948239

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HANXXX10.1177/1558944720948239HANDArnold et al

Surgery Article
HAND

Evaluation of the Seesaw Test as

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DOI: 10.1177/1558944720948239
https://doi.org/10.1177/1558944720948239

Thumb CMC Osteoarthritis journals.sagepub.com/home/HAN

Denise M. J. Arnold1 , Rachel Gottlieb1, Suzanne C. Wilkens1, Rohit Garg1,

Adam Nazzal1, Neal C. Chen1, and Sang-Gil Lee1

Abstract
Background: The seesaw test consists of flexion and extension of the thumb metacarpal on the trapezium, with
continuous axial pressure to keep the metacarpal base reduced in the carpometacarpal (CMC) joint. We aim to evaluate
this maneuver compared with the grind test. Methods: We prospectively enrolled 80 participants from March 2017
to March 2018 at a single institution, excluding those who had previous thumb surgery or pathology. Each participant
underwent both seesaw and grind tests by 2 independent examiners. We included 24 patients with a mean age of 73 years
in the CMC osteoarthritis group (Eaton stages 2-4) and 44 patients with a mean age of 66 years in the control group (Eaton
stages 0 and 1). We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV),
and multirater κ measure. Results: The seesaw test had a higher sensitivity than the grind test (42%-71% vs 13%-17%), but
a lower specificity (82%-86% vs 91%-98%). The PPV was more consistent between examiners for the seesaw test (63%-
68% vs 42%-80%), and the NPV was higher (73%-84% vs 66%-68%). There was a slight agreement between the attending
surgeon and the fellow performing the grind test (κ = 0.08) and a moderate agreement between the attending surgeon
and the fellow performing the seesaw test (κ = 0.59). Conclusions: The seesaw test is superior to the grind test, with a
much higher sensitivity, slightly lower specificity, more consistent PPV, and slightly higher NPV. Therefore, the seesaw test
could be a valuable addition or even replacement for the grind test, and we recommend considering it in daily practice.

Keywords: hand, CMC, arthritis, diagnosis, osteoarthritis, thumb, anatomy, cartilage, basic science, evaluation, research
and health outcomes, hand therapy, specialty, surgery, pain

