So You Think You Know How to Examine a Knee?

Surprisingly, and the data seems to bear this out, most physicians and surgeons don’t know how to examine—correctly—a knee. Why? One reason may be that there is no “home” for knee specialists.

In spine? You have a home base. Work with hands? You have an organization as well. Knees are your thing? Sorry, no home for you. And that, say our experts, means that orthopedists lack the expertise necessary to thoroughly assess knee problems.

Dr. Donald Shelbourne is the founder of the Shelbourne Knee Center in Indianapolis. When it comes to the number of in-depth knee examinations he has performed, think, “stars in the sky.” He states, “The problem in orthopedics is that despite the frequency of knee problems, there is no knee subspecialty. Someone with a foot and ankle or spine problem can seek out a specialist, but if you have a knee problem—and are in your 40s—you will likely be treated by a sports medicine specialist, whose expertise is ‘spread out’ over shoulder, elbow and other joints as well. If you are a 60 year old then you will probably see a total joint specialist, who, again, has several areas of focus. I can’t say exactly why our field has evolved this way, but to provide the best care for patients we need to change things.”

Dr. Shelbourne, who has worked solely with knee patients for 25 years, says that this situation is inevitably linked to the quality of knee exams that are being performed. “When people come to see me about their right knee it is because it feels somehow different than their left knee. People tend to know something is wrong because knees are supposed to be identical, as are hands.”

The problem is not just with orthopedists, says Dr. Shelbourne. Family doctors—often the starting point for orthopedic patients—play a part as well. “A family physician may get an X-ray, but seldom does he or she know how to do a knee exam. Or they might do an MRI, but they don’t know that it’s rarely normal in those over 30. So the patient thinks they have confirmation of their suspicion that something is wrong, brings the positive MRI to an orthopedist, and thinks they may need surgery. The problem is that few orthopedic surgeons know how to do a thorough knee exam—and even fewer know how to proceed with nonoperative care.”

Dr. Shelbourne is not just spouting opinions…he has the numbers to back up his words. “Last year I published an article, ‘The art of the knee examination: Where has it gone?’ in the Journal of Bone and Joint Surgery. In this study, I saw 900 patients over six months; about 410 of those had previously seen another orthopedist. I asked this subset of patients a series of questions, including, ‘How were you dressed for the exam (shorts/gown/ some type of situation where they had to remove their pants)?’ If they did have their knee examined I asked, ‘Did this doctor look at your normal knee before examining your involved knee?’ Amongst the 87% of patients who underwent knee exams, half did so with their clothes on. This makes it difficult to assess tenderness, effusion, and range of motion, amongst other things. Only one-third of patients had their normal knee examined before their involved knee; 70% of these patients underwent MRIs.”

Thus, says Dr. Shelbourne, an overreliance on technology and failure to understand the subtleties of a knee exam means that a lot more people end up being draped, prepped, and cut than need to be.

There is definitely too much knee arthroscopy being performed. I see a substantial number of patients who are seeking out a second opinion after having been told by another orthopedist that they need a total knee replacement. It is amazing that these people are surprised when I have them change into shorts for their exam…they were told they needed surgery and had never had their knee properly examined.

Dr. Shelbourne also fights this “pushing an MRI machine up a hill” battle when educating residents. “I recall a fourth year resident who said to me, ‘You saw 28 new patients today, but you only ‘signed up’ four patients for surgery and you could have done 20.’ There is a real tidal wave attitude out there of, ‘Lead with imaging and get to the OR.’”

To those who are willing to slow down and be medical detectives, Dr. Shelbourne explains, “The first thing I do is have the patient change into gym shorts. Typically, the person is complaining about a knee problem as compared to the other knee (when people play basketball for two hours and both knees are sore they don’t come see me). If a patient puts his hand out and says, ‘My thumb is swollen, ’ then the doctor is going to look at the other hand; it should be the same with knees.”

Photo courtesy: Andrew Huth

Unlike many physicians, Dr. Shelbourne is looking for garrulous patients. “I have them talk a lot…when and how did the injury occur…is it getting better or worse, etc. Most patients tend to ignore an injured knee for awhile, hoping that the pain will abate. They stop using that leg as much, the pain goes away; then they begin to use the leg again and the knee becomes sore. And orthopedists hate to see someone come in the door complaining of a ‘sore’ knee. Why? Because most of us don’t know what to do with this vague complaint…we are much happier to see a broken knee…that we know how to handle.”

