THE

DIAGNOSIS
SOME

BY A. GRAHAM

OF

MENISCUS

INJURIES

NEW

CLINICAL

METHODS

APLEY,

F.R.C.S.,

PORTSMOUTH,

ENGLAND

INTRODUCTION

In the year
derangement
somewhat
a meniscus

lesion.

firmation

was

almost

one

great

1803, William

Hey

of the knee.
vague,
description
However,

not

wrote

years,

but

the

Jones

and

later

his

patients
records

succeeding

which
but
that

he termed

it did
locking

by manipulation
hardly
any progress

twenty

or

so

years

internal

include
might

the first,
be due to

alone,
direct
in diagnosis

contain

confor

galaxy

of

names.
First.

results

Sir

Robert

of numerous

DArcy

meniscectomies,

and

Power,

focused

careful

analyses

feature

stands

of

seen
that

at operation.
in 30 per cent.

and

hypermobile

Despite

the

high

and

a discussion
Association;
large
series

the

of

recorded

the

split

as the

longitudinal

on internal
derangement
of
and since that time Bristow2,
of cases
of knee
injury,
with

meticulous

proportion

Morison

on the

work

cases

in

in

all

these

series,

no meniscus

which

quotes
a figure
of 10 per cent.,
while
was no split,
this proportion
including

one

split

Bristow
many

was

found
normal

menisci.

driven

to conclude

sprain

of

the

tibial

findings.

Sir Robert
Jones
of hmis cases
there

attempts

Many

had

timeir

out,-namely,

Martin,

attention

primary
lesion.
Thmen, in 1924, Bristow1
opened
the knee at a meeting
of The British
Orthopaedic
Platt5,
McMurray,
and others
have
described

or

of a condition

not a clear-cut
entity,
; and Hey suggested

he treated
The literature

as

obtainable.

imundred

of Leeds

This
was
of locking

at an explanation
that

this

in

which

knee,

collateral

already

group
the

ligament

been
of

damaged,

time difficulty

made,

but

an enigma.

attachments

were

emphasized

have
remained

the

had

in

as recently

However,
medial

also

as 1930

by this

meniscus

been

to

described

distinguishing

the

; and

a rotation

Platt

time

the

was

rotation

tibia,

capsule,

various

authors

sprain

from

a split

meniscus.
With

and

all

these

reliable

entiating

a split

some

advances,

two

pathognomonic
meniscus

methods

which

from

aim

at

The

causal

force

weight,

if

excessive

grinding

force

splits

extensions

same

may

force

ments,

thus

(and

therefore

whereas
ever,

is

78

producing

that

not
the

time history
Read

the

at

the

be

present

may
Spring

is clearly
meniscus

force

different

varieties

meniscus

away

rotation

sprain.

is essential

in the

Meeting

a rotation
may,

help

in
of

absence

of any

constant

DAMAGE

recognized.
With
the knee flexed
and
is fixed between
the tibial
and femoral

the

for

not

MENISCUS

the

so-called
force)

selfsame

IN

takes
place,
something
of the meniscus,
and

wrench

a grinding

FORCE

damage
the

producing

instead,

it need

therefore

May

occur,

may,

the

; and, second,
the difficulty
of differThe purpose
of this paper
is to describe

gaps.

Since

rotation
substance

first,

remain:

meniscus
sprain.

these

CAUSAL

occurs.

the

gaps

a split

a rotation

in meniscus

a twist

condyles,

for

filling

THE

bearing

notable

sign

on

sprain
occasion,

must
from
of

from
It

torn

occur.

produce

Sometimes
this
tear secondary

meniscus.

some

of its

is quite

production
to

give
way.
this primary

true
of

Precisely

peripheral
that

a split

weight-bearing

the

in

The

important

either

type

the

attachmeniscus,
point,

of

injury;

howand

differentiation.

The

British

Orthopaedic

Association,

Newcastie-upon-Tyne,

1946.
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

FIG.
Distraction

Time

roost

PRESENT

l)oltance,
imowever,

METHODS

a diffeieimt

tieclares

that

tianmage(I
testilmg

is not
joint
time

Time ioutine

2.

in

a truly

diagnostic
method

time knee
imianoeuvre

there

seem

reliable

sign.