Introduction test. We aim to determine the sensitivity, specificity, and

Thumb carpometacarpal (CMC) osteoarthritis (OA) is a
normal process that comes with aging,1 occurring in 13% of
men and 15% of women in their sixth decade, with increas-
ing prevalence with age.2 Nevertheless, it is a source of dis-
ability when symptomatic,3 which is the case in 3% of men
and 5% of women above the age of 70 years.4 As radio-
graphic evidence of CMC OA does not correlate well with
symptoms,5 clinical examination remains essential in
understanding the symptomatology. The most common
clinical test is the grind test, with reported sensitivity values
ranging from 30% to 64%.6-10
Radial-sided wrist pain can have a broad differential
diagnosis; hence, a more sensitive and specific clinical test
may be useful when evaluating patients with CMC OA. In
our experience, reduction of CMC subluxation accompa-
nied by flexion and extension of the CMC joint seems to be
a more effective test, which we have termed the “seesaw”
accuracy of the seesaw test in the diagnosis of thumb CMC
OA and compare the results with the most commonly used
diagnostic grind test. Both patients and physician would
benefit from a single, simple diagnostic test to aid in reli-
ably diagnosing CMC OA.
We tested the null hypothesis that there is no difference in
the sensitivity, specificity, and accuracy between the grind
test and the seesaw test for diagnosing thumb CMC OA. For
the secondary aim, we determined the interrater reliability of
1
Massachusetts General Hospital, Boston, MA, USA
Supplemental material is available in the online version of the article.
Corresponding Author:
Denise M. J. Arnold, Orthopaedic Hand and Upper Extremity Service,
Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114,
USA.
Email: dmj.arnold@gmail.com
2 HAND 00(0)
Table 1.  Inclusion and Exclusion Criteria.
Inclusion criteria
  35 years of age and older
  New presentation to hand clinic
  English fluency and literacy
 Suspicion of CMC OA/diagnosis unrelated to CMC or STT
arthritis
 Radiographs/fluoroscopic images as part of routine care
available
Exclusion criteria
  Previous arthroscopy or surgery for thumb CMC arthritis
  Other thumb pathologya
  Pregnant or lactating women
Note. CMC = carpometacarpal; OA = osteoarthritis; STT =
scaphotrapezial trapezoidal; UCL = ulnar collateral ligament.
a
Such as trigger thumb, UCL injury, STT arthrosis, and scaphoid fracture.
both tests and tested the null hypothesis that there is no
difference in interrater reliability between both tests.
Methods
After institutional review board approval, we prospectively
enrolled a total of 80 participants from March 2017 to
March 2018. All new patients, 35 years or older, with Eng-
lish fluency and literacy, suspected of having thumb CMC
OA or a diagnosis unrelated to CMC or scaphotrapezial
trapezoidal (STT) arthritis presenting at an urban hospital
in the Northeastern United States, were asked to participate
in this study. Patients who had previous arthroscopy or sur-
gery for thumb CMC OA, had other thumb pathology (such
as trigger thumb, ulnar collateral ligament injury, STT
arthrosis, and scaphoid fracture), or were either pregnant or
lactating were excluded (Table 1). All potential partici-
pants had radiographs or fluoroscopic images as part of
their routine care. After obtaining informed consent, demo-
graphic information was gathered by a member of the study
staff (age, sex, race, marital status, involved and dominant
hand, smoking history, and prior treatment) (Table 2).
Afterward, each participant underwent the seesaw test and
grind test twice—once by the attending hand surgeon and
once by a fellow in hand surgery. Although a single attend-
ing hand surgeon did all examinations, 5 different hand fel-
lows participated in this study, at different stages in the
year-long fellowship training. One fellow conducted 40 of
the 80 examinations, followed by 15, 14, 7, and 4 examina-
tions by the other 4 fellows, respectively. All fellows were
treated as 1 group. The tests were performed prior to regu-
lar clinical assessment and in the absence of the other
assessor. Both care providers were blinded to the partici-
pant’s reason for presenting to the clinic, and the order of
tests was randomized using a list of randomly generated
numbers (Stata 13). A member of study staff was present to
collect the data on both tests.
The grind test consists of grasping the thumb metacarpal
and exerting a combined rotation and axial compression of
the joint (Figure 1). The seesaw test consists of holding and
stabilizing the thumb metacarpal, reducing it in the CMC
joint; then, while continuous axial pressure is maintained to
hold reduction of the metacarpal base in the CMC joint,
flexion and extension of the metacarpal on the trapezium
are performed (Figure 2). Both tests are considered positive
if they elicit pain in the examined joint.8 Any grinding or
clicking felt by the examiner was also noted.
After performing both diagnostic tests, the attending
hand surgeon scored the radiographic stage of the partici-
pant’s thumb for CMC OA using the Eaton and Littler clas-
sification (Table 3). The scoring of radiographs was repeated
by the same hand surgeon at a minimum of 1 month after
the participant’s presentation to clinic. The second evalua-
tion was used to group all participants into 2 groups: par-
ticipants with radiographic evidence of CMC OA, defined
as Eaton stages 2 to 4, were included in the CMC OA group.
Participants with no or minimal radiographic evidence of
CMC OA, in accordance with Eaton stage 0 or 1, were
included in the control group.
Statistical Analysis
Based on the existing literature, the sensitivity for the grind
test was expected to be 0.40.6,7,9,10 Assuming that the sensi-
tivity of a meaningful test is 0.65,7 we would need a sample
size of 46 patients (n = 23 per group) to detect a meaningful
difference in sensitivity between the diagnostic tests, with a
type I error of 0.05 and 80% power. We planned on enroll-
ing a minimum of 50 patients in total (n = 25 per group).
Based on an empirical prevalence of new CMC OA patients
of about 30% within the patients selected from the schedule
in this clinic, we enrolled a total of 80 patients to ensure a
minimum of 25 confirmed patients with CMC OA. Twelve
radiographs were only available for the first evaluation,
resulting in 12 patients being excluded from the sensitivity,
specificity, and predictive value analysis.
To compare both groups, we used the Fisher exact test
for categorical variables and the Wilcoxon rank sum test for
nonparametric continuous variables. We calculated the sen-
sitivity, specificity, positive predictive value (PPV), and
negative predictive value (NPV). We used the multirater κ
measure described by Siegel and Castellan to estimate
agreement between the 2 rating care providers, a commonly
used statistic to describe chance-corrected agreement in a
variety of interobserver and intraobserver studies. The κ
values were interpreted using the guidelines proposed by
Landis and Koch (Table 3).11
Arnold et al 3

Table 2. Demographics.

