J Knee Surg 2018; 31(02): 118-129
DOI: 10.1055/s-0037-1608880
Special Focus Section
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Impact of Clinical Presentation on Imaging Evaluation to Direct Effective Treatment Strategies

Brandon L. Roller
1   Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
,
Christopher W. V. Schumacher
2   Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
,
Maha Torabi
1   Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
,
Leon Lenchik
1   Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
,
Cristin M. Ferguson
2   Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
› Author Affiliations
Further Information

Publication History

31 August 2017

15 October 2017

Publication Date:
07 December 2017 (online)

Abstract

A multitude of musculoskeletal disorders of the knee are commonly encountered in clinical practice. Ensuring an accurate diagnosis can be challenging. It is critical to establish a thoughtful and systematic approach to assessing the patient using history and physical exam followed by appropriate imaging studies. The physical exam may be complicated due to various test maneuvers designed to help make the diagnosis. It is also important to understand the limitations of each physical exam maneuver. When appropriate, imaging is obtained to help make the diagnosis and guide treatment. There are various imaging examinations to choose from when evaluating the knee, including X-rays, computed tomography, magnetic resonance imaging, and ultrasound. An algorithmic approach to choosing the best imaging study is often helpful to avoid unnecessary costs and burden to the patients. The combination of a thorough clinical assessment and appropriate imaging examinations will result in accurate diagnosis, which directs proper treatment.

