varus stress test sensitivity and specificity

The final study by Sae-Jung et al24 compared a modified version to McMurray's added axial compression, similar to that applied by Kurosaka et al6 but without added valgus or varus stress. Solomon DH, Simel DL, Bates DW, Katz JN, Schafter JL. However, other studies have shown MRI to be no more accurate than clinical examination for the diagnosis of meniscal tears14,15. Fritz JM, Wainner RS. The https:// ensures that you are connecting to the More recent research has shown that modifications to the original McMurray's test may have better validity and diagnostic accuracy than the original McMurray's test3,58. [5], The LCL stabilizes the lateral side of the knee joint, mainly in varus stress and posterolateral rotation of the tibia relative to the femur. Clinical Diagnostic Tests Versus MRI Diagnosis of ACL Tears. FOIA and transmitted securely. [2] Harilainen A et al. The differences in study populations are likely to have contributed to the wide variability of results across studies. . In chronic injuries, this test has a sensitivity of 92% and a specificity of 91%, but not in acute injuries. YWQ2ODI0ODM5NzE5MzVlYTlmMTRmMWEzM2NlYmU4OTViYTkwOTBmNjVjZGFj The modified weight-bearing test showed a higher LR+ and a lower LR than the McMurray's test (Table (Table7).7). 13th ed. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Download scientific diagram | AP and lateral radiographic images of a SE-4 fracture consisting of a spiral or oblique fracture laterally with a combination of an avulsion fracture medially. Intertester reliability of clinical judgements of medial knee ligament integrity. Boeree NR, Ackroyd CE. how likely a negative test result is in people who have the disease or dysfunction as compared to how likely it is in those who do not have the disease or dysfunction. The confidence interval (CI) attests to the precision of this estimate11. TP=true positive, FP=false positive, FN=false negative, TN=true negative. Published by Elsevier Inc. All rights reserved. Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD initiative. [2] Harilainen A. ZTEyZjE4YTgwNjcwY2IwOWVkNmUwZDVjODFiMTExMDBhN2MyOGE5NDdhYWUz official website and that any information you provide is encrypted Therefore, this study aimed to determine the differences between varus and valgus arthritic knees in the response to conservative treatment. Performed at 900 of knee flexion, and has a sensitivity of 90% and a specificity of 99% Isolated PCL translate > 10-12mm in neutral and >6-8mm in internal rotation. The sensitivity and specificity of the McMurray's test reported in the studies identified in this review vary widely (Table (Table5).5). Varus stress test video provided by Clinically Relevant, Additional tests for detecting LCL injury with other knee ligaments:[6], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. followers. Performance: A varus stress test is performed by stabilizing the femur and palpating the lateral joint line. ZTE1ZTU0YzgxZTBhZGFlNGI5YzcyODQ4YjdhNTE5Yzc0MmMzMTI2YmQ5M2E1 Bookshelf Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears. Based on the STARD scoring of each paper, it is possible to make a qualitative assessment about the methodological quality. [1] The therapist applies a valgus stress at the knee while the ankle is stabilized in slight lateral rotation either with the hand or with the leg held between the examiner's arm and trunk. Effect of Sectioning of the Anterior Cruciate Ligament and Posterolateral Structures on Lateral Compartment Gapping: A Randomized Biomechanical Study. Five studies compared modified versions of the test to McMurray's3,5,6,21,24 (Table (Table33). The remaining studies do not clearly state if their subjects were consecutive. Interpretation: If the knee joint adducts greater than normal (compared to the unaffected leg), the test is positive. The Management of Sofi Tissue Knee Injuries: Internal Derangements. Currently, a triple phase technium-99 bone scan (scintigraphy) is the most accurate method of diagnosing stress fractures with a sensitivity of 100% and specificity of 76%. MWQ3MmUzODg0NGJiYzhiODZlYmMxOGU3NzQ1ZTAwNmMxNTJjOTZiZDJlZGFi This site needs JavaScript to work properly. [3] McClure P,W et al. MTk2NGZhNDE4OTk1NmViZWEyZWM3NzcwNDY0NzA4Y2VmMzBjNjI3MjUwNzdj This is not surprising given the complicated nature of the technique and the difficulty in controlling the amount and direction of forces across testers. MeSH In: Campbell's Operative