All patients No CMC CMC

Demographics (N = 80) (n = 44) (n = 24) P value

Age, mean (SD) 66.4 (11.8) 66.1 (10.8) 73.1 (8.9) .009a
Sex, n (%)
 Male 40 (50) 26 (59.1) 8 (33.3) .75b
 Female 40 (50) 18 (40.9) 16 (66.7)  
Race, n (%) .54b
 White 75 (93.8) 42 (95.5) 24 (100)  
 Other 5 (6.3) 2 (4.6) —  
Dominant hand, n (%) .75b
 Left 7 (8.8) 2 (4.6) 2 (8.3)  
 Right 72 (90) 41 (93.2) 22 (91.7)  
 Ambidextrous 1 (1.3) 1 (2.3) —  
Dominant hand involved, n (%) .61b
 Yes 46 (57.5) 27 (61.4) 13 (54.2)  
 No 34 (42.5) 17 (38.6) 11 (45.8)  
Marital status, n (%) .91b
 Married 50 (62.5) 32 (72.7) 12 (50)  
 Divorced/widowed/separated 21 (26.3) 9 (20.5) 10 (41.7)  
 Single 9 (11.3) 3 (6.8) 2 (8.3)  
Smoking, n (%) 8 (10) 3 (6.8) 1 (4.2) >.99b
Prior treatment, n (%) .07b
 None 70 (87.5) 41 (93.2) 18 (75)  
 Splint 2 (2.5) — 2 (8.3)  
  Hand surgery not in CMC 3 (3.8) 1 (2.3) 1 (4.2)  
  Injection in CMC 1 (1.3) — 1 (4.2)  
  Injection not in CMC 4 (5) 2 (4.6) 2 (8.3)  

Note. CMC = carpometacarpal.

Bolded P values are statistically significant.
a
Wilcoxon rank sum.
b
Fisher exact.

Results Study Population Thumb CMC OA Group

In this study, we used an estimated sample size of 46
patients (n = 23 per group), with a type I error of 0.05 and
80% power. As described in the “Methods” section, the
hand surgeon evaluated the thumb radiographs for Eaton
classification both directly after clinical evaluation and at
least 1 month later. There were 78 radiographs scored in the
first evaluation directly after clinical evaluation: 51 (65.4%)
were classified as having no or only minimal radiographic
signs of CMC OA (in accordance with Eaton stages 0 and
1), 27 (34.6%) were classified as having radiographic CMC
OA (in accordance with Eaton stages 2 to 4), and 2 (2.6%)
were not graded. There were 68 radiographs scored in the
second evaluation at a minimum of 1 month later: 44
(64.7%) had no radiographic CMC OA, 24 (35.3%) did
show radiographic signs of CMC OA, and 12 (17.6%) were
not graded. Additional analysis showed no difference in
Eaton scoring directly after clinical evaluation and 1 month
later (P = .535).
We included 24 patients with radiographic CMC OA,
defined as Eaton stages 2 to 4. The mean age of patients was
73 years (SD = 8.9). All patients were white, and most were
right-hand dominant (92%). Two-thirds of all patients were
women (67%). Half were married (50%) and had their dom-
inant hand involved (54%). One patient (4.2%) smoked.
Most patients (75%) had no prior treatment, 2 patients
(8.3%) had a splint, and 1 (4.2%) had a previous corticoste-
roid injection in the CMC joint at another clinic. Two
patients (8.3%) had injections of the ipsilateral hand or
wrist elsewhere than the CMC joint (such as corticosteroids
for carpal tunnel syndrome or trigger finger), and 1 (4.2%)
had hand surgery unrelated to CMC OA.
Study Population Control Group
We included 44 control patients, defined as having no to min-
imal signs of CMC OA and were radiographically Eaton
4 HAND 00(0)

Figure 1.  The grind test. The grind test consists of (a) grasping the thumb metacarpal while stabilizing the trapezium and (b) exerting
a combined rotation and axial compression of the joint.