Many

surgeons

time surgeon
as Platt

exaimminiimg

imiechanics.

imis knee,

imeki

t.hmigii anti

thmeie

are

in time surgeons

time leg are

fixed

hmand.

unstable,

and

Its

cause
fail

Flonm

time

(healing

resolved
phisimeti
tiescribeti
time

by

time

tutiinal
VOL.

its

29, NO.

tiistinct

of

stress

a immeniscus

as, for
frag-

in position,
and
of time hmiglmest im-

lie in a different

find

it

at

all,

pain.

knee

altimougim

cases.
pull

Timus,

injui-y

patient

lying
pelvis,

these

not

on

two,

aticquately

his

on thmose

in time very

whichm

the

long

steadied

back
rests

by the

the

of

sui-geoim
armd time

time bed,

connecting

tissues

process

immethmotl is

anti
on

or

McMui-ray

levers

surgeons

()f time

imand.

SOLUTION

we

a confused

application
(or

constant
although

in hmis personal
nmust necessarily

points,-time

components.

First,

haying
time patient
on his face
later.
Second,
to effect a diagnostic

separating

for

of flexion,
a nmeniscal

paragraphms
it is evhient
timat, in the examination
of time knee,
problenm
of mechanics.
To solve
timis problenm,
it must

foiegoing

with

into

of exanmination

immy actively
confuse
time picture.
imas eimmphmasized,
is that
time present

A THEORETICAL

are

may
to

constant
rotation

Between
are

INJURY

is held in varying
degrees
is calculated
to displace

extraneous

With
two

nmetimod

time knee.

a (iiagnosis
can usually
he immade. All too often,
to be three
disadvantages
in thmis nmetimod of

click is reliably
of testing
by

a nielmiscus
injury,
Time timir(i tiisadvantage,

2
of

MENISCUS

click,
which
is palpable,
withm time hmistory
(whicim,

so producing

unstable

FOR

time present-day

sprain,

u0im

aimkle,

EXAMINATION

thmis paper)

anti

entirely.

in ti Iotatiolm

3.

in

while
Timis

fot-

based

OF

feature

tibia,
test.

is Imot ticalt
withm
signs
aic absent,

cxanminatioim:
1. A chick
in

Compression

produce
time well-known
time patient..
Togethmer

by

79

INJURIES

FIG.

iimmportant

to

MENISCUS

time knee.

injury
is iotation
of the
exaimmphe, in McMurrays
nment anti
iecognizeti

OF

1
of

TIlE

DIAGNOSIS

a longitudinal

distracting)

simould

1, JANUARY

stress
force,

be capable
1947

and

of easy

is

stabilization
and fixing
separation

required.

a compressing

application.

of
his femur
between

This
force;

stress
and

time levers

can

be

be

accoimm-

in a way
wimicim will be
meniscus
and soft tissues,
simoulti,
timese

alternately,
two

types

be
of

longi-

A. G. APLEY

80

(Time

various

illustrations

immize bothm time theoretical

and time I)ractiCal
tests.
are

easy

tient,

to

but

tiemonstrate

less

Figure
result

so

applying

turbed.

time

pa-

timeoretical
or dis-

separation

(For

tibial

snmml)hicitv.

Ofll

higammment

is simown

collateral

time (hagranm,
time

har

time

print..)

to time knee.
Clearly
, time
tissues
are
being
stretcimed,
time immeniscus
renmains
uimdis-

traction

soft
wimile

and

in

in

1 shmows

of

epitoarguments
These
tests

capsule

is,

(higanmentous,

capsular

I an(i
would

sinmi-

of

oim thmis
time

fibrous,
timese

of
be

based
test

in

fibers

un(ieig()

1 A test

thmerefore,

tissues
tt test

coronary

must

stretciming.

fact

time

iMit

time

soft

and

alone.

