










































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

18 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 

 
 

Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-
to-Practice Review 
Stephanie P. Ulshafer, MS, ATC; Samara D. Johnson, MS, ATC; Kevin N. Schoell, MS, ATC; Zachary K. 
Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

 

 
ABSTRACT 
The knee is the most commonly injured joint in sport, inherently meaning the knee is also the joint most frequently evaluated by 
healthcare providers. Clinicians evaluate and treat the knee as efficiently as possible to prevent long-term disability of the patient. 
Clinicians rely on physical examination tests such as McMurray’s Test, Apley’s Test, Joint Line Tenderness, Lachman Test, Anterior 
Drawer, Pivot Shift Test, and the Ottawa Knee Rules for initial diagnosis and initiation of care. These physical examination tests have 
varying levels of diagnostic accuracy and validity. Clinicians should know how definite they can be about a diagnosis from physical 
examination alone based on the tests’ validity and reliability. The purpose of this evidence to practice review was to evaluate the 
validity of the individual and combinations of two or more selective tissue tests for the knee. The authors included systematic reviews 
and meta-analyses that reported on the diagnostic properties of one or more physical tests for one or more knee disorders. The 17 
articles used were screened independently by two reviewers. Each article was appraised using the Assessment of the Methodological 
Quality of Systematic Reviews (AMSTAR) ranking system. Articles with the highest AMSTAR ranking for each injury and evaluated 
the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were used to make 
recommendations for validity. Physical examination tests of the knee included in the review were found to be most accurate when 
performed in combination with each other, as they had only low to moderate diagnostic properties. Physical examination tests for 
the meniscus, ACL, PCL, patellofemoral pain, and knee osteoarthritis are not valid to be used as individual diagnostic tests. The only 
exemption to this finding is the Lachman test; with a sensitivity of 85%, the Lachman test is suitable to rule out an ACL tear as a 
stand-alone test. 
 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Ulshafer SP, Johnson SD, Schoell KN, Winkelmann ZK. Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-to-
Practice Review. Clin Pract Athl Train. 2022;5(2): 18-23. https://doi.org/10.31622/2022/0005.02.4.  
 
Submitted: December 7, 2020, Accepted: March 3, 2021. 

 
ORIGINAL REFERENCE 
Décary S, Ouellet P, Vendittoli PA, Roy JS, Desmeules F. Diagnostic validity of physical examination 
tests for common knee disorders: An overview of systematic reviews and meta-analysis. Phys Ther Sport. 
2017;23:143-155. https://doi.org/10.1016/j.ptsp.2016.08.002  
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
The knee is the most commonly injured joint in sport, and thus the joint most typically evaluated by clinicians.1 
It is important to address and intervene with injuries to the knee as soon as possible to prevent secondary 
injury and chronic damage to the joint, as knee disorders often cause a decrease in quality of life from loss 
of optimal function and development of osteoarthritis.2 Healthcare providers will intervene by performing a 
myriad of physical examination tests to rule in or out pathologies for the patient. The physical examination 
is relied upon in many instances due to the significant costs incurred from clinical imaging and the time delay 
patients may experience while waiting for results and subsequent diagnosis.3,4 However, while physical 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2022/0005.02.4
https://doi.org/10.1016/j.ptsp.2016.08.002


Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-to-Practice Review 

 

19 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
  

examination tests are supposed to give patients and clinicians a firm diagnosis, most of these tests have both 
low sensitivity and low specificity.4 The clinician should be familiar with the validity (degree to which a test 
measures what it is intended to measure) and shortcoming of each selective tissue test they perform, and the 
shortcomings of certain diagnostic tests.5 Because of the inconsistent results with many diagnostic physical 
evaluation tests, the purpose of the guiding systematic review was to evaluate the validity of individual and 
combinations of selective tissue tests for the knee.5  

SUMMARY OF LITERATURE 

The guiding systematic review’s authors conducted a literature search using five databases: PubMed, 
Medline, CINAHL, Embase, and the Cochrane Database of Systematic Reviews. The authors used relevant, 
and MESH based keywords for articles published any time before January 2016 on all five databases to 
determine which systematic reviews and meta-analyses to include. To determine whether a study would be 
included in the guiding systematic review, the article, title, and abstract were all screened independently by 
two reviewers. Systematic reviews and meta-analyses that were included in the guiding systematic review 
had to meet the following inclusion criteria: (1) be a systematic review or meta-analysis, (2) report on the 
diagnostic properties of one or more physical tests for one or more knee disorders, and (3) be written in 
English or French.  