Dr. Shelbourne was the team doctor for the Indianapolis Colts. And, much to the disappointment of injured NFL players entering the draft process, he also brought his expertise to the NFL combine. Dr. Shelbourne says, “When working with professional football players who were preparing for the draft, I realized that if these athletes had subtle differences in their legs or minor knee problems, that they were never going to reveal that information. Working from the fundamental truth that knees are symmetric, I carefully examined the players for any difference in motion in the knee (strength loss, etc.). If someone is undergoing a Cybex (isokinetic) Test, and can handle 100lbs on one leg, but only 80lbs on the other then something is amiss. When I did find an asymmetry, I asked the player, ‘What did you do to your right knee?’ While the reply was usually, ‘nothing, ’ with some talking to they would break down and tell the truth.”

While most orthopedists will never see the legs of an NFL player up close, whomever walks in the door should have a thigh-high exam. Dr. Shelbourne: “When performing the physical exam, make sure you can see the patient’s thighs. You need to look for atrophy, as well as any asymmetry in the musculature. You want to find out what type of asymmetry is present, so you should assess whether they can hop on both feet equally as well, and whether they can squat equally. Once they are on the exam table then you should see how far the knee extends and how far it bends, determine if there is fluid in the joint, and see if there are obvious differences in the knee from side to side. Only then do you look at the X-rays to see if the normal and involved knees are different.”

“Five years ago I tracked 41 patients with obvious asymmetry who had osteoarthritis present on X-rays. Although they had all been told that they needed a knee replacement, my team and I found many nonoperative things we could do to make those knees symmetrical. Thirty-eight patients improved to the point where they didn’t need surgery.”

Dr. Shelbourne adds, “In the old days doctors were able to detect problems/discern subtleties with a stethoscope. Now the general sentiment is, ‘Why bother? If I examine someone it’s not going to help me because I don’t know what I am looking for. I might as well do an MRI.’”

Dr. Stephen Howell, an orthopedic surgeon in Sacramento, California, and the designer of the OtisKnee, is also concerned about these issues. He states, “Both surgeons and patients can get caught up the imaging. I recently treated a distance runner who read his MRI report and told me that he had a meniscus tear and wanted it removed to eliminate his pain. The physical examination of both his normal and symptomatic knee did not reveal any joint line pain. It turned out that the MRI was ‘overread.’ It took considerable discussion to convince the runner and his mother that scoping the knee was not the answer to his discomfort. The overread MRI can lead to unnecessary and ineffective surgery, which is best prevented by a careful history and physical examination of both knees.”

Detailing his procedure, Dr. Howell says, “I observe patients as they get up, and as they walk. I want to see if one leg is shorter than the other, if they are bowlegged, etc. They then walk toward me on their heels, and away from me on their toes; then they face me and do a squat so that I can assess muscle atrophy, balance, and alignment, and determine if they are flatfooted or knock kneed. If the patient has a meniscus tear, then they will feel sore on the joint line where the tear is when they walk on their heels and even more so when they squat. Let the patient tell you where the pain is…then your job is to examine them with your hands.”

“One example of an underdiagnosed and misdiagnosed condition is patellar tendonitis, so often missed because orthopedists don’t look for it. The most common cause of this tennis elbow-like condition is anterior knee pain. When patients squat and then get up they will point to the front of the knee as being painful—and they will have trouble getting up. Once they are on the table and in a supine position, assist them with internal and external hip rotation. Range of motion should be equal; if there is pain in the groin, thigh or knee when you rotate the hip then it is typically hip arthritis that is causing referred pain to the knee. You should also have the patient lift her heels off the table to see if she can extend equally…you are looking for muscle atrophy and fluid in the knee. Finally, ask them to bend the knee to see if they have full flexion. If they cannot do this, then there is fluid, arthritis, or both.”

Bottom line, slowing down and doing more medical detective work will deliver not only better patient outcomes, but will put you on the right side of the data.