Knee Meniscus Examination
Meniscal examination relies on joint line tenderness and provocative tests that trap and stress the meniscus. Examiners expect you to perform McMurray's test correctly, understand its limitations, and recognize that clinical examination has moderate sensitivity. Joint line tenderness is the most sensitive but least specific finding.
Quick Reference One-Pager
Key Clinical Features
- Joint line tenderness (most sensitive)
- Mechanical symptoms (locking, catching, giving way)
- Effusion (often delayed onset)
- Loss of full extension (bucket-handle tear)
Provocative Tests
- McMurray test
- Thessaly test (functional)
- Apley grind and distraction
- Bounce home test
Medial Meniscus
- More commonly torn (less mobile)
- External rotation + valgus stress
- Tenderness medial joint line
Lateral Meniscus
- Associated with ACL injuries
- Internal rotation + varus stress
- Tenderness lateral joint line
Anatomy and Function
Key Concepts
Meniscal Anatomy:
- C-shaped fibrocartilage structures
- Medial: Larger, more C-shaped, firmly attached (less mobile)
- Lateral: Smaller, more circular, loosely attached (more mobile)
- Blood supply: Outer 1/3 vascular (red zone), inner 2/3 avascular (white zone)
Functions:
- Load transmission (50-70% of load)
- Shock absorption
- Joint stability (secondary stabilizer)
- Lubrication and nutrition
Tear Patterns:
- Vertical longitudinal (bucket-handle)
- Horizontal cleavage
- Radial
- Complex/degenerative
- Root tears
Clinical Assessment
History Clues
Acute Tear (Young Patient):
- Twisting injury, often with knee flexed
- May have popping sensation
- Delayed swelling (hours, not immediate like ACL)
- Mechanical symptoms (locking, catching)
Degenerative Tear (Older Patient):
- Minimal or no trauma
- Insidious onset
- Aching pain, worse with activity
- May have night pain
- Associated with OA
Locking vs Pseudolocking:
- True locking: Knee stuck in flexion, cannot fully extend (bucket-handle tear)
- Pseudolocking: Pain prevents movement but no mechanical block
Physical Examination
Joint Line Tenderness
Special test
Joint Line Palpation
Localize meniscal pathology
Technique
- 1Knee flexed to 90°
- 2Palpate joint line between femoral condyle and tibial plateau
- 3Palpate medial and lateral compartments separately
- 4Use fingertip pressure along entire joint line
Positive Sign
Point tenderness at joint line (medial or lateral)
Indicates
Meniscal pathology (most sensitive but least specific sign)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Provocative Tests
Special test
McMurray Test
Meniscal tear
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Technique
- 1Patient supine, examiner holds heel and places other hand on knee (fingers on joint line)
- 2Fully flex the knee
- 3For MEDIAL meniscus: Externally rotate tibia, apply valgus stress, extend knee
- 4For LATERAL meniscus: Internally rotate tibia, apply varus stress, extend knee
Positive Sign
Palpable or audible click/pop at joint line, with pain
Indicates
Meniscal tear (posterior horn)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
McMurray Test Tips:
- The click must be at the JOINT LINE (not patellofemoral)
- A painful click is more significant than painless click
- Tests posterior horn primarily (most common tear location)
- Negative test does NOT exclude tear
Special test
Thessaly Test
Meniscal tear (functional, weight-bearing)
Technique
- 1Patient stands on affected leg, knee flexed to 20°
- 2Hold patient's extended hands for balance
- 3Patient rotates body (and knee) internally and externally three times
Positive Sign
Joint line pain or mechanical catching
Indicates
Meniscal tear
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Apley Grind Test
Differentiate meniscal from ligamentous pathology
Technique
- 1Patient prone, knee flexed to 90°
- 2COMPRESSION: Apply axial load through tibia while rotating (grinding)
- 3DISTRACTION: Pull tibia away from femur while rotating
Positive Sign
Pain on COMPRESSION = meniscal; Pain on DISTRACTION = ligamentous
Indicates
Compression stresses meniscus, distraction stresses ligaments
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Bounce Home Test
Block to full extension
Technique
- 1Patient supine, hold heel with knee in full flexion
- 2Allow knee to drop into full extension passively
- 3Note if knee 'bounces home' to full extension
Positive Sign
Rubbery block to full extension (does not fully extend)
Indicates
Mechanical block (bucket-handle meniscal tear, loose body)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Ege's Test
Meniscal tear (weight-bearing deep squat)
Technique
- 1Patient performs deep squat with feet in internal rotation (lateral meniscus)
- 2Repeat with feet in external rotation (medial meniscus)
Positive Sign
Pain or click at affected joint line during squat
Indicates
Meniscal tear
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Additional Signs
Special test
Steinmann's Sign
Meniscal tear
Technique
- 1Patient supine, knee flexed
- 2External rotation of tibia (medial meniscus) or internal rotation (lateral meniscus)
Positive Sign
Pain at joint line with rotation
Indicates
Meniscal tear
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Specific Patterns
Bucket-Handle Tear
Clinical Features:
- True locking (cannot fully extend)
- Loss of last 10-30° extension
- May unlock suddenly
- Audible clunk on reduction
Examination:
- Fixed flexion deformity
- Bounce home test positive
- Springy block to terminal extension
- May palpate displaced meniscus
Root Tear
Clinical Features:
- Sudden pop, often without contact
- Significant pain and effusion
- Loss of meniscal function → accelerated OA
Examination:
- Posterior joint line tenderness
- May be indistinguishable from regular tear clinically
- MRI essential for diagnosis
Differential Diagnosis
- location
- Medial joint line
- mechanical
- Yes (locking/catching)
- test
- McMurray (ER + valgus)
- location
- Lateral joint line
- mechanical
- Yes
- test
- McMurray (IR + varus)
- location
- Medial, above joint line
- mechanical
- No
- test
- Valgus stress +
- location
- Below medial joint line
- mechanical
- No
- test
- Point tenderness at pes
- location
- Joint line + diffuse
- mechanical
- Variable
- test
- Crepitus, X-ray changes
Summary Presentation
“45-year-old man with medial knee pain after twisting injury while gardening 2 weeks ago. Reports occasional 'catching' sensation.”
Medial vs Lateral Meniscus Testing
- medial
- External rotation
- lateral
- Internal rotation
- medial
- Valgus
- lateral
- Varus
- medial
- Medial
- lateral
- Lateral
- medial
- More common (less mobile)
- lateral
- Less common (more mobile)
- medial
- Less common
- lateral
- More common (lateral meniscal tear with ACL injury)
Examiner Tips
Do
- Palpate joint line precisely
- Perform McMurray with correct rotation for each meniscus
- Assess for loss of extension
- Use multiple tests (McMurray + Thessaly + Apley)
- Check for associated ACL injury
Don't
- Accept non-joint-line clicks as positive
- Forget to distinguish medial from lateral
- Miss a locked knee (bucket-handle)
- Ignore degenerative tears in older patients
- Rely on single test - use combination