Following the search using the criteria listed above, 17 systematic reviews and meta-analyses of the original 
6,750 systematic reviews and meta-analyses initially identified were included. Of these 17 studies, 11 were 
meta-analyses while the other 6 were systematic reviews that did not include a meta-analysis. Overall, the 
systematic reviews and meta-analyses explored selective tissue tests for meniscus injuries (n=8), anterior 
cruciate ligament (ACL) injury (n=6), the combination of tests from ACL/PCL/meniscus injuries and cartilage 
defects (n=2), while other systematic reviews and meta-analyses explored a clinical prediction rule for knee 
fractures (n=2) and knee osteoarthritis (n=2). Each systematic review and meta-analyses were appraised 
using Assessment of the Methodological Quality of Systematic Reviews (AMSTAR) ranking system. The 
AMSTAR is a reliable tool that is used to assess the overall quality of the systematic reviews and meta-
analyses. Each systematic review and meta-analyses were given an AMSTAR score out of 11 to assess the 
strength of evidence. A score of an 8 or higher is considered a high-quality systematic review/meta-analysis. 
A score between 5 and 7 is a moderate quality and a score less than 5 was considered low quality. The 
AMSTAR ranking for each study was averaged out and inter-rater agreement on each term was accounted 
for. From the 17 systematic reviews and meta-analyses, seven of them reached an AMSTAR score of 7 or 
higher.  

SUMMARY OF OUTCOMES 

The authors of this guiding systematic review extracted sensitivity (ability of a test to rule a diagnosis out), 
specificity (ability of a test to rule a diagnosis in), positive likelihood ratio (the odds of detecting an injury in 
a patient who has that injury), negative likelihood ratio (the odds of detecting an injury in a patient who 
does not have that injury) and provided diagnostic odds ratio (the measure of effectiveness of a diagnostic 
test) in each of the 17 articles.4-6 The authors then assessed the data for each of the following selective tissue 
tests from the studies: McMurray’s, Apley’s, Joint Line Tenderness, Lachman, Anterior Drawer, Pivot Shift, and 
the Ottawa Knee Rules. The authors of the guiding systematic review used the highest quality systematic 
reviews and meta-analyses for each selective tissue test of the knee, based on the respective AMSTAR scores, 
to assess the sensitivity, specificity, and diagnostic odds ratios of each diagnostic selective tissue test. The 



Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-to-Practice Review 

 

20 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
  

authors also reviewed the likelihood ratios to make recommendations on the validity of the selective tissue 
test, with ratio of 5 or higher indicating a positive likelihood ratio and 0.2 or lower indicating a negative 
likelihood ratio. If an injury is present, the test would prove to be positive, and if the injury is not present, the 
test will prove to be negative.  

FINDINGS AND CLINICAL IMPLICATIONS 

The authors of the guiding systematic review grouped their findings into six different knee pathologies 
through nine physical tests and one clinical diagnostic rule with two scenarios that can be found in Table 1. 
The first pathology was meniscus injuries, with eight systematic reviews and meta-analyses providing data 
on the selective tissue tests for this pathology. The AMSTAR assessment of the systematic reviews for the 
clinical tests had ratings between a 2 to an 8. The tests with the highest validity were the McMurray’s Test, 
which had a sensitivity of 70.5% (95% CI: 67.4-73.4) and Joint Line Tenderness test had a specificity of 
77.4% (95% CI: 75.6-79.1%).7 When determining likelihood ratios, the Joint Line Tenderness test provided 
the highest positive likelihood ratio (4.0; 95% CI: 2.1-7.5) and the lowest negative likelihood ratio (0.23; 
95% CI: 0.12-0.44). Tests for meniscal injuries of the knee should not be performed individually due to their 
low diagnostic validity.7  

