and with a negative exam 0.8%.
Authors of all meta-analyses noted the lack of standardization in physical examination maneuvers (especially the McMurray test)5 and, in some cases, no specification of how physical examination tests were performed. Authors analyzed the utility of the aggregate and composite knee examinations without specifying what constituted such an exam. No study included in the meta-analyses used control subjects without meniscal pathology, and few studies were blinded. Lack of blinding may have introduced verification bias; use of specialty patients in all studies made referral bias likely. Studies were heterogeneous and results were associated with wide confidence intervals, introducing an element of random error into the processes of combining and interpreting data.
TABLE
Physical exams for meniscal tear
| Summary characteristics | Solomon et al 4 | Scholten et al 1 | Jackson et al 3 |
| 9 studies 1018 patients Specialist population Specialist examiners | 13 studies 2231 patients Specialist population Specialist examiners | 4 studies 424 patients Specialist population Specialist examiners | |
| McMurray | Positive likelihood ratio (95% CI) | ||
| 1.3 (0.9–1.7) | 1.5–9.5 | 17.3 (2.7–68) | |
| Joint line tenderness | 0.9 (0.8–1.0) | 0.8–14.9 | 1.1 (0.7–1.6) |
| Aggregate exam | 2.7 (1.4–5.1) | — | — |
| Aggregate exam, medial meniscus tears | — | — | 3.1 (0.54–5.7) |
| Aggregate exam, lateral meniscus tears | — | — | 11 (1.8–20.2) |
| McMurray | Negative likelihood ratio (95% CI) | ||
| 0.8 (0.6–1.1) | 0.4–0.9 | 0.5 (0.3–0.8) | |
| Joint line tenderness | 1.1 (1.0–1.3) | 0.2–2.1 | 0.8 (0.3–3.5) |
| Aggregate exam | 0.4 (0.2–0.7) | — | — |
| Aggregate exam, medial meniscus tears | — | — | 0.19 (0.11–0.77) |
| Aggregate exam, lateral meniscus tears | — | — | 0.13 (0–0.25) |
| Note: The results are presented as likelihood ratios, which represent the change in the odds of a diagnosis, based on the outcome of the test. For example, given a positive likelihood ratio of 2, if a test result is positive, the odds of the disease being present is doubled. A positive likelihood ratio >10 provides strong evidence that the disorder is present. A negative likelihood ratio <0.1 provides strong evidence that the disorder is not present. Scores between 0.5 and 2.0 are neutral. In Scholten’s meta-analysis, likelihood ratios are given in ranges (no composite value given). | |||
Recommendations from others
The American Academy of Orthopaedic Surgeons’ clinical guideline on the evaluation and treatment of knee injuries lists the following findings as associated with a meniscal tear: delayed swelling of the knee, twisting injury, painful popping and catching, effusion, joint line tenderness, positive McMurray’s test, and negative radiography.6 The guideline fails to list the strength and type of supporting evidence for these associations.
The American College of Radiology’s Appropriateness Criteria for Acute Trauma to the Knee states that decision rules for meniscal tears and other soft tissue injuries to the knee are being investigated, but it fails to mention specific evaluation strategies for meniscal tears.7
Meniscus injury likely with suggestive history, joint line tenderness, and an inability to squat because of pain
Roy Henderson, MD
Director, Sports Medicine Fellowship, MacNeal Family Practice Residency Program, Chicago, Ill
I often suspect meniscal injuries as a cause of knee pain but am rarely certain based on physical examination alone. I look for a history of joint line pain, locking, or popping with movement. If the patient lacks joint line tenderness, a meniscal injury is unlikely. The McMurray test is usually negative. In the absence of another explanation for the patient’s symptoms, a meniscus injury is high on my list in the presence of a suggestive history, joint line tenderness, and an inability to squat because of pain. When my suspicion is high I usually resort to an MRI.
No single clinical examination element, or combination of such elements, reliably detects meniscal injury. The McMurray test is best for ruling in meniscal pathology. Assuming a 9% prevalence of meniscal tears among all knee injuries (a rate reflecting national primary care data), the posttest probability that a patient with McMurray’s sign has a meniscal injury ranges from <30% to 63% (strength of recommendation [SOR]: B). In contrast, the absence of any positive physical examination findings effectively rules out meniscal pathology, yielding a posttest probability of 0.8% for lateral meniscus injury, 1.0% for medial meniscus injury, and 3.8% for any meniscal injury among primary care populations (SOR: B).
