905

Meniscal Tears Missed on MR

Imaging: Relationship to Meniscal Tear
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Patterns and Anterior Cruciate Ligament

Tears

,.. :‘.?1-r’. - .., . -

I ‘c..:. #{149} .:‘

Arthur A. De Smet1 OBJECTIVE. MR imaging of the knee is a valuable technique for diagnosing menis-
Ben K. Graf2 cal tears, but some tears found at arthroscopy are not shown on MR imaging. The
purpose of this study was to determine whether or not tears were more frequently
missed in the presence of an anterior cruciate ligament tear or when tears had certain
locations or configurations.
MATERIALS AND METHODS. We reviewed the original MR reports and surgical
records of 400 patients who had both an MR examination and arthroscopy of the
knee. Using x2 analysis, we examined how the sensitivity for detecting meniscal tears
varied with the presence of a tear of the anterior cruciate ligament, with the location
of the tear within the meniscus, and among six configurations of meniscal tears. We
also studied whether sensitivity decreased with an increasing delay between MR
examination and arthroscopy.
RESULTS. In the presence of a tear of the anterior cruciate ligament, the sensitivity
decreased from 0.97 to 0.88 (p = .016) for medial meniscal tears and from 0.94 to 0.69
(p = .0005) for lateral tears. The overall sensitivity for lateral meniscal tears was sig-
nificantly less for posterior (p = .001) and peripheral (p = .005) tears than for other tear
locations or configurations. The sensitivities did not significantly differ between tear
locations and configurations in the medial meniscus or with an increasing delay until
arthroscopy. Patients with a torn anterior cruciate ligament were more likely to have
peripheral tears of the medial meniscus (p = .00004) and posterior (p = .0004) and
peripheral (p = .04) tears of the lateral meniscus.
CONCLUSION. Because of their location and configuration, meniscal tears associ-
ated with an anterior cruciate ligament injury are more difficult to detect on MR
images than are tears in knees with an intact ligament. If a tear of the anterior cruciate
ligament is detected, special attention should be given to the subtle peripheral tears
that may be present in either meniscus, but most commonly in the posterior horn of
the lateral meniscus. These tears are especially difficult to detect on MR images.

AJR 1994;162:905-911

As reported recently, many studies have shown that MR imaging of the knee is
an accurate method for diagnosing meniscal tears [1]. However, these same stud-
ies also show that a meniscus can appear intact on MR images but still be torn, as
proved by subsequent arthnoscopy.
We have also had patients in whom the MR examination did not show a torn
meniscus. On the basis of a preliminary review of these cases we believed that
Received September 24, 1993; accepted after
revision December 10, 1993. many misdiagnoses on MR were related either to the presence of an associated
I Department of Radiology, University of Wis- tear of the anterior cruciate ligament (ACL) on to meniscal tears whose location or
consin Hospital, 600 Highland Ave., Madison, WI configuration made them difficult to detect. It is unlikely that the presence of an

-3252 Address correspondence to A. A. De ACL tear that

assumed itself ACL
wouldtears cause a meniscal withtearother
are associated to be missedthat oncaused
factors MR images.
a tear to We
be
2Division of Orthopedic Surgery, University of . . . . .

Wisconsin Hospital, Madison, WI 53792-3252. missed. Possibly, the mechanism of injury for an ACL tear causes meniscal tears
0361-803X/94/1624---0905 that are difficult to detect with MR imaging. As a second possibility, patients with
©American Roentgen Ray Society an unstable knee owing to an ACL tear might sustain new meniscal tears after the
 906 DE SMET AND GRAF AJR:162, April 1994

MR examination. In these cases, the tear found at arthros-

copy would not have been missed on MR images because
the tear would have occurred after the MR examination.
To test these hypotheses, we reviewed our MR examina-
tions of the knee to identify those studies proved to be false-
negative on the basis of arthroscopy. We analyzed how the
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frequency of missed tears on MR images varied depending

Pedphe
on the presence or absence of an associated ACL tear, on
the delay between MR examination and arthroscopy, and on
the location and configuration of the tear. We also investi-
gated the association between the presence on absence of
an ACL tear and the location and configuration of associated

4t.
meniscal tears.