Figure 2.  The seesaw test.

The seesaw test also starts with grasping and stabilizing the thumb metacarpal, (a) reducing it in the carpometacarpal (CMC) joint while (b) stabilizing
the trapezium with the other hand. With continuous axial pressure on the metacarpal, keeping it reduced in the CMC joint, (c) extension and (d)
flexion of the metacarpal on the trapezium are performed while evaluating for pain and grinding or clicking.
Arnold et al 5

Table 3.  Classifications Used in This Study.

The Eaton and Littler classification of basilar thumb arthritis

Stage Description
I Slight joint space widening (prearthritis)
II Slight narrowing of CMC joint with sclerosis, osteophytes <2 mm
III Marked narrowing of CMC joint with osteophytes, osteophytes >2 mm
IV Pantrapezial arthritis (STT involved)

The Landis and Koch guidelines for κ values

κ value Level of agreement

0.00 No agreement beyond expected owing to chance
0.01-0.20 Slight agreement
0.21-0.40 Fair agreement
0.41-0.60 Moderate agreement
0.61-0.80 Substantial agreement
> 0.80 Almost perfect agreement
1.00 Total disagreement
> 1.00 Perfect agreement

Note. CMC = carpometacarpal; STT = scaphotrapezial trapezoidal.

Table 4.  Evaluation of Test Results.

Test results Grind test Seesaw test

  Surgeon Fellow Surgeon Fellow

CMC OA No CMC OA CMC OA No CMC OA CMC OA No CMC OA CMC OA No CMC OA

Positive 3 4 4 1 17 8 10 6
Negative 21 40 20 43 7 36 14 38
Sensitivity,% 12.5 16.7 70.8 41.7
Specificity,% 90.9 97.7 81.8 86.4
PPV, % 42.9 80 68 62.5
NPV, % 65.6 68.3 83.7 73.1

Note. No CMC = Eaton stages 0 and 1. CMC = Eaton stages 2 to 4. CMC = carpometacarpal; OA = osteoarthritis; PPV = positive predictive value;
NPV = negative predictive value.

stages 0 and 1. The mean age of patients was 66 years (SD =
10.8), which was significantly less than the case group (P =
.009). Most patients (96%) were white, right-hand dominant
(93%), and married (73%). Just over half of all patients were
men (59%) and had their dominant hand involved (61%).
Three patients (6.8%) reported smoking. Most patients (93%)
did not have prior treatment, 1 patient (2.3%) had hand sur-
gery unrelated to CMC OA, and 2 patients (4.6%) had injec-
tions of the ipsilateral hand or wrist elsewhere than the CMC
joint. Apart from age, the groups were comparable.
When performed by the attending hand surgeon and
hand fellow, respectively, the grind test had a sensitivity of
13% to 17%, specificity of 91% to 98%, PPV of 43% to
80%, and NPV of 66% to 68%. There was no significant
difference between the results of the grind test performed
by the attending hand surgeon and hand fellow (P = .434),
although the surgeon felt subtle grinding without pain twice
as often as the fellow (Tables 4 and 5). All 6 patients with a
negative grind test but positive grinding felt by the hand
surgeon had radiographically confirmed CMC OA.
The seesaw test had a sensitivity of 71% to 42%, speci-
ficity of 82% to 86%, PPV of 68% to 63%, and NPV of 84%
to 73%, performed by the attending hand surgeon and hand
fellow, respectively (Table 4). There was a significant dif-
ference between the results of the seesaw test performed by
the attending hand surgeon and hand fellow (P < .001)
(Table 5). The attending surgeon rated more seesaw tests as
positive (eliciting pain) and reported more grinding in the
joint both when testing positive and negative. Eight of 16
patients who had no pain (negative test) but perceived to
6 HAND 00(0)

Table 5.  Additional Test Findings and Interrater Agreement.