 
  • References

  • 1 Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001; 286 (13) 1610-1620
  • 2 Bronstein RD, Schaffer JC. Physical examination of the knee: meniscus, cartilage, and patellofemoral conditions. J Am Acad Orthop Surg 2017; 25 (05) 365-374
  • 3 Bronstein RD, Schaffer JC. Physical examination of knee ligament injuries. J Am Acad Orthop Surg 2017; 25 (04) 280-287
  • 4 Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 2006; 36 (05) 267-288
  • 5 Pacheco RJ, Ayre CA, Bollen SR. Posterolateral corner injuries of the knee: a serious injury commonly missed. J Bone Joint Surg Br 2011; 93 (02) 194-197
  • 6 Engebretsen L, Lind M. Anteromedial rotatory laxity. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2797-2804
  • 7 Tanaka M, Vyas D, Moloney G, Bedi A, Pearle AD, Musahl V. What does it take to have a high-grade pivot shift?. Knee Surg Sports Traumatol Arthrosc 2012; 20 (04) 737-742
  • 8 Larson RL. Physical examination in the diagnosis of rotatory instability. Clin Orthop Relat Res 1983; (172) 38-44
  • 9 Guenther D, Griffith C, Lesniak B. , et al. Anterolateral rotatory instability of the knee. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2909-2917
  • 10 Lopomo N, Signorelli C, Bonanzinga T. , et al. Can rotatory knee laxity be predicted in isolated anterior cruciate ligament surgery?. Int Orthop 2014; 38 (06) 1167-1172
  • 11 Cook C, Mabry L, Reiman MP, Hegedus EJ. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy 2012; 98 (02) 93-100
  • 12 Merchant AC, Fulkerson JP, Leadbetter W. The diagnosis and initial treatment of patellofemoral disorders. Am J Orthop 2017; 46 (02) 68-75
  • 13 Sheehan FT, Derasari A, Fine KM, Brindle TJ, Alter KE. Q-angle and J-sign: indicative of maltracking subgroups in patellofemoral pain. Clin Orthop Relat Res 2010; 468 (01) 266-275
  • 14 Conrad JM, Stanitski CL. Osteochondritis dissecans: Wilson's sign revisited. Am J Sports Med 2003; 31 (05) 777-778
  • 15 Doberstein ST, Romeyn RL, Reineke DM. The diagnostic value of the Clarke sign in assessing chondromalacia patella. J Athl Train 2008; 43 (02) 190-196
  • 16 Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports Phys Ther 2007; 37 (09) 541-550
  • 17 Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clin Rehabil 2008; 22 (02) 143-161
  • 18 Rayan F, Bhonsle S, Shukla DD. Clinical, MRI, and arthroscopic correlation in meniscal and anterior cruciate ligament injuries. Int Orthop 2009; 33 (01) 129-132
  • 19 Goossens P, Keijsers E, van Geenen RJ. , et al. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. J Orthop Sports Phys Ther 2015; 45 (01) 18-24 , B1
  • 20 Snoeker BA, Lindeboom R, Zwinderman AH, Vincken PW, Jansen JA, Lucas C. Detecting meniscal tears in primary care: reproducibility and accuracy of 2 weight-bearing tests and 1 non-weight-bearing test. J Orthop Sports Phys Ther 2015; 45 (09) 693-702
  • 21 Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med 2009; 19 (01) 9-12
  • 22 Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am 2005; 87 (05) 955-962
  • 23 Dieleman JL, Baral R, Birger M. , et al. US spending on personal health care and public health, 1996-2013. JAMA 2016; 316 (24) 2627-2646
  • 24 Williams EM, Walker RJ, Faith T, Egede LE. The impact of arthritis and joint pain on individual healthcare expenditures: findings from the Medical Expenditure Panel Survey (MEPS), 2011. Arthritis Res Ther 2017; 19 (01) 38
  • 25 Tuite MJ, Kransdorf MJ, Beaman FD. , et al. ACR appropriateness criteria acute trauma to the knee. J Am Coll Radiol 2015; 12 (11) 1164-1172
  • 26 Bennett DL, Nelson JW, Weissman BN. , et al. ACR Appropriateness Criteria® Nontraumatic Knee Pain. Reston, VA: American College of Radiology (ACR); 2012:1–12. Available at: https://acsearch.acr.org/docs/69432/Narrative/ . Accessed August 29, 2017
  • 27 Craft JA, Kurzweil PR. Physical examination and imaging of medial collateral ligament and posteromedial corner of the knee. Sports Med Arthrosc Rev 2015; 23 (02) e1-e6
  • 28 Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc Rev 2006; 14 (02) 84-90
  • 29 Olsson O, Isacsson A, Englund M, Frobell RB. Epidemiology of intra- and peri-articular structural injuries in traumatic knee joint hemarthrosis - data from 1145 consecutive knees with subacute MRI. Osteoarthritis Cartilage 2016; 24 (11) 1890-1897
  • 30 Cain Jr EL, Fleisig GS, Ponce BA. , et al. Variables associated with chondral and meniscal injuries in anterior cruciate ligament surgery. J Knee Surg 2017; 30 (07) 659-667
