New patients at Shelbourne Knee Center are often surprised when they're asked to wear shorts to their first visit. They’re even more surprised when K. Donald Shelbourne, MD, orthopedic surgeon at Shelbourne Knee Center, examines both of their knees. “A thorough knee exam on both knees is necessary to evaluate any knee problem or injury,” says Dr. Shelbourne. “When patients have unilateral knee pain, it’s impossible to diagnose the specific problem unless the noninvolved knee is evaluated for comparison.”
A thorough knee exam includes evaluation of range of motion, and of the presence of effusion, tenderness or crepitus, as well as many other factors. While examining both knees is the accepted standard taught in medical school and residency, in clinical practice, the use of technology often supersedes the physical exam.
Patients Seek Second Opinion
Shelbourne Knee Center sees many patients who are seeking a second opinion about total knee arthroplasty (TKA) or an ACL tear. Some of these patients were sent for an MRI before the first visit with an orthopedic surgeon. Others were told they needed a TKA based solely upon radiographic findings. Some patients are never asked about their pain and symptoms.
Physician Knee Exam Practices
In 2009, Shelbourne Knee Center surveyed 361 second-opinion patients to determine the current knee-exam practices of physicians. He published the results in the Journal of Bone and Joint Surgery, American volume in 2010 (1).
All of the patients had been seen by another physician for the same problem within six months of seeing Dr. Shelbourne. Their mean age was 42.4 + 18.7 years. The 67 patients who had seen more than one physician for the same knee problem completed a survey for each physician.
Primary diagnosis:
- Meniscal tear: 26%
- Osteoarthritis: 24%
- Knee ligament injury: 19%
- Knee stiffness, atrophy, or deconditioned knee: 19%
- Patellar dislocation: 5%
- Other: 7%
Survey Results (1)
The 428 knee exams were performed by:
- 202 orthopedic surgeons
- 154 primary care physicians
- 44 emergency department physicians
- 28 chiropractors
Only 54% of the physicians saw the patient’s knees during the exam. Of the exams performed with the knees exposed:
- 80% of patients wore shorts
- 15% of patients wore a gown
- 5% of patients said their knees were exposed in another way
During the knee exam:
- 87% of the physicians touched the involved knee
- 37% of the physicians touched the noninvolved knee
- 64% of patients had radiographs first
- 51% of patients had an MRI first
Among the 202 orthopedic surgeons:
- 63% had the knees exposed for the exam
- 89% touched the involved knee
- 37% touched the noninvolved knee
- 76% ordered radiographs
- 68% ordered an MRI
Of the 22 orthopedic surgeons who didn’t touch the injured knee, 16 ordered an MRI. Of the 75 orthopedic surgeons who did have the knees exposed for the exam 59 evaluated the knee through clothing and 13 evaluated the noninvolved knee (Data were not available for the other 3 surgeons).
“It’s reassuring to find that 89% of orthopedic surgeons had examined the injured knee; however, it’s a concern that 11% had not,” says Dr. Shelbourne. “Even more of a concern is that only 37% examined the noninvolved knee.”
Technological advances have led to surgery for many knee conditions based upon the findings of radiographs and MRIs without a thorough knee exam.
No Shortcuts to Patient Care
“There are no shortcuts to providing appropriate patient care,” says Dr. Shelbourne. “Such care begins by listening to the patient talk about his or her problem and performing a thorough physical examination.” When there are discrepancies between imaging results and the physical exam, the results of the exam are more important.
For more information about thorough knee exams, call 888-FIX-KNEE.
References
1. Shelbourne KD. The art of the knee examination: where has it gone? J Bone Joint Surg Am. 2010 Aug 4;92(9):e9. doi: 10.2106/JBJS.I.01691.