Six systematic reviews and meta-analyses provided data on the diagnosis of an ACL injury, with AMSTAR 
scores ranging from 2 to 8. The selective tissue test with the highest sensitivity was the Lachman test with a 
sensitivity of 85% (95% CI: 83.0-87.0%).8 The Lachman test also provided the highest positive likelihood 
ratio (10.2; 95% CI: 4.6-22.7) and the lowest negative likelihood ratio (0.20; 95% CI: 0.10-0.30) out of all 
other selective tissue tests performed in the systematic reviews and meta-analyses. The pivot shift test had 
the highest specificity with a score of 98% (95% CI: 96.0-99.0%).8 For ACL injuries, the Lachman test has a 
high diagnostic value to help rule in and rule out the pathology and the pivot shift test is best suited to 
complement the Lachman test when needing to rule in the condition.  

Two systematic reviews, one that included a meta-analysis, were evaluated to look at patellofemoral pain 
with AMSTAR scores of 6 and 7, respectively.9,10 The active instability test, pain using stairs, Clarke’s Sign, 
pain during prolonged sitting, and the patella tilt test were all assessed. When looking at likelihood ratios, 
no test has a significant clinical value to help include or exclude patellofemoral pain. It can be concluded 
that there are no individual tests recommended to diagnose patellofemoral pain and performing a 
combination of tests did not improve the positive likelihood ratio. 

Only one systematic review was used to look at posterior cruciate ligament (PCL) injuries. The systematic 
review was given an AMSTAR score of a 7.11 In the systematic review, 11 studies determined the posterior 
drawer test to be the most frequent test used to determine a PCL pathology. Based on poor likelihood ratios 
for the posterior drawer test and despite a high specificity ranging from 96% to 100% for the quadriceps 
active test, there was no sufficient evidence to help include or exclude a PCL injury with any selective tissue 
test.11  

For knee fractures, the Ottawa Knee Rules was examined in two systematic reviews. The Ottawa Knee Rules 
are used to rule in knee fractures and to avoid unnecessary radiographs.12 The two systematic reviews 
received AMSTAR scores of 2 and 7. For the higher scoring systematic review, the sensitivity for the Ottawa 
Knee Rules was 98.5% (95% CI: 93.2-100%), with a specificity of 48.6% (95% CI: 43.6-51.0%), and a 
negative likelihood ratio of 0.5 (95% CI: 0.02-0.23).12 The overall findings provide that the Ottawa Knee 
Rule can be used to help understand if a referral for radiographic imaging should be ordered or not. If one  



Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-to-Practice Review 

 

21 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
  

criterion from the Ottawa Knee Rules is deemed positive, then the clinician should not rule out a fracture and 
referral for radiographic imaging is warranted.  

Finally, knee osteoarthritis was examined in two systematic reviews. Each systematic review received a 1 
and a 2 for an AMSTAR score.4,13 The criteria of the American College of Rheumatology to diagnose knee 
osteoarthritis was examined in the systematic reviews. The criteria included age above 50 years, stiffness 
for more than 30 minutes, crepitus, bony tenderness, bony enlargement, and no palpable warmth. During an 
examination, if at least three criteria points are met, the sensitivity and specificity are 95.0% and 69.0%, 
respectively. When the fourth criteria point is found, the sensitivity and specificity are 84.0% and 89.0%, 
respectively.13 Based on the results, it was concluded that the American College of Rheumatology criteria 
can be used to determine knee osteoarthritis, but magnetic resonance imaging is also necessary to confirm 
the diagnosis as the AMSTAR scores for the systematic reviews included were low. 

 

 

Table 1. Summary of Diagnostic Validity of Selective Tissue Tests for the Knee 

Pathology Selective Tissue Test Number of 
Studies Sensitivity Specificity Diagnostic 

Odds Ratio 

Meniscus 

McMurray’s 14 71% 71% 4.5 

Apley’s 7 61% 70% 3.4 

Joint Line Tenderness 14 63% 77% 4.5 

ACL 

Lachman’s 21 85% 94% 70 

Anterior Drawer 20 55% 92% 21 

Pivot Shift 15 24% 98% 12 

Knee Fracture Ottawa Knee Rules 6 99% 49% .05 (-LR) 

Patellofemoral 
Pain Syndrome Clarke’s Sign 4 39% 76% N/A 

PCL Posterior Drawer 8 69% N/A N/A 

Knee 
Osteoarthritis 

American College of 
Rheumatology Criteria (3 

criteria points) 

2 95% 69% N/A 

American College of 
Rheumatology Criteria (4 

criteria points) 

2 84% 89% N/A 

Items in bold are considered to have good diagnostic perform with a sensitivity or specificity above 90%. 



Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-to-Practice Review 

 

22 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
  

CLINICAL BOTTOM LINE 

Athletic trainers learn about and implement numerous selective tissue tests of the knee during their evaluation 
and assessment of patients experiencing orthopedic pain or limitations. The purpose of the selective tissue 
tests is to provide criteria to the athletic trainer to diagnose the patient. Unfortunately, the guiding systematic 
review sheds light on the fact that some of the common selective tissue tests used and deployed in patient 
care do not yield the information we believe they do. It is becoming clearer that the physical aspect of the 
evaluation process is not as valid when used as a singular test. The findings support the use of Lachman test 
as a valid selective tissue test for diagnosing or excluding an ACL tear, whether used individually or in 
conjunction with other tests. In addition, the findings support the use of some clinical prediction rules14 such as 
the Ottawa Knee Rules to rule out a knee fracture and the American College of Rheumatology and European 
League Against Rheumatism (EULAR) Rules to diagnose knee osteoarthritis. However, there are no valid 
selective tissue tests to diagnose a meniscal injury.  

The guiding systematic review suggests that clinicians are often using a combination of many physical tests, 
as well as a thorough history, to complete a full evaluation of the patient. While not specifically mentioned 
in the guiding systematic review, there is a clinical prediction rule for meniscal pathology which includes: 1) 
history of “locking” or “catching”, 2) pain with forced hyperextension, 3) pain with maximum flexion, 4) 
positive result from McMurray’s, and 5) joint line tenderness to palpation.15 We suggest that athletic trainers 
utilize this clinical prediction rule which has between a 90-99% specificity when 3 or more of the 5 criteria 
are present in the patient.15 The high specificity takes the findings of the poor diagnostic validity for meniscal 
injuries and combines it with actionable items to implement when a one selective tissue test alone cannot 
diagnose the pathology.  

The guiding systematic review states that aside from the Lachman test, Ottawa Knee Rules, and EULAR Rules, 
clinicians should not base their clinical diagnosis from a singular selective tissue test. In terms of ACL injuries, 
while the pivot shift test and the anterior drawer test had good diagnostic performance, the tests were still 
not as accurate as the Lachman test (see Table 1). This guiding systematic review assessed many recent 
systematic reviews and meta-analyses about the validity of physical examination tests for the knee and 
found that the AMSTAR rating for these was typically moderate. Due to the limited and low-quality research 
on the validity of knee physical tests on their own, it is best to combine a physical exam with a thorough 
history or use a combination of data known as clinical prediction rules. For example, a clinician should 
consider the subjective history such as asking if the patient felt a pop or if their knee feels unstable or like it 
is going to give way. It is also important to determine what type of pain the patient is feeling; sharp pain 
refers to skeletal injury, aching pain can indicate muscular trauma or tendinopathy, and throbbing pain can 
mean a ligamentous injury or inflammation in the joint. Overall, the clinical bottom line from the guiding 
systematic review is to consider using clinical decision-making tools, such as a clinical prediction rule, to 
diagnose musculoskeletal pathologies. These clinical prediction rules incorporate history, physical 
examination, and selective tissue tests to improve the diagnostic accuracy rather than a singular diagnostic 
test. 