Additional test findings Grind test Seesaw test

Surgeon Fellow Surgeon Fellow

Positive 7 (8.8) 6 (7.5) 26 (32.5) 17 (21.3)
 Grinding — 1 (1.3) 19 (23.8) 9 (11.3)
 Clicking — 1 (1.3) 2 (2.5) 2 (2.5)
  Grinding and clicking — — 2 (2.5) 1 (1.3)
Negative 73 (91.3) 74 (92.5) 54 (67.5) 63 (78.8)
 Grinding 6 (7.9) 3 (3.8) 15 (18.8) 1 (1.3)
 Clicking — — 6 (7.5) 6 (7.5)
  Grinding and clicking — — 1 (1.3) 1 (1.3)
 Subluxating — — — 2 (2.5)
P value .434a .000a

κ values for interrater agreement

Expected Standard
Test Agreement, % agreement, % κ error P value
Grind 86.25 85.06 0.0795 0.1114 .238
Seesaw 83.75 60.06 0.5931 0.1073 .000

Note. Bolded P values are statistically significant.

a
Fisher exact.

have grinding in the joint during the seesaw test had radio-
graphic CMC OA. Of the 12 negative tests with clicking
(without grinding), none had radiographic CMC OA. Of the
28 positive tests with grinding, 21 had CMC OA on radio-
graphs and 7 did not.
Overall, the seesaw test had a higher sensitivity than the
grind test (42%-71% vs 13%-17%), especially when per-
formed by the attending hand surgeon (71%) compared
with the hand fellow (42%). The specificity of the seesaw
test was slightly lower when compared with the grind test
(82%-86% vs 91%-98%). The PPV was more similar
between the attending hand surgeon and fellow for the see-
saw test (68% and 63%) compared with the grind test (42%
and 80%). In case of a positive seesaw test by the attending
hand surgeon, there is a 68% chance the patient has CMC
OA identifiable on radiographs; in case of a negative test,
there is an 84% chance the patient does not have CMC OA
identifiable on radiographs.
The κ values for interrater agreement indicate there is a
slight agreement between the attending surgeon and the fel-
low when performing the grind test (κ = 0.08, P = .24).
There is a moderate agreement between the attending sur-
geon and fellow when performing the seesaw test (κ =
0.59, P < .001) (Table 5).
Discussion
Thumb CMC OA is challenging to diagnose purely with
clinical tests. The grind test is a commonly described test,
but it is inconsistent in our experience. We have used
flexion and extension of the metacarpal in the CMC joint
(the “seesaw” test) for many years because they seemed to
be more useful in our experience. This prospective study
aimed to determine the sensitivity, specificity, accuracy,
and interrater reliability of seesaw and grind tests in
patients with and without radiographic CMC OA. We
found the seesaw test had a sensitivity of 42% to 71%,
specificity of 82% to 86%, PPV of 63% to 68%, NPV of
73% to 84%, and moderate interrater reliability (κ =
0.59). The grind test had a sensitivity of 13% to 17%,
specificity of 91% to 98%, PPV of 42% to 80%, NPV of
66% to 68%, and slight interrater reliability (κ = 0.08).
The results of this study need to be interpreted in consid-
eration of its limitations. First, the tests were performed by
5 different hand fellows, not in equal proportion, and at dif-
ferent stages in the year-long fellowship training. One of
these fellows conducted half of the clinical examinations,
which could have influenced the interrater agreement.
Although all fellows were trained in using the seesaw test,
the performance characteristics of the test may improve
over time, as the most experienced surgeon had better test
characteristics. Second, both the grind and seesaw tests
were considered positive if they elicited pain, but it is
unclear what subtle grinding, clicking or a combination of
both means in the absence of pain (which we considered a
negative test). The hand surgeon found grinding without
pain in 6 patients (7.9%) during the grind test and in 16
patients (20%) during the seesaw test. All 6 of the grind
Arnold et al 7
tests with grinding but no pain and 7 of the 16 seesaw tests
with grinding but no pain demonstrated CMC OA on their
radiographs. When grinding without pain was considered a
positive test result, the sensitivity of the grind test improved
from 13%-17% to 29%-38%. The specificity remained
unchanged. The sensitivity of the seesaw test when per-
formed by the attending surgeon improved from 71% to
100%, whereas the specificity dropped from 82% to 64%
(Supplemental Table 1). This may indicate that an experi-
enced surgeon has an even higher sensitivity with the see-
saw test if grinding without pain is considered a positive
test result. Third, in this study, there was a relatively high
prevalence of CMC OA because of patient selection; there-
fore, it was more likely that patients with a positive test also
