Written by manual therapists Thomas T. Ødegaard and Roar Syltebø

In physical and orthopaedic medicine, clinical tests and examination have been characterised by a “hands-on” approach and various palpation tests. Having searched the literature, it is nevertheless difficult to establish who first systematised and formalised palpation of the knee joint line. Joint line palpation is used by most clinicians and is considered a provocation test of the knee joint that may point towards meniscal pathology. It is one of the most frequently used meniscal tests, together with the McMurray test.

Indication

Palpation of the knee joint line is indicated after acute knee injuries or in gradually increasing knee pain. Clicking and/or a sensation of locking in the knee raises suspicion of a meniscal or cartilage lesion, and is an important indication for joint line palpation. Note, however, that such “mechanical” symptoms are not specific to meniscal tears. In a large arthroscopic study, they were more strongly associated with cartilage damage than with meniscal pathology (Farina et al., 2021).

Procedure

Joint line palpation is performed with the patient supine. The affected knee is flexed to 90°, with the sole of the foot resting on the examination table. The examiner palpates and compresses the medial and lateral structures along the tibiofemoral joint line, from the border of the patellar tendon and posteriorly towards the back of the knee. Any pain provoked is compared with the contralateral knee and with the patient’s familiar pain.

Interpretation

The test is considered positive if palpation reproduces the patient’s familiar pain, and the tenderness is clearly greater than on the contralateral side. A meniscal lesion may then be suspected.

The gold standard for a definitive diagnosis of a meniscal tear is arthroscopy, and MRI is also widely used as a reference standard. MRI findings must, however, be interpreted with caution. Meniscal tears are a common incidental finding on MRI in middle-aged and older people, including those without knee symptoms, and the prevalence increases with age (Englund et al., 2008).

Noble & Erat (1980) is one of the first studies to describe joint line palpation. The test procedure itself is not described in this study, which is a clear source of error. In their material, 250 patients were referred for meniscectomy, but 50 were excluded from the study. Among the remaining 200, 73% were found to have a meniscal tear. These patients were examined clinically and arthroscopically. The patients were divided into three subgroups: vertical or oblique tear, horizontal tear, and normal meniscus. The proportion of patients with a positive joint line palpation test was 65.5% for vertical or oblique tears, 79% for horizontal tears and 87% for normal menisci (Noble & Erat, 1980). In other words, a positive test was at least as common in knees with normal menisci as in knees with a tear.

Anderson & Lipscomb (1986) investigated the accuracy of clinical examination compared with arthroscopy in 100 knees with a suspected meniscal tear. The clinical diagnosis was correct in 87 knees, correct but incomplete in 4 and incorrect in 9. Among the patients with a meniscal tear, 63% had pain localised to the joint line. Joint line tenderness was the most accurate clinical sign in their material: it was positive in 77% of the meniscal tears and false positive in 11%. The authors concluded that repeated examination and a combination of tests increase diagnostic accuracy. Positive pain provocation on joint line palpation is not a sufficiently good clinical test on its own (Anderson & Lipscomb, 1986).

In a systematic review of English-language articles from 1966 to 2000, Solomon and colleagues assessed the clinical accuracy of individual tests compared with arthroscopy, arthrotomy or MRI. They identified 88 articles, of which 23 were included. Joint line palpation had a positive likelihood ratio (LR+) of 0.9 and a negative likelihood ratio (LR−) of 1.1. On its own, the test therefore barely changes the probability of a meniscal tear. The authors concluded that joint line palpation alone is not clinically accurate enough to determine whether the knee has a meniscal tear, and recommended a combination of clinical tests together with an adequate history (Solomon et al., 2001).

Eren (2003) conducted a study of 104 male military recruits with a mean age of 19.2 years. The study assessed the clinical accuracy of joint line palpation for meniscal tears compared with arthroscopy, and describes the test as performed with the knee in 90° of flexion. About 75% of the recruits had probably sustained their injury before entering military service, and the remaining 25% were injured during service. Joint line palpation was correct for a meniscal diagnosis in 71 knees (68%) and incorrect in 33 (32%). Five medial and two lateral meniscal tears were seen at arthroscopy but were not detected by joint line palpation. The test was less accurate in combined injuries such as an ACL tear and/or chondromalacia patellae. For lateral meniscal tears, palpation of the lateral joint line had an accuracy of 96%, a sensitivity of 89% and a specificity of 97%. For medial meniscal tears, the accuracy was considerably lower, at 74% (Eren, 2003).

Cook & Hegedus (2012) criticise this study because the sample consisted only of young recruits. This is a selected group, which limits the usefulness and applicability of the results.

Rose (2006) studied joint line palpation alone compared with arthroscopy in 129 knees. The diagnosis was correct in 100 knees (77.5%) and incorrect in 29 (22.5%). Rose divided the tears into medial and lateral meniscal tears. A medial meniscal tear was suspected clinically in 63 knees and confirmed at arthroscopy in 46 (73%). For the medial meniscus, there were 46 true positives, 17 false positives, 4 false negatives and 62 true negatives.

