Now before you start the tender task
Of examination, you must ask
"Where is this pain? If you can be precise
"To show me its location would be nice"
It's at this stage and often not before
Some patients say "I'm absolutely sure
"It's here, not there where my knee's been treated.
"I feel to some extent that I've been cheated."
With his index finger then he'll point
To the painful region on the joint.
Most often he will indicate quite nicely
The pathology, located most precisely.
Most important, pay attention now,
Because it is extraordinary how
The patient knows, and you as well will see
How true the "finger pointing test" can be.
The test being positive it's now your turn
The patient's indication to confirm,
So take the chance before it is too late
And use your index finger to palpate
Physical examination - LOOK
Do your examination by the book
By Apley. Starting with the heading "LOOK".
Look in front, behind and then the sides.
See him standing, walking, watch his strides.
Look for scars -surgical? traumatic?
Are they small, medium or dramatic?
For every scar there'll be a tale to tell
Get that story, document it well.
Record physical findings
Document alignment and his gait;
Put him on the scales, record his weight.
Write down the thigh girth, calf girth, trophic changes;
Measure flexion and extension ranges.
Measure varus,valgus, angle "Q",
Foot pronation, supination too.
Pain receptors in the knee
You must be aware, palpating now
What to feel for, why and how.
The most receptors that transmit the pain
Sensations from the knee to reach the brain
Are in synovial structures in the knee
And also in the capsule where you see
The cruciates and menisci, which both owe
Their origin from capsule, as you know.
Scott Dye from San Francisco published his
Experiments to demonstrate just this.
With only anaesthetic to the skin
An arthroscope and instruments within
The synovial cavity of Scott Dye's knee
Were introduced to probe, to feel and see.
Healthy surface cartilage, he showed
Transmits no pain at all when it is probed.
A dullish ache arises from the bone
When this is probed, Professor Dye has shown.
Menisci, ligaments and capsule make
A more substantial pain with no mistake
About its source, its pressure and location.
This reality needs no imagination.
Synovial membrane in this context now
Is even more precise just where and how
Arthroscopic instruments can point
To their exact location in the joint.
Physical examination - FEEL
Allow your patient first to understand
The pressure of your fingers and your hand.
So first palpate the contra-lateral knee
Area by area systematically.
Now go to the symptomatic joint
Avoiding first the part where he did point.
That tender spot until the last is left,
And even then be gentle, accurate and deft.
Ask him once again " Is this the spot?
"is this the point of tenderness or not?"
Do not be prejudiced by his reply,
The finger pointing test will seldom lie.
Physical examination - MOVE (4 phases of gait)
Watch your patient walking without shoes -
The pattern of his gait and what he does.
Analyse his motion like a dance.
First his foot is on the floor in STANCE,
He then moves on to PUSH OFF from the toe
Then to the SWING THROUGH phase you watch him go
To HEEL STRIKE, and then back again to STANCE
To complete four phases of this dance.
Movements of the foot, the hip, the knee
Through all four phases now you have to see
As he walks towards you, then away
Then back again. Take notice of the sway,
The limp, the varus thrust, the length of stride -
Important observations to decide
What investigations you may need
Before deciding how you should proceed.
Dr (Mr) Angus Strover
Mr Strover is now retired but until 2012 was consulting at London Sports Orthopaedics at London Bridge Hospital, London, and was a founder of the Droitwich Knee Clinic (in Worcestershire, UK). He is President of the educational charity, The Knee Foundation, which runs both a fellowship training programme...read more