Materials and Methods

We reviewed the medical charts of 1294 patients with suspected Comp Dpiaced Rap Bucket hancie
meniscal tears who had MR examinations of the knee between Sep-
tember 1 , i 988, and December 1 2, i991 Of these 1294 patients, .

400 had subsequent knee arthroscopy but had not had prior surgery
Fig. 1.-Dlagram of six possible configurations of meniscal tears.
on that knee. The other 894 patients included 67 who had prior sur-
gery and then a second knee arthroscopy, 78 who were referred by
physicians outside of our institution, and 749 who did not have sur-
gery. Each MR examination was performed by using the same spin-
We used 2 analysis to compare the sensitivity ofdetection ofa menis-
cal tear as ‘it varied by tear location, tear configuration, and the presence
echo technique and a i .5-1 MR magnet with a transmit-and-receive
cylindrical extremity coil (General Electric, Waukesha, WI). Coronal or absence of a partial or complete ACL tear. If more than half of the
expected values were less than 5 or any single expected value was less
scans were obtained with the following parameters: 3-mm-thick
slices with a 1.5-mm interslice gap, two excitations, a 256 x 192 than 2, Fisher’s exact test was performed for 2 x 2 contingency tables [2].
matrix, and 600/20 (TRITE). Sagittal scans had the same slice thick- When there were multiple pairs for comparison, we first did 2 x n 2 anal-
ysis of all pains. This grouped comparison minimizes the risk of falsely
ness and interval but were obtained with one excitation, a 256 x 256
finding a significant difference, as may occur when comparing multiple
matrix, and 2000-2400/20,90 (TRITE). Phase encoding was in the
pairs indMdually in 2 x 2 tables [2]. If the 2 x n analysis showed a signifi-
superoinfenior direction to minimize anterior pulsation artifact from
cant difference, multiple pairwise comparisons were performed to find the
the popliteal artery.
combinations that differed. Spearman rank correlation was used to corn-
The 270 male and 130 female patients had an average age of 30
years. The average delay between the MR examination and knee
pane the number of missed tears and the number of days between the
MR examination and arthroscopy. For all measurements, a statistically
arthroscopy was 79 days, with a delay of less than 6 weeks in 41%
significant difference was taken to be one with a p value of less than .05.
of the patients. Thirteen partial and 132 complete ACL tears were
found at arthroscopy in the 400 patients. Fifty-seven (39%) of the
ACL tears occurred within a 6-week interval prior to arthroscopy.
Results
There were 211 medial meniscal tears and 122 lateral meniscal
tears. The sensitivity for detection of both medial and lateral
During the period of these original interpretations, an MR exami- meniscal tears was considerably lower in the presence of an
nation was interpreted as positive for a meniscal tear if the meniscus ACL tear (Table 1). The sensitivity of 0.88 for medial menis-
was distorted or if intrameniscal signal contacted the surface of the cal tears with an associated ACL tear was significantly lower
meniscus. On the original MR interpretations, we failed to diagnose
14 medial and 24 lateral meniscus tears later found at surgery.
Thus, the sensitivity for diagnosis of a tear was 0.93 (95% confi- TABLE 1 : Sensitivity of MR Imaging for Detecting Meniscal
dence interval: 0.89, 0.96) for the medial meniscus and 0.80 (95% Tears: Intact vs Torn Anterior Cruciate Ligament
confidence interval: 0.72, 0.87) for the lateral meniscus.
We used the operative notes and knee maps as the gold standard Anterior Cruciate Ligament
for the presence of a meniscal or an ACL tear. The knee maps were Location of Tear -- --

drawings made at the time of surgery that showed the location and Intact Torn Total
configuration of all meniscal and ligamentous abnormalities. To clas-
Medial meniscus
sify the location of a tear, each meniscus was considered to have No. of missed tears 4 10 14
three equal segments, the anterior, middle, and posterior thirds. A
No. of tears 125 86 211
meniscal tear could involve one, two, or three segments. Each tear
Sensitivity 0.97 088a 0.93
was categorized as having one of six configurations: oblique, radial,
Lateral meniscus
peripheral, complex, displaced flap, or bucket handle (Fig. i). For No. of missed tears 3 21 24
oblique, radial, and peripheral tears, the tear extended in only one
No. of tears 54 68 122
direction. An oblique tear could vary from a horizontal to a steeply
Sensitivity 0.94 069b 0.80
oblique orientation to the tibial plateau. Peripheral tears were vertical
tears that paralleled the circumference of the meniscus in the outer 5 asignificantly less than with anterior cruciate ligament intact (p = .016).
mm. A complex tear extended in more than one direction. bSignificantly less than with anterior cruciate ligament intact (p = .0005).
 AJR:162, April 1994 MENISCAL TEARS ON MR IMAGING 907

