From the Guidelines
The evaluation of a patient with knee pathology should begin with a thorough history and physical examination, followed by radiographic evaluation with weight-bearing plain films in anteroposterior, lateral, and sunrise views, as recommended by the most recent study 1. The physical examination should include:
- Inspection for swelling, deformity, and muscle atrophy
- Palpation for tenderness and effusion
- Assessment of range of motion
- Stability testing with maneuvers such as the Lachman test, anterior and posterior drawer tests, and varus/valgus stress tests
- Special tests like McMurray's for meniscal pathology and the patellar apprehension test The history should include details about the onset of symptoms, mechanism of injury, pain characteristics, functional limitations, and any previous knee problems. Radiographic evaluation is crucial in identifying fractures, degenerative changes, and alignment issues, and should be guided by the Ottawa rule criteria, which recommends radiographs for patients with focal patellar tenderness, joint effusion, or inability to bear weight 1. Advanced imaging, such as MRI or CT scans, may be necessary depending on the clinical suspicion, and laboratory studies, including inflammatory markers, synovial fluid analysis, or serology, may be indicated when infection or rheumatologic conditions are suspected. It is essential to note that the evaluation approach may vary depending on the specific condition, such as acute trauma or chronic knee pain, and the patient's age and medical history, as discussed in the studies 1.
From the Research
Approach to Evaluating a Patient with Knee Pathology
The approach to evaluating a patient with knee pathology involves a combination of history taking, physical examination, and diagnostic tests.
- The clinical examination is the most important component in the diagnosis of knee joint diseases, in addition to a differentiated history 2.
- The examination should include general inspection and palpation, as well as specific tests for the patella, menisci, cruciate ligaments, and collateral ligaments 2.
- The McMurray test, Apley test, and medial and lateral joint line tenderness are used to diagnose meniscal tears 3.
- The Lachman test, jerk test, pivot-shift test, anterior drawer test, and KT-2000 side-to-side difference are used to diagnose ACL tears 3.
- The accuracy of clinical investigation for meniscal tears associated with ACL injuries can be decreased due to the remnants of the torn ACL and synovitis 3.
- Stress radiography is an important and validated objective measure in surgical decision making and post-operative assessment for PCL injuries 4.
- Isolated grade I or II PCL injuries can usually be treated non-operatively, while acute grade III PCL ruptures with other ligamentous injury and/or repairable meniscal body/root tears may require surgery 4.
Special Considerations
- Medial meniscus posterior root tears are often caused by meniscal degeneration, while lateral meniscus posterior root tears are mainly caused by trauma, especially trauma associated with ACL injuries 5.
- In rare cases, both meniscal posterior root tears can occur with an intact ACL, and surgical treatment with single-transtibial pullout repair may be effective 5.
- Conservative management of ACL ruptures and nonoperative management of PCL injuries may be reasonable strategies, while isolated MCL injuries are usually treated with a brief period of immobilization and symptomatic management 6.