had radiographic CMC OA. If the seesaw test would be per-
formed in a clinic with a different population with lower
prevalence of basilar thumb OA, this might negatively
influence the usefulness of the test. Further testing in more
general patient populations could yield different results.
When the seesaw test is used in high-prevalence clinics
such as hand clinics, we believe it could be a valuable addi-
tion to the grind test.
For this study, we used the second evaluation of radio-
graphs in statistical analysis to reduce bias inherent in evalu-
ating the radiographs directly after clinical examination.
However, some of the radiographs made as part of routine
care were only available for the first evaluation, resulting in
12 radiographs not available for the second evaluation. Even
though additional analysis showed no difference in Eaton
scoring between both evaluations, this should be noted.
Clinicians have a battery of diagnostic tests available to
assess thumb CMC OA, including the grind, distraction,
traction-shift, and metacarpal base compression tests. Prior
studies have evaluated the grind test and have generally
found a low sensitivity (30%-53%) and high specificity
(80%-100%).6,7,9,10 Subsequently, the PPV is high (91%-
100%), and NPV is variable (24%-70%).6,9 In addition, the
interrater reliability is moderate (κ = 0.31-0.48).6,10 Our
study found the grind test has a very low sensitivity (13%-
17%) but high specificity (91%-98%). In other words, the
grind test is useful for ruling out CMC OA that would be
detected on radiographs, but does not effectively identify
patients who likely have CMC OA on radiographs. In our
cohort, more than 80% of patients with confirmed CMC OA
on radiographs have a negative grind test. In case of a posi-
tive grind test, there is a 43% to 80% chance that the patient
has CMC OA detectable on radiographs, although the PPV
differed greatly between attending surgeon and fellows.
With an NPV of 66% to 68%, a negative test does not
exclude the possibility of radiographic CMC OA.
More recently described diagnostic tests, such as the
lever, thumb adduction, and extension stress tests, dem-
onstrate higher values for sensitivity (82%, 94%, and
94%, respectively), specificity (81%, 93%, and 95%,
respectively), and interrater reliability (NA, 79%, and
84%, respectively).9,10 The seesaw test also had a sub-
stantial higher sensitivity than the grind test (71%-42%)
but lower specificity (82%-86%), missing 29% of the
patients with radiographic CMC OA when performed by
an experienced hand surgeon. Our study was not designed
to determine interrater reliability, but the interrater agree-
ment between the attending hand surgeon and fellow was
higher for the seesaw test compared with the grind test
(κ = 0.59 vs .08), suggesting that the seesaw test was
more consistent between the attending hand surgeon and
the fellow. Further study to compare the seesaw test
against other tests that seem to be superior to the grind
test should be considered. Currently, the seesaw test can
be considered as an addition to the battery of clinical
examination tools.
Conclusion
In conclusion, we have used the seesaw test for many years
and decided to examine this in comparison with the grind
test. We found that the seesaw test had a higher sensitivity
(42%-71% vs 13%-17%), slightly lower specificity (82%-
86% vs 91%-98%), more consistent PPV (63%-68% vs
42%-80%), and slightly higher NPV (73%-84% vs 66%-
68%) compared with the grind test. We also found that the
seesaw test demonstrated more consistent results between
different health care providers (κ= 0.59 vs 0.08). We feel
that it is a worthwhile test to consider for clinical assess-
ment of CMC OA.
Acknowledgments
We would like to thank Dr Daphne van Hooven for assisting in
subject identification and inclusion. We would also like to thank
all hand fellows for participating in this study by performing the
clinical examinations.
Ethical Approval
This study was approved by our institutional review board.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical stan-
dards of the responsible committee on human experimentation
(institutional and national) and with the Helsinki Declaration of
1975, as revised in 2008.
Statement of Informed Consent
Informed consent was obtained from all individual participants
included in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
8 HAND 00(0)
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Denise MJ Arnold https://orcid.org/0000-0002-2326-2981
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