Give a well-designed format of orthopaedic assessment for... Oear knee case. Which includes all the necessary assessment points so that I can take assessment of patient at OPD.
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I now have comprehensive textbook content for the knee assessment. I have enough material from Firestein & Kelley's Textbook of Rheumatology and Miller's Review of Orthopaedics to build a thorough OPD assessment format. Let me now compile the full formatted assessment.
Orthopaedic OPD Assessment Format - Knee Case
PATIENT DETAILS
| Field | Details |
|---|---|
| Name | |
| Age / Sex | |
| OPD No. | |
| Date | |
| Referring Doctor | |
| Occupation | |
| Dominant Hand | Right / Left |
1. CHIEF COMPLAINT
(List in patient's own words, with duration)
- Pain - site, duration
- Swelling
- Stiffness
- Locking / Catching / Giving way
- Difficulty walking / climbing stairs
2. HISTORY OF PRESENT ILLNESS
A. Pain Analysis (SOCRATES)
| Parameter | Details |
|---|---|
| Site | Medial / Lateral / Anterior / Posterior / Diffuse |
| Onset | Acute / Gradual / Insidious |
| Character | Aching / Sharp / Burning / Throbbing |
| Radiation | Down leg / No radiation |
| Associated symptoms | See below |
| Timing | Constant / Intermittent; Morning / Activity / Rest |
| Exacerbating factors | Stairs / Squatting / Walking / Standing |
| Relieving factors | Rest / Elevation / NSAIDs / Ice |
| Severity | VAS Score: ___/10 |
B. Key Symptom Enquiry
| Symptom | Present / Absent | Details |
|---|---|---|
| Locking (sudden inability to extend) | Implies loose body / meniscal tear | |
| Catching (momentary hesitation in ROM) | Less severe than true locking | |
| Giving way (knee buckles) | Implies ligamentous instability | |
| Swelling - onset after injury | Haemarthrosis within 2 hrs → ACL/fracture | |
| Swelling - gradual/recurrent | Effusion → meniscal / OA / inflammatory | |
| Morning stiffness | Duration: >30 min → RA; <30 min → OA | |
| Crepitus | ||
| Night pain | Consider malignancy / inflammatory arthritis | |
| Numbness / tingling | Rule out neurological component |
C. Mechanism of Injury (if traumatic)
- Direct / Indirect
- Valgus force → MCL / medial meniscus
- Hyperflexion / rotational → Meniscal tear
- Hyperextension → ACL / PCL
- Dashboard injury → PCL
- Contact vs. Non-contact
- Immediate weight-bearing ability post-injury
3. PAST HISTORY
| Details | |
|---|---|
| Previous knee injuries / surgeries | |
| Injections (steroid / PRP / visco-supplementation) | |
| Physiotherapy received | |
| Prior imaging (X-ray, MRI) | |
| Systemic diseases (DM, HTN, Gout, Psoriasis, RA, SLE) | |
| Medications (NSAIDs, steroids, anticoagulants) | |
| Allergies |
4. PERSONAL / SOCIAL HISTORY
| Details | |
|---|---|
| Occupation (sedentary / laborer / athlete) | |
| Activity level (sedentary / active / sportsperson) | |
| Sport / activity involved (if applicable) | |
| BMI | Ht: ___ cm, Wt: ___ kg, BMI: ___ |
| Smoking / Alcohol | |
| Family history (RA, Gout, OA) |
5. GENERAL EXAMINATION
- Built and nourishment
- Pallor / Icterus / Cyanosis / Clubbing / Lymphadenopathy / Oedema
- Pulse, BP, Temperature, RR
- Any systemic signs of inflammatory arthritis (nodules, rash, eye signs)
6. LOCAL EXAMINATION
A. INSPECTION
Standing (Alignment Assessment)
| Finding | Right | Left |
|---|---|---|
| Genu Varum (bow-leg; lateral deviation of knee) | ||
| Genu Valgum (knock-knee; medial deviation of knee) | ||
| Genu Recurvatum (hyperextension deformity) | ||
| Flexion deformity | ||
| Patellar position (alta / baja / lateral tilt) |
Gait Assessment
- Antalgic gait (shortened stance phase on painful side)
- Valgus / varus thrust
- Trendelenburg gait
- Stiff-knee gait
- Quadriceps avoidance gait (PCL injury)
Supine Inspection
| Finding | Observation |
|---|---|
| Skin changes (scars, sinuses, erythema, bruising) | |
| Swelling - suprapatellar (effusion/synovitis) | |
| Swelling - prepatellar (prepatellar bursitis - "housemaid's knee") | |
| Popliteal fullness (Baker's cyst) | |
| Quadriceps / vastus medialis atrophy | |
| Limb asymmetry |
B. MEASUREMENTS
| Measurement | Right | Left |
|---|---|---|
| Thigh circumference (15 cm above knee) | ||
| Calf circumference (10 cm below tibial tuberosity) | ||
| True limb length (ASIS to medial malleolus) | ||
| Apparent limb length (umbilicus to medial malleolus) | ||
| Patellar height (Insall-Salvati index if suspected patella alta/baja) |
C. PALPATION
(Always compare bilaterally; begin away from tender area)
Temperature & Skin