Orthopaedics. Obviously, if the test is performed differently and/or the interpretation of a positive test is not the same, the demonstrated accuracy of the test cannot be compared. Sensitivity: the ability of a test to correctly identify patients with a disease. PDF ssslideshare.com NCI CPTC Antibody Characterization Program. The sensitivity of a test reflects the proportion of people with the disease in question who are tested positive, whereas the specificity is the proportion of those without the disease who are tested negative. Harilainen A. YjQ3NDViZGE1YWVjODEwNTIzYzIyMmY1YjViMDhhNGI3Y2YyNTI4NmMwMjli Accessibility Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. ZTU5MGVlOWM4MDcwMGE2YmJiZjNjZTBiMjQ2N2E5OTFmNTliZDgyYzc4ZjQ0 Arthrosc Tech. Studies of specificity and sensitivity have demonstrated varied values as a result of poor methodological quality A recent meta-analysis reports sensitivity and specificity to be 70% and 71%. In order to make the retrieval of articles as comprehensive as possible, a generic search strategy was employed using Medline, CINAhL, and AMED databases through OVID, SPORTDiscus database through EBSCO, and SCOPUS, from 1980 to May 2008. Fowler PJ, Lubliner JA. While some studies have stated that greater clinical experience aids correct diagnosis3,5,19, the only current statistical evidence in this regard shows no difference between an experienced and inexperienced tester 23. It has been used previously for the systematic assessment of the methodology of studies into diagnostic accuracy10. These results have been supported by Karachalios et al21, who compared another weight-bearing modification (the Thessaly test) of the McMurray's with the original test. With a sensitivity of 86% and a specificity of 95%, . The final two studies20,21 limited their study population to patients suspected of meniscal injury. That is usually the journal article where the information was first stated. Evaluation of Knee Instability in Acute Ligamentous Injuries. The same maneuvers are performed in gradually increasing degrees of knee flexion to progressively load more posterior segments of the menisci. YzFjZGMyZmVmOTJjNWQ2NWYyNDVkNDE1OWM3Yzg5NjE2MWNhYTY1ZGZlNGYw NTc3ODRiOTRjOGU4N2ExOGU2NDEzYWVjZmNiMTQ1N2FjM2U4NjVmMzhlMzRi Painful conditions of the knee, inPain Management Vol 1.,2007. ZDZkZjczMGZkNzQ1OWMxZTQyNDY2ZTAzYTM5OTk2ZmQ1YjkzNDFjMDhmNzMy Each test is repeated with the knee in full extension. official website and that any information you provide is encrypted Unfortunately, it is not possible to accurately determine the precision of reliability of the Boeree and Ackroyd19 study as CIs could not be calculated. Sensitivity figures were higher than specificity for three studies5,20,25 (Table (Table5).5). 1173185. Evidence. document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); We use cookies to optimize our website and our service. [2]Meniscal tears may occur in acute knee injuries in younger patients or as part of a degenerative process in older individuals. This was also discussed by Evans et al23, who attributed their low sensitivity rates to wide patient entry criteria including differing pathologies (Table (Table44). 2008. OTY4NzkyOGEwY2VjNzA3NjZiZWFkZmRlNjgyOGUwMGYxNDhkNjlhNDBhZmVi Fowler and Lubliner22 attributed their low sensitivity results (compared to previous studies)5,25 to population differences between the studies (Table (Table5).5). Arthroscopy. Ciba M, Winkelmeyer EM, Schock J, Westfechtel S, Nolte T, Knobe M, Prescher A, Kuhl C, Truhn D, Nebelung S. Sci Rep. 2022 Jul 13;12(1):11858. doi: 10.1038/s41598-022-15787-2. [8], Mechanism of injury: (for more information, see the page on LCL injuries)[4], Patient position: Legs crossed with ankle resting on opposite knee (90 knee flexion, hip abduction and external rotation). 1987; 76: 269-273. Clinical diagnosis of meniscal tears: Description of a new manipulative test. A wide variety of clinical tests are used to diagnose meniscal pathology within the knee joint. Modified McMurray's to include valgus/varus stress. Of the studies evaluated in this review, six used the original description of the McMurray's test4,6,20,2224. The test is fairly solid. Winters K, Tregonning R. Reliability of magnetic resonance imaging of the traumatic knee as determined by arthroscopy. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. If the varus stress test is positive at 20, but negative at 0, only the LCL is torn. Valgus and Varus test of the knee can be graded by the following 1: Grade I: The joint space opening is within 2 mm of the contralateral side. Disease paper 2 .pdf - Jade Smith BIOL 2301 Sec. 001 Epub 2018 Jul 27. [1] It is one of 4 critical ligaments involved in stabilizing the knee joint. Studies were eligible for inclusion if they assessed measures of accuracy or validity of the McMurray's test or any modification of this test against a gold standard of either arthroscopy or magnetic resonance imaging (MRI) and were written in English. Diagnosis of acute knee ligament injuries: The value of stress radiography compared with clinical examination, stability, under anesthesia and arthroscopic or operative findings. Likelihood ratios overcome some of the problems involved with sensitivity and specificity values by summarizing the information contained in these values in a manner that can be used to quantify shifts in probability once the meniscal test results are known28. Thus, to avoid selection bias, it is important that a study include consecutive patients with pathologies that could be commonly confused with a meniscal tear and should not include patients without symptoms. YWU3NTg0YTg5NzcxMzE4M2I5NjZiYzgxNzlkYjQyNmRjYjE1OWNjZjJmNzVh Canada. A recent meta-analysis illustrates the difference in test characteristics when performed on patients under anesthesia. The proportion of people who do not have the disease or dysfunction who test negative. Four studies demonstrated that a positive test alters the probability to only a small, rarely important degree5,6,25, suggesting uncertainty that a positive test will indicate meniscal pathology (Table (Table5).5). ODFlNzFkZTQ2MDZmOTVkM2Q1MjEzNzY5YTlmZTU2MTRmYWFkYzY2ZmRmNzlj and transmitted securely. Knee, McMurray's, Meniscal, Reliability, Sensitivity, Specificity, Testing, Validity. Clinical Rehabilitation, 22(2), 143-61. Of the four studies that demonstrated the highest shifts in probability, only Corea et al4 and Akseki et al3 contained calculable CIs, which were relatively narrow (Table (Table55). NzM3NDQ2NDMzYThiNjlhNjA0M2M3MzVlMWFhYmE5ZDI3ZTI0YTIyZGIyNWM4 This is a key test to perform when assessing for posterolateral instability of the knee. No valgus or varus stress is applied. Symptoms related to an intra-articular knee pathology. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Operational definitions of diagnostic accuracy terms used in the studies investigating validity of McMurray's test for meniscal pathology (modified from Powell & huijbregts10). Karachalios et al21 incorrectly added valgus or varus stress as a component of the McMurray's. . [1]. A total of 232 patients were included: 98 patients in the FCL tear group (mean age: 33.6 12.2 years) and 134 patients in the control group (mean age: 44.0 17.2 years). Bhandari M, Guyatt GH. 2018 May 2;6(5):2325967118770170. doi: 10.1177/2325967118770170. Sensitivity: 25%. Therefore, articles were assessed using the STARD (Standards for Reporting of Diagnostic Accuracy) checklist of methodological quality9, which uses established criteria for quality assessment of different research formats10. ODU2Y2M1MDM5YjZiZGYwM2E5ZDEyYjk5Nzc0MTA0ZWQxYmE5MmJiMjRlYWQ2 Inclusion in an NLM database does not imply endorsement of, or agreement with, The studies that compared the diagnostic accuracy of the McMurray's test with that of modified versions of the test showed enhanced diagnostic accuracy for the modified tests. Current Orthopaedics. In an analysis of 20 available studies, the mean sensitivity and specificity of the anterior drawer test were 38% to 81% in awake patients and 63% to 91% in anesthetized patients, respectively. There are also discrepancies in the studies as to what constitutes a positive McMurray's test. Described a modified version (Ege's test) but no description of McMurray's. McMurrays Test - Physiopedia Specificity is the proportion of patients without the condition who have a negative test result and indicates the ability to use a test to recognize when the condition is absent11. MDUwOTJiNWVjMDExNzg5OTRkYzIwNjRlYzdhZmM2MzUyYjUwY2IxYTkzMTRk document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); If you want to assess the integrity of the medial collateral ligament (MCL), check out the Valgus Stress Test of the Knee. The best statistics for summarizing usefulness of a diagnostic test appear to be likelihood ratios (LR)17. Original Editors - Dorien Scheirs, Joris De Pot, Top Contributors - Saimat Lachinova, Admin, Joris De Pot, Dorien Scheirs, Kim Jackson, Rachael Lowe, Leana Louw, Oyemi