Joseph D. Lamplot, MD, an orthopedic surgeon specializing in sports medicine at Emory University, Atlanta, Georgia, and Samuel A. Taylor, MD, an orthopedic surgeon and sports medicine specialist at the Hospital for Special Surgery in New York City, discuss techniques and strategies for conducting an orthopedic exam of the knee via a video call visit in this video from the Hospital for Special Surgery. Lamplot and Taylor are coauthors on a related article appearing in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery. You can see other related videos and articles on orthopedic telehealth exams at the HSS' E-Academy site. This transcript has been edited for clarity.
Samuel A. Taylor, MD: Joe, we have a 17-year-old Amateur Athletic Union (AAU) basketball player who sustained a noncontact knee hyperextension injury while in California. What do you do?
Joseph D. Lamplot, MD: If this comes through our call center on a Monday, then I don't think this person necessarily needs an in-person evaluation. If it comes acutely, you have to make sure that there's not a tibial tubercle avulsion or something that's more urgent. For the most part, we can see and triage these things via telemedicine pretty effectively and get advanced imaging, if necessary, based on that visit.
I'm going to talk about the knee exam. This is what is send to all of my patients via email before their visit. It's diagrammatic and it shows them what they're going to be going through. I also make sure that they have an adequate internet connection. Without that, it's basically just a FaceTime visit, so you really need to have a good set-up.
On to the core knee exam. As Dr Taylor talked about for the core shoulder exam, we do this on all of our patients with a chief complaint of knee pain. You do an inspection for atrophy and alignment. They identify their point of maximal pain. You need 10 feet or so to see them walk forward and backward. You have them self-assess a range of motion, do a brief neurovascular exam, and — similar to what Dr Taylor talked about in the shoulder — we always do a lumbar spine exam for the knee as well.
For special testing of the meniscus, you can do a modification of the hyperextension test, for which they place either a rolled-up towel or a canned good underneath their foot. Then, they go from a slightly flexed to a slightly extended position and, similarly, from a hyperflexed to a slightly less flexed position.
One point that I wanted to make about virtual testing is that if somebody is unable to perform it, I consider that a positive test. If I ask somebody to do a Thessaly test and they're not willing to do it, there's clearly something wrong with their knee, and I consider that a positive Thessaly test.
For ligament testing, this can be a little bit difficult. You can get a sense of recurvatum by having them drop their heel up on a rolled-up towel or a canned good.
Dr Taylor is going to play the next video in the center for anterior cruciate ligament (ACL) testing. This is a patient with a right ACL tear. On the left side, he's pushing above the patella on the quadriceps. You can see the heel lifting off the bed, which means the ACL is intact. On the right side, he's pushing down on the quadriceps right above the patella. You can see the anterior aspect of the tibia coming forward and the heel staying put on the table, which indicates that the ACL is torn. This has been found to be more sensitive and specific than a Lachman test and doesn't really require a feel, so it can be adequately done remotely.
For the posterior cruciate ligament (PCL), you can similarly do a posterior sag or quadriceps active test by asking the patient to press their foot down and fire their quadriceps, which is pictured on the right. For patellofemoral testing, you can have the patient assess for a J-sign by doing an active range of motion from full extension into flexion.
You can also have the patient feel for crepitus by placing their hand on top of their patella. We've modified the patellar apprehension test by having the patient cross their affected side over the other ankle and then have them apply a force on the medial aspect of the patella directed laterally. Again, if the patient is reluctant to do this, I consider that suggestive of a positive exam.
Taylor: Joe, what do you do if your patient dislocates their own patella on the video?
Lamplot: I've never had it happen, and I don't think a patient will self-dislocate.
These are tables that we have available with the sensitivity and specificity of the in-person exams for documentation purposes, with everything written in layman's terms on the right. You can read this out loud to your patient and get a reliable exam each time. This is for meniscus testing, and this is for patellofemoral testing in the same manner.
Considering the pros and cons of the exam, many of these are completely unmodified from what we do in the clinic. As we showed, the exam does provide sufficient information for purposes of triaging. You can decide whether the patient needs advanced imaging, requires an in-person visit, or can go straight to physical therapy or another kind of intervention.
Some of the downsides are that there's no good strength assessment that we've come up with for the lower extremity, and the ligament exam is somewhat limited. Again, if a patient is not willing to do something, that's just about as good as a positive finding. Video conferencing is probably not completely sufficient for more subtle physical exam findings. Certain things that I haven't described here could be performed by an assistant or a family member, but they do require a second person, which isn't always available.
Taylor: See, you can do it anywhere.
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Cite this: Techniques for a Telehealth Exam of the Knee - Medscape - Nov 12, 2021.
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