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Thessaly test

Bodyexamination

Written by manual therapists Thomas T. Ødegaard and Roar Syltebø

The Thessaly test is one of the “newer” meniscal tests and was developed by a Greek research group in the early 2000s. In 2005, Karachalios and colleagues published an article describing the test. The Thessaly test is a provocation test for detecting meniscal tears in the knee. It is a weight-bearing, dynamic test intended to create mechanical shear forces in the knee at different degrees of flexion. The test is named in honour of Thessaly, a region of Greece with a history of more than ten thousand years as an academic and medical point of reference (Karachalios et al., 2005).

Indication

The Thessaly test is a meniscal test indicated in patients with knee complaints. Meniscal tests should routinely be performed both after knee injuries and in gradually increasing knee pain. A history of clicking and/or a sensation of locking raises the suspicion of a meniscal lesion. 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

The patient is standing, and the examiner stands in front of the patient and holds the patient’s hands. The patient stands on one leg with the knee in 5° of flexion. The patient then rotates the body and knee internally and externally three times, keeping the knee in 5° of flexion.

The procedure is then repeated with the knee in 20° of flexion.

The test is always performed on the uninjured side first, so that the patient can learn how the test should feel and be performed. The symptomatic knee is then tested (Karachalios et al., 2005).

As a modification, the examiner can support the patient’s shoulders or hips to ensure a full range of rotation.


Interpretation

The Thessaly test is considered positive if there is discomfort or pain at the medial or lateral joint line and/or a sensation of locking or catching in the knee. A positive test suggests a meniscal lesion. Karachalios et al. (2005), who both developed the test and studied its diagnostic accuracy, reported very good results. At 20° of knee flexion, the sensitivity was 89% for medial and 92% for lateral meniscal tears, the specificity 97% and 96%, and the diagnostic accuracy 94% and 96%, respectively (Karachalios et al., 2005).

The study by Karachalios et al. (2005) can be criticised for its case–control design, in which symptomatic patients were compared with healthy volunteers. This is not the methodological gold standard for diagnostic accuracy studies, and such a design tends to overestimate the accuracy of a test. The reported results should therefore be interpreted with caution. Karachalios and colleagues reported inter- and intra-examiner agreement of 95%.

In this study, the results differed between testing at 5° and at 20° of knee flexion. The best results were found at 20° of flexion. The authors suggest that this may be because the mechanical load increases at 20° of flexion, squeezing the fragments apart to a greater degree and thereby producing more positive responses. On the basis of this study, the group recommends the Thessaly test as a first-line screening test for meniscal tears. In addition to good clinical results, they argue that it is cost-saving compared with MRI (Karachalios et al., 2005).

Konan et al. (2009) examined the clinical accuracy of the Thessaly test and other meniscal tests in 109 patients. The mean age was 39 years, and all patients had a history suggestive of a meniscal tear. The tests were performed by an independent examiner who was blinded to the imaging findings, and the results were compared with MRI and arthroscopy. The research group assessed each meniscal test individually and in combination. The results for the Thessaly test, with arthroscopy as the gold standard, are shown below (Konan et al., 2009).

Thessaly 5° Medial meniscus Lateral meniscus ACL + medial meniscus ACL + lateral meniscus
True positives 24 3 5 1
True negatives 15 54 6 18
False positives 7 7 1 1
False negatives 34 16 13 5
Specificity 68% 89% 86% 95%
Positive predictive value 77% 30% 83% 50%
Negative predictive value 31% 77% 32% 78%
Diagnostic accuracy 49% 71% 44% 76%
LR+ 1 1 2 3
LR− 0.9 1 0.8 1
Diagnostic odds ratio 2 1 2 4
Thessaly 20° Medial meniscus Lateral meniscus ACL + medial meniscus ACL + lateral meniscus
True positives 35 6 8 3
True negatives 14 58 6 18
False positives 7 3 1 1
False negatives 24 13 10 3
Sensitivity 59% 31% 44% 50%
Specificity 67% 95% 86% 94%
Positive predictive value 83% 66% 89% 75%
Negative predictive value 37% 81% 38% 86%
Diagnostic accuracy 61% 80% 56% 84%
LR+ 2 6 3 9.5
LR− 0.6 0.7 0.6 0.5
Diagnostic odds ratio 3 9 5 18

The authors did not report the sensitivity of the Thessaly test at 5° of knee flexion (Konan et al., 2009).

Konan et al. (2009) found clearly lower values for the Thessaly test than the original article by Karachalios et al. (2005). The diagnostic accuracy was 61% for the medial and 80% for the lateral meniscus, comparable to the McMurray test (57% and 77%), whereas joint line tenderness had a diagnostic accuracy of 81% and 90%. Konan and colleagues therefore conclude that the Thessaly test alone does not increase diagnostic certainty for meniscal tears. They are nevertheless positive about using the Thessaly test in combination with other meniscal tests, particularly joint line palpation, as this increases diagnostic accuracy (Konan et al., 2009).

In April 2010, Ockert et al. published a meta-analysis from Germany, based on searches of Medline and the Cochrane Library. Their aim was to assess the value of clinical tests in suspected meniscal injury. In their review, the Thessaly test had the highest value of the clinical tests: sensitivity 91%, specificity 97%, positive predictive value 97%, negative predictive value 91%, positive likelihood ratio 31.1 and negative likelihood ratio 0.1. They conclude that the Thessaly test may improve the clinical examination of patients with a suspected meniscal lesion. This conclusion was, however, based on only one study (Ockert et al., 2010).

