A trim, otherwise healthy, 54-year-old male presented with an antalgic gait, favoring his left knee. His past medical history was positive only for a left knee medial meniscectomy in his early 30s. He had no allergies and was taking no medications. His left knee appeared swollen, but not inflamed. The swelling had begun insidiously about nine months earlier with no inciting event. The pain and swelling were not responsive to rest, activity modification, oral NSAIDs, physical therapy, knee bracing or a corticosteroid injection from his primary care physician.
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On inspection, there was normal alignment of the right knee, but the left knee exhibited a varus alignment of approximately 5 degrees. With his fingers, the patient localized the greatest area of pain to the medial femoral condyle of the left knee. While seated, the patient was not able to fully extend or flex the knee, revealing a 10-degree extension lag and loss of the last 30 degrees of left knee flexion. Placing a valgus force through the knee elicited no lateral knee pain nor gross instability. However, placing a varus force through the knee caused lateral knee pain, but no gross instability. Right knee Thessaly testing was normal. Left knee Thessaly testing was equivocal with some pain localized to the left medial knee.
Upon reviewing bilateral knee X-rays obtained one week prior, the orthopaedic specialist detected severe degenerative changes and obliteration of the left medial joint space. With this information, the provider explained that the most likely diagnosis was left medial knee joint osteoarthritis secondary to previous medial meniscectomy. Joint replacement was recommended.
The patient voiced understanding and agreed that once he selected a surgery date, he would make the 875-mile trip to Cleveland Clinic, where he would meet in person with the provider for the first time. Up to that point, his entire orthopaedic exam had been conducted virtually.
Orthopaedic specialists at Cleveland Clinic have found that telemedicine, now commonplace for patient-provider interactions not requiring hands-on care, also is useful for providing safe, effective physical exams of the lower extremity.
“We have debunked the idea that a musculoskeletal exam can only be done in person, with your hands,” says sports medicine physician Dominic King, DO, Director of Clinical Transformation for Cleveland Clinic’s Orthopaedic & Rheumatologic Institute. “We evaluated several elements involved in musculoskeletal evaluations of the hips, knees, ankles and feet — and studied how much information we could glean just by asking the right questions, setting up video capabilities the right way and guiding patients to perform the physical exam on their own. We were shocked by what we could achieve virtually.”
A comprehensive guide to virtual exams
While acute injuries or emergent issues are best managed in person, many orthopaedic patients with chronic conditions, acute flairs or questions about next steps can be served through telemedicine. According to Dr. King, the only requirements for telemedicine are:
- A patient who is motivated to have a virtual exam
- A provider who is trained to use technology in a way that enables innovative care
With the right amount of preparation, technological savvy is not mandatory, he adds.
Dr. King and a research team from Cleveland Clinic’s Department of Orthopaedic Surgery recently published their best practices for conducting virtual exams of the lower extremity in JBJS Reviews.
“When we were looking for guidance on conducting virtual exams step by step, we couldn’t find a complete resource,” says the study’s senior author, Nicolas S. Piuzzi, MD, Director of Adult Joint Reconstruction Research at Cleveland Clinic. “The literature had parts, but nothing comprehensive. That’s why we compiled best practices into one master guide.”
Tactics and technical recommendations
The article reviews various methods for performing palpation, checking range of motion and conducting strength testing on the hip, knee, ankle and foot. Patients can be directed to position their leg, angle their camera or perform a movement. Strength testing can be performed using household objects with standardized weights.
Also included in the article are guidelines for postoperative wound evaluation, including using a household ruler to assess dimensions and white gauze to assess color.
According to Dr. King, one of the highlights of the article is a list of technical recommendations:
- A computer with a camera, high-definition audio and a processing speed of 3.4 GHz
- A computer screen with at least a 720p display
- Internet connection speed of at least 25 Mbps
- Adequate lighting in front of the patient, with limited light sources behind the patient
- A steady camera positioned 3 to 6 feet (0.9 to 1.8 meters) from the patient
- A quiet environment
- Clothing that exposes the area to be examined, where appropriate
“Most people don’t even think about having proper front lighting, or reducing light if it’s too bright, or adjusting the color of light,” says study author Jonathan Schaffer, MD, MBA, of Cleveland Clinic’s Center for Adult Reconstruction. “Being aware of details like that makes a difference. You don’t need to spend a lot of money to conduct effective virtual visits, but you do need to set up your space properly, just like setting up an exam room in a clinic.”
Improving access to care
Dr. Schaffer, a champion of telemedicine at Cleveland Clinic, partners with Dr. King to lead Cleveland Clinic’s Orthopaedic Informatics Working Group (OIWG), a multispecialty, multisite cross section of caregivers working to transform musculoskeletal care operations. Since 2019, the group has been innovating ways to improve orthopaedic patients’ access to care. Telemedicine is a key effort.
“Telemedicine augments in-person visits,” says Dr. Schaffer. “We can improve patient access by offering both. Yes, there’s a limit to what we can and cannot diagnose virtually, but — as with an overseas patient I saw yesterday for a medial collateral ligament strain — you can certainly get a differential to assess many conditions.”
“The only thing you can’t do is shake the hand of the patient”
Removing geographic barriers to orthopaedic care is the goal of the JBJS Reviews article. It’s also the goal of a soon-to-be-published book, The Principles of Virtual Orthopedic Assessment, edited by Dr. Piuzzi with contributions from Drs. Schaffer and King.
“Human touch and in-person care is valuable for establishing interpersonal connection and trust,” says Dr. Piuzzi. “But, once that connection is established, there are very few aspects of an orthopaedic exam that we can’t do virtually.”
Dr. King concludes, “We have so comprehensively outlined how to conduct virtual visits in the article, and soon in the book, that the only thing you can’t do is shake the hand of the patient.”