Joint Line Tenderness of the Knee


Definition/Description

The joint line tenderness test is used to screen for sensitivity related to meniscal injuries. [1] The test can be used if pain is localized to either the medial or lateral aspect of the joint, this is usually due to pathology of either the articular joint cartilage or the medial or lateral meniscus. The test is used by physical examination in the diagnosis of meniscal tears.[2]

Symptoms that can occur with joint tenderness include joint stiffness, joint swelling, joint redness, joint warmth, joint pain and joint deformity.[3]

The test is performed with the patient lying on the table with the knee in a flexed position of 90°. The test can be executed for the lateral border of the knee and for the medial border of the knee. [4]


Menisci from Above
Meniscal Tear on MRI

Clinically Relevant Anatomy

The femorotibial joint contains two menisci, a medial and lateral meniscus located between the corresponding femoral condyle and tibial plateau. The meniscus is a shiny-white tissue comprised of specialized extracellular matrix molecules. Each of them has a region-specific innervation and vascularization. Both menisci are critical for a well-functioning knee joint. [5]

Purpose

Joint line tenderness has been reported to be the best common test for meniscal injury. The joint line tenderness test is used to screen for sensitivity related to meniscal injuries. [1]
A person with joint tenderness has joint pain that increases when pressing on the surface of the joint or moving the joint through its normal range of motion. [3]

Technique

[6]

The tibiofemoral joint line is palpated to evaluate the maximal sensitivity of the joint line, this means that the palpated point from the joint line gives discomfort and is more tender than the unaffected leg at the same anatomic location. [4][5]

The knee needs to be flexed in 90°. The border of the joint line at the sides of the patellar ligament and the soft border between the highness of the femur above and below the tibia should be identified. The joint line palpation of the knee starts from the medial border of the patellar ligament towards the posterior aspect of the knee. Beginning at the lateral border of the patellar ligament, the lateral joint line was palpated in a similar way along the joint line in the posterior direction. The medial and lateral joint lines have to be palpated separately. The borders of the tibial plateau and the femoral condyles were palpated to affirm the presence of isolated posterior/medial joint line tenderness. The borders of the patella will not be palpated for any tenderness. [4]

The test is positive if the patient cannot tolerate the pain during the palpation.[4][5]

Validity and Reliability

Test-validity helps ensure that a test is measuring what it is supposed to measure.
Reliability= Reliability refers to the consistency of a measure. A test is considered reliable if we get the same result repeatedly.

To be able to describe the basic model of the test, the most obvious choice is the likelihood ratio (LR). This ratio is a variable that combines information provided by the sensitivity and specificity of a test. [7]

The sensitivity of a test is the proportion of people having the disorder who show a positive test result, and who actually have the disease or dysfunction. [8] When we apply this definition to our specific topic, sensitivity can be described as the ability for the joint line tenderness test to correctly identify those individuals with JLT and having a meniscal tear. [9] On the other hand, the specificity of a test shows the proportion of people not having the disorder, showing a negative test result, being people who actually do not have the disease or dysfunction. [8] In other words, this is the chance of a negative outcome of the JLT when the person does not have a meniscal pathology. [9]

Different Types of Meniscal Tears

For the calculation of the LR, it is advised to use the following formula: [7]
• Likelihood ratio of a positive test = sensitivity/(1-specificity)
• Likelihood ratio of a negative test = (1-sensitivity)/specificity

For the interpretation of the LR, there are a few simple rules. First of all the LR of a positive test must be larger than 1, and the higher the LR, the more certain you can be that a positive test indicates that the person truly has the specific disorder. Secondly, on the contrary of the positive test, the LR of the negative test must be below 1. The lower it is, the more certain you can be that a negative test indicates that the person does not have the disorder. [7]


When we simplify the formula of the likelihood ratio, we can interpret it like this:
LR+ = true positive/false positive
LR- = false negative/true negative
True positive value: the proportion of people who test positive who have the disorder.
False negative value: the proportion of people who test positive who don’t have the disorder.
True negative value: the proportion of people who test negative who don’t have the disorder.
False negative value: the proportion of people who test negative who have the disorder. [7]

After conducting a short study of existing literature, we’ve managed to write a conclusion about the way the results of the Joint Line Tenderness Test can be understood. The specificity and sensitivity of the JLT test is high in general, so we can conclude that the reliability of the test is high. On the other hand it is remarkable that the scores of the test for the lateral meniscus are significantly higher than the scores of the test for the medial meniscus. For instance, in the study from T.E Osmon the medial sensitivity is 86% and the specificity is 67%. [2] In contrast to the lateral test, here is the sensitivity 92% and the specificity 97%.  These opinion was also confirmed by other authors. [10][11] When we look at the LR, we can see that the results are similar. The positive LR shows rather high scores, whereas the negative LR shows low scores. In addition, it is remarkable that the lateral test also scores higher than the medial test, as shown in the previous results. [11]

