Chapter 13: Off-the-Field Injury Evaluation

1. Chapter 13: Off-the-Field Injury Evaluation

2. Evaluation of Injuries • _____________skill for athletic trainers • Four distinct evaluations • Pre-participation (prior to start of season) • On-the-field assessment • Off-the-field evaluation (performed in the clinic/training room…etc) • Progress evaluation

3. Clinical Evaluation & Diagnosis • ______________ • Use of clinical or scientific methods to establish cause and nature of patient’s illness or injury and subsequent functional impairment due to pathology • Forms basis for patient care • Physicians make medical diagnosis • Ultimate determination of patient’s physical condition

4. Athletic trainers and other health care professionals use _______________ skills to make clinical diagnoses • Clinical diagnosis identifies pathology and limitations/disabilities associated with pathology • Athletic trainers have academically-based credential and in many states some form of regulation which recognizes ability and empowers clinician to make accurate clinical diagnosis

5. Basic Knowledge Requirements • Athletic trainer must have general knowledge of anatomy and biomechanics as well as hazards associated with particular sport • ______________ • Surface anatomy • Topographical anatomy is essential • Key surface landmarks provide examiner with indications of normal or injured structures • Body planes and anatomical directions • Points of reference (midsagittal, transverse, and frontal (coronal) planes)

6. Abdominopelvic Quadrants • Four corresponding regions of the abdomen • Divided for evaluative and diagnostic purposes • A second division system involves the abdomen being divided into 9 regions

7. Musculoskeletal Anatomy • Structural and functional anatomy • Encompasses bony and skeletal musculature • Neural anatomy useful relative to motion, sensation, and pain • Standard Terminology • Used to describe precise location of structures and orientation • Biomechanics (foundation for assessment) • Application of mechanical forces which may stem from within or outside the body to living organisms • Pathomechanics - mechanical forces applied to the body due to structural deviation - leading to faulty alignment (resulting in overuse injuries)

8. Understanding the Activity • More knowledge of _____________ allows for more inherent knowledge of injuries associated with activity resulting in more accurate clinical diagnosis and rehab design with appropriate functional aspects incorporated for return to activity • Must be aware of proper biomechanical and kinesiological principles to be applied in activity • Violation of principles can lead to repetitive overuse trauma • Increased understanding = better assessment and care

9. Descriptive Assessment Terms • Etiology - cause of injury or disease • Mechanism – mechanical description of cause • ______________ - structural and functional changes associated with injury process • Symptoms- perceptible changes in body or function that indicate injury or illness (subjective) • Sign - objective, definitive and obvious indicator for specific condition • Degree- grading for injury/condition • Diagnosis- denotes name of specific condition

10. ______________- prediction of the course of the condition • Sequela - condition following and resulting from disease or injury (pneumonia resulting from flu) • Syndrome - group of symptoms and signs that together indicate a particular injury or disease • Differential diagnosis – systematic method of diagnosing a disorder • Refers to a list of possible causes • Prioritizing of possibilities • Also referred to as hypothesis or working diagnosis • Utilize skills to make decision regarding condition

11. Off-the-field Injury Evaluation • Detailed evaluation on sideline or in clinic setting • May be the evaluation of an acute injury or one several days later following acute injury • Divided into 4 components • History, observation, palpation and special tests • ______________

12. _________________ • Obtain subjective information relative to how injury occurred, extent of injury, MOI • Inquire about previous injuries/illnesses that may be involved as well as past treatments • Ask the following questions • What is the problem? • How and when did it occur? • Did you hear or feel something? • Which direction did the joint move? • Characterize the pain

13. _________________ • Asymmetries, postural mal-alignments or deformities? • How does the athlete move? Is there a limp? • Are movements abnormal? • What is the body position? • Facial expressions? • Abnormal sounds? • Swelling, heat, redness, inflammation, swelling or discoloration?