than the sensitivity of 0.97 without an ACL tear (p = .016). the medial (p = .77) on lateral (p = .38) menisci between
Similarly, the sensitivity of 0.69 for lateral meniscal tears with those operated on within 6 weeks of the MR examination
an associated ACL tear was significantly less than the sensi- and those operated on later.
tivity of 0.94 without an ACL tear (p = .0005). Sensitivity was related to the location of the tear for the lat-
The sensitivities did not differ for either the medial (p = enal meniscus only. Lateral meniscal tears had a diverse distn-
.23) or lateral (p = .38) menisci between those operated on bution, with tears of the anterior and combined anterior and
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within 6 weeks of the MR examination and those operated middle thirds being less common than tears in the other four
on later. The sensitivity did not change with an increasing locations (Table 2). The sensitivity of 0.65 for tears in the poste-
number of days until operation for the medial (p = .07) or lat- rior third ofthe lateral meniscus was significantly less (p = .001)
eral (p = .27) menisci. When only those patients with ACL than the sensitivity for tears in other locations (Table 2). Figures
tears are considered, the sensitivities did not differ for either 2 and 3 illustrate cases in which the MR examination did not

TABLE 2: Sensitivity of MR Imaging for Detecting Meniscal Tears: Variation with Location of Tear

Locatio n of Tear in Medial a nd Lateral Menisci

Location of Tear Anterior Middle and

Anterior Entire Middle Posterior Total
and Middle Posterior
Third Meniscus Third Third
Thirds Thirds

Medial rneniscus
No. of missed tears 1 0 0 0 3 10 14
No. of tears 2 0 32 0 49 128 211
Sensitivity 0.5 0 1 .00 0 0.94 0.92 0.93
Lateral meniscus
No. of missed tears 1 0 2 2 3 i6 24
No. of tears 8 5 i8 21 24 46 122
Sensitivity 0.88 i .00 0.89 0.90 0.88 0#{149}65a 0.80

aThe sensitivity for tears in the posterior third of the lateral meniscus was significantly less than for the other loca-
tions combined (p = .001). No other difference was statistically significant.

Fig. 2.-Lateral meniscal tear mIssed on MR.

A, Diagram of tear of middle to posterior third of me-
dial meniscus (arrow) and tear of posterior third of later-
al meniscus (arrowhead) found at arthroscopy. Medial
tear was seen on MR (not shown).
B, Saglttal MR Image (2000/20) In area of lateral me-
niscal tear shows faint intramenlscal signal without cx-
tension to surface.

Fig. 3.-Lateral meniscal tear missed on MR.

A, Diagram of peripheral tear at root of lateral menis-
cus (arrowhead).
B, Sagittal MR image (2000/20) in area of lateral menis-
cal tear shows central menlacal signal (arrow) in posterior
horn oflateral meniscus wfthoutextension to surface. This
area is blurred by pulsation artifact from poplfteal artery.

