Medial Meniscal Tear: Benefits Of Ultrasound And Nonsurgical Treatment - Page #4
 

Working Diagnosis:
Medial Meniscal Tear of the left knee

Treatment:
Patient was initially treated with Prolotherapy. This was combined with physical therapy. Patient showed some improvement. Patient was then treated with Platelet rich plasma injections.

Outcome:
After 1 month of prolotherapy and physical therapy there was a 50% improvement of the L knee. After PRP injection and physical therapy L knee was 95% improved.

Patient was back to baseline knee function and was able to go back to hiking.

Author's Comments:
Merits of case: Importance of fundamentals. This case helped illustrate how important the history and physical exam can be when dealing with musculoskeletal injuries. Many times we rely too much on imaging. In this case the MRI did not show a meniscal tear. MRI is 86.3% accurate for diagnosing medial meniscus tear (Reference 1). But our history and exam did indicate a tear.
Also case showed value of ultrasound: ultrasound picked up a lesion which was not shown on MRI. Ultrasonography is almost universally available, is less expensive than CT or MRI, and utilizes no ionizing radiation. Several small prospective studies have found the sensitivity of ultrasound for meniscal tear to range from 83 to 86 percent [Reference 2]. Larger studies are needed to determine the accuracy and appropriate use of ultrasound in the evaluation of meniscal tear.
Finally case demonstrated use of non surgical therapies in the treatment of meniscal tears (Prolotherapy and PRP). This is quite important because even though surgical solutions are quite beneficial in the short term, in the long term many times we are just predisposing patients to degenerative arthritis.

Editor's Comments:
This case highlight's the importance of taking a detailed history of the patient's presenting complaint and past medical history as well as performing a thorough physical exam in order to make an accurate clinical diagnosis. To expand on the excellent comments above, meniscal injury can be detected by several functional tests. Of those commonly used the Thessaly test offers the most diagnostic accuracy. A 2010 meta-analysis of the value of physical examination in suspected meniscal injury revealed the Thessaly test was superior with a sensitivity of 91% and specificity of 97% (PPV: 97%,) when compared to the limited quality shown for the McMurray test (sensitivity: 51%, specificity: 78%, PPV: 70%) and "joint line tenderness" (sensitivity: 64%, specificity: 61%, PPV: 62%,) [5]. In patients with ambiguous findings on physical examination or with suspected combined injury, further diagnostic procedures such as magnetic resonance imaging are necessary to confirm the diagnosis. As emphasized above, in clinically certain cases the use of additional diagnostic imaging procedures should be avoided, as they do not come without risk and can often be misleading.

References:
1. "MRI vs. arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review" Br Med Bull. 2007;84:5-23
2. "Accuracy of hand-held ultrasound scanning in detecting meniscal tears."� Shetty AA, Tindall AJ, James KD, Relwani J, Fernando KW. J Bone Joint Surg Br. 2008;90(8):1045.
3. "The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine."� Harrison BK, Abell BE, Gibson TW. Clin J Sport Med 2009 Jan;19(1):9-12
4. "The value of ultrasonography in the detection of meniscal tears diagnosed by magnetic resonance imaging."� Park GY, Kim JM, Lee SM, Lee MY SO. Am J Phys Med Rehabil. 2008;87(1):14.
5. "Value of clinical examination in suspect meniscal injuries". Ockert B, Haasters F, Polzer H, Grote S, Kessler MA, Mutschler W, Kanz KG. Unfallchirurg. 2010 Apr;113(4):293-9.
6. "Predicted probability of meniscus tears: comparing history and physical examination with MRI". Yan R, Wang H, Yang Z, Ji ZH, Guo YM. Swiss Med Wkly. 2011 Dec 14;141:w13314.

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