Sillo, WikiSysop, Tony Lowe, Derycker Andries, Naomi O'Reilly, George Prudden and Kai A. Sigel. Three of the studies in this review considered a positive test to be the reproduction of a palpable thud or click4,6,22 (Table (Table4).4). However, this provisional diagnosis was also based on other symptoms that one might consider could be associated with pathologies other than meniscal tears, e.g., pain, recurrent effusion, muscle wasting, and instability. Studies were included for analysis if they compared the McMurray's test with a gold standard of knee arthroscopy or magnetic resonance imaging (MRI). These authors considered the overall accuracy of the axially loaded pivot shift test to be higher than that of the McMurray's test (Table (Table7).7). Once again, this affects the generalizability of the findings. Consecutive patients awaiting elective arthroscopy for suspected meniscal or other conditions based on history and physical examination. McMurray test | Radiology Reference Article | Radiopaedia.org Manzotti A, Baiguini P, Locatelli A, et al. Consider the findings of this test in conjunction with those of other tests to enhance the likelihood of a correct diagnosis such as joint line tenderness. Clinical assessment of meniscal pathology in the knee has proven difficult due to the wide number of tests available and variations in their interpretation and application. Whenever suspecting a posterolateral complex injury, one has to carefully perform a valgus stress test in 0 degrees and 30 degrees. Clinial oriented anatomy. Anderson AF, Lipscomb AB. Grade II: The joint space opens 3-5 mm more than the contralateral side in 20 degrees of knee flexion and less than 2 mm more than the normal knee in full extension. In total, 11 studies have been included in this critical review. The predictive value of Thve clinical signs in the evaluation of meniscal pathology. Patients suspected of having a meniscal tear on the basis of history and mechanism of injury excluding those with multiple injuries, history of knee surgery, early clinical and radiographic signs of osteoarthritis, articular cartilage injuries, neurological and musculoskeletal degenerative disorders, disorders of the synovium, acute injuries (less than 4 weeks post-trauma), and any abnormal findings on conventional radiographs. The review suggests that modifications of the interpretation of a positive test to include reproduction of pain either as well as or on its own may enhance the validity of the test. At the proximal level this ligament is closely related to the joint capsule, without having direct contact, as it is separated by fat pad, The insertion is augmented by the iliotibial band. ZmY3MzI2ODBmYTBhMDEzNzY3YmRkZjU0MDRhM2U2ODliZTFmOWMzYWI0MWI5 Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared with MRI, with an overall sensitivity of 70% compared with 66%, respectively. National Library of Medicine When evaluating any diagnostic test, commonly used parameters are its sensitivity and specificity. Am J Sports Med. A recent study by Winters and Tregonning13 showed a diagnostic accuracy for MRI to be 90% for the medial meniscus and 82% for the lateral meniscus. This was a purposeful strategy designed to enhance their ability to determine the true sensitivity and specificity of the McMurray's test in a population that reflects the symptomatic knee cohort that presents clinically. (1987) evaluated the varus stress test and found rather poor diagnostic accuracy. Each of these studies demonstrated improved diagnostic accuracy of these modified tests compared to the original McMurray's; however, they concluded that the modified tests should be used as well, as rather than as an alternative to other diagnostic tests3,5,6. The IR of the tibia followed by extension, the examiner can test the entire posterior horn to the middle segment of the meniscus. Only one study by Harilainen et al. A prospective study comparing the accuracy of the clinical diagnosis of meniscal tears with magnetic resonance imaging and its effect on clinical outcome. To evaluate the diagnostic accuracy of magnetic resonance imaging and varus stress radiographs for fibular collateral ligament (FCL) tears, and compare these modalities to intraoperative findings. eCollection 2019 Feb. This is a relatively new tool and has not been subjected to an analysis of its reliability at this time; however, the tool does provide a consistent framework on which to base the analysis of diagnostic studies. Elbow Varus Instability