14. _________________ • Bony & soft tissue • Special Tests • Used to detect specific pathologies • Compare inert and contractile tissues and their integrity • Assessment should be made bilaterally • Range of Motion Assessment • Active • Passive • Normal vs. Abnormal end points • Manual muscle tests • Goniometric measures vs. Digital inclinometers

15. Figure 13-4 A & B

16. Neurologic and circulation assessments • Brain • Cerebral, cranial nerve function, cerebellar function • Sensory & motor function • Dermatome • Area of skin innervated by a single nerve • Myotome • Muscle or group of muscles innervated by a specific motor nerve • Reflex testing • Involuntary response to a stimulus • Deep tendon – caused by stimulation of stretch reflex • Superficial – stimulation of skin which causes reflexive muscle contraction • Pathological – superficial reflex indicative of upper motor neuron lesion • Babinski’s sign, Chaddock’s, Oppenheim’s Gordon’s • Referred pain

17. Figure 13-5

18. Motor Testing • Testing Joint Stability • Testing Accessory Motions • Testing Functional Performance • Used to determine athletes readiness to participate or continue participation • Other tests • Postural • Anthropometric • Volumetric Figure 13-6

19. Documenting Injury Evaluation Information • Complete and accurate documentation is _______________ • Clear, concise, accurate records is necessary for third party billing • While cumbersome and time consuming, athletic trainer must be proficient and be able to generate accurate records based on the evaluation performed

20. _______________ Notes • Record keeping can be performed systematically which outlines subjective & objective findings as well as immediate and future plans • SOAP notes allow for subjective & objective information, the assessment and a plan to be implemented • S (subjective) • Statements made by patient - primarily history information and patient’s perceptions including severity, pain, MOI

21. O (Objective) • Findings based on athletic trainer’s evaluation • A (Assessment) • Athletic trainer's professional opinion regarding impression of injury • May include suspected site of injury and structures involved along with rating of severity • P (Plan) • Includes first aid treatment, referral information, goals (short and long term) and examiner’s plan for treatment

22. SOAP Note vs. Progress Note or Evaluation

23. Additional Diagnostic Tests • Due to the need to diagnose and design specific treatment plans, physicians have access to additional tools to acquire additional information relative to an injury • There are a series of diagnostic tools that can be utilized in order to more clearly define and determine the problem that exists

24. Plain Film Radiographs (X-ray) • Used to determine presence of fractures bone abnormalities and dislocations • Can be used to rule out disease (neoplasm) • Occasionally used to assess soft tissue • Arthrography • Visual study of joint via X-ray after injection of dye, air, or a combination of both • Shows disruption of soft tissue and loose bodies • Arthroscopy • Invasive technique, using fiber-optic arthroscope, used to assess joint integrity and damage • Can also be used to perform surgical procedures

25. X-Ray

26. Myelography • Opaque dye injected into epidural space of spinal canal (through lumbar puncture) • Used to detect tumors, nerve root compression and disk disease and other diseases associated with the spinal cord • Computed Tomography (_____________) • Penetrates body with thin, fan-shape X-ray beam • Produces cross sectional view of tissues • Allows multiple viewing angles • Bone Scan • Involves intravenous introduction of radioactive tracer • Used to image bony lesions (i.e. stress fractures) in which there is inflammation

27. CT Scan

28. Bone Scan and DEXA Scan Figure 13-8 F & G

29. DEXA Scan • Dual energy X-ray absorptiometry • Used to measure bone mineral density • Greater mineral density = greater signal picked up • Documents small changes in bone mass • Used on both spine and extremities • Less expensive, less radiation exposure • More sensitive and accurate for measuring subtle bone density changes over time

30. Magnetic Resonance Imaging (MRI) • Using powerful electromagnet, magnetic current focuses hydrogen atoms in water and aligns them • After current shut off, atoms continue to spin emitting different levels of energy depending on tissue type, creating different images • While expensive, it is clearer than CT scan and the test of choice for detecting soft tissue lesions • MRI Arthrography • Imaging study involving injection of contrast agent into joint prior to MRI • Allows for more detailed assessment of joint vs. traditional MRI • Contrast agent allows for highlighting of certain areas

31. Magnetic Resonance Imaging

32. ______________________ • Diagnostic ultrasound of sonography • Allows clinician to view location, measurement or delineation of organ or tissue by measuring reflection or transmission of high frequency ultrasound waves • Computer is able to generate 2-D image • Advancements in technology are allowing for 3-D imaging as well • Musculoskeletal Ultrasound • Allows for imaging and evaluation of soft tissue structures • Complimentary technique to MRI or CT • Non-painful, non-invasive, cost effective