A positive correlation has been found between joint line tenderness and meniscal lesions with a high sensitivity but a low specificity. However, patients with JLT would not exclusively have meniscal tears. [10][9] The accuracy of JLT predicting meniscal pathology decreases in the presence of an anterior cruciate ligament tear. [1]

Key research


The presence of JLT alone should not be used in the clinical decision making process to guide treatment. [12] It is proven that making use of joint line tenderness during a physical examination along with other tests such as McMurray test and the jointline fulness, the accuracy of clinically diagnosing of meniscal tears improves. [13] Physical examination and clinical meniscus tests in addition to a well taken anamnesis have still been the most important means of diagnosing a meniscal tear. For a well done taken anamnesis we refer you to ’het gezondheidsprofiel’ of P. Vaes. [14]  JLT has been reported to be the most accurate but the least specific meniscus test. [10] The joint line tenderness test has the highest rate of sensitivity compared with the McMurray test, the Apley’s test, the Ege’s test and the Thessaly test which reviews pain on forced extension. [10][2][15]

JLT has a lower rate of accuracy (83%) compared with other tests but is has a higher rate of accuracy in lateral meniscus compared with medial meniscus (93%). [10][15] We see that all the tests, except for the Ege’s test and the Thessally test, are performed in non-weight-bearing positions whereas most of the symptoms of a torn meniscus occur during weight bearing activities. [10] Ege’s test and the Thessaly test, have compression with weight bearing or clinician-applied axial rotation, were found to have the strongest diagnostic accuracy but with smaller samples in the studies. [10][16]

When we compare the JLT with the Ege’s test and the McMurray test we can conclude that there is no statistically significant difference between the three tests in detecting meniscal tears. We have noticed that JLT and Ege’s tests are the most accurate tests for medial meniscus tears but the specificity of the Ege’s test was higher. [10] Many studies showed a lower sensitivity for the McMurray test than for the joint line tenderness test in diagnosing meniscal tears. [2] We also compared the JLT with the McMurray and the Apley’s test. We have found the same results. JLT has a higher sensitivity but the specificity values were larger with Apley’s test compared to JLT and McMurray’s test. [10][16]

References

  1. 1.0 1.1 1.2 Akseki D. et al. The accuracy of the clinical diagnosis of meniscal tear with or without associated anterior cruciate ligament tears. Acta Orthop Traumatol Turc. 2003;37:193-8 (2B)
  2. 2.0 2.1 2.2 2.3 Osmon T.E. The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2003, pp 850–854. (1B)
  3. 3.0 3.1 Stephen J. et al. Joint tenderness overview. DSHI systems. Aug 19. 2010(5)
  4. 4.0 4.1 4.2 4.3 M.R. Wadey V., G.H. Mohtadi N., C. Bray R., B. Frank C., Positive predictive value of maximal posterior joint-line tenderness in diagnosing meniscal pathology: a pilot study, Can J Surg. 2007 April; 50(2): 96–100. (1B)
  5. 5.0 5.1 5.2 Elleftherios A. Makris et al. The knee meniscus: structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials. 2011 October; 32(30): 7411–7431. (5)
  6. Physiotutors. Joint Line Tenderness Palpation | Meniscus Tear. Available from: https://www.youtube.com/watch?v=XBle4px05ck
  7. 7.0 7.1 7.2 7.3 Davidson M. The interpretation of diagnostic tests: A primer for physiotherapists. Australian Journal of Physiotherapy, Vol. 48. 2002 (5)
  8. 8.0 8.1 Hing, W. Validity of the McMurray’s Test and Modified Versions of the Test: A Systematic Literature Review, The journal of manual and manipulative therapy, Vol . 17, No 1. 2009 (1A)
  9. 9.0 9.1 9.2 A Blackburn T., Craig E., Knee Anatomy: A Brief Review, PHYS THER. 1980; 60:1556-1560. (5)
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Akseki D, Ozcan O, Boya H, Pinar H. A new weight-bearing meniscal test and a comparison with McMurray's test and joint line tenderness. Arthroscopy. 2004, pp 951-8.(2B)
  11. 11.0 11.1 Horn, A. Diagnostic Accuracy of Orthopedic Special Tests for Meniscal Injury, Pacific University, CommonKnowledge, Critically Appraised Topic. 2011. (5)
  12. Shelbourne KD, Benner RW. Correlation of joint line tenderness and meniscus pathology in patients with subacute and chronic anterior cruciate ligament injuries. The journal of knee surgery. 2009, 187-190. (2B)
  13. Couture JF., Al-Juhani W., Forsythe ME, Lenczner E., Marien R., Burman M. Joint line fullness and meniscal pathology. Sports Health. 2012, 47-50.(1B)
  14. P. Vaes, Het gezondheidsprofiel, standaard uitgeverij, 2011, pp 0-160. (1A)
  15. 15.0 15.1 Kurosaka M., Yagi M., Yoshiya S., Muratsu H., Mizuno K. Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear. International Orthopaedics. 1999, 271–274.(1B)
  16. 16.0 16.1 Karachalios T., Hantes M., Zibis AH,. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005; 87: 955-62. (2B)