  • 31 Ringler MD, Shotts EE, Collins MS, Howe BM. Intra-articular pathology associated with isolated posterior cruciate ligament injury on MRI. Skeletal Radiol 2016; 45 (12) 1695-1703
  • 32 Temponi EF, de Carvalho Júnior LH, Saithna A, Thaunat M, Sonnery-Cottet B. Incidence and MRI characterization of the spectrum of posterolateral corner injuries occurring in association with ACL rupture. Skeletal Radiol 2017; 46 (08) 1063-1070
  • 33 Guerrero P, Li X, Patel K, Brown M, Busconi B. Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Med Arthrosc Rehabil Ther Technol 2009; 1 (01) 17
  • 34 Touten Y, Adachi N, Deie M, Tanaka N, Ochi M. Histologic evaluation of osteochondral loose bodies and repaired tissues after fixation. Arthroscopy 2007; 23 (02) 188-196
  • 35 Boublik M, Schlegel TF, Koonce RC, Genuario JW, Kinkartz JD. Quadriceps tendon injuries in national football league players. Am J Sports Med 2013; 41 (08) 1841-1846
  • 36 Boublik M, Schlegel T, Koonce R, Genuario J, Lind C, Hamming D. Patellar tendon ruptures in National Football League players. Am J Sports Med 2011; 39 (11) 2436-2440
  • 37 McKinney B, Cherney S, Penna J. Intra-articular knee injuries in patients with knee extensor mechanism ruptures. Knee Surg Sports Traumatol Arthrosc 2008; 16 (07) 633-638
  • 38 Alves TI, Girish G, Kalume Brigido M, Jacobson JA. US of the knee: scanning techniques, pitfalls, and pathologic conditions. Radiographics 2016; 36 (06) 1759-1775
  • 39 La S, Fessell DP, Femino JE, Jacobson JA, Jamadar D, Hayes C. Sonography of partial-thickness quadriceps tendon tears with surgical correlation. J Ultrasound Med 2003; 22 (12) 1323-1329 , quiz 1330–1331
  • 40 Sunding K, Fahlström M, Werner S, Forssblad M, Willberg L. Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale. Knee Surg Sports Traumatol Arthrosc 2016; 24 (06) 1988-1996
  • 41 Hoksrud A, Ohberg L, Alfredson H, Bahr R. Color Doppler ultrasound findings in patellar tendinopathy (jumper's knee). Am J Sports Med 2008; 36 (09) 1813-1820
  • 42 Warden SJ, Kiss ZS, Malara FA, Ooi AB, Cook JL, Crossley KM. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med 2007; 35 (03) 427-436
  • 43 Williams H, Jones SA, Lyons C, Wilson C, Ghandour A. Refractory patella tendinopathy with failed conservative treatment-shock wave or arthroscopy?. J Orthop Surg (Hong Kong) 2017; 25 (01) 2309499016684700
  • 44 Ogon P, Izadpanah K, Eberbach H, Lang G, Südkamp NP, Maier D. Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study. BMC Musculoskelet Disord 2017; 18 (01) 146
  • 45 Hayashi D, Li X, Murakami AM, Roemer FW, Trattnig S, Guermazi A. Understanding magnetic resonance imaging of knee cartilage repair: a focus on clinical relevance. Cartilage 2017; DOI: 10.1177/1947603517710309.
  • 46 Felli L, Garlaschi G, Muda A. , et al. Comparison of clinical, MRI and arthroscopic assessments of chronic ACL injuries, meniscal tears and cartilage defects. Musculoskelet Surg 2016; 100 (03) 231-238
  • 47 Ellermann JM, Donald B, Rohr S. , et al. Magnetic resonance imaging of osteochondritis dissecans: validation study for the ICRS classification system. Acad Radiol 2016; 23 (06) 724-729
  • 48 Van Dyck P, Kenis C, Vanhoenacker FM. , et al. Comparison of 1.5- and 3-T MR imaging for evaluating the articular cartilage of the knee. Knee Surg Sports Traumatol Arthrosc 2014; 22 (06) 1376-1384
  • 49 Hontoir F, Clegg P, Simon V, Kirschvink N, Nisolle JF, Vandeweerd JM. Accuracy of computed tomographic arthrography for assessment of articular cartilage defects in the ovine stifle. Vet Radiol Ultrasound 2017; 58 (05) 512-523
  • 50 Omoumi P, Michoux N, Larbi A. , et al. Multirater agreement for grading the femoral and tibial cartilage surface lesions at CT arthrography and analysis of causes of disagreement. Eur J Radiol 2017; 88: 95-101
  • 51 Kokkonen HT, Suomalainen JS, Joukainen A. , et al. In vivo diagnostics of human knee cartilage lesions using delayed CBCT arthrography. J Orthop Res 2014; 32 (03) 403-412
  • 52 Oo WM, Bo MT. Role of ultrasonography in knee osteoarthritis. J Clin Rheumatol 2016; 22 (06) 324-329
  • 53 Okano T, Filippucci E, Di Carlo M. , et al. Ultrasonographic evaluation of joint damage in knee osteoarthritis: feature-specific comparisons with conventional radiography. Rheumatology (Oxford) 2016; 55 (11) 2040-2049
  • 54 De Avila Fernandes E, Bergamaschi SB, Rodrigues TC. , et al. Relevant aspects of imaging in the diagnosis and management of gout. Rev Bras Reumatol Engl Ed 2017; 57 (01) 64-72