4uchm
in a rotation

positive

sprain.
FIG.
Rot

at iorm of

i o timknees--i

rmmanoeu

vre.

produceti,

tutes

itself

is beiimg

rotatiolm

a grinding

can

force

11G.

Rotatioim

ci-ushmeti.
be

addeti.

wimicim is an

In

this

position,

in

Timis combination
accurate
reprotluction

are

addition
of

clearly
to

time

FIG.

Time
THE

OF

time

relaxed,

for
soft

but

time

ah-eadv

rotation
(iestructive

constilot-ce

(list ra-tiomm

JOURNAL

Here

conmpression

conmpression
and
of time original

alone.

time basis

test.

compression

tissues
nmeniscus

2 illustrates

Figure

3
miehi rimmary

BONE

test.
AND

JOINT

SURGERY

THE

in nieniscus
forimm

the

basis

renmains

of

to

posterior

OF

daimmage, so timat a positive

in timese siiimpie ternms,

Expressed
It

DIAt;NOSIS

time

proposed

translate

grinding
time two

tests

timese

to

test

81

INJURIES

1)oiflts

unequivocally

manoeuvres

fulfill

theoretical

Immetimo(i of examination

MENISCUS

time

to immeniscus

of coimmpression

requireimments

considerations

and
put

previously

into

practice;

injury.

distraction

and,

to

forward.

do

timis,

is employed.

THE

POSTERIOR

EXAMINATION

OF THE

KNEE

For timis exanmination

time patient
lies on imis face.
He simould be on a coucim imot immore
thman two feet. Imigim, or time tests
beconme
difficult,
and he nmust l)e well over to time edge of
time

coucim

start

time

nearest

gras)s

one

nally

rotates

timen

flexes

timeir

linmit

imas

foot

hiimmited

tation,

an(1

tioim

of

later

in time

fixes

time

i)o\\erful
Timis
I(

ioim

left

patients

ilmmi)oltant

to

01)-

imis weighmt

levers

grasped

ai)solUtClv.

in

botim

imantis,

angle,

to a right

l)Ioduces

Next,

WithOUt

vhmile
in timis position

and

(ietellmmine(i

FI(m.

Time

l)ain.
chmalmgilmg time position

time surgeons
of (histraction,

Ul)\itI(I,
i)t

his

time

external
rotation
is apphie(i.
deternmines
wimetimer siimml)le

test

)t Itt

of

It is

bent

is

useful

timen applies

time

of
is

ktmee

again.

i)rves

back

4 )

Ofl(

anti

togetimer

in timis position

foot

imis

inward,

angles

time

timigim ( Fig.

Time

cimanges

feet

exaimmination.

Time surgeon

timat

to

timis iiimmit

imianoeuvie
tieimioniotation,
I)ainful
ro-

timese

to

and

time exact
angles
of flexthese occur ; time estiimma-

wimicim

serve

\Vimen

knees

exter-

togetimer

lie

time

strates

knee

l)ossibie,

i-eacimed,

l)rehilmminaly

at

imand,

as
.

To
surgeon

eacim
knees

t Fig.

time

Fimis

surgeon.
time

fat-

i)Otim

iotttes

eXtelmds

ion

in

as

been

gras),

time

exaimmination,

of time hands,

weigimt preents
time peiful

I ) vimetimer

ot

not

time femur
external

time immanoeuvre

grinding

test.

time i)atielmts

leg

is strongly

l)uhied

rising
off time couch
t Fig.
is repeated.
Two timings

froimm
rotation

produces

pain

2 ) , stiil

and

]1t0Ft

5
can
iimm-

i)ortant.,
vimethmei time pain is greatel
timan in rotation
alone
without
time distractiotm.
If time
l)itiim is gieatei,
the tiisti-action
test is positive,
anti
a rotation
sprain
nmay l)e tiiagnosed.
Thmen the surgeon
icalms \Vehl over time h)atient
anti, witim imis wimole body
weigimt,
coimmresses
time tii)itt
(iownwar(.i
olmto
time couchm
(Fig.
6) . Again
hme rotates
l)owel-fuhhy,
IIIm(i
again
ime asks tWo questions:
( 1 ) Does
it imurt.?
(2) How
immucim (toes
it imurt?
If time
additiolm
t)f coimmplessiolm
imas i)ioduce(i
an increase
of l)ain,
timis gI-in(ling
test is l)ositive,
alm(i
immeniscal (laimmage is (hiagnoseti.
Incidentally,
this question
of time aimmount of pain is not a matter
of fine imait-hitme mhistinc-

tioim;

time patient

immust

be

sure

of

THE

1.

