What is the approach to evaluating a patient with knee pathology?

From the Guidelines

The evaluation of a patient with knee pathology should begin with a thorough history and physical examination, followed by appropriate diagnostic testing, prioritizing the patient's morbidity, mortality, and quality of life as the primary outcome. The physical examination should include inspection for swelling, deformity, and skin changes; palpation for tenderness and effusion; assessment of range of motion; stability testing with maneuvers such as the Lachman test, anterior/posterior drawer tests, and varus/valgus stress tests; and evaluation of meniscal pathology using McMurray's test and Thessaly test 1.

Key Components of the Physical Examination

• Inspection for swelling, deformity, and skin changes
• Palpation for tenderness and effusion
• Assessment of range of motion
• Stability testing with maneuvers such as the Lachman test, anterior/posterior drawer tests, and varus/valgus stress tests
• Evaluation of meniscal pathology using McMurray's test and Thessaly test

Initial imaging typically includes weight-bearing radiographs in anteroposterior, lateral, and sunrise views to assess for fractures, degenerative changes, and alignment issues, as recommended by the American College of Radiology 1. Advanced imaging may be indicated based on clinical findings: MRI is valuable for soft tissue injuries including meniscal tears, ligament injuries, and cartilage damage, while CT scans help evaluate complex fractures.

Imaging Modalities

• Weight-bearing radiographs in anteroposterior, lateral, and sunrise views
• MRI for soft tissue injuries
• CT scans for complex fractures

Laboratory tests such as inflammatory markers, synovial fluid analysis, or serology may be necessary when infection or rheumatologic conditions are suspected 1. This systematic approach allows for accurate diagnosis and appropriate treatment planning, whether conservative management with rest, ice, compression, elevation (RICE), physical therapy, and anti-inflammatory medications, or surgical intervention for structural damage. The most recent and highest quality study, published in 2020, supports the use of a thorough history and physical examination, followed by appropriate diagnostic testing, to evaluate patients with knee pathology 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.