Commonly, knee joint effusion is qualitatively measured (minimal, moderate, etc) and that's not very helpful because those terms don’t have much inter-rater reliability. I don’t think most clinicians are aware that there is a simple, objective way to measure knee effusion called the stroke test. The stroke test is very easy to perform/grade and has good inter-rater reliability.1
How to perform the
stroke test for knee joint effusion:
- Have the patient lie supine with both knees relaxed in full extension (if the patient is missing a significant amount of knee extension, you won’t get an accurate assessment)
- Place your hands along the medial aspect of the proximal tibia and in a distal to proximal motion, sweep along the medial aspect of the knee up towards the suprapatellar pouch. I usually do 2-3 sweeps consecutively (alternating hands). You are trying to move the effusion out of the medial aspect of the knee.
- After you finish sweeping, keep your focus on the medial aspect of the knee to see if any effusion returns on its own.
- If nothing returns on its own, then perform a sweep from the lateral thigh downward past the lateral aspect of the knee. Again, keeping your eyes focused on the medial aspect of the knee.
- Typically, I repeat this 2-3 times and then also check the uninvolved side to see what the patient’s “normal” is.
How to grade the
stroke test:
- 0 – no wave produced with the lateral downward stroke
- Trace – small wave with the lateral downward stroke
- 1+ - large wave returns with lateral downward stroke
- 2+ - effusion spontaneously returns to medial side after upstroke (without lateral downward stroke)
- 3+ - so much fluid that it is impossible to move any of the effusion out of the medial aspect
How to use this
information:
I look at and grade knee joint effusion for two reasons (the
second reason is what I primarily use it for):
- To assess for the presence of intra-articular pathology. Obviously, this isn’t the only thing you would look at to see if there is some type of intra-articular pathology, but it’s another piece to add to the puzzle. And remember, an intra-articular pathology does not always have an associated effusion and vice-versa.
- To help me determine the appropriate progression (or regression) of a patient’s ther-ex/activity. Typically, I use it this way on post-op knee patients. You can use these effusion grades to help you determine progression/regression of your patient’s program, rather than have no real reason for doing so. I should also mention that I use joint soreness rules in addition to the effusion rules for progression/regression of ther-ex/activity. The effusion rules of progression/regression are:
- Ther-ex/activity not progressed when there is a 2+ effusion or more.
- If the effusion increases more than 2 grades or is now present when it was previously absent, ther-ex/activity is decreased to the level prior to the change in effusion.
The stroke test is a really simple test to perform/grade and
it gives you objective data to help determine a patient’s ther-ex/activity
progression.
Via Dr. Dennis Treubig, DPT - Modern Sports PT
Via Dr. Dennis Treubig, DPT - Modern Sports PT
1. Sturgill LP, Snyder-Mackler L, Manal TJ, Axe MJ.
Interrater reliability of a clinical scale to assess knee joint effusion. J
Orthop Sports Phys Ther. 2009;39:845-849.
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...
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