So

rotatiolm
VOL.

29.

far,

sprain.
NO.

1, JANUARY

attention

imas

Thmis is time first,

1947

difference,

a considerable

been
almd

USES

OF THESE

focuseti
l)elimal)s

on

and

indeeti

he

usually

is.

TESTS

differentiating

time nmost

iimmportant,

a nmeniscus
use

of

injui-v
timese

tests.

frommm a
Fime-

82

are

A.

also

duce

useful

in other

types

of cases,

G.

APLEY

however,

In

2.

signs
may

nmany

of meniscus
be grossly

patients

chary

of

the

damage
disabled.

imorn of time meniscus

may

operating

in

history

cannot
Again,

be difficult.

time

With
now

a suspected
time leg

tear

at

apparent

a rigimt

of

any

of which

it is necessary

in the

as well.
A third

3.
may

also

use

of time tests

be difficult

inward
instead
as to whether
both rotations

at times.

to intro-

of outward
this is worth
at all angles

diagnosis

Any diagnostic
test simould
easy
to do ; (2) it should

fairly
and

(3)

it should

The

grinding

careful
attention
in compression
all

important

As
distraction
presented
Since

to

be

negative

test

for

is not

to detail.
and rotation,
points,

too

other

the

accustomed

the

history

or

3)

; instead

The

the

of

importance

angle

is

of flexion

lateral

modified

grinding
test
the preliminary

THE

meniscus,

by

which

rotating

is performed.

manoeuvre,

the

foot

The

clue

in which

TESTS

: (1 ) It simould
lesion
concerned;

criteria
precise

the

be

lesions.

difficult,

neglect

unreasonably

in

is modified

of the
are

three
fundamental
positive
for

but

it does

The use of a low

and carrying
out

whether
the grinding
test with a soft-tissue
at a somewhat
early

becoming

all

tests

a reverse
given
by
performed.

be judged
by
be constantly

not

should
always
be repeated
at precisely
accurate
localization
of the meniseus

the

OF

l)hysical

limps
his way,
for
a second
use for the
diagnosis
(and
mci-

acutely.

(Fig.

of lesions

purpose

LIMITATIONS

are

test

more

manoeuvre

common

feature

grinding

much

the test
to obtain

; in other
words,
trying
is again
of flexion
were

the

surgeons

diagnostic

the

preliminary

this

and

vague,
although
the patients
of a lesion
of the posterior

therefore,
the patient
There
is, therefore,
the doubt
as to the

is flexed

is in the
For

of cases,
clear

horn,

knee

at which
pain is produced
by rotation,
for
this angie.
In timis way it may
be possible
lesion

types

posterior
the

precision

findings
are
the diagnosis

single

infrequently,
physiotherapy.
positive,
then
removed.

of the
angle,

of determining,

diagnostic

In both

absence

physical
examination.
Not
months
or years,
with
the aid of
tests ; for, if time grinding
test is
dentally
the meniscus)
should
be
holding

lacks

be elicited
; the
in many
patients

time

are

in some

modifications.

of which

need

a good

deal

couch,
the application
the test at the suitable
may

result

in

of practice

and

of considerable
angle
of knee

force
flexion

failure.

test is always
positive
with
a meniscus
lesion
and the
lesion,
it is perhaps
too early. to say.
This paper
is being
stage
in the hope that
more
widespread
trials
will follow.

to the

tests,

however,

the

author

has

been

surprised

by

their

constancy.
With
regard
to other
lesions,
the author
has three
times
found
the grinding
test positive
wimen timcre was a pedunculated
loose
body
other
than
a split
meniscus.
This
does not
seem to be a serious
drawback
for, quite
apart
from the help afforded
by roentgenograms,
operation
was no less indicated.
RESULTS

Time results
because,
simply

in

time

and

speaking,
mitted

firmly.

