Comprehensive Clinical Examination

Introduction

Before the incorporation of advanced imaging modalities into routine clinical practice, clinicians were dependent on a detailed clinical history and examination for formulation of a treatment plan. Many examination manoeuvres have been validated clinically or biomechanically and allow the clinician to predict the location and severity of injury to structures and support the selection of imaging studies. Further, the clinician may use this opportunity to establish a relationship with the patient and build trust. Key elements of the examination include visual inspection, palpation, neurovascular assessment, range-of-motion and ligamentous testing and dynamic evaluation via gait or more advanced activities if able. Careful documentation in a standardised fashion will serve as a baseline and allow future comparison during the treatment process. Comprehensive evaluation is not only critical for clinical practice, it is also essential for clinical research and is incorporated into outcome tools such as the International Knee Documentation Committee (IKDC) score.

Clinical Examination Overview

A standardised approach to the comprehensive clinical examination of complex knee injuries is presented along with evidence for basic and advanced concepts. Obtaining a detailed history from the patient is important and can guide the evaluation. Many complex knee injuries present acutely in a previously well-functioning knee, whereas others may result from recurrent injury in a knee with or without previous surgical treatment. The examination in these settings will have common themes, but knees with previous surgical treatment require careful attention to incisions and hardware.

In the acute setting, it is important to understand the injury mechanism in as much detail as possible. Key details include contact versus noncontact mechanism, pivoting, position of foot and velocity (i.e., high- versus low-energy injury). Although any combination may result in a complex knee injury, the assessment of an awkward landing after a layup in basketball is quite different from a high-speed motor vehicle collision. In the revision setting, it is important to obtain information on comorbidities, nature and number of previous surgeries, surgical details from the operative reports, history of wound healing difficulty, rehabilitation performed and precise nature of current symptoms.

After obtaining a detailed history and building rapport with the patient and family, a basic assessment of the injured knee is performed. The physical examination should always start with painless manoeuvres, whereas possibly painful portions of the examination should be performed last. Gross inspection for ecchymosis ( Fig. 1.1 ) and extraarticular swelling or a knee effusion will further guide examination. Anatomical landmarks for medial and lateral structures have been described, and tenderness over these sites may suggest injury. Observation of the resting position of the knee is important because a patient that is unable to fully extend the knee may have a locked meniscal tear or may have inhibition because of pain.

Palpation of extraarticular structures in the assessment of ligament injuries may provide useful information, specifically in the acute setting. This includes the medial collateral ligament (MCL) femoral and tibial attachments, proximal fibula, fibular collateral ligament (FCL) femoral and fibular attachments and the anterolateral complex (i.e., iliotibial band (ITB), capsulo-osseous layer of the ITB (COL), anterolateral ligament (ALL)). If tolerated, the knee position shown in Fig. 1.2 may be utilised for palpation of the anterolateral complex of the knee; tenderness at this site may suggest a rotational injury consistent with an anterior cruciate ligament (ACL) tear.

Neurovascular evaluation is an important aspect of all knee examinations. A screening lower extremity neurological examination should be performed. Common peroneal nerve injury is often associated with high-grade posterolateral knee injuries ^, and can be identified with diminished sensation at the foot as well as strength deficits with great toe extension, ankle dorsiflexion and eversion. A vascular assessment is mandatory and includes both the venous and arterial system. Deep vein thrombosis (DVT) can be encountered as a result of the soft tissue trauma and immobilisation; palpation of the calf for tenderness, and discomfort with forced ankle dorsiflexion may reveal a DVT and diagnostic imaging may be indicated. Although arterial injury is relatively uncommon in acute knee injuries, diminished distal pulses may indicate injury and should be evaluated with ankle–brachial blood pressure index and a potential computed tomography (CT) angiogram.

A classically held tenet of orthopaedic evaluation includes assessment of the ‘joint above and below’. High-energy mechanisms may be associated with hip, ankle and foot injuries, and assessment for pain with range of motion, deformity and swelling should be performed.

In all cases, both knees must be evaluated. This allows comparison of the injured knee with the healthy knee. This is facilitated by a flat examination table with ample room on both sides of the table to allow a side-to-side comparison of the knees. The examination may begin with the patient seated and the knees flexed off the edge of the table. Subsequently, the patient may be positioned supine on the table to allow full range-of-motion testing and examination manoeuvres as outlined in the following sections.

Patellofemoral Joint

Patients with a patellofemoral injury, especially in the acute setting, often guard against an assessment of patellar laxity and range of motion, complicating the examination. Palpation for sites of tenderness, including the medial patellofemoral ligament (MPFL) and its attachments, will aid in injury assessment. In patients with a recurrent patellofemoral injury, observation for healed incisions may indicate prior knee arthroscopy for a lateral release or incisions for medial repair or MPFL reconstruction. If tolerated, examination with the knee in full extension and the quadriceps muscles relaxed will allow assessment of patellar laxity ( Fig. 1.3 ). Compared with the contralateral side this can provide valuable objective information on potentially pathological increased or decreased motion, and patellar laxity can be quantified with the quadrant method.

A key element of examination of the patellofemoral joint is observation of active range of motion with the patient in the seated position. This allows the patient to control his or her movements, supports inspection of the static restraints and dynamic muscular control and allows the clinician to evaluate maltracking of the patella.

Lateral patellar instability is usually secondary to a lateral subluxation or dislocation. A large effusion is often observed, and significant guarding and quadriceps weakness are typical. Most patients have apprehension with lateral translation because of the acuity of the injury. Patients with chronic lateral patellar instability usually tolerate a more detailed examination. Objective testing of lateral laxity should be performed along with assessment of tracking, palpitation for crepitus and evaluation for apprehension with lateral translation. Assessment of the static Q-angle and observation of a dynamic J-sign add to the understanding of patellofemoral pathological conditions.

Medial patellar instability is most often observed in the setting of a previous lateral retinacular release, a procedure historically performed for anterior knee pain believed to be secondary to lateral patellar maltracking. Although this procedure is now infrequently performed, patients with a history of this procedure may present with anterior discomfort and a sensation of patellar instability with increased medial translation compared with the contralateral side. The diagnosis of symptomatic medial patellar instability may be confirmed with reverse McConnell taping, and treatment with a lateral patellotibial ligament reconstruction may be indicated if reverse McConnell taping provides relief of symptoms. Medial patellar instability may also be secondary to an acute traumatic instability event although this is less common.

Tibiofemoral Joint

As in the case of patellofemoral injuries, examination of tibiofemoral injuries in the acute setting may be limited by pain, swelling and guarding, although much information may be gleaned from this evaluation. The subsequent sections focus on ligamentous examination, although meniscal and chondral injuries are also discussed.