Evidence summary
The accuracy of physical examination findings for meniscal injury varies widely among meta-analyses. In a meta-analysis of 13 studies, no physical examination test—including assessment for joint effusion, McMurray test, joint line tenderness, or the Apley compression test—yielded clinically significant positive or negative likelihood ratios for a meniscal tear ( Table ). The McMurray test performed best, but at 9% to 11% pretest probability of JFP_1104_CI.final 10/18/04 11:06 AM Page 918 meniscal lesions, based on prevalence estimates among primary care/specialist populations,2 the posttest probability of a positive exam is still <30%.
A meta-analysis of 4 studies by Jackson compared the utility of the McMurray test and joint line tenderness.3 For detecting meniscal tears, the McMurray test had a clinically and statistically significant positive likelihood ratio of 17.33, corresponding to a posttest probability of nearly 61%. Negative likelihood ratios for the McMurray test and joint line tenderness (0.5 and 0.8) were not clinically significant, indicating that absence of the McMurray sign or joint line tenderness alone is of little benefit in ruling out meniscal injury.
In another meta-analysis including 9 studies of meniscal injury diagnosis,4 individual tests for joint line tenderness, joint effusion, the medial-lateral grind test, and the McMurray test failed to yield statistically significant likelihood ratios for the presence or absence of meniscal tears ( Table footnotes). Positive and negative likelihood ratios for aggregate physical examination were 2.7 (95% confidence interval [CI], 1.4–5.1) and 0.4 (95% CI, 0.2–0.7), which are statistically, but not clinically, significant values for ruling meniscal lesions in or out.
Jackson’s meta-analysis also calculated the posttest probability of injury for a composite meniscal examination. Based on the positive likelihood ratio of 3.1 (95% CI, 0.54–5.7) and negative likelihood ratio of 0.19 (95% CI, 0.11–0.77), the posttest probability of a medial meniscal tear was 17% in the setting of composite physical exam findings and 1% in the absence of physical exam findings. For a lateral meniscal tear, based on the positive likelihood ratio of 11 (95% CI, 1.8–20.2), and negative likelihood ratio of 0.13 (95% CI, 0.0–0.25), the posttest probability of injury with a positive exam was 41% and with a negative exam 0.8%.
Authors of all meta-analyses noted the lack of standardization in physical examination maneuvers (especially the McMurray test)5 and, in some cases, no specification of how physical examination tests were performed. Authors analyzed the utility of the aggregate and composite knee examinations without specifying what constituted such an exam. No study included in the meta-analyses used control subjects without meniscal pathology, and few studies were blinded. Lack of blinding may have introduced verification bias; use of specialty patients in all studies made referral bias likely. Studies were heterogeneous and results were associated with wide confidence intervals, introducing an element of random error into the processes of combining and interpreting data.
TABLE
Physical exams for meniscal tear
| Summary characteristics | Solomon et al 4 | Scholten et al 1 | Jackson et al 3 |
| 9 studies 1018 patients Specialist population Specialist examiners | 13 studies 2231 patients Specialist population Specialist examiners | 4 studies 424 patients Specialist population Specialist examiners | |
| McMurray | Positive likelihood ratio (95% CI) | ||
| 1.3 (0.9–1.7) | 1.5–9.5 | 17.3 (2.7–68) | |
| Joint line tenderness | 0.9 (0.8–1.0) | 0.8–14.9 | 1.1 (0.7–1.6) |
| Aggregate exam | 2.7 (1.4–5.1) | — | — |
| Aggregate exam, medial meniscus tears | — | — | 3.1 (0.54–5.7) |
| Aggregate exam, lateral meniscus tears | — | — | 11 (1.8–20.2) |
| McMurray | Negative likelihood ratio (95% CI) | ||
| 0.8 (0.6–1.1) | 0.4–0.9 | 0.5 (0.3–0.8) | |
| Joint line tenderness | 1.1 (1.0–1.3) | 0.2–2.1 | 0.8 (0.3–3.5) |
| Aggregate exam | 0.4 (0.2–0.7) | — | — |
| Aggregate exam, medial meniscus tears | — | — | 0.19 (0.11–0.77) |
| Aggregate exam, lateral meniscus tears | — | — | 0.13 (0–0.25) |
| Note: The results are presented as likelihood ratios, which represent the change in the odds of a diagnosis, based on the outcome of the test. For example, given a positive likelihood ratio of 2, if a test result is positive, the odds of the disease being present is doubled. A positive likelihood ratio >10 provides strong evidence that the disorder is present. A negative likelihood ratio <0.1 provides strong evidence that the disorder is not present. Scores between 0.5 and 2.0 are neutral. In Scholten’s meta-analysis, likelihood ratios are given in ranges (no composite value given). | |||
Recommendations from others
The American Academy of Orthopaedic Surgeons’ clinical guideline on the evaluation and treatment of knee injuries lists the following findings as associated with a meniscal tear: delayed swelling of the knee, twisting injury, painful popping and catching, effusion, joint line tenderness, positive McMurray’s test, and negative radiography.6 The guideline fails to list the strength and type of supporting evidence for these associations.
