# Comparison of Diagnostic Accuracy of Physical Examination and MRI in the Most Common Knee Injuries
## 4 Discussion
Based on European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) [24] recommendations it seems highly important to distinguish between pain caused by OA and meniscal lesions, because this changes the therapeutic route. Therefore we believe that this test should be incorporated in routine knee checkups. In our study we have also tested the diagnostic accuracy of the ACL deficiency test. We found the Lachman test to be the most sensitive in this regard, with high specificity in detecting ACL laxity. Our results correspond with the literature on this subject. A meta-analysis published byBenjaminse et al. [30] of 28 articles showed, similar to our results, a sensitivity of 85% and specificity of 94% for the Lachman test. However, papers with a reported sensitivity lower than 50% can also be found in the literature [31; 32]. In these articles, examination of the knee was performed in an acute stage after knee injury, and therefore hemorrhosis or post-injury pain might have affected the clinical findings. As mentioned above, the Lachman examination might have been hampered by knee pain or hemorrhosis, and for this reason many orthopaedic surgeons use the anterior drawer test in testing anterior laxity of the knee joint. In our study, the sensitivity of the anterior drawer test was found to be lower than 70%, which corresponded with recent literature on the subject [33]. [PERSON] et al. [30] even suggest that the sensitivity of the test could be lower than 50%. The authors suggest that such low sensitivity might be caused by hemorrhosis, inadequate relaxation of the patient during examination or locking of the knee joint by a torn meniscus. In our study we examined patients one day prior to surgery, which was on average 44 months after the onset of symptoms. Therefore, the bias of pain and discomfort during acute setting was not present at the time of examination. Rotational instability is the main patient-disturbing symptom of ACL deficiency [34; 35]. The commonly used pivot shift (PS) test was designed in order to detect rotational instability in the knee joint. Nevertheless, in our study we have found PS to be extraordinarily unsensitive in detecting ACL deficiency, although PS showed the highest specificity among all the tested examinations. Other studies have shown similar results in regard to PS examination [30; 33]. The sensitivity of the test is reported to grossly increase when the patient is sedated or under general anesthesia, with a sensitivity rate of 85% [31] due to the great discomfort of patients during the examination and their reactive muscle responses. To the best of our knowledge, our study is the fourth to evaluate [PERSON]'s lever sign for ACL deficiency. In his original work, [PERSON] [19] reported 100% sensitivity of his test even in an acute setting. In our study we found the sensitivity of the test to be 62.5%, with a specificity of 98% as in PS. Two other studies that can be found in literature on the subject also did not report such a high sensitivity. [PERSON] et al. [36] estimated the sensitivity of the test to be 83%, and the authors suggest that such a high diagnostic value reported in the original paper might have been caused by the methodology of the study in which the author verified his test on patients with known ACL deficiency, which could have affected the final result. Furthermore, in a study published by [PERSON] et al. [37], high sensitivity was again not confirmed. What is worth noting is the fact that this examination, contrary to others tested in the study, was independent of patient relaxation, and therefore it might be utilized in daily practice in an acute setting. MRI is considered to be the most accurate method of imaging of the internal knee joint structure, with sensitivity in detecting medial meniscus lesions ranging from 83% to 94% [38; 39]. Our study have showed similar sensitivity with regard to medial meniscus lesions reaching 95.6%. However, some studies suggest a lower sensitivity of the MRI in detecting medial meniscus lesions. [PERSON] et al.