Medial meniscus
Sensitivity	92%
Specificity	78%
Accuracy	83%
Positive predictive value	73%
Negative predictive value	93%

A lateral meniscal tear was suspected clinically in 45 knees, and 39 (86.7%) of these were confirmed arthroscopically. There were 6 false positives, 2 false negatives and 82 true negatives.

Lateral meniscus
Sensitivity	95%
Specificity	93%
Accuracy	93%
Positive predictive value	86%
Negative predictive value	97%

The author concluded that joint line palpation is accurate for lateral meniscal tears, but less so for medial tears (Rose, 2006). The study can be criticised for being retrospective and for the long interval between injury and arthroscopy, a mean of 19 months. Ockert and colleagues (2010) have also criticised the study because the author, the orthopaedic surgeon Rose, performed all the examinations himself (Ockert et al., 2010).

In knees with an ACL injury, the test performs considerably worse. The experienced knee surgeon Shelbourne and his colleague Benner examined joint line palpation in 3,531 patients who underwent ACL reconstruction more than 30 days after injury. Joint line palpation was performed immediately before surgery. In patients with a subacute ACL injury, joint line palpation had a sensitivity of 41%, a specificity of 56% and an accuracy of 50% for medial meniscal tears. For lateral meniscal tears, sensitivity was 57%, specificity 44% and accuracy 49%. In patients with a chronic ACL injury, the corresponding figures were 55%, 50% and 52% for medial meniscal tears and 46%, 52% and 50% for lateral meniscal tears. The authors concluded that joint line palpation alone should not be used to determine treatment (Shelbourne & Benner, 2009). Shelbourne’s research group had previously found similarly weak results in acute ACL tears, with a sensitivity of 45% and a specificity of 35% for medial meniscal tears (Shelbourne et al., 1995).

Konan and colleagues (2009) compared joint line palpation, the McMurray test and the Thessaly test with arthroscopy in 109 patients with a mean age of 39 years and a history suggestive of a meniscal tear. The examiner was blinded to the imaging findings. Of the three tests, joint line palpation had the highest diagnostic accuracy:

	Medial meniscus	ACL + medial meniscus
Sensitivity	83%	56%
Specificity	76%	89%
Positive predictive value	91%	90%
Negative predictive value	59%	53%
Diagnostic accuracy	81%	68%

	Lateral meniscus	ACL + lateral meniscus
Sensitivity	68%	57%
Specificity	97%	94%
Positive predictive value	87%	80%
Negative predictive value	59%	85%
Diagnostic accuracy	90%	85%

The authors nevertheless concluded that joint line palpation alone is not diagnostic for meniscal tears, and that several tests must be combined to achieve the best diagnostic accuracy. Combining joint line palpation with the McMurray test or the Thessaly test gave the following results (Konan et al., 2009):

	Joint line palpation + McMurray test	Joint line palpation + Thessaly test
Medial meniscus
Sensitivity	91%	93%
Specificity	91%	92%
Lateral meniscus
Sensitivity	75%	78%
Specificity	99%	99%

Several systematic reviews have pooled the results for joint line palpation, with varying results. Hegedus et al. (2007) included 18 studies published from 1966 to 2006 and found a pooled sensitivity of 63% and specificity of 77% (Hegedus et al., 2007). In a meta-analysis by Meserve and colleagues, based on eight studies with 1,374 participants, the pooled sensitivity was 76% and specificity 77%, with a diagnostic odds ratio of 10.98. Joint line palpation was the most accurate of the three tests examined, ahead of the McMurray test and Apley’s test (Meserve et al., 2008). In the most recent meta-analysis, Smith et al. (2015) found a sensitivity of 83% (95% CI 73–90%) and a specificity of 83% (95% CI 61–94%), compared with 61% and 84% for the McMurray test and 75% and 87% for the Thessaly test at 20° of knee flexion. The authors nevertheless concluded that the diagnostic accuracy of meniscal tests remains poor, and that the results should be interpreted with caution because of low methodological quality, few studies and substantial heterogeneity (Smith et al., 2015).

The reliability of the test is a significant weakness. Galli and colleagues (2013) found that agreement between examiners was low and that the results depended heavily on the examiner’s experience. Even for the most experienced examiner, an orthopaedic surgeon, joint line palpation had a sensitivity of 63%, a specificity of 50%, an LR+ of 1.26 and an LR− of 0.74 (Galli et al., 2013). In a primary care study, the inter-examiner reliability of joint line palpation was so poor (κ = 0.17) that the authors chose not to assess the diagnostic accuracy of the test (Snoeker et al., 2015).

The setting and the examiner’s experience also matter. In a large UK study using MRI as the reference standard, all patients were examined by both a primary care clinician and a musculoskeletal specialist. The diagnostic accuracy of joint line palpation was 54% when performed by primary care clinicians and 64% when performed by musculoskeletal specialists. None of the physical tests was a suitable substitute for MRI, and the best non-imaging method was a clinical history taken by an experienced musculoskeletal clinician (Blyth et al., 2015).