Groups
the

tests

Group
in

none

imowever,
the
at operation.

timcse

great

These
to

be

resulted

A consists

methods

majority

A and

a diagnosis

wimicim
anti

by

of

cases
B are

shown

cases,

in Table

the

orthodox

made;

whereas

Groups

correction

of

cases.

positive

was

In none

was

physical

clearly

positive,

sign

The

number

D,

of

cases

established

and only fifty

the application

C and
wrong

I.

methods

are therefore
omitted,
those
in which
only

in the

of ten

was a single
grinding
test

are

is small

the

diagnosis

cases remain.
of the new

especially

Group

D,

Broadly
tests
perare

those

in

diagnoses.

there

a history

found

and

by

in each

THE

typical

orthodox

a split

JOURNAL

of meniscus
methods.

meniscus

OF BONE

injury,
In

was

AND

JOINT

all

ten,

removed

SURGERY

DIAGNOSIS

THE

OF

MENISCUS

TABLE
.

Findings
No of
ases

Group

..

Tynical
..
rnsrory

of

13

Orthodox
.

Positive
Tests

Variable

Findings

Diagnosis

by

Actual
1-v
.

traction

est

Methods

iiis-

Grmdmg

Nomeniscus
lesion
Probably

New

Positive

Positive
.

Meniscus

Injury

RESULTS

Methods

Meniscus

10

----

by

83

INJURIES

Diagnosis

--

Test

10

Split
meniscus

13

Split
meniscus

no meniscus

Split
meni.scus
at operation
Split meniscus

found

lesion

15

Variable

Fairly

good

at operation

? Split
meniscus

Probably

15

split
meniscus

Miscellaneous

cases

--time histories

damage.

cases
varied

Again,

however,

sprain

(not

sprain

Rotation

Rotation

proved)

sprain

discussion

B, orthodox

__

physical

complete

vagueness

grinding

test

the

Rotation

23

of Group
from

Rotation

sprain

In time thirteen
but

for

lagnosis

examination

to more

was

constantly

was

or less

definite

positive

; and

again
hints

negative;
of meniscus

in these

cases,

too,

a split

nmeniscus
was removed
at operation.
In a few of time cases in Group
B, the history
alone
might
possibly
have
led to operation.
This links up with Group
C, for in the fifteen
cases of this group,
there
was a similar
variability
and vagueness
in the history,
coupled
with absence
of orthodox
physical
signs.
To all appearances,
therefore,
Groups
B and C are alike.
In all the cases
of Group
C,
however,
time distraction
test was positive,
and a diagnosis
of rotation
sprain
was therefore
made.
Group

D carries

the

time imistory

definitely

was

McMurrays
time distraction

diagnosis,
negative

a stage

suggestive

sign was
test positive,

I)oSit.i\e

anti

argument

further,

of meniscus

for

it

into the joint

but the results

of

nine

moreover,

probably
obtained.
Again
and a rotation
sprain
was

in Groups
C and D operation
au- artlmrogranms
were obtained,

consists

damage;

cases

in three

in whicim

of timem

the grinding
test was negative
therefore
diagnosed.
With
this

was
with

not indicated.
this method

In
are

a few cases
insufficiently

constant
to afford
proof.
Purely
conservative
methods,
including
manipulation
in some,
al)peal
to have
justified
time diagnosis.
It is not unlikely
that,
without
these
tests,
at least
time three
cases
nmentioned,
and probably
several
more
of this group,
would
have
come to
operation,
and that
normal
menisci
would
have
been removed.
Here,
timen, are cases
with
an apparent
diagnosis
sprain.
It is impossible
some

of timose

enigmatic
consists
on time basis

Group

was

of meniscus
to resist
the

and
also
remaining

a positive
two cases

grinding
test;
had previously

horn
remained,
diagnosed
distraction
test, however,-a
minmicking
rotation
sprain.
firmatory

evidence

One
very
VOL.

