Non-Traumatic Anterior Knee Pain Care Pathway

7. Physical Examination

 

A comprehensive clinical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

 

Observation: Abnormalities, asymmetries, posture, gait, movements, facial expression.

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Range of Motion: Active, passive, and resisted knee ROM in all planes (flexion, extension, internal rotation, and external rotation). Consider hypomobility, hypermobility and aberrant movement patterns.

 

Palpation: Identify discrepancies in temperature or areas of edema or tenderness in the knee and surrounding structures. Palpate the MCL, LCL, joint line, patella, retinaculae, patellar tendon, hamstrings tendons, popliteus.

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Neurological and Functional Examination:

Motor Strength:

• Key Observations: Asymmetry or weakness indicating nerve root involvement. Typical nerve root distributions are listed in brackets.

  • Hip flexion (L2)

  • Knee extension (L3)

  • Inversion (L4)

  • Dorsiflexion (L5)

  • Big to extension (L5)

  • Knee flexion (L5/S1)

  • Plantarflexion/foot eversion (S1)

  • Toe flexion (S2)

• Record the clinical findings for each. E.g., L5: Extensor hallucis longus (EHL) strength: L5: EHL – L 3/5, R 5/5.

 

Sensory Examination: 

• Key Observations: Check for sensory deficits in lower extremities, corresponding to specific dermatomal distributions:

  •  L3: Medial thigh at the knee.

  •  L4: Medial side of the calf.

  •  L5: Top of the foot and toes.

  •  S1: Lateral side of the foot and little toe.

• Record the clinical findings for each. E.g., "Patient reports that they perceive the same for sharp, light, and vibration for L3, L4, L5, and S1." "Patient reports a loss of perception of sharp and light for S1 on the right with all other sensations intact."

 

Reflexes:

• Key Observations: Asymmetry or absence of reflexes can indicate nerve root compression or other neurological conditions.

  • L4: Patellar reflex.

  • L5: Medial hamstring reflex.

  • S1: Achilles reflex.

• Record the clinical findings for each. E.g., L5: R 2/4, L 3+/4.

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Lower Motor Neuron Signs:

• Key Observations: Muscle weakness, muscle atrophy, fasciculations, reduced muscle tone, flaccidity, diminished reflexes. May indicate a systemic neurological condition (e.g., nerve compression, radiculopathy, trauma, peripheral neuropathy, amyotrophic lateral sclerosis).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)"

 

Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus), pyramidal weakness. May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries, amyotrophic lateral sclerosis, traumatic brain injury).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)"

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Special/Orthopedic Tests:

Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary. Record: For all tests, note the knee tested, whether the test is positive or negative, and include an observational note for the responses to the test to also inform the clinical picture. E.g., "Left knee McMurrays(+) patient reports pain in the anterior or medial aspect of the knee during the internal rotation of the knee." "Right knee Patellar Tilt Test (+) patient reports increased pain with lateral tilt of the patella." Tests include:

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Tests for Patellofemoral Pain (includes chondromalacia patellae, plica syndrome, quadriceps tendinopathy, patellar tendinopathy/Jumper’s Knee/infrapatellar tendinopathy, IT band syndrome).

1. Grind Test/Clarke's Sign: Positive Sign: Retropatellar pain and inability to maintain contraction without pain.

2. Noble’s Compression: Positive Sign: Palpable snapping or increased pain with pressure at or above the lateral epicondyle (IT band syndrome).

3. Eccentric Step (Decline Step-down)Test: Positive Sign: Pain during the descent of the step.

4. Patellar Tilt Test: Positive Sign: Increased or decreased tilt of the patella.

5. McConnell Test: Positive Sign: Pain reduction when the patella is manually corrected during resisted knee extension.

6. Ober’s Test: Positive Sign: Inability of the leg to adduct past midline, indicating tightness in the iliotibial band.

7. Patellar Apprehension Test: Positive Sign: Patient shows apprehension or resists movement when the patella is laterally displaced.

8. Patellar Glide Test (Medial and Lateral): Positive Sign: Pain or excessive movement when the patella is glided medially or laterally.

9. Compression Test: Positive Sign: Pain or discomfort when the patella is compressed against the femur.

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Tests for Osteoarthritis (OA)

1. Varus Stress Test (LCL): Positive Sign: Reduced joint movement/stiffness, pain.

2. Valgus Stress Test (MCL): Positive Sign: Reduced joint movement/stiffness, pain.

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Tests for Peripheral Neuropathy

1. Tinel’s Sign: Positive Sign: Tingling or shooting pain along the course of the nerve when tapped.

2. Nerve Tension Tests: Positive Sign: Reproduction of symptoms with limb movements that tension the nerve.

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Advanced Diagnostics:

Imaging: Generally, not recommended within the first six weeks unless red flags are present, to avoid unnecessary radiation exposure, overdiagnosis, and costs. ​Currently, there is insufficient evidence that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g., persistent pain and functional limitations).