Knee Assessment

Knee injuries are amongst the most common injuries next to shoulder, low-back, and neck pain seen in general practice (Picavet et al. 2003). They can be divided into two logical subgroups: traumatic and atraumatic knee injuries.

Traumatic injuries commonly involve a specific mechanism of injury such as during sports and they usually have a rapid onset. Atraumatic injuries on the other hand are rather overuse injuries that build up gradually over time with an insidious onset.

In primary care, the reported incidence is 13.7/1000 and the prevalence is 19/1000 persons per year for knee injuries (van der Linden et al. 2004)

Course

The course of knee complaints appears not to be too favorable. Reports show that at a 12-month follow-up, 33% of patients with atraumatic knee pain and 25% of patients with traumatic knee pain report full recovery (Wagemakers et al. 2012).

Prognostic factors

For atraumatic knee injuries, the following prognostic factors were associated with persistent knee symptoms after 1 year (Belo et al. 2009):

• age >60 years
• low educational level
• kinesiophobia
• comorbidity of the skeletal system

For traumatic knee injuries, however, Wagemakers et al. (2012) report the following prognostic factors:

• age >40
• female gender
• pain score >5
• popping sensation during trauma

Multivariate logistic regression analysis revealed that only age >40 was a prognostic factor for persistent complaints at the 1-year follow-up.

Red flags

There are several specific pathologies that count as red flags in the knee joint. These are:

Fractures

Characteristic signs and symptoms are:

• Swelling/bruising over the bone
• Deformity
• Painful ROM
• Tenderness

To assess for a fracture of the knee, you can make use of the Ottawa Knee Rules or Pittsburgh decision rule:

Post-traumatic neurovascular damage

This usually involves two or more ligament injuries as well (ACL, PCL, Collateral).

Characteristic signs are:

• Hematoma
• Groove at the lateral or medial joint line
• Markedly visible and palpable deformity
• Damage to the n. peroneus communis, n.tibialis (hypofunction of muscles innervated by the nerve), a. tibialis posterior and/or a. dorsalis pedis (àpalpate for pulsation)

Complete rupture of the extensor group

This may result from low-velocity trauma (elderly), sports or motor vehicle accident (adults)

Characteristic signs are:

• Inability to lift the extended leg
• Palpable groove in the quadriceps muscle
• Difference in level of the two patellae (alta: patella tendon affected, bacha: quadriceps tendon affected)
• Inability to bear weight on the leg

Monoarthritis

Inflammation of a joint due to infection from diagnostic or therapeutic intervention, skin damage, co-morbidities, endoprosthetics, STDs, GI infection, IV drug use, tuberculosis, gout, gonorrhea, acute rheumatic arthritis, sickle cell disease, reactive arthritis, medication use: diuretics, corticosteroids

Characteristic signs include:

• General malaise
• Swelling of the entire joint (not moving, tense skin)
• Redness of the joint
• Local increase in temperature
• Decrease in ROM

Spontaneous hemarthrosis

This is mainly a risk in people who have disorders such as hemophilia or those who use anticoagulants.

Bone- or soft-tissue tumor

While you assess for malignancy during your general screening, localized tumors can have the following signs:

• Mild, alternating pain over weeks
• Palpable mass at the end of long bones
• Swelling of soft tissues
• Growth in a lesion/swelling that’s been existing for a longer period
• Swelling below the muscle fascia
• Swelling at a site distant to the site of trauma

Basic Assessment

Depending on the outcome, your basic assessment can give you the following info:1) Limitations in range of motion and their end-feel can guide in structural assessment (e.g. bone to bone=osteoarthritis, empty=tendinopathy due to pain)

It’s best to start with Active Range of Motion Assessment:

Standard values for the range of motion in different directions are as follows:

AROM assessment is then typically followed by Passive Range of Motion Assessment (PROM) which you can watch with a click on the following video:

During PROM assessment, it’s important to compare the range of motion as well as the end-feel of the affected knee with the unaffected side.

References

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