Master the 2-Minute Knee Exam: Essential Tests & Techniques for Knee Pain
Knee pain, affecting 25-46% of adults and trailing only back pain in prevalence, accounts for 4 million primary care visits annually and represents 5% of all primary consultations. (1,2) Fortunately, evidence-based chiropractors are well-suited to manage many of these patients.
This week's blog and video will delve into the crucial aspects of a knee evaluation, featuring a comprehensive knee physical exam tutorial to help you elevate your diagnostic skills to the next level! In the next few minutes, you’ll review:
A practical knee exam tutorial video
The top tests for differentiating common pain generators
When to image a painful knee
Watch this webinar on performing a 2-minute knee physical exam.
What Are The Most Common Knee Diagnoses?
According to the ChiroUp Network Dataset Analysis of 631,970 clinical diagnoses collected from our 2,200 evidence-based chiropractic providers, the top three most common knee diagnoses in chiropractic offices were:
Patellofemoral pain syndrome
Iliotibial band syndrome
Knee osteoarthritis
While anterior knee repetitive stress disorders dominate the list, providers must consider various other potential diagnoses that can affect the bones, joints, cartilage, ligaments, tendons, muscles, and nerves.
Pro Tip: Knee osteoarthritis patients commonly report morning stiffness. However, if this stiffness exceeds 30 minutes, it may raise suspicion of inflammatory arthropathy. Download the ChiroUp Inflammatory Arthropathy Quick Reference Card for a handy refresher.
Essential Questions To Ask In A Knee Exam
Like most other musculoskeletal complaints, the patient history is the primary source of essential diagnostic information for knee-related issues. Key history questions during knee exams include:
Trauma history - Knee injuries are often linked to their mechanism of trauma:
Twisting motions cause meniscal tears.
Direct blows and deceleration forces can lead to ligamentous ruptures and cruciate ligament injuries; Noncontact actions like sharp turns or stops can sprain or rupture the ACL; A knee hitting a vehicle dashboard stresses the PCL.
Lateral or medial forces typically result in collateral ligament damage.
Hyperextension precipitates injury to both anterior and posterior cruciate ligaments.
Occupation and activities (aka Microtrauma history) - Overuse conditions, notably tendinopathies and iliotibial band syndrome, often stem from a consistent pattern of repetitive microtrauma.
Symptom location and character - Pain location can provide diagnostic clues.
Pro Tip: Streamline Your Patient History Collection Effortlessly!
Discover how you can gather a comprehensive and intuitive OPPQRST in just 4 clicks with our newest functionality: Chief Complaint Survey. Check out the video below for more information on this game-changing solution!
How To Perform A Knee Exam
The essential components of a knee physical exam include
Inspection - swelling, deformity
Range of motion - active, passive, and resisted movements
General palpation - tenderness, swelling, warmth, muscle wasting
Joint palpation - stability testing, motion palpation
Orthopedic assessment - specific to the differential diagnoses
Lumbar evaluation - an estimated 25% of knee problems arise from an asymptomatic spine. (3)
Pro Tip: Don't overlook the critical role of functional assessment in knee evaluations! Often, the key to resolving knee complaints lies in uncovering biomechanical deficits elsewhere, particularly in the hips or feet. Check out these popular ChiroUp clinical webinars to review the essentials.
When To Image The Knee
X-rays for acute presentations
The Ottawa Knee Rules define when plain film Imaging is appropriate for acute knee pain patients. (4)
Age >55 years
Isolated patellar tenderness without other bone tenderness
Tenderness of the fibular head
Inability to flex the knee to 90°
Inability to bear weight immediately after injury for four steps
A recent systematic review concluded that the Ottowa knee rules demonstrate 99% sensitivity for fracture. (5) Likewise, the Pittsburg Knee Rules also report 99% sensitivity for detecting fracture following blunt trauma or a fall AND any of the following (6):
The patient is younger than 12 or older than 50
Inability to walk four weight-bearing steps
X-rays for chronic presentations
The American College of Radiology advises that radiographs are generally suitable for those over 50 with chronic knee pain. (7) However, radiographic findings do not always align with symptoms, and the diagnosis of OA can often be made without imaging based on risk factors and typical symptoms. (8) Routine radiographic screening solely for knee OA is not generally recommended.