- Warmth over joint (suggests inflammation / infection)
- Skin texture
Effusion Tests
| Test | Technique | Result |
|---|---|---|
| Bulge sign (4-8 mL) | Stroke medial side proximally → tap lateral side → look for medial bulge | +/- |
| Patellar tap / Ballotment (>15 mL) | Compress suprapatellar pouch, push patella posteriorly against femur | +/- |
| Suprapatellar compression | Palm over distal thigh → feel for distension medially & laterally to patella | +/- |
Palpation Points (Tenderness)
| Location | Pathology | Tender R | Tender L |
|---|---|---|---|
| Medial joint line | Medial meniscal tear / medial OA | ||
| Lateral joint line | Lateral meniscal tear / lateral OA | ||
| Medial femoral condyle | OA, osteochondral lesion | ||
| Lateral femoral condyle | IT band syndrome | ||
| Medial collateral ligament (MCL) | MCL sprain/tear | ||
| Lateral collateral ligament (LCL) | LCL injury | ||
| Tibial tuberosity | Osgood-Schlatter (adolescents) | ||
| Patellar tendon | Patellar tendinopathy | ||
| Patella (poles) | Patellofemoral syndrome / bipartite patella | ||
| Pes anserine bursa (medial tibia, distal to joint line) | Pes anserine bursitis | ||
| Popliteal fossa | Baker's cyst, popliteal artery aneurysm | ||
| Fibular head | LCL attachment, biceps femoris, peroneal nerve | ||
| Gerdy's tubercle | IT band insertion |
Bony Landmarks
- Osteophytes (medial / lateral / patellar)
- Step deformity
D. RANGE OF MOTION (ROM)
(Use goniometer; measure active then passive)
| Motion | Normal | Active R | Passive R | Active L | Passive L |
|---|---|---|---|---|---|
| Flexion | 0-135° | ||||
| Extension | 0° (hyperextension up to -10°) | ||||
| Fixed flexion deformity | None | ||||
| Internal rotation (tibia on femur at 90° flex) | ~30° | ||||
| External rotation (tibia on femur at 90° flex) | ~40° | ||||
| Heel-to-buttock distance (if flexion restricted) |
- End feel: hard / soft / springy / empty
- Pain arc noted at: ___°
7. SPECIAL TESTS
A. Patellofemoral Tests
| Test | Technique | Positive Finding | Result R | Result L |
|---|---|---|---|---|
| Clarke's sign (Patellar grind) | Compress patella, ask patient to contract quads | Pain / apprehension | ||
| Patellar apprehension test | Push patella laterally with knee slightly flexed | Patient resists / apprehension | ||
| J-sign | Observe patellar tracking during extension | Lateral subluxation at full extension | ||
| Patellar tilt test | Attempt to lift lateral patellar edge | <0° tilt = tight lateral retinaculum |
B. Meniscal Tests
| Test | Technique | Positive Finding | Result R | Result L |
|---|---|---|---|---|
| McMurray's test | Flex knee fully, external rotation + valgus stress → extend (medial meniscus); internal rotation + varus → extend (lateral meniscus) | Click / pain at joint line | ||
| Apley's grind test | Prone, 90° flexion, downward compression + rotation | Pain = meniscal; pain on distraction = ligamentous | ||
| Thessaly test | Stand on one leg, knee at 20° flexion, twist body | Medial/lateral joint line pain | ||
| Bounce home test | Passively extend knee, let it "bounce" home | Incomplete extension / rubbery block = meniscal tear | ||
| Joint line tenderness | Direct palpation | Gold standard for meniscal pathology |
C. Ligament Stability Tests
| Test | Tests For | Technique | Grade (0/1/2/3) | Result R | Result L |
|---|---|---|---|---|---|
| Valgus stress test (0° & 30°) | MCL | Apply valgus force at 0° and 30° flexion | 0 = firm; 1 = <5mm; 2 = 5-10mm; 3 = >10mm | ||
| Varus stress test (0° & 30°) | LCL / PLC | Apply varus force at 0° and 30° flexion | Same grading | ||
| Anterior drawer test | ACL | 90° flexion, pull tibia anteriorly | Anterior translation vs. normal side | ||
| Lachman test | ACL (most sensitive) | 20-30° flexion, stabilise femur, pull tibia anteriorly | Firm / soft end point; displacement >5mm = +ve | ||
| Pivot shift test | ACL (rotational instability) | Valgus + IR + extend knee | Clunk/subluxation = +ve | ||
| Posterior drawer test | PCL | 90° flexion, push tibia posteriorly | Posterior sag / translation | ||
| Posterior sag sign | PCL | Supine, hips & knees at 90°, observe tibial sag | Tibia sags posteriorly = PCL tear | ||
| Dial test (30° & 90°) | PLC / posterolateral corner | Prone, externally rotate both feet at 30° & 90° flexion | >10° asymmetry at 30° only = PLC; at both = PLC + PCL | ||
| External rotation recurvatum | PLC | Lift both great toes, observe knee | Hyperextension + external rotation = PLC injury |
D. Other Special Tests
| Test | Condition Tested | Technique | Result |