Stress TestLateral Collateral Ligament Am J Roentgenol. The possibility of there being associated intra-articular pathology (such as anterior cruciate ligament rupture) confounds results, and the unknown validity, sensitivity, and specificity of the tests make it difficult for the clinician to be confident in making a definitive diagnosis3. These authors also observed that the studies on these new tests have only been subjected to scientific scrutiny on one occasion and further research is required on these tests. (2007)Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. Careers, Unable to load your collection due to an error. Simmel DL, Samsa GP, Matchar DB. Copyright 2018 Arthroscopy Association of North America. Comparable sensitivity and specificity were shown in regards to the Thessaly test, 85.4% and 54%, respectively. The statistical measures of sensitivity, specificity, and likelihood ratios were calculated from the information provided in the studies. This lack of consensus in the literature highlights the risk that the criteria indicating a positive test can influence the test outcome, irrespective of whether the test was performed in the same manner on the same patient. As a stand-alone test, it had a sensitivity of 78% and specificity of 67% the pain was used as the outcome measure and a sensitivity of 91% and specificity of 49% when laxity was the outcome measure. Evans PJ, Bell GD, Frank CY. This generic search strategy was then combined with a subject-specific strategy (Table (Table1).1). Useful tests should produce large shifts in probability once the result of the test is known. Valgus and Varus Stress Test - Physical Therapy Haven Describes clinical information available to raters, Describes statistical methods for comparing diagnostic accuracy and expressing uncertainty, Describes methods for calculating test reproducibility; if done, Reports when study was done with start and end dates for recruitment, Reports clinical and demographic characteristics of subjects, Reports how many subjects satisfying inclusion criteria did not undergo the tests; describes why these subjects were not tested, Reports time interval between researched and reference test and any treatment provided in between tests, Reports disease severity in subjects with target condition and other diagnoses in subjects without target condition, Reports cross-tabulation of researched and reference test, Reports adverse effects from researched and reference test, Reports estimates of diagnostic accuracy and measures of statistical uncertainty, Reports how indeterminate test results, missing responses, and outliers of researched test were handled, Reports estimates of variability between raters, centers, or subject subgroups; if done, Reports estimates of test reproducibility; if done, Discusses clinical applicability of study findings. Evaluation of knee instability in acute ligamentous injuries. The accuracy measure has limited usefulness in that it does not distinguish between the diagnostic value of positive and negative results11. (1987) evaluated the varus stress test and found rather poor diagnostic accuracy. YTY1NDM4NjNkYzAwMmMxNGU2MjgwMmMzODFlMTZkZmQyYjRmNTAzM2RkZWY4 Diagnosis and treatment strategies of the multiligament injured knee: a Similarly, Corea et al4 included consecutive patients who were clinically diagnosed as having torn menisci based on a number of signs and symptoms including locking, a positive McMurray's test, painful clicks, and giving way. Varus Test Of The Knee 2023 | OrthoFixar In testing the accuracy of a clinical test like the McMurray's test, ideally the study participants should consist of individuals who would be likely to undergo the test in clinical practice and who have a reasonable chance of having the condition16. Does the patient have a torn meniscus of ligament of the knee? Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Elbow Valgus Stress Test 2023 | OrthoFixar The majority of studies did not report intertester or intratester reliability of the McMurray's test. Mariani PP, Adriani E, Maresca G, Mazzola CG. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. If the CI is wide and contains values that are not clinically important, the usefulness of the measure may be questionable11. The fibular or lateral collateral ligament (LCL) is a cord-like band and acts as the primary varus stabilizer of the knee. Sensitivity: 25% . Philadelphia: Wolters Kluwer, 2010. The technical storage or access that is used exclusively for anonymous statistical purposes. In general, sensitivity figures are much lower than specificity and the CI limits are wider. Houten: Bohn Stafleu Van Loghum, 2005. Buy online Fucidin no RX - Trusted Fucidin no RX National Center for Biotechnology Information Three independent reviewers assessed each of the papers included in the review, and an overall STARD score of methodological quality was determined for each paper. Posterior drawer test Posterior sag test (godfrey test) Quadriceps active test Dial test Varus/valgus stress . The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. Fibular Collateral Ligament Reconstruction in Adolescent Patients. A recent literature review on composite testing of the diagnostic tests for the meniscus reported reasonable sensitivity and specificity when the findings of a number of tests are combined31. These authors excluded subjects with clinical or radiographic evidence of arthritis or fracture that would increase the accuracy of testing but decrease the generalizability of the findings. Before Federal government websites often end in .gov or .mil. Consecutive patients with knee pain of at least one year's duration that warranted arthroscopic investigation. How to appraise a diagnostic test. Knee Examination: Overview, Periprocedural Care, Technique - Medscape These studies have hypothesized that by incorporating aspects of varus/valgus stress and/or axial loading into the original McMurray's test, there is an increase in diagnostic value3,5,6. To some degree, this is achieved by sensitivity and specificity, which provide useful information for interpreting the results of diagnostic tests. The assessment results for methodological quality has been presented under the following headings: the STARD analysis, reference standard, population differences, blinding, description and interpretation of test, inter-tester reliability, diagnostic accuracy and validity, sensitivity and specificity, likelihood ratios, and McMurray's test compared to modified versions of the test. Sensitivity and specificity of a test. Generated by Wordfence at Mon, 1 May 2023 20:49:59 GMT.Your computer's time: document.write(new Date().toUTCString());. varus stress test: A test of ligament laxity, where a passive force is exerted on a joint that, in the presence of ligamentous insufficiency, would cause the lateral joint space to open, e.g., lateral collateral ligament of the knee and radial collateral ligament of the elbow. Three studies used only one tester4,5,25, and two studies did not mention how many examiners were used3,24. Fowler and Lubliner22 had a similarly broad population in that they included consecutive patients who warranted arthroscopic examination for any reason. The agreed quality for each paper is included in Table Table33. Orthopedic Physical Assessment: 5 th Edition. Specificity: not reported. Likelihood Ratio +/-. Limitations of this review relate to the search strategy used. Authors of 9 studies examined the Lachman test and reported sensitivity values ranging from 0.63-0.93 and specificity values ranging from 0.55-0.99. Patients who underwent arthroscopy to assess suspected meniscal or meniscal together with ACL injuries. The reliability of this test in extension is 68% and in 30 flexion only 56%. Assessment of the menisci and cruciate ligaments: An audit of clinical practice. Described a modified version (Medial-Lateral Grind test) but no description of McMurray's. Kurosaka et al6 stated that diagnostic accuracy is lessened in patients with multiple pathologies, whereas Akseki et al3 found that there was no reduction in diagnostic accuracy with an associated tear of the ACL. Evidence-Based Medicine: How to Practice and Teach EBM. The anterior portion of the meniscus is not easily tested because the pressure to that part of the meniscus is not as great. The objective of this paper was to critically review the literature with respect to the validity and diagnostic accuracy of the traditional McMurray's test and any modifications of this test. A prospective evaluation of a test for lateral meniscal tears. Were the raters blinded to the results of the other test? St. Louis, MO: Saunders Elsevier;2008. Prospective evaluation of the McMurray test. ZDg0M2Q2NDY1ZmIyNjFkZjBiOWE0MzQ3ZjJhZTY1NmRmYTUwYTBiMTNkNTIz MRI has also shown to be highly reliable, but due to its expensive cost, they are less frequently used.

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varus stress test sensitivity and specificity