Imaging should be considered if there are unexpected changes in clinical complaints, lack of response to care, or suspicion of alternate diagnoses. (9) Typical plain film views include an anteroposterior, lateral, and Merchant's view of the patellofemoral joint. (10)
MRI
MRI is a versatile diagnostic tool for diagnosing and grading a wide range of knee issues:
Meniscal disorders (like tears and cysts)
Muscle, tendon, and ligament abnormalities (including sprains and tears)
Extensor mechanism issues (such as tendon degeneration)
Osteochondral and articular cartilage abnormalities (like loose bodies or synovitis)
Osseous abnormalities including stress fractures
Iliotibial band syndrome
Pathology (like neoplasms and infections)
MRI is particularly useful for cases of prolonged or unexplained knee pain, significant acute trauma, mechanical symptoms like catching or snapping, instability issues, swelling or mass, and pre-surgical evaluation. (11)
Diagnostic Ultrasound
Diagnostic ultrasound is another potential tool for evaluating knee effusions or cysts, iliotibial band syndrome, and medial plicae. Ultrasound can detect peripheral meniscus tears and assess superficial structures such as tendons, ligaments, muscles, vasculature, and nerves. It shows utility in dynamic evaluations of the extensor mechanism, including the quadriceps and patellar tendons, and is effective in investigating mechanical issues like snapping or clicking through targeted palpation. (2,10)
Conclusion
Hopefully, this blog doesn't just guide your knee evaluations; it underscores the exceptional role chiropractors play in musculoskeletal health. Mastering precise diagnosis and effective treatment elevates our practice and patient outcomes to new heights. This is more than patient care; it's about showcasing our profession's transformative impact on health and well-being. Let's embrace this knowledge enthusiastically, reinforcing our status as the top choice for patients and payers alike. Together, we're not just treating joints – we're changing lives.
Pro Tip: ChiroUp subscribers can download exam forms for every region by visiting the Practice Resources forms library, and then selecting Clinical/ Regional exam forms.
In case you didn't catch last week's blog, we're thrilled to share exciting news about the launch of our Chief Complaint Survey. This groundbreaking tool is a game-changer, simplifying the collection of patient subjective information to enhance the diagnostic process significantly.
This innovative tool tailors questions specifically to the chief complaint, ensuring a more streamlined and patient-centric approach.
If you are not a ChiroUp subscriber and are Interested in witnessing the survey in action or sending one to yourself. You can access it through our 14-day Free Trial or schedule a consultation call with us.
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1. Duong V, Oo WM, Ding C, Culvenor AG, Hunter DJ. Evaluation and Treatment of Knee Pain: A Review. JAMA. 2023 Oct 24;330(16):1568-80. Link
2. Hunter CW, Deer TR, Jones MR, Chang Chien GC, D’Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA. Consensus guidelines on interventional therapies for knee pain (STEP Guidelines) from the American Society of Pain and Neuroscience. Journal of pain research. 2022 Dec 31:2683-745. Link
3. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30. Link
4. Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Cacciotti T, McDowell I, Smith NA. Derivation of a decision rule for the use of radiography in acute knee injuries. Annals of emergency medicine. 1995 Oct 1;26(4):405-13. Link
5. Sims JI, Chau MT, Davies JR. Diagnostic accuracy of the Ottawa Knee Rule in adult acute knee injuries: a systematic review and meta-analysis. European Radiology. 2020 Aug;30:4438-46. Link
6. Seaberg DC, Jackson R. Clinical decision rule for knee radiographs. The American journal of emergency medicine. 1994 Sep 1;12(5):541-3. Link
7. American College of Radiology ACR Appropriateness Criteria® Chronic Knee Pain Revised 2018. Accessed on 01/12/2024 from Link
8. Ebell MH. Osteoarthritis: rapid evidence review. American family physician. 2018 Apr 15;97(8):523-6. Link
9. Wang X, Oo WM, Linklater JM. What is the role of imaging in the clinical diagnosis of osteoarthritis and disease management? Rheumatology. 2018 May 1;57(suppl_4):iv51-60. Link
10. Bunt CW, Jonas CE, Chang JG. Knee pain in adults and adolescents: the initial evaluation. American family physician. 2018 Nov 1;98(9):576-85. Link
11. ACR-SPR-SSR Practice Parameter For The Performance And Interpretation Of Magnetic Resonance Imaging (MRI) Of The Knee. Revised 2020. Accessed on 01/12/2024 from Link
