Clinical Evaluation and Diagnosis
Build the Diagnosis, Do Not Guess It
Every evaluation starts with a thorough history: mechanism of injury, onset, location, quality, timing, aggravating and relieving factors, prior injury, and pertinent medical history. Use a consistent framework (HOPS - history, observation, palpation, special tests; SOAP for documentation) so nothing is skipped. Observation and palpation precede provocative testing.
Understand test performance: sensitivity rules out (SnNout), specificity rules in (SpPin). Lachman is the most sensitive test for ACL disruption; the anterior drawer is less reliable in an acutely swollen knee. McMurray and Thessaly help with meniscus; the Ottawa ankle and knee rules decide who needs radiographs. For the shoulder, Hawkins-Kennedy and Neer suggest impingement, empty can tests supraspinatus, Speed and Yergason the biceps/labrum, and apprehension anterior instability. Neurologic screening includes dermatomes, myotomes, deep tendon reflexes, and cranial nerves; grade strength 0-5 and document vascular status.
Recognize red flags that mandate immediate referral: neurologic deficits, night pain, unexplained weight loss, fever, bowel or bladder changes, saddle anesthesia, deformity, and laxity with a tense effusion.
Trap: stems often present a special test as definitive. No single test rules a diagnosis in or out; combine history, mechanism, and clusters of tests.
Worked example: a basketball player pivots, feels a pop, and develops a tense effusion within hours. Mechanism plus rapid hemarthrosis point to ACL injury; perform Lachman first, document neurovascular status, and refer for orthopedic evaluation rather than starting rehabilitation.