B
 908 DE SMET AND GRAF AJR:162, April 1994

show lateral meniscal tears of the posterior horn. Ninety-nine with an ACL tear, 90% of the peripheral tears occurred in
percent of the medial meniscal tears involved the posterior those with an ACL tear (p = .00004). For lateral meniscal
horn with or without extension anteriorly (Table 2). We found no tears, both a posterior location (Table 4) and a peripheral
significant difference (p = .26) in the sensitivity for medial configuration (Table 5) were significantly more common in
meniscal tears based on the location ofthe tear (Table 2). patients with an ACL tear than in those without a tear.
Sensitivity was related to tear configuration for the lateral Although only 36% of the patients had an ACL tear, 76% of
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meniscus only. Lateral meniscal tear configurations were van- the posterior third tears (p = .04) and 83% of the peripheral
ied, without a predominance of any one pattern (Table 3). The tears (p = .0004) of the lateral meniscus were seen in
sensitivity for detection of a lateral meniscal tear was signifi- patients with an associated ACL tear.
cantly better for complex tears and significantly worse (p =
.005) for peripheral tears (Table 3). Medial meniscal tears had
more distinctive patterns than lateral tears did. Medial tears
Discussion
were often oblique or complex, and radial tears were unusual Our results confirm our hypotheses that the sensitivity for
(Table 3). We found no significant difference between the sen- detection of meniscal tears is significantly worse with an
sitivities for the six configurations of medial tears (p = .77). associated ACL tear and with certain meniscal tear locations
The location of a medial meniscal tear was not associated and configurations. The sensitivity in the absence of an ACL
with the presence on absence of an ACL tear (p = .07, Table tear was excellent, with values of 0.97 for the medial and
4). However, the configuration of a medial tear differed sig- 0.94 for the lateral menisci. In the presence of an ACL tear,
nificantly between patients who did and who did not have an the sensitivity decreased moderately to 0.88 for medial tears
ACL tear (Table 5). Whereas only 17-46% of the bucket- and decreased markedly to 0.69 for lateral tears. Our results
handle, complex, flap, and oblique tears occurred in those are consistent with an earlier study of 25 patients with

TABLE 3: Sensitivity of MR Imaging for Detecting Meniscal Tears: Variation with Configuration of Tear

Configuration of Tear in Medial and Lateral Menisci

Location of Tear Bucket

Handle Complex Flap Oblique Peripheral Radial Total

Medial meniscus
No. of missed tears 4 3 0 5 2 0 14
No. of tears 37 61 12 79 21 1 211
Sensitivity 0.89 0.95 1 .00 0.94 0.90 1 .00 0.93
Lateral meniscus
No. of missed tears 2 1 4 10 6 1 24
No. of tears 11 32 16 38 12 13 122
Sensitivity 0.82 097a 0.75 0.74 050b 0.93 0.80

aSensitivity in the lateral meniscus for complex tears was significantly greater than for flap (p = .019), oblique (p =

.008), and peripheral (p = .002) tears.

bSensitivity in the lateral meniscus for peripheral tears was significantly worse than for all other patterns combined
(p = .005). No other difference was statistically significant.

TABLE 4: Association Between Tear of Anterior Cruciate Ligament and Location of Meniscal Tear

Locatio n of Tear in Medial a nd Lateral Menisci

Location of Tear Anterior Middle and

Anterior Entire Middle Posterior Total
and Middle Posterior
Third Meniscus Third Third
Thirds Thirds

Medial meniscus
ACLtorn 2 0 17 0 15 52 86
ACL intact 0 0 i 5 0 34 76 125
Lateral meniscus
1 5a 35b
ACL torn 3 1 6 8 68
ACL intact 5 4 12 13 9 11 54
Note.-ACL = anterior cruciate ligament.
asignificantly greater than anterior third, both anterior and middle thirds, entire meniscus, and middle third com-
bined (p = .02).
bSignificantly greater than all other patterns combined (p = .0004). No other difference was statistically significant.
 AJR:162, April 1994 MENISCAL TEARS ON MR IMAGING 909