The timing of the examination after injury and concomitant injuries also affect the result. Rinonapoli et al. (2025) examined 255 patients aged 20–45 years after knee trauma, using arthroscopy as the reference standard. Joint line palpation had a high sensitivity (94% at 5–7 days and 90% at 4–5 weeks after injury), but a low specificity (40% and 51%, respectively). Cartilage lesions in the medial compartment accounted for 50–60% of the false-positive tests, and ACL tears were also associated with false-positive findings (Rinonapoli et al., 2025). In line with this, Kawanishi & Kitamura (2026) found, in 186 arthroscopically examined knees, that medial joint line palpation performed markedly worse when there was a concomitant cartilage lesion in the medial compartment. In knees without cartilage damage, the specificity of medial joint line palpation was 98% (Kawanishi & Kitamura, 2026). Tenderness over the medial joint line may therefore just as well reflect cartilage damage as a meniscal tear, particularly in middle-aged and older patients.

Joint line palpation appears to be most useful as part of a combination of history and examination findings. Décary and colleagues (2018) found that the combination of a pivoting or falling injury mechanism, isolated medial or diffuse knee pain and positive medial joint line palpation could both identify (LR+ 8.9) and exclude (LR− 0.10) a traumatic symptomatic meniscal tear. For degenerative meniscal tears, the best combination was progressive onset of pain, medial knee pain, pain on pivoting, no varus or valgus malalignment and full passive knee flexion (LR+ 6.4, LR− 0.10). Cartilage lesions were not assessed as a separate diagnosis in the study (Décary et al., 2018).

Meniscal tear or cartilage lesion?

History and clinical examination may suggest a meniscal tear or an articular cartilage lesion, but they discriminate poorly between the two. In the American Physical Therapy Association (APTA) clinical practice guideline for meniscal and articular cartilage lesions, a twisting injury, delayed effusion (6–24 hours), catching or locking, joint line tenderness and a positive Thessaly test at 20° of flexion are listed as findings suggestive of a meniscal lesion. Acute trauma with haemarthrosis (0–2 hours), insidious onset aggravated by repetitive impact, catching or locking and joint line tenderness are listed as findings suggestive of a cartilage lesion (Logerstedt et al., 2018). Catching/locking and joint line tenderness thus appear on both lists.

As the studies above show, meniscal and cartilage lesions frequently coexist, and cartilage damage in the medial compartment can produce a positive joint line palpation (Rinonapoli et al., 2025; Kawanishi & Kitamura, 2026). Positive joint line palpation should therefore be interpreted as a sign of intra-articular involvement in the relevant compartment, not as a specific sign of a meniscal tear.

In most cases, distinguishing a meniscal tear from a cartilage lesion is probably of limited clinical relevance, as the distinction rarely affects the choice of further management. Accordingly, the APTA clinical practice guideline for meniscal and articular cartilage lesions classifies the two conditions together (Logerstedt et al., 2018). The distinction may still matter when there are signs that warrant further investigation, for example a locked knee, a suspected loose body, a larger traumatic injury in a young patient or a concomitant cruciate ligament injury.

In their book, Cook & Hegedus (2012) give joint line palpation a utility score of 3, meaning that the evidence minimally supports or does not support its use (on a scale from 1, strong support, to 3, minimal or no support). This assessment reflects the literature up to 2012 (Cook & Hegedus, 2012). More recent research presents a mixed picture. Smith et al. (2015) found better diagnostic accuracy than the score suggests, whereas poor inter-examiner agreement (Galli et al., 2013; Snoeker et al., 2015) and frequent false-positive findings in the presence of cartilage lesions (Rinonapoli et al., 2025; Kawanishi & Kitamura, 2026) support a cautious interpretation.

Body Examination suggests the following interpretation of joint line palpation of the knee:

• Reproduction of the patient’s familiar pain on palpation of the knee joint line points to some extent towards a meniscal lesion in the area where the symptoms are reproduced.
• Joint line palpation is a very simple clinical test that should be part of the clinical examination of the knee. Always compare with the contralateral knee.
• The test was originally described with the knee in 90° of flexion, but the degree of flexion can and should be varied, particularly towards deep flexion.
• Rotating the tibia internally or externally makes the tibial plateau more prominent and therefore easier to palpate.
• Do not palpate only the joint line itself. The clinician should distinguish between the structures being palpated: the femur, the joint line and the tibial plateau. Tenderness over the medial joint line is common in cartilage lesions and may give false-positive results.
• A positive joint line palpation suggests intra-articular involvement in the relevant compartment but discriminates poorly between meniscal and cartilage lesions. In most cases, this distinction is probably of limited clinical relevance. It is more important to look out for findings that warrant further investigation.
• Joint line palpation is fairly sensitive but has low and variable specificity, and agreement between examiners is poor. A positive test alone is therefore weak evidence of a meniscal tear, and the examiner’s experience is important.
• Joint line palpation of the knee is a simple test, but on its own it is not good enough to detect meniscal pathology. Combined with an adequate history, the McMurray test and the Thessaly test, its accuracy becomes relatively good.

Literature search, updating and translation were carried out with the assistance of AI (Claude, Anthropic). The professional content has been reviewed and quality-assured by the editor-in-chief, Roar Syltebø.

References

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