Roger Zhao, MS, DPTc

Spring Symposium 2012

PT 910

 Transmit weight bearing forces

Joint stability and protection
Increases congruity and contact area
Shock absorption
Nutrition, and lubrication for the
articular cartilage
Proprioception
*Limitation of extremes of flexion
and extension
* Load sharing, stress distribution
http://www.mendmeshop.com

(Chivers 2009, Greis 2002)

 Twisting injury or hyper-flexion

Rotation + Compression
Forces: +50-70% more load when in extension
and +85% with 90 of knee flexion

(Chivers 2009; Greis 2002)

 Tearing sensation
Delayed effusion
History of catching or locking
Pain with forced hyperextension or maximum flexion
Pain or audible click with special tests
Joint Line Tenderness (JLT)

(Lorenz 2011)

 2nd most common injury to the knee

Incidence: 60-70 per 100,000 individuals/year
(Logerstedt 2010)

(Poulsen 2011)

10-20% of all orthopedic injuries

50% of knee surgeries
(Harrison 2009)

(Logerstedt 2010)

 Injured knee playing Volleyball

Symptoms:
Knee stuck or locked
Pain weight bearing
Immediately tested:
(-) McMurray
(-) Apley
(-) Joint Line Tenderness (JLT)

www.creativerehab.com

 Orthopod: Performed tests

(-) McMurray, Apley, JLT

(+) Thessaly
(Arthroscopy)

Magnetic Resonance
Imaging (MRI):
Complex tear
Oblique + flap
~50% lateral mensicus

What are the current most common

meniscus special tests?

Meta-analysis of Current Tests

- Low specificity, sensitivity
- Clinical examination alone limited (Konan 2009)
Methodological Quality: Poor to Fair (Meserve 2008)
Large conflicting differences in diagnostic accuracy
(Chivers 2009)

Varying criteria for diagnosing meniscus tear.

(Chivers 2009)

 History alone is insufficient as a diagnostic

tool for meniscus tears
(Hegedus 2007)

Symptoms are often vague and non-specific

Current literature shows that knee meniscal tests

are not diagnostic and there is heterogeneity
between similar studies.
(Hegedus 2007)

 No current accurate tests to assess and diagnose

meniscal tears
Most current clinicians and recent studies base the
Thessaly test accuracy off of only one study,
Karachalios 2005, by the creator of the test.
No current systematic reviews or meta-analysis
combining all current original studies on Thessaly test

 Arthroscopy: 90-95% accuracy

Gold Standard (Konan 2009)
20% tears found on arthroscopy not
diagnosed on original MRI (De Smet 2008)

MRI: 59-97% accuracy

(Lorenz 2011, Jee 2003)

No difference between MRI and exam (Korcabey 2004)

Exam by clinician has shown greater accuracy (Lorenz
2011)

High cost and incidence of false positives (Konan 2009)

 Dynamic reproduction of
load transmission in the
knee joint performed at
5 and 20 of flexion.
(+) Positive: Medial or
lateral joint-line discomfort
and may have a sense of
locking or catching
(Karachalios 2005)

 Examiner supports patient

by holding his or her
outstretched hands while the
patient stands flat footed on
the floor. The patient then
rotates his or her knee and
body, internally and
externally 3X, keeping the
same amount of flexion.

(Karachalios 2005)

Rotation and
Compression
with Flexion

Re-created by
Thessaly Test

Ellicit Symptoms

High Diagnostic
Accuracy

 Frequently treat patients with vague knee pain and

variety of symptoms that could indicate meniscal
pathology.
Accurate diagnosis of underlying injury
Rehabilitation and Plan of Care
Decrease cost and time saved without need for imaging
(conservative treatment/direct access)
Referral to MD for further imaging

1. Evaluate the evidence of a relatively NEW, but

well accepted special test to rule in the diagnosis
of meniscal tears in the knee.
2. Provide a reliable, clinical first-line screening
tool that is accurate and easily performed.

Background: Diagnostic

Is the Thessaly Test a specific and

sensitive examination tool for
confirming the diagnosis of a
meniscus tear?

 Is the Thessaly test more accurate at 5 or 20?

Detecting lateral or medial meniscus tears?

Null
H0:

For confirming the diagnosis of a

meniscal tear the Thessaly test is not a
a) sensitive b) specific or c) both
sensitive and specific examination test.

Alternative
Ha:

For confirming the diagnosis of a

meniscal tear the Thessaly test is a a)
sensitive b) specific or c) both sensitive
and specific examination test.

 Limited to 1-5 studies

High sensitivity and specificity
Useful examination tool to be used in the clinic

 PubMed, PEDro, CINAHL, Cochrane Database, Google

Scholar
Checked reference lists and related articles

Search Terms:
Thessaly
Test
Diagnos*
Accuracy
Menisc*
Knee

 Inclusion Criteria:
English
2005 to current (creation of test date)
Adults with diagnosis of meniscal tear based off history and
MOI
Original validation study of Thessaly test

Exclusion Criteria:
Other Knee Injuries
Articles Excluded: 1 Non-English, 1 with concurrent ACL
tears, 6 non original study (meta-analysis in larger
meniscus test study or clinical commentary)

Sensitivity, Specificity,
Diagnostic Accuracy,
Likelihood ratios, Receiver
Operating Characteristic
(ROC) Curve
At 5 degrees (Karachalios
and Konan studies)

At 20 degrees (all 3
studies)

(Hing 2009)

*Secondary reviewer confirmed that the studies met the inclusion criteria

Study

Reference
Standard

Outcomes

#Tests
(n=subjects)

Karachalios Arthroscopy
et, al. 2005 and MRI

-Thessaly 5 & 20
-Medial vs Lateral tear
-McMurray, Apley, JLT

Tested:
1640
(n=410)