|---|---|---|---|
| Ober's test | IT band tightness | Side-lying, hip extended, abducted - lower toward table | Restricted adduction = +ve |
| Thomas test | Hip flexor tightness | Supine, flex one hip - observe contralateral hip | Flexion = +ve (relevant for knee alignment) |
| Patella alta / baja | Patellar height | Insall-Salvati ratio (lateral X-ray: patellar tendon/patellar length) | >1.2 = alta; <0.8 = baja |
| Tinel's sign (peroneal nerve) | Nerve injury | Tap fibular neck | Paraesthesia in distribution |
| Wilson test | Osteochondritis dissecans | Flex knee to 90°, IR tibia → extend → pain at 30° that resolves with ER | +ve if pain reproduced |
8. NEUROVASCULAR ASSESSMENT
| Assessment | Findings |
|---|---|
| Sensation (medial / lateral / posterior leg) | |
| Motor power - Quadriceps (L3-L4) | /5 |
| Motor power - Hamstrings (L5-S1) | /5 |
| Dorsiflexion / Plantar flexion (ankle) | |
| Popliteal pulse | Present / Absent / Diminished |
| Posterior tibial pulse | Present / Absent / Diminished |
| Dorsalis pedis pulse | Present / Absent / Diminished |
| Capillary refill time | < 2 sec / > 2 sec |
9. FUNCTIONAL ASSESSMENT
| Function | Ability |
|---|---|
| Walking distance (meters before pain) | |
| Stair climbing - ascent | Independent / Assisted / Unable |
| Stair climbing - descent | Independent / Assisted / Unable |
| Squatting / sitting cross-legged | Possible / Painful / Unable |
| Rising from chair without support | Possible / With support / Unable |
| Running / Sports activity |
Functional Scores:
- KOOS (Knee Injury and Osteoarthritis Outcome Score): ___
- Oxford Knee Score: ___
- Lysholm Score (ligament injuries): ___
- IKDC score (if sports injury): ___
10. INVESTIGATIONS
Imaging
| Investigation | Ordered | Result / Notes |
|---|---|---|
| X-ray Knee AP (weight-bearing) | JSW, osteophytes, alignment | |
| X-ray Knee Lateral | Patella position, posterior sag | |
| X-ray Knee Skyline view | Patellofemoral OA, trochlear dysplasia | |
| Long leg alignment film | Mechanical axis deviation | |
| MRI Knee | Soft tissue, meniscus, cartilage, ligaments | |
| Ultrasound Knee | Effusion, tendon, Baker's cyst | |
| CT Knee | Bony detail, TT-TG distance |
Laboratory (if inflammatory / metabolic suspected)
| Test | Result |
|---|---|
| CBC | |
| ESR / CRP | |
| Uric acid (Gout) | |
| RF / Anti-CCP (RA) | |
| ANA (SLE) | |
| HLA-B27 (SpA) | |
| Synovial fluid analysis (if aspirated) |
11. PROVISIONAL DIAGNOSIS
| # | Diagnosis |
|---|---|
| 1. | |
| 2. | |
| Differential Diagnoses |
12. WORKING PLAN
| Plan | |
|---|---|
| Investigations ordered | |
| Referrals | Physiotherapy / Rheumatology / Vascular |
| Conservative treatment | RICE / NSAIDs / Physiotherapy / Bracing / Orthotics |
| Intra-articular injection | Steroid / PRP / Hyaluronic acid |
| Surgical consideration | Arthroscopy / Ligament reconstruction / TKR / Osteotomy |
| Review date |
EXAMINER'S NOTES / CLINICAL IMPRESSION
Sources: Firestein & Kelley's Textbook of Rheumatology (9e), Chapter 40 - Knee; Miller's Review of Orthopaedics (9e)
Here is your complete orthopaedic OPD knee assessment format. A quick overview of what's included:
Structure of the format:
- Patient details - demographics, occupation, BMI
- Chief complaint - with duration
- History - full pain analysis (SOCRATES), key knee-specific symptoms (locking/catching/giving way), trauma mechanism
- Past history & Social history
- General examination
- Local examination:
- Inspection (standing alignment + gait, supine)
- Measurements (thigh/calf circumference, limb lengths)
- Palpation (effusion tests, 14 palpation landmarks)
- ROM with goniometry (active + passive)
- Special tests - organized by category (patellofemoral, meniscal, ligaments, others) - 20+ tests with technique and grading
- Neurovascular assessment
- Functional assessment + validated scoring tools (KOOS, Oxford, Lysholm, IKDC)
- Investigations (imaging + labs)
- Provisional diagnosis + working plan
Key clinical points to remember:
- Haemarthrosis within 2 hours of injury strongly suggests ACL tear or intra-articular fracture
- Lachman test is more sensitive than anterior drawer for ACL
- Test MCL/LCL at both 0° and 30° - at 0° a positive result implicates posterior capsule involvement as well
- Joint line tenderness remains the clinical gold standard for meniscal pathology
- Always measure thigh circumference at 15 cm above the knee (not closer, to avoid false results from a suprapatellar effusion)
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