REFERENCES 

1. Bollen S. Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med. 2000;34(3):227-
228. https://doi.org/10.1136%2Fbjsm.34.3.227-a 

https://doi.org/10.1136%2Fbjsm.34.3.227-a


Validity of Selective Tissue Tests for Knee Pathologies: An Evidence-to-Practice Review 

 

23 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
  

2. Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate 
ligament-deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 
2015;49(16):1033-1041. https://doi.org/10.1136/bjsports-2015-094864 

3. Stein LA. Making the best use of radiological resources in Canada. Healthc Pap. 2005;6(1):18-23. 
https://doi.org/10.12927/hcpap..17719  

4. Jackson JL, O'Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern 
Med. 2003;139(7):575-588. https://doi.org/10.7326/0003-4819-139-7-200310070-00010  

5. Décary S, Ouellet P, Vendittoli PA, Roy JS, Desmeules F. Diagnostic validity of physical 
examination tests for common knee disorders: An overview of systematic reviews and meta-
analysis. Phys Ther Sport. 2017;23:143-155. https://doi.org/10.1016/j.ptsp.2016.08.002  

6. Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM. The diagnostic odds ratio: a single indicator 
of test performance. J Clin Epidemiol. 2003;56(11):1129-1135. https://doi.org/10.1016/s0895-
4356(03)00177-x  

7. Hegedus EJ, Cook C, Hasselblad V, Goode A, Mccrory DC. Physical Examination Tests for 
Assessing a Torn Meniscus in the Knee: A Systematic Review with Meta-analysis. J Orthop Sports 
Phys Ther. 2007;37(9):541-550. https://doi.org/10.2519/jospt.2007.2560  

8. Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament 
rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36(5):267-288. 
https://doi.org/10.2519/jospt.2006.2011  

9. Cook C, Mabry L, Reiman MP, Hegedus EJ. Best tests/clinical findings for screening and diagnosis 
of patellofemoral pain syndrome: a systematic review. Physiotherapy. 2012;98(2):93-100. 
https://doi.org/10.1016/j.physio.2011.09.001  

10. Nunes GS, Stapait EL, Kirsten MH, de Noronha M, Santos GM. Clinical test for diagnosis of 
patellofemoral pain syndrome: Systematic review with meta-analysis. Phys Ther Sport. 
2013;14(1):54-59. https://doi.org/10.1016/j.ptsp.2012.11.003  

11. Kopkow C, Freiberg A, Kirschner S, Seidler A, Schmitt J. Physical examination tests for the 
diagnosis of posterior cruciate ligament rupture: a systematic review. J Orthop Sports Phys Ther. 
2013;43(11):804-813. https://doi.org/10.2519/jospt.2013.4906  

12. Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa knee rule to rule out 
knee fractures: a systematic review. Ann Intern Med. 2004;140(2):121-124. 
https://doi.org/10.7326/0003-4819-140-5-200403020-00013  

13. Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis of 
knee osteoarthritis. Annals of the Rheumatic Diseases. 2010;69(3):483-489. 
https://doi.org/10.1136/ard.2009.113100  

14. Laupacis A, Sekar N, Stiell lG. Clinical Prediction Rules: A Review and Suggested Modifications of 
Methodological Standards. JAMA. 1997;277(6):488-494. 
https://doi:10.1001/jama.1997.03540300056034  

15. Lowery DJ, Farley TD, Wing DW, Sterett WI, Steadman JR. A clinical composite score accurately 
detects meniscal pathology. Arthroscopy. 2006;22(11):1174-1179. 
https://doi.org/10.1016/j.arthro.2006.06.014 

 

 

https://doi.org/10.1136/bjsports-2015-094864
https://doi.org/10.12927/hcpap..17719
https://doi.org/10.7326/0003-4819-139-7-200310070-00010
https://doi.org/10.1016/j.ptsp.2016.08.002
https://doi.org/10.1016/s0895-4356(03)00177-x
https://doi.org/10.1016/s0895-4356(03)00177-x
https://doi.org/10.2519/jospt.2007.2560
https://doi.org/10.2519/jospt.2006.2011
https://doi.org/10.1016/j.physio.2011.09.001
https://doi.org/10.1016/j.ptsp.2012.11.003
https://doi.org/10.2519/jospt.2013.4906
https://doi.org/10.7326/0003-4819-140-5-200403020-00013
https://doi.org/10.1136/ard.2009.113100
https://doi:10.1001/jama.1997.03540300056034
https://doi.org/10.1016/j.arthro.2006.06.014

	ABSTRACT

