Telemedicine Examination of the Knee

Abstract

Introduction The coronavirus disease 2019 (COVID-19) pandemic has resulted in rapid healthcare system adaptations, including the acceptance of telemedicine in primary care. In the case of knee ailments, among the most common problems encountered in primary care, telemedicine provides a literal window to observe the patient performing functional activities. Despite its potential, there is a lack of standardized protocols for data collection. The purpose of this article is to provide a step-by-step protocol to aid in performing a telemedicine examination of the knee. Methods This article provides a step-by-step guide for a telehealth examination of the knee. Results A step-by-step examination of how to structure a telemedicine evaluation of the knee. A glossary of images of each maneuver has been included to demonstrate the components of the examination. Additionally, a table of questions and possible answers were included to help guide the provider through a knee examination. Conclusion This article provides a structured and efficient means of extracting clinically relevant information during telemedicine examinations of the knee.

Keywords: functional testing; gait; knee; telehealth; virtual examination.

Figure 1. Joint line of the knee

Palpation of the joint line that reproduces pain suggests possible osteoarthritis, patellar tendinitis, or proximal tibiofibular joint injury.

Figure 2. Active knee flexion and extension

A. Lateral view of the patient for knee range of motion approximation. B. There should be 0° to 15° of knee extension; limited extension suggests hamstring restriction. C. There should be approximately 120° to 140° of knee flexion; limited flexion can be caused by quadriceps or patellar pathology.

Figure 3. J sign

A. During knee extension, the patella should follow a smooth arc. B. A J-shaped pattern (J sign) suggests patellar instability.

Figure 4. Trendelenburg gait

A. During normal gait, the hip abductors stabilize the pelvis and keep it level. B. When there is hip abductor weakness, the hip is not level during the gait cycle. This lack of stability can alter force distributions in the kinetic chain and contribute to knee pain.

Figure 5. Body weight squat

A. Anterior view of smooth controlled squat descent. B. Medial collapse of the knee during descent (arrow) with pain suggests medial collateral ligament involvement and weakness in the involved extremity. C. Posterior view of smooth controlled squat descent. D. Hip shift (arrow) suggests weakness or restriction of motion in the side shifted away from.

Figure 6. Modified medial and valgus stress testing

A. Neutral standing position. B. Modified valgus stress. Instruct the patient to bend their knee medially (arrow). C. Modified varus stress. Instruct the patient to bend their knee laterally (arrow). Pain with either maneuver suggests ligamentous involvement on the side of the knee that is stressed.

Figure 7. Modified Noble's compression test

Instruct the patient to apply pressure at the distal insertion iliotibial band (A) and then extend the knee (B). Pain suggests possible iliotibial band syndrome or fibular head dysfunction.

Figure 8. Posterior sag sign

Instruct the patient to lay supine with knees at approximately 90° flexion, supporting the heels with a box. A noticeable difference in tibial height represents a posterior sag sign, suggesting the involvement of the posterior cruciate ligament of the knee.

Figure 9. Modified Thomas test

Instruct the patient to pull the unaffected knee to the chest and lay back. If the knee is extended, there is possible rectus femoris involvement. If the hip is flexed, there is possible psoas involvement. Rotation suggests iliotibial band restrictions or iliotibial band syndrome. Abduction of the hip suggests possible tensor fascia latae involvement as the source of pain.

Figure 10. Modified Thessaly test

A. Instruct the patient to stand on the affected leg with slight knee flexion. Have the patient turn their shoulders to the left (B) and right (C). Knee pain with this maneuver suggests possible meniscal pathology.