  • 55 Howard RG, Pillinger MH, Gyftopoulos S, Thiele RG, Swearingen CJ, Samuels J. Reproducibility of musculoskeletal ultrasound for determining monosodium urate deposition: concordance between readers. Arthritis Care Res (Hoboken) 2011; 63 (10) 1456-1462
  • 56 Filippucci E, Scirè CA, Delle Sedie A. , et al. Ultrasound imaging for the rheumatologist. XXV. Sonographic assessment of the knee in patients with gout and calcium pyrophosphate deposition disease. Clin Exp Rheumatol 2010; 28 (01) 2-5
  • 57 Spannow AH, Stenboeg E, Pfeiffer-Jensen M. , et al. Ultrasound and MRI measurements of joint cartilage in healthy children: a validation study. Ultraschall Med 2011; 32 (Suppl. 01) S110-S116
  • 58 Pradsgaard DØ, Spannow AH, Heuck C, Herlin T. Decreased cartilage thickness in juvenile idiopathic arthritis assessed by ultrasonography. J Rheumatol 2013; 40 (09) 1596-1603
  • 59 Spannow AH, Pfeiffer-Jensen M, Andersen NT, Stenbøg E, Herlin T. Inter -and intraobserver variation of ultrasonographic cartilage thickness assessments in small and large joints in healthy children. Pediatr Rheumatol Online J 2009; 7: 12
  • 60 Lefevre N, Naouri JF, Herman S, Gerometta A, Klouche S, Bohu Y. A current review of the meniscus imaging: proposition of a useful tool for its radiologic analysis. Radiol Res Pract 2016; 2016: 8329296
  • 61 Phelan N, Rowland P, Galvin R, O'Byrne JM. A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee. Knee Surg Sports Traumatol Arthrosc 2016; 24 (05) 1525-1539
  • 62 Lee W, Kim HS, Kim SJ. , et al. CT arthrography and virtual arthroscopy in the diagnosis of the anterior cruciate ligament and meniscal abnormalities of the knee joint. Korean J Radiol 2004; 5 (01) 47-54
  • 63 De Filippo M, Bertellini A, Pogliacomi F. , et al. Multidetector computed tomography arthrography of the knee: diagnostic accuracy and indications. Eur J Radiol 2009; 70 (02) 342-351
  • 64 Cook JL, Cook CR, Stannard JP. , et al. MRI versus ultrasonography to assess meniscal abnormalities in acute knees. J Knee Surg 2014; 27 (04) 319-324
  • 65 Rutten MJ, Collins JM, van Kampen A, Jager GJ. Meniscal cysts: detection with high-resolution sonography. AJR Am J Roentgenol 1998; 171 (02) 491-496
  • 66 Rowland G, Mar D, McIff T, Nelson J. Evaluation of meniscal extrusion with posterior root disruption and repair using ultrasound. Knee 2016; 23 (04) 627-630
  • 67 Turan A, Çeltikçi P, Tufan A, Öztürk MA. Basic radiological assessment of synovial diseases: a pictorial essay. Eur J Rheumatol 2017; 4 (02) 166-174
  • 68 Jaganathan S, Goyal A, Gadodia A, Rastogi S, Mittal R, Gamanagatti S. Spectrum of synovial pathologies: a pictorial assay. Curr Probl Diagn Radiol 2012; 41 (01) 30-42
  • 69 Desai MA, Peterson JJ, Garner HW, Kransdorf MJ. Clinical utility of dual-energy CT for evaluation of tophaceous gout. Radiographics 2011; 31 (05) 1365-1375 , discussion 1376–1377
  • 70 Fukuba E, Yoshizako T, Kitagaki H, Murakawa Y, Kondo M, Uchida N. Power Doppler ultrasonography for assessment of rheumatoid synovitis: comparison with dynamic magnetic resonance imaging. Clin Imaging 2013; 37 (01) 134-137
  • 71 Fiocco U, Ferro F, Vezzù M. , et al. Rheumatoid and psoriatic knee synovitis: clinical, grey scale, and power Doppler ultrasound assessment of the response to etanercept. Ann Rheum Dis 2005; 64 (06) 899-905
  • 72 Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D. Avulsion fractures of the knee: imaging findings and clinical significance. Radiographics 2008; 28 (06) 1755-1770
  • 73 Moatshe G, Dornan GJ, Løken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and injuries associated with knee dislocation: a prospective review of 303 patients. Orthop J Sports Med 2017; 5 (05) 2325967117706521
  • 74 Bottomley N, Williams A, Birch R, Noorani A, Lewis A, Lavelle J. Displacement of the common peroneal nerve in posterolateral corner injuries of the knee. J Bone Joint Surg Br 2005; 87 (09) 1225-1226
  • 75 Oshima T, Nakase J, Numata H, Takata Y, Tsuchiya H. Common peroneal nerve palsy with multiple-ligament knee injury and distal avulsion of the biceps femoris tendon. Case Rep Orthop 2015; 2015: 306260
  • 76 Lueders DR, Smith J, Sellon JL. Ultrasound-guided knee procedures. Phys Med Rehabil Clin N Am 2016; 27 (03) 631-648
  • 77 Lalam RK, Winn N, Cassar-Pullicino VN. Interventional articular and para-articular knee procedures. Br J Radiol 2016; 89 (1059): 20150413
  • 78 Mallinson PI, Coupal TM, McLaughlin PD, Nicolaou S, Munk PL, Ouellette HA. Dual-energy CT for the musculoskeletal system. Radiology 2016; 281 (03) 690-707