chronic ACL tears in whom an even lower MR sensitivity of ferences, they also found that most of their missed lateral
0.45 was found for lateralmeniscal tears [3]. meniscal tears were in the posterior horn [8].
Different proportions of patients with ACL tears may The association between tears that are missed on MR
account for some of the variation in meniscal accuracy in images and the presence of an ACL tear supports our theory
published reports. Thirty-six percent of our 400 patients had that the lower sensitivity with ACL tears is due to the type of
ACL tears. This is a higher percentage than in any other meniscal tears that occur with an ACL tear. Peripheral tears
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lange MR series in which both the frequency of ACL tears in the medial meniscus and both posterior and peripheral
and sensitivity for meniscal tears are given. In reviewing tears in the lateral meniscus were associated with the pres-
series with more than 100 patients, we noted low sensitivi- ence of an ACL tear. Our ACL tear association with certain
ties for lateral tears of 0.63-0.81 when 19-30% of the meniscal tear patterns is supported by the multicenter study
patients had ACL tears [2, 4, 5]. In the single lange series of 1 0, 1 1 7 knee anthroscopies by Poehling et al. [9]. They
with a higher sensitivity (0.92) for lateral tears, associated noted a striking similarity in the age and sex distribution of
ACL tears were present in only 16% of the patients [6]. patients with peripheral meniscal tears and those with ACL
The reason for the decrease in meniscal tear sensitivity tears. They concluded that peripheral meniscal tears were
with an ACL tear cannot be definitively determined from our traumatic lesions related to ACL injuries [9].
study. We had speculated that because of an unstable knee, The association between ACL tears and peripheral and
additional tears develop before arthnoscopy. However, we posterior tears has been reported previously [7, 10]. However,
found no association between missed tears and the delay the specific percentages of tear patterns do vary somewhat
until surgery. Indelicato and Bittar [7] also found no signifi- from our results. In 100 arthrotomy patients with ACL insuff i-
cant difference in the frequency of lateral meniscal tears ciency, Indelicato and Bittar [7] reported that 72% of the 71
when comparing patients with acute and chronic ACL tears. medial and 43% of the 28 lateral meniscal tears were peniph-
However, they did note an increased prevalence in medial eral and posterior. In a study of 102 patients having primary
meniscal tears in patients with chronic ACL tears. Our repair of an acutely torn ACL, Cerabona et al. [10] noted that
results for the medial meniscus likely differ from theirs owing 65% of the 25 medial tears were posterior and peripheral, but
to study design. We analyzed the time between MR exami- 65% of the 19 lateral meniscal tears had a radial pattern. In
nation and arthroscopy and not the time between the original our 145 patients with ACL tears, we had similar results, with
ACL tear and subsequent operation. 60% of the 86 medial tears and 51% of the 68 lateral tears in
We believe that a likely cause for the lower sensitivity in the posterior horn (Table 4). However, although peripheral
the presence of an ACL tear is the relationship between ACL meniscal tears were more common in the presence of an ACL
tears and certain types of meniscal tears. Presumably, the tear, we noted more diverse patterns of tears in both the
biomechanical forces that result in an ACL tear cause menis- medial and lateral menisci (Table 5).
cal tears that are in patterns that are difficult to diagnose on We believe that these study differences may result from
MR images. We found that the tears that are difficult to diag- three factors: variations due to sample size, differences in
nose are those in the posterior and peripheral aspects of the the definitions for tear types, and differences in populations
lateral meniscus. Only 65% of the tears in the posterior third of patients. The difference between populations of patients
of the lateral meniscus were prospectively diagnosed with may be the most significant cause, as 50% of our patients
MR imaging, compared with 88-100% of the tears in other with ACL tears had lateral meniscal tears whereas the other
locations. Similarly, only 50% of the peripheral tears in the two studies found lateral meniscal tears in only 1 9% and
lateral meniscus were diagnosed, compared with 74-97% of 28% of their patients.
the other tear configurations. A similar analysis of MR accu- One related issue is whether the tears missed on MR are
racy vs tear patterns was reported by Mesganzadeh et al. [8]. clinically significant. Thirty (79%) of the 38 meniscal tears
Although they did not calculate statistical significance for dif- missed on MR imaging were surgically nesected. In contrast,

TABLE 5: Association Between Tear of Anterior Cruciate Ligament and Configuration of Meniscal Tear

Locatio n of Tear n Medial and Lateral Menisci

Location of Tear Bucket
Handle Complex Flap Oblique Peripheral Radial Total

Medial meniscus
ACL torn 17 20 2 28 1 9a 0 86
ACL intact 20 41 10 51 2 1 125
Lateral meniscus
ACLtorn 5 16 7 23 10b 68
ACLintact 6 16 9 15 2 6 54
Note.-ACL = anterior cruciate ligament.
aSignificantly different from other medial tear configurations (p = .00004).
bSignificantly different from other lateral tear configurations (p = .04). No other difference was statistically significant.
 910 DE SMET AND GRAF AJR:162, April 1994