33. Doppler Ultrasound • Used to examine blood flow in arms and legs • Alternative to arteriography and venography • Detects blood clots, venous insufficiency, vessel closing, or altered blood flow • Arteriogram • Catheter inserted into blood vessel and contrast medium is injected • Using x-ray, images are taken to determine path of fluid flow in vessels • Venogram • Radiographic procedure used to image veins filled with contrast medium • Used for detecting thrombophlebitis and for tracing of venous pulse

34. Figure 13-8

35. Echocardiography • Uses ultrasound to produce graphic record of cardiac structures (valves and dimensions of left atrium and ventricles) • ___________________________ (EEG) • Records electrical potentials produced in the brain to detect changes or abnormal brain wave patterns • Electromyography (EMG) • Graphic recording of muscle electrical activity using surface or needle electrodes • Observed with oscilloscope screen or graphic recordings called electromyograms • Used to evaluate muscular conditions

36. Electrocardiography • Recording of electrical activity of heart at various stages in contraction cycle • Assesses impulse formation, conduction, depolarization and re-polarization of atria and ventricles Figure 13-9

37. Nerve Conduction Velocity • Used to determine conduction velocity of nerves and can provide key information relative to neurological conditions • After applying stimulus to nerve, speed at which the muscle reaction occurs is monitored • Delays may indicate nerve compression or muscular/nerve disease • Synovial Fluid Analysis • Detect presence of infection in the joint • Used to confirm diagnosis of gout and differentiates between inflammatory and non-inflammatory conditions (degenerative vs. rheumatoid arthritis)

38. __________________ • Complete blood count (CBC) used to screen for anemia, infection and many other reasons • Assesses red blood cell count, hemoglobin levels, hematocrit levels (RBC per volume), white blood cell count, platelet deficiency, & serum cholesterol • Urinalysis • Used to assess specific gravity, pH, presence of ketones, hemoglobin, proteins, nitrates, red & white blood cells, bacteria, electrolytes, hormones and drug levels

39. Urinalysis using dip and read test strips provide fast accurate results for a number of things including, specific gravity, WBC’s, nitrate, pH, protein, glucose, ketones, bilirubin and blood. • Large area on strip is impregnated with reagents which change color when dipped in urine that are then compared to color comparison charts.

40. Ergonomic Risk Assessment (ERA) • If working in a clinic or industrial setting an athletic trainer may be called upon to perform this assessment • Involves evaluation of factors within a job that increase risk of someone suffering a workplace-related ergonomic injury • Assess aspects and movements that could be modified to reduce risk • Injury prevention and intervention through ergonomic control measures and injury statistics

41. Using ergonomics • Improve efficiency (time and resources) • Reduce time lost due to injury • Reduce decreases in productivity • Consider how changes could impact physical requirements and demands • Investigate worker complaints and concerns • Proactive step towards reducing work-related injuries, workers compensation and time lost • If workers are experiencing pain and discomfort, there may be a safer and more effective way of doing the job

42. If an employee suffers an injury it is likely due to ergonomic stress • Must be addressed to prevent further and future injuries • Steps and tools of risk assessment • Identify and prioritize jobs • Maximizes impact of intervention • Workers must be briefed • Review injury statistics, worker concerns, physical demand analysis • Direct supervisor must be notified • Why the modification and what new expectations will be

43. Steps and tools of risk assessment (continued) • Management must be informed • Aware of costs associated with injuries, benefits of ERA • Company support professionals (nurse, engineer, safety personnel) • Use of videotape • Allows more access for people to assessment process • Utilize for training purposes as well

44. After risks have been identified • Athletic trainer should identify those that should be controlled in an effort to reduce injury rates • Consult workers, supervisors and management • May involve • Physical changes to job (sitting vs. standing, altering work surfaces) • Administrative changes (job rotations, lifting policy) • Personal protective equipment • Proposed changes should have an ERA performed on them to ensure that original risks have been reduced without introduction of new risks