Techniques for a telehealth examination of the knee

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Joseph D. Lamplot, MD, orthopedic surgeon specializing in sports medicine at Emory University, Atlanta, Georgia, and Samuel A. Taylor, MD, orthopedic surgeon and sports medicine specialist at the Hospital for Special Surgery in New York, discuss techniques and strategies for performing an orthopedic knee exam via a video call tour in this Special Surgery Hospital video. Lamplot and Taylor are co-authors of a item appearing in HSS Journal: The Musculoskeletal Journal of the Hospital for Special Surgery. You can see other related videos and articles on Orthopedic Telehealth Examinations at HSS ‘ E-Academy website. 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 suffered a non-contact hyperextension knee injury in California. What are you doing?

Joseph D. Lamplot, MD: If it goes through our call center on a Monday, I don’t think that person necessarily needs an in-person assessment. If this happens acutely, you need to make sure that there is no avulsion of tibial tuberculosis or something more urgent. For the most part, we can see and sort these things through telemedicine quite efficiently and get advanced imaging, if needed, based on that visit.

I’m going to talk about the knee exam. This is what is emailed to all of my patients prior to their visit. It’s schematic and it shows them what they’re going to experience. I also make sure they have an adequate internet connection. Without it, it’s basically a FaceTime visit, so you really need to have a good setup.

Let’s move on to the knee examination. As Dr. Taylor mentioned for the central shoulder exam, we do this on all of our patients who primarily complain of knee pain. You do an inspection for atrophy and alignment. They identify their point of maximum pain. You need about 10 feet to see them walk back and forth. You ask them to assess a range of motion themselves, do a brief neurovascular exam, and just like Dr. Taylor talked about the shoulder, we also always do a lumbar spine exam for the knee. .

For a special meniscus test, you can change the hyperextension test, where they place either a rolled up towel or a canned product under their foot. Then they move from a slightly flexed position to a slightly extended position and, similarly, from a hyperflexed position to a slightly less flexed position.

One point I wanted to make about virtual testing is that if someone is not able to do it, I consider it a positive test. If I ask someone to do a Thessaly test and they are not willing to do it, there is clearly something wrong with their knee, and I consider it a Thessaly test. Positive Thessaly.

For ligament tests, this can be a bit difficult. You can have a recurvatum feeling by having them place their heels on a rolled up towel or a good can.

Dr Taylor will be showing the next video at the Center for Anterior Cruciate Ligament (ACL) Testing. This is a patient with a ruptured right ACL. On the left side, it pushes above the kneecap on the quadriceps. You can see the heel lift off the bed, which means the ACL is intact. On the right side, he presses on the quadriceps just above the kneecap. We see the anterior aspect of the tibia come forward and the heel resting on the table, indicating that the ACL is torn. This has been found to be more sensitive and specific than a Lachman test and does not really require sensation, so it can be done adequately from a distance.

For the posterior cruciate ligament (PCL), you can also perform an active posterior sag or quadriceps test by having the patient press down on their foot and pull on their quadriceps, which is shown at right. For patellofemoral testing, you can ask the patient to assess a J sign by performing an active range of motion from full extension to flexion.

You can also ask the patient to feel a crackle when placing their hand on their kneecap. We modified the patellar apprehension test by having the patient cross their affected side over the other ankle and then apply force to the medial aspect of the patella directed laterally. Again, if the patient is reluctant to do this, I consider this to suggest a positive test.

Taylor: Joe, what do you do if your patient luxates his or her own kneecap on the video?

Street lamp : This has never happened to me and I don’t think a patient will self-luxate.

These are tables we have available with the sensitivity and specificity of in-person reviews for documentation purposes, with everything written in layman’s terms to the right. You can read this aloud to your patient and get a reliable exam every time. It’s for the meniscus test, and it’s for the patellofemoral test in the same way.

Considering the pros and cons of the exam, many of them are not changed at all from what we do in the clinic. As we have shown, the examination provides enough information for the purpose of triage. You can decide if the patient needs advanced imaging, requires an in-person visit, or can go directly to physical therapy or other type of procedure.

Some of the downsides are that there isn’t a good strength rating that we have offered for the lower limb, and the ligament examination is somewhat limited. Again, if a patient is unwilling to do something, this is about as good as a positive result. Video conferencing is probably not quite sufficient for more subtle physical exam results. Some things that I haven’t described here could be done by an assistant or a family member, but they require a second person, which is not always available.

Taylor: See, you can do it anywhere.

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