of the tears seen on MR, 94% were nesected. This difference sagittal planes is the most common protocol reported in pub-
suggests that many of the missed tears were not clinically lished studies. However, some authors have suggested the
significant. However, the surgical decision to resect or use of other imaging planes [12, 13]. A tear should be easi-
observe a meniscal tear is based on many factors, including est to diagnose when the tear is perpendicular to the imag-
stability, location, size, and depth. Our retrospective data do ing plane, so radial images may be the best for identifying
not allow conclusions to be drawn regarding the clinical sig- peripheral tears of the posterior horn. Radial imaging can be
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nificance of the various meniscal tears. done either by direct specification of radial slices before
Our correlation between ACL tears and meniscal tears scanning [14] on by reformatting radial images from a three-
that were difficult to diagnose was not perfect, as we found dimensional volume set [13, 15-18]. Three-dimensional MR
no variation in sensitivity with the location and configuration neconstructions have also been proposed to visualize menis-
of medial meniscal tears. It may be that other factors play a cal tears [12]. However, most of these reports have been
role in making the MR diagnosis of meniscal tears difficult small pilot studies, so the value of these special imaging
when an associated ACL tear is present. planes remains to be proved.
Our difficulty in detecting tears in the posterior third of the One large study did compare sagittal images with direct
lateral meniscus may be related to the anatomy of that radial images in 259 patients. The authors found no differ-
meniscus. The lateral meniscus has a shorten radius of cur- ence in sensitivity between the two imaging planes [14].
vatune than the medial meniscus does [11]. As a conse- They did subjectively note that “small tears of the posterior
quence, much of the posterior horn is obliquely oriented horn and the posterior junctional zone were better seen on
relative to coronal and sagittal MR images. These tears radial MPGRE images” [14]. However, we can see no
might also be missed because of the more complex anatomy advantage to adding radial images, because the sensitivities
where the popliteal tendon passes through the posterior reported in that study of 0.90 for medial tears and 0.80 for
horn of the lateral meniscus. In addition, the meniscus rises lateral tears using combined radial and sagittal images were
up posteriorly as it moves from the lateral plateau toward its similar to the sensitivities we achieved with coronal and sag-
insertion just behind the tibial eminence (Fig. 4). The combi- ittal images. We believe that the optimal protocol for imaging
nation of these two anatomic features results in a posterior meniscal tears has not yet been defined. Our findings sug-
horn that is not sectioned perpendicularly by either coronal gest that either additional or different sequences may be
on sagittal images. Such obliquity could result in volume useful to identify those tears that are missed with coronal
averaging that blurs the connection of intrameniscal signal to and sagittal imaging.
the surface. In summary, we have shown that meniscal tears are more
Another possible cause for missed tears in the posterior likely to be missed on MR images when an associated ACL
horns might be arterial pulsation artifact. Although we use tear is present, especially if the tear is in the posterior third
phase encoding in the supenoinfenior direction, one on two or peripheral portion of the lateral meniscus. Furthermore,
images of the posterior horn of the lateral meniscus often the two factors are related, in that posterior and peripheral
are obscured by pulsation artifact (Figs. 3 and 5). The impon- lateral meniscal tears are fan more common in knees with an
tance of pulsation artifact in missed tears remains specula- ACL tear. Physicians interpreting MR studies should be
tive, as we did not address this issue in our study. aware of these associations. When an ACL tear is detected
Our observations on tears that are difficult to detect raises on the MR study, special attention should be paid to the pos-
the question of which planes are optimal for imaging of tenon horn of the lateral meniscus, where a subtle peripheral
meniscal tears. Imaging of the menisci in the coronal and tear may be present.

-
.:r: Fig. 4.-Coronal MR image (600/20) shows
.
oblique orientation of posterior horn of lateral
meniscus (arrows) to tibial plateau, compared
with parallel orientation of medial meniscus
(arrowheads).

‘.

Fig. 5.-Sagittal MR Image (2000/20) through

posterior horn of lateral meniscus shows faint
blurring due to pulsation artifact (arrowhead)
that obscures peripheral tear on superior sur-
face found at arthroscopy.
5
 AJR:162, April 1994 MENISCAL TEARS ON MR IMAGING 911

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