The American College of Radiology’s Appropriateness Criteria for Acute Trauma to the Knee states that decision rules for meniscal tears and other soft tissue injuries to the knee are being investigated, but it fails to mention specific evaluation strategies for meniscal tears.7
Meniscus injury likely with suggestive history, joint line tenderness, and an inability to squat because of pain
Roy Henderson, MD
Director, Sports Medicine Fellowship, MacNeal Family Practice Residency Program, Chicago, Ill
I often suspect meniscal injuries as a cause of knee pain but am rarely certain based on physical examination alone. I look for a history of joint line pain, locking, or popping with movement. If the patient lacks joint line tenderness, a meniscal injury is unlikely. The McMurray test is usually negative. In the absence of another explanation for the patient’s symptoms, a meniscus injury is high on my list in the presence of a suggestive history, joint line tenderness, and an inability to squat because of pain. When my suspicion is high I usually resort to an MRI.
1. Scholten RJ, Deville WL, Opstelten W, Bijl D, van der Plas CG, Bouter LM. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract 2001;50:938-944.
2. National Ambulatory Medical Care Survey 1996. Available at: ftp://ftp.cdc.gov/pub/Health-Statistics/NCHS/Datasets/NAMCS/. Accessed on August 18, 2004.
3. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med 2003;139:575-588.
4. Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee?. JAMA 2001;286:1610-1620.
5. Stratford PW, Binkley J. A review of the McMurray test: definition, interpretation, and clinical usefulness. J Orthop Sports Phys Ther 1995;22:116-120.
6. American Academy of Orthopaedic Surgeons. AAOS Clinical Guideline on Knee Injury: Support Document. Last updated February 26, 2002. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2001. Available at: http://www.guidelines.gov. Accessed on September 30, 2004.
7. American College of Radiology (ACR) Expert. Panel on Musculoskeletal Imaging ACR Appropriateness Criteria for Acute Trauma to the Knee. Updated October 1, 2002. Reston, Va: American College of Radiology; 2001. Available at: http://www.acr.org/cgi-bin/fr?tmpl:appcrit,pdf:0365374_acute_trauma_to_knee.ac.p df. Accessed on September 30, 2004.
1. Scholten RJ, Deville WL, Opstelten W, Bijl D, van der Plas CG, Bouter LM. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee: a meta-analysis. J Fam Pract 2001;50:938-944.
2. National Ambulatory Medical Care Survey 1996. Available at: ftp://ftp.cdc.gov/pub/Health-Statistics/NCHS/Datasets/NAMCS/. Accessed on August 18, 2004.
3. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med 2003;139:575-588.
4. Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee?. JAMA 2001;286:1610-1620.
5. Stratford PW, Binkley J. A review of the McMurray test: definition, interpretation, and clinical usefulness. J Orthop Sports Phys Ther 1995;22:116-120.
6. American Academy of Orthopaedic Surgeons. AAOS Clinical Guideline on Knee Injury: Support Document. Last updated February 26, 2002. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2001. Available at: http://www.guidelines.gov. Accessed on September 30, 2004.
7. American College of Radiology (ACR) Expert. Panel on Musculoskeletal Imaging ACR Appropriateness Criteria for Acute Trauma to the Knee. Updated October 1, 2002. Reston, Va: American College of Radiology; 2001. Available at: http://www.acr.org/cgi-bin/fr?tmpl:appcrit,pdf:0365374_acute_trauma_to_knee.ac.p df. Accessed on September 30, 2004.
Evidence-based answers from the Family Physicians Inquiries Network