curious

obvious
29,

NO.

of the
case

McMurrays
1, JANUARY

which
that

were
actually
examples
of rotation
this may provide
the explanation
for

cases in which
normal
menisci
are removed.
of three
miscellaneous
cases.
In one, the diagnosis
of split
of the history,
a positive
physical
examination
by orthodox

made

damage,
speculation

1947

was

nevertheless
a normal
meniscus
was
had meniscectomy
; in both, a fragment

removed.
The
of time posterior

by the positive
grinding
test.
They
also
showed
curiosity
explained
by the presence
of postoperative
Thus
an apparent
contradiction
proved,
in fact,
validity

of these

seen.

The

patient

sign.

When

the

meniscus
methods,

a positive
adimesions
to be con-

tests.
had
grinding

a reasonably
test

was

suggestive
performed,

imistory
and

and

conmpression

84
and

A.

rotation

somewhat
unlocked
seem

were

to the
it three

applied,

there

authors,
the
times
in all.

to suggest

that,

in the

was

G.

APLEY

click.

a sudden

knee was
Fortunately

grinding

locked.
this

test,

Much

to the

patients

surprise,

To satisfy
himself,
the author
was not a very painful
process

the

correct

type

of force

and

locked
and
; and it does

is being

used.

SUMMARY

Some

new

tion sprain,
in knee-joint

tests

for time diagnosis

of meniscus

have been described.

These
injury,
and at reproducing

Witim wider
experience,
it is hoped
timat
in the diagnosis
of knee-joint
injuries.
NOTE
: In connection
Perkins,
Professor
Piatt,
most
grateful
to Brigadier
generous
cooperation
; and

with

the

injury,

they

preparation

may

of

this

help
paper,

hmis brother,

its

Dr.

J.

Apley,

for

differentiation

to reduce

time percentage

are

especially

criticism
and
and Colonel

his

from

rota-

the individual
components
force
of meniseus
damage.

thanks

and Mr. W. R. Bristow

for valuable
D. Fettes,
Colonel
E. M. Townsend,
to

and

tests aim at separating

the causal
grinding

invaluable

due

advice.
E. P.

of errors
to

The

Mr.

author

is also

Creagh

N.

George

for their

assistance.

REFERENCES

1. BRISrow,
Apr.
2.

3.
4.
5.
6.

W.

R. : Internal

Derangement

of

W.

R. : Internal

Derangement

of

BRISTOW,

July

1935.

HEY,

WILLIAM

JONES,

: Practical

On

ROBERT:

Birtimday

Volume,

MARTIN,

A.

M0RIS0N,

301-306.

Discussion

and

in

J. Bone

Knee-Joint.

on
Injuries

Knee

of

Joint.

Chap.

the

Knee.

J.

and

the

Diagnosis

British
to

time

and

Med.

J.,

2:

Bone

6.

London,

Clin.

J.,

of Internal
Derangements
London,
Humphrey
Miiford,

Dislocations.

RUTHERFORD:

the

Surgery,

Derangements

Time Diagnosis
pp.

M.:

Observations

Certain

T. P.:

MCMURRAY,

Thman Fractures
7.

the

Joint

Surg.,

and Joint

Surg.,

7 : 413-450,

1925.

51-64,

of

Cartilages

of time Knee

Treatment

of Displaced

605-626,

1906.

Knee.

Treatment
of Injuries
1070-1076,
1913.
Cartiiages

1803.

28:

of the
1928.

Semilunar

17

In
of

the

Knee-Joint.

Joint.

Acta

the

The

Robert

Jones

Knee-Joint
Chin.

Other

J., 42:

1-7,

1913.
8.

PLATT,

654-665,

HARRY:

Lesions

of

the Semilunar

Chir.

Scandinavica,

67:

1930.

9.

PLATT,

10.

POWER,

DARCY:

Personal

Britisim

Med.

HARRY:

Resuits
J., 1: 61-67,

Communication.

of the
1911.

Surgical

THE

Semilunar

JOURNAL

Cartilages

OF BONE

of time Knee.

AND JOINT

SURGERY