Arthroscopy
Harrison
et, al. 2009

-Thessaly at 20

Tested:
116
(n=116)

-Thessaly 5 & 20
-Medial vs. Lateral tear
-McMurray, Apley, JLT

Tested:
320
(n=109)

Konan
et, al. 2009

Arthroscopy
and MRI

 All papers high methodological quality:

1b

Independent blind comparison of an appropriate

spectrum of consecutive patients, all who have
undergone the diagnostic test and the reference
standard. - Sackett et, al. Diagnostic Criteria

Data

True +

True -

Thessaly Test +

413.00

93.00

506.00

Thessaly Test -

166.00

1,404.00

1,570.00

579.00

1,497.00

2,076.00

Study

Sensitivity

Specificity

Diagnostic Accuracy

Karachalios

80%

95%

91%

Harrison

90%

98%

93%

Konan

44%

85%

65%

Meta-Analysis

71%

94%

88%

71% of individuals with a meniscus tear will have a (+)Positive Test

94% of individuals without a meniscus tear will have a (-)Negative test

Study

PPV(%)

NPV(%)

LR+

LR-

Karachalios

80%

94%

15.07

0.22

Harrison

98%

86%

39.72

0.10

Konan

74%

62%

3.02

0.66

MetaAnalysis

82%

89%

11.48

0.31

82% of individuals with a (+)Positive Test will have a meniscus tear

89% of individuals with a (-)Negative test will not have a meniscus tear

Sensitivity
Study

Specificity

20

LR+

20

LR-

20

20

Karachalios

69%

90%

93%

96%

10.15

24.09

0.33

0.11

Harrison

NA

86%

NA

98%

NA

39.72

NA

0.86

Konan

35%

53%

83%

88%

2.08

4.31

0.78

0.54

MetaAnalysis

59%

78%

92%

95%

7.38

16.73

0.43

0.23

Thessaly at 20 significantly more accurate at sensitivity,

specificity, and likelihood ratios.

Sensitivity, specificity, and likelihood ratios (LR) of Thessaly test for

detecting medial vs. lateral meniscus tears.
Study

MetaAnalysis
(Karachalios
+ Konan)

Sensitivity(%) Specificity (%)

Medial Lateral

70

65

LR+

LR-

Medial

Lateral

Medial

Lateral

Medial

Lateral

94

93

11.98

9.75

0.32

0.37

*Confidence intervals incalculable due to absence of raw data.

ROC Curve for Thessaly Test

Sensitivity (True Positive Rate)

1
0.9

20

0.8
0.7

0.6
0.5
0.4
0.3
0.2
0.1
0
0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

1 - Specificity (False Positive Rate)

0.8

0.9

Test

Sensitivity

Specificity

McMurray*

70%

71%

Apley*

60%

70%

JLT*

63%

77%

Thessaly at
20

78%

95%

*Meta-analysis by Hegedus et, al 2007; JOSPT

12 patients excluded in study by Konan et,

al., could not complete test due to pain or
were not confident.
Karachalios et, al. reported at 20 degrees,
3.3% of patients in the symptomatic group
had an exacerbation of knee symptoms
requiring analgesics. One patient had the
knee lock requiring manipulation under
anesthesia.

 No additional cost to perform this test to the clinic

Simple physical examination that can be quickly performed in
a few seconds.
Reduce the need for magnetic resonance imaging (MRI) for
diagnostics.
Average Cost/Year

Thessaly Test

MRI

Operating

$0

$165

Procedure

NA

$2000

Machine

NA

$2,000,000

Maintenance (annually)

$0

$800,000

(Pogetti 2008)

 REJECT Null H0: For confirming the diagnosis

High Sensitivity and Specificity
of a meniscal tear the Thessaly test is not a
High Accuracy and Validity of studies
a) sensitive b) specific or c) both sensitive
High LR+, LRand specific examination test.
Area under ROC curve: Excellent
ACCEPT Alternate Ha: For confirming the
diagnosis of a meniscal tear the Thessaly test
is a a) sensitive b) specific or c) both sensitive
and specific examination test.

 Small number of studies (n=3)

>75% weighting from paper by Karachalios (1640/2076
tests)
Strict Exclusion Criteria:
Early clinical or radiographic signs of OA
Excluding many differential diagnosis or pathologies
likely to result in a positive Thessaly test and decrease
accuracy.
No acute patients, only 4-6 weeks post injury
Difficult measure knee ROM 5 vs 20
Unclear Instructions
Rotation from spine versus from hip and knee

 Recommendation for future studies:

Include with other tests and symptoms to find
combination with best diagnostic accuracy
Create a less aggressive test to decrease harm
Larger scale studies in general population without
strict knee exclusion criteria
Long-term follow up cost comparison

 The Thessaly test is an accurate and valuable diagnostic

tool in assessing meniscal tears in patients.
Easily performed examination maneuver that all physical
therapists can learn quickly.
May be too aggressive for acute or irritable patients
5 - no harm reported
20 - harm, but more accurate
Use subjective history, symptoms, current function, and
clinical judgment before deciding to use test due to
reported harm.

 Thessaly test is an accurate and valid valuable

diagnostic tool in assessing meniscal tears.
High diagnostic accuracy in terms of sensitivity and
specificity.
20 more accurate than at 5
Physical therapists should incorporate the Thessaly test
into their physical examination when a meniscus tear is
suspected.

Jeanette Lee, PT, PhD

Deepak Kumar, PT, PhD, OCS
Diane Allen, PT, PhD
Thomas Tsai, DPTc
Tin Pham, DPTc
Bryan Ausink, DPTc
Dan Lorenz, PT, OCS, CSCS
UCSF/SFSU Class of 2012

 Primary

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