In the same year, the research group of Mirzatolooei et al. (2010) in Iran published a study validating the Thessaly test for detecting meniscal tears in knees with an anterior cruciate ligament (ACL) injury. They performed the test at 20° of flexion only, in 80 patients with an ACL injury. The examiners were blinded to the MRI findings, and all patients underwent arthroscopy to assess any meniscal tears. Six patients had severe pain during the test and could not complete it according to the protocol. The results were: sensitivity 79%, specificity 40%, positive predictive value 56%, negative predictive value 66%, positive likelihood ratio 1.33, negative likelihood ratio 0.51 and diagnostic accuracy 60%. Because of the low specificity in patients with a combined ACL and meniscal injury, they conclude that the Thessaly test cannot be recommended as a diagnostic test in this group (Mirzatolooei et al., 2010).

Karachalios et al. (2005) and Solberg & Kirkesola (2007) conclude that inter- and intra-examiner agreement is high when the Thessaly test is performed. In a later study of unselected patients in primary care, however, inter-examiner reliability was moderate (κ = 0.54) (Snoeker et al., 2015).

Goossens et al. (2015) studied 593 patients referred to hospital for arthroscopy because of a suspected meniscal tear. The Thessaly test was performed by physiotherapists, and an orthopaedic surgeon blinded to the test results performed the arthroscopy. The Thessaly test had a sensitivity of 64% (95% CI 60–68%) and a specificity of 53% (95% CI 43–63%). A positive result on both the Thessaly test and the McMurray test gave a sensitivity of 53% and a specificity of 62%, which was not significantly better than the individual tests. The authors conclude that the Thessaly test, alone or in combination with the McMurray test, has poor diagnostic accuracy, and that it adds little beyond the pre-test probability of a meniscal tear in a hospital setting (Goossens et al., 2015).

Snoeker et al. (2015) studied the Thessaly test in unselected patients with knee complaints in general practice, using MRI as the reference standard. The positive and negative likelihood ratios were close to 1, and the authors conclude that the test is not accurate enough to detect or rule out meniscal tears in primary care. They point out that the high values in earlier studies were obtained in selected patients awaiting arthroscopy, compared with healthy controls (Snoeker et al., 2015).

In a large UK diagnostic accuracy study using MRI as the reference standard, Blyth et al. (2015) compared the Thessaly test with the McMurray test, Apley’s test, joint line tenderness and a standardised clinical history. All patients were examined by both a primary care clinician (general practitioner or physiotherapist) and a musculoskeletal specialist. When performed by primary care clinicians, the Thessaly test had a sensitivity of 66%, a specificity of 39% and a diagnostic accuracy of 54%. The corresponding figures for musculoskeletal specialists were 62%, 55% and 59%. The Thessaly test was no more accurate than the established tests, and the best non-imaging method for diagnosing a meniscal tear was a clinical history taken by an experienced musculoskeletal clinician (Blyth et al., 2015).

In a systematic review with meta-analysis, Smith et al. (2015) found a sensitivity of 75% and a specificity of 87% for the Thessaly test at 20° of knee flexion. The authors concluded that the diagnostic accuracy of meniscal special tests remains poor, but that the results should be interpreted with caution because of the low methodological quality of the included studies and substantial heterogeneity (Smith et al., 2015).

Rinonapoli et al. (2025) examined 255 patients aged 20–45 years after knee trauma, using arthroscopy as the reference standard. The Thessaly test had a sensitivity of 98% in the acute phase (5–7 days after injury) and 91% in the subacute phase (4–5 weeks after injury), while specificity increased from 27% to 66%. The authors suggest that the test may have a screening role in the acute phase and give a more precise diagnosis in the subacute phase. Anterior knee pain and lateral cartilage lesions were important sources of false-positive Thessaly tests. Among combinations of three tests, the McMurray test, Apley’s test and the Thessaly test together gave the fewest false positives. No single test was reliable enough to be used on its own. Only patients for whom the two examiners agreed on the test result were included, which may have made the tests appear more accurate than they are in everyday practice (Rinonapoli et al., 2025).

The gold standard for a definitive diagnosis of a meniscal tear is arthroscopy. Several of the studies above use MRI as the reference standard. 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). This also affects the interpretation of diagnostic accuracy studies that use MRI as the reference standard.

Several authors argue that diagnostic accuracy improves when history and physical examination findings are combined, rather than relying on single tests (Décary et al., 2018).

In their book, Cook and Hegedus (2012) give the Thessaly test a utility score of 2, meaning that the evidence moderately supports its use in the clinical assessment of patients with a possible meniscal tear (on a scale from 1, strong support, to 3, minimal or no support). This assessment reflects the literature up to 2012, which was dominated by the original study by Karachalios et al. (2005). The more recent and methodologically stronger studies described above, particularly those of unselected patients in primary care, call this score into question (Goossens et al., 2015; Snoeker et al., 2015; Blyth et al., 2015).

Body Examination suggests the following interpretation of the Thessaly test:

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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